Wednesday, February 11, 2009

They walk on solid ground, we walk on ice.

My last post was about a third way of looking at treatments. Let me give some meat. Here is the story according to me:

1) Genes or incident cause the development of an unstable speech system that cannot cope with normal demands

2) At age 2-3, the brain has developed to such an extent (mostly likely associated to use of sentences with grammar) that normal demands on the speech demands starts to exceed the abnormally low capacity of the speech system depending on the momentary situation.

3) The excess demand provokes a jam in the speech system leading to a abnormally long delay in initiation.

4) This delay is abnormally long, and causes instinctive reactions.

5) The delay and reactions are joined by conditioned and learned behaviours in response to corrective actions which in turn can make jams more likely.

6) The majority recovers because either the capacity of the speech system becomes better or changes in behaviours lead to fluent speech. For example, the ones with mild deficient capacities might be able to recover.

7) The others keep on stuttering adding further and changing behaviours, also social and psychological.

And the treatment approach is the following: 

1) People who stutter can speak fluently whenever the demand is low, e.g. reading aloud when alone and relaxed despite the abnormally low capacity of their speech system.

2) Stuttering occurs either because of a too-high-for-their-low-capacity-system demand on the speech system or triggers from conditioned and learned behaviours. And very importantly, you cannot change the low capacity, it will stay forever. But it will vary according to day form in the same way as every of your performances, be it intellectual or sports, will naturally vary.

3) The only way that a person who stutters is fluent is when the demands on the low-capacity system is lower than the low capacity AND there are no triggers from conditioned and learned behaviours.

4) An example is reading when alone and relaxed. Demand is slow because you know what to say, you do not have stress that impacts motor control, you are calm, you make longer pauses due to little time pressure, you read slower due to a lack of fighting for speaking time. Triggers are not triggered because there is no fear, no group pressure, no time pressure, or any other situations that you are conditioned for.

5) The key in therapy is to enable people who stutter to put less demands on their low-capacity speech system and to unlearn trigger to conditioned and learned stuttering behaviour. All therapies act on either of the two to achieve a reducing in stuttering.

6) Fluency shaping creates a new way of speaking and therefore the triggers from normal speech are not present, and this new way puts less demands on speech. For example, a gentle onset delays the start of vocalization and hereby gives the speech system more time to be ready. Moreover, the speech rate is slower, again helping to decrease demand. And fluency shaping is probably recruiting other brain regions with normal capacity processing, because the speech is not automatic and a lot of prosody is used.

7) Stuttering modification works on the stuttering event to identify and modify it which effectively means unlearning all unnecessary learned secondary and primary symptoms which again help triggering stuttering events. And a lot of psychological work to unlearn triggers of stuttering behaviour and strategies like longer pauses.

8) What I suggested is that both fluency shaping and stuttering modifications are indirect methods, especially fluency shaping. And further, the key is to work directly on lowering the demands on speech system and unlearning triggers or/and learning antidotes. You ignore the stuttering events and you do not re-shape your speech. You use your normal speech that you use for reading alone, and create the conditions that you are able to do it in more demanding situations processing and trigger-wise.

9) Here are a few examples. To reduce demands: longer pauses (well for some like me, just pauses would already help), slower speech rate, think before you speak, reduce stress and anxiety that impacts speech performance.  To reduce triggers: do not fight stuttering actively, ignore stuttering, focusing on fluent speech, repeating a sentence that you stuttered until you can say it comfortably fluent, focusing on normal breathing and so on.  Everything I wrote down are natural things that a good speaker does any way, and we are able to do them. All fluent speakers get away with a lot, we don't. We need to reduce the demands on our speech system and we need to unlearn the stuttering behaviours. They walk on solid ground, we walk on ice.

10) Needless to say that this is about changing behaviours, and we all know that a behavioural therapy is difficult and relapse is likely. But what I suggested is that this approach is the most direct way to the goal. I am not saying fluency shaping or stuttering modification do not work, but from my framework they look a bit as not coming to the point. It might well be that these approaches are used because they are easier to implement than a direct method.

OK. That's it! And please don't make the comment: So Tom if you are right, then why don't you try it yourself! Rest assured, I have asked myself the same question! :-)


ig88sir said...

You should have highlighted "you cannot change the low capacity, it will stay forever" and add "except if your Joe Biden!"

The results of speech tools are about 20% improved fluency in my stuttering moment. Sometimes I can sound fluent via my own tricks though I am really not saying what I want to say. I think this is better sounding than FS and coastal breathing though. People will still discriminate if your using these techniques as I have seen. They are simple too slow and odd sounding to pass as normal (esp in the Tri-State area of the US where everyone is a motor mouth). I do what I can to survive in this tight economy. That includes being a depressed and angry victim of PDS.

ig88sir said...

I want to ask.. Seems the answer to stuttering is a zap of white matter to our brain. I head Ritalin causes white matter growth. Neurosurgery perhaps? Anyone hear about the case where a lifelong PWS got beaten and robbed and stopped stuttering? Or Vicki Schutter's (from the NSA) car accident where she stopped stuttering for a period after the accident? I know I'm crazy.. not in this lifetime!

Anonymous said...


Joe Biden cure: Read to yourself outloud in front of a mirror and befriend another person who stutters. Have your mom slap some nun. "You can overcome anything if you put your mind to it!"

Bill Walton cure: Chew gum when you talk.

Bruce Willis cure: Kick someone's arse when they bully you about stuttering.

Jack Welsh cure: Make 7 million Dollars and stuttering don't matter as much.

SFA cure: Stuttering Modification therapy or Fluency Training or Lidcome.

Which Option is most appealing?

Anonymous said...

I don't think any kind of therapy can cure a pyhsical/neurological condition. Stuttering is a neurological condition, as much as Parkinson's or Tourette's. I don't know of many therapies that are being practiced for those conditions, yet therapies still exist for stuttering. I think it's just a lack of understanding of the true cause of stuttering and the related neurological aspects.

Here is a good summary of some of the brain studies, just in case some of you haven't read about them.

I do think some day there will be a cure, whether it be from deep brain stimulation, surgery, or a masked cure via drugs. But, I don't think therapy is the answer.

ac said...

I think your 'low capacity demand' explanation for how conventional smooth speech, or 'fluency shaping' techniques work is nice. It certainly matches with my experience, and suggests that it's not the precise technique that is important but rather the extent to which it dampens you speech 'bandwidth' usage.

Ora said...

Tom - a little less serious now...

Your lyrical - even poetic - title for this blog entry reminds me of the colorful and evocative pictures you so often choose to illustrate your posts. I miss seeing one here.

I wonder what image you would choose!

Satyendra said...

Dear Tom
I was hoping to see self acceptance as an important step in your list of treatments. I am fifty, stammered all my life and couple of years ago, developed great self-acceptance, after sharing my issue with a local saint. Since then, my speech is better (certainly not “cured”- wouldn't even bother about that now !); my frame of mind, even better.
I realize that every community differs: Instead of saints, you may have counselors in your society, who may charge an hourly rate for consultation, which may not be paid by social security etc. but I feel, that many PWS would benefit, if some one, or some group could help them accept themselves with their 'freckles and all'.. if some system or self therapy could help them see the big picture- many people dealing with all kind of diversity all the time, sometime obvious and sometime not so obvious- THEN, I think, they would struggle less, when talking – will deal more comfortably with occasional negative reaction from audience..
If there was a world view (not necessarily religious) which helped them to see their inner worth, independent of fluency and audience reactions.. All this would certainly help as much (if not more) as SM / FS..
Wonder what people (especially PWS) think of this in west..
Needless to say, I have been following your posts with great interest. Thanks for this service..

Ora said...

Good pic!

Ora said...

I worked for awhile in private practice with Phil Schneider, a speech therapist in New York.

He used an interesting metaphor (simile?): stuttering is like an allergy. It's a hypersensitivity reaction to stressors. For example, most people's speech is sensitive to rate of speed: faster means less fluent. Similarly with anxiety, etc. But stutterers are more sensitive to these stressors and our speech is affected more than a "normal" speaker's.

One of the techniques he asked me to use was simply "pause more". Say a few words or a phrase, stop, speak again. I asked him, "how many words, how long a pause?" He said: you don't need to analyze it so much; just try it and play with it and see what works for you.

It did have some benefit, and probably would have had more if I had been more consistent about using the technique. It worked, but it seemed too simple, and maybe that's why I didn't use the technique more conscientiously.

Greg said...

Hey Tom,

Yeah--this seems reasonable. It can't be labeled as a 'scientific' theory, per-se, as it can't really predict empirical data... but it seems like a very reasonable way to view the nature of the pathology.

I do have one question though:
"So Tom if you are right, then why don't you try it yourself!"

...Sorry, I just couldn't resist :)