We are pleased to welcome Catherine S. Montgomery, MS, CCC-SLP
and Adriana DiGrande, MS, CCC-SLP, as our guest hosts for the
SLP chat tonight, Monday, December 8, 2003 at 9:00pm EST. They
will be addressing the topic of Stuttering in the Teen & Adult

Catherine Montgomery has been a practicing speech-language
pathologist for nearly 30 years. For over 23 years, she has
devoted all of her attention to the study of stuttering and its
treatment. She is an internationally recognized leader in the
field of stuttering treatment and has worked with 2,000
individuals who stutter from 28 states and 15 foreign countries.
She is among the first in the United States to receive specialty
recognition in fluency disorders.

Catherine Montgomery is one of the few Board Recognized
Specialists in Fluency Disorders in the United States is the
Chairman-Elect of the ASHA Specialty Board for Fluency Disorders,
and was active in the project of creating guidelines for training
specialists in the area of stuttering treatment. She is also an
adjunct instructor, providing graduate student internships, with
several universities in the United States and Canada.  Catherine
is also involved with the National Stuttering Association and
Friends, self help organizations. She is associated with the
Stuttering Foundation of America as well. Catherine has been a
speaker at many of these organizations' conferences and has also
trained therapists from the U.S. and abroad.

Adriana DiGrande has been in private practice since 1997 and
continues to work exclusively with individuals who stutter. She
sees individual clients at her Lexington, MA office and continues
to conduct intensive stuttering therapy group programs for school-
aged children and adults in Boston.  In addition to her work with
older children and adults, Adriana has developed a pediatric
fluency program where she treats young disfluent children and
their families.  Adriana is a clinical instructor at Boston
University where she co-facilitates a student- training program
and adult fluency group. She teaches graduate level courses in
stuttering at Emerson College and the MGH Institute of Health
Professions at Massachusetts General Hospital and has presented
at numerous conferences and workshops on the topic of stuttering. 
Adriana also provides consultation services with regional school
systems and speech pathologists in the area of stuttering.  
Adriana was selected to become a member of the inaugural group of
Speech-Language Pathologists who are recognized as Fluency
Specialists by ASHA's Specialty Commission on Fluency Disorders. 

The recognition of Fluency Specialist insures that, beyond being
a certified SLP one : has a minimum of 5 years post- clinical
fellowship experience, demonstrates sustained interest in and
experience with fluency disorders, possesses knowledge about the
nature of fluency problems and the research base for that
knowledge, has experience in the evaluation and treatment of
individuals with fluency disorders, and participates in
continuing education in the area of fluency disorders on a
regular basis.                                             

<Robin> Welcome!  Tonight we are chatting with Fluency Specialists Catherine S. Montgomery, MS,
          CCC-SLP and Adriana DiGrande, MS, CCC-SLP, about stuttering in the teen and adult
<Robin> Catherine and Adriana, could you give us an overview of working with this population?
<Adriana_DiGrande> Our work with people who stutter (PWS) is mulitdimensional.  We help our
          clients make changes on a physcial, emotional and cognitive level so that the goal is
          more comfortable and effective communication.
<Catherine_Montgomery> Well, between the two of us, we have had about 50 years of experience
          specializing in stuttering and most of mine has been with the teens and adults. My
          greatest lesson over all of those years has been that we need address treatment from a
          whole person perspective as Adriana is saying. We know that stuttering has genetic roots
          and that most of our clients began to stutter as young children. It has been my belief
          for years that stuttering has neurological roots. The brain is sending mistimed
          signals to the vocal mechanism. It could be motor based or linguistic processing based.
          The researchers are studying this now.
<AnnaK> How does linguistic processing relate to stuttering?
<Adriana_DiGrande> Greater language demands may negatively affect fluency especially for
          who may be considered "fluency fragile".  The Capacities and Demands theories suggests
          that when the capacities of the child do not equal the demands placed on the child, the
          result may be dysfluent speech.
<AnnaK> Ah, now I understand.
<Robin> Adriana, what do you mean by fluency fragile?
<Adriana_DiGrande> My understanding is that it means those who's fluency is easily disrupted. 
          Some speakers are highly fluent under many conditions while others get "derailed" quite
          easily perhaps because of a weak motor system.
<Robin> How do you begin an evaluation with the teen and adult population?
<Catherine_Montgomery> Ok, I'll talk about the eval. I typically spend about an hour and a half
          on a first visit, getting to know the client, getting a sense of the dysfluency, but most
          importantly, I want to understand how the stuttering is affecting their life. I use the
          Perceptions of Stuttering Inventory, The WAASP Scale and the new OASES scale developed by
          Scott Yaruss & Bob Quesal. These are all self report instruments.
<Catherine_Montgomery> The self report measures are really important...much more so than any
          measure of the amount of dysfluency. I want to know how disabling or handicapping the
          stuttering is.
<Catherine_Montgomery> I also spend a great deal of time educating them about stuttering,
          research etc., and of course, find out what their goals for therapy are.  We talk about
          what we do here for tx and how we can help them reach their goals.
<AnnaK> Do you also interview family members or others that can comment about the patient's
          response to the stutter?
<Catherine_Montgomery> Yes, we encourage family members to come to this initial visit. I always
          meet with the teen individual first to get a sense of his/her own motivation. Are you
          here because Mom & Dad want you here or are you here for you?
<Catherine_Montgomery> It's important for the teen to know that you are on his side and will
          respect whatever he wants to do.....tx or not. Parents sometimes have to be counselled
          to know that waiting for their child to ask for help is really in everyone's best
<sheila> Is there any type of counseling, psychological or the like, that is helpful for these
<mashaz> Sheila...I think a lot of OUR therapy with stuttering ends up being almost like
          psychotherapy (at least with my patients).
<Adriana_DiGrande> Sheila, I think that counseling is an important part of the work that we do,
          but counseling as it relates to communication and obstacles to change.
<Catherine_Montgomery> "Counseling" can take so many different forms. For these age levels, we
          find that grouping them can be invaluable.  They need to know that they are NOT alone.
          We do a lot of work on acceptance of the stuttering ala Van Riper and Sheehan.
<Emily_B> What are some good ways or things to say or do for a preteen who stutters?
<Catherine_Montgomery> Accepting that it is a neurological condition that they (or their parents)
          did not cause and they don't deserve to carry the shame for it AT ALL!  That it's OK to
          go out there and stutter..to let people know that they stutter and be cool about it.
<Catherine_Montgomery> We talk about self advertising or self disclosure instead of trying so
          hard to hide it by saying something like "hang on a second, I stutter sometimes." It's
          meant to be done with self respect and dignity. It is not an apology!
<Robin> What are some typical therapy goals and approaches you use?
<Adriana_DiGrande> Our programs are considered integrated, that is combining stuttering
          modification goals (identification, desensitization) with fluency shaping goals (motor
          retraining to reduce vocal tract tension to improve fluency), followed by a structured
          transfer program to generalize skills outside of the clinical setting.   We also spend
          a great deal of time educating clients and family members on ways to better manage
          speech over the long term.
<mashaz> Can you talk about the "structured" aspect of the transfer program?
<Adriana_DiGrande> Structure meaning paying attention to the complexity of transfer so that we
          build from success.  You want to start with simple transfer activities, i.e.: one - two
          message calls and build up to ordering catalogues on the phone.
<Robin> Can we talk a little about modification goals (identification, desensitization)?
<Catherine_Montgomery> We work on a period of openly stuttering before we work on modifying
          speech using tools from both stuttering modification and fluency shaping.
<AnnaK> Are most of the patients you see long-time stutterers? I assume they bring more
          emotion to tx?
<Catherine_Montgomery> Yes, most have stuttered since early childhood and have a mix of therapy
experiences.  They typically have experienced a lifetime of difficulty that has taken an
          emotional toll.
<Taslim> Has anyone worked with a teenager who is a "covert" stutterer- maybe whose parents don't
          even know they stutter?
<Catherine_Montgomery> Yes, it's especially important for those "closet" cases to become open and
          desensitized. The avoidances are what often become so life-limiting in stuttering.
<mashaz> Yes...I am working with a 43 year old patient now who never talked about her stuttering
          with her husband or her children!
<Adriana_DiGrande> We've worked with many covert stutterers who spend a great deal of time hiding
          their stuttering from others through a set of well developed avoidance behaviors.  Often
          times if the avoidance strategies are well developed no one but the PWS knows that they
          stutter.  Working on acceptance and shame issues with these clients is an extremely
          important first step.
<mashaz> Now she is even telling coworkers...
<Taslim> Wow, that's a big burden for one to carry.
<mashaz> YES!!!!
<mashaz> She came into my office and started crying.
<Catherine_Montgomery> Mashaz...that's great!! That's what you want to have happen. It is so
          liberating!! Then the fluency skills are so much easier to use and work with.
<Taslim> I'm wondering what prompts someone to finally talk about it?
<mashaz> In my patient's case...she just couldn't take the burden anymore.
<Catherine_Montgomery> Taslim, hopefully a good clinician can be the catalyst for opening up.
          We ask our clients to do a simple survey about stuttering with family and friends. It
          really gets them talking about it.
<Emily_B> Is there a link between a stutterer, who hid their stutter for a long time and who
          recently "came out" and talk about their stutter, to have pragmatic problems?
<Adriana_DiGrande> PWS may have pragmatic issues especially if they are working hard to avoid
          their stuttering.   Often times these avoidance behaviors may resemble pragmatic issues,
          other times it's simply that the PWS may not have had a whole lot of experience
          interacting on a social level, so they need to develop these skills.
<Emily_B> Oh I see...
<Emily_B> I know a 20 year old female, who never talked before before, now she just accepted her
          stutter, and talks nonstop, in inappropriate settings.  The talking is wonderful, however
          her choice of situation to share is not...is this common?
<Catherine_Montgomery> I absolutely have seen pragmatic issues in my clients...and we need to
          work with that as well.
<mashaz> Yes...especially the eye contact.
<Adriana_DiGrande> For someone who has avoided all of their lives, work in pragmatics may be very
          a very important goal in therapy.
<Catherine_Montgomery> We work with eye contact as well during both the desensitization phase and
          fluency training phase. It can be a very powerful experience for someone to hold eye
          contact during the moment of stuttering.
<Catherine_Montgomery> We also work with the pragmatics of listening. Although many of my clients
          think they are "better listeners" because they stutter, I find on the contrary, many are
          not good listeners at all because they are often so wrapped up mentally and worried about
          their next response.
<Catherine_Montgomery> I find that many of my clients habitually interrupt...again due to the
          stuttering and the fear that they may not be able to "get started" if they wait.
<mashaz> Yes...about the listening...my client is ALWAYS scanning ahead for what she will say
           during a conversation. I wonder how she can scan and listen at the same time.
<Catherine_Montgomery> Yes, it's got to be so exhausting.
<Robin> Catherine and Adriana, what is the best way for a listener to respond a PWS?
<Adriana_DiGrande> The same things that are important in all communication, be a good listener,
          establish eye contact, convey the message that what the person is saying is important.
<Catherine_Montgomery> You know, you all, the most difficult thing we are helping our clients 
          overcome is serious public ignorance. That's why they try so hard to hide it. I had a
          blind client who said blindness was easier to deal with because people understand
          blindness but they don't understand stuttering.
<mashaz> Adriana and Catherine...do you feel as though fluency shaping is an effective tx tool?
<Adriana_DiGrande> Mashaz, our early training was in fluency shaping and I think that it's
          an essential component in the treatment of stuttering.  However, over the years, I have
          come to learn that it is first important to change a person's relationship with stuttering
          before launching into improving fluency.
<mashaz> Adriana, I VERY MUCH agree with you.
<AnnaK> When you say relationship with stuttering, do mean their emotional reactions?
<Adriana_DiGrande> Anna, many PWS spend so much of their time hiding and fearing their
          stuttering, all of this fear fuels the avoidance behaviors.   Stuttering is seen as
          something shameful and there is a great deal of baggage attached to it.. So when I talk
          about relationship, I really mean helping my clients with accepting their stuttering and
       themselves as PWS,  to "De-Awfulize" It (Bill Murphy's term) and disempower it, so that
          stuttering ultimately is viewed as neither bad nor good.
<Catherine_Montgomery> Regarding "changing one's relationship to their stuttering", for so many
          who stutter, the stuttering becomes THE focal point of their lives and they sculpt their
          lives around it.  What we are hoping we can help our clients do is accept stuttering as
          a part of their lives, but not the whole of it.....just a spoke on the wheel rather than
          the hub.
<Robin> What are some of the strategies you use for fluency shaping?
<Adriana_DiGrande> Fluency shaping involves reducing vocal tract tension during speech production. 
          Mostly coordinating muscles involved in respiration and phonation to produce more fluent
<Adriana_DiGrande> I spend a great deal of time on diaphragmatic breathing and voice onsets.
<Adriana_DiGrande> This work is motor kinesthetic so it's very important for the PWS to feel what
          the muscles are doing to generate fluent speech well as their stuttering.
<Robin> Do you use any kind of biofeedback?
<Catherine_Montgomery>  I no longer use any high tech form of biofeedback. I used to and I found
          that tuning them right into their own proprioception is by far the most powerful. As
          Adriana is saying.
<mok47> What is proprioception?
<Catherine_Montgomery> Proprioception means to FEEL the workings of the muscular system
<wendy> Would that be using a slow rate of speech?
<Adriana_DiGrande> Rate reduction is useful in that slower speech rates provide greater feedback
          from the muscles to gain a greater sense of control.
<Emily_B> I am a senior in undergrad, have not taken fluency yet, but I read about voice onset
          and there is at times /h/ used...how is that used?
<sheila> I have read in texts where the /h/ for easy onset is used more for voice patients.
<Adriana_DiGrande> Emily, I don't like to insert the /h/ prior to phonation because of how
       unnatural it sounds, and I don't feel that it's not a necessary part of gentle onset.
<Catherine_Montgomery> Also, Emily, it can exhaust the air supply really quickly. What we do
          is teach normal, natural voice production: simultaneous exhalation and voicing.
<Taslim> What can you do instead of a /h/ for a gentle onset?
<Catherine_Montgomery> The /h/ has been used as a way to open up the folds but we teach our
          clients to feel the natural coordination of exhalation and voicing with relaxed, open
<Catherine_Montgomery> We've learned that it is so important to teach fluency generating or
          modification skills from that perspective.
<Catherine_Montgomery> Just listening to the way one sounds or simply trying to do "easy onsets"
          is not enough.
<wendy> That's useful information because in my undergrad we were encouraged to use /h/ for easy
          onset rather than proprioception.
<Catherine_Montgomery> Try something...Everyone take in a breath of air and hold your breath for
          a moment keeping your mouth open. Feel the closure of the folds. This is what the
          stuttering block is.
<Emily_B> I see!
<sheila> wow
<AnnaK> That's a good illustration!
<wendy> Wow, I can see that would be frustrating for someone.
<mashaz> Nice...I like that
<jane> Wow!
<Isabele> Thanks for the great example!
<Catherine_Montgomery> I believe that is the physical core of stuttering and that everything
          else is a byproduct of the individual working his/her way out of that block.  Breathing
          becomes forced and difficult and the articulators kick into overdrive to help push sound
          and words out.  And of course, all of the mental and emotional responses are natural
          reactions to the difficulty in speech.
<Catherine_Montgomery> So, through the identification work we do our clients identify their
          physical (and mental) characteristics and then learn the process of changing the way
          their muscles work.
<Catherine_Montgomery> Yes, one more thing.........remember when I asked you to close your folds? 
          We teach our clients to tune into that and then discriminate the difference of the
          closure with open relaxed folds at the initiation of phonation.....y'all can try that on
          a vowel.
<mashaz> Good pointer!
<Taslim> Have studies been done looking at vocal fold vibration in people who stutter?  Or even
          in laryngeal structure of PWS?  Are there differences from the norm?
<Catherine_Montgomery> The good newws is that they have "all the parts required"...There is
          nothing wrong with their anatomy, just the signal system and we can bypass that
          disruption by tuning them into the physical sensations of coordination, much like a
          professional singer does.
<wendy> By going back to proprioception?
<Catherine_Montgomery> yes
<Catherine_Montgomery> Look at it this way, fluency is the byproduct of a coordinated muscle
          movement system.
<Catherine_Montgomery> Dysfluency is the byproduct of a miscoordinated movement system.
<Taslim> So, it's a matter of learning to use the anatomy?
<Catherine_Montgomery> What we do is teach our clients how to coordinate their muscle system
<AnnaK> I'm curious about your opinions of psychogenic stuttering (PS)?
<Adriana_DiGrande> Psychogenic stuttering is very interesting. I haven't worked with many cases. 
          One important question to ask when assessing psychogenic stuttering is time of onset.
          Late onset may imply PS (Developmental stuttering typically occurs between the ages
          of 2.5 - 4.0).   Other differences between DS and PS are are how a person behaves under
          certain fluency enhancing conditions, ie, choral reading, unison speaking, adaptation,
          etc. Usually PS stutterers will not experience increased fluency under these conditions.
<Taslim> Oh I see.
<AnnaK> Is PS easily resolved?
<Adriana_DiGrande> I don't think that PS is easily resolved, but here is a good case where the
          client should be referred out to a psychotherapist.
<mashaz> I had a patient with psychogenic stuttering--she had meningitis and she would have
          blocks when her temperature would increase!
<Robin> Very interesting!
<mashaz> It was so interesting!
<Catherine_Montgomery> That sounds more neurogenic than psychogenic.
<Catherine_Montgomery> I've had only one case (that I know of) of psychogenic stuttering.
<AnnaK> I've learned in school that it's pretty rare and likely not true. That person with PS
          most likely has stuttered all of her life.
<mashaz> Oh yes...that's right.
<Catherine_Montgomery> I've had only two cases of neurogenic stuttering, one from stroke and one
          from a head injury from a car accident.
<Robin> We have been chatting for almost an hour.....Adriana and Catherine, is there anything
          you'd like to add that we haven't covered or are there any more questions for our hosts?
<jane> How often do you see a patient for therapy?
<Adriana_DiGrande> I see my clients on both an intensive 4 week schedule and for individual
          hourly sessions 1x per week.
<Catherine_Montgomery> I work only in an intensive model with teens and adults, although we do
          have non-intensive tx available here at the Institute.
<Robin> How many times a week do you see someone for intensive therapy?
<Catherine_Montgomery> My intensive is 3 weeks, 5 days per week, 9-5, maximum 8 clients per
          program. I do this 8 times per year.
<Robin> Thank you very much, Catherine and Adriana, for sharing your expertise with us!
<Taslim> Thank you for your time and information!
<Catherine_Montgomery> We have a website at www.stutteringtreatment.org that is linked to
          other stuttering sites as well.
<Catherine_Montgomery> Thanks to all for your interest in stuttering.......it's been an
          incredibly rewarding area to work in. I still love it after all these years!
<Adriana_DiGrande> This was fun, thank you all for your questions.
<wendy> Yes, thank you.
<AnnaK> Thanks for sharing your knowledge!
<Emily_B> Oh thank you, I learned more here than in some classes! Have a great week everyone!
<mashaz> yes...thanks!
<kathy> Bye.
<Robin> Thank you all for coming......we will be having another chat about stuttering in the
          pediatric population in February.