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Presentation
for the International Stuttering Association's
9th World Congress for People Who Stutter
Buenos
Aires, Argentina - May 18, 2011
Copyright
© 2011 by William D. Parry
Introduction
My name is William Parry. I am a speech-language pathologist from
the United States.
For most
of my life I myself struggled with stuttering. After decades of failed
therapies, I found my own way to understand and overcome my stuttering in
the early 1980’s, using an approach that I call “Valsalva Control.” It
enabled me to pursue a successful career as a trial lawyer. Since then,
I have been active in the National Stuttering Association in the United
States, led stuttering support group meetings, shared my ideas at
workshops, and written a popular book on stuttering.
I am now pursuing my
second career – that of a professional speech-language pathologist – in
the hope of furthering the understanding and treatment of stuttering.
Over the past nine months I have been conducting a Multiple-Subject Case
Study of the Effect of Valsalva Control Therapy on Stuttering Blocks in
Adults with Persistent Developmental Stuttering. I will be sharing the
promising results of this the study with you today.
However, I would
like to begin by outlining my present beliefs regarding the nature of
stuttering and stuttering blocks.
Persistent Developmental Stuttering
First, I
want to be clear as to what I mean by “persistent developmental
stuttering.”
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“Developmental
stuttering” usually begins in childhood and is not associated
with brain damage. |
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It is “persistent”
if it continues into adulthood. |
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It is basically a
speech problem rather than a language problem. The person knows
exactly what he or she wants to say, but is sometimes blocked when
trying to say the words. |
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The person is able
to talk fluently some of the time, and stuttering severity may
vary depending on the speaking situation. |
Understanding Stuttering
Stuttering is a multi-faceted condition influenced by many factors,
depending on each individual. However, I believe that the best way to
understand and treat stuttering behavior is to view it not in terms of
“fluency” but rather in terms of effort.
The
Mechanism of Stuttering Blocks
I believe that the
underlying mechanism for stuttering blocks boils down to the following:
a neurological confusion in the motor programming of the larynx, in
which effort is substituted for phonation of the vowel sound in specific
syllables.
The Real Problem Is the Vowel
Most people assume that stutterers have trouble saying initial
consonants. However, these sounds are not the real problem. For example,
a person repeating /p/ in “puh-puh-puh-Peter” or prolonging the /s/ in
“S-s-s-s-s-sam” or the /m/ in “M-m-m-mary” is actually saying the /p/, the
/s/, and the /m/ perfectly well. In each case, the real problem is the
speaker’s difficulty in producing the vowel sound that follows.
Stuttering and Phonation
There is ample evidence that stuttering blocks may involve
interference with phonation. Consider the following:
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Persons who stutter have no trouble silently mouthing their words
or whispering. Therefore, stutterers’ articulation does not seem
to be impaired. |
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Stuttering does not occur until the person adds phonation.
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The problem is not
phonation in general, because the stutterer phonates when prolonging or
repeating voiced consonants like /m/, /n/, /r/ and /l/.
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However, when he
gets to the vowel sound –
He hits a “brick
wall.”
Therefore, the problem must be specific to phonation of the vowel sound
of the particular word or syllable in question.
Motor
Programming
This
phenomenon can be understood in terms of motor programming.
Before any bodily movement can occur, the brain must create a motor
program for the muscles involved. The same is true for speech. A
process called prephonatory tuning
must prepare the laryngeal muscles to bring the vocal folds together
properly before phonation can occur.
However, phonation
is not the only function of the larynx.
The
Valsalva Mechanism
The larynx is also involved in the exertion of physical effort
as part of the body’s Valsalva mechanism. The
Valsalva mechanism consists of the larynx and other muscles throughout the
body, including the abdominal and chest muscles.
These
muscles are neurologically programmed to build up air pressure in the
lungs by means of a Valsalva maneuver.
During a
Valsalva maneuver,
both the vocal folds and false vocal folds close tightly to block the
airway. This laryngeal function is called effort closure.
Meanwhile, the abdominal and chest muscles contract in order
to increase the air pressure in the lungs. The
more they squeeze to increase air pressure, the more tightly the larynx
closes to hold the air in.
Instances of Valsalva Maneuvers
The purpose of the Valsalva maneuver is to stiffen the trunk of the body
so that physical effort can be exerted more efficiently.
We instinctively
perform these maneuvers every day – usually when lifting, pushing, or
pulling heavy objects and when bearing down to make bowel movements.
The Valsalva maneuver may also be activated as part of the “fight or
flight” response to fearful situations.
Valsalva and Speech
But what might
happen if the Valsalva mechanism becomes involved in the effort to speak –
either in response to the anticipation of difficulty or as a reaction to
fearful speaking situations?
Activating the
Valsalva mechanism might instinctively feel like the right thing to
do, but it could interfere with speech in at least two ways:
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By promoting
forceful closures of the mouth or larynx to build up air pressure; and |
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By programming the
larynx for effort closure rather than preparing it to phonate the
vowel sound. |
Effort Inserted at Vowel Position
The
vowel is the natural place to insert the motor program for effort, because
it’s the heart of the syllable and has the most energy.
Possible Effects of Weakness in Motor Programming
Numerous studies have suggested
that persons who stutter may have weaknesses in parts of the brain that
put together the neurological programs for speech and other fine motor
skills.
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These weaknesses
may contribute to a person’s feeling that speech is difficult and
requires effort. |
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They might also
make a person’s motor programming for speech susceptible to
interference. Such interference could be precipitated by stress,
anxiety, and other emotional triggers, which would account for the
variability of stuttering. |
Anatomy of a Block on “Peter”
In
analyzing how a block might occur,
let’s use the name “Peter” as an example. The motor program for “Peter”
should have phonation on the “ee” (/i/) and the “er,"
which can be represented like this:
But,
because Peter anticipates that saying his name will be difficult, his
brain inserts a motor program for exerting effort where the “ee” should
be, which can be shown like this:
Without
the motor program for the vowel sound, Peter can’t get past the /p/ sound
to say his name. He feels as if there is a “brick wall” that requires
force to break through.
Peter may try to force through the block by building up air
pressure, as in a Valsalva maneuver, while closing his lips tightly on the
/p/, like
this:
This effort may instinctively feel like the right thing
to do, but the more he forces, the tighter his lips close to resist the
air pressure.
Or Peter might forcefully repeat the initial consonant, like
this:
as he waits for the vowel sound to be programmed. Notice that the “uh”
following the /p/ is not the proper vowel sound. It is basically
just a grunt, like you might make when lifting weights.
Prolongations & Initial Vowels
When the
beginning consonants do not completely block airflow, the result may be a
prolongation of the sound, such as:
In words that start with vowels (such as “apple”), the block
may focus on the laryngeal closure or “glottal stop” (/§/) that
commonly occurs just before the vowel when the speaker does a “hard
onset.” This may result in a prolonged laryngeal block or a repetition of
grunts, like “Ɂuh-Ɂuh-Ɂuh-Ɂuh.”
Reinforcement of Effort Programming
Fixation
on the initial consonants creates the false impression that these sounds
are causing the speaker to block, and that it’s hard to say words
beginning with these sounds. This expectation of difficulty causes the
brain to program the larynx for effort, resulting in the very blocks that
the speaker feared.
Use of Effort To Reduce Anxiety
Valsalva programming may also be reinforced through the use of effort
to reduce anxiety. All the participants in my study reported that, to
some degree, using effort helped them feel less anxious. This was
particularly true for participants whose parents were critical of their
stuttering. Using effort may have become a way to show how hard they were
trying to please.
Using effort was
reinforced because of its short-term benefit in reducing anxiety, even
though it perpetuated stuttering.
Understanding this dynamic was crucial to reducing the effort used in
speaking situations.
Valsalva Control Therapy
The purpose
of Valsalva
Control Therapy is to promote easy, natural, resonant speech by
eliminating interference from the body’s Valsalva mechanism and the urge
to exert effort.
Its
elements include education, Valsalva relaxation, exercises in phonation,
strengthening vowel production, various speaking exercises, role playing,
speaking situation hierarchies, attitude changing, and individualized
counseling.
Valsalva
Control
intentionally does
not emphasize fluency, because any effort to “stop stuttering”
would tend to activate the Valsalva mechanism and be self-defeating.
Instead, the goal is to communicate in an easy, effortless, and enjoyable
way.
Likewise, the participants’ reactions to outside speaking situations are
analyzed and discussed in terms of their urge to exert or display
effort, rather than whether or not they stuttered.
Handling Anticipated Blocks
Among
other things, clients are taught not to force through anticipated
blocks. Instead they should stop, take a breath, relax their abdomen as
they exhale, and focus on phonating the vowel sound. We have found that
pulling on clasped fingers may help to facilitate vowel production.
Clinical Trial – Phase I
In July
2010, I began the first phase of my clinical trial on the effectiveness of
Valsalva Control Therapy.
The
participants were five English-speaking males, ages 21-31, with
moderate-to-severe developmental stuttering. Appropriate consents and
authorizations were obtained.
Therapy was
administered in 25 weekly one-hour sessions, plus daily 30-minute exercise
routines and other homework assignments. All sessions were conducted by
video conferencing using Skype™ and video recorded.
During the course of
the study, the therapy evolved as new materials and exercises were added.
Average Results for All 5 Participants
The
following are the average results for all five participants in the study.
%
Syllables Stuttered in Oral Reading
The first graph
shows the reduction in percentage of syllables stuttered in oral reading
for all five participants. The black line shows a beginning average of
8.86 per cent stuttered syllables, reduced to an average of 1.26 per cent
after 24 weeks – a reduction of about 86 per cent.
Stuttering Severity Scores (SSI-4)
The next
graph shows the Stuttering Severity Scores for the five participants,
based on the Stuttering Severity Instrument-4. As shown by the black
line, the average score was reduced by 61 per cent, dropping from
“Moderate” to “Very Mild.”
OASES
Scores at 0, 8, 16 & 24 Weeks
The next graph shows
the overall impact of stuttering as measured by the OASES questionnaire –
the “Overall Assessment of the Speaker’s Experience of Stuttering.” This
test has a minimum score of 1.00 and a maximum score of 5.00. As shown by
the black line, the average impact was reduced from “Moderate-Severe,” to
“Mild-Moderate” – an average reduction of 50.63 per cent.
“Easy
and Effortless” Self-Reporting
Each
week the participants were asked to report how easy and effortless
their speech had felt to them in various speaking situations.
Participants ranked the amount of effort on a scale of 1 to 9, with 1
being “Very easy and effortless” and 9 being “Very difficult.”
The next
graph shows the average progress in “easy and effortless speech.” The red
line represents the average “most difficult” experience, the green line
represents the average “easiest” experience, and the blue line represents
the average rating of speech in general. As you will see, the average
effort in general was cut approximately in half, from around 5 down to
about 2.6.
Participants’ Evaluation of Program
At the
end of 24 weeks, the participants were given a questionnaire to evaluate
the therapy they had received. They were asked to rate how strongly they
agreed or disagreed with the following statements.
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5 out of 5
participants “Strongly Agreed” with these statements: |
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The
explanations about Valsalva-Stuttering accurately described my own
experience of stuttering.
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The program
helped me to understand my stuttering better.
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I will
continue to use Valsalva Control in the future.
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I learned
skills and insights that will help me to continue to improve my
speech on my own.
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I would
recommend Valsalva Control to other people who stutter.
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4 out of 5
participants “Strongly Agreed” and one “Somewhat Agreed” that: |
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The program
made speaking more enjoyable for me.
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Overall, I
was satisfied with the Valsalva Control program.
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3 out of 5
participants “Strongly Agreed” and two “Somewhat Agreed” that: |
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The program
made my speech easier and less effortful.
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The program
reduced the frequency of my stuttering blocks.
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The program
helped to reduce my anxiety about speaking.
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I find it
easy to use Valsalva Control in everyday speaking situations.
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My speech
sounds and feels natural when I use Valsalva Control.
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All
participants who had previous therapy “Strongly Agreed” that: |
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Valsalva
Control helped me more than any other therapy I have had.
Individual Case Study: DM
Now
let’s look at one of the individual case studies.
DM
was a
27-year-old male trial lawyer who began stuttering when he first started
to talk. His previous therapies included several years of speech therapy
in public schools, delayed auditory feedback (which was not effective
outside of the clinic), two weeks of precision fluency shaping at the
Hollins Institute (which was followed by a relapse within 6 weeks), and
the Speech Easy device (which was not effective).
DM’s
Results (including 2-week follow-up)
This table shows a
comparison of DM’s individual results before and after therapy. As you
will note, his percentage of syllables stuttered in oral reading dropped
from 9.70 per cent to zero. He began with a Stuttering Severity
Instrument Total Score of 29, considered “Moderate,” which dropped to 8,
which is in the “Normal” range – for a reduction of 72.41 per cent. His
overall impact of stuttering, as measured by the OASES test, dropped from
4.01, which is considered “Severe,” to 1.66, which is considered
“Mild-Moderate” – a reduction of 78 per cent. His Fluency Self-Report was
also greatly improved.
Conclusions
Based on this
preliminary trial, Valsalva Control appears to be a valid approach to
understanding and treating stuttering, while preserving the individuals’
own natural-sounding speech.
Furthermore, Valsalva Control provides practical insights and tools for
persons to make further progress on their own. This is important, because
deeply entrenched nerve pathways for any kind of behavior, including
stuttering, often take a very long time to change.
Three of
the five participants showed dramatically reduced stuttering both in and
outside of therapy sessions. The two other participants reported less
success in transferring Valsalva Control to outside speaking situations,
possibly due to anxiety issues. They may have needed more intensive
therapy than weekly Skype sessions.
Future Therapy
Trials
The late
addition of new therapy materials, exercises, and techniques appeared to
accelerate the progress of some participants. Therefore, I am planning a
more intensive Phase Two clinical trial to determine whether these
modifications to Valsalva Control will help to reduce stuttering more
quickly and effectively.
If you
would like further information about Valsalva Control Therapy, I invite
you to review the paper that I submitted, which is contained on your C.D.
of the Congress. and to visit my website, “The Valsalva-Stuttering
Network,” at
www.Valsalva.org.
Thank
you. |
Contact Information: