# Speech-Language Pathology/Stuttering/Beyond Fluency-Shaping

Fluency shaping stuttering therapy was developed before much was known about motor learning and control. Some speech clinics have not refined their therapy programs to reflect advances in the field.

## Improving Cognitive Stage Speech Motor Learning

In the first or cognitive stage of motor learning, you observe an instructor perform a motor skill that is new to you.
But speech-language pathologists may be the wrong people to model fluent speech motor skills. When learning a new motor skill, novices learn best by observing another novice making mistakes, then getting it right.
In contrast, observing a skilled person perform the task flawlessly doesn't do you much good. For example, millions of people watch Michael Jordan play basketball. Few of those people could go out on a basketball court and repeat his moves. The exceptions are people who are already skilled and want to get even better, e.g., college basketball players can improve their game by watching the pros.
A stutterer watching a speech-language pathologist model gentle onsets or pull-outs or whatever is like Joe Sixpack watching Micheal Jordan. The stutterer might learn more if the speech-language pathologist modeled the mistakes her other clients have made, e.g., two-second stretched words instead of two-second stretched vowels, and then showed how to correct those mistakes. Or the speech-language pathologist could prepare a video of her previous clients making mistakes, and then learning to correct their mistakes.

## Improving Associative Stage Speech Motor Learning

In the second or associative stage of motor learning, you learn to perform and refine a new motor skill. But are there better fluent speech motor skills than the five (or seven) skills taught in fluency shaping stuttering therapy programs?

### Lower Vocal Pitch

Speaking at a lower vocal pitch requires relaxing one's vocal folds, and reduces stuttering. Unlike other fluency-enhancing techniques such as a slow speaking rate or gentle onsets, listeners like the sound of a lower vocal pitch. A lower vocal pitch communicates confidence and relaxed authority. Some listeners even say that a lower vocal pitch sounds "sexy." Speaking with a lower vocal pitch makes one feel relaxed and confident. Yet this technique is not a target behavior in any fluency shaping stuttering therapy program.
According to multichannel processing theory, performing two different tasks is easier if you can integrate the tasks. E.g., dancing while playing the saxophone is easier than playing tennis while playing the sax. Using fluency shaping motor skills while paying attention to a conversation should be easier if the fluency shaping motor skills relate to the conversation. E.g., if your friend asks you what you've learned in stuttering therapy, and you reply that you learned slow speech with stretched vowels and gentle onsets, you can easily perform slow speech with stretched vowels and gentle onsets while responding. If you're trying to communicate that you're relaxed and confident, then using a "slow normal" speaking rate with a lower vocal pitch should be easier than using gentle onsets.
This technique can be trained by using relaxed, diaphragmatic breathing while feeling (with your fingers or your throat) and/or listening to your vocal fold vibrations. Begin by humming or saying "ahhhh." Bring the pitch up, then down, then up again, then down further. Repeat until your feel and hear yourself humming at a very low pitch. Now speak slowly, stretching vowels, while keeping your vocal pitch low.
Notice that your vocal volume drops as you lower your vocal pitch. Don't try to speak loudly with a low vocal pitch, you may damage your vocal folds. A lower vocal volume is usually acceptable unless you're speaking in a noisy environment or to a person with hearing loss.
Frequency-shifted auditory feedback (FAF) induces a lower vocal pitch in non-stutterers. Only one study tested whether FAF changes stutterers' vocal pitch, with negative results. However, anecdotal evidence suggests that a lower FAF setting than was used in the study induces a lower vocal pitch in stutterers. If you have an FAF device, set it for one-half or one octave down, and use the best-quality headphones you have. Then say "ahhhh" or speak slowly with stretched vowels, trying to slow your vocal fold vibrations to match the frequency you hear in the headphones.
Lower vocal pitch may be difficult for women speech-language pathologists to model, or for children or women stutterers to use (Lauren Bacall might contradict that statement!). Adult men are more capable of lowering their vocal pitch. Listen to an audio book read by a male actor and then listen to another audio book read by a female actor: you'll likely hear that the male actor can perform a wider variety and range of character voices.

### External Links

* Kay Elemetrics Visi-Pitch and other devices provide vocal pitch biofeedback
* Casa Futura Technologies Pocket Speech Lab and other devices provide vocal pitch biofeedback and frequency-shifted auditory feedback (FAF)

## Improving Autonomous Stage Speech Motor Learning

The third or autonomous stage of motor learning moves you from closed-loop motor control to open-loop motor control. In stuttering therapy, the autonomous stage makes fluent speech automatic and effortless.
Autonomous stage motor learning results from:
* Practicing target muscle movements faster and harder,
* While making no errors,
* In stressful situations,
* With an ideal practice schedule,
* For about three million repetitions.
For example, you take tennis lessons. Your coach shows you how to grip the racket properly, and swing at the ball. At first you execute this movement slowly, with little force. As your skill improves, you swing faster, and hit the ball harder. Whenever you make a mistake, your coach stops you and makes you begin again, slowly. At first your coach hits you easy balls. Then he hits harder balls to you, making the game stressful. Then you play tennis regularly. Over several years your game improves.

### Where Stuttering Therapy Fails

Most stuttering therapy programs do little to train autonomous motor learning:
* Your speech-language pathologist tells you to make a conscious effort to speak fluently. You're told that if your fluency fails, it's your fault for not concentrating on your speech.
* All practice is done with relaxed speech-production muscles. You never increase muscle tension.
* All practice is done at slow speaking rates.
* All practice is done in the speech clinic, or at home alone. You don't do practice in high-stress situations.

### Increasing Force and Speed

Stuttering therapy programs fail to train the autonomous stage of speech motor learning because of a counterintuitive aspect of stuttering. Stuttering is characterized by excessive speech-production muscle activity. The obvious but wrong treatment for stuttering is to reduce speech-production muscle activity, i.e., to speak with relaxed breathing, vocal folds, and articulation muscles.
As noted earlier, speech-language pathologists see that slowing down and switching to closed-loop speech motor control eliminates stuttering. They reach the obvious but wrong conclusion that stutterers must slow their speaking rate.
Fluency shaping therapy begins by training slow, relaxed, fluent speech motor skills. Similarly, golf and tennis instruction begins with slow, relaxed, correct movements. Golf and tennis instructors then have you increase your force and speed. In contrast, speech-language pathologists tell you not to increase your force and speed. It may seem counterintuitive, but after you master slow, relaxed fluent speech, you must increase both the speed and force of your speech, without making errors, to train automatic, effortless fluency.

### Increasing Force

The force of your speech is indicated by volume. Work on getting loud. But don't shout or yell. Instead, project your voice. Vocal volume is a factor of both exhalation volume and vocal fold tension. Increase your exhalation volume while keeping your vocal folds relatively relaxed. This result is high volume with the intonations of normal conversational speech. Stage actors do this.
Increase your onset speed while maintaining long syllable duration. Pretend that your forearm is a sports car's accelerator. When your fist is up, your vocal volume is quiet. As you push your fist down, your volume increases. When your fist is all the way down, you're at maximum volume. Listeners one hundred feet away can hear you.
Slowly lower your fist to produce a gentle onset. Then slam your fist down fast to go from silence to maximum volume. Then hold that volume while stretching the vowel. Pull your fist up fast to end the word with speed. This is slow speech with maximum effort.
Be careful not to damage your vocal folds. Stop if you feel hoarse or start to lose your voice.

### Increasing Speed

Shorten syllable duration from two seconds, to one second, to one-half second, to one-quarter second. Practice this both with relaxed, quiet speech, and with loud, forceful speech.
Using the practice word lists say each word four times:
* Slow and relaxed (quietly).
* Slow and projecting your voice (loudly).
* Relaxed (quietly) with a quick onset.
* Loudly projecting the word with a hard onset.

### Where to Practice Force and Speed

It's hard to practice loud speech in a small room. The ideal place to practice is an empty auditorium. Have your speech-language pathologist sit in the back row. Stand on stage and project your voice to her. She yells, "Can't hear you!" until you reach ideal volume.
Another place to practice is near a building that produces an echo. A third place to practice is on a freeway overpass. Demosthenes, the stutterer who became the greatest orator of ancient Greece, projected his voice over breaking waves at the seashore. Work on projecting your voice over the cars.

## Reinforcing On-Target Speech

Increasing speed and force myelinates or reinforces neural pathways in your brain. A mistake reinforces the wrong neural pathways.
Learning to talk fluently requires talking fluently 100% of the time. That sounds like circular advice, and it is. Reinforcing motor skills is a "virtuous cycle." Using target skills reinforces the skills, making the skills easier to use.
Conversely, stuttering reinforces undesirable speech motor skills (core behaviors) and bad communication habits (secondary behaviors). Stuttering sets up a "vicious cycle" instead of a "virtuous cycle."

### Swimming Analogy

I wanted to improve my swimming. At first I could swim only one length of the pool. But I got in that pool three times a week. I found that a flotation device helped me swim five or ten laps. After two months something "clicked" in my brain and I swam half a mile. It was easy, almost effortless. I didn't need the flotation device any more.
Then I moved to a building without a swimming pool, stopped swimming, and now I swim as poorly as I did before that summer.
Similarly, stutterers go to speech therapy three times a week for months. Then suddenly one day they find themselves talking fluently, without effort. If they discontinue speech therapy, this "lucky" fluency disappears and they go back to stuttering.
Stutterers' brains have two sets of speech motor programs. Sometimes our brains pick the fluent speech motor programs. At other times our brains pick the stuttering speech motor programs. Speech therapy reinforces the fluent speech motor programs. Eventually this fluent speech becomes habitual. But during "lucky" fluency this habit is precariously balanced. One stressful day, in which you allow yourself to stutter, can reinforce the stuttering motor programs, and your "lucky" fluency is gone.

### Speech Buddies

Children learn grammar by listening to other people talking, then speaking, then having their parents correct their grammar. You may not remember this, but after a family vacation to the seashore you told your mother's friend, "We went nearly to the beach every day," and your mother corrected you, "No, dear, we went to the beach nearly every day."
Your mom was your speech buddy. You need another speech buddy now, to correct your speech when you're dysfluent.
Ask your speech-language pathologist to let you organize a practice group with her other clients. Meet once a week to practice fluent speech. Exchange telephone numbers and arrange to call a speech buddy every day.
Here's an idea that'll get you talking fluently. If you have a spare bedroom in your house, call a local university and offer to let a speech-language pathology student live rent-free, in return for reminding you to use fluency shaping skills. If you don't have a university with a communication sciences department, call your school district and see if they have a speech-language pathologist who'd go for free rent.
Train your spouse, housemates, and the people you work with to remind you to use fluency skills. If you're a parent with a child in speech therapy, ask your child's speech-language pathologist to train you to correct your child at home (see SLPs vs. Parents vs. Computers).
Your spouse can come with you to speech therapy, or you can tell her what you're learning. You can tell your housemates or co-workers. But there's a problem. Suppose you wear a sign offering to pay $1 whenever a listener hears you stutter. Listeners are too polite to do that. They'd feel like they were getting paid to kick a paraplegic in his wheelchair.
And you can't wear a sign around your neck offering to pay $1 whenever anyone catches you doing a hard onset, or using thoracic breathing. No one but a speech-language pathologist knows what those behaviors are. Non-stutterers have no idea what they do to speak fluently. They don't know how to correct you or tell you what you did wrong.

### My Romantic Disaster of 1996

In eighth grade I had a teacher with a forceful personality and a large ego. He decided to cure my stuttering. Whenever I stuttered he stopped me, then told me to say it without stuttering. I hadn't had speech therapy and had no idea what to do. His method was as effective as teaching me Chinese by stopping me from speaking English and telling me to speak in Chinese. Twenty years later I'd completed several speech therapy programs. I dated a young woman who disliked my stuttering. Whenever I started to block, she'd give me a certain look. I'd stop, relax my breathing and vocal folds, and speak fluently. Within a few days with her I was talking fluently all the time. The relationship crashed and burned shortly after that.--Thomas David Kehoe 05:13, 28 March 2006 (UTC)
For an individual who hasn't completed a speech therapy program, a person pointing out their stuttering is the worst thing. Such an individual doesn't have any control over his speech. Telling him to talk fluently increases his stress and his stuttering. (See the section Modeling.)
But for an individual who has mastered fluent speech skills, pointing out his disfluencies and reminding him to use fluent speech skills will help him. When you're at that stage, find someone to do this for you.
Or pay listeners $1 whenever you stutter. I tried this and never stuttered. I'm not sure if that was a success or a failure.

### Start a Virtuous Cycle

Do whatever you need to get into the virtuous cycle. You may have to do things that are difficult or embarrassing&#151;e.g., telling your co-workers that you stutter (hint: they've probably already figured that out!).
Once you're in the virtuous cycle, fluent speech will become easier and easier with less and less effort. The difficult things will become easier, and the embarrassing things won't be embarrassing (or necessary). Done right, you'll only have to do these things for a few days or weeks.
Getting into the virtuous cycle may require:
* Using closed-loop speech motor control (very slow speech).
* Using an electronic anti-stuttering device.
* Taking a dopamine-antagonist medication.
* Talking in uncomfortable situations, e.g., to strangers or to telemarketers.
For a high-testosterone kickstart, see The Predator Approach.

### Practicing Under Stress

Autonomous motor learning requires practicing a new motor skill in stressful situations.
Design a hierarchy of stressful situations. The first might be leaving a message on your speech-language pathologist's answering machine. When you can do that comfortably and fluently, you might talk to telemarketers using closed-loop speech motor control (slow, fluent speech). Then you could join Toastmasters and make a series of speeches to your club. More about this in the chapter Speech-Related Fears and Anxieties.

### Practice Scheduling

The United States Postal Service studied workers learning to type on mail-sorting machines (similar to typewriters). All subjects received 60 hours of training. The scheduling varied between four groups.
One group had two two-hour sessions per day, for 15 days. A second group had one two-hour session per day, for 30 days. A third group had two one-hour sessions per day, for 30 days. The fourth group had one one-hour session per day, for 60 days.
The first group (two two-hour sessions per day) learned fastest, but in the long run had the worst performance. The fourth group (one one-hour session per day) took the longest to get "up to speed," but eventually had the best performance.
Surprisingly, the postal workers preferred the two-hour/two-session schedule, even though they had the worst performance. People are impatient. They don't want to spend 60 days learning something, if they think there's a 15-day shortcut.

### Extinguishing Maladaptive Motor Skills

We could simplistically conclude that you should practice stuttering therapy no more than one hour per day. But there's an essential difference between speech therapy and mail sorting. The postal workers were learning a new motor skill. Stutterers have to learn a new motor skill and extinguish an old motor skill. As noted earlier, coaches often prefer to work with individuals who have never played a sport and haven't learned bad habits, rather than work with experienced athletes and have to break their bad habits.
To extinguish an old motor skill you must stop doing it. Perhaps the ideal stuttering therapy is done one hour per day, and then you take a vow of silence the rest of the day. But that's unrealistic. To burn new fluent neural pathways, and extinguish old stuttering neural pathways, you must use fluent speech every time you talk. You must never stutter. Each disfluency weakens your new fluent neural pathways and strengthens your old stuttering neural pathways.
Extinguishing a maladaptive motor skill isn't the same as "breaking" a bad habit. Maladaptive motor skills enable you to perform a desirable behavior, but not as a well as another motor skill. E.g., touchtyping is better than two-fingered typing, but two-fingered typing also gets the job done. In contrast, picking my nose is an undesirable behavior. I wish that a teacher had taught me to touchtype when I was a child. I don't wish that a teacher had taught me a better way to pick my nose.
Because maladaptive motor skills enable you to perform a desirable behavior, it's hard to unlearn them and replace them with optimal motor skills. Stuttering isn't like picking your nose. Your mother could slap your hand and stop you whenever you pick your nose. If she stopped you every time you stuttered, you wouldn't be able to talk.
Extinguishing a maladaptive motor skill may involve "one step forward, one step back" temporarily. To speak fluently, you may have to speak much slower, or not respond immediately while you focus on your speech motor skills.

### Intensive Residential Speech Therapy Programs

Some stutterers go to intensive residential speech therapy programs. These programs typically last three weeks. You're surrounded by speech-language pathologists and other stutterers, and isolated from the real world. For the first two weeks, you use two-second stretch all the time. In the third week, you move to one-second stretch, then half-second, and finally quarter-second slow normal.
Intensive residential speech therapy programs are like the postal workers who did the "short cut" training. In three weeks of intensive therapy you learned to talk fluently. But many stutterers find that long-term results are disappointing.

### Your Ideal Practice Schedule

Work with your speech-language pathologist to develop a practice schedule. A severe stutterer may have to spend many hours a day doing "homework."
Don't practice sitting alone in a room reading endless word lists. This isn't going to produce carryover fluency to stressful situations.
A one-hour daily practice could have the following three elements:
* After breakfast, twenty minutes of high intensity (using projection and hard onsets) practice, using practice word lists.
* During the day, a stressful twenty-minute session while using a biofeedback device to keep your vocal folds relaxed. This could be calling strangers for your job.
* After supper, twenty minutes of very slow closed-loop speech motor control conversation. You could call another stutterer in your support group. Or you could talk to telemarketers or call infomercial toll-free numbers.

### How Long Does Autonomous Learning Take?

Gymnasts practice daily for about eight years to become proficient.
Motor learning researchers studied the manual (hand) skills of cigar-makers. Beginner cigar-makers worked three times slower than experienced cigar-makers. Becoming fully skilled required making three million cigars.
Three million repetitions were also needed for Japanese pearl handlers to become proficient. The Suzuki method of teaching violin to children requires the production of about 2.5 million notes. Basketball, football, and baseball throws require about a million practice throws.
This suggests that making fluent speech automatic and effortless requires saying about three million syllables. At five syllables per second, talking four hours a day (just your time talking, not combined talking and listening), you could produce three million syllables in six weeks.
If you got a job answering telephone calls, and you did your stuttering therapy skills on every call, and you connected a biofeedback device into your telephone to alert you when you missed a therapy target, and you spent your free time at Toastmasters clubs making speeches or volunteering at a hospital's information desk, fluent speech might become automatic for you in six weeks.
But most stutterers practice between ten minutes and one hour per day. If they were silent the rest of the day, they'd say three million syllables somewhere between six months and three years.
No one has studied whether using undesirable motor skills cancels out on-target practice. I.e., does a half-hour of on-target practice get cancelled out by not using fluency skills the rest of the day? Such a practice schedule might take years to produce automatic fluent speech&#151;or might never work.

### References

* ^ Ramig, P., Adams, M. Vocal changes in stutterers and nonstutterers during high- and low-pitched speech, Journal of Fluency Disorders, Volume 6, Issue 1 , March 1981, Pages 15-33
* ^ Elman, J. (1981). "Effects of frequency-shifted feedback on the pitch of vocal productions," Journal of the Acoustical Society of America, 70 (1). Burnett, T.A., Senner, J.E., and Larson, C.R. (1997). "Voice F0 responses to pitch-shifted auditory feedback: A preliminary study," J. Voice, 11, 202-211. Burnett, T.A., Freedland, M.B., Larson, C.R., Hain, T.C. (1998). "Voice F0 responses to manipulations in pitch feedback," Journal of the Acoustical Society of America, 103 (6) June 1998.
* ^ Natke, U., & Kalveram, K.Th. (2001) Fundamental frequency and vowel duration under frequency shifted auditory feedback in stuttering and nonstuttering adults. In H.-G. Bosshardt, J. S. Yaruss & H. F. M. Peters (Eds.), Fluency Disorders: Theory, Research, Treatment and Self-help. Proceedings of the Third World Congress of Fluency Disorders in Nyborg, Denmark. Nijmegen: Nijmegen University Press, 66-71. Abstract, Full version (PDF, 67 KB).; Natke, U., Grosser, J., & Kalveram, K.Th. (2001) Fluency, fundamental frequency, and speech rate under frequency shifted auditory feedback in stuttering and nonstuttering persons. Journal of Fluency Disorders, 26, 227-241. Abstract, Full version (PDF, 682 KB).
* ^ Kottke, F.J., Halpern, D., Easton, J.K.M., Ozel, A.T., Burrill, C.A. "The Training of Coordination." Archives of Physical Medicine and Rehabilitation, Vol 59, December 1978, 567-572.