Understanding and Controlling Stuttering: A Comprehensive New Approach Based on the Valsalva Hypothesis [4 ed.] 9781737955504

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Understanding and Controlling Stuttering

THE ULTIMATE EXPANDED FOURTH EDITION

Understanding & Controlling

Stuttering A Comprehensive New Approach Based on the Valsalva Hypothesis

William D. Parry, J.D., M.A., CCC-SLP

Illustrations by Amie Rumsey A Publication of

WORLDWIDE VALSALVA STUTTERING THERAPY Philadelphia

To my wife Marilyn . . . and to all the participants who helped further the development of Valsalva Stuttering Therapy. Copyright © 2021 by William D. Parry. Previous editions copyright © 1992, 1993, 1994, 2000, 2004, 2006, 2009, 2013 by William D. Parry. First Printing of Fourth Edition 2021 All rights reserved. Printed in the U. S. A. No part of this publication may be reproduced or transmitted in any form or by any means without permission in writing from the author. Published by William D. Parry, dba Worldwide Valsalva Stuttering Therapy. 520 Baird Road, Merion Station, PA 19066 Cover design by Bob Lombardo ISBN: 978-1-7379555-0-4

To the Reader: This book is not a substitute for diagnosis and treatment by a qualified speech-language pathologist. The discussions herein apply only to the most common kind of stuttering, known as “persistent developmental stuttering,” and may not be relevant to other types of disfluency. For further information: Visit the Worldwide Valsalva Stuttering Therapy website at www.stuttertherapy.com

e-mail: [email protected]

Table of Contents

v

Table of Contents Preface Acknowledgements

Part I. Chapter 1. Chapter 2. Chapter 3.

The Puzzle of Stuttering

vii xii 1

The Stuttering Experience The Stutterer's Quandary Pieces of the Puzzle

3 9 16

Speech and the Valsalva Mechanism

23

The Speech Mechanism The Basics of Speech The Valsalva Mechanism

25 31 38

The Valsalva Hypothesis

45

Putting the Pieces Together Valsalva Tuning and Forceful Blocks Valsalva Tuning and Phonation The Neurological Triggering of Blocks Analysis of Stuttering Blocks The Amygdala as “Bodyguard” Varieties of Stuttering

47 53 57 60 67 71 77

Perpetuation of Stuttering Behavior

83

Chapter 14. Chapter 15. Chapter 16.

The Valsalva-Stuttering Cycle The Valsalva-Stuttering System The Psychology of Stuttering

84 90 93

Part V.

Susceptibility to Stuttering

99

Part II. Chapter 4. Chapter 5. Chapter 6.

Part III. Chapter 7. Chapter 8. Chapter 9. Chapter 10. Chapter 11. Chapter 12. Chapter 13.

Part IV.

Chapter 17. Chapter 18. Chapter 19. Chapter 20.

The Origins of Stuttering Speech Functions of the Brain Heredity and the Stutterer's Brain The Brain and the Valsalva Mechanism

100 109 115 127

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Part VI. Chapter 21. Chapter 22.

Part VII. Chapter 23. Chapter 24. Chapter 25. Chapter 26. Chapter 27.

Part VIII. Chapter 28. Chapter 29. Chapter 30.

Part IX. Chapter 31. Chapter 32 Chapter 33. Chapter 34. Chapter 35. Chapter 36. Chapter 37. Chapter 38. Chapter 39. Chapter 40. Chapter 41. Chapter 42.

Part X. Chapter 43. Chapter 44. Chapter 45. Chapter 46.

Conclusion.

Fluency Enhancing Conditions

135

New Perspectives on Fluency Techniques The Effects of Hearing and Role Playing

136 145

Stuttering Therapy

155

Stuttering Therapies Revisited Psychological Approaches to Therapy Behavior-Oriented Therapies Drug Therapy Acceptance and Self-Help

156 166 174 185 189

Introduction to Valsalva-Stuttering Therapy 195 A New Approach to Stuttering Therapy Adopting a Valsalva-Free Attitude The Power of Intentions

196 206 214

Valsalva-Relaxed Speech Exercises

219

Exercise Overview Valsalva-Relaxed Breathing Valsalva-Relaxed Vowel Exercises Voicing the “Melody Message” Introduction to Humdronian Speech The Full Humdronian Speech Exercise Transition to Natural Sounding Speech The “SMEEch” Exercise Speaking with Melodic Intention The Word Recovery Response Demystifying Stuttering Blocks Transcendent Speech

220 223 230 235 240 244 250 255 258 260 265 270

Applying Valsalva Relaxed Strategies

273

Why Repetitive Exercises Are Important Implementation of Therapy Valsalva Control for Everyday Speech Learning from Experience

274 278 283 288

A New Outlook on Stuttering

295

Table of Contents

Appendix A. Appendix B. Appendix C. Appendix D. Appendix E. Appendix F. Appendix G. Appendix H. Appendix I. Appendix J.

vii

Appendices

303

Valsalva-Free Self-Talk Emotional Interactions in Speaking Situations Consonant-Vowel Word Exercises Key to Vowel Sounds Key Vowel Sounds in Multi-Syllable Words Sample Sentences and Phrases Sample Picture Naming Exercise Sample Vowel-Specific Sentence Lists Sample Initial-Sound Sentence Lists Sample Daily Practice Routines

304 306 308 312 313 316 318 322 325 334

Bibliography Index About the Author

339 349 354

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Understanding and Controlling Stuttering

Preface

I

F YOU ARE READING THIS BOOK, you probably share something in common with the people you might find at a stuttering support group meeting, like the ones I have led for my local chapter of the National Stuttering Association. Perhaps you are a person who stutters, a friend or family member of someone who stutters, a speech-language pathologist, or a visiting graduate student who is taking a fluency course. For one reason or another, you want to gain an understanding of this frustrating condition and to find a better way of controlling it. I hope this book, in its extensively revised and comprehensive Fourth Edition, will go a long way toward filling that need. Just as participants do at meetings, let me start by introducing myself. I am a person who struggled with stuttering for most of my life. I began stuttering at age four, and my disfluency became progressively worse as I entered adolescence. Although my visits to speech therapists didn’t help much, I discovered through elocution lessons that I had a fine speaking voice nonetheless. During recitals, I was able to act out roles before audiences with perfect fluency. Offstage, however, I could hardly say my name. Such variability is one of the paradoxes of stuttering that made me feel as if I was crazy. And so began my quest to understand and control my stuttering. Over the next three decades I read books on stuttering and psychology, volunteered for experiments, and submitted to a wide range of treatments. These included speech therapy at several university clinics, both in high school and at college. Because my speech was excellent in certain situations, I clearly had the capacity to be fluent. Therefore, my stuttering appeared to be “psychological,” based on the then-prevalent notion that stuttering was caused by unconscious emotional conflicts. Consequently, I saw a string of psychologists and psychiatrists, to no avail, and finally submitted to many years of intense psychoanalysis. Naïvely hoping that that psychoanalysis would eventually uncover and resolve the cause of my disfluency, I decided to become a lawyer. I attended a prestigious law school and was elected to serve on its Law Review. Otherwise, law school was a living hell, especially when called upon to answer questions in class. After I graduated and ventured into the job market, my stuttering persisted. I was explicitly rejected by law firms because of my stuttering. I was repeatedly told, “Because of your speech, you would be of limited value to us.” Consequently, I spent years as editor for a legal publication, and then in a deadend job for a lawyer who hired me for my research and writing skills. Although

Preface

ix

I stuttered almost all the time, I had the surprising ability to deliver eloquent closing arguments to juries. This was the only thing that kept me going. I finally quit psychoanalysis in frustration, because of the analyst's insistence that the cause of stuttering was purely psychological, without any physiological component. However, I did not fare much better with various behavior-type therapies -- such as those using a miniature metronome or the "airflow" technique. I hated the monotonous and unnatural sound of these artificial fluency methods and found that I soon relapsed back into stuttering. Furthermore, these approaches did not give me a satisfactory understanding of why I stuttered, or exactly how the psychological and physical factors interacted to cause stuttering in some instances but not in others. The effectiveness of such fluency techniques was based mainly on faith that they would make me fluent. Once they failed, I lost faith in them – after which they became totally useless. It became increasingly apparent that my stuttering was not caused by a lack of ability to speak but rather an interference with the ability I already had. At the instant before saying a word, it seemed as if a mysterious "switch" was thrown that caused a vise to clamp down on my speech. I often felt that words contained “brick walls” even before I tried to say them. I suspected that the "switch" was neurological or physiological in nature, but that it was tripped by psychological factors. I suspected that the answer to stuttering was not to control one’s speech, but rather to control the forces that interfered with speech. I hoped that, by discovering the exact mechanism involved, I would have a rational basis for understanding and controlling the problem. After terminating all therapy, I continued to search for the answer through personal experimentation, extensive review of medical literature, and consultations with professional researchers in the fields of laryngology and speech pathology. I studied hundreds of books and articles on not only stuttering, but also related areas of anatomy, neurology, and speech production. Through my reading, I learned about the body’s Valsalva mechanism. This mechanism is a neurologically coordinated combination of muscles in the larynx, chest, and abdomen, designed to build up air pressure in the lungs by performing a Valsalva maneuver. The maneuver’s normal purpose is to assist us in exerting strenuous physical effort or in forcing things out of the body. Through personal experimentation, I discovered that I was habitually activating this mechanism in my attempt to speak – particularly in situations where I felt the need to exert effort. Although “trying hard” seemed like the right thing to do, the neurological programming of the Valsalva mechanism interfered with the phonation of vowel sounds by my larynx. This led to the various symptoms of stuttering – including hesitations, repetitions, prolonga-

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tions, and forceful closures of my mouth or larynx in an attempt to force out words by building up air pressure. This will be fully explained in this book. While formulating my “Valsalva Hypothesis” of stuttering in 1984, I met with researchers at the Temple University Speech Department and the Pennsylvania Hospital Department of Laryngology and corresponded with other experts around the United States. On one occasion, I had a fiber-optic tube inserted through my nasal passage and down my throat to obtain videotapes of my larynx in action. My ideas were eventually published as a clinical note, entitled "Stuttering and the Valsalva Mechanism: A Hypothesis in Need of Investigation," in the December 1985 issue of The Journal of Fluency Disorders. Based on my hypothesis, I developed new exercises and techniques to control my Valsalva mechanism and reduce its interference with speech. This “Valsalva Control” approach increased my fluency dramatically, while allowing me to speak in my own natural way. My speech improved to such a degree that within a year I had a new job as a trial lawyer handling personal injury litigation for a prestigious law firm. For the next twenty-plus years, my fluency continued to improve and my career as a trial lawyer continued to blossom. In the meantime, I had become active in the stuttering self-help movement. In January 1985, I founded the Philadelphia Area Chapter of the National Stuttering Project (now the “National Stuttering Association”) and led its support group meetings for more than 15 years. In 1996, I was elected to the NSA's Board of Directors, on which I served for six years as Chair of its Advocacy Committee. I also published the first edition of my book, Understanding and Controlling Stuttering. Subsequent editions have been sold by the NSA. I have given workshops on the Valsalva Hypothesis at numerous annual conferences of the NSA, as well as presentations at conferences of Speak Easy International Foundation in New Jersey, the Canadian Association for People Who Stutter (now the “Canadian Stuttering Association”), World Congresses for People Who Stutter, the International Stuttering Association, and the British Stammering Association. Through these activities, I have met hundreds of persons who stutter from all parts of the United States and around the world. Their response to the Valsalva Hypothesis has been overwhelmingly positive. Persons who stutter have told me that the Valsalva Hypothesis described their stuttering experience more precisely than anything they had ever encountered. For the Valsalva Hypothesis to realize its full potential for helping people who stutter, I knew that much more work had to be done. As a lawyer, I was not in a position to gather “empirical evidence” to support my Valsalva Hypothesis, nor was I able to conduct clinical trials to test the effectiveness of the “Valsalva

Preface

xi

Control” approach to therapy. Therefore, I embarked on a new career as a professional speech-language pathologist. I attended a Master’s program in Speech, Language and Hearing Science at Temple University in Philadelphia, successfully completed a supervised Clinical Fellowship Year as a school speech-language pathologist, became certified in clinical competency by the American Speech-Language-Hearing Association (“ASHA”), and obtained appropriate state licensure. Then I spent a year conducting clinical trials and developing therapy materials, using volunteers who signed appropriate authorizations and informed consents. Almost all the trials were done by video conferencing. They confirmed the effectiveness of Valsalva Control in reducing stuttering and improving the participants’ attitudes toward speech. I presented the results at the International Stuttering Association’s World Congress in Buenos Aires, Argentina, in May 2011. Since then, I have used this approach to treat hundreds of persons who stutter, with favorable results. The participants have included males and females, ranging in age from teens to seniors, from many parts of the world. Many have been physicians, others in the medical profession, lawyers, business executives, and even some speech pathologists. Although therapy was conducted in English, many of the participants primarily spoke other languages, in which their fluency also improved. Those who had undergone other forms of therapy reported that the Valsalva Control approach was more helpful and made much more sense than any previous therapy. My clinical experience has led to further refinements of the Valsalva Hypothesis, as well as significant improvements in my therapy techniques. The resulting “Valsalva Stuttering Therapy” has now crystallized to the point where I feel confident in sharing it in this substantially revised Fourth Edition of Understanding and Controlling Stuttering. This book invites you to set aside any preconceived notions you might have about stuttering and to take a fresh look at the subject. It is intended primarily for adults and adolescents who stutter, but hopefully it will also be of interest to therapists and others concerned with the problem. It does not offer any quick and easy gimmicks to "cure" stuttering. Instead, its approach requires that we first gain a thorough understanding of what stuttering is and why we do it. Only then are we ready to master the principles of controlling the various factors that result in stuttering. Based on insights gained from the Valsalva Hypothesis, as well as actual clinical experience with Valsalva Stuttering Therapy, this book will present a comprehensive view of stuttering, including both its physical and psychological aspects. It will show how these factors may interact to cause and perpetuate stuttering through the "Valsalva-Stuttering Cycle." In this way, it will attempt

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to explain virtually every aspect of stuttering behavior, its paradoxes, its causes, and its treatment. The book will analyze the symptoms and circumstances of stuttering, the development of stuttering in childhood, the influence of heredity and neurological factors, and the physical and psychological conditions that tend to increase or reduce stuttering. It will then discuss existing therapies, point out the elements that many of them have in common, analyze their strengths and weaknesses in terms of the Valsalva Hypothesis, and show why most stutterers who undergo these therapies tend to relapse. Finally, I shall outline the principles of Valsalva Stuttering Therapy and suggest a self-help program that incorporates both physical and psychological techniques aimed at controlling the Valsalva mechanism and breaking the stuttering cycle. The suggested exercises have been substantially revised and expanded compared to those in the earlier editions, based on actual clinical experience. However, this book is not intended to be a substitute for professionally supervised therapy, and it does not contain all the materials used in Valsalva Stuttering Therapy. These discussions have been organized with the lay reader in mind, starting out as simply as possible and then gradually introducing more and more complexity as we go along. To ease the way, I have tried to avoid scientific jargon and to explain the physiological aspects of speech in simple, everyday terms. Likewise, I have used the ordinary English alphabet, in addition to the phonetic alphabet, in representing the various sounds of speech. Pronunciations are based on standard American English. Although I prefer the term “person who stutters” (abbreviated “PWS”), I occasionally use “stutterer” when necessary to avoid awkwardness. Likewise, I use the masculine pronoun when referring generically to persons who stutter (since most of them are male) and the feminine pronoun when referring generically to speech therapists (since the vast majority are female). Of course, there is no guaranty that any method will bring fluency to everyone. It would be extremely presumptuous to claim that anyone will be "cured" of stuttering just by reading a book. However, I hope that this book will help to strip away the mysteries of stuttering and point the way to easier and more enjoyable speech.

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Understanding and Controlling Stuttering

Acknowledgements

I

AM INDEBTED to the many people who have contributed to my understanding of stuttering: researchers around the world who have provided a growing foundation of scientific data; speech-language pathologists who have given advice and sent me articles and information; and members of the stuttering self-help movement who have shared their personal insights and experiences. While there was often disagreement on many points, the sharing of diverse views about stuttering helped me to continually refine and strengthen my ideas. Special thanks go to C. Woodruff Starkweather, Ph.D., for his consultations and review of my original paper on "Stuttering and the Valsalva Mechanism"; to the Journal of Fluency Disorders for publishing it; Joseph P. Atkins, Jr., M.D., of the Pennsylvania Hospital Department of Otolaryngology, who performed a fiber-optic study of my larynx and reviewed that paper prior to publication; John Paul Brady, M.D., of the University of Pennsylvania Department of Psychiatry; and numerous researchers and speech-language pathologists whom I have met through the National Stuttering Association (formerly the “National Stuttering Project”). Particularly crucial to this endeavor was the help I have received from members of the stuttering self-help movement. First and foremost, I wish to credit John Harrison, former Program Director of the NSP, who gave me the encouragement and moral support to complete the original book, and who did more than anyone to bring the Valsalva Hypothesis to the attention of stutterers and researchers around the world. Thanks also to Dr. E. Robert "Cy" Libby, Dan Weiss, and other members of the Philadelphia Area Chapter; to John Ahlbach, former Executive Director of the NSP, and to Tammy Flores, the current Executive Director of the NSA. I am grateful to the hundreds of participants who have helped me develop Valsalva Stuttering Therapy into is present form, including speechlanguage pathologists such as Matthew Fuston. Thanks also to my daughters Sara and Jessica for their help with the original book. Finally, my most profound gratitude goes to my wife Marilyn, for her enthusiastic support, advice, and encouragement in the presentation of my workshops, the development of Valsalva Stuttering Therapy, and for making this Fourth Edition possible.

xiv

Part I. The Puzzle of Stuttering

1

2

Chapter 1 / The Stuttering Experience

3

CHAPTER 1.

The Stuttering Experience LIVE IN A WORLD dominated by the spoken word. Almost everyW Ewhere—at home, school, work, social gatherings—speech is the way people get to know one another and share ideas, information, and feelings. By means of speech, we tell who we are, what we want, and why we are important. Through the give and take of spoken conversation, we develop friendships and become skilled in dealing with others. Speech is like a magic thread by which we weave ourselves into the fabric of society. It is easy for the average person to take speech for granted. When an idea springs into his mind, he simply opens his mouth. Automatically, his brain comes up with the right words and sends them off through the organs of speech. Almost instantly—without any conscious effort—he hears himself talking. He gives no thought to the complex interaction of brain cells, nerves, muscles, and other parts of the body that make his speech possible. The words just seem to flow, like the clear water of a mountain stream. To be sure, the average person may find some speaking situations more difficult. Answering a question in class, asking the boss for a raise, delivering a speech to a large audience, for example. The person may be unsure of what to say, afraid of angering someone, or worried about making a fool of himself. Rarely, however, will he doubt his ability to speak. Frightened and hesitant though he may be, he will nevertheless open his mouth, and the magic of speech will take over. But this is not true for the person who stutters. For the person who stutters, speaking is an entirely different experience. Speech doesn't flow smoothly, like the babbling mountain brook. Speech is more like the poor salmon, struggling to jump over waterfalls as it fights its way upstream to the spawning ground. If you are a person who stutters, you have no assurance that the words will spring from your lips on command. True, there are times when your speech may come easily. But in other situations, the flow of speech is blocked. Sometimes, when you try to say a word, your speech is so totally blocked that nothing comes out at all. The blocking may occur in the mouth, with your lips pressing tightly together like a vise. Or your tongue may feel like it's trying to push its way through the roof of your mouth. Sometimes the air gets stran-

4

Part I / The Puzzle of Stuttering

gled down in your throat, and you feel as if you had swallowed a cork. Other times your vocal cords seem frozen, unable to make a sound. You may grope desperately for words, but all you get are uh's and ah's and other embarrassing noises. Sometimes you find yourself making repetitive laryngeal closures and grunts (“uh-uh-uh-uh-uh”) before speaking. Sometimes the block is partial or intermittent. You may get stuck on a certain sound and keep prolonging it. For example, your pronunciation of "s-ss-s-s-s-s-snake" may hiss like the serpent it describes. Or you may keep repeating the first part of a word over and over, before being able to move onto the rest. When you say "buh-buh-buh-buh-basketball," you may give the impression that you're actually dribbling the ball down the court. But stuttering is not simply the repetition of sounds we see in the written depictions of stuttered speech. The hallmark of real stuttering is the stutterer’s feeling that a word is stuck – as if blocked by a “brick wall” — and the tremendous amount of physical effort the stutterer often uses in trying to force the word out. Instead of touching lightly and briefly during speech, the lips or tongue press harder and longer than necessary, or the larynx itself may clamp shut. While this is happening, the air pressure in the stutterer's body may increase to the point that he feels he is about to explode. In addition to the blocks, stuttering is often complicated by other kinds of physical and verbal behavior. In the struggle to force the words out, a person who stutters might twist and contort his face, jerk his head, blink his eyes, grind his teeth, bite the inside of his mouth, swing his arms, etc. He may insert unnecessary words, phrases, or sounds as "starters" before trying to say a difficult word. He may go back and repeat the previous few words over and over and over, as he tries again and again to leap over the hurdle. If possible, he may try to substitute a different word that is easier to say. Persons who stutter often sense that a particular word contains a “brick wall,” even before they try to say it. Therefore, some persons who stutter become adept at covert stuttering—struggling silently through the blocks before speaking, changing and censoring words in advance, and saying only the things they feel will not give them trouble. Their entire conversation is dictated by the effort to conceal their stuttering. Other persons who stutter go to equally great lengths to avoid talking altogether.

The Definition of Stuttering The precise definition of "stuttering" is a matter on which speech pathologists often disagree. Therefore, it may be helpful to explain exactly what is meant by the term when used in this book. Stuttering refers to a particular speech disorder in which the flow of speech is involuntarily blocked or disrupted. The block begins in the brain and is often sensed by the speaker before he attempts to say the word. The external manifestations include forceful closures of the mouth or larynx, repetitions or

Chapter 1 / The Stuttering Experience

5

Common Stuttering Behaviors • Being “stuck” on the initial consonant or glottal stop of a word or syllable and being unable to move on the the vowel sound that follows. • Tension in the mouth, larynx, chest, and/or abdomen. • Forcing on the initial consonant of a word or syllable, or on the glottal stop before initial vowel sounds. • Prolongation of the initial consonant. • Repetition of the beginning sound of a word or syllable. • Repetitive laryngeal grunts before speaking. • Hesitations. • Avoidance and delaying tactics (e.g., starters, interjections, word substitutions). • Grimaces, eye-blinking, or other extraneous behaviors. prolongations of sounds and syllables, hesitations or delays in making voiced sounds, and in some cases, a series of laryngeal grunts before speaking. Stuttering generally involves an excessive amount of effort, force, and struggle in the attempt to speak. It also may be accompanied by a variety of behaviors intended to avoid, postpone, or hide the blocks. Stuttering is sometimes called "stammering," especially in Great Britain. For our purposes, the two words are synonymous, and both refer to the same disorder. Stuttering must be distinguished from disfluency, which refers broadly to any interruption in the natural flow and rhythm of speech. Stuttering is a very specific kind of disfluency. Many people are disfluent from time to time, for a variety of reasons, but that doesn't necessarily make them stutterers. Such “normal disfluencies” include occasional interjections of “um,” “ah,” and effortless whole-word repetitions. Stuttering also differs from language disabilities such as aphasia, in which the ability to think of the appropriate words is impaired. A stutterer's problem is not in finding the words, but rather in saying them. Stuttering also differs from apraxia of speech, an oral motor speech disorder in which the brain has difficulty programming the movements of articulation, resulting in inconsistent distortions of speech sounds. In contrast, the stutterer’s articulators move into the proper positions, such as for initial consonants, but become stuck in that position as he exerts excessive force while trying to force out the rest of the word.

6

Part I / The Puzzle of Stuttering

Characteristics of Developmental Stuttering • Usually begins in childhood, but sometimes in teens. – Not associated with brain damage. – “Persistent” if it continues into adulthood. • Person who stutters (PWS) knows what to say but is blocked in saying the words. • Fluent some of the time, or in certain situations. • Severity varies depending on speaking situation. • PWS are almost always fluent when: – Silently mouthing words or whispering. – Singing or continuously phonating. – Speaking in unison with someone (choral reading). • Some PWS are fluent when: – Acting a role as somebody else. – Speaking with an assumed accent. We must also differentiate stuttering from a relatively rare kind of disfluency, sometimes called acquired stuttering, which may occur at any age following certain kinds of brain damage. Although it may involve stuttering-like symptoms, acquired stuttering is actually a very different disorder, as will be explained in a subsequent chapter. This book will be devoted exclusively to the usual, garden variety of stuttering—sometimes called developmental stuttering—which seems to develop of its own accord during childhood. It is called persistent developmental stuttering when it continues into adulthood. Therefore, the discussions in this book may have little or no application to a brain-damaged person with acquired stuttering. Developmental stutterers, as distinguished from acquired stutterers, are generally capable of fluent speech in at least some instances. Most have no trouble when singing or when reading in unison with someone else, and they are usually much more fluent when talking to themselves or to animals or small children. The severity of developmental stuttering often depends on the speaking situation. For example, many individuals have a particularly hard time saying their name, talking on the telephone, or addressing authority figures. Those are some of the basic characteristics of stuttering. The severity, frequency, and situations in which stuttering occurs will vary according to each

Chapter 1 / The Stuttering Experience

7

individual. We will examine all of these aspects of stuttering in greater detail as we go along.

The Prevalence of Stuttering If you stutter, you have probably experienced the feeling of being alone and out of place in our glib and garrulous world. But you are not the only one. It has been estimated that nearly one percent of the general population stutters. This would amount to more than two million persons who stutter in the United States alone. (However, the frequency of severe stuttering is probably less.) For some reason, stuttering is about four times more common in males than females. There is truth to the statement, "If you stutter you are in good company." Throughout history, there have been many notable people who stuttered. These include Moses, Aristotle, Virgil, Sir Isaac Newton, Joseph Priestley, Lewis Carroll, Charles Lamb, Clara Barton, Sir Winston Churchill, King George VI of England, W. Somerset Maugham, James Earl Jones, Joseph R. Biden, Jr., who was elected President of the United States, and many others. Stuttering usually starts in childhood, most often between ages two and eight, but sometimes as late as one’s teens. Roughly 4 to 5 per cent of people experience stuttering at some time during their childhood. Fortunately, about 80 percent of them become fluent by the time they reach adulthood, even without speech therapy. But the rest are not so lucky. Many go on to become adult stutterers, for whom stuttering is likely to be a chronic, persistent problem for the rest of their lives.

The Impact of Stuttering If you stutter, you know that the experience of stuttering is far more than just the blocks themselves. It can affect one's entire life. The experience of stuttering is the constant fear of speaking situations, the fear of ridicule and rejection. It is the uncertainty of not knowing whether the words will come out when you need them, or whether you will suddenly find yourself abandoned by speech in an awkward situation. It is the frustration of not being able to say what you want, of having important words bottled up inside you while other people babble nonsense with no trouble at all. Stuttering is the embarrassment of not being able to say your name when meeting someone. It is the exhausting struggle to tell people even the most routine information, such as your address and telephone number. It is the isolation of not being able to participate fully in everyday conversations. Stuttering is the inconvenience of walking or driving from store to store in search of an item, because you can't use the telephone to call ahead to see who has it. It is the disappointment of not being able to order the food you want in a restaurant and selecting an alternative that is easier to say.

8

Part I / The Puzzle of Stuttering

Stuttering is the disillusionment of seeing a job or promotion go to a less qualified but more fluent person. It is the resignation of settling for a job or career that is less rewarding than the one you really wanted, simply because it doesn't require you to talk as much. The experience of stuttering is the pervasive feeling of shame and guilt, and nagging doubts about your competence and worthiness as a person. It is the sense of forever being a little child, while other people are self-confident adults. And it is the indignity of constantly having to put up with people who tell you to "relax," who try to fill in words for you, or who keep giving you useless advice on how to stop stuttering.

General References ANDREWS, G., CRAIG, A., FEYER, A., HODDINOTT, S., HOWIE, P., & NEILSON, M. Stuttering: a review of research findings and theories circa 1982. Journal of Speech and Hearing Disorders, 1983, 48, 226-246. BLOODSTEIN, O. Stuttering: The Search for a Cause and Cure. Needham Heights, MA: Allyn & Bacon, 1993. BLOODSTEIN, O. & RATNER, N.B. A Handbook on Stuttering. 6th ed. Clifton Park, NY: Delmar, 2008. BOBRICK, B. Knotted Tongues. New York: Simon & Schuster, 1995. CONTURE, E. G. Stuttering: Its Nature, Diagnosis, and Treatment. Needham Heights, MA: Allyn & Bacon, 2001. COOPER, E. B. Understanding Stuttering: Information for Parents. Chicago: National Easter Seal Society, 1990. GUITAR, B. Stuttering: An Integrated Approach to Its Nature and Treatment, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2006. JEZER, M. Stuttering: A Life Bound Up in Words. New York: Basic Books, 1997. MURRAY, F. P. A Stutterer's Story. Memphis, TN: Stuttering Foundation of America, 1991. SHAMES, G. H., AND RUBIN, H., EDITORS. Stuttering Then and Now. Columbus, OH: Charles E. Merrill Publishing Co., 1986. STARKWEATHER, C. W. Fluency and Stuttering. Englewood Cliffs, N.J.: Prentice-Hall, 1987. STARKWEATHER, C. W., & GIVENS-ACKERMAN, J. Stuttering. Austin, TX: Pro-Ed, 1997. VAN RIPER, C. The Nature of Stuttering. 2nd ed. Englewood Cliffs, N.J.: Prentice-Hall, 1982. WINGATE, M. E. Stuttering: Theory and Treatment. New York: Irvington, 1976.

Chapter 2 / The Stutterer’s Quandary

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CHAPTER 2.

The Stutterer's Quandary

O

NCE THERE WAS a student who stuttered very badly. Whenever he had to stand in front of the class to give an oral report, he couldn't say anything, no matter how hard he tried. All that came out was, "Uh-uh-uh-uh ... Uh-uh-uh-uh ..." The teacher was a great believer in the power of positive thinking. One day he took the student aside. "Listen. I know how you can overcome your stuttering. All you need is self-confidence. From now on, I want you to stand up straight, look people in the eye, and keep telling yourself, 'I can say it! I can say it!'" The student took this advice to heart. A week later, he was called on to deliver another oral report. This time, he strode confidently to the front of the room, stood up straight, looked his classmates in the eye, and began: "Uh-uh-uh-uh ... I can say it! I can say it! Uh-uh-uh-uh ... I can say it! I can say it!" The preceding story illustrates a recurring experience — well-intentioned, simplistic advice that fails because it doesn't get to the heart of the problem. I myself once tried the same approach as in the story, with similar results. For years I used the slogan, "I can say it," as a crutch, silently mouthing those words over and over when I came to a block. It didn't help one bit. Instead, it became just another part of my stuttering behavior. Stuttering, while not the worst of handicaps, certainly can be one of the most frustrating. As bad as other handicaps may be, at least they are consistent. Everybody accepts the fact that disabilities like blindness and paralysis have physical causes beyond the victim's control. The disability is always there, and the handicapped person and those around him must learn to accept and adapt to it. No one keeps insisting that the person would be cured if only he would "think positive" or "relax." Stuttering is different. Unlike other disabilities, stuttering has the mystifying and maddening habit of coming and going. Even if you stutter severely, chances are that you will be perfectly fluent when singing, talking in unison with other people, and in certain speaking situations. You may do a great job acting out a role on stage, but not be able to say your name when asked. You may begin telling a joke with perfect fluency, but not be able to deliver the

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punch line. You may have long stretches of fluency when it really doesn't matter. Then, just when the words are most important, stuttering jumps out of the closet and pins your speech to the ground.

Popular Misconceptions about Stuttering People find these paradoxes difficult to understand. If you can speak normally some of the time, they may ask, what excuse do you have for not speaking normally all of the time? Instead of appreciating the seriousness of your predicament, some people may see your stuttering as an object of ridicule. Even worse, they may suspect that you are mentally defective or emotionally disturbed. Before long, you may start wondering the same things yourself. The worst torments are probably those inflicted by stutterers upon themselves — including feelings of shame, guilt, personal failure, low self-esteem, and even doubts about their own sanity. Lay people often assume that stuttering is caused by the same things that occasionally make them disfluent – such as nervousness, excitement, uncertainty, fear, emotional conflict, etc. So they offer advice like: “Just relax,” “Take your time,” “Take a deep breath,” and “Think before you speak.” Such advice might sound reasonable, but it rarely helps. The problem is that such advice is too simplistic. It does not address the underlying factors involved in stuttering. Therefore, it feels condescending and tends to make stuttering worse. Based on Internet advertising and television news stories about “miraculous” electronic devices, drugs, and therapy programs, lay people may also get the impression that stuttering can be easily cured. They may ask why we haven’t taken advantage of these wonderful opportunities. However, after stutterers spend thousands of dollars on these devices and treatments and the fluency doesn’t last, they may feel even more discouraged and may blame themselves for having “failed.”

Psychological Views of Stuttering For many years, stuttering was viewed by the experts as being primarily a psychological or emotional disorder. The root of the problem was thought to be some deep, emotional conflict, locked away in the unconscious mind. Persons who stutter were prescribed various forms of psychotherapy. They discussed their feelings, analyzed their dreams, dredged up childhood memories, and complained about their parents. I myself was shunted down this track. I consulted a string of psychiatrists, read books by Sigmund Freud, and spent more than a decade on an analyst's couch. I dug deeper and deeper into my unconscious mind, searching in vain for the key to my problem. When I still kept on stuttering, I figured that I must be even crazier than I had thought! Other experts dispute the idea that stuttering is an emotional disorder. They point to studies showing that persons who stutter, as a group, are no more neu-

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rotic or emotionally disturbed than the general population, and that psychotherapy, by itself, has not been very successful in treating stuttering. Nevertheless, the notion that stuttering arises from emotional trauma persists in some quarters to this day. The assumption that stuttering is purely “psychological” is much too simplistic. Although some people who stutter may have suffered emotional conflicts and traumas, most did not. Conversely, most people who had traumatic childhoods don’t stutter. This is not to say that the emotional aspects of stuttering should be ignored. They may be extremely important, depending on the individual. However, the role of emotion must be viewed in the context of other factors. Without understanding the neurological and physiological aspects of stuttering, the search for psychological solutions can become aimless and confusing.

Behavior-Oriented Therapies Around the 1960's, there was increasing emphasis on treating stuttering through various forms of therapy aimed at changing the outward stuttering behaviors, rather than looking for underlying causes. Despite recent advances in technology, the most commonly used therapies have been around for many decades. These include the stuttering modification approach, the fluency shaping approach, and the integrated approach, which combines the other two. These approaches often view stutterers as having problems with articulation. Many of the “fluency shaping” therapies seek to eliminate the blocks by training the stutterer to use a new method of speaking. This approach is aimed at controlling the mechanics of speech, such as movements of the mouth, rather than dealing with psychological or emotional issues. Persons who stutter may be told that the only way to stop stuttering is to use a particular speaking technique. Depending on the therapy, a person who stutters may be taught to slow down his speech, to breathe in a particular way, to ease into sounds, to articulate with “light contacts,” to stretch out his words, or to focus on specific speech “targets.” After several days of intensive therapy, there is a good chance that even severe stutterers will be talking fluently. But achieving fluency in the therapist's office is only the first step. The first big challenge is to carry the fluency out of the clinic and into the real world. Many persons who stutter have a tremendous resistance to using the new speaking method in everyday situations. The most frequent complaint is that it sounds funny and feels unnatural. The standard response to this objection is: “It’s better than stuttering!” Once that resistance is overcome, the greatest challenge is to maintain the artificial-sounding fluency for more than a few weeks.

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Fluency techniques generally break down under the stress of real-life speaking situations. Controlling and monitoring one’s speech becomes tiring and makes it hard to think of what to say. Many persons who stutter find this burden unbearable and conclude that they would rather stutter. Consequently, the rate of relapse is extremely high. We must therefore conclude that “fluency techniques,” by themselves, do not provide a satisfactory answer to stuttering. I know this from personal experience. I once received therapy using one of the more publicized methods of instant fluency. I practiced the method diligently, both in the therapist's office and out. After a short time, I had mastered the method and was quite fluent. Even if it did sound a little strange at first, it sure beat stuttering. But then, after about a month, I could feel the tension and fear starting to creep up on me. Hey, what was this, I wondered? I had thought I was cured. Why was I feeling this way again? I had been told that, as long as I used the method properly, it would be physically impossible for me to stutter. Now I wasn't so sure. One day I unexpectedly bumped into someone I had known before being "cured." As I began to talk, the old fears came crashing down on me. I tried in vain to use the method, but it was too late. I was choked up with stuttering. Suddenly I was back in the Dark Ages. Why? It didn't matter that I knew the method. It didn't matter that I had conscientiously tried to use it. Suddenly, all my skills and resolve were blown away by the Dark Dragon of Stuttering. The Dark Dragon had just been relaxing in his den for a while, chuckling at my flimsy new armor. Now he had stormed from his cave, and in one breath, had re-established who was boss. The method had been my little Talisman — a magical charm to protect me from the Dragon of Stuttering. As long as stuttering stayed away, the charm seemed to keep its magic, and I continued to talk. But once stuttering came back, the magic spell was broken. It was impossible to resume using the method with the same confidence as before. Since I had never been given an accurate understanding as to what really caused stuttering and why the method was supposed to work, I was never able to view it as anything more than a magical trick to give me confidence in speaking. When it failed, the only thing I learned was: It doesn't work when I really need it! With my faith shattered, the method seemed worthless. Some therapists have a tendency to pooh-pooh the stutterer's complaints of failure. They insist that their method works. Instead, they blame the person who stutters for failing to use the method properly. This attitude ignores the most important point: The reason that persons who stutter are unable to use a particular speaking method in times of stress may be the same reason that they stutter in the first place. An important factor

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may be the stutterer’s intention in speaking — such as to make a “good impression” by trying not to stutter. Until the underlying reasons for stuttering are understood, stutterers will continue to be at their mercy, regardless of what speaking method they try to hide behind.

Acceptance of Stuttering After repeated disappointments, many persons who stutter give up on therapy altogether. They resign themselves to the idea that they will always stutter and that the best they can hope for is “self-acceptance.” This message is echoed by stuttering support organizations and by speech pathologists who assert that stuttering is an inherited neurological condition that is “incurable.” Although this view may seem depressing, it is embraced by many persons who stutter because it relieves them of guilt feelings and of the stigma of emotional illness. “You see,” they proclaim, “it’s not my fault! It’s all neurological!” However, this view also is too simplistic, because it doesn’t explain why most people who stutter can speak fluently some of the time, nor does it account for numerous people who once stuttered and who went on to become fluent. Persons who stutter “covertly” are often encouraged to stutter openly rather than trying to hide their stuttering. Many therapists now prescribe “voluntary stuttering,” including “voluntary controlled repetition” or prolongations of the beginning of words. This practice has been promoted as a way to “advertise” one’s stuttering and to desensitize one’s fear of speaking. However, the emphasis on stuttering “openly” and “voluntarily” actually encourages persons who stutter to mimic the superficial struggle behaviors of stuttering, rather than addressing the underlying root cause of stuttering blocks.

Scientific Studies Without doubt, modern science has opened up new windows on stuttering. Functional brain scans have produced colorful images showing that stutterers’ brains, on average, function differently than those of non-stutterers. Other brain scans have discovered structural differences in various parts of stutterers’ brains. However, it still isn’t clear whether any of these differences are the cause of stuttering or the result of stuttering. As a practical matter, none of these studies have made speech any easier for people who stutter. Numerous laboratory experiments have also bolstered the idea that persons who stutter, as a group, have various neurological weaknesses compared to non-stutterers. We are told that persons who stutter tend to be slower in their reaction times and less proficient in tasks involving coordination and fine motor skills. Such studies have generated theories that stuttering is caused by defects in stutterers’ motor programming, timing of movements, auditory feedback loops, hemispheric dominance, or nerve connections in certain parts of the brain. Other research has tried to link stuttering with factors such as personality, intelligence, language skills, temperament, and social anxiety.

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Before too much weight is given to such findings, it should be noted that the reported differences only represent group averages. There is usually a great overlap between stutterers and non-stutterers. In other words, some person who stutter do better than the non-stutterers, and some non-stutterers do worse than persons who stutter. Consequently, there is no simple cause-and-effect relationship between the purported deficiencies and stuttering. In recent years, news reports prematurely held out hope that a pharmaceutical cure for stuttering was close at hand. One highly publicized theory is that stuttering is linked to increased dopamine levels in certain parts of the brain. However, despite extensive clinical trials of various drugs, medical science has yet to find a panacea for stuttering. Genetic studies have shown that stuttering often runs in families and that the risk is even greater if you have an identical twin who stutters. Recent gene studies have identified correlations between various genetic mutations and stuttering in certain families. However, it is still unclear how these mutations would affect speech – a matter that will be discussed further in a later chapter. It is also unlikely that gene therapy will ever provide a cure for stuttering. Although it is possible that certain inherited traits might make some people more susceptible to stuttering than others, it is not likely that these are the only factors that determine whether a person is actually going to stutter. Inherited factors alone would not explain why a person stutters some of the time but can be fluent at other times. Nor would they explain the cases in which one identical twin stutters, but the other twin (with the same genetic material) does not. Or the fact that as many as half the people who stutter do not have a family history of stuttering. Or the fact that some stutterers have gone on to become almost totally fluent — even without formal therapy. We know that most people who stutter are relatively fluent at certain times or under certain conditions. Some persons who stutter may be totally fluent more than 90% of the time but are blocked on important words, usually at the most inconvenient time. When researchers are asked how their theories can explain this variability in stuttering severity, they typically gloss over the issue by asserting that the stutterer’s neurological weaknesses are aggravated by “stress.” But – even assuming that some persons who stutter may have neurological weaknesses – this explanation is far too vague and simplistic to be helpful. Nor does it explain the many paradoxes of stuttering behavior – such as the ability of some stutterers to act out roles on stage, before large audiences, with perfect fluency. Despite what the researchers tell us, it is reasonable to conclude that most people with persistent developmental stuttering have the inherent capacity for fluent speech. The problem is not a lack of ability to speak, but rather an interference with that ability. Therefore, our task is to identify the source of this interference and to find ways to control it.

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The Stuttering Puzzle The puzzle of stuttering has been a ripe subject for conjecture and experimentation throughout history. In recent decades, it has been studied using almost every new technology that has come along. But, despite all the hope and excitement aroused by computerized brain scans, drug trials, and genetic research, we are still told that stuttering is a “mystery” with no known cause or cure. As impressive as the research has been, it has done little to help us understand or deal with stuttering in a practical way. In some respects, the scientific research has added to our confusion by generating models of stuttering that don’t jibe with our actual experience of stuttering on a daily basis. Instead of getting a coherent picture of stuttering, we are confronted with a disconnected jumble of puzzle pieces. These include a wide range of observations, scientific data, theories, and therapies — many of which seem inconsistent or contradictory. Too often, isolated puzzle pieces are proclaimed to be the answer to stuttering, without regard to all the other pieces that don’t fit. Too often, experts are quick to dismiss puzzle pieces that don’t support their preconceived notions or that come from sources outside their own professional circles. Too often, proponents of particular theories or therapies get embroiled in heated disputes, rather than considering the possible merits of other viewpoints and trying to find common ground. It is no wonder that our picture of stuttering remains confused and disjointed. Perhaps the reason our picture of stuttering is so fragmented is that additional pieces are needed to link together all the parts of the puzzle. Where can we find these pieces? We may wait patiently for scientific research to supply them, but people who stutter need relief now. Sometimes we must take matters into our own hands. If I had relied on the “experts” back when I was still stuttering in my early 40’s and not done my own research and experimentation, I might have remained in a dead-end job and not enjoyed more than 25 years as a successful trial lawyer. We don’t have to wait for scientists to give us answers in their peerreviewed journals. Many key pieces to the puzzle are already available to us, still lying in the pile, overlooked by the “experts.” We will evaluate them based on reason, our own observations and experiences as persons who stutter, and the knowledge provided by research. We will then use these pieces to assemble and test a comprehensive picture of stuttering. The picture may be complex and multifaceted, but we can figure it out. In so doing, we will improve our understanding of stuttering, find ways to control the forces behind the blocks, and make speech an easier and more enjoyable experience.

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CHAPTER 3.

Pieces of the Puzzle

H

AVE YOU EVER tried to put together one of those giant picture puzzles, made up of a thousand tiny pieces? You open the box, which shows on its lid the beautiful picture you are supposed to make, and find to your dismay a hopeless jumble of cardboard pieces, a total mishmash of colors and shapes. At first, it seems impossible that you could ever put them in order. If you just reached into the pile and tried to fit the pieces together at random, you would soon give up in frustration. Successfully completing a puzzle requires that we start as simply as possible. First, we must spread out the pieces on the table. Then we find the four corner pieces and the straight-edged pieces that go along the top, bottom, and sides. We concentrate on putting these pieces together first. Once we have the corners and edges linked up, we will have established the outline of the picture. Assembling the rest of the puzzle will now be a lot easier. We must now put together a puzzle to discover what interferes with our speech and causes stuttering. Assembling this kind of puzzle is a bit more difficult. For one thing, we don't have a picture on the cover of a box to guide us. For another, the corners and edges are not clearly defined. Even worse, we don't know how many of the pieces are missing. Perhaps our picture won't be complete. Nevertheless, we're bound to learn a great deal by doing the best we can with what we've got. We begin by spreading the pieces on the table — all the facts we know about stuttering, either from our own experience or from scientific studies. Sooner or later we will try to fit all of these pieces together, but for the moment we must select a few of them to start with. We are looking first for the corner pieces — the facts that are most fundamental to the stuttering experience.

Stuttering Variability For the first corner piece, let's look for a basic fact that tells about the kind of circumstances in which we stutter most often or most severely. We tend to be more fluent when talking to ourselves, to animals or small children, or to people with whom we feel comfortable. When I was young, I would converse with myself quite fluently as I walked home from school. Sometimes I would go off into the woods and give long, eloquent speeches to the tree stumps.

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Stuttering generally increases when we are speaking to authority figures, such as parents, teachers, bosses, policemen, judges, or other people we feel we have to please or impress.1 It can become particularly bad when the listener seems impatient with our speech and wants us to hurry up. Things become even worse when we are put on the spot in front of a group, with everyone waiting for us to get the words out. Imagine standing at a ticket window, with a long line of angry people behind you, as you try to buy a ticket for a train that's just about to pull out of the station. Some persons who stutter would sooner throw themselves in front of a locomotive than submit to that kind of ordeal. When we encounter a speaking situation that has given us trouble in the past, stuttering is likely to give a repeat performance. The more we fear that we are going to stutter, the more we usually do. Each individual may have different circumstances that are particularly difficult. Many stutterers (but not all) have an excruciating time whenever they use the telephone. One of my worst phobias was gas stations. I used to drive around with my tank almost empty, because I dreaded asking the gas station attendants to "fill it up." (The arrival of self-service gasoline pumps was a boon to more than one person who stutters that I know.) Stuttering is more likely to occur on the most important, precise, or meaningful words in a sentence.2 When certain words must be said exactly right, like the punch line of a joke, stuttering usually hits the hardest. A prime example is saying your own name —perhaps the biggest bugaboo of everyone who stutters. I once heard a story about a man who blocked so severely on his name that he finally changed it to something he could say easily. When the change became legal, he no longer had any trouble with the old name, but began blocking like crazy on his new name.3 In my own experience, I always found it easier to say the wrong word, whatever it was, than the precise word that was most appropriate. In answering the telephone, I could not simply say "Hello." In order to get it out, I would have to say "Yes, hello." But whenever "yes" was the right word instead of "hello," the situation would be exactly reversed. For example, when the person on the other end immediately said, "Hello, is this Bill Parry?" — I was not able to say "yes." Now I had to say, "Hello, yes, this is Bill Parry." One has relative ease in saying words that are unimportant or repetitious. When it is no longer important to say something (for example, after it has been said already), I have heard stutterers (including myself) repeat the same thing over and over again with great fluency. Is there an underlying fact we can draw from these speaking situations? It seems apparent that stuttering increases when a person is under some kind of "stress." However, this fact alone is a bit too general to serve our purpose. If we look more closely, we will see that all of the above examples involve circumstances in which we feel that the words themselves are especially im-

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portant, or we anticipate that speaking will be difficult. These are precisely the moments when we are preparing to have trouble talking, when we may feel that some kind of extra effort will be needed to get us over the hurdles. Therefore, I propose that we choose the following basic fact as our first corner piece: Stuttering tends to increase when we invest the words or speaking situation with emotional importance, thereby giving rise to the feeling that extra effort is needed to help us say the words.

Symptoms of Stuttering In the second corner of our puzzle, we should probably insert a basic fact that describes the symptoms of stuttering. As we look over the pieces, we may be confused, at first, by the different varieties of stuttering behavior. For example, there are forceful blocks, hesitations, repetitions, prolongations, word substitutions, muscle spasms, gasping for breath, teeth gnashing, avoidance tactics, etc. All of these will eventually fit in somewhere. However, it is likely that some of them are not basic to stuttering but are secondary struggle behaviors that have developed in the attempt to avoid, delay, or force through the blocks. In selecting our corner piece, let's go directly to the most extreme form of stuttering we know — the total, forceful blockage of speech. You may be painfully familiar with this experience. You are about to say a word. Your lips or tongue move into the proper position for the first sound. But instead of making a light, momentary contact and then relaxing as they should, they continue to press harder and harder, totally blocking your airflow and preventing any sound from escaping. The harder you try to force the words out, the harder your mouth clamps shut. When you are trying to say the “stop” consonants b or p, the tight closure is done by the lips. With other stop consonants, like d or t, the front of the tongue presses forcefully against the alveolar ridge behind your upper teeth. On hard g or k, the back of the tongue presses against the soft palate (or velum) at the back of the mouth. If the word starts with a vowel, like “apple,” the forceful closure may occur in the larynx, or voice box, shutting off the airway in the throat. This is because initial vowel sounds are often preceded by a brief laryngeal closure, or glottal stop, to build up a little air pressure and then release it, so as to accentuate the start of the vowel sound. Although produced in the larynx, the glottal stop is actually a stop consonant, rather than part of the vowel sound. You may force on the glottal stop, just as you would on the other stop consonants. While the mouth or larynx are clamped shut, the abdominal and chest muscles may tighten up, so as to build up air pressure in the lungs, as if straining to force air through the closure. But the harder you try, the stronger the block becomes.

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Of course, there are many instances in which the block is less severe. Sometimes it is spread out through repetitions. Consonants that do not stop airflow (such as soft ch, f, j, l, m, n. r. s, sh, v, w, y, and z) may be prolonged. But even in these cases, you are using much more force than speech requires. These observations bring us to our second basic fact: Stuttering is often characterized by excessive force and effort in the attempt to speak.4 Having established the first two corners of our puzzle, an interesting connection becomes apparent. Both the circumstances and the symptoms of stuttering are related to the exertion of effort. This brings to mind certain remarks of the late Henry Freund, a psychiatrist who was once himself a stutterer. He wrote that one of the primary experiences of stuttering is that of "an obstacle which needs force to overcome it,"5 and that such effort by the stutterer "only increases the force of the closure."6 Paradoxically, our effort to overcome the "obstacle" to speech becomes the very stuttering behavior that we are trying so hard to avoid. I myself wrestled with this paradox for most of my life. For example, I knew that when I wanted my car to go forward, I should step on the gas — not stomp on the brakes. Why, then, did I continue to close my mouth tighter and tighter when I tried to speak? No matter how I tried intellectually to recognize the futility of such effort, I found myself at a loss to control it. In the instant before stuttering, it seemed as if a mysterious "switch" was thrown that caused a vise to clamp down on my speech. I suspected that the "switch" might be triggered by psychological and neurological factors. This would suggest that we need to find something that would be activated when we feel the need to "try hard," and which would result in the kind of forceful closures that we experience.

Phonation and Stuttering In addition to forceful closures and blockage of air, there is another symptom that seems basic to stuttering behavior. This is the difficulty stutterers have with phonation – the vibration of the vocal folds in the larynx that makes the sound of our voice as exhaled air passes through. Furthermore, the problem focuses primarily on the phonation of vowel sounds. Over the past few decades, many speech researchers have found that stutterers have delays in phonation, compared to normal speakers.7 In some of the experiments, stutterers and non-stutterers were asked to voice vowel sounds in response to a signal. Invariably, the stutterers were slower.8 Other research has discovered abnormal muscular activity in the larynx during stuttering, which may interfere with phonation.9 Therefore, it seems clear that stutterers have difficulties and delays in phonation that play a significant role in stuttering. When a person who stutters makes no attempt to phonate, such as when he silently mouths his words or whispers, there is usually no problem.10 Converse-

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ly, when the larynx is specifically involved in phonating, as in singing, stuttering almost never occurs. While singing, the stutterer uses the phonation of vowel sounds to carry the melody.11 Meanwhile, his mouth is able to articulate the words of the song with perfect fluency. Several types of stuttering therapy employ various means of teaching improved phonation as a way to increase fluency. When a person who stutters learns to concentrate on phonation and vowel sounds, he tends to be more fluent.12 Difficulty in vowel phonation is a crucial factor that people tend to overlook. For example, most people would say that a stutterer struggling over the word "puh-puh-puh-potato" has trouble articulating the p sound. But that is obviously not true, since he is producing the p sound perfectly well. The same is true in prolonging the initial consonants in “S-s-s-s-sam” or “M-m-m-mmary.” Even during forceful blocks, his lips or tongue are in the correct position. This indicates that his real problem is not in articulating the consonant, but rather in moving on to the vowel sound that follows it. His vocal folds are not prepared to provide vowel phonation, which is needed to continue the word. In words that begin with vowels, such as “apple,” his problem would be in moving past the glottal stop to the actual vowel sound that follows. The problem is not necessarily phonation in general, because persons who stutter phonate when prolonging or repeating voiced consonants like m, n, r, and l. Therefore, the problem must be specific to phonation of the vowel sound of the particular word or syllable in question. Consequently, we now have a third corner piece: Stuttering is often characterized by difficulty or delay in phonating vowel sounds.

Awareness of Blocks before Speaking Persons who stutter often sense that an upcoming word contains a “brick wall,” even before they try to say it. This phenomenon provides a fourth corner piece to our puzzle. It indicates that the stuttering block begins in the brain during preparation of the motor program for speech, prior to the actual movements of speech. The external manifestations of stuttering — the repetitions, prolongations, and forcing — can be viewed as the stutterer’s struggle to break through this internally perceived obstacle. Because the block is internal, listeners may have no idea of the word on which the stutterer is blocking. If the speaker repeats “I — I — I —“, the listener may erroneously assume that he is blocking on “I.” However, the block is actually on the following word, which the listener never hears. Persons who are skillful at “covert stuttering” may succeed in hiding the block from their listeners by substituting a different word. This indicates that

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the block attaches to the specific word that the stutterer wants to say, regardless of the pronunciation of words themselves. For example, a person who stutters may block on “pizza” when ordering in a restaurant, but he is able to say something else, like “hamburger.” But if on the following day he wants to order a hamburger, that is the word he will block on, and he will be able to say “pizza.”

Assembling the First Four Pieces The four corner pieces give us important clues to finding other pieces of the stuttering puzzle. They will help us match up specific mechanisms that are: • • • •

Likely to be activated when we feel that extra effort will be needed to help us say the words; Associated with the exertion of physical effort to block airflow and build up air pressure to force out a word; Likely to interfere with the phonation of vowel sounds by the larynx; and Neurologically programmed by the brain prior to speaking.

There is a physical mechanism that helps tie these elements together. It is known as the Valsalva mechanism, and its purpose is to perform a Valsalva maneuver. This is a normal bodily function, found in every healthy human being, which involves the larynx and various other muscles. It is designed to assist us in many types of physical effort by blocking airflow and building up air pressure in the lungs, so as to stiffen the body. It is also associated with our instinctive reaction to fearful situations. However, if this mechanism is neurologically activated in the effort to speak, it could interfere with the phonation of vowel sounds, promote forceful closures of the mouth or larynx, and cause other manifestations of stuttering. Although only part of the total picture, the Valsalva mechanism is an important key to linking together many pieces of the puzzle, which otherwise seem so confusing and contradictory. As we will see in later chapters, the Valsalva mechanism, together with certain neurological and psychological factors, provides answers to some of the most perplexing paradoxes of stuttering. It helps to explain stuttering blocks, interference with phonation, the variability of stuttering, the perpetuation of stuttering behavior, and why certain speaking conditions tend to promote fluency. It can help us understand both the motivation and mechanisms of stuttering and suggest ways to make therapy more effective. Before we can fully comprehend how the Valsalva mechanism is involved in stuttering, we must first get a basic understanding of the physical mechanics of normal speech. It's easy to assume that we know how speech works, but are we really familiar with the details? In order to understand what goes wrong, we must know what is supposed to happen when everything goes right.

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Notes See Bibliography for complete citations of references. 1.

Van Riper, 1982, p. 148. Van Riper, 1982, pp. 151-152. 3. Schwartz, 1976, p. 51. 4. Starkweather, 1987, pp. 37-44; Freund, 1966, pp. 91-100. 5. Freund, 1966, pp. 94-95. 6. Freund, 1966, p. 91. 7. See, e.g., Adams and Reis, 1971; Adams, 1974; Bakker and Brutten, 1989, 1990; Borden, Baer, and Kenney, 1985; Healey and Gutkin, 1984; Mallard, Hicks, and Riggs, 1982; Reich, Till, and Goldsmith, 1981; Starkweather, Hirschman and Tannenbaum, 1976; Starkweather, Franklin, and Smigo, 1984; Starkweather, 1987, pp. 235-243. 2.

8.

Ibid. Conture, McCall, and Brewer, 1977; Conture, Schwartz, and Brewer, 1985; Freeman, Ushijima, and Hirose, 1975; Shapiro, 1980. 10. Perkins, Rudas, Johnson, and Bell, 1976. 11. See, e.g., Wingate, 1969; Van Riper, 1982, p. 425; Starkweather, 1987, p. 190. 12. Wingate, 1969, 1970; Weiner, 1978. 9.

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Chapter 4 / The Speech Mechanism

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CHAPTER 4.

The Speech Mechanism

W

ATCHING THE LIPS of a fluent speaker is a fascinating pastime for someone who stutters. How quickly they move! How lightly they touch! How easy it all seems! What could be the secret? We know, of course, that speech is a lot more than moving one's lips, or even one's tongue. These are only the most external, visible parts of the speech mechanism. No matter how much effort we put into our lips or tongue, they will not produce speech by themselves. In addition, we need voice, we need airflow. Therefore, to understand the speech mechanism we must go beyond the lips, beyond the mouth, deep into the body itself. We will now explore the various components of the speech mechanism — the caves and tunnels of the mouth, throat, and lungs — to discover the sources of speech. We begin by examining the lips of a fluent speaker. They open, close, purse, and widen, as if gently caressing the words as they emerge. The lips do not close tightly, but gently and briefly, as in a casual kiss. Behind the lips are the teeth. There is no biting or clenching of the teeth. The jaw moves gently, in a relaxed manner. We can feel the air flowing through. Behind the teeth is the tongue—a fleshy, muscular mass that constantly moves, undulates, and changes shape. We notice how the front of the tongue sometimes touches the tips of the upper teeth. Sometimes it touches the teeth ridge (the alveolar ridge, or gums) above the teeth. Sometimes the middle or back of the tongue rises up to meet the roof of the mouth, which is called the hard palate. However, the contacts between the tongue and other parts of the mouth are brief and gentle. Farther back, the roof of the mouth becomes the soft palate or velum—a muscular extension of the hard palate. It ends in the uvula, that cone-shaped projection you see hanging down at the back of the mouth. The velum can move up and down, to either close or open the passageway between the nasal cavity and the upper part of the throat, called the pharynx.

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THE MOUTH AND AIRWAY As we look down the pharynx behind the tongue, we see that it leads to two passageways. Toward the back is the food tube, called the esophagus, which leads to the stomach. The tunnel toward the front leads to the larynx—an oddly shaped box of cartilage and muscles, which is constantly moving in various ways. At the top is a tongue-shaped lid, the epiglottis. This closes off the top of the larynx during swallowing, to prevent food from accidentally going down the windpipe. FRONTAL-SECTION OF THE LARYNX During speech, it is open. As we proceed down into the larynx, we pass between two protrusions, called the false vocal folds or vestibular folds. Below them is a fascinating sight. We see what appear to be two lips, which are anchored together at the front and which open and close at the back. These are the true vocal folds (also called the "vocal cords"). Their posterior ends—those toward the back—are attached to two small pieces of cartilage, called the arytenoid cartilages, which swing open and closed like a little gate. When the vocal folds are open, the opening (called the glot-

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tis) is V-shaped. When the vocal folds are closed, the glottis is reduced to just a slit. The vocal folds are able to open and close almost instantaneously. While they are open, there is no sound—just the rush of air from below. When they are in the closed position, they still leave a tiny slit for the air to come through. The airflow causes the vocal folds to ripple and vibrate, which creates a buzzing called phonation. There are tiny muscles in the larynx that move the vocal folds together and others that move them apart. During speech, the vocal folds rapidly open and close to turn the voice on and off, depending on whether a voiced or unvoiced sound is being made. Another muscle — the cricothyroid — is involved in adjusting the pitch of the voice. This is done by moving the larynx in such a way as to increase or decrease tension of the vocal ligaments located in the vocal folds. However, the actual vibration of the vocal folds is not caused by muscular activity, but rather by the airflow passing between them. Below the larynx is the windpipe, or trachea. We come to a fork in the tunnel, with branches going left and right. These are the bronchi, which lead to the left and right lungs. The lungs are soft, spongy, elastic, cone-shaped organs. It is here that life-giving oxygen is transferred into the blood and carbon dioxide is removed. The lungs repeatedly expand and contract. As they expand, air rushes down the windpipe into the lungs. As the lungs contract, the air rushes up the windpipe, through the larynx, and out the nose or mouth. It is this outward flow of air that powers our speech. But what exactly causes the air to flow? To understand this, we must know something about the mechanics of breathing. The lungs, together with the heart, are located in the thoracic or chest cavity. This is the space within the chest, surrounded by the rib cage. Just below the lungs is a thin, wide muscle called the diaphragm. This separates the chest cavity from the abdominal cavity, which contains the stomach, liver, intestines, and other organs. When the diaphragm is relaxed, it is shaped like a dome— its center arching upward under the lungs and heart. But when the muscle fibers in the diaphragm tense up and contract, the diaphragm flattens out. In effect, the center of the diaphragm moves downward. This has two results—it causes the chest cavity to become larger and the abdominal cavity to become smaller. It squeezes down on the stomach, intestines, and other organs.

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The lungs are like balloons. As the chest cavity becomes larger, the surface of the lungs sticks to the inner wall of the chest cavity, causing the lungs to expand also. As the space in the lungs increases, air is sucked down the windpipe and into the lungs. This is the process of inhaling—sometimes called inspiration. When a person inhales by using the diaphragm, it is called diaphragmatic breathing or abdominal breathing. Another way in which people inhale is called chest breathing. Certain muscles in the chest (the external intercostal muscles) contract, moving the rib cage upward and outward. As the rib cage rises, this also expands the size of the chest cavity, causing the lungs to expand and to draw air in. You can tell if a person is chest breathing, because you can see his chest rising as he inhales and falling as he exhales. You can tell if he's using the diaphragm to breathe, because his abdomen will protrude as he inhales, since the diaphragm pushes down on the intestines, etc., causing them to bulge outward in front. The front of the abdomen then goes back in as he exhales. Typically, a person will use both the diaphragm and the chest muscles while inhaling. Inhalation, or inspiration, is the only part of breathing that requires muscular activity. Exhaling, or expiration, does not require activation of any muscles. It all can be done by simply relaxing the same muscles that were used for inhaling. The chest muscles relax and the rib cage lowers. The diaphragm relaxes and the abdominal organs push it back upward into its dome-shaped position. The lungs then contract because of their own elasticity—just as a balloon gets smaller when you let the air out. What significance does this have for speech? In the English language, all speech occurs while we exhale. Therefore, speech does not require much muscular effort for airflow. While respiratory muscles often help to maintain appropriate levels of air pressure to support vocalization, it is theoretically possible to speak with passive airflow, the air that naturally flows out while we relax. Of course, one can also force the air out of the lungs. This is called forced expiration. However, this is not usually needed unless we are exercising vigorously, blowing a trumpet, or inflating a balloon. In forced expiration, other

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muscles in the chest (the internal intercostal muscles) contract, drawing the ribs closer together and compressing the chest cavity. In addition, the muscles around the abdominal cavity may also tighten up, squeezing the intestines and other organs, forcing them upward against the diaphragm, pushing it higher into the chest cavity. This increases the air pressure in the lungs, causing the air to be squeezed out. The use of the abdominal muscles to force out air should not be confused with using the diaphragm. The diaphragm only contracts during inhalation. It

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relaxes during exhalation. The abdominal muscles, on the other hand, tighten for the purpose of increasing air pressure in the lungs, so as to force the air out. In normal speech, this effort is usually not very noticeable, unless we are shouting or singing loudly. Now that we have explored the depths of the speech mechanism, we will next examine how all of these parts work together in the production of speech.

General References BORDEN, G. J., HARRIS, K.S., & RAPHAEL, L.J. Speech Science Primer: Physiology, Acoustics, and Perception of Speech. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2003, pp. 41-85. CARLSON, A. J., JOHNSON, V., & CAVERT, H. M. The Machinery of the Body. Chicago: University of Chicago Press, 1961, pp. 252-262. DENES, P. B. & PINSON, E. N. The Speech Chain. New York: W.H. Freeman & Co., 1993. DICKSON, D. R., & MAUE-DICKSON, W. Anatomical and Physiological Bases of Speech. Boston: Little, Brown & Co., 1982. FINK, B. R. The Human Larynx: A Functional Study. New York: Raven Press, 1975. FINK, B. R., & DEMAREST, R. Laryngeal Biomechanics. Cambridge, Mass: Harvard University Press, 1978. GRAY, H. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1959. LADEFOGED, P. Linguistic aspects of respiratory phenomena. Annals of New York Academy of Sciences, 1968, 155, 141-151.

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CHAPTER 5.

The Basics of Speech

S

PEECH IS THE PROCESS of turning thoughts into sound. It begins with our intention to communicate. We choose the ideas we want to express. We select the appropriate words to convey those ideas. We know how those words are supposed to sound. Now we must use all the parts of our speech mechanism, described in the previous chapter, to make those sounds. But how? As will be explained in a subsequent chapter, certain parts of the brain create neurological motor programs for the specific movements that will be required to produce speech. Through a process called neuromotor tuning, the brain prepares the appropriate muscles to respond on cue when they receive triggering signals for the particular movements. The physical production of speech involves four basic elements: • • •

•

Inhalation – in which air is taken into your lungs. Outward airflow – in which air is exhaled from your lungs and travels up through your larynx and mouth. Phonation – the vibration of the vocal folds in your larynx as air passes through. This creates a vibrating column of air, which varies in pitch depending on the tension of the vocal ligaments. This provides the “melody” of speech. Articulation – the movements of your lips, tongue, and other parts of your vocal tract, which shape your oral cavity to form the vowel sounds and which partially or momentarily restrict airflow in various ways to create specific consonants.

In the previous chapter, we examined how our breathing apparatus produces the airflow that powers our speech. Breathing has two basic steps: inhaling (or inspiration) and exhaling (or expiration). Before we can speak, we must first inhale to fill our lungs with the air we will need for airflow. As we learned, inhaling is the only part of breathing that requires muscular activity. When we inhale, the dome-shaped diaphragm, which separates the chest cavity from the abdominal cavity, contracts so that its center moves downward. At the same time, certain muscles in our chest contract, raising the rib cage. Both of these movements cause the chest cavity to increase in size. As the space increases, the pressure of the air in our lungs becomes less than the air

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outside. As a result, air is sucked into the lungs. While this happens, our larynx remains wide open, letting the air flow in freely. The airflow of speech is produced by exhaling. All the sounds of speech are created and carried by the outward flow of air. There is no sound unless the air is moving. No one can speak while holding their breath. When we exhale, our chest muscles and diaphragm slowly relax, allowing the chest cavity and lungs to shrink automatically to their usual size. As the chest cavity becomes smaller, the pressure of the air in the lungs becomes greater than the air outside. Consequently, the air now flows out of the lungs, like air being released from a balloon. The air flows upward through the windpipe and the larynx. No force, no effort is required in order to exhale. All you need to do is relax. The result is passive airflow. As previously mentioned, it is possible to increase the force of the airflow by contracting our abdominal muscles. These muscles tighten around the intestines and other organs in the abdominal cavity, forcing them upward against the underside of the diaphragm. This pushes the diaphragm higher into the chest cavity, so as to increase the air pressure in the lungs. There is also a set of muscles in the chest which can operate to lower the rib cage, putting additional pressure on the lungs. The result is forced expiration.

Phonation Air rushing out through an open larynx makes very little sound. For voice to be produced, the vocal folds in the larynx must be brought together in such a way that they will vibrate as air passes between them. This vibration is called phonation. You can actually feel the larynx vibrating by touching your throat, around the Adam's apple, while you are making a voiced sound. The brain prepares the larynx to phonate through a neurological process called pre-phonatory tuning. This prepares specific laryngeal muscles to bring the vocal folds together at the right time and with the right amount of tension when the triggering signal is received. As we saw in the previous chapter, the vocal folds are anchored together at their anterior ends—that is, the ends toward the front of the throat. In order for phonation to occur, the posterior ends of the vocal folds must be brought into the

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closed position. This is done by certain tiny muscles in the larynx that move the arytenoid cartilages together and lock them in position. Other muscles are used for opening the vocal folds. Still other muscles give the vocal folds the proper tension needed for vibration. For present purposes, it is not necessary to list all the laryngeal muscles by name. However, it would be helpful if we actually got the feeling of how they operate. Start by making a steady flow of silent breath. Without stopping your breath, turn it into an "ah" sound. Then let your breath be silent again. When you heard your voice, the vocal folds were closed. When the breath was silent, the cords were open. Did you feel the movement in your larynx? Did you feel the vocal folds as they closed and opened? Continue to practice moving your vocal folds until you become familiar with where they are and how they feel. During speech, the vocal folds rapidly open and close to turn the voice on and off, depending on whether a voiced or unvoiced sound is being made. The voiced sounds include all of the vowels — e.g., the various sounds in English for the letters a, e, i, o, u, and sometimes y. Phonation is also needed for the voiced consonants—including the sounds for the English b, d, soft g, j, l, m, n, r, v, w, y, and z. Some of the consonants are unvoiced; they make use of airflow without phonation. These include the sounds in English for the letters c, ch, f, h, k, p, q, s, and t. While these sounds are being made, the vocal folds will open to cut off phonation momentarily. Then they will close again to give voice to the next part of the word. The English letters th are sometimes voiced (/ð/), as in “that,” and sometimes unvoiced (/θ/), as in “think.” Meanwhile, the pitch of the vocal folds is raised by stretching the vocal ligaments to increase their tension. As previously mentioned, this is done mainly by the cricothyroid muscle. This is a bilaterally paired muscle located slightly toward the front of the lower sides of the thyroid cartilage. The thyroid cartilage is the large structure that contains the vocal folds and forms the “Adam’s apple” in the front of men’s throats. If you hold your fingers against the sides of your throat, you can feel the cricothyroid muscle move as you change the pitch of your voice. It is important to notice that, during normal speech, there is very little muscular effort taking place in the larynx. The muscles do not themselves provide

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the power that makes the vocal folds vibrate. All they do is move the vocal folds in or out of the path of the airflow and adjust the amount of tension. The vibration is caused by the airflow, which is the result of relaxation of the chest and diaphragm.

Articulation As the airflow, now buzzing with phonation, passes up into the pharynx and mouth, it is shaped into the characteristic sounds of the words we are speaking. This shaping process is called articulation. Most articulation is done in the mouth. The soft palate or velum—the muscular extension at the back of the hard palate—is usually raised during articulation, thereby blocking off the nasal cavity to keep air from escaping through the nose. One kind of articulation is the formation of the vowel sounds. The term “vowel sound” does not refer to the name of the letter, but rather the actual sound that is heard. For example, the vowel sound in “box” is “ah” (/a/), even though the letter o appears in the spelling of the word. Some vowel sounds, like I (pronounced “eye” /ai/), are diphthongs – two vowel sounds linked together (e.g., “ah-ee”). Specific vowel sounds are created by changing the size and shape of the oral cavity by putting the tongue and lips in different positions. For example, we say "oo" by raising the tongue near the back of the mouth and rounding our lips into a little circle. When we say "ee," the tongue is raised near the front of the mouth and our lips are spread almost into a smile. (This is probably why photographers tell their subjects to say "cheese.") When we say "ah," the tongue is lowered and the lips are open. (Consequently, this is a helpful thing to say when the doctor wants to get a good look at our throat.) Another kind of articulation involves the various ways in which we create the sounds of consonants. Consonants can be viewed as gentle ripples made by the lips and tongue in the flowing stream of air. Although most people don't give this subject much thought, speech experts have gone to the trouble of classifying each consonant according to the place of articulation in the mouth and the manner in which the sound is made. The ter-

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minology used may vary, but the following descriptions of English consonant sounds will give you a general idea. A consonant is classified as labial if it is made by both lips (such as p, b, w, and m); labio-dental if made by one lip and the teeth (f and v), dental if made by the tongue against the teeth (th); alveolar if made by the tongue against the gums (d, t, l, n, r, s, y, and z); palatal if made by the tongue against the hard palate (sh and zh), velar if made by the tongue against the soft palate (k, g, and ng), and glottal if made in the larynx (h). In describing the manner of articulation, the consonants are usually classified as stops (or “plosives”), fricatives, affricates, liquids, nasals, and glides. The liquids and glides may also be referred to as semi-vowels. The stop or plosive consonants (p, b, t, d, k, and hard g) are made by blocking the airflow briefly, so as to let the air pressure build up a little, and then suddenly releasing it in a burst of sound. The blockage may be done by the lips together (as in p and b), by the front of the tongue against the alveolar ridge behind the upper teeth (as in t and d), or by the back of the tongue against the soft palate (as in k and hard g). In making the fricative consonants (f, v, th, s, z, sh, zh, and h), the airflow is blocked only partially. As the air escapes, this creates a hissing sound if the consonant is unvoiced or a vibrating sound if it is voiced. A distinctively different hiss or vibration is made depending on whether the air passes between the lower lip and the teeth (as in f and v), the tongue and teeth (th), the tongue and gums (s and z), or the tongue and the palate (sh and zh). Still another kind of hissing sound is made if the constriction takes place, not in the mouth, but in the larynx, as in the sound for h. The h is an unvoiced sound that is produced while the vocal folds are open and the false vocal folds (vestibular folds) are partially closed. This is very similar to what happens when we whisper. The affricate consonants – ch (/t͜ʃ/) and j (/d͡ʒ/) – are combinations of a stop and a fricative. The only difference between the two is that ch is unvoiced and j is voiced. The liquid consonants (l and r) are made by placing a part of the tongue against the gums and letting the voiced breath pass through the open space. In making the l sound, it is the tip of the tongue that makes contact. In r, the sides of the tongue curl up to touch the gums. The nasal consonants (m, n, and ng) are sounded through the nose. To accomplish this, the soft palate is lowered to permit voiced airflow to pass through the nasal cavity. At the same time, the mouth is closed by the lips (m), by the tongue and gums (n), or by the tongue and soft palate (ng). These are the only consonants in which the soft palate is not raised to block off the nasal cavity.

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The glides (w and y) are made by starting with the mouth in a vowel position and then sliding into the next vowel sound in the word. In making the /w/ say "oo," and then move right into the vowel that follows it. For example, “wish” would be shaped as “oo-ish, without actually saying the “oo.” In the case of /y/, you start as if you were going to say "ee," and then move to the next vowel. For example, the mouth position for "yard" is like "ee-ard." Not all articulation takes place in the mouth. The larynx is also used to give a plosive effect to vowels that come at the beginning of words—as in apple. This type of vowel articulation is known as the coup de glotte, or "glottal attack." We will refer to it as a glottal stop. The vocal folds and false vocal folds momentarily block the airflow, in order to build up air pressure. The air is then suddenly released in a little burst of phonation, which accentuates the beginning of the vowel sound. During normal speech, there is an overlap in the production of sounds, called co-articulation. While one set of muscles is making one sound, another set of muscles is already getting ready to make the next one. Notice, for example, the difference in the shape of your lips when you form the b sound in beet and in boot. In the first instance, the lips are wide, already prepared for the "ee" sound. In the second, they are pursed, ready to form an "oo." Or try bat versus brat. In the first, you say the b with the tongue flat. In the second, the rear sides of the tongue have already risen in preparation for the r sound.

THE FOUNDATIONS OF SPEECH

Speech as Melody and Movement Now we must put all of these elements together: a smooth and easy flow of air; a relaxed larynx, with vocal folds that are ready to close instantly as needed to produce phonation; and a tongue and lips that move gently from one position to the next.

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Normal speech is a continuous flow of melody and movement. By “melody” I don’t mean singing, but rather the natural inflection of speech, with constant changes in pitch and loudness. Speech requires very little effort. The flow of relaxed, exhaled breath ripples the loosely closed vocal folds to create a vibrating column of air, which begins as a buzz. The cricothyroid muscle continuously adjusts the tension of the vocal folds to change the pitch of phonation, creating inflection and melody. As the vibrating air moves through the mouth, it is molded by continuous movement of the lips and tongue to shape the sounds of vowels and consonants. When the tongue or lips momentarily block or restrict airflow, they touch lightly and release the air quickly, without force or struggle, and without building up a lot of air pressure. Without this continuous flow of melody and movement, there is no speech. The continuous movement of the lips and tongue turn the vibrating air into a symbolic sequence of sounds. The vibration of these sounds is carried by the air to the ears of your listeners. If they know your language, their brains automatically decode the sequence of sounds into words and meaning. If speech should be so easy, why do stutterers make it so hard? Why do they often treat words as physical objects to be forced out of the body? Why do they struggle so violently, press their lips and tongue so forcefully, and build up air pressure until they almost turn purple? Why, in attempting to force the words out, do they do everything in their power to block the words in? Could it be that certain parts of our speech mechanism have other biological functions that become activated when the stutterer tries to speak? Might these functions become confused with the speech process in such a way as to make speech so difficult? Next, we will explore just such a possibility.

General References BORDEN, G. J., HARRIS, K.S., & RAPHAEL, L.J. Speech Science Primer: Physiology, Acoustics, and Perception of Speech. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2003, pp. 81-150. DENES, P. B. & PINSON, E. N. The Speech Chain. New York: W.H. Freeman & Co., 1993. DICKSON, D. R., & MAUE-DICKSON, W. Anatomical and Physiological Bases of Speech. Boston: Little, Brown & Co., 1982. FINK, B. R. The Human Larynx: A Functional Study. New York: Raven Press, 1975. FINK, B. R., & DEMAREST, R. Laryngeal Biomechanics. Cambridge, Mass: Harvard University Press, 1978.

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CHAPTER 6.

The Valsalva Mechanism

A

S NATURAL AS SPEECH IS to the human species, there is no organ that is devoted exclusively to speaking. The eye is dedicated to seeing, the ear to hearing, the stomach to digesting, and the heart to pumping blood. Speech, on the other hand, requires the interaction of several different parts of the body, all having primary functions other than speaking. The mouth, with its tongue, lips, and teeth, is designed for eating and drinking. The lungs and windpipe are devoted to breathing. Even the larynx—the voice box itself—is not limited to phonation. It has another function, which has played an important role since the days our ancestors swung from trees. The larynx helps us perform acts of strenuous physical effort. To demonstrate what I mean by this, let's start with an exercise. If you are sitting at a heavy desk or table, put your fingers under the edge, take a full breath, and try to lift it. Alternatively, curl your fingers and link both hands together in front of your chest. After taking a full breath, try to pull your hands apart, without letting go.1 Pull hard (but not so hard as to give yourself a heart attack). Now relax. What did you notice while you were lifting or pulling? Obviously, your arms and hands were tense. Your chest and shoulders were rigid. You may have also noticed that the muscles in your chest and abdomen, all down the front of your body, were tight. But what else was happening? Try the same exercise again. Take another full breath, pull hard or try to lift, and this time pay attention to your throat. If you are like most people, you will notice that your throat is not only tense, but it is completely closed. Furthermore, the harder you try to pull or lift, the more tightly your throat squeezes shut. Now try to feel where in your throat this closure is occurring. You'll find that it's happening right behind your Adam's Apple, in the same place where your voice is produced—the larynx.

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The larynx is doing one of the basic tasks for which it is designed. It is called effort closure. It is the body's way of closing the upper end of the windpipe, in order to keep air in the lungs.2 During effort closure, the muscles of the larynx behave much differently than they do during phonation. Phonation is produced by bringing the vocal folds gently together, while a stream of air passes between them. This causes the vocal folds to vibrate, creating the sound of our voice. Meanwhile, the false vocal folds (vestibular folds), which are located above the vocal folds, remain open. Effort closure, in contrast, is accomplished by pressing both the false vocal folds and the vocal folds tightly together. The inside of the larynx squeezes shut, like a fist, totally blocking the airway.3 The larynx is designed to close with enough force to hold back any amount of air pressure that may come from the lungs. Now repeat the lifting or hand-pulling exercise and pay closer attention to what the rest of the body is doing. Notice the tension in your chest muscles. They are straining to pull your rib cage downward, in order to put pressure on your lungs. How about your abdominal muscles—the ones across the front of your body, below your navel? Do you notice how they have tightened up? These muscles are squeezing against the intestines and other organs in your abdominal cavity, forcing them upward against your diaphragm. As the center of the diaphragm is pushed upward, it also puts greater pressure on your lungs. And what about your lungs? Do they feel as if they're going to burst? It's no wonder. Your chest and abdominal muscles are doing everything they can to force air out of your lungs. At the same time, your larynx is straining equally as hard to keep the air blocked in. As a result, the air pressure in the lungs becomes greater and greater. What is going on? And why? You are performing a Valsalva maneuver. This is a normal bodily function that occurs in all healthy human beings when they exert strenuous physical effort.4 Although most people never give it a thought, the Valsalva maneuver has been known to medical science for more than three hundred years. It takes its name from Antonio Maria Valsalva, an Italian anatomist who lived from 1666 to 1723.

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When we do a Valsalva maneuver, we block our upper airway while we tighten our chest and abdominal muscles to put pressure on our lungs. This has the same effect as squeezing a partially inflated balloon. At first the balloon feels soft, but as we increase the air pressure by squeezing, the balloon feels harder and harder. When we do the Valsalva maneuver, it is like pressurizing a balloon inside our chest. Pressurized air can give strength and rigidity. We are all familiar with those inflatable rubber toys, which are soft and limp when there isn't much air in them. But when we blow them up with plenty of air, they become rigid; they stand up and hold their shape. A flat tire can't do very much. But when it's filled with pressurized air, it can support an automobile weighing thousands of pounds. Likewise, our body is firmer, more rigid, and can exert effort more efficiently when we pressurize our lungs by doing a Valsalva maneuver. Have you ever noticed how a weightlifter "holds his breath" as he strains to raise a heavy barbell over his head? He is doing a Valsalva maneuver. The air pressure in his lungs keeps his chest and shoulders firm and rigid, giving greater support to his arms. In this way, he can direct all his energy toward lifting the weight. Otherwise, some of that energy would be wasted as his chest and shoulders sagged. (However, please note that doing Valsalva maneuvers while lifting weights is not recommended and could result in a heart attack.) By using the Valsalva maneuver, we brace and stiffen the trunk of our bodies. This helps our arms and legs perform many kinds of strenuous tasks, such as lifting, pushing, pulling, rowing, climbing, and pressing downward with our feet. The next time you perform any of these activities, notice how your larynx instinctively closes up. You are doing a Valsalva maneuver. This does not mean that you must use the Valsalva maneuver when exerting effort. If you consciously think about it, you can tell your body not to close the larynx while you are pulling, lifting, etc. The Valsalva maneuver just helps us to do those jobs more forcefully.

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THE VALSALVA MECHANISM In a Valsalva maneuver, the contraction of the abdominal muscles places increased pressure on the rectum—the tube that carries waste material from the intestines to the anus. This pressure would create the danger of accidental evacuation of the bowels were it not for a muscle called the puborectalis. The puborectalis muscle forms a sling around the bottom of the rectum. During a Valsalva maneuver, the puborectalis muscle tightens, sealing off the rectum to keep anything from escaping.5

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The Valsalva maneuver can also help us bear down to force things out of the body, such as in defecation, urination, and childbirth.6 In these activities, we tighten our abdominal muscles in an effort to squeeze various things out of our abdominal cavity. The larynx naturally closes up, to keep air in the lungs. The resulting air pressure helps to stabilize the diaphragm, so that the abdominal pressure will be directed downward more efficiently. When defecation is intended, the puborectalis muscle relaxes, thereby permitting the bowel movement to be expelled. Again, the Valsalva maneuver is not absolutely necessary for defecation. You can consciously choose to keep your larynx open, if you wish.7 Even when you don’t hold your breath, the abdominal and rectal muscles are capable of moving the bowels on their own. The Valsalva maneuver simply allows us to apply additional downward force, in an effort to help the job along. All the muscles that we have discussed—muscles of the larynx, the chest, the abdomen, and the puborectalis—are linked together as a "team" by our nervous system. When performing a Valsalva maneuver, they are neurologically coordinated to contract at the same time, and they all tend to contract with the same degree of force in proportion to one another.8 Therefore, we will refer to this team of muscles as a single, coordinated unit, called the Valsalva mechanism. This is the mechanism we use to perform the Valsalva maneuver. Might this also be a physical mechanism involved in stuttering? As we discussed in Chapter 3, both the circumstances and symptoms of stuttering seem to be related to the exertion of effort. We tend to stutter more when we feel the need to "try hard" and to use extra effort in speaking. Similarly, stuttering is often characterized by excessive force and effort in the attempt to speak. Therefore, one would expect that the physical mechanism involved in stuttering should have something to do with the exertion of effort and the forceful blockage of airflow. The Valsalva mechanism obviously meets this requirement. We also observed that stuttering is often characterized by difficulty or delay in phonation. This suggests that the physical mechanism of stuttering must have some effect on the larynx. Again, the Valsalva mechanism qualifies. As we have seen, the Valsalva mechanism is well-designed to help us exert physical effort and to force out bowel movements. However, it is definitely not designed to help us speak or to force out words. On the contrary, it blocks the airflow needed for speech and causes the larynx to tighten up like a fist. Nevertheless, there is still more to be explained. Thus far, we have only discussed how the larynx closes during a Valsalva maneuver. While this might explain stuttering blocks that occur in the larynx, how do we account for stuttering blocks that occur in the mouth?

Chapter 6/ The Valsalva Mechanism

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We can quickly solve this mystery by going back to our hand-pulling or lifting exercise. Take a full breath, but before you start pulling your hands apart or lifting, put your lips together as if you were saying a p sound, as in “potato.” Now start trying to pull your hands apart or lift. What did you notice about your lips? Most people find that the lips press tightly together. The harder you pull your hands or try to lift, the more forcefully the lips close. Now see what happens when you press the tip of your tongue to the ridge behind your upper front teeth, as if you were saying the t sound, as in “table.” Take a full breath and start pulling or lifting. You will probably find the tip of your tongue pressing more and more forcefully. Finally, touch the back of your tongue to the roof of your mouth, as if you were making the k sound, as in “cat.” Take a breath and pull or lift again. Now it is the back of your tongue that is pressing forcefully. Do these forceful closures feel familiar? In all these instances, you are performing a Valsalva maneuver, but you are using your lips or tongue, rather than the larynx, to keep the air from escaping. The lips and tongue are acting the same as the larynx did, pressing more and more tightly to block the air pressure in the lungs. Therefore, your lips and tongue can also become part of the Valsalva mechanism. Whether it will be the lips, tongue, or larynx that performs the closure depends on which one would be used in forming the initial consonant or glottal stop in saying the blocked word. For example, if you are trying to force out a word that starts with a /p/ (as in “pizza”). your lips will take over the job of forceful closure during the Valsalva maneuver. Likewise, if the initial consonant is formed by some part of the tongue, the same part of the tongue will continue to exert pressure during the Valsalva maneuver. The harder the chest and abdominal muscles try to force the air out, the more forcefully the lips, tongue, or larynx will close, trying to block it in. The harder you try to break through the closure, the more forceful the closure becomes. That's what the Valsalva mechanism is all about. Isn't this remarkably similar to the forceful closures that occur during stuttering? Is it possible that somehow the Valsalva mechanism is neurologically activated when a stutterer tries to speak, thereby causing these forceful closures? Might the Valsalva maneuver be an instinctive struggle behavior aimed at breaking through the “brick wall”? What other factors might be involved? We shall explore these questions in the following chapters.

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Notes See Bibliography for complete citations of reference. 1.

2 3.

4.

5. 6 7. 8.

This exercise is medically known as "Jendrassik's maneuver." Its effect is to stimulate a Valsalva maneuver. Lastovka, 1970. . Fink, 1975, pp. 85-100; Fink and Demarest, 1978, pp. 45-63. As noted by Ardram and Kemp, 1967, p. 381, "the larynx is closed from the entrance to the vestibule [false vocal folds] to the level of the vocal folds; the laryngeal ventricles are obliterated." Fink and Demarest, 1978, p. 47, summarize the differences between effort closure and phonation as follows: "[W]hereas phonatory closure is confined to closure of the glottis, that is, to apposition of the vocal folds by adduction of the arytenoid cartilages, effort closure implicates in addition apposition of the vestibular folds [false vocal folds] and bases of the cuneiform cartilages by the thyroarytenoid muscles, as well as a variable amount of apposition of the median thyrohyoid fold to the top of the adducted vestibular folds." Carlson, Johnson and Cavert, 1961, p. 262; Ardran and Kemp, 1967; Fink, 1973; Fink, 1975, p. 89-92; Fink and Demarest, 1978, pp. 45-63. Fink, 1975, p.99. . Dickson and Maue-Dickson, 1982, p. 135. Ardran and Kemp, 1967, p. 381. Fink, 1975, pp. 93-97; Fink and Demarest, 1978, p. 46.

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Chapter 7 /Putting the Pieces Together

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CHAPTER 7.

Putting the Pieces Together

W

E HAVE SEEN that fluent speech requires very little physical effort. The airflow that powers speech comes from the relaxation of our diaphragm and chest muscles. Phonation results when we simply close our vocal folds and let airflow pass between them. Specific vowel sounds are made by the shape of the oral cavity, as determined by the position of the lips and tongue. The articulation of consonants is accomplished by gentle movements of the lips and tongue, which touch lightly and then relax quickly. In contrast, we have seen that stuttering is often characterized by excessive force and effort in the attempt to speak. Our chest and abdomen may tighten up. Our larynx may squeeze shut. Our lips or tongue may press tightly, stubbornly blocking both airflow and words, as the air pressure and frustration builds up inside us. We have seen that the harder we try to force the words out , the tighter the blockage may become. We have also seen that there is a bodily mechanism specifically designed to do these things to help us exert physical effort more effectively or to force things out of the body. This is the Valsalva mechanism. It includes muscles of the larynx, chest, abdomen, and around the rectum (the puborectalis) that act together to do a Valsalva maneuver. During a Valsalva maneuver, the larynx performs effort closure—one of its basic functions other than phonation. The larynx squeezes shut to block our upper airway, while our chest and abdominal muscles tighten to increase the air pressure in our lungs. The pressurized air makes the trunk of our bodies firm and rigid, allowing us to use our arms and legs more efficiently during strenuous physical activities. The Valsalva maneuver also helps us to expel things from our body, as when we force out bowel movements. As demonstrated in the last chapter, the mouth can also be used by the Valsalva mechanism to block the upper airway. A Valsalva maneuver can cause forceful closures by the lips and tongue, similar to the blockages that we experience during stuttering. In trying to figure out my own stuttering problem, I became intrigued by the similarities between the forceful closures of stuttering and the Valsalva maneuver. During severe blocks, my mouth or larynx would clamp shut, while my

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abdominal and chest muscles would contract, as if straining to force air through the closure. However, the closure would just tighten more than ever. This seemed identical to what happens during a Valsalva maneuver. As I studied my behavior more carefully, I noticed that my stuttering (even when less severe) was preceded and accompanied by tension in certain muscles in and around the mouth, larynx, abdomen, and puborectalis—all of which are connected to the Valsalva mechanism. I noted that I had difficulties or delays in phonation, which also involves the larynx, a part of the same mechanism. Could it be that the Valsalva mechanism was somehow involved in my stuttering?

A Fiber-Optic View of the Larynx One of the first things I wanted to verify was the similarity between the larynx's behavior during a Valsalva maneuver and during a stuttering block. My stuttering on words beginning with vowels (such as apple) involved tight closure of the larynx prior to phonation of the initial vowel. In saying words starting with vowels, it is common to close the larynx momentarily to build up a little air pressure in order to accentuate the beginning of the vowel sound. This brief closure is called a glottal stop. However, in stuttering the glottal stop became a prolonged and forceful closure. To me, this felt exactly the same as the effort closure done by the larynx during a Valsalva maneuver. To get an actual view of my larynx at work, I obtained the help of Dr. Joseph P. Atkins, Jr., Chief of Otolaryngology at the Pennsylvania Hospital in Philadelphia. His department was equipped with a fiber-optic nasopharyngoscope—a sophisticated instrument designed for viewing the larynx without interfering with the movement of the mouth. The device consisted of a long, flexible tube, containing hundreds of tiny glass fibers. A miniature camera lens focused an image onto one end of the bundle of fibers. The fibers carried individual dots of light to the other end of the tube, where they formed a picture. This was photographed by a television camera, displayed on a color TV monitor, and videotaped. The fiber-optic tube was inserted through the nose, snaked up through the nasal cavity, and then lowered down through the pharynx, behind the back of the tongue. Light from the tube illuminated the inside of the larynx as it was photographed. Meanwhile, I sat back in a chair and watched the TV pictures, as Dr. Atkins explained what was happening. We could clearly see the arytenoid cartilages, which control the opening and closing of not only the V-shaped vocal folds, but also the false vocal folds located above them. When I held my breath, as in a Valsalva maneuver, the arytenoid cartilages clamped together, tightly closing the false vocal folds to block the air. This was the larynx performing effort closure.

Chapter 7 /Putting the Pieces Together

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When I blocked on an initial vowel sound, the larynx looked exactly as it did during effort closure. Again, the arytenoid cartilages were clamped together, and the false vocal folds were blocking the air. When I stuttered repetitively on the glottal stop that precedes initial vowels ("uh-uh-uh-uh-uh-uh"), we could see the arytenoid cartilages and false vocal folds rapidly opening and closing. The closure of the larynx was not as complete when I used my mouth to block the air. I pressed my lips together to resist the air pressure during a Valsalva maneuver. The larynx closed somewhat, but not tightly enough to shut the airway. The same was true when I blocked on consonants in the mouth during stuttering. Although the larynx did not completely close, the arytenoid cartilages clearly jerked together at each stuttering block. The larynx seemed to be acutely sensitive to the stuttering blocks, even though the actual closure was taking place in the mouth. The fiber-optic study also gave me a firsthand view of how the various parts of the Valsalva mechanism interact with one another. For example, when I tightened my puborectalis muscle or my abdominal muscles, I could see the larynx automatically respond by closing tightly. Conversely, when I relaxed my puborectalis, the pictures showed the larynx return to a relaxed, open position.

Neuromotor Tuning Now that I had confirmed, to my satisfaction, the similarities between the forceful closures of stuttering and those of the Valsalva maneuver, my next question was how the Valsalva mechanism might interfere with the process of speech. It seemed possible that there might be, under certain circumstances, some kind of neurological confusion between speech and the Valsalva mechanism. I wondered how such confusion might take place. During my research in the medical literature, I learned some interesting facts about how our nervous system prepares our muscles for movement. Movement takes place by the contraction of muscles. The muscles contain fibers that contract—or shorten in length—when they become activated. When the muscle fibers are relaxed or "turned off," they return to their usual, longer length. An individual muscle fiber will contract completely, or not at all.1 The strength with which the entire muscle contracts depends on how many of the individual fibers are contracting at the same time. The muscle fibers are controlled by nerve cells called motor neurons, which receive impulses from the central nervous system (the brain and spinal cord) telling the muscle fibers when to contract. Each motor neuron controls a group of muscle fibers, called a motor unit. As in the case of muscle fibers, activation of each individual motor neuron is an "all or nothing" proposition.2

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Whether or not an individual neuron becomes activated depends largely on its excitability to the impulses it receives (also called its threshold level). In other words, the neuron is "set" to react to impulses of a certain strength. If the excitability of the neuSIMPLIFIED VIEW OF A MOTOR NEURON ron is low, it will be less likely to respond to an impulse, and therefore the muscle fibers will remain at rest. On the other hand, if the neuron is very excitable, it is more likely to stimulate a muscular contraction. There are other types of nerve cells, called sensory neurons, which pick up various sensations (including movement, pressure, etc.) through receptors in the skin or other parts of the body. These neurons also behave on the "all or nothing" principle. When the strength of the stimulus reaches the neuron's threshold level, the neuron sends an impulse to the central nervous system. Scientific studies have revealed that all physical activity (including speech) is preceded by neurological tuning of the excitability of all the motor and sensory neurons and nerve pathways that will be involved in performing the particular movement.3 This usually occurs a fraction of a second before the triggering impulse that actually signals the beginning of the movement. By means of this tuning, the central nervous system is able to designate, in advance, which combination of nerves and muscles will act together as a "team" to perform the desired motion. The tuning makes some of the neurons more excitable, and others less excitable, to the triggering impulse that is to follow. It is as if the nervous system says to some neurons, "Pay attention! Get ready to contract your motor unit when the next command comes!" To others it says, "Relax. Disregard the next command because it's not meant for you." A fraction of a second later, the triggering command comes down the line: "Go!" The neurons and their motor units either respond or don't respond, depending on their level of excitability. You can demonstrate this principle yourself, by playing this trick on your friends. First show them how, by contracting different muscle groups, you can make your hand into a fist, or do other things such as pointing a finger. Then tell your friends to make a fist, as fast as they can, when you say "Now!"

Chapter 7 /Putting the Pieces Together

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"Get ready to make a fist," you warn them. Then say, "Now!" as you make a fist yourself. "Not bad," you tell them, "But you're not doing it fast enough. Let's try again." Repeat this exercise a few times, so that everyone has gotten into the habit of making a fist as fast as they can. Then, after again instructing them, "Get ready to make a fist," suddenly say, "Point," and point your finger. I have found that most people will reflexively make a fist instead—because that is what their nerves and muscles are ready to do. I suspected that neuromotor tuning of the Valsalva mechanism might be a key to understanding why a person who stutters forcefully closes the mouth or larynx and builds up air pressure when trying to speak.

Forming a Working Hypothesis When scientists try to understand a phenomenon, they often begin by formulating a working hypothesis. This is a tentative explanation, arrived at through logical reasoning, that seems to fit whatever facts are already known about the subject. The scientists then use this hypothesis as a focal point for further research. They plan experiments and other studies designed to test whether the hypothesis is true or false. After analyzing the results of their experiments, they may confirm the hypothesis to be true, or they might have to modify it or discard it altogether. In any event, this method helps to increase the scientists' knowledge about the problem they are studying. In the case of stuttering, scientific studies provide only part of the picture. There are many blank spaces for which there is no “empirical evidence.” Many of the internal aspects of stuttering cannot be scientifically observed or measured. For these, we must go beyond the existing scientific literature. Furthermore, none of the standard theories adequately explains the great variability and paradoxes in stuttering behavior. Therefore, we must rely on our own best judgment based on our observations and experiences. To formulate a hypothesis that explains everything, we may have to think “outside the box.” We must ask, does our hypothesis accurately reflect our personal experience of stuttering? And even more important, does our hypothesis have practical value in helping us deal with our problem? Based on my research and personal experiences, I was now ready to formulate my own working hypothesis about stuttering—one that I would test and modify through my own experimentation. I called this the Valsalva Hypothesis.4 It started with the basic idea that stuttering blocks involve a neurological confusion between the voice and the Valsalva mechanism. My hypothesis assumed that the speech mechanisms of most persons who stutter are capable of reasonably fluent speech. (That was certainly true in my case.) I hypothesized that stuttering is not caused by stutterers’ inabil-

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ity to speak, but rather by an interference with the speaking ability they already have. When the speaker intends to say a word on which he anticipates difficulty or which he has invested with particular importance, the brain neurologically prepares the Valsalva mechanism to exert physical effort, through closure of either the mouth or larynx, in place of phonation of vowel sounds. This Valsalva tuning may occur continuously when the speaker finds himself in a feared speaking situation or one in which he anticipates difficulty. Although persons who stutter may instinctively feel that exerting effort is needed to overcome anticipated difficulties in speech, it actually makes fluent speech impossible, in at least two ways: (1) by promoting forceful closure of the mouth or larynx to block airflow and build up air pressure; and (2) by interfering with phonation. In this way, the neurological tuning of the Valsalva mechanism contributes to the very difficulties the stutterer is trying to avoid. In later chapters we will expand this hypothesis to include involvement of the brain’s amygdala, which may trigger stuttering blocks by suppressing phonation of a word’s Key Vowel sound and substituting a strong impulse to exert physical effort. Although this hypothesis is not something that can be verified by brain scans or scientific measurements, it provides the most logical explanation for virtually all the behaviors and paradoxes associated with stuttering blocks. If this hypothesis is true, then the purpose of stuttering therapy should not be to control the stutterer’s speech, but rather to identify and control the forces that interfere with his natural speaking ability. This may require adjustments to some of a stutterer’s habitual attitudes and speaking behaviors in order to make his speech less vulnerable to interference. We will now review the various ways in which Valsalva tuning can interfere with speech. Then we will examine how the triggering of blocks by the brain’s amygdala can cause certain words to feel as if they contain insurmountable “brick walls.”

Notes See Bibliography for complete citations of references 1.

Hole, 1981, p. 226.

2.

Brooks, 1986; Tortora and Anagnostakos, 1981.

3.

Zimmerman, Smith, and Hanley, 1981; Brooks, 1986, pp. 111-128.

4.

Parry, 1985b.

Chapter 8 / Valsalva Tuning and Forceful Blocks

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CHAPTER 8.

Valsalva Tuning and Forceful Blocks

T

HE CRUCIAL MOMENT that determines fluency or stuttering is the split second before a word is spoken. This is when our brain sends nerve impulses to the motor neurons that control the muscles of the larynx, mouth, and respiratory system, preparing them for the production of speech. Through the process of neuromotor tuning, the brain adjusts the excitability of the motor neurons, so that some will be more sensitive, and others less sensitive, to various stimuli that will come later. If we are to be fluent, the appropriate muscles of the speech mechanism must be "tuned up," so they will be ready to react quickly to the triggering signals that the brain sends out when speech begins. Conversely, the muscles of the Valsalva mechanism must be "tuned down," so they will remain inactive and not interfere with speech.

Forceful Closures of the Mouth or Larynx In the last chapter, we introduced the hypothesis that stuttering might result from a confusion in neuromotor tuning. Rather than tuning our larynx and speech mechanism for speech, our brain might instead tune our Valsalva mechanism for the performance of a Valsalva maneuver—a bodily function that blocks the upper airway in order to build up air pressure in the lungs. This would begin with the stutterer’s anticipation that a speaking situation or saying an upcoming word will be difficult and require extra effort. Because the Valsalva mechanism is designed to assist us in exerting physical effort and in forcing things out of the body, the person who stutters might develop a tendency to "tune up" the Valsalva mechanism in the mistaken belief that it will help him force out words. This Valsalva tuning can be analogized to my previous example of telling your audience, “Get ready to make a fist when I say Now!” However, if the body is tuned for a Valsalva maneuver, it is not ready for speech. On the contrary, the stutterer’s body will be ready to do things that make fluent speech impossible. The nerves and muscles of the larynx and other parts of the Valsalva mechanism become neurologically tuned to a high degree of excitability. They are geared up to perform a Valsalva maneuver the instant a triggering signal, or stimulus, comes down the line. Depending on the degree of excitability, almost

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anything might set them off. One kind of triggering stimulus might be the increase in air pressure that normally occurs during the articulation of consonants – especially in words that begin with stop consonants. (These would include words beginning with p, b, t, d, k, hard g, and glottal stops in words beginning with vowels.) When making these sounds, we would normally build up a little air pressure and then release it very quickly. This increase in air pressure is sensed by pressure-sensitive nerve endings (called mechanoreceptors) found in the lower part of the larynx and elsewhere along the respiratory tract.1 They would stimulate sensory neurons to send impulses to the brain, indicating the amount of air pressure. When just enough pressure has been built up, the brain would signal the lips, tongue, or larynx to let go. But if the Valsalva mechanism is tuned up instead, the brain might misinterpret the increased air pressure as being the start of a Valsalva maneuver. Then the lips, tongue, or larynx (whichever started the closure) would be recruited by the Valsalva mechanism to continue the Valsalva maneuver by closing ever more tightly to block the upper airway.

Anatomy of a Forceful Block Imagine that you have been invited to a dinner party. You are seated at a long table, surrounded by people you hope to impress. Although you are afraid of stuttering, you would like someone to pass the potatoes, which are at the other end of the table. If you were a normal speaker, you would simply say, "Pass the potatoes, please." But you have been having trouble with p-words lately, and this short sentence presents one hurdle after another. Nevertheless, you muster your courage, take a deep breath, and give it a try. What is supposed to happen at this point? After inhaling, your chest muscles and diaphragm should relax, allowing your lungs to contract naturally, releasing a gentle flow of air through your larynx and mouth. To form the p, your lips should close, momentarily blocking the airflow in order to build up a little air pressure. This closure should last about 1/10 of a second. Then the lips are supposed to relax, releasing a puff of air, which allows the p to open into the phonated vowel sound. That is what is supposed to happen. Now let’s see what might go wrong according to the Valsalva Hypothesis. Just before you begin speaking, things start to go haywire. Your brain, realizing that a dreaded p word is coming, anticipates that saying the word will be difficult. As shall be discussed in a later chapter, the brain’s amygdala might also trigger a “fight-flight-freeze” response, which suppresses phonation of the vowel sound. This contributes to the feeling that extra effort will be needed to

Chapter 8 / Valsalva Tuning and Forceful Blocks

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get over the hurdle. At the same time, you are overcome by an urge to "try hard" to force out the word. . A perfect example is the air pressure that builds up when you close your lips to say the letter p. As mentioned before, the increased air pressure causes mechanoreceptors to send nerve impulses to the brain. Normally, these impulses would tell the brain when to open the lips. However, if the Valsalva mechanism is overly excitable, these impulses could have just the opposite effect by triggering a Valsalva maneuver. As we have seen, the Valsalva mechanism cares nothing about the complexities of speech. It has but one purpose: to increase air pressure in the lungs, which it does by squeezing the chest and abdomen while forcefully closing the upper airway. Therefore, the signals from the mechanoreceptors would stimulate the lips to close more tightly, to keep the air from escaping. At the same time, your chest and abdominal muscles would be stimulated to contract, to increase the lung pressure even more. Across your chest, certain muscles would draw the ribs together and downward, compressing the chest cavity. This would create the sensation of the chest tightening up, or a great weight pressing down on the chest, which has been reported by many persons who stutter. The abdominal muscles would also tighten, as well as the puborectalis muscle. The trunk of your body would be tense all over. As the chest and abdominal muscles squeeze, the air pressure in your lungs would continue to rise. The increased air pressure would further stimulate the mechanoreceptors. They would send more signals to the brain, which would, in turn, stimulate the lips to close with proportionately greater force, to resist the increased pressure coming from the lungs. The result would be a vicious cycle, making fluent speech impossible for as long as the maneuver continued.

Blocking on Plosives The same type of blocking might be stimulated by the articulation of any sound that requires the momentary obstruction of airflow and a resulting increase in air pressure. Whichever part of the mouth starts the closure during articulation—the lips or tongue—will be the part that continues the forceful closure during the Valsalva maneuver. The Valsalva hypothesis would therefore provide a clue as to why persons who stutter have particular difficulty with plosive consonants (such as b, hard c, d, hard g, k, p, and t), which require a complete blockage of airflow during their articulation. It may explain why stuttering is more frequent at the beginnings of words and on stressed syllables2—instances in which abrupt increases in air pressure are most likely.3 It may also explain why stuttering may be reduced when the speaker uses a "gentle onset" of voice and "light contacts" in articulation, since such methods would tend to avoid abrupt increases in air pressure.

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Stuttering blocks can also occur on words that begin with a vowel (such as apple). In articulating an initial vowel sound, the larynx may first close tightly enough to build up air pressure before abruptly letting go, in order to accentuate the beginning of the sound. This is the glottal stop described in a previous chapter. Because of Valsalva tuning, the glottal stop may turn into effort closure, as part of the Valsalva maneuver. You would then feel the words choking in your throat, rather than in your mouth.

Prolongation of Certain Consonants The Valsalva mechanism may also respond to consonants that require only a partial blockage of airflow in their articulation. These include the fricatives (f, j, v, th, s, z, sh, zh, and h) and the affricates (ch and j). When Valsalva tuning occurs, the articulation of these consonants might also stimulate a Valsalva maneuver, to some extent, with closures that are more forceful than necessary. Some of the air may continue to leak out, since the closure was never complete to begin with. The resulting sound would not only be more forced than usual, but it may be extremely prolonged. For example, you may find yourself saying, "s-s-s-s-s-s-salad" or "f-f-f-f-f-fries," with a continuous, prolonged hissing sound. Such prolongations may also occur on certain voiced consonants, such as the sonorants l, m, n. r, w, and y. Even though your larynx is phonating, your mouth is frozen in a fixed position while waiting for a motor program to voice the vowel sound. There are also instances when the closures are not so long or forceful, although sufficient to impede the smooth flow of speech. In these cases, the Valsalva tuning may be relatively slight. Nevertheless, any involvement of the Valsalva mechanism is likely to disrupt our fluency, to one degree or another.

Notes See Bibliography for complete citations of references 1. Wyke, 1971. 2. Bloodstein, 1995, p. 283; Froeschels, 1961; Soderberg, 1966; Starkweather, 1987, p. 175; Van Riper, 1982, pp. 180-181. 3. Ladefoged, 1968; Starkweather, 1987, pp. 39-44.

Chapter 9 / Valsalva Tuning and Phonation

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CHAPTER 9.

Valsalva Tuning and Phonation

T

HE VOICE MECHANISM of a person who stutters often seems like a car with a badly tuned engine. It hesitates, stalls, and it’s hard to get started – usually at the most inopportune times. We may open our mouth and no voice comes out. Or our voice might suddenly cut off when we get to a vowel sound. Sometimes it seems as if our vocal folds won’t respond to the signal to start phonating. We previously referred to scientific studies showing that persons who stutter often have difficulties and delays in phonating, compared to non-stutterers. We also observed that a stutterer’s real problem is not in articulating consonants at the beginning of words, but rather in phonating the vowel sound that follows the consonant (or the glottal stop in words starting with vowels).

Interference with Vowel Phonation Neuromotor tuning of the Valsalva mechanism can cause the larynx to have difficulties and delays in phonating vowel sounds. Through neuromotor tuning, the brain "tunes up" the appropriate nerves and muscles of the larynx, so they will respond quickly to the triggering signals to begin phonation. The preparation for phonation also includes a process called prephonatory tuning. This adjusts the tension of the vocal folds, so they will be ready to vibrate at the right pitch as the airflow passes between them. Scientific studies have found that prephonatory tuning occurs from about one-half a second to 1/20th of a second before phonation is heard.1 Neuromotor and prephonatory tuning continue throughout normal speech. As we are making one sound, our nervous system is already preparing our speech mechanism to make the sound that follows it. If everything is tuned properly, one sound should flow smoothly into the next, without interruption. On the other hand, if something interferes with the tuning of a stutterer's larynx, the result could be delays in phonation, precipitating the various struggle behaviors we see in stuttering.

Silent Speech and Whispering If you have any doubt about the importance of phonation in stuttering, consider what happens when you talk without phonation. Have you ever spoken silently, without using your voice at all—simply forming the words with your

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mouth and letting people "read your lips"? This is sometimes called lipped speech or silent articulation. When persons who stutter use lipped speech, without any phonation, a strange thing happens. Almost all of them are able to form the words with perfect fluency. This is further evidence that stutterers’ articulation is not impaired. This principle was demonstrated at a workshop I once conducted. About 28 people—all of whom stuttered—were paired off and given lists of numbered sentences. In each of the pairs, one partner had to select a sentence and mouth the words silently. The other partner tried to read his lips and guess which sentence was being read. They took turns doing this until all the sentences were completed. When the exercise was over, I asked the participants if they had noticed any disfluency, in either themselves or their partners. To their surprise, everyone had been totally fluent during the unvoiced readings. The same results have been achieved in scientifically controlled experiments.2 It has been shown that stuttering virtually disappears during silent speech. When persons who stutter speak in a whisper, they are also relatively fluent. The full force of stuttering is not felt until the stutterer tries to speak with his voice—that is, with phonation. The Valsalva Hypothesis can explain these phenomena. Silent speech and whispering do not require phonation. Because phonation is not intended, the stutterer’s speech mechanism doesn’t have to wait for the larynx to get ready to phonate the vowel sound. The lips and tongue are free to move fluently on their own.

Singing and Continuous Phonation At the other extreme, persons who stutter tend to be fluent in situations that emphasize phonation of vowel sounds, such as when they sing.3 A common explanation for this paradox is that speech and singing are produced in different parts of the brain. However, the Valsalva Hypothesis can also explain this phenomenon. When we sing, our intention is focused on voicing the melody, rather than on making a “good impression” by not stuttering. We rely on phonation of the vowel sounds to carry the melody, and we stretch out the vowel sounds as we sing them. Therefore, our brain is constantly supplying motor programs for phonating the vowel sounds, which our amygdala might otherwise suppress in ordinary speech. As part of these motor programs, our cricothyroid muscle constantly adjusts the pitch of our vocal folds, and our larynx is ready to phonate almost all the time.4 Meanwhile, our neuromotor tuning is focused on phonation, rather than on activating the Valsalva mechanism. This allows our breathing to be coordinated

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with the rhythm of the song, so it does not get caught up in the performance of Valsalva maneuvers. Consequently, our lips and tongue are free to articulate the words fluently. A similar result is achieved when persons who stutter speak using continuous phonation, such as in the “Humdronian Speech Exercise,” which will be discussed later in this book.

Valsalva-Stuttering Blocks The Valsalva Hypothesis offers a logical explanation of how interference with vowel phonation might happen. Our brain may neurologically "tune up" our body's Valsalva mechanism, preparing it to "force" the words out by means of a Valsalva maneuver at the place where vowel phonation should be. The vowel sound is the natural place in which to insert the motor program for effort because it is the part of the word or syllable that is loudest and has the most energy. This neurological substitution is the fundamental “block” involved in stuttering. I will call it the “Valsalva-stuttering block.” All the stuttering behaviors that follow can be regarded as attempts to overcome this underlying block. Even if a full-blown Valsalva maneuver does not actually occur, the vocal folds are still not ready to phonate the vowel sound at the proper time. The effects of Valsalva tuning can be felt as muscular tension throughout the speech mechanism and trunk of the body. Persons who stutter are often aware that an upcoming word contains an obstacle even before they try to say it. This awareness may increase their anticipation of difficulty and intensify their urge to use effort to force through the perceived obstacle. Ironically, the effort that stutterers exert is exactly what gives substance to the “brick wall.” The more they activate the Valsalva mechanism to force out the word, the less the larynx is able to phonate the vowel sound. The result is a vicious cycle that further blocks their speech.

Notes See Bibliography for complete citations of references. 1. Wyke, 1971. 2. Perkins, Rudas, and Johnson, 1976. 3. Bloodstein, 1995, pp. 297, 304; Starkweather, 1987, p. 190; Van Riper, 1982, p. 425; Wingate, 1969. 4. Wingate, 1969.

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CHAPTER 10.

The Neurological Triggering of Blocks

T

HE SCARIEST THING about stuttering blocks is the way they can strike suddenly, involuntarily, and without any conscious control. Sometimes they seem to occur almost continuously in certain speaking situations. However, they can also target specific words, even when you don’t feel particularly anxious. You might be fluent 90% of the time but find yourself totally stuck on a word – usually an important one – at the most inconvenient times. You may feel as if the word contains a “brick wall” – often before you even try to say it. Paradoxically, you might be able to say other words, but not the word you want to say. You also may feel an overwhelming urge to force out the word by exerting physical effort on the beginning consonant or glottal stop, as in a Valsalva maneuver. But the more you build up air pressure, the stronger the block becomes. In your panic, you forget everything you may have learned in speech therapy and revert to your old struggle or avoidance behaviors. After a period of struggle, the word may eventually come out, but not always. These experiences may leave you feeling helpless, confused, frustrated, defective, and despairing of any hope for improvement. What powerful force could trigger these blocks, paralyze your voice, and activate the Valsalva mechanism – simply because you want to say a particular word? Why does this happen, and how might we control it? In the past, such blockages might have been viewed as “approachavoidance” reactions arising from deep-seated emotional conflicts over whether or not to speak. However, this theory did not adequately explain the phenomenon, nor did it offer a practical resolution. Even if stuttering has a psychological component, there must be some neurological mechanism that gives the block its power. The strength of stuttering blocks suggests a likely suspect: a part of the brain that is influenced by emotions and which triggers powerful physical reactions. This part of the brain is called the amygdala. To understand the triggering of stuttering blocks, we must first understand what the amygdala is and how it works.

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The Amygdala The amygdala consists of two almond-shaped structures, one in each hemisphere of the brain. The amygdala is located in the limbic system, the emotional part of our brain. The amygdala’s normal purpose is to help us respond to physical danger. It is a place where fearful memories are stored. When it senses something similar to a memory of something dangerous, it triggers the release of stress hormones, which prepare the body to respond to physical threats. Although the amygdala was originally designed to protect us in physically dangerous situations, its usual function nowadays is responding to social situations. For persons who stutter, this includes speaking situations. The amygdala is also neurologically involved in triggering Valsalva maneuvers. For example, functional MRI studies have shown that when normal individuals voluntarily perform a Valsalva maneuver, the first part of the brain to be activated is the amygdala. (Henderson,et al, 2002.)

The Fight-Flight-Freeze Response The amygdala helps to protect us from physical danger by triggering what is known as the “fight-flight-freeze response.” This is an automatic reaction in humans and other animals. When the amygdala senses a potential threat, it triggers the release of stress hormones, which instantly cause the body to freeze, to prepare for a fight, or to run to safety. For example, if you were hiking in the countryside and suddenly saw something at your feet that looked like a rattlesnake, the amygdala would cause you to automatically react to the danger, without even thinking. Your amygdala is programmed to do this instantaneously as an aide to survival. Your reaction might be particularly strong if you knew that the area was infested with poisonous snakes, and you were already worried about being bitten. Here’s how it works. The fearful stimulus – the vision of the snakelike object – is transmitted from the visual cortex of your brain to a part of the brain called the thalamus, which acts somewhat like a switchboard. The thalamus relays the information both to the amygdala and to the cerebral cortex — the “thinking” part of the brain. But it gets to the amygdala first, before you are consciously aware of it. If the stimulus is similar to something fearful, the amygdala automatically sounds an alarm, telling the hypothalamus to begin the “fight-flight-freeze”

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response. The hypothalamus does this by activating the sympathetic nervous system (a branch of the autonomic nervous system) as well as the adrenalcortical system, causing various glands to release adrenaline (also known as epinephrine) and approximately 30 other stress hormones into the bloodstream. Because the fearful stimulus gets to your amygdala before your cerebral cortex, you may react even before you know the reason why. As a result, you jump away from the snake-like object without even thinking. After obeying the stress hormones’ “flight” response, you are in a position of greater safety and your anxiety level is greatly reduced. All of this happens before your sensory cortex interprets the sensory data and your hippocampus compares it to other conscious memories in order to establish the proper context. After interpreting all the data, you may determine that the object is not a rattlesnake after all. Perhaps you determine that it’s a harmless garter snake or just a stick. But that doesn’t matter. The fightflight-freeze response assumes the worst and follows the “better safe than sorry” principle. After the perceived danger has been dealt with, the parasympathetic nervous system (another part of the autonomic nervous system) is activated and returns your bodily functions to their normal state.

Voice and the Freeze Response The “freeze” response is activated when neither fighting nor fleeing are options. The purpose is to inhibit movement in order to make one less noticeable

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to a predator or threatening adversary. The freeze response not only suppresses muscular movement; it also causes vocal inhibition. In other words, it freezes our voice as well as our body. How might this reaction have come about? The answer may be found in the evolutionary development of human behavior. Before the invention of agriculture about 12,000 years ago, humans lived as hunter-gatherers for hundreds of thousands of years. It is believed that men hunted wild animals for meat, while women and children gathered fruit, nuts, and edible plants. Back then, humans lived in the wild and were routinely threatened by large, ferocious animals as well as hostile tribes. Because this lifestyle persisted for as much as 95% of human existence, it is likely that many of our behavioral traits are based on the conditions that existed at that time. It is likely that we also inherited our ancestors’ instinctive responses to danger.

The Freeze Response to Danger Let’s imagine how vocal inhibition might have evolved as a mechanism for human survival in prehistoric times. As a hypothetical example, imagine that a stone-age human was suddenly confronted with a dangerous animal – like a lion on the plains of Africa. Upon seeing the lion, the person’s amygdala would trigger the release of stress hormones. Not being able to fight or out-run the lion, the person’s automatic response would be to freeze so the lion would be less likely to notice him. But it is also important that the lion not hear him. So, the stress hormones would not only freeze his body in a motionless position, but they would also suppress his voice so as not to attract the animal’s attention. At the same time, the stress hormones would activate the person’s Valsalva mechanism. The purpose would be to stiffen the trunk of his body by means of a Valsalva maneuver so he could fight more efficiently if he were attacked. The Valsalva maneuver would also cause tight closure of the person’s larynx, which would further block any vocal sounds that might give him away. Therefore, the overall defensive reaction would have two aspects: • Suppressing the voice, and • Substituting an impulse to build up air pressure by doing a Valsalva maneuver. The dual nature of this reaction is consistent with scientific findings that the freeze response involves coactivation of both the parasympathetic and sympathetic nervous systems – relaxing and activating parts of the body at the same time.

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Suppression of Vowel Sounds If the purpose of the freeze response is to prevent a person from being seen or heard in a dangerous situation, then suppression of vowel phonation makes perfect sense. This is because the vowel sound is the loudest part of a word or syllable and therefore the part most likely to be heard. In contrast, the freeze response would not prevent whispering because the lion would be less likely to hear it.

Interference with the Speech Motor Program How might these facts apply to stuttering? To begin with, our amygdala’s reactions are not limited to physically dangerous situations. The amygdala may respond to any situation we fear – including speaking situations – in the same defensive way as in the lion example. As previously discussed, every physical movement, including the movements involved in speech, must be preceded by a motor program formed by the brain. Therefore, there must be a motor program for every specific word that we say. These motor programs are created by certain parts of the brain (to be discussed in more detail later). Studies have indicated that the brains of persons who stutter may be less efficient in forming speech motor programs than those of persons who don’t stutter. Although these weaknesses would not necessarily cause stuttering, they could render speech more vulnerable to interference by stress hormones. Your experience may vary, but typically the Valsalva-stuttering response seems to work like this: You begin by entering the speaking situation with a variety of fears, unhelpful beliefs, expectations of difficulty, and/or intentions to make a “good impression” by trying hard not to stutter. These thoughts increase the sensitivity of your amygdala to words and situations associated with stuttering. When you come to a feared word, your amygdala may react to the word defensively, as if it were a physical threat. However, all it can do to help you is to trigger the release of stress hormones and initiate the fight-flight-freeze response. The stress hormones flood your brain and hijack its motor program for saying the word. Specifically, the stress hormones suppress the motor program for voicing the loudest part of the word – the vowel sound. In multisyllable words, the loudest part would be the vowel sound of the stressed syllable. We will refer to this as the Key Vowel Sound. Without a motor program to voice the Key Vowel Sound, that particular word cannot be spoken. The fact that persons who stutter are able to substitute words to avoid blocks indicates that the stress hormones only affect the motor program for the intended word and not others that the speaker doesn’t care about. Also, the motor program for forming the preceding consonant or glottal stop doesn’t

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appear to be affected. This may be because consonants and glottal stops usually aren’t very loud, standing alone, without the following vowel sound. This hypothesis may explain why persons who stutter have no trouble mouthing words silently and little or no trouble whispering. As illustrated in the lion analogy, whispering would be safer than speaking out loud, because an adversary would be less likely to hear it. The same effect may also apply to situations in which the stutterer can’t hear himself talk (as when using a device like the Edinburgh Masker). If the stutterer can’t hear himself voicing the vowel sounds, the amygdala has no basis for suppressing them.

Substitution of Effort In place of vowel phonation, the stress hormones may substitute a motor program for exerting effort by means of a Valsalva maneuver. You may feel an overwhelming impulse to press tightly on the preceding consonant or glottal stop to build up air pressure. We will call this the effort impulse. You may feel that you are trying hard to “force out” the word, when actually you are doing the same defensive maneuver as our hypothetical human in the lion analogy. Your lips, tongue, or larynx may close tightly to block airflow and build up air pressure. Their closure automatically becomes tighter and tighter to resist the air pressure. In words that start with vowel sounds, forcing on the glottal stop may turn it into effort closure. Although you may think you are trying to force through the block, you are really making the block even stronger. Sometimes your exertion of physical effort may discharge the effort impulse, after which you can say the word more easily. This leaves you with the false impression that physical effort succeeded in getting the word out. Therefore, these behaviors are rewarded, reinforced, and perpetuated. As illustrated in the lion example, the suppression of vowel voicing, together with activation of the Valsalva mechanism, may be a defensive response that we inherited from our prehistoric ancestors. This instinctive reaction, triggered by the amygdala, may be at the root of stuttering blocks.

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The Valsalva-Stuttering Response Listeners tend to define “stuttering” in terms of the various behaviors that they witness in persons who stutter. But for persons who stutter, these are merely external struggles in response to the underlying block. For them, the primary experience of stuttering is the feeling of being stuck in trying to say a word. You may feel as if the word contains a “brick wall” – which is actually an effort impulse in the place where vowel phonation should be. Without the motor program for phonating the vowel, you can’t say the word. You can say other things, but not the specific word or syllable that contains the motor program for effort. You may feel a jolt of fear. Your mind and body are taken over by the stress hormones, which focus your attention entirely on the struggle. The stress hormones cause you momentarily to forget anything you may have learned in speech therapy. They are screaming, “Force! Force!” Even if you remember what you are supposed to do, you feel totally out of control. You experience an overwhelming urge to build up air pressure in an attempt to force out the word as quickly as possible. In your panic, you find yourself reverting to the same kinds of forceful closures, prolongations, repetitions, and other struggle or avoidance behaviors that you used in the past. Blocking on the word reinforces your belief that speaking is difficult or that a particular word or sound is hard for you to say. This increases the sensitivity of your fear response even more. Therefore, blocking on one word may increase the likelihood that you will block on others.

General References CARTER, R. Mapping the Mind. Rev. ed. Berkeley, CA: University.of California Press, 2010. HENDERSON, L.A., MACEY, P.M., MACEY, K.E., FRYSINGER, R.C., WOO, M.A., HARPER, R.K., ALGER, J.R., YAN-GO, F.L. & HARPER, R.M. Brain responses associated with the Valsalva maneuver revealed by functional magnetic resonance imaging. J. Neurophysiology, 2002, 88, 3477-3486. LEDOUX, J. The emotional brain, fear, and the amygdala. Cellular & Molecular Neurobiology, 2003, 23, 727-738. NOBACK, C. R., STROMINGER, N.L., & DEMAREST, R. J. The Human Nervous System: Introduction and Review. 4th ed. New York: McGraw-Hill Book Co., 1991. WEBER, C.M. & SMITH, A. Autonomic correlates of stuttering and speech assessed in a range of experimental tasks. Journal of Speech & Hearing Research. 1990, 33, 690-706.

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CHAPTER 11.

Analysis of Stuttering Blocks ANALYZING how a Valsalva-stuttering block might work, let’s use the I Nname “Peter” as an example. T Blocking on “Peter” Before Peter can say his name, his brain must neurologically program the muscles of his mouth and larynx to make the necessary movements and to bring his vocal folds together at the right time and with the right amount of tension to say the vowel. The motor program for “Peter” should have phonation on the “ee” (/i/) and the “er” (/ɚ/). This can be represented in transliteration and the phonetic alphabet as follows:

P ee t r (/ ˈp i · t ɚ/) Because Peter anticipates that saying his name will be difficult, his amygdala may trigger a freeze response that suppresses the loudest part of his name. This would be phonation of the vowel sound “ee,” without which his name cannot be spoken. This type of block could be represented like this:

Ptr In place of vowel phonation, a motor program for effort is substituted. This causes Peter to feel as if his name contains a “brick wall” that requires force to break through. As a result, he becomes fixated on the consonant p, which precedes the missing vowel sound. He tries to force through the block by building up air pressure, as in a Valsalva maneuver. His lips press tightly together in the p position to block airflow, while his chest and abdominal muscles squeeze to increase pressure in his lungs. Because the muscles of the Valsalva mechanism are neurologically coordinated to build up air pressure, the more he forces, the tighter his lips close to block the air. To Peter, this effort instinctively feels like the right thing to do, but it actually strengthens the block and makes phonation of the vowel sound even more difficult. The forceful blockage of air by Peter’s lips might be represented like this:

P------- 

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Alternatively, the larynx’s unreadiness to phonate the vowel might cause Peter to repeat the initial consonant, like this:

Puh-puh-puh-puh  When the initial consonant is repeated during stuttering, it is usually followed by a neutral vowel sound, “uh” (/ə/), which is called the schwa. This is simply a soft grunt-like sound, rather than full phonation of the vowel that was suppressed. To Peter, it seems as if the initial p sound is causing the block. However, the real problem is his inability to move on to the vowel sound that follows it. When the preceding consonant does not completely block airflow, such as a fricative, liquid, or nasal, the result may be a forceful prolongation of the sound, such as:

ssssssssss  OR rrrrrrrr  OR

mmmmm 

Blockages may occur in either the mouth or the larynx, usually depending on where articulation occurred prior to the missing vowel. Because the “h” sound is produced by partial closure of the larynx, blockages that focus on that sound may also involve laryngeal closure. It should be noted that the difficulty in phonation is usually limited to a specific vowel sound in a specific word or syllable. Therefore, the larynx may be able to make prolonged phonation on initial voiced consonants like “r” or “m,” but not be able to phonate the subsequent vowel sound. The intensity of the speaker’s urge to exert effort may vary, depending on the word or the speaking situation. Therefore, some blocks may be relatively brief, such as:

Puh-puh  ee t r OR P---  ee t r In other instances, the block may go on indefinitely. Or it may continue until either the effort impulse is discharged or the muscles blocking the upper airway tire out. Nevertheless, any amount of excessive effort is likely to disrupt fluency. The speaker may also try to avoid, delay, or hide the blocks by interjecting extraneous words or sounds as “starters” (e.g., “um,” “you know,” “uhuh-uh-uh”) or by substituting words that he feels will be easier to say. Persons who stutter may also resort to a variety of other behaviors in their struggle to force out words. The above description of stuttering blocks has been confirmed by every person who stutters with whom I have worked. Whatever questions have been raised stemmed from confusion between how words are spoken and how

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they are written. These questions were easily resolved by the following explanations.

Words That Start with Vowels Many people who stutter have difficulty with words that start with vowels, such as “apple.” In these situations, the repetition or forceful blockage focuses on the laryngeal closure or glottal stop (/ʔ/) that commonly occurs just before the actual vowel sound. This kind of repetition or block could be represented as follows:

ʔuh-ʔuh-ʔuh-ʔuh  OR

ʔ--------------- 

The purpose of the glottal stop is to accentuate the beginning of the vowel sound by momentarily holding back some air and then releasing it. We usually don’t think about these glottal stops because they don’t appear as a separate letter before the vowel at the beginning of the words, and they don’t affect the word’s meaning. Although produced in the larynx, the glottal stop is not part of vowel phonation. Instead, the glottal stop is a consonant. It acts the same as the written consonants that stop airflow, such as b, p, d, t, g, and k, and should not be confused with the actual vowel sound that follows. Using a glottal stop before an initial vowel is sometimes called “hard onset.” This is distinguished from “easy onset,” in which the vocal folds are brought together gradually.

Stop-Liquid-Vowel Combinations A gentleman attending my workshop at a British Stammering Association conference in England asked how my hypothesis could explain his tendency to block on the b in “Bristol,” instead of on the r that immediately preceded the vowel. I explained that some of the sounds that we call “consonants” are very similar to vowel sounds. These include the “liquid” semi-vowels L and R. They are similar to vowels in that they are voiced and do not obstruct airflow. When an L or R appears by itself at the beginning of a word, it operates like any other consonant. It may be delayed, prolonged, or repeated while waiting for the larynx to phonate the following vowel sound. But when an L or R comes between a stop consonant and the vowel sound (as in “blue” or “train” or “Bristol”), it may act as part of the vowel sound. In these words, the struggle will focus on the stop consonant rather than on the liquid semi-vowel.

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Fear of Words Beginning with Certain Sounds Fixation on the initial consonants (or on initial vowels with their glottal stops) creates the false impression that these sounds are causing the speaker to block, when the real problem is the speaker’s inability to move on to the vowel sound that follows. The person who stutters may come to believe that it’s difficult to say words that begin with certain sounds, because he remembers blocking on such words in the past. This expectation of difficulty may trigger a fear reaction when the speaker comes to words beginning with these sounds. As a result, stress hormones cause the brain to suppress vowel phonation and substitute a motor program for exerting effort, as in a Valsalva maneuver. In this way, the speaker’s anticipation of difficulty perpetuates the very blocks that he feared.

Blocking on No Particular Word In some instances, the person who stutters feels the block or “brick wall” as soon as he forms the intention to speak, sometimes before he selects the particular word he wants to say. The larynx closes tightly and is unable to phonate any sound at all. In these cases, the block represents a motor program for effort that is created by the brain prior to the programming of a word. Often persons who stutter don’t have any specific word in mind while blocking. They may feel that there is no use in choosing a word at this point, and that trying to say a particular word might make the block even worse. In their struggle to break through the laryngeal closure, persons who stutter often make a series of forceful, repetitive grunts—glottal stops followed by the schwa. After making these grunts—which are like a series of miniValsalva maneuvers – a stutterer is often able to say an entire phrase without stuttering. For example:

 ʔuh-ʔuh-ʔuh-ʔuh. Please pass the potatoes. This exertion of physical effort can have the effect of discharging one’s urge to force, and it may momentarily reduce one’s anxiety. The Valsalva mechanism can then relax, and the brain can program the larynx to phonate, thereby allowing speech to proceed. This creates the false impression that effort helped to get the word out. Consequently, the grunting behavior is rewarded, reinforced, and perpetuated.

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CHAPTER 12.

The Amygdala as “Bodyguard”

A

LTHOUGH THE AMYGDALA may seem like a nemesis for persons who stutter, its real purpose is to be your friend. The amygdala’s primary purpose is to protect you from danger and save your life. And believe it or not, the amygdala is actually trying to help you in speaking situations. In order to understand and control what the amygdala is doing, I have found it helpful to imagine the amygdala as a person, rather than viewing it in abstract neurological terms. I like to compare the amygdala to the armed guard on a stagecoach in the Old American West. Let me explain.

“Riding Shotgun” In the early days of the American West, when a stagecoach was carrying valuable cargo, a guard with a shotgun would be seated next to the driver for the purpose of warding off bandits. This practice was known as “riding shotgun.” We might consider the amygdala also to be “riding shotgun” as we go through our daily life. Imagine the amygdala to be your personal bodyguard who is “riding shotgun” to assure your safety. When it senses physical danger, it triggers the release of stress hormones that help you run faster, fight harder, and exert greater effort and strength. Because he is our friend, who is trying to protect us from danger, we can call him “Amigo” (the Spanish word for “friend”). Likewise, we can imagine the fight-flight-freeze response to be like Amigo’s “shotgun.” There is no doubt that “Amigo” and his “shotgun” can save our lives in physically dangerous situations. But Amigo may also trigger his shotgun when trying to help us in situations that are not physically dangerous – such as speaking situations.

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Amigo Acts on Your Intentions Our friend Amigo tries to help us out by acting in accordance with our intentions. If our intention is to try hard to make a “good impression” by not stuttering or to “prove” that we can say a word fluently, Amigo is activated accordingly. We can imagine Amigo responding, “Oh, you want to be fluent? I can help you with that!” However, Amigo’s only tool is his “shotgun” – the triggering of stress hormones and the fight-flight-freeze response. Amigo may initiate the same defensive reaction as we saw in the lion analogy. This reaction replaces the vowel sound with an impulse to exert effort through a Valsalva maneuver. While this might save our life in a physically dangerous situation, it causes nothing but trouble when we try to speak.

The “Speech Alarm System” The amygdala’s sensitivity to stimuli may vary, depending on the situation. For example, if you were strolling through a safe, quiet neighborhood during the day, your amygdala would probably be on a low alert level, allowing you to think pleasant thoughts and enjoy yourself. In contrast, if you had to walk through a crime-infested neighborhood at night, your amygdala would probably be on high alert for muggers. Any movement in the shadows might cause it to send an alarm – triggering the release of stress hormones through your brain and body. Likewise, the triggering of stuttering blocks may vary greatly, depending on the speaking situation. We might better understand this variance if we view it in terms of a “Speech Alarm System.” Visualize the Speech Alarm System as having the following “Alert Levels”: • CLEAR; • LOW; • MODERATE; • HIGH; and • EXTREME As you enter speaking situations, you may habitually set the sensitivity of your “Speech Alarm System” based on your memories, thoughts, expectations, attitudes, and beliefs about the difficulty or danger of the speaking situation and/or the words you anticipate saying.

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The following is a hypothetical example of how the Speech Alarm System might work. This process may be conscious, unconscious, or semiconscious. It may seem to you as being so necessary, automatic, and inevitable that you feel you have no choice in the matter. •

•

•

•

You approach a speaking situation thinking, “I am a stutterer. Therefore, speech is difficult for me.” Already your Alert Level starts at LOW. Then you think, “In the past I have usually stuttered in this type of situation, or when speaking to this person. Therefore, I will probably stutter this time also.” This moves your Alert Level up to MODERATE. Next you think, “It is very important that I make a good impression by being fluent. Therefore, I must try hard not to stutter.” Your Alert Level is now at HIGH. On top of all this, you think, “I have blocked a lot on words that start with ‘p’ (or any other type of word on which you have had trouble). Therefore, I must try especially hard not to stutter on p-words. And here comes one now!” At this point, your Alert Level has shot all the way up to EXTREME.

Your amygdala is now on Extreme Alert for the dreaded “p-words” (or whatever other type of word you might fear). As you come to a “p-word,” your amygdala sends out an alarm: “Danger! Danger!” This triggers your sympathetic nervous system to initiate the fight-flight-freeze response. Your brain and body are flooded with stress hormones, which urge you to “Force! Force!” – as if you were in real danger and needed to fight off a mugger. But there is no mugger. It is only a word. You are safe. Your Speech Alarm System has given you a false alarm. Because speaking situations usually present no physical danger, all of its alarms are false alarms. The Speech Alarm System is actually unnecessary and counterproductive. If Amigo causes so much trouble with speech, why do persons who stutter give him so much power? Probably because he promises protection, just like the armed guard “riding shotgun” on the stagecoach. When Amigo triggers stress hormones in physical situations, we automatically respond for our own safety. Likewise, we also respond automatically when Amigo triggers effort impulses in speaking situations.

Reaction to Over-Invested Words Imagine that “Peter,” a person who stutters, wants to go to a restaurant and order a pizza. However, he has been blocking on words starting with

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the “p” sound, so he is afraid that he will stutter on the word “pizza” and make a “bad impression.” Therefore, while all alone, Peter practices saying “pizza” over and over again – “pizza, pizza, pizza” – with perfect fluency. So, there is no doubt that he is capable of saying the word without any difficulty at all. While traveling to the restaurant and getting a table, Peter constantly thinks of the word “pizza” and the importance of saying it correctly. Then the waiter comes and asks, “What will you have?” When Peter tries to answer “pizza,” the word won’t come out. It feels blocked, as by a brick wall. His intention to say the word is involuntarily transformed into physical effort. His lips press tightly together in the “p” position, blocking the airflow. At the same time, his abdominal and chest muscles contract, building up air pressure in his lungs in an attempt to force out the word. But the more he forces, the tighter his lips clamp together. Finally, Peter gives up trying to say “pizza.” At this point, he could have easily asked for something that he didn’t want – like “I’ll have a hamburger.” Instead, he points to “pizza” on the menu. The waiter sees what he is pointing to and says, “Oh, you want a pizza!” Suddenly the spell is broken, and the block disappears. Now Peter can say “pizza” easily. “Yes, I’ll have a pizza, pizza, pizza!” This example is a familiar experience for many persons who stutter. It shows that the speaker has the underlying ability to say the word – because he could say it when he was alone and even to the waiter, after the waiter already knew what the customer wanted. These facts indicate that the block was not caused by the word itself, or even by the mere presence of a listener. The word could be said easily when it became superfluous. The word was blocked only when saying it really mattered – when saying it was invested with emotional importance. Peter began with an intense fear that he would stutter on “pizza” when ordering. Perhaps he believed that stuttering would make a “bad impression” with the waiter. Or perhaps he wanted to prove to himself that he could say the word fluently. In effect, he was telling his amygdala that “pizza” is a difficult word and that it would be terrible if he blocked on it when ordering in the restaurant.

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When he practiced saying “pizza” alone, the word was not important and there was no potential danger in saying it. There wasn’t any listener to impress, and nothing was actually being ordered. Therefore, “Amigo” had no reason to trigger a fear response. However, Peter’s practicing for the purpose of trying “not to stutter” strengthened Amigo’s sensitivity to the word “pizza.” You might imagine that Amigo was now “gunning” for the word. When Peter arrived at the restaurant, he had already invested the word “pizza” with great emotional importance and viewed the speaking situation as a difficult and dangerous challenge. When the time came to order a “pizza,” Amigo reacted to the impending danger by triggering the fight-flight-freeze response. As a result, the voicing of the vowel sound was suppressed and replaced by an effort impulse. You can imagine Amigo shooting a “stress hormone” shotgun right at the heart of the word – its vowel sound. Without readiness of the larynx to phonate the vowel sound, the word could not be spoken. The stress hormones and effort impulse caused Peter to feel an overwhelming urge to “force out” the word, by means of a Valsalva maneuver. His lips instinctively pressed tightly together to block the airflow, while his chest and abdominal muscles squeezed to build up air pressure in his lungs. Although he felt that he was “trying hard” to say “pizza,” the blockage of airflow made phonation impossible. Once the waiter said “pizza,” the word became superfluous, unnecessary, and divested of all its emotional importance. Now Peter’s parasympathetic nervous system took over, relaxed his Valsalva mechanism, and allowed him to say the word normally.

Shifting Intentions in Therapy A common complaint about stuttering therapies is that the “fluency techniques” being taught (whatever they might be) fall apart when you really need them. The techniques may work fine when talking to the clinician during therapy sessions. However, they don’t work when you try to use them in ordinary speaking situations, or when saying a word really matters. How can we understand this phenomenon? The explanation may be one’s changing intention. When a person uses a technique in a therapy session, his intention is to demonstrate to the clinician how well he is using the technique. In this situation, Amigo is focused on the technique rather than protecting against stuttering. In ordinary speaking situations, on the other hand, the person’s intention

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is to use the technique for the purpose of not stuttering. Consequently, Amigo returns to his previous job of reacting to words associated with stuttering. It’s as if Amigo is again saying, “Oh, you want to be fluent? I can help you with that!” We already know how this will turn out. Therefore, as long as your intention is to ‘try hard not to stutter,’ Amigo will continue to react, regardless of what speaking technique you think you are using. Another phenomenon that I have observed during therapy sessions happens when a person who usually stutters severely finds himself reading aloud effortlessly during a speaking exercise. His speech is fluent for an extended period, but then he suddenly starts blocking on words. After telling him to stop, I would say, “I bet I know what you were just thinking. Were you thinking, ‘Wow, I’m fluent! I wonder how long I can keep this going’?” The answer is invariably yes. The participant’s original intention was to focus on the Valsalva-relaxed speaking exercise. Therefore, Amigo had no reason to interfere. Then, when his intention shifted to “being fluent,” Amigo stepped in to “help out” by triggering the same old defensive reaction.

Cues The amygdala may also trigger stuttering blocks for reasons of which we are not consciously aware. Our friend Amigo might be responding to certain stimuli known as “cues.” These could be something about the speaking situation, the surroundings, the listener’s appearance or manner, the subject matter being discussed, or anything else that your amygdala has come to associate with stuttering. Such responses may have become so habitual that they occur without any conscious input on our part.  Now that we have established the principles behind the two underlying manifestations of stuttering—forceful closures and difficulty in vowel phonation—we are ready to analyze and understand a wide array of stuttering and avoidance behaviors.

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CHAPTER 13.

Varieties of Stuttering

I

MAGINE THAT YOU ARE HIKING down a country road. Suddenly you come upon a high stone wall with a big, solid gate closed across your path. You push against the gate, but it won't open. You push harder, you pound repeatedly, but it still won't budge. Other travelers arrive. They also push and pound on the gate, to no avail. Then each individual comes up with a different method of attacking the problem. One takes a running start and throws his whole body against the gate. Another finds a crowbar and tries to pry the gate open. Others attempt to climb over the wall. Some travelers wander off the road, in search of a route around the wall. Still others, having learned that there is a gatekeeper on the other side, use various ploys to trick him into opening the gate. They will wait for the gate to open and then try to dash through before it shuts again. This story illustrates how a single obstacle—the closed gate—can provoke a wide variety of responses. The actions of the individual travelers may be different, but the underlying obstacle is the same. None of the pushing, pounding, running, climbing, and other strategies would have been necessary if the travelers simply had a key to open the gate. Those of us who stutter may find ourselves in similar situations. For us, the road is speech. The closed gate is the blockage of speech. As previously discussed, this blockage occurs when the brain substitutes a motor program for effort in place of one for phonating the vowel sound in a particular word or syllable. I have called this neurological substitution the Valsalva-stuttering block. Without a motor program for phonating the vowel, it is impossible for the speaker to say the word. When an upcoming word contains this obstacle, we may find ourselves doing a wide assortment of puzzling things that go beyond the forceful closures, prolongations, and part-word repetitions previously discussed. Here are examples of additional behaviors associated with stuttering: • Hesitations; • Repetitions of words, phrases, and even whole sentences; • Repetitive grunting (“Ɂuh-Ɂuh-Ɂuh-Ɂuh-Ɂuh”) prior to speaking;

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The use of "uh's," "ah's," stock phrases (e.g., "you know," "let's see"), and other unnecessary words and sounds; • Word substitutions and circumlocutions; • Gasping, panting, and other breathing irregularities; • Facial contortions, teeth gnashing, arm swinging, and other bodily movements. There is almost no limit to the bizarre things we might do in our struggle to speak. However, the superficial differences do not mean that each behavior has a cause that is separate and distinct from other types of stuttering. From the perspective of persons who stutter, the core of stuttering is not the external behaviors, but rather the experience of being stuck on a word. Like the travelers' activities in the story, the various stuttering behaviors are all attempts to overcome or avoid the same underlying obstacle. I myself have, at one time or another, engaged in almost every variety of stuttering that I have ever seen. Each individual might react to the underlying Valsalva-stuttering block in different ways, in an attempt either: (1) to break through the block and force out the word, or (2) to avoid, postpone, or conceal the block. The result may be a wide variety of struggle and avoidance behaviors, which become habitual features of the individual's own pattern of stuttering. Now let's examine a number of these behaviors to see how they might have come about.

Hesitations Hesitations in speech may be a direct result of the neurological suppression of vowel phonation as well as the physical blockage of airflow. We may also hesitate when we anticipate that a block is coming. Rather than crashing into the block head on, we might simply wait for the anxiety and pressure to subside. If we can't find our voice, we might pause until our larynx gets ready to phonate. If we are patient enough, the block may eventually go away. Waiting out a stuttering block might sound simple, but it can be murder during an actual conversation. Silence is extremely uncomfortable, both to the speaker and the listener. If we pause too long, the other person might either: (a) interrupt us by starting to talk; or (b) lose interest, walk away, or hang up the phone. Therefore, we may feel ourselves under great social pressure to show the other person that we are still trying to communicate. Doing or saying something – almost anything – may feel preferable to remaining silent. The fear of silence is an important motivation for many kinds of stuttering behavior. Most of us will not simply stop, relax, and wait for a block to pass. Instead, we may either: (1) show that we are struggling to talk, or (2) say something else that we feel won't be blocked.

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Signs of Struggle There are many ways to show the listener that we haven't quit speaking but are struggling to break through a block. If we really want to show how hard we are trying, we can go into a full-blown Valsalva maneuver, squeezing our mouth or larynx closed as we build up air pressure, perhaps until we are red in the face. Or we may split the Valsalva maneuver into a series of short bursts of effort. At the end of each burst, the mouth or larynx opens, releasing an audible sound. When the struggle is in the mouth, the resulting sound may be a repetition of the beginning sound, followed by a neutral schwa sound. ("Puh-puhpuh-puh-pass the puh-puh-puh-puh-potatoes.") When the struggle is in the larynx, the result may be a series of little grunts ("Uh-uh-uh-uh-uh"). Other muscles may also be brought into the struggle. Facial contortions may occur as we strain various muscles in an attempt to pull the mouth open. Or we may try to pry the mouth open by shifting the pressure onto the jaw instead. However, the forceful closure of the jaw only results in a painful clenching and gnashing of the teeth, sometimes causing us to bite the inside of our mouth. This struggle can expand even beyond the mouth and face, as more and more parts of the body become involved. We may end up with eyes closing, neck jerking, arms swinging, fists clenching, feet stomping, and so on.

Starters, Fillers, and Other Junk Words Another way to fill in the silence is to say things that are not likely to cause us to block. The most common examples are starters and fillers. These include meaningless sounds like "uh" and "ah," and stock phrases like "you know" and "let's see." Although normal speakers occasionally use these verbal crutches, persons who stutter are world champions at this activity. ("Uh, well, would you pass, you know, like, pass the, let's see, uh, the potatoes?") Because these are "junk" words—with no value or meaning—we feel no need to "try hard" to say them properly. They are not invested with any emotional importance. Therefore, neuromotor tuning of the Valsalva mechanism is less likely to occur and we are less likely to block. Unfortunately, we may overuse them to such a degree that they become more annoying than either stuttering or silence would have been. This might also explain why it was easier for me to say the wrong thing rather than the precise thing I wanted to say. The person who stutters may also fill in the silence by repeating what has already been said. This may be a word, phrase, or entire sentence. Having already been said, it is no longer important. Therefore, there will be less of an

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urge to try hard to say it, and the Valsalva mechanism will be less likely to interfere. There is a common misconception that the repeated word is the one on which we are blocking. On the contrary, we are repeating it precisely because it is not giving us trouble. Usually, we are anticipating a block on the word that follows it. In addition to filling in the silence, starters and repetitions may be used as a "running start" in attacking a word we fear will be difficult. Whether this really helps is questionable. Often, I hear persons who stutter repeating whole sentences, over and over, only to stop abruptly when they reach the feared word. The effect on the listener can be maddening.

Word Substitution When we find ourselves blocking on a particular word, we may attempt to avoid the block by substituting another word in its place. A substitute word is usually easier to say, because it is not what we had really wanted to say. Therefore, it is not invested with the same emotional importance and is less likely to activate the amygdala and the Valsalva mechanism. However, word substitution as many potential pitfalls. In many situations there is no appropriate word replacement. For example, saying one’s name, address, phone number, etc. Various occupations and professions have precise words that you are expected to know. For example, a surgeon is expected to know words such as “scalpel,” and a lawyer is expected to know words like “deposition.” Trying to substitute something else will make you sound incompetent. Word substitution can be carried to such an extreme that it becomes circumlocution. That is, a person who stutters may rephrase entire sentences in an effort to avoid stuttering on certain words. "Please pass the potatoes" may thus be transformed into "Kindly send over that bowl of mashed-up stuff." The stutterer tries to sustain an illusion of fluency by sacrificing the right to say what he really wants.

Timing Irregularities A stutterer's speech is rarely smooth. It often proceeds in a jerky fashion, at one moment lurching ahead with a rapid burst of words, then grinding to a halt. This tendency has led some experts to suspect that stuttering is caused by a lack of timing and coordination. However, it is also possible that jerky speech is a habit developed in an attempt to "fake out" the stuttering block. We may race through the words, hoping to outrun the block before it catches up with us. Or we may try to sneak up on the block, and then rush through.

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We change rhythm or verbally bob and weave like basketball players, as ploys to catch the block off guard.

Breathing Irregularities Persons who stutter may also do puzzling things with their breathing. These include huffing, puffing, panting, snorting, gasping, and trying to speak with little or no air in the lungs. We don't do these things intentionally. They just seem to happen sometimes, when we feel a block coming on. For example, I once had a tendency to huff and puff before answering the telephone. Upon closer examination, I found that I was rapidly contracting my chest and abdominal muscles, in response to an overwhelming urge to build up air pressure. Even though my mouth and larynx were open, these rapid contractions still resulted in temporary increases of air pressure in the lungs. I wasn't doing a full Valsalva maneuver, because my upper airway wasn't closed. Nevertheless, this behavior indicated that at least part of the Valsalva mechanism was at work – perhaps in response to an effort impulse. At other times, I noticed a great struggle going on between the muscles of the chest and abdomen. It seemed as if the muscles for inhaling were straining to keep the chest expanded, while the muscles of the Valsalva mechanism were squeezing to compress the chest cavity. The two opposing forces seemed to have reached a stalemate, so the air pressure in the lungs did not increase. My mouth and larynx remained open, but no air was moving in or out. Again, I had the impression that at least part of the Valsalva mechanism was at work. It felt as if the Valsalva mechanism was trying to exert force through the muscles of the abdomen and the chest muscles that are used to force air out but was thwarted by opposing sets of muscles. Although the Valsalva maneuver had been defeated, the victory was meaningless, since there was no airflow for speech. Trying to speak without air in the lungs may be another attempt to head off a Valsalva maneuver. Obviously, we can't build up much air pressure in the lungs if we don't have much air to start with. But this practice also interferes with speech by depriving us of airflow.

Habits of Desperation This discussion has touched on only some of the behaviors that persons who stutter adopt in their effort to overcome or avoid stuttering blocks. Most of the strategies are stumbled upon in desperation, usually without conscious thought. At first, they may seem better than nothing, even though they disrupt speech in ways of their own. And so we return to them, again and again. Eventually, they become a habitual part of our individual pattern of stut-

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tering. These behaviors may become as deeply entrenched, and as much of a problem, as the primary stuttering blocks that they were intended to combat. In the next part of this book, we will observe how Valsalva tuning is influenced by negative beliefs, expectations, fears, and intentions, which are reinforced by our reactions to stuttering and perpetuated by a vicious circle.

General References BLOODSTEIN, O. A Handbook on Stuttering. 5th ed. San Diego: Singular Publishing Group, 1995, pp. 11-22. STARKWEATHER, C. W. Fluency and Stuttering. Englewood Cliffs, N.J.: Prentice-Hall, 1987, pp. 117-127. VAN RIPER, C. The Nature of Stuttering. 2nd ed. Englewood Cliffs, N.J.: Prentice-Hall, 1982, pp. 111-143.

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CHAPTER 14.

The Valsalva-Stuttering Cycle

T

HE CIRCLE is a fundamental pattern found throughout nature. It is not merely a shape. It is a system in which one event leads to another, eventually arriving at the starting point, where the same events are repeated again and again, in a continuing cycle. Examples are everywhere: the alternation of day and night, the changing seasons, water evaporating into the air and falling as rain, the reproductive cycles of living things. Human beings have incorporated the circle into countless inventions, beginning with the wheel. The beauty of the circle is that it has no fixed beginning or end. Therefore, it can repeat itself indefinitely. Unfortunately, this same pattern on which life depends can also serve to perpetuate undesirable results. When this happens, it is sometimes called a vicious circle. Stuttering also follows a circular pattern, which neither begins nor ends with the disfluency itself. The physical aspects of stuttering, described in the previous chapters, are preceded by psychological factors (such as negative beliefs, expectations, fears, and intentions) and neurological reactions. The stutterer’s psychological response to stuttering confirms and reinforces his negative beliefs, expectations, and fears. This interaction of psychological, neurological, physiological, and behavioral factors creates a vicious circle, which both stimulates and perpetuates our stuttering behavior. We shall call this the Valsalva-Stuttering Cycle. We will now travel through the Valsalva-Stuttering Cycle (as depicted in the accompanying diagram) and follow the sequence of events according to the Valsalva Hypothesis .

Step 1. Negative beliefs, fears, expectations, and intentions. Let us begin our description of the Valsalva-Stuttering cycle by considering the mental attitudes we bring into a speaking situation. Our negative beliefs, expectations of difficulty, fears, and intentions set the stage for the neurological and physiological reactions that trigger stuttering. They will be discussed further in subsequent chapters about the psychology of stuttering, as part of the “Valsalva-Stuttering System.”

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As we have seen, we tend to stutter more when we feel that the words themselves are especially important, or we anticipate that speaking will be difficult. Often, we expect difficulty in saying a particular word. One week we may have problems with words beginning with the letter p. The next week it may be words starting with the letter f. The words or sounds that bother us are based on our own personal experiences and feelings. If we have had trouble with them in the past, we expect trouble in the future. Based on past difficulty, we may harbor the belief that effort is necessary to force the words out. The same is true with specific speaking situations. Some people may expect more difficulty when using the telephone, or when talking to authority figures, such as parents, teachers, bosses, policemen, judges, or other people they feel they have to please or impress. Therefore, many people who stutter go into speaking situations with the intention to “make a good impression” by trying hard not to stutter. Because we expect difficulty in speaking, it is natural for us to feel that extra effort may be needed to get us over the hurdles.

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The anticipation of difficulty may also be influenced by ambivalence, uncertainty, emotional conflict, and a variety of other psychological factors, to be discussed in subsequent chapters. Among these is the self-image we may have of ourselves as stutterers. As we shall discuss in subsequent chapters, some individuals may also have neurological weaknesses that impair fine motor control or speech or language processing. We may become so accustomed to these mental attitudes that we no longer give them any conscious thought. Nevertheless, they set in motion a chain of events that lead to stuttering. Adverse speaking conditions may also contribute to our feeling that speech will be difficult. These factors vary depending on the situation and the individual speaker. They may include temporary conditions, such as illness, fatigue, excitement, anxiety, and time pressure. Such conditions may impair our control of fine motor skills, including speech. As a result, the stutterer may feel that he must compensate for such conditions by using more effort in speaking.

Step 2. Amygdala triggers stress hormones and fight-flight-freeze response. As previously discussed, our amygdala is like a personal bodyguard who helps us to respond to danger by triggering stress hormones and initiating the fight-flight-freeze response. While this may save our life in physically dangerous situations, it can have adverse consequences in speaking situations. The amygdala’s reactivity is largely based on the negative beliefs, fears, expectations, and intentions that we bring into a speaking situation. When we come to a word that we fear or feel is difficult, the amygdala tries to help by triggering the release of stress hormones and the fight-flight-freeze reaction. (Remember the example of a prehistoric man confronted by a lion.)

Step 3. Motor program for vowel phonation is replaced by an effort impulse. The stress hormones flood our brain and corrupt the brain’s motor program for saying the word. In this way, the amygdala is trying to protect us by suppressing the loudest part of the word—the part most likely to be heard. The loudest part is phonation of the vowel sound. It is also the part using the most energy. In multisyllable words, it is the vowel sound of the stressed syllable. We will call this the Key Vowel Sound. Without a motor program for phonating the Key Vowel Sound – which is the heart of the word – the word cannot be spoken. Therefore, we feel blocked on the word. In place of vowel phonation, the stress hormones substitute a strong urge to exert effort—which we will call the effort impulse.

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Step 4. Activation of the Valsalva mechanism and Valsalva maneuver. In response to the effort impulse, our lips, tongue, larynx, and entire respiratory system are hijacked by the body’s Valsalva mechanism and are now programmed to tightly close for the purpose of building up air pressure as part of a Valsalva maneuver.

Step 5. Forcing and other stuttering or avoidance behaviors. While waiting for the larynx to get ready to phonate the vowel sound, our speech mechanism may become fixated on the preceding consonant or glottal stop – repeating it, prolonging it, or forcing on it, as described in previous chapters. The more we attempt to force out the word, the stronger the block becomes, and the less the larynx is prepared to phonate the vowel sound of the word. Alternatively, we may resort to a variety of behaviors, previously discussed, in an attempt to avoid, postpone, or hide the block. One of the most common is substituting a different word, which is usually less appropriate or has less emotional investment. We usually are able to say the substitute word because the stress hormones have only corrupted the motor program of the specific word that we originally intended to say. The word-substitution strategy has numerous drawbacks. For example, if we are called on in class to answer a question to which we know the answer, we may find it easier to give the wrong answer than the right one. And sometimes there is no appropriate substitute, such as when we must say our name or use a term that everyone in our occupation is expected to know.

Step 6. Reinforcement of negative beliefs, fears, expectations, etc. After the stuttering episode is over, the next part of the cycle is the way in which we mentally react to our experience. Blocking on the word reinforces our beliefs that speaking is difficult, that a particular word or sound is hard to say, and that effort is necessary. Forcing on the consonant or glottal stop prevents the word from being spoken. However, exerting effort may help to discharge the effort impulse. When the block finally dissipates and the word comes out, our struggle seems to be rewarded. We are left with two false impressions: (1) that the word was actually difficult and required effort: and (2) that forcing helped to get the word out. We may think, "I was right. That was difficult. If I didn't try hard, I never would have been able to say the word. Therefore, the next time I'll try even harder." In a similar way, we may also feel rewarded when the use of “starters,” “interjections,” and other strategies seem to overcome or avoid the block.

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In these ways, the negative beliefs, fears, expectations, and intentions are reinforced, bringing us back to Step 1 and a repetition of the ValsalvaStuttering Cycle.

Effort and Anxiety Reduction Another potent reinforcement is the effect that effort may have in reducing anxiety. When we respond physically to a perceived danger, we feel as if we are taking action to protect ourselves. Therefore, exerting effort in response to a Valsalva-stuttering block can momentarily help to lessen our fear – even though, in reality, it perpetuates the very thing we are afraid of. Regardless of the result, we may also feel entitled to some credit for having shown how hard we were trying. Ironically, the same behaviors that made us stutter are given credit for rescuing us from the difficulty. As a result, we tend to reinforce the very beliefs and behaviors that will promote stuttering in the future. At the same time, our evaluation of our speech also may reinforce negative ideas and feelings about ourselves. We may lose confidence in our ability to talk. We may feel embarrassed, ashamed, and guilty. For some people, the result can be a tremendous loss of self-esteem. The next time a speaking situation comes around, we may have increasingly negative expectations. Because speech was difficult the previous time, we anticipate that it will be difficult again. This may provoke an urge to try even harder than before, which may stimulate even greater Valsalva tuning and even more severe blocking. The Valsalva-Stuttering cycle may turn from a vicious circle into a vicious spiral. When we are in a downward spiral, we not only go round and round, but every time we complete the circle, we find ourselves at a point lower than before. Our rut becomes ever deeper and harder to escape. We are caught in a "Valsalva Trap."

Variations and Sub-Cycles Thus far, we have described a basic cycle, covering one stuttering episode to the next. To this may be added many variations, depending on the individual and the situation. Sometimes there may be smaller sub-cycles, in which certain steps reinforce and intensify one another. For example, when the motor program for effort creates the perception of a “brick wall,” this may reinforce and intensify the fear reaction and urge to “try hard.” The fear reaction may also be reinforced and intensified when we experience any of the other steps in the Cycle. As a result, the amygdala may trigger the release of additional stress hormones, thereby perpetuating the block.

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Our speech may also be subject to ups and downs that seem to follow larger cyclical patterns as well. For days or weeks, we may enjoy relative fluency, only to slip suddenly into a period of severe stuttering. The question of whether we will stutter, under what circumstances, and how severely is determined by the interaction of numerous factors. Each individual's stuttering is influenced by a lifetime accumulation of emotional baggage, which can make it as unique as his or her personality. In the following chapters, we shall examine more closely some of the psychological, neurological, and emotional factors that may affect stuttering.

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CHAPTER 15.

The Valsalva Stuttering System FIRST STEP in the Valsalva-Stuttering Cycle combines a number of THE psychological factors. These include one’s beliefs, expectations of difficulty, fears, and intentions in speaking. They lay the groundwork for the neurological fear reactions, motor programs for effort, and stuttering behaviors that follow. All these elements interact to form what we might call the “Valsalva-Stuttering System.” This system also shows how the psychological elements result in, and are reinforced by, neurological reactions and stuttering behavior. Therefore, it might be considered a supplemental perspective on the Valsalva-Stuttering Cycle that further elucidates the psychological aspects. The interrelationship of these elements is illustrated in the accompanying diagram. The individual parts of this system can be described in greater detail as follows:

Beliefs and Memories Many people who stutter harbor negative or unhelpful beliefs about such things as the difficulty of speech or of certain sounds or speaking situations, the shamefulness of stuttering, and the need to use effort to force out words. Some beliefs are based on memories of personal experiences and the way in which such experiences were interpreted and handled. Others may have been picked up from parents, peers, the media, or other external sources. Here are some examples of typical unhelpful beliefs: • I am a “stutterer.” • Speech is difficult and requires effort. • Certain words, sounds, and speaking situations are especially difficult. • Stuttering is shameful and embarrassing. • It will be terrible if I stutter. • I must try hard not to stutter. • Trying hard will help me force the words out.

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The Valsalva-Stuttering System

Perception of Difficulty As mentioned in the previous chapter, a stutterer’s expectation of difficulty (as well as his beliefs) may be influenced by many factors, both external and internal. Any condition that makes his speech feel more difficult may increase his urge to exert physical effort in an attempt to compensate. These conditions will vary depending on the situation and the individual and may include such things as: • • • • • •

Illness or fatigue; Excitement or anxiety; Emotional conflict or distress; Time pressure; Uncertainty about what to say; and Neurological deficiencies in fine motor control or language processing.

Expectations, Fear, and Excitement Negative beliefs lead to negative expectations. Based on past experiences and the belief that speech is difficult, the person anticipates that he will stutter on certain words or in certain speaking situations. These expectations may be associated with varying degrees of fear. Closely related to fear are feelings of excitement. Both emotions are associated with the release of stress hormones that can make speech more difficult.

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Intentions The negative beliefs, expectations of difficulty, and fears give rise to unhelpful intentions in speaking. As will be explained later in this book, changing one’s intentions may be an important key to overcoming stuttering. Some of the most common unhelpful intentions are: • To “try hard” to say certain words. • To “make a good impression” by trying hard not to stutter. • To show people how hard I am trying to please them. These intentions are associated with a neurological motor program for effort.

Motor Program for Effort In response to the speaker’s intention, the amygdala triggers the release of stress hormones that interfere with the brain’s motor program for saying the word. An effort impulse is substituted for the motor program for voicing the Key Vowel sound. This leads to neurological tuning of the speaker’s Valsalva mechanism to build up air pressure by means of a Valsalva maneuver. Simply stated, Valsalva-stuttering blocks can be viewed as neurological motor programs that manifest the intention to exert effort in trying to say a word. The substitution of a motor program for effort in place of phonation of the vowel sound makes it impossible for the speaker to say the word in question. The speaker may perceive this substitution as a “brick wall” – thereby reinforcing his perception of difficulty even before he tries to say the word.

Valsalva Activation and Stuttering Behavior Because the larynx isn’t ready to phonate the vowel sound, the speech mechanism gets stuck on the preceding sound or glottal stop – repeating, prolonging, or forcing on it as in a Valsalva maneuver. Alternatively, the speaker hesitates or uses avoidance tactics while waiting for the larynx to be ready to phonate the vowel. This experience adds to the speaker’s negative memories and reinforces his negative beliefs, expectations, and fears, thereby perpetuating stuttering.1 1

John Harrison has envisioned stuttering as an interactive system, which he has called "The Stuttering Hexagon." Its six components are speech behaviors, emotions, perceptions, beliefs, intentions, and genetics. Except for the genetic factor, which is constant, each of the other elements reinforces all the others, thereby perpetuating the system. Therefore, a change in only one of these components is not likely to last very long unless the other components are changed also. Harrison, J. C., Redefining Stuttering (formerly entitled How To Conquer Your Fears of Speaking Before People) 12th ed, New York: Nat'l Stuttering Ass'n, 2008.

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CHAPTER 16.

The Psychology of Stuttering of stuttering is complete without accounting for the N OgreatDESCRIPTION variability we see in stuttering behavior—not only between different stutterers, but even within the same individual. My own experience is a good example. Back when I stuttered severely, I often couldn't say a fluent sentence in a one-to-one conversation. However, I could stand before an audience and act out a role with perfect fluency. I could also be quite fluent when making an impassioned argument, or when letting out my anger at someone. At one time, I was both the best and worst speaker in my high school class. Such variables have, in the past, led some experts to conclude that stuttering was a purely psychoneurotic disorder, caused by emotional conflicts or other traumatic events that were repressed into the unconscious mind. This was, in fact, the prevailing view of stuttering from the early twentieth century through the 1960's. Many psychiatrists attempted to explain stuttering solely in Freudian psychoanalytic terms, rejecting any possibility of physiological factors. According to some theories, stuttering was due to an oral fixation, in which the stutterer unconsciously desired to suck or bite as if he were nursing. Others saw stuttering in terms of an anal fixation, reflecting the stutterer's conflict over expelling or retaining words as if they were feces. Still other theories viewed stuttering as an ego-defect neurosis involving certain kinds of conflict, anxiety, and ambivalence engendered by the stutterer's mother. These theories were of little practical value in the treatment of stuttering. Even worse, they did considerable damage by causing stuttering to be lumped into the category of "mental illness," thereby subjecting stutterers to untold prejudice and misunderstanding. Furthermore, they were contradicted by studies that showed stutterers, as a group, to be no more neurotic or emotionally disturbed than the general population. In reaction to the psychoanalytic theories, some experts completely rejected the importance of emotional factors in stuttering. They tried to explain stuttering solely in terms of either (a) learned or conditioned behavior, or (b) physical or neurological defects. It became popular to treat stuttering by various means of behavior modification, on a purely mechanical level. However, these ap-

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proaches were also incomplete. They failed to explain or resolve the psychological and emotional obstacles to fluency, which usually returned soon after the stutterer left the therapist's office. The inescapable conclusion—already mentioned in our previous chapters— is that stuttering arises from the interplay of physiological, neurological, and psychological factors.

Learning and Conditioning To some extent, the perpetuation and entrenchment of the stuttering cycle might be explained in terms of learned or conditioned behavior. It is well known that certain behaviors can be established by a psychological process called conditioning—sometimes referred to as "the carrot and the stick" principle. The basic concept is simple. When a person's behavior is followed by a reward (usually something pleasurable), he will tend to repeat the same behavior in the future. Such a reward is called positive reinforcement. On the other hand, if a particular behavior is followed by a punishment (called negative reinforcement), he will tend to avoid that behavior. Beginning in early childhood, we learn numerous behavior patterns through the everyday operation of conditioning. However, the process sometimes leads to unexpected results, because some kinds of behavior produce both rewards and punishments. Stuttering is a prime example. On the surface, stuttering behavior might be viewed as pure punishment. Stuttering is inherently unpleasant, and it sometimes provokes adverse responses (such as ridicule) from other people. Why, then, don't these negative reinforcements stop us from stuttering? The reason is that, on another level, the stuttering behavior is being strengthened by positive reinforcement. Remember, we entered the speaking situation with the belief that speech would be difficult. We responded to that belief by activating our Valsalva mechanism, in order to "try hard" to force the words out. After the struggle is over, and the words finally get out, our perception is that the obstacle has been overcome, and that the use of force was successful in doing so. Although the stuttering itself was a punishing experience, we are relieved that it's over. In this way, the use of force is rewarded. The combined result of these negative and positive reinforcements is doubly damaging. The negative reinforcement of stuttering teaches us to fear speaking situations and to try to hide our stuttering. This strengthens our belief that speaking will be difficult and will require extra effort. The positive reinforcement of force teaches us to activate our Valsalva mechanism and to use excessive force while speaking. Ironically, our minds tend to view Valsalva tuning and force as our saviors, rather than the culprits they really are!

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Individual Variations The basic stuttering cycle is subject to infinite variations, depending on the unique personality and psychological make-up of each individual. In particular, we all have somewhat different anticipations about the difficulty of speech, based on our own individual histories. As a general rule, we are more likely to anticipate difficulty with respect to those words, situations, and listeners that seemed to cause stuttering in the past. Conversely, we will tend to anticipate less difficulty with respect to situations that have seemed easy and pleasant in the past. Our anticipation of difficulty might be further stirred up by any number of things that remind us of previous stuttering experiences. For example, it could be the ringing of the telephone, some aspect of the listener's appearance or manner, the topic being discussed, or significant details about the surroundings. These and other factors that stimulate the anticipation of stuttering are sometimes called cues. Although we are not always conscious of them, they may affect our speech to a greater extent than we ever realize. Another important factor is the image we have of ourselves as speakers. The very fact that a person believes that he is a "stutterer" may carry with it the anticipation that speech will be difficult. If the person also feels that stuttering is shameful and should be hidden, his urge to use excessive effort in speaking may be further compounded. Unfortunately, it is not always easy to change these beliefs. A person's self-image as a stutterer may become such a fundamental part of his personality that he cannot abandon it without suffering a terrible sense of anxiety or loss. Such feelings can sabotage any attempts at stuttering therapy.

Emotional Conflict Even if we don't buy any of the psychoanalytic theories, we can't rule out emotion as a factor that may sometimes trigger or aggravate stuttering. Emotional conflict, uncertainty, and ambivalence may naturally interfere with anybody's speech. These feelings may be stirred up by various speaking situations, for reasons that are personal to each individual. Like the other psychological factors, they may also be unconscious. For the stutterer, emotional conflicts can be particularly troublesome, because they may further increase the anticipation that speech will be difficult. Therefore, emotional conflicts may serve as a trigger for stuttering. In addition, the struggle of stuttering may serve as a battleground on which the conflicts are then acted out. Through speech, we communicate more than just words. We reach out and touch people with our feelings. However, if we feel so conflicted that we can't express these feelings, we may end up holding back our words also. Conse-

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quently, we may find ourselves in an approach-avoidance conflict in which, on the one hand, we want to express ourselves, but on the other, we are afraid to do so. We may use the Valsalva maneuver as a means of acting out this ambivalence. It is perfectly designed for such a struggle, because it involves two conflicting forces: a physical effort to force air outward, while at the same time an equally forceful effort to hold the air in. In my own case, stuttering was worst when I felt tied up in emotional knots, when I felt confused, conflicted, and uncertain. In contrast, when my emotions all were in harmony and aimed in the same direction, my speech just seemed to flow along with the current. In those cases, I felt less of a need to use extra effort. Therefore, the Valsalva mechanism stayed relaxed, and speech came with less effort and greater fluency.

Secondary Benefits of Stuttering Stuttering is not something that we would consciously choose to do. However, after having been stuck with it for a while, we may have learned ways to turn it to our advantage. As a result, we may be reaping secondary benefits from stuttering that serve to reinforce our continued stuttering behavior. To some people, stuttering becomes a refuge, a convenient excuse for not doing things, not meeting people, not talking on the phone, not subjecting oneself to fearful situations. It can be a rationalization for not taking control over our lives, or for not having achieved all the great things we might have. Through stuttering, we might avoid the fear of expressing ourselves or taking responsibility for our words and thoughts. I myself once fell into this habit. If I had a conflict over what to say, I would just open my mouth and start stuttering. I figured that there was no sense in choosing my words carefully if I wasn't going to be able to say them anyway.

Using Effort To Reduce Anxiety As previously mentioned, using the Valsalva mechanism to exert effort may be reinforced because of its short-term benefit in reducing anxiety, even though it perpetuates stuttering in the long run. In addition to its role in assisting various physical activities, the Valsalva maneuver is a natural defense mechanism. Many animals use it to puff themselves up to look bigger and frighten off enemies. It also stiffens the body to help one strike blows or to defend against attacks. Because this behavior comes so naturally to animals and humans alike, it is understandable that stutterers may find it comforting in fearful speaking situations. All the stutterers with whom I have worked reported that, to some degree, using effort helped them feel less anxious. This was particularly true for those

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who had been criticized for stuttering as children. Using effort may have become a way to show how hard they were trying to please their parents. The display of effort in stuttering may also be calculated to gain pity or indulgence, especially if the listener is an authority figure of some kind. By doing a Valsalva maneuver, or by struggling over our words, we are showing the listener how hard we are trying to talk. The unconscious message might be: "You can't punish me. It's not my fault that I stutter. Look how hard I'm trying to please you!" Although this tactic may seem rather childish, as viewed by an adult stutterer, we must remember that stuttering almost always begins in childhood. Many of us learned as children that "trying hard" is supposed to be good. If we can't do well, at least we can get an "A" for effort. For example, the parents of one of the participants my program had constantly berated him for stuttering. They chastised him for “not trying hard enough” to talk properly. But the harder he tried to stop stuttering, the more he blocked. Because he was not able to please his parents by speaking fluently, all he could do to placate them was to show, through his effortful struggling, how hard he was trying to speak. A variation on this theme is illustrated by the case of a woman who stutters. For many years, her mother had spent considerable time and money trying to help her overcome her severe stuttering. This included a variety of therapies with numerous clinicians and two stints at an intensive precision fluency shaping program. Wanting to please her mother, she tried very hard to succeed at these therapies. When she continued to stutter, both her mother and her therapists exhorted her to “try harder” – which only made her stuttering worse. Even after she learned easy, effortless speech through Valsalva Stuttering Therapy, she had trouble overcoming her urge to use effort when speaking to her mother. This stemmed from her fear that not “trying hard” would be interpreted as a lack of appreciation for all her mother’s efforts.

Funneling Feelings into Force Speech is much more than simply saying words and transmitting information. It is also a means of expressing our feelings. In normal speech, we convey our emotions by changing our emphasis, pitch, and tone of voice as we say the vowel sounds in various words and syllables. Just as in singing, feelings are normally expressed in speech through the phonation of vowels. Stuttering, on the other hand, involves the substitution of a motor program for effort in place of one for the phonation of vowel sounds. Therefore, a person who stutters may have difficulty expressing his feelings through the phonation of vowels sounds. Instead, his feelings must find expression in his efforts to force on consonants and glottal stops and to build up air pressure in

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his lungs. Eventually, force itself may become a habitual means of selfexpression, which further perpetuates stuttering behavior.  In the next chapter, we will further explore the origins of stuttering in childhood and demonstrate how simple disfluencies can develop into struggle behavior and chronic stuttering.

General References BLOODSTEIN, O. A Handbook on Stuttering. 5th ed. San Diego: Singular Publishing Group, 1995, pp. 61-66, 211-237. FREUND, H. Psychopathology and the Problems of Stuttering. Springfield, Ill.: Charles C. Thomas, 1966. GLAUBER, I. P. Dynamic therapy for the stutterer. Specialized Techniques in Psychotherapy. New York: Grove Press, 1952, 207-238. SHEEHAN, J. G. Theory and treatment of stuttering as an approach-avoidance conflict. Stuttering Then and Now (edited by Shames, G.H., & Rubin, H.). Columbus, OH: Charles E. Merrill Publishing Co., 1986, 187-200. TRAVIS, L. E. The unspeakable feelings of people with special reference to stuttering. Emotional factors. Stuttering Then and Now (edited by Shames, G.H., & Rubin, H.). Columbus, OH: Charles E. Merrill Publishing Co., 1986, 93-122. VAN RIPER, C. The Nature of Stuttering. 2nd ed. Englewood Cliffs, N.J.: Prentice-Hall, 1982, pp. 261-322.

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CHAPTER 17.

The Origins of Stuttering

I

N PREVIOUS CHAPTERS, we have viewed stuttering in its fully developed, chronic form. We have seen how our amygdala may trigger the release of stress hormones that substitute effort in place of vowel phonation when we anticipate trouble speaking, resulting in stuttering blocks. We have seen how a combination of physical, neurological, and psychological factors might reinforce one another to create a Valsalva-Stuttering Cycle that perpetuates this behavior. These are the factors we must understand if we are to control our stuttering as it exists now. From a practical standpoint, they are probably all that really matter. However, they do not necessarily explain how or why we began stuttering in the first place. To discover the origins of stuttering, we must delve into deeper waters. Many possibilities must be explored: genetic factors, neurological factors, emotional factors, learned behavior, temperament, delays in speech development, parental attitudes toward speech, and so on. Although researchers have shed some light into these areas, the waters are still quite murky. There is no simple answer to why stuttering begins. The precipitating factors may be different for each individual. Their commonality is that they all contribute, in some way, to the feeling that speech is difficult and requires effort. At the outset, we must distinguish between two types of stuttering with clearly different origins: acquired stuttering and developmental stuttering.

Acquired Stuttering In a relatively few cases, the onset of stuttering can be traced to some kind of physical injury to the brain itself—perhaps caused by a blow to the head, a stroke, or other illness. This may occur at any age and is called acquired stuttering. How brain damage may cause stuttering is not yet clear. Somehow, the brain's ability to select words or to produce speech might be physically disrupted, making speech more difficult. The person may adopt various struggle behaviors—including activation of the Valsalva mechanism—in an attempt to overcome the difficulty and force the words out. In this respect, the person with acquired stuttering may exhibit some of the same behaviors as other stutterers, even though the underlying cause of the disfluency is distinctly different.

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Under extreme circumstances, stuttering might also begin at any age following a stressful or emotionally traumatic event, as sometimes happens to soldiers in battle. The adults who experience this may have had a previous history of stuttering when they were children.

Developmental Stuttering The vast majority of stuttering does not involve any physical injury or severe emotional trauma. It just seems to arise of its own accord, for no particular reason. Because this kind of stuttering is often connected with the development of speech and language skills, some experts have called it developmental stuttering. This is the kind of stuttering to which this book is devoted. Developmental stuttering usually begins in early childhood. At least 85 per cent of all cases begin between ages 2 and 8, with most starting somewhere between ages 3 and 5. The onset usually progresses from simple disfluencies into more advanced forms of struggle and avoidance behaviors.

Simple Disfluencies A stutterer's first disfluencies are not usually what we would call stuttering. They are more like the simple disfluencies that many children exhibit during their speech development. The child may hesitate, interject fillers like "umm" and "aah," and repeat whole words or phrases. He may say, for example, "Pass . . . pass . . . pass the potatoes." Although the child is not totally fluent, he is not really stuttering either. He does not try to force out his words by using the Valsalva mechanism. His repetitions are easy, without the physical struggle and avoidance tactics usually seen in stuttering behavior. Such disfluencies often occur when increased demands are placed on a child's speech and language abilities. Although he may have achieved fluency with simpler forms of speech, he is now confronted with longer words, more complicated sentence structure, complex rules of grammar and etiquette, and more difficult speaking situations. In addition, he must deal with subtle nuances of speech, such as inflection and intonation, that convey meanings beyond the words themselves. The child, for whatever reason, may not be ready to meet these demands. It may take him a while to choose his words and to link them together in a grammatical sentence. While groping for words, he may fill in the gaps with interjections and repetitions to show that he hasn't stopped Talking. (The same tactics are often used by normal adult speakers. Imagine, for example, a person trying to converse in a foreign language with which he is not totally familiar.)

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In most children, these simple disfluencies are not viewed by the parents as being any cause for alarm. The disfluencies normally decrease as the child becomes more experienced in speaking. In other children, however, they may be more frequent and troublesome. There are several possible reasons for this. Neurological factors. Some children may be delayed in their speech and language skills for various neurological reasons. For example, the speech centers of the brain may not have developed as quickly as in other children. The child may be slow in achieving the fine muscle coordination needed for speech. Consequently, his capacity for speech production may not be equal to the demands being made. Studies show that stuttering children had been slower in their speech development, on average, than non-stuttering children. But this is not true of all children who become stutterers. For example, the records of my childhood indicate that I had been quite advanced in my speaking skills before becoming disfluent. Emotional factors. It is possible that the original disfluencies may have been triggered by anxiety or stress. Disfluency may appear, in some cases, after an emotionally disturbing event, going to a new school, a death or illness in the family, being left by parents with relatives or caretakers, marital discord between the parents, or other disruptions in the household. My own stuttering began during a time of stress at age 4, when my father was in the Army and my mother and I were forced to live with numerous relatives at my grandmother's house. Disfluency may also increase when the child is excited. Excitement is associated with a stress reaction similar to that related to fear. Attitudes about speech. A child's difficulties can be aggravated if his parents or other adults put too much emphasis on the ability to speak well. In my own childhood situation, some of the grown-ups in the household had a habit of nitpicking at my speech. I was routinely scolded for bad grammar, using contractions (like "don't"), talking too loudly, or being rude. I lived in constant fear of "saying the wrong thing," and was warned that "a word once spoken can never be taken back." Speaking had all the perils of walking through a minefield.

The Progression of Stuttering Some experts feel that the development of stuttering may be related to the child's inability to speak as well as his parents and other adults expect. If the disfluencies are felt to be excessive, the adults may show distress, annoyance, or concern. Studies show that parents have a tendency to speak more rapidly to a disfluent child and to interrupt him more often than other children. The child may sense that his repetitions and interjections are slowing things down and making the adults impatient. Therefore, he may shorten and speed up his repetitions in an eagerness to get the words out more quickly. Starting with

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slower, less forceful repetitions of longer units (whole words), he may progress to more rapid repetitions of shorter units (part-words and beginning sounds) with more force. (This is described by Starkweather, 1987.) For example, instead of repeating the whole word "pass," the child may repeat only the first consonant and vowel, so it comes out, "Pa . . . pa . . . pa . . . pass the potatoes." As the child further shortens the repeated unit and speeds up the repetition, he will begin to say, "Puh-puh-puh-pass." Notice how the proper vowel (/æ/) has been replaced in the repeated segment by “uh” (/ə/). This is known as the schwa. It is a neutral sound that comes out when we are not trying to pronounce any vowel in particular. The next step would be to drop the schwa and simply repeat the consonant very rapidly, as in "P-p-p-p-pass." This progression can go still further by focusing on even smaller parts of the consonant itself. For example, the p sound is formed by (1) closing the lips to cause a slight build-up of air pressure; and then (2) opening the lips to release a puff of air. The child may repeat only the closure part of the consonant, without the release, resulting in a prolonged blockage of air.

Air Pressure and Force This scenario shows how slow, easy repetitions of whole words can progress into rapid repetitions of smaller units and finally into a forceful closure. While the child's original motive may have been to produce the words more quickly, what actually results is a tendency to build up air pressure and to increase the amount of force. In the word "pass," for example, the greatest air pressure is concentrated on the initial plosive, p. When the plosive is released, the air pressure decreases. However, if you skip the rest of the word and repeat the p sound rapidly, the air pressure will continue to build up. The more rapid the repetition and the smaller the segment being repeated, the more air pressure is sustained. During a prolonged closure, the air pressure would be greatest of all. The same is true when the child repeats the glottal stop (ʔ) preceding an initial vowel sound (as in ʔapple). As previously discussed, we typically close the vocal folds and false vocal folds to block air flow before an initial vowel. We let the air pressure build up slightly and then release it, in order to accentuate the beginning of the vowel sound. Here the air pressure is built up by closure of the larynx instead of the mouth. During this progression, the child may learn to associate the feeling of air pressure with his efforts to get the words out. This is where the body's Valsalva mechanism comes into play. It is specifically designed to build up air pressure in the lungs by tightening the chest and abdominal muscles, while forcefully

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closing the mouth or larynx to keep air from escaping. The greater the air pressure, the more forcefully the mouth or larynx closes. This process is the Valsalva maneuver, with which we are now familiar. Since it is the same maneuver that the child previously relied upon to help him in defecation and other types of physical effort, it is highly plausible that he would use it in his attempt to force out words. As a result, the Valsalva mechanism would increase the force with which he closes his mouth or larynx, as well as the amount of air pressure. It would give him the illusion that he is "trying hard" to produce the words and to please his impatient parents and other adults. Once the Valsalva mechanism gets involved, the child's disfluency takes on a whole new character. As we have seen, the neurological tuning of the Valsalva mechanism may interfere with the ability to phonate vowel sounds and may increase the likelihood of excessively forceful closures of the mouth and larynx. Therefore, the harder he tries to force the words out, the more his speech is blocked. Unlike the earlier disfluencies, the child's stuttering is now more likely to become focused on specific words or speaking situations. He will learn to anticipate difficulty and to activate the Valsalva mechanism in order to force the words out, resulting in the very difficulty he feared. He may then adopt various secondary behaviors in an attempt to avoid, postpone, break through, or hide the stuttering blocks. Before long, the child may find himself caught in the Valsalva-Stuttering Cycle previously described. This will tend to perpetuate the stuttering indefinitely, even if the original cause for the disfluency disappears.

The Crucial Question of Recovery It is estimated that approximately four to five per cent of children stutter at some time during childhood. However, it is estimated that about 80 per cent of them will become reasonably fluent by the time they reach age 16, even without therapy. This is called spontaneous recovery. Some experts have suggested that the crucial difference between stutterers and and non-stutterers may not lie so much in the original disfluencies or stuttering, but in the capacity to recover from stuttering. Some studies have shown that 75 per cent of those stuttering at age 4 and 50 per cent of those stuttering at age 6 will be better by age 16. However, if the child is still stuttering at age 10, his likelihood of spontaneous recovery drops to only 25 per cent. There seems to be a crucial period between ages 5 and 7 during which speech patterns become fixed. If a child continues to stutter during this period, the stuttering behavior will become firmly established and difficult to change. Therefore, stuttering should be treated as soon as possible, before it passes this critical phase.

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The ability to recover from stuttering may also vary according to sex. Some studies indicate that the simple disfluencies of early childhood are almost as common among girls as among boys. However, the girls are more likely than boys to recover. (It is also interesting to note that girls who are right handed are more likely to recover than girls who are left handed.) When we come to chronic stutterers, males greatly outnumber females by estimated ratios of at least four to one. Is there a way to predict which stuttering children will recover and which will persist in stuttering? Researchers exploring this question have suggested various neurological and psychological possibilities. But the difference I found most revealing is based on the child’s temperament – a trait that tends to be inherited. In comparing the two groups of children, researchers found that those who persisted showed a higher degree of emotional reactivity and a lower degree of emotional regulation than those who recovered. Other research has suggested that children who persisted in stuttering tended to be more perfectionistic. I could venture a guess as to how these traits might contribute to the persistence of stuttering. Both groups may have been disfluent because their ability to process speech had not fully developed. However, the children who persisted may have reacted more strongly to the fact that they were not able to speak as well as other people. Out of frustration, they may have developed the habit of using physical effort in trying hard to force out the words. This may have led to development of strong nerve pathways connecting speech and the Valsalva mechanism. As a result, their reliance on Valsalva maneuvers for speaking could have taken on a life of its own, which persisted even after their actual speech-processing ability had matured. Meanwhile, the other children may not have been as reactive to their disfluency. Therefore, they did not get trapped in the Valsalva-Stuttering Cycle and simply allowed their speech processing to gradually develop in a natural way.

Sex Differences and the Valsalva Mechanism What can account for the striking disparity between males and females in the prevalence of stuttering? Is there some physical, neurological, or behavioral difference that might be responsible? Various explanations have been offered for this differential. Some experts have noted that the predominance of males in stuttering is similar to that found in various neurological disorders, such as Tourette syndrome, autism, ADHD, and dyslexia. This may reflect the male brain’s greater vulnerability to developmental problems in the womb, perhaps due to the effect of testosterone or to an inherent genetic weakness in the male Y chromosome.

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Others have attributed the differential to the general tendency of boys to be slower in their speech development than girls, and therefore more likely to have difficulty in expressing themselves verbally. Or it may be due to a combination of factors. The bottom line is that such factors may increase the likelihood that boys will perceive speech to be more difficult and to require more effort. The Valsalva Hypothesis opens up yet another avenue of investigation, based on the possibility of sexual differences in the Valsalva mechanism. The Valsalva mechanism is common to both sexes. It is particularly important to women during natural childbirth, because the Valsalva maneuver helps to push the baby out of the uterus. However, the Valsalva mechanism seems to have developed to a greater extent in men, possibly because of its use in the kinds of strenuous physical activities that men have traditionally performed. The larynx—a key part of the Valsalva mechanism—is significantly larger in adolescent and adult men than in women, as evidenced by the familiar "Adam's Apple" that bulges out the front of a man's throat. This characteristic allows the larynx to perform effort closure more forcefully during a Valsalva maneuver, so as to retain greater air pressure in the lungs. In view of these physical distinctions in the Valsalva mechanisms of men and women, it would not be surprising to find neurological differences as well. Such differences might exist in children, even before the larynx increases in size during puberty. To the extent that boys are more physically active than girls, they may be more accustomed to performing Valsalva maneuvers while exerting effort. Consequently, boys might have a greater tendency to use the Valsalva mechanism when trying to overcome difficulties in speech.

Genetic Factors There is evidence that stuttering may be linked to genetic factors in at least half the persons who stutter. As will be discussed later, a child is more likely to stutter if he or she has a close relative who does. Also, the correlation of stuttering is much greater between identical twins than between fraternal twins. However, genetic factors are obviously not the whole story. While they may be involved in determining the likelihood of some children stuttering, genetic factors do not seem to have any correlation to how often or how severely a child will stutter. Furthermore, the most significant genetic factors seem to be less related to the original disfluencies than to the question of whether the child will be among the 80 per cent who recover from stuttering spontaneously or among the 20 per cent who persist in stuttering. Assuming that there is a genetic predisposition to stutter, it is not conclusive that the genes will in fact cause stuttering to occur. It is also unclear as to what exactly the genetic tendency would be. Is it a tendency to repeat? To hesi-

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tate? To force? It is not likely that the genetic influence would be that simple, as we shall see. And how might the genetic factors be related to the speech functions of the brain and the ability of a person to recover from stuttering?

Late Onset Stuttering Most models of developmental stuttering assume that it begins in early childhood before speech has fully developed. Certainly, this is true in the vast majority of cases. However, I have encountered a significant number of persons whose stuttering did not begin until they were adolescents. Despite years of speaking fluently and having no history of stuttering, they suddenly began blocking on words. Their onset of stuttering typically happened while reading aloud in class. Although reading aloud had not previously been a problem, one day – for no apparent reason – they found themselves struggling to get the words out. In another case, a woman’s stuttering began when she blocked on a friend’s name when asking to speak to her on the telephone. These persons found such experiences to be extremely upsetting and frightening. Before long, the stuttering blocks spread to their speech in general. In their panic, they soon began to exhibit all the effortful behaviors associated with developmental stuttering. Might the speech-blocking be due to an error in the “pruning” of nerve connections in the brain, which routinely occurs during adolescence? Might blocking be caused by increased levels of dopamine in the brain, or by other chemical and hormonal changes? Could it be related to the onset of social anxiety, which reportedly happens around the same time? I have asked several wellrespected experts how this late-onset stuttering could be explained, and none of them had an answer. These and other questions will be explored in subsequent chapters.

General References AMBROSE, N. G., COX, N. J., & YAIRI, E. The genetic basis of persistence and recovery in stuttering. Journal of Speech, Language and Hearing Research, 1997, 40, 56780. AMSTER, B.J. & KLEIN, E.R. The impact of perfectionism on stuttering. More Than Fluency: the Social, Emotional, and Cognitive Dimensions of Stuttering. San Diego: Plural Publishing, 2018. ANDREWS, G., CRAIG, A., FEYER, A., HODDINOTT, S., HOWIE, P., & NEILSON, M. Stuttering: a review of research findings and theories circa 1982. Journal of Speech and Hearing Disorders, 1983, 48, 226-246.

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BLOODSTEIN, O. A Handbook on Stuttering. 5th ed. San Diego: Singular Publishing Group, 1995, pp. 105-272, 359-392. BLOODSTEIN, O. & RATNER, N.B. A Handbook on Stuttering. 6th ed. Clifton Park, NY: Delmar, 2008, pp. 30-38, 92-105. FINK, B. R. The curse of Adam: Effort closure of the larynx. Anesthesiology, 1973, 39, 325-327. JOHNSON, W., ET AL. The Onset of Stuttering. Minneapolis: University of Michigan Press, 1959. JOHNSON, W., ET AL. A study of the onset and development of stuttering. Stuttering Then and Now (edited by Shames, G.H., & Rubin, H.). Columbus, OH: Charles E. Merrill Publishing Co., 1986, 125-129. PETERS, T. J., & GUITAR, B. Stuttering: An Integrated Approach to Its Nature and Treatment. Baltimore: Williams & Wilkins, 1991, pp. 43-107. SMITH, A. Factors in the etiology of stuttering. Research Needs in Stuttering: Roadblocks and Future Directions. ASHA Reports, 1990, 18, 39-47. STARKWEATHER, C. W. Fluency and Stuttering. Englewood Cliffs, N.J.: Prentice-Hall, 1987, pp. 37-47, 137-167. TUMANOVA, V., WILDER, B., ET AL. Emotional reactivity and regulation in preschoolage children who do and do not stutter: evidence from autonomic nervous system measures. Front. Human Neuroscience, 2020, Dec. 16. VAN RIPER, C. The Nature of Stuttering. 2nd ed. Englewood Cliffs, N.J.: Prentice-Hall, 1982, pp. 58-110. YAIRI, E., AMBROSE, N. G., & COX, N. J. Genetics of stuttering: a critical review. Journal of Speech and Hearing Research, 1996, 39, 771-84.

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CHAPTER 18.

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UR SEARCH FOR THE ORIGIN of stuttering ultimately leads to that infinitely complex and mysterious organ, the brain. Here are located the processing areas that translate words into detailed motor programs for speech, as well as the command centers that activate the appropriate muscles of the larynx, mouth, and respiratory system. This is also where the plans go awry— where phonation is supplanted by Valsalva tuning and excessive force, and where fluency is replaced by stuttering. How and why might this happen? Is there something peculiar about a stutterer's brain that creates a tendency to stutter? Are there physical or neurological factors that make it difficult for the stutterer to overcome the disfluencies of early childhood, as discussed in the previous chapter? To help us explore these questions more fully, we will quickly review the brain's structure and its areas devoted to speech and language.

Brain Matter Our brain is an intricate network of more than 100 billion nerve cells, called neurons. They come in many varieties, designed for particular purposes. Basically, each neuron has a cell body covered with hundreds or even thousands of branching fibers called dendrites. These are lined with little bulbs, called spines, which receive signals from other neurons. The neuron also has a long fiber called an axon, through which it sends impulses to other neurons. The axon is often covered with a fatty sheath called myelin, which helps to speed up the transmission of nerve impulses. Because the myelin is white in ap-

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pearance, those portions of the brain that carry many axons are called white matter.

The areas containing a heavy concentration of nerve bodies and dendrites are called gray matter. Each axon has many branches at its far end, which connect to the spines on the dendrites or neurons. The connection is called a synapse. The brain may have as many as one quadrillion synaptic connections in all. Inside the neuron, signals travel as electrical impulses. But when they get to a synapse, the signals have to cross a synaptic cleft, which is about a millionth of an inch wide. Here the signal is passed along by means of special chemicals, called neurotransmitters. These chemicals are released by a specialized knob called a synaptic terminal, located at the end of the axon branch. The chemicals travel across the synaptic cleft and enter the spines on the receiving neuron. Here they create an electrical charge, which travels to the cell body. When the total signals received by a neuron add up to a certain threshold level, the cell will fire an electrical impulse, which travels down its axon to the synapses where it connects to other neurons. In this way, nerve impulses are relayed from neuron to neuron, throughout the brain and to the muscles of the body. The routes that the impulses follow are called nerve pathways.

Anatomy of the Brain The neurons are organized into a number of larger structures within the brain, each with specialized functions of its own. By far the largest of these structures is the cerebrum, which fills the top of the head. About the size of a small melon, its surface is wrinkled like a walnut's. It is split down the middle

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into two halves, called hemispheres—the left and the right—separated by a deep valley called the longitudinal fissure. The surface of the cerebrum is folded into numerous ridges (gyri) and grooves (fissures or sulci). This design allows a large amount of surface area to be squeezed inside the skull. The surface is covered by a thin layer of gray matter called the cerebral cortex. The cortex contains nerve centers dealing with sight and hearing, voluntary movement, and higher mental functions, including language and speech. Beneath the cerebral cortex are vast areas of white matter, containing bundles of axons that connect the cortex with other parts of the brain and nervous system. These include a bridge of nerve fibers, called the corpus callosum, which connects the two hemispheres. Circling the innermost part of the cerebrum is a group of structures called the limbic system. This area is the seat of our emotions and other basic, animal drives. Beneath this are several masses of gray matter called the basal ganglia. They serve as relay stations for motor impulses passing between the cortex and other areas. Wedged under the back of the cerebrum is a cauliflower-shaped structure called the cerebellum, or "little brain," which helps to coordinate the movements of our body. The brainstem forms the base of the brain. It controls many bodily functions, such as respiration. It also provides a pathway from the brain to the body, since it is the source of the cranial nerves (which operate the mouth and larynx) and it leads to the spinal cord (which controls the respiratory muscles and the rest of the body).

Speech Centers of the Brain The principal centers for speech and language are almost always located on one side of the brain, which is referred to as the dominant hemisphere. This is on the left side in about 95 per cent of all people (including 99 per cent of right-handers and many left-handers as well). Therefore, we shall refer to the left hemisphere as being “dominant” for the purpose of our discussion. Most of the language centers are found in a region along the side of the dominant hemisphere known as the perisylvian zone. This zone contains a number of association areas, where we think about what we want to say and make the initial decision to speak. Another center of particular importance is Wernicke's area, which is located slightly above and behind the left ear. It helps us to understand language and to arrange our thoughts into intelligible words and sentences.

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SPEECH AREAS OF THE BRAIN Once the words have been properly put together in Wernicke's area, the signals travel forward in the brain, along a bundle of nerve fibers called the arcuate fasciculus, to a speech center known as Broca's area. This is located slightly above and to the front of the ear. Here the brain matches up the words with a detailed "motor program" for moving the appropriate muscles of our speech mechanism in just the right sequence. The signals are then sent to the motor cortex, which forms a strip arching over the top of the head. The motor cortex sends signals to the larynx, lips, tongue, and respiratory muscles to prepare for and execute the movements necessary for speech. Assisting in the preparations for speech is a strip known as the premotor area, just in front of the motor cortex, and the supplementary motor area, tucked inside the longitudinal fissure at the top of the head. There is also a small, third speech area, found at the top of the dominant hemisphere, slightly to the front of the motor cortex, called the supplemental speech area. During normal speech, all of these areas seem to interact with and assist one another in the production of speech. The non-dominant hemisphere (usually the right side) may make its own contributions to speech. The right hemisphere contains the area for music. It may supply the musical aspects of our speech—such as intonation, inflection, rhythm, and emotional expression. The right hemisphere may also have a limited amount of language ability. This is particularly true with regard to simple, emotionally charged words—such as the swear words and other exclamations we might utter when emotionally aroused.

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It is interesting to note that persons with severe aphasia, who are unable to speak because of damage to the left hemisphere, may still be able to sing or to shout expletives - indicating that these functions are preserved in the right brain.

The Interaction of Many Parts The production of speech does not simply move through the brain in a linear fashion, like automobiles on an assembly line. It is an organic process in which many parts interact, with each part influencing every other part. Speech also involves many structures in the brain besides the cerebral cortex. The limbic system provides the underlying drives that motivate our speech. The basal ganglia act as relay stations between the association areas and other parts of the brain. In addition, the basal ganglia may facilitate the movements of speech by inhibiting other types of motor activity that might interfere. The thalamus, located in the brainstem, may coordinate the activities of Broca's and Wernicke's areas. Some researchers believe that the thalamus also participates somehow in timing, initiating movement, modulating speech, and controlling respiration. The cerebellum helps to coordinate the rapid and precise movements of articulation, as well as the smooth transition from one position to the next.

The Effect of Experience The brain, unlike a computer, is a living organ. Although the number of brain cells does not increase after early childhood, our experiences and behavior can profoundly affect the number of synaptic connections within the brain— and, consequently, its ability to function. As we engage in new activities, the neurons' dendrites, spines, and synaptic terminals grow and make new contacts. This is particularly important during the early years of life, when the child is learning new skills and the brain is physically growing in size. However, the process continues to some extent throughout our lives. When we first learn a new skill, the neurons grope around, trying to form nerve pathways to those parts of the brain and the body that must participate in the necessary actions. Like explorers cutting a path through the wilderness, the neurons may go through a lot of trial and error as they look for the right connections. As we continue to practice, the nerve pathways become stronger and more efficient. With repeated use, the path becomes a road and then a highway. The more we engage in a particular activity, the more neurons and nerve pathways will become devoted to that type of behavior. Some skills, like riding a bicycle or throwing a ball, may become so habitual that we never forget them. Their nerve pathways are preserved in the network of neurons, axons, and dendrites in some part of the brain. Conversely, an activity that we neglect will have fewer neurons, fewer synaptic contacts, and weaker nerve pathways at its disposal.

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Nerve Pathways and Stuttering The same principle applies to speech. The more we talk, the stronger become the pathways that link the speech centers of the brain and the organs of speech. This fact may have an enormous impact on the speech development of a person who stutters. If a child's early disfluencies inhibit him from talking, his speech experience will be somewhat limited. Consequently, the speech areas of his brain may not develop as fully as in a child who speaks more often. This deficiency would be further complicated if he learns to build up air pressure, by using the Valsalva mechanism, in an effort to force out his words. By repeatedly performing Valsalva maneuvers while struggling to talk, he will establish strong nerve pathways from the brain's speech centers to the Valsalva mechanism. If this behavior continues during the formative years of brain development (especially during ages 5 to 7), these pathways may become permanently ingrained, at the expense of the pathways for phonation and fluent speech. As a result, the speech functions of his brain may remain chronically weak and subject to interference in times of stress. He will have a neurological tendency to tune his Valsalva mechanism, causing difficulty in phonation, excessively forceful closures, and other forms of stuttering behavior. In the next chapter, we shall discuss the question of whether the brain of a person who stutters is somehow different from that of a fluent person. We shall explore the extent to which stuttering may be influenced by heredity or various neurological conditions.

General References BEATON, A. Left Side, Right Side: A Review of Laterality Research. New Haven: Yale University Press, 1985. DIMOND, S. J. Neuropsychology. London: Butterworths, 1980. HOOPER, J. & DICK, T. The Three-Pound Universe. New York: MacMillan Publishing Co., 1986. LOVE, R. J. & WEBB, W. G. Neurology for the Speech-Language Pathologist. Stoneham, MA: Butterworth, 1986. NOBACK, C. R., STROMINGER, N.L., & DEMAREST, R. J. The Human Nervous System: Introduction and Review. 4th ed. New York: McGraw-Hill Book Co., 1991. SCIENTIFIC AMERICAN. The Brain. New York: W. H. Freeman & Co., 1979. THOMPSON, R. F. The Brain: An Introduction to Neuroscience. New York: W. H. Freeman & Co., 1985.

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TUTTERING CANNOT be fully explained by learned behavior or psychological and environmental influences. We must look elsewhere to determine why some people are more susceptible to stuttering than others. Many speech scientists believe that the tendency to stutter is inherited through abnormalities in the structure or chemistry of the brain. This possibility has profound implications for persons who stutter. Many stutterers welcome the idea that stuttering has an inherited, organic basis instead of psychological causes, because it removes the stigma of "mental illness" and personal guilt. Therefore, they can stop blaming themselves for their failed attempts at fluency. The fault lies not in themselves, but in their genes. On the other hand, I find it depressing – and inaccurate – to think of oneself as a helpless victim of an inherited brain defect. The idea that stuttering is totally genetic carries the implication that we can do little, if anything, to alleviate our stuttering. It implies that we can only wait for the scientists to provide us with a “cure” – hopefully within our lifetime – in the form of a drug or “gene therapy” that will magically make us fluent. What makes this dream increasingly problematical is the likelihood that different inherited traits contribute to stuttering in different individuals. I believe it is more helpful – and accurate – to take a balanced view. To begin with, stuttering would not be our "fault," even if we did not inherit it. And even if we did inherit some defect or trait that increased the risk of stuttering, that does not mean we can’t find ways to speak more easily. This chapter will address important questions about the hereditary factor in stuttering and the types of neurological defects that might be involved.

Is the Risk of Stuttering Inherited? The existence of an inherited predisposition toward chronic stuttering has long been supported by genetic studies, which have shown an increased risk among people with close relatives who stutter. On the other hand, approximately one-half of all chronic stutterers have no stuttering relatives—indicating that genetics might not be a factor for those individuals. (However, it is possible that some apparently non-stuttering relatives may have carried genes associated with stuttering, or simply that they were successful in hiding their stuttering.)

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The risk is by far the greatest if the stuttering relative is your identical twin—a person whose genetic makeup is exactly the same as yours. If one identical twin stutters, the chances are at least 58 per cent that the other twin will also stutter. (Some studies report correlations of up to 90 per cent.) In contrast, the correlation of stuttering between fraternal twins (those who are not genetically identical) is only about 13 per cent. These findings must be viewed with caution. To some extent, the prevalence of stuttering within certain families may reflect a similarity of environmental factors and attitudes about speech. This is especially true in the case of identical twins—who are often treated alike and who tend to identify closely with one another. For a truer measure of the genetic factor, we would need to compare stuttering in sets of identical twins who were separated at birth and grew up in different families. In the only such study of which I am aware, the researcher found no correlation of stuttering based on five sets of identical twins who were separated at birth. (Farber, 1981.) Genetic factors may play a greater role in chronic stutterers who are female than in those who are male. When you consider only those chronic stutterers who have relatives who stutter, the male-to-female ratio is only 1.57-to-one (or approximately 60% to 40%), as compared to approximately four-to-one (or 80% to 20%) in the general stuttering population. In contrast, those chronic stutterers who don't have stuttering relatives are overwhelmingly male. (Drayna, et al., 1999.) If the above figures hold true, they indicate that heredity is much more likely to be a factor in female chronic stutterers than in males. Even when genetic factors are present, they do not necessarily condemn us to stutter. Nor do they seem to control how frequently or severely we will stutter. They only increase the likelihood that we will do so. Whether this likelihood actually turns into stuttering may depend on other factors, discussed in previous chapters.

Stuttering Genes Technological advances in analyzing DNA have opened the possibility of finding specific genetic mutations related to stuttering. This quest reached a highly publicized milestone in 2010, when researchers at the United States’ National Institute on Deafness and Other Communication Disorders identified three genes in which mutations were correlated to stuttering in certain Pakistani families. (Kang, et al., 2010; Dryna, et. al., 2011.) Surprisingly, the genes identified – GNPTAB, GNPTG, and NAGPA – are not associated with speech, but rather with the recycling of waste materials in cell bodies. The function of these genes is to direct enzymes to a structure within cells called the lysosome, which acts like a recycling bin.

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Mutations in these genes may prevent the proper enzymes from reaching the lysosome and recycling the waste. As a result, the waste may accumulate and become toxic. This problem has been known to cause a variety of lysosomal storage diseases – some of which are fatal or have serious symptoms. The stutterers in the study did not exhibit the symptoms of such diseases, despite having mutations in those genes. At the time of this writing, the researchers believe that the mutations in stutterers were relatively mild and may have cut the enzymes’ cellular activity only in half. (Kang, et al., 2012.) Although the researchers are unable to explain how a cell recycling problem could result in the symptoms of stuttering, their current guess is that nerve cells in the speech areas of the brain may be particularly sensitive to such metabolic deficits. I would carry this line of reasoning a bit further. If lysosome toxicity causes speech-processing neurons to function less efficiently, this might contribute to a person’s feeling that speech is difficult. As discussed in previous chapters, the perception of difficulty is one of the factors that may trigger the urge to exert effort, causing the brain to create a motor program for effort closure of the larynx, as in a Valsalva maneuver, instead of phonation of the vowel sound. This would result in the neurological “block” – or “brick wall” – and the stutterer’s effortful struggle to break through it. To keep this genetic research in perspective, it should be noted the lead researcher in the Pakistan study has estimated that those three genetic mutations probably account for only about 10 percent of stutterers who have a family history of stuttering. (Drayna, 2012.) Therefore, there are probably many other genes to be identified, whose mechanism in causing stuttering is yet to be determined. And their discovery will still not account for the half of developmental stutterers who have no family history of stuttering. Researchers have also found rare variants in the AP4E1 gene in persistent stutterers in Cameroon, Pakistan, and North America. The AP4E1 gene is a component of intracellular trafficking, with no obvious connection to speech. (Raza, 2015.)

What Traits Are Crucial to Stuttering? Merely saying that we may inherit a "tendency to stutter" leaves many questions unanswered. What exactly is the crucial trait, and how does it promote stuttering? Some people might assume that stutterers simply inherit the outward symptoms of stuttering—for example, the tendency to repeat, to prolong sounds, or to block. This view of stuttering is from the listeners’ perspective. But this type of behavior, in and of itself, is probably not the trait that distinguishes stutterers from other people.

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Stuttering-like disfluencies are not unique to stutterers, and they are not necessarily abnormal. Almost anyone may occasionally hesitate, repeat or prolong sounds, or even block on a word. This behavior is quite common when people are afraid, confused, excited, or struggling to converse in an unfamiliar language. It is often seen in children, during certain stages of speech development. These simple forms of stuttering may simply be a natural reaction to circumstances that interfere with the flow of speech. A more extreme example of this behavior is seen in acquired stutterers— previously normal speakers who suddenly began to stutter after physical damage to the brain, caused by injury or disease. In view of the fact that acquired stutterers generally have no family history of stuttering, they provide dramatic evidence that stuttering-like behavior can exist in anyone—without the need for a genetic factor. The same is probably true of developmental stutterers, who began stuttering as children and then went on to become chronic stutterers as they got older. If they have a genetic defect, it is probably not the stuttering itself, but something less obvious that promotes stuttering. Some experts propose that the trait may involve delays in language development or defects in coordination. Others believe that the fundamental difference between chronic stutterers and non-stutterers is the inability to overcome the early forms of stuttering that most children outgrow. It has been suggested that chronic stutterers may have inherited characteristics that allow stuttering to persist during their formative years and to become deeply rooted in the nerve pathways of speech. As previously noted, the ability to spontaneously recover from stuttering is also related to a child's sex. Although the ratio between boy and girl stutterers is about equal when they are very young, a much higher percentage of the girls recover than boys. Consequently, the boys who persist in stuttering eventually outnumber the girls by a ratio of at least four to one. Those girls who don't recover are more likely to have relatives who stutter.

Does the Stutterer's Brain Have a Physical Defect? Researchers using sophisticated brain-scanning techniques have found various atypical anatomical features in the speech areas of developmental stutterers’ brains. For example, MRI studies found differences in the relative size of stutterers’ planum temporale – a part of the brain associated with auditory processing. (Foundas, 2001.) Other studies have found that developmental stutterers, as a group, tend to have deficiencies in the “white matter” nerve tissue that connects parts of the brain involved in speech. For example, a study using diffusion tensor imaging discovered reduced nerve connections through adult stutterers’ left rolandic operculum. (Sommer, et al., 2002.) An MRI study of boys aged 9 to 12 found

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reduced white matter integrity in the left hemisphere speech system of those who stuttered. (Chang, et al., 2008.) These are only a few of the growing number of studies looking for differences in stutterers’ brains. But keep in mind that such studies do not prove that everyone who stutters has such anomalies. Nor is it always clear whether such differences contribute to stuttering or whether they develop as a result of stuttering. Nevertheless, it is possible that neurological deficiencies, such as poor nerve connections, might slow down speech processing and make speech feel more difficult. This perception of difficulty might increase a person’s tendency to use effort, thereby increasing the risk of stuttering. Furthermore, these neurological deficiencies may make the formation of motor programs for speech less efficient and therefore more susceptible to interference by stress hormones.

Do Stutterers' Brains Function Differently? Another way to search for the distinguishing characteristic is to look for abnormalities in the way a stutterer's brain functions. Brain defects are sometimes indicated by irregularities in the brain's electrical impulses (or "brain waves"), by the amount of blood flow to various parts of the brain, and by its response to various stimuli. Although the studies are often conflicting, some scientists have found evidence that stutterers' brains operate differently than those of normal speakers. Patterns of brain activity. Since the 1980’s, researchers have been using sophisticated diagnostic equipment to produce computerized pictures showing subtle differences in the patterns of activity in stutterers' brains. Many of the earlier studies used a method called positron emission tomography ("PET"). After radioactive tracers are injected into a person's bloodstream, a PET camera is used to detect the emission of positrons (positive electrons) from various parts of the brain. The emission of positrons indicates which parts of the brain are most active, based on such things as relative blood flow or consumption of sugar. More recent studies have used a less invasive method called functional magnetic resonance imaging (fMRI), which relies on the paramagnetic properties of oxygenated and deoxygenated blood. Functional brain scans are first taken of the brain while the person is at rest or performing some baseline mental activity. Then the scans are taken during or immediately after the performance of specific verbal or auditory tasks. The computer then subtracts out the baseline results to show the relative degree to which various parts of the brain are more or less active as compared to baseline. Although each person's brain scan is unique, the computer combines the scans of numerous individuals to come up with an average group pattern. The computer then compares the group pattern of stutterers with that of non-

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stutterers to show how their brain activity differs during the performance of various tasks. To highlight the differences, the brain scan pictures usually show the relative degrees of activity in contrasting colors. There have been many functional brain scan studies, using different methods, subjects, and equipment, and the results have not been totally consistent. Most studies have shown that stutterers, as a group, had slightly less activity around the speech areas on the left side of the brain and more activity on the right side of the brain, when compared to non-stutterers as a group. While stuttering, the stutterers also had decreased activity in the auditory regions and diffuse over-activity in various motor areas. Many of these abnormalities were reduced or eliminated when stutterers spoke fluently under fluency-enhancing conditions (such as choral reading). Some researchers have focused on an area in the basal ganglia called the left striatum or caudate, which appears to have reduced activity in stutterers during both stuttered and fluent speech. (Wu, Maguire, et al., 1995.) In comparison to non-stutterers, stutterers were also found to have a significantly higher uptake of dopamine (a neurotransmitter) in certain parts of the brain that modulate verbalization. (Wu, Maguire, et al., 1997.) Those researchers have hypothesized that dopamine might be responsible for inhibiting activity in those areas of the brain. The meaning of these findings is uncertain. It is unclear whether differences in brain function were the original cause of stuttering, or whether they are instead the effect of many years of stuttering behavior. It is possible that stutterers' nerve pathways for normal speech are weak because of relative disuse, while the nerve pathways for force and struggle have been strengthened by constant use. If such is the case, it should be no surprise that stutterers have developed inappropriate patterns of brain activity. Hemispheric dominance. In the vast majority of people, the processing of speech is lateralized—that is, concentrated in one hemisphere of the brain or the other. The hemisphere containing the speech center is referred to as being dominant. Using a variety of neurological tests, researchers have found that nearly all right-handers and about two-thirds of the left-handers have their speech centers on the left side of the brain. In other people (primarily lefthanders), speech processing may be either on the right side or on both sides—a condition known as bilateral speech. According to some studies, a majority of stutterers show evidence of bilateral speech. In fact, the amount of speech activity in the right hemisphere seems to increase in proportion to the severity of stuttering. It is not known whether a stutterer's bilateral speech is inherited or learned.

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Some studies have shown that when a stutterer becomes more fluent through therapy, the speech activity tends to shift back to the left hemisphere. However, even after intensive fluency shaping therapy, the lateralization of brain function may not be totally normalized. (De Nil, 1998.) These facts have raised speculation that stuttering may somehow result from a lack of hemispheric dominance. The left hemisphere is usually superior in performing tasks that involve a rapid sequence of movements, such as speech. Therefore, some experts say that the left hemisphere must be dominant in order to give proper timing and coordination to the muscles of speech. Even if hemispheric dominance plays some role, the mere presence of bilateral speech cannot be the determining factor in all cases of stuttering. Many stutterers don't have bilateral speech, and the great majority of people with bilateral speech don't stutter. Furthermore, we still must explain the variability of stuttering within each individual. Brain function and emotion. It is also possible that stutterers’ right brain activity might reflect emotional reactions during speech. Brain scans have shown increased activity in the right insula and the anterior cingulate cortex, both of which have strong connections with the amygdala. (Guitar, 2006.) As previously discussed, the amygdala is the repository of fearful memories. It triggers the “fight-flight-freeze” response to fearful stimuli, and it is closely connected with activation of the Valsalva maneuver.

Do Stutterers Have Neurological Deficiencies? Still another approach to finding the inherited defect is to look for deficiencies in the way stutterers perform on various neurological tests. Over the years,

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many researchers have reported that stutterers, as a group, tend to show forthan-average performances on a number of levels. Here are some of the aspects in which differences have been found. Intelligence and language skills. Some researchers tell us that stutterers, on the average, perform significantly worse than the general population on tests of intelligence and language skills. In addition, the risk of stuttering is three times greater than average in the mentally retarded. (On the other hand, stutterers who are in therapy seem to be more intelligent than average.) Some of these findings may come as a shock to people active in the stuttering community, who have nurtured the idea that stutterers tend to be pretty bright. Indeed, some of history's greatest thinkers and writers have stuttered— people like Sir Isaac Newton, Charles Darwin, Sir Winston Churchill, Charles Lamb, Lewis Carroll, and W. Somerset Maugham, to name a few. Clearly, stuttering is not caused by, nor is it a sign of low intelligence. However, it is possible that people of lower intelligence are more prone to delays in language development, which may add to the difficulty of speech and thereby promote stuttering. In other words, these deficits may increase the risk of stuttering, but they certainly are not necessary or determining factors. Reaction speed. Studies show that stutterers are not as quick in their reaction time as non-stutterers. For example, when asked to press a button in response to a signal, stutterers take a few milliseconds longer, on the average, than normal speakers. When a vocal response is required (such as making a vowel sound while exhaling), the delay is even greater. Some speech pathologists interpret these results as indicating a defect in the way a stutterer's brain processes motor commands. These deficiencies are more pronounced in children than adults. Therefore, they may have more to do with the original disfluencies of childhood than with the chronic stuttering of later years. An interesting finding is that adult stutterers, unlike normal speakers, can make a voiced sound more quickly while inhaling than while exhaling. We must look to the involvement of some other factor—such as the Valsalva mechanism—to explain this phenomenon. Coordination and timing of movement. Researchers have tested stutterers' skills in activating and coordinating fine movements, such as rapid finger maneuvers and putting pegs in holes. Again, stutterers don't do quite as well as normal speakers. These results may suggest a neurological deficiency that affects more than just speech. Some researchers have suggested the possibility of weakness in the brain's supplementary motor area. The coordination of a stutterer's speech is, of course, severely disrupted during stuttering. But some speech pathologists report that stutterers continue to show subtle defects in coordination, even when they seem fluent. For exam-

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ple, sensitive instruments may indicate that a stutterer's phonation is slightly delayed or poorly coordinated with airflow and articulation. Other researchers have found no significant abnormalities when stutterers speak fluently. While a slight deficiency in coordination may tend to make speech more difficult, this would not necessarily cause stuttering. Regardless of the neurological deficits that might exist, they obviously can't be so bad if a stutterer is capable of speech that at least sounds fluent. The problem is not that stutterers lack the neurological capacity to coordinate speech, but rather that some force interferes with their ability to do so. Any signs of discoordination in a stutterer's fluent speech might simply indicate a residual amount of interference. The question remains as to what the interfering force is, and why it interferes more at some times than at others. Neuropsychological subgroups. Adding further complexity to the problem is the possibility that neurological weaknesses are not the same in all stutterers. Researchers in Edmonton, Alberta, put stutterers through a battery of neuropsychological tests, which revealed differences not only in the severity of their deficits, but also in the areas of the brain that seemed to be involved. The tests indicated deficiencies in such areas as the brainstem, left midbrain, thalamus, frontal lobes, pre-motor cortex, motor cortex, supplementary motor area, Broca's area, and the right prefrontal area. These were found in varying combinations and degrees, depending on the individual. Although most deficits were found in the left hemisphere, some stutterers had them mainly on the right side and others had them bilaterally. After analyzing the data, the researchers came up with five "clusters" or subgroups of stutterers based on their neuropsychological profiles.

What Is the Answer? Although much is still unknown, we have identified a number of neurological factors that might promote stuttering by increasing the difficulty of speech or by decreasing our control of interfering behavior. In some cases, these factors may have been inherited. Alternatively, they could have resulted from conditions that affected the brain in utero, during childbirth, or thereafter. However, these factors alone do not explain the development of stuttering behavior. As previously noted, the various deficiencies that have been mentioned by the researchers are not found in all stutterers, and they may also be found in persons who don't stutter. For a more complete answer, we must look further. We must consider the ways in which these neurological factors may stimulate and interact with the Valsalva mechanism. In the next chapter, we shall see how a better understanding of the Valsalva mechanism might help us link together the pieces of this complicated puzzle.

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General References AMBROSE, N. G., COX, N. J., & YAIRI, E. The genetic basis of persistence and recovery in stuttering. Journal of Speech, Language and Hearing Research, 1997, 40, 56780. ANDREWS, G., CRAIG, A., FEYER, A., HODDINOTT, S., HOWIE, P., & NEILSON, M. Stuttering: a review of research findings and theories circa 1982. Journal of Speech and Hearing Disorders, 1983, 48, 226-246. BLOODSTEIN, O. A Handbook on Stuttering. 5th ed. San Diego: Singular Publishing Group, 1995, pp. 100-102, 145-210. BLOODSTEIN, O. & RATNER, N.B. A Handbook on Stuttering. 6th ed. Clifton Park, NY: Delmar, 2008. BOBERG, E., EDITOR. Neuropsychology of Stuttering. Edmonton, Alberta: University of Alberta Press, 1993. BORDEN, G. J., BAER, T., & KENNEY, M. K. Onset of voicing in stuttered and fluent utterances. Journal of Speech and Hearing Research, 1985, 28, 363-372. BRAUN, A. R., VARGA, M., STAGER, S., SCHULZ, G., SELBIE, S., MAISOG, J. M., CARSON, R. E., & LUDLOW, C. L. Altered patterns of cerebral activity during speech and language production in developmental stuttering. Brain, 1997, 120, 761-784. CHANG, S-E, ERICKSON, K.I., AMBROSE, N.G., HASEGAWA-JOHNSON, M.A., & LUDLOW, C.L. Brain anatomy differences in childhood stuttering. NeuroImage, 2008, 39, 1333-1344. CONTURE, E. G., SCHWARTZ, H. D., & BREWER, D. W. Laryngeal behavior during stuttering: a further study. Journal of Speech and Hearing Research, 1985, 28, 233240. DE NIL, L. Some thoughts on the multidimensional nature of stuttering from a neurophysiological perspective. Int'l Stuttering Awareness Day 1998 Online Conference, The Stuttering Home Page, URL: www. mankato.msus.edu/dept/comdis/ isad/papers/denil.html. DRAYNA, D. Did Neanderthals stutter? – An update on genetic stuttering research with Dr. Dennis Drayna from the NIH (378). StutterTalk, Podcast 12/15/2012. URL: http://stuttertalk.com/did-neanderthals-stutter-an-update-on-geneticstuttering-research-with-dr-dennis-drayna-from-the-nih-378. DRAYNA, D. & KANG, C. Genetic approaches to understanding the causes of stuttering. J. Neurodev. Disord., 2011, 3(4), 374–380. DRAYNA, D., KILSHAW, J., & KELLY, J. The sex ratio in familial persistent stuttering. Am. J. Human Genetics, 1999, 65, 1473-75. FARBER, S. Identical Twins Reared Apart: A Reanalysis.New York: Basic Books (1981). FOUNDAS, A. L., BOLLICH, A.M., COREY, D.M., HURLEY, M., & HEILMAN, K.M. Anomalous anatomy of speech-language areas in adults with persistent developmental stuttering. Neurology, 2001, 57, 207-215. FOX, P. T., INGHAM, R. J., INGHAM, J. C., HIRSCH, T. B., DOWNS, J. H., MARTIN, C., JERABEK, P., GLASS, T., & LANCASTER, J. L. A PET study of the neural systems of stuttering. Nature, 1996, 382, 158-162.

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FREEMAN, J., & USHIJIMA, T. Laryngeal muscle activity during stuttering. Journal of Speech and Hearing Research, 1978, 21, 538-561. FRIGERIO-DOMINGUES, C., GKALITSIOU, G., ZEZINKA, A., SAINZ, E., ET AL. J. Communication Disorders, 2019, 80, 11-17. GOLDSMITH, M. F. Brain studies may alter long-held concepts about likely causes of some voice disorders. Journal of American Medical Ass'n, 1989, 261, 964-965. GUITAR, B. Stuttering: An Integrated Approach to Its Nature and Treatment, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2006, p.65.. HELM, N. A., BUTLER, R. B., & BENSON, D. F. Acquired stuttering. Neurology, 1978, 28, 1159-1165. JONES, R. K. Observations on stammering after localized cerebral injury. J. Neurology, Neurosurgery & Psychiatry, 1966, 29, 192-195. KANG C,, & DRAYNA D. A role for inherited metabolic deficits in persistent developmental stuttering. Molecular Genetics and Metabolism, 2012, 107, 276-80. KANG C., RIAZUDDIN S., MUNDORFF J., KRASNEWICH, D., FRIEDMAN, P., MULLIKIN J., AND D. DRAYNA. Lysosomal enzyme targeting pathway mutations and persistent stuttering. New England Journal of Medicine, 2010, 362, 677-685. KENT, R. D. Facts about stuttering: neuropsychologic perspectives. Journal of Speech and Hearing Disorders, 1983, 48, 249-255. MATEER, C. A. Neural bases of language. Neuropsychology of Stuttering (Boberg, ed., 1993), supra, 1-24. MOORE, W. H. Pathophysiology of stuttering: cerebral activation differences in stutters vs. nonstutterers. Research Needs in Stuttering: Roadblocks and Future Directions. ASHA Reports, 1990, 18, 72-80. MOORE, W. H. Hemispheric processing research. Neuropsychology of Stuttering (Boberg, ed.), supra, 39-53. PAULS, D. L. A review of the evidence for genetic factors in stuttering. Research Needs in Stuttering: Roadblocks and Future Directions. ASHA Reports, 1990, 18, 34-38. PERKINS, W., RUDAS, J., JOHNSON, L., & BELL, J. Stuttering: discoordination of phonation with articulation and respiration. Journal of Speech and Hearing Research, 1976, 19, 509-522. PETERS, H. F. M. & BOVES, L. Coordination of aerodynamic and phonatory processes in fluent speech utterances of stutterers. J. Speech & Hearing Res., 1988, 31, 352-361. RAZA, M.H., MATTERA, R., MORELL, R., SAINZ, E., RAHN, R., ET AL Association between rare variants in AP4E1, a component of intracellular trafficking, and persistent stuttering. American J. of Human Genetics, 2015, 97(5), 715-725. REICH, A., TILL, J., & GOLDSMITH, H. Laryngeal and manual reaction times of stuttering and nonstuttering adults. J. Speech & Hearing Res., 1981, 24, 192-196. ROSENFIELD, D. B., MILLER, S. D., & FELTOVICH, M. Brain damage causing stuttering. Transactions of the American Neurological Ass'n, 1980, 105, 181-183. SHAPIRO, A. An electromyographic analysis of the fluent and dysfluent utterances of several types of stutterers. Journal of Fluency Disorders, 1980, 5, 203-231.

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SOMMER, M., KOCH, M.A., PAULUS, W., WEILLER, C., & BÜCHEL, C. Disconnecting of speech-relevant brain areas in persistent developmental stuttering. Lancet, 2002, 360, 380-383. STARKWEATHER, C. W. Stuttering and laryngeal behavior: A review. ASHA Monographs, 1982, 21, 1-45. STARKWEATHER, C. W. Fluency and Stuttering, 1987, supra, pp. 143, 159-165, 209-232. VAN RIPER, C. The Nature of Stuttering, 2nd ed., 1982, supra, pp. 323-368. WEBSTER, W. G. Hurried hands and tangled tongues. Neuropsychology of Stuttering (Boberg, ed.), supra, 73-127. WYKE, B. The neurology of stammering. J. Psychosomatic Res., 1971, 15, 423-432. WU, J. C., MAGUIRE, G., RILEY, G., FALLON, J., LACASSE, L., CHIN, S., KLEIN, E., TANG, C., CADWELL, S., & LOTTENBERG, S. A positron emission tomography [18F] deoxyglucose study of developmental stuttering. Neuroreport, 1995, 6, 501-505. WU, J. C., MAGUIRE, G., RILEY, G., LEE, A., KEATOR, D., TANG, C., FALLON, J., & NAJAFI, A. Increased dopamine activity associated with stuttering. Neuroreport, 1997, 8, 767-770. YAIRI, E., AMBROSE, N. G., & COX, N. J. Genetics of stuttering: a critical review. Journal of Speech and Hearing Research, 1996, 39, 771-84. YEUDALL, L. T., MANZ, L., RIDENOUR, C., TANI, A., LIND, J., & FEDORA, O. Variability in the central nervous system of stutterers. Neuropsychology of Stuttering (Boberg, ed., 1993), supra, 129-163. ZIMMERMANN, G. Articulatory behaviors associated with stuttering: a cinefluorographic analysis. Journal of Speech and Hearing Research, 1980a, 23, 108-121. ZIMMERMANN, G. Stuttering: A disorder of movement. Journal of Speech and Hearing Research, 1980b, 23, 122-136. ZIMMERMANN, G., SMITH, A, & HANLEY, J. Stuttering: In need of a unifying conceptual framework. Journal of Speech and Hearing Research, 1981, 24, 25-31.

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CHAPTER 20.

The Brain and the Valsalva Mechanism

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HILE ORDINARY developmental stutterers don't exhibit the kind of brain damage found in acquired stutterers, speech scientists have reported a number of peculiarities in brain structure and in the way their brains function. As discussed in the previous chapter, these findings don't solve the riddle of stuttering, but they do raise many new questions. For example: • Is stuttering simply due to neurological weaknesses in the brain centers for speech, or is it caused by other forces that block an otherwise adequate speaking ability? • Why are stutterers slower than non-stutterers in making voiced sounds, and why can they make a sound faster while inhaling than while exhaling? • Are the abnormal muscle contractions in a stutterer's larynx due to reflexes that are triggered by changes in air pressure? If so, why would this happen only some of the time and not always during speech? • Why do stutterers show unusually high levels of activity in the right hemisphere of the brain while speaking, and what relevance does this have to stuttering? Much more research will be needed before these questions are finally answered. In the meantime, let's see if our Valsalva Hypothesis might suggest some logical explanations.

Weakness or Interference? We have been told that stutterers are slow in starting phonation and poor in coordinating the movements of speech. Based on these and other deficiencies, some experts claim that stuttering is caused by a neurological weakness in our brains' ability to plan or coordinate the movements of speech. But this can't be the whole story. As previously noted, there is considerable overlap between stutterers and non-stutterers: many stutterers are neurologically normal and many persons with neurological deficits don't stutter. Furthermore, it is not clear to what extent the neurological abnormalities are a result of stuttering.

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In addition, we know that developmental stutterers usually have no trouble coordinating the movements of articulation when mouthing words silently or whispering. Many are capable of excellent speech when they are not blocking, and some are quite eloquent when acting out a role on stage. Indeed, our firsthand impression of stuttering is not that we lack the ability to speak, but that our ability is blocked by a force beyond our control. What is the force behind these blocks? According to our hypothesis, it is activation of the Valsalva mechanism, together with suppression of vowel phonation. It is easy to see how this could throw off the timing and coordination of speech. When the Valsalva mechanism is activated, our body is neurologically programmed to perform a Valsalva maneuver—to build up air pressure, not to speak. Even when we seem to be fluent, there may still be some degree of interference, which could account for the slight delays that some researchers have detected in stutterers' fluent speech. Therefore, these symptoms would not necessarily indicate a defect in the speech mechanism. Even when neurological weaknesses do exist, they are probably not enough, by themselves, to block speech in the typical developmental stutterer. However, they may render the brain’s motor programs for speech more susceptible to interference. By making speech more difficult, these weaknesses may also increase a person's tendency to activate the Valsalva mechanism in an attempt to "force out" the words. Therefore, neurological weakness may be one of many factors contributing to the anticipation of difficulty, which is Step 1 of the Valsalva-Stuttering Cycle. These weaknesses would not necessarily compel a person to stutter; they would simply increase the likelihood of stuttering.

Delays in Vocal Reaction Time As discussed in the previous chapter, tests show that stutterers generally have slower reaction times than non-stutterers. This is particularly true in making a voiced sound in response to a signal. However, when the test subjects were asked to make a voiced sound while inhaling, the stutterer-nonstutterer difference in vocal reaction time was cut in half. Stutterers could make a sound faster while inhaling (called inspiratory phonation) than while exhaling (expiratory phonation), whereas non-stutterers were faster at the usual expiratory phonation. (Reich, et al., 1981.) Why should stutterers' vocal delay be greater while exhaling than while inhaling? The Valsalva mechanism provides a possible answer. During the tests involving expiratory phonation, the subjects were asked to inhale and to hold their breath while waiting for the signal. This was done by closing the larynx, causing a build-up of air pressure. If the stutterer's Valsalva mechanism were overly active, the increased air pressure may have stimulated

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the larynx to continue the blockage of air, as in a Valsalva maneuver. In other words, the larynx would have been neurologically prepared to perform effort closure rather than phonation. As a result, the larynx may have needed additional time to readjust for phonation, thus prolonging the stutterer's vocal reaction time. In contrast, you can't perform a Valsalva maneuver while you're inhaling, because then the lungs are expanding, have negative air pressure, and are sucking the air inward. Consequently, during the tests using inspiratory phonation, there would have been no increase in air pressure, no tendency to activate the Valsalva mechanism, and no interference with phonation. This explanation is consistent with reports that stutterers speak more fluently while inhaling. Therefore, a significant part of an adult stutterer's vocal delay may be a neurological effect of the Valsalva mechanism.

Laryngeal Reflexes Several researchers have linked stuttering to abnormal muscle contractions in the larynx that are inconsistent with phonation. These may include forceful closures of the airway, excessive muscular activity, and simultaneous contractions of opposing sets of muscles. Some experts have suggested that these may be involuntary reflexes that are stimulated by the increases in air pressure that occur during speech, and that the stutterer's brain may be deficient in its ability to suppress these reflexes. However, we know that air pressure always increases during speech (for example, when we momentarily block airflow to articulate consonants), and yet developmental stutterers only stutter some of the time. Why should increases in air pressure trigger abnormal reflexes in some instances but not in others? The Valsalva mechanism could account for this variability because it would be activated to a greater or lesser degree depending on our anticipation of difficulty. When the Valsalva mechanism is activated, the larynx is neurologically programmed to block the upper airway as part of a Valsalva maneuver. Certain laryngeal muscles will be ready to contract automatically in response to increased air pressure, in order to perform effort closure. The greater the air pressure during a Valsalva maneuver, the tighter the larynx closes to hold it in. The result would be a laryngeal block, such as those encountered on initial vowel sounds. The Valsalva Hypothesis might also help to explain the other kinds of abnormal laryngeal behavior as well. It is possible that, while the stutterer is blocking in the mouth, the larynx is simply reacting to that struggle. However, the Valsalva mechanism might also contribute to laryngeal reflexes in other ways—either (1) by increasing the strength of reflexes, or (2) by interfering with the normal suppression of reflexes during speech.

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The Valsalva maneuver is already known to strengthen certain reflexes. For example, I have seen doctors tell patients to do the hand-pulling exercise, previously described, in order to enhance the knee-jerk reflex. Both Valsalva maneuvers and stuttering blocks have been shown to increase a neurological reaction known as the "H-reflex." (Lastovka, 1970.) Therefore, it is conceivable that activation of the Valsalva mechanism could heighten laryngeal reflex activity as well. The second possibility is that Valsalva tuning may prevent the nervous system from suppressing the reflexes that interfere with speech. Neurological studies have shown that reflex activity (as measured by the H-reflex) is lower during fluent speech than when we are at rest. (Lastovka, 1970.) The "tuning down" of potentially disruptive reflexes may be a vital part of our preparation for speech. This process may get short-changed if we "tune up" the Valsalva mechanism instead.

Right Brain Involvement As we have discussed in the previous chapter, the vast majority of people process speech almost entirely in the left hemisphere of the brain. In contrast, it has been reported that most stutterers tend to use the right hemisphere also (the condition known as “bilateral speech”). As previously noted, the amount of speech activity in the right hemisphere seems to increase with the severity of stuttering and to decrease when stutterers become more fluent through therapy. Why should it matter which side of the brain we use while talking? To begin with, the two hemispheres are usually not the same. Each is specialized to perform in a different way. The left hemisphere is superior in performing tasks that involve a rapid sequence of movements, such as speech. The right hemisphere, on the other hand, is slower, more "holistic" in its approach to tasks, and better at dealing with objects and spatial relationships than with words. Experts have proposed a number of explanations relating stuttering to bilateral speech. Some say that the left hemisphere must be dominant in order to give proper timing and coordination to the muscles of speech. Another theory is that the right hemisphere is more "emotional" than the left. Therefore, when the stutterer splits his speech processing between both sides of the brain, he increases the risk that his speech will be disrupted by emotional factors in the right hemisphere. One researcher has hypothesized that stutterers may have a "fragile" supplementary motor area that is disrupted by emotional overflow from the right hemisphere. (Webster, W.G., 1993.) We shall now propose an additional answer: that certain characteristics of the right hemisphere may increase a stutterer's tendency to activate the Valsalva mechanism when he anticipates difficulty in speaking.

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Because the right hemisphere is more adapted to dealing with objects, it may view words as being things that can be forced out with the same kind of physical effort that is assisted by a Valsalva maneuver. When the person feels that speech will be difficult, the right hemisphere may try to supply extra effort by activating the Valsalva mechanism. It is hard to say which would have come first—the stutterer's use of the right hemisphere or his use of the Valsalva mechanism while speaking. Lateralization of brain functions develops gradually through childhood and may be influenced by learning. It is possible that stutterers have simply learned to process speech in ways that use the right brain's particular functions—such as viewing words as "things" rather than sequences of movement. Research at Vanderbilt University indicates that, between the ages of 3 and 5, non-stuttering children learn to process words as individual sounds (called "incremental processing"). In contrast, children who stutter continue to process words as a whole ("holistic processing"). Byrd, Conture, & Ohde, 2007. These findings may lend support to our suspicion that people who stutter tend to treat words as "things" rather than as sequences of movement. When, through therapy, a stutterer learns to approach speech as a timerelated sequence of movements, he would be turning more to the special skills of the left hemisphere. The left side would then appear to be more dominant.

The Valsalva "Switch" Even on the most fluent of days, we may feel that stuttering is "out there" somewhere, ready to pounce. We can be fluent at one moment and blocked the next. What can explain the swiftness with which our speech can change? Is there some kind of "switch" in the brain that quickly turns on the Valsalva mechanism? Unfortunately, there hasn't been much research into how the brain triggers a Valsalva maneuver. However, fMRI studies have indicated that, when ordinary persons voluntarily perform a Valsalva maneuver, the first part of the brain to be activated is the amygdala. (Henderson, et al., 2002.) Brain chemistry. As previously discussed, the amygdala consists of two little almond-shaped structures that store fearful memories and that initiate the “fight-flight-freeze response” when danger is perceived. This reaction releases approximately 30 stress hormones into the brain and body to prepare us to react quickly to threatening situations. For example, we are all familiar with the sudden rush of adrenalin we feel when confronted with frightening circumstances. The heart pumps faster, our breathing is faster and deeper, our rectal muscles tighten, and many other physiological changes occur.

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After years of research, scientists have found that this reaction is triggered by a chemical released by the brain's hypothalamus. This chemical travels to the pituitary gland, causing it to release a stress hormone into the bloodstream, which in turn stimulates the adrenal glands to pump adrenalin into the blood to stimulate the body to react to the emergency. The Valsalva maneuver is such a common and instinctive behavior that it would not be surprising to find that it also had a chemical trigger. Such a chemical might be released when a person anticipates the need to use strenuous physical effort, or when the stutterer feels he must try hard to force out words. The discovery of such a chemical might lead to the development of other chemicals to counteract its effects, opening up new possibilities for an "anti-stuttering pill." Alternative nerve pathways. We might also view the problem in terms of alternative nerve pathways in a stutterer's brain. As we have previously discussed, the neurons in the brain connect with other neurons to form nerve pathways for various kinds of activity. These pathways may link up with other pathways to form complex circuits and networks. Some types of behavior may be served by multiple pathways. It is possible that a stutterer's brain contains a number of different pathways for speech—including separate pathways for fluent speech and for stuttering. These pathways might follow different routes through the brain. Perhaps some go through the right hemisphere and others don't. Some might be linked to circuits that activate the Valsalva mechanism, while others aren't. Consequently, some of the pathways may lead to fluency, while others may lead to the Valsalva mechanism, resulting in excessive effort and force, interference with phonation, and other stuttering behavior. When we anticipate difficulty in speaking, the previously described fear reaction may switch us from a fluent pathway to one connected to the Valsalva mechanism. The more we use such a pathway, the stronger and more habitual it becomes. Where in the brain might this switch be located? We have already discussed the possible triggering effect of the amygdala. However, we might also want to consider the influence of other brain structures, such as the basal ganglia. The basal ganglia receive emotional inputs from the brain's limbic system. They are also involved both in turning on (through the thalamus) the appropriate parts of the cerebral cortex for speech and voluntary movement, and in turning off those bodily reflexes that might interfere with intended actions. The hypothalamus is already known for its ability to trigger rapid physiological changes in response to fear.

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The Need for Research Testing the Valsalva Hypothesis will require extensive research into the relationship between stuttering and the Valsalva mechanism—an area that has been virtually ignored by speech scientists. Because stuttering is not always accompanied by effort closure in the larynx (as would be expected in a typical Valsalva maneuver), researchers may have simply assumed that the Valsalva mechanism was not involved. They apparently overlooked the possible role of Valsalva tuning in causing forceful closures of the mouth, interference with the phonation of vowel sounds, and increases in reflex activity. There have been some studies in which voluntary Valsalva maneuvers and stuttering blocks were compared. For example, a series of studies done in Czechoslovakia compared the effect of a Valsalva maneuver with that of a stuttering block on one type of neurological measurement, the "H-reflex." (Lastovka, 1970, 1979a, 1979b.) While both increased this reflex, the effect of the stuttering block was somewhat greater, leading the researchers to attribute this increase to emotional factors. Until researchers come up with a better explanation, the Valsalva Hypothesis provides a useful model of stuttering that fits together not only the scientific findings, but virtually all the symptoms that stutterers personally experience. I have found it to be of tremendous value not only in my own case, but also in providing effective therapy to others who stutter. All the participants in the Valsalva Stuttering Therapy program have agreed that it accurately describes their own experience of stuttering and is the only explanation they have encountered that makes sense. Now that we have discussed the possible causes of stuttering, we shall examine, from the perspective of the Valsalva Hypothesis, certain conditions and techniques that seem to enhance fluency.

General References BEATON, A. Left Side, Right Side: A Review of Laterality Research. New Haven: Yale University Press, 1985. BOBERG, E., EDITOR. Neuropsychology of Stuttering. Edmonton, Alberta: University of Alberta Press, 1993. BYRD, C., CONTURE, E., & OHDE, R. Phonological priming in young children who stutter: Holistic versus incremental processing. American Journal of SpeechLanguage Pathology, 2007, 16, 43-53. HENDERSON, L.A., MACEY, P.M., MACEY, K.E., FRYSINGER, R.C., WOO, M.A., HARPER, R.K., ALGER, J.R., YAN-GO, F.L. & HARPER, R.M. Brain responses associated with the Valsalva maneuver revealed by functional magnetic resonance imaging. J. Neurophysiology, 2002, 88, 3477-3486.

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LASTOVKA, M. The monosynaptic spinal cord reflex activity changes in stuttering. Folia Phoniatrica, 1970, 22, 129-138. LASTOVKA, M. Influence of some psychopharmaca on the increase of the amplitude of electrically induced monosynaptic spinal cord reflex during the paroxysm of stuttering: I. effect of diazepam. Folia Phoniatrica, 1979, 31, 15-20. LASTOVKA, M. Influence of some psychopharmaca on the increase of the amplitude of electrically induced monosynaptic spinal cord reflex during the paroxysm of stuttering: II. effect of chlorpromazine. Folia Phoniatrica, 1979, 31, 21-26. NOBACK, C. R., STROMINGER, N.L., & DEMAREST, R. J. The Human Nervous System: Introduction and Review. 4th ed. New York: McGraw-Hill Book Co., 1991. REICH, A., TILL, J., & GOLDSMITH, H. Laryngeal and manual reaction times of stuttering and nonstuttering adults. Journal of Speech and Hearing Research, 1981, 24, 192-196. WEBSTER, W. G. Hurried hands and tangled tongues. Neuropsychology of Stuttering (Boberg, ed.), supra, 73-127. WYKE, B. The neurology of stammering. Journal of Psychosomatic Research, 1971, 15, 423-432.

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CHAPTER 21.

New Perspectives on Fluency Techniques

A

MONG THE MOST INTRIGUING characteristics of developmental stuttering is its tendency to disappear, as if by magic, under certain conditions. Even severe stutterers are likely to be fluent: • When singing; • When reading in unison with someone else; • When speaking in strict time to a metronome; or • When silently mouthing their words or whispering. Other conditions have a general tendency to increase fluency (although they might not prevent stuttering in every instance). These include talking to oneself, speaking very slowly, stretching out sounds, or using certain breathing techniques. In addition, some stutterers are quite eloquent when speaking with an assumed accent or acting out a role on stage. Stuttering can also be reduced by changing the way a stutterer hears his voice – such as by feeding it back to him through earphones with a slight delay (delayed auditory feedback) or blocking it out by masking. These are examples of fluency enhancing conditions. They do not "cure" stuttering. Once the special condition stops or the technique is not used, stuttering returns as usual. Therefore, the temporary improvement is sometimes called artificial fluency. Why should such a wide variety of conditions tend to alleviate stuttering? What factors do they utilize that might help us control stuttering on a more permanent basis? Again, the Valsalva Hypothesis provides promising answers.

Effects on the Valsalva-Stuttering Cycle The wheel of stuttering is turned by a combination of psychological, neurological, and physiological factors that reinforce and perpetuate one another in a vicious circle. This is the Valsalva-Stuttering Cycle, previously described. The fluency enhancing conditions can be explained by examining the ways in which they might disrupt various steps in this cycle.

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Here are the six crucial steps in the stuttering cycle and the principal ways in which each of them might be defeated: 1. Negative beliefs, fears, expectations, and intentions. Stuttering is usually preceded by our anticipation, either conscious or unconscious, that speech will be difficult. Based on past experience, we may expect trouble in saying a certain word or speaking in a particular situation (such as on the telephone). Or we may feel it's especially important to speak well under the circumstances. For whatever reason, we believe that extra effort is needed to get the words out. This anticipation may be lessened by techniques that simplify the mechanics of speech, making speech seem easier. Our anxiety may also be relieved by conditions that reduce the demand for good speech, such as by making the words seem less important or by eliminating our need to make a good impression on the listener. The expectation of difficulty is also fueled by our perception of ourselves as “stutterers.” Therefore, fluency might be enhanced by circumstances that improve one's self-image as a speaker. Valsalva-stuttering blocks can be viewed as neurological motor programs that manifest the intention to exert effort in trying to say a word. Persons who stutter often enter speaking situations with the intention to make a “good impression” by speaking fluently. When our intention is focused on trying hard to say a word without stuttering, we are inviting our amygdala to help out by triggering a fight-flight-freeze response. This suppresses phonation of the Key Vowel sound and substitutes a motor program for effort, resulting in stuttering. Therefore, one way to promote fluency is to change our intention in speaking. Many speaking techniques may achieve their effectiveness, at least in part, by requiring stutterers to change the way in which they intend to speak. 2. The amygdala triggers stress hormones and the fight-flight-freeze response. In reaction to a feared word, the amygdala triggers the release of stress hormones that suppress the brain’s motor program for phonating the Key Vowel sound and substitutes a powerful impulse to exert physical effort. At this point, a crucial mistake may occur. Because the word cannot be spoken without the Key Vowel sound, the brain may erroneously treat the word as if it were a "thing" that can be physically forced out of the body by means of a Valsalva maneuver. Therefore, rather than processing speech in the normal way – as phonation and a sequence of movements – the brain may activate the Valsalva mechanism instead. This tendency might be overcome by conditions that require us to treat words as phonation and as a sequence of movements, rather than as things to be forced out of the body. 3. The motor program for vowel phonation is replaced by an effort impulse. Normally, the brain sends signals to the larynx a split second before

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vocalization begins, neurologically "tuning" it for phonation. However, if vowel phonation is suppressed and the brain creates a motor program for effort, it will "tune up" the Valsalva mechanism instead. The larynx becomes the center of this confusion, because it is not only the voice box but also a key part of the Valsalva mechanism. Therefore, when the brain activates the Valsalva mechanism, it programs the larynx for effort closure as part of a Valsalva maneuver, instead of phonation of the “Key Vowel Sound,” which is the heart of the word or syllable. Therefore, this problem might be reduced by techniques and conditions that emphasize phonation and vowel sounds. 4. Activation of the Valsalva mechanism and Valsalva maneuver. As previously discussed, speech is blocked when the brain fails to program the larynx to phonate the Key Vowel sound of a word and instead programs the Valsalva mechanism to perform a Valsalva maneuver. As we have seen, a Valsalva maneuver is performed by blocking airflow in the larynx or the mouth, while the chest and abdominal muscles squeeze to increase air pressure in the lungs. Because the muscles of the Valsalva mechanism are neurologically coordinated to work in unison when performing a Valsalva maneuver, relaxing any set of muscles will shut down the entire maneuver. Therefore, Valsalva tuning may be countered by various methods that relax any or all parts of the Valsalva mechanism. They may include techniques that focus our attention on: (1) relaxing the abdominal muscles; (2) letting the air flow freely; and (3) phonating the vowel sounds. 5. Forcing and other stuttering or avoidance behaviors. In addition to interfering with phonation, Valsalva tuning also promotes forceful closures of the mouth or larynx to block airflow and build up air pressure in the lungs. Consequently, the momentary increases in air pressure that occur during articulation might accidentally turn into Valsalva maneuvers. The articulation of “stop” consonants might turn into forceful blockages of air by the lips or tongue. Glottal stops before initial vowel sounds might turn into forceful closures by the larynx. The risk of such forceful blockages might be reduced by techniques that avoid rapid increases in air pressure. 6. Reinforcement of negative beliefs, fears, expectations, and intentions. When we hear, or even expect to hear ourselves stutter, our original anticipation of difficulty is reinforced. Our ears are listening for the stuttering that we fear, and we are ready to respond with additional effort. We are taken right back to Step 1 and a repetition of the cycle. One way to control this reaction is to reduce the auditory monitoring of stuttering – such as by preventing the stutterer from hearing himself. If we can't hear our stuttering, we may be less apt to struggle against it. In addition, our amygdala will have no reason to react. Another approach would be to increase our perception of the fluent aspects of speech.

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Now we shall examine the various fluency enhancing techniques to see how they might affect the steps in the stuttering cycle.

Speaking to Oneself The most familiar of all fluency enhancing conditions is speaking to oneself in the absence of a listener. In most instances, stuttering either disappears or is greatly diminished when the stutterer is alone. Of course, this is not always the case, especially when one is talking into a voice recorder or dictating machine. Speaking alone affects Step 1 in the stuttering cycle by reducing the demand for good speech. Obviously, we don't need to make a good impression if no one is around to hear us. Therefore, we usually won't have as great an urge to "try hard." But this does not always guarantee fluency, because the presence of the listener is only one of many variable factors. Sometimes we can be our own harshest critics.

Silent or Whispered Speech Stutterers are completely fluent when they mouth words silently (a technique called lipped speech or silent articulation). Obviously, this is not very useful in ordinary conversation, unless you are addressing someone who reads lips. Nevertheless, it shows that stutterers are perfectly capable of moving the lips and tongue – at least as long as they don’t have to wait for the larynx to phonate vowel sounds. Therefore, speech is not affected by Step 4 in the cycle. Another explanation is that the absence of phonation simplifies the mechanics of speech, reducing the anticipation of difficulty (Step 1). Furthermore, the auditory monitoring of stuttering in Step 6 is eliminated, because we are silent. Words become simply a sequence of movements. During whispering, some disfluencies may occur, but the rate of stuttering is still much lower than in voiced speech. As in silent speech, the lips and tongue are free to move on their own, without waiting for vowel phonation, because no phonation is involved (Step 3). The larynx simply closes a little to cause continuous turbulence in the airflow passing through, creating the whispering sound. Because there is no vowel phonation, there is nothing for the freeze response to suppress.

Singing Stutterers, as everyone knows, almost never stutter while singing. A part of the reason may be that music is processed in a different area of the brain than speech and uses a separate set of nerve pathways. In addition, singing focuses our attention on phonation and vowel sounds, because the voicing of vowel sounds is what carries the melody. This would affect Steps 3. While singing, we stretch out the vowel sounds and phonate al-

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most constantly. As we listen to ourselves, we are not worried about stuttering, but rather we are concentrating on the pitch and musical quality of our voice. The pitch of the vocal folds is constantly being adjusted by the cricothyroid muscle. Therefore, our larynx is highly tuned for phonation instead of effort closure, and there is little chance that the Valsalva mechanism will interfere.

Continuous Phonation A similar effect occurs during continuous phonation (such as the “Humdronian Speech Exercise,” to be discussed in a subsequent chapter). When the vocal folds are always closed and are continuously phonating, stutterers are generally fluent, even though speech sounds rather strange. In this case, the lips and tongue don’t have to wait for the larynx to phonate the vowel sounds, because the vocal folds are already phonating everything.

Slowed and Prolonged Speech Slowed speech has long been recognized as a method of improving fluency. By this, we don't just mean pausing longer between words, but rather slowing down during the pronunciation of each word. For some stutterers, it may be necessary to speak very slowly, but there is almost always a point where fluency is achieved. (At least this is true in the therapist's office. In actual conversation the situation is a bit more complicated.) The first impact that slowed speech may have on the Valsalva-Stuttering cycle is by simplifying the mechanics of speech, thereby decreasing the anticipation of difficulty (Step 1). When practicing the piano, it is easier to play a piece more slowly, because you have more time to figure out the notes and move your fingers. The same is true in speaking. You have more time to coordinate the necessary sequence of movements. The muscles of the lips, tongue, and larynx have physical limitations on how fast they can move. According to some studies, these muscles move a bit slower in stutterers than in the average speaker. Therefore, stutterers may be attempting to talk at speeds beyond the capacity of their speech mechanism. This could increase the difficulty of speech and may create an urge to force out the words. Slowing down would remove this pressure by enabling the speech mechanism to work within its speed limits. Even in the normal speaker, the lips and tongue don't have enough time to produce each sound separately. Consequently, there must be an overlap in movement, called co-articulation. For example, while the lips are forming one sound, the tongue may already be starting to make the next one. Rapid speech increases the need for co-articulation, and therefore the complexity of speech. During slowed speech, we have more time to spread out the sounds and produce them individually. Therefore, speech is easier, and we have less temptation to force.

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Slowed speech also increases the emphasis on phonation, affecting Step 3. Studies have shown that, when a person slows down his speech, he increases the proportion of time spent on the vowel sounds as compared to the consonants (affecting Step 3). A similar method of increasing fluency is prolonged speech, in which the stutterer stretches out syllables, especially at the beginning of phrases. Because the vowel sound is lengthened more than anything else, the phonation of vowels is emphasized (Step 3). Slowed and prolonged speech also help us spread out the pronunciation of words into their component parts, so we can properly treat them as a sequence of movements, rather than as things to be forced out as a single lump (Steps 4 and 5).

Rhythmic Speech Rhythm is another time-honored technique for creating artificial fluency. This method is simple and usually quite dramatic. All you need is a metronome, the kind used for practicing music. Start by setting it at a relatively slow speed (such as 60 beats per minute), and then talk in strict time to the rhythm. Each syllable should be spoken exactly on the downbeat. It – will – sound – some – thing – like – this. Very mechanical to be sure, but the chances are that you won't stutter. This fluency phenomenon is called the metronome effect. After practicing a while, you can gradually speed up the metronome, first to 80 beats per minute, and then perhaps as high as 120. Even as speed increases, the fluency enhancing effect usually remains – as long as you say each syllable on the downbeat. The effect of rhythm on fluency has led many people to assume that stuttering is caused by a defect in the brain's timing mechanism. However, a leading authority, Marcel Wingate, has pointed out that rhythm also has a very definite effect on phonation. (Wingate, 1969.) When a person says each syllable in strict time to a metronome, he tends to say the loudest part of the syllable at the same time as the downbeat. What is the loudest part of a syllable? Usually it is the beginning of the vowel sound – the very point when phonation is greatest. As we speak in time with metronome, we will therefore be concentrating on phonating the vowel sound as we anticipate the downbeat. Consequently, the brain will neurologically tune the larynx to phonate the vowel sound rather than substituting a motor program for effort closure, thereby avoiding the problems in Steps 3, 4, and 5.

Choral Speaking and Shadowing Stutterers are almost always fluent during choral speaking – that is, while reciting words in unison with someone else. They would have no trouble, for example, in a group recitation of the Pledge of Allegiance.

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It's easy to speak along with a large group. There is no pressure to get the words out, because everybody else is doing it for you. Consequently, this situation reduces the demand for good speech (thereby affecting Step 1). However, choral speaking can enhance fluency even without a group to back you up. All you need is one other person to read along with you – even if the other person is also a stutterer! I have seen examples of this at stuttering support group meetings. Member A is at the lectern, blocking severely on some written material. When member B joins him in reading, A's stuttering usually disappears. As A continues to read, B gradually lowers his voice until it is barely audible. Nevertheless, A will continue to be fluent. Speech scientists have confirmed the fluency effect of choral speaking in a variety of situations. In one experiment, the stutterer would face an audience all by himself, while reading in unison with a person who was speaking over a telephone. Even though the stutterer bore the entire burden of communicating the words to the audience, he still tended to be fluent. This effect occurs even when the stutterers read different material from one another. Shadowing has a similar effect in reducing stuttering. In this technique, the stutterer has no written text, but instead plays "follow the leader." He listens to the speech of a fluent speaker and talks along with him, immediately echoing his words. You might try this sometime while listening to the radio. Why do these conditions promote fluency? It may reduce the pressure to “make a good impression” in speaking. Hearing another voice may also provide a pattern of speech for us to follow, thus making speech seem easier (Step 1). In some respects it may serve as a "crutch," like the metronome. But it may also remind us that speech is actually phonation and a sequence of movements. By following this pattern, our brain may be more likely to process speech in the proper way, rather than treating words as things to be forced out (Steps 4 and 5).

Various Pressure-Reducing Techniques There have been reports that stutterers speak more fluently while they are inhaling – a technique called inspiratory speech. I doubt it will ever catch on as fluency method, because it sounds terrible and is rough on the throat. Nevertheless, it does illustrate the relationship between stuttering and air pressure. You can't do a Valsalva maneuver while inhaling, because the air is going in the wrong direction. The lungs are expanding, causing air pressure to drop. Therefore, inspiratory speech defeats Step 5 in the stuttering cycle by reducing air pressure rather than increasing it. A number of less extreme speaking techniques may also affect Step 5 by avoiding abrupt increases in air pressure that might trigger a Valsalva maneuver. Here are brief descriptions of some common methods and how they work:

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The airflow technique. Before speaking, the stutterer gently exhales a stream of air through his open larynx. Then he eases into his speech, prolonging the first word, while maintaining the airflow. Although other theories have been used to explain this method, its obvious effect is to keep the larynx open as much as possible, thereby avoiding the tendency to build up air pressure. It is essentially an anti-Valsalva strategy. Easy onset. The stutterer begins his words and sounds in a soft and gradual manner. When beginning a vowel sound (as in "apple," for example), he starts with an open larynx and then gradually closes the vocal folds across the airflow until they start to vibrate. In contrast, a "hard onset" or glottal stop would start by closing the larynx, building up air pressure slightly, and then releasing the vowel sound. Light contacts. When forming consonants, the stutterer moves his lips and tongue as gently as possible, using a minimum amount of pressure. In this way, he tries to avoid physical effort and the forceful blockage of airflow. These techniques have been incorporated into a number of speech therapy programs, which will be discussed in a later chapter. While they generally work well in the therapist's office, they are not always sufficient, in times of stress, to overcome the stutterer's overwhelming urge to force.

Other Fluency Enhancing Conditions Many studies have shown that stuttering may temporarily disappear under conditions that change auditory feedback – that is, what the stutterer hears when he speaks. These findings have led some experts to speculate that stuttering is caused by a defect in the way we hear ourselves. In the next chapter we will point out the weaknesses of that theory and show how the fluency enhancing effects of masking, DAF, and other changes in auditory feedback are explained much better by the Valsalva Hypothesis. We will also explore the reasons why some stutterers can be extremely fluent when speaking with an assumed accent or when acting out a role on stage.

General References ANDREWS, G., CRAIG, A., FEYER, A., HODDINOTT, S., HOWIE, P., & NEILSON, M. Stuttering: a review of research findings and theories circa 1982. Journal of Speech and Hearing Disorders, 1983, 48, 226-246. PERKINS, W., RUDAS, J., JOHNSON, L., & BELL, J. Stuttering: discoordination of phonation with articulation and respiration. Journal of Speech and Hearing Research, 1976, 19, 509-522. ROSENFIELD, D. B. Stuttering. Current Problems in Pediatrics, 1982, 12, No. 8. SCHWARTZ, M. Stuttering Solved. New York: McGraw-Hill Book Co., 1976.

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STARKWEATHER, C. W. Fluency and Stuttering. Englewood Cliffs, N.J.: Prentice-Hall, 1987, 172, 188-196. VAN RIPER, C. The Nature of Stuttering. 2nd ed. Englewood Cliffs, N.J.: Prentice-Hall, 1982, 418-426. WINGATE, M. E. Sound and pattern in "artificial" fluency. Journal of Speech and Hearing Research, 1969, 12, 677-686.

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CHAPTER 22.

The Effects of Hearing and Role-Playing

I

N THIS CHAPTER, we shall continue our discussion of "artificial fluency" by considering two additional categories of fluency enhancing conditions. The first group includes techniques that temporarily reduce stuttering by changing what we hear during speech, and the second deals with the effect of various kinds of role playing.

Hearing and Stuttering Hearing the sound of our own voice is an important part of the speaking experience. This type of sensory information, called auditory feedback, enables us to judge the quality of our speech. While the various parts of our speech mechanism (the lips, tongue, larynx, respiratory muscles, etc.) are performing the physical movements of speech, our ears are listening for the final result – the sound of the words as they come from our mouth. Normally, this information is used in a constructive way to improve the way we sound. For example, it may help us to regulate the loudness of our voice or to correct our pronunciation of words. But for a person locked in the grip of stuttering, auditory feedback may not always be so helpful. It may even tend to make stuttering worse. The relationship between auditory feedback and stuttering has fascinated speech pathologists for many years. They have found that stuttering can be reduced by removing auditory feedback or by changing it in various ways. Four different approaches have been used to achieve this result: • Masking, which prevents the stutterer from hearing himself talk; • Delayed auditory feedback ("DAF"), which causes the stutterer to hear his voice with a slight delay; • Enhanced vocal feedback, which amplifies the vibrations of the vocal folds; and • Frequency altered feedback (“FAF”), which causes the stutterer to hear his voice at a different pitch. Why do these methods reduce stuttering, and what can we learn from them? As in the previous chapter, we shall approach this question from the viewpoint

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of the Valsalva Hypothesis. We shall see how each technique might disrupt various steps in the Valsalva-Stuttering Cycle, thereby reducing our tendency to activate the Valsalva mechanism during speech.

Masking The first of these techniques, called masking, uses a loud noise to "mask" the sound of the stutterer's voice. In speech laboratories, this is often done by having the stutterer wear earphones that emit a constant "white noise" (which sounds something like the static on a radio when it's not tuned to a station). As the noise is increased to the point where the stutterer can't hear himself, stuttering usually diminishes. For everyday use, some stutterers have worn a device called the Edinburgh Masker. Its main unit is a small box, about the size of a pack of cigarettes, which generates a loud buzzing sound while the stutterer is speaking. The noise is turned on and off by a small microphone strapped to the throat in front of the larynx. Plastic tubes carry the noise from the box to molded earpieces, which the stutterer wears in both ears. While masking doesn't "cure" stuttering, it does demonstrate that most stutterers tend to be more fluent when auditory feedback is eliminated. This phenomenon is called the masking effect. It has long been known that stutterers are often more fluent when surrounded by loud noise (such as the sound of a waterfall or machinery). Similarly, studies have shown that stuttering is relatively uncommon among people who are deaf. Effect on the Valsalva-Stuttering Cycle. In order to explain why the absence of auditory feedback helps fluency, we must first understand how the presence of auditory feedback might perpetuate stuttering. Auditory feedback allows us not only to hear ourselves speak, but also to hear ourselves stutter. In this way, it may heighten our sensitivity to possible disfluencies, thereby contributing to our anticipation that speech will be difficult (Step 1 of the Cycle). Because of auditory feedback, we may feel pressure not only to impress other people with our speech, but also to sound good to ourselves. Our anticipation of difficulty may then set into motion the subsequent steps of the cycle: the urge to "try hard" to force out the words by physical effort (Step 2); the neurological "tuning" of the Valsalva mechanism (Steps 3 and 4); the resulting vocal delays, forceful closures of the mouth and larynx, and the variety of behaviors we may adopt in an attempt to avoid, postpone, or break through the blocks (Step 5). Masking may alleviate our anticipation of difficulty by reducing the demand for good speech. As previously mentioned, our own ears are among the

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"judges" we are trying to please. There would be little incentive for us to try hard to speak well, if we know we won't be able to hear ourselves anyway. Auditory feedback may also have a significant impact on our reaction to stuttering (Step 6). Hearing our disfluencies may reinforce our original belief that speech would be difficult, leading us right back to Step 1 and a repetition of the cycle. Therefore, rather than helping us correct errors in our speech, auditory feedback may stimulate us to use even more force. Masking would minimize this reaction by reducing the auditory monitoring of stuttering. If we can't hear ourselves talk, we can't hear ourselves stutter. Therefore, we are less likely to reinforce our belief that speech is difficult (Step 1), or to respond by doing all those things that make stuttering worse. If we can’t hear the sound of our own voice, then we have no way of knowing whether our voice can be heard by anyone else either. Therefore, if the freeze response is triggered by our amygdala, it will have no basis upon which to determine and suppress the loudest part of our words – the vowel sound. The effect of non-auditory feedback. Masking may also disrupt the Valsalva-Stuttering Cycle by changing the way that we perceive and process speech. According to our Valsalva Hypothesis, the stutterer's brain may erroneously treat words as if they were "things" that can be physically forced out of the body by means of a Valsalva maneuver (Step 3). Masking might help us avoid this tendency by creating a condition that encourages us to treat words as a sequence of movements. Because masking eliminates auditory feedback, it forces us to rely exclusively upon various forms of physical feedback that come directly from the speech mechanism. One kind is proprioceptive feedback, which indicates the position of every part of our body in relation to every other part. This is what enables our finger to touch the tip of our nose while our eyes are closed. During speech, proprioceptive feedback tells us the exact location of our lips and tongue as we articulate. We also use tactile feedback, involving the senses of touch and pressure. We can feel the vibration of the vocal folds, the contacts made by the lips and tongue, and the changes in air pressure as we form the words. Whereas auditory feedback tells only about the final product (the sound of the words), the physical kinds of feedback deal with the actual process of speech. Whereas auditory feedback may permit us to treat words as "things," the non-auditory feedback helps us to experience words as a series of physical movements. To some extent, these movements may be so habitual that they can be performed automatically, without our being aware of any feedback whatsoever. Each movement may trigger the next one, in a kind of preprogrammed se-

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quence called feed-forward. Such a process might allow us to speak fluently when we are deprived of auditory feedback (and perhaps also on those occasions when we simply don't pay any attention to our speech).

Delayed Auditory Feedback Another technique for enhancing fluency is delayed auditory feedback ("DAF"). Here we speak into a microphone, which is connected to a device that delays the sound for a fraction of a second before feeding it back to us through earphones. Consequently, we don't hear our voice immediately, but must wait for a brief moment. The length of the delay is usually adjustable. Although the time lag may be annoying, DAF has been effective in temporarily reducing stuttering. One explanation may be that DAF forces stutterers to slow down their speech and to stretch out their words. As a result, DAF may produce the fluency enhancing effects of slowed speech and prolonged speech, previously discussed. By disrupting our usual auditory feedback, DAF may also force us to rely on non-auditory feedback, causing us to treat words as a sequence of movements rather than as "things" to be forced out. When first discovered in the 1950's, DAF created a stir because of reports that it not only made stutterers fluent, but also caused fluent people to "stutter." Actually, the so-called "artificial stuttering" produced by DAF had nothing to do with real stuttering. When normal speakers prolong or repeat sounds under DAF, the prolongations occur in the middle of words, and the repetitions usually come at the end like an echo – unlike real stuttering, in which disfluencies usually occur at the beginning of words. DAF has recently enjoyed renewed popularity in the form of miniaturized electronic devices, such as the SpeechEasy, which fit in the ear canal like a hearing aid. The results are not perfect, and background noise often causes a problem.

Enhanced Vocal Feedback A third approach is called enhanced vocal feedback. It changes the way we hear our speech by emphasizing the underlying sound of phonation. This could be done by placing a microphone against the Adam's apple, allowing us to hear the buzz of the vocal folds as they vibrate. The same vibrations can also be heard through the bones of the neck and skull. They travel from the larynx to the inner ear by bone conduction. Therefore, it is possible to amplify these vibrations from a point close to the ear, without running a wire and microphone to the throat. This method has been incorporated into a device called the Fluency Master, which resembles an over-the-ear hearing aid. It uses a tiny microphone pasted over the mastoid bone (directly behind the earlobe), to pick up the vibra-

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tions coming through the bones. The vibrations are amplified into a buzzing sound, which is heard through a molded earpiece. You can experience a similar effect simply by covering the opening of one ear while you talk (a trick we learned from Dan Weiss of our local National Stuttering Association group). Take the middle finger of your right hand, and lightly place the fleshy part of the fingertip over the opening of your right ear canal. (Be gentle, so as not to hurt your eardrum.) Do you hear a loud undertone as you speak? That is the sound of phonation, as carried by bone conduction. By covering your ear canal, you increase the resonance of bone conduction in your ear (a phenomenon called the occlusion effect), making it seem much louder than usual. As you have noticed, one's voice sounds much different through bone conduction than it does through air conduction – the route with which we are more familiar. Through air conduction, we hear the sound of our speech after it has been shaped by articulation in the mouth. In contrast, the sound of bone conduction is almost all phonation. (This is why our voice sounds different to ourselves than it does when we hear it played back on a recorder. The recorder hears only through air conduction, while we hear ourselves through bone conduction also.) Enhanced auditory feedback has been reported to increase the fluency of many stutterers. We have seen evidence of this at our group meetings, when a few members experimented with both the Fluency Master and the occlusion effect. In some instances, the initial improvement in fluency was quite dramatic. Over the long run, the results were not as impressive (perhaps indicating that the original success was partly due to distraction, as discussed later in this chapter). Nevertheless, the technique continues to be helpful to some degree. Enhanced vocal feedback may promote fluency because it tends to focus our attention on phonation. The more we concentrate on the vocal element of speech, the more our brain is encouraged to "tune" the larynx for phonation rather than for effort closure. This not only prepares our vocal folds to phonate more promptly, but also relaxes our Valsalva mechanism, reducing its tendency to interfere with speech. In this way, enhanced vocal feedback may help to defeat Step 3 of the Valsalva-Stuttering Cycle.

Frequency Altered Feedback Another variation on this theme is frequency altered feedback ("FAF"). As we speak, our voice is picked up by a microphone connected to a device that electronically changes the frequency of the sound and sends it back to us through earphones or an earpiece. We hear our words at the same time that we are speaking, but at a different pitch. The voice we hear may be anywhere from

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one-quarter of an octave to a full octave higher or lower than our own. As a result, the voice we hear sounds as if it is coming from someone else. FAF has been found to have a significant fluency-enhancing effect during oral reading and some other speaking tasks (although it is less effective during monologue speaking tasks). The reason is not fully understood. Perhaps, as in the case of enhanced vocal feedback, the change in pitch focuses our attention on phonation. This may encourage the brain to tune the larynx for phonation rather than effort closure, thereby countering Step 3 in the Valsalva-Stuttering Cycle. In addition, stutterers have reported that FAF makes them feel as if they are speaking in unison with another person. Therefore, it is possible that FAF may enhance fluency by creating the illusion of choral speaking. As discussed in the previous chapter, one reason why choral speaking promotes fluency may be that it reduces the demand for good speech (which would affect Step 1). This may also be true in the case of FAF, even though the "other speaker" is actually the stutterer himself! FAF is currently employed in miniature electronic devices such as the SpeechEasy, which combines FAF with DAF.

Do Stutterers Have a Hearing Defect? A number of speech pathologists, in attempting to explain the effects of auditory feedback techniques, have suggested that stuttering is a problem of hearing rather than of speaking. They have proposed that stutterers are defective in the way they process auditory feedback. There are several different versions of this theory, none of which have been proven. One says that the stutterer's brain simply can't handle auditory feedback and needs masking to block it out. Another says that stutterers have some quirk that delays the processing of auditory feedback, creating an effect similar to DAF. But this seems inconsistent with the fact that DAF makes stutterers more fluent, and that the disfluencies caused by DAF are unlike real stuttering. The story of the stapedius. Some experts have tried to connect stuttering to a tiny muscle in the middle ear. This muscle, the stapedius, regulates the loudness of sounds transmitted from the eardrum to the inner ear. It is also neurologically coordinated with the larynx, to protect the inner ear from the sound of our voice. When we intend to speak, the stapedius muscle contracts a fraction of a second before phonation begins. The timing of these contractions is the same in stutterers as in normal speakers. (Shearer & Simmons, 1965.) When a person stutters, however, the activity of the stapedius does not simply parallel the vocal sound, as it does during fluent speech. It may also contract during the blocks, even though no sound is being produced. (Shearer, 1966.)

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This behavior does not mean that the stapedius muscle causes stuttering, as is sometimes suggested. It is far more likely that the stapedius is simply reacting to signals being sent by the brain during the struggle to speak. Neurological deficiencies in auditory processing. Functional brain imaging and other studies have led some researchers to propose that persons who stutter may have irregularities in parts of the brain responsible for auditory processing. It has been further suggested that stutterers may have inadequate white-matter connections among brain regions that support auditory processing, motor planning, and motor execution – all of which are presumed to interact in speech. It has been hypothesized that masking and the various altered-feedback conditions might somehow temporarily make up for a stutterer’s auditory processing deficiencies. Weaknesses of the theories. Although the "hearing defect" theories stirred up considerable interest when first proposed, no one has yet been able to show that a specific hearing defect actually causes stuttering. Furthermore, the theories share some serious defects themselves. In particular: • They are far too narrow in their application. They attempt to explain disfluencies strictly in terms of a few facts related to hearing, while ignoring many other aspects of stuttering. They create the impression that stuttering can be controlled only by masking or other auditory feedback techniques, when we know that this is not the case. • They don't adequately explain the great variability of developmental stuttering. They simply assume that the defects are somehow aggravated by "stress" or "anxiety." • They don't explain silent blocks, when no sound comes out of the stutterer's mouth at all. As we know, stuttering often begins before any auditory feedback can be heard. In contrast, we have been able to explain all the fluency techniques in terms of the Valsalva-Stuttering Cycle and the Valsalva Hypothesis. This approach provides explanations that are not only inherently logical, but also consistent with our previous explanations about the other aspects of stuttering. In my view, there is nothing wrong with stutterers' ability to process auditory feedback. Instead, the problem may be in how we use the feedback. If we focus our attention on stuttering, auditory feedback may increase our urge to activate the Valsalva mechanism, making speech more difficult. On the other hand, if we listen for the music and resonance of our voice, auditory feedback can be a positive influence, guiding us toward improved phonation and fluency.

Distractions Another view is that masking, DAF, and similar techniques are merely distractions – gimmicks that temporarily seem to improve fluency by diverting our

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attention away from stuttering. "Distractions” have gotten a bad name in the stuttering community, because they usually lose their effectiveness when the novelty wears off. Even if distraction plays a role in the auditory feedback techniques, the results can still be explained in terms of the Valsalva-Stuttering Cycle. Anything that takes our mind off stuttering will tend to reduce both our anticipation of difficulty (Step 1) and our reaction to stuttering (Step 6).

The Fluency Effects of Role Playing One of the colorful characters in Woody Allen's movie, Broadway Danny Rose, was a ventriloquist who stuttered – but whose dummy was fluent! I did not find this to be at all far-fetched, remembering how my own stuttering would disappear when I gave puppet shows back in elementary school. When I later took elocution lessons, I found I could stand before an audience and act out a role with perfect fluency. My most dramatic experience occurred in a High School English class when we were studying Shakespeare. Everyone in class was assigned to memorize Hamlet’s soliloquy and then recite it before the entire class. Although I spent the previous evening practicing, this was no guarantee that the words would come out when I needed them. Then, while waiting at my desk to be called on, I had a sudden revelation. “It doesn’t matter whether or not I stutter!” I thought to myself. “All that matters is that I am Hamlet. I could be a stuttering Hamlet. Maybe Hamlet stuttered! That doesn’t matter, just as long as I am Hamlet!” When I was called on, I walked to the front of the class – not as myself, but as the Prince of Denmark. Without hesitation, I became immersed in my role: “To be or not to be – that is the question . . .” I acted out the soliloquy passionately and perfectly, and I received an A+ for my presentation. After I returned to my desk, I went back to stuttering. Adopting an assumed accent also seemed to work magic. I remember a high school trip to Washington, D.C., where I achieved fluency by speaking with a Southern drawl – until my classmates finally told me to cut it out. A noted speech pathologist once told me how he avoided stuttering in school by assuming a foreign accent. After a while, the fluency effects of that accent began to wear off, so he switched to a different foreign accent. Then he switched to another, and yet another. He said this drove his teachers crazy. Similar experiences have been reported by many people who stutter. One member of our support group became fluent when imitating JFK. John Harrison has told about his sudden fluency while portraying a Frenchman in a high school skit. (Harrison, 1999.) Some stutterers, such as James Earl Jones, have even become successful actors.

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Although not every stutterer shares this experience to the same degree, there is no doubt that acting a role, imitating another person, and putting on an accent can often enhance one's fluency. While this phenomenon has led some observers to conclude that stuttering must be purely "psychological," it actually can be explained by the Valsalva-Stuttering Cycle. As previously mentioned, our anticipation that speech will be difficult (Step 1) is based largely on our perception of ourselves as stutterers. We may view stuttering as somehow being an integral part of our personality. When we are really involved in acting, however, we set aside our old identity and let ourselves become another person. Consequently, this process may affect Step 1 by changing our self-image as a speaker. Playing a character gives us license to "act out" and "let go," without being held responsible for what we say. This factor could also reduce our anticipation of difficulty, by relieving some of the ambivalence and self-restraint we might ordinarily feel in speaking situations. When we "get into a role," we change the way we feel, move, and talk. We change our intention in speaking by intending to be someone else (Step 1). We also breathe in a controlled way and vocalize the vowel sounds with more phonation and emotional expression. All these changes help us break away from our old behavior patterns connected with Steps 3, 4, and 5 of the Valsalva-Stuttering Cycle. Similar changes in speech also occur when we put on an accent. Fluency may be enhanced because we are changing our intention in speaking. Instead of intending to try to say words in our usual way, we are intending to speak in a significantly different manner. When we speak with an assumed accent, one of the major changes is in the way we voice the vowel sounds. Therefore, we increase our focus on vowel phonation. The role-playing situations also change the way we hear ourselves. We don't listen to our usual voice and expect to hear stuttering. Instead, we listen to "someone else" talking in a different way. We pay attention to the character's unusual accent or patterns of speech. We forget about stuttering as we get caught up in the performance. As a result, these situations may disrupt Step 6 of the cycle by changing how we react to our speech. In addition, one can imagine that “Amigo” – our bodyguard – is only assigned to protect us personally. Therefore, he doesn’t bother to trigger stress hormones in speaking situations for a puppet, a dummy, a theatrical character, or a fellow with a strange accent. Consequently, there is no interference with motor programming for speech. 

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We have now completed our discussion of conditions that temporarily enhance fluency. In the next chapter, we shall turn our attention to therapy techniques aimed at controlling stuttering on a more permanent basis. We shall review the varied approaches to stuttering therapy, to see how they may affect the Valsalva-Stuttering Cycle and what might be done to increase their effectiveness.

General References ARMSON, J., & STUART, A. Effect of extended exposure to frequency-altered feedback on stuttering during reading and monologue. Journal of Speech, Language and Hearing Research, 1998, 41, 479-490. ANDREWS, G., CRAIG, A., FEYER, A., HODDINOTT, S., HOWIE, P., & NEILSON, M. Stuttering: a review of research findings and theories circa 1982. Journal of Speech and Hearing Disorders, 1983, 48, 226-246. BLOODSTEIN, O. A Handbook on Stuttering. 5th ed. San Diego: Singular Publishing Group, 1995, pp. 90-92. HARRISON, J. C. Why talking is easier when you are "being" someone else. How To Conquer Your Fears of Speaking Before People. 5th ed. Anaheim Hills, CA: Nat'l Stuttering Ass'n, 1999. ISMAIL, N., SALLAM, Y., BEHERY, R., BOGHDADY, A.A. Cortical auditory evoked potentials in children who stutter. Int. J. Pediatric Otorhinolaryngology, 2017, 97, 93101. KEHOE, T. D. Stuttering: Science, Therapy & Practice. Boulder, CO: Casa Futura Technologies, 1999, pp. 179-181. KIKUCHI, Y., OKAMOTO, T., OGATA, K., ET AL. Abnormal auditory synchronization in stuttering: A magnetoencephalographic study. Hearing Research, 2017, 344, 8289. MOORE, M.A.S., ADAMS, M.R. The Edinburgh Masker: A clinical analog study. J. Fluency Disorders, 1985, 10, 281-290. NEEF, N.E., ANWANDER, A., FRIEDERICI, A.D. The neurobiological grounding of persistent stuttering: from structure to function. Current Neurol. Neuroscience Rep., 2015, 15, 63. SHEARER, W. M. & SIMMONS, F. B. Middle ear activity during speech in normal speakers and stutterers. Journal of Speech and Hearing Research, 1965, 8, 203-207. STARKWEATHER, C. W. Fluency and Stuttering. Englewood Cliffs, N.J.: Prentice-Hall, 1987, 183-188. VAN RIPER, C. The Nature of Stuttering. 2nd ed. Englewood Cliffs, N.J.: Prentice-Hall, 1982, 369-395. WEBSTER, R. L. Fluency Master Procedures. Hardy, VA: Epic Corp., 1989. WINGATE, M. E. Effect on stuttering of changes in audition. Journal of Speech and Hearing Research, 1970, 13, 861-873.

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CHAPTER 23.

Stuttering Therapies Revisited

T

HE CONFUSION and controversies about stuttering are nowhere more apparent than in the realm of therapy. Through the centuries, hundreds of different methods have been used to treat people who stutter. These have included various forms of persuasion, punishment, surgery, mechanical devices, speech exercises, strange ways of speaking, relaxation, distraction, psychotherapy, drugs, attitude therapy, and behavior modification techniques. It is mindboggling to think that a single ailment could have inspired such a diverse assortment of remedies. We shall now explore this vast array of treatments, guided by the insights we have gained from the Valsalva Hypothesis. As we do so, it may be helpful to keep the following observations in mind: • While some therapies are clearly more effective than others, almost any form of treatment will seem to benefit someone – at least temporarily. • Although many therapies may seem totally unrelated to one another, or even contradictory in their approaches, virtually all of them can be explained in terms of their effect on the Valsalva-Stuttering Cycle. The success of any therapy may depend on its ability to disrupt one or more of the six steps in the Cycle, thereby reducing vowel suppression and the tendency to activate the Valsalva mechanism during speech. • Thus far, no form of therapy has been completely successful in treating everyone. All have had limitations and drawbacks, and most patients have tended to relapse back into stuttering sooner or later. • Many of these problems may be traced to a failure to understand and control the involvement of vowel suppression and the Valsalva mechanism in an adequate and efficient way. Therapies have concentrated on speaking techniques and mental attitudes that may have an indirect, "hit-or-miss" influence on the Valsalva mechanism. However, no previous therapy has focused directly on controlling the Valsalva mechanism itself. As a result, some therapies may have hit the edges of the target, but none has scored a bull's eye. In this chapter, we shall review some of the older methods of treating stuttering, which may help us to better understand today's therapies in their historical context.

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Speaking Exercises One of the earliest approaches to stuttering therapy was based on the theory that stutterers had an underlying weakness in their speech mechanism. Stutterers were told to strengthen the muscles used for breathing, voice, and articulation by exercising them in various ways. The most famous practitioner of this method was Demosthenes of ancient Greece. He strengthened his breathing by running up mountains with lead plates on his chest; he exercised his voice by shouting over the roar of the ocean; and he improved his articulation by learning to talk with pebbles in his mouth. These methods apparently helped Demosthenes, who went on to become the greatest orator in Athens. However, countless other stutterers who tried these methods have not been as successful. Stuttering has also been viewed by authorities as a bad habit that could be broken by rigorous exercises in proper speech. This approach was widespread since at least the early 1800's. Stutterers were endlessly drilled in breathing techniques, vocal gymnastics, lip gymnastics, and proper articulation. The old books on stuttering therapy are filled with long lists of words, sentences, and passages that stutterers were required to recite for hours on end. Through this laborious process (called massed practice), stutterers were expected to overcome their habit of stuttering and to replace it with normal speech. When they still continued to stutter, the answer was, of course . . . more practice! Similarly, many people who stuttered were once advised to take lessons in elocution. This is a method of public speaking that emphasizes clear and proper pronunciation, good vocal control, and dramatic gestures. I myself took elocution in my early teens. It greatly improved my skills in public speaking, enabling me to sound quite eloquent when reciting on stage. However, it did not cure my stuttering. Offstage, in normal conversations, I continued to block as badly as ever. Exercises in speaking skills, such as elocution, acting, and public speaking, can nevertheless be helpful—as long as they are done in a positive, supportive way. On a neurological level, the practice may strengthen the nerve pathways for fluent speech. On a psychological level, stutterers may increase their experience, confidence, and pleasure in speaking. This may affect Step 1 in the Valsalva-Stuttering Cycle by reducing their anticipation of difficulty, thereby decreasing their urge to use the Valsalva mechanism to force out the words. However, the strengthening of normal speech is only half the battle. Simply knowing how to speak well is generally not sufficient to control the forces that block speech. Other approaches must be found to accomplish that goal.

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Persuasion and Suggestion Since ancient times, many people have had the simplistic notion that stuttering is just a bad habit that can be overcome by exercising one's "will power." Therefore, stutterers have often been told such things as: "There's nothing wrong with you! You don't have to stutter like that!" In other words, "Snap out of it!" Similar exhortations have found their way into stuttering therapy. Using a technique called auto-suggestion, stutterers have repeated slogans aimed at convincing themselves not to stutter. Perhaps the most dramatic form of this approach is hypnosis, which enjoyed some popularity during the 19th and early 20th centuries. Stutterers were put into hypnotic trances and given post-hypnotic suggestions that they would not stutter when they awoke. Back in the days when hypnosis was performed before audiences as entertainment, this was sometimes even done on stage. Stutterers would suddenly become fluent before your eyes—at least for the length of the performance. These demonstrations furthered the misconception that stuttering was all in one's mind, as well as creating the myth that it could be miraculously cured by hypnosis. During my youth, I clung to the fantasy that my stuttering would someday be magically exorcised by means of hypnosis—a quick and easy cure that would require no responsibility on my part. In reality, however, post-hypnotic suggestions do not possess any special power. Consequently, the effects of hypnosis have been very unreliable and short-lived. Although the power of suggestion can be a powerful tool for changing behavior, a negative suggestion such as "don't stutter" is likely to do more harm than good. The effort to use "will power" may encourage us to try hard by activating the Valsalva mechanism, making the tendency to stutter even worse. A more beneficial approach would be the use of positive suggestions that emphasize, for example, the ease and fun of speaking regardless of fluency. These would affect Steps 1 and 2 of the Valsalva-Stuttering Cycle, by reducing our anticipation of difficulty and our urge to "try hard." Therefore, we would be less likely to activate the Valsalva mechanism in an attempt to force the words out. The effect of positive suggestion is occasionally seen when a stutterer strongly believes in a particular therapist or kind of therapy. Similar phenomena may occur in the context of faith healing or other spiritual approaches. For example, if a stutterer believes that his speech is being assisted by some "higher power," he may feel less fearful of speaking situations and less dependent on force. Unfortunately, positive suggestions usually have a hard time competing with the many negative memories about speech that we have accumulated over the years. At the first sign of relapse, a stutterer's faith may be shattered. Con-

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sequently, the power of suggestion is rarely enough to overcome stuttering all by itself.

Punishment When persuasion fails, punishment has always been a popular way to try to change someone's behavior. Sadly, the same has been true in regard to stuttering. Throughout the ages, many stutterers have been subjected to corporal punishment, as their parents or teachers literally tried to beat the stuttering out of them. On rare occasions this kind of brutality may have worked. However, it is far more likely that such beatings would aggravate the fear of speech and stuttering, making the problem even worse. Punishment has been a major component in many of the folk remedies that have been inflicted on stutterers. For example, stutterers have been forced to swallow goat feces, charred frog's tongues, raw eggs, mineral oil, and other unpleasant substances. They have been purged with cathartics, forced to chew garlic, and doused with freezing water. Elements of punishment are also present in many forms of modern therapy. Patients are reprimanded or penalized for undesired behavior, be it stuttering or failing to use a particular speaking method. Some types of behavior therapy use punishment as a form of negative reinforcement. Stutterers have received various kinds of aversive stimuli, including bright lights, loud noises, and electric shocks. One of my clients told of going to a therapist who pinched her arm every time she stuttered.

The Power of Distraction Distraction is an important element in many of the stuttering remedies that we will be discussing. People have repeatedly discovered that stuttering often disappears when some novelty is added to the speaking situation. Consequently, we will see that almost any method can bring temporary fluency—no matter how bizarre or illogical it might be. For example, a French physician once reported that he could control stuttering by pressing his thumb against his chin while speaking—clearly a method of distraction. Nevertheless, when I had members try this briefly at an NSA chapter meeting, some temporarily became more fluent. These gimmicks may seem to work magic, at least at first. In reality, they probably affect Step 1 in the Stuttering Cycle by diverting our attention away from our usual anticipation of difficulty or from other cues that trigger stuttering. Once the novelty wears off, stuttering usually returns. In many cases, the ineffective technique will remain as a habitual part of the stutterer's behavior, making his symptoms seem more bizarre than ever.

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Medical and Surgical Treatments For hundreds of years, stuttering was viewed as a physical or nervous disorder, for which motley assortments of medical treatments were suggested. Sometimes the remedies were relatively innocuous, such as rest cures, special diets, or the imbibing of warm wine to "loosen the tongue." Others were more unpleasant, such as the ingestion of nauseating potions, bloodletting, acupuncture, electric shocks, and the application of leeches to stutterers' lips. But the most horrendous measures were reserved for stutterers' tongues. During ancient and medieval times, various physicians have advocated cauterization (burning) of the tongue, cutting its nerves, or cutting the frenum (the web under the tongue), on the theory that stutterers were "tongue-tied." The heyday of tongue mutilation came in 1841, when a Dr. Dieffenbach of Germany popularized the cutting of triangular wedges out of the base of the tongue. This operation was performed on hundreds of stutterers around the world, causing agony, infection, and even death, until it was mercifully discontinued. Needless to say, such procedures had no therapeutic value whatsoever. If some stutterers initially seemed more fluent following their ordeal, it was probably because they were so distracted by pain that their anxieties about speech were temporarily forgotten. Today, medical science has shifted its attention from the tongue to other areas, such as the larynx. For example, some researchers used injections of botulinum toxin (similar to the botulism involved in food poisoning) to paralyze certain laryngeal muscles. At the NSA's 1993 convention, Dr. Christy Ludlow described such experiments conducted at the National Institutes of Health. The toxin was injected into stutterers' thyro-arytenoid muscle (which is used in closing the larynx). In some instances, a strong dose was used to paralyze the muscle completely on one side of the larynx. In other instances, lower doses were used to weaken the muscle on both sides. For a few months after the injections, the subjects had a weak voice but generally didn't stutter as much. When the poison wore off, stuttering returned. One reason for this effect may be that the paralysis prevented the larynx from blocking airflow, thereby reducing the possibility of a Valsalva maneuver. (When I spoke to her after the presentation, Dr. Ludlow acknowledged that the injections to the thyro-arytenoid muscle would have prevented or substantially weakened the larynx's performance of a Valsalva maneuver.)

Mechanical Devices Ever since the days of Demosthenes and his pebbles, people have been filling stutterers' mouths with all kinds of junk to keep them from stuttering. Some have been quite simple, like wads of cotton under the tongue or pieces of cork held between the upper and lower molars. Others have been more elabo-

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rate. Numerous contraptions were devised to keep the tongue in certain positions or to restrict its movement, including one with a sharp point to discourage the tongue from pressing too hard against the palate. Other devices featured tubes to keep the airway open and throat bands to compress the larynx. If these appliances ever improved fluency, the effect was probably due to distraction rather than anything else. Consequently, they have long been abandoned as having no therapeutic value. Nevertheless, we find that stutterers are wearing various kinds of "anti-stuttering" devices even today. Now, however, they take the form of sophisticated electronic gadgets. These include miniature electronic metronomes, such as the Pacemaster, worn like a hearing aid; the Edinburgh Masker, which produces a noise that prevents stutterers from hearing the sound of their voice; miniaturized delayed auditory feedback (DAF) devices, such as the SpeechEasy; the Fluency Master, which amplifies vocal vibrations; the Vocal Feedback Device, featuring an electronic vibrator on the throat; and frequency altered feedback ("FAF") devices, which cause stutterers to hear their voice at a different pitch (including the SpeechEasy, which combines FAF with DAF). While these newer devices may act as distractors to some extent, they may also have other fluency enhancing effects, as previously discussed in Chapters 21 and 22.

Rhythm The fluency enhancing effects of rhythm have already been discussed in Chapter 21. Its use in stuttering therapy is very old, dating back at least to the early 1800's. At that time, a French physician named Columbat devised a metronome-like device to help stutterers time their syllables to a steady beat. Stutterers have since been taught many methods for adding rhythm to their speech, including foot-tapping, finger-tapping, and arm-swinging. One technique had the stutterer silently tap the fingers of his dominant hand in sequence, from the little finger to the index finger, and time each syllable accordingly. Another method required stutterers to trace an imaginary figure-eight, timing their breathing and speech to various points on the figure. Rhythm dropped out of fashion during the first half of the twentieth century, only to re-emerge in the 1960's as a form of behavior therapy. It regained popularity with the introduction of miniature electronic metronomes, such as the "Pacemaster." Rhythm has never been a totally satisfactory method, because the speech it produces sounds so artificial and mechanical that few stutterers will tolerate it. The therapist must gradually move the stutterer away from the strict one-syllable-per-beat rhythm in order to make the speech sound more natural. However, this often weakens the metronome effect, causing fluency to fall apart.

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Novel Ways of Speaking Many stutterers are more fluent when they deliberately talk with a strange or artificial pattern of speech. While this may be partly due to distraction, the enhanced fluency might also result from effects on various points in the Valsalva-Stuttering Cycle, as previously discussed in Chapter 21. For well over a hundred years, speech therapies have conjured up fluency with such techniques as slow speech, prolonged or stretched speech, singing, whispering, speaking with a higher or lower than normal pitch, de-emphasizing consonants, emphasizing phonation, starting words with airflow or vowel sounds in order to keep the larynx open, and breathing in special ways. One factor that all these techniques have in common is that they require the stutterer to change his intention in speaking. Instead of trying hard to say words in his usual way, he must focus his attention on performing the unusual aspect of the technique. A continuing drawback of these "artificial fluency" techniques is that they sound so unnatural that stutterers are reluctant to use them. Furthermore, they are difficult to mold into normal-sounding speech without losing their fluency-enhancing effects. Although this approach to therapy was largely abandoned during the first half of the twentieth century, some of the old speaking methods were reborn in the guise of behavior therapy in the 1960's and 1970's. They still form the backbone of many "fluency shaping" programs, which will be described in a later chapter.

Breath Control Stutterers often display breathing irregularities during their struggle to speak. This fact has been known since ancient times. Exercises in abdominal breathing and other forms of breath control have long been a part of stuttering therapy. Concentrating on proper breathing may serve as both a distraction and an aid to relaxation, thereby affecting Step 1 in the Valsalva-Stuttering Cycle. It may also reduce Valsalva maneuvers by controlling the tendency to build up air pressure during speech. Focusing on a particular breathing technique, as opposed to trying hard to say words, may also have a beneficial effect by changing one’s intention in speaking. Full breath. Some of the earliest advice to stutterers included the admonition to “take a deep breath” before speaking. However, the mere taking of a deep breath does not, by itself, guarantee fluency. On the contrary, this practice sometimes becomes part of the person's stuttering behavior. For example, some stutterers may take a deep gasp for breath and then hold it in, using their mouth or larynx to block the airflow. In these cases, the deep breath may do nothing more than provide additional air pressure for a Valsalva maneuver.

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A prominent "fluency shaping" program includes as one of its targets the taking of a "full breath." This is not necessarily the same as a “deep breath.” However, it should be deep enough to provide an adequate air supply to power one's speech. Costal breathing. A more extreme form of taking a deep breath is a technique called "costal breathing." Before speaking, the stutterer first releases residual air from the lungs and then takes a fast, full breath through the mouth, using rapid rib expansion and full diaphragmatic movement. Speech then begins aggressively at the top of the breath, without hesitation. The emphasis is on powering speech from deep down—without resorting to slow speech, easy onset, light contacts, or other fluency techniques that might cause one to "hold back" while speaking. The costal breathing technique originated with Len del Ferro, an opera singer and voice coach who settled in Amsterdam. It is currently the speaking technique used by the McGuire Programme, which offers three- or four-day intensive motivational courses run primarily by recovering stutterers. My impression is that the rapid intake of air and the exaggerated expansion of the rib cage and lungs during costal breathing may cause a stutterer to displace his "urge to try hard" onto the inhalation before speech, rather than focusing his effort on speech itself. Furthermore, the extreme effort used while inhaling may set up a condition in which the abdominal muscles then tend to relax more readily during exhalation. This muscular relation may have the incidental effect of relaxing the Valsalva mechanism and thereby reducing the likelihood that speech will be blocked. While some people have found this technique helpful in controlling stuttering, costal breathing is nevertheless a strenuous, unnatural breathing pattern with distinct disadvantages. Among other things, it is hard to avoid making a loud gasping sound while inhaling, and using the technique during dinner conversation could be quite a challenge. Airflow technique. There has been a well-known therapy program that advocates the use of "passive airflow" as an aid to fluency. A gentle stream of air is released before easing into the first word. As will be discussed in a later chapter, such a strategy might serve to keep the airway open, thereby avoiding a build-up of air pressure that could trigger a Valsalva maneuver.

Relaxation Because stuttering is usually accompanied by tension, many people have assumed that stutterers would become fluent by relaxing. Consequently, many therapies have employed relaxation techniques in the hope of reducing stutterers' tension while speaking.

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These methods have included therapeutic bathing, sleep therapy, massage, prolonged periods of silence, hypnosis, auto-suggestion, visualization exercises, progressive relaxation, systematic desensitization, and biofeedback. We shall defer our discussion of modern relaxation therapies to a later chapter. For now, we will simply point out that relaxation has had limited success in actual practice. The level of relaxation that stutterers enjoy in the clinician's office is almost impossible to maintain in the stressful environment of the real world. However, relaxation techniques might be more effective if they focused on specific parts of the body, such as the Valsalva mechanism.

Commercial "Stuttering Schools" During the late nineteenth and early twentieth centuries, a number of commercial "stuttering schools" sprang up around the United States and elsewhere. They advertised heavily, charged high fees, and each promised a guaranteed "cure" for stuttering. Stutterers came to live at these boarding schools for several months at a time. The first phase of treatment was usually a period of enforced silence, lasting several weeks. During this time, the students were instructed in relaxation and breathing exercises. Then they were taught the school's secret "method" of fluency (which they were sworn not to reveal). These methods usually employed rhythm, sing-song speech, and similar tricks to produce temporary fluency. The students were drilled in these methods for weeks on end, given pep talks and slogans to build up their confidence in the method, and reprimanded when they failed to use the method diligently. Although many students seemed fluent when they finished treatment, the great majority relapsed after a short time. By the 1930's, these schools and their methods had fallen into disrepute, as more "enlightened" psychological approaches came into fashion. However, with the advent of behavior therapies in the 1960's, many of the stuttering schools' old methods were given a new lease on life.

Modern Approaches to Therapy The modern era of stuttering therapy began in the 1920's and 1930's, with the first serious attempts to approach the problem in a scientific way. At the University of Iowa, researchers developed radically new approaches based on stutterers' attitudes about their speech. Meanwhile, the writings of Sigmund Freud inspired efforts to treat stuttering through psychotherapy. In the next chapter, we shall examine the strengths and shortcomings of these psychological approaches to therapy, which dominated the field until the behavior-modification revolution of the 1960's and 1970's.

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General References BLOODSTEIN, O. A Handbook on Stuttering. 5th ed. San Diego: Singular Publishing Group, 1995, pp. 407-452. BLOODSTEIN, O. & RATNER, N.B. A Handbook on Stuttering. 6th ed. Clifton Park, NY: Delmar, 2008, pp. 342-345. VAN RIPER, C. The Treatment of Stuttering. Englewood Cliffs, N.J.: Prentice-Hall, 1973. WEBSTER, R. L. Fluency Master Procedures. Hardy, VA: Epic Corp., 1989. WESTBROOK, J. B. "Fluency-aids." Letting Go, Oct. 1992, 12, 10, pp. 1, 6-7. WILLIAMS, J. D. 2,000 years of therapy. Speak Easy Newsletter (Paramus, NJ), Fall 1989, 9, 3, 4-5. WILLIAMS, J. D. Use of the Edinburgh Masker. Speaking Out (Canada), May 1991, 8, 5, 7-9. WINGATE, M. E. Stuttering: Theory and Treatment. New York: Irvington, 1976.

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CHAPTER 24.

Psychological Approaches to Therapy 1920's and 1930's saw fundamental changes in the nature of stuttering T HE therapy. Earlier forms of treatment—such as elocution drills, rhythm, special speaking techniques, and other methods discussed in the previous chapter—fell into disfavor because of their failure to produce lasting cures. In their place arose a new generation of therapies, based on the premise that the key to stuttering did not lie in the mechanics of speech but rather in the stutterer's mind. The new therapies did not worry too much about the outward physical symptoms of stuttering. Instead, they focused their attention on various psychological factors that were thought to be at the root of stuttering behavior. The psychological approaches began largely as a reaction to the quackery that had pervaded the field of stuttering therapy up to that time. Some of their early advocates were, in fact, stutterers who had been stung by the commercial "stuttering schools"—which had promised "cures" but produced only temporary fluency that quickly fell apart. In contrast to the superficiality of the earlier methods, the new approaches were supposedly based on more "enlightened" views of stuttering. They offered the hope that stutterers could permanently overcome their problem by changing from within. These psychologically oriented therapies grew out of two separate schools of thought. The first approach, inspired by the psychoanalytic theories of Sigmund Freud and his followers, usually blamed stuttering on repressed emotions or conflicts, buried deep in the stutterer's unconscious mind. It tried to uncover and resolve these problems through various forms of psychotherapy. According to this theory, once the underlying conflicts were gone, the stuttering symptoms would disappear of their own accord. The second approach was developed by early pioneers in stuttering research at the University of Iowa. It attempted to reduce the struggle and avoidance associated with stuttering by changing stutterers' attitudes about their speech. Despite their good intentions, the psychological approaches ultimately created more confusion, frustration, and misunderstanding than ever before. To some extent, they were correct in recognizing that stuttering behavior can be greatly affected by unconscious thoughts and emotions. (Many of these factors have been previously discussed in Chapter 16.) However, in their singleminded pursuit of certain psychological aspects of stuttering, they usually tend-

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ed to ignore the physiological side of the problem. Even worse, there were many psychotherapists (the Freudians in particular) who dogmatically insisted that stuttering was solely the result of emotional conflicts or other personality disorders, without any physiological component whatsoever. In this regard, many of the psychological viewpoints suffered from the same kind of "tunnel vision" that has distorted other theories about stuttering. Therapies built on such narrow and shaky foundations provide little support for the person who stutters. As we shall see, they can even make matters worse.

Freudian Psychotherapy Sigmund Freud profoundly influenced modern thought by showing how human behavior can be influenced by emotions, desires, fears, conflicts, and traumatic childhood experiences that have been repressed into the unconscious mind. For treating these deeply rooted problems, Freud developed an elaborate form of psychotherapy known as psychoanalysis. In this intensive form of treatment, the patient lies on a couch and, guided by a specially trained analyst, embarks on an exhaustive search into his innermost thoughts, feelings, and memories. Among the techniques used in this process are free association (in which the patient reports whatever comes into his mind, allowing one thought to lead into another), analysis of the patient's dreams, and a phenomenon called transference (in which the patient develops feelings toward the analyst that are similar to those he originally felt toward his parents or other significant adults in his childhood). The analytic sessions may be as frequent as five times a week and may continue for several years. Because of the tremendous cost of psychoanalysis, most psychotherapy has been more modest in scale. Typically, the patient meets with a psychiatrist or psychologist once a week and sits in a chair rather than lying on a couch. The therapist encourages the patient to talk about his problems, feelings, and memories, and helps him to resolve various issues as they come up. It should be noted that Freud himself doubted that his psychoanalytic approach was appropriate for stuttering. Nevertheless, his followers came up with a number of theories (previously mentioned in Chapter 16) that attempted to explain stuttering in psychoanalytic terms. Stuttering therefore found its way into textbooks on "abnormal psychology." Stutterers were branded as "neurotic," and their mothers were often blamed for causing them to have defective, stuttering personalities. These theories not only proved to be worthless in the treatment of stuttering, but they also caused indelible harm to stutterers and their families by inflicting shame, guilt, and social stigma. Studies have shown that—regardless of its other benefits—psychotherapy is usually not an effective treatment for stuttering. The experience of the late

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Charles Van Riper, the well-known speech pathologist, is typical. After going through psychoanalysis, he found himself to be better adjusted, but still stuttering. I have heard similar stories from other persons who stutter. I myself spent years in various forms of individual psychotherapy and more than a decade in psychoanalysis, plumbing the depths of my unconscious mind in search of the key to my stuttering. While I did gain some valuable insights into various emotional factors that may have increased my tendency to stutter, I never discovered any psychological "smoking gun" that would finally solve my problem. The fact that psychotherapy rarely cured stuttering did not deter many devout Freudians. Instead of questioning the validity of their underlying theories, they interpreted their failures as merely demonstrating how deeply disturbed, and difficult to treat, stutterers really were. Thus, the fallacious view of stuttering as a "neurosis" was further compounded, leaving stutterers to feel more hopelessly crazy than ever. It is possible that some stutterers in psychotherapy did, in fact, have emotional or personality problems that tended to aggravate their stuttering behavior (as previously discussed in Chapter 16). However, there was no justification for assuming that all stutterers had these problems, that these problems actually caused stuttering, or that they were the only factors involved. On the contrary, it seems more likely that the frustration of stuttering caused the emotional problems, rather than vice versa. Furthermore, as previously mentioned in this book, studies have shown that stutterers as a group are no more neurotic than the general population. The limitations of Freudian psychotherapy can now be clearly understood in terms of the Valsalva-Stuttering Cycle. As we have seen, stuttering involves both physiological and psychological factors. Step 1 of the Valsalva-Stuttering Cycle begins with our anticipation that speech will be difficult. While emotional conflict may contribute to this perception, it is only one out of many factors that may do so. In addition, there are many other stresses or "cues" that may provoke stuttering in a given situation, even in the complete absence of emotional conflict. Freudian psychotherapy is therefore of limited value in alleviating stuttering because it does not address these many other contributing factors. Furthermore, because we cannot hope to eliminate all stress from speaking situations, an effective therapy program must help change the way we react to such stress – both mentally and physically. For example, it should help us to avoid the urge to "try hard" to force the words out, as if they were "things." It should also include techniques aimed at controlling the Valsalva mechanism in a physical way, to keep it from interfering with speech. Speaking situations should also be analyzed to help stutterers understand their motivation for exerting or displaying effort.

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Nevertheless, psychotherapy could be a useful adjunct to such a program, in helping to resolve emotional problems that may be aggravating a particular individual's stuttering or that may have resulted from years of disfluency. However, it must be based on a philosophy that recognizes the crucial importance of physiological mechanisms in stuttering behavior.

Varieties of Psychotherapy Over the years, many psychotherapists have broken away from strict Freudian concepts in their attempts to explain and treat stuttering. The following is a brief assessment of only some of these variations. Recognition of "repressed needs." One of my early experiences with psychotherapy introduced me to the rather simplistic notion that my stuttering was caused by my repression of unconscious needs and desires. Simply put, stuttering supposedly signified a conflict between what I was consciously trying to say and what I unconsciously really wanted to say. The proposed solution was to say only what I really wanted to, and to stop trying to say things that conflicted with my true desires. As a naive high school student, I found this formulation to have great appeal. It gave me permission to stop trying to please others when I spoke, and for a while it did seem to improve my fluency. But the theory had a fundamental flaw. If stuttering indicated conflict and fluency indicated harmony with my true desires, did this mean that I should say only what came fluently and avoid saying the things I stuttered on? (Like my name, for example?) Did this mean that I should avoid difficult speaking situations and confine my conversation to the kind of innocuous remarks that didn't cause me to block? And did it mean that I should refuse to answer when the teacher called on me in class? Obviously, this theory was neither accurate in explaining stuttering nor helpful in overcoming it. On the contrary, it was a prescription for disaster! Releasing repressed anger. Another once-popular theory saw stuttering as a symptom of repressed anger. Some therapists therefore attempted to provoke stutterers to feel and express their anger. Often, this release of emotion was accompanied by temporary fluency. This explanation seems to put the cart before the horse—since much of a stutterer's anger seems to be a result of his frustration over not being able to speak in the first place. Furthermore, the "anger" approach to fluency does not provide an appropriate long-term strategy, as I can again attest from personal experience. During high school, I learned that I could be perfectly fluent when I let my anger loose. Therefore, I experimented with speaking in an angry tone of voice whenever I felt I was going to stutter. For a while, this technique seemed to

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help, but I continually needed to increase my level of anger in order to maintain its effectiveness. Before long I had turned into a very surly, unpleasant person, whose angry fluency was rapidly alienating all his friends. "Expectancy neurosis" therapy. Some psychotherapists do not see stuttering in terms of emotional conflicts or repressed needs, but rather as an expectancy neurosis, based on the stutterer's fixed belief that speech is difficult. According to this theory, it is simply the stutterer's expectation of difficulty that produces the stuttering behavior. Therefore, the goal of therapy is to disabuse the stutterer of this idea and to convince him that speech is actually easy. (Obviously, this would affect the anticipation of difficulty in Step 1 of the ValsalvaStuttering Cycle.) In attempting to show the stutterer that he is capable of fluent speech, therapists have used some of the fluency enhancing conditions previously discussed in Chapter 21, such as unison reading and shadowing. The purpose was not to have the stutterer rely on these techniques permanently, but merely to change his mental expectations. During the 1930's and 1940's, a technique called breath-chewing was used by Froeschels and others for this purpose. Stutterers were taught first to make vocal sounds while moving their jaws in large motions, as if speaking in some savage language. Then they would speak while making chewing motions, and then imagine they were chewing their breath while speaking. These approaches to therapy might have an effect on Step 1 of the Valsalva-Stuttering Cycle, by reducing the stutterer's anticipation of difficulty and by changing his self-image as a speaker. However, it is hard to believe that stutterers' beliefs and behavior will be permanently changed by showing them a few gimmicks that conjure up temporary fluency. Most stutterers already know that they can be fluent some of the time! What stutterers really need is a thorough understanding of why they stutter when they do and a way to control that behavior. Therefore, therapy should not only show that speech is easy; it must also explain exactly why stutterers make it so hard. As we have seen, the stutterer's basic misconception is his unconscious assumption that words can be forced out, as if they were "things," with the assistance of the Valsalva mechanism. In addition to dispelling this belief on a psychological level, therapy must deal with the stutterer's tendency to activate the Valsalva mechanism during speech on a behavioral level as well. Cognitive behavior therapy. This approach to psychotherapy (sometimes called rational emotive behavior therapy) is based on the theory that our feelings and behavior are influenced by the beliefs that we carry around in our heads. The therapist therefore helps the patient to identify the detrimental things he is telling himself, to recognize their falsity, and to replace them with improved beliefs through a process of rational thinking.

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It is easy to see how this approach might be helpful in revising a stutterer's beliefs about the difficulty of speech, his attitudes about stuttering, and other harmful ideas. However, rational thinking alone is not sufficient to conquer stuttering. A clinical trial in Australia found that, although cognitive behavior therapy was associated with significant improvement in psychological functioning in persons who stutter, it did not improve their fluency. (Menzies, et al., 2008.) Therefore, cognitive therapy must be integrated with a holistic approach that encompasses all of the steps in the Valsalva-Stuttering Cycle – both psychological and physiological. A recent elaboration on the cognitive approach to stuttering therapy is called neuro-linguistic programming (NLP) or neuro-semantics. Its popularity seems to reflect stutterers’ need to address the emotional aspects of stuttering, as opposed to the strict behavioristic or fluency-shaping therapies. The NLP view of stuttering begins with the premise (as stated by a leading proponent) that “the origins of blocking and stuttering arise from emotional hurts experienced during childhood”. (Bodenhamer, 2011, p. 2.) It supposes that children then “internalize and express the hurt in the muscles used for breathing/speaking. They begin to block.” (Id., p. 3.) The therapy entails a psychological quest aimed at “identifying those painful emotions and . . . healing them.” (Id., p. 4.) In many ways, this search for the emotional roots of stuttering doesn’t seem much different from my decades of fruitless ruminations and dozen years of intensive psychoanalysis, before I finally got a handle on stuttering through the Valsalva Hypothesis. When I read the materials and internet discussions based on this approach, I am reminded of my younger self, groping aimlessly through a dark labyrinth of memories and emotions in search of the elusive psychological answer to my stuttering. I eventually abandoned the search for a purely “psychological” answer. Nothing made sense until I understood how the psychological, neurological, and physiological components all interacted to cause stuttering.

Attitude Therapy The second school of thought, mentioned earlier in this chapter, emerged out of stuttering research done at the University of Iowa in the 1920's and 1930's. Originally the experiments were about cerebral dominance and changing the handedness of stutterers. However, those efforts were eventually abandoned in favor of various therapies based on the stutterer's attitudes and anxieties about speech. This approach to treatment, commonly known as attitude therapy, was aimed at changing the stutterers' mental attitudes behind their stuttering behavior, such as their feelings and anticipations about speech and stuttering, their self-image as a speaker, their reactions to stuttering, etc. It was thought that

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many of these attitudes and feelings may have developed as a result of stuttering experiences. Although they were not the original causes of stuttering, they might nevertheless help to perpetuate stuttering behavior. Therefore, stutterers were taught to look objectively at their stuttering, without fear and emotional involvement. They were encouraged to talk about stuttering in a free and open way. They were told not to look at stuttering as an external force that afflicts them, but rather as something they themselves do. This was the first type of stuttering therapy to which I was exposed, beginning back in high school. Once or twice a week, I would take a nauseating bus ride from my home town to a nearby city, where I was enrolled at the speech clinic of a major university. I remember sitting with a group of hangdog, adolescent stutterers, telling a well-meaning young woman therapist how rotten we felt about stuttering. This went on for about a year, with nothing to show for it but several cases of bus-sickness. I was again placed in this type of therapy while I was in college, which at least did not require the bus ride. Viewed in terms of the Valsalva-Stuttering Cycle, attitude therapy may affect Step 1 (anticipation of difficulty) and Step 6 (reaction to stuttering). However, it is difficult to change mental attitudes without backing up the exhortations with a clear understanding of the exact mechanisms involved in stuttering and teaching the stutterer specific ways to change his behavior to promote fluency. Therefore, attitude therapy should be integrated with other forms of therapy that effect changes in other steps of the Cycle as well. Acceptance of stuttering. Some therapists carry attitude therapy to the point of saying that the goal of fluency is largely unattainable, and therefore the stutterer should simply learn to accept his stuttering and live with it. Rather than holding out false hopes, the therapist should teach the patient how to stutter openly in a more relaxed way. Certainly, it is better to be a "happy stutterer" than to be frustrated, angry, withdrawn, and miserable. However, it is the rare stutterer who is satisfied with this approach. Most of us go to therapy for the specific purpose of reducing our stuttering—not to be told by the therapist, "Don't worry about it!" Nevertheless, it is probably true that the road to fluency must begin with the acceptance of one's stuttering. It is difficult to understand and control stuttering while we are constantly hiding from it, denying its existence, or struggling against it. Therefore, some therapies use an exercise called voluntary stuttering, in which the stutterer is assigned the difficult task of stuttering on purpose in various situations. One of the objectives is to reduce his fear of stuttering, so he will not react so fearfully to speaking situations. This technique will be discussed at greater length in the next chapter, in the context of behavior-oriented therapies.

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Stuttering modification. Some practitioners of attitude therapy, including the eminent authority on stuttering, Charles Van Riper, eventually discovered that attitude change alone was not sufficient to control stuttering. People still continued to stutter, even when they no longer feared it. (This is not surprising, because the fear of stuttering is only one aspect of Step 1 in the Cycle.) Therefore, Van Riper expanded the scope of attitude therapy to include approaches aimed directly at the stuttering behavior itself. He devised various techniques to modify the stuttering symptoms and to help stutterers cope with their stuttering blocks. In the next chapter, we will discuss these techniques in the context of behavior-oriented therapies, as well as exploring other forms of behavior modification techniques and "fluency shaping" programs.

General References BLOODSTEIN, O. A Handbook on Stuttering. 5th ed. San Diego: Singular Publishing Group, 1995, pp. 407-452. BLOODSTEIN, O. & RATNER, N.B. A Handbook on Stuttering. 6th ed. Clifton Park, NY: Delmar, 2008, pp. 345-346 . BODENHAMER, B.G. I Have a Voice: How To Stop Stuttering. Bethel, CT: Crown House Publishing Co., 2011, p. 2. FREUND, H. Psychopathology and the Problems of Stuttering. Springfield, Ill.: Charles C. Thomas, 1966. FROESCHELS, E. New viewpoints on stuttering. Folia Phoniatrica, 1961, 13, 187-201. GLAUBER, I. P. Dynamic therapy for the stutterer. Specialized Techniques in Psychotherapy. New York: Grove Press, 1952, 207-238. MENZIES, R.G., O'BRIAN, S., ONSLOW, M., PACKMAN, A., ST CLARE, T. & BLOCK, S. An experimental clinical trial of cognitive-behavior therapy package for chronic stuttering. Journal of Speech, Language & Hearing Research, 2008, 51, 14511464. SHEEHAN, J. G. Theory and treatment of stuttering as an approach-avoidance conflict. Stuttering Then and Now (edited by Shames, G.H., & Rubin, H.). Columbus, OH: Charles E. Merrill Publishing Co., 1986, 187-200. TRAVIS, L. E. The unspeakable feelings of people with special reference to stuttering. Emotional factors. Stuttering Then and Now (edited by Shames, G.H., & Rubin, H.). Columbus, OH: Charles E. Merrill Publishing Co., 1986, 93-122. VAN RIPER, C. The Treatment of Stuttering. Englewood Cliffs, N.J.: Prentice-Hall, 1973. WINGATE, M. E. Stuttering: Theory and Treatment. New York: Irvington, 1976.

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CHAPTER 25.

Behavior-Oriented Therapies

I

N CONTRAST to the "psychological" approaches to stuttering therapy discussed in the previous chapter, behavior-oriented therapies focus on what stutterers do, rather than what they think or feel. Such therapies pay less attention to the attitudes and emotions that affect stuttering, and concentrate more on the physical act of stuttering itself. These therapies view stuttering in terms of its outward manifestations – the repetitions, prolongations, forcing on consonants, etc. These external behaviors may be what listeners consider to be “stuttering.” However, from the stutterer’s perspective, these are simply struggle behaviors in response to the “brick wall.” The behavior-oriented therapies usually don’t focus on the underlying block itself. A wide variety of therapies may fall into the behavior-oriented category. In this chapter, we shall look at several examples that have been popular in recent years. As usual, we shall analyze them from the viewpoint of the Valsalva Hypothesis, assessing their strengths and shortcomings in terms of their possible effect on the Valsalva-Stuttering Cycle.

Voluntary Stuttering The first method we shall discuss grew out of research by Bryng Bryngelson and others at the University of Iowa in the 1930's. At that time, speech scientists were rejecting the older forms of treatment (such as rhythm, elocution drills, and unusual ways of speaking), on the grounds that their results were superficial and short-lived. Hoping to achieve better long-term results, Bryngelson tried an approach that was just the opposite of most therapies. He called it voluntary stuttering. Instead of pressuring stutterers to speak fluently, this method required that they stutter on purpose. The stutterers were instructed to block intentionally on non-feared words—those on which no trouble was anticipated. This technique was based on the concept of negative practice. By stuttering intentionally, it was hoped that stutterers would be able to change the involuntary nature of their spasms into voluntary behavior that could be consciously controlled. Originally, stutterers were told to observe their precise stuttering behavior in front of a mirror, and then duplicate the actual blocks when stuttering voluntarily. This proved to be a difficult task. Consequently, this approach was soon

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abandoned in favor of an easier, modified form of voluntary stuttering, called voluntary controlled repetition (or "VCR"). The stutterer was taught to repeat the beginnings of words in an easy, relaxed way, without using the excessive force characteristic of real stuttering. The stutterer was then assigned to go around in public, intentionally tuh-tuh-talking something like thuh-thuh-this. Proposed benefits. Many speech pathologists have strongly recommended voluntary stuttering as a part of therapy. Several possible benefits have been suggested: • Acceptance of stuttering. By stuttering openly, we relieve the pressure and anxiety that comes when we try to hide our stuttering or pretend that it doesn't exist. The benefits of this can be seen in terms of the Valsalva-Stuttering Cycle. Because we no longer feel the demand for perfect speech, we reduce our anticipation of difficulty (Step 1) and our urge to use physical effort in speaking (Steps 2 and 3). Consequently, there may be less tendency to activate the Valsalva mechanism. • Avoidance reduction. Voluntary stuttering forces us to confront our stuttering directly, rather than avoiding it. It short-circuits our tendency to use starters, circumlocutions, and other avoidance behaviors. This could have an impact on Step 5 of the Cycle (avoidance behaviors). • Desensitization. Some experts believe that, by voluntarily stuttering in many different speaking situations, stutterers can reduce their fear of stuttering. To the extent that the fear of stuttering contributes to the anticipation of difficulty (Step 1 of the Cycle), this could ultimately result in less tension and greater fluency. Back in the early years of our local support group, about a dozen of us decided to experiment with voluntary stuttering at one of our meetings. We went around the table reading aloud using voluntary controlled repetition. When we got to one of our regular members, a man who always stuttered severely, he refused to do it. He thought it was ridiculous for stutterers to try to stutter on purpose. After much cajoling, he finally began reading aloud. But instead of using VCR as instructed, he spoke with absolute fluency! Amazingly, when he tried to stutter, he couldn’t do it! This episode demonstrated that, despite his usually severe stuttering, this individual had the capacity to speak with complete fluency before a group. What apparently changed was his intention in speaking. When he intended to stutter, rather than trying hard not to stutter, he paradoxically became fluent. Unfortunately, this fortuitous phenomenon was not easily replicated in others. Drawbacks. Despite its highly touted benefits, voluntary stuttering has had serious limitations. Its first and biggest drawback is that most stutterers simply refuse to do it! I can easily understand why.

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Although voluntary stuttering is supposed to help us confront our stuttering in an honest and open way, I have never felt very honest about using it. Voluntary controlled repetition doesn't sound or look like real stuttering, but rather like the pseudo-stuttering we sometimes hear when people try to mimic us. Listeners don't know what to make of it. Whereas a genuine block might arouse some degree of sympathy, the bogus quality of VCR is more likely to provoke nervous giggles or perplexed stares. Furthermore, voluntary stuttering is rarely an adequate therapy by itself. Fear and avoidance of stuttering are only two of the many factors that contribute to the Valsalva-Stuttering Cycle. I would rather practice techniques that could accomplish the same objectives while at the same time reducing the underlying blocks themselves. If one purpose of voluntary stuttering is to gain control over our spasms, then the behavior that we should target is not the tendency to repeat, but rather our tendency to activate the Valsalva mechanism.

Stuttering Modification Research at the University of Iowa spawned another influential approach to therapy, generally known as stuttering modification. Pioneered by the late Charles Van Riper (who was later at Western Michigan University), it sought to modify the way in which people stuttered, so that their symptoms would be less severe. The stuttering modification therapies generally viewed stuttering as a collection of inappropriate learned behaviors involving the lips, tongue, jaw, larynx, and other parts of the speech mechanism. Stutterers were sometimes told to "freeze" the moment of stuttering in order to identify the symptoms peculiar to their individual patterns of stuttering. Various techniques were then used to help stutterers combat these symptoms. One method was to replace the stutterer's tense struggles with a form of voluntary stuttering that utilized smooth prolongations of sounds. This type of speech is sometimes referred to as fluent stuttering. Block Correction Techniques. Van Riper developed a number of techniques designed to help stutterers deal with their physical blocks more effectively. These consisted of three principal methods: • Pre-block correction. Van Riper found that, before speaking, stutterers often held their mouths tensely in a fixed position, preparing to make the first sound. He referred to this initial position as a preparatory set. Van Riper believed that this rigid posture interfered with the relaxed movement needed for fluency. Therefore, he urged stutterers to adopt a preparatory set in which they began speaking with the mouth and jaw in a relaxed and neutral position. When saying the first sound, the stutterer was to keep moving through one articulatory position to the next, rather than becoming fixed in any one place.

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The stutterer was also supposed to begin airflow and voice immediately on the attempt to say the word. • Mid-block correction. When stutterers found themselves stuck in the middle of a block, they were taught not to struggle, but rather to use a technique called pull-out. They were to finish the word with a smooth, controlled, gliding prolongation. • Post-block correction. A third technique, called cancellation, was designed to correct a block after it was completed, on those occasions when the stutterer had not used the proper preparatory set or pull-out. After stuttering on a word, the stutterer was required to stop, think about what he had just done, and then say the word over again, this time in a more relaxed way. One of the purposes of this technique was to "cancel" the old way of stuttering and to replace it with "fluent stuttering." Effects on the Valsalva-Stuttering Cycle. Some of Van Riper's techniques may indirectly affect the Valsalva-Stuttering Cycle in a number of beneficial ways. Because the speech objective is defined as "fluent stuttering" rather than normal fluency, the stutterer may feel less demand for good speech, thereby reducing his anticipation of difficulty (Step 1 of the Cycle). The "preparatory set" technique, emphasizing constant movement through articulatory positions, may affect Step 2 of the Cycle (the urge to "try hard" by using physical effort). By reminding us that words are a sequence of movements, this technique may reduce our tendency to treat words as if they were "things" that could be physically forced out by means of a Valsalva maneuver. Finally, the techniques of "fluent stuttering" and "pull-out" both rely on the prolongation of sounds. Prolongation is a widely used fluency technique which helps one to focus on phonation of vowel sounds. Problems. Stuttering modification has proven to be a difficult approach, requiring individualized therapy and intensive monitoring of one's speech. Numerous strategies must be learned in order to cope with the many varieties of stuttering behavior. Remembering and coordinating all these techniques during speech is a complicated task that may quickly fall apart in times of stress. Even when the techniques work as they should, the result is still not normal fluency—it is only fluent stuttering. Stuttering modification therapies have had limited effectiveness because they fail to recognize and deal effectively with the neurological basis of stuttering blocks – the motor programming for effort, as in a Valsalva maneuver, in place of the phonation of vowel sounds. Merely trying to modify the movements of the stutterer’s articulators will not resolve stuttering, as long as these underlying neurological and physiological factors are ignored.

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Relaxation The relaxation approach to therapy, which has a long history, gained renewed popularity in the 1920's and 1930's. It has continued to appear in updated reincarnations to this day. The basic concept of relaxation therapy is simple. The therapist uses one of various techniques to put stutterers into a state of deep relaxation. Often this is done in a group setting, with several stutterers lying on mats, listening to a therapist speak in soothing tones. While they are perfectly relaxed, the therapist gradually instructs them to make sounds, form words, and speak sentences. During relaxation, stutterers usually experience an immediate and dramatic decrease in stuttering. Unfortunately, it is a fragile fluency, which quickly crumbles when the stutterer returns to the outside world. The big challenge has been finding a way to reproduce the same level of relaxation and fluency in the stressful environment of ordinary speaking situations. Relaxation techniques. Numerous methods have been used to induce relaxation in stutterers, of which only a few will be mentioned here. One example is visualization therapy, in which the stutterer is asked to imagine a peaceful scene described by the therapist. Visualization is sometimes combined with a technique called systematic desensitization. After becoming totally relaxed, stutterers are told to imagine themselves in various speaking situations. They start with easy ones, like talking to a friend, and move to others that are increasingly difficult, like using the telephone or speaking before a group. These exercises are supposed to help stutterers control their tension when the real situation comes along. However, many stutterers have found that imagination and reality are worlds apart. A more physical approach to relaxing the body is based on a technique called progressive relaxation, introduced by Edmund Jacobson in 1938. The patient is taught to relax various muscles groups, usually beginning with the toes and working all the way up. With each part of the body, the patient first tenses and then relaxes the muscles in question. Nowadays, a person's control over muscle tension can be electronically enhanced by means of electromyographic (EMG) biofeedback. Electrodes, pasted to the skin, are used to measure muscle tension in a part of the body. This information is converted into an audible tone, which changes in pitch depending on the amount of tension. The patient can easily tell when he is relaxing, because the pitch gets lower. The object is to achieve maximum relaxation by making the pitch go as low as possible. EMG biofeedback has been used in stuttering therapy to reduce tension in various muscles involved with speech. One researcher found that relaxation of the larynx and upper lip helped to reduce stuttering.

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Evaluation of relaxation therapy. Relaxation may promote fluency by affecting the Valsalva-Stuttering Cycle on several levels. Psychologically, it may reduce our fear of speaking, and therefore our anticipation of difficulty (Step 1). It might actually make speech easier from a physical standpoint, because relaxed muscles are more responsive than those that are tense and stiff. Relaxation would reduce our urge to use physical effort in speaking (Step 2), as well as relaxing the Valsalva mechanism and preventing its activation (Steps 3 and 4). Unfortunately, stuttering therapies based on general relaxation of the entire body have a serious practical problem. It is difficult to keep oneself sufficiently relaxed, when assailed by the demands and stresses of everyday life. As Van Riper once said, "It's hard to be a limp rag in a steel world!" However, fluency does not require relaxation of the entire body. The only muscles that really matter are those connected with the force behind stuttering—the Valsalva mechanism. It might be easier to maintain the relaxation needed for fluency if one simply concentrated on relaxing some of those muscles (for example, the abdominal and puborectalis muscles). Progressive relaxation or EMG biofeedback might help stutterers learn to do this, thereby enabling them to control the Valsalva mechanism during speech.

Fluency Training Programs During the 1960's and 1970's, the face of stuttering therapy was again transformed—this time by new concepts borrowed from the growing field of behavior psychology. After much trial and error, there emerged a new batch of therapies that might be called fluency training. Although many different methods were used, most of these therapies followed a similar basic strategy: • First, they would teach stutterers a peculiar method of speaking that promoted fluency. They relied heavily on fluency techniques of the past, such as slow speech, prolongation of sounds, continuous phonation, rhythm, or airflow. (The fluency enhancing effects of these and other methods have been discussed at length in previous chapters.) Stutterers were intensively drilled in the techniques until fluency was achieved. Often technological components were added, including delayed auditory feedback ("DAF") to slow the stutterer's speech, miniature metronomes worn in the ear to provide rhythm, or computerized monitoring of the stutterer's speech. • After the particular speaking technique was mastered in an exaggerated form, it was molded into more natural sounding speech. This had to be done gradually, to prevent the loss of fluency. • The final and most difficult step was training stutterers to use the new speaking method in their regular conversation. Modern behavior therapy techniques (including various forms of operant conditioning) were often employed to reinforce the use of fluent speech and to penalize stuttering. To help transfer

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the new skills to the outside world, stutterers would be assigned a "hierarchy" of speaking tasks, beginning with easy situations and working up to more difficult ones. Fluency training was less dependent on individualized therapy than stuttering modification had been, because all patients could be taught the same basic speech technique regardless of their specific symptoms. Consequently, this approach lent itself to the development of standardized programs that could be administered to many stutterers at the same time. Precision Fluency Shaping. Perhaps the most famous of these programs has been the Precision Fluency Shaping Program (now called "The Hollins Fluency System") sponsored by the Hollins Communications Research Institute in Roanoke, Virginia. Stutterers go for an intensive two-week program (previously three weeks) aimed at completely retraining their speech mechanism. For the first week, stutterers are drilled in saying one-syllable words, spoken at a snail's pace of two seconds per syllable. Assisted by computers, they shape their speech in accordance with specified "targets." These have such names as "stretched syllable," "gentle onset," "reduced articulatory pressure," "full breath," "reduced air pressure," "slow change," "transfer," and "amplitude contour." These targets incorporate numerous fluency enhancing techniques, whose effects on the Valsalva-Stuttering Cycle have already been discussed in previous chapters. Through massed practice, they are supposed to become habitual. The patients gradually move on to multi-syllable words and full sentences, until they master a technique called "slow normal speech." Then they are taken out to practice their skills in actual speaking situations. Hollins is only one of many fluency training programs conducted throughout the United States, Canada, and other countries. While some are patterned closely after the Hollins model, others use their own training methods and emphasize different fluency enhancing techniques. Although many stutterers have been helped by fluency shaping programs (including some prominent Americans like John Stossel and Annie Glenn), a great many others have not. Several participants in Valsalva Stuttering Therapy had previously attended intensive fluency shaping programs (sometimes more than once), only to resume stuttering as severely as ever within a month or so. All these persons had similar complaints about the fluency shaping approach: The prescribed speaking method sounded and felt unnatural. It was difficult to maintain in ordinary speaking situations. Speaking in this manner took too much effort and made it hard to remember what they wanted to say. More than one told me that, if they had to speak that way for the rest of their lives, they would rather stutter. Furthermore, the fluency shaping programs did not deal with the emotional issues involved in stuttering.

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To the extent that fluency shaping is successful, it may incidentally affect the Valsalva-Stuttering Cycle in the following ways. Slowing down speech encourages the stutterer to treat words as a sequence of movements, instead of “things” to be forced out of the body by means of a Valsalva maneuver. The same purpose is furthered by breaking down the movements of speech into many separate “targets.” Furthermore, the therapy requires the stutterer to change his intention in speaking, by focusing on hitting “targets” rather than on trying to say the words. This change of intention would affect Step 1 in the Cycle. Fluency shaping’s most fundamental problem is that it’s not like normal speech. Normal speech is easy, effortless, enjoyable, and spontaneous. Fluency shaping is not. It requires constant monitoring and control over one’s articulation and is difficult to maintain. It leads stutterers to believe that speech is difficult and that fluency takes a lot of effort. Therefore, it is no wonder that so many fluency-shaping clients fall back into the Valsalva-Stuttering Cycle. Phonation therapies. Some therapies emphasize phonation as a key to fluency. These include such techniques as continuous phonation, legato speech, prosody, and vocal control therapy. The general idea is to keep the larynx constantly vibrating, with little or no break in phonation between words. The monitoring of one's phonation can also be assisted by the "Vocal Feedback Device" or the "Fluency Master," previously described. Another approach to phonation therapy is Modifying Phonation Intervals (MPI), developed by Roger J. Ingham. It attempts to improve fluency by modifying the elapsed time of the voiced units of a stutterer’s speech. Unlike prolonged speech, which has the effect of stretching vowel phonation, MPI achieves a similar result by reducing the frequency of short phonation intervals. The stutterer’s modification of phonation units is assisted by electronic feedback, including a smartphone app. Therefore, the fluency effect may be due to increased focus on phonation, and especially the voicing of vowel sounds. As discussed in Chapter 21, any method that emphasizes phonation may affect Step 3 of the Valsalva-Stuttering Cycle by neurologically tuning the larynx for phonation rather than for a Valsalva maneuver. Airflow therapy. Another publicized fluency program uses the passive airflow technique, popularized by Martin F. Schwartz. The stutterer is taught to exhale a gentle stream of air through the larynx before beginning to talk. This is to be done in a very relaxed way, without forcing the breath at all. The stutterer then eases smoothly into speech, without interrupting the airflow, and stretches the first word or syllable. If stuttering still occurs, the stutterer then uses "low energy speech," talking softly, with as little effort and movement of the mouth as possible. When it was active, Schwartz's program consisted of a two-day seminar followed by a correspondence course and also

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included exercises aimed at stress reduction and reinforcing the patient's use of these techniques. According to Schwartz, his therapy was designed to combat the "physical cause of stuttering"—which he asserted was a locking of the vocal cords due to stress. While this theory has a certain simplistic appeal, it is contradicted by several studies showing that the vocal cords don't always lock during stuttering. (See Starkweather, 1982; Conture et al., 1985.) On the contrary, the point of blockage is often in the mouth rather than the larynx. To the extent that it is effective, airflow therapy can be explained much more cogently by the Valsalva Hypothesis. First, the airflow keeps the airway open, avoiding a build-up of air pressure that could trigger a Valsalva maneuver. Next, the stretching of the first syllable emphasizes phonation, affecting Step 3 of the Cycle, as previously mentioned. An additional element – which Schwartz himself mentioned at one point – involves a change of intention in speaking. Rather than intending to say a word, the stutterer focuses his intention on breathing.

Shortcomings of Behavior-Oriented Approaches Although modern fluency training programs may be more effective than therapies of the past, the astronomical "success rates" advertised by some programs should be taken with a grain of salt. Furthermore, “fluency” rates are of little relevance if they are based on artificial-sounding speaking techniques that you’d be reluctant to use in ordinary speaking situations. None of these programs should be considered a miracle cure for stuttering. Many stutterers resist using the speaking techniques taught by these programs because they sound "unnatural." The typical response to this objection is, “Well, it’s better than stuttering.” Many also find the need for constant monitoring of one's speech to be an exhausting task. All too often, patients are fluent at the end of the program, but relapse after a few weeks or months. The fact that fluency “maintenance” is so difficult indicates that the effects of therapy were only superficial and did not get to the root of the person’s stuttering. These problems may be due to the fact that the fluency techniques are not only difficult and unnatural sounding, but they don’t do a very good job at controlling the Valsalva mechanism. Even after completing a fluency program, stutterers will still be confronted with the Valsalva-Stuttering Cycle. When they anticipate difficulty in speaking (Step 1), they may feel an urge to "try hard" to use their new technique. Not knowing any better, they may again succumb to their old tendency to activate the Valsalva mechanism, in an effort to help things along by "forcing" the words out.

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Once the Valsalva mechanism takes command of the mouth or larynx, all attempts to use fluency techniques may prove futile. Suddenly, the person may find himself back in the grip of stuttering—without any idea of how it happened!

General References ANDREWS, G., CRAIG, A., FEYER, A., HODDINOTT, S., HOWIE, P., & NEILSON, M. Stuttering: a review of research findings and theories circa 1982. Journal of Speech and Hearing Disorders, 1983, 48, 226-246. BLOODSTEIN, O. A Handbook on Stuttering. 5th ed. San Diego: Singular Publishing Group, 1995, pp. 407-452. BOBERG, E. Relapse and outcome. Stuttering Then and Now (edited by Shames, G.H., & Rubin, H.). Columbus, OH: Charles E. Merrill Publishing Co., 1986, 501-513. BOBERG, E., HOWIE, P., & WOODS, L. Maintenance of fluency: a review. Stuttering Then and Now (edited by Shames, G.H., & Rubin, H.). Columbus, OH: Charles E. Merrill Publishing Co., 1986, 489-500. BURNS, D. & BRADY, J. P. Stuttering and speech disorders. Psychiatric Clinics of North America, 1978, 1, 335-348. CARLISLE, J. A. Tangled Tongue. Reading, MA: Addison-Wesley Publishing Co., 1985. CONTURE, E. G., SCHWARTZ, H. D., & BREWER, D. W. Laryngeal behavior during stuttering: a further study. Journal of Speech and Hearing Research, 1985, 28, 233-240. JACOBSON, E. Self-Operations Control. Philadelphia: J.B. Lippincott Co., 1964. LEE, B. S., MCGOUGH, W. E., & PEINS, M. A. A new method for stuttering therapy. Folia Phoniatrica, 1973, 25, 186-195. PERKINS, W. H. Replacement of stuttering with normal speech: II: Clinical procedures. Journal of Speech and Hearing Disorders, 1973, 38, 295-303. PERKINS, W. H. Do fluency controls ever promote automatic fluency? American Journal of Speech-Language Pathology. Jan. 1992. PETERS, T. J., & GUITAR, B. Stuttering: An Integrated Approach to Its Nature and Treatment. Baltimore: Williams & Wilkins, 1991. SCHWARTZ, M. Stutter No More. New York: Simon & Schuster, 1991. SCHWARTZ, M., AND CARTER, G. Stop Stuttering. New York: Harper and Row, 1986. SHAMES, G. H., AND FLORANCE, C. L. Stutter-Free Speech: A Goal for Therapy. Columbus, OH: Charles E. Merrill Publishing Co., 1980. SHAMES, G. H., AND RUBIN, H., EDITORS. Stuttering Then and Now. Columbus, OH: Charles E. Merrill Publishing Co., 1986. STARKWEATHER, C. W. Stuttering and laryngeal behavior: A review. ASHA Monographs, 1982, 21, 1-45. VAN RIPER, C. The Treatment of Stuttering. Englewood Cliffs, N.J.: Prentice-Hall, 1973. VAN RIPER, C. Speech Correction: Principles and Methods. 6th ed. Englewood Cliffs, N.J.: Prentice-Hall, 1978. WEBSTER, R. L. Evolution of a target-based behavioral therapy for stuttering. Stuttering therapy from a technological point of view. Stuttering Then and Now (edited

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by Shames, G.H., & Rubin, H.). Columbus, OH: Charles E. Merrill Publishing Co., 1986, 397-414. WEBSTER, R. L. Precision Fluency Shaping (Vol. 1). Roanoke, VA: Communications Development Corporation, 1974. WEBSTER, R. L., & STOECKEL, C. M. Precision Fluency Shaping Program: Speech Reconstruction for Stutterers. Roanoke, VA: Communications Development Corporation, 1987. WEINER, A. Vocal control therapy for stutterers: A trial program. Journal of Fluency Disorders, 1978, 3, 115-126. WINGATE, M. E. Stuttering: Theory and Treatment. New York: Irvington, 1976. WOLPE, J. Systematic desensitization based on relaxation. Behavior therapy of stuttering: deconditioning the emotional factor. Systematic desensitization. Stuttering Then and Now (edited by Shames, G.H., & Rubin, H.). Columbus, OH: Charles E. Merrill Publishing Co., 1986, 337-359.

Chapter 26 / Drug Therapy

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CHAPTER 26.

Drug Therapy

W

HILE IT IS NATURAL for persons who stutter to dream of a pill that will bring complete and instant fluency, medical science has yet to find one. Thus far, medications have had only modest and inconsistent results in treating stuttering. Complicating the search for a pharmacological cure is the fact that there is no one drug, or type of drug, that helps everyone who stutters. Some stutterers seem to benefit from one type of drug, others from a completely different type, and others aren’t helped by any drug at all. Meanwhile, many stutterers in the clinical trial control groups become more fluent simply by taking a placebo. This phenomenon, known as the “placebo effect,” shows that expectations may influence a person’s fluency, regardless of what’s actually in the pill being taken. It is apparent, therefore, that drug therapy for stuttering is not a simple matter. The inconsistency in the results may be due to the fact that each individual’s stuttering is affected by different factors that contribute to his perception that speech is difficult. (Step 1 in the Valsalva-Stuttering Cycle.) If anxiety is a significant aggravating factor, the individual may be helped by antianxiety medications. If an individual’s sense of difficulty reflects various neurological deficiencies, he might be helped by medications that improve neurological functioning. Therefore, the question of whether or not stuttering will be reduced by any particular drug depends entirely on the individual. The efficacy of a drug in reducing stuttering is only one consideration. There remains the serious question of whether taking a drug is worth the longterm risk of adverse side effects, when the same or greater increase in fluency might be achieved by non-pharmaceutical methods.

Dopamine Blockers Some persons who stutter have shown modest improvement while taking certain anti-psychotic drugs that block dopamine receptors in the brain. Dopamine is an important neurotransmitter – a chemical that transmits signals from one neuron to the next. Dopamine is involved in many neurological processes, including motivation, pleasure, cognition, memory, and fine motor control. Some researchers believe that stuttering may be associated with excess dopamine uptake that may inhibit those parts of stutterer's brains that modulate

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speech. Theoretically, dopamine-blocking drugs might enable those portions of the brain to become more active, making speech production somewhat easier. If this is true, the stutterer might feel less anticipation of difficulty (Step 1 in the Valsalva-Stuttering Cycle) and therefore less need to activate the Valsalva mechanism in an effort to force the words out. One such “dopamine antagonist” is haloperidol (Haldol), which has been used to treat schizophrenia and to control behavior disorders. Although it has been shown to reduce stuttering, its side effects are so unpleasant and potentially severe that stutterers generally refuse to use it. Another dopamineblocking drug, risperidone (Risperdal), has been found to reduce the severity, but not the frequency of stuttering. (Maguire, et al., 1999.) Although risperidone is more tolerable than haloperidol, it still has potentially severe (and possibly fatal) side effects. Researchers have also investigated other dopamine-blockers, including olanzapine (Zyprexa), and lurasidone (Latuda), which may have somewhat less severe side effects, but still potential risks. More recent studies have involved asenapine (Saphris), a drug used to treat schizophrenia and bipolar disorders, and the experimental drug, ecopipam. These drugs also have risks of potential side effects.

Dopamine versus the Valsalva Mechanism I was personally involved as a subject in one of the first experiments to test the dopamine hypothesis, at a major university in the mid-1970’s. The results – at least in my case – were far from what the researchers had expected. The study was conducted in nine sessions. At the beginning of each session, the researchers counted my disfluencies during oral reading and conversational speech. Then I was given an injection of one of three things: (1) haloperidol, which was supposed to lower my dopamine level and make me stutter less; (2) apomorphine, which was supposed to increase my dopamine level and make me stutter more; and (3) a saline solution as the placebo, which would have no effect. After half an hour, the researchers returned to measure my disfluencies and determine whether there had been any change. Each of the substances was given three times, in random order. This was designed to be a “double-blind” study, in which neither the subject nor the researchers were supposed to know which drug was being administered. However, I noticed distinct differences in how each of them made me feel. One of the drugs – which turned out to be the apomorphine – made me extremely nauseated. Luckily, there was a sink in the room because each of the three times I was given this drug I ended up vomiting violently. But then a strange thing happened. Although this drug was supposed to make me stutter more, exactly the opposite happened. Each time the researchers returned to test

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my speech after I vomited, I was almost totally fluent! The fluency lasted an hour or so, and then my stuttering gradually returned. The researchers were confounded by my sudden fluency because they interpreted the results solely in terms of dopamine levels, while ignoring the episodes of vomiting. The fact that I still stuttered on haloperidol but not on apomorphine seemed to undermine their hypothesis. I myself did not understand what had made me fluent until years later, when the Valsalva Hypothesis provided the answer. Then it all became clear. The act of vomiting employed muscles used in the Valsalva maneuver. After vomiting, these muscles were physically exhausted and had to relax. This shut down the entire Valsalva mechanism, leaving my larynx free to phonate and my lips and tongue free to articulate. When the muscles recovered, stuttering returned. The fluency I experienced did not necessarily disprove the researchers’ hypothesis. However, it did demonstrate that any effect of dopamine on my stuttering was insignificant compared to that of the Valsalva mechanism.

Other Drugs To the extent that anxiety is a factor in stuttering, some stutterers have reportedly been helped somewhat by various combinations of anti-anxiety drugs, such as alprazolam (Xanax), and anti-depressants, such as citalopram (Celexa) and clomipramine (Anafranil). However, none of these drugs are considered a "cure" for stuttering, and all can have serious side-effects. Researchers have also tested the effects of verapamil (a blood pressure medicine that controls muscle contractions), bethanechol (a remedy for constipation), beta-blockers, and many other medications. Such drugs may work on muscles or the nervous system in various ways that may influence the ValsalvaStuttering Cycle. The ideal drug might be one that specifically inhibited activation of the Valsalva mechanism. However, this approach has yet to be explored. More recently, many stutterers’ hopes were pinned on pagoclone, an antianxiety drug that acts as a gamma amino butyric acid (GABA) selective receptor modulator. Early results of a Phase I clinical trial seemed promising. It was reported that 55 percent of persons taking the drug showed a significant reduction in stuttering, compared to 36 percent of the control group taking a placebo. However, subsequent results were apparently less encouraging. The pharmaceutical company conducting the study decided that the results did not meet its “pre-specified criteria for success.” Consequently, the Phase II trial was terminated and government approval of the drug was not obtained. I have been told by a reliable source that pagoclone not only reduced stuttering in some individuals but also improved other aspects of fine motor control. As previously discussed, neurological deficiencies in fine motor

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control might increase the anticipation of difficulty in some individuals who stutter – since speech itself is a fine motor skill. Therefore, any medication that improves the neurological processing of fine motor control might reduce the anticipation of difficulty and the urge to use force.

Thiamine (Vitamin B1) Thiamine (also known as thiamin or vitamin B1) is a B-complex vitamin that plays a role in numerous bodily functions, including the nervous system and muscle movement. There have been reports indicating that thiamine supplements may help to reduce stuttering in some individuals. (Hale, 1951; Schwartz.) Thiamine is part of an enzyme that helps produce acetylcholine, a neurotransmitter in the brain. Therefore, any beneficial effect of thiamine might be attributed to an improvement in neurological functioning.

General References BLOODSTEIN, O. & RATNER, N.B. A Handbook on Stuttering. 6th ed. Clifton Park, NY: Delmar, 2008, pp. 376-380. BRADY, J. P. Alprazolam, citalopram, and clomipramine for stuttering. Stuttering Foundation of America website, URL: www.stuttersfa.org/Research/drugther.htm. BRADY, J. P. The pharmacology of stuttering: a critical review. Am. J. Psychiatry, 1991, 148, 1309-1316. BURNS, D. & BRADY, J. P. Stuttering and speech disorders. Psychiatric Clinics of North America, 1978, 1, 335-348. HALE. L.L. A consideration of thiamin supplement in prevention of stuttering in preschool children. .I. Speech & Hearing Disorders, 1951, 16, 327-333. MAGUIRE, G., FRANKLIN, D., VATAKIS, N.G., MORGENSHTERN, E., DENKO, T., YARUSS, J.S., SPOTTS, C., DAVIS, L., DAVIS, A., FOX, P., SONI, P., BLOMGREN, M., SILVERMAN, A., RILEY, G. Exploratory randomized clinical study of pagoclone in persistent developmental stuttering. J. Clinical.Psychopharmacology, 2010, 30, 48-56. MAGUIRE, G. A., GOTTSCHALK, L. A., RILEY, G. D., FRANKLIN, D. L., BECHTEL, R. J., & ASHURST, J. Stuttering: neuropsychiatric features measured by content analysis of speech and the effect of risperidone on stuttering severity. Compr. Psychiatry, 1999, 4, 308-14. MAGUIRE, G. A. & WITHER, L.G. Without Hesitation: Speaking to the Silence and Science of Stuttering. New York: National Stuttering Ass’n., 2010. SCHWARTZ, M.F. Thiamin and stuttering; a preliminary study. URL: http://www. stuttering.com/ research.html (viewed 1/18/13).

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CHAPTER 27.

Acceptance and Self-Help

A

T THE TIME OF THIS WRITING, stuttering therapy is moving in the direction of what is generally called acceptance therapy. Its growing popularity may be attributed to the beliefs that: (1) fluency therapies don’t work, and (2) stuttering has a neurological and genetic basis that cannot be changed. Therefore, many therapists consider the most realistic option for persons who stutter is learning to accept their stuttering and feeling better about themselves. Much of the stuttering community seems to agree.

Self-Stigma Many persons who stutter have accumulated negative thoughts and feelings about speaking since childhood. This is especially true if their disfluency had evoked negative reactions from their parents or other significant adults. It may have been compounded by ridicule and bullying from their peers. Their blocking on words may not only be frustrating, but also evidence that something is fundamentally wrong with them. Public ignorance about stuttering has given rise to false stereotypes that stigmatize stuttering and persons who stutter. These include notions that stutterers are nervous, anxious, shy, hesitant, reserved, self-conscious, emotionally disturbed, and less intelligent or capable than average persons. Before long, persons who stutter may come to believe these stereotypes and apply them to themselves. This may cause pervasive feelings of anxiety, shame, guilt and doubts about their competence and worthiness as persons. Even if they don’t believe the stereotypes themselves, persons who stutter often fear that their listeners might believe the negative stereotypes. As a result, many persons who stutter fear that, by stuttering in a speaking situation, they will make a “bad impression,” cause listeners to think less of them, and invite the possibility of ridicule and rejection. Consequently, most persons who stutter approach speaking situations with the belief that is very important to “make a good impression” by not stuttering. The stronger this attitude, the more dangerous stuttering will seem, and the higher your amygdala’s “Alert Level” will be in trying to protect you. The result may be stronger effort impulses to force out feared words, which will tend to block words even more. Many stutterers are so afraid of revealing their stut-

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tering that they resort to what is called “covert stuttering.” They try to hide their blocks by using word substitution, circumlocution, and other avoidance tricks. This desperate charade not only increases stress, but it prevents them from saying what they really want to say. These fears and negative perceptions about stuttering may have a broad impact on stutterers’ lives – affecting one’s self-image, relationships, and employment. Furthermore, one’s fear of stuttering tends to perpetuate Step 1 of the Valsalva-Stuttering Cycle.

Acceptance Therapy The goal of acceptance therapy is to diminish stutterers’ negative feelings about stuttering and to reduce their avoidance behaviors. The primary goal of acceptance-based therapy is not fluency, but helping stutterers feel okay with their stuttering, thereby increasing their self-acceptance and self-esteem. Stutterers are encouraged to pursue realistic, achievable goals that will allow them to accomplish what they want in life, regardless of stuttering. Often stutterers are taught to reduce their fear of speaking situations by using a technique called self-disclosure. Stutterers are encouraged to let listeners know in advance that they stutter by announcing it upfront in a neutral, informative, and non-apologetic way. Some therapists have adopted an approach called Acceptance and Commitment Therapy (ACT). Instead of avoiding, denying, and struggling with stuttering, stutterers are taught that stuttering should not prevent them from moving forward in their lives. Clients learn to accept their stuttering and commit to making necessary changes in their behavior.

Self-help Professional therapy is not the only avenue for persons who stutter. Many turn to various forms of self-help, either as an alternative or as a supplement to therapy. Some choose this route because they can't find therapy or can't afford it, or because the therapies they tried have failed. Others use self-help as a follow-up to therapy, a way of practicing and strengthening the fluency techniques they have learned. Self-help should be clearly distinguished from the blind struggle to "stop stuttering" that many stutterers get locked into. When we speak of self-help, we mean a disciplined approach to improving one's fluency based on sound therapeutic principles. Therefore, self-help should begin by educating oneself about the nature of stuttering and approaches to controlling it. An excellent resource is the Stuttering Foundation, which was founded by Malcolm Fraser in 1947. As discussed in previous chapters, most people have found that no therapy provides a total cure for stuttering. The early blush of fluency produced by

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some therapy programs may quickly fade in the harsh environment of the real world. A therapy that works wonders for one person may be a disaster for someone else. Many stutterers try several forms of therapy before they either find relief or give up on therapy altogether. Stutterers' opinions of therapy will naturally depend on the degree of success they have had. A widely accepted rule-of-thumb is that, among all stutterers who undergo therapy: • About one-third achieve substantial, long-term relief from stuttering; • About one-third improve somewhat; and • About one-third obtain no lasting benefit or end up worse than before.1 The most successful one-third will probably swear by whatever form of therapy brought them salvation. They may view therapy as being infinitely superior to self-help. The least fortunate ones, on the other hand, are likely to condemn all therapists as a bunch of charlatans. They may find self-help to be far more valuable (and economical) than the string of failed therapies that both dashed their hopes and depleted their bank accounts. The precise forms of self-help chosen will depend on each individual and the resources available in his or her community. One of the most valuable strategies has been for stutterers to get involved in activities that increase their opportunity to talk and interact with other people. These may include, for example, participation in community projects, religious organizations, amateur theatricals, public speaking clubs, and—most important— support groups in those localities where they are available. One's willingness to become more active and outgoing, despite one's stuttering, has brought greater long-term improvement in fluency than perhaps any other factor.

Support Groups During the past few decades, stuttering support groups have become a valuable resource for persons who stutter.2 In these groups, persons who stutter band together to help each other to help themselves. While the benefits of such an approach now seem obvious, the success of stuttering support groups has been a relatively recent development. Many experts had previously doubted that stutterers had the inclination to form groups. It was generally assumed that persons who stutter did not like to talk to one another, that hearing other people stutter made them feel uncomfortable. This seemed to explain why most attempts to start such groups fizzled after a short time.3 A notable exception was the "Kingsley Club" (named after Charles Kingsley, an English author who stuttered), which was founded by lawyer-philanthropist J. Stanley Smith and which held meetings in Philadelphia and New York during the 1930's and 1940's. Another was the "Plus Club" in Sweden.

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Stuttering groups did not gain a foothold until the late 1960's or 1970's— about the same time that other kinds of support groups became popular throughout our society. The National Council for Adult Stutterers began in 19664, the National Council on Stuttering was founded in 1974, and the National Stuttering Project—now known as the National Stuttering Association ("NSA")—was born in 1977.5 Other groups now include: the Canadian Stuttering Association,6 Friends:,7 SAY,8 and numerous similar groups in many countries. The movement has grown to world-wide dimensions, with the creation of the International Stuttering Association9 in 1995 and the periodic holding of international congresses for people who stutter. Support groups now meet regularly in many localities. These groups provide mutual support to help stutterers build self-confidence and self-respect. At the meetings, the group members can discuss their thoughts, feelings, and experiences about stuttering; gain experience speaking before a group in a supportive environment; practice fluency techniques they may be trying out; and socialize with people who have a common bond. The cost of joining such groups is usually minimal. Some groups are intended to serve as extensions of particular therapy programs. However, most groups (including the NSA) are not based on any fluency method but try instead to make people feel more comfortable with their stuttering. The current thrust of the support group movement is not improving fluency, but rather accepting one’s stuttering. Many of the groups maintain websites and internet chat rooms, which provide information about stuttering research and permit stutterers to share their experiences and ideas with one another. Other activities may include educating the public and combatting prejudice and discrimination against persons who stutter. Organizations such as the NSA periodically hold regional workshops and national conventions. Perhaps the greatest strength of support groups is that they give us the opportunity to meet and share experiences with other people who stutter. Many stutterers have grown up without knowing anyone else who has this problem. In this regard, the Internet has been a double-edged sword. On the one hand, it has provided video discussion groups, chat rooms, and social media platforms that have allowed stutterers to communicate with one another and to obtain information about stuttering. On the other hand, the Internet has reduced their motivation to get out of the house, go to meetings, and interact with other stutterers in person. Physically being with others is an experience not easily duplicated. Unfortunately, many people who would otherwise attend meetings now spend their time sitting at a computer. In terms of the Valsalva-Stuttering Cycle, participation in support groups may reduce the anticipation of difficulty in speaking, thereby affecting Step 1.

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The groups provide moral support, showing the stutterer that he or she is not alone. They help stutterers to view stuttering more objectively, and to feel less ashamed. These changes in attitude may also have a beneficial effect on Step 6 (the reaction to stuttering).

Removing the “C” in “Covert Stuttering” The current mantra of stuttering support groups is to stutter openly and proudly. Persons who stutter are encouraged to make friends with their stuttering and not to hide it. This approach could have a positive effect on Step 1 of the Valsalva-Stuttering Cycle. The “stutter openly” message has been focused especially on the so-called “covert stutterers,” who try to hide their stuttering by using word substitution and other avoidance tactics. They are admonished to stop avoiding and to “stutter openly” instead. Stuttering support groups have sponsored programs to “Remove the ‘C’ from Covert” – in other words, changing covert to overt. In practice, this means that covert stutterers should stop trying to hide or avoid blocks and instead confront the blocks directly – even if it means forcing, repeating, or prolonging sounds. However, even if we accept the premise that stuttering openly is healthier than trying to hide it, we still haven’t tackled the root of the problem. “Stuttering openly” boils down to the overt use of external struggle behaviors in response to the underlying blocks.

Limitations of Conventional Therapies Regardless of whether one pursues professional therapy, self-help, or a support group, one's success at controlling stuttering will depend largely on the therapeutic methods that are employed and the theoretical foundation on which they are based. As discussed in the preceding chapters, all the established therapies have limitations and shortcomings. Many of them perpetuate the unhelpful notion that speech is difficult. Furthermore, none of them focus sufficiently on controlling the Valsalva mechanism—which may be the principal force behind stuttering behavior. While many therapies affect some steps of the ValsalvaStuttering Cycle, they do so in an indirect and inefficient way. According to our hypothesis, therapy would be more effective if it directly attacked all six points of the Valsalva-Stuttering Cycle. It should also be a broad-based approach that deals with all aspects of stuttering – psychological, neurological, physiological, and behavioral. This is the objective of Valsalva Stuttering Therapy. In the next part of this book, we shall explore the ways in which you can use this new approach to free your natural fluency by controlling your Valsalva

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mechanism, changing your reaction to the “effort impulses” triggered by your amygdala, and breaking the Valsalva-Stuttering Cycle.

Notes See Bibliography for complete citation of references. 1.

Bloodstein & Ratner (2008), p. 384; Murray, F.P., Commentary, The Speak Easy Newsletter, Spring 1992, 12,1, p. 6.

2.

Yaruss, Quesal, & Reeves (2007), pp. 256-276.

3.

Van Riper, C., The Treatment of Stuttering, 168-170.

4.

See Van Riper, C., The Treatment of Stuttering, p. 169.

5.

Sugarman, M., NSP going strong: a little history C Part I, Letting Go, July 1990, 34; C Part II, Letting Go, Aug. 1990, 5-6.

6. Canadian Stuttering Association, P.O. Box 3027, Sherwood Park, AB T8H 2T1, Canada. Website: www.stutter.ca. Formerly the Canadian Association for People Who Stutter. 7.

Friends: The National Association of Young People Who Stutter. URL: www. friendswhostutter.org.

8 SAY: The Stuttering Association for the Young. Website: www.say.org 9.

International Stuttering Association. Website: www.stutterisa.org.

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CHAPTER 28.

A New Approach to Stuttering Therapy THAT WE HAVE PIECED together a detailed picture of stuttering N OW based on the Valsalva Hypothesis, we are ready to tackle the ultimate question: How can we use this new understanding to free ourselves from stuttering blocks and replace them with easier, less effortful speech? This part of the book will lay out a comprehensive new approach for reducing persistent developmental stuttering in adults and older children, while promoting easy, natural-sounding speech. Valsalva Stuttering Therapy assumes that most developmental stutterers have the underlying capacity for reasonably normal speech. Consequently, stuttering blocks are not caused by a lack of ability to speak but rather an interference with that ability. Therefore, the goal of therapy is not to control one’s speech, but to identify and control the forces that interfere with speech. The goal is to allow persons who stutter to speak freely in their own natural way. The suggestions in this Fourth Edition go far beyond the exercises described in earlier editions of this book. They are based not only on my personal recovery from stuttering and my many years as an NSA chapter leader, but also on my actual experience as a professional speech-language pathologist (SLP) working with hundreds of persons who stutter. The participants in my Valsalva Stuttering Therapy program have included adults, teens, and pre-teens of both sexes, from all over the world, whose stuttering ranged from mild to very severe. Participants in the program have told me that the therapy’s explanations accurately described their own experiences of stuttering, that they would continue using this approach, that their speech sounded and felt natural, and that they would recommend the therapy to others. Those who had previous forms of treatment reported that the Valsalva approach was more helpful than any other therapy they had tried. I will begin by outlining the components of Valsalva Stuttering Therapy, so you will have an idea of what to expect and what not to expect.

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Mental Attitudes and Expectations Do not expect any magical “tricks” that will automatically stop you from stuttering. Some people come to therapy looking for speaking techniques that will instantly make their stuttering permanently disappear. I have received numerous e-mails such as: “I have a job interview on Thursday and urgently need tips on how to stop stuttering.” Of course, it is impossible for speech-language pathologists to diagnose and treat stuttering by e-mail. Furthermore, any such “tips” would be sabotaged by the stutterer’s intention to make a “good impression” by being “fluent.” For therapy to be successful, the person who stutters must change his motivations and mind-set regarding speech. No matter how good a speaking strategy might be, it will be worthless if the stutterer tries to use it for the wrong intention. Here’s an analogy: Imagine a man trying to drive in a screw by hitting it with a hammer. He becomes frustrated because the screw won’t go in, no matter how hard he hits it with the hammer. His friend says, “That won’t work. Use this screwdriver instead.” The man looks at the screwdriver, grabs it by the shaft, and starts pounding the screw with the screwdriver’s handle. He complains, “This doesn’t work either!” In this analogy, the man was unwilling to let go of his intention to use physical effort for pounding. Likewise, for any therapy to work it is essential that you genuinely change your intention in speaking. As long as you feel compelled to make a “good impression” by trying hard not to stutter, or to use effort in response to anxiety, speech will continue to be difficult. In other words, it’s not enough to have the right tool; you must also use it with the right intention. It is unrealistic to expect that any speaking technique, by itself, will overcome all the factors involved in persistent developmental stuttering. The outward manifestations of stuttering are only the “tip of the iceberg.” In addition to addressing the physical and neurological aspects of stuttering behavior, an effective therapy must also address the beliefs, expectations, fears, and intentions that trigger and perpetuate stuttering. The self-defeating intention to make a “good impression” by being “fluent” is almost universal among persons who stutter. This obsession puts the amygdala on high alert for words and situations that it associates with stuttering. To discourage this way of thinking, Valsalva Stuttering Therapy tries to avoid the

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word “fluency” altogether. Instead, we talk about enjoying easy, effortless speech and focusing on one’s role and purpose in speaking.

Controlling Interference The exercises in this book do not intend to create “artificial fluency” by having you speak in a strange and unnatural way. As previously stated, the goal is not to control your speech but rather to control the forces that interfere with speech. In this book, we have identified and discussed the following sources of interference: •

•

• • • • • •

Negative beliefs, fears, expectations, and intentions, which cause us to fear stuttering and to invest words (or speech in general) with emotional importance. The amygdala (referred to herein as our friend “Amigo”) and its defensive reaction to words and situations that are associated with stuttering, resulting in the release of stress hormones and initiation of the fightflight-freeze response. Suppression of the brain’s motor program for voicing the Key Vowel sound of a word, without which the word cannot be spoken. Substitution of an “effort impulse” in place of vowel phonation, and the stutterer’s fear of not exerting effort in response. Activation of the Valsalva mechanism and performance of a Valsalva maneuver, resulting in forceful closures of the mouth or larynx. The erroneous impression that physical effort helps to “force out” the words, which reinforces and perpetuates stuttering behavior. Mental attitudes that interfere with our ability to give up effort and to use easier, less effortful speech in ordinary speaking situations. All of these factors play out against a background of possible neurological deficiencies, which may both make speech feel more difficult and render speech motor programming more susceptible to interference.

The exercises suggested in this book are aimed at controlling or eliminating each of these interfering factors. The exercises should not necessarily be regarded as “speaking techniques” for use in ordinary conversation. Instead, they are practice routines to replace the underlying causes of stuttering blocks with strategies for easier speech. Then you will combine these strategies to neutralize the sources of interference, allowing you to express yourself more freely through easy, natural-sounding speech.

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The Valsalva-Relaxed Speech Cycle To achieve easier, less effortful speech, one must adopt and implement helpful attitudes, intentions, and behaviors. These can be summarized in six basic rules, which we shall call the Valsalva-Relaxed Speech Cycle.

The accompanying diagram shows how one rule helps to facilitate your use of the next rule, and so on, leading back to the first. Carrying out the rules may be difficult the first time around, but with the help of the exercises suggested in this book, every time you repeat the cycle it will get easier. Change will not happen all at once but will come gradually through repeated practice. The rules are as follows:

Rule 1. Look forward to speaking as an easy and pleasant experience. Our negative beliefs, expectations, fears, and intentions about speech and stuttering set off a chain of psychological, neurological, and physical reactions that lead to blocks and other stuttering behaviors. To prevent this from happening, you will need to change your false and harmful attitudes by understanding

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the nature of stuttering blocks, the Valsalva mechanism, and the essential ease of speech. Instead of expecting the worst, look forward to speaking as an easy and pleasant experience. Rather than worrying about stuttering, accept the fact that sometimes you block on words, and don't try to hide it. Remember that a block is just a neurological glitch that interferes with your phonation of vowel sounds, which you will learn to resolve without struggling. These attitude changes are fundamental to a reversal of the Valsalva-Stuttering Cycle. You might also need to question and abandon some of your deep-seated mental attitudes about yourself, speech, and stuttering. Over the years, many persons who stutter develop a wide range of personal mythologies about their relationship to speech and stuttering. For example, some may believe that they are hopelessly defective, that their worthiness depends on fluency, or that they are in an epic struggle against stuttering in an heroic quest to achieve fluency. In one way or another, these beliefs invest speaking with emotional importance that encourages “Amigo” to try to help out by triggering the release of stress hormones, resulting in blocks.

Rule 2. Focus on your role and purpose in speaking. A significant element in the Valsalva-Stuttering System is our intention in speaking. When we form the intention to “try hard” to say words without stuttering, we dramatically increase the likelihood that blocks will occur. Our amygdala – which we may consider to be our friend, “Amigo” – acts in accordance with our intentions by trying to protect us. When we approach a feared speaking situation in which we feel the need to make a “good impression” by not stuttering, Amigo sets its “Speech Alarm System” on high alert for words that it associates with stuttering. This is especially true for important words in which we have invested great emotional importance. When such words are encountered, Amigo triggers a defensive reaction, releasing stress hormones that generate a fight-flight-freeze response. These stress hormones interfere with the brain’s motor program for voicing the vowel sound, preventing the word from being spoken. In its place, the stress hormones substitute an urge to exert physical effort, by means of a Valsalva maneuver, in an attempt to “force out” the word. Alternatively, we may hesitate or resort to various struggle or avoidance behaviors. Therefore, as a part of your attitude change, forget about trying to be fluent! Forget about trying to make a “good impression” by not stuttering. Focus instead on your role and purpose in speaking. You are not a child, and your listener is not a “judge.” View yourself as an adult expressing yourself to achieve a particular objective – whether it be asking for something, giving information, or simply being friendly. For example, if you go to a restaurant to order a pizza, your role is that of a customer and your purpose is to get a pizza

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– not to make a “good impression” to the waiter. Regardless of whether you are fluent or disfluent, all you will get is a pizza – which is all that you came for.

Rule 3. Treat your speech as melody and movement and focus on Key Vowel sounds. Persons who stutter often treat words as if they were physical objects that could be forced out of the body by a Valsalva maneuver. But while you are forcing and building up air pressure, there is no airflow to vibrate the vocal folds and the word cannot be spoken. Therefore, trying to force out words with physical effort is totally self-defeating. Words are not “things” but a continuous sequence of melody and movement. The melody of speech is also known as prosody. It contains a combination of elements, including continuous changes in the pitch, loudness, and inflection of the vowel sounds. The melodious airflow is then molded into a symbolic sequence of sounds by continuous movement of your lips and tongue. These sounds are carried as vibrations in the air to the ears of your listeners. If they understand your language, their brains will automatically decode the sequence of sounds into words and meaning. On the other hand, if you treat a word as a “thing” to be forced out by building up air pressure, then it is no longer a word. There is no melody, no symbolic sequence of sounds, and no meaningful vibrations to be carried through the air to your listeners. Several exercises in Valsalva Stuttering Therapy are specifically designed to focus attention on the melody and movement of speech. The Key Vowel sound is the loudest part of a word. Consequently, this would be the sound most likely to be heard if you were hiding from an enemy. (Remember our example of the prehistoric human and the lion.) According to the Valsalva Hypothesis, a stuttering block occurs when the brain’s motor program for phonating the Key Vowel sound is suppressed and replaced by an impulse to exert physical effort by doing a Valsalva maneuver. The logical remedy for this problem would be to restore the motor program for phonating the Key Vowel. Therefore, forget about trying to say the word itself and focus your attention instead on voicing the Key Vowel sound. The Key Vowel fits into the melody of speech by being the part of the word that begins at the highest pitch. The rest of the melody fits around it. Voice the Key Vowel sound with inflection and feeling and let the rest of the word “come along for the ride” without thinking about it.

Rule 4. Tense your puborectalis muscle to discharge the effort impulse, then relax your puborectalis and abdomen to relax your Valsalva mechanism. When blocking on a word, you are likely to feel a strong impulse to exert physical effort to force out the word by means of a Valsalva maneuver. This

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“effort impulse” is usually directed to the lips, tongue, or larynx – whichever is responsible for making the consonant or glottal stop preceding the vowel sound. That part of the speech mechanism will persist in forcing until the effort impulse is discharged, after which the word can be spoken (except in those instances when the effort impulse is never discharged). Rather than forcefully struggling in your mouth or larynx, you can learn to divert the effort impulse to a part of the Valsalva mechanism that is not involved in either speech or breathing. This is the puborectalis muscle (or “PR” for short). It is designed to squeeze the bottom of the rectum shut during a Valsalva maneuver, to prevent abdominal pressure from causing accidental evacuation of the bowels. As soon as you feel an effort impulse, you can divert it from your mouth or larynx by immediately squeezing the PR as you start to inhale. Squeezing the PR will help to discharge the effort impulse. Next, the PR can reduce the tendency to force on consonants and glottal stops. The muscles used in a Valsalva maneuver are neurologically coordinated to act together as a team. Therefore, the more the abdominal and chest muscles squeeze to increase air pressure in the lungs, the tighter the larynx or mouth will close to hold in the air. However, if any part of the Valsalva mechanism relaxes, the entire mechanism will automatically relax, preventing performance of a Valsalva maneuver and the blockage of airflow. The best part of the Valsalva mechanism to relax is the puborectalis muscle. After tensing your PR to inhale, slowly relax your PR as you exhale. This will relax your entire Valsalva mechanism and whatever muscles in your mouth or larynx are forcefully blocking the air. This will also free your larynx to phonate the vowel sounds. Be aware, however, that simply knowing what to do is not enough – especially when the stress hormones cloud your thinking. You will need repeated practice in Valsalva-relaxed breathing to overcome the urge to force.

Rule 5. Speak in phrases, and let the words flow on your relaxed outward breath. Saying sentences is easier when you break them into phrases, taking a Valsalva-relaxed breath between each phrase. Because phrases are shorter, they are more adaptable to Valsalva-relaxed breathing, less intimidating, and less likely to activate your amygdala. Speaking in phrases also helps your listener to understand what you are saying. Each phrase contains a chunk of information, which the listener has time to comprehend before you go on to the next phrase. Many persons who stutter try to speak rapidly, as if racing to get the words out before a stuttering block catches up with them. By trying to squeeze as many words as possible into a single sentence, you may find yourself running out of air. When this happens, your chest and abdominal muscles contract to force out

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more air. This will interfere with Valsalva-relaxed breathing and may set the stage for a Valsalva maneuver. Your Valsalva-relaxed outward breath is the substance for all the sounds of speech. View your exhaled breathing as being primary to everything else. Let your Valsalva-relaxed breath set the pace for all your speaking. The words should always be subservient to your breath. Let the words come when they are ready, carried along by the outward flow of air. Your breath should not be used to “push out” words, because that will build up air pressure and lead to blocks.

Rule 6. Objectively view your speech as a learning experience. The final step in the Valsalva-Relaxed Speech Cycle is to eliminate the negative reactions you may have to your stuttering. This is aimed at counteracting Step 6 of the Valsalva-Stuttering Cycle, in which the speaker views stuttering as confirming his original belief that speech would be difficult. Stutterers may also get the false impression that their use of effort ultimately succeeded in forcing the words out. The use of effort may also be reinforced by its short-term effect in reducing the stutterer’s anxiety. Therefore, view your speech objectively, without shame or blame. Imagine that you are like a scientist, examining a natural phenomenon without casting judgment. Learn from your speaking experiences, both fluent and disfluent, and maintain your self-esteem, regardless of fluency.

Motivation for Change Before beginning therapy, either on your own or with an SLP, it is important to take a good, hard look at your motivation for doing so. As we have seen, your intention to try hard to “stop stuttering” actually perpetuates stuttering by putting your amygdala on high alert for words and situations associated with stuttering. We can imagine your friend “Amigo” saying, “Oh, you want to be fluent! I can help you with that!” But all Amigo can do is trigger the release of stress hormones, which interfere with speech. In this way, the wrong motivation can undermine therapy and send you right back into the Valsalva-Stuttering Cycle. If your motivation is to gain approval from other people – your parents, relatives, teachers, employers, peers, etc. – you may find yourself exerting effort in an attempt to show how hard you are trying to please them. Therefore, you must begin by understanding that this therapy is not about pleasing them. Nor is it about pleasing your therapist. This therapy is only about you. Another sure recipe for disappointment is trying to show off how fluent you are, or to prove how effective a new speaking technique is in preventing stuttering. Attempts to demonstrate fluency are bound to fail, because your underlying motivation will be to try hard not to stutter. This motivation is almost sure to suck you right back into the Valsalva-Stuttering Cycle.

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It also doesn’t help if your motivation is based on your negative beliefs about stuttering – e.g., that it’s shameful, humiliating, or makes you less worthy as a person. Such attitudes stir up your anxiety and prompt you to use effort in trying hard not to stutter. In reality, stuttering is not shameful and has no bearing on your self-worth. It is simply the result of a neurological reaction, triggered by your amygdala, which replaces vowel phonation with the physical effort of a Valsalva maneuver. A much more helpful reason for pursuing therapy is simply that you would like your speech to be easier, less effortful, and more enjoyable. While stuttering is not shameful, it certainly can be inconvenient and annoying. In extreme cases, it can even be physically painful. Stuttering can waste tremendous amounts of physical and mental energy that you would rather devote to expressing yourself and saying what you want. Coincidentally, the same may also be true about unnatural “fluency techniques” that would require you to use even more effort in speaking. Valsalva Stuttering Therapy is different. If you find yourself “trying hard” to do the exercises in this book, you are completely missing their purpose.

Who Might Benefit The approach in this book is intended for adults and teens who have been struggling with the ordinary developmental type of stuttering. It probably would not be appropriate for people with severe neurological deficits or other types of disfluencies; for example: acquired stuttering (caused by brain injury or disease); apraxia of speech (an oral motor speech disorder affecting articulation); spasmodic dysphonia (a neurological condition affecting the vocal folds); or language impairments such as aphasia (the inability to think of words). Such conditions may require treatment of a totally different nature. The Valsalva Stuttering Therapy approach may be adapted for pre-teens, but it’s not intended for young children just beginning to stutter. While it is possible that some of its concepts and techniques might be adaptable for use with young children, this has not been tested. As we have seen, the factors that cause a child's original disfluency may be different from those that perpetuate stuttering in older children and adults. Today there are "stuttering intervention" programs designed to nip early stuttering in the bud before it becomes entrenched.

Individual Needs Persons who stutter vary dramatically in their severity, as well as in the kind of help they need. Some of the participants in my program were so severe when they started therapy that they blocked on almost every word during the first session – and sometimes more than once on multi-syllabic words. In contrast, there have been many participants who rarely displayed any overt stuttering during therapy sessions, but who reported serious problems in other speaking situations,

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such as when introducing themselves, giving presentations at work, or saying words for which there was no appropriate substitute. In these cases, much of the time was devoted to learning a “word recovery” response to blocks, role-playing exercises, and discussing and analyzing speaking experiences, fears, attitudes, and intentions. Even these persons needed repetitive practice in Valsalva-relaxed behaviors, in order to resist the urge to exert effort when stressful situations arose. Such practice has also helped “covert stutterers” deal with their internal blocks, so they can say exactly what they want, without word substitutions and other avoidance behaviors. Many aspects of stuttering therapy require individualized supervision and counseling for best results. Persons who stutter have varying abilities in processing speech and language, as well as different fears, experiences, and emotional baggage. Consequently, there is no “one size fits all” when it comes to stuttering therapy. Although Valsalva Stuttering Therapy is a structured approach, it is also very flexible. The results of any stuttering therapy, as well as the time required, will vary depending on the individual. For example, I have found that stutterers are less responsive to therapy if their speech is seriously affected by neurological or cognitive deficits or by deep-seated emotional problems. For others, the struggle against stuttering has become such an integral part of their personal identity that they resist making the necessary changes to their intentions in speaking. This has been especially true of older, retired persons who have little practical motivation to change. The best results have been achieved by young adults who viewed stuttering as an unwanted obstacle to their desired career goals.

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CHAPTER 29.

Adopting a Valsalva-Free Attitude

S

TRATEGIES FOR EASIER SPEECH will have little value as long as we harbor attitudes that make Valsalva tuning almost inevitable. Beliefs about the difficulty of speech and the need to "try hard" are what set the Valsalva-Stuttering Cycle in motion. Therefore, an essential part of Valsalva Stuttering Therapy is to challenge all the assumptions about speech and stuttering that we have accumulated through the years. Speech itself is not difficult. What is difficult is changing our attitudes and behaviors that make speech difficult. If you are like me, some of these attitudes date back to childhood, when stuttering first began. They are so long-standing that we rarely bother to question them. We unconsciously accept them as immutable facts of life, like gravity. However, they are the ground in which the Valsalva-Stuttering Cycle is rooted. We must now replace them with attitudes that are "Valsalva-free."

Identify Your Negative Attitudes The first step in the Valsalva-Stuttering Cycle is the expectation that speaking will be difficult, or that a particular word or sound will be hard to say. There is probably no stutterer in the world who doesn't have such a negative anticipation, at least on an unconscious level. Any number of factors may contribute to the expectation of difficulty, depending on the individual and the speaking situation. Some of these have been discussed in previous chapters. They may include: • • • • • • •

The belief that you are inherently inferior or defective because of stuttering; The belief that speech is difficult and that specific words, sounds, or speaking situations are especially troublesome; The memory of past experiences in which speaking was a struggle; Fear being judged negatively because of stuttering; Excessive concern about the importance of good speech and the need to “make a good impression” by speaking fluently; The feeling that you must show how hard you are trying to speak fluently order to please those who may “judge” you; The belief that using physical effort helps you “force” the words out;

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Uncertainty, emotional conflict, or ambivalence about talking; A feeling of impaired speaking ability due to fatigue, illness, inexperience, or other factors; and Your self-image as a “stutterer.”

Before these attitudes can be changed, we must be able to identify them and recognize the pernicious ways in which they interfere with our preparation for speech. The next time you feel anxious about a speaking situation, stop for a moment and notice what you are thinking. Are you thinking about how hard it will be to get the words out? Are you especially worried about saying certain words or sounds? Are you expecting to be judged according to your fluency or stuttering—as if speech were a test of your worthiness as a person? Are you viewing the prospect of speaking as a painful struggle, an uphill battle? For confirmed stutterers, thoughts like these may become so entrenched that they are accepted as self-evident truths. Their validity seems to be reaffirmed, time and again, by the whole agonizing experience of stuttering. However, they should not be taken at face value. As we have seen, the expectation of difficulty may become a self-fulfilling prophesy by setting in motion the Valsalva-Stuttering Cycle. Such thoughts are not true reflections of how speech has to be. On the contrary, they are part of the problem. Much has been written about the "self-talk" that constantly goes on in our minds, and how these internal dialogues affect the way we feel and behave. The same is true in stuttering. Therefore, in order to change our attitudes we must: • • •

Be aware of the negative things we are telling ourselves; Recognize their false and self-defeating nature; and Replace them with positive statements that will help us relax our Valsalva mechanism and deal more effectively with speaking situations. See the suggestions in “Valsalva-Free Self-Talk” in Appendix A to this book.

If your sense of difficulty is aggravated by emotional conflicts or other fears or ambivalence about speaking, you may have to dig deep into your feelings and memories to figure out what's bothering you. This may require, in appropriate cases, the help of a psychotherapist to help sort things out. However, psychotherapy should not be seen as a “cure” for stuttering itself. As we have repeatedly pointed out, emotional conflict is only one of many factors that may influence stuttering.

The Challenge of Being Objective Freeing oneself from stuttering requires, first of all, that we look at speech and speaking situations objectively. We must strip away the layer upon layers of beliefs and fears that we have accumulated. We must view speech in its simplest

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form, unencumbered by emotional baggage. Basically, speech is breathing, phonation, and articulation – all of which we know how to do, either separately or together (at least in some situations). In fact, many persons who stutter are fluent most of the time, but nevertheless block on important words when saying them really matters. Giving up familiar beliefs may leave some stutterers feeling naked and vulnerable. Some may have developed a personal mythology about their relation to stuttering that has become central to their self-identity. They may view themselves in a heroic struggle that gives “meaning” to their life.

Look Forward to Speaking The first rule of the Valsalva-Relaxed Speech Cycle is to develop a positive attitude toward speech. Of course, your deep-seated negative attitudes won't be changed overnight. They must be continually challenged, again and again, as part of a systematic attack on the entire Valsalva-Stuttering Cycle. The goal is to create an attitude in which you look forward to speaking as an easy and pleasant experience. You might start the process by searching your memory for speaking experiences that were enjoyable—even if you weren't fluent. Recall the fun you had conversing with your family, friends, or other people. Think of the satisfaction you felt when you spoke your mind, when you shared your ideas and feelings. Good memories may, at first, seem few and far between. However, they are bound to increase if you stop judging your speaking experiences according to fluency and concentrate instead on their enjoyable aspects. Likewise, when you speak, focus on the pleasure you can have, whether or not you stutter. Whenever you can, practice speaking just for the fun of it. You might read poetry or dramatic speeches aloud to yourself or into a tape recorder. Put expression and feeling into your readings. Let yourself be a "ham."1 Take pleasure in the music and resonance of your voice. Experiment with various kinds of intonation and emphasis, especially when saying the vowel sounds. Sense the way your mouth caresses the words as they are formed. Look for opportunities to speak in a relaxed, supportive environment. An ideal place may be a self-help support group, such as the National Stuttering Association (NSA). If there is one in your area, go to the meetings. Participate in the discussions. Get up and give extemporaneous speeches to the group. Feel good about yourself for speaking, regardless of your fluency. Remember, speech is not a test of your worthiness. It's simply a method of communication, which you are entitled to use as much as anyone else. So don't take it so seriously. Be playful about it and lighten up. No law says that you must constantly beat up on yourself for stuttering.

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Accept the Fact that You Sometimes Block “Acceptance of stuttering” is a theme echoed by many speech therapists and stuttering support organizations such as the NSA. To promote such acceptance, many therapists tell clients to “advertise” their stuttering by stuttering on purpose. Despite the inauthentic sound of “Voluntary Controlled Repetition,” this approach may have a beneficial effect by reducing the intention to “make a good impression” by hiding one’s stuttering. Some people find that voluntary stuttering reduces the fear, stress, and struggle associated with speaking. But many others are uncomfortable doing it and not satisfied with just being a “happy stutterer.” They would rather find a way to resolve their stuttering altogether. Nevertheless, if you are to overcome your stuttering, you must first be willing to accept its existence and look at it objectively. Some people feel that stuttering is too shameful and degrading to own up to. They go to desperate lengths to pretend that it's not really happening. I myself have tried this in the past. Whenever I started to block, my mind went into what's been called "the stutterer's fog." I momentarily "switched channels," so to speak, to avoid dealing with reality. This simply made my listener feel more uncomfortable than ever and destroyed any chance of honest communication. The more I tried to deny my stuttering, the more I abdicated control of the situation. By closing my eyes to what was actually going on, I never learned a damn thing. I let myself get sucked into a blind struggle to "stop stuttering," in which I kept making the same mistakes over and over again. I let myself become a helpless victim of the Valsalva-Stuttering Cycle. Accepting the fact that you stutter doesn't mean giving up easier, less effortful speech. On the contrary, it makes this more attainable. When you are less fearful of stuttering, you reduce, to some degree, your anticipation of difficulty (which is Step 1 in the Valsalva-Stuttering Cycle). Acceptance allows you to observe and understand your stuttering behavior in a constructive way. Furthermore, being honest with yourself about this important aspect of your life can be the foundation of genuine self-esteem and personal power. However, accepting the fact that you sometimes block on words does not mean that you must accept all the unhelpful behaviors, negative implications, and misconceptions commonly associated with the word “stuttering.” For example, the fact that you stutter does not mean: • That you are inherently incompetent as a speaker; • That you are unable to say certain consonants or initial sounds; • That you have defects in your brain or speech mechanism that compel you to repeat, prolong, or force when speaking; or • That you have a psychological or emotional disorder.

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When viewed objectively, there is nothing shameful about stuttering. It is not a sign that we are defective, crazy, or unworthy. According to the Valsalva Hypothesis, stuttering results from confusion between two otherwise normal bodily functions—the voice and the Valsalva mechanism. This now provides a plausible explanation for stuttering that you can discuss with other people without any cause for embarrassment. Based on the Valsalva Hypothesis, you can now accept and deal with your “stuttering” in a much more positive and useful way than in the past.

Selective Vowel Aphonia As previously demonstrated in this book, the neurological suppression of vowel phonation is at the heart of stuttering blocks. However, it is the consonants that seem to get all the attention. Many listeners find the stutterer’s hesitations, forcing, repetitions, and prolongations difficult to understand. They routinely hear that stuttering is a “mystery,” having no known cause or cure. Consequently, they may feel free to supply their own inaccurate ideas, which may fuel the stigma attached to stuttering. To head off such misconceptions, it might be helpful for you to disclose to your listeners, in a non-apologetic matter-of-fact way, that your stuttering is a “neurological” condition and that it’s no big deal. Alternatively, you might consider redefining your stuttering blocks in a more accurate, concrete way. Your new explanation can focus on the unreadiness of your larynx to phonate the vowel sound of a word. I have called this problem “selective vowel aphonia.” “Aphonia” is the inability to phonate, which is focused on vowel sounds, and which is selective because it only happens some of the time. By defining your blocks as simply a voice problem, this explanation avoids speculation about mental or emotional abnormalities. Here is what you need to accept, and what you can tell your friends and coworkers: “I have a voice problem. Sometimes my larynx isn’t prepared to phonate the vowel sound of a word. When that happens, I have to stop and get my larynx ready to voice the vowel sound.” Then, when you feel blocked, you can raise the palm of one hand to show that you’re not finished talking, and you can touch your throat with the fingers of your other hand to show that you are preparing your larynx to voice the vowel sound.

Resist the Urge To Use Force Resisting the “effort impulse” to force out words is the most difficult challenge in overcoming stuttering blocks. How you respond to the stress hormones triggered by your amygdala will determine your success or failure in transferring therapy strategies to ordinary speech. Perhaps the greatest misconception to plague stutterers is the notion that

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physical effort will help them “get the words out.” In the past, I was painfully aware of this tendency in myself. When I anticipated difficulty, I hit the "panic button." I was gripped by an overwhelming urge to force on the consonants or glottal stop while trying to push out the words with a Valsalva maneuver. Somehow, this felt like my only way to salvation. The very notion of not using effort seemed too frightening to contemplate. When the "moment of truth" arrives, the urge to use force may feel overwhelming; the idea of speech without effort may seem impossible. It takes courage not to hit the panic button. In addition to courage, you must develop faith that nothing bad will happen if you don’t use effort. One’s reaction to the effort impulse can involve both mental attitudes and learned behavior. Human beings have probably inherited the tendency to obey signals sent from the amygdala. In physically dangerous situations, our response could be a matter of life and death. Therefore, the same feeling of urgency may be carried over into speaking situations. Exerting effort in the mouth or larynx while doing a Valsalva maneuver may also help to discharge the effort impulse. Forcing itself does not get the words out. On the contrary, the blockage of airflow prevents words from being spoken. It is not until the effort impulse is discharged that the block goes away. Consequently, persons who stutter are left with the false belief that using force helped to get the words out. This reinforces the habit of forcing on consonants and glottal stops. As demonstrated by the exercises later in this book, there are ways to dissolve stuttering blocks without forcing on the words. However, persons who stutter often fail to employ the new strategies and resort to their old habits instead. They may feel that strategies to dissolve blocks will “take too long,” in the erroneous belief that forcing on the words will be quicker. Or, in their panic, they feel it too dangerous to rely on less effortful alternatives. Using effort may seem like the "good" and conscientious thing to do. It may relieve our feelings of guilt by showing people how hard we're trying to get the words out. However, in reality this attitude is self-defeating. It only increases our tendency to activate the Valsalva mechanism, which leads to even more blockage of speech. As we have seen, fluent speech requires very little effort. No matter how difficult the speaking situation seems, effort never helps to get the words out—it only serves to block them in.

Focus on Your Role and Purpose in Speaking When persons who stutter approach speaking situations, they often feel that their most important purpose is to “make a good impression.” This almost always means “try hard not to stutter” – and the result is almost always the same.

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For the reasons previously explained, this kind of intention virtually guarantees that stuttering will occur. Therefore, you must abandon any thought of “making a good impression” by not stuttering. Forget about fluency. None of that is important. View your speaking task in its simplest terms. Focus solely on your role or purpose in speaking and the things you want to communicate. Specifically: • What is your role in speaking? Focus on this role, instead of viewing yourself as a “stutterer” who is trying hard not to embarrass himself. Some examples are: friend, neighbor, family member, customer, sales person, student, teacher, group member, employee, co-worker, supervisor, patient, client, advocate, counselor, entertainer, public servant. Focus on doing a great job performing this role, whatever it is, whether you stutter or not. • What is your purpose in speaking? In other words, what is the result that you want to accomplish? Your purpose may be to make a request, to place an order, to obtain information, to convey a message, etc. Focus on this basic purpose, without paying any attention to extraneous notions such as proving your fluency, making a good impression, or showing how hard you’re trying. Those things are not your purpose in talking. • To whom are you speaking? Remember that your purpose is to communicate with another human being. If you are like many people who stutter, your awareness of a listener may cause you to feel anxious. If so, remember that the real problem is not the fear itself, but rather how you react to the fear. Confront your anxiety by letting yourself feel a communicative link with the other person. Make eye contact. Let yourself have fun communicating, without regard to fluency. You are not communicating when you turn the conversation into a personal struggle to force out the words. Your listener doesn’t care how hard you’re trying. Your listener doesn’t care what kind of impression you make. He or she just wants to hear what you have to say. • What are the specific things you want to communicate? These may include important bits of information, questions, comments, observations, warnings, compliments, complaints, criticisms, observations, thoughts, feelings, etc. Sometimes you can help focus your intention by writing down the main points in advance. • What words are needed to convey your message? Choose the words that seem most suited to your purpose and accept responsibility for saying them. Don’t fool yourself into thinking that the words will become any more powerful if you hang onto them and try to inflate them with air pressure from a Valsalva maneuver. Using excess effort doesn’t make your words any more effective. On the contrary, it blocks them. Relax, have faith in your words, and let them carry your meaning. If the words don’t seem to be achieving your purpose, you won’t improve things by resorting to effort. Just stay relaxed and choose

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other words. The less energy you waste on physical effort, the more energy you’ll have for thinking about what you want to say.

Visualize Your Speaking Role Visualization can be a powerful tool for improving one's attitude toward speech. In this technique, you create a detailed mental image of yourself in various speaking situations.2 The object of this exercise is to imagine all of the enjoyable and rewarding aspects of talking with other people—without any regard to stuttering. You should not try to picture yourself being fluent, at least in the beginning, because this may be an unrealistic goal that only increases your anxiety. Instead, your mental picture should focus on the underlying role that you are playing, while giving yourself permission to stutter all you want. For example, if you are going to perform a role on stage, you should imagine yourself as actually being the character—while at the same time pretending that the character is supposed to be someone who stutters. If you are giving a sales promotion, imagine that you are a very effective salesperson—who just happens to stutter. I have found this approach to be quite valuable during my legal career. When I first prepared to represent clients in court, I managed to subdue my fear of stuttering by concentrating on my role as a lawyer. I said to myself: "I am an advocate. I may be a stammering advocate, but, first and foremost, I am an advocate!" My zest for being a trial lawyer ultimately swept aside any concern about stuttering, allowing me to perform effectively in many trials and other challenging situations.3 One of the most effective ways to accomplish this is to change your intention in speaking. This will be discussed further in the next chapter.

Notes 1.

2.

3.

You may wish to try some of the public speaking exercises found in Harrison, J. C., Redefining Stuttering (formerly entitled How To Conquer Your Fears of Speaking Before People) 12th ed, New York: Nat'l Stuttering Ass'n, 2008. Some persons who stutter have told me that they have benefitted from the relaxation and visualization techniques found in Maltz, M., Psycho-Cybernetics (Hollywood, CA: Wilshire Book Co., 1960). As we shall discuss further in later chapters, the real obstacle is not fear itself, but the way we have learned to react to fear. See Jeffers, S., Feel the Fear and Do It Anyway, New York: Fawcett Columbine, 1987.

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CHAPTER 30.

The Power of Intentions

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VERCOMING STUTTERING cannot be accomplished, on any permanent basis, simply by learning “fluency techniques.” In order to free yourself from stuttering, you must confront and change all the steps in the Valsalva-Stuttering Cycle. This challenge begins with Step 1 in the Cycle – the beliefs, fears, expectations, and intentions that trigger Valsalva tuning and stuttering blocks. These psychological and neurological elements interact with and reinforce one another to form what we have called the “Valsalva-Stuttering System.” In order to overcome stuttering, this entire system must be dismantled. But where do we start? What part of the Valsalva-Stuttering System would be most susceptible to change?

Dismantling the Valsalva-Stuttering System The Valsalva-Stuttering System is founded on unhelpful beliefs about such things as the difficulty of speech, our incompetence as speakers, the shamefulness of stuttering, and the need to “try hard” not to stutter. To some extent, negative beliefs can be counteracted through education. But it is one thing to understand something intellectually and quite another to accept it emotionally. It’s not likely that persons who stutter will fully believe that speech is easy as long as they continue to struggle. Our beliefs lead into expectations and fears that we will stutter on certain words or sounds or in certain speaking situations. We also base these expectations on our past speaking experiences. Even if stuttering is shown to be a “self-fulfilling prophecy,” it is hard to change these negative expectations without first having positive experiences to counteract them. Based on our expectations, we form certain intentions: for example, to “try hard” to say certain words, to “make a good impression” by trying hard not to stutter, and to show people how hard we are trying to please them. These intentions are associated with specific neurological motor programs for exerting effort on the feared words. As a result, the brain prepares the larynx to perform effort closure, as part of a Valsalva maneuver, instead of phonating the vowel sounds. Then our speech mechanism gets stuck on the preceding sound or

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glottal stop – repeating, prolonging, or forcing on it – or we hesitate or use avoidance tactics while waiting for the larynx to be ready to phonate the vowel.

The Role of the Amygdala We must also consider the involvement of the amygdala (our friend “Amigo” discussed earlier in this book). Amigo’s role is to protect us – not only from physical danger but also from the things we fear in social situations such as stuttering. Consequently, Amigo tries to protect us from what we fear by acting in accordance with our intentions. If our intention is to make a “good impression” by not stuttering, we can imagine Amigo responding: “Oh, you want to be fluent! I can help you with that!” However, as discussed earlier in this book, all that Amigo can do is trigger the release of stress hormones and the fight-flight-freeze response. As a result, the stress hormones suppress the brain’s motor program for phonating the vowel sound and substitute an impulse to exert physical effort through a Valsalva maneuver. Therefore, as long as we approach a word or speaking situation with the same intention, we will tend to activate the amygdala and get the same result. This experience will reinforce our negative beliefs, expectations, and fears, thereby perpetuating stuttering.

Changing One’s Intention in Speaking Of all the parts of the Valsalva Stuttering System, intention seems to be the one most amenable to conscious control. By changing our intention to something other than trying to say words fluently, we may change Amigo’s reaction and avoid activation of our Valsalva mechanism. We have previously observed how some therapies may achieve temporary fluency by requiring the person who stutters to change his intention in speaking. Rather than trying hard to force out a word as he usually does, he focuses his intention on meeting “targets” or on speaking in some peculiar manner. These methods ultimately fail, because the new intention is not consistent with normal, natural-sounding speech and is difficult to sustain. But what if your changed intention was consistent with normal speech? What if you focused on an intention that relaxed your Valsalva mechanism, promoted effortless, natural-sounding speech, and was easy to maintain? By changing your intention, you could change the motor program for effort, freeing your larynx to phonate the vowel sounds. This would free your lips and tongue to articulate the words more easily. It would create positive speaking experiences that would gradually change your beliefs and expectations and reduce your fear of speaking. Therefore, intention may be the key to dismantling the Valsalva Stuttering System, shutting down the Valsalva-Stuttering Cycle, and overcoming stuttering blocks. This is the possibility we will now explore.

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A Golf Analogy Stuttering blocks may aptly be compared to a common problem that some people have when trying to hit a golf ball. I can vouch for this, having had experience with both. The recommended way to drive a golf ball is to swing your club so that the head of the club travels in a smooth arc that passes through the point where the ball is located. This is the best way to control the position of the club head, so that it contacts the ball squarely. However, just as the club approaches the ball, some golfers – including me – are overcome by an urge to hit the ball. This has been called the “hit impulse.” As a result, my muscles would tense up, causing the face of the club either to hit the ball incorrectly or to miss it altogether. I continued to be plagued by the “hit impulse” in golf even after I had overcome my stuttering. My “hit impulse” was especially strong when I had to hit the ball over a water hazard and was afraid of losing my ball. My intention was to hit the ball really hard. This instinctively felt like the right thing to do. However, it only made me tense up, hit the ball incorrectly, and I would end up losing the ball just as I had feared. The same thing kept happening over and over, creating a strong negative expectation whenever I encountered a water hazard.

Overcoming the “Hit Impulse” How could I change this behavior pattern, so as to make my golf game easier and more enjoyable? • First, I had to understand that making a bad shot or losing a golf ball is not a catastrophe. I had to be willing to make mistakes and lose a few balls, if I was to relax and enjoy the game. However, just losing a golf ball could not explain the intensity of my anxiety. I suspect that my terror stemmed from a fear of displeasing my father, which was preserved in my memory from childhood. My use of effort may have been a way of showing how hard I was trying to please. • Second, I had to accept the fact that no amount of effort could guarantee that my ball would clear the water hazard. Effort will not magically lift the ball over the water and place it safely on the other side. The only way I could improve my chances was to give up the “hit impulse” and to develop a smooth, consistent swing that allowed my club to contact the ball more reliably. • Third, in order to eliminate the “hit impulse,” I had to change my intention. Instead of trying to “hit the ball,” I had to focus my intention on swinging the club in a smooth arc that just happened to pass through the point where the ball was located. Realistically, swinging the club was the only thing I could

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do. Furthermore, it must always be done in the same way, whether I am facing a water hazard or not. So I decided to practice swinging the club without any ball. At the driving range there is a mat made of artificial turf with a little white rubber tube sticking up, which serves as the tee. I began practicing my swing without a golf ball. I swung my club so that it just brushed the top of the rubber tee, making it wiggle. As I practiced swinging, I remembered the feeling of my bodily movements until those movements became consistently reproducible. I kept doing this until every swing brushed the top of the rubber tube in exactly the same way. Only then did I put a golf ball on top of the rubber tee. Then I simply intended to swing the club in the same way I had been doing, for no other purpose than to wiggle the top of the rubber tee. I gave no thought to the golf ball, which just happened to be there. The smooth momentum of the golf club did all the work, brushing the top of the tee and – just incidentally – whacking the ball and sending it a hundred yards or so. This approach also helped me hit the ball more consistently on an actual golf course. I focused my intention on swinging the club and brushing the top of a regular tee. I didn’t worry about the golf ball. I just let it go wherever it wanted. I had plenty of spare balls to replace any that I lost. I accepted whatever happened as part of the game. When I came to some terrifyingly large water hazards, I again practiced just swinging the club, without any ball. Then an interesting thing happened. As I focused on repeatedly swinging the club in the same way, my awareness of the water hazard gradually receded. By concentrating my intention entirely on swinging the club, I found that I was able to block out the fear that previously would have overwhelmed me. Then I placed the ball on the tee, just swung the club, and was amazed to see the ball clear the water and reach the other side.

The “Hit Impulse” in Stuttering I believe that the “hit impulse” in golf is analogous to the urge to “hit” (or “try hard” to say) a word in stuttering. The problem is one of intention. When we intend to hit the golf ball or try to say a word, our neurological response is a motor program for effort, which results in the very difficulties that we fear. In golf, effort causes us to flub the shot. In speech, effort interferes with our phonation of the vowel sound and causes us to build up air pressure by blocking the air flow. Your intention in speaking affects the way in which your larynx is neurologically prepared to handle vowel sounds. If your intention is to “try to say” a word that you anticipate will be difficult, your amygdala is likely to try to help out by triggering the release of stress hormones, which suppress vowel phonation and substitute an impulse to exert physical effort in a Valsalva

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maneuver. This erroneous motor programming is what creates the “block.” Then your speech mechanism gets stuck on the initial sound while waiting for your larynx to get ready to phonate the vowel. Non-stutterers don’t think about “trying to say a word.” Often, they don’t even think of specific words at all. Their intention is simply to convey their message. All the rest comes automatically on their outward breath. Therefore, in order to make speech easy and effortless, it is crucial that you change your intention. What is behind our intention to “try hard” and to exert effort? Perhaps it is fear – the fear of being judged on our performance – whether in golf or in speaking. Perhaps we have an exaggerated idea about the consequences of “failure.” Perhaps we anticipate that, even if we fail, we will feel less guilty if we can show “how hard we tried.” Perhaps, because of our fear of being judged, the display of effort becomes a substitute for actual performance.

Refocusing Your Intention How can intentions be changed, when the urge to “try hard” is so strong? An example is the golf analogy of overcoming the “hit impulse.” Instead of trying to hit the ball, one’s intention is focused on swinging the golf club. Likewise, you must abandon your intention of trying hard to say (or “hit”) the word and focus your intention on something else – a new intention that is consistent with normal, natural-sounding speech. Ask yourself: “What is my intention in speaking?” Is it to “try hard” to say a word? Is it to “make a good impression” by not stuttering? If so, the motor program for effort is almost certain to kick in and interfere with your phonation of the vowel sound. In order to reduce stuttering blocks, it is essential that you create and affirm positive intentions that do NOT involve using effort, “trying hard” to say words, “making a good impression,” trying to be fluent, or trying not to stutter. Forget about trying to say the word. Focus instead on your role and purpose in speaking and on the message you want to convey, without regard to fluency. The following chapters will present specific exercises designed to relax the Valsalva mechanism and to promote easier, less effortful speech.

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CHAPTER 31.

Exercise Overview

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HILE RECENTLY STUCK IN TRAFFIC, I thought of the similarity between traffic jams and stuttering blocks. In a traffic jam, vehicles converge on a highway in such a multitude as to block each other from getting anywhere. A notorious type of urban traffic jam is called “gridlock.” A line of cars, waiting at a traffic light, is so long that it blocks the intersection of a side street. As a result, the traffic on the side street can’t get through and forms a line that blocks the preceding intersection on that street. This leads to similar obstructions all around the block, until none of the vehicles on any of the streets are able to move. The drivers remain trapped in that position until traffic police intervene to untangle the mess. Of course, the best way to deal with gridlock is to prevent it from happening in the first place. This might require a rule that no vehicle may enter an intersection unless and until there is space for it on the other side.

The Gridlock of Stuttering Blocks Stuttering blocks involve their own kind of gridlock, in which the psychological, neurological, and physiological elements combine to obstruct one another’s proper role in speaking. Consider what might happen when Peter (a person who stutters) must tell someone his name. Because he anticipates difficulty, he forms the intention, out of habit, to make a “good impression” by trying not to stutter. This might have originally seemed like a good idea, except that Peter’s friend Amigo (his amygdala) gets into the act and tries to help by triggering the release of stress hormones. The stress hormones initiate a fight-flight-freeze response, which suppresses Peter’s ability to phonate “ee” – the principal vowel sound in his name. Without the ability to voice the vowel sound, Peter can’t say his name. Without a vowel sound, Peter’s name no longer has the characteristics of a spoken “word” – which requires a continuous sequence of voice and articulation. It is now treated as if it were a physical “object” to be forced out of the body. In response, Peter’s respiratory system is commandeered by his Valsalva mechanism, which tries to expel his name by pressing hard on “p” and building up air pressure in a Valsalva maneuver. But the forceful closure of his lips blocks the airflow needed to vibrate his vocal folds, which further

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prevents him from voicing the vowel sound. Peter is now stuck in his own form of gridlock.

Purpose of the Exercises The elimination of this kind of gridlock requires lasting changes in underlying behavior patterns related to speech. Although mental attitudes and intentions are crucial, we must also change what we actually do to help us speak more easily. In the following chapters are exercises used in Valsalva Stuttering Therapy at the time of this writing. They are not to be used as superficial “fluency tricks” that quickly lose effectiveness in real-life speaking situations. Instead, the exercises are aimed at creating or strengthening nerve pathways that promote easier speech while weakening those that lead to effort. These changes can only be accomplished through intensive, repeated practice. Every exercise and strategy in this book has a specific purpose based on elements of the Valsalva Hypothesis and Valsalva-Stuttering Cycle. None of them should be taken “on faith.” There are objective reasons why they “work” when they do and why, in some instances, they appear not to work. These reasons can be rationally analyzed and understood, providing learning experiences that lead to ultimate success. Here are some of the objectives of the exercises that follow: • • • •

• • • •

Establishing slow, Valsalva-relaxed breathing patterns that facilitate easier speech. Strengthening motor programs for vowel phonation by focusing on Key Vowel sounds and the “Melody Message.” Tensing the puborectalis muscle while inhaling to discharge impulses to exert effort. Relaxing the puborectalis and abdominal muscles while exhaling to relax the Valsalva mechanism and prevent it from triggering Valsalva maneuvers that interfere with respiration and speaking. Preventing conflicts between phonation and articulation (by means of the “Humdronian Speech” exercises). Diverting effort impulses away from the mouth and larynx and discharging them by tensing or squeezing the puborectalis muscle. Processing words as melody and movement rather than as physical objects to be forced out of the body. Encouraging emotional expression through the prosody (melody, inflection, emphasis, rhythm, etc.) of speech.

Although we may realize that our effortful tendencies are counterproductive, they are so well-established that we may feel we have no alterna-

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tives. But with the help of the following exercises, we can dismantle those old tendencies and find that we do have easier and more successful alternatives after all.  The following chapters will describe the principal exercise routines used in the Valsalva Stuttering Therapy Program. Please note, however, that this book is not a substitute for diagnosis and treatment by a qualified speech-language pathologist (SLP) or other appropriate health care professional. Furthermore, it does not contain all the materials that would be used in the actual therapy program. While my suggestions should be helpful to most persons with developmental stuttering, each person’s stuttering is influenced by different factors and to different degrees. For this reason, self-help usually cannot replace the personal supervision and flexibility provided by an experienced clinician. These exercises should be done for 30 minutes every morning, before going to work, school, or other activities. An additional 30-minute practice should be done later in the day. However, the exercises are much more effective when done in the morning. These exercises should not be performed with the intention of “trying to stop stuttering.” Such an intention usually has the opposite effect by investing the words with heightened importance. Doing so will increase the likelihood that the amygdala will trigger a block when saying the words really matters. These exercises may help to improve how you process speech and to suggest more constructive intentions in speaking. Most of the exercises start off as procedures to change your underlying processing of speech rather than as “techniques” for speaking. Once that purpose is accomplished, the exercises evolve into easier, less effortful, natural sounding speech for ordinary use. Then they must always be practiced in actual speaking situations, throughout the entire day.

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CHAPTER 32.

Valsalva-Relaxed Breathing

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REATHING IS NOT ONLY ESSENTIAL FOR LIFE, but also for speech. All the ordinary sounds of speech are created and carried by our outflowing breath. If the air stops flowing, there is no sound and no speech. When the airflow is blocked by a Valsalva maneuver, speaking is impossible. The first component of speech is therefore the act of breathing. First, we must inhale a sufficient amount of air into our lungs to power what we intend to say. Then we must allow it to flow outward as we exhale. This process of inhaling and exhaling is what we call respiration. The exercises in this chapter are designed to help you breathe in a way that relaxes the Valsalva mechanism, so it won’t interfere with the respiration needed for speech. This Valsalva-relaxed way of breathing will be the foundation for all the exercises in Valsalva Stuttering Therapy.

Inhalation Almost all the physical effort in breathing happens when you inhale. Inhalation involves the following muscular activity: • Contracting the diaphragm. The diaphragm is a thin muscle that separates your chest cavity (which contains your lungs) from your abdominal cavity (which contains your intestines). While relaxed, the diaphragm has an upwardcurving dome shape. When the diaphragm contracts, it flattens out. This enlarges your chest cavity, allowing your lungs to expand. (It also compresses your abdominal cavity, causing the front of your abdomen to bulge out.)

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• Raising the rib cage by contracting certain chest muscles (the external intercostal muscles) to further enlarge your chest cavity. As your chest cavity gets larger, your lungs expand and suck in air. This air is what will power your speech.

Exhalation To release the air, you simply relax all the muscles you used to inhale! Your diaphragm relaxes back into its dome shape. (This allows the front of your abdomen to go back in.) Your chest muscles relax, allowing your rib cage to drop. As your chest cavity gets smaller, your lungs shrink in size, and the air gently flows up your windpipe, through your larynx, and out your nose or mouth. Imagine your lungs to be like a rubber balloon. All the effort goes into blowing into the balloon to fill it with air. Imagine pinching the neck of the balloon to hold in the air, and then releasing it. The air flows out the neck of the balloon on its own, without any effort on your part. All you need to do is let go and let the air flow. What significance does this have for speech? In the English language, all speech occurs while we exhale. Therefore, speech requires very little muscular effort for airflow. In other words, speech is powered by the outward flowing river of air, which is released as we relax. We can analogize breathing to riding a bicycle up and down a hill. We use effort to pump our way up the hill because we are working against gravity. Once we get to the top of the hill, we can relax and coast all the way down. Now we are letting gravity do all the work. The same is true with speech. Almost all our muscular effort is used to suck the air in. Then we can relax and let the air flow out on its own. We just relax and let the air flow freely.

BICYCLE-BREATHING ANALOGY

Airflow and Speech This relaxed, continuous flow of air is what powers, creates, and carries all the sounds of speech. The sounds of speech are ripples in this river of air. Your larynx gently brings the vocal folds together, so they are barely touching. As the moving air passes between them it rapidly blows the vocal folds open and sucks them closed, causing phonation. This results in a buzzing column of air. Called phonation. As the air passes through your mouth, the

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position of your lips and tongue shapes the buzz into distinctive vowel sounds, and their continuous movements make the consonants. The Valsalva Hypothesis explains what may happen if our amygdala triggers the release of stress hormones that interfere with speech. The hormones suppress vowel phonation and substitute an “effort impulse” to “force out” the word by activating the Valsalva mechanism. Our normal breathing is hijacked for the purpose of building up air pressure by means of a Valsalva maneuver. The more we force to build up air pressure, the tighter our lips, tongue, or larynx close to block the airflow. However, we cannot talk while holding our breath. If the air stops flowing, there is no sound and no speech.

Relaxing the Valsalva Mechanism The Valsalva mechanism consists of muscles throughout the body that are neurologically coordinated to act in unison to perform a Valsalva maneuver. Its purpose is to build up air pressure in the lungs to stiffen the trunk of the body. The larynx may squeeze tightly to prevent the pressurized air from escaping the lungs. This is called effort closure. At the same time, the abdominal muscles squeeze the abdominal cavity, causing the intestines to press against the diaphragm, forcing it upward into the chest cavity. In addition, certain chest muscles (the internal intercostal muscles) bring the rib cage down to further compress the chest cavity and lungs. As a result, the air pressure in the lungs increases, and the larynx closes tighter to resist it. The blockage of air can also be performed in the mouth by the lips or tongue. This closure is often associated with articulation of consonants. In words that start with vowels, such as “apple”), the blockage may occur in the larynx in association with a glottal stop (normally just a brief closure to accentuate the beginning of the vowel sound). Another part of the Valsalva mechanism is the puborectalis (PR) muscle, which forms a U-shaped sling around the bottom of the rectum. During a Valsalva maneuver (such as when lifting weights) the PR muscle contracts to squeeze the bottom of the rectum shut, to prevent the buildup of abdominal pressure from causing accidental evacuation of the bowels. Because all the muscles of the Valsalva mechanism are neurologically

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programmed to act in unison, relaxing any one of those muscles will relax all parts of the Valsalva mechanism, thereby preventing a Valsalva maneuver.

Relaxing the Puborectalis Because so many muscles comprise the Valsalva mechanism, it would be difficult to focus on all of them at the same time. Therefore, it is better to focus on relaxing a single point within the mechanism. The trick, however, is to find a Valsalva-related muscle that is easily distinguishable from other muscles that are normally active during speech. Relaxing the abdomen is important, especially while exhaling and starting to speak. However, there are times when some muscles in the abdomen are actively involved in providing breath support for phonation. Also, some individuals find it difficult to relax the abdomen in stressful speaking situations. As bizarre as it may sound, the best muscle to relax is in the pelvic floor at the base of your abdomen. This is the puborectalis (PR) muscle. During a Valsalva maneuver, such as when lifting weights, the PR muscle pinches the rectum shut so that the increased abdominal pressure does not cause accidental evacuation of the bowels. The PR muscle is an ideal target for relaxation because it is far removed from any activity involving speech and breathing. First, feel where the PR muscle is located. If you are sitting at a heavy desk or table, put your fingers under the edge, take a full breath, and try to lift it. Alternatively, curl your fingers and link both hands together in front of your chest. After taking a full breath, try to pull your hands apart, without letting go. Do this until you are aware of a tense muscle inside the lowest part of your abdomen, a little above your anal sphincter. This is probably your puborectalis. Voluntarily tense it (independently of your anal sphincter) and relax it several times. Relaxing the PR will be used to relax your entire Valsalva mechanism. Tensing a muscle before slowly relaxing it is a well-known technique known as progressive relaxation. After tensing the muscle, you slowly relax it

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back to where you started and then continue to relax beyond that. Tensing the PR first gives you a starting point to gradually relax from. It may also help to discharge effort impulses, as will be discussed in a later chapter. Tensing your PR while inhaling will not cause a Valsalva maneuver, because your air is going in the wrong direction and there is negative air pressure in the lungs. It is impossible to do a Valsalva maneuver while inhaling. You can imagine the PR muscle to be like the conductor of an orchestra. Tensing your PR will mark the start of inhalation, and slowly relaxing your PR will signal the start of exhalation and speech. Although the PR muscle neither breathes nor speaks, the act of tensing and relaxing the PR muscle can be like the conductor waving his baton, setting the tempo of your breathing and speaking. Therefore, we will call this PR-directed breathing (or simply PR breathing for short).

Introductory Exercise for Valsalva-Relaxed PR Breathing (Exercise instructions in this book will appear in sans serif type.) 1. Sit up straight with your feet on the floor. Place one hand on your abdomen (slightly below your navel). Hold the index finger of your other hand in front of your lips. 2. Tense your puborectalis (PR) muscle and inhale an easy, full breath through your nose, using your diaphragm. Feel your chest expand as your rib cage rises and your lungs fill with air. Your abdomen will bulge out slightly, as your dome-shaped diaphragm flattens out and compresses your abdominal cavity. You will always inhale this way. 3. Don’t hold your breath. Your larynx should be open and relaxed. 4. Relax your PR and abdominal muscles as you release all your air. Imagine that you are relaxing after having successfully completed a strenuous job. Feel your abdomen and lower part of your body collapse into relaxation as you let out a satisfied sigh. 5. Feel the front of your abdomen go back in as your diaphragm returns to its relaxed dome shape. Feel the air flow through your lips. 6. Continue to breathe this way a few more times, releasing satisfied sighs as you relax your abdomen and PR. 7. Then relax your PR and abdominal muscles more gradually and let the air flow out freely and gently on its own, without forcing it. 8. As you continue to inhale and exhale as described above, focus on the direct connection between the relaxation of your PR and abdomen and the flow of air through your lips. 9. Imagine that you are riding a bicycle up and down hills, as in the bicycle analogy. As you inhale, imagine that you are pumping your

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Part IX /Valsalva-Relaxed Speech Exercises way up the hill. Then, as you exhale, imagine that you are effortlessly coasting down the hill. Inhale for about 3 seconds and exhale for about 4 or 5 seconds. 10. Imagine your relaxed, outgoing breath to be a river of air that carries your self-expression. Pay attention to how you feel, both physically and emotionally, and let your feelings go with the flow. 11. As you continue to breathe in this way, feel the relaxation spread throughout your body, including your mouth and throat. 12. Get used to tensing and relaxing your PR while breathing. This will be the foundation for all the exercises in Valsalva Stuttering Therapy.

Standard Breathing Exercise Once you are familiar with Valsalva-relaxed PR breathing, the steps can be simplified as follows: 1. Gently tense your puborectalis (PR) muscle as you begin to inhale. 2. Inhale using your diaphragm and feel your chest expand. 3. To exhale, slowly relax your PR muscle, along with your abdominal muscles. 4. Inhale for about 3 seconds and exhale for about 4 to 6 seconds. 5. Feel the air flow as you relax your PR and abdominal muscles and exhale. Associate the outward airflow with relaxation of your PR. While first practicing the PR breathing exercise, you may optionally raise one hand as you inhale and slowly lower it as your exhale, to help coordinate your breathing. Remember that the physical effort required for breathing occurs during inhalation. For exhalation (when speech occurs), all you need to do is relax the muscles that you used for inhaling. While exhaling and speaking, consciously “dial down” your use of physical effort. Make it your goal to exhale and speak with almost no effort at all.

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Sequential Diagram of PR-Directed Breathing

Valsalva-Relaxed Breathing with Counting Slow breathing is more effective in relaxing the body when combined with words or phrases – sometimes called mantras. This can be as simple as counting your breaths. Breath-counting is a meditation technique that has been used for thousands of years. Breath-counting or using a mantra activates the thinking part of the brain, which may help to override the amygdala and avoid a fight-flight-freeze response to speaking situations. Here is my suggestion: • Coordinate the slow relaxation of your PR muscle with counting from one to six as you exhale. • While counting aloud, vary the pitch and inflection for each number, in an up-and-down manner, as illustrated below. Emphasize the numbers “one” and “four.” Four should be spoken loudest and at the highest pitch.

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CHAPTER 33.

Valsalva-Relaxed Vowel Exercises VOWEL SOUND is the heart of every word or syllable. It is the loudT HE est part, the part with the most energy, and the part through which we express our feelings by using inflection. When persons who stutter find themselves stuck when trying to say a word, it is usually because they don’t have a motor program for voicing the vowel sound. The suppression of vowel phonation is at the core of stuttering blocks and may be felt even before the person tries to say the word. According to our hypothesis, this may happen when stress hormones suppress the brain’s motor program for vowel phonation and substitute an impulse to exert physical effort. Persons who stutter may attempt to force out the missing vowel sound by forcefully closing the mouth or larynx while doing a Valsalva maneuver. Squeezing the larynx shut can turn a glottal stop into effort closure. However, any attempt to “force out” a vowel sound is physiologically doomed to failure. That is because: (1) when the vocal folds are involved in effort closure, they are not in position for phonation; (2) phonation cannot occur when airflow is blocked; and (3) the vowel sounds themselves are not formed in the larynx, but rather in the mouth. When we intend to voice a vowel sound, the larynx simply brings the vocal folds together and adjusts their tension. This allows the out-flowing air to ripple the vocal folds, creating a vibrating column of air that sounds like a buzz. The buzzing flow of air is then molded into various vowel sounds as it passes through the mouth. The larynx coordinates phonation with the shaping of the vowel sounds, but it does not create the vowel sounds themselves. The distinctive vowel sounds are created by the shape of the oral cavity, as determined by the position of the lips and tongue. Forceful closure that stops airflow will make the voicing of vowels – as well as speech itself – impossible. Instead, vowel sounds should be voiced on a relaxed, continuous, and unobstructed exhaled breath. There is never any reason for restriction, obstruction, or forcing. To summarize, the voicing of vowel sounds requires: •

A continuous, relaxed flow of exhaled breath;

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•

Bringing your vocal folds together, so the airflow can vibrate them, creating the buzz of phonation;

•

Adjusting the pitch of phonation, which is done by the cricothyroid muscle in accordance with your intention; and

•

Shaping the desired vowel sound by the position of your lips and tongue as the air flows through your mouth.

Purpose of the Exercises These exercises combine Valsalva-relaxed breathing, phonation, and vowel shaping. The lessons to be learned are: • That the formation of vowel sounds occurs in the mouth, by the positions of the lips and tongue, and not in the larynx. • That voicing vowel sounds requires phonation, which occurs in the larynx when the vocal folds gently close over an outward, Valsalva-relaxed exhaled breath. • That both phonation and the formation of vowel sounds require on a continuous, uninterrupted flow of air. • That the voicing of vowel sounds can be strengthened by changing their pitch and inflection, which occurs in the larynx. The following exercises will focus on four distinct vowel sounds, each formed in a different part of your mouth: • Ah /a/ (as in “box”) - formed in the back of your open mouth, with your tongue flat; •

Eh /ɛ/ (as in “bet”) - formed with the back of your tongue raised, farther forward in the mouth;

•

Ee /i/ (as in “beet”) - formed with your tongue making a narrow slit near the front of the mouth, with your lips in a smile position (as in “cheese”); and

•

Oo /u/ (as in “boot”) - formed by rounded lips, with the sides of the tongue curled up near the front of your mouth.

These sounds will be practiced with ordinary inflection and then a rising, falling, and up-and-down pitch, to enhance your laryngeal control.

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Instructions for Vowel Exercises Do the following procedure for all the vowel exercises: 1. Gently tense your PR muscle and inhale. 2. While inhaling, silently shape the vowel sound in your mouth. Keep shaping the same vowel sound, without interruption, both while inhaling and exhaling. 3. Slowly relax your PR and abdominal muscles and exhale a continuous, relaxed, and uninterrupted flow of outward breath, while you. continue to shape the vowel sound without interruption. 4. Bring your vocal folds together over the outward flow of air to begin phonation, as you continue to shape the vowel sound. 5. Ease into voicing the vowel sound, with no break in airflow or phonation. 6. The vowel sounds “ah,” “eh,” “ee” and “oo” will each be voiced with regular inflection and then with an rising pitch, a falling pitch, and an up-and-down pitch.

Avoid Glottal Stops! • When you begin voicing a vowel sound in the following exercises, be careful not to do a glottal stop. The glottal stop is a brief closure of the larynx to build up a little air pressure before releasing the vowel sound. It is customarily used to accentuate the beginning of the vowel sound. • You know you are doing a glottal stop when you feel a little catch in your throat before voicing the vowel, and the very beginning of the vowel sound is louder than the rest of it. • In these exercises, it is important to relax into the vowel sound, without letting a glottal stop block your airflow even for an instant.

Valsalva-Relaxed Voicing of “ah” a. Vowel Shaping “ah” i. Follow the above instructions, shaping the vowel sound “ah.” ii. Relax into voicing “ah,” with no break in airflow or phonation. iii. Repeat 5 times or as needed. b. Voicing “ah” with a rising pitch. i. Follow the above instructions, shaping the

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vowel sound “ah.” ii. Voice “ah” starting with a lower pitch and then ascending to a higher pitch. iii. Repeat 5 times or as needed. c. Voicing “ah” with a falling pitch. i. Follow the above instructions, shaping the vowel sound “ah.” ii. Voice “ah” starting with a higher pitch and then descending to a lower pitch. iii. Repeat 5 times or as needed. d. Voicing “ah” with an up-and-down pitch. i. Follow the above instructions, shaping the vowel sound “ah.” ii. Begin voicing “ah” at a lower pitch, ascend to a higher pitch, and then drop back down to the lower pitch. Voice “ah” continuously, with no break in phonation. iii. Repeat 5 times or as needed.

Repeating Exercise with eh, ee, and oo • Repeat the above vowel-shaping and vowel-voicing routines in exactly the same way, using the vowel sounds “eh,” “ee,” and then “oo.”

Valsalva-Relaxed Voicing of “ah-eh-ee-oo.” Now we will link all four vowel sounds together on one continuous breath and vocalization, as “ah-eh-ee-oo.” Glide from one vowel sound to the next, with no break in phonation. a. Vowel Shaping “ah-eh-ee-oo” i While inhaling, silently shape “ah.” ii. While exhaling a continuous, relaxed flow of outward breath, begin by voicing the “ah” sound. iii. With no break in phonation or airflow, glide your tongue into the “eh” position and voice “eh.” iv. With no break in phonation or airflow, glide your lips and tongue into the “ee” position and voice “ee.”

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Part IX /Valsalva-Relaxed Speech Exercises v. With no break in phonation or airflow, glide your lips and tongue into the “oo” position and voice “oo.” vi. Repeat 5 times or as needed. c. Voicing “ah-eh-ee-oo” with rising pitch. i. Do the same procedure as outlined above, but with a rising pitch. ii. Repeat 5 times or as needed. b. Voicing “ah-eh-ee-oo” with falling pitch. i. Do the same procedure as outlined above, but with a falling pitch. ii. Repeat 5 times or as needed. d. Voicing “ah-eh-ee-oo” with up-and-down pitch. i. Do the same procedure as outlined above, but with a rising, then falling pitch. ii. Voice “oo” at the highest pitch, and then continuously voice “oo” on the way down. iv. Repeat 5 times or as needed.

Use as a Mantra While practicing Valsalva-Relaxed PR breathing, you can gently voice “ah-eh-ee-oo” as a mantra, as you exhale and relax your puborectalis and abdominal muscles.

Additional Vowel Sounds The above exercises can also be performed using many other vowel sounds. A list of additional vowel sounds is contained in Appendix C.

Chapter 34 / Voicing the “Melody Message”

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CHAPTER 34.

Voicing the “Melody Message” DO IT. Chimpanzees do it. Just about all animals that have a voice B IRDS do it. Even baby humans do it. They all express themselves by vocal sounds without the use of words. While there is no consensus as to how spoken language evolved, it is reasonable to assume that our early human ancestors expressed themselves through variations in the sound of their voice, long before words were invented. The vocal variations might have included such things as changes in pitch, loudness, rhythm, length of utterance, and tone of voice. Self-expression through such a variety of vocal sounds would have formed the substrate upon which words were subsequently built. The first step in the evolution of words was probably the voicing of distinctive vowel sounds, produced by different positions of the lips and tongue. The vowel sounds carry our emotional expression and allow our exhaled air to flow freely. The consonants probably came later. Because they momen-

tarily restrict airflow in various ways, we can think of them as representing a negative element of speech. Various combinations of vowel sounds and consonants acquired symbolic meanings, called words, which increased the precision of human communication. Words have taken on lives of their own, as abstract “things” that exist independently of the emotional content of vocalization. Consequently, we often focus on the mechanical aspects of saying words, while ignoring the underlying foundation of speech: emotional communication and selfexpression through the voicing of vocal sounds. Speech is much more than simply articulating words and transmitting information. It is also a means of self-expression, self-assertion, and selfaffirmation. In normal speech, we convey our emotions by changing our emphasis, pitch, rhythm, and tone of voice as we say the vowel sounds in various words and syllables. Nobody enjoys hearing just a string of words delivered in a robotic monotone – no matter how fluently they are spoken.

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Prosody Normal speech is characterized by its emotionally communicative essence. The aspects of speech that make us sound human rather than robotic are referred to as “prosody.” The major prosodic elements include variations in: • pitch (including intonation and inflection – the rising or falling of the voice in speaking), • length of sounds, • loudness of sounds (for relative emphasis or stress), • rhythm of sounds and pauses between them, and • timbre (quality) of sounds and tone of voice. These elements of prosody make up the “Melody Message” that we send to our listeners. We convey this message through the vowel sounds of our speaking voice, without actually “singing.” Combinations oof these prosodic elements provide the emotional essence of oral communication. Our emphasis and inflection can often affect the entire meaning of our message.

Prosody and the “Melody Message” To illustrate what I mean by “Melody Message,” here is a computerized representation of the acoustical pitch and varying loudness of the sentence, “I’ll have a pepperoni pizza, please.” Notice the contours of the phonation of that sentence. Notice how the loudness and pitch of the voice rises and falls.

You can focus on the Melody Message of this sentence by humming it with varying emphasis and inflection. In these exercises, the humming will be done with the back of the tongue in the velar position.

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Velar Humming Humming is done by voicing the melody with our mouth closed and the air coming out our nose. At the same time, the soft palate (or “velum”) at the back of our mouth lowers to open up our nasal passage. Usually, we close off our mouth by putting our lips together, creating the nasal sound /m/. Other nasal sounds are /n/ and the “ng” sound in words like “angle” and “thing.” For reasons that will become clear in the following chapters, we will do our humming using the “ng” sound. To do this, raise the back of your tongue to touch your soft palate (“velum”), as you would do when pronouncing words ending in “ng.” The back of your tongue in your lowered velum will block off your mouth and send the air through your nose. You can practice by saying the following words and prolonging the “ng” at the end of each:

long / prong / song / strong / wrong / gong The phonetic symbol for the “ng” sound is /ŋ/, which is classified as a “voiced velar nasal.” Therefore, we will refer to this as the “velar position,” in which we will do “velar humming.” Keep your tongue in this velar position both as you inhale a Valsalvarelaxed PR breath and as you slowly relax your PR muscle and abdomen to exhale. Practice humming the /ŋ/ sound with a rising pitch, a falling pitch, and an up-and-down pitch. Now practice velar humming the melody for “I’ll have a pepperoni pizza, please,” which is illustrated below. The size and boldness of the symbols indicate their relative loudness, and their up or down position indicates their relative pitch.

ŋ

The next illustration will show how it would sound when the words are attached to prosody.

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Notice that the “ee” in “pizza” is both the loudest and highest pitched sound in the sentence. We will call this the “Key Vowel Sound.” In this example, the speaker is emphasizing that he wants a “pizza.” If the speaker wanted to request a specific kind of pizza, he could have placed the Key Vowel Sound on “pepper-OH-ni.” The same kind of adjustment of emphasis or inflection can change how a sentence is perceived by the listener.

Focus on the Key Vowel Sound and “Melody Message” You can experiment voicing Melody Messages for various sentences and phrases. Make up your own or use the sample Sentences and Phrases in Appendix F. The dominant part of each melody will be a Key Vowel Sound, which will be the loudest vowel sound and the one that starts at the highest pitch. Here are some examples:

The Key Vowel Sound will usually be on the stressed syllable of the word you want to emphasize. Alternatively, you can place it on the stressed syllable of the first word in a phrase. Do whichever works best for you. Changing your placement of the Key Vowel Sound can alter the underlying meaning of your message. Not all Melody Messages need to be “melodic.” You can choose to speak with a flat affect, as when delivering a stern warning (e.g., “DO NOT DISOBEY ME!”), if you do it intentionally.

Voicing Single Vowels with Melody Although there is only one vowel sound in singlesyllable words, this vowel sound should also be voiced with melody. Begin voicing the vowel sound at a high pitch and end the vowel sound by gliding down to a softer, lower pitch. Voice it with enthusiasm and feeling, without holding back. Here is an illustration using the word “box.”

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Speak in Phrases In this exercise, speak in phrases. Valsalva-relaxed speech is easier when you break long sentences into short pieces. Trying to force out long sentences interferes with relaxed breathing and may trigger a block. Take a Valsalva-relaxed PR breath between each phrase. Each phrase should be a length that you can voice comfortably on a single breath. Each phrase has its own Melody Message and should contain a “chunk” of information. Speaking one phrase at a time helps your listener absorb one chunk of information before you go on to the next.

Melodic Exercise Instructions The following are exercises for voicing Melody Messages. The first part will be called “Hummelodian Speech” in the second part “Melodic Intention.” Continue Valsalva-relaxed PR breathing throughout the exercise. 1. Select a phrase or sentence. Use one you fear you might block on. Alternatively, select sentences and phrases from Appendix F or other reading materials. Break sentences into phrases. 2. Imagine someone as your listener. Decide what emotional message you want to send to that person. Base this on your role and purpose in speaking, without regard to “making a good impression.” 3. Hummelodian Speech Exercise. As you tense your PR and inhale, imagine a Melody Message for the phrase. It should be based on the natural inflection (not singing) that you would ordinarily use. 4. Then, as you relax your PR and abdomen and exhale, hum the Melody Message out loud, using velar humming. Repeat as needed. 5. On your next Valsalva-relaxed PR breath, after inhaling and starting to exhale, voice the same Melody Message while letting the words come along on their own. The vowel sounds will carry the melody. Focus solely on the melody, without trying to say the words. 6. Let your variations in pitch and emphasis express your feelings. Use the melody and inflection as a means of self-expression, selfassertion, and self-affirmation, without holding back. 7. Melodic Intention. In the next part of the exercise, think the Melody Message while inhaling and then voice the same melody along with the words after you begin exhaling. Focus solely on the melody without trying to say the words. Repeat as needed. 8. Then practice part 7 in actual conversations and whenever you are speaking during the day.

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Take Pleasure in the Music of Your Voice A fundamental objective of Valsalva Stuttering Therapy is to change your intention in speaking. Instead of trying to “make a good impression” by not stuttering, your new intention is to enjoy expressing yourself through the music of your voice. It is through your voice that you express and assert yourself in speaking. To do this, you must be willing to let your feelings flow through the music of your voice, without holding back. After you have established the habit of speaking with Melodic Intention all the time, you may be able to create your Melody Messages while you are speaking, without having to plan them in advance. Imagine your breath, your positive feelings, and the music of your voice flowing like a river from you to your listener. This river forms the channel of communication through which you send your Melody Message. The words sail on the surface, like little boats, carried along by the melodic river. Trying to please your listener by not stuttering is a lose-lose proposition. You may project onto your listener the role of a “judge,” while putting yourself into the role of a child seeking approval. When your friend “Amigo” (amygdala) tries to help you by triggering the fight-flight-freeze response, your ability to voice the Key Vowel Sound is suppressed and replaced by an urge to exert physical effort. When this happens, the “river” is drained of its melodious flow, and you can imagine the “word boats” being stuck on a dry riverbed. You may try to push them by forcing on their initial consonants or glottal stops, but they don’t go very far. In your struggle to force the words out, the communicative link between you and your listener is broken. In this way, your intention to make a “good impression” backfires. You end up struggling and making your listener feel uncomfortable. Now consider what a positive interaction with your listener might look like. Instead of trying to please the listener, your new intention is to enjoy expressing yourself through the music of your voice. You focus on pleasing yourself, without regard to the listener’s approval. You do not fear the listener as a threatening judge. Instead, you welcome the listener as an opportunity to share your pleasure. As a result, Amigo is deactivated, and your larynx is free to phonate. At the same time, your pleasure conveys a positive message to the listener: Look how much I enjoy talking to you! The effect is that the listener senses your enjoyment in speaking to him. This makes the listener feel good about himself and also about you. By focusing on your own pleasure in speaking, rather than making a good impression,” you create a “win-win” experience for both yourself and your listener. A visualization of the above scenario can be found in Appendix B.

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CHAPTER 35.

Introduction to Humdronian Speech LIBERATION FROM STUTTERING did not begin until I quit all M Yforms of therapy and took matters into my own hands. After delving into the medical literature and formulating the Valsalva Hypothesis, my biggest challenge was to develop new therapy exercises that would really work. I did not want to end up with strange or robotic-sounding speech, as was offered by some of the therapies I had encountered. Instead, my goal was the freedom to speak in the same expressive, natural-sounding way that I had sometimes been able to do. Trying to find an effective exercise was a frustrating task. I kept encountering stuttering blocks whenever I intended to say words in the usual way – that is, with vowel phonation and articulation interacting together. It felt as if I could not coordinate one with the other without having a block. In desperation, I decided to begin by focusing on what I could always do without blocking. I came up with two things: • Silently articulating (mouthing) words; and • Continuously phonating a vowel sound or humming. I wondered what would happen if I combined these two elements. I devised an exercise in which I began by voicing the vowel sound “ah” while relaxing my puborectalis (PR) and abdominal muscles as I exhaled. Then, while continuously phonating through my nose, I silently articulated the words in my mouth. I called this exercise “Adronian speech,” because it started with “ah” followed by a drone of phonation. This exercise showed that I could phonate and articulate at the same time without blocking. Obviously, this exercise sounded strange and unintelligible, but it was very relaxing and the first step in changing the way I processed speech. It was followed by an intermediate step (Modified Adronian) and finally by “Resonant Valsalva-Relaxed Speech”” (RVR). The final result sounded like my own natural speech, but it was much easier, more relaxed, and with far fewer blocks. This newly liberated speech made a dramatic change in my life and opened up a successful career as a trial lawyer.

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Now as a speech-language pathologist, I have continually refined and modified this exercise to make it easier and more effective for therapy participants. The vowel sound has been replaced by humming, requiring a change in its name to “Humdronian speech.” It now employs velar humming, and increased emphasis is placed on the melody of speech. The intermediate step is called “Modified Humdronian,” which leads to an improved form of RVR speech.

Explanation of Humdronian Speech The first part of the Humdronian exercises is called “Full Humdronian Speech” (FHD). It is called “Humdronian” because every phrase begins with a hum, which continues as a drone of phonation. Following the initial hum, the lips and tongue silently articulate the words of the phrase while continuous phonation comes through the nose. This exercise is designed to promote easier, less effortful speech by reprogramming the way in which speech is processed. As explained in earlier chapters, stuttering blocks may involve a “freeze response” triggered by the brain’s amygdala. As a result, stress hormones suppress the brain’s motor program for voicing the loudest vowel sound of a word and substitute an “effort impulse” to exert force on the preceding consonant or glottal stop by means of a Valsalva maneuver. Therefore, a key to easier speech is to have your larynx always ready to phonate vowel sounds. Full Humdronian Speech is designed to accomplish this goal through continuous phonation by the larynx. Another key is to prevent the exertion of effort by relaxing the body’s Valsalva mechanism. This is accomplished through Valsalva-relaxed, PR-breathing, as discussed in a previous chapter. PR breathing requires you to tense your puborectalis (PR) muscle as you inhale and to slowly relax it, along with your abdomen, as you exhale. Because the puborectalis is neurologically coordinated with the body’s Valsalva mechanism, relaxing the PR automatically relaxes the entire Valsalva mechanism and prevents forcing on words. FHD combines two things that almost every person who stutters can do easily: humming and mouthing words silently. The only difference in this exercise is that both are done simultaneously. The result sounds strange and the words are not intelligible, but almost no one stutters while doing it. Full Humdronian is reminiscent of the Scottish bagpipes. The bagpipes have big pipes at the back of the bag, called “drones,” which play a constant drone of sound, while the piper plays the melody on the chanter at the front of the bag. In Full Humdronian Speech, the constant drone of phonation comes out your nose. Meanwhile, you silently move your lips and tongue as if to play the “notes” of articulation.

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Speech as Melody and Movement One of the main objectives of Valsalva Stuttering Therapy is to treat speech as melody and movement, rather than treating words as if they were physical “objects” that could be forced out of the body by a Valsalva maneuver. In Full Humdronian, continuous phonation is done with the same inflection as you would use in ordinary speech, including appropriate variations in pitch and loudness. This is what we will call the “melody” of speech. (It is not the same as singing.) At the same time, the words are silently articulated in the mouth by continuous, uninterrupted movements of the lips and tongue. This represents the movement of speech. Full Humdronian separates phonation from articulation by sending the phonated airflow through the nose while the lips and tongue move in the mouth. This separation helps us to experience speech as consisting of two distinct elements: continuous melody and continuous movement. Phonation and articulation are no longer strictly locked together in a way that allows them to interfere with one another. The larynx phonates freely without regard to articulation, and the lips and tongue move freely without regard to phonation. In this way, neither is subject to interference by the other. When this exercise is done properly, phonation and articulation are totally divorced from one another. Exhaled breath and the sound of phonation flow without obstruction through the nasal passage instead of through the mouth. At the same time, the lips and tongue move freely to articulate the words. The lips and tongue have no opportunity to block airflow and build up air pressure, because no air is coming through the mouth. For the same reason, the lips and tongue are unable to shape voiced airflow into the sounds of speech. Consequently, the words being articulated cannot be heard.

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When you are humming, your larynx is continuously phonating. Therefore, your speech mechanism is free to articulate the words, without having to wait for the larynx to get ready to provide phonation for the vowel sounds. When your larynx is continuously phonating, it is not able to do effort closure as part of a Valsalva maneuver. As a result, the entire Valsalva mechanism is deactivated. By treating words as melody and a sequence of movements rather than as “objects,” FHD deconstructs the effortful interaction between articulation and phonation that occurs during stuttered speech. Articulation can no longer be interrupted by the unreadiness of the larynx to phonate for vowel sounds, because phonation is continuous. Conversely, the airflow needed for phonation can no longer be blocked by forceful closures in the mouth, because the exhaled air continues to

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flow freely through the nose instead of the mouth. Because your exhaled breath flows freely through your open nasal passage, your body can’t build up air pressure to do a Valsalva maneuver that blocks speech. Because FHD separates phonation from articulation, rather than having them strictly linked together, your brain must process words as phonation and a sequence of movements, rather than as physical objects to be forced out of the body by a Valsalva maneuver. Processing words as phonation and a sequence of movements rather than as “objects” may help your brain organize speech processing in the way that most non-stutterers do it – in the left hemisphere, which is better at handling rapid sequences of movement than the right hemisphere. (In contrast, stutterers’ speech processing seems to be scattered over both hemispheres of the brain.) When you are humming, your attention is focused on phonation instead of forcing on the consonants. FHD not only treats words as phonation and movement, it also absorbs them into meaningful phrases. This deprives the amygdala of a “target” on which to focus vowel suppression and the effort impulse. When practicing Full Humdronian Speech, you will also change your intention in speaking. Instead of trying hard not to stutter, your intention will be to phonate continuously and let the air flow freely, while you simply move your mouth. This reduces the likelihood of interference by your amygdala.

The Next Steps Full Humdronian Speech enables you to phonate and to articulate freely – while doing both simultaneously. With continued practice, effortless phonation and articulation will feel more natural. Once this skill is mastered, you will be ready for Modified Humdronian Speech (MHD), in which you retain the initial hum before each phrase, but gradually allow more air through your mouth. This re-integrates phonation and articulation in a new, less effortful way, and speech will sound more intelligible. The next step will be to gradually soften the initial hum until it is just imagined during the start of your relaxed, exhaled breath, but not voiced. The result is Resonant Valsalva-Relaxed Speech (RVR), which can be used in ordinary speaking situations.

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CHAPTER 36.

The Full Humdronian Speech Exercise CHAPTER WILL PROVIDE INSTRUCTIONS for practicing the Full T HIS Humdronian Speech Exercise (FHD), which combines Valsalva-relaxed PR breathing, continuous humming, and silent articulation of words. During FHD, all your exhaled breath must be directed through your nasal passage instead of your mouth. The exhaled breath carries the continuous buzz of phonation from your larynx and out your nose as you hum. In ordinary humming, the airflow is diverted through the nasal passage, instead of through the mouth, by lowering the soft palate or “velum” (VEE-lum) and blocking airflow through the mouth with the lips or tongue. We usually do this by bringing our lips together and humming a prolonged /m/ sound. We might call this “bilabial humming.” But airflow through the mouth can also be blocked by the tongue in its position for the nasal consonants /n/ (using the front of the tongue) or “ng” (using the back of the tongue), as shown in the following diagram. For the FHD exercise to have its intended effect, it is mandatory that all your voiced airflow be directed through your nasal cavity, while your lips and tongue fully (but silently) articulate the words in your mouth. This means that you must hum in a way that allows your lips and tongue to articulate freely, while you continuously phonate through your nose. Of the three types of humming, only the “ng” position permits your lips and most of your tongue to articulate freely. This is the same tongue posi-

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tion used to voice the nasal sound “ng” in “gong,” “thing,” “angle,” etc. To get used to humming in this way, repeat the following words and prolong the “ng” at the end of each:

song / tong / wrong / long / gong The back of the tongue touches the lowered velum, thereby keeping the voiced airflow from entering the mouth and sending it instead through the nasal cavity and out the nose. (This is illustrated by the accompanying diagram.) Meanwhile, the lips and the rest of the tongue are free to articulate words. When you put the back of your tongue up against your lowered velum (soft palate), no air flows through your mouth. Therefore, your lips and tongue have no way to block your airflow, to build up air pressure, or to trigger a Valsalva maneuver. Instead, the air flows without obstruction through your nasal passage, reducing the likelihood of stuttering blocks. The phonetic symbol for the “ng” sound is /ŋ/ (or “hooked n”), which we shall use throughout this chapter. It is classified as a “voiced velar nasal consonant” because it is formed when the back of the tongue touches the lowered velum. Therefore, we shall refer to humming with /ŋ/as “velar humming.”

ŋ

How Full Humdronian Speech Is Done In the Full Humdronian exercise, the back of your tongue should always be in the /ŋ / position, touching your soft palate, even while you are inhaling. Do Valsalvarelaxed PR breathing for each phrase. Here are some step-by-step instructions: 1. Raise the back of your tongue to touch your soft palate, in the /ŋ / position. 2. Tense your PR muscle, contract your diaphragm, and inhale a full breath through your nose. Feel your chest expand as your lungs suck in the air. Put one hand on your abdomen and feel it bulge out as you inhale. 3. Exhale by slowly relaxing your PR muscle and abdomen. With your hand, feel your abdomen go back in as you slowly exhale. 4. Keep the back of your tongue in the /ŋ / position and divert all your airflow through your nasal passage instead of your mouth.

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While relaxing your PR and abdomen and exhaling freely through your nose, begin to hum /ŋ/ . This is done by closing your vocal folds across the relaxed airflow of your exhaled breath. The airflow will vibrate your vocal folds, resulting in phonation. The vibrating airflow is turned into a hum as it goes through your nasal cavity. Continuously hum while slowly relaxing your PR muscle. In the Full Humdronian exercise, start each phrase with a PR breath and humming “/ŋ / . ” Then, about half a second after you begin humming, silently articulate the words of a phrase with your lips and tongue, while you continue to hum through your nose. In this way, you will perform phonation and articulation independently of one another, but simultaneously. Repeat this process for every new phrase. Phonate continuously until the end of each phrase. When articulating, move your lips and tongue fully and distinctly, without forcing. Do not stop your phonation when articulating normally unvoiced consonants. If you do the Full Humdronian exercise properly, nothing that you articulate will be intelligible. This is because no air is coming through your mouth, and therefore your mouth can’t produce any sound. You will only hear “/ŋ ŋ ŋ ŋ /” coming out your nose. Give your humming the same inflection that you would normally use when saying the phrase that you are articulating, with variations in loudness and pitch.

Learning Full Humdronian Learning to speak in Full Humdronian can be tricky at first. Here are some suggestions to help you get started. Always begin with a Valsalva-relaxed, PR breath before each phrase. Tense your puborectalis (PR) muscle at the beginning of phonation and put the back of your tongue in the /ŋ/ position. As you exhale, keep your tongue in the /ŋ/ position and slowly relax your PR muscle and abdomen. While doing Full Humdronian, there is an easy way to monitor your phonation. Use the fleshy part of your middle finger to completely cover the opening of one of your ear canals. This will create an “occlusion effect” that causes you to hear the amplified sound of your humming. This is the sound of your larynx phonating, which is carried through the bones and cartilage of your body directly to your inner ear.

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To familiarize yourself with velar humming, begin by humming the /ŋ/ sound with changing pitch and inflection. The following diagram is an example. Note that, during inhalation, the tongue is in the /ŋ/ position (shown in gray), but it is not voiced until phonation begins on the exhaled breath.

Next you can practice shaping vowel sounds while continuously humming /ŋ/ through your nose. Shortly after you start humming, try to shape the “ah” sound with an open mouth. If you are doing Full Humdronian correctly, all you will hear is /ŋ ŋ ŋ /. The same Humdronian vowel-shaping can be done with any vowel sound. You can start with “ah,” “eh,” “ee,” and “oo,” with the back of your tongue in the velar position. Even if you exaggerate the shaping of the vowel sounds with your lips and tongue, all you should hear is /ŋ ŋ ŋ ŋ/. For each vowel sound, do a neutral hum, falling pitch, rising pitch, and up-and-down pitch. Then do the same with the combination “ah-eh-ee-oo.” Regardless of what vowel you shape, the only sound you should hear is /ŋ/ coming out your nose. Next, silently articulate the numbers one through six while velar humming an up-and-down pitch. Hum the loudest and at the highest pitch while articulating the number “four,” as shown in the illustration below.

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Melody and Movement in Full Humdronian The next step will be to silently articulate words in your mouth while humming /ŋ/ through your nose. This may feel tricky at first, but most participants are able to get the hang of it by following these steps: • Choose a sample word or phrase to practice with. (For example, “How are you today?”) • Close your eyes (except when reading written material) and silently articulate the word or phrase, without any humming or voicing. Exaggerate the continuous movements of your lips and tongue, without pressure or force. Closing your eyes helps you to pay attention to the feeling of continuous movement in your mouth. The articulation by your lips and tongue should be precise – not just random movements. • Next, while imagining the word or phrase, but not articulating it, hum /ŋ/ with the same inflection in pitch and loudness that you would normally use when saying the words. Keep your mouth open to avoid accidental articulation. Pay attention to the natural melody of your voicing of the word or phrase. Replicate this melody as many times as necessary. • Alternate the humming humming and articulation until you feel ready to combine them both.

• Start humming /ŋ/ and then begin articulating the word or phrase silently, as you continuously hum throughout the entire word or phrase, using the same inflection in pitch and loudness as you previously replicated. Here is a diagram of how the various elements of FHD should interact.

FULL HUMDRONIAN SPEECH DIAGRAM (The elements flow from bottom to top.)

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• Next, practice Full Humdronian on complete sentences. Break the sentences into phrases where appropriate. Begin each phrase with a Valsalva-relaxed, PR-breath and hum. Then glide into silently articulating the phrase, with no break in phonation as you hum. When reading in FHD, do it phrase by phrase. You may use any reading materials, including those in Appendix F to this book. • Even though you are continuously phonating, you do not have to speak in a monotone. Freely change your pitch and loudness to put inflection and expression into your voice.

Phonate Continuously through Phrases One purpose of the FHD exercise is to restructure your speech so that your larynx is always free to phonate, regardless of what your mouth is doing. Therefore, you must learn to phonate continuously throughout the entire phrase, without any break between the words. Hum until the end of the phrase, at which point you stop and take a Valsalva-relaxed, PR breath. Full Humdronian reminds us that words are melody and a continuous sequence of movements by the lips and tongue. Likewise, phrases are also melody and a continuous sequence of movements. Let the movements of your lips and tongue flow continuously from one word to the next until the end of each phrase. Your PR and abdominal muscles must slowly and continuously relax through the entire phrase, and your relaxed, outgoing breath must continue to flow, without interruption, until the phrase is completed.

The Importance of Practice For FHD to accomplish its purpose, it must be practiced for at least half an hour every morning, an additional half hour in the afternoon or evening, and at every other opportunity for at least one week. The most effective time to practice is in the morning, before beginning your daily activities. This allows the effects of practice to carry over for the rest of the day. Do not practice Humdronian with the intention of becoming “fluent.” As we have seen, focusing on “fluency” almost always backfires. Diligent practice of FHD will teach you to process phrases as melody and movement, rather than treating words as objects to be forced out of the body. You must deconstruct your old speaking pattern, in which phonation and articulation are rigidly locked together, allowing them to interfere with one another. FHD will help you appreciate that phonation allows speech to flow more easily, and that articulation does not require effort. This will lay the foundation for the next Humdronian Speech exercises.

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CHAPTER 37.

Transition to Natural-Sounding Speech MASTERING Full Humdronian Speech, you can gradually modify A FTER it to sound more natural. The first transition is to Modified Humdronian Speech (MHD). Its purpose is to make speech more intelligible while enjoying the same Valsalva-relaxed breathing and unobstructed phonation and articulation as you did in Full Humdronian. Therefore, you will begin by speaking in FHD, and then gradually allow more and more of your exhaled breath to pass through your mouth as you articulate. After a while, your words will sound intelligible. Then move on to natural-sounding Resonant Valsalva-Relaxed Speech (RVR), to be discussed later in this chapter.

Instructions for Modified Humdronian Speech Here are instructions for transitioning from FHD to MHD: 1. When practicing, place one hand on your abdomen to feel it bulge out as you inhale and go back in as you exhale. 2. Before each phrase, tense your PR muscle and use your diaphragm to inhale. Keep the back of your tongue in the /ŋ/ position. 3. Concentrate on slowly relaxing your PR muscle and abdomen as you exhale. Feel your abdomen go back in as you slowly exhale. 4. Start each phrase with a velar hum (ŋŋŋ), but after humming for about a second, gradually allow more airflow through your mouth as you articulate the words. Glide smoothly from the hum into the words, without a break. As you permit more air to flow through your mouth after humming, the words will become more intelligible. But continue to imagine the continuous phonation that you did in FHD. 5. Continue to keep your nasal passage partially open as you speak. In this way, your nasal passage can act as a “safety valve” to prevent the blockage of air and a possible Valsalva maneuver. 6. Put feeling and expression into your voice as you speak. 7. If you feel a block, temporarily go back to Full Humdronian to regain your Valsalva relaxation.

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The result should sound almost like ordinary speech, except for the initial hum before each phrase. This is illustrated below:

MODIFIED HUMDRONIAN SPEECH DIAGRAM (The elements flow from bottom to top.)

You can practice MHD on the sentences and phrases in Appendix F. Incorporate your answers into sentences of your own construction. You can also practice MHD with your family, friends, and therapy partners.

Resonant Valsalva-Relaxed Speech The next step is transitioning from Modified Humdronian Speech to Resonant Valsalva-Relaxed Speech (RVR). In RVR, the initial hum before each phrase is gradually softened until it is no longer heard, so that your speech sounds totally normal. Nevertheless, your phonation and articulation will still be processed independently of one another, as they were in Full Humdronian. Your larynx will always be ready to phonate the vowel sounds, while your lips and tongue move freely, without triggering Valsalva maneuvers. Meanwhile, your nasal passage will remain partially open as a “safety valve” to further guard against a build-up of air pressure. RVR speech is done as follows: 1. Continue to use Valsalva-relaxed, PR breathing. Tense your PR muscle as you inhale, with the back of your tongue in the /ŋ/ position. Then slowly relax your PR muscle and abdomen as you exhale. Let the air flow freely, without any force, restriction, or interruption. 2. Start off by velar humming (ŋŋŋ) at the beginning of each phrase, as you did in Modified Humdronian. But gradually soften the hum until it can no longer be heard. 3. Continue to touch the back of your tongue briefly and silently to your soft palate, in the /ŋ/ position, while imagining the hum but not voicing it.

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(See the illustration after the next paragraph, which shows the silent humming in gray.) 4. Then glide effortlessly into the word or phrase. Begin to phonate the words on a Valsalva-relaxed, exhaled breath, while continuing to slowly relax your PR muscle and abdomen. This can be illustrated as follows:

RESONANT VALSALVA-RELAXED SPEECH DIAGRAM (The elements flow from bottom to top.)

One of the objectives of RVR speech is to maintain the same relaxed phonation and easy, continuous movement of the lips and tongue as you did in Full Humdronian, without effort or force. If you feel a block, temporarily go back to MHD or FHD. RVR speech can be used in everyday conversations and speaking situations. Consciously use RVR speech whenever you speak, and in all speaking situations. RVR speech will require constant practice for it to become your habitual way of speaking. Practice it while doing readings from the Appendices or your own materials.

Transition Exercises A good way to Transition from Full Humdronian to Modified Humdronian and then to Resonant Valsalva-Relaxed Speech is to practice them in succession on the same sentence. Be sure to take a Valsalva-relaxed PR breath before each phrase. • First, with the back of your tongue in the velar position, wordlessly hum the sentence with the same inflection that you would normally use. Do this a few times. You will replicate the same inflection (or “melody”) in all the following steps. •

Next, say the sentence in Full Humdronian, using the same inflection as when humming.

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Then say the sentence in Modified Humdronian, using the same inflection.

•

Finally, use the same inflection while saying the sentence in Resonant Valsalva-Relaxed Speech.

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Then move onto the next sentence.

Appendix F provides ideal written material for practicing transition, in the form of common phrases and sentences. You may also use sentences from this book. In addition to using written sentences, apply the transition exercises to sentences that are fully or partially extemporaneous. The transition exercises can also be applied to sentences and phrases containing words that you find troublesome. Also try the exercises on sentences and phrases that you routinely use during the day.

Not About “Fluency” Beware! RVR speech should not be used with the intention of being “fluent.” As previously discussed, the intention of being “fluent” stimulates one’s amygdala to try to “help out” by triggering the release of stress hormones and the initiation of a “fight-flight-freeze response.” While this might be a lifesaving reaction to physical danger, it is counter-productive for speech. On several occasions I witnessed the following scenario happen when therapy participants first experienced the effect of RVR speech. As they began reading, each enjoyed a long stretch of easy, effortless speech. Then suddenly they began to block. In each case, I stopped the participant and said, “I know what you were thinking just now. You were thinking, ‘Wow, I’m fluent! I wonder how long I can keep this up.’” In each case I was correct. When the participants started thinking about maintaining “fluency,” I could envision their amygdala responding, “Oh, you want to be fluent? I can help you with that!” Soon the stress hormones began initiating the “fight-flight-freeze response,” which suppressed the phonation of vowel sounds and substituted an “effort impulse” to force on words. So, don’t even think about “fluency.” Rather, allow yourself to enjoy the melody and movement of easier, effortless speech. Pay attention to the message you are conveying in each phrase and your purpose in saying it. Be aware of your feelings about the message and express those feelings with your inflection and tone of voice.

“Dial Down” Your Effort in Speaking Many persons who stutter customarily invest their speech with a high degree of physical effort – when, in fact, speech usually requires almost no physical effort at all. Our speech is powered by our exhaled breath as we relax. Pho-

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nation does not require any muscular effort in our larynx. All that our vocal folds need to do is gently close and allow the outward airflow to vibrate them. As the vibrating air flows through our mouth, our lips and tongue can shape the sounds of speech without needing to force. Some of the effortful behavior may be habitual. Sometimes effort may be defensive, like the suits of armor worn by knights of old. Going into a speaking situation without effort may make a stutterer feel as vulnerable as a knight going into battle without his protective armor. It takes courage to resist the effort impulse generated by the amygdala. It takes faith that nothing bad will happen to us if we don’t use effort – if we simply let our words flow unrestrained in the relaxed river of air, if we stop trying to control the outcome of our speech through effort. While doing Valsalva-relaxed, PR breathing, see what happens when you “dial down” the amount of effort you use in speaking. Keep dialing it down lower and lower, until your effort in speaking is at the absolute minimum. Just let the words come on their own, without trying to force them out. If reducing the effort makes you feel anxious, accept and embrace your anxiety. Anxiety, by itself, does not prevent you from talking. As the saying goes, “Feel the fear and do it anyway.”

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CHAPTER 38.

The “SMEEch” Exercise OF THE LINCHPINS of the stuttering mindset is the tendency to O NE treat words as if they were “things” – physical objects to be forced out of the body by a Valsalva maneuver. But words are not “things.” They are, instead, a series of sounds produced by our relaxed, exhaled breath. They are a combination of melody and movement, requiring very little effort, riding on a relaxed, outward flow of air.

Word-Stretching Exercise One way to dispel the erroneous view of words as “things” is to articulate them in extremely slow motion. Imagine a slow-motion video used to analyze an athlete’s movements in sports, such as swinging a golf club or a high diving performance. Speaking in extremely slow motion makes us aware of exactly what our lips and tongue do during speech. This helps to demonstrate that words are not “things,” but a sequence of continuous, gentle movements. At the same time, we can experiment with extremely exaggerated inflection. This focuses our attention on the role of the larynx in phonation. When we intentionally change the pitch of our voice, the cricothyroid muscle in the larynx adjusts the tension of our vocal ligaments while we shape the vowel sounds in our mouth. This is the purpose of Slow-Motion Extremely Emotive Speech, an exercise that we will abbreviate as “SMEEch.” Although many stuttering therapies teach slow speech as an aid to fluency, SMEEch is not intended to be a “speaking technique” for ordinary conversation. Slowing down and stretching the words in SMEEch will almost always eliminate the tendency to block. Nevertheless, SMEEch is not for the purpose of “fluency shaping” or controlling your articulation. Rather, its purpose is to enhance your ability to process speech as melody (inflection) and a sequence of movements.

Instructions for Exaggerated SMEEch Choose a word or phrase that you have recently blocked on, or on which you are afraid you might block in the future. Like the other exercises in this

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therapy, all aspects of SMEEch must be done in coordination with Valsalva-relaxed, PR-directed breathing. 1. While doing Valsalva-relaxed PR breathing, say the word or phrase in extremely slow motion. 2. Stretch out all parts of the word or phrase as much as possible. Don’t just stretch the vowels, but slow down all the movements that comprise each word, so it sounds like what happens when you slow down a tape recording of speech. 3. Feel the slowly changing positions of your lips and tongue. Exaggerate those movements, using light contacts and not forcing. You may also observe the movements in a mirror as you do them. 4. Identify the Melody Message of the phrase, based on your usual pattern of inflection, and voice it through the vowel sounds with extremely exaggerated inflection. Especially exaggerate the Key Vowel Sound of the word or phrase (usually the loudest and highest pitched sound). 5. Repeat the word or phrase several times in this manner, until you thoroughly understand that it is not a “thing,” but rather melodious phonation in your larynx and a continuous series of gentle movements in your mouth. To illustrate the slow-motion aspect of SMEEch, here is how the phrase “I’ll have a pepperoni pizza, please” might sound when stretched out:

Experimenting with Exaggerated Inflection Exaggerating your pitch may help you pay closer attention to the phonation of vowel sounds in your larynx. Exaggerating the Key Vowel Sound may strengthen the brain’s motor program for voicing it and reduce the likelihood that it will be suppressed by the fight-flight-freeze response. SMEEch may also be good practice in expressing your feelings through the voicing of vowels, rather than funneling your feelings into effort and force. This may help to desensitize you to any fear or inhibition you may have about expressing yourself through inflection. To illustrate relative loudness and pitch, see the computerized representation of the acoustical pitch and loudness of the phrase, “I’ll have a pepperoni pizza, please” on page 236. Notice the spike in pitch on the “ee” in “pizza” – the Key Vowel Sound of the phrase.

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You can practice this exercise by stretching out and exaggerating the pitch and loudness of short phrases. Remember always to use Valsalvarelaxed, PR-directed breathing and link together all the words in each phrase. There is a list of short sentences and phrases in Appendix F that you can use for practicing.

Transition to Moderate SMEEch Although exaggerated SMEEch usually eliminates stuttering blocks, the sound of it is obviously too bizarre for use in ordinary conversation. However, speaking in SMEEch can be gradually modified to sound more normal while still enabling you to process speech as melody and movement. Here are instructions for transitioning to Moderate SMEEch: 1. Use Valsalva- relaxed PR breathing throughout the exercise. 2. Select a word or phrase on which to practice. 3. Begin by voicing the word or phrase in exaggerated SMEEch. Repeat this a few times until you are familiar with the exaggerated “melody” (changes in pitch and loudness). 4. Next, repeat the same word or phrase several times with the same melody and inflection. Replicate the relative pitch and loudness of the vowel sounds, but each time say the word or phrase with incrementally less stretching and exaggeration. 5. During each repetition, continue to focus on the melody and movement of the word or phrase. After the exaggeration has been gradually reduced, the word or phrase should sound more natural, although slightly slower and more expressive than it previously may have been.

Conversational SMEEch In actual conversations, you don’t have to speak with extreme slowness or greatly exaggerated inflection. However, continue to maintain the same awareness of speech as melody and movement. In other words, you can intend to talk in SMEEch, imagining yourself to have great latitude in time and inflection, even while letting your speech sound more natural. Continue to focus on the same pleasurable feeling of phonation resonating through your body, while you express your feelings through voicing of the vowel sounds. Visualize the SMEEch exercise as a way to widen and deepen your “channel” for vowel-sound expression – just as widening and deepening a ship channel makes it easier for ships of all sizes to pass through. Likewise, after you get used to exaggerating melody and movement in SMEEch, speak-

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ing with natural inflection and expressiveness may come more easily in actual speaking situations. When blocking on a word, it may be helpful to imagine it stretched out in SMEEch. This could be done in conjunction with the Word Recovery Response, to be discussed in the next chapter.

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CHAPTER 39.

The Word Recovery Response

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HE CORE OF THE STUTTERING EXPERIENCE is the perception that an upcoming word contains an obstacle, or “brick wall,” that prevents the word from being said. Often the person who stutters feels this “brick wall” in advance, even before he tries to say the word. This feeling of being stuck on a word is what we call a stuttering block. Our working hypothesis is that stuttering blocks happen when the brain’s amygdala triggers the release of stress hormones, which initiate a “fightflight-freeze” response. The stress hormones interfere with the brain’s motor program for saying a specific word. The freeze response is designed to protect an individual from being seen or heard by an adversary. Therefore, it suppresses the brain’s motor program for voicing the part of a word that is loudest and therefore most likely to be heard. The loudest part of a word is the vowel sound, so that is the part that is suppressed. In a single-syllable word, vowel suppression would attach to the first and only vowel sound. In multi-syllable words, the freeze response would focus on suppressing the loudest vowel sound, which would be the vowel sound in a stressed syllable. These are the “Key Vowel Sounds,” without which words cannot be spoken.

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Key Vowel Sounds can be recognized not only by their loudness, but also because their voicing normally begins at the highest pitch in the word or phrase. In place of the vowel sound, the stress hormones usually substitute an impulse to exert effort on a preceding consonant or glottal stop. The speaker may feel an overwhelming urge to build up air pressure in an attempt to force out the word by means of a Valsalva maneuver. The forcing and other struggle behaviors may perpetuate the block, but may eventually discharge the effort impulse, after which the word may be spoken.

Word Recovery Strategy. The strategies and exercises in this chapter are not intended for ordinary speaking. They are reserved for recovering words that are blocked. Stuttering blocks vary in strength and persistence, which will determine how much response is necessary to recover the word. These are the basic elements of the Word Recovery Response: 1. As soon as you feel the block, immediately STOP! Release any air pressure that you may have built up. 2. Squeeze your puborectalis (PR) muscle while inhaling, to discharge the effort impulse. 3. Your larynx should be relaxed and in a low position in your throat. When your larynx is in a lower position, it phonates more easily and is less likely to do effort closure (which happens when the larynx is in a high position. You can determine the position of your larynx by touching the sides of your throat with your fingers. One way to lower your larynx is to press your tongue against your lower teeth as you inhale. 4. While inhaling, imagine voicing the melody of the word (or even of the entire phrase) with exaggerated inflection and feeling. This will automatically include the melody of the Key Vowel Sound, which will be the loudest vowel sound and the one that starts at the highest pitch. You can voice melody even in single-syllable words. Start the vowel sound loudly at a high pitch and then glide down to a softer, lower pitch. 5. You may shape the Key Vowel Sound in your mouth as you inhale and as you begin to exhale. Do what works best for you.

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Part IX /Valsalva-Relaxed Speech Exercises 6. Slowly relax your PR and abdomen as you exhale. This will relax your Valsalva mechanism. Let a little exhaled breath escape before gliding into the word. 7. Focus your attention on replicating the melody and voicing the Key Vowel Sound with enthusiasm and feeling. Voicing the Key Vowel Sound should start at a higher pitch and then glide down to a slightly lower pitch. 8. Let the initial consonant and rest of the word come along with the melody, without trying to say them. 9. Use Valsalva-relaxed PR breathing throughout the procedure.

Discharging Effort Impulses Overcoming effort impulses is the greatest challenge to incorporating Valsalva-relaxed strategies into ordinary speaking situations. When encountering a block, you may find it difficult to resist forcing on the initial consonant or glottal stop. You may feel terrified of what might happen if you don’t use effort. This may be due to the amygdala’s role in protecting us from physical danger, when our response to the effort impulse could be a matter of life or death. So, it may feel the same in speaking situations – when there is no physical danger. Furthermore, when your brain is flooded by stress hormones, you may forget everything you learned in speech therapy. You can only do what is instinctive, habitual, or very well learned. Or you may feel that you “don’t have time” to use recovery techniques and that forcing on the word will get it out faster. In reality, struggling on the word usually takes even longer. Therefore, it is crucial that you train yourself always to use the Word Recovery Response when you encounter a block – without exception! This must be your only response to stuttering blocks, both on single and multi-syllable words. Otherwise, you will revert to the same old struggle behaviors that you have relied upon in the past, and nothing will ever change. Make a list of words and phrases on which you have blocked in the past or on which you fear you might have trouble. Use these for practicing the Word Recovery Response. Also practice with words on which you just imagine you are blocking. The Appendix contains lists of words and phrases on which you might practice.

Responding to Blocks on No Particular Word Some persons who stutter may encounter Valsalva-stuttering blocks as soon as they form the intention to speak, even before consciously choosing the words they want to say. This may reflect fear of the speaking situation in general, rather than fear of a specific word or sound. The larynx may close tightly and be unable to make any voiced sound at all. When I was young, I

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sometimes felt that it was pointless to select specific words, because I wouldn’t be able to say them anyway. Instead, I made a series of forceful, repetitive grunts – “Ɂuh-Ɂuh-Ɂuh-Ɂuh-Ɂuh-Ɂuh” – as I struggled to force through the block, hoping that something would eventually come out. This grunting behavior – which is similar to a series of mini-Valsalva maneuvers – may tend to discharge your “effort impulse” and to reduce your anxiety. After grunting, your larynx and Valsalva mechanism may relax, thereby freeing your voice and allowing you to say the next few words without stuttering. As a result, the grunting behavior seems to be rewarded. Therefore, it may become a habitual tactic for overcoming blocks. It may feel like the familiar and “safe” thing to do, regardless of how effortful and annoying it might be. Several years ago, I felt an urge to return to this behavior when asking questions at continuing education lectures. I was surrounded by dozens of my peers and worried about looking foolish. But, instead of panicking, I decided to take control of the situation. This is what I did: First, I disregarded my fear of blocking and chose the exact wording I would use. This avoided the awkwardness of having to construct a coherent sentence under stress. My sentence was in the form of: “Could you please explain the difference between A and B?” Second, I focused entirely on the vowel sound of the first word, “could.” I shaped the vowel sound in my mouth while I imagined the melody and did Valsalva-Relaxed PR breathing. I completely ignored the initial consonant. When called upon by the lecturer, I voiced the vowel sound with inflection and feeling. The rest of the word came along for the ride without my trying to say it. After I successfully said the first word, the rest of the sentence came easily. Then I made it my practice to ask questions in the same way whenever I attended continuing education lectures. My fear gradually subsided, and I was able to ask questions in a relaxed, conversational way. If you want to change this stuttering behavior, stop and consider what the block actually might be. Instead of blaming yourself for being “defective,” view the block as being just a defensive reaction triggered by your friend “Amigo” (your amygdala) in anticipation that speech will be difficult. Here are some suggestions that might help you move past this struggle: • Instead of forcing in your larynx, squeeze your puborectalis (PR) muscle to discharge the effort impulse. •

Do Valsalva-relaxed PR breathing.

•

Think of your role and purpose in speaking. Decide what you want to say and choose the words you will use.

•

As you think of the first word, identify its Key Vowel Sound and shape it in your mouth. Imagine yourself voicing its melody.

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As you relax your PR and abdomen, voice the Key Vowel Sound with inflection and feeling. The Key Vowel sound is the part of the word or phrase through which you express and affirm yourself as a person. So, voice it enthusiastically without holding back. Let the rest of the word come along for the ride without trying to say it.

•

Voice the rest of the phrase with inflection and melody, using Resonant Valsalva-relaxed speech.

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CHAPTER 40.

Demystifying Stuttering Blocks

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EW EXPERIENCES are as frightening and frustrating as being helplessly in the grip of a full-blown stuttering block. You may feel that your speech has been captured by some malevolent external force. Or you may view it as punishment for your underlying defectiveness. In my youth, I imagined blocks to be a powerful dragon that stopped me from saying what I wanted. Stuttering blocks are both mystifying and maddening. But unless we get a clear picture of what they really are, we will continue our blind struggle to “stop stuttering.” Hopefully, this book has shed some light on stuttering blocks. But knowing something intellectually, by itself, does not always change our physical and emotional reactions to blocks. Therefore, this chapter will suggest some additional ways to get in touch with our friend “Amigo” and his troublesome “brick wall.”

Reducing Your Fear of the “Brick Wall” When encountering a block, most persons who stutter usually panic. They try to make the block go away quickly by using the same old struggle behaviors that usually make matters worse. Sometimes they go into what’s called the “stutterer’s fog” and try to pretend that it’s not really happening. How can we eliminate this kind of panic? The primary way to reduce a person’s fear of something is desensitization. One of the procedures is to have persons relax while presenting them with incrementally stronger representations of the feared stimulus. If the person fears snakes, for example, he or she might first be shown a picture of a snake, then maybe a video, then a harmless snake in a glass container, and then the person might actually touch the snake. In this way, desensitization may be achieved by repeated exposure to the panic-producing stimulus in a non-threatening way. Likewise, our fear of blocks might be reduced by: (1) accepting the fact that the block is really happening; and (2) not reacting to it. Instead, we must have courage to feel the “brick wall” without reacting or fighting against it. We must take whatever time is necessary to observe the block calmly and ob-

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jectively, as if we are scientists studying a natural phenomenon – like measuring an earthquake on a seismograph, seeing how long the tremors last, and how strong they are on the Richter scale. Of course, stopping to wait out blocks is usually impractical in ordinary situations. You must feel free to take as much time as you need. Therefore, the best opportunities are probably during therapy sessions or when conversing with a family member or friend who understands what you are doing. You can signal your listener by holding up the palm of one hand and touching your throat with the other. In appropriate situations, commit yourself to do the following exercise: 1. When you feel a block coming or when you find yourself in the middle of one, STOP immediately. Don’t try to force out the word or use any avoidance or delaying tactics (such as interjections, “starters,” or word substitutions). 2. Accept the fact that a block is happening. Instead of panicking or fighting the “brick wall,” relax and wait for it to dissipate on its own. 3. Feel the physical target of the block – such as pressure in the lips, tongue, or larynx. Relax that pressure instead of trying to force out the word. 4. Do Valsalva-relaxed PR breathing throughout the exercise. 5. Identify the Key Vowel Sound and shape it in your mouth. 6. Observe and measure the block objectively. You can measure its length by the number of Valsalva-relaxed breaths you do before it ends. You can visualize the relative strength of its effort impulse by pinching your thumb and middle finger together. 7. Meanwhile, think to yourself: “That’s my friend Amigo (my amygdala). He’s trying to help me, but he doesn’t have the vowel sound. Therefore, I’ll supply it myself.” 8. As the block gradually subsides, voice the Key Vowel Sound softly, starting at a higher pitch, along with the word’s melody, and let the word come when it is ready. Remember, your objective in this exercise is not to say the word. It’s to observe the brick wall and make friends with it. By acknowledging blocks and refusing to respond, you will gradually reduce your fear and improve your ability to control them.

Curbing the Urge to Force on Consonants Persons who stutter generally focus on the first sound of a feared word – usually the beginning consonant (or the glottal stop on words that start with

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vowels). During stuttering blocks, persons who stutter may become so fixated on the consonant that they totally forget about what vowel sound is supposed to follow. Instead, they press hard on the consonant, in an attempt to “force out” the rest of the word. Sometimes the consonant may be in the middle of a word, at the beginning of a stressed syllable. In words that begin with vowels (e.g., “apple”), persons who stutter may build up air pressure by forcefully closing the larynx. This kind of blockage seems to be triggered by the speaker’s intention to say the consonant (especially if it is one on which he anticipates difficulty) and by the unreadiness of his larynx to phonate the vowel sound. Contrast this with normal speech, in which consonants are usually articulated in a very brief and gentle way. In normal speech, consonants are quickly released as the vowel sound is voiced. Many consonants can’t even be heard unless closely followed by a vowel sound. Vowel sounds are the heart and soul of every word and syllable. They are the loudest part, the part with the most energy, and the part through which we express our feelings. The preceding consonant can be viewed simply as an opening for the vowel sound that follows. Imagine a consonant to be like an automatic sliding door, such as the ones you may have seen at grocery stores or other commercial establishments. The door starts off closed, but as you approach it, a motion detector triggers motors that slide the door open. Now you are free to walk through the doorway without ever touching the door. In contrast, imagine what would happen if the door was programmed to operate in the opposite way. The door starts off open, but as you approach it, the motion detector triggers the door to close. You may try to pry the door open, but the door continues to close tightly. This is like what happens when a person who stutters forces on a consonant in trying to say a word. Instead of quickly opening to let the vowel sound through, the lips or tongue tightly close, preventing passage of the vowel sound. Of course, it’s not that the person consciously wants the consonant to block speech. It just seems to happen automatically, like the sliding door in our analogy.

The Passive Consonant Exercise The purpose of this exercise is to subordinate initial consonants to the vowel sounds that follow. This is done by focusing all your attention on voicing the Key Vowel Sound or Melody Message of the word and giving up all intention to say the consonant. The initial consonant and rest of the word will take care of themselves. They already have a motor program. It’s the motor program for voicing the Key Vowel Sound that’s missing. As with all the exercises in this program, always do Valsalva-Relaxed PR breathing. In this exercise, your lips and/or tongue will begin by relaxing and

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resting in the position of the initial consonant. They should be completely passive, and you should have no intention to say the consonant. Focus all your intention on saying the vowel sound. Forget about the consonant. Simply allow your lips or tongue to get out of the way and let the vowel sound through. Don’t worry about whether the consonant will be heard. Usually it will be, but for the purpose of this exercise, it doesn’t matter. You can practice this exercise on the Consonant-Vowel Sound tables in Appendix C. The tables have vowel sounds at the top of each column and consonants at the beginning of each row. Each cell where they intersect contains a word that combines the consonant and vowel sound. For example, where the row for /b/ meets the column for “ah” (/a/), the word is “box.” Here’s how the exercise would be done: 1. Shape your mouth for the consonant /b/, with your lips together in a relaxed, resting position. You are simply allowing your lips to rest in that position, with no intention of making a /b/ sound. 2. Take a Valsalva-relaxed PR-directed breath and relax your puborectalis and abdominal muscles as you exhale. 3. Exhale with the sole intention of voicing the vowel sound “ah.” Do NOT intend to say the /b/ sound at all! The consonant should be totally passive. 4. Voice and shape “ah” with inflection and feeling, paying no attention to /b/. Don’t try to control the /b/ sound or your lips in any way. Forget about them. Everything will be motivated and powered solely by your voicing of the vowel sound “ah.” In the above example, let your lips open on their own as the vowel sound comes through. In most instances, a brief, gentle /b/ sound will probably be heard as the lips open. However, this will be purely incidental. Whether the result sounds like “ox” or like “box” doesn’t matter. Either is fine, as long as you don’t try to say the /b/.

Voice the Key Vowel Sound with Inflection Voicing the vowel sound is easier when you treat it as the Key Vowel Sound (which it is). The Key Vowel Sound is not only the loudest part of the word, but it is also voiced at the highest pitch. Therefore, voice the vowel sound with enthusiasm, voicing the beginning of the vowel sound at a higher pitch, and then gliding downward to end the vowel sound more softly and at a slightly lower pitch. You can also experiment with other inflections to see which best expresses the feelings you want to convey.

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Mindfulness Mindfulness is another approach to reducing the fear of blocks. It is generally described as the practice of maintaining a nonjudgmental state of heightened awareness of our thoughts, feelings, and bodily sensations on a moment-to-moment basis, without being overly reactive to what’s happening around us. To be “mindful” In Valsalva Stuttering Therapy, direct your full attention to your physical movements and sensations during the production of speech. For example, you can focus on how it feels to activate your muscles to inhale and then to relax them as you exhale; on the feeling in your larynx as your free-flowing air vibrates your vocal folds; and on the movements of your lips and tongue as they shape the sounds of speech. Observe all these activities in a completely neutral way, without judging them in terms of “right” or “wrong,” “fluent” or “disfluent”; without trying to please anyone, to prove anything, or to make a “good impression.” Let your thoughts focus only on what you are actually doing and sensing in the present moment, without judging it in terms of “fluency.” When you experience fear or anxiety in a speaking situation, calmly and objectively observe those feelings. Accept the fact that you are feeling afraid or anxious, without reacting to these emotions or judging them as good or bad. If you encounter a block on a word, don’t react to it or try to fight it. Calmly and objectively observe how it feels. If you find yourself using more physical effort than necessary, let yourself be aware of this, without judging. This approach is not about “fluency.” Its purpose is to reduce stressful speaking patterns, to increase your non-judgmental awareness of breathing and speaking, and to help you treat speech as melody and movement.

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CHAPTER 41.

Transcendent Speech EXERCISES in Valsalva Stuttering Therapy are not intended to control T HE your speech, but rather to control the forces that interfere with your natural speaking ability. These forces are primarily your amygdala and your Valsalva mechanism. The exercises teach strategies to free your speech from their interference. The purpose of continuing practice is to reinforce this liberation until it becomes habitual. The ultimate goal is to have easy, effortless speech come so naturally that you don’t have to think about using any strategies at all. This goal will be called Transcendent Speech (TS). Its purpose is to transcend or “go beyond” the speaking exercises up to this point. It should not be regarded as a “fluency technique,” because its purpose is to transcend the whole concept of “fluency versus stuttering” and render both irrelevant. Transcendent Speech must come on its own, in its own good time, independently of any intention on our part to be “fluent.” The exercise in this chapter cannot be expected to achieve that goal, but it may give you a little taste of what TS might be like.

Liberation from Your Amygdala In addition, this exercise may help you “go beyond” your self-identity as the individual who is speaking. This can have a dramatic effect in reducing the amygdala’s interference with speech. We previously discussed the hypothesis that Amigo is only interested in protecting us personally. Therefore, it is less likely to react when we assume a different identity by speaking with an assumed accent, speaking through a puppet, or acting out a role in which we pretend to be someone else. However, such fluency is only temporary, and stuttering returns when we go back to being ourselves. Nevertheless, this paradox opens the possibility that we might deactivate our amygdala and speak more easily when we imagine that we are not actually speaking the words. In this exercise, imagine that speech is being independently produced by your abdomen as it relaxes, rather than by yourself. Begin by placing one hand on the front of your abdomen as you do Valsalva-relaxed PR breathing. Feel the front of your abdomen bulge out as you inhale and go back in as you slowly

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relax and gently exhale. You can imagine that the words are coming out your navel. Directly connect abdominal relaxation with “abdominal speech.” In other words, imagine that your abdomen “speaks” as it relaxes. Imagine that you have no control over the words your abdomen is speaking, no responsibility for how they are said, and no obligation to use effort in saying them. While pretending to be someone else may bring temporary fluency, this Transcendent Speech exercise can have a lasting effect because it focuses your attention on relaxing your own abdomen when speaking. Relaxing your abdomen is, in fact, what initiates the outflowing breath that makes speech possible. Relaxing your abdomen, along with the PR muscle, relaxes your entire Valsalva mechanism, which reduces the tendency to exert physical effort and to block. In this way, the TS exercise reinforces the principles of Valsalva Stuttering Therapy that you have been practicing. In ordinary speaking situations you can practice allowing your speech to come automatically, while continuing to associate speaking with the simultaneous relaxation of your abdomen.

Instructions The Transcendent Speech exercise is to be done in an easy, relaxed way, without exerting any effort or conscious control over your speech whatsoever. Instead, rely on your Valsalva-relaxed airflow to automatically create whatever words or messages spontaneously arise from your abdomen. The steps are as follows: 1. As usual, begin the exercise by doing Valsalva-relaxed PR breathing. (You may choose whether or not to put the back of your tongue in the velar position.) 2. Choose a sentence or phrase on which you have had difficulty in the past, or about which you may have some anxiety. 3. Place one hand on your abdomen to feel it bulge out slightly as you inhale and go back in as you exhale. You may leave your hand on your abdomen throughout the exercise. 4. Imagine that you hear the sentence or phrase coming from your abdomen as it slowly relaxes and goes back in. 5. While relaxing your abdomen and using no effort at all, gradually allow yourself to supply a voice to the sentence or phrase. Imagine that you are talking in unison with your abdomen, just as you would when reciting along with someone else (a fluency-enhancing condition). Take your time and let your voice come on its own. Let your voice start softly, but then let it gradually increase to an easy and effortless normal level. 6. Use Transcendent Speech to voice other sentences and phrases in a spontaneous, effortless way. Use sentences and phrases that you fre-

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During the day, focus on “speaking from your abdomen.” Recognize abdominal relaxation as being the source from which your speech springs. Let your speech flow spontaneously as you relax your PR and abdomen, without exerting any effort or conscious control over your speech whatsoever. Get used to this easy and spontaneous manner of speaking and allow it to become habitual, without any conscious thought.

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CHAPTER 43.

Why Repetitive Exercises Are Important OME PERSONS WHO STUTTER have asked, “What’s the benefit of doing daily practice by myself when I’m already fluent when I’m alone? How does this help me speak to other people?” I respond by explaining that the point of repetitive practice is not to become more fluent while practicing, but to strengthen behavior patterns that will help you reduce blocks in real speaking situations. For example, if you were a pianist preparing to perform at a recital, would you practice new pieces beforehand, or would you wait until you were in front of the audience? If you wanted to perform well, you would continue to practice until your fingers were automatically able to play the right notes without your having to think about it. Other participants have questioned the need to adopt Valsalva-relaxed strategies on a regular basis, when they already speak fluently 90% of the time. In response, I point out that the mere fact that they are usually fluent has done nothing to immunize them from blocking on words on other occasions. The purpose of the Valsalva-relaxed exercises and strategies is to prepare your larynx to phonate vowel sounds and your Valsalva mechanism to relax, making speech easier when it really matters. If the motor program for saying a word includes phonation of the Key Vowel Sound, then the word will not contain a “brick wall,” you will not feel the urge to force out the word, and your speech mechanism will not get stuck on the initial consonant or glottal stop. Therefore, repeated practice is needed to assure that your brain will create the proper motor program under stress. This is because your amygdala may continue to trigger fear reactions in speaking situations. The resulting stress hormones will suppress phonation of the Key Vowel Sound and substitute a powerful urge to exert physical effort to force out words. Because the stress hormones will also make it hard to think rationally, your new behavior must be very well learned, so that you do it easily and automatically, without thinking. Otherwise, you will continue to resort to your habitual or instinctive behaviors, even though they are totally inappropriate and self-defeating. This principle is dramatically illustrated by the following example.

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The Amygdala and “Brain Freeze” In the early hours of June 1, 2009, an Air France jumbo jet flying from Rio de Janeiro to Paris crashed into the Atlantic Ocean, killing 228 passengers and crew. The cause of the crash was a mystery until the wreckage of Flight 447 and its “black boxes” were recovered from the ocean two years later. It turned out that the major culprit in the disaster may have been a co-pilot’s amygdala. The captain had gone to take a nap, leaving the controls in the hands of a less experienced co-pilot. As the plane flew over a storm, the air-speed sensors malfunctioned because of ice crystals, causing the autopilot to shut down. Soon the aircraft experienced what is called an aerodynamic “stall.” In other words, the plane lost the aerodynamic “lift” normally produced by air flowing over and under the wings. As a result, the plane began to fall – and the co-pilot panicked. If you were piloting a plane that was losing altitude, what would be your instinctive response? Would you pull back on the controls and point the nose of your plane upward? Or would you push forward on the controls and point the nose downward? Our instincts would probably tell us that, if we want the plane to stop falling, we should pull back on the controls to go up. In his panic, that is exactly what the co-pilot did – and it was exactly the wrong thing to do. Various psychologists have surmised that the co-pilot’s amygdala triggered a fear reaction that partially shut down his brain’s pre-frontal cortex. This reaction is sometimes called “brain freeze.” When this happens, a person is unable to engage in complex reasoning and can only perform behaviors that are instinctive, habitual, or very well-learned. In this case, the fear reaction caused the co-pilot to forget a basic tenet of flight training: In order to get out of a stall you must push forward on the controls and point the nose down, in order to speed up the plane. Pulling back and pointing the nose up – the instinctive thing to do – slowed down the plane and made the stall worse. Influenced by his amygdala, the co-pilot did the instinctive thing instead of the smart thing, resulting in the tragic consequences.

Practice a New Response Investigation into the disaster raised questions about whether pilots were adequately trained to respond appropriately to emergency situations like the one encountered. However, airplane pilots are not the only ones who must be trained to perform under frightening circumstances. Soldiers, police officers, firefighters, paramedics, emergency room personnel – all must be repeatedly drilled so that they will behave in the correct way, without hesitation, regardless of the circumstances. Repeated practice and drilling is also necessary for athletes, martial artists, musicians, and anyone else who wants to excel in a particular sport or activity.

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Repeated practice can establish and strengthen nerve pathways to a point where the desired behavior comes easily and automatically, without conscious thought or effort. This can be crucial when the amygdala and stress hormones are trying to shut down our ability to think. For persons who stutter, the amygdala triggers a neurological response to feared words, sounds, or speaking situations. Stress hormones are released, which cause the speaker to forget the lessons of speech therapy and to resort instead to his habitual stuttering behaviors in an attempt to “force” his way through the perceived “block.” Don’t be surprised when these false alarms continue, even after speech therapy. They will gradually diminish only after you learn to respond to them in a different way. If you continue to respond in the old way, by using force, nothing will change. You must learn to do what is smart, rather than what is instinctive.

Muscle Memory Repetitive practice of specific bodily movements can produce what has been called “muscle memory.” The motor program for each movement becomes so strong that it seems as if the muscles themselves “remember” what to do automatically, without any conscious thought on our part. This phenomenon was dramatized in the 1984 film, The Karate Kid. Daniel, a high school student who has been harassed by bullies, seeks to learn karate from an elderly Japanese martial arts master. Daniel is puzzled when the Master begins by telling him to wax the Master’s automobiles. The Master instructs Daniel to put “wax on” by using a circular motion with one hand, and to take “wax off” by moving the other hand in a circular motion in the opposite direction, while at the same time paying attention to breathing. Subsequent “lessons” consist of other laborious chores: sanding the wood floor of a deck with similar circular hand motions, painting a fence with up-and-down motions, and painting the Master’s house with side-to-side motions – all while paying attention to breathing. Daniel fails to see how doing these chores has any relevance to learning karate. When he expresses his frustration, the Master says, “Show me ‘sand the floor.’” Then, when the Master attempts to strike with his hand, Daniel instantly uses his circular hand movement to ward off the blow. The other movements are also used to ward off blows. Without Daniel realizing it, the hand movements he repeatedly used in performing the chores had created “muscle memory” for defensive blocks in karate. For persons who stutter, the relevant “muscle memory” involves muscles of the larynx and the Valsalva mechanism. Unfortunately, these muscles already have “memory” for performing effort closure and Valsalva maneuvers

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during speech. The trick now is to change their muscle memory to phonation by the larynx and relaxation of the Valsalva mechanism.

The Four Stages of Learning Any New Skill Learning Valsalva-relaxed speaking behavior is similar to learning any new skill. Don’t expect it to come instantly or automatically. Learning any new skill is a gradual process that has often been viewed as encompassing the following four stages: • “Unconscious incompetence.” You begin by not realizing what you are doing wrong. For example, you may erroneously believe that you stutter because certain words or sounds are difficult to say, and that you must use effort to force through the blocks. • “Conscious incompetence.” You understand the importance of relaxing your abdomen, letting the air flow, and phonating the vowel sounds, but you are not yet able to overcome the urge to exert effort. Nevertheless, you can learn from observing your mistakes. • “Conscious competence.” You have learned to overcome blocks by relaxing your abdomen, letting the air flow, and focusing on the vowel sounds. However, you must consciously think about doing this. The more you continuously practice, the more natural it becomes. • “Unconscious competence.” You have now practiced your Valsalvarelaxed speaking behavior so much that you do it easily, automatically, and habitually, without having to think about it – just like normal speakers. This is the ultimate goal, but reaching it will take time and a lot of practice.

Changing the “Valsalva Stuttering System” Repetitive practice is only one part of Valsalva Stuttering Therapy. You must change the entire “Valsalva Stuttering System.” As previously discussed, this is an interactive system that includes memories, beliefs, perceptions of difficulty, expectations, fears, and intentions, which trigger and perpetuate your stuttering behaviors.1 You must begin by changing your intentions in speaking, as discussed in previous chapters. Your new intentions must be practiced repeatedly, until they become habitual. This is the basis for the numerous exercises in this book. You must continue to practice these exercises long after formal therapy is completed. The new intentions will gradually produce new behaviors, with easier and less effortful speech. Easier speech will gradually generate more positive expectations and beliefs and reduce the fear. These more positive attitudes will further help to strengthen your new intentions and easier speech.

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CHAPTER 44.

Implementation of Therapy

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HIS CHAPTER WILL DESCRIBE the approach that I have been using to implement Valsalva Stuttering Therapy over the past several years. My therapy program has continually evolved and improved, thanks to the input of more than 200 therapy participants. I call them “participants,” rather than “patients” or “clients,” because we all have the common purpose of understanding stuttering and finding better ways to deal with it. Our sessions are mutual learning experiences. I learn as much from them as they learn from me, and then I share what I learned with other participants. My therapy sessions are done online through video conferencing. This is the only practical way to administer therapy because of the distances involved. It also allows participants to experience therapy in their own home or work environments. My standard therapy program is fifteen hours. The time needed to achieve optimal results will vary depending on the individual. The therapy sessions can be extended at the participant’s option. After explaining various concepts during sessions, I generally ask the participant, “How does that resonate with you?” Or “Have you ever had a similar experience?” Participants share their experiences and feelings. When participants practice new exercises, I generally ask, “How did that feel to you?” The principal purpose of the exercises is to help participants’ speech to feel easier, less effortless, and more relaxing. I tell them, “If you find yourself ‘trying hard’ to do the exercises, you’re missing the point.”

Measuring Progress During the first session, I take baselines, discuss the participant’s history, and have participants rate their relative ease or difficulty when talking in various situations during the previous week. The participants make the same self-report at the beginning of each session to see what, if any, progress has been made since the previous session. What matters is not how easily the person speaks during therapy sessions, but rather in ordinary situations where speech really matters. The “Easy and Effortless Self Report” begins with these instructions:

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“Your goal in this therapy is not ‘fluency’ per se, but easy, effortless speech. When answering these questions, think only about how easy or difficult the physical act of speaking felt to you. Give me a number from 1 to 9 on a sliding scale. One is very easy and effortless; nine is very difficult.” The following is a list of items in the questionnaire. The answers are recorded in a separate column for each session. Very easy & effortless

1

2

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5

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Very difficult

1. Since the last session [or during the past week], how easy or difficult has your speech been in general? Score: 2. Since the last session [or during the past week], how easy or difficult has your speech been, on average, in the following situations? Home Socializing Others Work/School Telephone 3. Since the last session [or during the past week], how easy or difficult as your speech been, on average, when speaking to the following persons? Close friend Stranger Others Family Authority figure 4. Since the last session [or during the past week], how would you rate your easiest speaking experience when talking to someone? Score: 5. Since the last session [or during the past week], how would you rate your most difficult speaking experience? Score: 6. How easy or difficult is your speech right now, as you are talking to me? Score: 7. Overall, do you feel that your speech was easier (E), the same (S), or more difficult (D) than it was before our previous session? [Not applicable to first session.] E/S/D: (The format and some categories were adapted from “Clinical Use of Self-Reports” in Riley, G. D., Stuttering Severity Instrument – Examiner’s Manual (4th ed. 2009).

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Some of the “Other” categories commonly used are: saying one’s name, ordering food, speaking before a group, giving directions, explaining something, asking or answering a question, etc. If the participant reports that speech was “easier,” I will ask, “In what respect was it easier, and what if anything do you think helped?” Likewise, if speech was “more difficult,” I may ask in what respect it was difficult and what factors may have contributed to the difficulty. Regardless of the previous answer, I may ask the participant to describe his or her most difficult speaking experience since the last session. I may ask the participant to identify a particularly difficult word, phrase, or sentence and then use it as an example for teaching exercises. This information can be helpful in addressing issues and choosing the exercises and strategies to be covered during the rest of the session. If a participant feels a block during the session, he or she must signal me and stop, so we can use this opportunity to practice word recovery.

Therapy Materials At the time of this writing, the written therapy materials in my program consist of about two dozen “Modules,” each covering a separate topic or exercise. These include educational modules, exercise modules, and reading materials to be used in practice. In addition to modules with instructions for specific speaking exercises, some of the modules can be used for practicing any of the speaking exercises. Here are descriptions of some of the modules. Consonant-Vowel Tables. These tables provide various combinations of consonants and vowels sounds. They are intended to help participants strengthen vowel phonation while reducing the tendency to force on consonants. The tables contain twelve vowel sounds, one at the top of each column, and twenty-two rows for consonants and initial vowel sounds. A word combining the consonant and vowel sound appears in each box where the rows and columns intersect. One of the tables contains single consonants and the other contains words starting with consonant clusters. These tables are found in Appendix C. Sentences and Phrases. This Module contains a list of forty conversational phrases, to be used in practicing various exercises. Picture Naming Exercise. This Module contains almost 200 small pictures of easily identifiable things. While practicing various exercises, the participant must name the item while focusing on the Key Vowel Sound, and then use the name in a sentence. Sample pages appear in Appendix G. Initial-Sound Sentences. Each page of this Module contains a list of sentences in which the important words all begin with the same consonant, plus one page devoted to initial vowel sounds. The purpose is not to practice saying consonants but rather to desensitize the participant to words starting with feared sounds. Sample pages are found in Appendix I.

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Vowel Sentences. This Module follows the same format as the Module for Initial-Sound Sentences, except that each page is devoted to a specific vowel sound. See samples in Appendix H. Time-Pressure Exercises. This Module contains a variety of exercises designed to put time pressure on the participant. However, the underlying purpose is not to practice rapid speech, but rather to practice resisting the time pressure while speaking at a comfortable rate. One of the sections contains a short-answer quiz in which the participant must think of the answer while doing a speaking exercise at the same time. Daily Practice Routines. This Module contains more than a dozen different exercise routines that participants are assigned to practice on their own for at least half an hour every morning. Examples can be found in Appendix J. Reading Materials. Other Modules contain extensive materials to be read aloud when practicing. These include excerpts from Understanding and Controlling Stuttering, with phrase markings. Other reading materials contain poetry and famous speeches.

Affirmations and Reflections When appropriate, the therapy sessions and daily practice routines end with the following readings. Each slash indicates the beginning of a phrase and the taking of a Valsalva-relaxed PR breath.

The Relaxed River of Air / My outgoing breath / needs no effort at all. / I relax my PR and abdomen / and let the air flow freely. / My relaxed, outgoing breath / is a river of air / that creates and carries / all the sounds of speech. / My speech flows / in the river of air. / My feelings flow / in the river of air. / I take my time / and go with the flow.

Valsalva-Relaxed Affirmations / I am safe. / I am strong. / I am free. / Speech is easy. / Speech is fun. / I enjoy talking.

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Therapy for Children Valsalva Stuttering Therapy is primarily designed to treat established stuttering behaviors in adults and teens. Nevertheless, I have found that children as young as eight years may also benefit, depending on their mental capacity and willingness to practice. The therapy may need to be simplified for some children. If they are forcing and building up air pressure on initial consonants and glottal stops, they can be taught about the Valsalva maneuver and why forcing only makes blocks stronger. They can be taught to treat words as continuous melody and movement instead of “things” that can be forced out of the body. Children can be taught to do Valsalva-relaxed breathing. I have found it helpful to explain breathing in terms of the bicycle illustration. All the effort is for inhaling (going up the hill) and no effort is needed for exhaling and speaking (coasting down the hill). They can also focus on how the front of their abdomen bulges out slightly as they inhale and goes back in as they exhale.

Children can be encouraged to slow down and speak in phrases. They can focus on voicing the vowel sounds of words instead of trying to say initial consonants. They can pay attention to the melody of the phrases, to identify the Key Vowel Sounds, and to voice the key vowels with emphasis, inflection, and feeling. If children have difficulty identifying and controlling the puborectalis muscle, they can focus instead on relaxing their abdomen while exhaling and speaking. Most important, children should be assured that stuttering is nothing to be ashamed of. It does not make them less worthy, nor does it mean that they are in any way “defective.” Children can learn that there are reasons why they sometimes get stuck on words, and that there are things they can do to make speech easier, less effortful, and more enjoyable. The purpose of speech is not to be “fluent,” but rather to have fun communicating and interacting with others.

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CHAPTER 45.

Valsalva Control for Everyday Speech

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OUR HALF-HOUR morning exercise routine is not the end of your daily practice, but only the beginning. As you go about your business, hold onto all the elements of Valsalva relaxation that you experienced during your practice session. Now you must practice transferring your Valsalva-relaxed attitudes, intentions, and behaviors to ordinary speaking situations.

Focus on Your Valsalva-Relaxed Intentions As you approach and enter every speaking situation, focus on your Valsalva-relaxed intentions. You don’t have to focus on all of them at the same time – one or two at a time will do. Focus on these intentions instead of trying to say words, trying to make a “good impression,” or trying not to stutter. • Focus on your role and purpose in speaking and on the things you want to communicate. Give up any intention to “make a good impression.” •

Do Valsalva-relaxed PR breathing and RVR speech.

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Speak in phrases.

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Relax your PR and abdomen as you exhale and speak.

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Identify the Melody Message and Key Vowel Sound of each phrase.

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Voice the Key Vowel Sound and/or Melody Message with inflection and feeling.

•

Take your time and go with the flow.

Responding to Valsalva-Stuttering Blocks Don’t expect stuttering blocks to magically disappear. Don’t be distressed when you feel an overwhelming urge to force on a word. This is only your friend Amigo (your amygdala) trying to help you in the absolutely wrong way. Because of your previous experiences you may feel that forcing is a matter of life and death – but it isn’t. It takes courage to resist the effort impulse and faith that nothing bad will happen to you if you don’t use effort.

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Be prepared to use the Word Recovery Response – and only that response – whenever you feel a block. Don’t fool yourself into thinking that you don’t have time to do word recovery or that you can’t keep your listener waiting. If necessary, you can signal your listener by holding up the palm of one hand and touching your throat with the fingers of the other. Word recovery usually takes no longer than struggling against the block. When participants tell me that they’re afraid to make the listener wait, I asked them: “What’s more important – keeping your listener from waiting a couple of seconds or the rest of your life?” If you’re not willing to change your response to blocks in these situations, nothing will ever change. You might also fool yourself into thinking that there’s no harm in using one of your old habits “just this one time.” This is like a recovering alcoholic deciding to take “just one drink.” Once you start down that path, you will find yourself back to square one. I remember one occasion when I felt a potential block while on a conference call with a judge and another lawyer. Although I should have known better, I felt reluctant to use word recovery because I would be acknowledging to myself that I stutter. I figured that no one would notice if I just said “ah” as a starter. However, after saying “ah,” I continued to feel the block and ended up continually repeating “ah-ah-ah-ah-ah.”

Responding to Anxiety Don’t expect that speech therapy will cause your fear reaction to disappear immediately. No therapy can do this. Remember that fear is not a sign of failure. It’s just an emotion, triggered by old memories and negative expectations. What matters is how you react to it. Anxiety by itself does not mean that you will necessarily stutter. A certain level of anxiety about speaking is not only normal; it can even be used in a positive way. Professional speakers have a saying (attributed to Helen Keller):“It’s OK to have butterflies in your stomach. Just get them to fly in formation.” When you feel anxious about going into a speaking situation, do some Valsalva-relaxed PR breathing. If circumstances permit, you can do velar humming as you exhale. Instead of worrying about stuttering, focus on your role and purpose in speaking, what you want to say, and the things you want to accomplish.

A Transactional Perspective on Stuttering When entering speaking situations, you may feel more in control by applying some of the principles of Transactional Analysis (TA). Transactional Analysis was popularized in the 1960’s by Dr. Eric Berne in his book, Games People Play: The Psychology of Human Relationships. The

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underlying premise is that each person carries within him or her three psychological “ego states”: a “Parent,” an “Adult,” and a “Child.” These ego states do not necessarily relate to specific individuals. Instead, they are three different kinds of roles that a person psychologically assigns to himself and to others involved in an interpersonal transaction. The assignment of roles may change, depending on the situation. •

The “Parent” represents the ego state of a person’s parents (or substitute parents), as that individual perceived them. We might imagine persons in this role to be powerful, dominant, superior, authoritative, controlling, and judgmental. • The “Adult” ego state is the one capable of objective data processing. We might imagine persons in this role to be practical, reasonable, independent, and selfreliant. • The “Child” ego state represents the relics of a person’s childhood emotions and behaviors. We might imagine persons in this role to feel weak, inferior, helpless, and dependent on the approval or judgment of others. Transactional Analysis does not explain the cause of stuttering, but it may help us understand the dynamics that exacerbate stuttering in certain situations and that reinforce the Valsalva- Stuttering Cycle. For example, persons who stutter often feel themselves in the Child ego state, and they project on the listener the role of Parent. As a result, they may feel themselves to be in the subservient position in which they must gain the approval of the listener as Parent. This stimulates the urge to “make a good impression,” and causes Amigo to trigger the release of stress hormones that increase stuttering blocks. This may explain why many participants report increased stuttering when they visit their actual parents. Another example involves a discrimination case brought by a volunteer firefighter who was rejected for a job in a city fire department because he stuttered during his interview. The interviewers wrongfully assumed that he

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stuttered due to nervousness, and therefore he wouldn’t be able to communicate during a fire emergency. However, his fellow firefighters from the township testified that he had no trouble speaking during actual fire emergencies. TA provides a possible explanation for this paradox. When fighting a fire, the firefighter was in his Adult ego state, communicating with other Adults. His underlying message was, “Let’s put out this fire!” During the interview he was in the ego state of a Child trying to please the interviewers on whom he projected the role of Parent. His underlying message was, “Look how hard I’m trying to please you!” Alleviating stuttering in these situations may require elevating yourself from Child to Adult and imagining the listener to be just an Adult rather than a Parent or a judge. However, on some level the role of Child may feel safer and more comfortable than accepting the independence and responsibilities of an Adult. By being aware of these issues, you will at least have an opportunity to think about them.

Adjust Speed to Conditions Being tired, sick, or emotionally distressed impairs fine motor skills, including speech. Because speech feels more difficult, people who stutter often try to compensate by using more effort in speaking. Although this might seem like the intuitive thing to do, the extra effort usually makes matters worse by increasing the blocks. When driving a car, you slow down for adverse road conditions, such as rain or snow. The same principle applies to speech. Therefore, if your speech feels more difficult because of fatigue, illness, or stress, accept the fact that you’re not at your best. Make allowance for your impaired condition. Instead of trying harder to speak, ease up on yourself and slow down.

Things To Do During the Day Here are suggestions of what you can do during the day to relax your Valsalva mechanism and practice your new intentions and behaviors. • Use Resonant Valsalva-Relaxed Speech in all situations. Remind yourself to do this at the beginning of every speaking situation. This is the best way to keep your Valsalva mechanism relaxed and your larynx programmed for phonation, thereby reducing the tendency to block.

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• Give up any intention of trying to “say the words.” Instead, focus your intention on voicing your Melody Message and expressing the Key Vowel Sounds with inflection and feeling. • Let your Valsalva-relaxed breath control everything. Let your words flow on your relaxed breath rather than trying to use your breath to push out the words. The words must always be subservient to your breath • When circumstances permit, practice saying the Key Vowel Sounds and Melody Messages with exaggerated expression, intonation, and inflection (as in the SMEEch exercise). Express your feelings by stretching the vowels in some words, saying some with a rising pitch, saying others with a falling pitch, saying some more loudly, others more softly. Practice doing this with friends, family, or therapy partners for the purpose of feeling more expressive and less inhibited. You can also have fun doing this when reading poetry aloud. • Give up any intention of trying to “make a good impression” by trying hard not to stutter. Instead, focus on your role and purpose in speaking and what you want to say, without regard to fluency. Look forward to speaking as an easy and pleasant experience, whether or not you stutter. • Keep your larynx open, phonating, or ready to phonate at all times. When you find your larynx closing or holding your breath, take a Valsalvarelaxed PR breath, relax your abdomen and puborectalis, and do velar humming. If you’re not in a position to hum out loud, imagine that you are humming as you relax your abdomen and exhale. • Practice Valsalva-relaxed PR breathing and velar humming at every opportunity. Keep your larynx in constant readiness to phonate by either imagining yourself humming or actually humming. • Practice Full Humdronian Speech when you are alone. (For example, when driving alone in your car, you might read road signs, billboards, and license plates in Humdronian). • When doing things that would ordinarily involve a Valsalva maneuver (e.g., lifting weights or making bowel movements), consciously refrain from holding your breath. Phonate vowel sounds or hum instead. • Imagine and visualize various speaking situations while practicing Valsalva-relaxed breathing and silent or audible velar humming. Imagine having pleasure expressing yourself, without regard to fluency. • Be aware of and correct negative self-talk. Note the negative things you tell yourself about your speech or speaking situations. Replace them with positive thoughts, such as the Valsalva-Relaxed Affirmations and those in Appendix A. Do not focus on being “fluent,” because that may activate your amygdala and be self-defeating.

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CHAPTER 46.

Learning from Experience

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ONTROLLING STUTTERING is, of course, not as simple as going through the steps of a recipe. There will be many memories, beliefs, expectations, fears, and behavior patterns working to sabotage you. These may include not only your attitudes before speaking, but also your mental reaction to the experience of stuttering. As described in Step 6 of the Valsalva-Stuttering Cycle, persons who stutter may view stuttering as confirming their original belief (in Step 1) that speech is difficult. At the same time, they may also get the false impression that their excessive effort ultimately succeeded in forcing the words out. This may reinforce their tendency to activate the Valsalva mechanism and to use force, avoidance, and other stuttering behavior as ways of overcoming the imagined obstacles to speech. In place of these detrimental reactions, Rule 6 of the Valsalva-Relaxed Speech Cycle suggests the following: • View your speech objectively, without shame or blame. • Don't consider speech to be a "test" or stuttering to be a "failure." Instead, learn from all your speaking experiences, both fluent and disfluent. • Don't be fooled into thinking that force, struggle, or avoidance behaviors had anything to do with getting your words out. • Increase your speaking activities as much as possible, and don't let stuttering spoil the fun of communicating with others. • Maintain your self-esteem, regardless of fluency.

View Speech Objectively There is a natural tendency to view one's stuttering in very personal terms. Through the years, stuttering may have acquired deep emotional significance. It may be experienced as a personal failing, a loss of "face," or a sign of unworthiness. One's reactions may include anger, frustration, embarrassment, shame, guilt, and despair.

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I grew up feeling I had an obligation to berate and blame myself whenever I stuttered. To some extent, this may have been my way of pre-empting the grownups' disapproval. I would "beat them to the punch" by showing remorse for the "bad" thing I had done. Perhaps I even believed that self-punishment would eventually force me to be fluent. However, it's now clear that this approach is self-defeating. It simply increases one's anxiety and the urge to "try hard" in speaking – thereby perpetuating the Valsalva-Stuttering Cycle and making stuttering worse. On the opposite side of the same coin is the tactic of denial. Because I could not accept my stuttering, I sometimes tried to pretend that it wasn't really happening. This allowed me to feel good about myself for at least a little while. But sooner or later, I would get seriously stuck on a word, or someone would call attention to my stuttering. Suddenly my fragile self-esteem would collapse, and I'd go back to blaming myself more viciously than ever. These attitudes and reactions can be serious obstacles to understanding and controlling stuttering. We must shed our feelings of shame or blame and look at our speech objectively – as if we were scientists studying a natural phenomenon.

Learn from Your Stuttering As we have previously stated, Valsalva Stuttering Therapy is not intended to produce "instant fluency" by artificial means. Instead, it is a gradual process of neurologically reprogramming the Valsalva mechanism to reduce its tendency to interfere with speech. Therefore, you should not expect stuttering blocks to disappear all at once. The occurrence of blocks should not be considered a "failure"—either of you or the Valsalva approach. Instead, it should be recognized as an important opportunity for learning. Think back on what expectations and intentions you had when going into the speaking situation. Were you expecting speech to be difficult? Was your intention to “make a good impression” by trying hard not to stutter? When you felt that an upcoming word contained a “brick wall,” what feelings were you experiencing, both physically and emotionally? Did you feel anxiety and an overwhelming urge to force? Did you feel tightness in your larynx, chest, and abdomen? Did you recognize that the urge to force was simply the stress hormones talking? Were you able to resist this urge? Were you able to carry out your Valsalva-relaxed intentions by focusing on the vowel sound instead of trying to say the word? Did you tense your puborectalis muscle while inhaling, to discharge the effort impulse? Then were you able to relax your abdomen and puborectalis muscle, let the air flow, and voice the vowel sound with feeling? If you were able to do these things, did the block disappear, allowing speech to proceed more easily?

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On the other hand, if the urge to force was too strong to resist, did using effort to force out the word make speech any easier, or did it strengthen and prolong the block? Were your familiar habits of struggle or avoidance rewarded because they relieved your anxiety momentarily? Nevertheless, did you feel disappointed at having repeated the same old behavior all over again – thereby perpetuating stuttering and your fear of future speaking situations? Did you feel bad about having “chickened out”? If so, don’t waste time blaming yourself about it. Instead, learn from the experience! Don’t be discouraged if you don't succeed at first; the physical reactions in your Valsalva mechanism may be too strong. Nevertheless, you should at least be aware of these reactions. Awareness is the first step in learning to control them. Also check on your mental attitudes. Are you really following Rule 1 of the Valsalva-Relaxed Speech Cycle? Are you looking forward to speaking as an easy and pleasant experience? Or do you expect it to be a difficult ordeal in which you must "try hard" to hide your stuttering? Is your intention to “make a good impression” or to try hard to say a particular word? It may not be possible for you to change these attitudes on the spot. But again, it will help if you are aware of them.

Speaking Is Not a "Test" Speaking situations should not be viewed as a kind of "test." Such an attitude only increases the urge to try harder to force the words out and thereby activates the Valsalva mechanism. Instead, look forward to speaking with a view toward getting as much satisfaction as possible from communicating with your listener – as well as the emotional pleasure of expressing your feelings through the music of your voice. Whenever I felt I had to "prove" that I could say a word fluently, I usually was doomed from the start. On those occasions, I had little success in using any fluency technique (Valsalva Control included). As I reached the moment of truth, I would tense up, my breathing would become spasmodic, my larynx would be unable to phonate, and I would find myself totally blocked. Trying to say the word would become a fixation, charged with increasing fear and frustration. (This intention, as we now know, only strengthens the motor program for effort.) When I eventually gave up, or resorted to word substitution or some other cop-out, I would feel angry with myself and disillusioned with whatever fluency method I had been trying. Later, when I began noticing what happened during these episodes, I found that I was tense throughout my Valsalva mechanism. I realized that, by viewing speech as a "test," I had already taken the first two steps of the Valsalva-Stuttering Cycle – the anticipation of difficulty and the urge to try hard. As long as I persisted in trying to "prove" that I didn't stutter, I would remain locked in the same old neurological rut that led to Valsalva tuning and blockage.

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To get out of this trap, it was first necessary to abandon the struggle. I'd have to stop for a moment and remember Rule 1 of the Valsalva-Relaxed Speech Cycle. Instead of worrying about fluency, I would focus on my emotional interaction with the other person. I would imagine myself communicating in a warm, relaxed, friendly, and pleasurable way. Another way to get out this trap, which we previously discussed, is to stop intending to say the word. Focus instead on relaxing your abdomen, letting the air flow, and saying the vowel sound with feeling – perhaps visualizing the bicycle imagery. This demonstrates the paradox that can occur when we "force" ourselves to use a fluency method in an attempt to avoid stuttering. The effort may backfire by increasing stress and triggering the Valsalva-Stuttering Cycle. If this happens, don't be discouraged. Remember my golf-swing analogy. Forget about trying to “hit” the word. Forget about trying to be fluent. Just continue to practice your Valsalva-relaxed intentions for the purpose of having an easy, enjoyable time expressing the things you want to communicate.

Responding to Fear and Other Emotions Even after you have gained an intellectual understanding of stuttering and mastered the techniques of Valsalva-relaxed speech during practice sessions, you may still find yourself overwhelmed by fear and the urge to force when confronting outside speaking situations. This is the crucial juncture at which virtually all fluency techniques tend to break down. When you approach a speaking situation and feel the fear rise up, don't panic! After all, it's just an emotion. Let yourself feel the fear, without flinching. The real problem is not the fear itself, but the way you have learned to react to it. (See Jeffers, 1987.) Based on the Valsalva Hypothesis and the lessons of Valsalva Stuttering Therapy, you no longer need to respond with useless effort and struggle. You now know a way that is easier and more productive – if you only have the courage to use it. You can learn to react by relaxing rather than tensing the Valsalva mechanism. I learned to do this as a trial lawyer, in order to cope with the highly stressful environment of the courtroom. Now we have additional relaxation techniques based on the lessons of Valsalva Stuttering Therapy. You can visualize the bicycle image – inhaling with your diaphragm as you imagine yourself going up the hill, relaxing your abdomen and PR and letting the air flow as you coast down the hill, and cheerfully saying or thinking “Wheeeeeee!” as your mantra, on your relaxed, out-flowing breath. The same approach can be applied to other emotions, such as anger and excitement, when they seem to be messing up your speech. The idea is to let yourself feel the emotion while relaxing your larynx, abdomen, and PR and letting the air flow freely. You will discover that you can be in touch with disturbing emotions while relaxing your Valsalva mechanism at the same time. Then

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go ahead and talk using Valsalva-relaxed speech and express your emotion by voicing the vowel sounds with feeling. As previously discussed, suppression of the Key Vowel Sound and activation of the Valsalva mechanism are part of the fear response triggered by the amygdala. The use of physical effort is reinforced because it seems to reduce anxiety, even though it actually strengthens the block and perpetuates stuttering. Therefore, much of the transfer part of Valsalva Stuttering Therapy is devoted to discussing, analyzing, and understanding the stutterer’s urge to exert effort in response to his fear of various speaking situations. In many cases, this behavior can be traced back to his attempts as a child to show how hard he was trying to please his parents or other grownups. This is particularly true if his parents or relatives had been critical of his speech. As an adult, the stutterer may continue to rely on effort to reduce anxiety, particularly when dealing with employers or other authority figures or when trying to “make a good impression.” Maybe this feels like the necessary and conscientious thing to do, but it doesn't score him any points. In the adult world, useless effort impresses no one – and the effort he exerts in stuttering is worse than useless. It is actually a counter-productive physical struggle against himself. If you catch yourself doing this kind of behavior, stop, take a breath, and think about it. What are you feeling? What is your motivation? Who are you trying to impress? What is all your effort really accomplishing?

Fear Management Strategies Feeling fear does not necessarily mean that you are going to stutter. What’s important is not the fear itself, but how you react to it. Fear-management is crucial for persons in the military and those who must respond to emergencies. For them, panic is not an option. The training of U.S. Navy SEALs is a good example of how neuroscience can be applied to manage fear under extreme circumstances. In addition to exposing SEALs candidates to stressful situations, the SEALs training program teaches four techniques to help the “thinking” part of the brain override the amygdala. Let’s see how the SEALs’ four strategies might be used by persons who stutter. 1. Goal Setting. Set realistic, short-term goals for yourself, not based on fluency. Focus on your role and purpose in speaking. 2. Mental Rehearsal through Visualization. Imagine succeeding in whatever you need to do, without regard to fluency. 3. Positive Self-Talk. See the examples in Appendix A. 4. Arousal Control through Slow Breathing. For this we have the Valsalva-relaxed PR breathing exercise.

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While the SEALs’ mental training is focused on controlling the amygdala’s response to physically dangerous situations, our focus must be on its reaction to speaking situations. For persons who stutter, fear of speaking can be greater than fear of physical danger. One therapy participant, an Army officer, said that he wasn’t afraid of parachuting from airplanes but was terrified of speaking before groups of people.

Benefitting from Professional Help Changing your habitual reactions to speaking situations will require a lot of practice and self-discipline, and perhaps the assistance of a support group or a professional therapist. It's not easy to confront one's fears and feelings and to deal with them objectively, in a new way. Therefore, you may need an appropriate speech-language pathologist to help you master not only speaking skills, but also the challenges of overcoming your fears and using those skills in the outside world. Therapy is usually more effective when you have a knowledgeable professional to coach and guide you. For example, a major part of Valsalva Stuttering Therapy deals with the emotional aspects of stuttering. After the first few sessions, much of the therapy time is devoted to understanding and reducing speech-related anxieties, overcoming the urge to exert effort, changing the participant’s intentions in speaking, and transferring Valsalva-relaxed speech to actual speaking situations. When seeking therapy, look for a speech-language pathologist who will be compatible with your personality and best suited to address your individual needs. It doesn’t matter whether the SLP is male or female (although the vast majority are women), as long as you and the therapist understand one another and can establish a good therapeutic alliance. The following are some questions you may wish to consider when choosing an SLP for stuttering therapy:  Does she have extensive experience with stuttering and all its emotional and social implications – whether personally or in treating others?  Is she familiar with, or willing to learn and use the principles of Valsalva Stuttering Therapy described in this book?  Is her therapy based on a theory that fully and accurately describes your own experience of stuttering and that makes sense to you?  Are her goals for therapy consistent with yours?  Does she teach a way of speaking that feels and sounds natural to you and will be easy to maintain?  Does she understand the psychological, neurological, physiological, and emotional aspects of stuttering and how they interact?  Does she understand the ways in which activation of the Valsalva mechanism can interfere with speech?

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Part X / Applying Valsalva Relaxed Strategies  Does she understand that the real problem in stuttering is not difficulty in articulating consonants, but interference with the phonation of vowel sounds?  Is she willing and able to counsel you regarding your attitudes, fears, expectations, intentions, and urge to exert effort in speaking situations?  Is she willing to adapt or modify her therapy to suit your specific needs, such as through role-playing or time-pressure exercises and other individualized activities?  Does she have the patience, perseverance, and empathy needed to help you understand and overcome whatever challenges you may encounter?

Go Out and Talk People who have overcome stuttering often say that what helped them most was their willingness to get more involved in things – to become more active and outgoing. You can start by joining a self-help support group for persons who stutter – such as the National Stuttering Association – if you haven't already done so. Meet the challenge of participating in discussions and giving talks in front of the group. Many new members are scared to death at first, but in almost no time they feel extremely comfortable. Then keep pushing back the frontiers of your speaking experiences, confronting new situations, even if you aren't fluent. Such opportunities might be found in community projects, religious organizations, amateur theatricals, and public speaking clubs, to name a few examples. Demosthenes began to argue cases even before he practiced with the pebbles. I myself became a lawyer before I became fluent. Likewise, you shouldn't just wait around for fluency to come and change your life. It won't happen. Instead, you've got to go out and get involved, talk, and take risks – whether you stutter or not. This is the only real way to gain confidence in speaking. We should not stake our self-esteem on the shifting sands of fluency. If we are to improve our speech, we must build on firmer ground – beginning with the fundamental qualities of courage, persistence, and a deeply rooted sense of selfrespect.

Notes Jeffers, S., Feel the Fear and Do It Anyway, New York: Fawcett Columbine, 1987.

Conclusion / A New Outlook on Stuttering

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CONCLUSION:

A New Outlook on Stuttering

G

UIDED BY the Valsalva Hypothesis, we have been able to fit together many pieces of the stuttering puzzle. Where once lay a confusing jumble of seemingly contradictory facts and theories, an understandable picture of persistent developmental stuttering is now emerging. While still incomplete, this vision has the potential to lead us out of the "stutterer's quandary," described in Chapter 2, and to alleviate our frustration over the maddening paradoxes of stuttering. Furthermore, it may lay to rest any stigma, any feelings of guilt or shame, and any doubts about our worthiness as human beings.

The Partially Assembled Puzzle Let’s step back and survey the picture we have thus far assembled from the pieces of our stuttering puzzle. Although gaps remain, we have linked together enough pieces to form increasingly clear images of many aspects of stuttering and of their relationships to one another. The first thing we recognize is that no single piece explains everything about stuttering – just as no single factor creates the same predisposition for stuttering in everyone. In addition to a variety of genetic and neurological factors, there may also be many psychological factors that affect the variability of stuttering in different individuals. The great disparity in these factors may at first seem confusing, but we can now see how they all fit together in the overall stuttering picture. While no single factor may directly cause stuttering blocks, they all have something in common. Each of these factors may, in its own way, increase a person’s feeling that speech is difficult. The anticipation of difficulty, together with an emotional investment in making a “good impression” by not stuttering, may activate the brain’s amygdala. The amygdala, acting as our “protector,” may trigger the release of stress hormones that suppress phonation of a word’s Key Vowel Sound and substitute an “effort impulse” to force on the preceding consonant or glottal stop. This creates the false impression that a stutterer’s problem is difficulty in articulating consonants, when actually he is forming the consonants perfectly well. We now see that the outward behaviors that people call “stuttering” are actually strug-

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gles to overcome or avoid the underlying blockage of vowel phonation. This behavior is then reinforced and perpetuated – psychologically, neurologically, and behaviorally – through the “Valsalva Stuttering Cycle.”

Implications for Stuttering Therapy The Valsalva Hypothesis provides insights that may improve the treatment of stuttering. It focuses on the underlying neurological “block” – the substitution of a motor program for effort in place of phonation of vowel sounds. Instead of trying to force through blocks, the stutterer is taught ways to discharge the effort impulse while inhaling and to relax his Valsalva mechanism and focus on the Key Vowel Sound while exhaling. He is taught to view speech as continuous melody and movement instead of treating words as if they were physical objects that could be forced out of the body. He is taught to focus on his role and purpose in speaking, instead of trying to make a “good impression” by not stuttering. The goal of Valsalva Stuttering Therapy is not “fluency” per se, but making speech easier, less effortful, and more enjoyable. At the same time, the emotional aspects of stuttering are analyzed in terms of the individual’s intentions in speaking and his urge to exert effort in speaking situations. Although stuttering always has its ups and downs, Valsalva Stuttering Therapy offers an approach that, with continued practice, should be less susceptible to relapse. It is the only therapy that teaches persons who stutter about the Valsalva mechanism and how “trying hard” to use a prescribed fluency technique can draw them into the Valsalva-Stuttering Cycle. Furthermore, it promotes a manner of speaking that is consistent with normal speech, that sounds and feels natural, and that is effortless and easy to maintain. Persons who had previous therapy have agreed that the Valsalva Stuttering Therapy approach was more helpful than any other treatment they had tried.

Educating the Public Persons who stutter are frequently the victims of ridicule, discrimination, and negative stereotyping. As with many forms of prejudice, the underlying causes include ignorance and lack of understanding. The general public has no comprehension of the physiological forces that block a stutterer's speech. Most people cling to the popular notion that stuttering is caused by "nervousness." Studies indicate that this is due to people's tendency to equate stuttering with their own moments of disfluency—which may have been prompted by nervousness, fear, uncertainty, or emotional conflict. They assume that the stutterer is experiencing similar feelings – only more so. Consequently, they may view stutterers as being "nervous," slow, ineffectual, indecisive, or mentally unstable.

Conclusion / A New Outlook on Stuttering

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Attempts have been made in recent decades to disabuse people of the notion that stuttering is an "emotional problem." In its place, the public has been offered a picture of stuttering that refers instead to possible neurological and hereditary causes. While this view may remove the stigma of mental illness, it may also leave a negative impression, in some minds, that stutterers are hopelessly brain-damaged or inherently defective. The Valsalva Hypothesis avoids the stigmas that might be associated with both the extreme "psychological" and "neurological" viewpoints by providing an explanation that emphasizes the stutterer's basic normality. We can now talk to people more confidently about stuttering. We need not hem and haw about its mysterious and unknown causes (which may seem potentially sinister to some people). We don't have to tell them that we were psychologically screwed up as children or that we have abnormal fears of speaking, a possible brain deficiency, or vague inherited defects. Now we have a hypothesis that makes things a lot easier. We can honestly tell people: “Much is unknown about the cause of stuttering, but there’s a new hypothesis that explains it pretty well. Stuttering is basically a neurological voice problem. Sometimes my larynx isn’t prepared to phonate the vowel sound of a word, and I get the urge to try to force the word out. When that happens, I have to stop and get my larynx ready to voice the vowel sound.” We might even demonstrate by having our listeners do the hand-pulling or table-lifting exercises described in Chapter 6, to experience how the Valsalva mechanism works. They can then personally feel the pressure in their own larynx, lips, and tongue and imagine how this could interfere with their own speech. Having experienced the physiological force behind stuttering, they may feel less dubious about our mental health and more comfortable about our problem. We can now go on to share a lot more about the stuttering experience.

Overcoming Negative Stereotyping Research has confirmed that persons who stutter are subject to negative stereotypes, which have significantly harmed their employment and promotion opportunities. These negative views of persons who stutter are shared by almost all groups studied – students, teachers, employers, parents, and speech-language pathologists as well. Even worse, studies show that persons who stutter also believe these stereotypes – and tend to behave accordingly. It seems that people who stutter are not only victims of the stereotype, but they themselves may help to perpetuate it. Ironically, the negative image of stutterers may be made even worse by our attempts to avoid or to disguise our stuttering. For example, rather than ac-

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knowledging a block, we might pretend that we have forgotten the word, can't decide what to say, or don't know the answer to a question. Or we might engage in inappropriate word substitutions or circumlocutions. While we may think we have fooled people by doing this, we really haven't. We have merely confirmed the stereotype that stutterers are hesitant, indecisive, or stupid. In terms of listener reaction, research has shown that trying to hide our stuttering is actually the worst thing we can do. Studies have shown that listeners have a much more favorable impression of stutterers who acknowledge their stuttering than of stutterers who do not. Listeners also have a more favorable reaction to actual stuttering blocks, repetitions, and prolongations than to the kind of interjections (um's and ah's, etc.) that we often use when we try to avoid stuttering. Therefore, if we are to break the negative stereotypes, we must accept and acknowledge our stuttering. We must let employers and others know that stuttering is no stigma and nothing that anyone should be ashamed of. At the same time, we can make our speech easier and less effortful by learning to use Valsalva-Relaxed Speech.

Fighting Discrimination Of the many obstacles faced by people who stutter, perhaps the costliest is employment discrimination. I am convinced that this discrimination against stutterers is at least as pervasive as racial or sexual discrimination. In some ways it is even more insidious, because: (1) stutterers are a much smaller minority with less political clout; and (2) many people feel justified in assuming that stuttering is a legitimate job disqualification or a sign of incompetence. The occurrence and impact of discrimination may vary from person to person depending on a variety of factors – such as the severity of stuttering, the kind of work, and the marketability of the individual's skills. Some stutterers say that they have never encountered employment discrimination. Many people have achieved success despite their stuttering. Given a chance, people who stutter have distinguished themselves in all walks of life – including business, law, medicine, science, literature, entertainment, and even politics. Nevertheless, for persons not so fortunate, employment discrimination continues to be a problem with serious consequences. During my many years as a National Stuttering Association chapter leader and six years as Chair of the NSA's Advocacy Committee, I have heard from stutterers who try to hide their stuttering on the job for fear of being fired, who suffer harassment or unfavorable evaluations by intolerant supervisors, and who have been denied promotions to supervisory positions or jobs that involve speaking or dealing with the public. I personally felt the sting of employment discrimination early in my legal career, when I was openly rejected by firms because of my stuttering, despite my academic qualifications.

Conclusion / A New Outlook on Stuttering

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One’s right to equal opportunity should not be conditioned upon fluency. Individuals who stutter should be judged by employers solely upon their ability to perform the essential requirements of the jobs in question. A pretext commonly used by employers to reject stutterers is the job requirement of "excellent oral communications skills." Often this has been invoked simply because the job occasionally involved answering the telephone or speaking to people. Employers must learn that (except in the most severe cases) persons who stutter are capable of adequate – and often very effective – oral communication, regardless of their disfluency. If stuttering disqualifies them from every job that involves some speaking or use of the telephone, they will be excluded from vast areas of the job market – and particularly from the most desirable jobs. In fighting stuttering discrimination, we can each be our own best advocates. We can begin by: • •

•

Rooting out our own negative stereotypes and feelings of shame about stuttering; Presenting our stuttering in a positive, open, and straightforward way (as suggested above), without trying to hide behind annoying and selfdefeating avoidance behaviors; and Educating employers and the public about the nature of stuttering, helping them to feel more accepting of it, and showing how intolerance only aggravates the situation. The Valsalva Hypothesis might help in this regard.

Legal Remedies As a last resort, we may pursue legal remedies to challenge acts of discrimination. In the United States, many state and federal statutes now purport to outlaw discrimination against persons with handicaps or disabilities. The Americans with Disabilities Act of 1990 ("ADA"), as amended, is a federal statute that bans discrimination "against qualified individuals because of a disability, in regard to job application procedures, hiring, advancement, discharge, compensation, job training, and other terms, conditions, and privileges of employment." It currently applies to employers with 15 or more employees. The Rehabilitation Act of 1973 provides protection for handicapped individuals employed by federal agencies or employers receiving federal funds. Other employers may be covered by various state laws. Each statute has its own specific terms, applicability, and procedures, which must be followed precisely. I appreciate the fact that many people who stutter dislike being called "handicapped" or "disabled." Of course, we know that stuttering need not be a handicap. But the purpose of these laws is to protect us from discrimination by

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people who aren't so enlightened. To qualify for legal protection, we must therefore be open about our stuttering. The worst mistake would be to try to hide your stuttering in a way that truly interferes with your job performance (such as by not talking, avoiding the phone, etc.). This might give the employer a legitimate excuse for firing you – even if stuttering itself wouldn't be. Unfortunately, discrimination cases are usually very hard to win, even for experienced attorneys, so they should not be undertaken haphazardly. Because stuttering is such a complex and misunderstood disorder, stuttering discrimination cases must be carefully planned and prepared in order to avoid disaster. As in other disability cases, the threshold question will be whether the individual's stuttering qualifies as a "disability" as defined in the relevant statute. This determination must be made on a case-by-case basis and is subject to many legal technicalities. Due to the great uncertainty of litigation, you should never be tempted to exploit your stuttering in the hope of winning a lawsuit. In most cases, it would be healthier and more productive to take advantage of whatever opportunities are available to improve your speech and to move on with your life.

A Closing Word In this book, I have described my way of understanding and controlling a problem that had tormented me since childhood. With the help of the Valsalva Hypothesis and related exercises, I was finally able to get a handle on my stuttering and change my life. Now as a speech-language pathologist, I have refined and expanded this approach, which as of this writing has already helped hundreds of participants in Valsalva Stuttering Therapy. However, a book like this can’t provide "the answer" for everyone. Because stuttering is such a personal matter, the only "answer" that really counts must be discovered by each individual who stutters. Stuttering need not define who we are, nor should it limit what we can do. However, while seeking to improve our fluency, we must also remember that fluency is not the meaning of our existence. As we have seen, the quest for perfect speech is unrealistic, unnecessary, and ultimately self-defeating. We may never reach the point where we are absolutely fluent all the time. Ingrained in the nerve pathways of our brains, stuttering may linger with us, to one degree or another, throughout our lives. Nevertheless, we can understand stuttering to the extent that it no longer torments us, and we can control stuttering to the extent that it no longer interferes with our ability to communicate effectively with others. We now have an exciting opportunity to transform our speaking experiences into something far easier and more enjoyable than ever before.

Conclusion / A New Outlook on Stuttering

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General References HURST, M. L., & COOPER, E. B. Employer attitudes toward stuttering. Journal of Fluency Disorders, 1983a, 8, 1—12. KALINOWSKI, J. S., LERMAN, J. W., & WATT, J. A preliminary examination of the perception of self and others in stutterers and nonstutterers. Journal of Fluency Disorders, 1987, 14, 127—134. LASS, N. J., RUSCELLO, D. M., SCHMITT, J. F., PANNBACKER, M. D., ORLANDO, M. B., DEAN, K. A., RUZISKA, J. C., & BRADSHAW, K. H. Teachers' perceptions of stutterers. Language, Speech. and Hearing Services in Schools, 1992, 23, 78—81. OPP, K. L., HAYDEN, P. A., & COTTRELL, G.T. Stuttering and employment: A survey report. Annual Convention of the American Speech. Language, and Hearing Association. Boston, Massachusetts, 1997. PARRY, W. D. Being Your Own Best Advocate & Stuttering as a Disability under the Americans with Disabilities Act of 1990. Anaheim Hills, CA: Nat'l Stuttering Ass'n, 2001. PARRY, W. D. Stuttering and employment discrimination. Int'l Stuttering Awareness Day 1999 Online Conference, The Stuttering Home Page, URL: www.mankato. msus.edu/dept/comdis/isad2/papers/parry.html. WHITE, P. A., & COLLINS, S. R. C. Stereotype by inference: A possible explanation for the "stutterer" stereotype. Journal of Speech and Hearing Research, 1984, 27, 567—570. WOODS, C. L., & WILLIAMS, D. E. Traits attributed to stuttering and normally fluent males. Journal of Speech and Hearing Research, 1976, 19, 267—278. YEAKLE, M. K., & COOPER, E. B. Teacher perceptions of stuttering. Journal of Fluency Disorders, 1986,. 11, 345—359.

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Appendices

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APPENDIX A:

Valsalva-Free Self-Talk Detrimental Self-Talk  I am a stutterer. I am person who stutters.

Helpful Self-Talk ☺ I accept the fact that sometimes I block on words. However, I would rather identify with what I want to do. I am a person who talks. I have valuable things to say. I feel good about talking in an easy, relaxed way.

Stuttering is bad, shameful, embarrassing, etc.

Stuttering is neither bad nor good; it’s just inconvenient. It doesn’t indicate anything negative about me. It results from a neurological confusion of two normal bodily functions – voice and the Valsalva mechanism.

Speech is difficult and requires a lot of effort.

Speech requires very little physical effort. I am able to speak easily and without effort. Speech is easy. Speech is fun. I love to talk.

I always stutter on words that start with certain sounds.

I can say every sound easily. I will relax my abdomen, let the air flow freely, and think instead about phonating the vowel sound with feeling. The vowel sound is the heart of the word. Everything else is decoration.

The upcoming word has a brick wall in it. I must force my way through the block.

My motor program for this word is missing the vowel sound. Forcing will just strengthen the block. I will stop, take a breath while thinking of the vowel, and relax my abdomen as I say the vowel sound with feeling. The vowel sound is the key to opening the word.

I usually stutter when speaking in this situation or to this person.

The more I speak in this kind of situation, the easier it will be to speak in similar situations in the future. I am looking forward to speaking easily and effortlessly, using Valsalva-Relaxed Speech.

If I stutter, this person will think poorly of me.

This person is interested in what I have to say. Stuttering doesn’t matter. I don’t have to be perfect. I will enjoy saying what I want in an easy, relaxed way.

It’s important to make a good impression by not stuttering.

Trying to please my listener by not stuttering is a losing proposition. Instead, I will enjoy expressing myself through the music of my voice and focus on my role and purpose in speaking.

Appendix A / Valsalva-Free Self-Talk

Detrimental Self-Talk 

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Helpful Self-Talk ☺

I must prove that I don’t stutter when using this speaking technique.

Trying to “prove” I don’t stutter is self-defeating, regardless of what speaking technique I use. I will think about what I want to say. Then I will say it in the easiest, most enjoyable way.

I’m afraid to stop and correct myself when blocking. I’ll just struggle, pretend it’s not happening, and nobody will notice.

Continuing to force and struggle perpetuates stuttering, interferes with communication, and doesn’t fool anyone. When I encounter a block, I will stop and use the Word Recovery Response. I will keep eye contact with my listeners and signal them to wait. I will help them understand that sometimes I block and need to stop and prepare my larynx to phonate the vowels.

I must force myself to talk quickly, or the listener might cut me off.

It doesn’t matter how impatient this person might be. I will speak easily and effortlessly, at my own pace, using Valsalva-Relaxed Speech, because that’s the most efficient way for me to communicate.

I must show I’m trying really hard to talk. If I don’t use a lot of effort, I’m afraid of what might happen.

Using effort can be a childish attempt to reduce my anxiety or guilt by showing how hard I’m trying to please. But I’m not a child anymore. Useless effort impresses no one and only blocks my speech. I will relax and speak in an easy, effortless way, regardless of whom I’m talking to.

The fact that I blocked proves that speech really is difficult.

Speech would have been easier if I hadn’t used so much effort. However, I was able to learn from the experience and practice some Valsalva Relaxation, and that's what really counts.

Forcing helped me get the word out, so next time I will force even harder.

Forcing on a word prolongs the block, but may eventually discharge the “effort impulse.” Next time I’ll stop and use the Word Recovery Response.

Using the telephone is especially hard, because all the attention is on my speech.

The telephone (or cell phone) is just a convenient tool that I enjoy using to communicate with other people. It’s also a good opportunity to practice ValsalvaRelaxed Speech. The more I talk on the phone, the easier it becomes.

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APPENDIX B:

Emotional Interactions in Speaking Situations If you are concerned about making a “good impression” when speaking, consider how this intention may affect the emotional interaction with your listener.

Emotional Interaction - Negative

Speaker

Listener

Intention: To make a “good impression” by trying hard not to stutter. Message: Look how hard I’m trying to please you.

But are you really trying to please the actual listener? Or are you projecting onto the listener the role of a “judge?”

Result: Amygdala is activated and triggers stress hormones, creating a “brick wall.” Your connection with the listener is broken, while you struggle to force out the words. Effect: The experience is painful for both you and the listener. Trying to make a “good impression” backfires. The result is a “lose-lose” situation.

Appendix B / Emotional Interactions

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Emotional Interaction - Positive

Speaker

Listener

New intention: To enjoy expressing yourself through the music of your voice. You are focused on pleasing yourself, without regard to the listener’s approval. You do not fear the listener as a threatening judge. Instead, you welcome the listener as an opportunity to share your pleasure.

Result: Amygdala is deactivated and your larynx is free to phonate. “Hi! How are you today?”

At the same time, your pleasure conveys a positive message to the listener: Message: Look how much I enjoy talking to you! Effect: The listener senses your enjoyment in speaking to him. This makes the listener feel good about himself and also about you. By focusing on your own pleasure in speaking, rather than making a “good impression,” you create a “win-win” experience for both yourself and your listener.

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APPENDIX C:

Appendix C / Consonant-Vowel Tables

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Appendix C / Consonant-Vowel Tables

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APPENDIX D:

Key to Vowel Sounds (based on standard American English) æ - /æ/ - as in “bat” ah - /a/ - as in “box” aw - /ɔ/ - as in “bought” ay - /e/ - as in “bait” ee - /i/ - as in “beet” eh - /ɛ/ - as in “bet” er - /ɚ/ - as in “bird” eye - /ai/ - as in “bite” * ih - /I/ - as in “bit” oh - /o/ - as in “boat” oo - /u/ - as in “boot” ouh - /ʊ/ - as in “book” ow - /aʊ/ - as in “house”** Oy - /oi/ - as in “boy”*** uh - /λ/ - as in “but” *Note that “eye” /ai/ is a diphthong – a combination of two vowel sounds, in this instance, “ah” followed by “ee.” When doing preliminary vowel shaping or voicing, begin by shaping the “ah” sound. **”Ow” /aʊ/ is also a diphthong, starting with “ah” and gliding into “ouh” (as in “book).” ***”Oy” /oi/ is also a diphthong, starting with “oh” and gliding into “ee.” The symbol ʔ is for a “glottal stop” — a consonant made int the larynx that briefly stops the airflow to build up and then release a little air pressure to accentuate the beginning of words beginning with vowel sounds. It is not part of the vowel sound. It is marked with a strike-out (ʔ) to show that it is not necessary and should be avoided.

Appendix E / Key Vowels in Multi-Syllable Words

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APPENDIX E:

Key Vowels in Multi-Syllable Words. 1. Examples of Key Vowel Sounds in First Syllable ambulance argument author backward

æ ah aw æ

benefit blatant breakfast Canada caution chemical college company courage destiny dictate Eastern exit finance general global gracious hospital internet Italy legal legislate Mexico

eh ay eh æ aw eh ah uh er eh ih ee eh eye eh oh ay ah ih ih ee eh eh

motion movement notice offer operator pension perfect practical primary profit purchase quarantine residence salvage seven soccer social station subject supervisor table testing tedious thrilling throttle yesterday zero

oh oo oh aw ah eh er æ eye ah er aw eh æ eh ah oh ay uh oo ay eh ee ih ah eh ee

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2. Examples of Key Vowel Sounds in Second Syllable accelerate accountant adjudicate adjustment America amygdala Antarctica Atlantic attorney balloon banana behave campaign Columbus compete computer conservative coordinate Dakota deliver democracy detective dictation disaster discovery disease economy election employment evacuate environment extreme fraternity

eh ow oo uh eh ih ah æ er oo æ ay ay uh ee oo er aw oh ih ah eh ay æ uh ee ah eh oy æ eye ee er

gazelle geography habitual historic instructor invader Jerusalem legitimate mosquito negotiate Nevada Ohio Pacific pandemic parade polite procedure proposal republic responsible revision semester society sustain theatrical today tomorrow tremendous tuition united vaccine Valsalva Wyoming

eh ah ih aw uh ay oo ih ee oh ah eye ih eh ay eye ee oh uh ah ih eh eye ay æ ay ah eh ih eye ee æ oh

Appendix E / Key Vowels in Multi-Syllable Words

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3. Examples of Key Vowel Sounds in Third or Later Syllable absolutely aeronautical Alexander Argentina Arizona beneficiary calculation California Carolina chandelier Colorado competition corporation deposition destination discrimination education electricity entertainment European explanation graduation habitation Halloween hospitality ideology inhalation insurrection

or aw æ ee oh ih ay aw eye ee ah ih ay ih ay ih ay ih ay ee ay ay ay ee æ ah ay eh

Isadora Japanese kangaroo legislation locomotive Louisiana macaroons Mauritania negativity oceanic operation opportunity pepperoni politician population possibility presentation problematic registration rehabilitate representative sanitation superintendent transportation university vaccination veterinarian zoological

aw ee oo ay oh æ oo ay ih æ ay oo oh ih ay ih ay æ ay ih eh ay eh ay er ay æ ah

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APPENDIX F:

Sample Sentences and Phrases 1.

Hello.

2.

Good morning.

3.

How are you today?

4.

Fine, thank you.

5.

My name is (your name).

6.

What’s your name?

7.

Where do you live?

8.

I go to school in the city.

9.

I work in an office downtown.

10. Let me introduce you to my friend. 11. See you later. 12. Have a nice day. 13. Thank you. 14. What time is it? 15. It’s nine o’clock. 16. I need to see a doctor. 17. When can I have an appointment? 18. My car won’t start. 19. Can you send a tow truck? 20. Please fill it with regular.

Appendix F / Sample Sentences and Phrases

21.

Could you please help me carry this?

22.

Please answer the telephone.

23.

Wait for me!

24.

Good afternoon.

25.

How much does this cost?

26.

You must be joking.

27.

Do you take credit cards?

28.

I’ll have a pepperoni pizza.

29.

What would you like to drink?

30.

I’ll have a mocha cappuccino.

31.

Please pass the potatoes.

32.

Waiter, the check please.

33.

Where are the restrooms?

34.

I’m late for my meeting.

35.

Please take me to the railroad station.

36.

When does the train leave?

37.

Two tickets, please.

38.

Thanks for a nice evening.

39.

Good night.

40.

See you tomorrow.

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APPENDIX G:

Sample Picture-Naming Exercise See Chapter 44, p. 280.

Appendix G. / Sample Picture Naming Exercise

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Appendix G. / Sample Picture Naming Exercise

321

Key: 1: bee, pig, cake, bed, bat, pie, duck, bird, box, foot, goat, shoe. 2: cow, saw, boy, key, fish, nail, snake, tent, spoon, apple, clock, tree. 3: shell, sun, chair, lock, ring, hook, house, plug, blimp, broom, brain, dress. 4: crown, table, whistle, screw, zebra, spider, candle, elephant, star, eight, girl, unicorn.

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APPENDIX H:

Sample Vowel-Specific Sentence Lists Ah - /a/ - as in “box” NOTE: Glottal stops /ʔ/ are indicated for words starting with vowels, in order to distinguish them from the actual vowel sounds that follow. They are marked with a strikeout (ʔ) to show that you should omit the glottal stop and instead ease into the actual vowel sound.

1.

John’s frog hopped ʔon the dock.

2.

ʔOscar dropped the box.

3.

The jolly Scot ʔoperated the trolley.

4.

Cocky Don mocked Bob.

5.

Polly’s ʔodd drama flopped.

6.

The cop stopped the robber.

7.

The swans flocked ʔon the pond.

8.

Ron was fond ʔof modern products.

9.

Rotten logs clogged yonder bog.

10. The hot llama trotted ʔon the rocks.

Appendix G. / Sample Vowel-Specific Sentence Lists

323

Ay - /e/ - as in “bait” NOTE: Glottal stops /ʔ/ are indicated for words starting with vowels, in order to distinguish them from the actual vowel sounds that follow. They are marked with a strikeout (ʔ) to show that you should omit the glottal stop and instead ease into the actual vowel sound.

1.

Jane painted the gate.

2.

The rain ʔin Spain stays mainly ʔin the plain.

3.

Gale waited ʔon tables ʔall day.

4.

ʔAbe sails ʔon the waves ʔin the bay.

5.

Daisy ʔate the cake she baked.

6.

Kate is ʔable to make the payments.

7.

Mabel fainted ʔat the baby snake.

8.

Jake’s gray mare ʔate hay.

9.

Dave hated to play baseball.

10. Blake came from the state ʔof Maine.

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Eye - /ai/ - as in “bite” NOTE: This is not a simple vowel sound but rather something called a “diphthong” – a combination of two vowel sounds. You start with your mouth in one vowel position and then glide into another vowel position. “Eye” begins with “ah” and then glides into “ee.” Therefore, when doing preliminary vowel shaping and voicing, voice the first part of the vowel sound – “ah” – as the key vowel and let any consonants slip in as you coast down to voice the entire vowel sound, “eye.”

1.

Byron’s kite flies high ʔin the sky.

2.

Michael rides his bicycle to ʔIdaho.

3.

Dinah is frightened of mice.

4.

Guy tried to climb the white pine.

5.

ʔIra dined ʔon lime pie.

6.

Tyler spied a white rhinoceros.

7.

Lyle might buy a nice tie.

8.

Violet likes fried rice.

9.

Nigel takes pride ʔin identifying fine wine.

10. The spiteful child cried ʔall night.

Appendix I / Sample Initial-Sound Sentence Lists

325

APPENDIX I:

Sample Initial-Sound Sentence Lists Test Sentences For initial evaluation to detect patterns of blocking. 1. 2.

Isn’t Alex arriving this afternoon? Oscar entered his antique auto in the event.

3. 4. 5. 6. 7. 8. 9.

Bobby boldly bashed the baseball with his bat. Charity is a champion cheerleader. Diana dreamed of dancing dolphins. Frank fixed the flat tire on his Ford. Greedy Gilbert gobbled the green grapes. In Hertford, Hereford and Hampshire, hurricanes hardly ever happen. Justin gingerly juggled jars of jelly.

10. 11. 12.

Carrie keeps cocoa in her cupboard. The leopard leaped from the lofty ledge. Mary’s mother is making many muffins.

13. 14. 15. 16.

My niece Nancy has a knack for knitting. Please place the plates on the purple platter. Round the rugged rock the ragged rascals ran. The seamstress sewed striped shirts for seven sailors.

17. 18. 19. 20. 21. 22. 23.

Shirley shucks shells by the shore. The tailor told Tyler to try on the trousers. Thornton wrote thrilling things for the theater. Vernon the veterinarian used voodoo. Washington weathered the winter and won. Yesterday the youths played yoyo in my yard. Zack saw zebras at the zoo.

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Initial Vowels Omitting the Glottal Stop /ʔ/ Please note: The “glottal stop” (/ʔ/) is a closure of the larynx that is commonly done at the beginning of words that start with vowels (e.g., “apple”). We normally don’t think about initial glottal stops, because they don’t appear in the written words. Consequently, we tend to confuse them with the actual vowel sounds. In the following sentences, the glottal stops are spelled out as “ʔ” (which is similar to a question mark, but without a dot at the bottom). Glottal stops /ʔ/ are indicated for words starting with vowels, in order to distinguish them from the actual vowel sounds that follow. They are marked with a strikeout (ʔ) to show that you should omit the glottal stop and instead ease into the actual vowel sound.

1.

ʔAdam ʔasked ʔEve for an ʔapple.

2.

ʔIsn’t ʔAlex ʔarriving this ʔafternoon?

3.

ʔEvery ʔevening ʔAndrea ʔeats ʔartichokes.

4.

ʔOscar ʔentered his ʔantique ʔauto ʔin the ʔevent.

5.

The ʔannual ʔauction ʔattracted ʔEarl’s ʔattention.

6.

ʔArthur ʔenjoys ʔItalian ʔice.

7.

ʔAble’s ʔoffering was ʔaccepted.

8.

ʔHonest ʔAbe was ʔeasily ʔelected.

9.

ʔIn ʔApril ʔI ʔate ʔon the ʔEiffel Tower.

10. The ʔawful ʔarsonist was ʔarrested. 11.

Do ʔalpacas ʔinhabit the ʔAndes of ʔEcuador?

12. ʔAdorable ʔAlice ʔexcelled ʔat the ʔaudition. 13. ʔOffenbach’s ʔopera ʔopened in ʔOctober. 14. ʔEduardo was ʔeager to ʔescape to ʔAmerica. 15. The ʔartic ʔowls ʔinvaded ʔAnchorage, ʔAlaska. 16. ʔEddie ʔeats ʔeighty ʔeggs ʔeach ʔEaster.

Appendix I / Sample Initial-Sound Sentence Lists

327

B - /b/ Focus your attention on voicing with inflection the Key Vowel Sound in each phrase. Let the consonants come on their own without trying to say them.

1.

Bill bought a big bunch of bananas.

2.

The bad butter made Betty’s batter bitter.

3.

Bobby boldly bashed the baseball with his bat.

4.

The boys behaved like a bumbling band of baboons.

5.

My brother wore boots on Bob’s boat.

6.

Briana’s blouse has bright blue buttons.

7.

Bertha’s blue balloon burst with a bang.

8.

The black bear broke into the bunk house.

9.

Becky found a brown bug in her bed.

10. The brake on Brendon’s bike is broken. 11. Barbie blew big bubbles in her back yard. 12. Benjamin braved the bucking bronco.

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Understanding and Controlling Stuttering

D - /d/ Focus your attention on voicing with inflection the Key Vowel Sound in each phrase. Let the consonants come on their own without trying to say them.

1.

Dustin drove a Dodge to Dover, Delaware.

2.

Dennis Dryna made a dramatic discovery.

3.

Isadora Duncan danced in the desert.

4.

Donald Duck doesn’t need a dentist.

5.

The daring diver discovered denizens in the deep

6.

DHL delivered a dozen double damask dinner napkins.

7.

Danny danced daringly with Donna.

8.

David's daddy’s dog dug deep down in the garden after dark.

9.

Dillon dipped a Dunkin Donut in his daiquiri.

10. A dozen Dutchmen dug dirt out of the ditch. 11. Donna is dusting the dining room drapes. 12. The daunting dinosaur died on a dreary day. 13. Diana dreamed of dancing dolphins. 14. Daniel drew dazzling diagrams of hydroelectric dams. 15. Do drop in at the Dewdrop Inn. 16. Dora dumped dirty dishwater down the drain. 17. The dinner was a dreadful debacle. 18. Dan drove to the downtown Dairy Dream for diet drinks. 19. Dudley Doright discovered a dozen deer in the dusky dell. 20. Ding dong, the witch is dead.

Appendix I / Sample Initial-Sound Sentence Lists

329

Hard G - /g/ Focus your attention on voicing with inflection the Key Vowel Sound in each phrase. Let the consonants come on their own without trying to say them.

1. What’s good for the goose is good for the gander. 2. Gus gasped as he gave up the ghost. 3. Gwen gazed at the gracefully grazing gazelles. 4. Al Gore gabbed about global greenhouse gases. 5. Galahad glanced glowingly at the gorgeous Guinevere. 6. Greedy Gilbert gobbled the green grapes. 7. Gandhi greeted a great gathering at the Ganges. 8. Flash Gordon glided giddily through the galaxy. 9. The glamorous gal glared at the goofy gardener. 10. Gary was grateful for the game of golf.

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Understanding and Controlling Stuttering

M - /m/ Focus your attention on voicing with inflection the Key Vowel Sound in each phrase. Let the consonants come on their own without trying to say them.

1.

Mary’s mother is making many muffins.

2.

On Mull there’s a monument to Mendelsohn’s music.

3.

Mordred marveled at Merlin’s magic.

4.

Mind your manners when you meet Marilyn.

5.

Megan moved to a mansion in Malibu.

6.

The mysterious man meandered on the misty moor.

7.

The moon over Miami made Mildred feel mellow.

8.

Mickey made money on “March Madness.”

9.

Martin puts mint mustard on his meat.

10. The malicious mosquitoes can make Maine miserable. 11. Maid Marian served mead to the merry men. 12. Marvin munched on macaroons at the movies. NOTE: M is classified as a sonorant consonant. A sonorant is a voiced speech sound that is produced without obstructing or causing turbulence in the outward flow of air.

Appendix I / Sample Initial-Sound Sentence Lists

331

P - /p/ Focus your attention on voicing with inflection the Key Vowel Sound in each phrase. Let the consonants come on their own without trying to say them.

1.

Peter Piper picked a peck of pickled peppers.

2.

Patty picnicked in a part of Pennypack Park.

3.

Pablo poked Pam with his pencil.

4.

“The Pink Panther” was a popular picture in Peoria.

5.

The police pursued the perpetrators.

6.

Polly the parrot perched on the pirate.

7.

Peggy politely poured punch for her parents.

8.

Percy packed popcorn and popsicles.

9.

Porky played the piano for Petunia.

10. Pedro put on a plaid poncho. 11. Please place the plates on the purple platter. 12. Paul plowed out the parking places. 13. The Pittsburgh Pirates played poorly. 14. The prize pony pranced proudly. 15. The poor peasants planted peas in the pasture. 16. The President pardoned the penitent prisoner. 17. The peaceful protestors paraded in the plaza. 18. Priscilla and Preston planned a pizza party. 19. The pink pig plopped into the puddle. 20. Pierre practiced for the ping-pong playoffs.

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Understanding and Controlling Stuttering

S - /s/ Focus your attention on voicing with inflection the Key Vowel Sound in each phrase. Let the consonants come on their own without trying to say them.

1.

I am Sam. Sam I am.

2.

Samantha slurps soup with a spoon.

3.

Sid snored on the sofa.

4.

Skippy slid down the slide.

5.

The seagulls soared in the sun.

6.

The seamstress sewed striped shirts for seven sailors.

7.

The spotted spider got stuck in the syrup.

8.

The sick swan sang a sad song.

9.

Sally stood on a stool when a snake slithered by.

10. Steven sold six sacks of summer squash. 11. The surgeon sewed six stitches in the soldier’s side. 12. What did Sophie say to the southern senator? 13. Sven is the strongest soccer player in Sweden. 14. The Scotsman sold Simon a special sporran. 15. Seymour was a super salesman. 16. Sara saved several stamps from Switzerland. 17. The somber son sailed over the sea to Skye. 18. The salmon swam up the stream to the spawning ground. 19. Somebody stole Sidney’s stash of strawberries. 20. Saul played cymbals in Sibelius’s Sixth Symphony. Some sentences were adapted from “Say and Do Action Artic Cards,” copyright © 1998 by Super Duper Publications

Appendix I / Sample Initial-Sound Sentence Lists

333

W and Wh - /w/ and /hw/ Please note: W (/w/) is a special kind of consonant known as a “glide.” It is made by closely rounding the lips as if to make “oo” (/u/) and then gliding into the vowel sound. Phonation begins softly with the “oo” sound and then becomes louder as it moves to the main vowel sound. W is also classified as a sonorant consonant. A sonorant is a voiced speech sound that is produced without obstructing or causing turbulence in the outward flow of air. Focus your attention on voicing with inflection the Key Vowel Sound in each phrase. Let the consonants come on their own without trying to say them.

1.

What did the women wear to the wedding?

2.

Where are the watermelons?

3.

Why was Wesley whistling?

4.

Willie watched “Welcome to Wayne’s World.”

5.

Walter washed the windows with warm water.

6.

The wizard waved his wand at the wicked witch.

7.

Wyatt’s wagon wobbled in the wind.

8.

Warren watched wildcats in Wyoming.

9.

Washington weathered the winter and won.

10. Wilbur went whale watching on Wednesday. 11. Walt Whitman had white whiskers. 12. The worm wiggled on the wet walkway. 13. Woodrow Wilson wished for wisdom in the World. 14. Whining wolves wandered in the West. 15. When will the waiter bring our waffles?

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APPENDIX J.

Sample Daily Practice Routines First Daily Practice Exercises

Suggested Time

1. Slow, Valsalva-Relaxed, PR-Directed Breathing. (See Chapter 32, pp. 227-228.) Maintain this breathing throughout the entire routine.

5 min.

2. Valsalva-Relaxed Vowel Voicing of “ah,” “eh,” “ee,” “oo.” (See Chapter 33, pp. 232-234.)

5 min.

3. Practice Voicing the “Melody Message.” Using the sentences in these Appendices, identify and voice the Key Vowel Sounds with inflection and feeling. (See Chapter 34, p. 239.)

15 min.

4. Read aloud the “The Relaxed River of Air” and Valsalva-Relaxed Affirmations. Voice them with melody. Voice the Key Vowel Sounds with inflection and feeling. (See p. 281.)

5 min.

Total:

30 min.

During the Day •

ALWAYS use slow, Valsalva-relaxed PR-directed breathing throughout the entire day. Tense your PR muscle as you inhale and slowly relax it as you exhale. Place one hand on your abdomen to feel it bulge as you inhale and go back in as you exhale and relax your PR muscle .

•

Pay attention to melody and movement in your speech. Speech should always be subservient to your out-flowing Valsalvarelaxed breath as your abdomen relaxes. Let the words be carried by your breath without trying to force them.

•

•

Whenever possible, do Valsalva-relaxed vowel voicing to keep your larynx always ready to phonate.

Appendix J / Sample Daily Practice Routines

335

Humdronian Practice Routines Exercises

Suggested Time

1. Slow, Valsalva-Relaxed, PR-Directed Breathing. (See Chapter 32, pp. 227-228.) Maintain this breathing throughout the entire routine.

2 min.

2. Valsalva-Relaxed Velar Humming. Voice /ŋ / with changing pitch. (See Ch. 34, pp. 239.)

5 min.

3. 1st Week: Full Humdronian Speech (FHD). Practice sequence of humming /ŋ / with inflection and then adding silent articulation. Then read aloud in FHD. Words should be unintelligible. (See Chapter 36, pp. 245-246; 248-249.) 2nd Week: Transition to Modified Humdronian (MHD). Practice sequence of humming with melody, FHD, and then MHD. Read aloud in FHD and then in MHD. (See Chapter 37, p. 250.)

20 min.

3rd Week: Transition to Resonant ValsalvaRelaxed Speech (RVR). Practice sequence of humming with melody, FHD, MHD, and then RVR. Read aloud in FHD, MHD, and then RVR. (See Chapter 37, pp.251-25.) 4. Read aloud the “The Relaxed River of Air” and Valsalva-Relaxed Affirmations. Voice them with melody using FHD, MHD, or RVR. (See p. 281) Total:

3 min. 30 min.

Duringthe Day • • •

Always use slow, Valsalva-relaxed PR breathing throughout the day. Use RVR Speech in ALL speaking situations, WITHOUT EXCEPTION! Think of your role and purpose when going into speaking situations. Your purpose should not be to “make a good impression” by not stuttering. You don’t have to be perfect.

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Understanding and Controlling Stuttering

Humdronian/RVR Maintenance Exercise Exercises 1.

Slow, Valsalva-Relaxed, PR-Directed Breathing. (See Chapter 32, pp. 227-228.) Maintain this breathing throughout the entire routine.

Suggested Time 1 min.

2. Valsalva-Relaxed Velar Humming. Voice /ŋ / with changing pitch. (See Ch. 34, p. 239.)

1 min.

3. Read aloud in Full Humdronian Speech (FHD). Hum /ŋ / with inflection and silent articulation. Words should be unintelligible. (See Chapter 36, pp. 245-246; 248-249.)

10 min.

4. Read aloud in Modified Humdronian(MHD). (See Chapter 37, p. 250.)

5 min.

5. Read aloud in Resonant Valsalva-Relaxed (RVR) Speech. (See Chapter 37, pp.251-254.)

10 min.

6. Read aloud the “The Relaxed River of Air” and Valsalva-Relaxed Affirmations. Voice them with melody using RVR speech. (See p. 281.)

3 min.

Total:

30 min.

During the Day •

• •

ALWAYS use slow, Valsalva-relaxed PR breathing throughout the day. This should take precedence over everything else. Let your relaxed, out-flowing breath carry the words when they are ready. Don’t use your breath to try to force out the words. Use RVR Speech in ALL speaking situations, WITHOUT EXCEPTION! Think of your role and purpose when going into speaking situations. Your purpose should not be to “make a good impression” by not stuttering. You don’t have to be perfect. Think about what message you want to convey and what you would like to accomplish.

Appendix J / Sample Daily Practice Routines

337

Slow-Motion Extremely Emotive Speech (“SMEEch”) Exercise Exercises

Suggested Time

1. Slow, Valsalva-Relaxed, PR-Directed Breathing. (See Chapter 32, pp. 227-228.) Maintain this breathing throughout the entire routine.

1 min.

2. Valsalva-Relaxed Vowel Voicing of “ah,” “eh,” “ee,” “oo.” (See Chapter 33, pp. 232-234.)

3 min.

3. Starting with Exaggerated SMEEch, gradually transition to Moderate SMEEch. (See Chap. 38, pp. 256-257.) Practice using your own sentences and phrases or those in these Appendices. Start with extreme stretching of the sentence or phrase and greatly exaggerated inflection of the Key Vowel Sound. Focus on the melody and movement. Repeat the same phrase or sentence several times, each time with incrementally less exaggeration and stretching. Continue to focus on the same melody and movement as you gradually transition to Moderate SMEEch. 4. Read aloud the “The Relaxed River of Air” and Valsalva-Relaxed Affirmations with inflection using Moderate SMEEch. (See p. 281.) Total:

23 min.

3 min. 30 min.

During the Day •

Take your time and speak in phrases.

•

Practice doing slow, Valsalva-relaxed PR breathing for each phrase.

•

Use the Word Recovery Response (Chapter 39)) whenever you encounter or anticipate a block.

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Understanding and Controlling Stuttering

Hummelodian/Melodic Intention Exercises Exercises

Suggested Time

1. Slow, Valsalva-Relaxed, PR-Directed Breathing. (See Chapter 32, pp. 227-228.) Maintain this breathing throughout the entire routine.

1 min.

2. Valsalva-Relaxed Velar Humming. Voice /ŋ / with changing pitch. (See Ch. 34, pp. 239.)

1 min.

3. Hummelodian. (See Chapter 39, p. 258.) Break sentences into phrases. On your first exhaled breath, velar hum a “Melody Message” for the phrase, based on natural inflection. On your next exhaled breath, speak the phrase using the same melody, which will now be carried by the vowel sounds. Focus only on the melody and let the words come along without trying to say them. Repeat each phrase as needed. 4. Melodic Intention. (See Chapter 39, p. 258.) Before saying each phrase, imagine its Melody Message while inhaling. Then voice the same melody as you relax your PR and abdomen and start exhaling. Let the words come along without trying to say them. Practice first when reading and then when speaking extemporaneously. 5. Read aloud the “The Relaxed River of Air” and Valsalva-Relaxed Affirmations, using Melodic Intention. (See p. 281.) Total:

15 min.

10 min.

3 min. 30 min.

During the Day •

Think the Melody Message of each phrase while tensing your PR and inhaling. Then voice the phrase with Melodic Intention while slowly relaxing your PR and abdomen and exhaling.

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339

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Index

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Index (Page numbers in italics refer to diagrams, tables, or exercises.) abdominal breathing 28 abdominal cavity 27 acceptance 13, 190, 209-210 Acceptance and Commitment Therapy (ACT) 190 acquired stuttering 100-101 adrenal-cortical system 62 adrenaline 62 adverse speaking conditions 286 Affirmations and Reflections 281 air conduction 149 Air France disaster 274-275 air pressure and force 103-104 airflow 31-32, 224-225 airflow technique 143, 163 alprazolam (Xanax) 187 alternative nerve pathways 132 alveolar ridge 18, 25 amygdala “riding shotgun” 71 amygdala 60-62, 61, 215 arcuate fasciculus 112 Aristotle 7 arousal control 292 articulation 34 arytenoid cartilages 26 asenapine (Saphris) 186 association areas 111 attitude therapy 171-172 attitudes about speech 102 auditory feedback 145 autonomic nervous system 62 axon 109 Barton, Clara 7 basal ganglia 111, 120 behavior-oriented therapies 11- 12 beliefs and memories 90 Berne, Dr. Eric 284

beta-blockers 187 bethanechol 187 Bicycle-Breathing Analogy 224 Biden, Joseph R., Jr. 7 bilateral speech 120 blocks on no particular word 70 blocks on plosives 55-56, blocks on stop-liquid-vowel combinations 69 blocks on words starting with vowels 69 blocks, awareness in advance 20-21 bone conduction 148 brain anatomy 110-111, 110 brain freeze 274-275 brain, top view brainstem 111 breath control 162-163 Breathing 223-229 breathing 28 breathing irregularities 81 Broadway Danny Rose 152 Broca's area 112 bronchi 27 Canadian Stuttering Association 192 Carroll, Lewis 7 caudate 120 cerebellum 111 chest breathing 28 chest cavity 27 childhood recovery 104-105 children, therapy for 282 choral speaking 141-142 Churchill, Sir Winston 7 circumlocution 80 citalopram (Celexa) 187 clomipramine (Anafranil) 187

350 co-articulation 36 cognitive behavior therapy 170 Columbat 161 commercial "stuttering schools" 164 consonant classifications 35-36 consonants 266-267 continuous phonation 59, 140 controlling interference 198 coordination and timing of movement 122-123 corpus callosum 111 costal breathing 163 covert stuttering 193 cranial nerves 111 cricothyroid 27, 33 cues 76, 95 curbing the urge to force on defects 118 defensive reaction Del Ferro, Len 163 delayed auditory feedback ("DAF") 136, 145, 148 delays in vocal reaction time 128-129 demystifying blocks 266 developmental stuttering 101 Devices 160-161 diaphragm 27 diaphragmatic breathing 28 dismantling the Valsalva-Stuttering System 214 distractions 151-152, 159 dominant hemisphere 111 dopamine 120, 185, 186-187 Drugs 185-188 During the day, things to do 286-287 easy onset 143, 163 ecopipam 186 Edinburgh Masker 161 educating the public 296-297 effort 19, 92, 254-255 effort and anxiety reduction 88 effort closure 38, 47 effort impulse 65 emotion 121 Emotional Factors 95, 102 emotional reactivity and regulation 105

Understanding and Controlling Stuttering enhanced vocal feedback 145, 148149 epiglottis 26 epinephrine 62 exaggerated inflection 257-258 Exercises 220-272 exhaling 28 expectancy neurosis therapy 170 expectations, fear, and excitement 91 experience, effect of 113 external intercostal muscles 28 false vocal folds (vestibular folds) 26 fear management strategies 292-293 fear of certain sounds 70 fear pathways 62 feed-forward 147 fiber-optic nasopharyngoscope 48 fight-flight-freeze response 61-62, 63-64 fighting g discrimination 298-299 Fluency Enhancing Conditions 136143 Fluency Master 148-149, 161 fluency training programs 179-182 forceful blocks 54-55, 97-98 Foundations of Speech 36 Fraser, Malcolm 190 frequency altered feedback (“FAF”) 145, 149-150 Freud, Sigmund 166-167 Freund, Henry 19 Friends 192 Full Humdronian Speech exercise 242, 244-249, 247-248 function 119-121 Games People Play: The Psychology of Human Relationships 285 genetic factors 106-107, 115-117 George VI, King of England 7 glottal stop 18, 20, 36, glottis 26-27 goal setting 292 Golf analogy 216-218 gray matter 110 haloperidol (Haldol) 186 Harrison, John 92, 152 Hearing 145-152

Index hemispheres 111 hemispheric dominance 120 hesitations 78 hippocampus 62 hit impulse 216-218 Humdronian Speech exercises 240243 Hummelodian exercise 258 hypnosis 158 hypothalamus 61 identify your negative attitudes 206 implementing therapy 278 implications for therapy 296 individual needs 204-205 individual variations 95 Ingham, Roger J. 181 inhalation 28, 31, 223 inspiratory speech 142 Int’l Stuttering Association 192 intelligence and language skills 122 intentions 72, 92 internal intercostal muscles 29 Jones, James Earl 7 Karate Kid, 276 Key Vowel sound 64 Lamb, Charles 7 larynx, 18, 26, 33, 129-130 larynx, frontal view 26 late onset stuttering 107 learn from your stuttering 289-290 learning and conditioning 94 learning new skill 276-277 left rolandic operculum 119 left striatum 120 legal remedies 299-300 light contacts 143 limbic system 61, 111 Lion analogy 63-64 longitudinal fissure 111 lurasidone (Latuda) 186 masking 136, 145-147 Maugham, W. Somerset 7 McGuire Programme 163 measuring progress 278-280 mechanical devices 160-161 mechanoreceptors 54 medical and surgical treatments 160

351 melody 31, 240 melody and movement 36-37 Melodic Intention 258 Melody Message 236-238, 239 mental attitudes and expectations 197198 mental rehearsal 292 metronome effect 161 mindfulness 268-269 Moderate SMEEch 258-259, 258 Modified Humdronian speech 250-251 Modifying Phonation Intervals (MPI) 181 Moses 7 motivation for change 203-204 motor cortex 112 motor program 64 mouth and airway 26 mouth and airway 26 mouth and airway 26, 26 muscle memory 276 National Stuttering Association ("NSA") 192 negative stereotyping 297-298 nerve pathways 110, 114 Nervous system 49-50, 60-66, 109114 Neuro-Linguistic Programming (NLP) 171 neurological deficiencies 121-123 neurological deficiencies in auditory processing 151 neurological factors 102 neuromotor tuning 49-51, 53, 57 neurons 109, 109 neuropsychological subgroups 123 neurotransmitters 110 Newton, Sir Isaac 7 non-auditory feedback 147-148 non-dominant hemisphere 112 novel ways of speaking 162 Objectivity 207-208, 288 occlusion effect 149 olanzapine (Zyprexa) 186 operant conditioning 179 Organizations 191-193 Other Therapy Approaches 166-193

352 Pacemaster 161 pagoclone 187 parasympathetic nervous system 62 passive airflow 28 passive airflow technique 181 Passive Consonant Exercise 267-268, 268 perception of difficulty 91 perfectionism 105 perisylvian zone 111 persuasion and suggestion 158-159 pharynx 25 phonation 19-20, 27, 31, 32-34 phonation and stuttering 19-20 phonation therapies 181 pitch 33 Pizza example 73-75 placebo effect 185 planum temporale 118 popular misconceptions 10 positive attitude toward speech 208 positive self-talk 292 PR-directed breathing 227, 229 Precision Fluency Shaping 180-181 prephonatory tuning 57 prevalence of stuttering 7-8 Priestley, Joseph 7 professional help 292-293 progression of stuttering 102-103 progressive relaxation 226-227 prolongations 56, proprioceptive feedback 147 prosody and the “Melody Message” 236, 236 psychological theories 10-11, 93-94 psychotherapy 167-171 puborectalis (pr) muscle 41, 225, 226, 226-227 punishment 159 purpose of exercises 221-222 reaction speed 122 reaction to over-invested words 73-75 recognition of repressed needs 169 rectum 41 reducing fear of “brick wall” 265266, 266 refocusing your intention 218

Understanding and Controlling Stuttering relaxation 163-164, 178-179 relaxing the Valsalva mechanism 225 releasing repressed anger. 169 repetitions 20 repetitive exercises 274-276 resist the urge to use force 210-211 Resonant Valsalva-Relaxed (RVR) Speech 251-253, 252 responding to blocks 283 responding to fear and other emotions 284, 291-293 rhythm 141, 161-162 right brain involvement 130-131 risperidone (Risperdal) 186 role and purpose in speaking 211-213 role playing 152-153 SAY 192 Schwartz, Martin F. 181-182 scientific studies 13-14 secondary benefits of stuttering 96 Selective Vowel Aphonia 210 self-help 190-191 self-stigma 189-190 sensory cortex 62 sex differences and the Valsalva mechanism 105-106 shadowing 142 signs of struggle 79 silent articulation (lipped speech) 58 simple disfluencies 101-102 singing 58-59, 139-140 slow breathing 292 slowed and prolonged speech 140-141 Slow-Motion Extremely Emotive Speech (SMEEch) 255-257, 256 soft palate (velum) 18, 25 speak in phrases 239 speaking exercises 157 speaking from abdomen 272 speaking not a test 290-291 speaking to oneself 139 speaking with assumed accent 152153 Speech Alarm System 72-73 speech as melody and movement 243 speech centers of the brain 111-113, 112

Index Speech Mechanism 29 speech mechanism 29 SpeechEasy 148, 150, 161 spinal cord 111 Standard Breathing Exercise 228 stapedius 150-151 starters, fillers, and junk words 79 Stuttering Foundation 190 Stuttering Hexagon 92 stuttering modification 173, 176-177 stuttering variability 16-18 stuttering, definition 4-7 substitution of effort 65 supplemental speech area 112 supplementary motor area 112, 122 Support groups 191-193 suppression of vowel sounds 64 sympathetic nervous system 62 symptoms of stuttering 18-19 synapse 110 tactile feedback 147 thalamus 61, 62, 113 therapy materials 280-281 thiamine (Vitamin B1) 188 thoracic cavity 27 thyroid cartilage 33 timing irregularities 80-81 top view 121 trachea (windpipe) 27 traits crucial to stuttering 117-118 Transactional Analysis 284-286 Transcendent Speech 270-272, 271272 triggering signals 53 U.S. Navy SEALs 292-293 University of Iowa 166 unvoiced consonants 33 using effort to reduce anxiety 96-97 Valsalva "switch" 131-132 Valsalva activation and stuttering behavior 92 Valsalva Hypothesis 51-52 Valsalva maneuver 21, 39-43, 39, 40, 225

353 Valsalva mechanism 21, 41, 42 Valsalva mechanism 41 Valsalva Stuttering System, changing 277 Valsalva Stuttering Therapy 195-198 Valsalva-Relaxed Intentions 283 Valsalva-Relaxed PR Breathing 227228, 229 Valsalva-Relaxed Speech Cycle 199203, 199 Valsalva-Relaxed Vowel Exercises 231-234 Valsalva-stuttering blocks 59 Valsalva-Stuttering Cycle 84-88, 85 Valsalva-Stuttering Response 66 Valsalva-Stuttering System 90-92, 91 Van Riper, Charles 168 velar humming 237, 237, 245, 245246, 246-247 verapamil 187 Virgil 7 visualization 213 292 Vocal Feedback Device 161 vocal folds 19-20, 26, vocal folds, top 27 vocal inhibition 63 voiced consonants 33 voicing Key Vowel sound 268 voicing the Melody Message 239 voluntary stuttering 13, 174, 175-176 vowel phonation interference 57-58 vowel sounds 20 vowel voicing 230 neurological weakness or interference? 127-128 Weiss, Dan 149 Wernicke's area 111 whispered speech 139 whispering 65 white matter 110 Word Recovery Response 260-264, 263-264 word substitution 80

About the Author . . . William Parry is a licensed speech-language pathologist who previously overcame his own stuttering to become a successful trial lawyer. He received his law degree from the University of Pennsylvania Law School, where he was an Editor of the Law Review. He earned his Master's Degree in Speech, Language and Hearing Science from Temple University. He is certified by the American Speech-Language-Hearing Association and is licensed in Pennsylvania and a dozen other states. He provides Valsalva Stuttering Therapy by video conferencing where permitted by law. After struggling most of his life with severe stuttering, Parry became frustrated with existing theories and therapies, which had not helped him to either understand or control his stuttering. Consequently, he began his own research and experimentation, which resulted in his "Valsalva Hypothesis" (published in the Journal of Fluency Disorders in December 1985) and a new therapeutic approach called "Valsalva Control." This dramatically improved his fluency, which opened up his legal career. Parry founded the Philadelphia Area Chapter of the National Stuttering Association in 1985 and led its support group meetings for 17 years. He served for six years on the Board of Directors of the National Stuttering Association and as Chair of its Advocacy Committee. He has appeared on TV and radio talk shows and, in 1987, received the "Spirit of Philadelphia Award" from WCAU-TV Channel 10 News. He has given workshops and presentations on the Valsalva Hypothesis at national conferences of the NSA, the British Stammering Association, the Canadian Stuttering Association, World Congresses for People Who Stutter, and the International Stuttering Association. A preliminary edition of his book, Understanding and Controlling Stuttering, first appeared in 1992, followed by a completed edition in 1994. The Second Edition was published in 2000 and was also published in Korean by the South Korean Speech and Hearing Association. The Third Edition was published in 2013. The current Fourth Edition brings together a decade of clinical experience, experimentation, and practice-based evidence with Valsalva Stuttering Therapy, involving the participation of more than 200 persons who stutter from all over the world. It also contains detailed instructions for therapeutic exercises in use at the time of this writing. Further information about Valsalva Stuttering Therapy can be obtained by visiting its website at www.stuttertherapy.com or by e-mailing Mr. Parry at [email protected].

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