Overt and Covert Components. Successful treatment addresses the physiological and psycho-social aspects of stuttering. Establishing confidence in producing fluent speech and overcoming the emotions, feelings, beliefs, attitudes, and behaviors that develop in response to disfluent speech are core components of therapy. These facets are interrelated and are pursued concurrently. Therapy progresses along several dimensions and clients may work on different individual aspects of treatment simultaneously.

The physiological components (observable disfluent speaking behaviors) of stuttering are addressed by learning to better manage stuttering moments and learning new, fluency-enhancing speaking behaviors. Therapy is, in part, symptom-specific, addressing core features of the individual's speech dysfluencies while forming new, more efficient speaking habits.

The psycho-social aspects (covert components) of stuttering are the reactions and behaviors that result from stuttering. Since many attempt to keep their stuttering a "secret", these feelings, behaviors, attitudes and beliefs deeply complicate and compound the problem. These covert components contribute strongly to the feeling that stuttering is "uncontrollable" and "unpredictable". For many, these covert features operate 'just below the surface', and their effects are barely recognizable.

The course of therapy seeks to have each client:

Managing Stuttering. Therapy usually begins by reviewing the normal process of speaking (describing respiration, phonation and articulation). This forms the basis for the client to learn to describe the overt attributes of their stuttering. With knowledge of their stuttering, the client begins to purposefully change the way he or she stutters, beginning to gain more and more control over disfluent moments.

Fluent Speaking Behaviors. Clients are also instructed to use speaking techniques which address the differences in their speaking patterns (the symptoms of their stuttering). These speech "targets" promote fluency, usually in a way which overcomes his or her habitual pattern of stuttering. By systematically "replacing" stuttering with fluency-enhancing speech targets, clients become more aware of their speaking differences and better able to speak in a way that results in fluency.

Emotions: Thinking and Feeling. The way each person thinks about their stuttering and speaking abilities has a strong influence on the severity, persistence, and degree to which stuttering handicaps his or her life. Consequently, discussing, challenging, testing, and modifying the client's thoughts and feelings about his or her stuttering is an important part of the therapeutic process.

These three therapy components are presented concurrently. But, as illustrated in the diagram below, the amount of focus on each component changes as therapy progresses.

The overall approach is flexible enough to adapt to a client's experience with a previous treatment program, or work to build a new treatment regimen to support them. Therapy begins at the level of the client's current abilities; progress develops at the pace of the individual.

With adolescents and adults, habits usually develop that contribute to the severity of stuttering behaviors. The strength of many years of habit patterning is difficult to overestimate and often represents a considerable obstacle to transitioning fluency into speaking situations perceived to be stressful. It may also contribute to relapse. Many have never developed a normal sense of communicating and find even simple conversations awkward and threatening.

Fluency is not usually the terminal goal of therapy, but merely a direction toward achieving confidence and competence as a successful communicator. The end product of therapy then is to enable the client to appropriately participate in any communication situation encountered in activities of daily living. Clients also need to be prepared to handle relapse and the day-to-day variation in their fluency. Many go on to redefine themselves as communicators, reshaping their self-image and self-perception as a confident and competent speaker, even in the most challenging situations.

THE COMPONENTS OF THERAPY

Speech Aspects of Stuttering Therapy

Awareness - Therapy begins with a review of the normal process of speaking (respiration, phonation, and articulation). The client is then lead to identify each dysfluency and later describe the type and place of the dysfluency.

Speech Change - The client generally effects changes in his or her stuttering using a stuttering modification and fluency enhancement approaches. Stuttering modification may consist of either stretching out a block (while releasing the tension), bouncing through a block, or stuttering in a different way than is their regular habit. By learning to alter the existing stuttering, clients learn to modify (minimize) their disfluencies, which gives way to lessening the severity, and eventually, beginning to control stuttering. Fluency enhancement approaches "re-pattern" the client's speech to be more consistent with normal , efficient speaking processes; these usually emphasize breathstream management or voice onset. The purpose of the Speech Change is to weaken the old habit pattern which results in stuttering, learn that one need not be held 'captive' by a dysfluency, and begin to release the excess tension used in the articulatory process.

Preparation - Speech Targets are selected based upon the individual symptoms of the client's stuttering. Targets promote fluency by countering the maladaptive aspects of the speaking process in the stuttering pattern. Targets are used in preparation for speaking fluently. Thus, it is incumbent upon the client to take responsibility for being fluent (compensating for his or her habits which precipitate stuttering). Both Speech Change and Preparation progress through a hierarchy of difficult/stressful speaking situations.

Habitualization - The number of Speech Targets is reduced to one that serves to bring all aspects of fluency together - the Keystone Target. The Keystone Target simplifies the encumbrance of multiple targets, allowing the client to shift resources to the content of his communication more easily. As confidence builds, emotions are excited less and excess tension during speaking diminishes.

Emotional Aspects of Stuttering Therapy

Awareness - For some, the pain of stuttering is so great that they have shut down their emotions as a means of self-protection - they allow themselves to feel no pain and are unable to acknowledge it. This is not a healthy situation. Confronting the pain can be a delicate and painful experience in therapy, but nonetheless a very important one. Awareness may begin in recognizing the physical symptoms elicited when emotions are set into play, learning the client's signs of anxiety or tension. Others may be more open to sharing their feelings and their emotions may be labeled and discussed more easily.

Identification - Learning which emotions are brought into play by stuttering and the meaning of these emotions can be a starting point for discussions. Group discussions, composed of people who do and do not stutter, may be useful in highlighting commonalties and differences in feelings about speaking among people who stutter and among all people. Identification of emotions enables the clinician to build a composite of the client's attitudes and beliefs about stuttering that underlies much of their maladaptive behaviors and habits.

History - Discussing details of childhood and adult experiences in which stuttering has played a part is helpful in revisiting those experiences and addressing them now with adult coping skills. Telling the story of one's injustices relating to their stuttering is therapeutic in being able to revisit them as an adult and gaining the understanding with the support of others. Modification and Implementation - Maladaptive beliefs about speaking are challenged to force the client to reorganize his or her attitudes and self-perceptions. Like speech targets, the client engages speaking situations with reality based emotional targets as well.

Integrating the Aspects of Stuttering Therapy

Clients learn that the new speech and emotional targets can be integrated to reduce the fear, anxiety and avoidances that increase their muscular tension, and diminish their cognitive abilities to better monitor their speaking, and use speech techniques. Habit pattern strength is gradually diminished and new, more productive habits replace the old, maladaptive ones. The benefits generated by this combination empower the client to manage his or her fluency and maintain responsibility for it.

© Rentschler, 2002