Shifting
to a
Global
Perspective
A Comprehensive Approach
to Stuttering Treatment
Mateleine Eshnaur, M.S., CCC-SLP
Metro Speech-Language Symposium
February 8th, 2014
Oh no, not a stutterer…
Many SLPs report feeling
uncomfortable with treating
fluency cases (National Stuttering
Foundation).
 Where does this discomfort come
from?
 A sense of being ill-equipped
and/or unsuccessful with
treatment?

What is more important?
Helping your student become the
most fluent speaker he/she can
be?
 Helping your student be the most
effective communicator he/she
can be?
 Is there a difference between the
two?

The Iceberg Analogy:
Overt vs. Covert Stuttering
“Your stuttering is like
an iceberg. The part
above the surface,
what people see and
hear, is really the
smaller part. By far the
larger is the part
underneath the shame,
the fear, the guilt, all
those other feelings
that we have when we
try to speak a simple
sentence and can't,”
Dr. Joseph Sheehan
Message to a Stutterer
Shifting the Perspective
In line with Sheehan’s analogy, effective
treatment must also address the covert
aspects of stuttering, rather than focus
solely on the overt aspects.
 “Stuttering is a result of approach-avoidance
conflict, of opposed urges to speak and hold
back from speaking. The ‘holding back’
may be due to learned avoidances or to
unconscious motives,” (Sheehan, 1953).
 This model shifts the perspective from
valuing fluent speech as the primary
treatment objective, to placing more value
on the speaker’s attitudes, feelings, and
beliefs about his/her ability to speak.

Shifting the Perspective…
In making this shift, the whole treatment
environment changes for both the SLP and
students.
 Speech modification techniques are taught
within a larger context of changing attitudes
and beliefs around talking, and forming
new, more positive experiences.
 Attitudes of both SLP and student become
more accepting of stuttering.
 Treatment focus shifts to effective
communication by combining speech
modification techniques with exercises to
improve speaker attitudes.

Break-out #1: Selecting a
Case Study (8 minutes)
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Use the handout provided to select a
student (past or present).
Handout will guide you on providing
necessary information.
Share your case study briefly with
someone near you. Why did you select
this case?
PLEASE DO NOT SHARE INFORMATION
THAT COULD RESULT IN A BREACH OF
CONFIDENTIALITY (PERSONALLY
IDENTIFYING INFORMATION)
“I've stuttered all my days. I
guess I'm one of those
incurable stutterers. Everyone
has his own personal demon
and mine is stuttering. I found
that once I accepted it as a
problem and learned to cope
with it by not avoiding or
hiding or struggling with it, my
demon lost its hold on me.”
Dr. Charles Van Riper
So why is it that the same
person, given a
consistent level of
impairment, can
experience different
degrees of impact
throughout his/her
lifetime?
Impairment vs. Disability
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World Health Organization (WHO)
Impairment is defined as the
disruption to normal body function
or structure.
Disability is defined as the impact
the impairment has on life functions,
to include activity limitations and
participation restrictions.
Contextual factors refer to the
environmental and personal factors
that influence disability (create
barriers or access).
Adapted from Yaruss & Quesal (2004)
The research shows…
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A study of adult stutterers in South Africa
showed, “most participants felt that stuttering
had affected their self-esteem and selfimage...findings suggest the need to
incorporate subjective feelings about
stuttering into clinical practice,” (Klompas and
Ross, 2004).
Eight out of ten children who responded to a
survey conducted in 2009 by the NSA
(National Stuttering Association) reported
being bullied because of their stuttering.
From the same survey, 40% of adults reported
being denied a promotion or job due their
stuttering.
This is not the future we want
for our students…
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In a survey conducted by Klein & Hood (2004) of
232 PWS over 18years:
71% reported that stuttering decreases chances of
being hired
70% reported that stuttering interferes with
promotional possibilities
65% agreed that “average person who stutters
believes their stuttering interferes with job
performance”
385 college students were asked to report on their
perceptions of PWS in different professions;
perceptions were largely negative indicating
perceived inability to perform due to stuttering
(Gabel, Blood, Tellis, Blood & Althouse, 2004)
This is just a small sample of
the research that shows
stuttering frequently and
significantly impacts people
in all aspects of life, personal
and professional.
As SLPs we are tasked with
minimizing the impact, or
disability, of stuttering.
How…?

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The elements of the model that SLPs can directly
influence:
1. Function: By teaching the SWS (student who stutters)
about normal speech production, and how to positively
impact his/her own speech production through speech
modification (i.e., fluency shaping and stuttering
modification).
2. Environmental Factors: By educating the SWS, those
in the school setting, and family about stuttering in an
effort to create awareness and acceptance. By
proactively dealing with negative social consequences
(e.g., teasing/bullying).
3. Personal Factors: By changing attitudes about self
and speaking.
Capturing the Elusive…
Understanding attitudes, thoughts,
feelings, beliefs, and associated
behaviors in determining life impact
(a mouth full!), when assessing
stuttering.
Relationship to the
Colorado Severity Rating Scale

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School-based clinicians are required
to answer if the student engages in
“escape behaviors and avoidance.”
We must also determine if
disfluencies: occasionally, frequently,
or consistently impact a student’s
participation in educational settings.
We need to consider assessing these
aspects when determining if a
student will receive an SLI (speechlanguage impaired) eligibility for a
fluency disorder.
How can we effectively assess attitudes,
beliefs, feelings, and thoughts?
How do we understand these
needs, that are individual and
variable for each student, in the
assessment and planning process?
 Observation…
 Interview: students, teachers,
parents…
 Self-report measures…

Observation is a crucial skill,
but…
Looking for signs of: tension, struggle,
avoidance, circumlocation, secondaries, etc.
are an important part of the evaluative
process and helps us in understanding the
severity of the stuttering…
 But how much can we observe at any given
moment of time?
 How much do our observations help us
understand impact if impact is largely
internal?
 Observation does not lead to understanding
of: thoughts, feelings, beliefs (i.e.,
attitudinal components).

Assessment: Interviews
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Interview forms can be provided from a variety of
sources or may be self-created
Important points:
Do not ask leading questions; try to maintain an openended format that does not “color” or lead the
questions
Try not to insert your own descriptors: “How does that
make you feel when you can’t get the words out?”
versus “Does that make you feel nervous/anxious/bad,
etc.?”
Focus on listening, not questioning
Take time to develop a rapport
Be sensitive to the needs of the interviewee; take breaks
as needed
But interviews have significant
limitations…

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Outside of directly interviewing SWS, other
people can only give insight into observable
behaviors, but cannot tell you what the
student is directly experiencing.
Interviews can be valuable and should be
included in the assessment process, but there
are a variety of factors that can influence the
quality of information gained from interviews
such as: memory/accuracy, how forthright the
interviewee is, quality of relationship between
interviewer/interviewee, communication
barriers (e.g., language, cultural, SES), bias
(e.g., of parent, teacher), anxiety, distrust etc..
OASES
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OASES: Overall Assessment of the Speaker’s Experience of
Stuttering (Quesal & Yaruss, 2010)
Protocols for ages: 7-12; 13-17; 18 and older
Aligns with the WHO’s IFC model in examining the impact
of stuttering in examining four areas: general information,
reactions to stuttering, communications in daily situations,
and quality of life.
Provides an impact score in each area, from mild to severe.
Is helpful in planning treatment; manual gives general
guidelines for treatment depending on which area(s) the
client/student scores higher in.
For instance, a PWS who scores high in section II (reactions
to stuttering) would benefit from treatment that includes,
“strategies aimed at desensitizing the speaker to
stuttering…and helping the speaker to accept stuttering,”
(Quesal & Yaruss, 2010).
Break-out session #2: Assessing your
student (10 minutes)
How did you assess these elements of
the Colorado Severity Rating Scale when
determining eligibility. If the assessment
was done by another SLP, do you think
these aspects were addressed?
 Would you assess differently now given
this information?
 How would you plan to assess this
student currently if you had to
reevaluate?
 Go over your plan briefly with another
SLP.

Planning Treatment
HOW TO INCORPORATE BOTH
OVERT AND COVERT ASPECTS OF
STUTTERING INTO TREATMENT PLANNING
Locus of Control
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Locus of control refers to a concept in psychology
where an individual tends to place control of outcomes
in their lives on internal or external forces or factors.
Those with an internal locus of control feel more in
charge of their lives and destinies, because they
attribute outcomes to their own actions, efforts, and
beliefs.
Establishing an internal locus of control in treatment:
stuttering is something that comes from me not
something that happens to me.
If stuttering is something that happens to me I have no
control; if stuttering is something that comes from me,
I can effect my own stuttering.
“Those who continue to rely on the clinician and the
clinical environment for reinforcement and who fail to
take the necessary responsibility for their fluency are
more likely to relapse once formal treatment is
completed,” (Manning, 2001).
Providing Speech Modification
within a Larger Context
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Tools for modifying speech are more likely to
be used if provided within a more
comprehensive treatment program that
addresses the covert aspects of stuttering and
minimizes the negative impacts of stuttering
CITE.
A review by McClure and Yaruss of a survey
conducted by the NSA (National Stuttering
Association) of 710 of its members reported,
“greater success with speech treatment that
focuses on attitudes than on speech
modification,” (2003).
Changing Environmental and
Personal Factors
Attitudes: change attitudes by creating…
 Acceptance: both of self and in others
(students, staff, family)
 Awareness: self-awareness and awareness
within the student’s school community and
family
 Broadening view of self: beyond speaking
alone
 Becoming the expert: on one’s own stuttering
and then sharing that knowledge
 Challenging established beliefs: of what
stuttering is and how stuttering has to be
 Creating new thoughts: of self and speaking
abilities

Speaker Attitudes
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The cognitive-behavioral model links thoughts
and feelings with physiological responses and
behavioral reactions CITE.
Negative predictions such as, “They’ll think
I’m stupid,” or “I won’t ever get the words
out,” create a negative feed-back loop of
anxiety, fear, shame, etc., which results in a
heightened physical state and avoidant
behaviors.
Treatment seeks to change this feedback loop
through changing environmental and personal
factors, thereby creating new speaking
experiences.
Treatment Activity: Catch a Mistake
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Ask student to make a point of observing
other speakers to “catch mistakes.”
Encourage student to do this with a variety of
speakers: you, other students, parents,
teachers, people on T.V., etc..
Student takes notes and shares observations
of what mistakes they have caught with others
speakers.
Point: To help
broaden
student’s
understanding
of “normal”
speech
production
Acceptance &
Awareness

Creating a treatment environment where stuttering is
accepted and the content of the message is considered
more than the delivery
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Desensitization Activities: Openly stuttering (student
and SLP); self-disclosure
Education: Materials given to students, teachers, and
parents that educate on creating supportive
communication environments and habits; student takes
active role in educating others and self-advocacy
Support: Linking students to supports (local, national)
Treatment Activity: Did you know…?

Research a famous person who stutters
that the student is interested in. How
did he/she overcome stuttering?
Treatment Activity:
Linking Supports
Help student discover different ways of
creating support to include: family,
teachers, friends, local support groups,
national organizations.
 Create a chain link with the student
where he/she describes different forms
of support (e.g., My friends can listen to
me when I’m upset.)
 Create a virtual memories book
describing a time when different people
gave support.
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Broadening View of Self
Discussing aspects of student
beyond speaking behaviors and
experiences alone
 Creating a view of self that is not
dominated by stuttering
 Example activity: All About Me
book that discusses student
holistically (e.g., family make-up,
likes/dislikes, hobbies, strengths,
etc.)
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Break-out #3: Design an
Activity (8 minutes)
Partner with 1-2 other people
 Design a treatment activity
(individual and/or group) that
targets: attitudes, acceptance,
awareness, and/or view of self.
 If time allows, reflect on how this
activity may help the student you
have selected for your case study.
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Becoming the Expert
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Building foundational knowledge and vocabulary
around normal speech production
Learning to be aware of what is happening during
moments of stuttering and being able to describe
those behaviors with specific terms
Example Activities: The Speech Machine; Tool Box
Being able to relate knowledge of normal speech
production with stuttering behaviors and what
tools (i.e., speech modification strategies) to use
when
Being able to teach others (e.g., teachers, parents,
friends) about stuttering
Example Activity: class presentation
Treatment Activity:
Speech Man (or Woman)
Allow student to select color of paper
 Outline/draw/photograph torso of student
(adjusted for age, appropriateness)
 Have cut-outs of basic speech parts: brain,
lips, tongue, voice-box, lungs, diaphragm
(can adjust language based on
developmental/educational level)
 Students paste cut-outs in appropriate
locations, label, and briefly describe function
 Helps students become more familiar with
speech anatomy and creates a tool that can be
used in future sessions
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Challenging Established &
Creating New Beliefs
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Identifying current beliefs (e.g., I can’t talk
right ever; everyone else talks perfectly)
Challenging those beliefs (e.g., seeing that
there are times where talking is successful;
studying other people talking to see that
everyone makes mistakes when speaking)
Creating new belief systems: I’m in control of
my speaking, it’s okay if I stutter, they won’t
think I’m stupid, I can tell them I stutter, no
one speaks perfectly all the time, etc..
Treatment Activity:
Cartooning
Student creates a cartoon of what
he/she imagines stuttering to be
 Student then creates himself/herself in
a cartoon, super hero form
 Various situations with stuttering can
be cartooned using these and other
characters to include: confronting
avoided situations, practicing issues
around bullying, and countering
negative beliefs/thoughts (Murray).
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Treatment Activity:
Role-playing/Confronting
Role-playing difficult communication
situations and building to a level of
confronting the actual situation.4
 Example: making a telephone call to a local
library.
 Analyzing the speaking situation with the SLP
to look at both the positive and negative
aspects of the exchange.
 Accentuate the positive, and frame negative
aspects as something that can be changed for
future situations.
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Creating New Experiences
Purposeful stuttering: starting with the
treatment environment and moving into the
school community
 Self-disclosure
 Educating self and others
 Participation in support groups: local to
national; your treatment sessions can double
as a support group
 Confronting feared/avoided speaking
situations
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Social Consequences: Bullying
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Minimizing Bullying for Children Who Stutter: A Practical
Guide for SLPs (Murphy, Quesal, ReardonReeves,Yaruss, 2013).
Talks not only about what SLPs can do to help students
with bullying, but what students, parents, teachers, and
school administrators can do regarding bullying within
the unique context of SWS.
Comparing the SLP
and Student roles
(Murphy, Quesal, Reardon-Reeves, Yaruss, 2013)
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SLP needs to…
Teach about stuttering
Teach about bullying
Help the student think
differently about
stuttering
Help develop
appropriately assertive
responses
Help educate others
(other students,
teachers, parents)
Help link students to
resources for support
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Student needs to…
Learn the facts (e.g.,
stuttering is not my fault,
bullying is not right)
Give the facts by talking
to others in a variety of
situations (e.g.,
discussing with teachers,
parents, peers)
Learn how to help
themselves (e.g., learn
purposeful ignoring; learn
how to self-advocate)
Gain support of others
Treatment Activity:
Let’s Make a Movie
(adapted from Minimizing Bullying…)
Role-play scenarios: real or imagined
 Record, review, respond: record role-play (after
practicing), review in a comfortable environment, talk
about possible responses, decide on response(s), record
the “new way.”
 Allows for repeated practice in a fun, inventive, and
inovative way, “repeated practice will increase children’s
mastery and confidence so they can manage to respond
appropriately, even in the face of increased anxiety,”
(Murphy, Quesal, Reardon-Reeves,Yaruss 2013).
 Allows for opportunities to create community amongst
SWS, as well as involve other peers and even staff to
extend community and support (as well as provides
natural opportunities to educate and create awareness).
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Preschool
Making mistakes in general okay
 Approach stuttering in a relaxed, comfortable
way that does not convey concern, anxiety, or
disapproval; encourage others to do the same
 Approach talking with appropriate turntaking, time allotted for extended wait-time
as much as possible, reduced questions
 MODEL what you want to hear (slower, easier
talking); encourage parents/teachers to do the
same; discourage comments like “slow down”
 Be a good listener, pay attention to the
message not the content
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Preschool Contd.
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Teach basic awareness of body and talking
as is developmentally (and individually)
appropriate
Learning to be aware of the body (relaxed
versus tense)
Thinking good things about self
Teaching to parents and preschool staff
Approach the topic of stuttering with
parents and staff in a direct, but
comfortable, manner
Provide educational materials/links to
support