I want to share an experience I had a little while ago with an eight year old boy. He was referred by his mother at the recommendation of the school speech-language pathologist because of a fast rate of speech, stuttering and unintelligibility. He had been involved in speech therapy three different times with three different therapists and no improvement in his speaking pattern. To protect identity and for ease of discussion, I will name the client David.

At the assessment, David told me that he liked the way he talked, and that he didn't mind being different -- in fact, he liked it. He felt that his friends understood him, so he was not all that interested in changing his speech pattern. It was clear from my conversation with David that listening to him required careful attention due to his fast rate, revisions, disfluencies and unintelligibility. I found myself guessing at what he said, and I wasn't always right! David also did not use his lips much when he talked. Speech sounds requiring upper lip movement were made using the upper teeth in place of the lip. David clearly loved to talk and rarely paused for me to take a turn. His mother assured me that he took turns at home. I asked David to speak using a pacing board and using "turtle talk" which he had learned in previous therapy. Both resulted in slower speech and increased intelligibility. The potential for change was evident. The challenge would to motivate David to change.

Fortunately I was able to videotape David during the assessment. As I reviewed the video recording after the session, I wondered if David had ever seen or heard himself talk from an audio or video recording. I wondered if he would understand everything he had said. I decided that we would watch his video at the next session and make observations from it. My hope was that David would come to realize how difficult it was to follow his discourse and that he would consequently become interested in changing his speaking behaviours.

I also felt it would be important for David to commit to making change by setting self-identified objectives for himself. I came up with the idea of asking him to write a letter addressed to himself about the video. The letter would outline what he saw and heard, what he liked, and what he didn't like so much. We would then establish whether he felt it would be important to change the "things" he didn't like so much, and why he thought it would be important to do so (desired outcome). From there, we would identify what would be required in order to realize change (therapy objectives). I also asked David to identify people who could help him in achieving his goals. With his mom's approval, we even included a motivating "big" reward to be awarded by his parents when he had achieved his goals.

The plan worked better than I could have imagined. David immediately identified from the video that he talked "like a beaver," a description that surprised me. David thought he looked "weird" and quickly stated that he did not want to look weird in front of his friends. There was our catalyst! He identified three things he wanted to change: beaver talk, fast talking, and repeating (in his words). We mailed the letter together at a nearby mailbox on his way home from the clinic. He would receive it a few days later and he would read over his observations and stated goals.

David got to work immediately starting with the beaver talk which bothered him the most. In fact, his mother reported that the next day, he self-identified two separate occurrences of beaver talk in his speech. She was encouraged by this because David had never shown awareness before.

When it was appropriate, we began using the stuttering severity ratings chart from the Lidcombe Early Stuttering Intervention Program, except that instead of stuttering, we tracked beaver talk. A rating of 1 indicated that there had been no beaver talk; 2, mild beaver talk; and 10, extremely severe beaver talk. David's mother assigned the daily ratings. We incorporated speech rate into the beaver talk ratings as we addressed it in therapy. (Interestingly, disfluencies disappeared as speech rate decreased so we never addressed them directly.) Daily ratings were initially at 7 and gradually decreased until David reached ratings of 1 in the sixth week of therapy. David's mother used verbal feedback and rewards, and pointed out diminishing daily ratings along the way to help keep him motivated. Family friends and relatives made comments about how much easier it was to understand David.

Nearing the end of weekly therapy sessions, we recorded new samples of David's speech and watched the "before and after" video recordings. This time, he identified the changes that had taken place. I asked David to write a congratulatory letter to himself describing the changes that he saw and how he achieved them, identifying the "things" he wanted to continue doing, and the persons that would help him keep up his new speaking style. We mailed that one, too!

You can post Questions/comments about the above paper to the author before May 4, 2010.