Two Sides of the Coin

 

 

I grew up as a youngster with a developing problem of stuttering. Then at ages 14 to 16, I had therapy during two six-week summer programs. When I was a junior in college, I became a student in the field of speech-language pathology, followed by my professional career. I want to share with you some of most important things I have learned about stuttering therapy using my own experiences during these periods as a frame of reference.

 

Like the many teenagers and adults I have known during my professional career, my goal in therapy was to stop stuttering and speak fluently. This was a very natural desire, considering the frustration and embarrassment associated with the problem. I perceived treatment as consisting of being silent (no conversation) for periods of time in which syllables, words, and sentences were practiced as I learned ways to control and eliminate stuttering.

 

I had not thought about people having normal disfluencies in their speech. In what was called “word analysis” we learned a rule for the production of each consonant, and as we said a word we thought of the rule for the initial consonant. For example, the rule for ‘b,’ a voiced consonant, was “start the voice from below the tongue (in the voice box) and make a smooth movement into the following vowel”; for ‘p’ a voiceless consonant, “start the voice from above the tongue, etc.” In word analysis, transitions between sounds were very smooth, but words were spoken one at a time. I wrote home that I was unlearning the old habits of stuttering and learning a new way of talking. At the end of two weeks, we were allowed to converse using word analysis. To a girl, with whom I had been writing notes while on silence, I was now able to say, “P-A-T, W-O-U-L-D Y-O-U L-I-K-E T-O G-O T-O T-H-E M-O-V-I-E-S S-A-T-U-R-D-A-Y N-I-G-H-T?” After that first weekend, we were not allowed to converse again for almost two weeks. I wrote more notes to Pat and practiced phrasing from a manual of sentences. In phrasing, only the first word of the phrase was analyzed. I was able to say, “Pat / would you like to go / to the Biltmore Hotel / for dinner / on Saturday night?” In addition to the improvement in speech, I progressed in two weeks from a movie to dinner at a fancy hotel. This was very exciting for a 15-year-old!

 

This was my first introduction to what we now designate as the “speak-more-fluently” approach to therapy. Little or no attention was given to monitoring the way in which my speech was disrupted by blocking voice flow at the vocal folds or closing my lips tightly and pushing hard when attempting words beginning with “P” or “B.” The emphasis was on replacing stuttering with word analysis and phrasing.

 

Although I was conscientious in practicing words and sentences every day using my rules, and being more open to others about work on my speech, several months after I returned home I began to have increasingly more trouble. However, like most people who stutter that I have known, every therapy method is helpful to some extent, and this was true for me. 

I never had as much difficulty again as I had before that first summer. 

 

A year later when I went back to review methods of word analysis and phrasing, I began to realize that I had concentrated on the speech aspect of therapy and missed a great deal of the part having to do with attitude. I recalled that the clinicians had talked about how people who stutter become very sensitive about the fluency of their speech. I began to see that if I stuttered I was very hard on myself!

 

Later in college, Wendell Johnson’s ideas helped me to understand that I should not attempt to evaluate myself as “either I am a stutterer or I am not a stutterer.” I began to view myself more and more as a person who stuttered sometimes as he talked. I realized that I was going through a process of change. I also saw more clearly that I had to take responsibility for making others feel comfortable in my presence. Since I was doing something constructive, I could smile more about my difficulties. When I was more at ease, I stuttered less and felt that those around me were more comfortable. During my second year in college, the writings of Charles Van Riper influenced me to be willing to stutter on purpose. Keeping good eye contact with my listener as I introduced myself, I was able to say, “I’m Hugo Gre-Greeegory,” varying the way in which I feigned stuttering. I was amazed by the effects of this. I realized that I could not fear stuttering as much if I was willing to do it on purpose! Within a short time my expec­tation of difficulty in­troducing myself began to decrease more and more. I employed vol­untary stuttering in many situations. These beginning insights into the attitudinal features of stuttering therapy have been expanded as I have helped other people who stutter to understand how their therapy is a step by step process involving both attitude and speech change.

 

When I went to Northwestern University to study “speech correction,” as the field of speech-language pathology was known at that time, I realized that some of the reading I had done and some of my own experiences, such as the use of voluntary stuttering, had prepared me to understand another model of therapy known as the “stutter-more-fluently” approach. The objective of this method was to reduce the tendencies to inhibit and avoid disfluency and stuttering by monitoring, analyzing, and modifying stuttering: i.e., learning to stutter more easily but not stop it! In my own continuing self-therapy, I began to study my stuttering more and learned to modify instances of stuttering, first by immediately going back to say a word in a different, more relaxed way, and then by modifying the stuttering by easing the tension and moving forward more smoothly 

and easily.

 

At this point, therapy based on both “speak-more-fluently” and “stutter-more-fluently” approaches had helped. I was able to use relaxed initiations with phrasing. I was willing to modify my speech just after an instance of stuttering or even during an occurrence of stuttering. Just as I have now seen in many people during therapy, my self-confidence about talking was continuing to increase as I explored and changed not only my stuttering, but also my speech in general!

 

As I progressed in my professional life, I began to recognize inadequacies of a therapy program based on either an avoidance reduction/stuttering modification approach or a direct fluency enhancing model. The stutter-more-easily approach may not result in post-therapy speech that is as normally fluent as it could be. On the other hand, building fluency may not reduce the fear of stut­tering as much as is desirable. I began to combine the two meth­ods in my work with others, in ways similar to what I had done in my own therapy. I have guided teenagers and adults who stutter toward monitoring their stuttering by changing and modifying it. The person learns to stutter more easily, followed by the monitoring of relaxed speech beginnings, smooth transitions between words, more adequate pause time between phrases, and resistance of time pressure. In my clinical practice and teaching I called this working with two sides of the coin: decreasing sensitivity to stuttering and disfluency in gen­eral is one side of the coin, and then building fluency is the other side of the coin. I adopted a gesture, pointing to the palm of my hand as decreasing sensitivity to stuttering and the back of my hand as building fluency, emphasizing an attitude of doing both continuously, as I turned my hand first one way and then the other! 

 

With reference to this personal and professional experiences, I help clients to do the following: 

 

• Listen and watch their own stuttering (using audio and video recordings), gradually seeing that they can reduce the tension involved, thus being able to stutter with “full tension” or “50% reduction of tension.” Clients need considerable support for this negative practice that is only done during therapy sessions, in practice alone at home, or with a person with whom they feel comfortable. Concealment has been a strong motivation since childhood. Almost immediately, most express a feeling of relief that comes with, as Dr. Van Riper would have said, “touching their stuttering.” 

 

• Based on observations of each individual’s stuttering, I then help a person to reduce tension and make a more adaptive, easy, relaxed approach to a phrase, with a smoother movement between sounds and words; then pausing at the end of a phrase and repeating the process. In the parlance of stuttering therapy, this has become known as ERA-SM (easy relaxed approach-smooth movement). An important objective is to contrast the tension and fragmentation of negative practice with ERA-SM and for the persons who stutter to monitor what they are doing. 

 

• To resist time pressure in communication, which is a problem for everyone, but even more so for people who stutter that have insecurities about initiating and maintaining fluent speech, I teach delayed response. Now that clients have more confidence in initiating speech, they can learn to delay, using a count of two in their minds as a guide, before speaking in situations such as when answering a question, giving their phone number, taking their turn in conversations or even between phrases as they talk.

 

• Clients also learn to use “voluntary disfluency” by adding normal disfluencies in their speech, such as “I, I, I,” “have you, have you,” “It’s uh, uh, uh, plane, it’s uh uh superman.” As the person gets good at the voluntary disfluency, I challenge them to add more of “a real stutter” in their speech. Obviously, this helps to douse the fear of disfluency and stuttering. Many people who stutter have not thought about all speakers as being disfluent.

 

• All during treatment, I stress that therapy activities not only help to reduce stuttering, but also enable a person to “be a better than average speaker,” even though there may occasional stuttering. In this connection, the last objective is to build flexibility in speaking by varying the length of phrases, speech rate, loudness and inflection, etc. ERA-SM undergoes change as therapy continues, becoming speech that is just more relaxed. Monitoring speech should not be seen as a chore, but as an opportunity to learn the many things people can do with their speech mechanisms. Self-monitoring is involved in all skilled behavior! Better speakers are able to keep in mind how they are talking, as well as what they are saying. However, as new responses are acquired, less attention is required. 

 

All of these procedures for modifying speech are done first in easier speaking situations and gradually in ones that are more difficult. Lastly, since each individual’s stuttering problem is different, each person must become a problem solver focusing on certain feelings, beliefs, and experiences. People who stutter should see how effective change involves evaluating what they do in situations, planning for the next time, and continuing the process of self-evaluation and change.