The treatment program is best suited for a certain subgroup of people who stutter. The subgroup can be identified by several factors which are not necessarily exclusive. The identification of factors which contribute to a particular person's eligibility for this stuttering treatment program is still a work in progress. That is, they may be modified sometime in the future. For the present (1977), however, the eligibility criteria are as follows:
There are multiple purposes of this program. They are:
For the purposes of this treatment program, and to clarify terms related to this program important to share some restricted definitions pertinent to the program. They are as follows:
NORMAL SPEECH: the generation of a naturally continuous airflow, which is voiced or unvoiced, and which is resonated and articulated upon in such a way that it does not call any personal reaction or negative attention to itself by the speaker or listener.
FLUENT SPEECH: the generation of continuous airflow, voiced or unvoiced, which is resonated and articulated upon but in some way may engender a personal reaction or negative attention by the speaker or listener.
STUTTERED SPEECH: an unnatural disruption in the continuous airflow, voiced or unvoiced, which causes a personal reaction or calls negative attention to itself by the speaker or listener.
Each of these definitions combines mechanical and perceptual properties. The important difference between the first two is that a person can be mechanically fluent, but perceptually speech "different." The speech may draw attention to itself in the mind of the speaker or listener. Normal speech may have disruptions in the mechanics of production but these disruptions generally do not call attention to themselves or are not chronic. Normal speech may be fluent but fluent speech may not necessarily be normal
Once a client is identified as eligible for program participation, a brief description of the treatment program and the processes the client will engage in are provided The client's consent and willingness to participate in the program is also obtained.
THE TREATMENT PROGRAM:
The first item of business is to explore with the client the use of cognitive secondary mannerisms The use of avoidances, substitutions, circumlocutions, and starters are identified and mechanisms to eliminate them initiated. The older the person is, the more likely these kinds of secondary mannerisms may occur. Some people do these behaviors so quickly and with such sophistication that they hardly realize it or are cognizant of it only after the fact. Mechanisms to eliminate them include 1) the clinician's addressing and confronting suspected avoidances, substitutions, circumlocutions, and/or starters, 2) charting particular behaviors, 3) keeping a diary of specific behaviors, and 4) reinforcing client's identification of potential mannerisms and verbalization of initially intended words. Clients are educated that these secondary mannerisms are "tricks" which actually keep the stutter going, quietly confirm the person's inability to manage their speech, and ultimately reinforce the stutter (behaviorally).
When these secondaries are eliminated, the underlying tension and struggle are greatly reduced and an inappropriate strategy is eliminated. In the short run, the elimination of the cognitive secondary mannerisms may result in an increase in observable physical struggle in speaking (with physical secondaries). These physical secondaries are NOT addressed The client is, in fact, told stuttering is quite acceptable, regardless of its observable severity, as long as they are not using the cognitive secondary mannerisms. It is stressed and emphasized that the client is to say what s/he intends to say with the words s/he initially and truly wishes to use. Whenever the clinician observes any of these unwanted mannerisms, it should be addressed immediately-even if it means interrupting the utterance to identify the problem and encourage the statement of the original sound, word, or thought. So the first step is to identify and eliminate cognitive secondary mannerisms. In many cases, this will be a process that is simultaneously addressed with other initial portions of the treatment program.
The second step is to increase the client's awareness of sensory inputs. Typically, the client (and any attending individuals or significant others) is asked to go through a short exercise. The exercise is as follows: The client is asked to close his eyes. He is then asked to extend his right arm out forward in front of him. After 'briefly holding it there, he is asked to swing it out to the side, away from his body. Then he is asked to bend it at the elbow ninety degrees, with the palm facing the ceiling. Then he is asked to raise his hand to the ceiling, hold it there, then make a fist. Then he is directed to place his fist on his head, hold it there, then on his lap. Now he is asked to open his eyes and is asked, "How do you know you did what you were asked to do?" Answers vary from "my brain told me what to do" to "I felt it.". This last answer is the closest: one can feel it. Three different sensory inputs were used: 1) proprioception, which informed the client where a particular body part was in space, 2) kinesthesia, which informed the client direction and how much a body part was moved or stopped, and 3) tactility, which informed the client when, what, and how much one body part came into contact with another body part. It is these sensory inputs which allow us to monitor and manage our motor outputs. That is how the client knew his right arm (not the left) was extended forward, then laterally from his body. This is how the client knew he bent at the elbow (not the wrist or knee) and was able to raise his hand straight up (not some other compass direction). That is how the client knew he made a fist (and how tight a fist), knew he contacted his head, and ultimately placed it in his lap (not to the side of the chair). The proprioceptive, kinesthetic, and tactile information allowed the accurate motor movements requested of him.
The exercise is briefly repeated (with eyes closed) to enhance awareness of sensory parameters in postures and movements underlying respiration (i.e.: depth amounts, inhalation/exhalation, short/rapid or long/slow), phonation (i.e.: voice on/off, sustained/broken, volume or pitch changes), and articulatory posturing (i.e.: jaw open/closed, lips pursed/retracted, tongue up/down or in/out). The client is instructed that the use of these various sensory feedback systems to manage motor (or muscular) events underlying normal speech production is what will be emphasized throughout the treatment process. Auditory feedback is also important but generally plays a much lesser role than these other sensory systems. Many clients are able to express what it "feels like" to stutter but are less able to express what it "feels like" to speak without the stutter (like with a pet).
Muscular events, however, do not occur in a simple "on and off" fashion. There are degrees of muscular tension and change as well as degrees of sensory feedback before, during, and after these changes take place. For example, when holding a rubber ball, one can squeeze it very tight, hold it with average pressure and effort, or barely hold it at all and still keep if from falling to the floor (i.e.: resting it at edge of thumb, middle, and little fingers.) Sensory information is used to determine and monitor the amount of muscular effort desired to hold the ball. The degree of sensory feedback experienced can be rated from "one" (hardly any felt) to "five" (average amount felt) to "ten" (an extreme amount felt.) In the same way, clients are trained to rate the amount of sensory feedback used with various techniques they learn in the treatment process (from one to ten, with "ten" being maximum sensation experienced with use.) Being able to respond to degrees of sensory feedback in the use of specific treatment techniques is very important to develop exaggerated use of techniques, to develop self-monitoring, to aid in "grading" motor events, and to allow successful use of techniques outside the clinic environment. Clients are asked to rate themselves on how much they are using particular techniques throughout the treatment process.
Such assessments are also made by the clinician so some commonality (interjudge reliability) is determined regarding achievement of specific targets. Clients soon learn to make differential assessments of how much a particular target is achieved. Initially, clients will be encouraged to exaggerate targets at "ten" levels to help achieve, reinforce, and habituate the productions of neuromuscular patterns and physiological processes. Productions at these levels across time (different amounts for different people) and increased ability to grade (adjust) amount of technique used helps develop normal patterns and less need to exaggerate techniques.
An understanding of the process of change a client will experience is also presented. Feeling and managing the motor events underlying the mechanics of speaking is not enough. Adjustments to behavioral changes and perceptual changes will also have to occur. To get a "window of understanding" to this process, the following task is presented: The client is asked to hold his hands out in front of him, at shoulder width, with fingers spread and palms facing each other. He is then asked to bring palms together and interlace fingers. After a momentary hold in that position, he is asked to return the hands to the original position (spread apart) then brought back together and interlaced again. The process is repeated a few times. At some point he is asked to hold the posture of interlaced fingers and note if right thumb is over left thumb, right forefinger is over left forefinger, etc. (or the opposite). This posture is labeled "the old way." Then the client is asked to return hands to the original spread position but this time bring the hands together with the fingers laced the opposite way (if formerly right over left, this time digits left over right.) The position is held and labeled "the new way." (Be sure all digits are interlaced.) Often people have a hard time achieving "The new way", struggling to get the finger(s) just right. Most people describe the sensation as "weird" or "strange." The client is then asked to separate his hands to the original start position, then interlace the fingers "the new way". This is repeated several times until the client does it rather smoothly. Eventually the client is asked to hold "The new way" position and asked if it feels less strange or weird Most say it feels more comfortable. The initial awkward feelings and sensations, the trials and adjustments in the motor planning of successfully achieving "the new way", and the course of adaptation experienced before the movements and postures became easier and more natural are reviewed The fingers are still interlaced in "the new way" but it took some time, use of sensory feedback to adjust motor outputs, and repeated experiences before "the new way" became accepted and perceived as "o-kay".
The client is instructed that this is the process of change that will be experienced as new techniques for fluent speech production are learned and implemented. He is directed to how sensory information was needed and used to manage motor movements, how that knowledge was applied over several trials before it became easier and more natural, and that if the sensory-motor loop is not tapped into, then he is likely to revert to "the old way" if asked to interlace his fingers again in fifteen minutes from now. Only after many trials over a period of time of doing it "the new way," will a new muscular pattern and eventual habit be formed and eventually automated so that it is done without thinking. In the same way, various speech techniques taught in this treatment program must be felt, repeatedly done and applied in increasingly longer and complex conditions, accepted and perceived as "o-kay", and eventually habituated before becoming automated in normal conversational speech. Speaking without stuttering will often "feel strange" as the new way of interlacing fingers felt strange. The process of achieving fluent speech and later normal speech is a similar process (albeit more complex and integrated) as the process experienced with interlacing fingers in a new manner.
Developing Belly-breathing:
The client is shown a picture of a "stick person" lying on its back (fig. 1.) The ribcage, spinal column, and pelvic girdle are identified. The client is asked to paint out where the lungs are found (at the site of the ribcage.) Then the client is asked how air gets into the lungs to breathe. Most say "the chest moves", "the ribs go out", or "the diaphragm moves", or something to that effect. It is noted that to inflate the lungs with rib movement only requires a great deal of muscular effort as the respiratory system must push against rigid structures (the ribs and spinal vertebrae). It is also shown that the lung dimensions can be increased by lowering the bottom area below the ribs. A partial ellipse ( "(" ) to represent a diaphragm is drawn pointing towards the ribcage. Then a dotted partial ellipse ( ")" ) (or mirror image) to represent the diaphragm during inspiration is drawn pointing away from the ribcage. It is noted that by lowering the diaphragm muscle (reversing the ellipse shape of the muscle from "pointing up" to "pointing down"), we can increase the volume of the lungs without exerting any chest effort. The lowering of the diaphragm is achieved by extending the abdominal muscles. By extending the abdominal muscles outward (straight out and laterally), one draws the diaphragm down. Hence the term "abdominal-diaphragmatic breathing." As this is a mouthful, the technique is re-named "belly breathing" for our purposes. It is easier to feel and understand the use of the belly muscles when using this than during breathing tasks. When belly breathing, one does not have to push against any fixed structures (like the ribs). Belly breathing also draws muscular tension away from the thorax (chest) and laryngeal (throat) areas. Next, a picture is drawn to help the client imagine an old fashioned bellows beside then as part of the stick person with the handles at the level of the navel (belly button) and the opening around the level of the neck. By pushing on the handles of the bellows, one can drive the airstream with great force and efficiency. If one tries to drive air from the bellows by squeezing the fabric close to the opening of the bellows, then air is collected and expelled quite inefficiently. A lot of effort is expended with little result. Many people who stutter experience tight, inefficient squeezing at the level of the chest during silent blocks. Little or no air is expelled and silence results. So it becomes quite important that the client learns to drive the air from the belly with belly breathing.
Now the client is asked to lie down on his back on the floor. He is asked to quietly lie there and breathe. As soon as he calms down sufficiently, it becomes apparent that the belly is participating in the breathing process. The client is asked to draw his attention to the movement of the abdominal muscles (the belly muscles). As he is doing this, some challenges are proposed: observe an infant sleeping on its back: it is primarily a belly breather. Also, if the client will observe his own breathing just before he nods off to sleep tonight (if he sleeps on his back), have him note the type of breathing he is doing. Most likely, he will be belly breathing as it is the most natural and efficient manner of breathing. The respiratory system works with greatest ease that way. With the client lying on his back he is asked to feel the muscles of the belly stretching and contracting, pulling and letting go, as he naturally breathes. A heavy book is placed on the belly (the center of the book over the site of the navel), and the rise and fall of the book is felt. In all of this the absence of chest breathing is emphasized. If there is some chest breathing, efforts are made at this level to minimize it: let all respiration be under belly breathing control. The book rises on inspiration, falls on expiration. The client is directed to pay attention to the physical feeling accompanying the motions. He is asked to take a slightly deeper belly breath and note greater book excursions with the breath. Slowly and gradually, the amount of belly breath (with abdominal excursions) is increased while maintaining no chest movement. In some cases, it helps to have the client place one hand on the belly (instead of the book) and the other hand on the chest with direction to monitor movement of the lower hand and no movement of the upper hand While focusing on the feel of the muscles working at the belly site, the client continues this awareness of breathing process until volitional smooth, deep, and continuos inspiratory through expiratory cycles are achieved. The easy movements of the belly muscles are contrasted with the loose, relaxed, non-moving muscles of the chest muscles. The lack of feel of the chest muscles is also noted. His attention is directed to the proprioceptive and kinesthetic feedback he is experiencing during the natural ebb and flow of his quiet breathing.
As the client slowly deepens the inspiratory and expiratory cycles of each breath, ask him to compare the feel of the muscular feedback with the baseline feelings established during quiet breathing. Point out and reinforce that the client is volitionally changing the depth of his breathing cycles and volitionally controlling the degree of relaxed muscular posturing through the proprioceptive and kinesthetic feedback he is experiencing. Breathing should be through an open mouth. Be sure the inward and outward airflow is continuous: not turned off at the level of the glottis (vocal folds.) Ask the client to take a deep breath, hold it momentarily with the belly extended (not by closing off the vocal folds), then release it while again monitoring and registering the sensory feedback and volitional control of the muscles he uses during these respiratory cycles. Again, no chest movement. Also ask the client to fully expire air, wait a moment with an open glottis, then inspire normally again while continuing to feel and maintain the loose muscular movements. Maximum use of the belly breath is rated a "10". Engage the client in rating the amount of success he has in sensing and achieving the belly breathing movements. When you are confident the client is fully feeling, volitionally moving, and cognitively registering the muscular actions he is experiencing in these activities, then it is time to move on to variations of belly breathing control.
The client should be encouraged to adjust and develop easy belly breathing in five conditions while lying on the floor. (fig. 2) The client is asked to rate (l - 10) his degree of success with each trial in each condition. The first is simply quiet, passive breathing. In the second, the client is asked to take a very deep breath and slowly let it all out before resuming passive breathing. The third condition is broken into two parts: The first is to take a deep breath then release half the air, hold it momentarily with the belly muscles (not at the throat), then release the second half of air and resume passive breathing. The second part is to take a deep breath and release the airstream in thirds: one third expired, hold, second third expired, hold, and last third expired then resume passive breathing. Again, direction to feel the control of air expulsion and control through belly muscles. The fourth condition is also broken into two parts: the first is to take a deep breath and release a long breath (about 75% or 80% of the airstream), pause, then release a short breath (the last 20% or 25% of air) before resuming passive breathing. The second part is to do the reverse: first let out a short breath, pause, then release a long breath and resume passive breathing. Finally, the fifth condition is to take a series of five deep inspiration-expiration cycles: deeply in, deeply out, deeply in, deeply out, et cetera. Throughout all conditions be sure the client is using only belly breathing, not chest breathing. Once. belly breathing is firmly established lying down, repeat the conditions standing up. Again, self-ratings are encouraged. Once they are established standing up, repeat them with the client sitting down. Be sure the client is FEELING the sensory inputs and adjusting motor outputs accordingly. Reinforce the volitional use and control of these abilities and be sure they are firmly established before moving on to the next step.
Developing an Open Throat posture:
The second major technique to teach is the "open throat." This is where an open, relaxed, pharyngeal structure through which the airstream will flow is emphasized. This posture will initially cause a resonance change, especially in the exaggerated (rating of "10") levels. There is often a breathy quality in the early phases of word and phrase training, but allow this during the process of establishing the "feel" of the open throat. Resonance change and breathiness are not to be components in the final form of speech production but may be experienced in the process of change to that final form. The open throat feeling can be achieved in any one of four methods.
The first method is called the "hot potato." Tell the client to imagine he is eating dinner at the White House with the President. Imagine biting off a hot piece of food and, instead of impolitely spitting it out of his mouth, he gingerly rests it on the back of his tongue. There, with lips slightly parted, back of tongue lowered, and back of throat dilated, he inhales and exhales air forcefully across the back of his tongue in an effort to politely cool the "hot potato." As the client draws the air back and forth across the back of his tongue, ask him to FEEL the throat muscles dilate. FEEL the openness through which he is passing air up and down over the back of the tongue. The awareness of air turbulence should be felt behind the tongue: not mid-mouth or at the level of the lips. Sufficient time should be allowed to feel maximal pharyngeal dilation and the continuous free airflow through the structures.
The second method is called the "cold mirror" approach. In this case the client is asked to imagine fogging up a cold mirror or glass (those who clean their glasses this way get the idea real fast.) In doing so, the client relaxes his jaw in an open posture and drives air from the oral pharynx. As the person does this, ask him to FEEL the dilation of the pharyngeal muscles as he exhales air. FEEL the openness as air is released from the back of the throat. Emphasize how he feels the muscle postures accompanying the open throat sensation.
In the third method the process of a natural yawn is described. The client is directed to the times when he has experienced a natural yawn. During it, he slowly dilated the pharyngeal muscles in an attempt to draw in more air. At some paint there is a "peak experience" of maximally opening the throat, sometimes during which one last small gulp of air is conducted prior to exhalation. A simple graph of this experience (a curve with a bubble at the peak to denote maximum relaxation of throat muscles-the peak experience) is drawn for the client. The client is encouraged to FEEL the peak experience and try to make it occur volitionally. Then, his attention is drawn to the FEEL of increasing the duration of the peak experience. He is asked to use the feeling of exceptional openness to volitionally keep the throat open. All of this is done without making a sound. Just the feeling of air moving in and out through the open throat posture is emphasized. Please note that this particular method is difficult to accomplish from a "fake" or "forced" yawn: it takes a natural and automatic yawn that is NOT stifled (which is often a natural reaction in a non-private moment) to fully appreciate the peak experience. If natural yawns can be stimulated in a treatment session, or if a natural yawn is produced as a reflex to yawning models, then immediately point out what the client is experiencing as the event occurs. Do not allow yawn inhibition. Encourage the client to take the feeling and "use it."
The fourth method to achieve an open throat posture is to simply ask the client to lower his larynx. In all the above examples, the larynx drops as the open throat posture is achieved. Some people have enough conscious muscular control of their larynx that they are easily able to lower it. While keeping the larynx lowered, ask the client to FEEL the dilated pharynx and the air sliding back and forth through it. Encourage increasing time duration (up to one minute) of holding this posture.
All four methods are designed for the same purpose: feeling and volitionally achieving a loose and open pharyngeal structure. Regardless of the method used, the client is encouraged to rate the degree to which he achieves an open throat posture and give the sensation of maximum openness a rating of "10". It does not matter which method is used as some people find one more helpful (or easier to employ) than another. The point is that they develop the feeling of the muscular posture to achieve maximum openness for least restricted airflow. Once the open throat posture is achieved, the client is returned to the floor. While lying on his back, the client is asked to review the five easy belly breathing conditions but this time while simultaneously sustaining an open throat posture. Between this treatment session and the next, the client is given the homework assignment of practicing the integration of open throat posture with belly breathing
Developing the Easy Voice Onset:
As the client practices belly breathing through an open throat posture, lots of emphasis is placed on FEELING the air flow through the throat. The client is asked to note and attend to the feel of the musculature throughout the pharyngeal region as breath moves in and out. The feel of air moving through different degrees of openness in the throat is experienced repeatedly. Then instruction in the two primary aerodynamic events which affect vocal fold vibration is provided.
In many cases of stuttering, too much effort is expended at the level of the larynx to produce vocal fold vibration. Sometimes the excessive effort results in complete blockage (full glottic closure) of the airstream. This may be due to more neuromuscular action than necessary: the client is generating too much neurological energy to the muscles resulting in too much muscular contraction. In vegetative breathing or reflexive sighing only a minimal amount of muscular effort is required to posture the vocal folds. In reflexive sighing, the vocal folds are mainly vibrated by two aerodynamic forces to generate the sound Explanation is provided to the client of how sound vibrations are made by these two aerodynamic forces: The Bernoulli effect and an air pressure differential. Pictures are provided to the client of how in the Bernoulli effect the air molecules draw the vocal folds together. Then, once the folds are closed by the Bernoulli effect, a pressure differential develops where greater pressure builds up below the level of the vocal folds compared to less pressure existing above the level of the vocal folds. Once the pressure below the folds reaches a critical point, h pushes (or blows) the vocal folds apart, completing a close to open cycle. The process is repeated again and again resulting in a series of vocal fold vibrations heard as sound. It does not require as much neuromuscular effort as it does aerodynamic events. It is more a process of physics than of neurology. The movement from quiet airstream to voiced airstream is gradual and continuous. It should be a natural, effortless event. At this point the client is presented a graph contrasting this gradual continuous (aerodynamic) onset condition with a sudden spike-like (neuromuscular) onset condition. The idea of "seamless change" is described as when day becomes night and night becomes day: it is continuous and gradual and not on-off like a lightswitch. Pictures demonstrating this continuous change are also provided (fig. 3). It is then that the clinician should physically demonstrate the integration of belly breathing with an open throat in the achievement of easy voice onset. One can feel and hear the correct versus incorrect production. After multiple demonstrations by the clinician, the client is asked to lie on the floor and practice achieving the smooth transition from voiceless airstream to voiced airstream. Attention is directed to the looseness of the laryngeal and pharyngeal structures as the airstream is driven from the belly. Initially the productions may be excessively breathy and this is permissible at this level of treatment as the client is learning to feel the "seamless change" from voicelessness to voice. A sliding motion is emphasized Immediate feedback is provided by the clinician regarding the smoothness of transitions versus the suddenness of error transitions. Errors are often described as a "click", "small catch", "step", or "speedbump" change. Of the techniques taught, this one is often experienced as the most difficult to master due to its subtlety. In children, the transition for easy voice onset is described as a glider taking off and the hard onset described as a rocket suddenly blasting off. With the airstream driven from the belly, the major focus becomes feeling the voiceless airstream become a voiced airstream, however momentary it may be. It is effortless and nearly spontaneous, much as a natural ''sigh" sound occurs in a yawn or reflexive "huh" of acknowledgment. The focus is on the transition to voice, not on the actual sustainment of voice.
Once awareness of the feel of easy voice onset is achieved, a series of drills are presented where the spoken vowels of speech are practiced one at a time. The feel of exaggerated airflow with "h" followed by the mid-vowel "uh" as one continuous sound production is developed. As skill is developed in feeling easy voice onset in this condition, the "h" is combined with all the spoken vowels in the traditional vowel chart. Once competence is achieved with "h" plus vowels, the process is repeated with feeling the easy voice onset with "w" plus vowels. Once competency is systematically developed with "w" plus vowels, single words are presented which begin with "h", "wh", and "w". After competency is demonstrated with these various words, practice of feeling easy voice onset on words initiated by the various spoken vowels is initiated This includes all vowels in the traditional vowel chart plus the "y'' (phonetically /j/). The client continues to focus on the feel of voice initiation. As greater skill and competency is demonstrated in the production of easy voice onset at the single word level, the use of easy voice onset in short phrases heavily loaded with "h" or "w" is practiced Then a series of short easy voice onset phrases heavily loaded with vowels are presented. Additional awareness of continuous airflow is developed in the production of these phrases. At this point in the treatment, the sound produced may be slightly breathy and resonance slightly fuller (rounded, lower pitched) as the client is asked to exaggerate the production of these phrases with a feel of "10" levels. This is not the ultimate vocal tone which will be achieved. Right now the focus is on the feel of the seamless transition in initiating voice. Once 100% exaggerated productions in 20 consecutive phrases is achieved the client is moved to longer sentences which are also heavily loaded with vowels and glides. In longer sentences more than one breath group may be required, but each breath group should be initiated with the same level of easy voice onset. When competency is demonstrated on the easy voice onset sentences, the client is ready to move to the next technique.
Developing Light Articulatory Contacts:
In the next phase emphasis is placed on experiencing the feeling of very soft touching and limited muscular effort. In one example to demonstrate this feeling, the clinician may rest a hand on a table with the index finger extended fleshy side up. The client is asked to touch the finger, which is typically done with a moderate degree of pressure (finger tip to finger tip.) Then the client is asked to repeat the touch but this time with the slightest amount of contact: almost to the point of a imperceptible tactile contact. This is an exaggeration of light touch. It is pointed out that the contact is made but the slightest amount of pressure or muscular effort is exerted. In the same way, the parts of the mouth used to articulate sounds will be used ever so slightly. This is the light articulatory contact, also referred to as light touch.
Another example of degrees of effort to accomplish a task is demonstrated with a rubber ball. The clinician presents the rubber ball and holds it in his hand, palm downward The ball may be squeezed very tightly (this is demonstrated), be held with a moderate (regular) amount of effort (this is demonstrated), or held so loosely that it is barely supported by the palm and first finger joints (and this is demonstrated) In each case the ball was suspended from the floor and kept in the hand. In the last demonstration the action was accomplished with the least amount of physical effort One may feel the different amounts of effort as well as actually regulate the amount of effort. In the same way, the client is instructed that the least amount of effort possible will be expended to produce consonant sounds through the use of light articulatory contacts. The physical effort will be regulated by the awareness of sensory inputs (touch, pressure, and tension) which tell us how much effort we are expending. Production of consonants at a light articulatory contact touch level of "10" is subsequently practiced in a systematic manner. It is very important that a light articulatory contact as opposed to a no contact is made. This should be noted as some clients become so sophisticated in making light contacts that the actually make no contact yet the actual consonant sound targeted is perceived Light contacts at a "10" level to a point of distortion from insufficient pressure is permitted at this level of training but a "no contact" production is not acceptable.
A list of single words beginning with each targeted consonant is presented. The degree of muscular effort is focused upon with emphasis on using sensory inputs to lessen and make aware of the lack of physical effort required to make the target sound The experiences in holding the rubber ball and feeling finger-to-finger contact is re-emphasized The first sounds introduced are the "h" and "w" sounds to reinforce the easy voice onset concept combined with an awareness of looseness in the jaw and/or lip areas. Noting the degree of absence in muscular tension in those sites is emphasized The same process is repeated with lists of "y" and "r" initiated words, with emphasis on the feeling of limited muscular tension and effort experienced in the tongue. Belly breath, open throat, and easy voice onsets continue to be preliminary elements prior to the production of the light articulatory contact target. Feeling, modifying, and barely approximating the lips during the production of "m"-initiated word lists is then presented The same degrees of feeling, modifying, and slightly approximating the tongue tip to the alveolar ridge for "n"-initiated words is practiced The process is repeated for "t"-initiated word lists. Up to this point, the easy voice onset actually preceded the light articulatory contact.
The next sounds introduced are the "f" and "v" sounds. Not only is the sensory awareness emphasized in the production of light articulatory contacts and easy voice onsets in "f" and "v"-initiated words, but also the timing of the two concepts is illustrated in minimal pair words. For example, compare the words "fine" and "vine. In the word "fine" a light articulation of the upper teeth to the lower lip is made and a slight exhalation of unvoiced air occurs. This air expulsion is the "u" sound which must be followed by an easy voice onset into the "i" of nine. In this way, the light articulatory contact of "f" precedes the easy voice onset of "ine" in the word "fine." However, in the word "vine" the opposite occurs. The voice is already vibrating (initiated with easy voice onset) before the lower lip (which is lightly touched by the upper teeth) is sent into vibration. This occurs in milliseconds and still requires extremely light contact for the "v" production. The voice continues through the "ine" to produce "vine." To further illustrate the point, a series of minimally paired "f" and "v"-initiated words are practiced with awareness directed to the timing of the elements of light articulatory contacts and easy voice onsets. Given this awareness, a series of "f"-initiated words are practiced at a level n 10~. emphasis of the light articulatory contact to competency levels. Then a series of "v"-initiated words are practiced to similar competency levels of light articulatory contact use.
Use of sensory inputs to manage the appropriate articulators in the production of light articulatory contacts for voiceless "th" and voiced "th" is presented next. The tongue should barely be presented between the teeth. The lack of pressure, tension, touch and effort is reinforced with each production of each word in the voiceless "th"- initiated word list and the voiced "th"-initiated word list. The elements of timing light articulatory contact versus easy voice onset is again examined. Minimal pair drill examination of the timing elements involving light articulatory contacts versus easy voice onsets are examined to various degrees in subsequent phoneme cognate pairs, depending upon client needs. The awareness of the timing element is important because later on if a difficulty arises with a particular word some people will misdiagnose where the breakdown may be occurring: for example, thinking the problem may be with a hard articulatory contact when in reality the problem is with lack of easy voice onset. Most importantly, though, is the continuing process of sensory exploration and manipulation of light articulatory contacts (at "10" levels) in single words of "s"-initiated and "z"-initiated word lists, "p"-initiated and "b"-initiated word lists, "t"-initiated and "d"-initiated word lists, and "k"-initiated and "g"-initiated word lists. Additionally, light articulatory contacts with awareness of airflow movement and feeling is practiced in "sh"-initiated words to competency levels. Finally, the affricates "ch" and "j" are practiced last as they require the most pressure for the longest durations of all the consonants . But the same process is repeated using awareness of sensory inputs to modify the degree of contact to the lightest amounts possible. Again, sound distortions at these single word levels is permissible to develop awareness of a "10" level of light articulatory contact. After competency is demonstrated (i.e.: 100% in 20 consecutive productions) with each consonant, the client is ready to apply this new skill at a higher level.
At the next level, the client is given lists of phrases to drill and practice the light articulatory contact. Each phoneme practiced at the single word level is revisited, in the same order, but with multiple use within a given phrase. Emphasis is placed on sustaining use of sensory inputs to keep light articulatory contacts on any targeted phoneme throughout the phrase and to its end Again, level "10" productions are stressed This is done with the glides, fricatives, sibilants, plosives, and affricates. Clients have varying degrees of success in applying light articulatory contacts at these phrases levels. If a client is noted to produce a monotone voice, then he is encourage to vary loudness, pitch, or both in any given phrase while maintaining the light articulatory contact. If rate is abnormally slow, then he is guided to practice the phrases until near normal rates of speaking are achieved The only distortions accepted should be in the precision of articulation of the phonemes, which would naturally be distorted by the extreme imprecision of articulation a level "10" production of light articulatory contact would require. As the phrases are being practiced, the client is also asked to increase his awareness of the continually uninterrupted airflow as he lightly articulates through each phrase. Though there may be breathiness or distortions from imprecise articulation, the client is encourage to develop awareness of an "open speech system" where air is driven from the belly through open respiratory, phonatory, and articulatory sites. Once competency is demonstrated with multiple use of each consonant at phrase levels, the client is ready to move to the next technique.
Developing Continuous Phonation:
By this point in the treatment program, the client has integrated belly breathing with the open throat posture to achieve an easy voice onset. The easy voice onset has been combined with light articulatory attacks in such a manner that the client is able to initiate any word without a stutter. Different individuals will report exerting varying degrees of mental, emotional, and/or physical effort to accomplish this, but it should be occurring with 100 percent reliability at single word levels and short phrase levels. In the phrase levels, the client has begun to experience the sense of continuously moving and uninterrupted airflow in his verbal utterances. Given this and the reliability for initiating sounds in words, the client is ready to develop the awareness and skill of continuous phonation.
In the context of natural speech, the vocal folds are constantly put into and out of a state of vibration creating voiced and voiceless sounds. In both conditions, air is continuously moving, whether vibrated on not. On a larger scale, when one hums there is continuous vibration. When one "breathes heavily" (without vocal sounds), there is no vibration. The client is asked to hum or sustain a vowel and while doing so, feel the vibration occurring in the neck region. The client is then asked to sustain a tone for several seconds (as an eastern monk might sustain a chant) and focus his attention to the sense and feel of vibration in the laryngeal, pharyngeal, oral, and facial sites. Then, while exaggerating the vibration, say a simple sentence such as "how are you." A comparison is made between a non-exaggerated "how are you" and an exaggeratedly vibrated "how are you." The sense of "droning" while talking is noted. The client is also asked to observe television reporters (when he is home) to see if he can notice a "drone" off of which the reporter speaks while reporting the news (most are able to identify this.) The exaggerated droning is the continuous phonation we wish to develop. After practice on some sentences, a level "10" is identified and mutually agreed upon. A sense of sliding across sounds with light contacts and exaggerated continuous phonation is developed. Occasionally, voiceless sounds will be distorted with voice. During the initial phase of continuous phonation development, such distortions are allowed. The main point is to feel the continuing vibrations as sentences are spoken. With the exaggerated drone (or continuous phonation) the client increases awareness of the continuous movement of air through the laryngeal, pharyngeal, and oral cavities.
To develop the feel of continuous phonation at sentence levels, the client conducts lots of drill and practice in a series of sentences heavily loaded with particular phonemes. Sentences come directly from the Voice and Articulation Drillbook (second edition) by Grant Fairbanks. In all sentences, the continuous phonation is added to the previous techniques learned. Rate of production is not important though slower rates allow easier self-monitoring of continuous phonation (as well as integration of other techniques.) In some cases, clients may produce sentences with a monotone, but this is not a requirement and not necessarily desired. In some cases, the client is asked to exaggerate inflection and stress in the sentences to dampen the effects of the monotone. Sometimes changes in pitch only, loudness only, or both parameters together are directed to enhance variability in voicing. Sometimes an exaggerated, almost melodramatic production is encouraged to demonstrate how the voice should stay on over variations in loudness or pitch. Self-rating of amount of continuous phonation is frequently encouraged The client is guided to enhance his awareness of internal control as he keeps the air and voice moving in these sentences. After competency is demonstrated in all the sentences, the client is ready to move to the next level of treatment.
Review and Inclusion of Others:
At this point the client is asked to review what has been learned to this point. As part of the review, a significant other is included in the treatment session (if s/he has not already been a part of the treatment process.) The client is asked to verbalize to the significant other (ie: spouse, friend, parent) what has been learned The process of belly breathing through an open throat to achieve an easy voice onset should be briefly explained and demonstrated (BB + 0T = EVO). The combination of easy voice onset, light articulatory contacts, and continuous phonation lead to mechanically fluent speech (EVO + LAC+ CP=FS). Mechanically, if all components are in place the client will not stutter, as the combined components are incompatible with stuttered speech. The idea of rating the degree of use of the techniques should be illustrated to the significant other. The idea of being one's own therapist with monitoring and manipulating variations in the amount of use of various techniques should be conveyed. If it has not already spontaneously occurred, the idea of "trying out" the new speech style with loved ones should be presented. This means, in those conditions where the client feels comfortable and the listener knows what the client is doing, the client should be applying the speech fluency techniques with significant others in real life environments. These significant others should become discriminative stimuli to help encourage practice outside the clinic situation. It is also at this point that the client should develop a personal list of speaking situations or conditions and hierarchically arrange them from easiest to hardest. A minimum of ten conditions is encouraged
Integration and Expansion of Techniques:
After reinforcing self-monitoring and exaggeration of all techniques in sentences, the client is asked to apply these skills in longer and more complex contexts. Simple reading material (provided by therapist or client) is presented. The client is asked to read a couple of sentences with exaggeration of techniques. After two to five sentences are read with exaggerated hyperfluency, the client is then asked to assess how well he used each component learned thus far: belly breath support, open throat, easy voice onset, light articulatory contacts, and continuous phonation. Those areas which are not noted or underutilized are then emphasized in the reading of the next two to five sentences. The process is repeated until the client reports an ability to feel and "sense" how successfully he is integrating all techniques in the production of hyperfluency (and still abnormally exaggerated speech production.) Although still analyzed separately, there is less emphasis on each particular technique and more emphasis on the synergy or "holistic integration" of the feel in speaking fluently with use of technique. This ability to integrate technique to a "greater whole level" is applied to reading which is timed with a stopwatch. Initially, the clinician will want to reinforce with comments about good application (or the need to increase exaggerated application) of various techniques at various points in the oral reading as the client is reading. If a stutter occurs, an analysis is made of where the breakdown in the system(s) occurred. The target problem is repeated with the appropriate exaggerated technique(s). The clock is reset to zero with reading and timing subsequently resumed. Generally, it is helpful to reinforce technique use at " 10" levels intermittently until ten consecutive minutes of hyperfluent reading is achieved. After that point, verbal reinforcements are faded out and the client is given verbal encouragement to monitor, manage, and sustain the integration of techniques by himself. The hyperfluent reading is conducted until 20 consecutive minutes are achieved After that accomplishment, a new target is set.
The next target is to achieve 20 consecutive minutes of hyperfluent conversation. During the conversation portion, the stopwatch is started when the client is talking and stopped when he is not talking or the clinician is talking. This way approximately 20 minutes of the client's talking (and not the clinician's talking or pause time within conversations) is accumulated Normally, conversational topics are neutral: not intended to stimulate emotive response. Like in the reading condition, the first ten minutes of the client's talking time is reinforced when "10" levels of technique are noted. Additionally, when the client demonstrates an exaggerated and easy general flow of fluent speech (as perceived by the clinician), this is also noted and reinforced by the clinician. Distorted exaggeration is still acceptable though degrees of distortion are explored: instead of a "10" level of easy voice onset the client may use an "8" level of easy voice onset. This may feel more comfortable to the client (though perceptually he may still consider it distorted and for him compared to his history, it is) and also be indiscernible from what is considered "normal" speech. Feedback with a tape recorder helps with the initial adjustment to accepting the new manner of speaking as acceptable and worth continuing. Neutral topics are continued until 20 consecutive minutes of hyperfluent conversation is achieved.
At this point, if it has not already been discussed, a discussion of "normal" speech begins. The type of hyperfluent speech the client just completed is identified as something that does NOT occur in normal speech all the time. In normal speech there are many hesitations, stops in speech flow, part and whole-word repetitions, fumbling around and restructuring of sentences. These disruptions in speech may occur due to various emotional states (surprise, unsureness, sadness, urgency, anxiety, desire to impress, etc.), problems in organizing thoughts, difficulty in articulating unusual sound or word combinations/productions, various physical states (i.e.: during exercise or if ill), problems remembering words, or other states of being. Sometimes they catch the speaker's or listener's attention, sometimes they don't. But neither party has an abnormal reaction to it. Sometimes the speech disruption is unnoticed or ignored, sometimes corrected by either party (i.e.: "what I/you meant to say was...~), sometimes laughed off (spoonerisms or "Freudian slips of the tongue"), and sometimes directly addressed with a remark (ie: "Darn! I can't get my tongue to work!"). In all cases the disruption does not distract the speaker or listener from the flow of communication. The disruptions are easy, natural, and normal. For the stutterer, it becomes important to identify a "naturally occurring" disruption to speech versus a "stuttered" disruption of speech. this may be defined by the client ("it felt like a stutter") or by the clinician ("that looked/sounded like a stutter"). If differences are identified by either person (typically on minute or micro-stutters), each is encouraged to explain why it was identified, what could be done to prevent it from occurring, or how it could be dealt with appropriately.
Breaking Perceptual Barriers:
Up to this point in the treatment program, emphasis has been placed on changing the observable or mechanical characteristics of the stuttering problem. If treatment were to stop at this point, relapse would be assured Although mechanically fluent, the client still knows himself as a stutterer. He still believes, feels, and internalizes his self-concept, in part, as a stutterer. For lasting effects to occur, he must change and accept a new internalized self- concept as a competent and normal speaker. For this to occur, the perception of oneself as a speaker must often radically change. Many perceptual barriers must be broken, over a period of time, before one's self-perception as a speaker can change and remain changed.
First, let us define a perceptual barrier. A perceptual barrier is a mental or emotional construct which filters data or information for assimilation by a person (adapting reality to one's own mental or emotional structures) and thereby affects that person's accommodation to the real world (adapting one's own mental or emotional structure to environmental circumstances.".)
Let us explore this through an example. Let us pretend that as a stutterer, whenever I speak with a stutter I see strange or quizzical looks from my listener and this makes me uncomfortable, self-conscious, and generally feeling "bad". In my mind (mental construct) and heart (emotional construct) I have learned and believe people look at me strangely when I talk. More attention is placed on how I am talking than on what I am saying. That is how I assimilate the world and my perception is based on real-life experiences. But with speech therapy I have learned to have both fluent and normal sounding speech. When I speak to someone with such a speech pattern, and the listener responds to what I am saying and the communication event is eventually concluded, I still leave with the belief that the listener looked at me strangely: I am taking my past mental and/or emotional constructs and applying them (inaccurately and wrongly now) to the communication event. I still believe the listener is paying attention to the "how" instead of the "what" of the communicative event even though there is no real data to support this belief. I am now applying my uncomfortable, self-conscious, or bad feelings to the communicative event. I may even tell myself "whew, I made it through that! (little talking event)" just like the few times I may not have stuttered when my stuttering was REAL bad. In each case, either mentally and/or emotionally, I am experiencing my successful speaking event as a stutterer. That is my perceptual barrier. Until I truly (mentally and/or emotionally) experience my successful speaking event(s) as a successful (regular) speaker (or normal speaking event as a normal speaker), I will always be a stutterer. It will take many repeated successful speaking events to occur in many speaking conditions for me to finally change my "perceptual set" as a normal speaker. The more perceptual barriers I break or cross, the closer I get to the desired perceptual set. There are varying degrees of perceptual sets from "stutterer" to "normal speaker" and where I finally end up will depend on many, many factors. These factors include (but are not limited to) my personality, my need for fluent or normal speech in various situations, my desire to attend to my communicative style, my willingness to apply various degrees of exaggerated use of techniques, the kind of "tapes" (self-talk) I choose to run in my head, the amount of influence or control I give to my listeners regarding my communicative interactions, my comfort levels or moods at any given time, and/or other factors.
The example above is a description of a process of change and various factors that may influence that process of change. Different individuals will require different amounts of guidance in moving through the process of change affecting their self-perception as a communicator. Some are quite independent and require little assistance. Others need to be systematically guided and challenged step-by-step through many speaking experiences. But all must go through it. All clients should be instructed on this process of change, with repeated instruction as needed in transfer and generalization activities. The older an individual is, or the longer the individual has stuttered, the more time may be required to undergo this process of change. For some, the process continues even after formal termination of therapy.
Transfer and Generalization:
With the understanding of "normal speech with normal disruptions" versus "stuttered speech with abnormal disruptions" the client is engaged in conversational topics which have particular relevance to him or may place him under some communicative stress or distress. From this point forward, treatment sessions should be held outside of the formal clinic environment whenever possible. Neutral topics may be extended by the clinician and stressors of inattention, interruption, disagreement, competition, encouragement to rush, antagonism, oppositional behaviors/opinions/beliefs may be introduced, depending upon client needs. Additionally, topics which are more complex and/or personal may be introduced: exploration of beliefs regarding stuttering, discussion of particular anxieties and fears associated with stuttering or communicating generally or specifically, identification of factors affecting confidence and/or acceptance of self as a speaker or person, the role shame or guilt may play in the experience with stuttering, and descriptions of "normal" versus "stuttered" speech, to name a few. Topics may vary with the particular needs of the individual. Attached is a list of some general discussion topics (table 1). It is not an exclusive list and many items may not pertain to many individuals. Additionally, the clinician should engage in discussion of various personal items which arouse a particular client's emotions, allows exploration of any challenging life experiences, or challenges given personal opinions or beliefs. In the latter case, the clinician would do well to be the "devil's advocate" on a particular topic while reinforcing the client's good use of techniques in defense of his verbal arguments or positions. This role playing helps approximate real world situations. However, one should always tell the client at the conclusion of the session if one truly believes what was defended as "the devil's advocate" or not, and the reason in taking the opposite position (i.e.: to develop control of speech fluency in emotional contexts.) This process should continue with the client taking an increasing role in being his own therapist by managing speech fluency in various conversational topics, integrating and modeling techniques while generalizing and "settling into" the feeling of the ongoing flow of air and voice as he speaks. In the process the client should move from "micro-management" of speech fluency to "macro-management" of speech fluency (settling into the general "flow" of easy, ongoing speech experiences.) After several conversational experiences, the client is videotaped when engaged in a clinical conversation. This videotape should be replayed and compared with a videotape taken at the initial evaluation (or audio recording done at this point compared with audio recording done at initial evaluation.) The experience often has a tremendous impact in the client giving himself "license" to use and accommodate to using fluent speech. The experience of seeing and listening to stuttered versus unstuttered speech samples of oneself is a major contributor to breaking perceptual barriers to normalizing speech fluency.
At this point the hierarchy of personal speaking conditions and/or topics the client had previously outlined (after reviewing and instructing significant others in the treatment techniques) is directly addressed. They are ranked from easiest to hardest. The easiest items are addressed first. In some conditions, an item may have to be further broken down into its component parts, practiced in segmented parts, then slowly and gradually increased in level of difficulty until it is addressed in its originally described form. As each part, item, and level is addressed, discussion ensues regarding the speaker's (client's) perception of what occurred, what he thinks about it, and how he feels about it. Discussions may be about comfort levels, what he is telling himself, what he is experiencing emotionally, what he thinks is going on, what he thinks the listener might be responding to ("how" versus "what"), the overall naturalness of the communicative event, and/or other influencing factors. For many clients, it is not only assessment of the client's reactions to his fluent speech events that is important but also the client's assessment of the various listeners' reactions to the fluent speech events. For many clients, increasing awareness of the listener's non-reactions is extremely important and "eye-opening". Goals should be slowly shaped to longer and more complex speaking tasks. The use of tape recorders or video recorders is especially helpful as they give immediate feedback to just experienced real life events. This allows comparison of "just recorded" versus "just experienced" (the same thing) communication events. Clients are directed to identity degrees of successes and failures and WHY successful or not. In some cases, the clinician should demonstrate exaggerated use of techniques and let the client observe reactions/nonreactions of listeners and later comment on and/or analyze the communicative event. Then the client should engage in a similar communicative event. As each speaking event is successfully experienced and reinforced, the ability to accommodate new mental or emotional constructs to communication is made. Another part or whole perceptual barrier is broken. After the client's hierarchies of speaking conditions are addressed, the process is continued with clinician-directed activities. More one-to-one conversations, in public places, with or without significant others, with visits from surprise visitors, and under various conditions of client-centered comfort (or discomfort) are engaged. All slightest of communicative concerns the client may express or imply should be addressed In doing so, more perceptual barriers are broken. Included in table 2a and table 2b are lists of some activities directed at breaking various related perceptual barriers: some related to telephone use, some related to general speaking experiences. The client is also asked to report speaking experiences which occur between formal therapy sessions.
The more the client settles into the new loose and fluent speaking style, under various conditions and circumstances, with revolving attention to conscious use versus no conscious use of various techniques, the more he habituates the motor skills and perceptual constructs that underlie normal speech. With overpractice, a more natural and automatic use of desired speech patterns or processes is achieved. Additionally, he is encourage to "play" with the varying degrees of fluency skills learned. To manage occasional small stutters or undue pressure a client may place upon himself to speak too fluently, the idea of "pseudostuttering" may be introduced. In pseudostuttering there are purposeful interjections, part or whole word repetitions, hesitations, prolongations, and the like that are finally under the speaker's control. They do not have the "feel" of real stuttering and can be expanded or contracted at will. Conversational flow is maintained and the controlled non-fluencies mimic normal nonfluencies. Many individuals report that pseudostuttering not only enhances their fluency and control of their speech (if this is an issue for them), but also "frees-up" the individual to apply fluency shaping techniques with greater exaggeration as learned in the clinic situation. The client is encouraged to assess his perceptions and challenge them in the face of reality. He is encourage to allow himself to "mess up" his communication interactions and note his and other's responses to such "mess ups." In short, he is encouraged to continue being his own therapist. Habituation of successful mechanical skills and changed perceptual constructs occurs with consistent successful communication experiences. Normally sounding speech becomes more automatic when successful communication experiences occur across a period of time. Such a time period will vary from individual to individual. This is a process that must continue beyond the formal termination of treatment.
Termination of Treatment:
Many clients achieve such a high degree of fluency that they become "cocky" or have such feelings of communicative "omnipotence" that they give up or lessen self-monitoring, use of fluency enhancing techniques, or respect of "micro-stutters" as warning signs prematurely. These individuals, if not forewarned of this in the treatment program (usually soon after the 20 minutes of hyperfluent conversation), will experience a stinging (sudden) relapse. This is sometimes a desired experience as it helps reinforce the need for continued monitoring and vigilance of appropriate behaviors. Clients are urged not to prematurely "rest on their laurels" as the years of stuttering usually take months of fluency (and often years) before their belief system or self-image as a normal speaker is fully changed. But most clients, who towards the end of therapy are being seen once every two weeks or once a month, voluntarily recognize the appropriateness of treatment termination.
In a final treatment session, it is recommended that the client and clinician review, discuss, and counsel on the factors which affect the client's continued communicative independence. Topics may include relative strengths/lack of use of techniques used, the sense of "being" a normally speaking person, non-communicative reasons for listener reactions or non-reactions, amount of internal control experienced, amount of self-reinforcement and kinds of self-talk the client uses, not owning other people's problems, and distinguishing normal versus non- normal dysfluencies. Clients become their own therapists and learn to honestly assess and adjust physical, mental, and emotional parameters associated with communicative situations. Although intermittent exaggerated use of techniques may be applied (using it when you don't need to), letting oneself "be" communicative in a natural, non- monitored manner is encouraged The positive feelings and perceptions associated with normal speaking experiences should be noted and reinforced by the clinician and the client. If indicated the clinician should provide references (for independent pursuit) to further enhance the client's positive belief systems of himself. If desired references to classes or organizations which enhance rhetorical or public speaking skills should also be made. And finally, the client should know that the clinician is always available to address special or unexpected needs that may crop up anytime in the future. But in most cases, the client already has the tools to deal with those issues should they even come up.