What treatments are available for stuttering? The right therapy will depend on what you want to achieve.
Are you looking to significantly reduce your stuttering? Or, perhaps, you would just like to worry less about stuttering or want to learn to stutter in a more relaxed, manageable way? Read on to find the right therapy for you or have a look at our top 5 things you to know if you're thinking about therapy.
Click here for a free information sheet about Fluency Shaping therapies.
Stuttering therapies can be broadly split into two camps:
Fluency Shaping – which seeks to replace stuttering with fluent speech using new speaking patterns and intensive practice. Download a free information sheet about Fluency Shaping therapies by clicking the picture to the right.
Stuttering Modification – which focuses on becoming more aware of the physical process of stuttering, as well as learning to challenge any negative thoughts and feelings that accompany it. The speaker learns techniques to manage moments of stuttering and to stutter more easily.
Therapy can also incorporate both of these approaches – for example, minimise stuttering but also help you accept and manage any stuttering that might remain.
Fluency Shaping Therapies Prolonged Speech In this therapy you will start by learning to produce fluent speech at a very slow rate, prolonging each sound. It is important to not simply add pauses between words to slow the speech rate – but to prolong each speech sound. You will then slowly increase the speech rate until you find the optimum rate at which you can still speak without stuttering. Therapy focuses on using this new speaking style in progressively more difficult speaking situations. There is good evidence to support the use of prolonged for reducing stuttering (Bothe et al., 2006).
Modifying Phonation Intervals 2 (MPI-2) This is an exciting new therapy that makes use of an iOS app to give you feedback about your speech and helps you to speak more fluently. The app analyses your speech and helps you to reduce the number of short phonation intervals (i.e. times when your vocal folds switch on and then off very quickly). Reducing the frequency of these short intervals has been shown to reduce stuttering (Ingham et al., 2015). As with prolonged speech, you then learn to maintain this reduction of short intervals during a series of progressively more challenging speaking situations (e.g. starting with reading aloud alone, working towards situations such as speaking on the phone). This approach has many of the advantages of prolonged speech but is able to achieve more natural sounding speech. The use of an app allows the user to practice independently in a highly structured programme.
Easy onsets (aka gentle voice onsets) Easy onsets are a strategy used to produce vowel sounds at the start of words. Sudden movement of the vocal folds and excess tension around the vocal folds can lead to blocking, repetition or prolongations on vowel sounds at the start of a word or phrase. Easy onset speech refers to the slow initiation of vocal fold vibration (Max & Caruso, 1997). Imagine the voice like the engine of a car. Easing the accelerator slowly will result in the smooth movement of the car, while jamming your foot down on the accelerator all at once will likely result in stalling the engine. Something similar is at work in the vocal folds during speech.
You can get a sense of what easy onsets are like by adding a quiet “h” sound before the vowel. “h” is a voiceless sound and adding this to the start of the word ensures that the vocal folds do not go straight from a closed position to vibrating as the voice slowly turns on. So, “after” might be produced more like “hhafter”. Therapy begins by easing into vowel sounds in a very exaggerated way, before learning how to use this strategy in a more natural way for everyday speech.
Soft contacts (aka light articulatory contacts) Moments of stuttering are often associated with excess tension of the tongue and lips. Speech sounds that involve increased constriction of the oral cavity, e.g. the plosive sounds /b/, /p/, /t/, /d/, /k/, & /g/, may be produced with overly hard, tense lip or tongue movements (Max & Caruso, 1997).
Soft contacts refers to the deliberate use of light mouth movements to minimise or prevent moments of stuttering. As with easy onsets above, reduced tension (this time in the tongue and lips) helps the speaker to flow more easily from one speech sound to the next without becoming stuck on a particular sound.
Stuttering Modification Stuttering Modification Therapy, developed by Charles Van Riper, focuses on developing the speaker’s awareness of the moment of stuttering (how it feels, what they are thinking, what the body is actually doing) (Van Riper, 1973). Instead of trying to eliminate these moments of stuttering, this approach tries to modify the stuttering into a more relaxed, easy style that does not disrupt the forward motion of speech. This approach helps the person who stutters to confront and start to change the patterns of fear and avoidance that can develop from living with a stutter.
Once the speaker has identified how they stutter, therapy moves on to desensitising them to stuttering. This might involve becoming more open about your stutter (e.g. self-advertising to others about your stutter and your therapy for it), detailed self-analysis of what you are doing in the moment of stuttering, and techniques to desensitise you to the act of stuttering (e.g. voluntary stuttering). Negative thoughts and assumptions about stuttering are challenged.
Strategies are then taught to help the speaker modify their moments of stuttering. These modification techniques are:
Cancellations: where the speaker repeats a word on which they have stuttered, except in a slow and controlled.
Pull-outs: where you learn to change your speaking style mid-way through a stuttered word, switching to a slower and more controlled delivery for the rest of the word.
Preparatory sets: where the speaker anticipates a word being difficult to say and works through the sounds of the word using a slow rate and light articulatory contacts. This slow, controlled speaking style is maintained for the rest of the word.
While there is no consensus amongst researchers and therapists about which stuttering therapy is the most effective, we can draw a few conclusions from the research.
One thing to emphasise is that there is a lot of variation between people who stutter. The experience of stuttering and desired therapy goals will differ from person to person and will even vary for individuals at different times in their lives.
While there is a lot of evidence that therapy for stuttering works overall (Baxter et al., 2016), it is more challenging to determine which approaches are the most effective. One difficulty is that different therapies have different objectives, for example some seek to reduce stuttering itself while others are more focused on changing how people think and feel about their stuttering, and so the results of these therapies are difficult to compare.
Evidence from a Systematic Review and a Meta-analysis One way to get an idea of which stuttering therapies are most effective is to look at a systematic review. This is a study that analyses the results of a range of previous studies and tries to summarise the overall findings. In their systematic review Bothe et al. (2006) found that the most powerful therapy for adults who stutter involves intensive prolonged speech treatment as part of a highly structured programme with an emphasis on self-management, real-world practice, and developing speech naturalness. A meta-analysis (which is similar to a systematic review) by Andrews et al. (1980) also found prolonged speech to be one of the most effective therapies, along with easy onsets. (See here for details of prolonged speech and easy onsets).
Evidence for Stuttering Modification Many therapists provide stuttering modification therapy, or variations upon this. Developed by Charles Van Riper (see Van Riper, 1973), this approach seeks to help people to stutter less and in a more manageable way, largely by helping them change their attitude to stuttering. The speaker is taught to challenge how they think about stuttering (for example, avoiding situations less and becoming more comfortable with the act of stuttering) and taught strategies to move past stuttering smoothly where it occurs in their speech.
While this a very popular approach to therapy, there is very limited research into its effectiveness. One example is Blomgren, Roy, & Callister (2005), who delivered The Successful Stuttering Management Program, a 3-week intensive stuttering modification programme, to 19 adults who stutter. After completing the programme, participants showed a significant improvement on a measures of stuttering severity as well as measures of struggle, avoidance and expectancy. At follow-up 6 months after the programme, some positive changes were still apparent – specifically, how the participants thought about their stuttering and their anxiety levels. However, there was no long term effect on frequency or severity of stuttering, nor did this programme reduce muscular tension when stuttering or the speaker’s perception of struggling when trying to speak.
Another study, by (Laiho & Klippi, 2007), delivered intensive stuttering modification groups to school-age children and teenagers who stutter (6.8-14 years). The study found a significant overall reduction in stuttering for participants immediately after treatment (i.e. 14 participants saw a reduction in stuttering, 4 saw no change, and 3 saw a slight increase). There was also a significant overall reduction in avoidance behaviours and struggle when stuttering after the group finished (again approximately two thirds of participants saw an improvement). A follow-up questionnaire sent to participants and their parents 9 months after the groups showed that all but one teenager and one parent who responded reported that positive changes had continued. The best we can say from the Laiho & Klippi study is that intensive stuttering modification treatment may be helpful for some children and teenagers who stutter. Unfortunately, Laiho and Klippi’s follow-up testing consisted only of subjective survey responses from participants and their parents. No objective data was collected regarding stuttering frequency at follow-up so it is not possible to know whether the reduction in stuttering was maintained long-term.
What about costal breathing techniques (as used in the McGuire Programme and others)? Costal breathing is taught in the McGuire Programme, amongst others (e.g. The Starfish Project), as a speech technique to overcome stuttering. There are certainly those who have attended these courses and found them beneficial, as well as those who have not found the approach helpful. However, there are as yet no peer-reviewed studies into whether the McGuire Programme or similar programmes reduce stuttering (Ward, 2018).
Summary The best evidence we have seems to point to a highly structured prolonged speech programme, or variants on this, as the most effective way to reduce stuttering frequency.
Given the psychological effects of living with a stutter, it may also be beneficial to carry out therapy to target any negative thoughts and behaviours that have developed around stuttering. This may help reduce avoidance of situations and anxiety. There is, however, no compelling evidence that this type of behavioural therapy reduces stuttering itself.
References Andrews, G., Guitar, B., & Howie, P. (1980). Metaanalysis of the effects of stuttering treatment. Journal of Speech and Hearing Disorders, 45, 287-307
Baxter, S., Johnson, M., Blank, L., Cantrell, A., Brumfitt, S., Enderby, P., & Goyder, E. (2016). Non-pharmacological treatments for stuttering in children and adults: a systematic review and evaluation of clinical effectiveness, and exploration of barriers to successful outcomes. Health Technology Assessment, 20(2), 1-302
Blomgren, M., Roy, N., & Callister, T. (2005). Intensive stuttering modification therapy: A multidimensional assessment of treatment outcomes. Journal of Speech, Language and Hearing Research, 48, 509-523
Bothe, K., Davidow, J.H., Bramlett, R.E., & Ingham, R.J. (2006). Stuttering treatment research 1970-2005: I. Systematic review incorporating trial quality assessment of behavioural, cognitive and related approaches. American Journal of Speech-Language Pathology, 15(4), 321-341
Ingham, R., Ingham J., Bothe, K., Wang, Y., & Kilgo, M. (2015). Efficacy of the modifying phonation intervals (MPI) stuttering treatment program with adults who stutter. American Journal of Speech-Language Pathology,24(2), 256-71
Laiho, A., & Klippi, A. (2007). Long and short-term results of children’s and adolescent’s therapy courses for stuttering. International Journal of Language and Communication Disorders, 42(3), 367-382
Max, L. & Caruso, A. J. (1997). Contemporary techniques for establishing fluency in the treatment of adults who stutter. Contemporary Issues in Communication Science and Disorders, 24, 45-52
Van Riper, C. (1973). The Treatment of Stuttering. Englewood Cliffs, NJ: Prentice-Hall
Ward, D. (2018). Stuttering and cluttering: Frameworks for understanding and treatment. 2nd Ed. Abingdon: Routledge
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