Chapter 16 • Treatment of Adolescents: Advanced Stuttering 371

can move to doing it with real stutters. If they miss a moment of real stuttering, they can go back into the target word using a voluntary stutter and practice it that way. At first, many adolescents will feel very uncomfortable with this activity. After all, they thought they were coming to you so they could learn how to stutter less and here you are telling them to stutter more . It’s important to offer a very strong rationale for why you are asking them to hold and tol erate. I may say something like this: “Our therapy room is a safe place to explore moments of stuttering—not by fighting them, but by learning how to work with them so that eventu ally they become less scary and easier to move through. So we’re going to try to hold onto stutters—both fake ones and real ones—for longer than we need to or longer than feels natural. Something like this [model an example, synchroniz ing your verbal model with your fist closing and opening as described in the previous paragraph]. By taking our time in these moments, we are giving our body and brain enough time to tune in and learn. It may feel odd or uncomfortable to stay in stutters longer than you’re used to, especially if you’re wanting them to be shorter not longer. But this is an important step in teaching your body and brain that you can be brave and courageous when stuttering. The more you do this, the less scary stuttering will be and in time, you’ll be able to make the stutters shorter.” The use of analogies can be particularly useful here. For example, it can be helpful to do something you’re afraid of (eg, flying without your parents, learning how to drive) by taking small steps toward it in a safe way. If there’s an example from the client’s own life that you can draw on, this would make the point more effectively. Using Hierarchies to Level Up For those who want to stutter more easily, the ultimate goal is to be able to do so across interactions and situations in the “real world.” But how does a new behavior become reliable and engrained? By systematically practicing it in situations of increasing difficulty. This applies to all populations that clini cians serve, not just those who stutter. In the world of stutter ing therapy, we often talk about “hierarchies” to help clients gradually work their way up to using new communication behaviors in more challenging situations. There are two types of hierarchies that are relevant for stuttering therapy: linguistic hierarchies and situational hier archies . A linguistic hierarchy is similar to that which is used in traditional articulation therapy where new sounds are acquired in isolation, then words, then phrases, then struc tured conversation, and finally unstructured conversation. A linguistic hierarchy is most useful within stuttering therapy sessions when clients are first learning to hold, tolerate, and ease out of stutters; it offers a structured roadmap for how to practice the new skill in increasingly complex utterances. While a common linguistic hierarchy is applicable to lots of people, a situational hierarchy is highly unique to each cli ent and therefore should be created together with the client

to ensure that it is personally relevant to them. A situational hierarchy is a list of social interactions that are ordered from easiest or least stressful, to hardest or most stressful. These can include certain people (eg, talking to specific family members, peers) or certain contexts (eg, talking in specific classes, giving class presentations, ordering at a restaurant, talking on the phone). A situational hierarchy is useful within and outside therapy sessions because the people and contexts on the hierarchy likely exist outside the therapy room (eg, talking to a teacher or coach, giving a class presentation). A savvy clinician uses both linguistic and situations hier archies to support gradual skill development in an inten tional way that feels safe to the teen. Both types of hierarchies are effectively visualized using a staircase or a ladder that can make the process concrete for teens. The process can also be gamified to make it more engaging for teens; once they have “beaten” a level, they move to the next level in their hierarchy. Over time, it’s likely that their comfort zone will expand and they will approach harder situations with a bit more confi dence. It’s important to tune into the client’s comfort level. While it’s appropriate to gently nudge when it is clear that the teen is capable and ready for a new challenge, do not ask teens to do something that is too stressful for them at that moment as that damages the trust you have worked so hard to establish. This is described in greater detail in the section “Expanding Comfort Zone” toward the end of the chapter. Across all challenges, always offer to model first either in a role play or real scenario as you shouldn’t ask your client to do something that you yourself are not willing to model. Also, always offer to be there as a support person as appropriate or feasible; your presence as a trusted partner can minimize the scariness of doing something new.


Behaviors can be both overt and covert. There are behav iors that are visible to others, and there are behaviors that are invisible to others like thoughts, feelings, and memories (Ciarrochi et al., 2005). Thus, addressing how a young person thinks and feels about communication is a behavioral goal within our scope of practice (American Speech-Language Hearing Association, n.d.).

My perspective is that negative thoughts and feelings about stuttering are typical reactions to an atypical stressor—that they arise because young stutterers are learning how to navi gate a fast-paced society that is often unwelcoming to people who need more time to do anything, including talking. And this is unfolding at a period in their life when social approval is paramount to their well-being. Repeated experiences with being interrupted, teased, bullied, told to talk differently, or reminded to “slow down, think about what you want to say” when stuttering has nothing to do with fast speech rate or Copyright © 2023 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.

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