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Communication effectiveness can be diminished if gains in fluency are achieved through avoidance or through the use of speaking techniques that are so burdensome and unnatural that the individual has difficulty using them on a consistent basis e. Thus, many clinicians recommend maintaining an emphasis on effective communication which focuses on emotional support as well as the acquisition of speaking techniques. Blood combined a computer-assisted biofeedback program for reducing stuttering with a CBT component which encompassed problem-solving, cognitive restructuring and non-directive supportive counselling.

Menzies and colleagues examined the effects on anxiety and stuttering through a CBT package for social anxiety Menzies et al. In addition, several review articles have proposed the incorporation of psychological therapies such as CBT and Mindfulness Boyle, ; Menzies et al. Unlike CBT programs, ACT does not focus on control or thought regulation but proposes a different approach to the management of experiential avoidance and emotional instability.

The focus of ACT in treatment is not an attempt to eradicate negative thoughts and feelings; rather, frustration is reduced through acceptance and a focus on valued living. Under the ACT auspices, the goal of self-concept is to develop flexibility in how the person views and defines themselves.

The core process of defusion promotes behavioural flexibility while acceptance teaches the client to embrace emotional and cognitive events without attempts to change. The mindfulness process teaches perspective on the present rather than dwelling on thoughts and experiences in the past. In summary, ACT is unique in that it focuses directly on values identification, values clarification, and behavioural decisions linked to personal values. The authors deemed the proposed ACT treatment to be particularly appropriate for a cohort of adults who stutter given that their daily struggle is often defined by the value placed on communicating fluently.

Individuals who stutter require treatment that facilitates self-efficacy and self-responsibility Craig, , and the ACT approach investigated in this study may provide a means for adults who stutter to accomplish these goals. The study also examined whether these improvements were maintained over a 3 month follow-up period of time.

Methods 2. Each adult had a clinical diagnosis of stuttering confirmed by two speech pathologists with no less than 10 years of clinical experience in the assessment and treatment of fluency disorders. Two of the 10 participants lived in rural areas ranging from km south-west to km north-east of Perth, Western Australia.

All other participants resided in the Perth metropolitan region. Participants reported an onset of stuttering in early childhood in a manner consistent with developmental stuttering. No participant had received treatment within the previous 12 months. Integrated ACT program The integrated ACT program, which was adapted specifically for individuals who stutter, consisted of 2-h group therapy sessions conducted weekly for eight consecutive weeks. This study reports results for two treatment groups 10 participants per group. Each group was conducted by two group leaders one speech pathologist and one clinical psychologist with three undergraduates, final year speech pathology students in attendance.

Both group leaders have specialised clinical experience working with adults who stutter. The speech pathology component of the group program was assimilated into the ACT activities in each session. That is, as the ACT activities for each session were practiced, each participant was encouraged and supported to undertake the discussion and conversation about the activities using the individualised speech fluency strategies, negotiated with them based on their pre-treatment assessment. The participants all had individual tasks that were co-designed each week to take home to practice throughout the week.

The focus of the speech pathology intervention was to enhance fluency, reduce the severity and occurrence of stuttering behaviors and improve overall communication. At the first session, the speech data were analysed, fluency goals negotiated with each client and a range of different speech management techniques trialled. The ACT components of the group program addressed all six core processes described above.

In identifying this, it leads clients away from defining themselves solely by any outstanding idea, emotion, or characteristic and instead assists them to become more flexible in how they define their self-concept. This session also introduced the concepts of willingness and acceptance as alternatives to experiential avoidance.

Within the ACT framework, emotional and cognitive discomforts are viewed as normal, unavoidable consequences of being human. Although it is not possible to eradicate the content or occurrence of undesirable private experiences, it is possible to reduce impact through acceptance.

ACT provides a fulcrum for relinquishing old behaviours that are not working. The third session involved the identification of private events to target for defusion and acceptance work. This session further introduced acceptance interventions, self-evaluation and the practice of mindfulness skills.

With the ACT model, there is no attempt to change thought patterns such as in a CBT treatment paradigm rather cognitive defusion involves the ability to notice each thought as being a thought, rather than adhering to thoughts as facts. The fourth session further extended defusion work and expanded the mindfulness skills into daily life. The sixth session instigated committed action and management of client identified barriers to such action.

The seventh session promoted continuation of value- directed activities. In the values component of ACT, clients are asked to identify the domains of life most meaningful to them and personal resources that were previously devoted to the management and avoidance of negative life experiences become directed toward achieving defined personal values.

The eighth and final session processed the reactions of the client to the conclusion of the treatment program, reviewed the ACT strategies and techniques and set goals to promote post-treatment maintenance of therapeutic gains. Procedures Ethics approval was obtained for this study through the requisite Human Research Ethics Committee. Informed consent was obtained from all participants. All participants completed a questionnaire booklet consisting of five quantitative ques- tionnaires see Section 2. In each of the three data-collection sessions, the order of presentation of five questionnaires was counterbalanced to control for order effects.

Measures 2. Stuttered speech frequency Stuttered speech frequency was determined by collection and rating of a representative natural conversational speech sample for each of the 20 participants for each of the three assessment time periods. The speech samples were obtained from a 20 min conversation each person had with an undergraduate student clinician. The conversations included topics such as family, work, recreation activities, sporting interests and travel experiences. A minimum of syllables of speech was obtained and rated by two speech pathologists.

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Inter-rater reliability, calculated using a one-way independent group random effect model of analyses Howell, , revealed a correlation coefficient of. This indicates that judgements were both satisfactorily correlated and in agreement. Intra-rater reliability was calculated using the same method, and an intra-class correlation coefficient of. The questionnaire is divided into four sections. Section III Communication in Daily Situations contains 25 items assessing the degree of difficulty speakers have when communicating in general situations, at work, in social situations, and at home.

For each item on the OASES, response scales are organised so that higher scores indicate a greater degree of negative impact associated with stuttering and lower scores indicate less negative impact. Using a six-point Likert scale almost always to almost never , respondents rate how often they have experiences of being open and receptive to present moment experiences across cognitive, emotional, physical, interpersonal, and general life domains.

It has a good internal consistency of. This measure was designed to assess the general tendency to be mindful in daily life, to measure various components of mindfulness and to be understood by general and clinical populations. It assesses elements of experiential avoidance, including negative evaluation of and tendency to avoid or control aversive internal stimuli and inability to take constructive action while experiencing these stimuli. The AAQ-II has been shown to have good internal consistency, a single factor structure, and significant correlations with measures of mental health Bond et al.

Results The data were scanned for any univariate and multivariate outliers with no significant outliers identified. Mahalanobis distances were computed to identify any multivariate outliers with no significant outliers found. Results at the three measurement time points pre-treatment, post-treatment, and at follow-up are also presented graphically in Figs. Results show significant differences across all measures at the three measurement time points. A repeated measures ANOVA was conducted to compare the outcome measure scores between time-points pre- treatment, post-treatment and follow-up in order to investigate the effectiveness of the ACT group treatment program for adults who stutter.

Results shown in Table 1 reveal Fig. Note group mean is designated by —. An alpha level of. The repeated measures ANOVA indicated that frequency of the stuttered speech was reduced and maintained significantly over time Table 1, Fig. Stages of change questionnaire The repeated measures ANOVA indicated that participants who registered precontemplation scores pre-treatment, low- ered their precontemplation scores post-treatment and maintained these improved lowered scores at follow-up.

In addition, the action and maintenance scores increased significantly and were maintained over time indicating that the participants reported that they were engaged in a tangible and deliberate process of therapeutic change in which they were actively maintaining therapeutic effort and attention over an extended period of time. By contrast, the contemplation scores showed no significant difference over time indicating that participants who were involved in this treatment program maintained their behavioural intention to active change Table 1, Fig.

Mindful attention awareness scale As reported in Table 1 and Fig. These results indicate that the participants rated that they were more open and receptive to present moment experiences across cognitive, emotional, physical, interpersonal, and general life domains. These results demonstrate that the participants had a greater tendency to be mindful in daily life through the acquisition and practice of various mindfulness skills.

Acceptance and Action Questionnaire The results provided by this self-report assessment of psychological flexibility indicated that the participants gained a more complete awareness of the present moment, including their thoughts and feelings. At the same time, they modified their unhelpful behaviours to behaviours which were more consistent with their valued goals. Discussion In the present study, the authors investigated the effectiveness of a novel integrated ACT program on psychosocial functioning, readiness for therapy and change, utilization of mindfulness skills and psychological flexibility, and frequency of stuttering in adults who stuttered.

The program is unique in that this is the first research to demonstrate the use of ACT as distinct from previously researched CBT approaches in the treatment of stuttering for adults. ACT involves therapeutic approaches that are focused on awareness, acceptance and understanding of the context of thoughts rather than on direct challenges or changes to the content of thought per se Hayes, ; Hayes et al.

The authors deemed ACT to be an appropriate genre of treatment for adults who stutter because of the psychological flexibility underpinning the basic philosophy.

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The results also indicate how the ACT philosophy appealed to the participants given that they attended every session and each person saw the program through to completion and follow-up three months later. Results from this study showed statistically significant gains across all measures of interest from pre-treatment to post- treatment and continuing on to three months follow-up. Further, these psychosocial and fluency gains were maintained for a three month period after the treatment ceased.

Within the group program, participants identified their avoidance behaviours and then used the ACT strategies to reduce their experiential behavioural, emotional and cognitive avoidance patterns. Significant improvements were found in partic- ipants recognising and identifying a need for change, then engaging in and maintaining a commitment to therapeutic effort over an extended period of time.

The fourth aim of the study was to bring about an improvement in fluency and a reduction in the frequency of stut- tered speech measured by changes in per cent syllables stuttered. Significant improvements in frequency of stuttering were achieved during the program and maintained by participants for a period of three months post treatment. These results underpin the success and importance of individually tailored speech programs for adults who stutter. Flexibility of speech pathology management was achieved successfully for the participants in the absence of programmed, manualised instruction.

In fact, one interesting aspect of the findings is the fact that all 20 of the participants in the study reported experiencing such changes in their lives. Although no treatment can be said to be effective for everybody, the consistency of the changes reported across participants is notable. This suggests that helping people who stutter focus on their personal values through a flexible treatment paradigm that incorporates both speech changes and psychological changes in an ACT framework, can lead to consistent, positive changes for a wide range of individuals who stutter. Specifically, it might seem paradoxical for clinicians to work toward helping clients modify disfluent speech behaviors to increase fluency while simultaneously helping them increase their acceptance of such behav- iors.

Results from this study clearly demonstrate that it is possible for individuals who stutter to work toward both of these goals simultaneously and that the results of treatment aimed at acceptance and modification can complement one another. The result is that speakers can speak more fluently and communicate more effectively, all while living their lives with a greater sense of acceptance and a reduced burden from their disorder.

Thus, such treatment can result in improved psychosocial functioning as well as improved speech fluency and communication. This program was adapted specifically for individuals who stutter and constituted an integrated continuous set of activi- ties, strategies and resources for a mixed gender cohort of adults. Participants demonstrated the value of the program through their attendance and commitment. In addition, all participants made significant progress statistically and clinically on all measures.

Primary reasons for this consistency and effectiveness may be the non-confrontational nature of the ACT approach plus the importance and focus on acceptance. The emphasis on acceptance, mindfulness, and core values of the client may be likely to promote the therapeutic alliance as well cognitive restructuring by the client resulting in an agentic lifestyle. An increase in the number of participants is clearly recommended plus a replication to extend these preliminary findings regarding the clinical potential for this treatment package.

A further recommendation is to extend the maintenance follow-up period beyond three months. This would permit more detailed consideration of the durability of psychosocial improvements and fluency gains over an extended time frame. This project is a preliminary evaluation of an integrated ACT program. As such, it advances the integration of ACT into a contemporary vantage point when considering options for effective treatments for individuals who stutter. The authors would also like to thank anonymous reviewers for their helpful comments in improving this manuscript.

References Andrews, G. Stuttering: Overt and covert measurement of the speech of treated subjects. Journal of Speech and Hearing Disorders, 47, 96— Andrews, G.

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Sydney: Prince Henry Hospital. Does behaviour therapy still work when the experimenters depart? An analysis of a behavioural treatment programme for stuttering. Behavior Modification, 9, — Baer, R. Assessment of mindfulness by self-report: The Kentucky inventory of mindfulness skills. Assessment, 11, — Beilby, J. Effectiveness of a mindfulness-based acceptance and commitment therapy to improve quality of life of adults who stutter. Evaluation of the effectiveness of a mindfulness and acceptance group program to improve communication fears, experiential avoidance and quality of life of adults who stutter.

Acceptance and commitment therapy for people who stutter. Perspectives on Fluency and Fluency Disorders. The impact of a stuttering disorder on western Australian children and adolescents, in press.

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Byrnes, M. Effectiveness of acceptance and commitment therapy group program for individuals post spinal cord injury and stroke and people who stutter: Similarities and differences. Blanchard, K. Motivational subtypes and continuous measures of readiness for change: Concurrent and predictive validity. Psychology of Addictive Behaviors, 17, 56— Blood, G. A behavioural-cognitive therapy program for adults who stutter: Computers and counseling.

Journal of Communication Disorders, 28, — Bloodstein, O. Stuttering: The search for a cause and cure. A handbook of stuttering 6th ed. New York: Thomson Delmar Learning. Blumgart, E. Journal of Fluency Disorders, 37, 83— Bond, F. Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42, — Boyle, M. Mindfulness training in stuttering therapy: A tutorial for speech-language pathologists.

Journal of Fluency Disorders, 36, — Brown, K. The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84, — Carey, K. Assessing readiness to change substance abuse: A critical review of instruments. Clinical Psychology: Science and Practice, 6, — Carlson, L.

I invite you all to entertain the following scenario: You know exactly what you have to say, your listener is waiting patiently to hear you speak, but you simply cannot … Get. As someone with a severe stutter, this is what I face every waking moment of every day. It is a battle I take pride in. It is an obstacle that has taught me things about myself I would otherwise never have discovered. Much of what I have to share with the world would be unknown to me if I had been born a smooth and fluid speaker. Stuttering has given me the great ability to listen to the person with whom I am conversing.

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I know exactly how it feels to be speaking to someone who is looking directly at me, their attention aimed at me, and yet they are not listening; their minds are somewhere else. People get distracted by my speech, or lack of it. Interruptions and loss of eye contact ensue. The conversation has been disrupted. Take your shoes off your feet, because the place upon which you stand is holy soil. Being hung up on while making a call, being made fun of for speaking in an unfamiliar way, or having a friend speak on my behalf are all par for the course for stutterers.

All this has naturally had an effect on me. To be able to withstand these challenges and not let them define you takes great will and energy. To keep at it, to continue engaging with the world, speaking to anyone you want to, stutter or not, builds inner strength that is deep and lasting. There are situations in life that overwhelm all of us. There are times when we are intimidated and made to doubt our ability to accomplish a goal, big or small. We need to remember that we can do whatever we put our mind to, and that people respect others who overcome their challenges.

To be mindful of our hardships, and despite it all to continue on our path, is what will lead to great things. Stuttering has made me someone unique. When I converse with someone, the listener is given the opportunity to pay closer attention to me and my message, and to have the patience to allow me to get the words out.

When asked their name, not many people take 30 seconds to get out that one seemingly simple word. I work at not leading with my speech challenge. Regardless, it makes me memorable. But I hope it is the way I approach my challenge that is the most memorable. I am inspired by Joseph. He had a life full of hardship, from having his brothers sell him as a slave, to being wrongfully accused and incarcerated in Egypt. And through it all, he kept his uniqueness, shared his talents and uplifted those around him. I believe that the fact that he was able to rise to become the viceroy of Egypt was precisely because he was able to learn from his hardships and use them to his advantage.

They gave him the gift of resilience, the fortitude to keep his faith and overcome any obstacle that came his way. All of us have qualities that are distinct. Each of us has our struggles, our stutters in life, those things that we think impede our ability to reach greater heights. The goal is to remember that strength and beauty are in the struggle, in overcoming hardships and in being open to people about your struggle. Try that for yourself. Put the challenge up front so that you can put it aside from the start. Be like Moses, leaving the preconceived notions at the door, and be resilient like Joseph, continuing to pull through.

I hope this story of my struggle and the strength it has given me can add value to your life as well. We are in this journey of life together. With resilience, kindness and an honest ear, we can add light to our lives and the lives of those around us every day. Dear Shalom Goodman, I was very touched by your experiences with stuttering. I am Christian and happened to come across your article while looking up other information, a happy accident. I congratulate you on your positive approach to a difficult challenge. I also empathize with you because many decades of my life were plagued by stuttering and the resulting embarrassment of being different, as if I were an alien from another planet.

I hated the times people would not look at me when the problem showed itself or when someone filled in a word. As I grew older and got more experience with speaking in public and on the theatrical stage, my breath control and maybe confidence improved, resulting in what I consider fluency most of the time. But, on occasion, I do revert to incidences of non-fluency. Am still very uncomfortable during those times but your article has given me a kind of hope on how to deal with those incidences and, as you wisely say, not let them define you.

Thank you Reply. Wonderful Advice! Rabbi Goodman, Thank you for sharing your inspiring story regarding stuttering. Your suggestions are very insightful. We live in a society that is so fast-paced and it is rather difficult for some to grasp that for some there may be a delay in speech aside from tone of voice, accent, and etc. I have also stuttered my entire life and have always found it very helpful to directly indirectly bring awareness to the topic. This puts you at ease as well as those you are communicating with and allows you to break through any barriers to living a full life that stem from stuttering.

It isn't the stuttering itself that is a barrier or holds one back, but the stigma, rejection, and ridicule faced or perceived that presses upon the stutterer. It is important that we don't allow stuttering to define us as individuals put on this earth to live life by GD. Thanks again for this article; Rabbi! Wonderful Advice Rabbi Goodman, Thank you for sharing your inspiring story regarding stuttering. I'm moved and inspired by you.

I agree that we grow stronger bacause of our challenges, and they can be the building blocks for success, both personally and as a Jewish people. Thank you for your warmth and candor. Kol ha kavod! You are well named, Shalom! Your words like your strength of character invite and point the way through the beautiful gate of Jerusalem, a citadel and community that is at unity in itself psm Thank you for the encouragement Reply. I am reminded of a story of the Steipler Gaon. It was said that when he went to meet his kalla [bride] the sister of the Chazon Ish that she remarked how he was unable to hear.

This was due to an incident that occurred in which he was mikadesh shaim shamayim.

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The Chazon replied to her that he may not be able to hear you but the whole world was going to hear about him. Shalom, you may have difficulty speaking but there are a lot more people listening then you realize. Your article is so timely! It is also beautifully written. Thank you!! Mazel Tov! Shalom, Rabbi Goodman. I commend you on a very insightful article!

I'm also one who severely stutters, and in addition I have a speech pathology background. I can relate on a personal level to all your points, and completely agree with everything you've written. You've expressed the essence of our daily challenges most admirably!

Mazel Tov on your ordination, and for meeting the challenges of stuttering with such bravery and success! Thank you. So, inspired. Lamese Reply. My son stutters slightly, and he sent me the article to share with his siblings! Guess he related to it. Toda Raba, Thank you so much for those uplifting words of encouragement.

I too have a stutter except it is in my brain where it is difficult to think of the words I want to say and usually my brain remains empty in conversations. I've struggled with this for the past 6 years and at times feel like I'm losing the battle. Working with special needs children, I have learned a lot through. I enjoyed the connection made through Moses and Joseph.

Great article Reply. I had problems speaking as a child. Everyone called it stammering. They claimed I was thinking too fast for my mouth to keep up. As an adult I was mostly able to overcome this, but several years ago after a stroke I had to completely relearn how to talk and every so often some of that old stammering problem comes back. Even Moses had a speach impediment and he was the greatest of us all. Dear Rabbi, more or less we are all as stuttering as you say very well. But we often prefer to ignore it. I was a stammer and stutter victim until my senior year in High School when a MD worked with me with hypnosis.

I could not telephone, but could speak sometimes without affliction.

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I was worst than the King in The Kings Speech. My parents tried speech therapists year after year with almost no affect. I would guess that after my 'awaking' that the possible cause is tension from early childhood. The King's problem was caused by his father. Mine was found out later that I will NOT share. Singing works, see Mel Tillis. It was the worst years of my life. Every time I hear someone with the problem I talk about what I did.