Most clients report that some speaking situations represent bigger challenges than others in terms of their fluency. The specifics of this information are very important in designing therapy because clients usually begin using their targets in speaking situations that are less difficult, and work along through situations that are progressively more taxing.

Consequently, one of the first things clinicians need to do is work with their client to establish a list of speaking situations that are difficult for them. Next, we attempt to arrange them in a hierarchy (a sequence from least to most difficult). This is often accomplished by talking with the client to learn when their stuttering is more pronounced. Some clients find it difficult to articulate their difficult speaking situations; the clinician might then suggest scenarios for the client to respond to. These might include speaking to their boss or an authority figure, giving a presentation to a large audience, speaking in a noisy environment, answering the telephone, making a phone call, leaving a message on an answering machine, making introductions, making an appointment with a doctor's office, interviewing for a job, speaking with someone who is angry, etc.

Sisskin (2002) suggests constructing communication hierarchies based upon four parameters; where, who, what , and when. Where describes the environmental context of the communication – at the office, in the waiting room. Who depicts the person or group of people – my boss, my parents. What delineates the type or form of communication – conversation, reading aloud. When refers to the particulars of a situation – when angry, when rushed, when nervous. Clinicians can create a hierarchical matrix to guide their planning of the client's treatment sessions.

Patient progress can be monitored by tracking the level of success the client achieves as he or she moves along the dimensions of their hierarchy.

Note: Clients are often perplexed and disappointed by the difference in their performance levels between working in the clinic and practicing in other situations. The therapeutic environment is often perceived as “a magical place” where their targets seem to work much better than after they leave. It is important for the client to understand that the “ideal conditions” of the treatment room are much different (by design) than the real world. Clinicians can use their hierarchy as a way to explain this phenomenon and help the client understand and prepare for the challenges that other situations present.

I sometimes tell clients that their ability in the therapy room is a “window into the future” and that, with practice and perseverance, they will soon be able to do equally well in other environments too.

Source: Sisskin (2002), Therapy Planning for School-Age Children who Stutter, Seminars in Speech and Language, 23, 173-180.

© Rentschler, 2004