Mental preparedness is an important factor in the successful use of the new process in daily life. Our mind, brain and body work together and affect the way we function. Neurologists believe that sensations and thoughts are stored and become memories that are linked into neural networks by means of synaptic connections. Dr. Shad Helmstetter, a highly acclaimed psychologist wrote, “Every thought we think, every conscious or unconscious thought we say to ourselves, is translated into electrical impulses which, in turn, direct the control centers in our brains to electrically and chemically affect and control every motion, every feeling, every action we take, every moment of every day.” This is why people who stutter feel that their stuttering is triggered by certain situations, such as talking on the phone, speaking with sales people, etc. Imagining that they are going to stutter subconsciously triggers the control mode for speaking. During therapy, clients work just as diligently to change their thoughts as well as their speech production processes.  Work in both realms is done simultaneously. This insures that a link between new thoughts and experiences and the new neural network is established. Mindfulness training, aspects of cognitive psychology such as NLP, REBT, guided imagery, etc. are an integral part of the therapy process, especially for older clients who have negative memories and thoughts that relate to stuttering.

Here we see that trying to transfer fluency is an impossible and debilitating task that results in frustration. Taking steps that allow the process of normal speech production to seep into the mind, brain and body is possible. It requires changes in neurophysiological processes and the thoughts, perspective, and behaviors of our clients. This can be challenging not only for our clients, but also for clinicians. We must challenge our perspective, our beliefs, our thoughts and orientations. We all know that as much as they try and perhaps because they try, clients cannot transfer fluency into their lives. It doesn’t work. We also know that it is not necessary to accept stuttering as a life decree. There are ways to help our clients make the necessary changes so that the speaking experience is easy and automatic in the therapy room and outside.

The process of creating natural speech is, of course, a simple process that requires no thought or effort, as every fluent speaker knows. As a matter of fact, I tell my clients, “If it isn’t simple and comfortable, it can’t be right.” However, using this process both during the therapy sessions and in daily life is not so simple. Clients come to therapy with a whole host of false expectations, frustrations, the lack of belief that they can do anything to change the way they speak and a lack of trust that giving up control of speaking and using an automatic process is possible in general and for them specifically. Therapy, therefore, involves so much more than changing the neural network of speech production. It also involves helping the client to have realistic expectations.

One of the false expectations that is almost universal is the thought “I spoke fluently in therapy so now I want to see if it will work all the time.” This one expectation contains so much of the answer as to why what is done in the therapy session is not done outside the therapy room even when the goal of treatment is to speak naturally.

“I spoke fluently in therapy so now I want to see if it will work all the time.” contains these problems:

1. I’m still focused on fluency.
2. I’m looking for results not focusing on process.
3. I’m trying to do something before I have internalized it.
4. I’m testing to see if it works, because I don’t trust what I’m doing.
5. I’m expecting perfection.
6. I want to use a new neural network before it is hard wired.

During therapy we need to help the client remain focused on process rather than looking for the false reward of succeeding to get a word out in any way possible. If the client “tries to use” the new process in their life too quickly, they might work for the false reward. Most clients do not come to therapy with a lot of patience. They want a quick fix. This is why I actually tell my clients that they are not supposed to use the process until it seems so natural and logical that they are excited, happy and confident about using it in life. The surest way to lose the client’s motivation and perspective is to tell them to use the process in their life before they show me that their focused awareness is in the right place and that they are mentally prepared to use the process.

Alternatively the goal of therapy may be to get the clients to accept that they will always stutter so they should embrace it. These clients may work on avoidance reduction, stuttering on purpose, stuttering more easily, and advertising stuttering. Although there are many benefits in reducing avoidances and not hiding stuttering, when this is the essential goal, the client may feel very frustrated and guilty, because they are being taught that they should like their stuttering when in their hearts they still want to be able to speak with the ease and comfort that everyone else has. This can lead to emotional and even processing conflicts. In their own way, both of these approaches don’t consider an important factor: it is work to stutter. Therefore, we should not establish goals that add more work and more thought to an already heavily overloaded system. In real life, when either stuttering or fluency is on the speaker’s mind, and when the person is trying to either speak fluently or stutter in a different way, it is very hard to carry on a conversation.

Goals that are logical and that lead to automatic natural speech production can be transferred from the therapy room to real life are goals. They include doing all that we know that normally fluent speakers do to produce speech. In normal speech production we develop speech automatically in our brain as a progression of syllables. The execution of speech requires activating the vocal folds to produce phonation that expresses intonation. The voice is shaped into speech sounds by uncontrolled movements of the articulators.

In this case, fluency or stuttering is not the goal of therapy. The goal is to change the way the brain is functioning to create speech. A brain that is functioning in a normal way for speaking will, of course, result in normally fluent speech. The speech will sound normal and it will be produced with the same ease and comfort that normally fluent speakers experience. The good news is that according to the laws of neuroplasticity, the brain can change itself. New neural networks can be created at any age. Hebb’s Law states that neurons that fire together wire together. This means that the more the client uses the new way of processing speech, the more hard wired it becomes. Alternatively, if you don’t use it, you lose it. Therefore, as the new process is used, the strength of the old process is reduced. This means that repetitive use of the new process makes it easier, more dependable and possible to use even when under conditions of stress.

However, time put into practice is not the key to successfully rewiring brain function. Rewiring the brain requires focused awareness. We need to understand that the brain wants to function the way it has always functioned so keeping awareness is not so simple when the brain is wired to focus on the speech and the fluency. As a matter of fact, getting the clients to see what they need to focus on is not at all easy. The criterion for success is never non-stuttered speech. Maybe this is why I have found that it isn’t easy to get clients to achieve goals in therapy. When clients are not doing the process in the natural automatic way, the stuttering is there. The clients feel it and I may also hear it, although perceived stuttering is not required. Stuttering can be covert as well as perceived by the listener. I have seen that beyond doubt, there is a direct relationship between internal processes and the ease, comfort, and fluency of the speech produced.

Knowing that differences exist, we need to specifically identify what our clients are doing differently from fluent speakers. Then we need to help our clients to function in the same way as people who speak fluently. You may ask if this is possible. My answer is absolutely yes. Up to date, through what research has told us and from my own clinical experience, I can now identify many of the specific functions that need to be changed. I am certain that these findings will become even more refined as research continues and as more people join me in looking at stuttering from the internal system perspective. Knowing what to change makes it possible to change. If it were not possible, and if I had not witnessed it myself, I would not be here today talking to you about this subject. I would be agreeing with those colleagues who believe that nothing can be done to help people who stutter speak fluently

This brings us to the subject of goals. What are the goals that will lead to our clients’ ability to speak fluently in their daily life? Before I tell you about the goals that I have found allow this to happen, I want to emphasize that there are some goals that can result in less stuttered therapy-room speech, but that make transfer outside next to impossible. These goals include any techniques that do not lead to speaking naturally and automatically. When clients are asked to do things that are not related to normal speech production, they will, of course, still have difficulty speaking. The speech won’t sound natural, and the whole activity will be mentally and physically taxing. Making the situation even worse, if the clinician tells clients to practice these artificial techniques for hours a day, the client will reinforce unnatural processes that still make it hard or harder for them to talk.

Sometimes clinicians ask clients to use a special abnormal way of speaking, such as speaking slowly, taking a deep breath, etc., during therapy and advise that once they get used to using the technique they will automatically speak in a more or less normal way in life. This makes no sense to me. If they practice and reinforce big breaths, that ‘s what the clients will do, or, alternatively, the clients will drop the big breaths outside the therapy and go back to their old way of talking. In this case clients justifiably are not motivated to transfer what they have done in therapy to the outside world.

If the goal of therapy is to learn a way of speaking that sounds unnatural such as slow, monotone, or rhythmic speech, the client will also be unwilling to speak this way in their daily life. In this case there is,  of course, no carryover into everyday life. Unfortunately, the blame is sometimes placed on the client for not working hard enough.

Why is it so difficult to transfer speech fluency outside of the therapy room? This is a question that has troubled SLP’s and clients alike to this day. However, the answer is actually so simple that it can be summed up in one sentence: Fluency cannot be purposefully transferred, because consciously trying to speak fluently goes against the principles of normal speech production. It goes against nature. I don’t mean just the nature of people who stutter. I mean against my nature, yours, and everyone’s. In fact, anyone who stutters knows that the more you try to be fluent, the more you stutter.

Does this mean that if people who stutter can’t transfer fluency, they can’t speak fluently? No, this is obviously not at all the case. There are countless examples of people who stuttered in the past who have later spoken fluently in their daily life. There are also examples of people who spoke fluently who later began to stutter. Speech fluency can change and we as clinicians can do a lot to facilitate this change. I will spend the remaining time of my talk explaining why people who stutter have difficulty achieving fluent speech and what we can do to improve the situation.

Facilitating real-life improvements in our clients’ speech fluency depends on the following factors:

• Perspective
• Goals
• Laws of Neuroplasticity
• Expectations
• Mind and body connection

Our and our clients’ perspective of stuttering is critical to their ability to speak fluently in their real life. As the field of stuttering therapy developed, the perspective has traditionally been focused on what we can see and hear, and mostly on the speech itself. Emphasis is placed on the type of disfluencies, the rhythm of speech, the presence of involuntary movements, breathing, etc. I call this the external perspective.

There is a different perspective from which to view stuttering. I call this the internal system perspective. We can see stuttering as a malfunction of the speech generating system. Instead of focusing on the stuttering, we can focus on what we know about speech science, the anatomy, physiology, neurobiology and psychology of speech production. We can also consider what brain imaging studies have been telling us. Research has shown that, for reasons not yet understood, people who stutter, when speaking, have differences in their brain function from people who speak fluently. Today I will not describe all that is known about these differences, I will just make this simple comparison that to me sums it up:

Fluent speakers: All the components of speech production function automatically in parallel.

Stuttering Speakers: They actively TRY to GET OUT WORDS.

If we analyze these differences, we can see that fluent speakers don’t do much of anything to speak. There are processes that develop from pre-birth through the late teens that function automatically when there is intent to speak. People who stutter, on the other hand, work at speaking. They also have processes that have been developed and reinforced, but their processes require much more consciousness. At least some of the time, they are involved in TRYING to talk. Unlike normally fluent speakers, they know what words they want to say and are putting thought and effort in trying to get them out. I know it appears that people who stutter have involuntary movements, and they do. However, these movements occur when the overall process is conscious and there are attempts to control speaking. Exactly how this happens is the subject for another talk.