I began working with single patients and with patients in pairs, and found
performance in the paired situation to be clearly superior. The presence
of another patient increased stress by making the performance not private
but slightly public. And the element of competition enlivened things a
Initially, I matched patients according to age and sex. But I found
no differences when I paired dissimilar individuals. The same held true
for closet versus overt stutterers as well as for both type (I - IV) and
severity of stuttering.
I then began to experiment with larger groups. First three people, then
six, twelve, ..... Again, no difference could be seen for the variable
of number of participants, except, of course, as the number grew larger,
the amount of time necessary to achieve the desired therapeutic goals lengthened.
I finally settled on fifteen patients as the maximum I would treat at once,
and the length of each treatment session increased from one hour to three
hours and then to an entire day. I found that the group structure coupled
with a full day gave each patient ample opportunity to participate during
the session, and maintained just enough stress that speaking was a challenge
but not an impossibility. Patients learned from one another's mistakes
and each time a patient spoke it was, by definition, public speaking.
After much trial and error, here is the treatment format that we found to be most effective, and that we now use in our workshops at The National Center for Stuttering.
We start by teaching patients to breathe passively from their mouths.
I ask them to imagine themself with a cold, with their noses stuffed and
able only to breathe from the mouth. I reinforce this by saing that they
carry with them at all times the perfect model of the breath. It is the
calm breathing they engage in when they are sitting quietly, doing nothing
- except now it's through the mouth. I continue to talk to them and watch
their mouths, chests, and abdominal walls for signs of passive outflows
Once passive air flows from the mouth are established we move on to
the use of passive airflows before monoysyllables and then multisyllables.
At this point we introduce several feedback techniques that have been developed
for monitoring Air Flow. By enabling patients to hear their own breathing
patterns, these devices help them recognize the particular sound quality
of a totally passive air flow. This quality of sound is called Flutter,
and differs from person to person since everyone's respiratory system is
shaped differently. Every patient must learn to recognize his own characteristic
Flutter pattern. For some this takes no time at all; for others it takes
more practice -- but whatever the time involved, no progress can be made
in Air Flow Treatment without first attaining a consistent Flutter.
The simplest, and probably the most effective feedback technique involves
a piece of rubber tubing about a foot long. One end of the tubing is placed
directly in front of the speaker's lips and the other placed in his ear.
Thus the patient, as he breathes, can listen to his breath. Another feedback
device commonly used is a tape recorder. A special microphone is employed
for all patients, a microphone capable of picking up minute Air Flows from
the mouth and recording them. The microphone is placed in front of the
mouth and the Air Flow is tape-recorded and played back for evaluation.
The patient must learn to recognize his Flutter on the tape recorder.
The most important point about Flutter is that its presence indicates
a passive air flow. When the air flow is no longer passive, flutter vanishes
and is replaced by one of two classes of breathing sounds: pushed or squeezed
flows. A pushed flow indicates that the patient is now actively aiding
the outflow of air while a squeezed air flow is one that is produced when
the vocal cords are already locked and the air is being forced between
them. During Workshops, pushed and squeezed flows are recorded on the patient's
recorder and played back for training purposes. Pushed and squeezed flows
invariably lead to stuttering and are to be avoided at all costs.
Proper awareness of Flutter is crucial since fluency will always be
present in the absence of stress. So if a patient is practicing at home
alone, he will be comfortable and relaxed and probably completely fluent;
at the office, on the other hand, he may have pressures that increase his
stress level so that his stuttering returns. Thus the patient needs some
form of external objective indication of the correctness of practice. Flutter
provides just such an indication.
In Workshops Flutter is demonstrated through the use of the tape recorder
and each of the participants is trained in methods of producing absolutely
passive outflows. Much time is spent practicing this extremely basic and
critical phase of the program.
When Flutter before single words is produced in a consistent fashion,
we proceed to the production of Flutter before short phrases and then before
short sentences. Two rules are taught to deal with the problem of the quick
start. The first rule applies to the condition in which a phrase or sentence
begins with a one-syllable word. The rule states: "When a sentence or phrase
begins with a one-syllable word, we are to put a comma, a mental pause,
between the first word and the rest of the sentence." The second rule relates
to the situation wherein a phrase or sentence begins with a multisyllable
word. This rule states: "When the first word is a multisyllable, we must
say each syllable with equal slowing, much as if it were spoken to the
rhythm of a slow me-tro-nome."
All patients are given special lists of phrases and sentences to practice.
All practice is performed using the rubber tube to monitor for the presence
or absence of Flutter and the slowed first word. In addition, periodic
samples are recorded on a cassette and played back for evaluation.
During the Workshop, the technique is continually likened to a sport.
The sport consists of two strokes: a passive outflow of air followed by
a slowed first word. The presence of flutter and a slowed first word are
the signs that the sport is being played correctly.
Since public speaking is usually described as painfully difficult, I
developed a routine, in the first morning of treatment, of having each
patient stand in front of his fellows at the end of the session and give
a short speech. A few hours earlier, the thought of such an activity would
have been an impossibility; now they were standing and speaking perfectly
- without a trace of a stutter.
As each person's turn comes to speak, the others are required to subvocally
practice with the patient. In this way, practice is fairly continuous.
In addition, I continuously scan the room observing these subvocal practices
to make certain that they are done correctly. If I see a misuse of air
flow or a failure to slow the first word, I note it publicly and forcefully,
thereby stressing the extreme importance of powerfully attending to technique.
I developed a one minute exercise called Contract to deal with the problem
of attending to technique. After patients demonstrate both an understanding
and ability to produce a passive air flow together with a slowed first
word, they are required to recite a string of unrelated sentences out loud
for one minute in front of an audience. Unrelated sentences are chosen
initially because related ones would form a context which might distract
the patient's attention away from his fledgling technique. Each sentence
must be perfect, and if the speaker happens to stutter, he is required
to pay a dollar for every block. My typical comment in announcing this
is, "Now that you have shown that you can control your stuttering you must
pay for the privilege of inflicting your struggle behavior on the world
around you." Initially, contract is done for one minute a day. Later the
duration is increased.
We have found that patients' attention to technique while under contract
is outstanding. The slightest tendency for the mind to wander is effectively
cancelled by the knowledge that if they stutter they have to pay up. All
monies collected during Contract were given usually to the youngest individual
at the Workshop who has been elected to buy me lunch. Alas, I often can't
even raise enough money for desert.
I recall treating a young man from Houston whose father was a fabled
Texas Oil Man. This nineteen-year-old received a monthly allowance of $3500.
He came to the Workshop in his Turbo Porsche and when I proposed that he
would have to pay a dollar a stutter, his response was, "Dr. Schwartz,
that ain't no money!" To which I replied, "Roger, for you it's fifty dollars
a stutter!" To which he replied, "More like it sir!".
Patients are required to practice Contract with someone at home for
several months. If the Contract is done with a close friend or spouse,
the money, instead of given to the individual, is simply to be thrown out
the window. The thought of doing this clearly has the potential of upsetting
all parties and increases the impulse for careful attention to technique.
Patients learn and practice Contract at the Workshop and many have found
it helpful in dealing with stressful situations long after the workshop
I recall one patient calling the Center to tell me that he had gone
on an interview for a position and as the interviewer began to ask the
first question, the idea crossed the patient's mind that the situation
was like a sort of Contract and that the instant he realized that, he went
into what he called, "Contract Mode". I asked him what he meant by that
and he described it as a psychological space he was in when under Contract
- a space associated with a powerfully focused attention to technique.
In this space, nothing could "throw" him. Needless to say, in so far as
speech was concerned, the interview went perfectly.
Another exercise that has proved extremely effective is called Toughening.
It is designed to make the stutterer resistant to the speed of the speech
of those around him. There is a tendency for people to respond in kind.
That is, if one is spoken to quickly, the tendency is to respond quickly.
If the stutterer attempts to respond quickly, he will scarcely leave time
for implementation of his technique. Time is required to let a small bit
of air flow out passively from the mouth and to slow the first word. Toughening
teaches the stutterer to take this time.
Like Contract, Toughening requires another person. The other person
asks a question, which the patient then answers in a single sentence, employing
the air flow technique. In the middle of the sentence, the assistant interrupts
with a second question. The patient has to stop in mid-answer, generate
another airflow, and, employing a complete sentence, respond - whereupon
in mid-sentence he is again interrupted. This goes on for a minute. The
patient tends to speed, discarding his technique in responding to the rapid-fire
questioning. The goal is to retain the Passive Air Flow and continue to
slow the first word regardless of the speed of the question.
I frequently tell patients at workshops that, in a sense, I wish they
would all develop a peculiar form of paranoia. I wish they would believe
that everyone in the world was being paid by me to toughen them. This would
put them on their guard and make them highly resistant to the verbal speed
demands of the world around them.
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