The Gameplan: putting stuttering research into action to improve fluency

The Gameplan: putting stuttering research into action to improve fluency This chapter makes a lot of references to my [two](https://www.reddit.com/r/Stutter/comments/pl522u/neuropathology_why_stutterers_brains_produce/?utm_source=share&utm_medium=web2x&context=3) earlier [posts](https://www.reddit.com/r/Stutter/comments/pruw9f/speech_therapy_and_neuroplasticity_how_and_why/?utm_source=share&utm_medium=web2x&context=3) on the neuroscience of stuttering, but you shouldn't need to read those to understand the gist of it. If you're curious about the neuroscience of stuttering, I would recommend them. I've put a comment at the bottom with links to the sources, if you'd like to read more from the original studies. # The Gameplan Earlier chapters established how stuttered speech is the result of pathology in the brain's speech system. We also saw that the brain can respond to this neuropathology with patchwork adaptations that try to increase fluency but instead further destabilize the speech system and exacerbate dysfluency. However, intensive speech therapy can increase fluency by removing those maladaptations and routing speech through default pathways. We're going to tackle these problems now by turning the scientific research into an actionable plan: to either make the most of a speech therapy experience or use an equally-effective self-directed program. This section also addresses mental health since anxiety disorders and avoidant behavior patterns can prevent stutterers from utilizing their newfound fluency. This journey is how we put an end to the suffering and get to a place of durable safety. **Speech Therapy** To best replicate the neuroplastic improvements observed in the studies of Luc De Nil, Christian Kell, and Katrin Neumann, we should aim to replicate their interventions. It's important to note that these studies used intensive programs - multiple hours per day for two-to-three weeks - yet many stutterers seeking treatment attend only one speech therapy session per week. While I did not find any studies on the neuroplastic effects of weekly sessions, research on other disorders has shown that weekly programs produce less neuroplastic change than intensive ones; in other words, fifty hours of therapy over three weeks will be more effective than fifty hours spread over five months. These findings suggest that stutterers who are not satisfied with their progress in weekly sessions should consider switching to an intensive program. Most intensive speech programs largely follow the same patterns and use the same tried-and-true exercises as one another. The program outlined in Gordon Blood's 1995 paper does not represent the totality of treatment, but it serves as a good example. Participants in Blood's study progressed through the program depending on their ability to successfully complete speech exercises. It took participants about fifty hours to complete the program, split into three or four sessions a week for three weeks. These exercises rebuilt speech motor execution from the ground up, first removing bad habits and then exaggerating fluency-inducing aspects of speech. After secondary behaviors - like eye blinks, fist clenching, and facial grimacing - were removed, participants learned new breathing patterns. They practiced producing a steady stream of air -- first in isolation, then while speaking. They also practiced gentler transitions between syllables through easy onsets to speech and worked on maintaining phonation through the entirety of an utterance. Participants mastered these components in isolation before learning to apply them all simultaneously. This manner of speech, while more fluent, also sounds unnatural; the final stage was to sound more natural while applying these techniques. After completing this intensive program, participants enrolled in a maintenance program. Fluency-inducing techniques are often taught as mitigation techniques, to be used to work through blocks while speaking in the real world. While these techniques may help stutterers prevent and work through blocks, they also sound unnatural and require deliberate effort, so it's difficult for stutterers to consistently use them; these techniques can't become a default way of speaking. Performing these exercises for several hours at a time, however, drives neuroplastic change that correlates with higher rates of fluency. Intensive programs also improve fluency in only one-to-three weeks of training; it seems unlikely that weekly speech therapy can compete with that. Interestingly, speech therapy can be delivered in a variety of ways. Traditionally, a speech therapist would teach a client these techniques, practice them with the client, and then deliver feedback and coaching on the client's execution. This was the method used in De Nil's study. However, speech therapy can also be delivered through computer programs, as was the case in the studies of Blood, Kell and Neumann. Computerized programs typically rely on a microphone (and in some cases a respiratory sensor) to gauge whether the client performed a technique correctly. After the participant successfully hits the specified targets for the technique a predetermined number of times, the program advances to the next task. It's incredible to me that computer programs can effectively deliver speech therapy with little to no personal coaching. Blood's 1995 produced incredible results despite the the technology of that era being quite rudimentary compared to modern computing. If a computer running on the MS-DOS operating system was able to deliver a complete speech therapy program, it's reasonable to believe that a smartphone app could do the same. Therapy-seekers would still need the self-discipline to commit about fifty hours over three weeks, but this easy and cost-effective access to treatment is incredibly exciting. These studies also show the importance of enrolling in a maintenance program after completing the intensive portion of therapy. Maintenance programs protect against the threat that fluency gained in the clinic may not translate to the real world. Additionally, Neumann showed that neuroplastic improvements continued to mature over the course of the one-year maintenance program. While we do not yet know whether it's necessary to be in a maintenance program to realize those maturations, it almost certainly doesn't hurt. In Blood's study, maintenance sessions began with a fifteen-minute refresher on the computer program, followed by thirty-five minutes of cognitive-behavioral counseling. Counseling focused on the personal side of stuttering management; topics included attitude change, relapse management, self-esteem, self-responsibility and coping skills. Blood's participants completed three maintenance sessions a week for six-to-eight months. De Nil's maintenance program required fewer hours than Blood's but was equally effective. His participants had one session every week for the first month, then one every other week during the second month, and one session per month for the final ten months. It's important to acknowledge that not everyone with a stutter will have both the resources and desire to complete an intensive clinical program. For that reason, it's also worth examining some alternatives to clinical speech therapy. These self-directed programs increase fluency and drive many of the same neuroplastic changes as traditional interventions, but they can be done independently at little-to-no cost. **Self-Directed Speech Therapy** If the intensive practice of clinical speech therapy's fluency-inducing techniques stimulates neuroplastic change, could stutterers achieve similar results using other fluency-inducing techniques? Earlier, we showed that faulty internal timing is one of the neuropathologies that contributes to stuttering.\* The brain needs steady timing to coordinate the individual components in complex processes like speech production. The brain has a timing circuit that aligns to external cues as well as an internally-driven one, and it can switch between the two. \*(See Chapter 7 for an in-depth explanation of timing, beta oscillations, and the basal ganglia.) Stutterers have a healthy external timing circuit, which explains why stutterers are significantly more fluent when they time their speech to external cues like music, a metronome, or to the rhthym of other speakers. The internal timing circuit, however, is compromised in stutterers. When there are no external cues to align to, the brain must rely on the internal timing circuit; intermittent failures in the timing circuit are liable to disrupt the smooth production of speech, resulting in blocks and dysfluency. These disruptions are caused by too-weak signals coming from the stutterer's basal ganglia. In a 2011 study, Akira Toyomura showed that metronomic speech increased stutterers' basal ganglia activation to levels that match those of fluent speakers. This raises the question: Could consistent metronome training make the temporary benefits of metronomic speech more permanent? Two significant studies investigated just that, one from Jean Paul Brady in 1971 and the other by Toyomura in 2015. The training programs were slightly different, but participants in both studies improved their fluency. All of Toyomura's participants - regardless of their initial levels of dysfluency - qualified as mild stutterers by the end of the metronome regimen. Some of Brady's participants still had moderate dysfluency, but those were the same participants with the most severe dysfluency at the start of the program. Brady suggested that the most severely dysfluent stutterers might consider wearing a metronomic device in their ear, similar to a hearing aid. These participants reported that the minor inconvenience of wearing such a device was worth the drastic improvement in their fluency. Like in his 2011 study, Toyomura measured the basal ganglia activation of his participants. These brain scans showed that the temporary benefits of metronomic speech had become more permanent over time; activation in the participants' basal ganglias during self-paced speech had increased to match that of fluent speakers. Toyomura also found decreased activation in the cerebellum, implying less of a need to correct motor execution and timing. Though both studies centered on metronomic speech practice, they differed in structure. Toyomura's participants were instructed to read aloud to a metronome for at least fifteen minutes a day, at least five days a week, for eight weeks. Participants who did longer or more frequent sessions saw greater gains. Brady's program was structured more like traditional speech therapy; once Brady trained participants on how to use the metronome, they were expected to practice metronomic speech for forty-five minutes a day for the first two-to-four weeks. As this intensity tapered off, Brady then asked his participants to incorporate metronomic speech into their daily lives, whether through conversation with family members and friends or by reading aloud with those people as an audience. Once his subjects saw improved fluency and comfort with metronomic speech, they gradually replaced training sessions with real-world application. Interestingly, the two studies also put forth different philosophies for progression as participants became more competent with metronomic speech. Toyomura instructed his participants to always speak one syllable per beat but to increase the speed of the metronome as they improved. Participants typically started with the metronome at around 90 beats per minute but progressed to around 120 beats per minute by the end of the program. It's interesting that the participants' speech naturalness improved, despite this somewhat-rigid speaking pattern. This is also exciting, considering that clinical speech therapy usually leads to a temporary drop in speech naturalness. Brady took a different approach to progression; instead of speeding up the beat, his participants spoke more syllables per beat. Brady encouraged them to speak two syllables per beat, then to fit entire phrases and even sentences into a single beat. He also taught participants to better mimic the flow of natural speech by occasionally skipping a beat. Unfortunately, Brady did not measure speech naturalness in his study; however, since naturalness improved in Toyomura's study - where speech patterns were more rigid - I believe we can expect that Brady's participants also made gains in speech naturalness. Toyomura's program ended after eight weeks of at-home training, but Brady's program had real-world application built into it. Participants made a ranked list of challenging speaking situations and then practiced taking them on. To ease them into each situation, participants first practiced these real-life scenarios with the metronomic device playing in their ear, acting as a sort of lifeline. As they became more comfortable and fluent, they gradually decreased their use of the device, eventually speaking exclusively without it. Brady did advise his participants to return to metronome training when they experienced drops in fluency; he reported that these recovery sessions usually corrected potential relapses after only a few days. Brady's study included follow-up measurements for each participant. While the timing of follow-up differed between participants - on average fourteen months, but ranging from six months to four years - almost every participant not only retained their therapeutic gains, but continued to improve even after the program ended. Toyomura's study concluded at the end of the training program, so unfortunately we don't know if these neuroplastic changes endured, or for how long. However, in light of how well fluency was retained, I believe it's reasonable to expect the neuroplastic changes lasted for a long time. These programs are an incredible boon to stutterers given how simple and accessible they are. Metronomes are relatively cheap, and many websites offer metronomic functions for free. That means there are almost no barriers to stutterers implementing these programs in their own life. Another self-directed program emerges from the work of Chunming Lu. His intervention was somewhat particular to languages like Mandarin Chinese, which are written in pictographic characters. That said, the principles are broad enough that we can adapt aspects of his program to benefit anyone with a stutter. One can suppose that, even for native speakers, translating pictographs into syllables and phonemes adds an extra cognitive step to speech production. Therefore, Lu investigated whether making the phonetic content of words more obvious would improve fluency. Lu's participants completed an intensive seven-day program that focused on the recitation of syntactically-simple words; each word was composed of only two syllables, and each syllable followed a consonant-vowel pattern (such as *baby, busy, dizzy*). In the first of three training sessions, the participant worked through a list of these words with a diction expert; the diction expert recited each word twice, and then the participant recited it back twice. In the following two sessions, the participant read aloud from the wordlist by themselves. In the read-aloud sessions, the words were printed in Pinyin Chinese, since this spelling is more phonologically transparent. In Pinyin, words are written in Roman characters instead of pictographs; for example, the word for "building", 建築, would be written as "jiàn zhú." There was always a speech therapist present during these training sessions, but the therapist did not provide feedback until the end of each day, at which point the speech therapist and participant would review and discuss the speaker's performance. As in Brady and Toyomura's programs, participants were encouraged to apply strategies from the study when they encountered dysfluency in real life. At the end of the program, participants had fluency gains matching those of traditional clinical programs. Additionally, brain scans showed increased activation of the LIFG and decreased cerebellar activation. Lu conducted this intervention twice, using different scanning technologies, and found similar improvements both times. How can we adapt this program to languages that do not use pictographic characters while still retaining its effectiveness? We don't have enough information to pinpoint the exact causal mechanism(s) of Lu's program, but the two most salient factors appear to be the conversion to Pinyin spelling and the intensive recitation of syntactically-simple words. In the absence of studies that separate the two components, we can't confidently determine how much each one contributed to the program's success. However, I believe that one could gain most of the neuroplastic changes and improved fluency of Lu's program by reciting syntactically-simple words for several hours a day. It seems to me that syntactically-simple words are a great training tool for independent speech practice. Stutterers are more fluent than normal when reciting syntactically-simple words. Many repetitions of highly-fluent speech - proper executions of the speech system - could drive corrective neuroplastic change; this practice functions like intensive speech therapy, but without fluency-inducing techniques. However, reciting simple words for several hours a day would likely be painfully monotonous and thus difficult to sustain on one's own. So I propose a practice that may be more amenable: reading aloud. All you have to do is take out a book you enjoy, go someplace where you have a reasonable amount of privacy, and read aloud for twenty minutes. Reading aloud gives you limitless material with which to practice your speech. It also removes all effort and attention from *what* to say and allows you to focus solely on *how* you say it. By doing this in the privacy of your own home, you can mindfully notice what strategies allow you to work through blocks when you encounter them. From my own experience, after ten minutes of reading aloud, I've lost whatever self-consciousness or anxiety I started with. I usually stop after twenty minutes due to mental fatigue; at that point, my brain feels spent, but it also seems like it's operating more effectively. Subjectively, my baseline fluency also feels improved afterwards. This reading doesn't need to be dry or monotonous. In her work on stuttering and prosody, Neumann noted that emotional and linguistic prosody activate the LIFG more than flat, affectless speech. She posited that speaking with prosody could further stimulate the neuroplastic healing of white matter connections in the LIFG. Therefore, if you practice reading aloud, it would be most beneficial to speak with emotional affect and flow with the rhythm of the writing. Reading aloud can be your primary training tool, but this idea also applies well to other speaking situations. I often practice reading aloud when I have an important or stressful speaking situation on the horizon. Even though my fluency is usually pretty good and I'm relatively comfortable in those situations, I still get jitters. I think of it like an athlete warming up before a game: reading aloud doesn't guarantee fluency in the live scenario, but it does better prepare me for success. Or, sometimes you may go for days without speaking to others, and you feel like your speech system is accumulating rust, that your fluency will be poor when it comes time to speak again. Reading aloud is an easy and accessible way to loosen the gears in your speech system and get over the mental hurdle of returning to speech. Alternatively, I'll use reading aloud to counter a relapse in fluency, similar to the way Brady's participants used metronome refreshers. Be deliberate with the reading material you select; choose something that you enjoy and expect to make you feel better. Personally, I like reading essays by Ralph Waldo Emerson, because I find his work enlightening and inspiring. After twenty minutes of reading Emerson, not only have I exercised my speech system and improved my fluency, but I'm also in an elevated state of mind. **The Personal Side of Recovery** The pain of stuttering can come just as much from fear of dysfluency as from dysfluency itself. Avoiding speech for fear of blocking undercuts a stutterer's self-confidence and sense of agency. If you are to mitigate the totality of a stutter, you should not leave this unresolved. **Agency, Well-Being and Fluency** We've seen that speech therapy can greatly improve fluency. Can improved fluency remove that fear of dysfluency and lead to behavioral change? Is improved fluency enough to relieve the suffering caused by stuttering? These questions were addressed in a 2008 study led by Ross Menzies. In this study, all elements of real-world application and cognitive-behavioral change - which are typically part of speech therapy - were removed. This boiled down the therapeutic program solely to training and practicing speech motor correction. Participants were given a battery of assessments at different stages of the study. In addition to measuring fluency, participants were assessed on mental health, well-being, and agency. One assessment was specifically designed to measure the participants' ability to take on difficult speaking situations. Participants made a list of ten challenging speaking situations, ranked them from easiest to most difficult, then indicated the most difficult task they would be willing to do. This stripped-down therapeutic program produced fluency gains commensurate with full clinical programs of the same duration, and a one-year follow-up found that participants maintained their improved fluency.\* Results indicate that the program successfully improved fluency; would this improved fluency also increase participants' well-being and sense of agency? \*(Participants were offered maintenance sessions, but it was not indicated how many took advantage of that.) In general, assessments suggested that the participants' mental health was slightly better immediately following the end of the program, and it had improved further by the one-year follow-up. At both measurements, participants increased the number of tasks they were willing to perform. However, their rates of social phobia did not change, even after living with improved fluency for an entire year. These results show that improved fluency by itself will not resolve the suffering and limitation caused by stuttering. Participants were significantly more fluent after this clinical program, yet stuttering was still a major mental obstacle and source of distress. Fortunately, these participants were only one half of a split-cohort study. The real intention of the study was to isolate the effects of cognitive-behavioral therapy (CBT) on clinical speech therapy. This first group was the "control" group; they showed the efficacy of speech therapy when all cognitive-behavioral elements were removed. The other half of participants, the CBT cohort, provided insight into how CBT would affect agency, well-being, and fluency. The CBT cohort completed ten weekly sessions of CBT before starting speech therapy. This alone produced immediate benefits for the participants' mental health. These gains were roughly equal to the control group's cumulative improvement at the one-year follow-up. With no changes to their fluency, the CBT cohort was willing to take on 90% of challenges from their task list, up from 30% at first measurement. For comparison, at their best, the control group participants were willing to do 65% of the items on their task lists. From this data, we can see that the CBT group began speech therapy in a much better state of mind. Interestingly, the two cohorts showed only minor differences in fluency throughout the course of the program. The CBT cohort's well-being and agency, however, was improved at the end of speech therapy and had improved even further by the follow-up measurement. Immediately after therapy and at one-year follow-up, most of the CBT group members were willing to complete every item on their challenge list. The clearest difference between the groups was in their rates of social anxiety. Throughout the entire course of the study, the control group remained at a 50% diagnosis rate. In contrast, half of the fourteen CBT participants were diagnosed with social anxiety at intake. At follow-up, that number was *zero*. Recall from earlier chapters that there is a high prevalence of distress and mental health disorders in stutterers. Menzies' study suggests that CBT (and similar mental health interventions) could directly address this problem. That the CBT cohort saw major gains in agency even before starting speech therapy suggests that, no matter how dysfluent someone may be, they don't need to be limited by distress and anxiety. Cognitive-behavioral therapy paired so well with speech therapy because it helped participants put their new fluency into action. In fact, it's critical that you change your attitudes and habits, not just your speech patterns, in order for improved fluency to have a meaningful impact on your life. For contrast, a study led by Lisa Iverach shows us what can happen to fluency if behavior patterns and mental health diagnoses are left unresolved. Iverach's participants completed a week-long intensive clinical program followed by seven weekly maintenance sessions. All participants had improved fluency at the end of the intensive program, but at six-month follow-up, only one-third had retained their gains; the rest regressed about halfway back to their original levels of fluency. To be fair, the therapeutic program was relatively short, and the maintenance program did not seem to be as rigorous as many others we've seen. This shorter program could be a contributing factor to the relapse, but when we look at the participants' mental health, the picture becomes clearer. The participants completed a mental health questionnaire before the start of the therapeutic program. This questionnaire placed emphasis on anxiety disorders and the participants' penchant for avoiding stressful situations. The two-thirds of the cohort that relapsed all qualified for at least one mental health diagnosis, while the one-third without any diagnoses retained their fluency. To further demonstrate the effect of mental health, those with two or three diagnoses lost more fluency than those with only one. It can be inferred from this data that the two-thirds who relapsed had difficulty utilizing their new fluency in the real world. Even though their improved fluency made them more likely to be fluent, they continued to avoid stressful speaking situations. This study hammers home an important point: if you do not use your new fluency, you lose it. Successful speech therapy therefore demands cognitive-behavioral change and real-world application. Menzies' study in particular highlights why these elements are typically included in speech therapy and why they are so important. Therefore, it would be wise to ensure that your speech therapy program incorporates elements of CBT. These studies also show that relatively-good fluency does not necessarily protect from the distress and limitations of stuttering. If your fluency is relatively good but you are still suffering, you may consider enrolling in a CBT program. If you are going the way of self-directed speech therapy, consider working with a CBT professional to assist you in maintenance and real-world application. However, not everyone has the time, resources, or interest in this professional support; therefore we'll take a look at what a self-directed application and maintenance program may look like. **Self-Directed Application and Maintenance** Cognitive-behavioral therapy works by helping clients modify behavioral patterns and correct cognitive distortions. It's a broad philosophy with many useful strategies and techniques, but we'll focus on two tools which are particularly applicable to stuttering. The first is systematic desensitization, also known as graduated exposure. This is a process in which the participant deliberately exposes themselves to scary situations in order to expand competence. When systematic desensitization is used properly, participants can gradually develop the attitude, fortitude and competence to regularly do things that used to scare them. You can guide yourself through systematic desensitization by adapting a procedure used in the work of Brady and Menzies. Write down between ten and twenty challenging speaking situations, and then rank them from easiest to hardest. Figure out which ones you are reasonably comfortable doing, and then push yourself into a situation that is just one ranking more difficult. Take the challenge on, even though it's uncomfortable, even scary. Each time you do that task it will become less stressful, less fear-inducing. Eventually, that task will not be particularly challenging; you'll become confident and competent when doing it. Once you reach that point, move on to the next-hardest item on your list. This is all the strategy and technique you need; achieving progress only requires you to supply the discipline and commitment to sustain this practice. Doing something outside your comfort zone is -- by definition -- uncomfortable, and you will likely be dealing with stress when it comes time to act. This anxiety will likely lead to overly-pessimistic expectations; by definition, anxiety is overestimating the actual threat of something. When you are anxious about a situation, your mind will likely conjure vivid theoretical scenarios of the attempt going poorly; if you have a stutter, you may worry that you will block, that you will embarrass yourself, that people will laugh at you. To be fair, those are all valid possibilities. They could happen. Your brain may try to convince you that these worst-case scenarios *will* happen, but the truth is that you really can't know until you try. If reality turns out any better than your worst fears, your anxiety will have done you a disservice. If that is the case, you would benefit from training yourself to set better expectations. To help manage the stress and anxiety that comes from pushing boundaries, we turn to our next CBT tool: *behavioral experiments*. If you record your expectations, you can compare them to the actual outcome after the fact. The attempt may have turned out really well. Or it may have been quietly neutral; a non-event. Or maybe it did go poorly, but it wasn't nearly as painful as you may have feared. If you record and compare your expectations enough times, you will learn about your expectations, and you will be able to compare them to how reality usually turns out. Then, you can learn to set more reasonable expectations. This practice can help the next time you are facing a scary situation. In those moments when your brain is conjuring up all kinds of terrible outcomes, when you can see yourself blocking and getting laughed at, you can mentally take a step back and remind yourself "I've felt this way before. And nearly every time, it didn't go as poorly as I feared. Even when it did, the reality of the outcome was not as bad as I had feared." This will help you calm yourself down, contain the anxiety, and detach from the stress of the situation. Another strategy that can help you detach yourself from a chaotic internal experience is mindfulness; mindfulness is, in my opinion, one of the best tools for the lifelong management of a stutter. We know that fluency varies with your internal state; good internal states lead to better fluency, and bad ones lead to worse dysfluency. Combining my personal experience with the neuroscientific literature, I posit that once the neurological maladaptations of severe dysfluency have been normalized, the greatest potential gains lie in managing one's internal state. And while it is impossible to always be in good states and to never be in bad ones, mindfulness can help you encourage the former and let go of the latter. The detachment from internal experience that comes with mindfulness practice can function in much the same way as behavioral experiments. By practicing mindfulness, you learn to notice your internal state and detach from your feelings. With practice, you can take a mental step back from stress and instead think "Ah, I am feeling anxious about this situation. Because I am anxious, my expectations are likely to be unrealistically negative. Therefore, I should not let myself be affected by these predictions." As your practice develops, you learn to not only notice your internal state, but also to gently guide it; therefore, you could learn to let go of the nervousness you were feeling and instead stay calm and centered on the task at hand. Meditation may also help mitigate some of the neuropathology of stuttering, as was shown in a 2019 study by Daiki Miyashiro. Recall that delayed audio feedback (DAF)\* paradoxically makes stutterers nearly perfectly fluent but induces stuttering in fluent speakers. In Miyashiro's study, a cohort of fluent speakers spoke under DAF while researchers recorded the fluency of their speech and their neurological responses to audio. For the next eight weeks, half of the participants meditated everyday for ten minutes, and then the entire group was measured again. At the second measurement, after a brief warm-up meditation, the meditation group showed improved fluency and neurological responses under DAF; the control group showed no change. \*(Under DAF, audio feedback of one's speech is artificially delayed by a short interval, usually 200 milliseconds or fewer.) Miyashiro posited that the meditation group was better able to allocate their attention, and thus could ignore audio feedback that would normally make them stutter. This effect would be helpful for stutterers because blocks can be caused by problems with parsing audio feedback and incorporating it into speech production. Additionally, one can optimistically suppose that - whatever the causal mechanism may be - if mindfulness enabled fluent speakers to be more fluent under DAF, it may help stutterers be more fluent in our "normal" circumstances. Lastly, I believe that stutterers would benefit from processing their own feelings about stuttering. Let's be honest: stuttering sucks. Some well-meaning people may try to offer short-term relief by saying "It's okay, you can do anything a fluent speaker can do"; that is true, but it's not the whole truth. The reality is that having a stutter - even one that is well-managed - is objectively worse than not having a stutter. Ask yourself, or any other stutterer, if you would ever wish a stutter on another person, and I expect you would get a clear, emphatic "no." Acknowledge to yourself that you have been burdened, that your stutter has and will continue to cause you pain. That's just part of the game for us. We can and should minimize its effects through careful management, but it's okay to acknowledge that this is still a challenge. I think it's wise to confront the fact that you did nothing wrong to deserve this burden. Somewhere along the line, for whatever reason, your speech system happened to develop this way, and it's nobody's fault. As far as the current science shows, there isn't anything that anyone could have done differently to save you from this lifelong affliction. It sucks that no matter how hard you work or how carefully you manage it, you can't "beat it"; there will always be the potential for you to block on any word you say for the rest of your life. That was a very painful lesson when I first learned it. I experienced a period of rapid personal growth in my early twenties. This newfound maturity and confidence translated to major improvements in my fluency, to the point that I was nearly-perfectly fluent. I thought that I had "beat" my stutter, that with confident action and proper management, my stutter would be a thing of the past. Then, a bout of dysfluency set me back. I did some research in hopes of regaining my fluency, and that's when I learned that a stutter can't be eradicated once it persists to adulthood. I had thought that if I worked hard enough and did the "right" things I could free myself of this burden for good, so discovering otherwise was incredibly disheartening. No matter what I did, my stutter would always be there on some level. It was difficult to come to terms with that reality, but I'm glad that I did. This understanding prevents me from wasting my time and effort being upset about my present circumstances, or fantasizing about some future miracle cure solving the problem for me; my energy only goes towards what I can do about it. Make peace with your reality, grieve for the things you can't have, and move on. It's healthier to live with unpleasant realities than to tell yourself well-meaning half-truths. Although speech impediments are difficult, no human being lives without problems. As terrible as stuttering can be, there are many afflictions that are far worse. Stuttering happens to be one of your problems, but it is within your power to mitigate its ability to negatively impact your life. It's not your fault that you have a stutter, but it is your responsibility to do something about it. You can work through these feelings in a variety of ways: talk therapy, stuttering support groups, or journalling are all helpful approaches to processing. Choose whichever tools work best for you. Professional therapists are experts at working through unpleasant feelings and grief; they can help you work out these feelings in conversation in a safe, understanding environment. Similarly, stuttering support groups and talking with others who have had the same thoughts, feelings, and experiences can be deeply validating. If you prefer to work through these matters on your own, consider writing in a journal. Journalling gives you the mental and physical space to freely express whatever thoughts and feelings are on your mind in the comfort of privacy. Sit down with pen and paper or at your computer, and express how you feel about your stutter, how it has affected your life, and what you hope for in the future. **Closing** There is no reason for anyone to suffer through severe dysfluency and all its attendant effects; thanks to the research, we now know how to manage stuttering so that it is no worse than mild dysfluency. If you follow the guidance of the research literature, you will have all the tools you need to improve your fluency. I know that people can be apprehensive about trying a new "cure" when so many promising treatments have failed in the past; it hurts to feel like you've ended up at the same place where you began despite all your work and sacrifice and to have one less potential solution to the problem. I think this is especially true for stuttering, since it is so intangible and difficult to understand. Still, do not let that stop you from committing yourself to the treatments above. These approaches are built on rigorous research and large sample sizes, not a single person's self-generated theories. They do not promise perfection, but they do offer hope. Have faith that if you put in the time and the effort, you can improve your fluency and your life. There is reason to be even more optimistic: Mild dysfluency isn't the best possible outcome. Next, we'll set our sights on *successful management*.