New Insights and Tools To Beat Stuttering Blocks

Based on the Author's Presentation at the National Stuttering Association's

Annual Conference, Ft. Worth, Texas - July 7, 2011

Introduction

My name is William Parry. I am a speech-language pathologist from Philadelphia and leader of the Philadelphia Area Chapter of the National Stuttering Association (NSA).

For most of my life I myself struggled with stuttering. I began stuttering at age four. After decades of failed therapies, I found my own way to understand and overcome my stuttering in the early 1980�s, using an approach that I call �Valsalva Control.?nbsp; It enabled me to pursue a successful career as a trial lawyer. Since then, I have been active in the National Stuttering Association, founded the Philadelphia Area Chapter, led its stuttering support group meetings for more than 15 years, served on the NSA�s Board of Directors, shared my ideas at numerous workshops, and wrote a popular book on stuttering ?Understanding & Controlling Stuttering ?/i> which is sold by the NSA.

I am now pursuing my second career ?that of a professional speech-language pathologist ?in the hope of furthering the understanding and treatment of stuttering. Over the past year I have been conducting clinical research on the effectiveness of Valsalva Control Therapy in reducing stuttering blocks in adults with persistent developmental stuttering. Last month I began a new trial of a more intensive therapy program. This has already produced dramatic results, as you will see in the video recordings I will present later in this workshop. In addition to research results, I am going to share with you some new insights and techniques that you might find helpful.

I will begin by outlining my present beliefs regarding the nature of stuttering and stuttering blocks.

Persistent Developmental Stuttering

First, I want to be clear as to what I mean by �persistent developmental stuttering.?/i>

	�Developmental stuttering?usually begins in childhood and is not associated with brain damage.
	It is �persistent? if it continues into adulthood.
	It is basically a speech problem rather than a language problem. The person knows exactly what he or she wants to say, but is sometimes blocked when trying to say the words.
	The person is able to talk fluently some of the time, and stuttering severity may vary depending on the speaking situation.

The Puzzle of Stuttering

            Stuttering has confounded people throughout history. It is a multi-faceted disorder, involving the interaction of many factors, which may vary for each individual. Many different theories have been proposed as to its cause and a wide variety of treatments have been tried. However, none of the theories or therapies adequately explained or relieved my stuttering. Furthermore, I did not want to replace my natural speaking voice with an artificial-sounding �fluency technique.?/span>

My Quest

            My speech mechanism seemed basically all right, because I had learned to act out roles in front of an audience with perfect fluency. However, in other situations, it seemed as if a powerful force clamped down on my speech like a vise, causing me to block. My problem wasn�t any lack of ability to speak, but rather an interference with that ability. I suspected that the interference was physiological in nature, but that it might be activated by psychological factors.

          Around 1983, I quit therapy, began doing my own research into stuttering, and developed my own approach to therapy. I am now continuing that research clinically as a speech-language pathologist.

Stuttering and Effort

            My personal experience, my observation of others who stutter, and my clinical research have all led me to the conclusion that the best way to understand and treat stuttering behavior is to view it not in terms of �fluency?but rather in terms of effort.

           As I will demonstrate, stuttering is the result of misplaced effort in the attempt to speak. Therefore, the key to fluency is understanding and treating the motivations and mechanisms behind the use of effort.

The Mechanism of Stuttering Blocks

I believe that the underlying mechanism for stuttering blocks boils down to the following: a neurological confusion in the motor programming of the larynx, in which effort is substituted for phonation of the vowel sound in specific syllables.

The Real Problem Is the Vowel

            Most people assume that stutterers have trouble saying initial consonants. However, these sounds are not the real problem. For example, a person repeating /p/ in �puh-puh-puh-Peter?or prolonging the /s/ in �S-s-s-s-s-sam?or the /m/ in �M-m-m-mary?is actually saying the /p/, the /s/, and the /m/ perfectly well. In each case, the real problem is the speaker�s difficulty in producing the vowel sound that follows.

Stuttering and Phonation

            There is ample evidence that stuttering blocks may involve interference with phonation. Consider the following:

Persons who stutter have no trouble silently mouthing their words or whispering. Therefore, stutterers?articulation does not seem to be impaired.

Stuttering does not occur until the person adds phonation.

The problem is not phonation in general, because the stutterer phonates when prolonging or repeating voiced consonants like /m/, /n/, /r/ and /l/.

However, when he gets to the vowel sound ?



He hits a �brick wall.?nbsp;

            Therefore, the problem must be specific to phonation of the vowel sound of the particular word or syllable in question.

Motor Programming

            This phenomenon can be understood in terms of motor programming.



                Before any bodily movement can occur, the brain must create a motor program for the muscles involved. The same is true for speech. A process called prephonatory tuning must prepare the laryngeal muscles to bring the vocal folds together properly before phonation can occur. However, phonation is not the only function of the larynx.

The Valsalva Mechanism



         The larynx is also involved in the exertion of physical effort as part of the body�s Valsalva mechanism. The Valsalva mechanism consists of the larynx and other muscles throughout the body, including the abdominal and chest muscles.



          These muscles are neurologically programmed to build up air pressure in the lungs by means of a Valsalva maneuver.

           During a Valsalva maneuver, both the vocal folds and false vocal folds close tightly to block the airway. This laryngeal function is called effort closure.

            Meanwhile, the abdominal and chest muscles contract in order to increase the air pressure in the lungs. The more they squeeze to increase air pressure, the more tightly the larynx closes to hold the air in.

Instances of Valsalva Maneuvers

            The purpose of the Valsalva maneuver is to stiffen the trunk of the body so that physical effort can be exerted more efficiently. We instinctively perform these maneuvers every day ?usually when lifting, pushing, or pulling heavy objects and when bearing down to make bowel movements.

          The Valsalva maneuver may also be activated as part of the �fight or flight?response to fearful situations.

Valsalva and Speech

But what might happen if the Valsalva mechanism becomes involved in the effort to speak ? either in response to the anticipation of difficulty or as a reaction to fearful speaking situations?

Activating the Valsalva mechanism might instinctively feel like the right thing to do, but it could interfere with speech in at least two ways:

By promoting forceful closures of the mouth or larynx to build up air pressure; and

By programming the larynx for effort closure rather than preparing it to phonate the vowel sound.

Effort Inserted at Vowel Position

            The vowel is the natural place to insert the motor program for effort, because it�s the heart of the syllable and has the most energy.

Possible Effects of Weakness in Motor Programming

            Numerous studies have suggested that persons who stutter may have weaknesses in parts of the brain that put together the neurological programs for speech and other fine motor skills.

These weaknesses may contribute to a person�s feeling that speech is difficult and requires effort.

They might also make a person�s motor programming for speech susceptible to interference. Such interference could be precipitated by stress, anxiety, and other emotional triggers, which would account for the variability of stuttering.

There are many other factors that may contribute to the feeling that speech is difficult or that promote the the urge to exert effort - e.g., developmental delays, psychological factors, demands on speech that exceed the child's capacity, etc. These factors may differ, depending on the individual.

Anatomy of a Block on �Peter?/font>

            In analyzing how a block might occur, let�s use the name �Peter?as an example. The motor program for �Peter? should have phonation on the �ee?(/i/) and the �er," which can be represented like this:

            But, because Peter anticipates that saying his name will be difficult, his brain inserts a motor program for exerting effort where the �ee?should be, which can be shown like this:

            Without the motor program for the vowel sound, Peter can�t get past the /p/ sound to say his name. He feels as if there is a �brick wall?that requires force to break through.

            Peter may try to force through the block by building up air pressure, as in a Valsalva maneuver, while closing his lips tightly on the /p/, like this:

            This effort may instinctively feel like the right thing to do, but the more he forces, the tighter his lips close to resist the air pressure.

            Or Peter might forcefully repeat the initial consonant, like this:

as he waits for the vowel sound to be programmed. Notice that the �uh? following the /p/ is not the proper vowel sound. It is basically just a grunt, like you might make when lifting weights.

Prolongations & Initial Vowels

            When the beginning consonants do not completely block airflow, the result may be a prolongation of the sound, such as:

          In words that start with vowels (such as �apple?, the block may focus on the laryngeal closure or �glottal stop?(/?) that commonly occurs just before the vowel when the speaker does a �hard onset.?nbsp; This may result in a prolonged laryngeal block or a repetition of grunts, like ?#577;uh-Ɂuh-Ɂuh-Ɂuh.?nbsp;

Reinforcement of Effort Programming

            Fixation on the initial consonants creates the false impression that these sounds are causing the speaker to block, and that it�s hard to say words beginning with these sounds. This expectation of difficulty causes the brain to program the larynx for effort. With no vowel program, the person can�t get past the initial sound, resulting in the very blocks that the speaker feared. The person erroneously believes that the initial sound was the problem, thereby reinforcing and perpetuating his fear of words starting with that sound. Repetition of this behavior eventually establishes nerve pathways in the brain that may be very difficult to change. As a result, stuttering behavior may take on a life of its own and continue even after the precipitating causes have disappeared.

Use of Effort To Reduce Anxiety

            Valsalva programming may also be reinforced through the use of effort to reduce anxiety. All the participants in my first study reported that, to some degree, using effort helped them feel less anxious. This was particularly true for participants whose parents were critical of their stuttering. Using effort may have become a way to show how hard they were trying to please.

Using effort was reinforced because of its short-term benefit in reducing anxiety, even though it perpetuated stuttering.

            Understanding this dynamic was crucial to reducing the effort used in speaking situations.

Valsalva Control Therapy

            The purpose of Valsalva Control Therapy is to promote easy, natural, resonant speech by eliminating interference from the body�s Valsalva mechanism and the urge to exert effort.

           Its focus is on relaxing the Valsalva mechanism, rather than fluency-shaping �targets?or artificial-sounding speaking techniques. It seeks to liberate the client�s natural fluency ?since his mouth already knows how to talk.

             Valsalva Control intentionally does not emphasize fluency, because any effort to �stop stuttering? would tend to activate the Valsalva mechanism and be self-defeating. Instead, the goal is to communicate in an easy, effortless, and enjoyable way.

          Likewise, the participants?reactions to speaking situations are analyzed and discussed in terms of their urge to exert or display effort, rather than whether or not they stuttered.

Elements of Valsalva Control ?Education

          Valsalva Control Therapy begins with education about:

The speech mechanism & and the basics of normal speech production. The participant learns that fluent speech requires very little physical effort. Most of the muscular effort occurs prior to speech, during inhalation, as the chest muscles and diaphragm contract to enlarge the chest cavity to suck in the air. The airflow that powers speech mainly comes from the relaxation of those muscles.

The participant learns about the Valsalva mechanism and the Valsalva maneuver.

The participant learns how the urge to exert effort leads to motor programming of the Valsalva mechanism and interferes with the phonation of vowel sounds.

Valsalva Relaxation

            The next element is Valsalva relaxation. This includes:

Inhaling using the diaphragm.

Concentrating on relaxing the abdominal muscles as you exhale and begin speaking. Because all parts of the Valsalva mechanism are neurologically programmed to act together, you can't do a Valsalva maneuver when you're relaxing your abdomen.

The exhaled breath is like a satisfied sigh of relief. The Germans call it seufzen (ZOYF-zen): "To heave a sigh of relief." The chest and abdominal muscles collapse into a state of relaxation.

When speaking, forget about your mouth (your mouth already knows how to talk) and imagine that speech is coming from your navel.

During the day, refrain from doing ordinary Valsalva maneuvers ?such as when lifting heavy objects or making bowel movements. Vocalize instead of holding your breath.

Adronian Speech Exercise

            The next stage of Valsalva Control Therapy involves emphasis on phonation.

            Persons who stutter almost never stutter when they sing. This is probably because they are focusing more on the melody that the words. Therefore, the brain is constantly programming the larynx to phonate, rather than to do effort closure, thereby preventing a Valsalva maneuver. Valsalva Control incorporates this principle through the �Adronian Speech?exercise.

            Adronian Speech incorporates Valsalva relaxation, plus saying �aaa?at the beginning of each phrase and continuous phonation of all sounds. The client begins by speaking in very short phrases.

            It should be emphasized that Adronian is not a permanent speaking technique, but simply a temporary bridge to gradually ease into the next stage, which is:

Resonant Valsalva-Relaxed Speech

            Resonant Valsalva-Relaxed Speech is:

Natural sounding speech, with Valsalva relaxation and concentration on vowels.

You begin with very short phrases, and gradually lengthen them.

There are numerous exercises to help clients focus on and strengthen vowel production.

One technique is to pull on clasped fingers when saying the vowel sounds. Alternatively, you could press up under edge of a desk or table. This technique also displaces the urge to exert effort away from the larynx.

After this technique is mastered, the activity can be reduced to something inconspicuous like pressing the thumb and forefinger together (i.e., pinching) while saying the vowel sounds. This activity is then gradually faded out.

Transition

            Therapy continues through individualized counseling until easy, effortless speech is achieved in all speaking situations.

The client�s reactions to speaking situations are analyzed in terms of the urge to exert effort.

Speaking situation hierarchies are utilized, based on difficulty and importance to client.

Negative attitudes and self-talk are analyzed and replaced with more helpful ones.

Transition Exercises

            Transition exercises include:

Role playing exercises based on actual speaking situations.

Time-pressure exercises.

The client is encouraged to focus on his or her role or purpose in speaking, rather than trying to make a �good impression?by trying not to stutter.

Handling Anticipated Blocks

            Among other things, clients are taught not to force through anticipated blocks. Instead they should stop, take a breath, relax their abdomen as they exhale, and focus on phonating the vowel sound. We have found that pulling on clasped fingers (later reduced to "pinching" the thumb and forefinger together) may help to focus on vowel production and to displace the urge to exert effort.

            However, I must caution you that this advice is not a substitute for therapy. It is only effective after a person has become skilled in the fundamentals of Valsalva Control.

Clinical Trial ?Phase 1

            In July 2010, I began the first phase of my clinical trial on the effectiveness of Valsalva Control Therapy.

         The participants were five English-speaking males, ages 21-31, with moderate-to-severe developmental stuttering. Appropriate consents and authorizations were obtained.

         Therapy was administered in 25 weekly one-hour sessions, plus daily 30-minute exercise routines and other homework assignments. All sessions were conducted by video conferencing using Skype?and video recorded.

During the course of the study, the therapy evolved as new materials and exercises were added.

Average Results for All 5 Participants

            The following are the average results for all five participants in the study.

% Syllables Stuttered in Oral Reading

The first graph shows the reduction in percentage of syllables stuttered in oral reading for all five participants. The black line shows a beginning average of 8.86 per cent stuttered syllables, reduced to an average of 1.26 per cent after 24 weeks ?a reduction of about 86 per cent.

Stuttering Severity Scores (SSI-4)

            The next graph shows the Stuttering Severity Scores for the five participants, based on the Stuttering Severity Instrument-4. As shown by the black line, the average score was reduced by 61 per cent, dropping from �Moderate?to �Very Mild.?/span>

OASES Scores at 0, 8, 16 & 24 Weeks

The next graph shows the overall impact of stuttering as measured by the OASES questionnaire ? the �Overall Assessment of the Speaker�s Experience of Stuttering.? This test has a minimum score of 1.00 and a maximum score of 5.00. As shown by the black line, the average impact was reduced from �Moderate-Severe,?to �Mild-Moderate??an average reduction of 50.63 per cent.

�Easy and Effortless?Self-Reporting

            Each week the participants were asked to report how easy and effortless their speech had felt to them in various speaking situations. Participants ranked the amount of effort on a scale of 1 to 9, with 1 being �Very easy and effortless?and 9 being �Very difficult.?

            The next graph shows the average progress in �easy and effortless speech.? The red line represents the average �most difficult?experience, the green line represents the average �easiest?experience, and the blue line represents the average rating of speech in general. As you will see, the average effort in general was cut approximately in half, from around 5 down to about 2.6.

Participants?Evaluation of Program

            At the end of 24 weeks, the participants were given a questionnaire to evaluate the therapy they had received.   They were asked to rate how strongly they agreed or disagreed with the following statements.

5 out of 5 participants ?b>Strongly Agreed?with these statements:

o   The explanations about Valsalva-Stuttering accurately described my own experience of stuttering.

o   The program helped me to understand my stuttering better.

o   I will continue to use Valsalva Control in the future.

o   I learned skills and insights that will help me to continue to improve my speech on my own.

o   I would recommend Valsalva Control to other people who stutter.

4 out of 5 participants ?b>Strongly Agreed?and one �Somewhat Agreed?that:

o   The program made speaking more enjoyable for me.

o   Overall, I was satisfied with the Valsalva Control program.

3 out of 5 participants ?b>Strongly Agreed?and two �Somewhat Agreed?that:

o   The program made my speech easier and less effortful.

o   The program reduced the frequency of my stuttering blocks.

o   The program helped to reduce my anxiety about speaking.

o   I find it easy to use Valsalva Control in everyday speaking situations.

o   My speech sounds and feels natural when I use Valsalva Control.

All participants who had previous therapy ?b>Strongly Agreed?that:

o   Valsalva Control helped me more than any other therapy I have had.

Conclusions - Phase 1

            Based on the Phase 1 trial, Valsalva Control appears to be a valid approach to understanding and treating stuttering, while pre�serving the individuals?own natural-sounding speech. Furthermore, Valsalva Control provides practical insights and tools for persons to make further progress on their own. This is important, because deeply entrenched nerve pathways for any kind of behavior, including stuttering, often take a very long time to change.

            Three of the five participants showed dramatically reduced stuttering both in and outside of therapy sessions. The two other participants reported less success in transferring Valsalva Control to outside speaking situations, possibly due to anxiety issues.   They may have needed more intensive therapy than weekly Skype sessions.

           Furthermore, it appeared that the standard one-hour weekly sessions were not intensive enough to establish sufficient changes in the habitual behavior of some participants. Consequently, the results were not as rapid or as consistent as I would have liked.

Clinical Trial ?Phase 2

            A few weeks ago I began a more intensive Phase 2 clinical trial of Valsalva Control Therapy. The new therapy sessions will be longer, more frequent, and more structured than in Phase 1. They will include new therapy materials, exercises, and techniques that were developed during Phase 1. The new trial will determine whether these modifications will help to reduce stuttering more quickly and effectively.

            In the new, intensive format, therapy begins with at least two 3-hour sessions per week for the first three weeks, then tapering off. Participants must also do at least 30 minutes of practice every morning, plus an additional 30 minutes during the day. Participants must actually practice their speaking exercises (including �Adronian? outside of therapy sessions (e.g., with a friend or family).

           This format has already produced dramatic results within the first two weeks, as you will see in the video.

Individual Case Study: RP

            The first participant in Phase 2 is RP, a 22-year-old male college student and part-time cook. He began stuttering around age 5. His mother and one of her brothers stuttered as children. RP�s stuttering is extremely severe, especially in conversational speech, with approximately 25 percent stuttered syllables and blocks that often last 25 seconds or more. His total score on the Stuttering Severity Instrument-4 was 41 ?Very Severe.   His overall score on the OASES questionnaire, which measures the impact of stuttering, was 4.07 �Severe.

            RP�s prior therapy included a 12-day precision fluency shaping program last summer, similar to the program at Hollins. The techniques were helpful for about a month, but then trying to make the targets became too stressful and his stuttering returned as severe as ever.

            RP recently completed four 3-hour Valsalva Control Therapy sessions on Skype during a 10-day period. As you are about to see, his stuttering was dramatically reduced.

Videos of RP Before and After 2 Weeks of Therapy

            Now let�s hear from RP himself. Here are video recordings made before therapy began and ten days later, after four 3-hour sessions of Valsalva Control Therapy.

Videos of RP Before and After 2 Weeks of Therapy

(Time: 8:48)

Further Information

            If you would like further information about Valsalva Control Therapy, I invite you to visit my website, �The Valsalva-Stuttering Network,?at www.Valsalva.org.