Introduction
When asked, people who stutter say that they are bothered more by the feelings and emotions that accompany their stuttering than the actual speech disfluencies themselves. Chronic stuttering is complicated by psychological and emotional overlays which are common to virtually all adults and adolescents who stutter. [Let me be clear - stuttering is not a psychological or emotional problem; but PWS (people who stutter) do have strong feelings and emotions about their stuttering.] There are two related issues here - the feelings and emotions about stuttering and the behaviors that stem from them. In order to find a successful resolution, these features of stuttering must be addressed in addition to the speech disfluencies.

Considerably more has been written about managing the speech components of stuttering than the ways of managing the emotional aspects. The notion that working solely to diminish the speech disfluencies somehow serves to eliminate all the negative feelings about speaking and stuttering has not been demonstrated; in fact, it is suggested that this line of reasoning paves a pathway to relapse.

Feeling embarrassed, anxious about talking, ashamed, or lacking confidence in one's speaking ability all significantly impact verbal communication, even among people who do not stutter. These feelings are naturally reflected in a speaker's behaviors. For example, a speaker's rate commonly increases when anxious. An apprehensive speaker may innately speak very softly. A nervous speaker is prone to forget what he or she is about to say. For the most part, these common reflexive reactions to emotions are considered Œnormal' because they are evidenced in practically all speakers.

People who stutter commonly demonstrate these emotion-related features and some additional ones as well. These reflexive behaviors usually contribute to the frequency of stuttering and increase the outward appearance of its severity. Learning to manage these reactions and better cope with the emotions which underlie them is the focus of this paper.

Behavioral Symptoms
The aberrant speaking (and other) behaviors observed with stuttering are based in emotion and triggered by specific events or situations. It is sometimes difficult to determine if these behaviors are intentional or reflexive, but in either regard, they are difficult to overcome. Being able to manage them successfully is an ambitious and meritorious goal.

Some PWS report that they intentionally try to do something to avoid stuttering when they fear being disfluent. Ironically, many of these attempts actually increase the likelihood of stuttering instead of reducing it. Often, these behaviors are, at first, intention attempts to avoid or somehow overpower stuttering. But they soon become a habit which becomes increasingly less effective, and later, add to the severity of the stuttering problem and the feeling of being out of control.

Behaviors commonly observed include speaking rapidly, abrupt onset of voice, excess muscular tension when articulating, discoordinated breathing, struggling to move muscles (even "frozen" postures), rapid inhalation of air, diminished range of motion of the muscles used to articulate sounds, diminished auditory and physical monitoring, hard glottal attack, and many more. These behaviors often become habitualized and patterned, stringing a sequence of behaviors together. The PWS feels locked into a rut in which he or she seems incapable of escaping.

The behaviors are predictable, habituated, often chained. PWS often proclaim that they can predict when their stuttering will happen. This predictability usually heightens anxiety, which sets the nervous system on edge, lowering the threshold which initiates the behaviors, thus strengthening the behavioral response.

PWS vary in their objective awareness of their behaviors and their ability to objectively describe them. There is a sense that something is wrong or not working. Some describe their behaviors in emotional terms ("That was really bad."), while others are able to be more specific and objective ("My vocal folds get locked together and can't vibrate.") A good goal is to increase awareness (and knowledge), becoming more objective and specific in describing what is happening.

Triggers. Careful observation usually reveals a specific triggering situation or event that initiates the behavior(s). Making a phone call for example, it might be when the other person picks up and says "hello" that is the actual behavior trigger. Or, it may be the realization of the ritualistic obligation to say your name during an introduction that is the trigger. In most situations, there is a specific point at which the PWS falls prey to the trigger which sets off the series of habituated behaviors.

There are also factors related to the unpleasantness (negative emotions) of stuttering that interfere with objectivity. The fear and anxiety diminish the PWS's cognitive skills when behaviors are elicited. The loss of control while stuttering is embarrassing, and the PWS naturally tries to protect his or her ego. One ego- protection mechanism is denial; leading yourself to believe that nothing happened. Although simplistic, convincing yourself that nothing happened or, that "it wasn't as bad as it seemed", spares the ego some of the pain. While the triggers are usually well-known to the PWS, it appears difficult to translate the message of impending danger into an action other than the habituated response behavior.

How Physiology Contributes
There are physiological mechanisms that contribute to explaining why PWS can become overwhelmed by emotions. They include the "emotional reflex", the power of emotional learning, and brain processing that bundles together responses triggered by emotionally-laden stimuli.

• The Emotional Reflex - LeDoux (1996) describes how the brain has two pathways through which emotionally-laden stimuli are processed. One pathway is reflexive and it is shorter, hence quicker than the other. It allows the individual to react more quickly to fear and danger. [You see an object thrown at you and you duck as you don't know what the object is.]

  The other pathway processes stimuli through "association areas" of the brain, responding to danger in a way that is better thought out or reasoned. This pathway is longer and requires more time to complete, but provides more accurate information. [You recognize the object being thrown at you as a nerf ball; you block its path with your hand and laugh.]

  The quicker pathway alerts us to trouble; the second pathway helps us judge the degree of danger and determine how to react appropriately. With stuttering, PWS seem to rely mostly on the quicker, reflexive pathway.

• The Power of Emotional Learning - If you were to pick up a dish that just came out of the oven with your bare hand it would burn your fingers. The intellectual lesson about needing to wear gloves when handling hot dishes is punctuated by the memory of how much your hand hurt afterwards (the lesson of pain).

  Emotions serve to accentuate some of the things we learn. We learn that we usually stutter when we say our name. That lesson is punctuated by remembering how we felt when we stuttered saying our name. Of the two types of memory, the "punctuated" or emotional learning is far stronger. This is why PWS report that they dislike the way they feel when they stutter more than the stuttering itself.

• Response Bundling - Ellis et al (2004) hypothesize how fear conditioning, triggered by an environmental stimulus and mediated by the hippocampus, binds together a quickly-initiated, patterned response behavior. This response is easily triggered and particularly resistant to change. As such, an event or situation may trigger a highly-integrated series of behaviors which renders the individual to feel victimized and helpless to alter the response. This helplessness engenders more fear and anxiety which heightens the magnitude of the response, further diminishing the feeling of being able to control the response.

If PWS are hyper-aware of and anxious about the events and situations which trigger their stuttering, how can these effects be minimized or overcome?

Tools, Steps, and Strategies
Understanding what is happening at a deeper level, as I've described, is a worthy initial step. But the "heavy lifting" actually comes in doing things in new and different ways. Here are some ideas to start out.

Assessment A first step comes in getting an accurate assessment and description of the behaviors and the reasons behind them. Developing an accurate, objective listing of the behaviors and understanding the underlying mechanisms by which they operate are equally important. In the end, the PWS needs to learn more about their behaviors, how they work, and why they are there. He or she can do it themselves or recruit the help of a good friend or SLP. For the PWS to do it themselves is usually difficult because they are emotionally invested in the behaviors.

Things to look for include the PWS's

• knowledge of difficult situations, words and sounds, persons, superstitions
• ability to identify disfluent moments
• ability to accurately describe stuttering in objective terms
• accurate, objective description of behavioral characteristics related to stuttering moments
• ability to describe feelings related to stuttering
• recognition of the association between feelings, disfluencies, and behaviors
• behaviors other than smooth, relaxed, effortless speaking

Triggers. Many behaviors are triggered by a thought or event; this is the point at which control is lost. The PWS must learn to listen and put into words the inner messages being sent to begin to understand their anxieties and why the process is difficult.

By very closely observing the process of speaking, sometimes the triggering event can be determined. This is best done with someone to assist the PWS or by reviewing a videotape of the speaking event. Watch for the first signs of the natural, relaxed process of speaking being interrupted.

For the PWS, the trigger feels like a "black out" in which he or she knows they are supposed to use a therapy target, but was unable to employ it. They are usually left without a reasonable explanation as to why they didn't. The only logical explanation seems to be "I forgot."

Pre-Behavior Status. Some situations or feelings increase the client's sensitivity to triggers and heighten the strength of the behaviors. Situations include events that have not gone well before, like introducing yourself or answering the phone. A history of non-successes is projected into the current situation; anxiety increases, self-confidence decreases, muscular tension increases, etc. all because Œhistory repeats itself'.

Many PWS can readily name the situations, sounds, words, and events they have learned are difficult. That history becomes part of their belief system - "I can't say my name", which represents another focal point for change.

Challenging Beliefs. Beliefs can be overgeneralized to other events and situations. Beliefs create apprehension which heightens the sensitivity of the nervous system, putting the person "on edge". Diminishing this pre-event tension can significantly improve fluency and confidence. One means of working toward this end comes in changing inaccurate beliefs that ill-serve the PWS.

Determining the beliefs of a client who stutters takes time and a good listening ear. Often the PWS is not aware of his or her beliefs until they are asked to talk about them. It is common that the sum of these beliefs creates a web or box, so restrictive, that any person functioning to speak under these restrictions could not do so effectively.

The approach to some beliefs requires a challenge, while others involve modifications or adjustments. Beliefs often close doors to even attempting a speaking activity. Beliefs often have consequences attached to them that are usually the result of previous learning -- "When I talk on the phone I always stutter and then I'm so embarrassed." The PWS is thus unwilling to use the phone because they believe that there are no circumstances under which they will not stutter. Therein lies the challenge; to make any utterance to any person on any phone without any stuttering. The search for a successful starting point is initiated. It may be sitting face-to-face in the same room with someone "safe", cell phone to cell phone, just saying "me, me, me, me" and ending the call. And thus, a small chunk of the belief is debunked and work continues up the hierarchy etching away, challenging, and disproving the belief.

Behavioral Substitutes. As an intermediate step, substituting another behavior for the habitual behavior can work to break up the strength of the habituated pattern. Thus, anything you can do differently creates an opportunity to diminish the behaviorsŠ.change, any change, is a first step.

Pre-Emptive Modifications. For the PWS who knows they "always stutter on Œb' words", it's time to use that knowledge to their advantage instead of their determent. If the PWS knows they always stutter on Œb' words, why do they always do the same thing that leads to stuttering time after time? --- do something differently; break up the pattern using those professed "predictive" powers! When you see a series of potholes in the road ahead, you don't keep heading right into them one after another. Take some evasive action or your heading to the repair shop for an alignment!

Changing Attitudes. From life's experiences, PWS usually have less than positive attitudes about speaking and their effectiveness as a communicator. This often sets the stage for self-fulfilling prophesy. Attitudes take a while to change. Sometimes it takes the help, support, insights, and guidance of someone else to supply the advice, feedback, and counter arguments needed to slowly change a companion's attitudes.

Responding v. Reacting. From another perspective, habit patterns appear to be reflexes because they happen so quickly and don't require any thinking for them to happen - it's easy to feel out of control. Learning to respond to a stimulus, rather than react (reflex), can be another tool toward change. It is easier to respond when you can predict that you will stutterŠ. again using your predictive powers to your advantage. Doing something differently than what comes "naturally" (reflexively) works to enhance the ability to intentionally determine what your response will be.

Here's a practical example to help clarify my point. Compare these similar situations. A child hides behind a door. As you pass by, he pops out and says "boo", taking you by total surprise. You're fright reflex is initiated; you didn't need to think, you just acted! Now contrast that scenario with the situation in which you see the child hiding behind the door before he jumps out and says "boo". That knowledge, seeing him and expecting him to jump out, allows you to respond to the situation instead of reacting reflexively. You don't go directly into a fright reflex. If you can predict that a situation is likely to elicit your stuttering, you can learn to use that information to your advantage by responding rather than reacting.

Summary
Finding a satisfactory resolution to chronic stuttering entails minimizing existing stuttering moments, employing fluent-speaking behaviors, and developing coping mechanisms to deal with the emotions that develop with stuttering. Of these three components, managing the emotions is the most difficult.

The combination of components reviewed in this paper can be used together to begin to manage and overcome the emotional issues related to stuttering. Changing, or learning new skills, is a slippery slope. Be prepared to do your share of slipping and falling before you reach your goal. But once achieved, the responsibility for speaking fluently is far more attainable.

References

Ellis, J., Dodge, D., & Ramig, P. A Neurological Model of Fear Conditioning in Individuals Who Stutter, ASHA Convention, Philadelphia, 2004.

LeDoux, J.E. The Emotional Brain. New York: Simon & Schuster, 1996.

-Discussion-