Written by Matthew O’Malley
Have you ever asked yourself, “Isn’t there someone who has sat down and looked at all the characteristics of stuttering and figured out what’s going on?”
“Isn’t there some researcher somewhere who has put all of these puzzling pieces together to explain stuttering?”
“Isn’t there someone who has come to understand stuttering’s nature and figured out a good way to treat it?”
After all, even the lay observer is intrigued by it and has a sense that this enigma is solve-able. You’d think it would be solved by now.
“Why do people not stutter in some situations and stutter significantly in others?”
“Why is it that a person who stutters can block on a word for a few seconds and then the word all of a sudden comes out? What changed?!”
If you have asked these questions or ones similar, then we have something in common. I also asked them a number of years ago and there was seemingly nowhere to turn for satisfactory answers. I had sought out the world’s leading experts on the subject, sought treatment for my own stuttering and was disappointed with both the answers and the results. I simply wanted sensible explanations and reasonably effective treatment for stuttering and, had I received it, would have walked away from the world of stuttering and never looked back.
That’s not what happened though.
After seeking these answers and receiving various treatments, I was still stuttering and was still mystified by it. Its accompanying struggles had consumed my life for many years up to that point. The fact that I could not find a reasonable remedy to deal with my stuttering lead me through some very challenging times in life. I decided since stuttering was already consuming my life, why not make use of that.
In my asking the question “Isn’t there someone out there who has figured out stuttering and put all the pieces together?” I had received my answer. The answer was “No”. So instead of continuing to ask that same question, I started asking a new one. “Why not me?”
In answering this new question, I decided to use my life to serve this cause; to answer these questions. My inability to resolve my stuttering earlier in my life had caused many challenging times. It is part of the human journey I have been on; a human journey that involves significant pain and suffering. While I believe suffering is inherently purposeful, I also hope to transform my own into purpose by giving to this cause. I consider myself humbly in service to those who have asked or one day will ask these same questions. I hope to serve well.
Since dedicating to this path about five years ago, I have graduated cum laude with a degree in speech-language pathology. I have also worked as a developmental therapist treating speech and language delays. Most importantly however, I have stayed passionately curious and deeply motivated to answer the above questions and have been in the trenches doing just that. Fortunately, I believe this process is bearing fruit.
The initial point of this entire journey to understand stuttering was to get to a place of effective treatment based on a real understanding of the nature of the stuttering condition. Throughout this process I have kept my eye on that ball (treatment). The first part of that process was gaining a sufficient understanding of stuttering as one needs an understanding of a condition to to design effective treatment. Up to this point, working to understand stuttering’s nature has consumed the vast majority of my work. However, within this article/guide for the first time, I dive deeply into treatment design as I have reached a sufficient understanding of stuttering’s nature to do so.
Within this guide, you will find brief summaries of the above mentioned understanding of stuttering’s nature. However, links will also be provided to the full articles explaining this understanding of its nature linearly and in much more detail. It will be part of the treatment to read them so you can operate from a place where you understand why you are doing each aspect of the treatment.
In addition, in laying out the self-treatment guide, it is necessary to provide some background information. Much of that is below. It precedes the actual “Stuttering Self-Treatment Guide” section where “what to do” is laid out.
Also, I worked diligently to ensure this guide is not vague. Instructions on “what to do” will be as explicit and direct as I can make them. Many have written theory on stuttering and offered vague ideas and explanations on what to do to make changes to one’s stuttering. This can be frustrating for the person working to “self-treat”. To improve upon this, I’ve worked to make the self-treatment guide as clear and explicit as possible in regards to how to go about self-treating. I have also worked to communicate the clear understanding of stuttering’s nature that the treatment guide is based on.
Problems in Research/Academia & My Differing Approach
Firstly, I want to state that much good comes out of academia and research and you will see in this article I use much of the research. There are many advantages to the academic process and many intelligent people who part-take in it. I admire all in the research community and am truly thankful for their hard work and contributions.
At the same time academia and the research process is not flawless nor is it without significant limitation. This is not news to those within it as researchers have concurred with this view in conversational exchanges we’ve shared.
In getting to it, however, in current and past research on stuttering there is far too little time spent on synthesizing/combining information we already have. Well-intended researchers end up spending five years on a study which uncovers the most minute new piece of information on stuttering.
Inherent in the above pursuits of new information is a belief that what we need is new information. However, the problem isn’t so much a lack of information on stuttering. It is more a problem of lack of competent synthesis of all of the information we have. Many insights about the condition are ready for the drawing if you zoom out a bit and look at the big picture.
In addition, as many researchers concur, much of the academic process is not conducive to the passionate pursuit of answers. The process of a research study can become energy-draining and more about paper pushing and meeting obligations than answering the questions you set out to answer in the first place.
As a result of these problems I have taken a different approach. I have allowed my passionate curiosity to be the unabated director of my pursuit of answers. I have observed my own stuttering and that of many others and trusted my observations and insights. I have focused on synthesizing the already-existing information. I have believed nothing that I did not understand myself. While I do dive deeply into the tedious details of academic research I also make sure to maintain a level of common sense. Too many seeking answers end up not being able to see the forest for the trees. Also to my benefit, we live in the information age and this has yielded many advantages.
Lastly, before diving in, I’d like to share that I work hard to make my explanations of stuttering clear and linear and work to stay away from convoluted academic jargon. I could write that way but choose not to. I choose to write with simple clarity (which is actually far more difficult) so the reader, no matter their background, can understand it and evaluate its veracity for themselves. You don’t need to look for a piece of paper on my wall when evaluating the credibility of my explanations (though I have some) as you can assess the strength and clarity of the logic for yourself. That being said, know that when I am explaining something, it is going somewhere. It may seem indirect at times as I must provide some background information, however, it is not.
An Introduction to the Nature of Stuttering
What if you learned the severity of the movement disorder Parkinson’s disease fluctuated with changes in the environment just like stuttering?
What if you learned people with Parkinson’s in some circumstances regain virtually normal movement control just like someone who stops stuttering when alone?
What if you learned there were non-speech behaviors that people “stuttered” on? What if golfers froze mid-swing and lost the ability to complete their swing? What if sometimes dart-throwers’ arms involuntarily froze under pressure and they could not release the dart? What if these same golfers and dart-throwers could perfectly make these motions in practice but not in competition? Doesn’t that sound a lot like stuttering?
What if you learned the amount of “stutter-like” behaviors went on and on affecting many different types of behaviors/movements unrelated to speaking?
What if you learned people stuttered in sign language just like they do in verbal speech?
What if you realized that “speaking out loud” was movement of the body and started getting more interested in how movement works?
What if you learned that unconscious processes started making your own movements before you even knew you wanted to make the movement yourself?
What if you learned speaking was mostly an unconscious process?
What if you learned that blocking and stuttering were also unconscious processes and it was possible to understand what factors go into these unconscious processes?
What if you learned the reward system was deeply interlinked with all movements (motor system), including speech movements? What if you started to understand this link and how it interacts with the environment? What if this link could explain why stuttering fluctuates so much?
What if you learned the fear of stuttering and the shame that comes with it is rooted in an evolutionary fear of death through social ostracism, abandonment, and rejection? What if you learned this was why the anxiety could be so powerful?
What if you started seeing speech as movement and learned that based on evolution all movement is goal oriented and the subconscious must deem a movement “rewarding” and beneficial to support it?
Again, what if you learned speech was movement? What if you learned the subconscious was constantly assessing the environment and preparing what-it-deems-to-be-advantageous movements for that specific environment? What if each possible movement was assigned a projected reward/punishment outcome? What if the subconscious in people who stutter equated speech movements with reward-system “punishment” when the environment contained other people in it? What if it did not prepare nor allow these speech movements as it believed them to result in reward-system “punishment” and even deemed them a threat to survival?
What if you learned all of the above was true? Would this begin changing your understanding of stuttering? What if you learned we could use all of this “new” information to paint a much clearer picture of the nature of stuttering? What if you learned we could use this new understanding of stuttering to implement more effective treatment?
Well, the above ‘questions’ are true.
And, yes, we can use their answers to understand stuttering.
And, yes, we can use this new understanding to layout a treatment regimen.
And we not only can, but we are.
Diving Into Research on Stuttering Treatment
The above is a pie chart which was included in a presentation at the American Speech-Language-Hearing Association in 2008 by a prominent stuttering research professional from The University of Iowa. (Zebrowski, 2008) The presentation dove into the treatment of stuttering and its effectiveness.
The pie chart represents different factors that contribute to an effective treatment experience across numerous treatment fields and the percentages represent how important each factor is to treatment effectiveness.
Take a moment to look at the chart.
I will dive into each “piece of the pie”, however, I want to hone in on “technique” first. “Technique” is considered to be the treatment professional’s specific type of treatment. This can range from teaching “voluntary stuttering” to “fluency shaping” to “pull-outs” to “easy onsets” as well as many other treatment approaches. This “technique” aspect accounts for a mere 15% of treatment effectiveness.
Going even further, there is no variance in effectiveness from technique to technique. Stated differently, there is no difference in treatment outcome based on whether a clinician teaches fluency shaping or easy onsets or any other specific type of treatment. In backing this claim with research, in 2006, a group of researchers conducted a “meta-analysis” of different stuttering treatments. A “meta-analysis” is when researchers gather many already existing research studies on their topic of interest and systematically combine all of the collective data to draw conclusions. Well, as stated, in 2006 researchers performed a meta-analysis looking at the effectiveness of treatment overall as well as comparing the effectiveness of differing stuttering treatment approaches (different techniques). Their study drew an important but clear conclusion. It states, “These data support the claim that intervention for stuttering results in an overall positive effect. Additionally, the data show that no one treatment approach demonstrates significantly greater effects over another treatment approach.” (Herder, Howard, Nye & Vanryckeghem, 2006)
It reasonably follows that the simple fact that there was a treatment approach accounts for the 15% of its effectiveness; not the specific type of approach. It didn’t matter what the treatment approach was. Across treatments, there was insignificant change in effectiveness based on differences in “technique”. It did not matter which technique/treatment was being used. The simple fact that treatment was taking place seems to account for this mere 15% of technique effectiveness; not the specific technique itself.
The same article states, “A more positive treatment outcome is likely to be predicated on the client’s hopefulness, but also on the clinician’s hope and expectation that the client has the ability to change, and that they will be able to help the client bring about such change.” (Herder, Howard, Nye & Vanryckeghem, 2006)
In going further, let’s look at the chart again and dissect it.
40% of treatment effectiveness is attributed to “extra-therapeutic change”. “Extra-therapeutic change” includes factors such as a person’s readiness to change, knowledge base, life experiences, strengths/abilities, etc.
30% of treatment effectiveness is attributed to the “therapeutic relationship”. This refers to the quality of relationship between client and treatment professional. Factors within the “therapeutic relationship” that positively contribute to treatment effectiveness include elements like the establishment of an emotional bond (between client and therapist) as well as a shared perspective (between client and therapist) on what the treatment goals should be and what types of treatment methods should be utilized to achieve them.
15% of treatment effectiveness is attributed to expectancy of positive results (placebo). If the client believes the treatment will work, it improves outcomes.
And as discussed above, 15% of treatment effectiveness is attributed to “technique”. It was also shown that it did not matter which technique was used in regards to effectiveness, thus showing that the simple fact that therapy was taking place is the important element; not the “technique” itself.
Inferring from the above
Based on the chart, 85% of treatment effectiveness has nothing to do with speaking or mastering a technique. The other 15% cannot tell the difference between techniques.
Within the 85% of what is attributed to treatment effectiveness are elements such as readiness to change, knowledge base, hopes, beliefs, expectations of success, motivation, emotional bonds, shared outlook (between client and clinician) etc.
Addressing Belief, Psychology & The Mind
“The mind” plays a large role in stuttering. Many become offended when the topic of psychology is approached when it comes to the origin of stuttering or its treatment. It’s as if this somehow implies that people who stutter are abnormally scarred psychologically and that this is the utter root of all things stuttering. However, this is not the case nor is this case being made within this self-treatment guide. Including psychological factors into the understanding of stuttering and its treatment does not automatically imply that people who stutter have had an exceptional amount of psychological pain and that this is the root of their stuttering. However, it is clear if you look at the facts around the condition of stuttering, that stuttering is profoundly affected by psychological factors, at minimum. The fact that talking to one’s self vs. talking to someone else can cause wide fluctuations in stuttering severity cannot be ignored. The fact that certain people trigger more stuttering than others cannot be ignored. The fact that stuttering disappears in certain contexts like when one is acting or “playing a character” cannot be ignored. I could continue with examples ad infinitum. Contrary to ignoring these realities, they must be deeply explored and embraced if we are to understand stuttering’s nature and treat it effectively. The role of psychology and the mind in stuttering and its treatment is going to get a lot of attention in years to come as it should. This should not be an offensive topic. Psychology and the mind do play a major role in stuttering. Period. Let’s not put blinders on to this.
Going Deeper into The Mind & Stuttering
“The belief itself is the technique.”
Numerous years ago, before I was on my own mission to understand stuttering, I was being treated by a speech-language pathologist who was also a board certified fluency specialist. For those who don’t know, that is the highest certification a person can receive as a stuttering treatment professional. I still hold this person in high regard, however, I was being taught a speech technique by this professional intensively for a couple of weeks. I was bringing up some problems I was running into with the technique and they said to me as an aside, “It is not the technique that works, but your belief in the technique.” When they said this, I was very disappointed. I knew this meant it was some “mental trick” that made it work and not the technique itself. To that point, I was under the impression that there was inherent value in this technique and it worked based on reliable physical laws. Never before had it been mentioned that I needed to “believe” in the technique for it to work. Ironically when they said this it devalued my belief in the technique as I then knew it was not the technique itself that worked but it was my “belief in the technique” that made it work. It reasonably follows that “the belief” itself is the technique. We will dive into research below that supports this view as well as supports the need to work on other “psychological” areas as part of stuttering treatment.
It is important to mention at this point that the method I am teaching is not only psychological. That is just the part I am beginning to address right now. A large aspect of the method that will be explained in this guide works directly on speech. It works to strengthen neural networks for automatic/natural speech as well as increase the subconscious linking of reward and speech movements and decrease the subconscious linking of speech movements and pain (shame etc.) in different contexts. You don’t have to understand what all that means right now.
In continuing, it turns out this “aside” mentioned to me by the speech pathologist years ago that “it was the belief in the technique” that worked has some merit and research behind it. We’ll dig into that shortly.
First let’s look at the placebo and nocebo effects.
Nocebo vs Placebo
Many people have heard of the placebo effect and how it can impact health conditions. Oxford Dictionary (2017) defines the placebo effect as “a beneficial effect , produced by a placebo drug or treatment, that cannot be attributed to the placebo itself, and must therefore be due to the patient’s belief in that treatment.”
In an example, if a person has high blood pressure and is given a fake medication to treat it but believes the medication works, their blood pressure often goes down, despite their being no physical impact from the fake medication. Their belief in the idea that they are taking a medication that will lower their blood pressure often actually does lower their blood pressure based on belief alone.
On the other hand, there is a term most people are less familiar with which is “the nocebo effect”. The nocebo effect is the opposite of the placebo effect. Oxford Dictionary (2017) defines it as, “a detrimental effect on health produced by psychological or psychosomatic factors such as negative expectations of treatment or prognosis.”
In an example of the nocebo effect, if a person strongly believes that a treatment for a health condition will not work, this belief has a detrimental effect on how well the treatment works. Studies have been conducted that demonstrate this to be true. In an example, a patient may be given a medication for blood pressure that has been proven effective but because they strongly believe it will not be helpful, the positive effects of this medication are minimized or nullified.
Let’s look at this further and apply it to stuttering. The placebo effect and the nocebo effect have impact on the treatment of conditions that are very physically based. By this, I mean that the placebo effect can impact physical conditions of the internal organs which seemingly have little to do with the mind or psychology. The nocebo effect can do the same. This means that the mind’s beliefs can impact seemingly purely physical conditions.
Take that and apply it to a condition which has an abundance of evidence that it is intrinsically tied to the mind and psychology and it is reasonable to infer that the effects of placebo and nocebo would be significantly more powerful on a condition of this type. Stuttering is one such condition that has intrinsic and direct ties to the mind and psychology making placebo and nocebo effects likely much more powerful than their effects on “purely physical” conditions.
Also, let’s consider this. If a person is indifferent to whether they believe a treatment will work (they don’t have a strong opinion on whether it will work or it won’t) then the placebo and nocebo effects are likely minimized as belief is not affecting the treatment outcome. However when someone believes a treatment will work, its effectiveness goes up in comparison to the indifferent person. When someone believes that a treatment will not work, its effectiveness goes down compared to an indifferent person. There is an even wider gap in treatment effectiveness when you contrast someone who strongly believes a treatment will work with someone who strongly believes a treatment won’t work. To restate, there is a huge gap between a patient who experiences the nocebo effect vs one who experiences the placebo effect.
What does this mean for changing your stuttering?
An extremely helpful element in making changes in your stutter is believing strongly and deeply that what you are doing is working. It is of high importance. It is actually part of the treatment. The person who stutters entering treatment with a persistent conviction that the treatment will be very effective is light years more likely to make positive changes than the person who stutters entering treatment with an attitude of “There’s no way this will work. Stuttering is untreatable.” You must persist in a deep belief that you will make the changes you desire. Make sure you’re on the right side of that equation.
Belief matters. Belief that you can make major changes in your stuttering matters for innumerable reasons. It matters in your daily attitude as you approach making changes. It matters in the moment of interaction when you’re thinking about stuttering. It matters every morning when there are things you have to do that day to work on your speech. If you believe your labors will bear no fruit, you won’t perform them. You have to believe the plan will result in the desired change you are seeking; otherwise you will not work for it. After all, what’s the point in working for nothing? There isn’t one. That’s why you have to believe. Belief is monumental in this journey. Persistence of belief is as well. Period. This ageless adage is applicable to the journey of “overcoming” stuttering : “Whether you think you can or you think you can’t, you’re right.” Belief can fluctuate. Keep pushing to believe as much and as often as you can. Belief matters.
And lastly but most importantly…
You matter. You have a voice. You have a personality. You have gifts and talents. You have so much potential and so much to offer. You matter. Your journey matters. Your life matters. No matter where your stuttering journey and life journey takes you, I’m rooting for you. I know the deep struggle of stuttering. I know the imprisonment. I know the frustration. I don’t know what your life journey is but I’m rooting for you. For what it’s worth, I believe your struggle with stuttering is purposeful. Keep pushing and find your path. I’m rooting you on.
Some final research quotes which are highly applicable
“Bruce Wampold and his colleagues have been in the vanguard of such research in the psychology literature and their findings have relevance for our attempts to ascertain which therapies are most effective in treating stuttering. They have found that even drug therapies are more effective when administered by some clinicians then others (Wampold & Brown, 2005; McKay, Imel, & Wampold, 2006). In some studies that have been conducted in clinical psychology and psychiatry, the amount of variance accounted for by the therapy is in fact less than the amount accounted for by the clinician (Wampold, Lichtenberg, & Waehler, 2005). For example, Wampold and Brown found that clinicians who were historically most successful in alleviating patients’ symptoms actually obtained better results using a placebo medication than did poorer clinicians who administered an active pharmaceutical agent.” (Bloodstein & Ratner, 2008) They continue (2008), “Recent attention has also been paid to the role of the patient’s mindset in approaching therapy. Patient readiness for change has been explored in other fields where a treatment is sought for a chronic condition. They suggest after examining the related literature involving behavioral, cognitive and affective change…..that it might be appropriate to match therapies or therapy components to the stage that characterizes the client’s current belief set.” (Bloodstein & Ratner, 2008)
Important Information Before Diving Into The Self-Treatment Guide
One of the first parts of the treatment regimen is going to intertwine what I call “strengthening automatic/natural speech” with significantly enhancing your understanding of stuttering’s nature. In accomplishing both of these tasks simultaneously, you are going to read a handful of my previous articles on the nature of stuttering “out loud”. (I’ll explain “strengthening automatic/natural speech” and how to approach “reading aloud” in the section below labeled “The Self-Treatment Guide”) Towards the bottom, under “Stuttering Self-Treatment Guide” you will find the reading list. You can not worry about keeping track of links etc. as the most important articles are placed in the order they should be read there.
While it is of high importance that you read the articles in their entirety, I provide important quotes and/or a very brief synopsis of some of the more important articles below. However, as stated it is important that you do read them in their entirety as they are explained much more clearly and linearly than in the quotes and brief sysnopses below. I worked hard to make my articles easily understandable and follow-able by anyone who reads them. Some of the brief quotes and synopses below leave out important connecting information that is contained in the full articles. There are also parts below that may sound “academic” but they are also illuminated more clearly in the full articles. It is not required that you deeply grasp everything that is stated in the quotes and synopses below. It is more to get your feet wet in regards to the understanding of stuttering’s nature I’m explaining. When you read the articles in their entirety you then should and will be able to follow and grasp everything that is explained.
Let’s look at some snippets from the more important articles.
Connection, approval and belonging are deep needs of the human as a social animal. The opposite of connection, approval and belonging is rejection, shame, humiliation and abandonment. Evolution and survival have shaped the human need for connection and belonging. As a result, a situation which presents the possibility of social rejection, abandonment and/or disapproval is perceived as a threat to one’s very survival. Social rejection is as feared as death, because evolutionarily, to be ostracized from the group did equal death. A person must be accepted into groups to survive in the wild. In addition, a human child is helpless to survive on his/her own. They must bond and connect to survive. This fuels the child’s fear of abandonment which also equals death. Because lack of acceptance and belonging are perceived as survival needs subconsciously, when these needs are threatened, the subconscious of the human perceives this threat the same way it perceives a predator threatening physical harm or death. The mind, body and nervous system, as a result, react the same way to a threat of social rejection and/or abandonment as they do to a threat of physical death. The response the human system has to these threats has been termed the fight/flight/freeze response. The fight/flight/freeze state is an anxiety laden state designed to provide maximum energy to muscles that enable a human to fight or flee from a predator.
The above explains why people often fear public speaking as much as death and why they can enter into powerfully anxious states during these experiences.
The person who stutters often faces a social situation perceiving the possibility of social disapproval and/or rejection. In these situations, the person who stutters enters into the anxiety ridden state of fight/flight/freeze as this threat of social rejection is treated subconsciously as a threat of death.
Speech is movement. It is a fine motor act. It is the contraction and relaxation of muscles.
The fight/flight/freeze response is designed to enable a human to maximize the power and ability of gross motor muscle performance. To achieve this, the body alters its postural readiness, its muscular tension and many aspects of the nervous system. These alterations which occur in the body and nervous system of the person who stutters in a social arena based on entering the fight/flight/freeze state, negatively affect the fine motor ability of speech resulting in increased stuttering (using fine motor muscles like those needed for speech is not of high importance in a life or death scenario).
The subtle and unpowerful movements of the speech muscles are not what the fight/flight/freeze state is designed to enable. Contrarily, the fight/flight/freeze state is designed to maximize powerful muscular groups to empower the human to fight a predator with immense force or flee danger with maximum speed. The many alterations that accompany the fight/flight/freeze state have detrimental effects on the person-who-stutter’s ability to initiate and execute low energy, fine motor speech movements, thus exacerbating stuttering symptoms (blocks and repetitions).
All of the above results in significantly increased rates of social anxiety in the person who stutters compared to the general population. Experiences of disapproval, rejection and/or abandonment due to stuttering can be considered traumas and when the person who stutters re-enters social arenas, past memories of “trauma” are triggered and their entrance into the fight/flight/freeze state repeats and is reinforced. “Unsuccessful” interactions where the person who stutters feels disconnected or rejected lead to a shame state following interaction. These shame and anxiety states are usually deeply ingrained into the subconscious. The person who stutters often knows consciously they should not be anxious or ashamed.
Interaction is a fundamental part of functioning in society, yet it often provokes fight/flight/freeze reactions in the person who stutters. A highly interactive day for a person who stutters with social anxieties, can be likened emotionally to a day in the wild with a high number of near death encounters. Repeated exposure to this has a cumulative effect over time. It often leads to exhaustion, frustration, and other unpleasant emotions. It can also lead to avoidance of interaction. This results in people who stutter falling far short of meeting their needs for human connection, which can lead to isolation, loneliness and other unpleasant emotions.
Processes that enable human movement operate below the level of conscious awareness. As speech is movement, these unconscious processes are what support, enable, and create both fluent speech as well as “blocked/”stuttered” speaking attempts. Underlying all human movement, including speech movement, is an unconsciously perceived motive to perform the movement(s). Determining this motive is an unconscious calculation of each movement’s expected reward/punishment outcome. For movements to be prepared and supported, their unconsciously projected outcome must be deemed beneficial (rewarding). If a movement is deemed likely “painful”, “punishing”, or a significant threat to survival, the unconscious motivation necessary to perform the movement will not be provided. As humans are social animals, ostracism, rejection, and/or abandonment are unconsciously perceived as threats to survival. In people who stutter, the unconscious processes that underlie movement determine speech movements in certain environments to likely be painful and/or a threat to survival. As a result they are not supported nor prepared. The result is an impotent attempt to summon speech movements by the conscious mind (as the person who stutters consciously desires to speak) which results in blocking and stuttering behaviors as speech movement must be supported by unconscious processes to be performed. These unconscious processes factor in the environment and the calculations change from moment to moment based on environmental changes etc. Treatment for stuttering should focus on changing the unconscious perception/projection of expected pain (shame, ostracism) linked with speech movements in problematic environments (often ones with other people in it). The treatments should target the removal of the unconscious expectation of pain (shame, ostracism). Anxiety/fear is an indicator of this expectation of pain. Many have hypothesized on the role of fear in stuttering and there is one. However, the more important treatment goal should be removing the unconscious expectation of pain (not the anxiety itself) linked with speech movements. Fortunately for treatment prognosis, these unconscious processes/projections are receptive to alteration. In illuminating the above, the article discusses similarities between Parkinson’s disease and stuttering which includes a phenomenon of Parkinson’s known as kinesia paradoxa. Kinesia paradoxa is the term describing dramatic alterations in a person-with-Parkinson’s ability to move based on environmental changes. At the root of these changes are alterations in unconscious motivation as discussed above. This is a very brief introduction and these processes are illuminated in clearer language in the above link.
Speech is movement
Speech is a complex task involving the formulation of language. However, the physical performance of speech is movement. When a person “speaks out loud”, movements of various parts of the person’s body are required. The speaker must move their lips, tongue, and jaw which is nothing more than the contraction and relaxation of muscles. The speaker must move muscles associated with the inhalation and exhalation of the lungs. They must move muscles that enable vibration of the vocal folds. The important point here is speech is movement. When a person speaks out loud, they must move their bodies. It is a motor act.
Stuttering presents as an inability to perform speech movements as desired
The observable symptom of stuttering is the inability of the person who stutters to make the desired speech movements. The person who stutters attempts to “say something out loud” (speech movements) and the appropriate movements do not occur. There can be a complete “block” (no movement) in their speech or there can be repetitions (sound/syllable/word/phrase) or even non-speech-related movements (secondary behaviors). In any case, the speech movements the person who stutters is attempting to make are not happening.
Speech is an automatic ability performed below the level of the conscious mind
We’ve all heard the saying, “It’s like riding a bike.” What that saying implies is you are just able to hop on the bike and ride it. However, how is this possible? If you think about the complexity of this task, it seems like a lot. You have to coordinate a significant amount of muscles as well as balance etc.
So, how is this possible?
It’s possible because the unconscious mind is doing all the required tasks below the level of conscious awareness. Riding a bike is an example of what I call an “automatic ability”. In academia, the term used for the automation of a process such as riding a bike is automaticity.
How it works is, after learning and mastering a motor/movement skill (riding a bike, playing piano, choreographed dancing), it becomes automatic. It no longer takes a significant amount of attention to do. The person is just able to do it. For example, if I go to ride a bike, I do not get on the bike and focus on contracting each leg muscle that is needed etc. I just hop on the bike and ride it. My unconscious knows how to do all of the required muscular contractions and balancing etc. without my conscious control. This is an “automatic ability”.
Speaking is also an automatic ability. When a person who does not stutter speaks, they are not focusing on contracting and relaxing the speech muscles. They “just know” how to do it and they “just do it”. This is because it is an automatic ability. I mentioned above the number of muscles involved in speaking out loud. It involves the lips, tongue, jaw, lungs, larynx, etc. All these muscles are controlled at once and in coordination to speak out loud. The complexity of this task is far too great for the conscious mind to handle. It is not possible for the conscious mind to focus on moving the tongue perfectly, the lips perfectly, the lungs, the larynx, etc. It is far too great a task. Therefore, any time a person speaks, unconscious processes have a large hand in performing the speech movements. There is no other way it can happen.
Bottom line: The movements required for speaking are automated. Speaking out loud is an automatic ability performed by the unconscious mind. The speaker does partly select and edit the meaning and message we choose to convey, but the speaking movements required to “speak out loud” are automatic and are performed below the level of the conscious mind.”
Article #3: Stuttering May Not Be Speech Related
In looking at the common denominators/similarities between stuttering and these other stutter-like behaviors (the yips, dartitis) it becomes fairly clear that neither the physical apparatus nor its neurological “wiring” are the root of the problem. In baseball pitching, the freezing/jerking/loss-of-control happens in the arm and hand. In speaking, freezing/jerking/loss-of-control happens in the speaking apparatus. With football kickers, the freezing/jerking/loss-of-control happens in the leg, ankle, and foot. So, as we can see, the common denominator is not the part of the body. This points strongly towards the fact that what is causing this freezing/jerking/loss-of-control does not reside in the part of the body affected.
Well if the problem is not in the physical apparatus affected, where could it be?
Well, what underlies each of these behaviors is the human motor system in general. What we are observing in these stutter-like behaviors or “yips” is a phenomenon of the motor system; not of any specific behavior nor physical body part. Stutter-like behaviors can manifest in any part of the physical body where fine motor learned skills are possible. It just so happens as speech is a skill learned by everyone, that stuttering is by far the most common manifestation of this phenomenon of the motor system.
The required conditions for developing stutter-like behaviors are, for one; it is a learned movement skill. Two; there is pressure on the individual performing the movement skill to do it right and well. Three; upon attempting or completing the movement skill, there will be feedback, either positive or negative, instantly. This feedback provides a reward or punishment for the person who performed the movement skill. Four; because the performance of the movements can bring about punishment or reward, there is often focus on performing it well, as the person desires achieving the “reward” and not the “punishment”. Five; the uncertainty of the outcome (reward or punishment) for performing the movement often creates an anticipatory anxiety.
Throughout this post, a case has been made that stuttering’s nature is not rooted in speech nor the speech mechanism at all. However, its origins are rooted in the motor system in general. This is based on the notion that there are many other “conditions” that are nearly identical to stuttering that affect various different parts of the body (arms, legs, etc.).
In further examining the nature of the motor system there is strong evidence that elements like fear and other emotions can be significant influences on motor performance. Better yet these elements can at times, directly control motor performance (movements) or inhibit it.
Based on my experience with stuttering as well as the above information and other information on stuttering, I believe there are many factors that affect motor movements and stuttering/blocking specifically. There are numerous elements that can contribute to a block. As was demonstrated in the above post, fear (amygdala) and emotions (limbic system) can impact the motor system. However, there are likely more factors.
Experiencing a speech block or a stutter is something the person who stutters feels detached from. It feels as though they are not in control. It feels as if they are not the ones bringing on the block. It feels as though an element outside of their control is causing their speech block/stutter.
In explaining this, I believe there is a subconscious formula that determines when an individual blocks and when an individual does not block.
As has been shown, there are elements outside of the motor system that affect its functioning. The two we have discussed are fear and emotion. As stated, there are likely more.
In making this information practical and to give the person who stutters some level of control, we need to begin to affect some of these outside factors that contribute to blocks. We need to impact the elements of the subconscious formula.
I am going to list a few of the factors I believe affect whether a block/stutter occurs or not. I believe that based on the combination of these factors and more, the subconscious will determine whether it should block speech flow or enable it. Here are a few factors:
- Level of fear/anxiety
- What the attention is focused on
- How mandatory one believes it is that they speak well and do not stutter
- How aroused/excited/anxious one’s body is
- What the underlying beliefs about stuttering are
As stated, in making this practical, what one would do to begin improving fluency is working to mold each one of the elements towards fluency. Molding each one of the elements towards fluency will make it more likely that the subconscious formula for blocking will determine it should allow speech flow instead of block it. Here are some examples on how one might go about molding the factors above which correspond to their numbers. Some of the below strategies would need to be practiced consistently over time to have a measurable effect on fluency.
- The less fear the better. There are numerous strategies to lower fear. Daily meditation is a good way to start. Relaxation techniques are also helpful. You can re-frame how you see interaction. Instead of “oh my gosh I’m going to stutter and this is going to be a disaster”, you can start inserting thoughts like, “well, let’s go for it! I’m going to talk to this person. Big deal if my lips don’t move immediately. I can’t believe I stress over that.” Those are a few ways off the top of my head to begin moving the needle.
- You want your attention focused on stuttering as little as possible. The mind often creates what it thinks about. It’s actually best if the attention is not focused on the mechanics of speaking at all. It is also very good to focus on all positive things. Focus on the message you are trying to deliver. Focus on how easy speech is. Focus on a good memory. Focusing on positive things will increase the odds of fluency.
- The less you believe it is utterly mandatory that you speak perfectly, the better. Think thoughts like, “mistakes are beautiful”, “who cares if I stumble”, “I’ve stuttered before and I’m still here standing”, or “the world actually will go on if I stutter some”.
- Calming the physical body is also good. The more relaxed the body is all around, the better. This doesn’t mean you have to be a zombie who never gets excited. It’s a general rule. Check in with the body. Release tensions in it when you check in. Take deep breaths (I know many PWS hate to hear that but it can have an effect over time). Do progressive muscle relaxations. Keep the body tension free. There is something called the vagus nerve that monitors all the systems in the body and reports it back to the brain. This information is likely used in the “stuttering or not subconscious formula”.
- The more positive your beliefs are about speech and stuttering, the better. It’s better to believe you will be able to make improvements on your speech than to think you are forever at the mercy of stuttering. It’s better to believe you are a good communicator than to think you aren’t. It’s better to believe you will connect with people than to think stuttering will be an obstacle. The more positive the beliefs the better. I’ll also say that the mind is good at believing lies. Even if you are not an excellent communicator it is good to believe you are, and consistent thoughts have a way of becoming realities.
There are more factors that likely contribute to the subconscious formula that determines whether one will have a speech block or will have fluency. Working on the above elements and more over time consistently will likely yield results in fluency improvement as well as in the reduction of anxiety. Based on this the stuttering cycle can begin snowballing backwards.
Let me talk a little about the skill of speaking. Again, for most people (people who do not stutter), speaking is an automatic ability that they are able to do with minimal effort. They just know how to do it and they just do it.
To demonstrate the nature of an automatic ability to yourself, take out a pen and piece of paper. We are going to use the mastered skill/automatic ability of writing in this example. Write three sentences in your native language and observe the movements of your hand. Observe how you write each letter properly without thinking about how to make the movements; without dedicating a lot of attention to properly controlling the movements. I find it kind of miraculous. We are just able to do it. We know how to do it and we just do it. We have mastered this skill and therefore we can make these movements on automatic. To me it is almost ghostly when I observe myself writing in that I am not consciously controlling my hand but it is perfectly executing the proper movements to write exactly what I intend to write.
SIDENOTE: Imagine if you were watching somebody write, and all of a sudden they started writing the first letter of a word over and over. You could tell they were struggling and embarrassed. They experienced a block in between the writing of these letters and stopped writing. Then after about five first letter repetitions they wrote the whole word they were intending and continued on to the next word. A few words later, the same thing happened. This is fairly analogous to what happens with speech and stuttering.
Time’s relationship with speaking
The skill of speaking is a profound form of self-expression. We are quickly able to express our thoughts, ideas, dreams and personality through speech. What we express through speaking manifests and is heard by our listeners in real time. In other words, as we execute the skill of speaking (moving our articulators (lips, tongue etc.), vibrating vocal folds, breathing etc.) we are heard, evaluated and judged based on what we say and how we say it immediately. Our listeners react to what we say very shortly after we say it. The skill of speaking is used for real time interactions. Therefore, at the time we speak we immediately get feedback from our listeners about what we expressed and how we expressed it. This feedback can be good or bad. If we tell a joke and everybody laughs we are pleased with the immediate feedback we have received. We feel good about the interaction. If we say something inappropriate, can’t carry a conversation or are awkward in how we speak and interact, the feedback is negative. During and after the speaking interaction we likely feel bad or embarrassed. Again this feedback comes virtually instantaneously. Concisely, as we speak in real time, we are judged in real time. With the act of speaking there is time pressure.
Speaking is a complex process involving the coordination of fine motor control across a large number of muscles. Some of these include controlling the muscles of the lips, tongue, and jaw; controlling the muscles that enable vocal fold vibration; controlling the muscles that impact breath inhalation and exhalation. When contemplating the complexity of the task of speaking, it reasonably follows that the conscious mind is inadequately equipped to perform the task of speaking. The vast majority of speaking must be performed by the unconscious mind. There is no other way to do it properly.
Most would agree that as a result of stuttering/disfluencies, the person who stutters begins placing a significant amount of focus on speech. This focus on speech far exceeds a fluent speaker’s level of focus on speech. The person who stutters begins trying to control speech in an effort to “not stutter” or “not block” as a result of past situations where control of speech was lost, which resulted in unpleasant experiences. This begins a cycle that reinforces itself. This cycle increases conscious awareness of speech and increases the desire to control one’s speech.
Other Excerpts from various articles:
Have you heard of the term “inner speech” or subvocalization? Inner speech is simply when you talk to yourself in your head. It is audible thought in the form of words. As you read this silently, you are hearing yourself perform inner speech. It is the voice in your head that is reading these words. Inner speech is a term that was used by Lev Vygotsky, a Russian psychologist who died in 1934. Others since have viewed “inner speech” as having an important role in social development as well as in developing language and cognition.
As an influential figure in the field of developmental psychology, Vygotsky made assertions on the process of speech and language development in children. He believed that when children first learn to speak, they verbalize every word that comes to mind. As a result, children do not have inner speech in the early stages of speech development. However, as children develop, in response to social pressures, they begin inhibiting some overt speaking behaviors (speaking out loud) and internalizing them (inner speech). This results in inner speech. This means that every child in the early stages of speech and language development must transition from saying every word out loud to inhibiting words they do not want to say out loud. As most children who stutter begin to stutter early in their speech development, this period of transitioning from saying all speech out loud to inhibiting some speech and saying it internally, takes place around the same timeframe as when most people begin to stutter. As you will see, this inhibiting of “out loud” speech plays into the theory on stuttering I am explaining heavily.
Tourette’s syndrome is in some ways the opposite of stuttering. While only a fraction of people with Tourette’s involuntarily say or shout profanities, it is a part of the disorder. What happens in Tourette’s is the neurological system of a person with Tourette’s determines that it should perform “inner speech”. It is unsuccessful in suppressing inner speech. So, when a person with Tourette’s says some version of profanity in their heads (just like everybody else does occasionally), the neurological system determines it should perform this action and say it out loud. While the person with Tourette’s is simply saying this profanity as part of their “inner speech”, it ends up being said out loud because that’s what the neurological system determined it should do. In this way, it is the opposite of stuttering.
Challenges of Behavior Change
The Stuttering Self-Treatment guide below requires a person to engage in self-treatment activities regularly. As a result, I would like to address some of the challenges of sticking to new behaviors.
Sticking to new behaviors can be challenging. Numerous factors go into how successful a person is. Some of these include: How motivated is the individual? How strongly does the individual believe they will get the desired result if they stick to the new behaviors? How much do they fear the alternative of not sticking to the disciplines? How enjoyable are the new behaviors or how unenjoyable are they? What does their schedule currently look like and is it conducive to the new behaviors? How disciplined are they naturally? I could go on. There are many factors.
I wanted to start by pointing this out because behavior change is largely a science. One’s ability to stick to a newly laid out plan depends on many factors outside of human will power. I’m all for the human will and using it to its maximum but the idea that it is all powerful is just not accurate. I have spoken with many individuals who set out to change their stuttering and had a plan in place but were unable to stick to the plan. I am convinced this has happened to many yet some are hesitant to share that they did not stick to the plan for fear of being perceived as “lazy” or “unmotivated”. Some even go to the length of seeing themselves this way and chastise their own “laziness”. Be kind to yourself. There is far more to it than white knuckling.
This should not be an undiscussed topic. It is very applicable to making changes to and around stuttering. I, as an example, am a motivated person who can usually stick to plans relatively well, yet have had my own struggles with sticking to very rigorous “stuttering plans”. Some of these struggles are what have taught me of the limited power of the will. If you embark on implementing the methods below, let figuring out how to allow you to stick to it be an open topic. That being said, some should be able to do it right off the bat and of course this is what you should aim for. However, if you struggle with sticking to it, which many will, this is not a negative reflection on you at all. I don’t see it that way and I don’t think you should either. We are human. There is no shame in struggling to stick to an intense regimen of what can be boring work. The goal should be to make the activities inherently rewarding. This way we almost long to do them. However, if we’re going to sit down for three hours (or whatever it may be) and do something we don’t enjoy, the subconscious will powerfully resist and usually win out in the end. This is human nature. Talk about it. Seek ideas and get creative to enable you to stick to it.
That being said, only report on how well the methods worked for you if you were able to stick to it. And again, there is no shame in not having immediate success in sticking to it.
The O’Malley Stuttering Self-Treatment Guide can be found at the link below:
Asay, T. R., & Lambert, M. J. (1999). The empirical case of the common factors in psychotherapy: quantitative findings. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The heart and soul of change: what works in therapy. Washington DC: American Psychological Association. doi:10.1037/11132-001
Bernstein Ratner, N. (2005). Evidence-based practice in stuttering: some questions to consider. Journal of Fluency Disorders, 30.
Bloodstein, O., & Ratner, N. B. (2008). A handbook on stuttering. Clifton Park, NY: Thomson Delmar Learning.
Franken, M. J., Schalk, C. J., & Boelens, H. (2005). Experimental treatment of early stuttering: A preliminary study. Journal of Fluency Disorders, 30(3), 189-199. doi:10.1016/j.jfludis.2005.05.002
Herder, Howard, Nye & Vanryckeghem (2006). Effectiveness of behavioral stuttering treatment: A systematic review and meta-analysis. Contemporary Issues in Communication Sciences and Disorders, 3, 76-81.
Lambert, M. J., & Bergin, A. E. (1994). The effectiveness in psychotherapy. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change. New York: Wiley.
McKay, K. M., Wampold, B. E., & Imel, Z. E. (2006). Psychiatrist effects in the psychopharmacological treatment of depression. Journal of Affective DIsorders.
Nocebo | Definition of nocebo in English by Oxford Dictionaries. (n.d.). Retrieved December 30, 2017, from https://en.oxforddictionaries.com/definition/nocebo
Placebo | Definition of placebo in English by Oxford Dictionaries. (n.d.). Retrieved December 30, 2017, from https://en.oxforddictionaries.com/definition/placebo_effect
Wampold, B. E., & Brown, G. S. (2005). Estimating variability in outcomes attributable to therapists: A naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology, 73, 914-23.
Wampold, B. E., Lichtenberg, J.W., & Waehler, C.A. (2005). A broader perspective: Counseling psychology’s emphasis on evidence. Journal of Contemporary Psychotherapy, 35, 27-38.
Zebrowski, Patricia. “EBP in stuttering treatment for children: The Common Factors.” 2008. PowerPoint File.