Table of Contents.

GUIDED 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 stuttering is now emerging. While still hypothetical and 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, any doubts about our worthiness as human beings.

The Valsalva Perspective

As we have seen, the Valsalva mechanism may play a key role in stuttering behavior. If confused with speech, this normal bodily function might cause excessively forceful closures of the mouth or larynx and delays in phonation - two of the basic symptoms of stuttering. The many other varieties of stuttering behavior (described in Chapter 10) could then be explained as attempts to avoid, postpone, or conceal these underlying blocks.

Our hypothesis suggests why we may instinctively block airflow and build up air pressure in an attempt to force out words as if they were "things." We can now understand why this feels like the necessary thing to do - even though it makes fluent speech impossible.

While the Valsalva mechanism is only part of the total picture, it may help us link many of the other pieces together in the proper perspective. Through the Valsalva-Stuttering Cycle, we have seen how the one's activation of the Valsalva mechanism might be prompted by the anticipation that speech will be difficult or that extra effort will be needed. This may explain why stuttering occurs in some situations more than others, and why it usually hits hardest on the most important words.

Other factors may also fit into this picture, insofar as they contribute to the anticipation or perception of difficulty. For example, some stutterers' speech might be affected, to varying degrees, by neurological impairments (either inherited or suffered in utero or thereafter) or emotional problems. Even when the initial difficulty is due to a neurological weakness, the Valsalva-Stuttering Cycle may describe the individual's learned reaction, which may greatly aggravate the symptoms.

Not every stage of stuttering involves the Valsalva mechanism. As discussed in Chapter 13, a child's earliest disfluencies may arise from a number of factors, such as delays in the neurological development of speaking skills, emotional stress, or excessive demands for good speech. We then saw how the child's effortless, whole-word repetitions might gradually progress into forceful blockages, bringing the Valsalva mechanism into play.

The child - already accustomed to using the Valsalva maneuver when exerting effort or expelling bowel movements - may instinctively assume that words can be forced out in the same way. As noted in Chapter 12, this display of effort could also be the child's way of telling his parents: "You can't punish me for stuttering. Look how hard I'm trying to please you!"

Continuation of this behavior during certain critical years of childhood may influence the development of nerve pathways in the brain. The pathways linking speech to the Valsalva mechanism might be strengthened by constant use, while those for fluent speech may remain underdeveloped. In this way, the tendency to involve the Valsalva mechanism in speech would become permanently "wired" into the stutterer's brain.

The Valsalva Hypothesis also provides insights that may improve our control of stuttering. In Chapters 19 through 21, we saw how various types of therapy could be explained in terms of their effect on the Valsalva-Stuttering Cycle; how many competing forms of therapy have certain elements in common; and why relapses may occur when stutterers "try hard" to use fluency techniques and thereby activate the Valsalva mechanism.

Our hypothesis views most developmental stutterers as having the basic capacity for reasonably fluent speech. The major problem, in our view, is usually not a lack of ability to speak, but rather an interference with that ability by the Valsalva mechanism. (Even for the person whose speech is affected by neurological impairments, using the Valsalva mechanism to force the words can only make matters worse.)

Therefore, our approach to fluency does not concentrate on retraining the speech mechanism, but rather on controlling the Valsalva mechanism. Our suggestions for Valsalva Control include both physical and psychological aspects, as seen in the Fluency Cycle. Although we have incorporated a number of fluency methods from the past, they are now intended for the specific purpose of relaxing the Valsalva mechanism and breaking the Valsalva-Stuttering Cycle.

No speaking technique can, by itself, guarantee fluency. However, there is still value in practicing speaking skills. By improving our underlying speaking ability, we can increase our self-confidence and strengthen our nerve pathways for speech. This, in turn, may help to reduce our anticipation of difficulty and our urge to activate the Valsalva mechanism.

One of the practical advantages of Valsalva Control is its compatibility with other forms of stuttering therapy. Therefore, one need not rely exclusively on this approach. Various elements of Valsalva Control can be selected to improve or supplement other treatment programs, and to deal with the tendency to relapse.

Stimulating Further Research

It is truly amazing that researchers have paid so little attention to the Valsalva mechanism, given its potential for explaining so much about stuttering. One reason, I suspect, is that they have viewed it merely in terms of the laryngeal closures that typically occur during an ordinary Valsalva maneuver. Because the larynx does not always close in this fashion during stuttering, researchers may have simply assumed that the Valsalva mechanism was not involved.

In contrast, we have taken a much broader view of the Valsalva mechanism. As we demonstrated in Chapter 6, it can stimulate forceful closures in the mouth as well as the larynx. We have also raised the possibility that neurological preparation for a Valsalva maneuver might interfere with the normal prephonatory tuning of the larynx, thereby delaying phonation and interfering with speech.

I recognize that the Valsalva Hypothesis is still only that - a hypothesis - and that considerable scientific research is needed to establish the true role of the Valsalva mechanism in stuttering. As previously suggested, this research might include EMG studies of muscular activity in the Valsalva mechanism during stuttering; testing the effect of Valsalva relaxation on fluency; exploring the neurological relationship between speech and the Valsalva mechanism; and searching for neurotransmitters or other chemicals that may trigger the Valsalva maneuver.

Because I am not a speech pathologist and don't have access to a speech lab, I can't obtain this data on my own. My only avenue has been to explain my hypothesis and its ramifications as comprehensively as possible, to explore these ideas with other persons who stutter, and to try to stimulate speech pathologists to pursue the necessary research.

Whether or not one accepts my hypothesis, I can see no scientific justification for refusing to investigate the Valsalva mechanism. Researchers have delved into countless aspects of stutterers' behavior and physiology - rarely on the basis of any theory that would explain as much about stuttering as the Valsalva Hypothesis. Unfortunately, it's not likely that the scientific community will undertake this task any time soon, given the fact that research money is scarce and speech scientists already have enough trouble getting their own projects funded.

Although the scientists have not yet confirmed the validity of the Valsalva Hypothesis, we who stutter need not wait. We can informally experiment with it ourselves. We can be our own researchers, our own subjects, using our minds, bodies, and speaking experiences as our laboratories. While this approach may not be "scientific," it's all that we have - and all that may really matter.

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 may 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.

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:

      "No one knows the cause of stuttering for sure, but there is a new hypothesis that seems to explain it as well as anything.  Stuttering may be largely due to a neurological confusion between two basically normal bodily functions - speech and the Valsalva mechanism.  When I anticipate that speaking may be difficult, I may have a tendency to activate the Valsalva mechanism, which is something everybody normally uses to help them exert effort or to force things out of the body."

      We might even demonstrate by having our listeners do the hand-pulling 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 the 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 þ students, teachers, employers, parents, even speech-language pathologists.  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 acknowledging 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 come "out of the closet" and let employers and others know that stuttering is no stigma and nothing to be ashamed of.

 Fighting Discrimination

 Of the many obstacles faced by people who stutter, perhaps the most costly 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 other 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 15 years as a National Stuttering Association chapter leader and then 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.

 Our right to equal opportunity should not be conditioned upon our fluency.  Every person who stutters should have the right to accept his or her own stuttering - and to insist that employers judge them solely upon their ability to perform the essential requirements of the job 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.

The greatest obstacle to communication comes when people feel compelled to hide their stuttering out of fear of reprisal.  For employers to demand fluency as the price of one's job only creates a vicious spiral of stress and anxiety that makes stuttering worse.

 A Closing Word

 In this book, I have described my own way of understanding and controlling a problem that had tormented me since childhood.  With the help of the Valsalva Hypothesis and Valsalva Control, I was finally able to get a handle on stuttering and change my life.

 However, I don't claim to have "found 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.  We must each find our own way "out of the woods."

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.

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.  Stuttering and Employment Discrimination.  Int'l Stuttering Awareness Day 1999 Online Conference, The Stuttering Home Page, URL:  www.mnsu.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.