This article is adapted from Chapter 21 of Understanding & Controlling Stuttering (2d ed., 2000, 5th Printing, updated 2009).

This and other articles on this website will discuss various forms of stuttering therapy in the context of the Valsalva Hypothesis and their possible effects on the "Valsalva-Stuttering Cycle."  For a more thorough introduction to the Valsalva Hypothesis and the Valsalva-Stuttering Cycle, see Stuttering and the Valsalva Mechanism: A Key to Understanding and Controlling Stuttering Blocks.

IN CONTRAST to the "psychologi�cal" ap�proaches to stutter�ing ther�apy dis�cussed in the previous chap�ter, behavior-oriented therapies focus on what stutterers do, rather than what they think or feel.  Such thera�pies pay less attention to the atti�tudes and emotions that affect stut�tering, and concen�trate more on the physical act of stut�tering it�self.

A wide variety of therapies may fall into this category.  In this chapter, we shall look at several exam�ples that have been popular in recent years.  As usual, we shall analyze them from the view�point of the Valsalva Hypo�thesis, assessing their strengths and shortcomings in terms of their pos�sible effect on the Valsalva-Stut�tering Cycle.

Voluntary Stuttering

The first method we shall discuss grew out of research by Bryng Bryn�gelson and others at the University of Iowa in the 1930's.  At that time, speech scientists were re�ject�ing the older forms of treat�ment (such as rhythm, elocu�tion drills, and unusual ways of speak�ing), on the grounds that their results were super�ficial and short-lived.  Hop�ing to achieve better long-term results, Bryn�gelson tried an approach that was just the oppo�site of most therapies.

He called it voluntary stutter�ing.  Instead of pressur�ing stut�terers to speak fluently, this method required that they stutter on purpose.  The stutter�ers were in�structed to block intentional�ly on non-feared words C those on which no trouble was antici�pated.  This technique was based on the concept of negative practice.  By stuttering inten�tionally, it was hoped that stut�terers would be able to change the involun�tary nature of their spasms into volun�tary be�hav�ior that could be con�sciously con�trolled.

Originally, stutterers were told to observe their precise stuttering behavior in front of a mirror, and then dupli�cate the actual blocks when stutter�ing voluntarily.  This proved to be a difficult task.  Conse�quently, this ap�proach was soon abandoned in favor of an easier, modi�fied form of volun�tary stut�tering, called voluntary con�trolled repetition (or "VCR").  The stutterer was taught to repeat the begin�nings of words in an easy, relaxed way, with�out using the excessive force characteristic of real stutter�ing.  The stut�terer was then assigned to go around in public, inten�tion�al�ly tuh-tuh-talking something like thuh-thuh-this.

Proposed benefits.  Many speech pathologists have strongly recommended voluntary stuttering as a part of therapy.  Several possible benefits have been suggested:

Drawbacks.  Despite its highly touted benefits, volun�tary stuttering has had serious limitations.  Its first and biggest drawback is that most stutterers simply refuse to do it!  I can easily understand why.

Although voluntary stuttering is supposed to help us con�front our stuttering in an honest and open way, I have never felt very honest about using it.  Volun�tary controlled repetition doesn't sound or look like real stut�tering, but rather like the pseudo-stuttering we sometimes hear when people try to mimic us.  Listeners don't know what to make of it.  Whereas a genuine block might arouse some degree of sympa�thy, the bogus quality of VCR is more likely to provoke nervous giggles or per�plexed stares.

Furthermore, voluntary stuttering is rarely an adequate therapy by itself.  Fear and avoidance of stuttering are only two of the many factors that con�tribute to the Val�salva-Stuttering Cycle.  I would rather prac�tice techniques that could accom�plish the same objectives while at the same time promoting fluency in a more tangi�ble way.

If one purpose of voluntary stuttering is to gain control over our spasms, then the behavior that we should target is not the tendency to repeat, but rather our tendency to activate the Valsalva mechanism during speech.  Volun�tary stuttering might be more effective if, instead of repeat�ing the beginning sound of a word, we silently blocked on the word by doing a Valsalva maneu�ver C that is, by tightly closing the mouth or larynx and build�ing up air pressure.  We would then practice a method of releas�ing the block by relaxing certain parts of the Valsalva mech�anism.

This exercise, called voluntary Valsal�va, will be discussed in more detail in a subsequent chap�ter.  It would not be as conspicuous as VCR, and yet would pre�serve many of the theoreti�cal benefits attributed to volun�tary stuttering.  But most impor�tant, it would give the stutterer valuable practice in controlling and relaxing the Valsalva mecha�nism C the physiologi�cal key to stut�tering behavior.

Stuttering Modification

Research at the University of Iowa spawned another influen�tial approach to therapy, gener�al�ly known as stut�tering modifica�tion.  Pioneered by the late Charles Van Riper (who was later at Wes�tern Mich�i�gan Uni�versity), it sought to modify the way in which people stut�tered, so that their symp�toms would be less severe.

The stuttering modification therapies generally viewed stuttering as a collection of inappropriate learned be�haviors involving the lips, tongue, jaw, larynx, and other parts of the speech mechanism.  Stutterers were some�times told to "freeze" the mo�ment of stuttering in order to identify the symp�toms peculiar to their in�dividual patterns of stut�tering.  Various techniques were then used to help stutterers combat these symptoms.

One method was to replace the stutterer's tense strug�gles with a form of voluntary stuttering that utilized smooth prolon�gations of sounds.  This type of speech is sometimes referred to as fluent stutter�ing.

Block Correction Techniques.  Van Riper developed a number of techniques designed to help stutterers deal with their blocks more effec�tively.  These consisted of three principal methods:

Effects on the Valsalva-Stuttering Cycle.  Some of Van Riper's techniques may indirectly affect the Valsalva-Stut�tering Cycle in a number of benefi�cial ways.  Because the speech objec�tive is defined as "fluent stuttering" rather than normal fluen�cy, the stutterer may feel less demand for good speech, thereby reducing his anticipation of diffi�culty (Step 1 of the Cycle).

The "preparatory set" technique, emphasizing constant movement through articulatory positions, may affect Step 2 of the Cycle (the urge to "try hard" by using physical ef�fort).  By reminding us that words are a sequence of move�ments, this tech�nique may reduce our tendency to treat words as if they were "things" that could be physi�cally forced out by means of a Valsalva maneuver.  Finally, the techniques of "fluent stutter�ing" and "pull-out" both rely on the prolongation of sounds.  Prolon�gation is a widely used fluency tech�nique, whose effect on the Valsalva-Stut�tering Cycle is discussed in Chapter 17 of Understanding & Controlling Stuttering.

Problems.  Stuttering modification has proven to be a difficult approach, requiring individualized therapy and inten�sive monitoring of one's speech.  Numerous strategies must be learned in order to cope with the many varieties of stuttering behavior.  Re�membering and coordinating all these tech�niques during speech is a com�plicated task that may quickly fall apart in times of stress.  Even when the tech�niques work as they should, the result is still not nor�mal fluency C it is only fluent stuttering.

Stuttering modification therapies have had limit�ed ef�fec�tiveness because they fail to recognize the cru�cial role played by the Valsalva mechanism in block�ing speech.  Merely trying to modify be�havior of the speech mechanism is not enough to control stutter�ing, as long as this underly�ing physi�ological cause re�mains un�checked.

Relaxation

The relaxation approach to therapy, which has a long histo�ry, gained renewed popularity in the 1920's and 1930's.  It has continued to appear in updated reincar�na�tions to this day.

The basic concept of relaxation therapy is sim�ple.  The therapist uses one of various techniques to put stut�terers into a state of deep relaxation.  Often this is done in a group setting, with several stutterers lying on mats, listen�ing to a therapist speak in sooth�ing tones.  While they are perfectly relaxed, the therapist gradually instructs them to make sounds, form words, and speak sentences.

During relaxation, stutterers usually ex�perience an imme�diate and dramatic decrease in stut�ter�ing.  Unfortunately, it is a fragile fluency, which quickly crumbles when the stutterer returns to the out�side world.  The big chal�lenge has been finding a way to reproduce the same level of relaxation and fluency in the stressful environment of ordinary speaking situa�tions.

Relaxation techniques.  Numerous methods have been used to induce relaxation in stutterers, of which only a few will be mentioned here.  One example is visualiza�tion therapy, in which the stut�terer is asked to imagine a peaceful scene de�scribed by the therapist.

Visualization is sometimes combined with a technique called systematic desensitization.  After becoming totally relaxed, stutterers are told to imag�ine themselves in vari�ous speaking situations.  They start with easy ones, like talking to a friend, and move to others that are in�creasing�ly difficult, like using the tele�phone or speaking before a group.  These exercises are sup�posed to help stut�ter�ers con�trol their tension when the real situation comes along.  However, many stutterers have found that imagina�tion and reality are worlds apart.

A more physical approach to relaxing the body is based on a technique called progressive relax�ation, introduced by Edmund Jacobson in 1938.  The pa�tient is taught to relax various muscles groups, usual�ly begin�ning with the toes and work�ing all the way up.  With each part of the body, the patient first tenses and then relaxes the mus�cles in question.

Nowadays, a person's control over muscle ten�sion can be electronically enhanced by means of electromyo�graphic (EMG) biofeedback.  Elec�trodes, pasted to the skin, are used to measure mus�cle tension in a part of the bod�y.  This infor�mation is converted into an audible tone, which changes in pitch depending on the amount of ten�sion.  The patient can easily tell when he is relax�ing, be�cause the pitch gets lower.  The object is to achieve maxi�mum relax�ation by making the pitch go as low as possible.

EMG biofeedback has been used in stuttering therapy to reduce tension in various muscles in�volved with speech.  One researcher found that relaxation of the larynx and upper lip helped to reduce stutter�ing.

Evaluation of relaxation therapy.  Relaxation may pro�mote fluency by affecting the Valsalva-Stut�tering Cycle on several levels.  Psychologically, it may reduce our fear of speaking, and therefore our anticipation of difficulty (Step 1).  It might actually make speech easier from a physical stand�point, be�cause relaxed muscles are more respon�sive than those that are tense and stiff.  Relaxation would reduce our urge to use physical effort in speaking (Step 2), as well as relaxing the Valsalva mechanism and pre�venting its activation (Step 3).

Unfortunately, stuttering therapies based on general relaxation of the entire body have a seri�ous prac�tical prob�lem.  It is difficult to keep one�self suffi�ciently re�laxed, when assailed by the de�mands and stresses of everyday life.  As Van Riper once said, "It's hard to be a limp rag in a steel world!"

 However, fluency does not require relax�ation of the entire body.  The only muscles that really matter are those connected with the force behind stuttering C the Valsalva mechanism.  It might be easier to maintain the relaxation needed for fluen�cy if one simply concentrated on relax�ing some of those mus�cles (for example, the ab�domi�nal and rectal muscles).  Progressive relax�ation or EMG bio�feed�back might help stutter�ers learn to do this, thereby enabling them to con�trol the Val�sal�va mechanism during speech.

Fluency Training Programs

During the 1960's and 1970's, the face of stut�tering ther�apy was again transformed C this time by new con�cepts borrowed from the growing field of behavior psy�chology.  After much trial and error, there emerged a new batch of therapies that might be called flu�en�cy training.  Al�though many different methods were used, most of these thera�pies followed a similar basic strategy:

Fluency training was less dependent on indi�vidu�alized therapy than stuttering modification had been, because all patients could be taught the same basic speech technique regard�less of their specific symp�toms.  Conse�quently, this approach lent itself to the development of standardized programs that could be administered to many stutterers at the same time.

Precision Fluency Shaping.  Perhaps the most famous of these programs has been the Precision Fluency Shap�ing Program (now called "The Hol�lins Fluency Sys�tem") spon�sored by the Hollins Commu�nications Re�search In�stitute in Roanoke, Virginia.  Stutter�ers go for an inten�sive two-week program (previously for three weeks) aimed at completely retraining their speech mecha�nism.

For the first week, stutterers are drilled in saying one-syllable words, spoken at a snail's pace of two seconds per syllable.  Assisted by comput�ers, they shape their speech in accordance with specified "tar�gets."  These have such names as "stretched sylla�ble," "gentle onset," "reduced articu�latory pressure," "full breath," "re�duced air pres�sure," "slow change," "trans�fer," and "ampli�tude con�tour."

These targets incorporate numerous fluency enhancing tech�niques, whose effects on the Valsal�va-Stuttering Cycle are discussed in various chapters of Understanding & Controlling Stuttering.  Through massed practice, they are supposed to become habitual.  However, it is doubtful that a person could remember them all when speaking under stress (for ex�ample, when responding to an angry boss).

The patients gradually move on to multi-sylla�ble words and full sentences, until they master a tech�nique called "slow normal speech."  Then they are taken out to practice their skills in actual speaking situ�ations.

Hollins is only one of many fluency training programs conducted throughout the United States, Canada, and other coun�tries.  While some are pat�terned closely after the Hollins model, others use their own training methods and emphasize differ�ent fluency enhancing tech�niques.

Phonation therapies.  Some therapies empha�size phona�tion as a key to fluency.  These include such techniques as con�tinuous phonation, legato speech, prosody, and vocal control therapy.  The general idea is to keep the larynx constantly vibrat�ing, with little or no break in pho�nation between words.  The monitoring of one's phonation can also be assisted by the "Vocal Feed�back Device" or the "Flu�ency Mas�ter," previously described.

As discussed in Chapter 17 of Understanding & Controlling Stuttering, any method that em�phasizes phonation may affect Step 3 of the Valsalva-Stuttering Cycle, by neurologically tuning the larynx for phonation rather than for a Valsalva maneuver. 

Airflow therapy.  Another highly publicized fluency pro�gram uses the passive airflow tech�nique, popular�ized by Martin F. Schwartz.  The stutterer  is taught to exhale a gentle stream  of air through the larynx before beginning to talk.  This is to be done in a very relaxed way, without forcing the breath at all.

The stutterer then eases smoothly into speech, without interrupting the airflow, and stretches the first word or sylla�ble.  If stuttering still occurs, the stutterer then uses "low energy speech," talking softly, with as little effort and move�ment of the mouth as possible.  Schwartz's pro�gram (which con�sists of a two-day seminar followed by a corre�spon�dence course) also in�cludes exercises aimed at stress reduction and reinfor�cing the patient's use of these tech�niques.

According to Schwartz, his therapy is designed to com�bat the "physical cause of stuttering" C which he asserts is a locking of the vocal cords due to stress.  While this theory has a certain simplistic appeal, it is contradicted by several studies show�ing that the vocal cords don't al�ways lock during stutter�ing.  (See Stark�weather, 1982; Conture et al., 1985.)  On the con�trary, the point of blockage is often in the mouth rather than the larynx.

Airflow therapy can be explained much more cogently by the Valsalva-Stuttering Cycle.  First, the air�flow keeps the airway open, avoiding a build-up of air pressure that could trigger a Valsalva maneuver C as seen in Step 4(b) of the Cycle.  Next, the stretching of the first syllable emphasizes phonation, affecting Step 3, as previously men�tioned.

Shortcomings.  Although modern fluency train�ing pro�grams may be more effective than therapies of the past, the astronomical "success rates" advertised by some pro�grams should be taken with a grain of salt.  None of these programs should be considered a miracle cure for stutter�ing.  Many stutterers resist using the speaking techniques taught by these pro�grams because they sound "unnatural."  Others find the need for con�stant monitor�ing of one's speech to be an exhaust�ing task.  All too often, patients are fluent at the end of the program, but relapse after a few weeks or months.

These problems may be due, in part, to the fact that fluency techniques are only indirect and relative�ly ineffi�cient ways of controlling the Valsal�va mecha�nism.  Even after completing a fluency program, stutterers will still be confronted with the Valsalva-Stuttering Cycle.  When they anticipate difficulty in speaking (Step 1), they may feel an urge to "try hard" to use their new technique (Step 2).  Not knowing any better, they may again suc�cumb to their old tendency to activate the Val�salva mech�anism, in an effort to help things along by "forcing" the words out (Step 3).

Once the Valsalva mechanism takes command of the mouth or larynx, all attempts to use fluency  techniques may prove futile.  Suddenly, the per�son may find himself back in the grip of stut�tering without any idea of how it happened!