Treating 5% of the Disorder

One of the founders of our field, Charles Van Riper, once said, "Stuttering is everything you do trying not to stutter." What does this actually mean and what are the implications?

There is a growing divide between SLP's who specialize in stuttering on whether we should change the way a person who stutters talks (fluency shaping) or accept the stuttering, but modify the way the person stutters (stuttering modification). Fluency shaping, specifically the prolonged speech approach, is frequently adopted by many school-based SLP’s. It has a large evidence base and is relatively straightforward for SLP's to implement without having an extensive knowledge base of stuttering. It makes sense - connect each syllable, word, and phrase together, so that it becomes physically impossible to stutter. Fluency - check. But take this technique into real life and it often fails. Why?

Because the answer is not what we think the answer is. It’s actually quite counterintuitive. Enter the iceberg analogy of stuttering developed by Joseph Sheehan. When we talk about icebergs, we usually think about the Titanic. The part that the titanic saw was the tip, and it looked pretty harmless – a small iceberg so gently peaking out of the water. So, why did the boat sink? It sunk, not because of the tip, but because of what was underneath. The bottom is the most detrimental to the boat. Years of formulation, consolidation, and freezing shake and break the boat. We can melt the tip, but it’s just going to come back.

       

Let’s take an example from some teens who stutter:

There are roughly 50 things in the iceberg. Only 3 of them are what we typically classify as stuttering: prolongations, repetitions, and blocks. In the case of someone who is covert, an SLP might look and see a tiny iceberg, or they may not see an iceberg at all. It’s because they are only seeing the tip, the part that is visible to the naked eye. Maybe the child who stutters frequently does not speak in school, avoids oral presentations, consistently avoids social situations, and changes words to avoid stuttering. No tip of the iceberg = no stuttering. WRONG!

If only 5% of stuttering is what people actually think stuttering is, and 95% is what people are doing to avoid stuttering, how do we treat it?

Sheehan said it this way: “Don’t avoid, don’t hide, don’t deny your stuttering. The only way you’ll ever get over your fear of stuttering and thus become genuinely fluent; is to meet it head-on. Always do the thing you fear, and gradually you will learn not to fear it.”  

Think of it this way: no one would ever go to a doctor who kept prescribing ibuprofen and acetaminophen to treat the symptoms of some underlying disorder. No doctor would say, “Just put a band-aid on your cancer spot.”

But yet, we are sending our kids to SLP’s who are doing just that. Focusing on the physical aspect of stuttering, the 5%, could actually become detrimental.

I have been interning at the American Institute for Stuttering during their teen and adult intensive therapy programs. At AIS, many assignments specifically target the bottom of the iceberg, such as advertising your stuttering, voluntary stuttering, and going out and talking to people about stuttering. These paradoxical assignments reduce fear by letting the “worst” happen. They slowly break pieces of the iceberg, from the root up. The teens in the program, in the midst of school-based speech therapy, said it best:

“I try and try and try to use my techniques, but I can’t use them.”

"I don't want to put an “h” sound in front of everything I say. I sound stupid. I sound unintelligent."

“When I came here I said that stuttering really isn’t me, but now that I’m here stuttering is me and the techniques aren’t really me.”

Why aren't we listening to what our clients are telling us? Throughout this internship, I have heard story after story of unsuccessful fluency shaping. If fluency shaping is targeting 5% of the disorder, no wonder it’s not working.

I was recently talking to an adult who stutters who had been through years of school-based speech therapy. She told me about the inherent message that stuttering was not allowed. She did not do school presentations and she didn’t speak in class. She was on a vicious path of avoidance. She told me, “Speech therapy not only didn't help; it stopped me from living my life.”

The message we are sending to our kids and teens is that it is not okay to stutter. This dangerous message fuels the bottom of their iceberg. A parent of a teen in the program said, “She was paralyzed with fear for years.”

Reinforcing that stuttering is bad is detrimental. Forcing and rewarding normalcy is debilitating our kids and teens who stutter. We can no longer let them suffer in silence. It’s time to dig deeper.