Click on the title in this index to go directly to the discussion below.
From: Keith Boss ISA Chair of Outreach
I would be interested to hear from our Team of Professors what 1. they understand by Early Intervention; 2. method(s) of Early Intervention they advocate; 3. ideas they have to persuade every government of the world to sign up to Early Intervention. (My assumption is that Early Intervention will cost the state less than the cost or drain on the state to deal with an adult stutterer who has learned to have low self esteem and low self worth and has difficulty getting a job.) Keith
From: Klaas Bakker, Springfield Missouri
Keith, all of your questions are of a type that invite long answers. I'll try to control myself! First, I agree with you that successful early intervention is cost effective (it takes less time as there are fewer and typically less severe symptoms to work on than would be the case with older children who stutter). However, early intervention also prevents the stress, negative experiences, of significant part of one's life. That could be called "emotional cost" that can be avoided. I consider great early interventions: (1). behavior therapy following the Lidcombe approach (where parents do the actual behavior changing mostly in real life) (2). to analyze how a child and others in the family interact (to see how we can make speaking easier for the child; or to avoid situations where speaking is stressful or demanding), and (3). anything we can do to make speaking fun and not having to be concerned about it. How to affect governments towards supporting early intervention is not my specialization, but I assume organizations that specialize on stuttering or other fluency disorders could accumulate power, and lobbies, to consider investing in reducing the costs of lengthier therapies later in life, and of having have many people's life quality negatively affected by this problem for many years!
From: Pamela Mertz
I am interested in learning more about how SLPs are trained to help the covert stutterer. I have been covert for most of my adult life, and only recently starting talking about my stuttering experience. I have learned from attending self-help and the NSA conferences that the covert experience is quite unique, and sometimes scary, to a new clinician. My baggage is often quite heavy, and sometimes it seems like the emotional stuff is what should be handled, as opposed to speech mechanics stuff. In the expert's opinion, what is the most important piece in establishing an effective therapeutic relationship with a covert stutterer? Thanks! Pam
From: Barbara Amster
Great comment, Pam Often it is not the stuttering itself but how we think and feel about stuttering that causes distress. Clinicians need to establish an environment of safety and trust in any therapeutic relationship. Cognitive Behavioral Therapy is one among several treatment modalities that can help us change negative thoughts so that we can become more self-accepting and less apt to hide stuttering. Best, Barbara
From: Vivian Sisskin
Pam, The general public barely understands the complexities of the stuttering problem when it is quite overt, let alone understanding someone who manages to keep their stuttering hidden. As a clinician, I think it is important to acknowledge that covert stuttering is a serious problem. I am told that some speech-language pathologists will actually send someone with a covert stuttering problem away, saying, You sound fine to me, don't worry about it. Listening to the client and learning how concealment efforts impact his/her quality of life and ability to function on a daily basis is the first step. Validating that the mental gymnastics required to manipulate conversations, time responses to questions, limit verbal expression, and avoid words/situations can help to establish trust. The client needs to know that their clinician really gets it. The PWS makes the most progress when (s)he decides to move towards giving up the false role they hold on to, the role of a fluent person. This is not an easy process. Self-acceptance as a PWS takes time and a good deal of cognitive restructuring, resulting in changing one's definition of success and failure. The transformation from viewing stuttering as a failure to viewing stuttering as a success, at least in early stages of therapy, is a life-changing and freeing experience.
From: Klaas Bakker
Pam, with the stuttering being mostly covert, of course, there are no overt behaviors to work on. This simply means that other aspects of the problem can now be worked on instead. Like you suggested there are the worries and concerns you experience. As situations in which you talk with others go on trying to not stutter can become a great drag and fatiguing. So even if you don't stutter you still suffer from the consequences. Along a different vein, I would like to bring up the issue of to what extent you use other words to substitute for possible stutter words. If you are good at doing this, your concerns continue to live on. Also, you do not actually say what you want to say. This is called circumlocution. It could actually take more of your energy to do this then just accept that you occasionally stutter. In other words I think therapy can be very helpful, you just address other things than overt stuttering.
From: Walt Manning
Pam, you have had some helpful responses and I agree with what's been said. As Klaus said, many people who stutter have many covert aspects and, unfortunately the more successful they are at hiding the greater the problem in many ways. Of course, many people who are "covert stutterers" never show up at the SLP's office so asking for assistance is the first step in approaching the problem. As you suggested, attending support groups such as NSA and Friends is empowering and is a wonderful step in the right direction. I believe the most important thing an SLP can do to promote and effective therapeutic alliance is to demonstrate their UNDERSTANDING about the experience of stuttering and be willing to do the things they ask their client to do. Breaking the link between out of control/helpless and stuttering is essential for any adult who happens to stutter but especially so for a highly covert form of stuttering. Once you have "permission to stutter" especially in an easy manner you can begin to experiment with your stuttering and even begin to have some fun with it. It is difficult to do but moving away from the problem (any problem)generally makes it worse (more restricting and handicapping) while approaching the problem often makes it better (and less handicapping and mysterious). For people who are highly covert in their stuttering a sure sign of progress is more stuttering that can be altered into good stuttering . . . and often into speech that is fluent. Hope this helps.
From: Pam Mertz
Everybody's responses have been great. It is a very useful discussion to have. One expert asked to what extent do I use word substitution. I would love to say that, as a recovering covert, barely any substitutions, but that would not be true. In being honest with myself, I do sometimes choose to substitute one word for another. I work in a school, and I catch myself often substituting "instructor" for "teacher". Teacher always comes out ta-ta-ta-teacher, so I switch and say instructor. I am conscious of the fact that I do this - as open and honest as I try to be, however, I still revert to this habit. No one else refers to the teachers as instructors, just me. A fellow PWS pointed out to me "that's what makes me special". :)
From: sachin
Some of my best moments of healing came when I saw someone else do something truly courageous: like a senior colleague one day shared openly his struggles with his speech in a meeting. This forced me to think- can I / when will I emulate his example? To get out of covert 'cell', one needs lot of inner courage. This comes to us in those rare moments, when our backs are against a wall- a real crisis- when we can run away no more OR when we see a living example right in front of our eyes.. I think 'time' factor too is important. Only when we have suffered enough and seen the futility of running away, does a crisis helps us to bring out the inner resources of courage.. So, I guess SLPs could help by putting us in touch with such resources- like this conference, where one comes across such real life examples.
From: Dave Williams
"Covert stutterer" is a misleading label. He/she is simply a "standard" stutterer who tries desperately to hide/avoid/conceal/disguise his/her stuttering in every way possible. He may succeed for varying lengths of time, but the effort can be psychologically draining, and taxes his 'creativity' as he constantly seeks ways to keep people from identifying him as a stutterer. It's a hell of a way to live.
From: jonesd
My client does well with me one-on-one, but once he starts to speak spontaneously to novel speakers outside of the treatment room, his rate increases and he doesn't use easy onset like we have practiced. Do you have any ideas on what I can do with him other than interrupting him in the middle of conversation with others?
From: Dale Williams
The first thing that jumps to mind is to model the speech pattern you want him to use. That is, when you're talking to new listeners, you do it first, using exaggerated EOs. That sometimes motivates clients to try the new techniques. To get him back on track, you can join the conversation using your EOs. If this (or something else) works, let me know, as transfer is the most difficult part of stuttering treatment. Clinicians and clients alike are continually frustrated by how easily skills can be mastered in the therapy room and how quickly they can fall apart everywhere else.
From: Walt Manning
JonesD, As Dale suggested, modeling the behavior for the speaker and taking turns with him/her may provide the support the person needs to practice beyond the treatment setting. Working with the speaker to construct hierarchies or ladders of increasingly difficult communication situations is often essential to transferring abilities to daily situations. You might have the person role play some of these situations and them immediately leave the treatment setting and do some experiments - that is, have the speaker predict their success in using EOs or whatever, and then rate their level of success following the experience. Fluency in the treatment setting doesn't mean much - just as scoring baskets on the practice court. It's usually more effective to seek out gradually more difficult game conditions where there are things like time pressure, distractions, unexpected and dynamic circumstances. Hope this is helpful.
From: Charlie Healey
Dale and Walt have offered some great suggestions but I would like to offer a couple of others. First, be sure he is able to use the Easy Onset strategy or another technique you are working on in therapy in a variety of ways. That is, help him use a strategy in an obvious way and then help him learn to produce variations of an easy onset such that it gradually becomes hard to detect but it's still being used. At that level, I ask the client to use a strategy while reading something, underline words where is going to use the strategy without me looking, and then I can count the number of times he used the strategy while he reads. If the strategy use is subtle, it will be hard to detect but hopefully the client knew he was using it. Second, I would role play the use of the strategy as Walt and Dale suggested but be sure you gradually increase the amount of information he is talking about. For example, if you are working on strategies in simple sentences, you might want to move to picture description, then reading and retelling stories, and then move to discussing a topic that he is familiar with as a way to mirror conversational speech. If he is able to move through those linguistic levels with some ease and use of a strategy, then you have helped prepare him for unstructured conversation. Self monitoring is also important in the early stages before any client can expect to use strategies or modify stuttering in conversation. So, help him improve or maintain good self-monitoring skills while speaking along a continuum of easy to difficult topics and have him tell you what he is focusing on when he talks. That might give you some clues as to why transfer is not working so well. Bear in mind though that all of us clinicians have problems with transfer so you are not alone. Hope my suggestions are helpful.
From: Lynne Shields
You have received some wonderful ideas that are all important to the process of transferring skills outside of therapy. In addition to what has been suggested, I wonder if you have talked with this client about how he perceives his speech when he is using easy onsets. This ties in with helping him gradually modify the EO's to be less noticeable, I think. If he views EO's as making his speech sound weird, he may not be inclined to ever transfer them outside of therapy. Spending time talking about how speech sounds and feels different when using their treatment tools compared to when they talk normally. Use of sports analogies can help, too, or any other analogy related to activities the child enjoys doing--for example, if the child plays soccer, ask him how it feels to be learning a new skill or practicing making changes in a skill based on coach input. I think it is helpful to address the feelings that often accompany making a motor behavior change. Best wishes as you work with this young man, Lynne
From: Rick
Hi! Why do 80% of children who stutter recover with or without therapy. Of the 80% of children who do recover spontaneously, when they grow up and have kids: should their male children have early intervention and/or should the parents be extra careful since there is a stuttering history? I once heard a private SLP/SLP instructor who said she had a child client who stuttered and she didn't do anything except help potty-train the child...and the parents were thankful. Thanks! Rick
From: Joe Klein
Wow, Rick, that's a difficult question. Because we do not know exactly why people stutter, it is hard to know why they recover, but let me answer at least part of the question, and hopefully others can add to this. First, I think it is no accident that stuttering starts between the ages of 2 and 4. This is a time of tremendous change and growth: physical growth, language growth, speech growth, cognitive growth, etc. Whatever the cause of stuttering is, it's no wonder that the stuttering "shows up" during this time of great change, which places big demands on tiny people. While the change is great, children's ability to adapt seems to be great, as well, and so in a matter of time, many children appear to be able to overcome whatever the "stuttering" is, and, like you said, 70 to 80% seem to "outgrow" the stuttering, or at least the speech symptoms of the stuttering -- the neurological or genetic cause of the stuttering may still exist, yet the child becomes a normally fluent speaker. I am a pws and have two children, ages 4 and 6, who are normally fluent speakers, although both went through short periods of "borderline stuttering." My son continues to have mild word finding difficulties, but with no associated speech tension. I would have to say that, no, I don't think that just because a parent stutters the children should automatically be in therapy. Being a really good listener, taking your time, having lots of periods of silence while you are together, I believe, are important. If the child does begin to show some signs of stuttering for a period of time, then a speech evaluation may be a good thing. Hope this was helpful. Take care, Joe
From: linamenj
How does a clinician know that a client is ready for discharge from stuttering therapy?
From: Dale Williams
Great question, as this is always a tricky issue. Given the relapse inherent in stuttering, I find it best to wean the client off therapy (as opposed to just stopping). What I mean is that, once the client appears to be able to communicate what he wants to say in any setting, decrease the frequency of visits & see if he or she is able to maintain this level. Then decrease it more. I hope this helps.
From: Vivian Sisskin
I agree with Dale that a maintenance program with the opportunity for periodic check-ins can be helpful, along with involvement in support groups. I also think it is important to prepare a client for discharge by including in the treatment plan goals for 'becoming your own therapist'. These goals are aimed at problem-solving independently to reduce relapse. For example, being able to identify what a success would be in any particular speaking situation (sometimes it is using a strategy and sometimes it is JUST TALKING and not avoiding). If expectations are set realistically, then the client will be able to build on success and not 'spiral down' because they could not do 'on the outside' what they could do in the context of therapy. Another example would be to identify CUES that indicate the need to do a bit of structured work. If a client notices that they are beginning to use an old habit that leads to struggle, then catching this early, and implementing a plan, could prevent reverting to old habits in time.
From: Ellen-Marie Silverman
A very useful question . . . Engaging the client as a collaborator in the therapy process to the maximum extent possible helps. From the very beginning, with that orientation in mind, discuss and negotiate the terms of treatment, which includes the criteria for termination, i.e., goals to be met and general requirements, such as attendance and payment of fees. Keep in mind and share with the client/caregivers that the conditions for a mutually agreeable conclusion are subject to change as new information becomes available, which then, too, become open to discussion and subject, as need be, to negotiation. >>>> As is known, skills and mind-sets introduced and practiced within treatment sessions and monitored situations elsewhere are not as strong, even at the conclusion of formal treatment, as older, competing habits of behaving and thinking, so there will be inevitable lapses. Discussions with clients prior to the conclusion of regularly scheduled sessions about what to expect when these sessions end need to include statements to the effect that lapses will occur, that reverting to older stronger behaviors and mind-sets will undoubtedly happen because the older behaviors and perceptions currently are stronger, and to recognize that all is part of learning, nothing more. When this happens what is needed is to resume applying the new behaviors and related mind-sets that lead to desired outcomes. There is no need for self-recrimination, although problem-solving as to why the lapse occured can be helpful but not necessary. What is necessary is to resume doing what is known to be helpful. That action, of itself, strengthens the desired behaviors and weakens the unwanted ones. >>> So much can be said in response to this basic question. I hope this has been helpful. Thank you for asking it.
From: B. Humphrey
I agree with the responses posted so far. I think it helps to have periodic discussions with clients about their - and our - evolving end goals. It may take some clients time to learn that reaching a "nonstuttering" level of fluency may not be realistic for them, but they may still become effective communicators.
From: Walt Manning
linamenj, You have received some thoughtful responses and I'll just add a few additional . It's often useful to ask the speaker, ever at or near the outset of treatment, a question like "How will you know when you don't need to see me any more?" The point of our assistance, of course, is for the speaker to become independent of us and placing at least some of the responsibility for making the decision on them. It also helps to focus all involved on the finite nature of the time we have together in the therapy process. Often people respond to this question by saying "You're the expert, you tell me." That provides a good opportunity to point out that this is their journey and that they are in charge, even during therapy and certainly following it. I think it's also important to leave the door open for additional sessions, maybe group therapy, maybe supportive booster sessions. Coming back for additional therapy simply means that they are wise enough to ask for additional help and, as others have pointed out, is not a sign of failure. I also think that the people who make the most progress following therapy are those who are involved with with support groups and advocate for others who also face fluency problems. That, by the way, is a final step in in many (e.g., 12 step)programs.
From: Dave Williams
I think the client is ready to terminate therapy when he has demonstrated that he is able and willing to carry out the behaviors and attitudes that he has learned from therapy to the degree that he can be independent and self-motivated. If feasible, arrangements should be made whereby the client can return for further 'refresher' work or consultation if necessary.
From: Courtney Heberling
What types of things do adults often do with children who stutter that is thought to be helpful, but is actually problematic?
From: Vivian Sisskin
I am smiling as I write this, but I would say the most commonly cited bad advice: – Slow down; take a deep breath; and think about what you are going to say'. Slowing rate may be an effective treatment strategy, but not realistic in the moment of stuttering without sufficient practice in a systematic way. That advice just doesn't help the PWS slow down when in the midst of struggle. Taking a deep breath might seem like good advice when parents are observing their child struggling and out of breath. If that advice is followed, it can lead to a maladaptive pattern of inhalation while trying to speak (we speak on exhalation). And finally, most of the time, PWS DO know what they want to say and really don't need to think about it. This advice can lead to a postponement pattern where the PWS waits (perhaps pretending to be thinking), resulting in long silences before content words, a pattern not typical of comfortable speech.
From: Charlton Knowles
Hi Walt glad to see your'e doing the conference again this year. You know my history of therapy well and we have discussed the difficulties of transferring technique generated speech to the outside environment. The question is would you (1) agree that most if not all techniques work in producing better speech? (2) the difficulty in reproducing techniques in the non clinical environment is largely due to the fear/anxiety that we stutterers have in doing something different than our engrained pattern of talking/stuttering and the belief that struggling, avoiding etc will get us out of the situation, no matter how maladaptive it is to achieving better speech. In my case, that's why I think relapse after successful therapy has been my demise. Spontaneous fluency is seductive, it leads the stutterer to think he/she has gotten away with something, when in fact you eventually stutter more as you continue in conversation. From were I sit and my many years of therapy etc, my conclusion is that the only way out of the stuttering cycle is to address the stuttering moment and force myself to use technique generated speech. However,easily said than done What's your thoughts?
From: Walt Manning
Hi there Charlton, As David Williams so nicely explains in his paper 'Some thoughts on stuttering therapy' many techniques 'work' in helping the speaker to produce more fluent speech. Many of them also create speech that, while technically fluent, also feel and sound unnatural. Speakers are used to the experience of stuttered speech and anything new is going to sound and feel weird ' at least for a good while. And, of course I agree with you that transferring the ability to use and be confident when using the techniques to beyond-treatment environments is a major part of making the techniques functional. But change (therapeutic or self-directed) is not as much about techniques as it is about reorganizing the interpretation of your problem (in this case stuttering) and what you are capable of doing about your problem. Yes, improved fluency is an important goal and an indication of success. But goals such as not avoiding, recruiting the understanding and support of others, and assuming responsibility for taking action on many levels are more important. Experienced and wise clinicians should be able to help with all of those things. I hope this response is helpful.
From: Kelly O'Connor
12 y.o boy uses a tongue in left cheek behavior at least 75% of the time when initiating a word. Also accompanied by a prolonged /s/ (no matter what phoneme the word begins with). Frequently the /s/ is sustained, which results in excess saliva. Can produce sentences fluently in very structured activities, but consistently unable to carry this fluency even to spontaneous monosyllabic words. Extremely frustrating for client and family.
From: Greg Snyder
First off--there's no sense trying to change or remove behaviors if the client doesn't want to (or has the maturity to) change his behavior. Many times, the parents are in greater need of direct therapy services when compared to the "client". In any event, I have found (personally and professionally) that a great way to reduce 'secondary' stuttering behaviors is the use of volitional stuttering, negative practice, and the use of gentle/controlled bounce or stretch to initiate speech production. Consistent use of VS seems to be pretty effective at reducing unwanted secondaries.
From: Kim
I have a related question. How do you eliminate/reduce secondary behaviors when the client is no longer stuttering. My client (8y.o) is about 75% fluent in conversation, but squeezes his eyes shut or stretches his mouth open about every 2 utterance.
From: Jack McDermott
What many stutterers have said, and what has helped me — reading or talking to a mirror. Joe Biden credited this exercise with helping him become extremely fluent (and a great public speaker). It is important to focus on a few things though: eye contact, jaw motion, hand/leg/foot movement, and tongue placement. It is difficult to focus on all at once, so I try to focus on each behavior a few times each.
From: Greg Snyder
Hi Kim. Well--to be honest, it sounds like your client is still stuttering. He's just doing a better job at hiding or suppressing overt primary stuttering moments. The notion that stuttering should be clumped into "primary" and "secondary" behaviors is one in which I simply do not subscribe. To me, stuttering is what the body does to compensate or overcome some kind of block occurring at the neural level. So whether the kid does this via repetitions or with eye-blinks is immaterial. It's still a bodily compensation attempting to help force the initiation of a speech gesture. So the client (at least in my eyes) is still very much stuttering. So what to do? Very similar approaches as before. Volitional stuttering (which will negate the need for the eye blinks and the mouth opening). Cancellations--but instead of cancelling out overt stuttering moments, you're cancelling out 'secondary' behaviors. Make healthy eye contact another specific treatment objective. ... Don't let him fool you; he is still stuttering quite a bit (especially if it's every other utterance). He's just allowed his symptoms to take another form, which will significantly impact his effective communication.
From: Melissa M.
I am a student clinician and my client has great anxiety about her stuttering, so much so that she refuses to come to group therapy because she would have to talk in front of strangers. What can I do do address this issue in individual therapy?
From: Klaas Bakker, Springfield MO
It looks like your client needs to learn to control the anxiety in individual sessions with you first. You could do relaxation exercises and learn what it feels like to be relaxed. Then try to maintain those feelings while imagining being in a group of people and having to talk. You could build that imagination up in steps from nonthreatening to more threatening configurations. If relaxation is maintained during this (which is a skill to be learned) we can to make steps in the direction of facing one, then several, others again while maintaining a relaxed feeling. If this works maybe we are ready to face the whole group. This is systematic desensitization and has been an affective approach for many years. Another approach could be cognitive therapy and try to control fear provoking thoughts by more realistic and positive thoughts about the group situation that is so hard. Just some ideas! Hope this is helpful.
From: Lynne Shields
Klaas shared some good ideas for working with your client directly on the anxiety issues in individual sessions. One other suggestion is to consider building up to speaking with others slowly, rather than jumping right to the group setting. At some point, you and the client can create a hierarchy of situations in which speaking with others is involved. Perhaps the easiest step on the 'ladder' might be inviting a friend or close family member to join a therapy session and talk about non-stuttering topics with you and the family member, then stuttering, then inviting someone else at your clinic or school with whom the client is familiar, and so on. Eventually, the client may be able to transition to the group sessions fairly easily with a graduated approach. Regards, Lynne
From: Charlie Osborne
Melissa: I'd like to add to what Lynne suggested, working with your client through a series of structured tasks, arranged from easier to more difficult speaking situations. Providing your client the opportunity for success, in graduated steps, may help her to change her belief system regarding her abilities as a speaker. Working through a speaking hierarchy, one jointly developed by your client and you, will allow her to see that change is possible and that as a speaker she has the ability to make changes. There is nothing as powerful as being able to experience 'success,' to be able to reflect on the experience ('What did I do? What effect did it have on my speech?, etc.), and to project the possibility of further successes. When working with someone on a speaking hierarchy, it is important to let the individual know that there are degrees of success (from not very to a great deal) and that when moving from an easier step to a more difficult one on the hierarchy, it is likely that the level of success may be less, at least in the initial attempts. If the client develops the notion of success as being on a continuum, she will be able to enjoy the degrees of progress she makes as she advances.
From: Brian Humphrey
Melissa M.Wrote: I am a student clinician and my client has great anxiety about her stuttering, so much so that she refuses to come to group therapy because she would have to talk in front of strangers. What can I do do address this issue in individual therapy? Melissa, Is your client anxious about other things too, or only about stuttering?
From: Dave Williams
Anxiety reduction was always my biggest problem as a stutterer. Sometimes the weirdest-seeming events seem to help. In a college Voice and Diction class, I was up front reading aloud a poetry selection. As usual, I was tense and stuttering. There were about ten people in class, and we were fairly familiar with one another. I came to a certain spot in my reading and really got stuck. After a few moments one of my classmates, a girl famous for her loud horselaugh and outspoken , called out: "Why don't you stop that damned stuttering?" A couple of students snickered, and I laughed. Strangely, it was exactly what I needed at that moment. It broke the ice of my intense self-absorption and struggle, and my tension disappeared. I knew the girl did not dislike me, and she was really trying to be helpful in her crude way. I proceeded to finish reading the poem with complete fluency. I certainly do not recommend this 'technique' as a means of anxiety reduction. I only want to point out that there are many ways to reduce anxiety, and the clinician must learn the client's personal psychological makeup and how he responds to different stimuli. My classmate's admonition resulted in only my temporary relaxation, but it was only one of countless experiences that culminated in my realization that my stuttering could not and should not be concealed, that I should face it honestly, let everything hang out. Only then could I achieve real anxiety reduction, confidence, and natural fluency. And it has happened!
From: James
I heard that VP candidate Joe Biden used to stutter, is that true? What was his stuttering like and what did he do to become a fluent speaker today? What speech technique did he use when he had speech therapy. Thank you very much.
From: Michael Retzinger
Joe Biden has publicly shared that the way he overcame stuttering is he practiced reading aloud in front of a mirror and - during law school - befriended a stutterer and worked with him regularly on his speech. The NSA has an interesting review of his keynote presentation at the 2004 NSA Convention on its website.
From: Judy Kuster
There is also a short audio clip of Senator Biden telling how his stuttering could also be considered a gift. It is attached to http://www.mnsu.edu/comdis/isad11/papers/gift11/GIFT.htmlIf you watched the vice-presidental debate last night or his acceptance speech a few weeks ago, a very critical eye would have seen a few times when there were dysfluencies that could possibly be labeled overt stuttering symptoms - remnants of what he probably reacted to as a child. They are currently mild, basically unnoticeable, and he doesn't react to them. I believe he considers himself a recovered stutterer. He is certainly an effective communicator.
From: Mario
Dear Professors Has there ever been a research about Alprazolam. The psych in Belgium gave it to me to be more social and spontaneous. The effect was that my speech increased, and I didn't stutter anymore or lesser than I ever did. I began to practice my phonecalls, I dare to ask almost everything, but side effects were if I did nothing, then I slept much. Sometimes the doctor subscribed me 2 mg a day, and then I slept almost for 3 days, and felt lazy, down, ... So I don't advertise this medicine to anyone. Just asking if there has been any research about it ? Second question is : has there ever been research about stuttering and bipolarity. At Stutt-L has been recently a topic about it, and I have cat II, but I'm sleeping a lot (could be the Alprazolam mixed with the meds for bipolarity) and sometimes I'm very manical (that I have looooooooooots of energy, plans very much, but when I'm down again, then I cancel almost every date I make with friends and isolate myself again. Thanks for your answers, and thanks for being here always, every year again, and taking time to answer our questions. Mario from Belgium
From: Greg Snyder
Hi Mario. Great question, but I'm afraid there's not much to report. To the best of my knowledge, there have been no rigorous or well controlled studies relative to the use of Alprazolam. Some (very) small "studies" (which are really better described as anecdotal accounts) do suggest that Alprazolam may be of some help to some people. Side effects will vary, and the cited dosage was 1 mg twice a day. Why Alprazolam may reduce stuttering is still speculative. It may seem intuitive to suggest that a reduction anxiety may be associated with a reduction in severity; however, other neuromechanisms should also be considered.
From: Michael Retzinger
A knowledgeable parent of a child who stutters - attending a support group for parents of children who stutter and professionals - asked this question at a recent meeting: "Outside of the research and reported findings regarding the effectiveness of the Lidcombe Therapy Program, what research and studies have been completed with children as subjects showing the effectiveness of either fluency training/fluency shaping therapy and stuttering modification therapy?" I found it difficult to answer, and am wondering if the professors would be willing to share a response each of you might have for this parent's question. In advance...Thank you for your responses.
From: Walt Manning
Hi Retz, I've enjoyed reading your replies to several of the other papers at this year's conference. I am aware of three studies that point to the equivalency of both empirically- validated and informed treatments in fluency disorders. The first, Hunick et al. (2004) was conducted with adults and the other two are with children. Marie -Christine Franken found similar result when comparing the outcome of the Lidcombe and the Demands and Capacities treatment approach. She and her colleagues in the Netherlands are in the process of conducting a large study comparing these two treatment protocols. As has already been done in other areas (counseling, psychotherapy, etc.) some of the recent research in fluency disorders is also beginning to demonstrate that it is not the particular 'brand' of treatment per se that facilitates successful therapeutic change, but rather the essential components of treatment that are common across several empirically- informed treatments. Nan Ratner and Patricia Zebrowski have also discussed this issue (see the paper by the two Joes ' third one listed at the conference). 1.Huinck, W. J. & Peters, H. F. M. (2004). Effect of speech therapy on stuttering: Evaluating three therapy programs. Paper presented to the IALP Congress, Brisbane. 2.Hancock, K., & Craig, A. (1998). Predictors of stuttering relapse one year following treatment for children aged 9 to 14 years. Journal of Fluency Disorders, 23, 31'48. 3.Franken, C. M., Van der Schalk, C. J., & Boelens, H. (2005). Experimental treatment of early stuttering: A preliminary study, Journal of Fluency Disorders, 30, 189-199.
From: Julia Irani
Hello! I'm a PWS in Karachi, Pakistan and we've been working on establishing the Pakistan Stammering Association ( pakistanstammering.org) with the help of the ISA. The aim is to spread awareness and create an outlet for those who stutter in Pakistan. We're in the very early stages right now and we're currently holding support group meetings(SGM) in Karachi and Islamabad. I lead these meetings in Karachi. One aspect that has concerned me is that initially we held these meetings for anyone who stammers/stutters (all ages). We had an 8 yr old boy, along with a 70+ yr old gentleman attending the same meeting. I could tell that the child was being overpowered by the older folks. Also, I think adults carry with them a lot more baggage about stammering than a child ever would - so in my opinion, that didn't work well and I didn't go out of my way to encourage parents to bring their kids who stutter to these SGMs. I am curious - do SGM help kids if they were catered for kids alone? What age groups should be grouped together? What approach should be taken? What can we do at these SGMs? I know at the adult SGM, we discuss the stuttering iceberg and try to address teh issues below the surface, we discuss our fears, we use the meeting as a practice ground for public speaking (witha focus on different aspects for each speech - I use the excersizes in John harrison's book "how to overcome your fears of speaking before people", we act out plays and laugh hysterically, and just really engage in speaking - which seems to help adults. What can we do for kids? And for parents of these kids? I should also add, that Pakistan does not have a lot of qualified therapists available, and majority of the people will not be able to afford therapy even if it was available. Currently, a lot is based on "home remedies" and prayers. Therapy is somewhat of a western concept and in a country where survival and providing basic necessities is a constant effort - therapy is a privillege. Could someone please guide me on the fllowing: - How to create the best outlet for kids? - What I need to tell the parents in order to help their kids Look forward to getting some great advice! Thanks Judy - this is a fantastic outlet for us who need guidance about stammering in countries where there isn't much available! Best, Julia
From: Joe Klein
Hi Julia. Wow, what an important question. Definitely visit the website: www.friendswhostutter.org, which is a support group here in the US for kids who stutter and their families. I think there is something to be said for separating kid support and teen support from adult support, but I think it can also be really helpful for kids who stutter to see adults who stutter. Kids as young as 4 attend the Friends conferences, but I think at that age (and younger) it is really the parents who need the support more than the kids, although seeing other kids who stutter certainly helps to normalize the problem. Take care, Joe
From: Julia
Thanks for the response Joe. I did check out the website you mentioned - I think it's great resource, thank you! You made some valuable points about kids seeing aduts who stutter, I do see the benefit, but perhaps it's not necessary on a weekly or biweekly basis?
From: Judy Kuster
I can help lead you to a few resources that you might find helpful. I'm not sure what languages your support organization or the children you are working with speak, but one suggestion is to ask Jane Fraser at the Stuttering Foundation for permission to translate "Because I Stutter" by Eelco de Geues into the language most of the children use. It has good information for kids between 7-12 and would be a good project for the adults in your group, who would also learn a lot about stuttering from translating it. It is already translated into several languages. The SF has other helpful materials as well. There are also a LOT of material in past ISAD online conferences that could give you good ideas. Check some of the following *****A Magic Place: A Magic World by Taro Alexander http://www.mnsu.edu/comdis/isad10/papers/alexander10/alexander10.html **** Messages for Teens Living with Stutteringhttp://www.mnsu.edu/comdis/isad10/isadcon10.html **** Seven Ways to Help the Child Who Stutters (SFA) http://www.mnsu.edu/comdis/isad10/papers/translation10/pdfs/sfa7.pdf is already translated into several different languages on last year's online conference at http://www.mnsu.edu/comdis/isad10/papers/translation10/translation10.html **** Some of the following powerpoints might be helpful in a support group meeting for kids http://www.mnsu.edu/comdis/isad8/papers/ppt/ppt8.html **** The ISAD online conference at http://www.mnsu.edu/comdis/isad7/isadcon7.html has many excellent resources that can be used for children and teens - Looking Back and Looking Forward - It Gets Easier, Kids and Teens Support Projects panel, Presentations by Kids Who Stutter, Several very good "stories" about stuttering, FRIENDS and Family Day: One-day workshop for supporting children who stutter and their parents.
From: Julia
Thanks Judy - these are great! Jane is wonderful, she's already sent me a bunch of reading materials and DVDs. I think it's a great idea to see if we could translate "because I stutter". I'll ask Jane. Oh this is exciting! Thanks for leading me to some fantastic resources :)
From: Lynne Shields
Julia, Joe and Judy have given you some wonderful input and some resources to help you out. I have been associated with FRIENDS: The National Association of Young People Who Stutter here in the United States for a number of years. My good friend and colleague, Susan Short, and I plan 1-day workshops for children who stutter, their families (including siblings) and professionals who want to learn more about stuttering. Lee Caggiano, co-director of FRIENDS, helps us put these events on in the St. Louis, Missouri area. The parents have the opportunity to talk with other parents of children who stutter as well as professionals; the children who stutter have an entire day of being with lots of people who stutter, kids and adults, where stuttering is no big deal; and professionals have the opportunity to learn what stuttering is about from the child and parental point of view. If I can be of any assistance to you in developing a similar model for use in Pakistan, I am more than happy to correspond with you. My email address is: lshields@fontbonne.edu. Regards, Lynne
From: Julia
Wow wow wow! Lynn thank you! I'll surely be e-mailing you ... would love to work with you and learn from your experience! Thank you so much! :)
From: Bob age 11
It's proven that girls stutter less then guys, i was wondering why?
From: Greg Snyder
Hi Bob. It's generally accepted that more girls than boys will have persistent developmental stuttering. Depending on the study, the ratio seems to be anywhere from 3 boys to every 1 girl, to 5 boys to every 1 girl. (Somewhere from 3:1 to 5:1.) Why do boys tend to stutter more than girls? I wish we knew. Maybe the genetics of stuttering are such that boys are more susceptible to girls. Another possible explanation is to suggest that there is a language component to stuttering, and that girls may be better at language use than boys, and therefore stutter less. And there are a couple of other possible ideas why boys may stutter more than girls, but they're all just guesses. Wish I could give you a better or more definitive answer--but I hope this helps.
From: Judy Kuster
Bob, you ask a very good question! Some people believe that when boys and girls are just starting to "stutter," there are about as many boys as girls who have stuttering in their speech. Then, for some reason, more of the girls seem to stop the stuttering. But many of the boys will also stop the stuttering. We aren't sure why more girls seem to get over stuttering than boys. It may be that there are some differences between boys' and girls' language and speech abilities when they are learning to talk. It may be that people expect different things from boys than they do from girls (like some girls are quieter or have less pressure to talk than some boys. Maybe when they talk less, they don't have as many times to notice and get upset by any stutters and as parts of their brain mature, their speech and language improves to a point where the "stutters" in their speech just disappear). It may be something that researchers haven't even thought of yet! Some day maybe you can research this question! When you do research this question, you will discover the same 4:1 (boys to girls) ratio in some other areas, too! When people do research, the first thing they have to do is come up with a good question like you did!
From: Peter Reitzes
Bob, thanks for your question, it is a good one! Greg and Judy did a great job of answering you. I want to add that many people have pointed out that boys often have more difficulties than girls. For example, I work in a school with several classrooms for children with learning disabilities and for children who have speech and/or language problems. In these special classes, most of the students are boys. There is only one girl in each class. Every year I work with about 50 children who have speech and language problems including stuttering. The majority of my students are boys. Most all of my students who stutter are boys. One year, I worked with 8 children who stuttered in my school, all were boys. My students didn't believe me that girls stuttered. So, we did two things. We watched a great video called 'Stuttering: For Kids, By Kids.' This video, by the Stuttering Foundation, features children who stutter including girls who stutter. You can see the video at: http://video.google.com/videoplay?docid=-8736850042887806894 We also planned a stuttering workshop at my school (it was kind of a stuttering party). Speech teachers from local schools brought their students who stuttered including some girls who stuttered. It was a lot of fun to hang out with a bunch of students who stuttered and their speech teachers.
From: Vincent age 16
I was wondering whether normal fluent people feel the same stress as I do. When i miust do an oral presentation I my palms get sweaty and I can't stop thinking about it. It is the same when I am called on in class.
From: Rick
I think Dr. Conture is trying to studying CWS. Nothing is proven without evidence.....talk is cheap. Also the chicken or the egg dilemma...are cws/pws more sensitive...or more sensitive because they were diff. (maybe some other physical traits) or adults/people in their environment more sensitive. I think PWS are just stereotyped to be nervous...and that is unfortunate. We will be asking the same questions 10-20 years from now. Maybe even 50 years from now, scary!
From: Greg Snyder
As a previous poster replied--this is almost a chicken/egg scenario. Are stutterers more anxious as people, thus we stutter? Or--have people who stutter been beaten down by society, thus they have increased speech-related social anxiety. The only real way to answer this question is to do anxiety screenings on children prior to the emergence of stuttering--and see if "anxiety" will predict stuttering behaviors. But with that said--no, I don't think that stuttering is caused by anxiety or some kind of personal character flaw--regardless of what select "research" may suggest. And there's tons of research to support such a position.
From: Charlie Osborne
Vincent: A very good question! I am a teacher and often require students (graduate level) to do oral presentations in class. These are students who do not stutter (at least about 99.9% of them). Some appear very comfortable talking in front of the class, but many do not. I'm not sure how dry their palms are, but often their voices sound a little jittery. Some also stumble over words or repeat them and some use too many interjections. When I ask a question in class or try to generate a discussion, it sometimes feels like I'm pulling teeth to get a response (and I don't think it is because I'm a scary guy; I'm not). Interestingly, the same students provide exceptional, well thought out answers when the discussion is on-line! I guess the whole point to this rambling response is that I believe it is common to feel anxious when speaking in front of a group or when answering a question in class. I don't stutter, and I get anxious in these situations. I have had the opportunity to observe many of my clients who stutter speak in these situations and speak well (whether they stuttered when speaking or not). I don't know if I would have the courage to do what they do if I stuttered or not. My hat is off to you for participating in these activities!
From: Walt Manning
Vincent, Those who stutter certainly appear more nervous than those who don't. Without going into the details (I'll send some references if you'd like) several have suggested and some have found evidence to support the idea that because PWS sometimes do what fluent speakers do when they are nervous the common perception is that PWS are nervous. As it turns out, PWS do not typically have more trait anxiety than those who do not stutter. It's also good to keep in mind that - as I heard Glyn Riley point out at a conference a few years ago - nearly all measures of social anxiety include a large majority of items about speaking with others. So it's not surprising that PWS often show higher anxiety scores on such scales. It seems to me it would be a lot like taking someone who couldn't swim out to the middle of a lake and asking them how the feel about being thrown overboard. There's a good chance the person would indicate some anxiety. It's perfectly normal to show anxiety about attempting things you aren't very good at doing. As another person has already pointed out on this theme,people who do not stutter are also afraid of many speaking situations. I'll never forget my surprise during high school when this big tough football player who sat across from me expressed his fear about giving a book report in class. Since he didn't stutter like I did I had a difficult time understanding why he was afraid. It's normal.
From: Ellen-Marie Silverman
Hello, Vincent. I see you have gotten some pretty good information already. What I want to add is to remind you of something I think you already know but just forgot as you were writing, and that is: People who don't have stuttering problems are no more normal than people who do. They are just people without stuttering problems! >>> All of us have problems of one sort or another. If you think about your friends and relatives and celebrities in the media, you know what I mean. So, it's not that those of us with stuttering problems aren't normal and those who don't have the stuttering problems are; we're actually all pretty much in the same boat. We all have things about ourself we want to change to feel we are more like we think everyone else is. Those of us with stuttering problems work on learning to speak with more ease and predictability to say what we want to say with little to no struggle or conspicuousness. Those who don't have stuttering problems don't, of course, but most do work on what they feel needs working on to feel they are more like they want to be. So, please, take a good look around you: Most of us have something about ourselves we think needs work. And, so, from that perspective, we are normal! I hope these words give you something to think about. Best. Elle-Marie Silverman
From: David Shapiro
Hi Vincent, You're asking a good question. Those of us who stutter often wonder what others who do not stutter experience as they anticipate speaking experiences. Stage fright seems to be common. Also, I have found that people who appear to be most confident and who are the most talented often carry around insecurities and fears that we couldn't imagine; indeed this is normal. People who stutter, however, may become concerned (with sweaty palms and the works) when we anticipate a speaking experience; we predict that we will stutter because we have stuttered and we are stuttering. All of us predict our future on the basis of our past. To me, this means that by creating opportunities to experience fluency success (i.e., often with the guidance of a speech-language pathologist), we can change what we expect. We can come to expect fluency control and fluency success on the basis of accumulated successes. You might want to consider this. Also, you might consider talking with your teacher outside of class about stuttering and how it is handled in class (e.g., volunteering answers rather than waiting to be called on by the teacher, participating in smaller group activities, engaging in active listening, etc.). I bet you and your teacher can come up with a number of suggestions that could be of benefit to all. Good luck.
From: Steve age 9
I was wondering why I've never seen a girl stutter.
From: Rick age 28 and Apology
I wanted to apologize. I am a person who stutters, I did not know any real person who stuttered until I was 22. So I can understand why you are asking this question, it is a good question. More boys stutter compared to girls, so you see more boy stutterers. Certainly there are many male and female stutterers in this world. As you get older and older, you will meet more people, and more people who stutter just like you. Places to meet some people who stutter are the National Stuttering Association www.westutter.org. and FRIENDS who stutter www.friendswhostutter.org. Many females and male stutter all over the world. For many females and male people who stutter, stuttering is not such a big deal and they just sometimes stutter, so you may not be aware that they are stutterers. Certainly, no one stutters all the time. We all have our bad and good moments when speaking.
From: Judy Kuster
Hi Steve. Thank you for asking a good question! A lot of people have never seen anyone stutter, especially girls, since there are a lot more boys that stutter than girls. But the Stuttering Foundation has a great video about stuttering, called Swish, that will show you some examples of both boys and girls who stutter, talking about stuttering. Maybe you want to watch it with your mom and dad or with your speech teacher. It is on the internet at http://www.stutteringhelp.org/default.aspx?tabindex=486&tabid=496
From: Cindy
I am a mother of a child who stutters. It's sometimes difficult for me to know what to work on at home because my child's stuttering changes. whatever we are working on is not what we should be focusing on. It's sometimes frustrating for me as a parent because how do I know what particular tool to practice at any given time. Can you please be sure to speak to the changing nature of stuttering?
From: Vivian Sisskin
Certainly, your SLP can give you some direction here, but I will make some comments on this topic. As you mentioned, stuttering is variable, and there are times when your child may demonstrate a good deal of fluency and other times when struggle becomes severe. Most strategies require practice so that they become habituated or so that your child can access them when needed. New habits can best be learned under conditions when your child is not struggling. I often advise children to practice in low-feared situations, or when only minimal symptoms are present. It is very difficult to feel success from practice when trying to implement strategies in the moment when one feels a loss of control. This is probably true for other motor learning tasks as well — a musician doesn't try a new technique during a performance, and an athlete doesn't try a new skill during a competition. So, it may be that a good time to practice a given strategy is when your child may not appear to need it.
From: Lynne Shields
Cindy, Vivian made some excellent suggestions. When you talk with your child's SLP you might also want to see if all three of you (SLP, your child, you) can work together at times, so that you can learn the therapy tools and be comfortable using them yourself. Your child may find it easier to practice if you, too, are using the techniques when you practice together. And, your child may also have fun teaching you how to use those easy onsets, or whatever method is being used. During the session, you all might also want to talk about what the child wants to practice at home and in what situations. As Vivian suggested, practicing in low stress situations is going to be most effective for acquiring new skills. If the child has a choice in the selection of those easier situations, you might find him/her more likely to feel good about practicing with you. Best wishes, Lynne
From: Michael Retzinger
Cindy - You ask a great question! I know that parents of children who stutter are their child's best hope, and your seeking education regarding what to do is excellent! I am going to offer you some suggestions - as well as my reasoning - behind the suggestions. I apologize if my response is lengthy - I hope this is alright by you! No doubt, Stuttering is a complex disorder. In my personal and professional experiences, stuttering is often initially diagnosed by its disfluency characteristics, and can often develop into a more severe type of stuttering. I have found that the frequency - as well as the severity levels - of stuttering can/will fluctuate greatly over time. I believe there are lots of reasons for this. Regarding your question about what "particular tool to practice at any given time" -- I always suggest to parents that they pursue educating themselves at a deeper level to become active decision makers in their child's therapy...To become their child's best therapist! As a professional, I am very goal oriented. I recognize that the goals of stopping, controlling or managing stuttering are much different than the goal of talking. I am wondering - What are your goals for your child? In my professional practice, I share the following information for parents I have the privilege of working with -- The National Stuttering Association (NSA) is the largest self help group for people who stutter in the world. The NSA has a publication entitled "Letting Go" which can be an excellent resource for PWS, Parents of Children Who Stutter, and Professionals. In the late 90's, there were a number of articles published in "Letting Go" authored by Dr. William Perkins, recipient of the Distinguished Emeritus Award at the University of Southern California for his 50 years of Stuttering Research, as well as receiving the prestigious Honors of the American Speech and Hearing Association. He is - by many - regarded to be one of the past GIANTS in the field of stuttering. He is one of the original "Specialists in Stuttering" who strongly - ferociously- argued for fluency technique based therapy. Anyways - In my work with parents of CWS, I assign parents to read a lot of information from "both sides of the coin" including the articles by Perkins that have been published in "Letting Go", such as "Why Stuttering Hasn't Been Solved", "An Odyssey", "Do Fluency Controls Ever Promote Automatic Fluency?", and "Declaring War On Fluency" to assist them in making educated decisions regarding therapy for their child. Some of the thought provoking and discussion idea's parents have brought to me after reading these articles by Perkins's are generated by statements from Perkins in these articles such as "I (Perkins) assumed, however, that if we could keep our people fluent long enough, eventually their fluency skills would become habitual. Not once did that ever happen." Another quote is this: "My (Perkins) declaration of war on fluency points to a conclusion the experts choose to ignore -- they don't have a clue about what causes stuttering." The blame for failed therapy "lay in the professional failure to recognize that fluency is not the proper objective of therapy". "I (Perkins) discovered that the neural mechanisms of naturally fluent speech production cannot be brought under voluntary control no matter how long you try." And finally (Whew!!) "Voluntary controlled fluency is the wrong scientific objective, to say nothing of the wrong treatment objective. Indeed, the very existence of self-help groups speak to the failure of professional therapy to address the needs of those who stutter, which is not about making speech acceptable to listeners. It's about coping with the feelings that create stuttering and understanding how they offer a path to full recovery." I humbly suggest considering Deepening your education and understanding of the disorder. Have the therapist your working with get these NSA articles for you to read. Know what your goals are for the therapy your child is engaged in. Dr. Richard Curlee once told me that - regarding therapy for those who stutter - "One Shoe Does Not Fit All..." My suggestion for you is this - Find out as much about the shoes - all of them - that you can. Try the shoes on yourself...wear'em for a while before you decide to buy the shoes for your child. He will wear them for a long time, and poorly fit shoes can cause tremendous problems. As you wear them, you will know if your child will find the shoes comfortable... Thanks for letting me respond!
From: Peter Reitzes
Cindy, it would be helpful if you provided a little more information such as your sons age and what the focus of therapy is. For example, it would help to know how your son feels about therapy and stuttering and what activities and speech tools are being used in therapy.
From: Donalyn
Cindy - My 7 year old son did not enjoy having to practice techniques. He told us we should listen to him. His speech therapist in school said he needed to practice more if his stuttering was to get better. We decided to not practice any more techniques as it just created to much hassle for us and him. His speech teacher had a difficult time demonstrating the easy speech things she wanted him to do. The response of Mike Retzinger makes a lot of common sense to me. How do I contact the NSA to get the articles?
From: David Shapiro
Hi Cindy, You are asking a good question and already received some great feedback and suggestions. As noted earlier, I too would need to know more in order to make specific suggestions. However, it sounds as if you could benefit from some guidance from your speech-language pathologist (i.e., assuming that one is working with you and your child). You are right - Home activities indeed are a critical part of the intervention process. For that reason, I recommend that clinicians not only tell the families what should be done outside. Good teaching involves at least telling what should be done, showing what should be done, and then coaching the family in doing what they have heard and seen. I recommend that home activities be designed to support what has been mastered or is being mastered in treatment. That way, the child continues to succeed; this is important. Eventually, home activities are designed with the families and, ultimately, by the families. I hope this helps. Good luck. David Shapiro
From: Pamela Mertz
Hi everybody! I have been doing some reading lately on voluntary stuttering, chatting with pws on the covert list serv, and trying it periodically myself, in my most challenging situation, the workplace. I know several of the experts on this group really believe in the benefits of VS. My question is: how common is it for the voluntary stutter to actually turn into a real stutter? And what then is the best way to manage when that happens? It has happened to me, and the real stuttering moment then becomes much more uncomfortable. Thanks , Pam
From: Charlie Osborne
Pam: I don't have the answer to your question. I am a clinician who doesn't stutter, but I use voluntary stuttering at different points in therapy with most of my clients. When I ask whether or not the voluntary stuttering feels real, the client almost always says that it does. Depending on the client, sometimes we may try to do more VS with an emphasis on changing the way the client is stuttering or on modifying the stuttering during the stuttered moment (or listening to the stuttering on the tape recorder and reflecting on possible options of how to change). My hope is that by practicing options within the confines of therapy will allow the client an opportunity to try the same in ADLs.
From: Peter Reitzes
Hey Pam, it is very common for voluntary stuttering to turn into real stuttering. In my own experience, this seemed to happen a lot less the more I stuttered on purpose. You ask what is the best way to manage voluntary stuttering when it turns into real stuttering? I don't know the best way to manage voluntary stuttering when it turns real, but I can suggest that you may wish to stick to your initial goal of using purposeful stuttering during that moment. For example, if you are using voluntary stuttering to reduce the fear of stuttering (desensitization), I am not sure that you have to do anything except stay in the moment. If you are using voluntary stuttering to practice eye contact, you may wish to maintain the eye contact when the purposeful stuttering turns real. If you are using voluntary stuttering to practice a speech tool such as pull-outs, you may wish to stay with the goal of using the speech tool (the only difference is, now you are using the pull-out in a real stutter, not a purposeful stutter).
From: Walt Manning
Pam, It's not unusual, especially early in therapy - when the speaker has yet to become desensitized to a sufficient degree - for voluntary stuttering to turn into real stuttering. When that occurs it provides the opportunity for the speaker to stay in the moment, continue to stutter, slowing changing the form of the stuttering and achieve VS again. If they are unable to do this - rare, but it does happen for some people, it's a good sign that they need to become much more desensitized about stuttering. Giving oneself "permission to stutter" and to experiment, vary, even play with the stuttering, not only aids in desensitization but begins to break the link between (real) stuttering and being helpless and out of control. There is an important - even critical - distinction between fake and real stuttering. Real stuttering is an out-of-control and helpless experience. It's no wonder it's scary. I ask my fluent students who pretend to stutter in daily speaking situations to see if they can "lose it" to the extent that they can't immediately get back to their fluent selves. PWS can benefit from distinguishing the cognitive experience of being in control of their fake stuttering vs. the lack of control of their real stuttering. When they get good at it they can achieve control of their real stuttering by staying in the (real) stuttering moment long enough to begin creating systematic behavioral change. As the speaker begins to appreciate that it is possible to stutter and not be completely helpless, they can begin to determine HOW they are stuttering.
From: John Tetnowski
Pam, I have been learning quite a bit about voluntary stuttering myself over the past few years. Most of this "learning" comes to me through some collaboration with one of my doctoral students who is finishing her dissertation on voluntary stuttering. I can refer you to her off-line if you would like. Her defense is coming up soon and I just don't want to distract her at this point. However, one of the key things that I learned about voluntary stuttering is that it is used for several different reasons. Among the most common are "negative practice", and "desensitization". I will let you know that preliminary results are showing that voluntary stuttering does decrease "real stuttering" as well as "physical concomitants". As for your main question, "what do you do when voluntary stuttering turns into real stuttering?". I would say that the answer to the question depends on why voluntary stuttering is being done as part of the therapy. If it is used to simply desensitize, then nothing should be done. If it is being used as negative practice, then the client should have a technique to "pull-out" of the real stuttering. Great question.
From: Ellen-Marie Silverman
Hello, John. Just curious . . . did the doctoral student to whom you referred investigate paradoxical intention? If so, what conclusions did she draw about the use of that logotherapy technique. Thanks for your consideration of this element of personal curiosity, something, I myself had intended to investigate, but didn't because other matters just always seemed so much more pressing. Ellen-Marie Silverman
From: John Tetnowski
Ellen, No she did not, but her results are still quite interesting. After her defense, we'll start publishing the results.
From: David Shapiro
Hi Pam, What a good question. I don't tend to use voluntary stuttering personally, although I am aware of many instances of success when people who stutter do. However, I often demonstrate different types of disfluencies while instructing classes and seminars on stuttering. I shouldn't be surprised any longer when my voluntary stuttering becomes an instance of real stuttering. Indeed I need to work though the block when this occurs. I don't believe it is clear why we who stutter have this experience while others who do not stutter, in contrast, can easily terminate the voluntary stuttering and return to fluent speaking. Theories abound. Nevertheless, voluntary or pseudo stuttering is helpful for many people who stutter to maintain a relative easiness or looseness in the stuttering. When the voluntary stuttering becomes real, these are valuable instances to practice the fluency facilitating controls. Hope this helps.
From: Gary J. Rentschler
Pamela: A similar and related activity I have some of my clients do is to "freeze" or hold onto their stuttering moment for an extended period of time. The point of this exercise is to feel the stutter transition from feeling involuntary to becoming voluntary (in other words, after a while the stutter only continues because you are holding on to it as part of the exercise). Once the stutter comes into your control, you can end it. My rule of thumb is to have my clients freeze in the stuttering moment until they start to smile, finding some humor in the silly notion that they are now stuttering on the same sound for a full minute of more. At one stage of therapy, this helps to demonstrate that stuttering is controllable, but only after you get beyond the discomfort of it seeming involuntary. This may not be something to try in the workplace, but perhaps with a friend who you can explain what you are doing. Congrats on having the courage to look your stutter squarely in the eye!
From: Dave Williams
In 1945-46 at the U. of Iowa Speech Clinic, we used to go out in pairs and speak to people on the street or in stores and practice "faking" (voluntary stuttering). We would decide beforehand just what and how we would do it. It was helpful because we were "doing the thing we feared" and this helped to desensitize us. It was scary at first, but we got used to doing it and it could be fun. Sure, in the beginning our faked blocks would turn into real blocks now and then, but this simply meant that we needed more practice and desensitization. It was important that nonstuttering students training to become speech therapists should practice "faking" because they should never ask a client to do something that they were afraid to do themselves. The good citizens of Iowa City became used to being accosted by "stutterers" (real or phony) on the street!
From: Jack McDermott
Hello, I was wondering what the "Prof" would say are the best therapies and methods in both fluency shaping and stuttering modification. What do you find most helpful to monitor speech? What exercises and practice types are there? Also, how often do you recommend speech practice? Thanks!
From: Joe Klein
Hi Jack. You asked about the best therapies, methods, and practice schedule for people who stutter. The short answer to all of those is the best therapy is the one that works best for you. To me, the best therapy is some mixture of fluency shaping (FST)and stuttering modification (SMT) therapy. It all begins, though with a real awareness of what you are doing. From a FST perspective, when you are fluent or stuttering, are you breathing easily? Are you voicing? Are you moving your tongue and your lips, or do you keep them stuck together? From a SMT viewpoint, what are you doing once you begin to stutter? Do you push? Do you lose awareness? Do you get tense and struggle? So, once you know what you are doing, you will know what aspects you may need to focus on. And, as far as practice goes, the more you practice, the better, especially if it is practice in "real" situations. Practicing by yourself helps some people and does other people zippo. The best practice will be, once you have a handle on some of these things, to practice them in public as much as possible. Two more quick notes here: #1: voluntary stuttering, the question prior to yours, is great. If you find you have fears about stuttering, the best way to help that is to stutter in those situations on purpose. Once you do a few times, and realize the world has not ended, it will be tons easier to speak easier in that situation. Last note: It's time to end the idea of fluency shaping/stuttering modification. They are both helpful, and I have no idea where one ends and the other begins... Hope this helped. I wish you the best. Joe
From: Philip
You are limiting a stutterers hope greatly when it is inferred that fluency shaping and stuttering modification therapies or a combination therapies offer the best hope for a stutterer. Just a suggestion: Expand your training. They may have been your best therapy, but there are many many of us who have been harmed by those therapies. Have you ever considered John Harrison's ideas? He doesn't suggest stutterers use the techniques you claim. You say not to focus on which therapy is better, yet you imply they are the best therapy options when put together. Sounds kinda double talk.
From: Joe Klein
Hi Philip. Against my better judgment, I will respond. The question asked was about fluency shaping and stuttering modification. I responded as such. I have read Mr. Harrison's stuttering hexagon and have seen him present at more than one NSA conference. I believe his work adds another piece in the answer to the stuttering puzzle. I also believe that for the majority of people who stutter, it is not enough by itself. Stuttering is not an anxiety disorder. Stuttering is not a psychological disorder. Stuttering is a speech disorder. It is my personal belief (and the belief of many others) that for the majority of people who stutter, work needs to be done in at least 3 areas: 1) Speech 2) Attitudes and Feelings 3) The communication environment. There are some PWS who have no negative attitudes and feelings and do not have environmental triggers, and only need to work on speech (a small percentage of PWS, in my opinion) There are also people who stutter who do not need to work on their speech, but only need to work on their attitudes and feelings, and the environments which trigger them (again, a small portion of PWS). If you were among that small portion, and all you needed was attitudes and feelings change in multiple environments, I am very happy for you. Please do not assume that what worked for you works for everyone. It does not. Also please assume that when I am asked about the paradigms of stuttering therapy, and I answer about those topics, that I believe they are all there is to know about stuttering. They are not. In my humble opinion, people who don't understand that stuttering is a multidimensional problem that needs to be treated as such do not understand stuttering. Thank you for your support. Joe
From: Joe D.
JAck, I agree with Joe K. when he suggests that we need to stop discussing which approach is better. It depends on what your goal is and where you are on your personal journey. For example, if you are avoiding stuttering and making decisions based on what you can say without stuttering, then you will select very different procedures than if you goals relates to reducing the tension in your speech.
From: John Tetnowski
Jack, I also agree with the two Joes. I would also make the point that we should use the literature as a guide to our practice, but at the same time we should be assessing the individual needs of the client. The literature will guide us to what are the best methods for the masses, but a complete and comprehensive evaluation will lead to what is the best method for the individual. A rule of thumb that I use for my clients is summarized in this little verse, "Give the client everything they need to be successful.....and nothing more." What it means is that sticking with one approach may work at times, but it may add extra layers of unnecessary time, effort, money, and other resources on behalf of the client, their family, and the clinician. Keep lots of tools in your toolbox, and use the ones that best fit the job in front of you. Thanks, John T.
From: Jack McDermott
I appreciate you taking the time to respond, however, you misinterpreted my question. I did not mean to start a commotion when you may have inferred that I was asking which therapy is "better" (I have learned the cons of "selective" therapy the hard way). Of course, every stutterer is different. But, in the moment of stuttering many behaviors are the same, and the reaction (block, prolongation, reptation) of this moment appears vastly different. With over fifteen years of attending therapy and support groups, I find these two therapie to be the most complete, concrete therapies for the "masses" as you say (not to be confused with the "best"). My original question, clarified, was: Over your long-term careers, which individual methods WITHIN fluency shaping (i.e. voice monitoring, tape record, breathing) and modification therapies (i.e. pullouts, cancellations, voluntary stutters) do you find most helpful with the least potential for harm?
From: John Tetnowski
Thanks for the clarification Jack. I have found that slightly prolonged speech is probably the technique that has worked best within a fluency shaping paradigm. Pull-outs (accomplished in different forms) seem to have the longest lasting results in stuttering modification, therefore, I would say the most successful. There was no official tally taken here, just pulling back from lots of memories. Thanks for the original question and the clarification. Of course, I still must add again that giving the client what they (the PWS) need most to accomplish THEIR goals is the best advice I can give any clinicians who may read this. The best advice I can give a PWS who is seeking services from an SLP is to let them know what your expectations are. Talk it over and come to mutually agreed upon goals.
From: Jack McDermott
Thanks John, that's exactly what I am looking for! Anyone else with similar or contrasting results (no official statistics needed) please add on... Also, to what John was saying: At what rates do you use for prolonged speech(1 syllable per 2 seconds, etc.)?
From: Judy Butler
I am wondering if any of you observe barriers to increased fluency that prevent someone from changing his/her identity from a person who stutters to a person who is increasingly more fluent. 1. The person who stutters resisting letting go of his/her own identity as a person who stutters; 2. Persons in the environment resist the 'stutterer' becoming a more fluent person. I've read Dr. Montgomery's paper about the benefits of stuttering. I understand that becoming more fluent translates into behavioral changes. The book "Why I called my sister Harry" has a powerful chapter written by the wife of a PWS about her negative feelings as her husband's communication skills improved. Please speak beyond the sense of - now the PWS makes his own phone calls... - and talk about how there may be a mourning the loss of the identity of a person who stutters. For example, a know a wife who says her children whine that their father would not be their father if his fluency improved. I actually think I see this same phenomenon in elementary school children. Thank you.
From: Ellen-Marie Silverman
Hello, Judy. As I reflect on my experience helping people change, I am certain that to one degree or other, redefining oneself presents a necessary challenge to be faced by clients of all ages, which is a task we all face as we grow and evolve. By the time someone with a stuttering problem enters speech therapy, they will have established a portion of their personal identify as someone different from others, usually in limiting ways. So, the process of removing the problem generates the challenge of re-defining oneself, i.e., by substituting a usually broader self-concept for the generally limiting one cudrrently in place. That can be done at various levels depending on need and understanding of the existential question: Who Am I? Not to get too philosophical, here. . . >>> I think you raised well-stated questions about an essential element of treatment, i.e., the need for the client (and, possibly, those closely associated with the client) to expect and prepare for a broadened self-concept that incorporates many or all of the opportunities greater fluency brings. Thank you for doing this.
From: Jack McDermott
Great question Judy! As I have become more mature and in control of my stutter, I have felt this sort of "childhood loss" if you will. From an early age, I was over-trained to hearing my speech with a stutter. Now, when mostly fluent, I think about the growth and changes that have come. From an emotional side of the question, it is difficult to let go, just as it would be to sell an old painting or your vinyl records. This was undoubtedly the largest barrier in my case. However, it is important to understand that you DO have control of your stuttering outcome and to realize (as many SLPs have noted) that stuttering is truly a gift.
From: Peter Reitzes
Judy, great question. Let me speak about elementary school children and older children as well. It has been my experience that using speech tools often means that we are tampering down the child's natural excitement and enthusiasm for speaking. Speech tools are not only speaking in a different manner, but they often require the speaker to sound less dynamic. It seems to me that children (and many adults) are not resisting identify change, but are resisting sounding, well, "boring" or "weird." I know that we SLP folks are fond of saying that speech tools should become natural sounding, but for many, they don't. In addition, some children (and adults) who stutter associate "fluency" strategies more with stuttering than with 'normal' sounding speech. I can show my 4th and 5th graders videos of themselves stuttering and then speaking "fluently" using speech tools. Mom and dad are impressed by the "fluency" takes, but the child is often much less impressed. For the children I work with, I don't sense it is about a loss of identify. I feel it is more about all of the effort it takes to use speaking strategies, the unnatural sounding aspect of speech tools and the lack of motivation to focus on such strategies.
From: Pamela Mertz
Hi Judy, I am not one of the expert professors, but felt I could add a piece here, in response to this great insight. I have had a somewhat similar experience, not with my increased fluency, but with my increased openness talking about my stuttering. For years, I was covert, in many senses. I hardly talked, never initiated conversations, rarely interacted socially, etc. My partner knew all that and became used to how I was, and had a certain amount of "control" in our relationship. After coming out of the closet, and having remarkable change occur in my life - like attending self-meetings, joining Toastmasters, doing radio and tv interviews - he doesn't know what to make of all this. He can hardly keep up with me, and is somewhat shell-shocked. I am very cognizant of the dynamics in our relationship changing, and am careful to include/invite him to participate fully with me. He doesn't - and its hard for him to adjust to the "new me" if you will. // So, I can definitely relate. He is maybe mourning the loss of the me that he was used to for almost 20 years, and is trying to get to know this different side of me. And as a side note, my fluency has not really improved - if anything, I am allowing myself to stutter more openly and more comfortably, which helps me tremendously. Pam
From: Gary J. Rentschler
Growing into fluency is not always as easy at it might intuitively seem. Similarly, people who undergo weight loss take a while to begin changing their self-image as someone who is overweight. For some, stuttering can become an "ego-protecting" justification for not having succeeded at many things in life, or not trying. Once that justification is removed, it can be somewhat scary as you now find yourself as an adult who has never "practiced" trying to attain goals... in other words, you are not skilled because you've never tried before (hope that is making some sense to you?) It can take some counseling and support to make the "final hoop" in therapy... adjusting your self-image as a communicator to match your new fluency skills.
From: Jack McDermott
Professors, I was wondering if you find the incorporation of DAF/FAF into your therapy to prove helpful? If so, in what therapy context? What exercises are best suited for DAF/FAF (phone calls, reading, conversation, etc)?
From: Greg Snyder
Hi Jack. A real quick view of the background...Since we don't know the specific cause of stuttering, we can't really treat the core of the pathology. Instead, our treatments basically try and manage the overt symptoms of stuttering--and are thus limited. As a consequence, I'm really excited about some of the options that are just becoming available. Traditional behavioral therapy, alone, can significantly improve the quality of lives in people who stutter--but the results (relative to speech alone) can be limited in many clients. Similarly, the (sole) use of prosthetic DAF/FAF will likely have limited results. (As will the sole use of pharmaceutical stuttering managements.) But what excites me is the possibility of including traditional behavioral therapy, prosthetic and pharmaceutical stuttering managements. I'm excited to see if and how the synergy of the three will impact overall quality of life and relative ease towards effective communication. In any event--to answer your question, yes--prosthetic use of DAF/FAF can fit well with traditional behavioral speech techniques. (Caveat is that the client must have a realistic view of what prosthetics offer--not a "cure", but they can make life easier for many people.) Traditional fluency shaping techniques are often good matches for DAF/FAF, which would benefit from the gentle-onsets, as well as prolongation of the initial syllable in the phrase or breath group. Targets like amplitude contour (or continuous phonation) would likewise be a good match with what DAF/FAF can offer. Similarly, the 'stretch' (most commonly associated with stuttering modification) would be a very applicable speech tool as well. Anything to help speech initiation while giving the DAF/FAF a voiced sonorant speech signal to 'feedback' through the auditory pathway. And as an interesting side note, some of the benefits of DAF/FAF use (along w/ traditional speech therapy) include increased self-confidence (even though there may not be a big change in actual overt stuttering frequency). Further, many clients have anecdotally reported to me that the use of prosthetic stuttering management devices help them concentrate on their behavioral techniques (or they seem to be able to use their behavioral techniques to better effect).
From: Klaas Bakker, Springfield, MO
Awesome suggestions from Greg. I just wanted to add to this that FAF/DAF may not work similarly in all clients. So in addition to fine-tuning the reason for wanting it in the first place (a "crutch" for tough situations and in addition to therapy, or sometimes even as a tool during therapy) there is also the need to find out what it does with one's actual client. Several freeware, or cheapware, downloadable software programs exist that can be used in assessments to determine how these manipulations work with your client in controlled settings (ask me for details if you are interested: KlaasBakker@missouristate.edu). I get frequent requests by phone about SpeechEasy and I am uncomfortable to send clients this way before checking out what the auditory feedback manipulations can do in the clinic. Even after that I would still recommend therapy (which ensures better self control) as the preferred long term solution. Hope this helps.
From: sachin
I am a covert stutterer, who has been practicing self disclosure, desensitization, bouncing and some prolongation. I have two questions: 1. How does one bounce on words starting with a combination of two consonants like Prepare? Should it be: Pr-pr-pr-prepare OR pa-pa-pa-prepare? 2. What should I do to deal with occasional laryngeal blocks? when no sound seems to be coming out of larynx? The whole system does not seem to be ready to go ahead? Many thanks in advance.
From: Charlie Healey
Sachin: First, I would like to make a few before I get your questions. Using strategies to become more open about your stuttering is a great step in helping you feel more comfortable about your stuttering. Working hard to cover it up will usually lead to more effort in controlling your stuttering so using self disclosure and working on reducing the emotional sensitivity you have to stuttering is a great idea and something that will take time. So, be patient with yourself as you go through this process. Relative to your questions, I would recommend that you use the pr-pr-pr-prepare approach to the bounce if you are going to do that. However, there is a lot of movement that involves turning on the voice on for the "r" sound that you have to start again after each bounce. You might want to try a slide into the word by using less tension in the lips and more airflow as you say the first sound as another alternative...like phhhrepare (it's hard to graphically show how it should sound). But, using a light contact of the lips and/or tongue on the first sound and then use lots of air as you go into the vocal sound and as you make that next "P" sound, do the same thing to keep the air and voice moving through that sound transition. This might work a little better than the bounce. When a laryngeal block occurs, I suggest you do what you can to stop pushing the voice on and struggling. That will not help. Rather, release the tension and slowly approach the voiced sound of the word. Try using the same approach as above and focus on getting the airflow started first, then move into the gradual voicing onset. Or, you could try soft voicing as you gradually move into the vocal sound, like, iiiiiI want to go. The gradual onset is a form of easy onset or you can use the generation of a easy, smooth airflow at the beginning to start the voiced sound. The other thing to pay attention to is what you are doing with your breathing and making sure you have control over the breathstream BEFORE you initiate phonation. Hope this helps!
From: Gary J. Rentschler
Charlie makes a lot of sense and has plenty of good information you should find helpful. Disclosing that you stutter can be a huge step. It's less about how you stutter, than your willingness to let it out that you stutter. Most of my clients have wanted their stuttering to be authentic in your situation. Some have found that their "fake" stuttering becomes real... So it would be my suggestion that your first attempts be to stutter in a way that is unlike your own stuttering, then gradually, as you get more and more comfortable, emulate a stuttering pattern that is like your own. This is an unpleasant task for most of us who stutter, but the results can be quite significant. Congratulations on building up the courage to taking the step and best of luck!
From: Stacy Dreelan
I have a 5th grade student who stutters. His dysfluencies are really "secondary characteristic" looking (glottal sounds and lip smacking). Can you give me any advice about treating secondary characteristics? We have been practicing purposeful stuttering, stretching, bouncing etc... (in addition to social-emotional discussions) but I feel like I am ignoring his secondaries. Any advice would be greatly appreciated. Have a great day.
From: Greg Snyder
Hi. It seems like you're on the right track. My first instinct would be to start volitional stuttering as well. Create as pure, effortless and avoidance-free a stutter as possible (i.e., creating good habits) and let the secondaries fade away. If this isn't happening naturally, I would try two things: (1) Cancellations. Increase awareness of the secondaries, and then cancel them out when presented. (Remember that cancellations can be used in terms of primary stuttering, but also secondary or avoidance-behaviors as well.) (2) I would begin to target one secondary at a time. (And I would target them from easiest to hardest, to give the client a taste for success.) Hope this helps,
From: Shaina Pappadia
I have noticed that some people who stutter are not aware of all of their secondary characteristics. How to you help them to become more aware in a way that makes them feel comfortable?
From: David Shapiro
Hi Stacy, You are asking a really good question, one that is more complex than might appear. At its heart, you are asking about behavioral change. There are many ways to change behavior. Typically, clinicians seek to eliminate unwanted behaviors, such as learned reactions to stuttering behavior (i.e., secondary behaviors). Here is another idea for you to consider. Even in the speech of people whose disfluency is frequent and/or severe, there are islands of fluency. I recommend before eliminating the disfluent and secondary behaviors that you consider working to increase the child's awareness of his fluency. Specifically, by heightening the child's awareness of what he does (and thinks and feels) when he is fluent, he becomes aware of what he already is doing that is fluent and what he can do even more often. For example, when I converse with a school-age child and hear him demonstrate an instance of fluency (e.g., an easy onset or gentle stretch), I highlight it by saying, "That's it. You just did it." Then I will model and describe what the child did (e.g., "When you said the word 'boy,' I saw that you put your lips together very gently on boy. That is great. That's what we want to do even more often."). We do this repeatedly, whereby I identify the instance of fluency, model it back, and describe for the child what he did. Given that children (i.e., and adults) have come to expect a focus on disfluency, they are surprised when I focus on what they already are doing right. Eventually, I step back as follows. When I hear the child demonstrate a fluent instance, I identify the moment ("That's it; you just did it again.") and follow up with a question ("What did you do?"). The child might say, "I said sssee gently." To this, I follow up and model and describe more completely. You see how the child's role in the treatment process becomes increasingly active, engaged, and positive. Here, the next logical step is for the child to become his own clinician, by identifying, modeling, and describing. The child might say, "Did you see what I did?" to which I would respond, "You bet I did; Tell me about it." Then I add to the child's description and model back what the child did, celebrating all the way. Daily home practice is built around this sequence as well (i.e., focusing on what the child has done correctly; that would take me a while to explain). The point is that by increasing the child's focus on fluency and his understanding of what he does when he is fluent, he becomes more aware of the fluent elements and produces them more often. In other words, both the absolute and relative frequency of fluent productions increase; the absolute and relative frequency of disfluencies and secondary behaviors decrease. Only then would I target the disfluencies. All the while, I collect data on the speech behaviors, in addition to that reflect changes in thoughts and attitudes (i.e., usually they move from negative to neutral to positive; e.g., they move from I can't to I can and from I am controlled by the outside to I am in control). Another essential point is that accentuating the positive is very different than negating the negative. In this way, treatment remains collaborative, successful, and fun. I didn't intend to be so long winded, but I hope these ideas might resonate with you. All of us are motivated to do more of what we feel we are good at and what, by our own experience and by accountable data, we discover we can do. Hope this helps. Thanks for your excellent question. Good luck. David Shapiro
From: Stacy
Thank-you so much for your helpful comments and ideas!
From: Vivian Sisskin
Stacy, I work directly on elimination of the secondary behaviors prior to modification of the moment of stuttering. Secondary behaviors are often initially developed to escape the moment of disfluency, and because of that, they continue to prevent the child from getting on to the sound of the word they want to say. This is true of a tongue click, an interjection ("uh"), or a pause (what I call a postponement device). The goal is to have the child reduce the avoidance behavior, stutter directly on the intended sound/word, and then use modification strategies. I find that modification strategies are much more successful when practiced on �clean� stuttering (stuttering without secondary behavior). I start by having the child become aware of the behavior, and even name it (funny names are even better (�lip pulls�) by monitoring it (identifying when it occurs in speech). A good deal of the behavior will decrease just through monitoring. I then encourage the child to get right on the sound of the word they want to say and stutter on it. Speech strategies are much more efficient and generalize better when the child is on the sound of the word he wants to say rather than doing an unrelated behavior.
From: Rick
What are some of the valid subgroups in stuttering? Is covert stuttering really a diff. category, or is covert stuttering just stuttering. Is differentiation by age or severity appropriate. How come some stutterers say they started stuttering at age 9 or age 15???
From: [no name]
Rick, you wrote: What are some of the valid subgroups in stuttering? Is covert stuttering really a diff. category, or is covert stuttering just stuttering. - - - - - Covert means covered. People who stutter covertly may be working quite hard to avoid sounds or words they are afraid they may not say fluently. I once evaluated a woman who sounded quite fluent initially, but the story she told me of the effort she put into planning her utterances to be fluent was amazing. It was very draining for her.
From: Peter Reitzes
Rick, yes, covert stuttering, in its strictest sense, is a difference category. Covert stuttering is often discussed and even hotly debated in the stuttering world. While most people who stutter avoid stuttering at times, covert stutterers do everything they can not to be heard or seen as stutterers. In addition, covert stutterers are largely successful at hiding their stuttering from the world. Many covert stutterers have parents, friends and even wives or husbands who have no idea they stutter. To answer one of your other questions, many of my students have said that they started stuttering at 7, 8, 9 years of age or even older. This is probably because many children are not evaluated for stuttering until they are older or the child is simply reporting the age when he or she first became aware of the stuttering. Or, a child may simply be repeating a parent's memory of the stuttering. For example, a young child may start to stutter and "recover," only to begin stuttering at an older age. The parent may not consider the preschool stuttering to be stuttering at all and thus reports a late onset. The child, hearing the parent, is simply reporting what mom or dad has said.
From: B. Humphrey
Rick, You wrote: How come some stutterers say they started stuttering at age 9 or age 15??? - - - - I assume that the people you are referring to are probably people with developmental stuttering - the usual kind. However, acquired stuttering exists. One kind of acquired stuttering is neurogenic stuttering. Neurogenic stuttering is the result of a brain injury. Fortunately , it is often transient. but it needs to be considered whenever someone reports a late onset. For more about neurogenic stuttering see Dr. Luc de Nil's presentation in the 2007 ISAD confrence, and see my presentation in the 2007 ISAD conference as well. - B. Humphrey
From: DavisR
What are some ways to have my client get his targets to be a habit and part of his speaking routine? He uses the targets when reminded, but as soon as he goes to speak in natural conversation, he does not use them.
From: Lynne Shields
Davis, This is the $1,000,000,000.00 question, isn't it? I think it might be helpful for you to consider answers to a few questions with the client to help you sort this out. First, what does your client think of the treatment techniques? Does he think they make him sound better? Do they feel natural to him? Or, does he really not see them as a fit, as useful? If that is the case, perhaps some modification of treatment goals may be in order. Second, is your client motivated to change his speech? If so, perhaps helping him to feels some ownership in the process of transfer may be helpful. What I mean is having him help select the skill to be transferred and plan specifically what he will do , when and how often. The two of you can write up weekly contracts and sign them, bringing them out the following session to review the results. You are not alone in struggling with issues of transfer, and I wish you the best as you work with your client to solve this puzzle. Regards, Lynne
From: David Shapiro
Hi Davis, I see that you are asking about building and maintaining motivation to use fluency controls over time and place. This is one of the most vexing challenges of all intervention approaches. In an earlier post to Stacy, who asked about treating secondary characteristics, I addressed the importance of creating an opportunity for the client to succeed by focusing on, understanding, and increasing the fluent behaviors, before attending to the disfluent behaviors. Success, I have found, is the biggest motivator of all. For that reason, I keep in mind the following when designing intervention: collaboration, success, and fun. You might want to look at the earlier posting. Good luck. David Shapiro
From: a stuttering group for kids
we are a group of four kids who stutter who meet once a week for therapy. how can other people help us with our stuttering? how often does stuttering go away on it's own?
From: Brian Humphrey
A stuttering group for kids wrote: we are a group of four kids who stutter who meet once a week for therapy. how can other people help us with our stuttering? how often does stuttering go away on it's own? - - - - Hi! I'm glad that your group is participating in the conference! Perhaps your first question would be a good one to discuss in your group. Deciding how you would like other people to help you - and deciding how to tell them - could help you all; and it could help the other people too. Would you like to list some of the things you are thinking of saying here, in this conference? Then we could help you with ideas. Our best information seems to be that stuttering goes away for about 3/4 of the kids who start to stutter. We know that as kids grow into teenagers and adults, stuttering is more likely to stay - and that can be all right. Even if stuttering stays, people who stutter can learn to have better control of speech and stuttering. Even if stuttering stays, people who stutter can communicate effectively. All the best to your group!
From: sachin
Great! You may have to help others so that they can help you! For example, you may have to tell them more about your problem, your difficulties, and how you feel when you are having difficulties etc. You may have to tell them what specifically can they do to help you: Like speaking slowly themselves; not interrupt; not ask too many questions etc. You can do this by writing letters or in some other creative ways. It may not go in some cases- but I am sure one day, you become much bigger than you stutter and it stops mattering. Keep talking and sharing!
From: Steve Sheasby
What should be the long-term goal of adult stuttering therapy, and why?
From: Lynne Shields
Steve, Are you someone who stutters yourself? If so, what goals do you have for yourself? I think the goals can vary, depending on the needs and wishes of the person who is seeking treatment for stuttering. I hope you will respond, as I think this is an important question. Thanks for posting! Lynne
From: Steve Sheasby
Yes I'm a person who has been affected by stuttering. I co-run a self-help group for PWS in London (UK) so I meet many persons on many different journeys. For myself, when I am totally open about stuttering to myself and others, the problem seems to melt away.
From: Lynne
Steve, You wrote that, "when I am totally open about stuttering to myself and others, the problem seems to melt away". So, your primary goal to be open about stuttering has made a significant difference. It seems that you have been quite successful in achieving your goal because it is a good fit for you. As a speech-language pathologist, I couldn't wish for anything more for a client than to figure out and focus on a goal that fits their needs, personality and wishes so well. In my early years of practice, I spent too much time trying to make the client fit the goals rather than the other way around. Of course, that seldom resulted in the best outcome. Now, my early sessions with clients centers on what they would like to achieve from treatment. And, I revisit that periodically, as someone may revise their goal(s) over time. Thanks for posting your question. I hope others will contribute to this topic. Regards, Lynne
From: sachin
I am an adult covert stutterer. Recovering now. Goal for me (self therapy)- more self-acceptance, more techniques to help me communicate better (to stutter fluently, easily, comfortably).. But I guess, it can change over years and life situations.
From: Lynne Shields
Sachin, You wrote that your goals are, "more self acceptance, more techniques to help me communicate better (to stutter fluently, easily, comfortably).. But I guess, it can change over years and life situations.." I agree with you, as I mentioned to Steve, that goals may shift over the years, and that can be a good thing. Once one goal is achieved, another may appear to take its place. Any of us, as we age, find that we have different goals than we had when we were young people. I think it is good to pursue the goals that are important to you, while at the same time being open to accept changes as they come. Best wishes, Lynne
From: Keith in the UK
This is a fascinating topic. I have set many goals in my life at many times. When I changed my mental approach to my Stammering in 2006, I set myself new goals, and as per the advice, I worked out possible ways to achieve my goals. I have been fortunate enough to have spent 90 minutes a day meditating, over the last 18 months. This has had a profound effect on my life, and also my attitude to goals, the way I set them and the way I plan my journey towards my goals. My own personal goal is to improve my communication skills day by day. This is definitely achievable most days, and is a "towards goal" rather than an "away from goal". I find this important as well. Take care, Keith
From: Columbia, SC NSA Chapter
In our discussion this evening we were contemplating why it is that more males than females are diagnosed with stuttering. What are your thoughts on this subject?
From: Dale Williams
Some literature suggests that at early ages (younger than 3 y/o), the gender ratio is roughly 1:1. This implies that females recover more often than do males. Given that, neurologically speaking, females are the stronger gender, this was seen by some as an indicator of a neurological component in the development of stuttering, something widely believed today.
From: Klaas Bakker, Springfield, MO
Neurogenic differences are believable but still require more scientific evidence. I believe the evidence points to interactions between gender, neurogenics, and genetic factors and all of this is tentative. All over the world the majority of adult PWS are male. Nevertheless, there is some evidence that it is actually females more than males who pass on the trait. So, by the time they do they may not themselves stutter anymore (or never did). This is a pretty complex area but I hope I pointed to some possibilities. As Dale said very early on a gender ratio is not so evident, but later it is.
From: Rick
Hi, I have a question regarding Responsibilities of the Client and the SLP. Is the SLP only responsible for teaching the client the "technique" like vowel prolongation and the onus is on the PWS to practice and practice and practice? When there is failure in speech therapy...either the client not making any positive progress or bad relapse. Who is responsible for it? (who is to blame...is it right for the SLP to not accept any responsibility) With stuttering treatment, is it all about motivation or is there a limit. No matter how hard the client is willing to work...sometimes he/she needs to accept his/her stuttering (and the SLP needs to not always focus on 100% fluency or allow the PWS to stutter a little bit)
From: Dale Williams
That's a tough one to answer Rick, given that every client-clinician relationship is different. The client cant show up expecting to be fixed without putting forth some effort. OTOH, I'm not a fan of programs that take credit for gains but tell clients it's their fault if they don't succeed. RE motivation, you're right — sometimes it is not enough. There are individuals for whom managing or reducing disfluencies is not feasible. As you suggest, however, many of them can still find acceptance.
From: Peter Reitzes
Rick, I think it is a great mistake for the client and the SLP to focus on what you called '100% fluency' and on what I call the absence of stuttering. Sure SLPs and clients need to accept responsibility, but not for 'fluency.' My job is to work with my clients to identify what their stuttering problem or challenges are and to work with them to figure out strategies and ideas to change how they react to stuttering and related issues. I do see motivation as being the key issue, but having an SLP who 'gets it,' who listens and who pushes and backs off at the right time doesn't hurt. You write that 'sometimes' the client 'needs to accept his/her stuttering.' I would say that accepting stuttering all of the time is more appropriate. In my view, stuttering is always okay. In my opinion, one can accept stuttering while also accepting that he or she wants to make changes. On a related topic, I recently heard a poker podcast where the hosts were talking about taking risks, trying new strategies and getting over this idea that losing a hand is the worst thing in the world. The hosts were saying that a good exercise for online poker players is to play in a low stakes game (so you can't lose much money) and to cover up the part of their computer screen that shows their hole cards (this way, you can bet, but you can't see your own cards). Players were encouraged to bet and fold depending on how they thought their opponents would act (If the player felt a big bet would cause everyone to fold, they were encouraged to try it). The idea is that many poker players play their cards instead of playing their opponents and using all available information. The idea was to face a situation by trying something completely different. When I first started speech therapy, I went in knowing that any stuttering was failure. But my therapist knew something I didn't' that I could see stuttering differently and that stuttering was okay. My therapist knew that I would have to try something completely different. For me, that meant accepting stuttering.
From: Walt Manning
Rick, as others have suggested there are many variables here, including gender, age, timing of treatment. I assume, by the way, that you are talking about a speaker who is an adolescent or adults. The clinician can support and encourage the speaker by understanding, challenging, and taking the field with the person they are assisting. Not asking the speaker to do something that you (as a clinician) aren't willing to do first is a good guideline. The speaker's successful management of is their responsibility just as running a long race is the ultimately the runner's responsibility. As a clinician, it is their race, not mine. But as the coach it is my responsibility to create conditions where they are likely to succeed, gain insight, self-esteem, and begin to make better decisions that result in a more fulfilling life. How that is done with different people at different times is the challenge and the excitement of treatment. As clinicians we cannot "push the river" as the Gestalt psychologist J. Zinker has said but we can "prepare the canvas".
From: David Shapiro
Hi Rick, You are asking a good question and received some excellent replies already. Imbedded in your question is an assumed definition of success and failure. Is 100% fluency the working definition of success? If so, therein is a big problem - no one, whether the person is one who stutters or not, can succeed under this unrealistic expectation. If a person who stutters comes to use his communication skills in ways s/he hadn't previously (e.g., socializing, speaking in class, ordering in a restaurant, interviewing for jobs), independent of the fluency count (i.e., referred to as the 'frequency fallacy' years ago by Gene Cooper), isn't this increased use of communication reflective of success? In my mind, treatment needs to be characterized by collaboration, success, and fun. These characteristics usually enable each person who stutters to achieve his or her own best. That, in my mind, should be the clinical objective. Also, casting blame can be futile. As a person who stutters and a speech-language pathologist, I realize the importance of embracing a dual commitment to change and to be the agent or catalyst of change. I hope this helps. Keep succeeding! Good luck.
From: John
Dear Professors: In general, is there any advantage for a boy who stutters to have a male clinician (who can sort of be like a big brother). And for a girl in speech therapy to have a female clinician. 93% of speech therapists are female. Any research results or evidence one way or the other? What about race and cultural background considerations? I read somewhere that there is preliminary evidence that it may be helpful...
From: David Shapiro
Hi John, I'm not aware of any data reporting on the effectiveness of a clinician based upon gender alone. So many characteristics must come together in order for a clinician to be effective. These characteristics, among others, include commitment, competence, and compassion. Years ago, Lon Emerick (1974) referred to the interaction between a clinician and a client as the element of 'clinical magic.' I think his notion continues to hold relevance, particularly today. The gender of a prospective clinician, however, occasionally is dictated by the cultural traditions and beliefs of the prospective client or the client's family. You might be interested in a paper I published in 1994 (Tender Gender Issues, in the November issue of Asha), where I addressed your question directly. Good luck.
From: Steve Sheasby
Is voluntary stuttering more challenging for covert PWS than for overt PWS? A good friend of mine is (primarily) covert and he is sure that he has a tougher time than me (primarily overt [or maybe unsuccessful covert]) doing voluntary stuttering. I'm not sure. Any thoughts?
From: Peter Reitzes
Steve, I think the answer to your question has to be 'It depends.' Having said that, let me share some thoughts. Recently I was speaking to an extremely overt person who stutters and I asked her if she had ever tried voluntary stuttering. She jokingly responded by saying, 'You silly boy.' Her response is one I have heard many times over the years from very overt stutterers. But when my buddy and I spoke with her about the reasons that voluntary stuttering may still be worth trying, she responded by saying, 'Why would I stutter on purpose when I stutter so much?' This statement is similar in many ways to what a covert stutterer often says, 'Why would I stutter on purpose when I try so much not to stutter [overtly]?' At the end of the day, I think that overt and covert stutterers may be equally challenged by voluntary stuttering. Both overt and covert stutterers are faced with the fundamental question of, 'Why would I stutter more when I want to stutter less?' I have met very overt stutterers who are just as negative or positive towards voluntary stuttering as are covert stutterers. I can remember facilitating a voluntary stuttering activity at a self-help meeting well before I was a speech pathologist. I suggested to the group that we have an additional sharing section where the goal would be to stutter the most, not the least, by using voluntary stuttering (of course, participation was voluntary). A few very overt members were furious at this activity because their personal goals were very 'fluency' based. Such a 'fluency' based outlook can be very similar, in my opinion, to covert stuttering. So to summarize, in my opinion, voluntary stuttering can be equally challenging to both overt and covert people who stutter. Let me add that voluntary stuttering can also be equally rewording to both overts and coverts.
From: Steve Sheasby
I've heard that voluntary stuttering should be made progressively more like one's old way of stuttering. Why is this?
From: Charlie Healey
Steve: That's an interesting notion that voluntary stuttering is used to progressively resemble an actual stuttering behavior. I begin right away with trying to help the client pseudostutter in the same way he stutters normally. Many times when I use voluntary stuttering to help a client learn how his stuttering feels and sounds, a fake stutter immediately turns into a real stutter. I always ask if a faked stutter felt or sounded real. When you can do something on purpose that is usually considered out of control, then you have much better learning and understanding taking place in knowing what to do to make changes in way one talks. The sooner we can make stuttering real, the better, at least in my mind. Also, bear in mind that the focus of voluntary stuttering is not only to learn what is happening when stuttering occurs, but to also bring stuttering out in the open and do it on purpose for those clients that tend to push the stuttering down inside and are afraid that someone will hear them stutter. So, there are lots of ways voluntary stuttering can be used in therapy but I don't think that gradually moving from very artificial stuttering to real stuttering is the way I would think about the purpose of voluntary stuttering.
From: Peter Reitzes
Steve, there are numerous reasons to use voluntary stuttering. Here are a few: To reduce your fear of speaking and stuttering (desensitization), to practice speaking strategies such as pull-outs or cancellations, to practice stuttering with eye-contact, to practice staying in the moment and listening to others while stuttering, to stutter without shame, to set a model for how you want to stutter such as stuttering easily with eye contact and to demonstrate to others that stuttering is not shameful. You ask ,'voluntary stuttering should be made progressively more like one's old way of stuttering. Why is this?' Perhaps someone was suggesting to you that a person may begin stuttering easily as a child and that voluntary stuttering should return the speaker to this easy manner of stuttering. I have heard this said before. Many people who stutter begin using secondaries near onset (maybe even at onset). So I think it is a myth to say that stuttering begins easily. However, that being said, I have no problem with voluntary stuttering being used to model or practice easy, forward moving stuttering. I just also know that voluntary stuttering has many other uses as well such as hard or noticeable stuttering for desensitization purposes.
From: John Tetnowski
Steve and Peter, I agree with Peter that voluntary stuttering (VS) can be used for several different reasons. Some very old research shows that the use of a specific type of VS (part word repetitions) actually has the effect of reducing "real stuttering" (not to mention, a potential decrease in anxiety....i.e., desensitization). This theory was recently tested by one of my doctoral students and held up through experimental trials. She is defending her dissertation on November 7, so I hate to speak for her, but the results are very exciting. The results WILL be published soon. Great thread!
From: Jim
I am wondering if you can comment about the changing nature of stuttering. I have a nine year old son who has been stuttering since he was five. In that time, we have seen his stuttering change from mild to severe and back to mild again and the process repeats itself every so often. We try to identify triggers but often we are unable to pinpoint the cause of the change. He sees a private therapist who specializes in stuttering as well as a school SLP. I am curious to know your thoughts. Thanks.
From: Barbara Amster
Jim One of the difficult things about stuttering is that it can be quite variable and sometimes seeming to be episodic. Although sometimes these changes may relate to environmental triggers, at other times I think that they may be related to the child's thoughts and feelings. Also, speaking is a motor act and you may have noticed that whenever we perform a motor act such as exercising, sometimes we are better at it than at other times. I suggest that you try not to pay too much attention to the day-to-day changes in your son's fluency rather focus on overall communication and participation with others. Hope this is helpful, Barbara.
From: Vivian Sisskin
Jim, Yes, it's true — stuttering frequency and severity are variable. I agree with Barbara that focusing on 'good day vs. bad day' can lead to frustration. Sometimes it's a good idea to focus instead on what strategies or coping skills your child can USE in those situations. This is also helpful for the child because he begins to focus on what he can DO to work towards increased comfort in communication rather than 'what is happening to him' at any given moment. For example, he might understand that on a day with mild symptoms he can work on a speech motor strategy, and on a day with severe symptoms he can work on just saying what he wants to say rather than avoiding. In both of these scenarios he will experience success, which translates into mastery of long term goals.
From: Tom Brennan
I would appreciate input from some experts on a question that I have. As clinicians, we are told to monitor and that much of stuttering is related to problems in monitoring hence the use of daf etc. As my Meniere's disease progresses I find that my stuttering is reduced the less I can auditorially monitor myself. I say this both through my impressions as well as more formal measures of my stutter.
From: Brian Humphrey
Tom, you wrote: As my Meniere's disease progresses I find that my stuttering is reduced the less I can auditorially monitor myself. I say this both through my impressions as well as more formal measures of my stutter. One of the effects of altered auditory feedback, like DAF, is that it may bring about a change in the way we self-monitor. It is a question that invites further study. When we speak, we can pay attention to auditory, tactile, and/or kinesthetic feedback. For example, when I am using Delayed Auditory Feedback — for example, when demonstrating DAF to a class — I have noted that DAF causes me to pay more attention to how my mouth is moving and to other sensations of speaking, rather than to the sound of my message. There has been some speculation that frequency altered feedback may work because it may lead us to perceive ourselves to be "speaking in chorus" with another voice that is "not our own. We have known for a long time that choral reading is a fluency-enhancing condition. Let's see if others may have additional insights about your question.
From: Rick
The Great Famous basketball play Wilt Chamberlain, did he used to stutter?
From: Judy Kuster
Although there are several pretty famous basketball players who stutter(ed), including Bill Walton, Ron Harper, Bob Love and Kenyon Martin, I can find no evidence that Chamberlain was a person who stuttered. Your question however, is already on the fourth page of Google search if you use the key words "Wilt Chamberlain" +stutterer!!
From: Judy Kuster
You may be interested in a long list of Famous People Who Stutter(ed) that can be found on the Stuttering Home Page. The direct URL is https://ahn.mnsu.edu/departments/center-for-communication-sciences-and-disorders/services/stuttering/information-about-stuttering/fun-information/famous-people-who-stutter/
The Stuttering Foundation also has a nice list at http://www.stutteringhelp.org/Default.aspx?tabid=128
From: Jay
Do we say that Joe Biden used to stutter, a former stutterer, a recovered stutterer, or still a stutterer? What about Bruce Willis, James Earl Jones, or Julia and Eric Roberts. Do those famous people mind being called a stutterer or prefer the term "used to stutter"? I believe Bill Walton calls himself a "recovered stutterer" and it is too bad Bill Walton doesn't do more for the stuttering community since his voice is so famous now! Why doesn't he???
From: holzmannd
My client stutters (primarily blocks) when he says his first name and occasionally on vowel sounds. The average listener generally does not notice and even I, as a student clinician, have a difficult time recognizing his stuttering moments. Our therapy targets focus on slow rate and easy onset, but my client has repeatedly expressed to me that he feels he sounds worse using his targets. This is because he thinks his speech sounds unnaturally slow. I have a difficult time helping him with his stuttering if he does not see the targets as beneficial. Any advice on how I can convince him to consistently use his targets?
From: Joe D.
Talking slow is very difficult to use naturally and most people prefer to speak as fast as they can. Perhaps you and the client can explore the value of reducing his rate and explore several different rates to see what he can use functionally. The second issue relates to him being safe stuttering the way he does now. You mentioned that nobody notices his stuttering so why would he switch to something that everyone would notice -like talking slowly? This is a risk as it might draw more attention to the exact thing that he wants to hide.
From: Brian Humphrey
holzmannd wrote: My client stutters (primarily blocks) when he says his first name and occasionally on vowel sounds. The average listener generally does not notice and even I, as a student clinician, have a difficult time recognizing his stuttering moments. Our therapy targets focus on slow rate and easy onset, but my client has repeatedly expressed to me that he feels he sounds worse using his targets. This is because he thinks his speech sounds unnaturally slow. I have a difficult time helping him with his stuttering if he does not see the targets as beneficial. Any advice on how I can convince him to consistently use his targets? Holzmannd, You write that most people do not notice his dysfluency. How much does it bother him? Is your client a child, a teen, or an adult? Who decided that he should participate in therapy? If most people do not notice his dysfluencies, who is/was concerned about his dysfluencies? Is your client concerned? Your story reminds me of a young client who told me that he did not want to speak slow; he wanted to speak fast. He had been in treatment for a while, so we tried an experiment. I let him talk as fast as he wanted, and I measured his percentage of dysfluencies. Then, I enforced a slow rate, and I measured his dysfluencies. He was more fluent when he was allowed to talk as fast as he wanted to. Reduced rate probably helped him to establish fluency; however, I now remember to check periodically to see if a client may be ready to speak at a faster rate. It is easy to forget that a slow rate may be a treatment technique but not necessarily an end goal. - BH
From: James
Hi, I read from www.stutteringhelp.org: "Top-ranked golfer Tiger Woods tells CBS's 60 Minutes that it takes hard work and a competitive spirit to overcome childhood stuttering. 'The words got lost, you know, somewhere between the brain and the mouth. And it was very difficult, but I fought through it. I went to a school to try and get over that, and I just would work my tail off,' Woods told the news program. Does anyone know which speech school Tiger Woods went to? Thanks!
From: Judy Kuster
I can find no reference to the specific "speech school" Tiger Woods attended when he was a child. There is reference to "a school" and also insight into how he overcame stuttering in the Newsletter of the Demosthenes Society, April 2008 (p. 2) >>Tiger Woods says the competitiveness he learned from his mother helped him overcome a child- hood stutter. In an interview with CBS '60 Minutes' televised on March 19, 2006, the world's No. 1 golfer says, 'The words got lost, you know, somewhere between the brain and the mouth. And it was very difficult, but I fought through it. I went to a school to try and get over that, and I just would work my tail off.' Woods had some extra help, too. 'I would talk to my dog and he would sit there and listen, and he'd fall asleep,' Woods says. 'I finally learned how to do that, without stuttering all over myself.<<
From: Yvette Halpern
Would appreciate ideas/activities for transfer and maintenance with a 21 year old technical college student, particularly in monitoring/reducing use of fillers (uh) combined with glottal tension, and in using more natural intonation.
From: Lynne Shields
Yvette, You asked about transfer activities, so I assume that your client can monitor his use of fillers in the clinic setting and an also use more natural intonation there. If that is the case, then perhaps you and your client can spend some time planning a series of transfer activities, beginning with whatever the client believes would be the easiest activity and working up to more challenging. It is hard to say what that might entail, as it depends on the situations in which he can envision himself transferring those two behaviors, and with what frequency, etc. For example, if he thinks that he is able to monitor his use of fillers in a conversation with a friend or family member (one-to-one) for 5 minutes a day, you can ask him to 'collect' as many of his uses of fillers during those daily periods and report them back to you. Once he can 'catch' them easily, then he can begin attempting to reduce their number, if that doesn't happen as a byproduct of catching occurrences. The client can decide ahead of time what number of fillers would constitute 'success'. At first, you might expect him to catch quite a few fillers, and eventually, once he is more aware of them, you would expect the number of fillers to reduce to, as an example, no more than 1-2 per minute of conversation, or something of that nature. Once he sees success in that situation, he can decide on a more challenging situation, and continue moving up the heirarchy of difficulty in tranfer activities. The same can be done with intonation. I'm not quite sure what you mean by naturalness there--are you focusing on his naturalness while using speech modification techniques, or simply in using more normal intonation, regardless of whether or not he stutters? I hope this is helpful. Perhaps you can elaborate more on the problems you and your client are experiencing if I haven't sufficiently addressed the concerns. Regards, Lynne
From: Pamela Mertz
I am practicing for a speech I am giving tomorrow night at Toastmasters. Typically, I will write out my speech and practice it until it feels natural, and then just use that as a guide. Unfortunately I do not have this speech memorized. As I have practiced it today several times, I notice that I am stuttering much more than normal, even while alone. I have noticed this too in the past, I stutter more when reading aloud. I am more fluent with extemporaneous speech. A friend in my support group has the same challenge - more stuttering when reading from notes or script. Is there anything in the research that supports or explains this? I feel pretty nervous when practicing, thinking that I am going to stutter more overtly when its time for the real deal. I have been open with my Toastmasters club - they know I stutter. So, I shouldn't be anxious, because its already out there, but I don't want to stutter a lot in tomorrow's speech. Thoughts?
From: Brian Humphrey
Pamela, you wrote that you have noticed more dysfluency when reading aloud than when speaking extemporaneously. I have noted that with some clients, while others have been more fluent when reading aloud. Although reading aloud may help us to plan for words that we are about to speak, reading aloud also requires us to say the exact words on the page.
From: David Shapiro
Hi Pamela, As a person who stutters, I can relate personally to your predicament. Let me offer my thoughts by way of sharing a story. Several years ago, the Chancellor at our university asked me if I could be available to give the commencement address. Mind you, when the Chancellor asks, you don't say, 'I'll check my calendar.' You say how happy you are to do so, and later you worry about what you got yourself into. Well, after writing the speech, I could predict every word on which I could be disfluent (i.e., this is common among people who stutter and referred to as the anticipation effect). After driving my family nuts with my anxiety, I went up to the Blue Ridge Parkway in the Great Smoky Mountains where we live to practice the speech and visualize its delivery. I presented to some of the most majestic pine trees, swinging back and forth. They seemed very pleased. Well, you should have seen the reactions of the many tourists who drove by to enjoy the mountains, observing me presenting to the trees. When it got to the day of the presentation, I figured that nobody's reaction could be as strange as those I had already experienced. One of my colleagues knew what this speech meant to me personally and professionally; she told me that if I became anxious, she would be wearing a big, black rimmed hat and sitting in the center balcony. If I needed, she said to look up, find the black hat, and she would be smiling at me with confidence. Well, getting started was hard, but there she was. With the tourists'reactions and her smile, I nailed it. You will too. I recommend that when you practice in your place of peacefulness, you visualize the audience and the location. You probably noticed in the recent Olympics that athletes do this as well. Remember that those around you are smiling at you with confidence. We all need to borrow a little confidence from others at times. What goes around comes around; you will return the favor to someone in due time. I'm rooting for you. Your friends and colleagues in Toastmasters are rooting for you. Go for it. Be buttressed by the confidence others have in you. Good luck.
From: Pamela Mertz
Thanks so much for sharing your story. I did my speech this evening. I did well. It wasn't perfect, but it didn't need to be. Several minutes in, I found myself no longer glancing at my notes, but just telling the story. I missed a beats, but NO ONE KNEW BUT ME, so it was fine. People laughed, and I got through one of my biggest challenges. Telling a humorous story. Some one once told me, the victory is in doing, and I did it. Thanks again for the very encouraging sharing.
From: Ed Feuer
To what extent have misguided beliefs about professional solidarity or a code of silence impeded real advances in the treatment of stuttering and caused coverups of incompetence and flawed research methodologies? I refer to such go-along-to-get-along imperatives as: Thou shalt never criticize practices of the profession and by implication, other members of the profession. What penalties exist for violating that code? And what protection does ASHA provide for whistle-blowers?
From: Gary J. Rentschler
Ed, most professions have the "niceties", and SLP is no different. I think you'd find there to be a great deal of diversity in beliefs about stuttering amongst those in the field. Amongst the things I've learned in life is not to try to make myself look better by putting others down. I hate when I have a carpenter or plumber to fix something in my house and have him badmouth to previous guys who did work for me. The whole situation just leaves a bad taste in my mouth. But don't mistake that for a lack of diverse opinions and beliefs. When clients ask me my opinion about another therapist or researcher, I'm happy to provide my bias and explain how my personal views differ from others.. but that doesn't come along with "an attitude". Every profession has its "prevailing thoughts" and theories.. the same for SLP. Yet there are always those mavericks out there exploring other avenues... same in SLP. So I don't see that any lack of criticism is playing any role?! The ASHA Code of Ethics does not have a specific prohibition about bad mouthing or being critical of others... its just in bad taste, perhaps reflecting poorly on the profession. The sanctions for violating the Code of Ethics can be significant... including losing your certification.. this is paramount to not being able to be employed as an SLP. Almost all therapists are certified, but the same is not true of researchers. I'm inferring from your question that you feel that SLPs in stuttering are just large, solidified unit.... from my vantage point I'm not seeing that. Its a free market out there. Anyone is free to do any research they wish and invent any treatment they wish. But not every research or treatment endeavor is successful or based in good science. But if someone doesn't explore their ideas wouldn't that decrease the likelihood that good findings would result? Maybe there's a profession that's different than that, but I'm not aware of it. I don't see the conspiracy to which you allude.
From: [no name]
Ed, I don't see it either. I don't know of any other specialization that has so little inhibition in expressing opposite opinions, or to point to flaws in research, as stuttering. Your question seems to be an example of it. if a new thought doesn't generate criticism it may not be of interest to our specialization.
From: Ed Feuer
Gary, I attempted to get discussion going in this section last year on the more salient failings of the SLP profession regarding stuttering therapy. Apart from one guy who quickly went to ad hominem attack, none of the many professors here wanted to talk about the continuing travesty of clinic-room fraud; token therapy; short-term quickie fixes; distractor devices and some SLPs peddling these devices; the false hope of the pink pill; flawed research methodology in which subjects are not differentiated according to severity, age, gender, overt, covert, before or after intensive treatment; school boards paying SLPs unqualified to treat kids who stutter; and other SLPs not blowing the whistle in such situations; ASHA not enforcing standards; and the absence of genuine multidisciplinary interaction. That silence was instructive. Stuttering is by no means solved and one would think there would be a great deal of spirited discussion and disagreement. Not so. That's why from what I've seen here and in other places, it's so easy to conclude that misguided professional solidarity and a code of silence limits the vital exchange of differing opinions one sees in other disciplines. I advocate enlisting relevant experts from other disciplines who have expertise that SLPs don't have to work with SLPs in a a coordinated multidisciplinary team approach in the treatment of stuttering. Once SLPs realized I wasn't talking about a Lone Ranger, sole practioner "eclectic approach," many of them became hostile. Others preferred to remain silent. Tell me, Gary, what would happen professionally to someone with the three C's who advocated what I do? Care to speculate? Would they suddenly find they can't get their work published in peer-reviewed journals? Would they find they don't get invited to present at SLP forums? Would they get hired in your university departments? Would those who now work in academia find the road to tenure blocked? Enlighten us.
From: Gary J. Rentschler
Like Vivian, I too spend my time teaching graduate students how to do stuttering therapy and providing continuing education for SLPs. In response to your question about what would happen to an SLP if they expressed the views you do.... There are legal actions for SLPs and the lay public to pursue... but accusations differ from facts. An inaccurate accusation is slander. There are ethical sanctions for SLPs who do not provide services competently to clients Ethical complaints submitted to ASHA are taken very seriously and resolved. So I must conclude that others, including yourself, don't have the factual data to support their accusations, or are satisfied with their own inaction. I would submit that there are adequate systems in place to deal with unprofessional behaviors... so why do you think they are "untested" in the area of stuttering? You suggest a "code of silence"... in my view, this is unlikely because there is nothing to prevent any person, SLP or not, from filing a complaint. With regard to peer-reviewed research articles, I have not seen your concerns to be borne out. As a profession, we are looking for new ideas, not "reassurances" that our current thinking is "the only way". I see the tenure process in the same light. Our society is so quick to jump to legal action that tenure committees and reviewers for journals would not risk a discrimination suit. Is the world perfect? No. But again, we seem to have a very different perspective on this issue.
From: Vivian Sisskin
Ed, I am not sure that I observe a code of silence. I do observe a fair number of clinicians who are put in a position to treat PWS without enough training and education to feel confident or to problem-solve effectively. Those who specialize in stuttering, and some of us who are active in ASHA's Division 4, are working towards providing the appropriate continuing education experiences to fill this gap for clinicians. I will speak for myself and say that rather than criticizing others, I find my time is better spent learning more about stuttering, mentoring new clinicians, responding to questions from clinicians who would like to problem-solve better, getting information out to SLPs who are seeking resources, and encouraging graduate students to continue to read the literature when they are out working in the field. I tend to learn something from all SLPs who work with PWS, regardless of their specific treatments or ideology.
From: Lynne Shields
Ed, As others have pointed out, ASHA has a clearly-defined set of procedures for anyone, consumer or peer, to report unethical practice in the field of audiology or speech-language pathology. These are utilized and ASHA investigates and, if warranted, decides on disciplinary actions, which are reported in our professional publication. As Vivian stated in her response, those of us who have experience working with people who stutter make it a part of our practice to consult with other SLPs who do not have as much specific expertise in the area. I consult regularly with school SLPs in my area and give in-services in area school districts. I work with colleagues to present information on stuttering treatment at local and state conventions in my area, and help to organize support activities for children who stutter, their families and SLPs who want continuing education in fluency disorders. I know that this is happening in many locations around the country. Whenever I have an opportunity to present on the topic of fluency disorders, there is always a large audience, so I know that there are many SLPs who are eager to learn more about this disorder. Other SLPs in area hospitals and clinics refer clients to our clinic as well as to other SLPs in our area where fluency specialists are employed. So, while the system is not perfect, I see a growing awareness of ways to insure that those who stutter and who wish to engage in treatment can obtain effective services. Regards, Lynne
From: Ellen-Marie Silverman
[[To what extent have misguided beliefs about professional solidarity or a code of silence impeded real advances in the treatment of stuttering and caused coverups of incompetence and flawed research methodologies?]] Hello, Ed. Stirring things up as usual I see . . . smile. I appreciate all your many efforts to help those of us who are speech-language pathologists become better acquainted with our intentions regarding our own and our collective approach to and conduct of professional service. In this matter, though, you must know that speech-language pathologist, like all members of a regulated service profession, experience solidarity in the sense that we subscribe to a code of conduct, or ethics, and that we enjoy the opportunity to meet face-to-face annually for the purpose of maintaining and up-dating our individual and collective skill and knowledge base at our annual Conference. Then there are the special interest groups where we teach and learn from one another, and the journals to which we contribute and which we read . . . So, what's new? Speech-Language pathology shares a structure common to regulated service professions to bring members into and maintain members within a professional community based on common purpose, i.e, to provide high-quality service to the general population. In fact, it would be impossible to conceive of and establish a service profession without a sense of solidarity, i.e., shared purpose. But this doesn't mean speech-language pathology advocates or subscribes to a code of silence. Like all organizations, most of which were instigated, if not structured, by innovators, ASHA might now seem a bit conservative as it seeks to protect its legacy of commitment to preparing members to function at at least a satisfactory level. All organizations of which I have become familiar, even artists' leagues, function similarly. So, the long and short of it, Ed, from my perspective, is that ASHA is an organization committed to preparing its members to provide quality service. If you are privy to examples of the application of a code of silence within the profession, especially if you perceive it to have caused harm, then be the whistle-blower. Bring that knowledge to the attention of the appropriate parties. That's the right and, I think, duty of any concerned individual. >>> Best wishes and thank you again for your efforts to help us become more thoughtful, effective practitioners. As such, we share a particular solidarity.
From: Ed Feuer
Ellen-Marie accuses me of "stirring up things as usual." Well, to that I can only say that given the current sad state of affairs in stuttering therapy, it's incomprehensible why SLPs are not doing the stirring up. Regarding incompetent clinicians, I refer those who replied to Woody Starkweather whom I quoted last year at: http://www.mnsu.edu/comdis/cahn_mnsu_edu/10profin/_disc53/0000006a.htm His statement on the subject (which broke the Code of Silence) might be somewhat tougher to spin away than mine. Gary said "there is nothing to prevent any person, SLP or not, from filing a complaint." Tell me, Gary, how many complaints have SLPs filed to ASHA about SLPs who lack competence to treat stuttering? I have put forth some of the severe failings of what currently passes for stuttering therapy, most of which the professors here have not and cannot refute. So what's it going to take for real change? Will people who stutter have to file a class action against ASHA? Maybe it's time for the SLP profession to get out of stuttering altogether. Maybe instead they should concentrate on their hot new area of swallowing disorders (gulp) -- something that has nothing to do with speech or language although there is pathology and not necessarily on the part of the patients. Maybe stuttering should be handled by clinical psychologists with a specialization in desensitization. And maybe they'd prove to be better facilitators in a coordinated multidisciplinary team approach. There is something about stuttering that produces much denial, and take note students, that denial also affects practitioners invested in the status quo.
From: Ellen-Marie Silverman
Ed, your reference to the post I sent you suggests the content was different from what it actually was. The post I sent you was/is a statement of appreciation for the encouragement your have of reminding us to be aware of our intent and actions in the service of those who have or may have stuttering problems, and it was an invitation for you to file any and all complaints you may have against speech-language pathologists whose professional activities you know to have harmed clients with the appropriate entities. Nothing more and nothing less.
From: Ed Feuer
Thank you, Ellen-Marie, for your "statement of appreciation." But I think that what we (the professors and I) have here -- at best -- is a failure to communicate. My view is that those professors who are concerned about the current sad state of affairs in stuttering therapy should be speaking up in various forums including this one. Things won't be fixed until those professionals with integrity are willing to admit publicly and in a forthright manner that there are problem. Take clinic fraud, please. There are variants but clinic room fraud consists basically of the following: It's not too difficult for a practitioner to get a stuttering client relaxed in the clinic room, greatly reducing dysfluencies, while the client is given a "technique" (cha-ching, cha-ching). When the client goes out into the real world, falls flat on his or her face and has the courage to report that to the clinician, he or she is told, "Oh, you're just not working hard enough." While such token therapy might work for persons with a very minimal problem and a high degree of suggestibility, it doesn't work for by far the majority of people who stutter if the goal is long-term efficacy. What is needed in their case includes genuine and thorough in-vivo systematic desensitization, healing and strengthening. Anything less amounts to clinic room fraud. I invite anyone to look at ASHA's Code of Ethics and Scope of Practice to list the various provisions violated by clinic room fraud. To put the needs of the clients first, truth, rather than doing public relations for the profession, must come first. I submit the treatment of stuttering is too big for SLPs, alone. I want SLPs to admit that. And if society ever gets serious about the treatment of stuttering, we will see coordinated multidisciplinary treatment teams.
From: A Stutterer...Who Continues to stutter...
Ed Feuer....This thread and the responses of the professors is very revealing to me. This ISAD conference is primarily very much a group of "mutually admired amongst each other" professors giving props to each other for their perceptions of being so successful in providing effective and successful therapy to those of us who stutter. To them, there is no code of silence. They are all doing the right thing and there are no mistakes in therapy or bad therapy...ever. They are letting you know you are wrong and that you have a problem. I heard a guy talk at the NSA Conference this past summer and something he said that has really stuck with me is this - The "experts" really believe this: THE FAILURE IN THERAPY FOR STUTTERING IS NEVER THE FAULT OF THE THERAPY OR THE THERAPIST ... IT IS ALWAYS THE FAULT OF THE CLIENT OR PARENT. We who stutter need to get this. Are you getting it Ed? If not, the experts think you should start to get it. I know the professionals have greatly failed those of us who stutter. All one has to do is look at the ASHA required (not) preparation to work with those of us who stutter. Or look at the very successful (not) therapy for kids who stutter in the schools. Challenge ASHA? You had better have both lots of time and unequaled $ to do so. The Self-Help groups are so far up the a**** of the ASHA Organizations and the SFA that the self-help groups no longer represent the needs of those of us who stutter as an organization. As to when it will change? A parent of a CWS will have to recognize how a professional messed up with their kid, have a lot of money, and sue 'em for all they got. Has to be legally accomplished much like what was done in the area of Autism in order for change to occur. I don't believe the professors would be so disrespectful to you if they were in a courtroom with a lawyer whose purpose was their pocketbook... OF COURSE THERE IS A CODE OF SILENCE!!! But they won't ever admit or tell you that. But Ed...We who stutter are also at fault because we have failed ourselves to go after the posers. We believe all their crappy crap crap. And we take on their belief that WE are the fault. I feel quite confident in saying that in 25 - 30 years, stuttering will no longer be allowed to be treated by speech and language trained pathologists. It will be addressed in a multidisciplinary approach head by a psychiatrist. Now start to get it, Ed. Or get a lawyer and start the change...
From: Pamela Mertz
Wow, there has been so much said on this topic, and so heatedly discussed as well. As an adult who stutters, I am very glad that the SLP community is interested in having dialog with the stuttering community. We may never agree, but robust dialog is so important. That is what prompts thoughts, ideas, and change. I heard from some in self-help that it was not too long ago that SLPs were sort of "unwelcome" at self help meetings and events, and now both groups interact and exchange ideas. I think we have a lot to learn from each other, even when we disagree, or especially when we disagree.
From: Ed Feuer
To "A Stutterer ... Who Continues to Stutter": Yes, for a problem whose treatment is so deeply stuck in the mud, the everything's-just-peachy pose struck by the professionals does indeed seem strange. The misguided notions of professional solidarity, the code of silence and the public relations circling-of-the wagons mode are the last things required at this time. The needs of the clients should come before fear of breaking ranks. And while that seems obvious to persons who stutter, it's ever more apparent that the interests of the latter and SLPs do not always coincide. I would remind those reticent profs now as I have done in the past that dirty laundry that is not washed in public is laundry that is likely to stay dirty. As for the coordinated multidisciplinary team approach which I advocate, the true major obstacle is cost but to many of the professionals, the fear is that any admission that the concept has merit is regarded as a threat to the monopoly edifice. I would prefer that SLPs play a central role in the collaborative treatment team. The basic treatment template I advocate for such a team is that presented by Charles Van Riper in his classic, The Treatment of Stuttering -- a program far too immense for individual SLPs both in terms of time and expertise. They lack the tools to do what is necessary in the process of unlearning, learning and relearning coupled with genuine desensitization, healing and strengthening. In theory, however, SLPs with SID4 specialty training could gain comprehension of how big the treatment challenge really is so as to provide them the humility to see they can't do it all.
From: Tom Brennan
Ed, I've seen you posting accusations and unfounded nonsense since the first ISAD conference. I'm wondering if you're either a stutterer or a clinician. For the record, I'm both. I noticed that you completely failed to respond to a post concerning exactly what you advocate having been tried in Europe. If you're going to make all these claims it's long past time that you back them up with something more than that chip on your shoulder. Let's have a little hard evidence without your having to blame anyone's personal failings or successes on anyone but yourself.
From: Ed Feuer
Tom, what I advocate, a coordinated multidisciplinary team approach for the treatment of stuttering has not been tried anywhere. What currently passes for treatment is stuck in the mud. Too often discussion with SLPs quickly ends with their resort to personal attack because to counter what I say they have nothing, rien, nada, gournisht, shoom devar.
From: Pam Mertz
Ed, out of curiosity, since you didn't answer the last question asked, I'll ask it again. Are you a PWS or SLP? Knowing that might help the reader understand a little better where some of your strong opinions come from. Pam (a PWS)
From: Julia Irani
Hi all - as you may have read in my earlier post - I'm leading support group meetings in Pakistan and I have always been very overt with my stuttering. It was no secret that I stuttered - merely because I was unsuccessful at keeping it a secret - so disclosures were actually easy for me. I have met a few coverts at our meetings and I was wondering what the best approach is to help them? Some are so covert that NONE of their friends and family even know they stutter. I imagine asking them to go around "breaking the news" isn't the most reasonable advice. What do you suggest?
From: Peter Reitzes
Julia, great question. You wrote, 'I imagine asking them to go around "breaking the news" isn't the most reasonable advice.' Actually, I think that is exactly what is needed. Covert stutters sometimes ask for intermediate or gradual steps to come out of their covert 'closets.' But I really don't think there is such a gradual way to come out and say, 'I stutter.' As a former covert stutterer, I found it helpful to tell people I stutter while also stuttering openly and using voluntary stuttering. I know covert stutterers who attempt to come out of their covert closets by talking about stuttering, but without stuttering openly. I think that tends to confuse people.
From: Vivian Sisskin
Sometimes people who are covert find that there is a bit of an identify crisis at first. It is uncomfortable to show their stuttering to people they already know and find it easier to advertise or open stutter with strangers at first. We sometimes call these 'throw-away' situations, for example, an interaction with a store clerk, or a simple question on a phone call : 'What time do you close?' This is sometimes a good way to start. Also, starting out with a huge task (to stutter openly) can be overwhelming. Sometimes it is a good idea to start with a concrete assignment. For example, focus on word substitutions or word avoidances, and plan to say the word you want to say (and stutter openly) instead of substituting, one time per day. Initial success (nothing terrible happened, except a puzzled look from the listener) will lead to more success.
From: Jen SLP
Hello. I work with a teenage boy who stutters. He is such a pleasant and bright young gentleman. Recently he needed to do a presentation in front of his teacher and myself (SLP). He was quite nervous, but I thought he would do okay because he had his script in front of him. To my surprise, he fell apart. He was disfluent on almost every word. I stopped him shortly after he has started because I knew that it was taking a toll on him. He did start to cry when I stopped him. When he stopped we talked about how he had given speeches in the past and if he has ever given speeches into a tape recorder or been video taped, which he hadn't. I provided him support and told him that I understood how challenging this task was for him and that he wouldn't be downgraded because he couldn't complete the task. We are going to try to get him to video or audio tape his speeches to see if that makes a difference, but my question is...how can I help him? He appears to stutter more when he is reading than when he is casually talking with his friends in the classroom. I think it has to do with anxiety. He doesn't want to be different and therefore doesn't like to leave the classroom. Everyone wants the best for him. I'm thinking we have to look at constructing a "ladder" and examining situations for fluent vs. disfluent speech. Would this be a good place to start? He has been receiving SL therapy since Kgd and is now in 7th grade.
From: John Tetnowski
Dear Jen, Great question and one that I would love to take a shot at. It is a common assumption that spontaneous tasks will be more difficult than reading or repetition tasks. With many PWS this is not the case. As a matter of fact, it may be the complete opposite. I see this as a key factor when evaluating PWS. What I mean is that the difficulty they have in reading (and maybe repetition, as well) could be due to specific word and/or sound fears. That is, they can avoid saying words or sounds when speaking spontaneously (and thus not stutter as much), but they cannot avoid words or sounds that may be problematic when reading (or repeating). This type of client needs to deal with these fears and needs desensitization as part of their therapy regime. Another possibility is that the teen has a reading problem. The reading task may require more cognitive load and thus cause stuttering to be more severe (along with performance anxiety issues). I suggest re-evaluating his stuttering across tasks (spontaneous, reading, and repetition) and make comparisons. Word or sound fear may well be the issue, and this may cause you to alter your therapeutic philosophy, or to rebuild your treatment hierarchy. Great question,
From: Lynne Shields
Jen, John gave wonderful input on some ways to proceed with this young man. I would add that I think your idea about working together with this client to develop a ladder, or hierarchy, of situations is a great way to begin to address his feared situations. You might start by having him identify the situation/s that he thinks he would find the easiest for talking and the worst, and then begin to fill in between those two extremes. Then, you can ask him to locate a situation on the ladder that he wants to address. It might be making a class presentation, or maybe that feels too difficult just yet. Or, he might want to address presentations, because he needs to do those, as well as one other situation on the ladder. At any rate, once a situation has been selected, you can assist him in constructing a hierarchy for that specific situation. If oral presentations is the choice, then ask him to describe a scenario where he would feel the most comfortable giving a presentation. That might be presenting in an empty room, or to his best friend, in clinic with you, or even while talking to his pet cat. Whatever it is--he is choosing. The hardest might be in class in front of all of his classmates with the principal present. Once the extremes have been identified, fill in the slots between. Talk about what level he is willing to begin at, and what supports he needs at that level. If reading the presentation isn't the way to go, and it seems not for this client, what will make this easier for him to do? Note cards with just a few words about the main points, visuals to help him focus attention away from himself, etc. Will advertising his stuttering at the beginning of his talk reduce his anxiety about stuttering? Talk about what his expectations are in terms of what he would consider as a success. Is some stuttering O.K.? Why or why not? What about getting his main points across? Being able to insert some humor? Helping him to see all of the factors that are important in an oral presentation is probably an essential component of this process--a person can stutter quite a bit and still have a successful presentation. There's more to communication ability than just fluency. Once he has agreed upon the specific level of the presentation and has prepared and practiced, it is going to be important to have a de-briefing session afterward, to find out what he thinks went well, what he can modify next time--talking about it objectively can have a desensitizing impact and get him engaged in problem solving, as opposed to obsessing about how fluent he was or was not during the presentation. When he is comfortable with his accomplishment at the level he chose, then it's time to move up to a higher level for presentations--maybe he'll next choose giving his presentation in the clinic room with you, his best friend and his teacher, for example. You begin the same process at this new level. By engaging him in the process of developing the hierarchy, choosing the level at which to begin, problem solving the entire process and then reviewing afterward, you are giving this boy the opportunity to see himself as capable, as successful, and as a more powerful person when it comes to managing his stuttering. I hope these ideas are useful to you. Best wishes in working with this boy. Regards, Lynne
From: Ardell Fitzgerald
I am evaluating a child who stutters (3-7) using prolongations, blinking, grimaces, turns head to the side, hides behind hands. His father also stutters. The child has non-developmental speech errors on w,m,n,p,b (baby is da-yee, nose is joze)and is about 30% intelligible. He is self-conscious and he cried when asked open ended questions by evaluator, saying "I can't say it!" He also cried when his blocks fell down which, according to parents, is common when things aren't exactly the way he wants it. Could his sound substitutions be influenced by sounds he thinks he's going to stutter on? He's been stuttering for a year and his stuttering has changed to prolongations. I'm wondering what the priority should be in treatment?
From: Brian Humphrey
Ardell, if the three and a half year old boy stutters and has a number of concomitant behaviors in addition to articulation/phonology errors that are more than developmental articulation problems, you may want to consider treatment for fluency and articulation/phonology concurrently. First, consider reducing his concomitant behaviors and improving his use of fluency techniques. With better fluency control, he may find it easier to focus on improving his articulation/phonology. With regard to articulation/phonology, I would consider prioritizing sounds and contexts that A. are easy to teach him, B. may lead to transfer of skills to other 'new' sounds, and C. may make a significant difference in his intelligibility.
From: Vivian Sisskin
Ardell, I have had some experience in working with 3 and 4 year olds who stutter severely who have highly unintelligible speech. I have had success by first working on fluency issues (since that was causing the most distress), and with increased fluency, begin addressing articulation. Occasionally, I have returned to work on fluency for short periods of time, then back to work on articulation. I find it helpful to use strategies that are more indirect for the articulation work (lots of modeling), rather than intense drill or high demands for exaggerated production of speech sounds.
From: jo - age 10
What is the best thing about being a speech therapist?
From: Lynne Shields
Jo, What a wonderful question! Picking just one thing is hard--I was lucky enough to find a career that I really love, and there are lots of things I like about this job. If I have to pick one thing, it would be the variety of experiences. I get to work with so many people of all ages. I get to work with toddlers, school-agers, high schoolers, and adults. Each person is unique, and that makes every session so interesting. There are many options for work settings, too. I have worked in schools, speech & hearing clinics, hospitals and, for the past 28 years, I have been a teacher in a university where I help to train people who want to become speech therapists. I also get to work in our speech-language-hearing clinic on the campus where I teach. So, being a speech therapist is fun and I'm always learning new things from my students and my clients. I can't think of anything else I'd rather be doing. Thanks for your great question. What would you like to be when you are grown? Regards, Lynne
From: Gary J Rentschler
Jo: There are so many things I truly enjoy about being a speech therapist. But the two best are helping other people who stutter, and helping students become speech therapists. I have worked as an SLP for many (MANY!) years and when I look back at what gives me the most enjoyment and the most satisfaction, its about helping others out of their problems stuttering. Some of the jobs I've done have entailed doing a lot of therapy and others have entailed being an administrator; but the best part is working with people and seeing that I've had something to do with assisting them to make changes in their lives for the better. Thank you so much for asking this question... it brings a huge smile inside of me.
From: David Shapiro
Hi Jo, You asked a really good question. I have been a speech-language pathologist for 32 years and I think I am even more excited today about my work than I was when I first began my career. The thing I like best is meeting with such interesting and diverse people and families and realizing that I can learn something new from them everyday. Also, as a person who stutters and as a speech-language pathologist, I really like the stuttering community. There are so many good people who are committed to understanding stuttering. Did you know that there are people who stutter all over the world? As I write this to you, I am in the Czech Republic where I am working with people who stutter, teaching other stuttering specialists, meeting lots of new people, and learning so many new things. When you get older, maybe you will want to become a speech-language pathologist too. Good luck to you and keep asking such good questions. David Shapiro
From: Rick
Hi, the current ration of female to male stutterers is 1:4. But some research has shown that in 1, 2 year olds, the ration is 2:1 or even 1:1. Are people (adults, parents) more likely to notice boys stuttering....public perception. Actually, the question I want to ask is: are females/women "better communicators" And if females are indeed better communicators vs. Men. Then does this "better communicators asset" contribute to less female stutterers in the world. And thus the 4 to 1 ratio.
From: Klaas Bakker
The way your question is worded makes it difficult to specifically answer it. I don't think communication and speaking (fluency) are necessarily at the same level of abstraction. One (good speech) may be, but not always is, a part of the other. I am sure there are very good speakers who can be poor communicators and the other way around. Then, I also believe there can be good speakers (as well as good communicators) who speak dysfluently while the reverse is possible as well. So, we need to know what "better" means in this context, and ... Consider differences between speaking, fluency, and communication. I realize I am not answering any questions. But I thought it necessary to raise these new ones to make this a productive discussion. Another hesitation I have to assume that women are better "communicators" has to do with communication style. Although poorly documented I am convinced that there maybe gender specific communication styles.
From: Rick
Hi, Thanks! I appreciate it. I was just trying to figure out why more males stutter than females. Note: If we can determine the differences b/w males and females and male pws vs. female pws (perhaps male and females stutter differently), then we can better understand stuttering and what causes stuttering. Is it societal expectations or brain differences. Also, we hear all the time that women "are better communicators." Are females in general better at learning languages?
From: Rick
I am an Adult. Certain words at different times give me trouble as I just sort of freeze up! If I think I can't say a word then It will take me forever to say it!(If at all) Any suggestions?
From: Klaas Bakker, Springfield, Mo
Rick, Could you describe more specifically what you mean by not getting words out? Do yo believe it is stuttering, or could there be other reasons why you can't seem to be able to use words you need? (Maybe you can't think of the word either?) Not being able to say certain words seems to me one of the most common difficulties people who stutter have, so I am not sure why you were asking the question the way you did?
From: Rick
I know the word but just can't say it because something in my mind is saying "You cannot say that word" My muscles in my throat and face tighten and there I am stuck again!
From: Pamela Mertz
I have been working on acceptance and being open, but its still so easy to fall back into old habits. This week, at our school Open House, I was chatting with a parent about her daughter's college plans. She asked me where I went to college (I went to Keuka College). I got stuck on the "K" and it it came out "KKKKKK" and couldn't get past it, and then she guessed, "Cayuga?" and I agreed, even though it was NOT where I went. I silently kicked myself, knowing I shouldn't do that, but old habits are hard to break. I share this experience in the hopes that maybe someone else who stutters will realize that's our "human-ness" tends to kick in at the most inopportune moments. I know I should not beat myself up over something this little, and I told myself I let it go, but it bothered me that I am still thinking about it, after all I have learned about being open. Thoughts? How would you advise a PWS who relates that this happens or happened?
From: Lynne Shields
Pam, Well, you really don't need an answer, since you already figured out that you want to let this incident go. You just haven't quite yet figured out how to go in this particular instance. In the past, when you have become too focused on something and know you just need to move on, what has been successful in helping you do this? Thinking about how you want to manage another similar situation in the future? Seeing the humor in what happened? Perhaps you could to tell a friend the story about how you went to Cayuga University. Meditating on the situation until you have thought about it enough to imagine it slip through your fingers and fall to a small pile of 'it's over and done' on the floor? From what I've read on this conference, you seem to be a person who has some great personal resources. That, of course, doesn't mean you won't ever do anything that you regret. But, it does suggest to me that you have the strength to get past this one event and move on. I'd like to hear how you finally figure this one out. Regards, Lynne
From: Ellen-Marie Silverman
Hello, Pam. Yes, our humanity . . . We who have stuttering problems are human just like everyone else, and the process of change applied to our stuttering problems is like the process of change applied to any other personal problem we may wish to address in that older, undesirable mind-behavior sets replace newer, preferred ones, especially when we begin the process. Should that give us grief and reason to berate ourselves and lead us to quit concluding we have failed or the program isn't any good or the therapist isn't helpful? You know the answers: "No," "No," "No," and "No." I think most would answer the same way. Now what do we do when we revert to our old ways? As the lyricist for a song wrote, "Pick ourselves up, dust ourselves off, and start all over again," or as Hasidic Jews are known to say, "The tzaddik (righteous person) falls seven times and rises seven times." and as we say in common parlance, "If you fall off a horse, get right back on again." So, we resume applying our new mind-behavior sets. With effort and consistency, the new thought-behavior set becomes familiar and strong, and the old ones, weak. And we relapse less and less. Key to the process of strengthening the new while weakening the old is to be kind to ourselves when we relapse. We remind ourselves how courageous and wise we have been making the change we already have and encourage ourselves to keep on keeping on because eventually, as we do, the odds are will be communicating more and more as we wish. >>> I'm so glad you raised this issue for discussion, Pam, because many times this matter can be a "make-or-break" element of therapy, as it can be for weight reduction programs, etc. When we accept these relapse as inevitable, especially when starting a program of change, we won't falsely interpret reverting to old ways to mean "I failed." "I can't do it." As it has been said, "No one ever became overweight by eating a slice of cake. We become overweight by eating slice after slice after slice." As we see the times when we revert to old patterns of stuttering for what they are, ie., old patterns, we can resume doing what we need to do to strengthen the new patterns we have chosen to cultivate. Best Wishes, Pam.
From: rachel
Hi! I am a 20 yr old who stutters. I would say I stutter "moderately or severely." Anyone who talks to me can immediately tell I stutter (probably on half the words I say). Most of my blocks are pretty tense (noticeable facial tension, head jerks, averted eye contact, lots of interjections and such). I was wondering if anyone could give me some information on the use of cancellations. What specifically is a cancellation? What purpose does repeating a previously stuttered upon serve? Won't I just block again when I say it over? Thanks!
From: Joe Klein
Hi Rachel. Great question. This is how I do and teach a cancellation. You have to do three things: 1. finish the word you are stuttering on. 2. Pause for at least two seconds, gather yourself, make sure you are breathing, etc., and 3. say the word again (and I like to do a little stretch on that word, but you don't have to). Now, why would anyone want to do this. Well, there are lots of good reasons to do a cancellation. 1. It naturally slows down your rate of speech. PWS often get frustrated with how long it takes to talk, and are amazed to realize how fast they are trying to talk, and this is a very good way to remind yourself to slow down. 2. It gives you a change to "correct" that moment of stuttering, and to realize how to say it more easily, right in the moment. 3. It advertises your stuttering. It lets people know, I stutter and I am working on it. Thanks for your patience. 4. And this is related to #1 & 2, it doesn't allow you to race through the stuttering. You have to hang in there, stop, gather yourself, and move forward slowly, rather than barreling through the stuttering, which only makes it more likely that you will stutter again very soon. 5. It helps you really identify what you are doing in the stuttering. Right there, in the moment, you can feel what you are doing... I will stop at 5, but in my classes we have come up with as many as 12 positive reasons to try cancellations. Now, will you stutter again. Maybe. But, did you stutter slower the second time? Did you stutter differently? It gives you a chance to problem solve what, exactly, you are doing with your speech in that moment in time. And, it's always okay to stutter.
From: rachel
thanks joe! that makes good sense to me. i would love to hear the other 7 or so reasons? also, when you write, "did you stutter slower," what exactly did you mean by that? thanks!
From: Joe Klein
Hi Rachel, by "stutter slower," I just mean easing through the word a little bit. Walt Manning gave a great answer, that you are changing, in the moment, the way that you just stuttered. So you learn that you can stutter differently, and more easily. Often, I think it's asking a lot to go from stutter to fluent. There is a middle ground, and techniques like stuttering help you to find that. Great question.
From: Walt Manning
Hello Rachel, Joe mentioned some great reasons for using cancellations. I think a related, and maybe the most basic reason, is to "take charge of the word you originally stuttered on". The cancellation is the last chance to do that if you were unable to intentionally stutter on the feared sound/word at the outset (pref-set) or slide out/pull out of the word during while stuttering on the word. It's usually somewhat easier - although you do need to achieve a reasonable degree of desensitization and be able to stay in the moment of stuttering - to catch and modify stuttered words into smoother forms of stuttering by going back and canceling the word. It's good to remember that you aren't canceling in order to be fluent but to take charge. Most people don't do a lot of canceling beyond the treatment setting. Prep sets and pull-outs are more common. No matter when you catch and modify the old, habitual and automatic form of stuttering (and thinking) it is wonderful to find out that you have some choice about how you stutter and there are likely to be easier, smoother forms of stuttering that speakers can learn. One other thing, using these techniques can lead to spontaneous fluency.
From: James
I was just wondering if there are any negative connotations to covert stuttering? Is there any consent among SLP whether or not covert stuttering is personally manageable, or does it become too much to handle for many PWS? I have a friend who is a covert stutterer (I didn't know he had any stutter at all for almost a year) and he has told me that his stuttering is quite a touchy subject, so I've neglected to ask him about it.
From: Evelyn Klein
James, In my experience treating people who stutter, my clients convey that covert stuttering is quite distressing. They find it difficult to continually try to 'change the word' when they expect to stutter on it. They say that this changes their affect at times and the message they want to express. They have also said that it is similar to constantly 'being on guard'. My patients who have been covert in their stuttering have been somewhat relieved when they can stutter openly.
From: Michael Sugarman
Hello, Thank you for providing valuable information to pws and slp's. Just wondering whether slp's use psychologist, clinical social workers or marriage family therapists in a team approach with children/parents or pws?
From: Ken St. Louis
Hi Michael, I'm not one of the "profs" this year, but I thought I'd weigh in on your important question. My sense is that most SLPs are not as likely to bring in mental health professionals into the treatment regimen as they are to consult traditional doctors or pediatricians. Many do not typically consult either in their treatment of stuttering unless there are "red flags" that suggest the necessity or desirability of other professional consultations. I've worked with a few stuttering clients where we clearly needed the help of mental health professionals. I'm recalling two cases who frequently talked of suicide. In those cases, I found it useful to work in a co-therapist arrangement, where my students and I met regularly with the mental health professional while both of us treated the client. Of course, the clients were aware of this arrangement. That being said, I do not believe that most stutterers require the treatment of licensed psychologist, social workers, and so on. The evidence is quite clear that stuttering is not the result of a psychological problem in the vast majority of cases. Yet, as you WELL KNOW, many SLPs are reluctant to treat people who stutter for lots of reasons. One of those reasons is that they feel uncomfortable dealing with the common emotions associated with stuttering, e.g., anxiety and reduced self-esteem. My guess is that these clinicians simply assume that there are other SLPs who would be better able to treat the emotions of the persons in question. It's a case of "benign neglect," possibly. On a positive note, the pendulum seems to be swinging back to dealing more with emotions in stuttering. And, given the advances in brain and neurochemical research, it is unlikely that we'll find ourselves in the mire of the view--typical of the 1950s--that stutterers are all neurotic and all we have to do is deal with their underlying conflicts in order to treat their stuttering. Best wishes, Ken
From: Michael Sugarman
This is why the online conference is so much fun and valuable. I finished reading a paragraph about the research being done by I think Anne & others on social anxiety and general anxiety in PWS. The research was done in 2004. Anne used Ross Menzies a clinical psychologist in the field of management of anxiety. Maybe mental health professionals (CBT) can work with slp's for PWS with anxiety? :) I will try to find the 2004 article.
From: Salad Jillo Tutana Kenya
I asked this question during the last Online conference but nobody bother to comment and again I will put it to professor to judge. From my personal observation I observed that my stuttering become severe in the absence of moon light and during the presence of moon it quite okey. Its not a believe. From my own degree of stuttering I can know whether there is moon or not with looking up the sky. Kindly help on this
From: Judy Kuster
Salad! Nice to see you active in the online conference again this year! Regarding your interesting question, and apparently your personal experience, I can find no research regarding phases/cycles of the moon and stuttering, but there has been research about phases/cycles of the moon and psychiatric problems. A couple of example -- Owen et. al's article 'Lunar cycles and violent behaviour" (2002) Australian and New Zealand Journal of Psychiatry, vol. 32, issue 4, pp 496-499 concludes that there is "no signifiant relationship" found between "total violences and aggression or level of violence and aggression and any phase of the moon." A similar conclusion was reached by Lester in Temporal Variation in Suicide and Homicide, American Journal of Epidemiology Vol. 109, No. 5: 517-520 which concluded that there was no lunar variation found on homocide or suicide. However, I did find an interesting article by Raison, The moon and madness reconsidered, Journal of Affective Disorders, Volume 53, Issue 1, pp 99-106 that suggests where that idea may have come from. It suggests that it originated with problems associated with sleep deprevation. And many people report increased disfluency when they are tired, even those who are not people who stutter. The abstract states "Belief that the full moon is associated with psychiatric disturbance persists despite 50 years research showing no association. This article traces the historical roots of belief in the power of the moon to cause disorders the mind, especially insanity and epilepsy. Putative mechanisms of lunar action are critiqued. It is proposed that modern findings showing lack of lunar effect can be reconciled with pre-modern beliefs in the moon's power through a mechanism of sleep deprivation. Prior to the advent of modern lighting the moon was a significant source of nocturnal illumination that affected sleep'wake cycle, tending to cause sleep deprivation around the time of full moon. This partial sleep deprivation would have been sufficient to induce mania/hypomania in susceptible bipolar patients and seizures in patients with seizure disorders. The advent of modern lighting attenuated this lunar effect, especially in modern urban areas, where most 20th century studies of lunar effects on the mind have been conducted. The hypothesis presented in this article is open to empirical validation or falsification. Potential tests for the sleep-deprivation hypothesis of lunar action are discussed." This idea however does not match your personal experience of being more fluent when the moon is full. I wonder if anyone else ever reports this experience. Do people in your self-help organization in Kenya have the same experience?
From: salad kenya
Thank you Judy for your explanation. Some of the people from our self help group have observe this connection, the degree of stuttering differ during waning and waxing phases of the moon. I greatly welcome any research interested on this.
From: David Shapiro
Hi Salad, It was so nice to meet you in Douala, Cameroon and to hear from you again. You are asking a really good question. I did not see your question posted previously. My honest response is that I really don't know. However, those are the questions that I like best. Judy Kuster provided some really good information' as usual! I wonder, and this is only a hunch, if variations in stuttering could be more indirectly related to the moon, in that the absence of light could cause changes in mood or state (e.g., feelings of sadness or feelings of reduced confidence in oneself as a person or as a communicator) and that those changes in state may be reflected in increases in stuttering. Or, are there any indigenous beliefs relating to the presence or absence of moonlight and could those beliefs more indirectly relate to changes in stuttering? I am hoping that you will attend the 2nd African Stuttering Conference in Burkina Faso next week. It would be such a pleasure to visit with you again and to ask you more about your experiences and those of other people who stutter in Kenya. You have me thinking. I hope to see you soon.
From: James
Hello! News reports say that Biden used to stutter. If Biden still calls himself a stutterer or admit that he is still a person who stutters (which is no big deal). How would the public perception be? It seems that the public respects and admires someone who used to stutter and did something to overcome it, but still don't understand stuttering and/or views stuttering and a stutterer negatively. Has the public perception of stuttering changed at all in the past 10-20 years and will it ever change? The negative stigma attached to stuttering?
From: Mark Irwin
Hello James, I am not a SLP Prof but I have a particular interest in the field of public awareness (served as ISA Board Chair for 6 years.) Since others have not responded to you I'll take this opportunity to jump in. My paper in this online conference addresses this issue as does my replies to Ed Feuer and Ann Packman. I also responded to John Tetnowski's paper. In my view the public perception of stuttering has not changed and will not/ cannot change until new terminology linking stuttering with Social Anxiety Disorder (SAD) is developed. I am suggesting Stuttered Speech Syndrome as the term for disorder affecting pws with SAD. In short JOE BIDEN MAY STUTTER BUT HE DOESN'T HAVE STUTTERED SPEECH SYNDROME. Obviously I think this proposal is logical, helpful and necessary. However it will need support from the SLP leadership to make it happen.
From: John
Hi Mark, I agree with you. But will this ever happen??? I think many people agree with you, but will anything ever change. When will there be a new term for stuttering...5 years, 10 years, 50 years??? It is hard to imagine...something needs to change "In my view the public perception of stuttering has not changed and will not/ cannot change until new terminology linking stuttering with Social Anxiety Disorder (SAD) is developed"
From: Mark Irwin
I repeat a previous comment that most SLPs I have met are well meaning and considerate. However is there a crisis of leadership within the speech pathology profession? Are potential leaders so afraid of ruffling feathers that the pace of much needed change in therapy and public awareness has halted? I refer particularly to an article in this year's conference 'What Clinician Should Know!' (exclamation mark included!) in which the author states that 'evidence indicates that Prolonged (Smooth Speech) should be the therapy of choice for adults who stutter.' Surely this statement should be challenged by senior SLPs not only because of the extremely high relapse associated with this type of therapy, but also because percentage stuttered syllables can hardly be seen as a comprehensive measure of the stuttering syndrome. This paper has been read by and no doubt influenced many SLP students many of who have commented on what they see as a 'great paper'. If future SLPs are to improve their clinical abilities do you not agree then that the 'therapy of choice' comment needs to be called into question? (As a pws I have already asked questions directly but have received no reply either publicly or privately.) What is the mechanism for instituting change within the profession?
From: Walt Manning
Hello Mark, I certainly don't agree that prolonged speech is the treatment of choice. I don't believe that any one particular treatment qualifies as the "treatment of choice". I as well as others have spoken and written about on many occasions the idea that one form or brand of therapy is better than the others is silly. The question isn't which treatment protocol is somehow the 'best' by whatever definition but rather 'what does this person who happens to stutter need from me now' (something Van Riper said may years ago). This issue has been argued in psychology and counseling for years and for good reasons the studies comparing the efficacy or effectiveness of various treatment approaches has been termed 'horse race research'. Assuming a treatment protocol is empirically informed or possibly empirically validated (and few are in many fields), as long as the protocol contains the important common factors for facilitating therapeutic change it is a reasonable approach to take. Whether the approach corresponds to what a person may benefit from at a particular time is another question. And perhaps more important, as several researchers are finding, it may be more important to shop for an experienced and wise clinician than it is to shop for a particular treatment. There are a number of good references which address these issues and I'll come back with some of them if you or others are interested.
From: Mark Irwin
Walt, Thanks for your reply. I am certainly aware that Prolonged (Smooth Speech ) does not have universal appeal. My comment was directed to better informing SLP students. Why does the SLP leadership allow these papers to go unchallenged? Do you agree that by not doing so the clinical expertise of future SLPs is compromised? I would be very interested to see your references (maybe other SLP students who thought the paper I referred to was so great might want to see them too.) Also I have previously offered solutions to issues of differential diagnosis so inexperienced SLPs (the only game in town for many pws) might better direct a multidisciplinary approach. What is the process by which this could be suggested for incorporation into "best practice"? Is there a chain of command? To what extent are standards enforceable?
From: Walt Manning
Mark, I actually think some of the papers are challenged at professional meetings, in some texts, and in some published manuscripts. The references I referred to are at the end of this note. They are the initial investigations in our field that indicate the equivalency of empirically informed approaches to stuttering treatment. The common factors that are found across effective treatment are things like clinician expertise, allegiance to the program and the clinician-client alliance. This is discussed in Wampold's work and others as I'll indicate. Inexperienced SLP for treating PWS are a big problem as the literature indicates. In most cases, however, while a multi-discipline approach is not necessary, a multifactor approach often is. Best practice depends on many things and there is no one best practice for all or most people. I'm not sure what you mean by'chain of command'. Early evidence for the equivalency of some stuttering treatments Hancock, K., & Craig, A. (1998). Predictors of stuttering relapse one year following treatment for children aged 9 to 14 years. Journal of Fluency Disorders, 23, 31'48. Huinck, W. J. & Peters, H. F. M. (2004). Effect of speech therapy on stuttering: Evaluating three therapy programs. Paper presented to the IALP Congress, Brisbane. Franken, M. C., Van der Schalk, C. J., & Boelens, H. (2005). Experimental treatment of early stuttering: A preliminary study, Journal of Fluency Disorders, 30, 189-199. The essential equivalency of good treatments: Wampold, B. E.. (2001). The Great Psychotherapy Debate: Models, Methods, and Findings. Lawrence Erlbaum Associates: Mahwah, NJ. Wampold, B. E., & Brown, G. S. (2005). Estimating variability in outcomes due to the therapist.: A naturalistic study of outcomes in managed care. J. Consul. Clin. Psychol. 73(5), 914-923. Wampold, B.E., Mondin, G.W., Moody M., Stich, F., Benson, K. & Ahn, H. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically,'all must have prizes.'Psychological Bulletin, 122, 203-215. Manning, W. (2004b).'How can you understand? You don't stutter!'Contemporary Issues in Communication Science and Disorders, 31, 58-68. Manning, W. H. (2006). Therapeutic change and the nature of our evidence: improving our ability to help. Chapter 9 (pp. 125-158). In N. Bernstein Ratner & J. Tetnowski, Current Issues in Stuttering Research and Practice. Mahwah, NJ.: Lawrence Earlbaum, Inc.
From: Joe D.
Mark, I see your point regarding teaching SLP graduate students that there is more to stuttering than merely syllable counts. I also understand your concern with teaching inexperienced clinicians that the gold standard of therapy for every client is behavioral procedures alone. However, I think that the ISAD has provided the flip side of the coin. For example, Charlie Healey discusses the importance of looking at stuttering from a multidimensional perspective and his article actually states that solely teaching techniques is not the answer. In my view, the mechanism for instituting change within the profession starts in conferences like this where a multitude of perspectives are discussed. I would also argue that when pws voice their opinions about programs or techniques, that can be as effective as having the "senior SLPs" voice their opinions. Finally, a glimmer of hope can be seen in the professional literature where increasingly more papers are being published that look at stuttering from a wider perspective and even employ methodologies from other disciplines. Is it great, certainly not but I do see strides in the right direction.
From: Melissa R
I am a student but also a mom of a child who at 2 exhibited stuttering with strong head turning and eye blinks/slight grimace for about 2 weeks then stopped. Her stutters were mainly on "I" repetition and other initial sound repetitions. Everything I am studying suggests that young CWS do not have secondary characteristics. Since she exhibited these characteristics could she be at risk for recurrence? She is now 3 1/2 and no further episodes have occured out of the norm. Thank you
From: Klaas Bakker, Missouri State University
Melissa, while it is encouraging that no new episodes have occurred it is very difficult to predict, with certainty, that the particular episode your child experienced predicts recurrence. I would like to believe (my opinion) that it doesn't. All it tells us is that your child somehow was aware of something different and reacted to it pretty strongly. The secondary behavior is not stuttering itself. It is her reaction to it. Other than treatment there are also options that reduce the risk of the (re?)development of stuttering. I don't know if you are a speech pathology student, but a speech pathologist, especially one with experience in early onset stuttering could help you determine how much of a problem there is, and what can be done as "prevention" of relapses. I hope this helps.
From: Rick
Regarding the cause of stuttering...would it be safe to say now or in a few years that there is definitely a neurological basis for stuttering...Can someone please describe how neuroscience/neurobiology might possibly be related to stuttering. In layman's words because brain science is really complicated. Thanks!
From: Klaas Bakker, Missouri State University
Rick, I believe the situation is more complex even than you describe in your question. While certain strands of evidence are getting more supportive of a neurological explanation for stuttering over the years, there are definitely also facts that suggest that this could not be the entire truth. For example (just one example), what is neurogenic about stuttering should already be there when children begin to speak and we know that at this age there is very little. So there have to be multiple other explanations for which the problem can develop into something very different later in life, or ... just go away. Also, if a neurogenic predisposition for the development of stuttering is supported, there is still the question which aspects of the problems of a PWS exactly is neurogenic in predisposition? Fully mature stuttering is very complex, and much of it is likely not neurogenic in nature. No one at this time can predict when the evidence will be sufficient to prove (of support) the neurogenic hypothesis. Even if that would happen there is still also a good amount of possible interaction with hereditary factors. These are reasons why I believe the neurogenic hypothesis, no matter how feasible, is only a part of the picture.
From: Charlie Healey
Rick: Perhaps you are wanting to know more about brain differences in people who stutter and those who don't. There have been a number of studies over the past several years that have shown that adults who stutter seem to process speech in the right hemisphere of the brain rather than the left side like most people who don't stutter. There is also heightened activity in the area of the brain that contributes to the emotionality of speaking (Anterior Cingulate Gyrus). By contrast, there is decreased activity in the temporal lobe of the brain during speaking suggesting that people who stutter are not able to monitor their speech very well simply by listening to themselves while they talk. If you Google brain imaging and stuttering, you will find all kinds of information on the internet about this topic.
From: Tom Brennan
Over the years I've worked with a very few blind stutterers who were either teens or, at least, old enough to have pretty much mastered braille. I also went to elementary school with a girl whom I'm certain was a clutterer. I have noticed that, in the braille of both of these very small samples, there is what I would call stuttering. Braille writing usually involves the use of a machine with seven keys. These keys can be pressed individually or in any combination the person wishes to produce the dot patterns of braille. My question is is there any literature out there on stuttering in braille writing?
From: John Tetnowski
Tom, Great question, and your do not surprise me. I do not have all of my resources in front of me right now, but I seem to recall a paper quite a few years ago related to stuttering in deaf individuals (I will look up the reference). The deaf clients who stuttered when using oral communication, also had some hesitancies when they also just used manual sign language. In a study by DeNil et al., (2000), they found activation in the brains of PWS to be different from matched nonstutterers. The pattern continued even when the speaker silently read the stimuli. This seems to indicate that stuttering occurs at the cortical level. Therefore, it does not surprise me to hear that your blind PWS had some differences. Finally, I wish that you would summarize your findings and get them published someplace. I would love to see your results and would be willing to help you get them in order so that we can all share in your most interesting findings. If you wish to contact me, my e-mail is tetnowski@louisiana.edu Great work! Happy ISAD!
From: Judy Kuster
Tom, I can find nothing that addresses your interesting question. John mentioned stuttering in sign. You may be interested in a paper Greg Snyder wrote to the 2006 online conference (http://www.mnsu.edu/comdis/isad9/isadcon9.html)which has a pretty extensive bibliography. The Existence of Stuttering in Sign Language and other Forms of Expressive Communication: Sufficient Cause for the Emergence of a New Stuttering Paradigm?
From: Joe
Hello, How does the Valsalva Control help with my stuttering? I looked online and found this website. Valsalva Hypothesis: stuttering blocks may involve a neurological confusion between speech and the Valsalva mechanism. Such confusion would tend to occur when we anticipate the need to "try hard" to speak properly or to force the words out. Valsalva Control: its objective is to control the Valsalva mechanism through both psychological and physical means to reduce the likelihood that it will interfere with our natural speaking ability. I developed or adapted a number of relaxation, breathing, and speaking exercises designed to relax or "tune down" the Valsalva mechanism.
From: Greg S
Hi Joe. The 'Valsalva Hypothesis' is one person's non-professional opinion that made sense to (the author). So it's really not a 'scientific' approach or explanation to stuttering, but rather one person's experience. I'll try and do my best to explain his experience / theory. We use 3 very complex systems to produce speech: (1) Respiratory; (2) Laryngeal (i.e., "vocal chords"); (3) Supralaryngeal (everything above the vocal cords). The 'Valsalva' is essentially valving that occurs (using the 'vocal chords') to increase pressure in your chest. Increased pressure in your chest is pretty important, relative to movement and exercise. So it's my interpretation that the author of this hypothesis is saying that "controlled breathing" (or controlling the primary respiratory valve) was a major variable toward controlling his stuttering. In all honesty, I'm glad that this helps some people--but it's my professional opinion that a well qualified and experienced SLP (specializing in stuttering) is the better choice. Hope this helps,
From: Judy Kuster
The live, threaded discussion part of the 2008 ISAD online conference is now closed. The conference paper and responses made here during the conference will remain online. Thank you for stopping by. Judy Kuster