Cognitive Stage Failure
In the cognitive stage your SLP shows you motor skills such as diaphragmatic breathing and gentle onsets. This takes mental effort and cognitive skill. If your child has Downs syndrome and stutters, fluency shaping may be beyond your child’s cognitive abilities.
Associative Stage Failure
In the associative stage you learn to do these motor skills with closed-loop speech motor control.
Delayed Auditory Feedback
A severe stutterer told me that he’d failed at this stage. He completed a three-week intensive residential therapy program but couldn’t speak fluently even at two-second stretch in the speech clinic.
They let him do the program a second time, free. He still couldn’t do the motor skills. They looked through a closet and found an old DAF device. “This will test if you have a neurological disorder,” the SLPs said.
He tried the DAF and talked fluently for the first time in his life.
The SLPs told him that this proved that he had nothing neurologically wrong. They put away the DAF device and offered to let him do the fluency shaping program a third time, again free.
He asked where he could buy a DAF device. The SLPs told him that a DAF device wouldn’t help his speech.
He declined to do the program a third time and contacted me to buy a DAF device.
One of the neurological abnormalities associated with stuttering is underactive auditory processing. DAF (and other altered auditory feedback devices) are the only treatment for this auditory processing disorder. Some stutterers have only a little disordered auditory processing and don’t need a DAF device to do fluency shaping techniques. I have strongly disordered auditory processing. I could do fluency shaping in the speech clinic but I couldn’t transfer this fluent speech outside of the speech clinic. The severe stutterer in the above story apparently had extremely disordered auditory processing and needed DAF to produce fluent speech in the speech clinic. To move on to the autonomous stage you must increase the speed and force of the muscle movements.
Transcranial Direct Current Stimulation
Transcranial Direct Current Stimulation (tDCS) uses electrodes on your head to deliver a low electrical current through your brain. There’s a positive electrode, which increases activity in the area of the brain it’s near, and a negative electrode that decreases activity in the area it’s near.
tDCS doesn’t make you “smarter.” Rather it makes one area “smarter” while making another area “dumber.” It’s used for treating depression and for memory issues with Parkinson’s and Alzheimer’s.
Enhancing motor learning is a recent area of interest in tDCS research. Several research papers have been published recently finding that tDCS boosted the effectiveness of stuttering therapy by about 25%.[ref]Chesters, J., Möttönen, R., & Watkins, K. E. (2018). Transcranial direct current stimulation over left inferior frontal cortex improves speech fluency in adults who stutter. Brain: A Journal of Neurology, 141(4), 1161–1171. https://doi.org/10.1093/brain/awy011. Investigating the feasibility of using transcranial direct current stimulation to enhance fluency in people who stutter. Jennifer Chesters, Kate E. Watkins, Riikka Möttönen. Brain and Language, Volume 164, January 2017, Pages 68-76. https://doi.org/10.1016/j.bandl.2016.10.003. tDCS and stuttering. Naheem Bashir, Peter Howell, Brain Stimulation. VOLUME 8, ISSUE 2, P429, MARCH 01, 2015. DOI:https://doi.org/10.1016/j.brs.2015.01.369[/ref] The other stuttering therapies were similar to fluency shaping. I’m hesitant to recommend tDCS because I haven’t tried it but I’m hoping to try it after the pandemic is over.
Cognitive Behavioral Therapy (CBT)
If you talk fluently in a speech clinic but can’t transfer fluency outside of the speech clinic due to anxiety or other psychological issues, make an appointment with a psychologist. I’ve seen stutterers who use their stuttering to hide a bigger psychological issue. I stopped selling DAF/FAF devices to France after getting three returns with the same story:
[French accent] The device made me completely fluent. But now I must face my real psychological problems. I can no longer hide behind a facade of stuttering. I would rather stutter than face my real problems.
Cognitive Behavioral Therapy (CBT) has improved stutterers’ fears and anxieties when done in combination with stuttering therapy. CBT alone has no effect on stuttering.[ref]Menzies, R. G., O’Brian, S., Onslow, M., Packman, A., Clare, T. S., and Block, S. (2008). An experimental clinical trial of a cognitive-behavior therapy package for chronic stuttering. J. Speech Lang. Hear. Res. 51, 1451–1464. doi: 10.1044/1092-4388
Autonomous Stage Failure
In the autonomous stage your new motor skills become automatic and effortless. You speak fluently at a normal speaking rate without thinking about your speech (open-loop motor control). This didn’t happen to you because fluency shaping programs don’t teach the autonomous stage of motor learning. The programs stop at the associative stage, leaving you doing slow, closed-loop motor control, and concentrating on how you’re speaking when you should be focusing on the conversation. To go on to the autonomous stage requires increasing speed and force of the motor movements.
What the Experts Say
In the 1990s, twenty years after it had proven effective, fluency shaping was gaining the approval of some experts (in particular, Barry Guitar in his textbook Stuttering). However, many other experts refused to give up “traditional therapy,” which meant Wendall Johnson’s Indirect Therapy and Charles Van Riper’s Stuttering Modification Therapy.
In 2021, almost fifty years after fluency shaping was proven effective, experts place fluency shaping equally with “traditional therapies.”