NOTE: The therapy
discussed in this paper (now called "Valsalva Stuttering Therapy") has
evolved and expanded since this presentation, and exercises have been
added, revised, and improved.
My name is William
Parry. I am a speech-language pathologist from Philadelphia and leader of
the Philadelphia Area Chapter of the National Stuttering Association (NSA).
For most of my life I myself struggled with stuttering. I
began stuttering at age four. 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, founded the Philadelphia Area
Chapter, led its stuttering support group meetings for more than 15 years,
served on the NSA’s Board of Directors, shared my ideas at numerous
workshops, and wrote a popular book on stuttering – Understanding &
Controlling Stuttering – which is sold by the NSA.
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 year I have been conducting clinical research
on the effectiveness of Valsalva Control Therapy in reducing stuttering
blocks in adults with persistent developmental stuttering. Last month I
began a new trial of a more intensive therapy program. This has already
produced dramatic results, as you will see in the video recordings I will
present later in this workshop. In addition to research results, I am
going to share with you some new insights and techniques that you might
will begin by outlining my present beliefs regarding the nature of
stuttering and stuttering blocks.
Persistent Developmental Stuttering
want to be clear as to what I mean by “persistent developmental
stuttering” usually begins in childhood and is not associated
with brain damage.
It is “persistent”
if it continues into adulthood.
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.
The person is able
to talk fluently some of the time, and stuttering severity may
vary depending on the speaking situation.
The Puzzle of Stuttering
Stuttering has confounded people
throughout history. It is a multi-faceted disorder, involving the interaction
of many factors, which may vary for each individual. Many different theories
have been proposed as to its cause and a wide variety of treatments have been
tried. However, none of the theories or therapies adequately explained or
relieved my stuttering. Furthermore, I did not want to replace my natural
speaking voice with an artificial-sounding “fluency technique.”
My speech mechanism
seemed basically all right, because I had learned to act out roles in front of
an audience with perfect fluency. However, in other situations, it seemed as if
a powerful force clamped down on my speech like a vise, causing me to block. My
problem wasn’t any lack of ability to speak, but rather an interference
with that ability. I suspected that the interference was physiological
in nature, but that it might be activated by psychological factors.
Around 1983, I quit
therapy, began doing my own research into stuttering, and developed my own
approach to therapy. I am now continuing that research clinically as a
experience, my observation of others who stutter, and my clinical research have
all led me to the conclusion that the best way to understand and treat
stuttering behavior is to view it not in terms of “fluency” but rather in terms
As I will
demonstrate, stuttering is the result of misplaced effort in the attempt
to speak. Therefore, the key to fluency is understanding and treating
the motivations and mechanisms behind the use of effort.
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
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:
Persons who stutter have no trouble silently mouthing their words
or whispering. Therefore, stutterers’ articulation does not seem
to be impaired.
Stuttering does not occur until the person adds phonation.
The problem is not
phonation in general, because the stutterer phonates when prolonging or
repeating voiced consonants like /m/, /n/, /r/ and /l/.
However, when he
gets to the vowel sound –
He hits a “brick
Therefore, the problem must be specific to phonation of the vowel sound
of the particular word or syllable in question.
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 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.
muscles are neurologically programmed to build up air pressure in the
lungs by means of 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?
Valsalva mechanism might instinctively feel like the right thing to
do, but it could interfere with speech in at least two ways:
forceful closures of the mouth or larynx to build up air pressure; and
By programming the
larynx for effort closure rather than preparing it to phonate the
Effort Inserted at Vowel Position
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
may contribute to a person’s feeling that speech is difficult and
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.
There are many other factors that may
contribute to the feeling that speech is difficult or that promote the
the urge to exert effort - e.g., developmental delays,
psychological factors, demands on speech that exceed the child's
capacity, etc. These factors may differ, depending on the
Anatomy of a Block on “Peter”
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:
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:
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
This effort may instinctively feel like the right thing
to do, but the more he forces, the tighter his lips close to resist the
Or Peter might forcefully repeat the initial consonant, like
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
beginning consonants do not completely block airflow, the result may be a
prolongation of the sound, such as:
In words that startwith 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. With no vowel program, the person can’t
get past the initial sound, resulting in the very blocks that the speaker
feared. The person erroneously believes that the initial sound was the
problem, thereby reinforcing and perpetuating his fear of words starting
with that sound. Repetition of this behavior eventually
establishes nerve pathways in the brain that may be very difficult to
change. As a result, stuttering behavior may take on a life of its
own and continue even after the precipitating causes have disappeared.
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 first 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
Valsalva Control Therapy
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
Its focus is on
relaxing the Valsalva mechanism, rather than fluency-shaping “targets” or
artificial-sounding speaking techniques. It seeks to liberate the client’s
natural fluency – since his mouth already knows how to talk.
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
Likewise, the participants’ reactions to speaking situations are
analyzed and discussed in terms of their urge to exert or display
effort, rather than whether or not they stuttered.
Elements of Valsalva Control – Education
Control Therapy begins with education about:
The speech mechanism & and the
basics of normal speech production. The participant learns that
fluent speech requires very little physical effort. Most of the
muscular effort occurs prior to speech, during inhalation, as the chest
muscles and diaphragm contract to enlarge the chest cavity to suck in the air.
The airflow that powers speech mainly comes from the relaxation of
The participant learns about the Valsalva mechanism and the
The participant learns how the urge to exert effort
leads to motor programming of the Valsalva mechanism and interferes with the
phonation of vowel sounds.
The next element is Valsalva relaxation. This includes:
Inhaling using the diaphragm.
Concentrating on relaxing the
abdominal muscles as you exhale and begin speaking. Because all parts of
the Valsalva mechanism are neurologically programmed to act together, you
can't do a Valsalva maneuver when you're relaxing your abdomen.
The exhaled breath is like a
satisfied sigh of relief. The Germans call it seufzen (ZOYF-zen):
"To heave a sigh of relief." The chest and abdominal muscles
collapse into a state of relaxation.
When speaking, forget about
your mouth (your mouth already knows how to talk) and imagine that speech is coming from your navel.
During the day, refrain from
doing ordinary Valsalva maneuvers – such as when lifting heavy objects or
making bowel movements. Vocalize instead of holding your breath.
Adronian Speech Exercise
next stage of Valsalva Control Therapy involves emphasis on phonation.
stutter almost never stutter when they sing. This is probably
because they are focusing more on the melody that the words.
Therefore, the brain is constantly programming the larynx to phonate,
rather than to do effort closure, thereby preventing a Valsalva maneuver.
Valsalva Control incorporates this principle through the “Adronian Speech” exercise.
incorporates Valsalva relaxation, plus saying “aaa” at the
beginning of each phrase and continuous phonation of all sounds. The
client begins by speaking in very short phrases.
It should be emphasized that Adronian is not a permanent speaking
technique, but simply a temporary bridge to gradually ease into the next stage,
Resonant Valsalva-Relaxed Speech
Natural sounding speech,
with Valsalva relaxation and concentration on vowels.
You begin with very short
phrases, and gradually lengthen them.
There are numerous exercises to
help clients focus on and strengthen vowel production.
One technique is to pull on
clasped fingers when saying the vowel sounds. Alternatively, you could
press up under edge of a desk or table. This technique also displaces the
urge to exert effort away from the larynx.
After this technique is
mastered, the activity can be reduced to something inconspicuous like
pressing the thumb and forefinger together (i.e., pinching) while
saying the vowel sounds. This activity is then gradually faded out.
Therapy continues through individualized counseling until easy, effortless
speech is achieved in all speaking situations.
The client’s reactions to
speaking situations are analyzed in terms of the urge to exert effort.
Speaking situation hierarchies
are utilized, based on difficulty and importance to client.
Negative attitudes and self-talk
are analyzed and replaced with more helpful ones.
Transition exercises include:
Role playing exercises based on
actual speaking situations.
The client is encouraged to
focus on his or her role or purpose in speaking, rather than
trying to make a “good impression” by trying not to stutter.
Handling Anticipated Blocks
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 (later reduced to "pinching" the thumb and
forefinger together) may help to focus on vowel production and to displace
the urge to exert effort.
I must caution you that this advice is not a substitute for
therapy. It is only effective after a person has become skilled in
the fundamentals of Valsalva Control.
Clinical Trial – Phase 1
2010, I began the first phase of my clinical trial on the effectiveness of
Valsalva Control Therapy.
participants were five English-speaking males, ages 21-31, with
moderate-to-severe developmental stuttering. Appropriate consents and
authorizations were obtained.
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
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)
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.”
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.
and Effortless” Self-Reporting
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.”
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
Participants’ Evaluation of Program
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.
5 out of 5
participants “Strongly Agreed” with these statements:
explanations about Valsalva-Stuttering accurately described my own
experience of stuttering.
helped me to understand my stuttering better.
continue to use Valsalva Control in the future.
skills and insights that will help me to continue to improve my
speech on my own.
recommend Valsalva Control to other people who stutter.
4 out of 5
participants “Strongly Agreed” and one “Somewhat Agreed” that:
made speaking more enjoyable for me.
was satisfied with the Valsalva Control program.
3 out of 5
participants “Strongly Agreed” and two “Somewhat Agreed” that:
made my speech easier and less effortful.
reduced the frequency of my stuttering blocks.
helped to reduce my anxiety about speaking.
oI find it
easy to use Valsalva Control in everyday speaking situations.
sounds and feels natural when I use Valsalva Control.
participants who had previous therapy “Strongly Agreed” that:
Control helped me more than any other therapy I have had.
Conclusions - Phase 1
Based on the Phase 1 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
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
appeared that the standard one-hour weekly sessions were not intensive enough to
establish sufficient changes in the habitual behavior of some participants.
Consequently, the results were not as rapid or as consistent as I would have
Clinical Trial – Phase 2
A few weeks ago I
began a more
intensive Phase 2 clinical trial of Valsalva Control Therapy. The new therapy
sessions will be longer, more frequent, and more structured than in Phase 1.
They will include new therapy materials, exercises, and techniques that were
developed during Phase 1. The new trial will determine whether these
modifications will help to reduce stuttering more quickly and effectively.
In the new, intensive format, therapy begins with at least two 3-hour sessions
per week for the first three weeks, then tapering off. Participants must
also do at least 30 minutes of practice every morning, plus an additional 30
minutes during the day. Participants must actually practice their speaking
exercises (including “Adronian”) outside of therapy sessions (e.g., with
a friend or family).
This format has already produced dramatic results within the first two weeks, as
you will see in the video.
Individual Case Study: RP
The first participant in Phase 2
is RP, a 22-year-old male college student and part-time cook. He began
stuttering around age 5. His mother and one of her brothers stuttered as
children. RP’s stuttering is extremely severe, especially in conversational
speech, with approximately 25 percent stuttered syllables and blocks that often
last 25 seconds or more. His total score on the Stuttering Severity
Instrument-4 was 41 – Very Severe. His overall score on the OASES
questionnaire, which measures the impact of stuttering, was 4.07 –Severe.
RP’s prior therapy
included a 12-day precision fluency shaping program last summer, similar to the
program at Hollins. The techniques were helpful for about a month, but then
trying to make the targets became too stressful and his stuttering returned as
severe as ever.
recently completed four 3-hour Valsalva Control Therapy sessions on Skype
during a 10-day period. As you are about to see, his stuttering was
Videos of RP
Before and After 2 Weeks of Therapy
Now let’s hear from RP
himself. Here are video recordings made before therapy began and ten days
later, after four 3-hour sessions of Valsalva Control Therapy.
Videos of RP
Before and After 2 Weeks of Therapy
If you would like
further information about Valsalva Control Therapy, I invite you to visit my
website, “The Valsalva-Stuttering Network,” at