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New Insights and Tools for Understanding and Reducing Stuttering Blocks William D. Parry, J.D., M.A., CCC-SLP Chapter Leader, National Stuttering Association Philadelphia, Pennsylvania, U.S.A. Prepared for the International Stuttering Associations 10 th World Congress for People Who Stutter Lunteren, Netherlands June 2013 Copyright 2013 by William D. Parry Slide 2 My Background Struggled with stuttering most of life. After decades of failed therapies, began my own research and experimentation in early 1980s. Valsalva Hypothesis and exercises in Valsalva Control - dramatically improved fluency and enabled me to become a successful trial lawyer. Active as a leader in the National Stuttering Association (U.S.) since 1985. Presented many workshops on stuttering and wrote Understanding & Controlling Stuttering, now in a Revised and Expanded Third Edition. Copyright 2013 by William D. Parry ISA 10th World Congress 20132 Slide 3 Second Career as an SLP Now a professional speech-language pathologist treating persistent developmental stuttering in adults and teens in Philadelphia and world-wide through video-conferencing. Developed a new approach Valsalva Stuttering Therapy with the participation of approx. 3 dozen persons who stutter from all over the world. Self-help program based on this therapy is contained in the Revised and Expanded Third Edition Understanding & Controlling Stuttering (2013), available from the National Stuttering Assn (U.S.) on Amazon.com. Copyright 2013 by William D. Parry ISA 10th World Congress 2013 3 Slide 4 Copyright 2013 by William D. Parry4 The Stuttering Puzzle Slide 5 Questions What originally causes a child to stutter? Are the factors different for different individuals? What makes a person continue to stutter? Is it different from the original cause? Why is stuttering severity so variable, even in the same person? What, if anything, can be done to make speech easier? ISA 10th World Congress 2013Copyright 2013 by William D. Parry5 Slide 6 Original Causes of Stuttering? ISA 10th World Congress 2013Copyright 2013 by William D. Parry6 Demands vs. Capacities Neurological Weaknesses Delayed Speech or Language Development Emotional Factors Inherited Traits Increased Perception that Speech Is Difficult and Requires Effort Different factors may increase the risk of stuttering in different individuals. Increased effort is the effect they all have in common. Slide 7 Interference vs. Ability Despite possible neurological and genetic anomalies in some persons who stutter (PWS), most developmental stutterers have the inherent ability to speak fluently. Problem is not a lack of ability to speak, but rather an interference with that ability. Key to reducing stuttering blocks is not to control ones speech, but to understand and control the forces that interfere with speech. Copyright 2013 by William D. Parry7ISA 10th World Congress 2013 Slide 8 Awareness of Blocks before Speaking PWS often feel that a word contains a brick wall even before they try to say it. The underlying block must occur in the brain before the actual movements of speech begin. ISA 10th World Congress 2013Copyright 2013 by William D. Parry8 Slide 9 Outward Stuttering Behaviors The behaviors regarded as stuttering are reactions to the brick wall: Hesitations Laryngeal closures or grunts (e.g., uh-uh- uh-uh) before speaking Repetition of the beginning sound Prolongation of the initial consonant Forcing on the initial consonant or on the glottal stop before initial vowels Copyright 2013 by William D. Parry9ISA 10th World Congress 2013 Slide 10 Avoidance Behaviors Various tactics to avoid stuttering, such as: Word substitution and circumlocution Interjecting starters, fillers, and junk words or phrases Refraining from talking Copyright 2013 by William D. Parry10ISA 10th World Congress 2013 Slide 11 Standard Stuttering Therapies Focus on the struggle or avoidance behaviors that occur in response to the brick wall, rather than on the brick wall itself. ISA 10th World Congress 2013Copyright 2013 by William D. Parry11 Slide 12 What Is the Brick Wall? The brick wall is at the core of stuttering behavior. Before we can effectively deal with stuttering, we must first understand what the brick wall really is and what causes it. Copyright 2013 by William D. Parry12ISA 10th World Congress 2013 Slide 13 The Real Problem Is the Vowel Although attention is usually focused on the beginning sound in a word or syllable, the real problem is phonating (voicing) the vowel sound that follows. E.g., Puh-Puh-Puh-Peter Sssssss-Sam Mmmmm-Mary uh-uh-uh-Amy Copyright 2013 by William D. Parry13ISA 10th World Congress 2013 Slide 14 Stuttering and Phonation PWS usually have no trouble silently mouthing their words or whispering. Articulation is not the problem. Stuttering only occurs when the PWS tries to add phonation. Voiced consonants usually okay. Vowel sound is where PWS hits... Copyright 2013 by William D. Parry14ISA 10th World Congress 2013 Slide 15 The Brick Wall Copyright 2013 by William D. Parry15ISA 10th World Congress 2013 Slide 16 Nature of the Interference A neurological failure to program the larynx to phonate, or vocalize, the vowel sounds in specific words or syllables. Response to fear or the anticipation of difficulty in saying a word. Larynx is neurologically programmed to close tightly to exert effort, rather than to phonate the vowel sound. Speaker gets stuck on the beginning part of the word, because the larynx is not ready to phonate the vowel that follows. Copyright 2013 by William D. Parry16ISA 10th World Congress 2013 Slide 17 Motor Programming Brain must create a motor program for all bodily movement, including speech. Copyright 2013 by William D. Parry17ISA 10th World Congress 2013 Slide 18 Top View of Vocal Folds Phonation requires prephonatory tuning of laryngeal muscles to bring the vocal folds together properly. Copyright 2013 by William D. Parry18ISA 10th World Congress 2013 Slide 19 The Valsalva Mechanism Copyright 2013 by William D. Parry19 ISA 10th World Congress 2013 Slide 20 A Valsalva Maneuver Copyright 2013 by William D. Parry20ISA 10th World Congress 2013 Slide 21 Copyright 2013 by William D. Parry21ISA 10th World Congress 2013 Slide 22 A Valsalva Maneuver Copyright 2013 by William D. Parry22ISA 10th World Congress 2013 Slide 23 Instances of Valsalva Maneuvers Copyright 2013 by William D. Parry23ISA 10th World Congress 2013 Slide 24 Blockage of Airway by the Mouth Blockage of the upper airway can be done either by the larynx or by the lips or tongue. At the same time, the abdominal muscles squeeze to build up air pressure. Relaxing the abdominal muscles stops the forceful closure of the mouth or larynx. Copyright 2013 by William D. Parry24ISA 10th World Congress 2013 Slide 25 Valsalva and Speech Involvement in effort to speak. Anticipation of difficulty. Reaction to fearful speaking situations. Copyright 2013 by William D. Parry25ISA 10th World Congress 2013 Slide 26 Valsalvas Interference with Speech Promotes forceful closures of the mouth or larynx to build up air pressure; and Programs larynx for effort closure rather than phonating the vowel sound. Vowel-phonation gap in motor programming of the word. Speech gets stuck while waiting for larynx to phonate the vowel sound. Copyright 2013 by William D. Parry26ISA 10th World Congress 2013 Slide 27 Why Stuttering Doesnt Occur When: Whispering Phonation is not involved. Singing Larynx is already programmed to phonate the melody, which is carried by the vowel sounds. Continuous Phonation Larynx is already phonating all the time. Copyright 2013 by William D. Parry27ISA 10th World Congress 2013 Slide 28 Effort Inserted at Vowel Position Copyright 2013 by William D. Parry28 The vowel is the natural place to insert the motor program for effort, because its the heart of the syllable and has the most energy. ISA 10th World Congress 2013 Slide 29 Anatomy of a Block on Peter p ee t r p t r P------- Puh-puh-puh-puh Copyright 2013 by William D. Parry29ISA 10th World Congress 2013 Slide 30 Prolongations & Initial Vowels Ssssssssss Rrrrrrrrrrr Mmmmmm uh-uh-uh- Copyright 2013 by William D. Parry30ISA 10th World Congress 2013 Slide 31 Blocking on No Specific Word uh-uh-uh-uh. Please pass the potatoes. Copyright 2013 by William D. Parry31ISA 10th World Congress 2013 Slide 32 The Amygdalae One almond-shaped amygdala is in each hemisphere of brain. They store fearful memories. Purpose is to alert us to danger. When stimuli are similar to fearful memories, the amygdalae trigger a fear reaction. Neurologically involved in triggering Valsalva maneuvers. Copyright 2013 by William D. Parry32ISA 10th World Congress 2013 Slide 33 The Fight-Flight-Freeze Response Copyright 2013 by William D. Parry33ISA 10th World Congress 2013 Slide 34 Fear Reaction in Stuttering Feared words, sounds, or situations. Amygdalae trigger fear reaction. Larynx programmed for effort instead of phonating vowel sound (brick wall). Stress hormones cloud thinking and create urge to force out the word. Speech gets stuck on consonant or glottal stop before vowel. Effort, Valsalva maneuvers, struggle. Reinforces fear of words, sounds, situations. ISA 10th World Congress 2013Copyright 2013 by William D. Parry34 Slide 35 Valsalva Stuttering Cycle 1. Negative beliefs, fears, expectations & intentions Fear reaction and urge to exert effort Valsalva tuning and motor program for effort With no vowel program, PWS cant get past the initial sound Stuttering and avoidance behaviors PWS thinks that the initial sound was the problem Copyright 2013 by William D. Parry35ISA 10th World Congress 2013 Slide 36 Use of Effort To Reduce Anxiety Using or displaying effort may have short-term effect of reducing anxiety in some PWS. Look how hard Im trying! This may re-enforce the use of effort. Long-term effect is to perpetuate anxiety by perpetuating stuttering. Understanding this dynamic is crucial to reducing effort used in speaking situations. Copyright 2013 by William D. Parry36ISA 10th World Congress 2013 Slide 37 Valsalva Stuttering Therapy Approaches stuttering in terms of effort rather than fluency. Natural fluency cannot be forced. Attempts to stop stuttering are usually self-defeating. Goal: To communicate in an easy, effortless, and natural way. Copyright 2013 by William D. Parry37ISA 10th World Congress 2013 Slide 38 The Valsalva Stuttering System Copyright 2013 by William D. Parry38ISA 10th World Congress 2013 Slide 39 The Power of Intention Stuttering blocks can be viewed as neurological motor programs that manifest the intention to exert effort in trying to say a word, in response to anxiety and/or the anticipation of difficulty. Therefore, one way to switch to a different motor program is to switch to a different intention, other than trying to say the word. ISA 10th World Congress 2013Copyright 2013 by William D. Parry39 Slide 40 Change Your Intention in Speaking My Golf Analogy: The Hit Impulse Copyright 2013 by William D. Parry40ISA 10 th World Congress 2013 Slide 41 Overcoming the Hit Impulse Copyright 2013 by William D. Parry41ISA 10 th World Congress 2013 Intend to swing the club instead of trying to hit the ball. The same principle applies to trying to hit the word. Slide 42 The Power of Intention (contd) The fluency-enhancing effect of many fluency techniques may be understood as ways of changing ones intention in speaking. E.g., intending to hit a target or saying the word in an unusual way. However, the new intention may break down if it is too difficult to maintain, or if it does not feel or sound natural. Therefore, the new intention must be consistent with normal, natural-sounding speech. ISA 10th World Congress 2013Copyright 2013 by William D. Parry42 Slide 43 Change Your Intention in Speaking Eliminate any intention to try hard to say words, or to make a good impression by not stuttering. Focus on your role and purpose in speaking and the message you want to convey. Copyright 2013 by William D. Parry43ISA 10th World Congress 2013 Slide 44 Your Intention in Speaking (contd) Forget about trying to say the word. Focus your intention on doing one or more of the following: Inhale a full breath using your diaphragm; Relax your abdomen and let the air flow freely; Say the vowel sounds of the stressed syllables with feeling. Copyright 2013 by William D. Parry44ISA 10th World Congress 2013 Slide 45 Focus on the vowel sound as the heart and soul of the word or syllable. Regard everything else as mere decoration. ISA 10th World Congress 2013Copyright 2013 by William D. Parry45 Slide 46 Speech Is Easy! Speech requires very little effort. Most of the effort involves inhaling, when we are not speaking. Speech is powered by an out-flowing stream of air, which is released when we relax. Phonation occurs when the relaxed airflow ripples the gently closed vocal folds. Articulation is a series of brief and gentle ripples in the stream of air. ISA 10th World Congress 2013Copyright 2013 by William D. Parry46 Slide 47 The Bicycle Imagery ISA 10th World Congress 2013Copyright 2013 by William D. Parry47 Inhale Up the hill! Coast down on the vowel sounds with feeling! Slide 48 Exercise Routines Purpose: To establish new muscle memory for phonating vowels sounds. Valsalva-Relaxed breathing and phonation Valsalva-Relaxed Vowel Intention Exercises Consonant-vowel combinations Picture naming exercises Vowel-specific word and sentence exercises ISA 10th World Congress 2013Copyright 2013 by William D. Parry48 Slide 49 Picture Naming Exercise ISA 10th World Congress 2013Copyright 2013 by William D. Parry49 Slide 50 Exercise Routines (contd) Valsalva-Relaxed Phonation Exercises Full Humdronian Speech A form of continuous phonation Modified Humdronian Speech Resonant Valsalva-Relaxed Speech Easy, resonant, natural-sounding speech. ISA 10th World Congress 2013Copyright 2013 by William D. Parry50 Slide 51 ISA 10th World Congress 2013Copyright 2013 by William D. Parry51 Slide 52 Redefine Your Condition While talking, I occasionally have a neurological glitch in which my brain programs my larynx to exert effort rather than phonating the vowel sound of a word. When this happens, I need to stop and get my larynx ready to phonate the vowel sound. ISA 10th World Congress 2013Copyright 2013 by William D. Parry52 Slide 53 Responding to the Brick Wall STOP! Resist the urge to force. Remember, this is simply a vowel-phonation gap. Your job is to get the motor program for phonating the vowel sound. Keep eye contact with your listener. Hold up palm of your hand to signal your listener to wait. Forget about trying to say the word. Inhale through your nose, using your diaphragm. Focus your intention on relaxing your abdomen and letting the air flow freely. ISA 10th World Congress 2013Copyright 2013 by William D. Parry53 Slide 54 Responding to Blocks (contd) Focus on the first vowel sound of the word. Begin by intending to say just the vowel sound, without the decorations. Say the vowel sound with feeling and pinch on it. Then repeat the vowel sound and let the decorations come automatically, if they havent already done so the first time. Purpose: Teaching the brain to bridge the vowel-phonation gap. ISA 10th World Congress 2013Copyright 2013 by William D. Parry54 Slide 55 The vowel sound is the key to opening the word. ISA 10th World Congress 2013Copyright 2013 by William D. Parry55 Slide 56 Adjust Speed to Conditions Being tired, sick, or emotionally distressed impairs fine motor skills, including speech. Trying to compensate by using more effort only increases the blocks. Make allowance for your impaired condition. Instead of trying harder to speak, ease up on yourself and slow down. When driving a car, you slow down for adverse road conditions, such as rain or snow. The same principle applies to speech. Copyright 2013 by William D. Parry56ISA 10th World Congress 2013 Slide 57 Other Aspects of Therapy Individualized counseling to promote easy, effortless speech is in all situations. Role-playing exercises based on actual speaking situations Reactions to speaking situations are analyzed in terms of the urge to exert effort. Negative attitudes and self-talk are analyzed and replaced with more helpful ones. Extensive therapy materials. Copyright 2013 by William D. Parry57ISA 10th World Congress 2013 Slide 58 Valsalva Relaxed Affirmations and Intentions Affirmations: I am strong. I am free. Im okay. Speech is easy. Speech is fun. I enjoy talking. Intentions: I inhale with my diaphragm to go up the hill. I speak by simply coasting down. I relax my abdomen and let the air flow freely. My speech flows in the river of air. I focus and pinch on the vowel sounds. I say the vowel sounds with feeling. I think of my role and purpose in speaking. I take my time and go with the flow. ISA 10th World Congress 2013Copyright 2013 by William D. Parry58 Slide 59 The Revised and Expanded Third Edition (2013) Now available from: National Stuttering Association (USA) www.WeStutter.org Amazon.com www.Amazon.com www.Amazon.com ISA 10th World Congress 2013 Copyright 2013 by William D. Parry59 Understanding & Controlling Stuttering Slide 60 Further Information Visit my websites: The Valsalva-Stuttering Network www.Valsalva.org www.Valsalva.org or www.StutteringTherapist.comwww.StutteringTherapist.com My e-mail: contact@Valsalva.orgcontact@Valsalva.org or stutteringtherap@aol.comstutteringtherap@aol.com Questions? Copyright 2013 by William D. ParryISA 10th World Congress 201360