Dismantling the “Brick Wall” of Stuttering

parryAbout the author: William Parry, J.D., M.A., CCC-SLP, is a speech-language pathologist currently developing a new approach to the treatment of stuttering. He previously overcame his own stuttering to become a successful trial lawyer.  He is founder and leader of the National Stuttering Association’s Philadelphia Area Chapter, former NSA board member, and author of the NSA’s best-selling book, Understanding and Controlling Stuttering.  He graduated from the University of Pennsylvania Law School, has a Master’s Degree in Speech, Language, and Hearing Science from Temple University, and is a certified member of the American Speech-Language-Hearing Association.  He has given presentations at World Congresses for People Who Stutter and national conferences of the NSA and the British Stammering Association.

The following experience is frustratingly familiar to virtually everyone who stutters:  In the midst of a conversation, you suddenly feel that an upcoming word contains a “brick wall.” You actually feel an inherent obstacle that will make the word impossible to say.  At the same time, you also feel an overwhelming impulse to exert effort to break through the “brick wall” and force out the word.

Imagine, for example, that you feel a “brick wall” in the word “pizza.”  In your attempt to say the word, you close your lips to form the “p” sound.  But instead of briefly touching and then releasing a puff of air, your lips clamp tightly together.  Meanwhile, your chest and abdominal muscles contract, causing air pressure to build up in your lungs, as if trying to force the word through the tight closure of your lips.  However, the harder you force, the tighter your lips press together to block the air.  Alternatively, you may find yourself helplessly repeating the “p” sound (“puh-puh-puh-puh”) as you struggle to force out the rest of the word.  On other sounds, you might find yourself blocking the air with your tongue, prolonging the sound, or tightly closing your larynx.

When confronted by the “brick wall,” you may suddenly forget everything you learned in speech therapy.  Even if you remember what you were taught about “pull-outs,” “easy onsets,” and “light contacts,” you may find these techniques to be totally unworkable in your panic to force out the word.

The perception of a “brick wall,” together with other aspects of the foregoing scenario, appears to be almost universal among persons with persistent developmental stuttering.  I base this observation on my own experience as a person who stuttered for most of his life and on my questioning of hundreds of stutterers as a chapter leader of the National Stuttering Association, as a presenter of numerous workshops at stuttering conferences, and now as a speech-language pathologist who treats stuttering.  A similar observation was made by Henry Freund, a psychiatrist who was once himself a stutterer, who wrote that one of the primary experi­ences of stuttering is that of “an obstacle which needs force to overcome it” and that such effort by the stutterer “only increases the force of the closure.”  (Freund, 1966, pp. 91, 94-95.)

I find that standard stuttering therapies, including the “stuttering modification” and “fluency shaping” approaches, focus primarily on treating the external symptoms of stuttering, without addressing the internally perceived obstacle that triggers them.  Therefore, their techniques tend to fall apart when stutterers encounter the “brick wall” in actual speaking situations.

I have taken a different approach.  I believe that the “brick wall” is at the heart of stuttering.  In order to understand and deal with stuttering effectively, we must first understand what the “brick wall” is and what causes it.

Understanding the “Brick Wall”

The following are some clues about stuttering based on stutterers’ perception of the “brick wall” and their common reactions to it:

  • We begin with the general observation that most persons with persistent developmental stuttering exhibit reasonably fluent speech at least some of the time.  (See Bloodstein &  Ratner, pp. 261-262. )  This is true regardless of what researchers may tell us about stutterers having various neurological abnormalities or deficiencies in timing, coordination, rhythm, etc. (id., pp. 114-146 ).  Therefore, I view stuttering as involving not a lack of ability in speaking but rather an interference with the speaking ability that a person already has.  Accordingly, the object of therapy should not be to control one’s speech, but rather to identify and control the forces that interfere with one’s speech.
  • Because the “brick wall” is perceived prior to the act of speaking, it is likely that the underlying stuttering block arises in the motor programming for speech – probably in the neuromotor tuning phase – rather than in the execution of the physical movements of speech.
  • Although stutterers’ anticipation of difficulty often focuses on initial consonants, the actual articulation of consonants is not the real problem.  When blocking on “pizza,” for example, the stutterer will put his lips in the proper position to form the “p” sound. When he repeats the initial sound (“puh-puh-puh-puh”), he is articulating the consonant perfectly well.  The same is true regarding the prolongation of consonants.
  • The real problem appears to be difficulty in phonating the vowel sound that follows.  The problem is not phonation in general, because stutterers phonate when prolonging voiced consonants such as m, n, l, and r.
  • Therefore, the “brick wall” appears to be a failure of the brain to program the larynx to phonate the vowel sound of a word or syllable.  As a result, the person’s speech mechanism gets stuck on the initial consonant – repeating, prolonging, or forcing on it – while waiting for the larynx to get ready to phonate the vowel.  In words that start with vowels, the person may get stuck on the laryngeal closure, or glottal stop, that is customarily used to build up air pressure to accentuate the beginning of the vowel sound.  Alternatively, the person may hesitate, use “starters,” grunt, substitute words, or resort to other struggle or avoidance behaviors.
  • The cause of this “vowel phonation gap” appears to be the substitution of a motor program for effort in place of phonation of the vowel sound.  Consequently, laryngeal muscles are prepared to perform effort closure as part of a Valsalva maneuver – an instinctive bodily function designed to increase pulmonary pressure to stiffen the trunk of the body, so that physical      effort can be exerted more efficiently. Accordingly, persons who stutter often report tightness in their throats when encountering blocks.  However, even when the larynx does not actually close, it still is not prepared to phonate the vowel sound.
  • Persons who stutter may find themselves doing Valsalva maneuvers in an attempt to force out the word.  While the chest and abdominal muscles contract to build up air pressure in the lungs, the mouth or larynx automatically closes more tightly to hold the air in.  Although this exertion of effort instinctively feels like the right thing to do, it actually blocks the flow of speech.

Many different factors may originally cause disfluencies in children, depending on the individual.  Each in its own way could contribute to the feeling that speech is difficult and requires effort.  A natural reaction would be to “try hard” to force the words out by activating the Valsalva mechanism.  This behavior would create a self-perpetuating cycle of effort and blocking, which may persist even after the original cause of disfluency has abated.

The effort impulse typically occurs when the person anticipates that saying a particular word will be difficult.  The programming for effort replaces the vowel sound because the vowel is the part of the syllable that has the greatest energy.  In addition, activation of the Valsalva mechanism is part of the “flight-flight-freeze” reaction, triggered by the brain’s amygdalae in response to fearful speaking situations.  Due to the release of stress hormones, the speaker is overwhelmed by his habitual urge to use force, and he momentarily forgets any “fluency techniques” he may have learned in speech therapy.  Exerting effort may serve to reduce the stutterer’s immediate anxiety, thereby reinforcing and perpetuating stuttering behavior.

Dismantling the “Brick Wall”

The external behaviors regarded as “stuttering” can be understood as the speaker’s attempt to overcome an internal block caused by the neurological substitution of effort in place of phonation of the vowel sound.  Therefore, I believe that the best way to treat stuttering is to focus on reducing the stutterer’s urge to exert effort, rather than trying to increase fluency.  Emphasis on fluency tends to increase one’s effort in speaking, making stuttering worse.  Natural fluency cannot be forced.  When speech becomes easy and effortless, fluency will automatically follow on its own.

Stuttering is influenced by many factors, depending on each individual.  Therefore, my approach to dismantling the “brick wall” is multi-faceted and individualized, addressing the various psychological, neurological, and physiological factors involved.  The following are brief descriptions of some of the main elements of this approach:

  • First it is necessary that the speaker have a basic understanding of normal speech, Valsalva maneuvers, and how exerting effort through activation of the Valsalva mechanism can interfere with speech.
  • Next, the speaker must become accustomed to using Valsalva-relaxed breathing, phonation, and speaking – all of which are consistent with normal, natural-sounding speech. Rather than “trying hard” to say words, the speaker intentionally focuses on relaxing the abdomen, letting the air flow freely, and saying the vowel sounds with feeling and inflection.  Often persons who stutter seem to funnel their emotions into force, rather than expressing themselves through phonation of the vowel sounds.
  • Through various exercises, the speaker learns to treat the vowel sound as the heart of words and syllables and to regard the consonants as mere “decorations.”  Repetitive practice is used to establish “muscle memory” in the larynx for phonation instead of effort closure, in order to facilitate the phonation of vowel sounds under stress.
  • No fluency technique can make the “brick walls” stop happening immediately.  Their frequency will diminish gradually as the amygdalae become desensitized to speaking situations.  Therefore, one must accept the fact that “brick walls” will continue to happen.  The important thing is to change the way in which one responds to them.
  • When encountering a “brick wall,” the speaker must resist the urge to force.  He must remember that there is no real obstacle, simply a “vowel-phonation gap.”  Rather than using effort, he must stop, breathe in a Valsalva-relaxed way, and prepare his larynx to phonate the vowel.  He must forget about “trying to say the word,” and instead focus his intention on saying the vowel sound with feeling.
  • The occurrence of “brick walls” can be reduced by changing one’s intention in speaking.  For example, instead of trying hard to “make a good impression” by not stuttering (which almost always backfires), it is better to focus on one’s role and purpose in speaking and on having fun communicating in a Valsalva-relaxed way, without regard to fluency. Instead of using effort to show how hard you are trying to please your listener, focus instead on the message you want to convey – as one adult speaking to another – and on your pleasure in expressing yourself through the vowel sounds.

A more extensive discussion of this approach to understanding and dismantling the “brick wall” is contained in the revised and expanded Third Edition of my book, Understanding and Controlling Stuttering (Parry, 2013), which is available from the National Stuttering Association.

Implications for Therapy

The above principles form the basis of “Valsalva Stuttering Therapy,” which I have been developing over the past 3½ years, with the participation of dozens of persons who stutter from all over the world.  The results have been very encouraging.  Participants have reported that this approach makes more sense, and has been more helpful, than any other form of therapy they have encountered.

Furthermore, by recognizing the role of effort as a response to anxiety, Valsalva Stuttering Therapy provides new perspectives for analyzing and addressing emotional factors that perpetuate stuttering (often incorporating elements of transactional analysis, cognitive behavior therapy, and “mindfulness” training).  This understanding has been crucial in helping participants speak more easily in all kinds of real-life situations.

References

Bloodstein, O. & Ratner, N.B.  A Handbook on Stuttering.  6th ed.  Clifton Park, NY: Delmar, 2008.

Freund, H.  Psychopathology and the Prob­lems of Stut­ter­ing.  Springfield, Ill.: Charles C. Thomas, 1966.

Parry, W. D.  Understanding and Controlling Stuttering: A Comprehensive New Approach Based on the Valsalva Hypothesis.  3rd ed.  New York: National Stuttering Ass’n, 2013.

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Comments

Dismantling the “Brick Wall” of Stuttering — 52 Comments

  1. Is there a way that this approach could be used with children or adolescents who stutter, possibly before the person even learns the strategy of speaking with excess force?

  2. Excellent point. I have already found my approach to be very helpful with adolescents who stutter. Thus far I have had only limited experience with children in grade school who stutter, but the few I have seen also seemed to be responsive to this approach.

    I believe that the basic principles could also be very helpful for younger children as well, if adapted to their level of understanding. This has yet to be explored. Meanwhile, I think that parents, teachers, and SLPs could be more helpful (and do less potential harm) by becoming familiar with the this approach to understanding stuttering, instead of reinforcing the child’s use of effort in “trying hard” to talk fluently.

  3. Since focusing on fluency can increase stress, what techniques do you have to relax an easily frustrated adolescent client?

    • I am not aware of any stand-alone “techniques” that will relieve the anxieties and frustrations of an adolescent who stutters. The adolescent often finds himself or herself trapped in a vicious cycle of fear, effort, blocking, and more fear, which is perpetuated by an overwhelming urge to exert even more effort. This “effort impulse” is usually exacerbated by the adolescent’s intense desire to “make a good impression” by trying hard not to stutter.

      Any “technique,” by itself, will not resolve these underlying issues, and will most likely be misused in an effortful attempt to “stop stuttering.” Therefore, I have found that a more holistic approach is preferable, involving not only practice in specific techniques for Valsalva-relaxed breathing and phonation, but also understanding the underlying emotional and physiological factors and changing one’s intention in speaking.

      Although there is much more to this approach, the following are some general suggestions. Instead of trying to “make a good impression,” the client should focus on his or her role and purpose in speaking. In addition, the client’s intention should be focused on expressing and asserting himself through the phonation of vowel sounds, by relaxing the abdomen and letting the vowels flow with feeling. Physically, it may be helpful to imagine the vowels coming from the bottom of the throat (farthest from the location of effort closure) while relaxing the abdomen and letting the air flow freely. The client should take the time to enjoy the feeling of expressing his feelings through inflection and intonation of the vowel sounds.

  4. I am very interested to read about your approach of focusing on the vowels themselves rather than the initial consonants in order to reduce the “vowel-phonation gap.” While I have seen fluency shaping techniques in therapy (which emphasize the word-initial sounds whether consonant or vowel), I am very curious how words themselves look when they are spoken with the emphasis being placed on the vowels alone. Has your experience shown you that the consonants are naturally articulated both before and after the vowel or is there a risk that those sounds can be lost in articulation? I appreciate your willingness to share your experiences!

    Allison F.

    • In my experience, consonants are not the problem. Articulation of consonants occurs automatically and clearly once the vowel sounds are able to flow.

      One of the images used by participants in my program is that of a bicycle going “up the hill” when inhaling with the diaphragm and coasting effortlessly “down the hill” while relaxing the abdomen and letting the vowels flow with feeling. The vowel sound is the heart of the word or syllable and the vehicle for self-expression. The consonants are regarded simply as “decorations” that are allowed to hop into the bicycle basket on their own and come along for the ride, as the speaker coasts down on the vowel sound.

      WDP

      • Thank you for your reply and for the example! Your article has certainly broadened my perspective on therapy techniques.

  5. As a graduate student currently enrolled in a fluency course, I must say that yours is a very different theory than those we have learned thus far. While the example you provided with the word “pizza” is relatively clear, I am curious about words with vowels in the initial position. I did read your mention of this above,as well as your note that a person who stutters may have a block on the glottal stop that typically occurs prior to uttering a vowel sound. However, I am wondering how your theory would relate to a person who stutters experiencing a part-word or single sound-repetition type of disfluency, particularly in words with initial vowels. For example, a person who stutters may say “uh-uh-uh-undergraduate”. In such a case, hasn’t vowel phonation already occurred, rather than the block preceding the utterance? I am trying to form a bridge between these types of disfluencies and your theory on programming the larynx for vowel phonation. Expanding upon this, how would your theory relate to whole-word repetitions experienced by a person who stutters?

    In relation to the first comment by smithe1, do you plan to do further research on the efficacy of your theory with younger children? Is it possible that you would later adapt your technique into something that could be more easily understood among preschool and school age children?

    Thank you for sharing, and thank you in advance for any clarification that you are able to offer.

    Sarah Savarese
    WCU Graduate Student

    • I agree that you will not find my hypothesis about stuttering and the Valsalva mechanism in any of your standard textbooks. I have yet to find a fluency textbook that even mentions the Valsalva maneuver or effort closure of the larynx. I find this puzzling, because the medical profession knows about the Valsalva mechanism. Physical therapists, trainers, and voice coaches know about it. Even musicians are aware that the Valsalva maneuver can cause “stuttering” in the playing of brass instruments like the trombone, trumpet, and French horn. (There are websites devoted to this problem, and I have personally discussed it with brass players from major orchestras.) Although my hypothesis may not appear in the SLP curriculum on stuttering, persons who stutter have consistently reported that this explanation is the one that most accurately describes their own stuttering experience and the only one that makes sense to them.

      Your question about stuttering on “uh-uh-uh-undergraduate” provides an example of how misunderstandings can result when we try to represent stuttered speech with the ordinary English alphabet. In this case, the “uh-uh-uh” does not represent phonation of the word’s initial vowel sound. It is actually a repetition of the unwritten glottal stop that precedes the initial vowel. It is series of little grunts, each consisting of a glottal stop followed by a schwa (a neutral vowel sound). Although the schwa may superficially seem similar to the initial vowel of the word “undergraduate,” it is not the same. The grunts are like mini Valsalva maneuvers, in which effort is exerted by closing the larynx, building up air pressure in the lungs, and then releasing it.

      Some persons who stutter habitually exhibit a similar “uh-uh-uh” behavior at the beginning of phrases, without regard to what the initial word or sound might be. For example: “Uh-uh-uh. Please pass the potatoes.” These grunts may serve to discharge the stutterer’s effort impulse and to reduce anxiety, thereby freeing the larynx to phonate the vowel sounds in the phrase that follows.

      When a stutterer does whole-word repetitions, the repeated word is generally not the one on which he is blocking. His real problem is with the word that follows. For example, a person repeating “I–I–I–I” is saying the “I” perfectly well. Most likely, he is anticipating difficulty on the word that was to come after it – a word that the listener may never get to hear.

      With respect to research, I am continuing to focus on making Valsalva Stuttering Therapy as effective and efficient as possible in helping adults and adolescents to overcome their stuttering. The resulting therapy might thereafter be modified for trials with younger children.

      WDP

  6. I am interested in your explanation of stuttering as a problem of motor programming for speech. Have you considered how, in this case, there might be a link between stuttering and other speech motor disorders such as dysarthria and apraxia of speech? How might you go about proving such a link?

    • In addition to treating developmental stuttering, I have had some experience with both dysarthria and apraxia of speech in adult stroke victims, childhood apraxia of speech in school-age children, and a case of neurogenic stuttering in an adult. The impairments I observed in these conditions were dramatically different from the kind I have seen in ordinary persistent developmental stuttering.

      Dysarthria involves muscular weakness that is not usually seen in persons who stutter. The motor programming errors in apraxia of speech randomly affect all kinds of articulation, both of consonants and vowels, and they happen almost all the time. In contrast, all the developmental stutterers I have seen have been able to speak with normal articulation. They were also able to speak fluently some of the time, even before therapy.

      Based on my observations and experience, it appears that the motor programming error in developmental stuttering specifically involves the substitution of effort in place of phonation of the vowel sound of a word or syllable. Furthermore, it tends to be triggered by psychological factors that vary depending on the speaking situation.

      Because of these distinct differences, I doubt that a significant link can be found between developmental stuttering and the other conditions you mentioned. This does not rule out the possibility that more subtle neurological weaknesses or developmental delays may have existed in SOME developmental stutterers during childhood, which may have created the perception that speech was difficult and required effort.

  7. I am a graduate student currently taking a fluency course. This approach is interesting and puts a name to what I have been learning about. My professor emphasizes that the goal of fluency treatment is for the person to be able to say what they want when they want wherever they want. This approach follows that and gives a solid explanation of a brick wall and the anatomical aspects of it. How young can the person be and this approach will still work?

    Brianna

    • I believe that the underlying principles of Valsalva Stuttering Therapy can be applied to children with ordinary developmental stuttering at whatever age they are now receiving speech therapy. These principles would have to be translated into age-appropriate games and activities that promote enjoyable, non-judgmental self-expression through Valsalva-relaxed breathing and phonation of vowel sounds. Parents and teachers must also learn to nurture these principles, rather than reacting in ways that increase the child’s anxiety about speaking and tendency to “try hard” to force words out.

      WDP

  8. Mr. Parry,
    I am a graduate student currently in a fluency course, so I am just beginning to get a taste of all the aspects involved in treatment for stuttering. I enjoyed reading about your approach. It is interesting to hear that the Valsalva mechanism is well known in other disciplines but not as much in speech-language pathology because it does make sense as mechanism contributing to stuttering. Thank you for breaking this approach down in a way that is easy to understand. This is probably true when learning any new technique, but does focusing so much on the vowel sounds cause the PWS to lose track of what he/she was trying to say? In your experience, how long does it take this change in muscle memory from force to phonation to occur so that the PWS is able to focus on what they are saying instead of how they are saying it?
    Kristin

    • In the Valsalva Stuttering Therapy approach it is much easier to keep track of what you want to say than it is in the various “fluency shaping” approaches. The speaker’s intention is specifically focused on his role and purpose in speaking (rather than on trying to be fluent) and on expressing himself by relaxing the abdomen and letting the vowels flow with feeling. Therefore, keeping track of what one wants to say is rarely an issue.

      The time required to overcome the “effort impulse” in speaking depends greatly on the individual. Four to six months is probably the minimum. Generally speaking, the less prior therapy the better. I have found that a history of fluency-shaping therapy impedes progress, because the participant must unlearn many unhelpful behaviors and beliefs that were acquired during therapy. Young adults who are motivated to move on with their lives and careers seem to be the most responsive to this therapy. Less responsive are older, retired persons who have become entrenched in a life-long struggle to “stop stuttering,” with no practical reason to change their attitudes or intentions. Neurological and cognitive deficits and deep-seated emotional issues may also complicate matters for some individuals.

  9. Very interesting point to reduce the urge to exert effort to treat stuttering. If I understood your approach correctly, putting it this way makes the sometimes vague ’emotional’ components of stuttering more concrete and easy to pin point. It seems the modern shift in therapy is steering away from ‘trying to be fluent’ and focusing more on reducing the negative emotional aspects that stand in the way of being a confident communicator. Interesting approach, thank you.
    -Karissa
    Idaho State University Graduate Student

  10. I am a graduate student of speech language pathology, currently enrolled in a fluency course. I find your explanation about the valsalva mechanism as it relates to stuttering to be both enlightening and very logical.

    You indicated that the valsalva mechanism is often activated by the amygdalae in response to fearful situations. Does this carry implications for practicing whole-body relaxation techniques and increased exposure to fearful speaking situations as a way of reducing the valsalva mechanism from becoming activated in PWS? Also, What elements of stuttering are addressed in Valsalva Stuttering Therapy (I know you mentioned a focus on addressing the vowel-phonation gap and valsalva breathing?) Do you incorporate any cognitive behavioral therapy or other approaches in conjunction with the Valsalva therapy?

    • I do not use whole-body relaxation, because I have found it to be too generalized and difficult to maintain in actual speaking situations. Relaxation is focused on specific parts of the Valsalva mechanism, such as intentionally relaxing the abdomen while exhaling and speaking. Valsalva Stuttering Therapy seeks to address all elements of stuttering – psychological, emotional, neurological, and physiological – as an interactive system. In addition to speech exercises, the therapy incorporates elements of cognitive behavior therapy, transactional analysis, role-playing exercises, desensitization, and mindfulness training, depending on the specific needs of the individual.

      WDP

  11. Mr. Parry,

    I am a graduate student currently enrolled in a fluency course. Thank you for introducing your approach, as well as, the Valsalva maneuver. As I have learned thus far, results of stuttering therapy cannot be guaranteed based on the fact that long-established nerve pathways for stuttering may be weakened, but they cannot be totally eliminated. Therefore, do you think that starting this approach with children and adolescents who are ready for therapy might prove to be more effective than with adults whose pathways may be further embedded?

    -Dana

    • Theoretically, this would seem to make sense. However, age isn’t necessarily the most important factor. In practice, I have found that the most responsive participants seem to be young adults who regard stuttering simply as an unwanted obstacle to their career ambitions. In contrast, treatment of adolescents is often complicated by their feelings of frustration and shame about stuttering, impatience with therapy, and their strong urge to try hard to “make a good impression” in social situations. Therefore, they often have a hard time giving up their habitual use of effort in speaking and their urge to use force when encountering blocks.

  12. Mr. Parry,

    The above described approach is refreshing as it relates to the speaker’s perspective as opposed to the overt features of stuttering. I am very interested in the establishment of “muscle memory” using the Valsalva approach. In your experience, have you used imagery or any instrumentation (i.e. spectrography) to assist the client in your treatment?

    • Not having access to a high-tech laboratory, I have only been able to experiment with some simple forms of biofeedback. I quickly decided that they were not worth the trouble. They were not as sensitive or as useful as the participant’s own self-monitoring and self-reporting. Furthermore, my objective is to develop an effective form of therapy that any SLP can administer herself, in her own office, without the need for expensive equipment.

  13. Thank you for describing the Valsalva Stuttering Therapy approach. I am a graduate student in speech-language pathology and currently taking a fluency course. I am always interested in hearing about old and new techniques and figuring out what might be beneficial for people who stutter. I also believe that fluency-shaping techniques may not always be the best solution and that helping a person who stutters to break through the “brick wall” may be more effective. Is this technique at all similar to the stuttering-modification approach that includes relaxation techniques and reducing anxiety associated with stuttering? If so, would you suggest implementing stuttering modification techniques in conjunction with the Valsalva Stuttering Therapy approach?
    Thanks again,
    Chaya N.

    • The Valsalva Stuttering Therapy approach is fundamentally different from stuttering modification. Stuttering modification techniques focus largely on modifying the overt symptoms of stuttering (such as the forceful closures of the mouth or larynx), which are actually the stutterer’s struggle or avoidance behaviors in response to the “brick wall.” Valsalva Stuttering Therapy focuses instead on resisting the “effort impulse,” relaxing the Valsalva mechanism (by relaxing the abdominal muscles), and programming the larynx to phonate the vowel sound.

      The only aspect of stuttering modification that I recommend is that of “cancellation.” The participant is taught to stop immediately whenever he encounters the “brick wall,” to use Valsalva-relaxed breathing, and to focus on phonating the vowel sound instead of trying to force through the block. Individualized counseling is also given to help reduce anxiety about speaking situations. This includes exercises in changing one’s intention in speaking, as discussed in my article.

      WDP

  14. Mr. Perry,
    I am currently a graduate student enrolled in a fluency class. Thank you for explaining so clearly what a PWS feels physiologically when they are faced with the brick wall. I have not heard of the Valsalva maneuvers or that the “brick wall might be caused by failure of the brain to program the larynx to phonate the vowel sound of a word or syllable”. I find this to be interesting. Can you share an example of the speech exercises used in the Valsalva therapy approach? Typically how many days a week and for how long during a day does an individual using this approach use these exercises and this therapy technique as a whole? I know that everyone responds to therapy at different rates, however in your research is there an average time frame in which people state they are “feeling” a difference? Thank you for your time!
    Lisa

    • The speech exercises used in Valsalva Stuttering Therapy are described in detail in the revised and expanded Third Edition of my book, Understanding and Controlling Stuttering (2013), which is available from the National Stuttering Association and from Amazon.com. The purpose of the exercises is to establish easy, effortless speech by promoting Valsalva-relaxed breathing, phonation, and changed intentions. Principal exercises include:

      – Valsalva-relaxed breathing.

      – Valsalva-relaxed phonation.

      – Valsalva-relaxed vowel intention exercises. The purpose is to replace the habitual motor programming for effort with a new behavior pattern in which the speaker relaxes the Valsalva mechanism and expresses himself through the phonation of vowel sounds. The speaker focuses on relaxing the abdominal muscles and saying the vowel sound with feeling, instead of trying to say the word. One such exercise is the “Picture Naming Exercise,” which utilizes a series of pictures of various objects. Using Valsalva-relaxed phonation techniques, the participant first says and stretches only the principal vowel sound, without the consonants. Then he stretches the vowel sound and allows the consonants to come along. Then he says the word more naturally, while still focusing on the vowel sound and saying it with feeling.

      – The Humdronian Speech exercise, designed to promote Valsalva relaxation, vowel phonation, and hemispheric lateralization of speech processing through a form of continuous phonation. This transitions to Modified Humdronian Speech and then to normal-sounding Resonant Valsalva-Relaxed Speech.

      – Daily practice routines, each for 30 minutes, to be done twice a day, every day.

      Participants are usually able to feel a difference in their speech during therapy sessions almost immediately. Transitioning this feeling to ordinary speaking situations takes longer and varies greatly depending on the individual. I would estimate that this generally takes from four to six months on average.

      WDP

  15. Hello Mr. Parry. I’m always encouraged to see a professional recognize the inherent risks of “reinforcing the child’s use of effort in “trying hard” to talk fluently.” (from one of your responses). My husband and I heard you speak at our first NSA conference way back in 2004. What you shared made sense to us, we even purchased your book. Our son is now 17 and still struggles but he is not at all interested in focusing his energy on his stuttering. He’d rather talk to his girlfriend and do chemistry homework…What’s that all about?? Every once in awhile I pull your book out, and maybe one of these days he’ll feel compelled to take a peek. Thank you for dedicating so much effort to finding a way out of this mystery…I have no doubt you’ve helped many.
    Best,
    Dori Lenz Holte

    Reply ↓

    • Thanks for your comments. Regarding my book, please be aware that the previous edition, which you may have, does not set forth the Valsalva Stuttering Therapy described in my above article. For that, your son will need to refer to the Revised and Expanded Third Edition (2013).

      Whether or not your son pursues speech therapy is something that he must decide on his own, when he is ready, for his own reasons. The motivation should be to make speech easier and more enjoyable for himself, rather than trying hard to be fluent in order to please others. Furthermore, it is important that your son not limit his career choices because of stuttering. Despite what others might lead you to think, there is much that can be done to overcome stuttering and make speech easier.

      WDP

      • Thank you so much – I will check out the new edition! Have you come across my book, “Voice Unearthed: Hope, Help, and a Wake-Up Call for the Parents of Children Who Stutter?” Yes, at 17, he’s on his own. To do or not to do… I know there is much he can do, but it’s got to be his journey at this point. So far he’s not limiting his career choices — he seriously wants to go to the moon. 🙂
        Best,
        Dori Lenz Holte

  16. Great article. It makes sense to me as a life-long stutterer for there to be an alternative to the traditional FS and SM therapies, which I’ve heard from other adults don’t always work so well.
    It is interesting that you specifically tie anxiety into the mix, as effort as a result of anxiety. As I get older and reflect on my stuttering, I definitely can see where my blocks are often tied to anxiety around speaking situations, and non-speaking related anxiety as well.
    You mentioned the incorporation of CBT training and mindfullness. Do you do that now in therapy?
    -Pam

    • Thank you for your comments. I believe that the role of effort as a response to anxiety is a key to understanding and stuttering. In the past I put more emphasis on cognitive behavior therapy and on trying to replace the participant’s erroneous and negative “self-talk” with more helpful self-talk. This was not as effective as I had hoped, and I have read studies indicating that CBT doesn’t do much to improve fluency. Therefore, I am now integrating more transactional analysis and mindfulness into the speech therapy.

      WDP

  17. Mr. Parry, your approach to stuttering therapy is both enlightening and eye-opening. As a graduate student enrolled in Stuttering II, I am still learning about the various ways to treat stuttering. Your analogy of a “brick wall” is perfect. The step-by-step explanation can be easily understood by people who stutter and clinicians treating stuttering. Describing stuttering as an “internal obstacle” or “interference” can help clinicians better understand the physical struggle their clients face.

    I have a few questions. You describe steps for dismantling the “brick wall.” I am curious about how long you expect the average client to be working towards the first two steps. For example, how long should it take a client to understand Valsalva maneuvers and become accustomed to using relaxed breathing, phonation, and speaking? From reading your explanation of Valsalva Stuttering Therapy, high client motivation seems to be a requirement for success. Would you agree?

    Sally Newcomer
    ISU Graduate Student

  18. Thank you for your comments. In response to your questions, I would expect the average participant in the Valsalva Stuttering Therapy program to understand Valsalva maneuvers and the Valsalva Hypothesis within the first two weeks. I would expect him to become accustomed to Valsalva-relaxed breathing, phonation, and speaking during therapy sessions within the first four weeks.

    Transferring Valsalva-relaxed speech to ordinary speaking situations is a gradual process, which depends largely on the type of speaking situation and the amount of anxiety the person attaches to it. On average, I expect to see significant improvement within six months.

    As with any kind of therapy, the participant must have proper motivation in order to achieve the most benefit. In Valsalva Stuttering Therapy, this involves not only the willingness to do practice routines every day, but also the willingness to change one’s beliefs about stuttering, responses to anxiety, and intentions in speaking. Some persons who stutter have the motivation to change, but others do not. Those persons who are just looking for a quick and easy “fluency technique” to “stop stuttering” are not appropriate for my program.

    WDP

  19. Could you please describe in more detail the justification of the Valsalva-relaxed breathing?

    • The purpose of the Valsalva-relaxed breathing exercises is to replace your habitual stuttering behavior with a new behavior pattern that will allow you to speak easily and effortlessly. Valsalva-relaxed breathing exercises are intended to help you reduce the Valsalva mechanism’s interference with speech by:

      • Establishing a proper breathing pattern for speech, by inhaling a full breath using your diaphragm, relaxing your abdominal muscles when exhaling, and letting the air flow freely (instead of blocking the airway and building up air pressure as in a Valsalva maneuver). The out-flowing
      breath creates and carries all the sounds of speech and requires very little physical effort. Speech cannot occur when you are holding your breath. Almost all the effort is used to inhale, when you are not speaking. The exhaled breath necessary for speech is produced when you relax the muscles that were used for inhaling.

      • Relaxing your abdominal muscles while exhaling, in order to relax your Valsalva mechanism and reduce its interference with speech. When one part of the Valsalva mechanism is relaxed, the other parts (including the laryngeal muscles for effort closure) relax also, because they are neurologically coordinated to act in unison.

      • Focusing on vowel sounds, rather than consonants, in order to prepare your larynx to phonate the vowel sounds rather than to exert effort.

      • Emphasizing the ease and effortlessness of speaking on your relaxed breath.

      • Changing your intention in speaking to relaxing your abdomen, letting the air flow freely, and letting the vowels flow with feeling, rather than “trying to say the word.”

      • Using the vowel sounds and freely-flowing air to release and express your feelings, instead of channeling them into effort and air pressure.

      This new behavior must be practiced repeatedly, until it becomes so habitual that you will do it without thinking – even in the face of stressful speaking situations.

      WDP

  20. Your brick-wall analogy is a useful one. My first thought is that I have several ways now to go over, around and through that wall. My second thought is that I feared that wall for many years, but now that fear is gone. Like my speech is unique, perhaps my brick wall is unique also. Enjoyed your presentation. Good thinking point.

  21. Mr. Parry,

    My name is Wes, and I am currently a graduate student studying speech-language pathology. Stuttering and fluency is one of the areas of our profession that has caught my interest. Though I haven’t been able to participate in any direct intervention for stuttering yet, I am interested in different approaches and techniques that I can use for when I do begin my intervention.

    In my learning about therapy for stuttering, there are three core elements that keep showing up: evenness of rate, gentleness of onset, and naturalness of inflection. Through Valsalva Stuttering Therapy, the PWS is taught to initiate words on a gentle exhale. The abdominal muscles are taught to relax, and the speaker focuses on the vowels, rather than the “brick wall” consonants. This approach to therapy includes each of these three core elements. Another aspect that I have discovered as a core element of stuttering intervention is behavior modification/therapy, pertaining to targeting the emotions, presumptions, and anxieties associated with stuttering. However, this approach (VST) is the first approach I have have learned about that does not seem to target behavior directly. Do you present this technique as a behavioral approach to your clients? Is behavior therapy a secondary aspect? Do you present it solely as a physical, anatomical approach? Do you suggest there exists a place in stuttering intervention where behavior therapy isn’t warranted?

    I have a fascination with stuttering intervention. Since you have (almost) put behavior therapy out of the picture with this approach, it challenges my own assumptions about stuttering intervention, which I enjoy. I know I just bombarded you with questions in the previous paragraph, but I have become very tuned to your paper, and very intrigued by your intervention approach. I thoroughly enjoyed reading and learning about your experiences and the success you have experienced through this approach. Thank you very much for sharing.

    Wes

    • Actually, Valsalva Stuttering Therapy does devote a great deal of attention to the “emotions, presumptions, and anxieties associated with stuttering.” VST views the emotional, psychological, neurological, and physiological aspects of stuttering as all being important elements of an interactive system.

      WDP

  22. I am very intrigued by your paper and efforts to break down the “brick wall” of stuttering. It’s exciting to read about therapy approaches that address stuttering in a holistic manner, helping PWS find their own voice through physiological, emotional, and behavioral modifications. Combined, these approaches seem to reduce the effects of the anxiety experienced by PWS.

    Research by Horovitz, Johnson, Pearlman, Schaffer & Hedin (1978) found an increase in the stapedial reflex (triggered by laryngeal tension) of PWS when they became more anxious. Have you studied the effect of VST on laryngeal tension in PWS?

    Thank you for sharing your thoughts and expertise,
    Jennifer Dutton
    Student, Undergrad SLP program

    • Although I don’t have access to high-tech apparatus to measure laryngeal tension electronically, there is no doubt from subjective reports that Valsalva Stuttering Therapy helps to reduce laryngeal tension.

      I am also familiar with research and theories regarding the stapedius muscle, and I doubt that it has anything to do with the cause of stuttering. In the past, some experts have tried to connect stuttering to the stapedius, a tiny muscle in the middle ear. This muscle regulates the loudness of sounds transmitted from the eardrum to the inner ear. It is also neurologically coordinated with the larynx, to protect the inner ear from the sound of our voice. When we intend to speak, the stapedius muscle contracts a fraction of a second before phonation begins.

      The timing of these contractions is the same in stutterers as in normal speakers. (Shearer & Sim¬mons, Middle ear activity during speech in normal speakers and stutterers, Journal of Speech and Hearing Research, 1965, 8, 203-207.1965.) When a person stutters, however, the activity of the stapedius does not simply parallel the vocal sound, as it does during fluent speech. It may also contract during the blocks, even though no sound is being produced. (Shearer, Speech: behavior of middle ear mus¬cle during stuttering, Science, 1966, 152, 1280.)

      This behavior does not mean that the stapedius muscle causes stuttering, as is sometimes suggested. It is far more likely that the stapedius is simply reacting to signals being sent by the brain during the struggle to speak.

      Although the stapedius theory and other “hearing defect” theories stirred up considerable interest when first proposed, no one has yet been able to show that a specific hearing defect actually causes stuttering. Furthermore, the theories share some serious defects themselves. In particular:

      – They are far too narrow in their application. They attempt to explain disfluencies strictly in terms of a few facts related to hearing, while ignoring many other aspects of stuttering. They create the impression that stuttering can be controlled only by masking or other auditory feedback techniques, when we know that this is not the case.

      – They don’t adequately explain the great variability of developmental stuttering. They simply assume that the defects are somehow aggravated by “stress” or “anxie¬ty.”

      – They don’t explain silent blocks, when no sound comes out of the stutterer’s mouth at all. As we know, stuttering often begins before any auditory feedback can be heard.

      In my view, there is nothing wrong with stutterers’ ability to process auditory feedback. Instead, the problem may be in how we use the feedback. If we focus our attention on stuttering, auditory feedback may increase our urge to activate the Valsalva mechanism, making speech more difficult. On the other hand, if we listen for the music and resonance of our voice, auditory feedback can be a positive influence, guiding us toward improved phonation and fluency.

      WDP

  23. Hi I’m armina I’m 19 yrs. Old armina still studying I also stutter.,.. can I ask what is the best thing to do to lessen your stuttering.. hhmm sometimes its hard for me to stop my stuttering..

    Thanks,

    • People often ask speech therapists for simple tricks or speaking techniques that will make their stuttering quickly and permanently disappear. However, it is impossible for any SLP to diagnose and treat stuttering by e-mail. Furthermore, any “tips” that she might give would prove to be worthless.

      It is unrealistic to expect that any speaking technique, by itself, will overcome all the factors involved in persistent developmental stuttering. As the Valsalva-Stuttering Cycle in my book illustrates, the outward manifestations of stuttering are only the “tip of the iceberg.” An effective therapy must also address the beliefs, expectations, fears, and intentions that trigger stuttering, as well as all the psychological and physiological factors that tend to perpetuate it.

      To be successful, stuttering therapy must include three aspects: education, practice of new intentions and behaviors, and then transfer of the new attitudes and behaviors to ordinary speaking situations. Therefore, just as stuttering is multi-faceted, therapy must also be multi-faceted.

      WDP

  24. Dear Mr. Parry,
    My name is Sarah and I am a speech-language pathology graduate student. I enjoyed reading about your new and different technique to fluency therapy and found it very interesting. As I was reading the article I questioned if this technique works on all patients who stutter or PWS who have more specific stuttering characteristics? In addition, I would like to know if this approach is more effective because it targets the psychological and fluency aspects of stuttering?

    Thank you.

    • As long as it is ordinary developmental stuttering, the specific stuttering behavior (e.g., repetitions, prolongations, forceful closures, hesitations, word substitutions, etc.) doesn’t matter. Other factors are more problematical, such as significant neurological or cognitive deficits, deep-seated emotional issues, and personal resistance to changing one’s intentions in speaking. I think Valsalva Stuttering Therapy is particularly effective because it targets the effort impulse in speaking (rather than fluency per se), as well as the psychological aspects of stuttering.

      WDP

  25. You noted that the stress and anxiety one experiences when stuttering often causes them to momentarily forget the techniques that they have been learning in therapy. How does your approach address this disconnected between learning the technique and being able to apply it in real life situations? In other words, how do help ensure that your patients remember to utilize the Valsalva-relaxed stuttering techniques outside of therapy?

    • First, the participant must be aware of this phenomenon and understand why it happens. Second, there must be repetitive practice in the new behavior (in this case, phonation of the vowel sound) to the point that it becomes habitual, even under stress.

      WDP

  26. It was very interesting to read about your approach to stuttering therapy. I like how you address the psychological and emotional aspects of stuttering directly. So many of the therapies currently utilized focus on increasing fluency instead of decreasing the emotional and psychological response to stuttering. How many sessions are typically needed for this therapy technique to be effective and result in easier speech?

    • Most of the participants in Valsalva Stuttering Therapy have achieved easy, natural-sounding speech within two or three hours of therapy, within the context of therapy sessions. Transferring this to real-life, stressful speaking situations takes much longer, depending on the individuals and the amount of emotional baggage they have accumulated. Veterans of “fluency shaping” and “stuttering modification” programs generally take longer than those who have had no prior therapy, because they must first unlearn some extremely detrimental beliefs, intentions, and behaviors that these programs tend to promote.

      Generally, very good results can be achieved in about 15 hours of therapy over a period of period of about 4 months. Excellent results are generally achieved in about 25 hours of therapy over a period of about 6 months.

      WDP

  27. Hi Bill,

    I enjoyed reading your insightful paper and can thoroughly recommend your book to all. I’m sure that many people will find both of interest and value. Fortunately, I’ve already dismantled the brick walls that I once experienced, so the paths that I’ve always wished to tread are no longer impeded. 🙂 

    Kindest regards

    Alan

    • Hi Alan,

      Thanks for your kind comments. I’m glad you enjoyed my book.

      Best wishes,

      Bill