MY LAST LECTURE ON STUTTERING

DRAFT

STUTTERING:

A Personal Perspective

Frances J. Freeman, Ph.D. 

For Graduate Stuttering Seminar at UT Dallas, Callier Center

Oct. 17, 2022

THIS THESIS IS LABELED “DRAFT”’ because I need assistance in completing and editing it.  I am asking every student in the class to add one or more questions (or suggestions) for content or organization.  Any others who stumble on this Blog are similarly invited to contribute to the completion.  I’ve tried to write this three times before, and each time it began at a different place, but circled  to the same conclusions.  The story seems to be a circle.  Let me know what you think and where you think I should begin and end.  Further, I need feedback to understand what I should and should not include or discuss more in depth.

OBJECTIVES FOR THIS LECTURE

1. To persuade some of you that stuttering is a fascinating disorder; that people who stutter deserve treatment from knowledgable clinicians; and to motivate some of you to continue to learn more about the disorder and the people it affects.
2. To seduce one or two of you into spending your careers focused on stuttering either through research or clinical work or both.
3. To find one or more of you who are seeking a research topic, possibly for a thesis or dissertation.  In the course of preparing this lecture, I stumbled into a relatively unexplored area just primed for some straight-forward research, and I’m looking for someone to go with it..

OBJECTIVES FOR THERAPY

1. TO HELP THE CLIENT TO ACHIEVE HIS POTENTIAL AND LIVE A FULL (FULFILLED) LIFE.

2. TO HELP THE CLIENT ACHIEVE HIS POTENTIAL AS AN EFFECTIVE COMMUNICATOR, WHO CAN ENJOY COMMUNICATIVE INTERACTIONS WITH OTHERS.

3. TO EMPOWER THE CLIENT WITH KNOWLEDGE & SKILLS IN COMMUNICATION.

4. TO HELP THE CLIENT OVERCOME UNREALISTIC NEGATIVE SELF-PERCEPTIONS AND BUILD A HEALTHY EGO, HOPEFULLY WITH EMPATHY FOR OTHERS.

PRIMARY THEORETICAL CONSIDERATION

Everything called STUTTERING is NOT the Same

When my Grandmother was a girl, “FEVER” was a disease — a specific diagnosis with prescribed treatment.  Now we know that “fever” is a symptom of many different diseases.  In this analogy, the forms of disfluency we group together and call “stuttering" are not a single disorder.  “Dysfluency,” and its chronic form, which we call “stuttering,” do not constitute a unitary (homogeneous) disorder.   Rather, what we have called stuttering, is a symptom (or observable behavior) characteristic of a number of different underlying problems, which alone or in combination, can lead to disruptions in a complex cognative-language-speech formulation and production system. 

STUTTERING IS HERTOGENOUS NOT HOMOGENEOUS

Evidence from Research and Treatment:  Almost every treatment ever applied to groups of people who stutter has had the same result (and this includes behavioral, psychological, surgical, and drug treatments): 

Some get better; 

Some get worse; 

Some don’t change..  

Almost every research study of people who stutter has resulted in conflicting findings when replication was attempted.  That is, one scientist hypothesized an underlying “causal” factor for stuttering, and tested a group of stutterers for that factor, and found the hypothesized difference.  The next scientist attempting to replicate that finding tested another group of stutterers and did not find any significant difference between stutterers and non-stutterers on that factor.  Many hypothesized etiologies and predisposing characteristics underlying stuttering have been rejected because different groups of stutterers do not demonstrate consistent research findings.  With each proposed “cause” or “predisposing factor,” some of the tested stutterers demonstrated the hypothesized response while others did not.  Clearly, the significance of results from each study was dependent on the participants chosen for that study.  

If Stuttering (as we have defined it clinically) is a heterogeneous not a homogeneous disorder, these are exactly the results that would be expected from treatment and research.  We have not found THE cause of stuttering or THE treatment for stuttering because we have considered “stuttering” as a single, unitary disorder.  If we consider stuttering as a symptom and work toward a DIFFERENTIAL DIAGNOSIS which defines sub-types of stutterers or different disorders, we could make progress focused on both etiology and treatment.

A start in the right direction has been made by the diagnostic criteria established for differentiating between “Cluttering” and “Stuttering.” But the overwhelming problem remains:  We do not have a DIFFERENTIAL DIAGNOSTIC paradigm that will allow us to look at sub-groups of those who stutter to learn which treatments are effective for which groups.

I had hoped to find the right tools to approach this differential diagnosis during my career in research and treatment.  As it turned out, I spent most of that career just trying to persuade our profession that “stuttering” is not a unitary disorder, and that differential diagnosis is actually needed, and I did not succeed in establishing a differential diagnosis paradigm.

Treatment Principles Based in the Heterogeneous Assumption:

Or What to do Until We Know What We Are Doing?

You cannot treat all stutterers the same.  

1. Individualized Treatment is essential.  Each client has unique needs; each client will respond differently to methods, techniques, and approaches.

2. Diagnostic treatment is essential; different methods and approaches have to be tested and explored, and those that demonstrate effectiveness used, while those that do not work are modified or discarded.  No two clients can be treated exactly the same.

3. Client input into the treatment process is critical. Each treatment program will be different and individualized to meet the client’s special needs.  The client’s felt needs and preferences are to be evaluated and considered in treatment planning.  Their feedback is valuable and to be greatly valued in the planning and conduct of treatment.  

4. Treatment is a COLLABORATIVE Endeavor. Therapy a special relationship in which the Client and Clinician work together as partners.

KNOWLEGE MAY NOT ALWAYS SET YOU FREE, BUT IT IS ALWAYS EMPOWERING.

DIFFERENCES THAT MAKE A DIFFERENCE

While I can’t tell you how to do a differential diagnosis to determine the cause and best treatment approach for each dysfluent client, I can share some critical guidelines from both research and clinical experience.  I can only hope that one of you may decide to take this work further.  Below I discuss the most critical differential issues first.  I discuss the most critical difference first, and at the end enumerate other differences of interest.

BLOCKS

DOES THE CLIENT EXPERIENCE BLOCKS?

This the most critical differentiation.  Many experts believe that ONLY those who experience “blocks” are actually stuttering, and that without blocks it is not stuttering, but some other form of disfluency.  

Definition of Blocks —  A block is an involuntary, loss of control of the speech production mechanism.  The person who stutterers experiences this loss of control, and reacts to it.  Most of what we call stuttering, in behavioral terms or descriptions, is what the stutterer does to avoid or control his blocks.  The clinician needs to understand as much as possible about the client’s blocks, and how he experiences and responds to them.

Only the stutterer experiences the “block.”  Sometimes an experienced observer  can recognize the blocks and sometimes they can’t.  The best way to verify information about blocks is to carefully question the person experiencing them.

Blocks are the Core of Stuttering — I subscribe to the belief that “real stuttering” as opposed to other forms of dysfluency/disfluency is characterized by blocking.  Whether this is a valid position or not, those who experience blocking constitute the vast majority of the clients we treat for this disorder.

Blocks are Frightening — To lose voluntary control of any bodily function, whether that be urinating, defecating, swallowing, breathing, standing, walking, blinking your eyes, or speaking is a frightening experience.  Loss of volitional control creates a feeling of helplessness and vulnerability, and can lead to panic or a fight/flight biological response.  Chronic, mysterious loss of volitional control of a bodily function destroys self-confidence, creates self-doubt, and fosters a sense of humiliation.  “Why am I different?  Why can’t I control myself?  What is wrong with me? If I can’t control simple things, how can I ever hope to control big, important things?”   Much of the anguish experienced by stutterers can be directly traced to the emotionally debilitating, humiliating feelings of loss of control. The stutterer seeks to avoid blocks and to hide his blocks.  He will try multiple ways to control his blocks. How the stutterer responds to his blocks constitute the behaviors we evaluate when diagnosing the severity of his stuttering.

Stuttering Symptoms and Severity — How the client habitually reacts to blocks determines the specific, observable behavioral symptoms we typically call stuttering.  Those who are successful in avoiding, disguising/hiding, or minimizing/controlling their blocks, are called “Covert Stutterers;” while those who are not successful in these endeavors are called “Overt Stutterers.”  

Our behavioral measures of stuttering severity are based in exactly that — behaviors.  We measure stuttering severity as it relates to what an observer sees and hears.  I would postulate that the severity of stuttering is not a matter of counting behaviors, but of the effects of stuttering on the life of the person who stutterers.  The number and duration of repetitions, prolongations, etc. are not an index of the extent to which life choices, successes, and failures are linked to stuttering.  In this regard, understanding covert stuttering is critically important to understanding overt stuttering.

OVERT vs. COVERT STUTTERING

Unfortunately, most clinicians only see “overt” stutterers, and most stuttering research and most text books on stuttering are devoted almost entirely to”overt” stuttering.  A typical text devotes less that 3 pages to a discussion of  “covert” stuttering.  

As a clinician, only three “covert” stutterers sought my help in over 40 years.  Fortunately, as a researcher, I investigated families with high incidence of stuttering, and in other investigations, interviewed numbers of “cured” or “recovered” stutterers.  In this way, I got to know and learn from “covert” stutterers.  

These experiences led me to conclude that “outgrowing,” ”recovering,” or being “cured” of stuttering are just labels applied to the process of changing an “Overt” stutterer into a “Covert” stutterer.  Indeed I have come to believe that most of what we call successful stuttering therapy is, just transforming an overt stutterer into a covert stutterer.

In this case, you might wonder why any covert stutterers seek help from a speech pathologist?  Well, two came to me for the same reason — they were tired of the efforts they had to exert in order to avoid or hide their stuttering.  They wanted me to help them experience fluency without the constant vigilance that they used to avoid or disguise their stuttering.  These covert stutterers hoped I could help them find natural. effortless fluency.  They wanted to experience easy, normal fluency.  The third covert stutterer wouldn’t come to the clinic for a consultation because he was a politician about to seek a high profile office.  We met over lunch instead.  He hoped I might know how he could improve on the methods he used to disguise/hide his stuttering.  We exchanged information on techniques, and I learned as much as he did.  He was very good, and he won his election.

Unfortunately, I have come to believe that the goal of “effortless fluency” is not achievable for most adult stutterers.  I believe that successful early treatment can enable a stutterer to become a naturally fluent speaker (not a perfectly fluent speaker, because this doesn’t exist).  After adolescence I believe that stutterers can learn to control their overt stuttering (become controlled fluent speakers), but maintaining their fluency requires effort and vigilance.  Their fluency is achieved at a cost, and in the end, the costs must be balanced against the benefits.  The following are some Principles that I believe apply to Good Stuttering Therapy:

Good Therapy gives the stutterer the ability to Control their blocks.

Good Therapy minimizes the effort and vigilance required for Control.

Good Therapy frees the Client to decide how fluent he wants to be.

The Client can choose the cost vs. benefits for the fluency he desires.

WHAT IS FLUENCY?

OR How to Define A Block

Speaking fluently requires fine temporal integration of the following:

1. Cognitive processes — the thoughts/ideas you wish to communicate.

2. Linguistic processes — the words, grammar, phonemes, prosody, etc.

3. Motor Speech processes — respiratory, phonatory, articulatory, etc.

4. Feedbacks — related to all three processes.

These processes are interactive and parallel rather than sequential.

For all stutterers, these systems (cognitive, linguistic, motor speech, and feedback) can and do function in a coordinated way much of the time.  That is, no system is broken.  The only thing necessary for fluency breakdown is a disruption in the timing (temporal coordination) between or within these systems.  

The timing (temporal coordination) can be as fine as 5 -10 milliseconds. 

(Note: the faster the speech, the shorter the margin of timing error).

These systems operate at very different speeds.  That is, the mechanisms required for thinking about what you want to say operate in very different (faster) temporal parameters than the much slower motor systems that control the movements of the speech production system.  Even within a system, rates of processing differ.  For example times required for word retrieval differ from times required for phonemic sequencing.  And in the motor system, the rates and timing for respiration differs greatly from the rates of timing for laryngeal muscle activities, which differ from those for articulatory movements.  Indeed, the relatively slower movements of the tongue body for vowels must be temporally coordinated with the the faster dynamic movements for consonants — all within the articulatory system.

These systems are differentially effected by a variety of environmental factors.. For example air quality, humidity, temperature, noise, light, and other factors exert differential effects on how we think and how we breathe and ultimately how we speak.  Physiological factors such as fatigue and psychological factors like stress will also differentially effect these systems.  The larynx as part of the respiratory system is so markedly affected by the “startle” or “fight/flight” response that expressions like “scared speechless” or “struck dumb” occur in almost all human cultures.

A temporal delay or mistiming in the integration of any of the cognitive, linguistic or motor processes will result in disfluency.  When the temporal error or mistiming occurs within the respiratory, phonatory, articulatory, or motor feedback processes, a “Block" (breakdown in speech motor coordination) occurs..  Since timing (temporal processing) underlies the failures or breakdowns, temporal factors, including rate and pauses will impact frequency and duration of system failures (disfluencies and disfluencies).

It follows then that manipulating the tempo or timing of speech production will increase or decrease the occurrence of blocks (breakdowns in temporal coordination).  Speed speech up and there will be more frequent blocks.  Slow speech down and there will be fewer blocks.  Change the timing of segments in specific ways and blocking can be eliminated.  Every successful technique that I know for controlling stuttering has the effect of lengthening the duration of speech segments, and slowing the rate of segment transitions.  In other words, old Granny was right when she advised the stuttering child to, “slow down.”  Slowing down in very specific ways is an underlying constant in most successful stuttering treatment.

CONSCIOUS CONTROL vs. 

AUTOMATIC PILOT

When flying a modern aircraft, the pilot has varying degrees of control.  He can totally fly the plane, attending to every detail; but this is an inefficient use of his time.  To be more efficient, a pilot can delegate less variable or critical factors to an automatic pilot while he manages a sub-set of more critical flight factors.  Alternatively, a pilot can set the automatic pilot to fly the plane while he checks flight plans, consults his charts, talks with the copilot or navigator, checks on other issues, or just takes a rest.  The pilot analogy can be applied to our speech production.  

We can consciously control every aspect of our speech/language generation system, but this is inefficient, and requires great concentration.  Rather, we “automate” the more predictable programmable aspects of speech/language generation, while concentrating our conscious efforts on higher cognitive functions such as “thinking” and analyzing the reaction of listeners.  For example, we seldom give conscious thought to the pitch of our voices or to the prosodic patterns of statements and questions.  Only under special speaking conditions do we consciously control these omnipresent aspects of our speech production.  

Similarly, we can consciously control our articulation, carefully producing and enunciating each sound and syllable.  When speaking to a child or a hearing impaired or elderly person, we often make these adjustments.  However, under ordinary circumstances, we don’t pay active attention to our pronunciation or articulation.  Typically we put speech production in AUTOMATIC MODE while devoting conscious mental efforts to choosing the thoughts or words important to our communication.  

IN STUTTERING, THE AUTOMATIC MODE IS EFFECTED, not the Conscious Control Mode.  When a speaker shifts into a conscious control mode of speech, in which he monitors lower level aspects of speech production (such as pitch, segment duration, articulation accuracy and timing, prosody, accent, dialect, etc.) stuttering ceases.  All of the known fluency evoking techniques force the speaker to focus conscious attention on one or more aspects of speech production, moving speech out of automatic mode, and into a conscious control mode.

It should also be noted that a side effect of moving speech into conscious control mode is a decrease in the rate of segment production (that is, under conscious control we increase the duration of each segment and of each syllable).  It follows that every known fluency-evoking technique increases the duration of speech segments, and decreases the rate of segment production (slows speech).  

In summary, we can talk fast (produce very short segments and syllables) when we speak in AUTOMATIC MODE.  When we shift into CONSCIOUS CONTROL MODE, we slow the rate of segment production by increasing the length of each segment.  In AUTOMATIC MODE, we talk faster, and breakdowns in temporal coordination (blocks) occur.  In Conscious Control Mode we talk slower (with longer segments and transitions) and we don’t block.

How do you get a speaker to shift from Automatic Mode into Conscious Control Mode?  You use one of the “fluency-evoking” techniques.  Every known fluency evoking technique from singing to whispering to speaking with an accent or with altered auditory feedback, forces a speaker to shift from “automatic mode” into “conscious control mode.”  Every fluency evoking technique works for as long as it forces the speaker to use “conscious control.”  If a fluency evoking technique is habituated to the point that it can be produced in “automatic mode” it ceases to be effective in preventing blocks.

The Magic of Longer Segments:

Discovering the Transition

There’s Slowing Down & There is Slloowwing Doown — 

One of the longest lines of research in stuttering focuses on the “loci” of stuttering blocks.  Martin Adams made a major contribution to our understanding of stuttering when he realized that the repeated sound or the prolonged sound, as in “KakakaKaty” or  “Mmmmmmoon” is not the location of the block.  The stutterer is saying a perfectly find /k/” and a perfectly acceptable /m/.  The block is occurring at the transition between the consonant and the vowel.  The stutterer can’t get from the consonant (which he repeats or prolongs) into the vowel.  The block is at the transition. 

The presence of the shwa (or neutral vowel) in stuttering repetitions is further evidence that the repetitions demonstrate a failure in the coordination of the transition between the consonant and the following vowel.  Blocks can also occur with the initiation of a Vowel sound at the beginning of a word, although this is far less common than between an initial consonant and a vowel.  In this case the “transition” is the onset of phonation (that is, transitioning from silence into phonation).  

Blocks never occur on the closing transitions in a CVC or VC.  That is no one ever stutters, “catttt” or “mannnnn.”  This type of disfluency occurs only when we deliberately induce fluency breakdown by placing normal speakers under delayed auditory feedback (DAF).

Every fluency evoking condition studied to-date causes speakers to increase the duration of the segments of speech.  Vowels which are longer and more elastic temporally have the greatest absolute lengthening, but consonants are also lengthened proportionally, and the transitions between segments are longer.  When transitions are longer, blocks are far less likely to occur.  It is tempting to hypothesize that the extended segment and transition durations, provide extra time for the system to coordinate the elements and smoothly execute the movements. 

THE SECRET OF GETTING A STUTTERER TO SPEAK FLUENTLY; OR TO ELIMINATING BLOCKS (which is the same thing) IS TO GET THE STUTTERER TO LENGTHEN TRANSITIONS INTO VOWELS (typically in CV; but occasionally in V; or VC word initial syllables).

THE EASIEST WAY TO ACCOMPLISH THE LENGTHENING OF SPEECH TRANSITIONS IS TO MOVE SPEECH FROM AUTOMATIC MODE TO CONSCIOUS CONTROL MODE.

THE FLUENCY EVOKING TECHNIQUES ARE A PRIMARY MEANS FOR SHIFTING A SPEAKER FROM AUTOMATIC MODE INTO CONSCIOUS CONTROL MODE.

THE “SPEAK MORE FLUENTLY” vs. “THE STUTTER MORE FLUENTLY” APPROACHES:

SEVERITY, AWARENESS, and ANTICIPATION IN DIFFERENTIAL DIAGNOSIS

Stutterers differ greatly on these variables (Severity, Awareness, and Anticipation), and exploring these variables is critical to formulating a treatment approach.  I don’t use the traditional “stutter more fluently” approaches, but with stutterers who only block occasionally, and/or who are highly aware and can anticipate their blocks, I use a “Block Management Approach” in which the client uses his speech techniques only when he anticipates or recognizes the approaching block.  For Clients who have frequent blocks, we modify their entire speaking pattern in order to manage the blocks effectively.  THIS IS AN EFFICIENCY APPROACH, which aims to allow the Client to use the least effort to achieve the greatest improvement.  Some Clients who being using a total speech modification approach, may eventually be able to move to a block modification approach.  This is in response to the major Problem in using any technique that shifts speech into Conscious Control Mode.

PROBLEM

PEOPLE DON’T LIKE TO SPEAK IN CONSCIOUS CONTROL MODE.  Conscious Control mode requires more mental energy; reduces the resources available for other parallel mental activities.  Speech under Conscious Control lacks the spontaneous, naturalness, that is characteristic of Automatic Speech.  

We can learn more about speaking in conscious control mode from other speakers who employ this mode.  Principle among these are “old-time” radio/TV announcers, stage actors, and most recently performers of audio books. .  These professions use conscious control of their voice and speech to achieve specific objectives.  In almost every case these professionals are aware of techniques they use to achieve specific desired effects.  They are also aware of the effort (mental and physical) and self discipline required to speak in control mode.  They talk of turning their professional voices on and off; and of speaking naturally vs. performing.  In other words, they are very aware of turning the Control on and off.

THE VICIOUS CIRCLE OF CONSCIOUS CONTROL TECHNIQUES IN STUTTERING:

1.  A new unpracticed technique requires the greatest conscious effort, and produces the least natural sounding speech.

2. With lots of practice the speaker can habituate the new speech pattern, and reduce the effort and increase the naturalness of the speech

3. BUT, If the technique becomes completely habituated, it will no longer require conscious control; it will become automatic, and stuttering and blocking may return. 

Note that in #3, I used the word MAY.  It seems that some people who stutter can habituate their new speaking pattern, and will continue to produce fluent speech without excessive blocking.  For others, habituation of a pattern means a loss of its fluency-evoking potency and a return to stuttering.  This area is worthy of research, but it will not be easy work. 

DIAGNOSIS OF OTHER SPEECH AND/OR LANGUAGE PROBLEMS:

Stuttering Plus vs. Stuttering Only

In my clinical experience, stuttering that occurs in the context of other speech and language problems differs from stuttering which is the only speech or language problem exhibited by the Client.  Both Stuttering Plus and Stuttering Only can occur in families (possibly genetic).  However, with very few exceptions Stuttering Plus occurs in families where there are many individuals with speech and language problems (some of whom stutter)’ While Stuttering Only occurs in families with primarily normal speech and language development and function (except for stuttering).  That is, why client’s pattern reflects the familial pattern.  

In my experience, Clients with Stuttering Plus frequently also clutter, or have a history of childhood cluttering.  Stuttering Plus requires broader intervention strategies than simply a focus on fluency.  If you have Stuttering Plus without blocking, do careful language testing, consider word-finding and grammatical formulation difficulties as contributing to the disfluency.  Place emphasis on using 

pauses and time to formulate utterances before initiating.  Treat articulation and pronunciation difficulties.  If you have Stuttering Plus with Blocking use combined approaches, seeking first to change the factors that most distress the client.

 OTHER CRITICAL DIFFERENCES IN DIAGNOSIS

Allergy/Asthma as A Factor

When stuttering occurs in the context of allergies and/or asthma, medical intervention can be a remarkable assist in controlling blocks.  Typically, treatment of the Asthma/Allergies alone will not improve the stuttering, but treatment by a good allergist combined with behavioral treatment are powerful.  You should be aware that there is a relatively rare form of asthma, which effects the laryngeal system (called laryngeal asthma) which is often undiagnosed.

Response to Alcohol As A Variable 

As with m most drugs, alcohol has a variable, but predictable effect on stuttering (some get better; some get worse; some don’t change).  I find response to a couple of drinks to be a clue as to whether “social” interactions problems OR “motor speech control” problems are major variables.  If social fears are critical, then stuttering tends to improve with a drink or two.  If motor speech control is a contributing factor, speech tends to get worse with a drink or two

Good General Motor Control vs. Poor Motor Control

In a similar way, general motor control (both large and small muscle) dexterity can be a differential diagnostic window on speech motor control.  Some stutterers are sensational (or better than average) athletes.  Others are highly skilled musicians or artists.  Look at general motor control for clues into speech motor control issues.