10 Practical Strategies for Thawing the Stuttering Iceberg

Stuttering is one of the hardest disorders to treat because it’s more than just disfluency. Speech-language pathologists often break stuttering into three parts, or the “ABC’s”:

• Affective Components – The feelings and emotions that accompany stuttering.
• Behavioral Components – The physical stuttering that we typically think of as disfluencies (this also includes secondary behaviors).
• Cognitive Components – The negative thoughts and beliefs that perpetuate the problem of stuttering.

How do we address all of these in therapy? Below are ten different approaches to get started.

The Stuttering Iceberg

The iceberg analogy of stuttering is a great place to begin therapy and tie the three “ABCs” together. Developed by Joseph Sheehan¹, this model compares the disorder of stuttering to the iceberg that destroyed the Titanic. The underneath-the-surface features of an iceberg do the most damage to the boat. Here’s how this model works:

1. Begin by drawing a picture of an iceberg, with one part above the surface of the water and another part underneath.
2. Label the tip of the iceberg, the part that lies above the surface of the water, as “physical behaviors”. These accompany stuttering, and include your classic stuttering behaviors such as prolongations, repetitions, and blocks, as well as secondary behaviors such as eye blinks, head movements, foot tapping, etc.
3. Label the bottom of the iceberg, the part that lies below the surface of the water, with the thoughts, feelings, and life impact associated with stuttering. This may include words such as “frustration, shame, or embarrassment” or phrases such as “substitute words” or “not participate in meetings.”

After completing this exercise it becomes clear that the substantial impacts of stuttering are the emotions and activities affected rather than the physical manifestations.

Educate

Many clients who come to therapy have very little knowledge of stuttering; and, having a disorder that you know nothing about can be scary.

Try offering an education packet discussing causes, symptoms, treatment, and FAQ of stuttering. The client can then share this packet with their family, friends, and/or coworkers. You can also have them present the packet to you. This is a great way to practice strong communication skills!

It may also be helpful to draw a diagram of the vocal mechanism. Explain how each system works and its role in stuttering. There are many different ways to get “stuck.” Have the client play around with tension in different areas. Start with the chest and move up to the lips. Practice saying words with 100% tension, 50% tension, and very little tension.

Use Monologues for Monitoring

Working on a skill like eye contact or easy onsets? Break it up into monologues. It’s nearly impossible for a client to practice a skill for the entire session. Set a timer, have them talk for 2 minutes, measure accuracy, and share it with them. Often, adult clients want to know how they performed. Be specific and clear – hold them accountable for only that target only during that monologue.

Suggest Books about Stuttering

There are many great books about stuttering. Assign a chapter a week for homework then discuss it the following week. Have the client highlight their favorite parts. Here are a few recommendations:

• “Advice to Those who Stutter” from the Stuttering Foundation
• “Out With It” by Katherine Preston
• “Stuttering: Inspiring Stories and Professional Wisdom” from Stuttertalk

Play Table Topics

This is an activity done regularly at Toastmasters meetings. It’s best for stuttering groups, but can be modified for an individual session.

• Have clients write down 3 topics on small pieces of paper. These can range from anything as vague as “potatoes” to something more specific like “tell me about the coolest vacation you’ve taken.”
• Once each person has written down 3 ideas, put the topics in a hat or cup.
• Have the first person draw a topic. They must talk for 2-3 minutes about this topic. Each client takes a turn.

Write it Down

This is a simple, yet powerful activity. Have a client who can’t stop talking about the awful experience he had at work? What about the client who can’t seem to shake off the anxiety associated with going out on a date?

• As the client is talking, take notes. Write down their thoughts (belief statements) and their feelings (I feel…). Seeing your thoughts on paper can help defuse from them.
• Have the client close their eyes and visualize an anxiety-provoking event. Then, have them write down everything they saw, heard, smelled, experienced, etc. When they are finished, have them bunch up the piece of paper and throw it out.

Get Out of the Therapy Room

Go to a coffee shop, park, mall, or anywhere where the client can talk with new faces.

Before you begin, make a fear hierarchy that includes a list of people and situations arranged from least feared to most feared. For instance, “my wife” might be at the bottom, “talking to people on the street” might be in the middle, and “my boss” might be at the top. This is really important to do before going out of the therapy room. You don’t want to start with anything too fearful. Once outside the therapy space, suggest the client try the following:

• Ask people for directions
• Give stuttering surveys to people at the park. I usually create a survey that has the following questions:
  • What do you think causes stuttering?
  • Do you feel uncomfortable or embarrassed when talking to a person who stutters?
  • Do you know anyone else that stutters?

Just remember to always begin the activity by modeling it first!

Teach “Planning to Feel”

This idea comes from Avoidance Reduction Therapy for Stuttering.² Discomfort is an inevitable feeling for people who stutter. Instead of trying to fight it, have clients plan to feel uncomfortable or embarrassed. This is especially useful for class or work presentations, where discomfort runs rapid. Practice using this cognitive skill in a conversation in the therapy room first.

Get People Who Stutter in the Same Room

Have multiple clients who stutter? Bring them together.

• Refer them to the National Stuttering Association or FRIENDS: The National Association of Young People Who Stutter. Both of these organizations have annual conferences for people who stutter, and the NSA has local chapters throughout the country.
• Start a stuttering group with similar clients. Examples include a teens who stutter group, young professionals group, and a women who stutter group.
• Only have two clients who stutter? Host a duo! Field questions for discussion, have some small talk practice, and play games to practice speech techniques.

Just Listen

Stuttering is hard! Sometimes we don’t have the answer. Listening empathetically, validating clients’ experiences, and providing them with a safe space to share their struggles are the most important things you can do.