A hierarchy of difficult situations has been a cornerstone of treating people who stutter (PWS) to face their fears. We present the hierarchy to our adults and adolescents as a way to gradually face difficult situations and to become desensitized to the emotions and anticipation associated with stuttering. We ask our clients to focus on what they anticipate the situation will be like before they talk or what thoughts (negative or positive) emerge before speaking. Then we have them evaluate the situation after it occurred. This sometimes helps them to see that their anticipation or anxiety may be worse than the actual situation and that their negative thoughts may be affecting the outcome.

Benefits of the Hierarchy
When used appropriately and at the right time, a hierarchy can have the following benefits in therapy:

• Each hierarchy is individualized to the specific client's fears and attitudes related to stuttering.
• Therapy can be overwhelming and intimidating. A hierarchy shifts the focus to what the PWS can do, in bite-sized steps, and away from what the PWS thinks he cannot do.
• Reshapes the definition of successful communication. The definition of success shifts away from fluency, to something more important: planning to take a risk and following through with it, and saying "I did it," or "Sure I stuttered, but at least I spoke up for myself and said what I really thought."
• Risks are taken in a safe, well-planned environment. The PWS and the Speech-Language Pathologist (SLP) work together to decide which challenge the PWS will take on. Together, they plan the event together, as much as necessary, and define the parameters of a successful outcome.
• A hierarchy can help the client realize the anticipation of the event carried a much greater burden, in terms of stress and doubt, than was necessary. Some of the client's energy is being spent on analysis, and, therefore, hopefully less on the emotional response to stuttering.

Proceed with Caution--When to Use the Hierarchy
With input from the client, the SLP needs to determine if and when the client will benefit from such a structured, task-oriented approach. At its best, the hierarchy can serve as a catalyst in therapy. Organized and regular assignments create accountability. They can drive a PWS to take well-advised risks she may not have done in the absence of accountability. While the SLP may want to encourage the use of a hierarchy in therapy, it should be a mutual decision.

Designing the Hierarchy
Once the PWS has provided us with a list of about 30 situations that are difficult for them, we create an Excel spreadsheet, and place them in their order from easiest to hardest. For each situation, we ask a set of questions that the PWS needs to answer. The depth and type of question the client answers is individualized. An adolescent may answer simpler, broader questions than an adult. However, it is important that the questions encompass what the PWS was thinking and/or how the PWS felt before and after the event, and maybe even during the event. These situations could include specific situations that have been avoided, the use of desensitization techniques, and the expression of feelings and attitudes about their stuttering.

Working through the Hierarchy
Each week the PWS chooses one situation from the hierarchy he or she will attempt and then analyze. Each person's journey through the hierarchy is individual. As the SLP, it is very important that we demonstrate understanding and patience as the PWS faces increasingly challenging situations. If a challenge was too difficult to face one week, we must emphasize that this is not a failure. It is merely a data point. We now know that more time and discussion is needed before the PWS is ready to take on that specific challenge.

The End Game
The SLP's job is to gently nudge and encourage risks, offer support, and help redefine what success is in terms of effective communication. The clients have the more challenging role of rolling their sleeves up, facing these challenges, and letting the SLP know what is helping and hindering their progress in therapy.

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