Counseling in Stuttering Treatment: Practical Strategies

Editor's Note: This text is an edited transcript of the course Counseling in Stuttering Treatment: Practical Strategies, presented by Craig Coleman, MA, CCC-SLP, BCS-F, ASHA Fellow.

(*Click here for supplemental handout.)

Learning Outcomes

After this course, participants will be able to:

• Describe various counseling approaches used in therapy for people who stutter.
• Identify potential therapy goals to target negative reactions.
• Describe ways to incorporate counseling goals into daily progress monitoring.

Introduction

Counseling plays a significant role in our approach to stuttering treatment. As we move through this course, I’m excited to discuss this topic because it truly addresses the core of our work with people who stutter.

Counseling can also be one of the more challenging aspects of stuttering therapy, especially when it involves navigating difficult conversations and helping clients shift their thoughts or beliefs. My hope is that by the end of this presentation, you’ll feel more comfortable approaching these conversations in your own practice.

One fascinating aspect of working with people who stutter is that, based on surveys of speech-language pathologists, stuttering is often the area in which they feel least comfortable. This is likely because, unlike many traditional treatment approaches, stuttering therapy involves a substantial counseling component. This need for counseling skills has prompted us to reevaluate our training practices. In fact, a few years ago, we revised our curriculum to include a dedicated counseling class, recognizing its essential role in speech-language pathology.

Counseling and SLPs

Let’s start by reviewing ASHA's guidelines on counseling within our scope of practice. This is an ongoing conversation about whether SLPs should engage in counseling and, if so, what that should entail. Referring back to ASHA's wording is essential here, as it provides clarity on our professional boundaries and responsibilities. I’ll briefly cover this and then highlight aspects particularly relevant to stuttering.

"SLPs Counsel by Providing Education, Guidance, and Support" 

The first sentence in ASHA's guidelines is especially important: "SLPs counsel by providing education, guidance, and support." This definition frames counseling in our field as a role centered around education. We’re continually educating clients and their families about stuttering—what it is and what it isn’t—which is a crucial part of our work. While society's understanding of stuttering has improved significantly compared to 20 or 30 years ago, misconceptions still persist. Dispelling these myths through education remains a critical component of our counseling efforts.

Support is another essential element. We’ll dive deeper into this today, but it’s worth noting that every treatment approach should include some level of support, even if it varies from person to person. For some clients, simply attending therapy is a significant first step and a form of support in itself.

For others, support might involve assessing the environment around them. Do they have a positive, understanding family that embraces their experience with stuttering? Do they have friends, peers, or colleagues who are supportive of their communication style? In some cases, individuals benefit from more formalized support, such as connecting with others who stutter. This can be incredibly empowering—seeing others who face similar challenges and learning how they navigate them can provide a sense of solidarity and reassurance.

This connection is especially impactful for children. For a twelve-year-old, meeting other kids who stutter can be incredibly empowering. Therapy should consider the types of support individuals need not only to feel better—since feelings, while important, are only one layer—but also to help them shift their perspective on stuttering itself. This goes beyond surface-level reassurance; it involves fostering an environment where clients can begin to see their stuttering in a new light.

It’s valuable to show kids who stutter that famous, successful people also stutter—examples like Ed Sheeran can be inspiring. But it’s equally important to highlight relatable, everyday role models. Knowing there’s a teacher down the street, a local lawyer, or another student nearby who stutters and is thriving can make a big difference.

Famous figures can feel distant; they don’t always feel like “real” people in the same way that community members do. Connecting kids to role models within their own environment helps them see that people who stutter are not only successful on a global stage but also within the spaces they inhabit daily. This kind of local connection reinforces that stuttering is just a part of life for many people in their own communities.

"Individuals, their families and their caregivers are counseled regarding acceptance, adaptation, and decision making about communication, feeding and swallowing, and related disorders." 

The second sentence in ASHA's guidelines clarifies that counseling should focus on helping individuals, their families, and caregivers with issues around acceptance, adaptation, and decision-making specifically related to communication, feeding, swallowing, and related disorders. This is a key point, as it defines the boundaries of our counseling role. 

For instance, if a client comes in with a general anxiety disorder, providing counseling for that would fall outside our scope of practice. Our role is to address counseling needs directly tied to communication or swallowing issues, ensuring that we stay within our professional guidelines while supporting clients in relevant, impactful ways.

However, if a client feels anxious specifically because they stutter, that is well within our scope of practice to address. Here, their anxiety is directly tied to their communication difference, making it appropriate for us to provide counseling support. This distinction is crucial in guiding our approach.

"...Interactions related to emotional reactions, thoughts, feelings, and behaviors resulting from a communication disorder, feeding and swallowing disorder, or related disorders.”

The next sentence provides further clarity, stating that the SLP’s role in counseling includes addressing emotional reactions, thoughts, feelings, and behaviors that stem from living with a communication, feeding, or swallowing disorder. This definition captures the heart of our counseling responsibilities. Our role goes beyond just treating the technical aspects of the disorder—we are also there to help clients process and manage the emotional and psychological responses that accompany their condition.

Specific Activities SLPs Engage in Related to Counseling

Specific counseling activities that SLPs might engage in are outlined in the next section, but we won’t go into each one individually since we’ll address them in more depth shortly. However, I want to highlight the next-to-last bullet: discussing, evaluating, and addressing negative emotions and thoughts related to communication. This area can sometimes feel like a gray zone—are we stepping beyond our scope? But remember, as long as these emotions are directly connected to a communication issue, we are entirely within our professional scope to address them.

To clarify, let me share two examples I often use when teaching courses on stuttering. Imagine someone experiencing shortness of breath, chest pain, and anxiety about it. Would you want them to see a counselor, or would you refer them to a cardiologist? The answer is the cardiologist because a specific health condition triggers the anxiety. Similarly, when someone’s anxiety stems from their communication disorder, it’s appropriate for them to see an SLP for counseling related to that issue.

Now, consider a person with general anxiety unrelated to communication or health conditions—they should see a counselor, not an SLP or a cardiologist. This distinction is key, helping us understand when we’re in our zone and when it’s best to refer clients elsewhere.

I once worked with a young teenage client whom I had seen for about a year. He had gone through significant life changes unrelated to his stuttering or speech, and while he was progressing well in stuttering therapy, his mother approached me about seeing a psychologist or counselor to help him process these other experiences. I wholeheartedly agreed.

However, after meeting with the psychologist, the mother called me from the parking lot, devastated. During the session, the psychologist asked her, "What did you do to him when he was younger to make him start stuttering?" This question was not only hurtful but also reflected a misunderstanding of stuttering—a topic the family had become knowledgeable about through therapy. The psychologist's lack of understanding led to misplaced assumptions, and the family felt discouraged from seeking further help.

This experience underscores the importance of our role as SLPs in counseling clients who stutter. Although it may sometimes feel challenging or outside our comfort zone, we must remember that, as professionals, we are the best prepared to address the unique thoughts, feelings, and reactions associated with stuttering. Other professionals may lack this specialized background, which can lead to unhelpful or even harmful interactions. Our expertise allows us to support clients effectively, particularly in areas directly tied to their communication experiences.

Stuttering and Counseling

What is Counseling?   

I really like two quotes from David Luterman. If you ever have the opportunity to hear him speak or read his work, I highly recommend it. He’s an audiologist whose contributions to counseling within communication disorders have been invaluable. His insights focus deeply on the unique challenges of working in our field, and two of his quotes have profoundly influenced my career and understanding of counseling.

The first quote is, “Counseling is not a mantle the professional puts on when a client is present and then discards the rest of the time. It’s an attitude, something that is lived.” This idea has always resonated with me, underscoring that effective counseling isn’t a script or technique we adopt temporarily. Instead, it’s an integral part of who we are as professionals, woven into our approach and interactions. This means that each of us must find our own authentic counseling style—one that aligns with who we are—rather than trying to simply mimic someone else’s approach.

When you consider different counseling styles, you’ll notice a variety of approaches that reflect individual personalities. For instance, I’ve observed people who take a softer, more validating approach, similar to a "Mister Rogers" style. Luderman himself often used this style—he would gently challenge clients but always in a very kind and affirming way. This style works wonderfully, especially for those whose personalities naturally align with it.

For me, though, that style doesn’t quite fit. My approach is a bit more direct and a bit sarcastic, and humor plays a large role. I’ve come to recognize that while I may not excel at the softer Mister Rogers style, I do have a skill for handling difficult conversations in a way that is clear yet supportive. I might be straightforward, but I’m careful to avoid coming across as condescending or harsh. Knowing this about myself allows me to use my own approach to push people a little more, helping them to make progress while still feeling supported.

Ultimately, effective counseling requires self-awareness. Understanding and embracing your unique style can allow you to genuinely connect with clients in a way that feels both natural and impactful.

Luterman’s second quote that I find especially meaningful is: “The goal of counseling is not to make people feel better, but to separate feelings from nonproductive behavior.” This perspective is essential in our work because it acknowledges that people are entitled to feel however they feel. Our role is not to dictate or minimize these feelings but to help clients understand and navigate them constructively.

Consider this example: Imagine I have an employee named Amy. During her performance review, I tell her she’s getting a raise. Amy leaves my office, goes to a colleague, and says, “I’m really upset about this.” The worst response her colleague could give would be, “You shouldn’t feel upset.” When counseling, statements like “you should” or “you shouldn’t feel” rarely help because they invalidate the person’s experience. Instead, we need to explore why Amy feels the way she does.

Maybe I promised Amy a 10% raise last year, but only gave her a 3% raise. Her reaction would then make sense, as there’s a specific reason behind her disappointment. Or perhaps something else happened in the meeting that triggered her feelings. Either way, by understanding her reaction, we can address the root of her feelings rather than dismissing them. This approach allows us to support clients by acknowledging their emotions while helping them find ways to respond productively, which ultimately leads to more meaningful progress.

Let’s apply this to a typical scenario in stuttering therapy. Imagine a client saying, “I’m really nervous about giving this presentation,” or “I’m nervous about speaking to this person.” The worst response we could give is, “Oh, it’ll be fine—you shouldn’t be nervous.” Not only would that invalidate the client’s experience, but it would also ignore the fact that their nervousness is entirely reasonable. Feeling nervous as a person who stutters is valid; it’s a natural response to a challenging situation.

Now, consider a different scenario where the client says, “I can’t do this presentation because I’m stupid since I stutter.” Here, we’re no longer dealing with a feeling; we’re dealing with an invalid thought—a belief that is incorrect and harmful. While we acknowledge and respect the client’s emotions, we also have to avoid validating beliefs that aren’t true. A feeling is subjective and valid by nature—if a client says they’re upset, then they’re upset. But if a client believes they’re “stupid” because they stutter, we know that’s objectively untrue and needs to be addressed.

As clinicians, it’s our job to help clients distinguish between feelings and beliefs, guiding them toward a reality-based perspective. Everyone is entitled to their beliefs, but beliefs aren’t the same as facts. When clients base their thoughts and actions on distorted beliefs—especially negative ones like “I’m stupid because I stutter”—they may begin avoiding situations, altering their personality, or steering clear of meaningful experiences to avoid discomfort.

Our role is to help them confront these unproductive thoughts and encourage constructive actions, even if they feel nervous. Feeling nervous as they take on new challenges is natural, even expected, as they progress in tackling something that’s difficult for them. By validating their feelings but working to reshape harmful beliefs, we guide clients toward a healthier mindset. This balance allows them to move forward without letting nonproductive behaviors or negative, invalid thoughts hold them back.

Counseling Can Serve Many Purposes

Counseling serves several important purposes in stuttering therapy. One purpose is to help clients gain clarity. For instance, a client might come to us uncertain about whether they can pursue a career as a teacher while managing their stutter. In such cases, they’re looking for reassurance and guidance—clarification that, yes, they can succeed in that role. Our role is to help them explore and affirm those possibilities.

Counseling also helps clients uncover aspects of their experience they may not have considered. I’ve had many clients over the years who say things like, “I want to work in computers because I don’t have to talk to people.” This often leads to an interesting conversation. My typical response is, “Okay, let’s say you work in software and you develop a new program or method. Then your company asks you to present it to teams across the organization. Would you change careers at that point?” This question usually catches them off guard because they haven’t considered it.

When people feel limited, they often look for narrow solutions, thinking, “I’ll just avoid talking by choosing a specific field.” But in reality, most jobs today require some form of communication. This discussion generally shifts toward a broader perspective: instead of choosing a career path based on perceived limitations, let’s focus on what you can do. Let’s help you see your strengths and capabilities, allowing you to make career choices from a place of confidence. This isn’t resolved in a single session, but it opens the door to meaningful conversations that can begin right away.

Sometimes, clients come to us simply seeking support. They want to meet others who stutter and to feel less alone in their experiences. Often, they wonder if the thoughts and feelings they have about stuttering are valid, and they need reassurance or at least a reality check. Counseling helps validate their experiences where appropriate and provides a space to explore these thoughts openly.

Counseling also helps clients make decisions and stick with them. However, it’s important to remember that we can’t convince anyone of anything. This is true not only in stuttering therapy but in all areas of life—real change has to come from within. People must decide to make changes on their own terms.

What we can do is offer support. We can listen to their decisions, help them weigh the positives and negatives, and empower them to stay committed when they’ve chosen the right path. And when they take a misstep, we’re there to support them as they learn from it and find their way back to a more constructive choice.

Sometimes, clients simply need permission—permission to talk openly or to feel a certain way. This is particularly important when conversations become difficult or emotional. Clients may cry or have strong reactions, and that’s completely okay. In fact, I like to frame it this way: if someone is getting emotional in your presence, it often means you’re doing something right. You might be the only person in their life providing a safe space for them to express those feelings.

Over the years, I’ve seen many clients who, upon opening up about their stuttering in a meaningful way, become visibly emotional. These clients often make the most progress, as they’re finally confronting their experiences rather than avoiding them. For some, the therapy room might be the first place they feel comfortable enough to process these feelings openly. This is incredibly powerful and can mark the beginning of real change. So, rather than stopping or discouraging these emotions, we should allow and support them, as they’re a productive part of the healing process.

It's About Who We Are

Counseling is largely about who we are at our core. We can’t simply adopt someone else’s style and expect it to resonate. Another essential aspect of counseling is being “okay” within ourselves. But what does that mean, exactly? I’ve often heard that to be effective in counseling, you need to have yourself “together,” but that’s a vague and somewhat unrealistic expectation. None of us are ever completely settled or without challenges; every day brings new situations we handle with varying levels of success. There’s no finish line where we’re suddenly “ready” to counsel others.

In reality, the concept of being “okay” is much more fluid. One day, we might be dealing with a tough work issue, a family problem, or something personal that makes the day feel difficult. Then we might meet someone who has just lost their home or who’s grieving a loved one. In that moment, despite our own struggles, we may realize we’re still in a position to offer support because, comparatively, we’re in a place to help. Being “okay” enough to counsel isn’t about having everything perfectly together; it’s about being able to set aside our own challenges, even temporarily, to be there for someone else in need.

As I’ve come to understand over the years, the essence of counseling isn’t about being perfectly “okay” yourself. It’s about whether, in that moment, you’re in a place where you can help someone else work toward being okay. It also involves a continuous self-assessment of our own areas for growth. We all have skills we can improve and strengths we can use to support others.

For instance, I may be able to work with a person who stutters, helping them find their footing and feel empowered. But there may also be parts of my own life that feel less stable, and I might need to seek support myself to work through those issues. Counseling work often involves holding space for heavy conversations and, at times, carrying others’ burdens, which can weigh on us.

It’s critical to recognize that it’s okay to need an outlet to process that weight. We’re human, and acknowledging that we, too, need support is important. Offering people the space to share openly is vital, and it brings us back to what we discussed earlier: that effective counseling requires not only empathy but also the willingness to manage our own well-being so that we can genuinely be present for others.

Stuttering Involves Thoughts and Feelings

Stuttering is influenced by factors like genetics, neurophysiology, and brain function. Thoughts and feelings don’t cause stuttering—they aren’t the root of it. However, these emotional and cognitive responses can significantly impact how a person experiences and reacts to their stuttering.

To help clients make real progress, we have to address both aspects. On one hand, we focus on the physical side: working on reducing physical tension, managing secondary behaviors, and helping words come out more smoothly. On the other hand—and often more impactful—we need to address the client’s thoughts and feelings about their stuttering and, more importantly, their perceptions of themselves as people who stutter.

Talking about these issues is challenging, requiring many difficult conversations. There are key things to remember when it comes to these hard conversations. First, humans don’t change easily. We can’t expect someone to walk into our office, hear something profound, and instantly overturn 25 years of thinking. Real change takes time. One idea I always share with students, and that’s valuable for us as professionals too, is that we may be an agent of change for someone—or we might simply be the person who plants the seed. Both roles are equally important.

If we’re the seed planter, it’s natural to feel frustrated when we don’t see immediate results. But often, that seed needs time to grow. Maybe years down the line, the person will think back and realize that what we discussed has finally clicked for them. Perhaps they’ll recognize how our conversations fit into their life goals and their ability to adapt. It’s rewarding to witness these transformations firsthand, but sometimes, we don’t get to see the impact of the seeds we plant. And that’s okay. The act of planting those seeds, giving clients the tools and insights they may later draw from, is powerful in itself.

Another key point is recognizing that thoughts cause feelings. While our goal isn’t to change someone’s feelings, we do want to challenge irrational thoughts that may be fueling negative emotions. We’ll delve into this more shortly.

One of the most critical aspects of counseling is aligning our expectations with reality. Where is the client now? Where do we hope they’ll be in a few years? Setting long-term goals and envisioning their future progress is essential. Equally important, though, is identifying the very next step on their journey. If the client is currently on step three, and we aim for step ten as their next move, we risk setting them up for failure. Realistic, gradual progress ensures they stay on the ladder and don’t feel overwhelmed by goals that feel out of reach.

I was giving a presentation on counseling and stuttering when a woman in the audience shared a relevant story. She said, “This is a really good conversation because I just experienced this with a school-age girl I was working with.” They had spent several weeks preparing for the girl to give a presentation to her class on stuttering. The therapist felt she was ready and confident.

But on the day of the presentation, she later asked the girl how it went, and the girl replied, “Oh, I didn’t do it. I had someone else give it for me.” Initially, the therapist’s reaction was to feel she had failed as a clinician because the girl hadn’t reached the goal. But as they talked further, she realized that for the girl to ask her friend to present on her behalf, she first had to talk to her friend about her stuttering. This was the first time she had ever shared her experience with someone outside of her family—a huge step.

She wasn’t quite ready for step ten, but she successfully moved from step two to step three. This is a valuable lesson for us as clinicians: sometimes, the steps we initially envision are too large. In this case, speaking openly with a friend was a meaningful therapeutic milestone. Recognizing and celebrating these incremental achievements helps us set realistic expectations and support genuine progress, even if it looks different from the original goal.

Now, let me share an example on the opposite side. I was working with a high school senior who had been in therapy with me for about six to nine months and was progressing well. After one session, his mom approached me with a form, saying, “I need you to sign this.” Curious, I asked, “What am I signing here?”

She explained that it was a request to excuse her son from giving presentations at school. I asked her to elaborate on the reason, and she said that, due to his stuttering, his teacher, counselor, and parents felt it would be best if he didn’t have to present. I paused and said, “But he’s doing well in therapy. This could be a really positive next step for him. Plus, it’s an ideal time, as we can work together to prepare—talk through strategies, manage any negative thoughts and feelings, and build his confidence.” She agreed to think about it, saying they would discuss it further and return the following week.

The next week, they returned with his dad, and the mother reiterated, “We really need you to sign this. He doesn’t want to do the presentation.” I turned to the teenager and asked, “Do you not want to do this because it makes you physically ill just thinking about it, or do you not want to do it because you simply don’t feel like it?” He admitted, “I just don’t want to do it.” At that point, I told him, “That’s not a strong enough reason, given where you are in therapy. Based on the progress you’ve made, I don’t think I can sign this.”

The first week he had to give his presentations, he was nervous and scared. It was awful. We talked about it. By the time he did the fifth or sixth one that semester, he wasn’t even mentioning it to me anymore. I’d ask, “Hey, don’t you have a presentation coming up?” and he’d say, “Oh, yeah, but I’m fine with it.”

At the end of the school year, his mom told me he had a capstone presentation to give in front of the whole school. She shared that he actually wanted to talk about how he had dealt with his stuttering. She said, “I know your schedule is busy, but if you could come, that would be amazing because you pushed him in the direction to be able to do this. Without that, he probably wouldn’t have done it.” I attended, and he did a great job.

Afterward, an older man in his eighties who also stuttered approached him and said, “I really wish someone had talked to me about stuttering like you did when I was a kid. It could have probably changed my life.” That was a powerful moment for the student.

If he had initially told me that presenting would make him physically ill, I wouldn’t have pushed him. But I knew where he was in therapy and what he was capable of. He was ready for this, and pushing him was the right decision.

Caught Up In What to Say Next

At times, we can get caught up in focusing on what to say next. But our real focus should be on what to do next. Where is the client headed? Where do we want them to be, and, more importantly, where do they want to be compared to where they are right now? These are the questions that should guide us in developing meaningful goals.

Rational and Irrational Thoughts

Rational Thoughts

For people who stutter, a rational thought might be, “This presentation will be hard.” We can validate that by saying, “You’re right. It might be hard.” Or if they say, “I’m so nervous to talk to her,” we can acknowledge, “I can see why you would be nervous. That’s going to be a challenging situation, but I believe you can get through it. Let’s talk about how.” Similarly, if a client says, “I don’t want to raise my hand in class,” we might respond, “I understand how that can feel challenging. Let’s explore some ways to help you overcome that.” Those are all rational conversations and rational thoughts.

Irrational Thoughts

I'm stupid because I stutter. Irrational thoughts are statements like, “I’m stupid because I stutter.” You can’t validate that. You can’t say, “Oh, yes, you are stupid because you stutter.” Instead, this is a thought you must challenge right away. You might respond, “Actually, that’s not true. Stuttering has no connection to intelligence. In fact, you’ve shown your intelligence in many other ways.” Here, it’s important to provide information and address irrational beliefs. 

Other irrational thoughts include statements like, “I can’t be a teacher because I stutter.” These are limiting beliefs that aren’t grounded in reality. If a client says, “I can’t be a teacher because I stutter,” we can point out, “Actually, there are many teachers who stutter, proving that it’s possible. Whether or not you choose to pursue it is up to you.” This approach both challenges the irrational thought and affirms the client’s ability to make empowered choices.

I will never be able to go to college. Disputing irrational thoughts is one of the hardest parts of our work, as it often involves difficult conversations. For example, a parent may come to us expressing concerns like, “I’m worried my child won’t be able to go to college because they stutter.” I’ve encountered this even with parents of kindergarteners. My response is usually something like, “Let’s back up a bit. There’s no early admission process from kindergarten to college.” Of course, I’m joking to lighten the moment, but the point is valid—college is far in the future, and projecting limitations this early is unreasonable.

This kind of thinking is particularly concerning because of the impact it can have on children. Research shows that simply hearing others’ projected biases or discrimination can affect kids as profoundly as experiencing it directly. If a child repeatedly hears messages like, “You may not be able to go to college because you stutter,” they may internalize this belief, leading them to think, “My stuttering is so severe, it’s going to stop me from reaching my goals.” Similarly, I’ve had parents say things like, “What if they can’t get married because they stutter?” These are huge projections, and it’s important to address them early to help families understand the impact of such assumptions on their child’s self-concept and future.

I am afraid that my child will have an uncertain future. One of the concerns I often hear from parents is, “I’m afraid my child will have an uncertain future as a person who stutters.” I like to respond by saying, “Let’s do a quick survey—raise your hand if you have an uncertain future.” That’s just the nature of the future. Unless we’re some kind of fortune-teller, none of us knows exactly what lies ahead.

We have to be cautious with statements like, “My child will have an uncertain future because they stutter.” This is projecting a normal experience—facing an unknown future—and attributing it solely to stuttering. The reality is we all face uncertainty about the future, regardless of whether we stutter. The future is uncertain because that’s its very nature.

Self-Messages

What are some messages people might tell themselves, and how can we reframe that thinking? Let’s consider a few common self-messages people who stutter might have: “I’m bad at talking,” “I can’t possibly give this presentation,” or “People are going to make fun of me and laugh at me.”

To work through these self-messages, we guide the person to identify a few key elements:

• Current Scenario: What is their current experience or behavior? For example, if they’re avoiding raising their hand in class, that’s the current scenario.

• Preferred Scenario: What would they like to happen instead? In this case, it might be raising their hand in class.

• Is the Preferred Scenario Reasonable? We then assess if this goal is achievable. Wanting to participate more in class is reasonable and can be broken down into small, manageable steps. However, if someone’s preferred scenario is, “I never want to stutter again,” that’s not reasonable, and we need to address it directly. If the preferred scenario is unattainable, we work to adjust their goals to something more achievable.

Take, for example, a person who wears glasses. If their current scenario is, “I wear glasses,” and their preferred scenario is, “I don’t need glasses anymore,” without wanting contacts or surgery, that’s not a reasonable scenario. They would need to either change what they want (accept wearing glasses) or change what they’re willing to do (get contacts or surgery). Similarly, with stuttering, if the preferred scenario involves no stuttering at all, we help the person explore alternatives, focusing on achievable steps that promote growth rather than perfection.

Case Study

Let’s consider a ten-year-old boy, Jake, who is very bright but avoids talking in class because he’s afraid that if he stutters when answering a question, his classmates will laugh at him. To cope, he uses the restroom during question-and-answer time. Now, he wants to change this behavior, but he’s understandably scared.

First, let’s ask ourselves, Is his fear valid? Absolutely. There’s a chance that if he stutters, someone might laugh. So we need to acknowledge his feelings: “I understand why you feel that way—there’s a possibility that could happen.” Validating his experience is important.

Next, let’s break it down. Currently, he’s using the restroom to avoid speaking. What does he want? He wants to participate in class. So how do we help him make that change? Here’s what we can’t do: we can’t simply tell Jake, “Tomorrow, you’re going to talk in class.” That’s far too simplistic.

One thing I’ve learned about stuttering—and life—is that complex problems require thoughtful solutions. Trying to solve a complex issue with a simple fix rarely leads to lasting results. Instead, we need a gradual approach that respects Jake’s fears while helping him take manageable steps toward his goal.

Here’s our approach: What can we help Jake do first? Maybe it’s simply role-playing or talking through how he feels during that time and what he hopes to achieve. What scenario would make him more comfortable? Eventually, we can work toward a goal of having him participate once and build from there. It’s these small steps that will lead to progress—this scenario illustrates just how effective gradual, intentional steps can be.

What Counseling Is Not

This also clarifies what counseling is not. Counseling isn’t about telling people how to feel or applying a one-size-fits-all approach. Different people need different levels of support—some need a little push, while others may need a cushion to fall back on. Counseling isn’t just about being nice; it’s about challenging people in a compassionate way.

Effective counseling involves a lot of listening and gathering information. A strategy I use often, even in work settings, is to sit back initially and let others share their thoughts. In a diagnostic session, for example, I let the person talk while I listen, gather perspectives, and then start processing to determine the best course of action. As clinicians, we have to approach counseling with the same mindset—listening first to gain insights.

Counseling in stuttering doesn’t address general anxiety or focus on fluency, as fluency itself isn’t strongly tied to negative thoughts and feelings. For instance, someone who stutters minimally may still feel significant distress. Understanding these distinctions helps us target our support where it’s needed most.

Getting to Action: Stages of Change

So, how do we move toward action? We can look to the stages of change model developed by Trish Zabrowski and her team. These stages include:

1. Pre-Contemplation – The person isn’t even considering making a change yet.
2. Contemplation – They recognize a need for change but aren’t ready to act.
3. Preparation – They’re aware they need to make a change and are gathering information, though they may not be ready to take action yet.
4. Action – They’re ready to actively work on making the change.
5. Maintenance – They’re working to sustain the progress they’ve made.

In the pre-contemplation stage, they aren’t ready for therapy. In contemplation, they might be open to exploring the idea. In preparation and action stages, they’re ready for active participation in therapy, and they’ll need support to maintain their progress as they move forward.

Stuttering as a Chronic Condition

Stuttering is a chronic condition, which makes counseling an essential part of treatment. One of my least favorite terms in the context of stuttering and counseling is “relapse.” In chronic conditions, there isn’t a relapse; instead, there are periods where symptoms are more or less impactful. That’s simply the nature of a chronic condition.

Consider allergies as an example. You might go through an entire season with minimal symptoms, and then, due to environmental changes, your allergies suddenly flare up. That’s not a relapse—it’s a response to different circumstances. Similarly, people who stutter may experience fluctuating challenges based on life stages or stressors.

Clients may need to return to therapy at various points in their lives, which is about aligning expectations with reality. This doesn’t mean they’ll be in therapy forever; it just means they might need additional support during certain times.

What Do We Target  

In counseling for stuttering, we address attitudes, emotions, and the thoughts that drive them. We focus on reducing communication-related avoidance and improving overall communication skills to help the person become a more effective speaker. Additionally, we work on facing fears related to both communication and stuttering specifically, helping clients gradually confront challenging situations. This can include working on handling interactions with people or navigating situations that may be particularly difficult for someone who stutters.

When Is Therapy Done

Therapy, in this sense, is a lifelong journey, though formal therapy isn’t continuous. There may be times when a client returns for a session or two, but throughout their lives, they continue to learn about themselves and their stuttering. The goal is to help clients reach a point where they feel confident using their strategies when they choose to, without it defining their self-worth.

At this stage, they see themselves as experts in their own experience and can even educate others about stuttering. They know stuttering doesn’t have to prevent them from fully engaging in social, educational, or professional activities, and it doesn’t significantly impact their quality of life. All of this progress can be meaningfully documented by using descriptive language to explain sessions and goals.

Counseling in Action

When we consider where a person needs to be when they leave therapy, it’s not about them loving the fact that they stutter—it’s about reaching a place where they’re okay with it. This can involve desensitization activities, practicing self-disclosure, connecting with others who stutter, engaging in mindfulness exercises, and simply staying present as a person who stutters and learning to accept it.

Acceptance is crucial, especially with any chronic condition. It’s the foundation that allows them to move forward in a healthy, empowered way. Through acceptance, they can approach life with confidence, without letting stuttering define or limit them.

Questions and Answers

Do you have any tips on how to talk to parents about their expectations for therapy regarding their child’s stuttering?

At the end of evaluations, I typically sit down with parents and ask, “What are your goals for therapy?” For older kids and adolescents, I’ll ask them directly, with the parent present, so both can share their goals. Often, the child’s first response is, “I want to stop stuttering.” This provides a chance to clarify: “I understand that’s your goal. However, what we know about stuttering is that if you’re still experiencing it at age seven or older, the likelihood of it disappearing completely is low.” So, while eliminating stuttering may not be realistic, I explain our goals, which include helping the child become an expert on their own stuttering.

We’ll focus on educating them about stuttering, reducing tension when they speak, minimizing struggle, and ensuring that stuttering doesn’t interfere with their life or choices. We’ll also address their thoughts and feelings about stuttering and aim to reduce its impact. Ultimately, my goal for them is to pursue whatever they want in life, but now as a person who stutters—whether that’s being an astronaut, a singer, or anything else.

This initial conversation is crucial to align everyone’s expectations. Miscommunication can happen when therapy goals aren’t clear from the beginning. For instance, if after six months of progress, when the child is speaking more, interacting confidently, and feeling less anxious, a parent still expects full fluency, they might feel disappointed. Setting clear expectations prevents this and helps everyone understand the realistic goals of therapy.

These conversations can be emotional, especially if it’s the first time the child hears that stuttering may not go away. But they’re necessary. Avoiding the reality only leads to long-term frustration and potential harm to the child’s self-esteem.

Here’s an example: I once spoke with a ten-year-old about therapy goals, explaining that stuttering might be something they live with long-term. At one point, the mother pulled me aside and asked, “Could you be more positive and just tell him he’ll stop stuttering?” I explained that doing so would be unethical, as I couldn’t guarantee that outcome, nor did I believe it was likely. After discussing it further, we returned to the room, and I asked the child how he felt. He replied, “I feel pretty good.” Surprised, his mother asked, “How does that make you feel good?” He explained, “Because up to now, everyone’s been telling me it will just go away. I’ve been wondering what I’ve been doing wrong, because it hasn’t.” This was a turning point for the parent, who realized the burden false expectations had placed on her child.

This example shows the importance of managing expectations. False hope can be damaging, especially in conditions like stuttering, where progress can be unpredictable. Misunderstandings around stuttering—like believing it’s fully controllable because a child occasionally has fluent days—can reinforce unrealistic expectations. Stuttering is inherently variable; a child may have a fluent day followed by increased stuttering, and that’s normal. Educating both the child and parents about these realities helps create a supportive, understanding environment where the child can thrive.

What do you recommend for pushing your clients to the next level and ensuring their safety?

In extreme cases, such as suicide attempts or severe stress and anxiety, referrals are essential. If a client is experiencing suicidal thoughts, that’s outside of my scope because it’s usually not solely a reaction to stuttering; there are often multiple factors in their life contributing to those feelings. This is when I would involve other professionals with specific expertise.

For example, if a client expresses anxiety related to communication, that’s something we can address within therapy. However, if someone says they are suicidal, even if they attribute it to stuttering, I would still bring in a specialist. My training in counseling does not cover cases involving suicide, so it’s critical to refer them to someone with the appropriate skills. This distinction is vital for ensuring both effective support and client safety.

I have a ten-year-old female client with a sudden onset of stuttering and no known precipitating event. Both the child and parents are eager for the stuttering to disappear as quickly as it appeared. I’ve been trying to gently explain that stuttering in older children usually doesn’t resolve quickly, but I’m struggling to find research on outcomes for sudden onset at this age. How can I discuss the prognosis realistically and help adjust their expectations?

It’s true that there are rare instances where stuttering starts later in childhood, and in such cases, it typically doesn’t disappear on its own. Given her age and the sudden onset, I would first consider ruling out psychogenic or neurogenic factors, as it’s unusual for stuttering to begin suddenly at age ten without a clear cause.

Additionally, it can be helpful to dig into the child’s history, as sometimes there may be a past period of stuttering that was forgotten or overlooked. Families may initially report no history, but upon further discussion, they might recall brief episodes when the child was younger, around age three or four, for instance.

If this case is indeed sudden onset at age ten with no prior history, it’s likely that the stuttering won’t simply go away. Having an honest conversation about the prognosis is important, helping the family understand that treatment can focus on effective management rather than expecting complete resolution.

I’m working to balance counseling, fluency practices, self-acceptance, and validating neurodiversity in my therapy. Stuttering awareness has recently gained traction, which is wonderful. However, I see many SLPs suggest that fluency work and neurodiversity-affirming approaches can’t coexist. So far, I’ve been letting my clients’ goals guide our work, which typically includes both fluency and self-advocacy.

You’re approaching this in exactly the right way. Therapy should absolutely be guided by the client’s goals. Other SLPs cannot dictate what individuals need from a neurodiversity perspective—you need to listen to the client. If a client expresses that working on fluency is important to them, we shouldn’t dismiss it by saying it will inherently harm self-acceptance or neurodiversity.

Instead, you can acknowledge their goal and discuss how we can integrate it meaningfully: “We can work on fluency, but it doesn’t need to be the primary focus. Here’s why.” Then, you can explore both fluency strategies and self-advocacy techniques that help them feel empowered. There’s absolutely nothing wrong with this balanced approach, as long as it respects the client’s preferences and promotes their well-being.

*See handout for a full list of references.