The consistent use of Air Flow brings total fluency. Patients are delighted with an easy-to-use technique that handles stuttering effortlessly. And following the twelve-to-fifteen week period of Basic Training, the habit is both automatic and strong. Many patients think that continued application of the technique will eventually secure permanent fluency.

But it is not always that simple. Patients' use of technique is frequently compromised by the extreme stress associated with certain sound, word and situation fears. These fears, which formerly had been directly responsible for the locking of the vocal cords, now produced the same locking in an indirect fashion - by completely filling the patient's conscious awareness and preventing attention to the technique. The result is inevitable: the patient stutters, which, in turn, raises stress further, leading to still more difficulty. Early success is reversed by a tenaciously persistent array of anticipatory stresses.

In order to secure their fluency, patients need to be able to handle these stresses consistently. Indeed, it is the elimination of these speaking fears and scanning behaviors, rather than the initial fluency produced by mastering the Air Flow Technique, that signals the permanent result. These fears will not abate by themselves, however, and merely wishing them away won't work. They need conscious attention - a deliberate, planned strategy - and sometimes they take months to overcome. Of course, everyone has his own personal methods for dealing with stress, but here are a couple we have found to be particularly effective in dealing with anticipatory stress in stutterers.

Systematic Desensitization. Developed by psychologists to help patients overcome situation fears, systematic desensitization involves creating a hierarchy of examples of a stress situation (from low to high), and then slowly and successfully negotiating the patient through each step to gradually build confidence. For example, if a patient reported a fear of job interviews, he or she would be advised to interview first for jobs that held no interest for them. The rationale was that there would be virtually no stress associated with the interview. After initial success, the patient would be encouraged to interview for positions for which they might have an interest. The hierarchy is obvious: the least desirable position would be interviewed for first, the most desirable one would be reserved for last. And after a week or two, if the hierarchal steps were chosen properly, the fear of job interviewing should be extinguished.

I found this procedure to be very effective in eliminating anticipatory stress in stutterers. An example shows the process in detail. Several years ago I treated a man from New Jersey who, in spite of a severe stutter, had managed to develop a successful automobile dealership. Now, at forty, he seriously wished to marry and have a family. But he always stuttered severely when meeting women socially.

He suffered from an interesting if not altogether unusual hierarchal affliction: the prettier the woman, the greater the stress and the more he stuttered.

He confided this dilemma to me one morning as we sat in my office. The description of his fear hierarchy prompted an idea. I suggested that he and I visit a series of bars. I would choose the bars and he would engage in a systematic desensitization while we bar-hopped. He agreed to the proposal.

At the appointed time and location, in a somewhat disreputable part of town, we entered a bar, and I pointed to a "bag lady" sitting disconsolately in a corner. My patient, when told to approach her with an offer of a drink, balked, saying that this was not a stressful situation since the woman was unattractive. My response was that this was a fine place to begin.

He approached the woman, bought a drink and offered it to her. The conversation was brief and the technique excellent. No stuttering occurred.

At our next location we encountered a fiftyish woman of obvious means but with a clear addiction to alcohol. She had already had several drinks and was intoxicated as my patient sidled up to her to engage in conversation. Again the technique was employed and again fluent speech ensued. Later I pointed out that this woman was far more attractive than the one he had spoken with just twenty minutes earlier and that, as a result, we should proceed to the next step.

A taxi ride to the other side of town brought us to a favorite after-work spot frequented by secretaries and young executives who worked in the many office buildings in the neighborhood. We chose as our next "victim" a woman in her late thirties who, while sober and moderately attractive, was not too eager to speak with my patient since she was looking for a friend. He persisted, however, and found that he could still attend to technique in spite of the fact that the disinterest shown by her had been misinterpreted by him as rejection and had caused an elevation of his Base Level Stress. He reported later that he had been "on the edge" but had managed to hold on to technique.

I decided not to proceed further up the hierarchy and chose, instead, another woman about the same age who seemed both unincumbered by the expectation of meeting someone and more self-contained. My patient found in her an immediate conversation partner and spoke at length. After the conversation he reported that his stress was again low. I noted to him that this woman was very attractive and he acknowledged this with a smile.

In the next bar he soloed, that is, as soon as we had selected our person, I left and it was his task to both initiate conversation and sustain it with perfect technique. I chose a remarkably attractive woman and left. Twenty minutes later my patient skipped out of the bar in obvious delight and as he approached, pulled a slip of paper from his pocket, a slip bearing a phone number which she had given him.

I suggested that the night was young and that he continue to mass practice in as many of bars he could find until his fear was completely gone. This he agreed to do, and in the course of the next several days, he extinguished a lifelong fear. Two and a half year later I attended his wedding.

The same hierarchal procedure can be applied to deal with word or sound fears. A common example is the difficulty some stutterers have saying their name. The reason is obvious: one cannot word substitute one's name and it is often the first thing said in a conversation, where the peak of the stress is greatest. Many stutterers remember sitting in a classroom on the first day as the teacher went around the room having the students say their names. As their turn approached, the stress mounted to horrific proportions and the result was always a stutter.

With such a history it is no wonder that some patients, in order to avoid stuttering on their name, either always spell it or never leave home without a business card. One patient went so far as to have his name changed to one which he could say easily, only to discover that the stress had now shifted and he could not say his new name.

The solution to this problem of saying a feared word such as one's name is to first practice saying it with perfect technique a thousand times. Employing a leisurely pace, and practicing approximately a half hour a day, four days will produce the required number of repetitions. Following this, the patient is encouraged to repeat his name with perfect technique to the closest person he knows, whether it be a spouse, parent or best friend. Twenty five repetitions per day for a week suffices and he is to increase, on a daily basis, the number of people with whom this practice is performed.

The hierarchal concept is at work here since the patient starts first with the easiest, least fearsome, person and then progresses to more and more difficult ones.

The next step is to use lists of 800 numbers to make calls. When the operator responds, he is required, with perfect technique, to say his name and hang up. This may appear rude, but I have always justified it as the operator's momentary minor inconvenience against the patient's life.

The next step is to begin mentioning one's name in ongoing conversations. A number of strategies have been developed. For example, a patient would talk about a hard-of-hearing elderly grandparent who could not comprehend speech over the telephone. In the course of telling the story the patient would say the following: "I would repeatedly say, this is John Smith and yet he still wouldn't recognize his own grandson". Whether or not John Smith really had a hard- of-hearing grandfather is immaterial; the fact was he was practicing saying his name in conversation.

I've had patients call hotels to find out if someone with their name was registered, have had patients page themselves at airports, have had them call information for their phone numbers - one patient even made up a fictitious company name which was in fact his own and used this to describe a wonderful stock investment he had heard about. Of course, this ruse worked only with strangers!

For some, the extinction of word or sound fears occurs rapidly; for others it is a long, arduous process. There seems to be great variability in the number of successful experiences required for a person's subconscious to become convinced that there is no longer any need to look ahead for feared words or sounds. Some individuals are highly suggestible: a few instances are all that are required for persuasion. While others have anticipatory stresses that linger for weeks or months before finally slipping into the abyss of extinction. 

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