Stuttering therapy

Stuttering therapy is any of the various treatment methods that attempt to reduce stuttering to some degree in an individual. Stuttering can be a challenge to treat because there is a lack of evidence-based consensus about therapy. Some believe that there is no cure for the condition, and experts have argued that the preferred treatment outcome is one that involves satisfaction on the part of the stutterer, with both his communicative performance and the therapy process. While there is disagreement about acceptable treatment outcomes from stuttering therapy, a wide range of methods have been developed to treat stuttering, and these have been successful to varying degrees. The Stuttering Foundation provides a list of speech-language pathologists who specialize in stuttering treatment.

Goals

In general, stuttering therapy aims to reduce stuttering to some degree in an individual, although there is disagreement about acceptable treatment outcomes from stuttering therapy. Some believe the only acceptable therapy outcome is a significant reduction in or total elimination of stuttering, others believe that speech which contains some stuttering, as long as the stuttering has become less tense and effortful, is just as acceptable, and yet others believe that the most important therapy outcome is the increased confidence a person has in his or her ability to talk, whether or not stuttering continues to be present. Additionally, the many different methods available for treating stuttering, and a history of promoting unsuccessful treatments, have left both stutterers and clinicians confused and frustrated about what can be accomplished with stuttering treatment.

In 1997, experts argued that in the case of a stutterer seeking professional treatment from a clinician, the "preferred treatment outcome" is that the stutterer will demonstrate feelings, behaviors, and thinking that lead to improved communicative performance and satisfaction with the therapy process. They argued that the criteria for a treatment to be viewed as successful includes the stutterer being satisfied with her therapy program and its outcome, feeling that she has an increased ability to communicate effectively, feeling more comfortable as a speaker, and believing that she is better able to reach her social, educational and vocational goals.

Robert W. Quesal, an associate professor who teaches courses in fluency disorders, anatomy, and speech and hearing science, defined successful stuttering therapy as one that leads to a change in speech fluency, a reduction in the impact of stuttering on an individual's life, and an increased acceptance of stuttering on the part of the stutterer; and J. Scott Yaruss, Ph.D., an assistant professor of Communication Science and Disorders at the University of Pittsburgh, suggests three instruments for clinicians to use to document changes in the stuttering of their clients: the reaction of the stutterer to the fact that she stutters, how much stuttering interferes with the stutterer's ability to perform daily tasks, and the impact that stuttering has on the client's ability to pursue their life goals.

Approaches

There are many different approaches to stuttering therapy. While some believe that there is no cure for the condition, stuttering can be reduced and even eliminated with appropriate timely intervention, and various therapy methods have reduced stuttering in individuals to some degree. In any case, for all persons who stutter, the successfulness of speech therapy depends on the combination of education, training, and individualized treatment provided.

For a child that stutters, the focus of treatment to prevent the worsening of the condition, and families play an important role in the process. Successful elimination of mild stuttering is likely when treatment is initiated before four years of age. For those who have more advanced forms of stuttering and secondary behaviors, therapy is generally a variation or combination of two approaches: a fluency-shaping technique that replaces stuttering with controlled fluency, and stuttering modification therapy, which focuses on reducing the severity of stuttering.

Therapy for children

Treatment of mild stuttering in children younger than six years of age focuses on the prevention or elimination of stuttering behaviors. Families play an important role in the management of stuttering in children: therapy is usually characterized by parental involvement and direct treatment, and providing an environment that encourages slow speech, affording the child time to talk, and modeling slowed and relaxed speech can help reduce stuttering.

For example, the Lidcombe Program, which has become prominent in recent years and is effective in preschoolers who stutter, involves a parent or some significant person in the child's life being trained and delivering treatment in the child's everyday environment. In the program, family members are to provide an environment that encourages a child to speak slowly, and one in which the child receives praise for fluent speech in the child’s daily speaking and, occasionally, correction of stuttering. Some of the most effective preschool intervention programs call for direct acknowledgment of stuttering in the form of contingencies such as “that was bumpy” or “that was smooth.”

Several organizations organize summer programs for children, including summer camps, to help treat stuttering. These programs offer a range of services from providing a fun outdoor experience in a nurturing and supportive environment that is free from ridicule, to providing "intensive work on communication skills". Ellen M. Bennett, an assistant professor who has practicing speech therapy for at least 18 years, encourages "public school therapists to advocate for the establishment of summer programs" for children who stutter.

Fluency shaping

Fluency shaping therapy focuses on changing all the speech of the person who stutters, and not just the portions of speech in which he or she stutters. This type of therapy involves teaching the stutterer to use a speaking style that requires careful and prominent self-monitoring; examples of such therapy include one in which the stutterer slows his speech down and smoothes out all his words, and one in which the physical mechanisms used in the speech production are retrained. Fluency shaping therapies do not address attitudes, feelings, and self-concept issues under the assumption that eliminating the stuttering will eliminate these issues. Proponents of this type of therapy believe that the outcome of any therapy depends directly on its focus:"if clinician and client focus on changing stuttering, they'll get stuttering; if they focus on changing fluency, they'll get fluency". This type of approach can reduce stuttering, although in children its effectiveness decreases if stuttering persists after eight years of age; Woody Starkweather, as at 1998 a Professor of Communication Sciences, asserted that in his experience this type of therapy improves speech only when used with other techniques.

Certain devices, known as fluency-shaping mechanisms, use this approach in an attempt to reduce stuttering. For example, delayed auditory feedback devices encourages the slowing down of speech by replaying the stutterer's words. The stutterer is then forced to slow her rate of speech to prevent distortions in the speech that is heard through the device. The effectiveness of such devices varies with stuttering severity.

Stuttering modification

Stuttering modification therapy, also known as traditional stuttering therapy, was developed by Charles Van Riper between 1936 and 1958. It focuses on reducing the severity of stuttering by changing only the portions of speech in which a person stutters, to make them smoother, shorter, less tense and hard, and less penalizing. This approach attempts to reduce the severity and fear of stuttering, and strives to teach stutterers to stutter with control, and not to make the stutterer fluent. Therapy using this approach tends to recognize the fear and avoidance of stuttering, and consequently spend a great deal of time helping stutterers through those emotions. This approach generally does not eliminate stuttering events, but it helps minimize the impact and occurrence of stuttering. Since its creation, many clinicians have improvised on Charles Van Riper's basic stages and strategies. The stages of Van Riper's therapy can be summarized up in the acronym MIDVAS:

1. Motivation

   The person who stutters needs to assess his motivation for seeking therapy, and the speech-language pathologist (SLP) needs to help the person build and maintain the motivation necessary for successfully changing speech behaviors and attitudes.

2. Identification

   In this stage the client and clinician identify all of the behaviors, feelings, and attitudes that go along with the person's stuttering.

3. Desensitization

   Van Riper designed this stage to help drain away the negative emotions, the fears, and the anxieties associated with the act of stuttering. The most common strategy used in this phase is called voluntary stuttering, in which the person stutters on purpose.

4. Variation

   The individual is now able to change how he stutters and his reactions to the stuttering; he learns how to stutter differently in this phase. For example, if the person usually prolongs the initial "s" in "sister", the SLP may have him repeat the sound or stutter on a different sound in the word.

5. Approximation

   The individual now learns specific strategies to smooth out and minimize the moments of stuttering. The three most common strategies for altering the stuttering are cancellation, in which the person stutters all the way through a word, stops immediately, and then repeats the word stuttering a different way; pull-out, in which the person gains control over a moment of stuttering while it is happening and smooths it out; and preparatory set, in which the person prepares for a moment of stuttering before it happens, starts it gently and glides through it smoothly.

6. Stabilization

   In the stabilization phase, the individual becomes his own clinician by using the new stuttering controls in more and more situations of daily life. The individual also continues to stutter voluntarily and to seek out communication situations which s/he previously avoided.

Integrative approaches

Integrative approaches combine fluency shaping and stuttering modification techniques; there is a wide variety of such approaches.

Contemporary devices

Contemporary devices used to reduce stuttering alters the frequency of the speaker’s voice to mimic the “choral effect”, a phenomenon in which person's stutter decreases or ceases completely when she is speaking with a group of others, or slows the rate of speech through delayed auditory feedback (above). Studies on the long-term outcome of these devices have not been published.

Diaphragmatic breathing

The Freeing Voices, Changing Lives award given by the American Institute for Stuttering to people who stutter who have achieved great professional success.

Several treatment initiatives advocate diaphragmatic breathing (or costal breathing) as a means by which stuttering can be controlled.

Self-therapy and support groups

Self-therapy

Some stutterers are only able to seek self-therapy because adequate clinical treatment is not available to them, and some experts in the field believe that stuttering therapy is largely a do-it-yourself project anyway.

As a form of self-therapy, Malcolm Fraser, founder of the Stuttering Foundation of America and life member of the American Speech-Language-Hearing Association recommends the following guidelines for stutterers needing immediate relief, even temporarily, in his book Self-Therapy for the Stutterer:

1. Make a habit of always talking slowly and deliberately whether you stutter or not.
2. When you start to talk, do it easily, gently and smoothly without forcing and prolonging the first sounds of words you fear.
3. Stutter openly and do not try to hide the fact that you are a stutterer.
4. Identify and eliminate any unusual gestures, facial contortions, or body movements which you may possibly exhibit when stuttering or trying to avoid difficulty.
5. Do your best to stop all avoidance, postponement or substitution habits.
6. Maintain eye contact with the person to whom you talk.
7. Analyze and identify what your speech muscles are doing improperly when you stutter.
8. Take advantage of block correction procedures designed to modify or eliminate your abnormal speech muscle stuttering behavior.
9. Always keep moving forward as you speak (keep moving your voice from one word or sound to the next, without repeating or back-tracking).
10. Try to talk with inflection and melody in a firm voice.
11. Pay attention to the fluent speech you have.

Support groups

As of 2002, stuttering support groups had gained prominence and visibility and were rapidly becoming an important part of the recovery process for stutterers, even though the vast majority of adults who stutter did not participate in support groups (or treatment). A growing number of speech–language pathologists were also encouraging their clients to participate in support groups, even though little was known about the individuals that joined stuttering support groups and the benefits they derived from their participation.

Studies involving members of support groups of the National Stuttering Association have found that 57.1% of survey respondents said that the support group had affected their self-image "very positively", with no respondents indicating that it had a negative impact.

Self-help organizations

Several organizations have been set up in various countries that provide literature and a support network for stutterers seeking self-therapy. These include the National Stuttering Association in the United States, which provides publications, a newsletter, local chapters and workshops; Speakeasy New Zealand Association, a self-help organisation that has branches throughout New Zealand; the British Stammering Association in the United Kingdom; the Indian Stammering Association, Israel Stuttering Association (AMBI) and the China Stuttering Association, a self-help organization in China.

Pharmacologic therapy

Several pharmacologic, i.e. drug-based, methods to control or alleviate stuttering events have been studied, but each has either proved ineffective or have had adverse effects. In addition, no large-scale trials on pharmacologic therapy have been published, and there are no trials including children. A comprehensive review of pharmacologic interventions for stuttering showed that no agent leads to valid improvement in stuttering or in secondary social and emotional consequences.

Post-therapy recurrence of stuttering

Every clinician who has worked extensively with adult stutterers has encountered the tendency for the stutterer to begin to stutter again after treatment has helped the person talk with little or no stuttering; only preschool children seem immune from this tendency. It has been suggested that this return to stuttering be avoided by dealing with a stutterer's fears during therapy.

For example, stutterers whose speech had been improved by fluency shaping techniques may stutter again if he becomes tired of the effort involved in trying to maintain a nonspontaneous, unnatural form of speaking; the stutter itself was never dealt with in the first place. While attempts may be made to render the learned manner of speech more natural-sounding and less burdensome, these attempts cannot address the problem that the new way of speaking does not feel right to the stutterer, which may lead him to decide to return to his pre-therapy manner of speech. Moreover, experts have argued that fluency shaping is stuttering in a new form, and Starkweather (1998) asserts that the return of stuttering is a fault of the treatment.

Additionally, there is a tendency for stuttering behaviors to return after stuttering modification therapy. While this type of therapy requires less effort that in fluency shaping, some concentration nonetheless needs to be applied. Moreover, a client that feels as if he has been cured of stuttering and stops doing the various exercises associated with the treatment may develop "microstutters", which lead to the use of avoidance behaviors that increase the fear of stuttering further, which in turn leads to more severe stuttering. The main issue is that the fear of stuttering was not removed by therapy in the first place. If the microstutters were simply accepted as a reality, or if voluntary stuttering were used to prevent the development of new fears, the microstutters may occur but a relapse into severe stuttering may not.

In another form of recurrence, a stutterer who has undergone therapy has an emotional reaction to a situation as a result of previous experiences, that causes him to stutter. This is often related to "struggles and forcing learned when the stutterer was very young". The solution to this is to resurrect and focus on as much "unfinished business" as can be found during therapy, which may, for example, include dealing with a fear of reading aloud in front of a group that is related to avoidance and humiliation experienced in similar childhood situations. Clinicians trained in experiential techniques know how to find such "business" and "finish" it.

See also

• "The Monster Study", 1939 experiment condemned for using mockery of orphans' speech as a corrective tool
• British Stammering Association
• The Indian Stammering Association
• Israel Stuttering Association (AMBI)
• National Stuttering Association, United States