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Stuttering Treatment for Adults: An Update
on Contemporary Approaches
Michael Blomgren, Ph.D.1
ABSTRACT
Thisarticle provides a brief overview of historical and current
approaches to stuttering treatment for adults. Treatment is discussed
in terms of stuttering management approaches, fluency-shaping
approaches, and combined approaches. The evidence base for these
various approaches is outlined. Fluency-shaping approaches have the
most robust outcome evidence. Stuttering management approaches
are based more on theoretical models of stuttering, and the evidence
base tends to be inferred from work using the approaches of cognitive
behavior therapy and desensitization with other disorders such as
anxiety. Finally, comprehensive approaches to treating stuttering are
discussed, and several clinical methods are outlined. Comprehensive
approaches target both improved speech fluency and stuttering man-
agement. Although it is presented that a comprehensive approach
to stuttering treatment will provide the best results, no single
approach to stuttering treatment can claim universal success with all
adults who stutter.
KEYWORDS:Stuttering, treatment outcomes, stuttering
management, fluency shaping, cognitive restructuring Downloaded by: SASLHA. Copyrighted material.
Learning Outcomes: As a result of this activity, the reader will be able to (1) explain the nature of stuttering
management techniques, (2) explain the nature of fluency-shaping techniques, and (3) explain the rationale and
basic procedures for providing comprehensive stuttering therapy to adults.
Stuttering is a multidimensional disor- the core behaviors of stuttering—the repeated
1,2
der. Stuttering includes core, or ‘‘surface,’’ articulatory movements, the fixed articulatory
elements as well as elements that exist ‘‘below postures, and any nonverbal- or verbal-associ-
thesurface.’’ Surface elements include aspects of atedstutteringbehaviorssuchasfacialgrimaces,
1Department of Communication Sciences and Disorders, Guest Editor, J. Scott. Yaruss, Ph.D.
University of Utah, Salt Lake City, Utah. Semin Speech Lang 2010;31:272–282. Copyright #
Address for correspondence and reprint requests: 2010 by Thieme Medical Publishers, Inc., 333 Seventh
Michael Blomgren, Ph.D., Associate Professor, Social & Avenue, New York, NY 10001, USA. Tel: +1(212) 584-
Behavioral Sciences Building, Rm 1203, 390 South 1530 4662.
East, University of Utah, Salt Lake City, UT 84112-0252 DOI: http://dx.doi.org/10.1055/s-0030-1265760.
(e-mail: Michael.Blomgren@health.utah.edu). ISSN 0734-0478.
Stuttering Treatment: BecominganEffectiveClinician;
272
STUTTERINGTREATMENTFORADULTS/BLOMGREN 273
interjections, and circumlocutions. Elements STUTTERINGMANAGEMENT
that exist below the surface include covert or ANDCOGNITIVE-RESTRUCTURING
affective aspects of stuttering, such as speaking APPROACHES
avoidance, reduced social and occupational par- Many individuals who continue to stutter into
ticipation, and negative affective functioning in adolescence and adulthood develop a series of
3
areas like locus of control, mood, and anxiety. negative reactions to their stuttering. For some
Therefore, it appears that stuttering would be people who stutter, these negative reactions
best treated using a multifaceted approached may lead to additional struggle behavior and
that includes addressing both the core, or sur- debilitating anxieties and fears related to stut-
face, elements as well as elements of stuttering tering and speaking. Stuttering management
that exist below the surface. therapies are based on combinations of proce-
However, there is often disagreement dures directed at desensitization to stuttering,
regarding the essential components of stutter- increasing acceptance of one’s stuttering, and
4–8
ing treatment. This disagreement is exem- motoric techniques directed at decreasing the
plifiedbythewidevarietyofstuttering tension associated with stuttering moments.
treatment options. Historically, many hetero- Oneofthehallmarksofcognitive-restructuring
geneous approaches have been used to treat or stuttering management therapies is that they
stuttering; however, many of these approaches tend to be primarily anxiolytic (i.e., anxiety
may be categorized into two broad groups. reducing) in emphasis, but they also include
These categories may be viewed as either (1) techniques targeted at changing the nature of
primarily cognitive/anxiolytic (anxiety reduc- stuttering events. The early foundations of
ing) or (2) focused primarily on speech flu- stuttering management were laid down by
ency. These divisions are often referred to as Wendell Johnson and his student Dean
stuttering management or fluency shaping,re- Williams14–16 at the University of Iowa. For
spectively. Stuttering management ap- this reason, stuttering management therapy has
proaches have typically focused on teaching been referred to as the ‘‘Iowa approach.’’
the individual to stutter less severely, and The Iowa approach focused on reducing
fluency-shaping approaches have focused on ‘‘undesirable behaviors’’ that interfere with flu-
teaching the individual to speak more flu- ent speech. In 1957, Dean Williams published
9
ently. oneofthefirstarticles on ‘‘cognitive-behavioral
In the past 10 to 20 years, there has been therapy’’ approaches to stuttering. The focus of
an increasing attempt to combine fluency- this therapy was to teach the individual who Downloaded by: SASLHA. Copyrighted material.
shaping approaches with stuttering manage- stutters to feel and monitor his or her speech
ment approaches. For instance, well-known processes to improve speech fluency. Addition-
15
intensive stuttering programs such as the Com- ally, Williams believed that many stutterers
prehensive Stuttering Program at the Univer- consider their stuttering to be an ‘it’ that they
sity of Alberta,10,11 the Intensive Treatment carry aroundwiththem.Theyfeelthatithasan
Program at the American Institute of Stutter- entity of its own. As long as he retains this ‘it’
ing,12 and the Fluency Plus Program13 have all he cannot see his behavior. The belief that
somewhatrecentlyaddedsubstantialcognitive- stuttering happens to you creates a feeling of
restructuring and/or stuttering management helplessness and being trapped (p. 392).’’ The
components to their traditional fluency-shap- goal of therapy was for the individual not to
ing emphasis. This article aims to summarize view stuttering as who he or she is, but to view
some of the currently available stuttering stuttering as simply something he or she does.
treatment approaches. The summary will Later, Charles Van Riper,17 another Iowa
include historical elements as well as an graduate, further operationalized many specific
overview of currently available treatments. stuttering management techniques. Van Riper
The overarching goal of this review is to encouraged working on eye contact, self-
present stuttering as a multidimensional prob- disclosure of stuttering, pseudostuttering
lem that will ultimately be best treated in a (faking stuttering moments), freezing (holding
comprehensive way. a moment of stuttering to analyze it), ceasing
274 SEMINARSINSPEECHANDLANGUAGE/VOLUME31,NUMBER4 2010
avoidance behaviors, and tolerating frustration. program, the Successful Stuttering Manage-
Most of these strategies focused on reducing ment Program (SSMP).31 The SSMP is based
the tension, anxiety, and avoidance associated on the classic treatment approaches of Van
17
with stuttering. In an effort to decrease these Riper. The aims of the SSMP are to reduce
18
anxieties, Van Riper encouraged ‘‘a bath avoidance behavior, anticipation of stuttering,
of stuttering’’ to produce desensitization to and social and cognitive anxiety through de-
stuttering. A bath of stuttering could be sensitization to stuttering. The overarching
accomplished through ‘‘real’’ stuttering or rationale of the SSMP treatment approach is
through pseudostuttering. The goal of stutter- to teach the person who stutters ‘‘to manage his
ing desensitization was to reduce the individ- stuttering and his speech so that he can com-
ual’s fears, frustration, and shame. municate as a stutterer in any situation without
Theproblemwithcognitive-restructuring unduestress andstrain to himself or his listener
or stuttering management approaches is that (p. 5).’’31 A series of 14 fluency- and affective-
very little treatment outcomes research exists based measures were used to assess treatment
4,19
to support their efficacy. Most of the re- immediately after and 6 months after treat-
search that does exist is dated and tends to be ment. The results indicated that no durable
based on unidimensional assessments.20–25 reductions were identified in (1) decreasing
The justification for stuttering management overt stuttering frequency, (2) decreasing stut-
approachescomesprimarilyfromtwo-compo- tering severity (measured as composite of stut-
26
nent models of stuttering. That is, the first tering frequency, stuttering moment durations,
component of stuttering (the actual stutter and secondary behaviors [Stuttering Severity
events) leads to the second component (the Instrument 3]),38 (3) self-assessed stuttering
anxiety and affective components). Propo- severity, (4) self-assessed perception of struggle
nents of stuttering management therapy be- to speak, (5) self-assessed amount of muscular
lieve that it is the second component of tension, (6) self-assessed improvements in
stuttering that is the appropriate objective of mood, (7) self-assessed improvements in locus
treatment. These approaches, although not of control, or (8) self-assessed improvements in
strongly evidence-based, are rooted in the state or trait anxiety. However, the SSMP did
cognitive learning literature.27–30 appear to reduce certain anxiety-related fea-
It has often been argued that evaluating tures of stuttering such as self-perceived avoid-
such cognitive approaches is difficult because ance and expectancy of stuttering and self-
the outcomes are often challenging to quantify reported psychic and somatic anxiety. In this Downloaded by: SASLHA. Copyrighted material.
and the exact treatment methodologies have respect, the SSMP was deemed to be an in-
8
historically been poorly documented. Ryan effective treatment for decreasing stuttering
hasassertedthatforanytreatmenttobetrusted, and related struggle behaviors, but it was an
the treatment procedures must be adequately effective treatment in decreasing some of the
described so as to permit replication. Most anxiolytic sequelae of stuttering.
stuttering management approaches would ap- Twobroaderconclusionsmaybeextrapo-
4
pear to be less structured than most operant- lated from the Blomgren et al findings. First,
based fluency-shaping treatments. Still, stutter- stuttering frequency does not appear to auto-
ing management approaches continue to be matically decrease in concert with decreases in
popular as evidenced by their continued support self-reported anxiety. In other words, decreas-
1,9,31–37
in recent stuttering texts. Therefore, ing anxiety alone is not sufficient to decrease
careful evaluation of stuttering management stuttering frequency. Second, and inversely, it
treatment outcomes is essential to understand does appear possible to decrease anxiety re-
their benefits and limitations. lated to stuttering in the absence of any
A recent attempt was made to evaluate corollary decrease in stuttering frequency. In
the treatment outcomes of an intensive stutter- summary, the anxiolytic sequelae of stuttering
ing management program.4 Blomgren et al4 do appear to be treatable, even in the absence
assessed 19 adults who stutter in a 3-week of related decreases in stuttering frequency
intensive stuttering management treatment and severity.
STUTTERINGTREATMENTFORADULTS/BLOMGREN 275
SPEECH-RESTRUCTURING/ most contemporary writers, his techniques
FLUENCY-SHAPINGAPPROACHES were early precursors of prolonged speech and
Speech restructuring refers to any treatment other programmedinstruction/fluency-shaping
approach that teaches a person who stutters therapies.
to use a new speech pattern. It may be argued Somewhat remarkably, there was little
that the first speech-restructuring therapy goes written on speech prolongation techniques
back as far as the great Greek orator Demos- again until the 1960s when Goldiamond44
thenes (384 to 322 BC). It has often been showed that stuttering speakers could remain
reported that Demosthenes stuttered and ap- stutter-free while using a prolonged speech
parently treated his stuttering by placing peb- pattern. By 1980, there were enough studies
bles under his tongue.39 It is conceivable that onthetreatment effects of prolonged speech to
speech-motor movements needed to compen- conduct a meta-analysis of a variety of treat-
sate for a mouth full of pebbles—such as slower ment approaches, including prolonged speech.
speech and decreased movement trajectories— Andrews, Guitar, and Howie45 concluded that
would be fluency facilitating in various ways. the most effective technique for decreasing
It may be better argued that modern flu- stuttering was prolonged speech. Since that
ency-shaping therapy began during the mid to time, several stuttering treatment programs
late 1800s. One of the first published texts on have emerged that are based on variations of
fluency shaping was written by Oskar Gutt- the prolonged speech technique.
mann.40 Guttmann’s therapy regimen con- The goal of fluency-shaping therapy is to
sisted of speech-motor restructuring through apply techniques that facilitate a new speech
a series of exercises for breathing and speech production pattern. This new pattern would
prolongation. The exercises were taught in a better operate within the speaker’s speech
hierarchy of speech tasks—the process now motor control abilities, resulting in less stutter-
referred to as fluency shaping. First, clients ing. Some fluency approaches focus only on
were instructed to take a comfortable breath speech rate modification using prolonged
46–49
prior to every syllable in an utterance. Syllables speech techniques. Frequently, these pro-
were to be spoken in a monotone and pro- longed speech techniques are referred to as
longed manner. This prolonged speech techni- stretched syllables, controlled rate, slow speech,
que was then practiced producing two syllables or smooth speech. Other fluency-shaping
per breath and progressed to full, semantically approaches address speech rate in combination
complete, utterances. Finally Guttmann had with one or more other fluency-facilitating Downloaded by: SASLHA. Copyrighted material.
10,13,43,50
clients speak ‘‘the whole line not syllabically techniques.
48
(monotone), but rhetorically (with normal in- The Camperdown Program is an exam-
tonation), without any force, guided only by ple of a treatment approach that is primarily
feeling’’ (p. 214). This process is remarkably based on prolonged speech. The Camperdown
similar to the basis of many ‘‘modern’’ speech Program is a speech-restructuring treatment
reconstruction therapies. that was developed at the University of Sydney.
Guttmann further understood the impor- In the Camperdown Program, clients are
tance of coordinating breathing, voice, and trained to imitate a video recording of an
articulation, a notion that would not be revis- individual modeling prolonged speech. No ex-
ited until nearly 100 years later.41–43 Guttmann plicit instruction is given in terms of exact
acknowledged that ‘‘breathing, voice and speech timing or any other fluency-facilitating
speech are, from the start, simultaneously ac- techniques such as gentle vocal onsets or soft
tive’’ and that ‘‘treating the various parts as articulatory contacts. The program is comprised
parts mechanically [is] a practice which never, of four stages: (1) introduction to the prolonged
or seldom, leads to a favorable result; for the speech technique, (2) within-clinic practice of
human organ of voice and speech acts from the prolonged speech technique so that speech
childhood as a whole, and should be treated is fluent and ‘‘natural sounding,’’ (3) general-
as such in the [speech] exercises’’ (p. 216). ization of the prolonged speech technique to
Although Guttmann’s work is little known by out-of-clinic speaking environments, and (4)
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