Introduction

This paper discusses two  frameworks  and their vocabularies  used to describe, measure, and treat fluency disorders. The first, which  I refer to as a segmental framework of fluency, is more widely known of two. The second, what I call "communication fluidity", is based on a systems framework. Most of the concepts of communication fluidity are key elements presented in "A Systems Approach to Stuttering Treatment (SAST) [1] Obviously, this is a complex and often controversial issue and I beg the patience (and forgiveness I'm sure) of readers who find some comments clinically or scientifically over simplified.

Few concepts in this paper are original.  Specifically, I see the systems approach to therapy as a tapestry, woven from the ideas, successes, failures, and experiences of colleagues, clients, students, and friends.  I only present a vision of how the threads interweave to create a final image. Special acknowledgment is given to the work and memory of Dean Williams. His concept of "easy talking", combined with his artistry as a shaper of natural speech continues to impact development of the systems approach to treatment and a common sense approach to talking.

Speech "Fluency": A Categorical/Segmental Approach

         I begin each undergraduate and graduate course (anatomy and physiology, speech science, diagnostics, and fluency) by asking students to describe in their own words,  "talking". I do the same with clients during initial diagnostic or treatment sessions. After twenty-eight years as a clinician/teacher (a speech scientist piece falls in there somewhere) responses are remarkably similar. Lay persons and a surprising number of speech-language pathologists rely on a language-based vocabulary to describe how we talk. Most often, talking is described as sequencing sounds, syllables, words, phrases, and sentences together. When then asked to describe "fluency", responses are similar. "Getting words out smoothly" and "when speaking without any hesitations, interjections, repetitions or blocks" are common. Such descriptions of talking and fluency are natural outgrowths of the way we process information. We organize and perceive thought using a segmentally-based language code. That is, we hear others and ourselves (self-talk) as strings of meaningful sounds, syllables, words, phrases, etc. Our brains perceive these segments categorically, where each segment is meaningfully different from other segments. Unless educated otherwise, one would perceive and describe variations in dynamic processes of speech, such as articulation and fluency (to name just two), as behaviors that occur ON the units attempted.

         From this point of view fluency and disfluency become categorical opposites. Sounds, syllables, or words are perceived as being spoken either fluently or disfluently.  The important implication here is that this framework relies on a segmentally based linguistic vocabulary to describe  (and measure) complex, dynamic processes of continuous speech. Children are particularly creative at this, describing their fluency problems as encounters with invisible demons in their mouths, or insurmountable obstructions holding their words hostage. The two theoretically and clinically significant themes of this framework are that  (1) the problem is perceived as occurring on sounds or words and (2), the speaker is perceived as a passive recipient of words and whether they "come out" fluently or stuttered. In essence, speakers become helpless to do what they believe they should already know how to do - talk.

         A categorical framework of fluency and fluency disorders can be appealing to the clinician, in part, because of its theoretical and measurement simplicity.  Utterances are broken down into finite sets of linguistic segments (e.g. sounds, syllables, words, and phrases). Each segment is then categorized and counted as fluent or disfluent based on a predetermined set or criteria.  In essence,  description, assessment, and quantification of complex dynamic processes are confined to binary, "yes", and "no" type decisions.  This becomes problematic and controversial with lack of consensus over relevant criteria for disfluency types, what constitutes normal versus stuttered disfluencies, and so on.

         Does a categorical approach sacrifice understanding and shaping natural communication attitudes, perceptions and behaviors for measurement simplicity? Folkins and Bleile (1990) present a compelling argument in this regard, presenting how phonetic and phonological taxonomies often have little basis in actual production processes. Let's consider the impact on goals of therapy and assessment of long-term successful talking. When clients are asked to describe their treatment goals and expectations from therapy the answer is inevitably some variation of, "to talk without stuttering". I believe reinforcing this thinking forces the client into what I call subtractive criteria for successful talking.  That is, successful talking is fluency and fluency is talking without stuttering. Regardless of whether assessment is based on counts of words stuttered or words fluent, the result is the same. Moments of disfluency and stuttering are the focus of attention and become the basis of talking success or failure.

         A fluency/stuttering dichotomy is inconsistent with what we know about the natural function of the communication processes.  For some, stutter-free speech might be an unrealistic goal given their potential predisposition and sensitivity to speech disruption, at least for that time in their lives. Stutter-free methodologies, no matter how effective on a moment-by-moment basis, often come to be perceived as "techniques" designed to prevent or escape the experience of stuttering.  Reoccurring bouts with stuttering (and we know this often DOES happen) can be perceived as failure of the "technique" resulting in an exasperated  and sometimes emotionally distraught client.  This is particularly important for the young child experiencing bouts of speech disfluency. Sporadic episodes of speech disruption, if interpreted as speech failure can actually reinforce some degree of stuttering anticipation and anxiety in some clients.

         Emotional arousal, anticipation, fear, reduced fine movement coordination, speeding, and tensing are all normal and often instinctive responses to the perception of performance failure. These responses are not unique to stuttering but are fundamental properties of human action. To deny the role of these components in the description, development and shaping of effective communication is to deny the reality of human behavior and performance.

SPEECH "FLUIDITY": A SYSTEMS BASED FRAMEWORK FOR DESCRIBING AND SHAPING COMMUNICATION 

Systems, Communication, and Fluidity

         Evidence in the cognitive psychology and human performance literature repeatedly demonstrates that focusing attention on negative behavior and/or outcomes inhibits effective organization and performance. This is compounded under conditions of performance stress and can lead to a spiraling effect of negative imagery, emotion, and behavior.  Most everyone has experienced this in one form or another during performance based activities such as golf, acting, gymnastics, dancing, and so forth.  But the opposite is also true. Focusing attention on and developing visual imagery of positive behaviors and outcomes can significantly enhance performance. It is reasonable to assert the importance of developing a common framework and vocabulary for understanding and enhancing natural communication processes. The treatment process should demystify talking, stuttering and all that goes with it. When stuttering is presented and understood within a framework of natural communication processes the mysteries, fears, and struggles of talking begin to subside.  The client focuses not on the negative aspect of stuttering, but builds on the positive foundation, imagery and behavior of talking.  Management of disfluent speech is viewed as successful variation back to more fluid speech rather than variation out of a stutter. The talker should always be moving toward something positive  (feeling of easy talking) rather than out of something negative (stuttering).

         I view a systems approach to understanding, analyzing, and shaping communication behavior as a ground-up process.  Almost any action, whether mechanical (e.g. a pocket watch) or human (e.g. running, playing tennis, taking an exam, or talking) is based on interaction of multiple parts. Variation, normal or atypical, in any one or combination of parts has a natural and often predictable influence on the system and its output. A pocket watch, for example, is a myriad of gears, springs, nuts bolts, and hands. Each must function effectively as well as interact with the other parts to produce a desired behavior. Unstable gear attachment might then be perceived symptomatically as inconsistent and jerky hand movements. The jerky hand movements are merely overt symptoms of inconsistent gear behavior. Treating the symptom, perhaps by tightening the hands, might produce short-term reduction in jerky movement. But it would have little or no influence on long-term effectiveness of the watch function. 

         We can apply the same concept to human behavior, whether running, playing golf, taking an exam or talking. Voluntary human behavior involves interaction of thought, arousal, language, and movement at each moment in time. These interactions are dynamic, changing with the physical, psychological, and emotional conditions at hand. Inconsistent or inappropriate function of any one or combination of components has a reasonably predictable influence on our actions.  Clearly, some individuals are inherently more sensitive to intermittent disruption in the organization and coordination of ongoing speech. Environmental, developmental, and learned conditions can trigger disruption at a particular moment in time. The specific sensitivity to disruption varies across individuals and can be influenced by cognition, language, motor organization, neural transmission, structural movement, and emotional arousal.

         A systems framework describes developmental stuttering as a natural  (albeit unfortunate) response pattern to intermittent and involuntary disruption in both the forward communication of a message and speech movement over time.  One does not HAVE stuttering as one might have a disease, nor does stuttering occur on sounds, syllables, or words. An individual might be predisposed to intermittent breakdown in speech organization that, in turn, triggers normal, albeit problematic, psychological, emotional, and behavioral responses from the system. The original disruptions, combined with the normal adjustment strategies that stem from them, reduce the natural fluidity of speech and the perceived inability to finish an utterance.

This framework uses a vocabulary that functionally describes both the natural and atypical function of our communication system. The clinician helps demystify stuttering by understanding how thoughts, emotions, and adjustments are natural responses to intermittent disruptions in forward flow of the intended message and the fluid movements of speech. From this understanding, clients explore and evaluate their own experiences with talking and whether what they do to help themselves talk is consistent with natural communication.  Attention is drawn away from counting fluent and disfluent words (segments) as criteria for success and failure. Instead, focus is placed on using the communication system in the most natural and effective way possible given any inherent limitations in their system and the demands of the communication task at hand. The core components addressed and measured in the SAST program include interaction of 1) thoughts (including attitudes, perceptions, and self-talk) 2) language, 3) arousal, 5) fluid speech movement, and 5) adjustment strategies (both voluntary and involuntary). The specific emphasis and goals of treatment are easily modified to meet a client's individual profile, development, and needs.

The Essence of Movement "Fluidity"

         Perhaps we should replace the concept and vocabulary of "fluency" with communication "fluidity". Some might say this is merely semantics, but I don’t think so. As described in the first section of this paper, traditional definitions and measurement of fluency are categorical or event based. I view speech  "fluidity" as an action-time oriented concept. Fluidity describes perception of the rhythm, smoothness, and blending of complex movements across time. It transcends segmental boundaries. Fluidity is not unique to speech production but describes the perception of coordinated action of all forms, like walking, running, swimming, throwing a ball, playing the violin, or talking. One only needs to observe and/or feel the graceful flow of the accomplished dancer, the seemingly effortless golf swing, and the mesmerizing flow of fingers across a piano keyboard to understand fluidity. Fluid speech is no more confined to the sequence of individual segments of utterances than the quality of a piano performance is confined to the sequence of individual notes. 

         Assessing and shaping communication fluidity is not always easy. It requires that the clinician and client develop a common vocabulary that accurately describes the client's perception of fluid and nonfluid movement, movement disruptions and how they change across time. Starkweather (1987) discusses concepts such as continuity, rate, effort, and rhythm of word sequences as fundamental to speech fluency. Wingate (2002) presents an excellent case from the literature and speech analysis that fluency is much more than the "flow of words". Continued efforts are needed to establish a clinically based vocabulary for describing and measuring patterns of communication naturalness, effectiveness, and fluidity. Such a base vocabulary should 1) accurately reflect fundamental parameters of movement fluidity, 2) be functionally applicable across speech and non-speech movement examples, 3) be measurable, and 4) be compliant enough to vary across the different experiences and age group of the client.

Vocabulary of Communication Fluidity

Description, measurement, and shaping communication naturalness and fluidity in the SAST program are presently based on three interactive elements. These elements are used to describe what someone is doing, thinking and feeling at any moment in time to facilitate or inhibit natural communication  (I can hear Dean Williams talking now!). These elements are not absolutes, but should be viewed as starting points for suggestion and variation. They should be flexible, varied to meet the needs of each client based on age, experiences, and vocabulary.  I have found that having client's themselves establish specific terminology for the perceptions they experience is particularly helpful. They draw from their own experiences to understand the concepts of fluid talking. The three elements include 1) phases of movement, 2) parameters of movement and 3) communication pace and are briefly outlined below.

Phases of Movement: Phases of movement are used to depict any portion of a movement as a function of time. This provides a temporal reference to the behavioral descriptors. The client and clinician observe, evaluate, and shape specific behavioral features of speech movement across the phases of the utterance. The phases presently used are the (1) pre-onset phase  (before movement begins), (2) onset phase  (beginning a movement), (3) continuous phase  (between onset and offset of a movement), (4) offset phase (ending a movement), and (5) post-offset phase   (after a movement has ended). The offset phase becomes the onset phase for combined complex movements, such as ongoing speech. During therapy, the phases are blended together into a single ongoing flow of speech.

Characteristics of Movement: Characteristics of movement are the specific physical, kinematic, and temporal descriptors of movement. This program presently focuses on movement  (1) sequence,  (2) speed, (3) abruptness,  (4) pushing, (5) blending, and (6) rhythm.

Communication Pace. Communication Pace is a term I use to describe how we perceive and react to the passage of time, that is, how rapidly or slowly time is passing at a given moment. Pace incorporates the physical characteristics of movement speed and rhythm with the perceptual flow of interaction between speakers and listeners.   The latter is often characterized by location and length of pauses both within and between speaker/listener groups. Pace is a primary contributor to our perceptions of relaxation and time pressure and is critical to effective behavior control under conditions of performance demand and communication stress.  I have found that clients, both children and adults react very favorably to the concept of pace. Visual imagery and non-speech movement activities are very helpful in teaching and training clients to perceive and alter their "pace".

Measurement

         Any treatment protocol must be able to accurately assess communication effectiveness and consistency across time.   Measurement protocols for communication disorders should reflect the multidimensional characteristics of our communication system (thoughts, arousal, speech and non-speech behavior, etc.). Continuum based psychometric scaling tools are particularly useful in this regard.  With minimal training, clients of all ages are able to accurately and consistently self-assess self-talk, anticipation, levels of arousal, pace, and characteristics of movement. Several measurement protocols, including a multidimensional individualized communication profile, have been developed for this purpose. Work continues in this area.

 

References

Cross, D.E. A Systems Approach to Stuttering Treatment (SAST). 3^rd  ed. Ithaca College, 2002.

Folkins, J. W. and Bleile, K.M. (1990). Taxonomies in Biology, Phonetics, Phonology, and Speech Motor Control. JSHD, 55, 596-611.

Starkweather,  C.W. Fluency and Stuttering NJ: Prentice-Hall, 1987.

Wingate, M.E. Foundations of Stuttering. San Diego, Ca.: Academic Press, 2002.