David Shapiro, in his book "Stuttering Intervention," discusses the following factors that need to be considered when working with adolescents, adults, and senior adults who stutter: 1) "teens & adults have been stuttering for a long time...many for a number of years". In addition, 2) "the age of the stuttering is thought to be a more significant prognostic factor than age of the person who stutters." Furthermore, 3) "the stuttering behaviors, thoughts and feelings tend to increase in complexity the longer one stutters". Treatment approaches for this population must deal with behaviors, beliefs and thoughts that have developed over a long period of time. Activities for this population must also address long-standing emotions and thoughts about communication. The clinician somehow must find ways to approach these complex and long-standing responses to stuttering.

Recently, one of my friends emailed a PowerPoint presentation by George Carlin called "Philosophy for Old Age!" To be honest, I almost deleted it! However, the messages Carlin conveyed about life and aging were applicable to some of the ideas included in this paper. Here is part of his message delivered in synopsis form:

• Throw out the nonessential numbers in life
• Keep Learning
• Laugh Often - Laugh Long and Loud
• Things Happen: endure, grieve & move on!
• Don't Take a Guilt Trip
• Keep it simple; enjoy all accomplishments
• Learn to Love; Be okay with Crying

After reading Carlin's message, I could not help but relate these aspects of his message to many of the treatment concepts that I use with teens and adults who stutter. Let me explain.

1. Frequent fluency counts with this population seem unnecessary (nonessential). I often comment on the number of times I observe a tension reducing strategy or a timing strategy in a sample. In my mind, fluency counts can become "nonessential numbers" with the teen/adult population. Counts in treatment can and should focus on the positiveŠi.e. using pausing, easy onsets, cancellations, etc.
2. Adults/Adolescents need to learn about stuttering, especially what is known about the causes and treatment at this time. As a result, the teen/adult can make some choices and feel a part of the treatment process while being educated concerning the current thinking in the field.
3. Laughter is the essence of handling tough situations. Stuttering is a way of speaking...an important concept in treatment. Often challenging situations lead to discussions that result in problem solving or analyzing difficult speaking interactions and hopefully, to discover behaviors that might make the situation easier in the future. While all emotions are accepted and discussed, I celebrate when my clients can smile/laugh in treatment. This is a sign of progress!
4. When a client has a difficult communication interaction, the clinician needs to listen in a nonjudgmental manner. I will often "map out" the interaction in a web form to provide a visual framework of the interaction. During this process, the client will frequently self-analyze the interaction and develop some options that work for future interactions.
5. Guilt must be handled in any therapeutic relationship. Communication in treatment should allow the client to talk about emotional issues, learn about communication and resolve guilt over perceived failures from the past. However, investing in treatment and committing to the process if change is critical for change. In addition, the source of the guilt needs to be discussed. I worked for a couple of years with a 48 year old man who had attended an intensive (and expensive) treatment program when he was 18. He brought his battered workbook from this program to therapy. The exercises targeted the motor aspects of stuttering. He cried on more than one occasion that he had "let his parents down" by not maintaining his fluency in a program that occurred 30 years ago! After much discussion, he finally concluded that the program did not provide for support or carryover once he returned home which allowed him to "let go" of his guilt and move forward in treatment.
6. Communicating the complexity of stuttering is essential in the clinical environment. Teen and adult clients have grown up with parents/friends/relatives questioning "why" certain situations are more difficult? Often well-meaning friends or family members offer advice..."slow down"! Clients often find the explanation of the complexity of stuttering is a relief. I recently had a mother email me about her teen-aged daughter who has been in treatment for about one month. Onset of her stuttering occurred post-seizure about three years ago. The mother could not understand why her daughter did not use any "strategies" in conversations with friends. In a previous session, this young person indicated that her friends accept her "no matter what," so she does not feel the need to monitor her speech when talking to them. Education must also include the family members.
7. Keep it simple! Treatment activities need to simplify concepts and provide a plan for practice and carryover. Tasks should be designed for success and carryover. The client should walk out of the door feeling positive and empowered to make change!

Treatment of stuttering is like no other disorder! Enough said! I have included some activities that I have used with teens/adults who stutter that help clients deal with the concepts listed in the summary.

1) Pat's Reactions to Giving a Speech. At the time of treatment, Pat was a college student who had stuttered mildly for several years. He had no treatment prior to entering college. He had managed his stuttering by changing words or avoiding speaking situations. In college, he had to take the dreaded "public speaking" class as part of a graduation requirement. This class prompted him to seek treatment. In preparing for a speech, I videotaped Pat. The attached handout was developed from Pat's initial comments while watching the video. Most were negative. In treatment, he altered these statements into positive comments. Pat (on his own) talked to his professor about his stuttering. She also set up practice sessions with him and provided support to help him improve his public speaking skills. I use this worksheet with other teens/adults using Pat's comments as starting point for discussion.

2) Strategies to Deal with Stress. This handout review concepts related to breathing and body tension. Body positions and postures that promote a relaxed stance are reviewed. In addition, breathing techniques are reviewed.

3) Fearlessness. This handout begins with a quote on "Fearlessness" (O magazine, April 2007). The client lists personal strengths and then moves to the emotional and cognitive aspects of stuttering. Again this is a worksheet of self-discovery. I have listed a few, sample responses from a client.

4) The Inner Games of Tennis (Gallwey) This handout was formulated from a chapter in Gallwey's book that I have used in treatment (and for my tennis game) for several years. Gallwey links the mental/emotional side of performance to the physical aspect. This worksheet summarizes Gallwey's concept and has been adapted for use with teens and adults who stutter.

5) Which Skills should You Develop? This handout focuses on developing positive thinking by going through a process of analyzing accomplished skills and potential skills to develop. The client then relates these skills to positive thinking and activities to acquire new skills.

Bibliography:

Gallwey, W. Timothy, (1974), The Inner Game of Tennis, New York, Bantam Books.

Jensen, Eric, (2006), Enriching the Brain. Jasey-Bass.

Shapiro, D. A., (1999), Stuttering Intervention: Collaborative Journey to Fluency Freedom. Austin, Tx. Pro-Ed.

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