I recently had an opportunity to be interviewed by Pam Mertz on her podcast Women Who Stutter: Our Stories. I particularly liked the title she gave to the episode, Free To Speak Freely. It is the essence of what I know from my experience in working with people who stutter. Giving up control and allowing yourself to be free from planning, trying to get words out and consciously monitoring what you say and how you say it is the key to enjoyable, comfortable and fluent speaking. I invite you link to this podcast and to the many other podcasts that Pam has posted.
One of the enigmas about stuttering is that most people who stutter when talking don’t stutter when singing. Actually, it is often thought that no one stutters when they sing, but I have observed a few exceptions. Of the thousands of people who I have either evaluated or treated, a handful have stuttered occasionally when singing, particularly when starting to sing. Nonetheless, stuttering is very rare when singing.
An acceptable theory of stuttering has to account for this phenomenon. Therefore, I am going to explain from the perspective of my theory why people who stutter don’t stutter when they sing and what the difference is between speaking and singing.
When singing, the subconscious intent is to produce a voice that contains a sequence of varied vocal tones. This sequence makes up the melody of the song. The melody of a song is developed in the brain. As this is done, the motor area of the brain sends signals to the muscles of the larynx so that they will vibrate with the right pitch and rhythm. If you want to see this for yourself, sing a song silently. If you become aware of what happens in your throat, you will sense that your vocal folds are prepared to vibrate, even though you want to remain silent. The brain sends these signals automatically whether you are singing silently or aloud. Singing is all about voice and melody. When the song contains lyrics, nothing changes. The speech sounds are formed automatically without any thought or effort. Singing works this way for almost all people.
For the fluent speaker, speaking and singing are created in a similar way from the same exact anatomical structures. The same signals to vibrate the same vocal folds are subconsciously sent from the brain. This creates intonation, the speech equivalent to melody. Intonation becomes speech sounds as the mouth moves automatically. This can happen because fluent speakers are not aware of the words they are saying. For people who stutter speaking and singing are done differently. When speaking, the focus of attention for people who stutter is the words. In one way or another, they are concerned with saying words and “getting them out”. Intonation takes a backseat as the brain tries to control word formation. Subconsciously, the brain is busy sending signals to lips, tongue, jaw, etc. Instead of the mouth automatically shaping the voice (intonation) into speech sounds, the voice becomes a vehicle for pushing out already formed speech sounds and words. For people who stutter the processes of speaking and singing are done very differently. For people who speak fluently, they are almost identical. During Dynamic Stuttering Therapy, clients begin to understand this difference between these 2 ways of speaking and they report a big difference in the ease of speaking when they do it in the way that it is don by normally fluent speakers.
“She’s got it, by George, she’s got it!!!” That’s what I said over and over again as I read Speech is a River: My Recovery From Stuttering, by Ruth Mead. This book explains so much about the inner game of speaking from the viewpoint of a person who stuttered and who no longer stutters. With clarity, wit, humor, and a not a small measure of political incorrectness, Mead takes on many of the false beliefs that perpetuate and exacerbate stuttering.
Ruth Mead is a writer. I don’t know if she is a professional writer, but she is a personable writer who opens a window into the mind that is behind the stuttering. In Speech is a River she describes her own mind, thoughts and observations, but I don’t think there are many people who stutter who will read this book and not recognize something of their own mind, beliefs, reactions, perceptions and behaviors.
The main premise throughout the book is that people who stutter let their conscious mind try to control the natural spontaneous speech that can flow within. She talks about her own discovery that “Speech is not amenable to coercion”, and explains how she stopped trying to plan and think about how to say words or push air through the block she felt in her throat..
Mead is no stranger to speech therapy. She discusses her experiences with some of the therapy approaches that she is familiar with. She then goes on to explain her recovery through a self-help journey that changed not just her speech; it changed her state of being.
As much as I agree whole-heartedly with everything that Ruth Mead says, I have to add, from the perspective of a clinician who sees many people who stutter, there is more to the “journey” than changing one’s worldview of speaking. There are brain processes that come into play that might intensify the mind’s attempt to control speech. Nevertheless, no therapy will be beneficial when the conscious mind is trying to get out words or say them consciously. That is why this book is so important. It really is the only book that I know of that discusses in length the debilitating tendency to plan, rehearse, think about and try to say words.
As a person who is determined to understand stuttering and guide people to overcome it, I am personally grateful to Ruth Mead for sharing her experiences and making her book available as a free download http://stutterers-anonymous.com/. This is a book that every person who stutters and their families and friends would benefit greatly from reading.
Now that summer (at least over here in the the northern hemisphere) is over, life is getting back to normal and I want to get back to my efforts to explore the validity of my theory about stuttering. Central to this theory is my belief that there is interaction between speech planning, beliefs, emotions, and the pre-motor and motor programs involved in speech execution. Speaking is meant to happen automatically, but when there is over control of planning words and how to say them, the result might be feelings of anxiety, as well as the wrong signals being sent to the mouth and vocal folds that need to keep vibrating if the speech is going to flow.
Now the question is can this hypothesis be validated through research? Not being a researcher myself, I was very excited to attend a lecture at the NSA Applied Research Symposium by Dr. Jennifer Kleinow of LaSalle University. Kleinow’ et al.’s research related to Smith and Kelly’s Multi-factorial Model of Stuttering, a model that I have referenced many times. The study she presented was designed to see if something in the internal monitoring system of people who stutter is different than in people who speak fluently. What Dr. Kleinow and her colleagues found is that stutterers showed heightened peaks in looking for errors, regardless of whether an error was actually committed. This supports the vicious cycle hypothesis that says stuttering results from over-monitoring the speech plan.
In addition, Kleinow explained that the part of the brain that tells you to stop and start all over might be the anterior cingulate caudate (ACC). This area is a kind of switchboard between the premotor, linguistic, cognitive, limbic system. It is active during speech production, apparently overactive in some people who stutter.
So here we have some support that stuttering is not just a linear problem of blocks, rate of speech, breathing or voice production. It is most likely a problem of system function and is effected, at least in part, by over control of speech planning. There may be other areas of control as well, but this study related to the monitoring of phonological errors before they happen. It is my hope that learning about this connection might encourage those of you who stutter to be aware that planning what you are going to say gets in the way of what you want – the ability to speak without effort.
Understanding stuttering would be much easier if we knew what we don’t know. We think in a certain way, so we are not aware of the possibility of thinking differently. This seems confusing, but what is very clear is that by thinking the same way we thought before, keeps us in a state of confusion.
Today people who stutter are confused. If you stutter, you have probably asked yourself, “What made me stutter this time?” or “Why can I speak in one situation, but not in another?” Wouldn’t it be great if there were a theory that would explain the why and how of stuttering, and how people who stutter can speak with ease and comfort?
So far there is no widely accepted comprehensive theory of stuttering. Furthermore, there never will be one, if we keep thinking about stuttering from the same perspective. By opening our minds and realizing that there is more to know and many different ways of looking at stuttering, we may be able to put crystal clarity on a condition that has until now been surrounded by a cloud of confusion.
For the past quarter of a century, I have been asking myself what is it about stuttering that I don’t know. Trying to find the answer to that question lead to observations that lead to another question. Through this process, I eventually found myself with the beginnings of a theory of stuttering. In this blog I want to check out this theory, but I will need your help. You see, if my theory can be proven to be true, it has to be able to explain all of what you know now about the characteristics, and nature of stuttering and fluency inducing factors. It also has to explain the speech behaviors, attitudes and feelings of people who stutter and how stuttering begins and develops. If my theory is valid it has to be testable and applicable to all people who stutter. It also has to be able answer all your questions or at least generate questions for research that can answer your questions. This is where you can help. In the weeks to come, I am going to explain my theory and see if it is plausible. So please post your questions below and let’s get a dialogue going. Let’s see if together we can get to know what we don’t know.
To get started, I will give you a basic overview of what I think stuttering is. As I comment on your questions and comments, I will explain it in more detail, but for now, it goes like this:
Stuttering is a condition in which the normally automatic way the brain transforms thoughts into language while producing a voice that is automatically shaped into speech sounds comes under too much control. Instead of all the elements of speaking working simultaneously, the speaker pays attention to words and then tries to get them out.
All the symptoms we see in people who stutter, such as blocks, repetitions facial and body tension, a lack of breath, fear of speaking, discomfort and so much more are the result of the malfunctioning neurological system that involves speech planning and production. Genetics, learned behavior, misconceptions about speaking, attitudes, reactions to outside stimuli and emotions can affect and may be affected by the way the system functions.
I look forward to explaining this theory further and to being stimulated by your questions.
“The King’s Speech” is officially the Oscar winner for this year’s best film, but what I love most about the movie is its effect on people who stutter.
“The King’s Speech” is a catalyst for bringing stuttering out in the open. A few weeks ago, I was sitting in a crowd of people who, with the exception of a few, were strangers to me and to each other. After I mentioned that I specialize in treating people who stutter, the topic of “The King’s Speech” came up. A man in his seventy’s mentioned that he had just seen the movie. From the one sentence he said, I realized that he stutters, so I asked him for his reaction to the film. In his reply he answered, “Actually I once stuttered….”. Later, a woman who knows him well told me that she had never before heard him discuss stuttering. In fact, she said that this man hardly ever speaks in a social group setting. Due to the film, on that evening, this person who still has the remnants of stuttered speech did both. I think that story sums up why I vote for “The King’s Speech” as the best media happening of the decade for people who stutter.
There are some negative aspects of “The King’s Speech”. The movie does mention many of the false beliefs people have that relate to stuttering. It does seem to reinforce the fallacy that stuttering is a symptom of emotional issues. Would that the world knew that fear of speaking is a natural reaction to the difficulty in speaking, and not the other way around! Bertie’s feelings were so normal and appropriate. At the same time, Bertie is a great example of a person attempting to deal with these feelings and overcome his fears in order to function well in his life and role as a King and as a person.
Hopefully most viewers will understand that the therapy techniques shown in the movie are not necessarily accepted today. However, while watching the film, I cried inside, because as a science, stuttering has not progressed nearly enough since those pre-WWII days. People who stutter are still being asked to do things that are sometimes ineffective, sometimes a ridiculous waste of time, and sometimes even detrimental. The shaking, dancing, rhyming, putting marbles in the mouth, and smoking for relaxation that we saw Bertie being asked to do are not techniques used today. However, other techniques that are equally far removed from learning to produce natural automatic speech are still being used. To me, this is a sad and painful state of affairs. The time has come for us to use more than intuition when treating people who stutter. Researchers are doing great work in learning more and more about stuttering. Therapy must incorporate these findings.
The New York Times recently published an article about research in stuttering. In the article they quoted Dr. Ann Smith explaining, “Speaking involves brain areas responsible not only for language, but for hearing, planning, emotion, breathing and movement of the jaw, lips, tongue and neck. While some researchers are considering all these aspects of speaking, most therapies do not consider stuttering as symptom of dysfunctional system. So often, instead of working to change how the brain functions, therapy comes down to learning motor controls or trying not to stutter by doing what Bertie did: bouncing or gliding through words, using light contacts, slightly prolonging sounds, emphasizing speech sounds and pausing after saying a word or two.
There is a science of speaking. It is time that this science guides therapy approaches. Bertie’s speech therapist gave him wonderful emotional support. That, of course, is important to the therapeutic process. However, I believe clients want more than emotional support. They also want to change themselves into people who can speak with ease. This is the best catalyst for becoming a self-confident speaker.
Stuttering Online Therapy and Communication Therapy Institute Director Barbara Dahm will be featured in a televised interview in New York and North New Jersey. It will air at 6 PM, 7:30 and 11 PM on Thursday, January 27. In New York, as well as North Jersey, it will also air on 13/WNET at 6 PM, as well as on NJN. Please let Ariel know, too.
UPDATED: You can now watch the interview online here.
Several weeks ago I started a 3 part series in which I talked about whose fault it is that so many people who stutter are disappointed and dissatisfied with their treatment experiences. In part 1, I discussed that the approaches for treating stuttering need to be revised. In part 2, I talked about the inability of professionals to change the paradigms that they were taught and trained to believe are the best that can be. Today I am focusing on the people who are being treated, the people who stutter.
First I want to say that I strongly believe that everyone who comes to therapy wants to “get rid of the stuttering”. Furthermore, I think that most clients put their trust in their clinician and are willing to work hard to become fluent speakers. To some extent, while they are doing their absolute best to do what the clinician asks of them, it is this trust that is part of the problem. I believe that there are some clients who need to take a more proactive role in the therapy process. When they are asked to use a technique, they need to question how it is meant to help. Also, if they have honestly tried to do what was asked of them and found it to effortful or difficult to do, they have the responsibility to say that the technique is not working for them and, together with the clinician, explore where the problem lies.
Speech is one of the neurophysiologic systems of the human body that is meant to work automatically. It should not be an effort to speak. If it is an effort, something is wrong. Clients should not accept directives and goals that add layers of cumbersome controls. Clients who come to therapy without questioning what is being asked of them are at fault when they don’t get what they want.
It is very understandable that clients need to be encouraged to investigate the logic behind what they are being asked to do. This is why Dynamic Stuttering Therapy explains the process of normal speech production and is so centered on self exploration. I don’t want clients to do something because I say so; I want them to do what makes sense to them. Some clients do begin therapy thinking that I can make them fluent without their help. They do not want to be bothered with the details. Explanations and discussions are of little interest. During the initial intake it is normal to want to know results of therapy. However, during therapy clients who continue to believe that change comes by osmosis do not make the change that is necessary for a successful therapy experience.
Clients who expect that therapy is a quick fix cause their own disappointment. Therapy is a process of self-change. To be honest, speaking naturally is not a difficult process to learn. However, learning the process is only part of what therapy entails. I sometimes see clients who after 3-4 hours of treatment begin speaking with a degree of ease and fluency that is unfamiliar to them, even during their more fluent moments. In their joy, they expect to go off into their lives and their speech will remain fluent. This expectation is unrealistic. Developing a normal speech production system requires developing or at least strengthening the specific neurological network that results in fluent speech. This can only be done, with intention, mindfulness and repetitive experience.
I have discussed the three factors that are at fault for the failure of therapy to bring the understandably desired results. At the same time, I have touched on how these three factors can improve the situation. The poor outcomes that are traditionally associated with stuttering therapy need not be allowed to perpetuate. Open minds on the part of clinicians and clients will enable more people who stutter experience effective treatment and the ability to speak with ease and fluency.
For the past 60-70 years treatments for stuttering have been based on the concept that stuttering is an uncontrollable thing that happens to people. This “thing” is often described as repetitions, prolongations and blocks that stop the forward flow of speech. Not knowing why and how this happens, the focus has been on the stuttered speech and the consensus for treatment is to accept, control, tame or get rid of it by trying to identify and change the external conditions that are assumed to disrupt speech.
Some conditions that tend to disrupt speech:
- Rate or rhythm of speech
- Fear of stuttering, speaking, or words
- Pressure to speak
- Physical and mental tension
- Lack of control
- Faulty breathing
Over the years this concept of stuttering has become deeply ingrained in the psyche of most people who do and do not stutter. Today it is the basis for most treatments, coping strategies, and advice for people who stutter. In fact it has become so ingrained that ideas that do not fit into this concept are often rejected or not considered serious enough to be investigated.
Over the past 20 years, while treating people who stutter, a different concept became apparent to me. I realized that there was more to stuttering than meets the eye or ear. The “how” stuttering is created started to emerge. I’d like to share this concept with you.
Within each speaker there is a speech production system and, as in all systems, the way it functions determines the outcome. I came to see stuttering as a breakdown in the way the speech system functions. The result of this breakdown is the variety of symptoms that people who stutter may exhibit.
Symptoms of a breakdown in the speech production system:
- Repetitions, prolongations and blocks in speech
- Facial tension
- Eye blinks
- Loss of eye contact
- Body tension
- Emotional tension
- Low self-esteem
- Uncontrollable movements of body and speech muscles
- Poor vocal quality
- Unclear speech
- Unusual pausing
- And many others
Fortunately, many people have helped me understand stuttering. First and foremost, I have learned so much from listening to and closely observing my clients, and other people who stutter, stuttered and never stuttered. I have also learned a lot from studies on the brain functions of people who stutter, neuroplasticity, and from researchers such as Levelt (1989) who describes how normally fluent speech is developed, as well as Smith & Kelly (1996); Watson, et. al. (1997) who through their research have also come to look at stuttering from the perspective of system function.
It is difficult to change ingrained concepts, because it is human nature to stick with the way we see things. I believe this is the reason that therapy for stuttering has not changed much in 60 years. The focus of therapy then and now is on stuttering as speech, rather than on the process of producing speech. Over and over again we hear that there are two basic treatment approaches – stuttering modification and fluency shaping. You either learn to live with stuttering or learn how to control or modify stuttering/fluency/speech.
There is an alternative stuttering therapy that doesn’t try to solve the problem by treating the symptoms. It focuses on how all of the processes of speech production interact, as well as on all the factors that influence the way the brain functions. I call this a speech processing approach. In this approach the focus is on changing brain functions so that speaking is virtually effortless and automatic. The treatment guides people who stutter to use their system according to Levelt’s model of a normal speech production. Stuttering disappears when the processes function naturally.
The process of normal speaking:
- Attending to the nonverbal idea that the person is expressing
- The brain automatically transforming ideas into language
- The brain simultaneously sending a signal to the speech motor system so that a natural voice that contains intonation is produced
- The mouth simultaneously moving subconsciously and automatically
In normal speech production there is no conscious word awareness, no control over motor activity, and no such thing as trying to “get words out”. People who stutter may produce speech in this way some of the time, but it is not their exclusive way of speaking. If it were their speech would not be stuttered.
Changing how the brain creates speech is the goal of the treatment program Dynamic Stuttering Therapy. The treatment process involves exploration and self-discovery, identifying what changes need to be made and learning how to make them. It involves making a commitment to effect neurological, cognitive, and behavioral change, and reinforcing these changes until they become habitual.
The specific goals of therapy that relate to neurological functions are not techniques for controlling speech. They are simply processes normally used by speakers to produce speech.
Specific goals of Dynamic Stuttering Therapy:
- Learning to develop internal (sub vocal speech) naturally without any attempt to get it out
- Allowing the speech muscles to work on an automatic mode
- Generating your voice naturally in a way that allows for the expression of mood and meaning
Many people who have learned to use techniques for controlling their stuttering balk at the idea of not using these controls. They say, “Sure I would like to produce speech more automatically, but I need a way to get out of blocks and to control my stutter”. It is hard to grasp that the point of learning to produce speech naturally is that when you do it, stuttering doesn’t happen. Most people are so locked into their way of thinking that they cannot fathom speaking without effort and thought. They do not realize that there can be a scenario where there is no need for speech controls. Training yourself to function in a new way requires awareness and repetitive use of the brain function. It is moving away from thought about how to say words and control speech, toward the automatic expression of thought.
Speaking naturally is different; it is possible; it is not physically hard to do and requires no special skills, but changing long held concepts and being open to a new approach is a great human challenge.
- Levelt, W.J.M. (1989). Speaking: From intention to articulation. Cambridge, MA: The MIT Press.
- Smith, A. and Kelly, E. 1996). Stuttering: A dynamic multifactorial model. In Curlee, R. and Siegel, G. (Ed.)Nature and treatment of stuttering: new directions, (2nd ed.) (p.204-217) Needham Heigts, MA: Allyn & Bacon.
- Watson, B.C. & Freeman, F.J., (1997) Neurophysiologic behavioral evidence for a fluency-generating system. In W. Hulstijn, Pascal H.H.M. van Lieshout, & H.F.M. Peters, (Eds.), Speech production: motor control, brain research and fluency disorders. (pp. 341-349) Amsterdam, Netherlands: Elsevier.
A common complaint of people who have undergone stuttering treatment is that the results don’t last. This complaint relates to many other conditions, such as weight loss, anger management, addictions and so forth, and is discussed in a wonderful book, Changing For Good, by Prochaska, Norcross, & Diclemente. The authors discuss the reasons that people who come to treatment wanting to achieve certain goals do not maintain their accomplishments, and they outline a program to overcome this problem. I believe it is a must read for people who want to help themselves to make long-term changes in their behaviors and attitudes. In fact, I have incorporated the principles of this program in the Dynamic Stuttering Therapy Workbook.
Over and above the general difficulties of maintaining change, stuttering is a condition that presents special difficulties for the maintenance of change. One of these is that there is most likely an innate tendency for the brain to use an ineffective way for processing speech. Another is that most people who stutter are usually trying to change the wrong thing. I would like to address these two issues.
Research has shown that there are functional and possibly structural difference in the brains of fluent speakers and people who stutter when speaking. These findings are overlooked in most treatment programs. When working on speech tools, the goal is usually to change speech without any consideration of how the speech is being produced. Tools include smooth, slow speech, gentle onsets, pullouts, cancellations and voluntary stuttering. Working on using these techniques is like trying to change how the cake looks when it is finished instead of changing the ingredients and how they are put together. They deal with the result of speaking, the speech, instead of working on how to make it.
In Dynamic Stuttering Therapy we relate to the neuro-physiological process of speaking. During therapy one of the biggest challenges is to get clients to report on how they process speech both in practice and conversations between therapy sessions, instead of on whether or not they stuttered. I find that the clients who succeed in making this switch in perspective are the ones who maintain the new process and enhance their ability to speak fluently. This makes sense. If you are trying to be fluent, who knows what you are doing. It’s all a matter of chance. If you have a way of making speech that results in natural fluency, as happens when you use the processes you have used during therapy, you can make certain you use it.
Once we accept that there is a correct and incorrect process for making speech, there is still a need to cope with the innate tendency of the brain to function the way it is used to functioning. We have a clearly defined process for producing fluent speech, but that does not mean that just because you know the process and have used it, the brain will always function this way. People who stutter have to decide to use the process. The process doesn’t happen to them. They make it happen. Brain processes become stable only when they are repeated over and over again with awareness for at least 6 months to a year. This requires carrying out the process with awareness for a long time after knowing what and how to do it.
When the goal of therapy is to process speech normally, the issue of regression changes. Stuttering doesn’t come and go. You do not have to hope that you will maintain results. There is a direct connection between what you do and the fluency of speech. Regression does not happen, although the speaker might not use the effective process all the time. In this case stuttering may occur. Nevertheless, if you know the processes for producing fluent speech, you know how to return to it. Being able to do this is not a matter of chance. It is an empowering experience.