Therapy and Its Importance

original author: Melissa Jorgenson, former student
revised by: Cindy S. Spillers, current web master



The earliest known references to stuttering date back to about 2000 B.C. Throughout history the treatment methods for stuttering have been a dime a dozen. From the distant past until the recent these methods have included everything from holding pebbles in the mouth to drug therapy. Stuttering therapy has many variations yet no treatment method has successfully and positively cured stuttering in an individual.

In general, treating stuttering behaviors involves changing the time and tension domains of talking. For time, the person slows down her/his rate of speaking to give the articulators time to move from one place to the next. For tension the person learns easier, smoother ways to move the articulators. The methods for changing time and tension vary with the client's age, awareness level, individual needs, and treatment program.

Following is a discussion of some of the speech therapy approaches to treating stuttering. This discussion is divided into treating early stuttering in young children, treating stuttering in older children, and treating advanced stuttering in adolescents and adults. Three important ideas need to be kept in mind: 1) therapy is not appropriate for every person who stutters; 2) no one therapy approach works for every person who stutters; 3) no treatment approach offers a quick fix; treating stuttering takes time.

Treating Early Stuttering in Young Children

Not all young children who have dysfluencies in their speech stutter. Children normally repeat words and phrases as they learn how to use a very complicated language. Stuttering often shows warning signs, of which parents should be aware. (See Onset and Development for information on the warning signs of stuttering.) Once parents notice signs of early stuttering or once they have concerns about their child, the child should be evaluated by a certified speech-language pathologist. Therapy for stuttering usually begins following this assessment and a diagnosis of a fluency disorder. As with any disorder or illness, early intervention holds the most promise for successful management of the problem.

One of the goals of treating stuttering in preschool aged children is to reduce the demands for fluent speech and give the child's capacities a chance to catch up. This therapy is best carried out through modeling and demonstration by family members and is often called "indirect intervention." Children are more likely to slow down and smooth out their own speech when those around them speak slowly and smoothly. Simply telling young children to slow down usually does not help for two reasons: First it sends the stuttering children the message that something is wrong with the way they talk and that their talking is not acceptable. Secondly, unless the environment changes pace to accommodate a slower talking child, the child will be penalized for following the advice to slow down. The other fast talkers will make it impossible for the slower talking child to survive in the conversation.

In addition to teaching and encouraging family members to use a slower and smoother rate of speech with the child, the speech-language pathologist (SLP) may make some suggestions similar to those found in the Do's and Don'ts section of this site. It is important to remember that the behaviors and circumstances which SLPs suggest families change don't cause stuttering. We don't know what causes stuttering yet; we do know that some behaviors and circumstances will make stuttering worse once it begins, and these are the things that SLPs recommend families try to change.

One area of controversy in the treatment of early stuttering in pre-school aged children involves the dilemma of whether to call the child's attention to the stuttering. Many clinicians believe that young children rarely are aware or concerned about the stuttering behavior and calling attention to it is unnecessary and may make the stuttering worse. Other clinicians believe that children usually are aware that they have difficulty talking, although they may not show any concern about their difficulty. By not talking about the stuttering, family members and SLPs may unwittingly participate in a conspiracy of silence that can permeate the child's life with stuttering later on. Parents need to decide if they should talk to their children about stuttering, and if so, how to bring up the subject. In general, open communication about stuttering helps to relieve children of some of their unexpressed anxiety and reassures them that mom and dad are aware of their struggles and are willing to help. As Mr. Rogers says, "if it's mentionable, it's manageable."

Treating stuttering in school aged children

With older children the parents and SLP can talk more directly about what happens when the child gets stuck on words and the child can learn specific strategies for smoothing out the bumps in her/his speech. School aged children can take responsibility for learning to talk smoother and slower. They can also handle the freedom of deciding for themselves when they want to control their stuttering and when they don't. In order to get to this level of freedom and responsibility, children need to accept their stuttering and break the cycle of fear and avoidance. This is much easier said than done. Family support and acceptance of the child and her/his stuttering goes a long way toward helping the child to accept her/himself and to accept her/his own stuttering.

SLPs may introduce a variety of strategies to children to help them smooth out their speech and control their stuttering. These strategies become tools that the child can use in everyday life situations. Some common strategies include easy onset, in which the child starts a word gently and slowly, and bouncing, in which the child takes a tense, hard repetition and makes it easier and more rhythmic, like bouncing a ball. Slowing down the overall rate of speech also helps children who stutter by relieving the pressure to talk fast.

When fears and anxieties have built up in a child they must be addressed in therapy along with the speech behaviors. In particular, a child's strong desire to avoid stuttering and listener penalty must be addressed so that the child can overcome the strong temptation to avoid. If an attitude of avoidance and fear of stuttering persists, then any tools the child learns to help manage the stuttering become strategies for avoiding. Strategies for avoiding are secondary behaviors and eventually become part of the stuttering.

Therapy approaches for treating stuttering in school aged children, adolescents, and adults generally fall into two categories: stutering modification (stutter-more-fluently) or fluency shaping (speak-more-fluently). Stuttering modification therapies focus on changing individual moments of stuttering to make them smoother, shorter, less tense and hard, and less penalizing. Stuttering modification approaches do not strive to make a stutterer fluent but rather, to stutter with control. Stuttering modification therapies tend to recognize the fear and avoidance that builds up surrounding the stuttering and consequently spend a great deal of time helping people who stutter to work through those emotions.

The fluency shaping therapies focus on changing all speech of the stutterer, not just the moments of stuttering. These therapies have a more global approach because they teach the person to slow down and smooth out all of their words. Proponents of fluency shaping therapies believe that the outcome of therapy depends directly on the focus of therapy: if clinician and client focus on changing stuttering, they'll get stuttering; if they focus on changing fluency, they'll get fluency. As a rule the fluency shaping therapies do not address attitudes, feelings, and self-concept issues under the assumption that, since these components are directly related to the stuttering, eliminating the stuttering will eliminate these negative emotions. Many clinicians have encorporate such topics into their therapy plans anyway after encountering stutterers for whom these elements did not change. The details of both stuttering modification and fluency shaping therapy categories are discussed below.

Treating stuttering in adolescents and adults

Once a person who stutters reaches adolescence or adulthood the stuttering behaviors have become entrenched, as have the fear, avoidance, guilt, shame, and embarrassment. Many adolescents and adults who stutter view their stuttering as a major personal problem and stuttering interferes with many aspects of their lives. Many SLPs believe that successful stuttering therapy must help the person address these emotional and self-concept issues otherwise the new found improved fluency will be short lived. Just as we can't put new wine into old wineskins, we can't put new speaking behavior into an old self-concept. The person who develops new fluency skills but continues to avoid ordering in restaurants or talking on the telephone, limits her/his ability to use the new fluency skills and make them part of her/his speech habits. Furthermore, giving in to those old fears prevents the person from gaining control over the fears and over the stuttering. The fears, anxieties, and self-concept issues constitute the most difficult aspects of successful stuttering therapy.

Stuttering Modification

The classis stuttering modification therapy approach was developed by the late Charles Van Riper in the middle of the 20th century. Since then many clinicians have improvised on Van Riper's basic stages and strategies. The stages of Van Riper's therapy can be summed up in the acronymn MIDVAS:

Motivation - the person who stutters needs to assess her/his motivation for seeking therapy and the SLP needs to help the person build and maintain the motivation necessary for successfully changing speech behaviors and attitudes. Facing one's weaknesses squarely enough and long enough to change them is not easy for humans to do. Therapy for stuttering is not something to enter into lightly; it takes a large investment of time, physical energy, emotional energy, and money. Motivation gets addressed throughout therapy.

Identification - in the identification stage the client and clinician identify all of the behaviors, feelings, and attitudes that go along with the person's stuttering. This is like picking the stuttering apart. They identify the core stuttering behaviors, any secondary behaviors, physiological components, such as changes in heart rate, feelings of fear, anxiety, shame, guilt and hostitility, and avoidances. Identification can be very difficult for people who stutter because it exposes their shame and feelings of inadequacy. Motivation can take it's first dip in this stage.

Desensitization - after the emotionally draining work of identification, the person who stutters moves into the desensitization stage. Van Riper designed this stage to help drain away the negative emotions, the fears, and the anxieties associated with the act of stuttering. These negative emotions give stuttering its power over the individual. In order for the individual to have control over the stuttering, s/he must drain away these emotions from the act of stuttering so that stuttering becomes a neutral event, sort of a "no big deal." The most common strategy used in the desensitization phase is called voluntary stuttering, in which the person stutters on purpose. By choosing when and how to stutter, the individual begins to gain control over the stuttering and the fear and anxiety begin to diminish.

Variation - once some of the negative emotions have drained away from the act of stuttering the individual is able to change how s/he stutters and change her/his reactions to the stuttering. Actual work on changing stuttering behaviors does not happen until the fourth stage of therapy because much ground work needs to get done first. Many people who stutter find the initial ground work more difficulty than they had bargained for and drop out of therapy before reaching this stage. Much of a stutterer's behaviors and reactions become engrained to the point of being stereotyped. The same stimulus (e.g. ringing telephone) will set off the same chain reaction of feelings and behaviors in the person. Varying these stereotyped responses weakens their power over the individual and helps the individual continue gaining control over the fears and the stuttering. Van Riper suggests having individuals change their reactions to word fears, situation fears, communicative stresses, and frustration and penalty. In addition, the individual learns how to stutter differently in this phase. For example, if the person usually prolongs the initial "s" in "sister," have her/his repeat the sound or stutter on a different sound in the word.

Approximation - Once the stereotyped pattern of the stuttering has broken up, the individual can learn 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. Strategies such as bouncing, sliding, easy onset, and light contacts represent variations on these three techniques.

Stabilization - after successfully moving through the previous phases of therapy with the close guidance of a clinician, the person who stutters needs to become her/his own clinician. In the stabilization phase, the individual uses 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. Many people who stutter find that joining organizations like Toastmasters helps them to continue their own desensitization and keep the fear and avoidance at bay.

Fluency Shaping

The fluency shaping therapies teach the person who stutters how to slow down and smooth out all of their words, not just the words on which they stutter. The ultimate goal is to have the fluent speech replace the stuttered speech. One common fluency shaping approach begins with establishing fluent speech in short, one word, utterances, and then gradually increases the length and complexity of the utterances while maintaining fluency. A second common fluency shaping approach requires the stutterer to alter her/his speaking pattern in a dramatic way and then move that altered, fluent speech closer and closer to normal sounding speech. Some clinicians have combined these approaches by having clients alter their speaking pattern in an exaggerated way, for example speaking at 1 syllable per second by stretching out every sound in a word, establish fluency with this method in single syllable words, move up to longer words and sentences, and increase the rate to something more normal, all the while maintaining a high level of fluency. Some fluency shaping thearpy programs have used the delayed auditory feedback device to help clients alter their speech. This device makes the person hear their own voice slightly delayed. In order to overcome the delay, the person who stutters must talk very slowly and smoothly by stretching out the vowels and sliding all of the words together. In print it might look something like this: "Hooowwwaarrreyyoouu?" The stutterer begins at an extremely slow rate, around 50 wpm, and then builds up to something slightly slower than normal, maybe 140 wpm, while maintaining the smoothness and sliding words together.

The Best of Both Worlds

Recently some clinicians have successfully combined elements of stuttering modification and fluency shaping therapies. These therapies usually begin by teaching the person who stutters fluency shaping strategies to slow down and smooth out all of their speech. This eliminates most of the overt stuttering behavior. For the moments of stuttering that remain, the individual learns to manage them with stuttering modification strategies. In addition, the stuttering modification phases of motivation, identification, and desensitization get encorporated into therapy to help the individual manage the negative emotions that have built up around the stuttering.

Conclusion


Treatment of stuttering is based on a developmental continuum since stuttering is a developmental and progressive disorder. The client-clinician relationship is an important variable in the outcome of therapy. The clinician needs to guide the client through the steps of therapy, and provide release and support during those difficult moments of therapy. Ultimate responsibility for change rests with the person who stutters. Change in speech behaviors constitute only part of the picture; changes in attutudes must also occur in order for the new found speech behaviors to last. Attitude changes take a long time and a lot of hard work. Learning to accept stuttering by facing the fear that surrounds it is an essential part of any successful treatment.

posted May 1997
revised January 2001





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