What is a vital, but often overlook component of stuttering therapy? Do you feel like there’s a missing piece with some clients who stutter, but you can’t put your finger on it? Find that missing piece in Episode 48 of The Mindful SLP. 

— Useful Links —

Treating the School Age Child Who Stutters by Carl W Dell Jr.

Avoidance Reduction Therapy in a Group Setting, seminar by Vivian Sisken

Dancing the Macarena on an Iceberg

Impossible R Made Possible 

Music: Simple Gifts performed by Ted Yoder, used with permission

Transcript

Denise: Do you ever feel like you’re playing whack-a-mole when you’re treating stuttering? You’d get one behavior under control and another one pops up? Your clients don’t seem to progress to independently managing their stuttering, and they’re dependent on you for cues. Well put down your mallet. Today, we are talking about what the problem could be, and I have a potential solution for you.

Welcome to The Mindful SLP, the show that explore simple but powerful therapy techniques for optimal outcomes. I’m Denise Stratton, a pediatric speech language pathologist of 30 years. I’m closer to the end of my career than the beginning, and along the way, I’ve worked long and hard to become a better therapist.

Join me and I’ll do my best to make your journey smoother. I found the best therapy comes from employing simple techniques with a generous helping of mindfulness. Joining me in the conversation is Dan, my technical wizard and office manager.

Dan: Welcome back. Today, we’re going to be talking about a step in stuttering therapy that often gets overlooked.

Last time we were talking about dancing the Macarena on an iceberg, treating all those underlying conditions before you can actually address stuttering. We’re going to continue with the case history. After you had wrapped up all these underlying issues that this client had. What’d you do next?

Denise: First I want to tell you a story that has to do with this. So I had mentioned before that I took voice lessons and I got a whole lot better, so much better in fact that I thought I could sing a song at my mother’s wedding. I had sung it at recital. I did really well, but her wedding was outside and I didn’t realize how different my voice would sound if it wasn’t reflecting back to me, there were no walls around me and I didn’t really have time to practice, my accompanist was late because of traffic. And so people were gathering by the time she got there, I was like, oh, I can’t practice now. I mean, I practice this song the whole day long inside, inside the house. And I nailed it inside. I got in front of those people. I started singing and my voice was just like disappearing into the wind.

It was so terrifying and it was a train wreck. It was a total train wreck, but here’s the thing. I knew I sounded bad, I didn’t know where I was messing up. I didn’t know which note I was off on. I just knew it, it was horrible. And I couldn’t bring it back because I didn’t know where I was messing up. So contrast that with a recital I had a few months later. I opened my mouth, the first note I was flat on, I knew I was flat. I said to the pianist, let me start over. We started over and it went great.

Dan: So, what does this have to do is treating stuttering?

Denise: Well, people who stutter, know they stutter. If they didn’t, it would be cluttering, which we’ll talk about in a later podcast, usually anxiety about how they sound is a part of the disorder. So we might come to the conclusion that, of course they know what words or sounds they’re stuttering on because they’re anxious about it. They know they’re stuttering. But actually they might have no clue. Really, just like I had no clue what notes I was messing up on.

Dan: You just knew you were messing up.

Denise: I knew I was messing up and then my anxiety played into it and it just snowballed until I was like, please just let this song be over so I can go sit down. Sorry, mom. But most of the training I have had centered on these few steps. You help the child identify their speech helpers, you know, you’ve got your lips, you’ve got your tongue and things can get messed up if those don’t work correctly, so let’s know where speech helpers are. The practicing how to mitigate the stutter things like soft contact, easy onsets, some negative practice to remove fear and discomfort.

And then you practice using these techniques in evermore complex speaking situations.

Dan: So this is the classic stuttering training that you get in college.

Denise: And even after college, I read some books, I went to some classes and no one really mentioned helping the client identify what particular word they were stuttering on. So when it came to treating school-age clients who stutter, I mean, this approach never really worked for me. I never really felt confident in it. I was great with preschool stuttering. That’s sort of a different ball game, but it turns out I wasn’t confident because I was missing this really important piece.

So back to this case history, once I resolved those underlying issues, then that imposter syndrome came back to me, ’cause I was like, now I really have to treat this stutter and I’m not showing very good at it. I was good at those other things, but I was so fortunate, I was going through a magazine that I get from The Stuttering Foundation. They have products in there, my eyes lighted on this book and something in me was like that’s the book you need.

Dan: And that goes back to our other episode, where we talked about just listening.

Denise: So I ordered that book right away, Treating the School Aged Child Who Stutters by Carl W. Dell Jr., It is fantastic.

Dan: And we’ll have a link to that in the show notes, of course.

Denise: So in this book, he addresses different severities of stuttering and how to work with each group. Ongoing diagnosis and emotional ways to talk about it. It is full of tons of valuable information. But what I really want to talk about is the steps that he describes in helping the child just identify what word they stuttered on, because there’s a huge gap. Or there can be a huge gap. I should say. I’ve had some clients who this is pretty easy and they could go on to other steps. But for this particular client…

Dan: She really had to struggle to get to the point where she could recognize just where the problem was starting.

Denise: She couldn’t even recognize what words she stuttered on. It was like a hole in her mind and her memory. It was like, I know I stuttered, but I have no idea where, I don’t know what word I messed up. If she were to say, I will want an apple. And I would say, oh, I think you bounced a little bit on one of those words. Can you tell me what word it was? She would have no idea.

She would have no clue. How can you fix something if you don’t know where it’s happening? How can you stop and modify a stutter if you don’t know where it’s happening? Cause that’s what we teach them to do. We teach them to modify a stutter into an easier stutter. You can’t do that, and that’s why some clients fail to become independent.

They might be hit and miss here and there and figure out how to modify a few, but it can’t really become integrated if I don’t know where it’s happening.

Dan: In this book, Treating the School Aged Child Who Stutters, Carl Dell talks about several steps to help the child learn where they’re actually having the stuttering problem. Now there’s a lot of steps here.

Denise: There are a ton of them. We can’t go through them all, you’d get bored. I’m going to talk about a few of those, but I just want you to know that he has a lot of focus on where and helping the child identify where, both in themselves and in you as the clinician, more than how. So, you’re really helping the child notice where you stuttered as a clinician or where the child’s stuttered. A lot of time is spent on that before you move to how, and we tend to skip to the how, just straight to the how,

Dan: Okay, give us an example. What’s one of the steps?

Denise: So as the clinician, you stutter, and then you might say, oh, I was a little bouncy there. Do you know what word I bounced on? Just like that. And they might identify it or they might not. If they don’t, then you might do it again. Or you might record yourself and play the recording again. Because they just aren’t tuned into hearing that.

Dan: It takes some repetition to learn that skill. That makes sense.

Denise: And then you might play a game where you identify each other’s disfluencies. So after you’ve done it for yourself, then the child can get more comfortable with you saying, oh, I noticed that you bounced a little bit there. Do you remember what word you bounced on? That sounds very simple and is very simple, but he takes it in such nice little incremental steps. I’ve actually got 10 steps listed here and I was like, oh, we can’t write all 10 of those. Really, you just need to get the book. But what is really interesting, I think is after you get through a lot of this, where the center happens. He has a couple of techniques that I hadn’t been introduced to before on how to reduce the number of repetitions a child has, or the length of the prolongations, because you want to reduce the severity of the stutter. So for example, you might have them count how many times you bounced bup, bup, bup, bup, a ball.

Dan: Oh wow. That’s definitely one where they have to go back and listen to it.

Denise: Yeah, you could record it. And then you make them in charge of how many repetitions you make. They have to hold up three or four or five fingers or ten, if you want to, and you have to bounce that many times.

Dan: Oh, you the clinician have to bounce that many times.

Denise: Cause then once they can do that, then you can turn it around and say, okay, now I’m going to tell you how many times to bounce. And then every once in a while you can put in zero. So they’re learning to control, oh, I can do zero bounces. And the same thing with prolongations, how many seconds are you going to hold the sound out? And then they get to practice holding it out and really feeling in control of the stutter. And then sometimes you’ll do zero. You’re not going to prolong the sound at all. So I thought that was just a brilliant clinical strategy.

Dan: Wow. It does sound like a good book.

Denise: Now that’s just a sample of a few things. One other thing that Carl Dell writes in the book is sample dialogue. Like this is how you can talk to the child about it in a way that’s just very non-threatening and very matter of fact.

Dan: Boy, that’s helpful, I bet.

Denise: I thought I was kind of good about talking to kids about their stuttering in a non-threatening way, but his dialogue is just so masterful. It’s just so good. You read it and you can picture yourself, oh, I can picture myself saying this to the child.

Dan: And that helps them relax and do it right.

Denise: Well, it’s just, um, yeah, I can’t even describe it. It’s just really good, it’s really masterful writing, so just get the book. You know, let me just read some of what this dialogue is and then you’ll get an idea of how good it is instead of me just going on and on. This is a little sample where he says, first, we must make the child aware of his fluency. So we’re going to focus attention on that they can be fluent a lot of the time. So the SLP says, okay, now let’s do some work. Let me have all the toys over here. Now, see if you can say just what I say, the car is red. The child says it’s red. That’s not what I said. Listen again, the car is red. Can you say that the child says the car is red. That’s right, the car is red. Did you bounce on any of those words? And the child says no. So then the child gets the red car. Now the SLP says, now say this, the kangaroo has a long tail. The child says the kangaroo has a long tail. And SLP says, say it again, but put your hand over your mouth so you can feel how you said it.

Feel your lips moving and your jaw and tongue. They’re feeling how they can be fluent. And then the clinician says, now how about this one? Say the elephant has a trunk, but this time, shut your eyes and listen to how you would say it. And the child goes, the, the elephant has a trunk. Did you bounce on any of those words? Yeah, I said that the, the, and then the clinician says, yes, I thought I heard you say that the, the elephant too, if you say it without bouncing how it sound? The elephant has a trunk. And then SLP says yes, that probably felt and sounded smoother.

Dan: I liked that part about what would it sound like if you didn’t bounce on that? That’s, that’s a brilliant idea.

Denise: I know, and I never thought about saying something like that. That’s a brilliant way to word it. And there’s just pages and pages of that kind of dialogue.

Dan: Wow, that’s good.

Denise: One point that Del brings up is never make a child do anything you haven’t done first. So you’re always going to model how you stutter first.

Children with confirmed stuttering need to spend a lot of time and what he calls touching this stuttering. So becoming really familiar with it, becoming really comfortable talking about it, identifying where it happens before you ask them to modify. Before you ask them to change how they’re stuttering before you ask them to do less repetitions, less prolongations. You’ve got to spend a lot of time on this identification piece. Talking about it because they’re just not ready to modify yet.

Dan: It makes it so that it’s, it’s, they’re stuttering. It’s nothing to be embarrassed about. It’s not something to be afraid of. They can’t really conquer it until they’re no longer afraid of that stutter. And I liked that touching their stuttering, becoming comfortable with stuttering.

Denise: Yeah, and they have to be able to approach it. And I think perhaps part of the reason this client I worked with had so much difficulty identifying the particular word she stuttered on was she was afraid to approach it. She had buried it and buried it and buried the emotions and everything to do with it just so far down.

Dan: Yeah. I mean, there’s a whole lot of shame involved and guilt. We don’t want that. That will keep them from conquering it. Okay, let’s get back to the case history, then.

Denise: This book was my roadmap. It’s highlighted everywhere. In fact, I even let her parents borrow it. There’s a section at the back for parents specifically. So I have two copies of this one that I can lend out to parents. And actually, I think it’s so well written that parents could read the clinician stuff too, and sort of get how to talk about stuttering.

Dan: Oh, I think that could be really huge because if you’re working on helping the child own their stuttering and, you know, and be comfortable with their stuttering. The parents have to too, because if the parents are constantly hammering on him about it, that’s going to be counter-productive.

Denise: Or sometimes the parents just don’t want to talk about it because they’re not sure how to talk about it in an unemotional way, without fear, without anxiety for their child’s future. As I said, this book was my roadmap. I cannot tell you how hard it was for her to begin to identify even a word that I stuttered on, much less a word that she stuttered on.

We were doing very short, simple sentences with little games that we played. And I got out my recording app because she couldn’t identify a word that she stuttered on. I don’t know what it was, identify, remember not be afraid to listen to for it. And so we would listen to the recording multiple times until she was able to understand. And she started to be able to identify where the stutter happened and then we could move forward in all these sequential steps. So only after they can do this, can they be intentionally fluent.

Dan: What do you mean by intentionally fluent?

Denise: I love intentional fluency and this was a new concept to me. I took a class through The Stuttering Foundation. It was taught by Vivian Siskin. And if that class is still being taught, I’ll link that too. She said intentional fluency is when the client knows that they’re going to stutter or that they’ve just stuttered and they modify it in the moment. People who stutter have a lot of fluency, I mean a lot of fluency. They maybe stutter on 10% of the syllables, but it’s really noticed. You might have a client who is very fluent one day and you’re thinking, oh yeah, we’re doing great, we’re making so much progress. They were so fluent, but they were just unintentionally fluent. Yeah, it was just that kind of day for them.

Dan: It’s not fixed, it’s accidental.

Denise: So what Vivian said is, you don’t learn anything from unearned fluency, you do from earned fluency. This client had a lot of moments of unintentional fluency, when I thought, oh, here we go. We’re making progress before I got this book by Dell, right. We weren’t really making inroads. We weren’t really moving the marker.

Dan: Oh, this is, this is so good. There’s so many other places that this applies as well.

Denise: I do use this quote of Vivian Siskins in my R course, Impossible R Made Possible, right? Because you have clients who are unintentionally correct with R, but they don’t realize when they’re incorrect. It’s kind of the same idea.

Dan: Well, this is really going back to mindfulness too, because if they’re not mindful of their mistakes, then they can’t ever really correct a mistake, they’ll just not make it. There’s a difference between fixing it and just not making it.

Denise: And mindfulness is really what I saw the first moment that we saw this little girl be intentionally fluent. It was so awesome. Her mother was in the session with us and we were reading a script. We did these little plays and she just got mindful. I don’t know quite how to describe it, but you see it, you know it when you see it, and a little part that she had been disfluent on before there were these lines that repeated that her character said over and over again, she got it. She nailed it. She was intentionally fluent and her mom and I just looked at each other, like what just happened? That was so cool. Because from there she began to make progress.

Dan: Yeah, that’s great. That’s great.

Denise: If I had not known this whole piece about, you’ve got to identify where the stutter happens. I don’t know, she might still be in therapy. No, her parents would have probably found another therapist. We just wouldn’t have moved the marker.

Dan: Well, this sounds like a great approach, way better than just playing whack-a-mole, just trying to find something that works and hoping that it stays working.

Denise: Well. It helps us as clinicians get rid of that imposter syndrome with stuttering therapy, because truthfully, we don’t get a lot of clinical hours in stuttering. Most of us get just enough so we can get our certification because we have fewer stuttering clients around. And so there’s more discomfort with it. So here you go. This is what it can do for you. This book can really help you overcome any discomfort you have with treating the school age child who stutters.

All right. So again, the book by Carl W. Dell Jr. Is Treating the School Age Child Who Stutters. We’ll have a link to it in our show notes. We’ll be back next time with another episode of The Mindful SLP. Thanks for listening to The Mindful SLP. We invite you to sign up for our free resource library at slpproadvisor.com slash free. You’ll get access to some of Denise’s best tracking tools, mindfulness activities, and other great resources to take your therapy to the next level. All this is for free at SLP proadvisor.com/free. If you enjoyed this podcast, subscribe, and please leave us a review on apple podcasts and other podcast directories .