About the presenter: Michael Sugarman was co-founder of the National Stuttering Project (NSP) in 1977. He became the Executive Director of NSP 1978-1981 and again in 1995-1997. Published numerous articles on self help in academic journals and other publications. Named to the Stutterers Hall of Fame. Currently, Chair of the International Stuttering Association. He writes: Thirty-two years I have enjoyed the company with adults/teens and children who stutter. I have had many memorable moments - one was to witness integration of children/teens who stutter and parents at a National Stuttering Association conference during 1990's.

You can post Questions/comments about the following paper to the author before October 22, 2012.

Addressing Anxiety: A Mindful Collaboration between Behavioral Health Therapists and Speech Language Therapists

by Michael Sugarman
from California, USA


Understanding anxiety and its psychosocial impact on people who stutter (PWS) is necessary in order to best serve clients who experience anxiety in addition to their stuttering. Collaboration between speech language and behavioral health therapists may provide better treatment outcomes for PWS with anxiety. Because anxiety can negatively impact the quality of one's life, when appropriate, it should be addressed in conjunction with traditional goals of speech therapy.

My Background

I work at Alameda County Medical Center Ambulatory Care clinics in Alameda County as a behavioral health therapist. I see patients with multiple medical and psychiatric issues in group, family or individual sessions. I use a variety of therapy skills ranging from Acceptance and Commitment Therapy, Cognitive Behavior Therapy, Dialectical Behavior Therapy and Mindful Based Cognitive Therapy.

As a person who stutters, I have experienced my fair share of social anxiety. I worried about how I spoke and how others would react to me. When I stuttered I felt embarrassment, shame and frustration. I focused on my speech "problem." The content or drive to communicate would get lost in the mechanics of speaking.

Being both a therapist and person who stutters made me recognize the importance of treatment for both stuttering and psychosocial issues. In fact, in my practice, my personal and professional concerns came together in treating a woman, I will call Wendy. She had generalized anxiety disorder and stuttered. Wendy wanted to communicate with her sister and felt that her stuttering hindered communication. She participated in the group process as well met with me for individual therapy once every two weeks. She attended a local support group twice. We discussed speech therapy options and attempted to enroll her into private therapy, but due to transportation and financial issues it was not possible.

I am not a speech language therapist and was concerned that behavioral therapy alone would not be sufficient to address my patient's needs. However, in therapy and group, we were able to further explore communication with her sister -- including identifying what Wendy wanted to say and the triggers that stopped her. At the conclusion of her therapy, Wendy reported, "I make more 'I' statements with my sister and feel more comfortable talking with her. I still stutter, but that will not stop me from telling her how I feel." They started to have a relationship, including going out together shopping and getting together as a family. While I cannot assess whether Wendy's stuttering decreased, it was clear that with behavioral therapy, her communication skills increased.

Research Linking Stuttering and Anxiety

In an article published on the British Stammering Association webpage entitled "What is the relationship between stuttering and anxiety," Professors Ashley Craig and Dr. Yvonne Tran, from the Department of Health Sciences at the University of Technology in Sydney, set forth evidence suggesting that people who stutter have higher levels of social anxiety. In addition, anxiety is more likely a consequence, rather than a cause of stuttering. This simply means that people who stutter are more likely to experience social anxiety than those who do not, and that their anxiety is likely a direct result of their stuttering.

Craig and Tran further found that many people who stutter are socially anxious. This raised anxiety could be considered a reasonable reaction to difficulties faced when dealing with physical symptoms and psychosocial feelings which are the consequences of stuttering. The article further suggests that children with speech difficulties have increased risk of developing an anxiety disorder in their early adulthood. Teenagers who stutter have been shown to have higher levels of communication fears and worries than teenagers who do not stutter.

Craig and Tran reported that a majority of people who stutter believe that anxiety plays a part in stuttering and most clinicians who treat stuttering also believe anxiety to be an important component of the problem. The paper showed a strong relationship between high levels of anxiety and high risk for relapse. PWS who had relapsed following treatment have been shown to be three times more likely to experience high anxiety levels than those who have not experienced relapse.

The article concludes that for a person who cannot always be fluent, this increased social and personal responsibility will take its toll and result in increased stress. When this stress is not dealt with appropriately, it can result in negative outcomes, such as, limited vocation goals and social avoidance. All of this information is critical for improving management and treatment of stuttering.

Application and Conclusion

Growing evidence supports modifying protocols for stuttering treatment to include ways to manage anxiety. Effective treatment can reduce psychosocial issues and mitigate anxiety. Reducing anxiety can help people who stutter cope with their stuttering, be more open to treatment and avoid relapse. Collaboration between speech language and behavioral therapists may be able to better treat people who stutter, particularly those who experience anxiety as a result of their stuttering.

A self administered screening test The Zung Self-Rating Anxiety Scale (SAS) to determine PWS anxiety level is available. Information quoted below about this scale from the Select Behavioral Health website provides information about the test and explains the scoring:

I have been a strong advocate for peer support groups along with speech therapy services. Now, I suggest expanding appropriate professional help for PWS in managing anxiety by collaborating with behavioral health therapists in your community.


  • Craig, Ashley and Tran, Yvonne, "What is the relationship between stuttering and anxiety,"Professors Ashley Craig and Dr. Yvonne Tran http://www.stammering.org/anxiety/html.
  • Select Behavioral Health, LLC - http://selectbehavioralhealth.com/wp/zung-anxiety-screening-test/

    You can post Questions/comments about the above paper to the author before October 22, 2012.

    SUBMITTED: September 1, 2012
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