Counseling, Support, and Advocacy for Clients Who Stutter

Suzanne Altholz and Martha Golensky

Fluency disorders are communicative disabilities that can lead to psychosocial and emotional issues. The most prevalent of these disorders is stuttering. People who stutter may cope with stigmatization and discrimination throughout their lives as a result of misconceptions and misinformation about the disabilitys etiology and manifestations. Mental health professionals have contributed to these negative experiences by their lack of knowledge about stuttering. This article provides information on the physical, psychological, and social causal factors and implications of fluency disorders, so that social workers can engage in ethical practice to alleviate the mental anguish of their clients who stutter and enable them to reach their full potential. An advocacy role with other professionals, such as educators and speechlanguage pathologists, is described.

Key words advocacy collaborative treatment counseling fluency disorders stuttering

or most people, speaking is as natural as breathing. However, 1 percent of adults and 3 percent of children in the world who stutter cannot take fluency of speech for granted (Bloodstein, 1993). Fluency refers to the effortless flow, rate, rhythm, and patterns of stress and intonation in speech production. Fluency disorders may be caused by cerebral accidents, Tourettes syndrome, and other medical conditions, but the most common fluency disorder is stuttering (Cooper, 1997). Stuttering is characterized by disrupted synchrony of respiration, phonation, and articulation and is usually accompanied by excessive muscular tension (Hulit, 1996). On average, three times as many males as females stutter (Bloodstein, 1993). The listener is apt to perceive a speech disfluency as stuttering when the speaker repeats a sound or syllable, prolongs a sound, makes an unusual pause between sounds or syllables of a word, or repeats a monosyllable word. Perception is the operative word; a determination of overt stuttering is therefore based on the listeners interpretation of the sounds, words, or phrases that are vocalized (Conture, 1990). Many people who stutter consult speechlanguage pathologists (SLPs) for assistance because these professionals are experts in the anatomy, physiology, and motor systems of the speech mechanism and can provide education and behavior modification to achieve greater control over speech (Cooper, 1997). Because stuttering is commonly characterized by emotional, behavioral, and cognitive components that may inordinately affect interpersonal and social relationships of the speaker, many SLPs include counseling in the treatment plan. Yet, many SLPs are reluctant to make referrals to social workers or counselors because of a belief that mental health professionals are generally uninformed about disfluency (Luterman, 1996). Nevertheless, an interdisciplinary approach can help people who stutter achieve a better quality of life and improved chances of maintaining acquired skills in speech management. This article informs social workers about the physical, psychological, and social causal factors and implications of stuttering to enable them to establish effective partnerships with SLPs and,
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most important, effective therapeutic relationships with clients who stutter.

Characteristics of Stuttering
Because no definitive cause for stuttering has been proven, and there is controversy about factors involved in its development, studies or authors who claim to have discovered its etiology should be viewed with skepticism. Theories that consider parents at least partially to blame or list individual psychological factors that contribute to stuttering are no longer considered accurate (Hulit & Wirtz, 1994). The predisposition to stutter appears to be genetic, but this is not viewed as the only cause (Logan, 1999). Although stuttering is believed to have some connection with neurological coordination or timing of the speech mechanisms, it is not an emotional problem or nervous disorder (National Stuttering Association [NSA], 1999). Yet, principles of learning and emotional reactions to stuttering contribute to its development and maintenance (Logan). In other words, although the block is neurophysiologically determined, the negative emotional response is learned.

Stuttering most often begins between ages two and a half and seven (Culatta & Goldberg, 1995). Dr. John Hanley, chairman of the Speech Pathology and Audiology Department at Western Michigan University, noted that speech and language are learned around age three, when the mechanisms for speech are not fully developed, a possible contributing factor to the onset of stuttering (personal communication, November 4, 1998). When a young child has difficulty with a task, the natural tendency is to push harder or use force, but this increased use of force causes the speech mechanisms to block, making it even more difficult for the child to say the word or sound. In addition, children who are more sensitive may be overly responsive to sensory input, including disruptions in their speech. If such disruptions are identified as a problem, it may put these children at risk of stuttering (Williams, 1989).

Emotional and Social Aspects of Communicative Disorders

When communication is blocked or distorted, strong feelings may arise that affect every aspect of an individuals existence, including self-concept, roles, and ways of living: [Stuttering] is an impediment in living. . . . [and] even those who manage to cope with the disorder can do so only by continual vigilance (Van Riper, 1971, p. 2). Common emotional responses include frustration, anxiety, guilt, shame, fear, stress, grief, denial, helplessness, anger, depression, isolation, and low selfconcept, which may have a substantively greater impact on the person who stutters and his or her family than the behavior itself (Crowe, 1997c). The intermittent nature of stuttering reinforces the feeling of powerlessness over control of the symptoms (Conture, 2001; Crowe, 1997a). The sense of helplessness stems from a perception that the cause of the stuttering is not internal but rather an alien source in conflict with the self, often referred to by people who stutter as it. Attempts to manage stuttering involve concealing, avoiding, and struggling with an intractable part of the self to better understand the circumstances in which it is apt to take over speech. Even when speaking fluently, an individual who stutters may watch for signs that the listener is reacting not to what is being said but to the way it is said (Petrunik & Shearing, 1988). Any verbal situation can expose the stutterer to negative reactions and rejection. Simple, takenfor-granted activities such as being asked to introduce oneself, talking on the telephone, or seeking

The predisposition to stutter appears to be genetic, but this is not viewed as the only cause.
These negative reactions result in secondary symptoms as the individual engages in behaviors that temporarily make the stuttering seem less severe, which include movements to get the sound or word started (for example, closing the eyes, tongue protrusions, clenching of fists, gasping, emptying the lungs or stopping breathing, or interjecting sounds or words) (Bloodstein, 1993). Word substitution is a common practice to avoid words or phrases that may be viewed as difficult to pronounce (Jezer, 1997). These behaviors are learned by association with success in overcoming a block, that is, when a persons speech mechanism ceases to move forward to the next sound position (Conture, 2001, p. 7). Such practices become habitual and often are performed unconsciously (Bloodstein). However, the effectiveness of the behavior diminishes over time, and new, more effective behaviors are adopted and become incorporated as the pattern is repeated (Logan, 1999). This process results in lengthening the stuttering block and exacerbating the emotional response.
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directions become major tasks. The tension and feelings of shame that occur can be overwhelming and may lead to self-imposed isolation to escape the negative consequences of public speaking, which can affect personal relationships and life choices (Jezer, 1997). Misconceptions, lack of information, and even fear, have caused much of the discrimination and oppression experienced by people who stutter (Bloodstein, 1993). For example, a teacher who views stuttering as strange and embarrassing behavior can exacerbate a students problems by treating the child differently and unconsciously blaming him or her for perceived willfulness (Williams, 1989). According to the NSA (1999), negative stereotypes exist; individuals who stutter often are assumed to be nervous, incompetent, and mentally ill. Undocumented generalizationsfor example, that most people who stutter have difficulty forming intimate relationshipscontinue to be made (Linn & Caruso, 1998). Educators have even discouraged people who stutter from pursuing careers that require a high degree of verbal skill because of erroneous beliefs about individual capabilities. Many individuals who stutter distrust professionals in general and therapists in particular, because their lack of knowledge about stuttering has resulted in unintended negative experiences (Jezer, 1997). In research conducted by Altholz (1998b), more than 28 percent of social workers in private practice in Michigan who responded to a survey about clients who stutter believed that stuttering could be viewed as a preliminary sign of an inherent character weakness and that people who stutter have psychological problems. Such preconceptions color the social workers counseling. Of special concern is that stuttering is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM)(American Psychiatric Association, 1994), even though it is no longer considered a psychiatric disorder. Although individuals who stutter are not exempt from emotional problems, they are no more likely than the general population to have psychological disturbances. It has been estimated that only 5 percent to 10 percent of all people who stutter may warrant professional evaluation and counseling beyond the skill level of the SLP (Conture, 2001). Some researchers may have misled mental health professionals to assume that it is relatively simple to help a client achieve fluency (Jezer, 1997). In truth, stuttering is complex and idiosyncratic. The type and frequency of disfluency are different

for every individual and can vary at various times of life. Few components of stuttering are considered to be universal, and even those components are not present in every case (Cooper, 1997). Individuals who stutter may be able to sing, talk in unison, and speak to a beat fluently (Van Riper, 1971). However, these moments of fluency do not carry over to conversational situations; operating on the wrong assumption can subject the client to interventions that increase the sense of failure and shame (Murphy, 1999).

Counseling Clients Who Stutter

It is important to consider the implications of stuttering in the therapeutic relationship. In addition to drawing on the literature, which at this time is almost totally from the fields of speech pathology and psychology, the personal experiences of one of the authors and other people who stutter in her recent research study can help illustrate the issues. The primary role for social workers in practice with clients who stutter, regardless of years of professional experience, is to help the client become self-actualizing and fully functional. For purposeful intervention social workers should give information to and receive it from the client, help the client develop decision-making and problem-solving skills about the communicative disorder to use in daily living, help the client resolve problems stemming from the impediment, help the client develop or regain self-esteem, and help parents or significant others develop realistic, supportive acceptance of the disorder (Crowe, 1997b). General rules applicable to anyone who listens to someone who stutters are listed in a brochure put out by the Stuttering Foundation of America (SFA, 1993) The rules include the following: Refrain from making remarks like slow down or relax, which can be interpreted as demeaning and are not helpful. Do not finish sentences or fill in words. Maintain natural eye contact, and try not to look embarrassed while waiting patiently until the person is finished. Use a relaxed, relatively slow rate in your own speech, but not so slow as to sound unnatural. Show the person you are interested in what he or she says and not how he or she says it by your manner and actions. Be aware that people who stutter usually have more trouble controlling their speech on the
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phone and allow sufficient time for a conversation to be initiated. When the social worker focuses on the clients stuttering, the client receives the message that stuttering is inappropriate, which may increase the sense of shame and guilt (Murphy, 1999).

Engagement, Data Collection, and Assessment

When first meeting a client who stutters, it is important to know how to react to the stuttering if trust is to be established. The social worker should give the client the opportunity to explain why he or she is seeking help and not assume that the problem stems from the communicative disability, just as a good practitioner would not jump to the conclusion that being very tall or overweight is necessarily the issue. Two examples illustrate this point. An author of this article sought help to leave an abusive relationship, but the social worker concentrated on the stuttering rather than the emotional abuse. The client discontinued therapy, and the abuse was not dealt with until two years later. At the other extreme, an adolescent entered therapy to cope with her stuttering; instead of helping with social skills as the client desired, the therapist focused on the clients alleged problems with her mother (Altholz, 1998b). A client is likely to be sensitive to the social workers reactions and must be validated as a person before stuttering is discussed (NSA, 1999). In working with clients from different cultures who stutter, knowing how the person feels about therapy, health, and disability can help the professional determine an effective approach and communicate in a culturally appropriate manner. Explaining the roles and responsibilities of the practitioner and the client can help clarify what the intervention involves and what the client can expect. Verbal communication for clients who stutter is influenced by their culture and their disorder. Social workers must be even more sensitive to kinesics, facial expression, eye contact, silences, rate of speech, and other behavior that could be determined by the clients culture, speech avoidance behaviors, or secondary characteristics of stuttering. Also to be considered are cultural myths about stuttering, many of which may exacerbate guilt and stigmatization and lead to denigratory treatment of the client (Robinson & Crowe, 1998). Because many stutterers have spent their lives avoiding speaking in social situations, they may
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not be knowledgeable about the syndrome (Jezer, 1997). The assessment should include the misperceptions, affective significance, and cognitiveaffective disparities the client may have about stuttering (Cooper, 1997). Being aware of issues related to stuttering can help the therapist understand the complex reactions clients have in various situations. During the first interview, it may be beneficial to explore the clients coping mechanisms, because the level of stuttering severity does not necessarily indicate how the person feels about him- or herself (Jezer). A better indicator would be the level of avoidance of speaking in social situations and the motivation the client has to resolve negative feelings. The clients history may help the therapist understand the nature of the problem, but the focus should be on what can be accomplished in the present. Moreover, the social worker must respect the clients right to self-determination. If the client chooses to work on issues not related to stuttering, the practitioner should not judge this decision negatively. For social work to be ethical, intervention must be based on the clients goals and should be aimed at improving the clients quality of life (Loewenberg & Dolgoff, 1992).

Intervention
Interventions need to be individualized. If the client identifies stuttering as a problem, therapeutic goals might include developing a reality-based perspective on the behavioral, affective, and cognitive ramifications of stuttering and coping patterns; enhancing the clients self-esteem; and constructing strategies to accomplish these tasks (Crowe, 1997c). Gentle confrontation about dysfunctional beliefs communicates that the practitioner cares about the client and is honest about what is going on in sessions and begins the task of identifying feelings and beliefs related to stuttering. Contracting for a set number of sessions can encourage a focus on change and discourage rumination about past experiences and feelings (Cooper, 1997). It is important to make the client aware that there is no quick fix or guaranteed cure for stuttering and that work in a social work setting is not speech therapy (Jezer, 1997). Efforts to achieve fluency must be with a speech therapist trained in fluency disorders. It is important to convey to the client that working toward self-acceptance and learning more effective coping and problem-solving skills does not necessarily increase fluency. In

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fact, as the client starts to make progress, manifested by reducing the avoidance of speaking situations, increased stuttering is likely to occur. Reassuring the client that this is normal and a sign of growth can alleviate fears and encourage toleration of breaks in fluency. Over time, fluency should improve and stuttering episodes should be easier to handle (Cooper, 1997). Because the client may have misconceptions about the causes of the impediment, providing information about stuttering may provide relief from self-blame and give a sense of hope that coping with stuttering is possible. Bibliotherapy, or the use of reading as an adjunct to psychotherapy, may help the client. It is not only a means to learn more about the issue, but for clients who have spent their lives trying to hide their speech impediment, this method is a nonthreatening first step in dealing with their condition (Jezer, 1997). Suitable information is available at a nominal cost from the SFA or similar organizations. Cognitivebehavioral and problem-solving approaches are also appropriate for working with clients who stutter (Crowe & Cooper, 1977). The individual may overgeneralize the level of personal responsibility for perceived difficulties. Common misperceptions of individuals who stutter include considering themselves inadequate, unattractive, incompetent, and undeserving, which may lead to increased isolation (Crowe, 1997c). Informing the client about famous people who have been successful despite their stuttering, from Aristotle to Winston Churchill to Bruce Willis, may assure the client that stuttering does not have to limit career choices and provide useful role models (Kuster, 1999). Group therapy can provide a way to convey information and share feelings and promote personal growth among individuals who stutter (Luterman, 1996). As Sugarman (1998) noted, self-help groups have been in existence for more than 30 years (see the Appendix for several listings). In this kind of nonthreatening social environment, each member can talk without having to worry about how listeners react. This can be liberating by validating that what an individual has to say has worth, regardless of speech disfluencies. Along with an increase in the members self-esteem is the realization of having the right to be treated with dignity, to speak openly, and to be recognized as an equal in society. However, many of these clients are hesitant to go to a support group because of nervousness about their own reactions to being around others who stutter

and their avoidance of stuttering. Explaining the benefits of such groups may be a necessary first step to encourage the client to attend a meeting. As noted earlier, clients who want to improve fluency should work with a specialist in speech disorders, but exploring the clients prior history may be indicated. For many adults, earlier therapy may have been counterproductive because of erroneous beliefs that contributed to negative selfconcepts, such as the idea that people who stutter are mentally ill or incompetent. Ideally, the SLP should be in agreement with the mental health professional about the clients needs: [We] must go beyond the goal of fluent speech, which often is a temporary condition, and learn self-acceptance, internalization of locus of control, increased selfesteem, and increased assertiveness, especially in communicative situations (Bloom & Cooperman, 1999, p. 260). Discussing the costs and benefits of speech therapy would also be appropriate. Adults must have great determination and time to practice the techniques necessary to maintain fluency; some may find the personal risk, effort needed, and the resulting loss of spontaneity not worth the price. The decision should be left to the client and be validated by the social worker (Hulit, 1996). If the client is a child, the social worker may interact with the parents. Parents sometimes question whether their child has a speech problem, and a first point of intervention may be to identify signs to look for, such as multiple repetitions, prolongations, and using of a schwa or unstressed mid-central vowel sound in a syllable repetition rather than the actual vowel sound (guh-guh-goat versus gogo-goat). These disfluencies occur occasionally with all speakers, but increasing occurrences may indicate potential for the development of stuttering. Other indicators that are not common in normal speech development are tremors around a childs mouth when he or she seems to get stuck on words, a rise in pitch or loudness during prolongations of a sound, showing signs of struggle or tension while speaking, avoidance of pronouncing anticipated difficult words, and not speaking when it appears the child has something to say (Williams, 1989). Although it is true that 60 percent to 70 percent of young children up to age eight who exhibit stuttering behavior achieve fluency without formal treatmenta phenomenon referred to as spontaneous recoverythe danger is that the third who need assistance may be overlooked at a time when the stuttering is remediable. Parents counseled by an uninformed professional to wait and
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see whether the child grows out of stuttering may delay action until it is too late; spontaneous recovery rarely occurs after age 12 (Cooper, 1997). A second point of intervention is in the childs environment, because communicative and interpersonal stress may exacerbate stuttering (Williams, 1989). These stresses may come from speaking rapidly, interrupting the child, guessing what the child has to say, speaking immediately when the child pauses or stops talking, bombarding the child with too many questions, and establishing an environment in which the child needs to compete with others to talk. Other sources of stress include unrealistic demands on the child, conflict about discipline, hectic or inconsistent family routine, fastpaced family life, and experiences in which the child feels ashamed. Encouraging the parent to adopt slow, comfortable speech patterns as a model and to minimize stressful speaking situations by reducing interruptions and competition among those wishing to speak may reduce the number of disfluencies in the childs speech (personal communication with Dr. J. Hanley, February 23, 1998). Family members also are affected. Parents may not know appropriate ways to support their child and needlessly worry that they have inadvertently caused the condition. They may experience guilt and shame and be uncomfortable handling the situation (Crowe & Cooper, 1977). A parent who stutters may be concerned that an offspring will stutter. However, being aware of how to deal with stuttering if it appears alleviates much of the concern, because a family can influence the childs selfimage, fluency, and coping abilities in either positive or negative ways (Apel & Masterson, 1997). In some instances, advocating for the client to resolve problems related directly or indirectly to their communicative disorder can be helpful. This is especially true when the client is a child or teenager; the social worker may need to educate school staff about how to provide a supportive environment. Helpful approaches include talking to the childs classmates to lessen their fear and misunderstandings about stuttering, helping the teacher find ways for the student to be more comfortable participating in class, and sharing appropriate methods to interact with the child to show acceptance of the disfluency as one aspect of personal identity while promoting positive relationships with others (Gregory, 1997). Social and self-esteem issues are especially significant for adolescents; the therapist needs to work with these clients on assertiveness and interpersonal skills. A support
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group can help teenagers realize that they are not alone, and speech therapy can increase their sense of control over the disability (Fraser & Perkins, 1997).

Termination and Evaluation

During the termination phase, discussions about ending the therapeutic relationship are likely to encompass both feelings of loss and a positive sense of accomplishment. The client may have concerns about losing some of the gains achieved and may benefit from reviewing what has been learned as well as how to use new coping skills in the future. Clients who have achieved more self-acceptance are more apt to be successful in speech therapy and less likely to relapse. However, relapses in feeling out of control during speaking situations are to be expected. When this happens, the client should be encouraged to assess the process of thinking and reacting to regain a sense of balance and control (Crowe, 1997a). If the intervention was successful, specific outcomes can be identified: a change in attitude about the meaning and consequences of stuttering better coping skills and easier interpersonal relationships, no matter how fluently the person speaks empowerment for the client and less internal stigmatization. In addition, people who stutter can help others feel more comfortable by briefly explaining stuttering and teaching them how to listen appropriately. Modeling self-acceptance is an effective technique for overcoming negative stereotypes by demonstrating that stuttering need not limit a persons ability to communicate. If the clients goal was to minimize the fear of stuttering and resistance to speech therapy, evaluating progress with the SLP can provide an indication of the effectiveness of the therapeutic intervention (personal communication with Dr. J. Hanley, February 23, 1998). Such results can be the basis for future interventions.

Final Observations
The Code of Ethics of the National Association of Social Workers (NASW, 2000) states that social workers should advocate for individuals and groups of people who are subjected to discriminatory practices. Because negative attitudes about disfluency can affect the prospects for individuals who stutter to reach their full potential, educating the public about stuttering is important.

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School social workers, for instance, are in an ideal situation to advocate for children who stutter and to help schools and communities understand this issue. Social workers should be familiar with the organizations founded to provide information about stuttering and promote the rights of people who stutter (see Appendix). The NSA offers articles and ideas to raise community awareness during National Stuttering Awareness Week and International Stuttering Awareness Day (October 22). Social workers can encourage their clients who stutter to participate in such events and adapt the sample radio announcements and newspaper articles available through the NSA for use at the local level. Mental health professionals might also join forces with the NSA and the American Speech LanguageHearing Association to have stuttering removed from the next edition of the DSM. A related area of concern is to encourage a rethinking of the diagnosis of social phobia, which is not considered applicable for a person who stutters if the anxiety is directly related to the stuttering (Altholz, 1998a; Stein, Baird, & Walker, 1996). We believe that social workers are the most appropriate professionals to deal with the social and emotional aspects of disfluency; therefore, our purpose was to set forth some of the common physical, psychological, and social causal factors and implications related to stuttering. This knowledge can help the practitioner determine what strategies might best serve their clients who stutter and relieve them of the burden of having to explain the disorder, which is especially critical when the individual does not have insight into the causes of stuttering or how to effectively cope with the syndrome. The key issue is lack of awareness and sensitivity, not lack of basic skills. To ensure that social workers, whether new to the profession or highly experienced, acquire the necessary information, schools of social work should include a discussion of stuttering in an appropriate course in the curriculum of BSW and MSW programs and as the topic of a continuing education workshop. Based on the limited empirical evidence, the most useful interventions for this population appear to be the cognitivebehavioral and problemsolving approaches. These approaches may facilitate collaborative treatment with an SLP. For example, one technique used by speech therapists is to encourage fluent stuttering, that is, maintaining airflow and voicing between words to reduce tension and gain more control over speech pro-

duction, allowing the individual more freedom to speak naturally by eliminating the need to say each word perfectly. This behavior modification method, and others like it, can easily be reinforced by the social worker. However, attitudes toward stuttering will not improve if people in general remain uninformed about the realities of disfluency and the characteristics of those living with it (Hulit & Wirtz, 1994). It is therefore even more critical for social workers and other professionals who work in the public domain to be informed about stuttering and to advocate for the rights of people who stutter to be respected and valued in society. More research is warranted, especially regarding the effectiveness of individual intervention strategies, practice in small group settings, and working with clients who stutter in conjunction with speech therapists.

References
Altholz, S. (1998a). Social phobia diagnosis, assessment, and treatment in relation to people who stutter. Unpublished manuscript, Grand Valley State University, Grand Rapids, MI. Altholz, S. (1998b). A study on the attitudes and knowledge social workers have in relation to people who stutter. Unpublished manuscript, Grand Valley State University, Grand Rapids, MI. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Apel, K., & Masterson, K. (1997). Child language learning disorders. In T. Crowe (Ed.), Applications of counseling in speechlanguage pathology and audiology (pp. 220237). Baltimore: Williams & Wilkins. Bloodstein, O. (1993). Stuttering: A search for a cause and a cure. Boston: Allyn & Bacon. Bloom, C., & Cooperman, D. (1999). Synergistic stuttering therapy: A holistic approach. Boston: Butterworth-Heinemann. Conture, E. (1990). Stuttering. New York: Prentice Hall. Conture, E. (2001). Stuttering: Its nature, diagnosis, and treatment. Boston: Allyn & Bacon. Cooper, E. B. (1997). Fluency disorders. In T. Crowe (Ed.), Applications of counseling in speechlanguage pathology and audiology (pp. 145166). Baltimore: Williams & Wilkins. Crowe, T. (1997a). Approaches to counseling. In T. Crowe (Ed.), Applications of counseling in speech language pathology and audiology (pp. 80117). Baltimore: Williams & Wilkins. Crowe, T. (1997b). Counseling: Definition, history, rationale. In T. Crowe (Ed.), Applications of counseling in speechlanguage pathology and

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audiology (pp. 329). Baltimore: Williams & Wilkins. Crowe, T. (1997c). Emotional aspects of communicative disorders. In T. Crowe (Ed.), Applications of counseling in speechlanguage pathology and audiology (pp. 3047). Baltimore: Williams & Wilkins. Crowe, T., & Cooper, E. B. (1977). Parental attitudes toward and knowledge of stuttering. Journal of Communication Disorders, 10, 343357. Culatta, R., & Goldberg, S. (1995). Stuttering therapy: An integrated approach to theory and practice. Boston: Allyn & Bacon. Fraser, J., & Perkins, W. H. (Eds.). (1997). Do you stutter? A guide for teens. Memphis, TN: Stuttering Foundation of America. Gregory, H. (1997). The speechlanguage pathologists role in stuttering self-help groups. Seminars in Speech and Language, 18, 401410. Hulit, L. M. (1996). Straight talk on stuttering: Information, encouragement, and counsel for stutterers, caregivers, and speechlanguage clinicians. Springfield, IL: Charles C Thomas. Hulit, L. M., & Wirtz, L. (1994). The association of attitudes towards stuttering with selected variables. Journal of Fluency Disorders, 19, 247267. Jezer, M. (1997). Stuttering: A life bound up in words. New York: Basic Books. Kuster, J. (1999, December 24). Famous people who stutter. Retrieved March 15, 2000, from http:// mankato.msus.edu/dept/comdis/kuster.famous/ famouspws.html Linn, G., & Caruso, A. (1998). Perspectives on the effects of stuttering on the formation and maintenance of intimate relationships. Journal of Rehabilitation, 64(3), 1215. Loewenberg, F., & Dolgoff, R. (1992). Ethical decisions for social work practice. Itasca, IL: F. E. Peacock. Logan, R. (1999). The three dimensions of stuttering: Neurology, behavior, and emotion (2nd ed.). London: Whurr. Luterman, D. (1996). Counseling persons with communication disorders and their families (3rd ed.). Austin, TX: Pro-Ed. Murphy, B. (1999). A preliminary look at shame, guilt, and stuttering. In N. Ratner & E. C. Healey (Eds.), Stuttering research and practice: Bridging the gap (pp. 131143). Mahwah, NJ: Lawrence Erlbaum. National Association of Social Workers. (2000). Code of ethics of the National Association of Social Workers. Washington, DC: Author. National Stuttering Association. (1999). Changing the rules about stuttering. Retrieved May 18, 2004, from www.nsastutter.org/subcat/index.php?subid=206 Petrunik, M., & Shearing, C. (1988). The I, the Me, and the It: Moving beyond the Meadian conception of self. Canadian Journal of Sociology, 13, 435450.

Robinson, T., & Crowe, T. (1998). Culture-based considerations in programming for stuttering intervention with African-American clients and their families. Language, Speech, and Hearing Services in Schools, 29, 172179. Stein, M., Baird, A., & Walker, J. (1996). Social phobia in adults with stuttering. American Journal of Psychiatry, 153, 278280. Stuttering Foundation of America. (1993). How to react when speaking with someone who stutters. Memphis, TN: Author. Sugarman, M. (1998). Peer counseling and self-help group facilitation for people who stutter. Retrieved May 18, 2004, from http:// www.mnsu.edu/dept/ comdis/kuster/SupportOrganizations/ peercounseling.html Van Riper, C. (1971). The nature of stuttering. Englewood Cliffs, NJ: Prentice Hall. Williams, D. (1989). What do I tell people about my childs stuttering? In E. Conture & J. Fraser (Eds.), Stuttering and your child: Questions and answers (pp. 3342). Memphis, TN: Stuttering Foundation of America.

About the Authors

Suzanne Altholz, CSW, is a mental health clinician, 757 62nd Street, Pullman, MI 49450; e-mail: suzalthoz@hotmail. com. Martha Golensky, DSW, is associate professor, School of Social Work, Grand Valley State University, Grand Rapids, MI.
Original manuscript received August 3, 2000 Final revision received October 15, 2001 Accepted October 31, 2001

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Appendix. Resources for People Who Stutter

Organizations that Provide Information about Stuttering

American SpeechLanguageHearing Association, 10801 Rockville Pike, Rockville, MD 20852 (800) 638-8255 (Web site: www.asha.org) National Council on Stuttering, P.O. Box 344, Rochelle, IL 60601 (815) 562-5202 Stuttering Foundation of America, 3100 Walnut Grove Road, Suite 603, Memphis, TN 38111 (800) 992-9392 (Web site: www.SFA.org; e-mail: stutterSFA@aol.com) Stuttering Resource Foundation, 123 Oxford Road, New Rochelle, NY 10804 (800) 232-4773

Support Groups for People Who Stutter

Compulsive Stutterers Anonymous, c/o Susan Reed, 506 Lynn Avenue, Sycamore, IL 60178 Friends: Association of Young People Who Stutter, c/o John Ahlbach, 1220 Rosita Road, Pacifica, CA 94044 (650) 355-0215 (Web site: www.friendswhostutter.org) National Stuttering Association, 5100 East La Palma Avenue, Suite 208, Anaheim, CA 92807 (800) 364-1677 (Web site: http://nsastutter.org; e-mail: NSPmail@aol.com) Passing Twice (An organization for gay and lesbian people who stutter), P.O. Box 93713, Durham, NC 27708 (Web site: http://www.geocities.com/WestHollywood/3323/; e-mail: passing_twice@hotmail.com

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