I recently read Anders Ericsson’s book Peak, about how individuals develop skills and improve performance. Ericsson is a professor of psychology at Florida State University. He developed the concept of deliberate practice and has applied it to music, sports, medicine, and other fields.

Ericsson is interested in physical skills, not intellectual knowledge. For example, he notes that medical students learn much knowledge at medical school, but when they graduate they aren’t ready to be doctors because they lack the physical skills necessary to perform procedures.

Malcom Gladwell quote

The principles of deliberate practice are:

1. Work with a teacher or coach. The teacher should have a step-by-step plan that has worked for other students.

2. Conceptual models, or breaking down the target skill into pieces. In fluency shaping therapy, fluent speech is broken down into respiration (diaphragmatic vs. thoracic), phonation (gentle onsets, continuous phonation), and articulation (relaxed lips, jaw, and tongue).

3. Immediate feedback. You must have a person or a machine immediately inform you when you perform the skills correctly or incorrectly, what you did wrong, and how to fix it. Speech-language pathologists aren’t good at feedback because speech is complex and speech production movements aren’t visible and are executed very fast, e.g., in hundredths of a second. Biofeedback devices provide faster, more accurate feedback, plus they never get bored listening to you. However, directly monitoring vocal fold activity is impossible unless we sink needle electrodes deep into your neck. Instead we use microphones to measure aspects of vocalization, such as changes in amplitude (Hollins’ Voice Monitor) or duration of phonated intervals (MPI therapy). Monitoring respiration and articulation are more straightforward but you’d be wearing two straps across your chest and half-dozen electrodes taped to your face. This might be OK in a speech clinic but no one would do that in daily life.

4. Pushing your comfort zone. Ericsson says that if you learn to play the piano as a child and master some songs as a teenager, then spend the next thirty years playing the same songs the same way you won’t get better. In fact you’ll get worse. Ericsson found that older doctors who have performed a procedure the same way for decades are worse than young doctors (they become sloppy when the young doctors are meticulous about performing each detail correctly). To become a great pianist the student continually pushes him- or herself with more difficult pieces, such as Rachmaninoff. In tennis or golf, a coach trains you to swing at the ball with perfect form, slowly and gently. You then increase your speed and force while your coach watches that you maintain the same form. Richard Harkness and I developed a post-fluency shaping therapy in which you increase the speed, force, and volume of words, alternating with slow, relaxed, quiet words. Demosthenes practiced at the ocean speaking over the noise of the waves. You might do this therapy standing on a stage bouncing your voice off the back wall of the auditorium, or standing on a freeway overpass speaking loudly (not yelling) over the traffic noise.

Stutterers should also push their social comfort zone when speaking. For example, join Toastmasters and work on your public speaking. When I built my first DAF telephone device I’d talk to telemarketers, very slowly. I’ve told this to hundreds of stutterers and no one else has done this. One man said that he couldn’t talk slowly to telemarketers because he’s a Christian! If a speaking situation is stressful for you, that’s when you should be using your therapy techniques. If you only use therapy techniques in safe situations, such as your SLP’s office or practicing alone, and then in conversations with strangers refuse to use therapy techniques, your speech won’t get better and you’ll likely lose whatever fluency you gained in therapy.

Ericsson notes that deliberate practice is usually used with skills that can be practiced alone, such as playing a musical instrument, and less commonly used with skills that require interacting with people, such as public speaking.

5. Practice, practice, practice. Malcolm Gladwell’s book Outliers has been misinterpreted as saying, based on Ericsson’s work, that there’s a “10,000 hour rule,” i.e., that if you do anything for 10,000 hours you’ll become world-class at the skill. Both Gladwell and Ericsson say that this isn’t true. Ericsson trained a student to memorize strings of numbers, and after about one hundred hours of practice he’d smashed the world record by remembering numbers up to 82 digits. Ericsson, as noted above, also found that doctors and pianists who spend decades and tens of thousands of hours doing the same easy stuff over and over get worse, not world-class. But both Gladwell and Ericsson agree that you have to practice a lot. In my book No Miracle Cures I calculated out how much stuttering therapy practice you need to do, based on studies of manual motor skill learning, from cigar rolling to Suzuki violin lessons. Three million syllables seems about right, and if you talk four hours a day (i.e., get a job making phone calls and spend your free time volunteering at a hospital’s information desk) you could produce three million syllables in six weeks. But there’s a couple of problems here. First, most stutterers have jobs and social activities where they don’t talk much. Second, and this is unique to speech therapy, most stutterers use therapy techniques for part of their talking and then revert to habitual speech the rest of the time. This would be like a tennis player doing what her coach told her to do for her warmup, and then playing games using her old, bad techniques. If you’re going to do stuttering therapy you have to do it in all conversations.

I’ll add a principle that Ericsson didn’t discuss: tools and aids. Swimmers have many such aids, from buoyancy devices to flippers to wetsuits. As you improve your skills you no longer need these aids but when you’re starting out they help you maintain good form. In stuttering treatment delayed auditory feedback (DAF) is the most-used tool in this category. The two neurological abnormalities most associated with stuttering are overactive speech motor processing (excessive, jerky muscles movements) and underactive auditory processing (something is wrong with how we hear our voices). DAF boosts our auditory processing and slows down our speech motor processing, reducing stuttering immediately 70% or more, without training, mental effort, or abnormal-sounding speech. Casa Futura Technologies DAF devices have been proven effective in more than twenty studies, including two long-term studies that found more than 50% carryover fluency, i.e., when the subjects weren’t using the devices. The confusing things about aids is that the people at the highest skill levels don’t need the aids and some teachers, coaches, or SLPs will say that beginners shouldn’t use these “crutches,” but they’re wrong.

Ericsson also discusses skills that are easiest to learn for children or young adults. Speech is one of the most age-dependent of skills, with a “window” to learn speech and language in childhood. If you’re an adult who stutters, you’re going to have to work harder to develop fluent speech.

Ericsson says that music and sports are where deliberate practice has been best developed. You can hire a teacher or a coach, work hard, and expect to become at least reasonably good. Ericsson talks about a man who’d never played golf, who hired a coach and trained, then hired more advanced coaches as his skills outgrew his first coach, and became a professional golfer in three years. Other fields are less well-defined.

How does stuttering therapy rate for the principles of deliberate practice? Let’s look at Hollins. Their conceptual models are A+. Their immediate feedback includes clinicians and the Voice Monitor device. I’ll give them a B for immediate feedback. As for pushing skills levels, Hollins is mostly easy, relaxed speech in the clinical environment, plus short phone calls to local businesses. I’ll give them a gentleman’s C on pushing skills levels. As for post-therapy practice, it’s not like joining a tennis club. I’ll give them another gentleman’s C. Finally, on tools, Hollins has the Voice Monitor but not DAF. Let’s say that’s another gentleman’s C. All of the components of deliberate practice are there but some areas could be improved.

The Successful Stuttering Management Program (a.k.a. Breitenfeld) pushes stutterers out of their comfort zone by going to a shopping mall where the stutterers approach strangers, introduce themselves, and say that they stutter. A+ on pushing one’s social comfort zone! But the program doesn’t teach fluency shaping conceptual models, provide immediate feedback, or use any devices.

A typical stutterer who buys a DAF device does nothing else, e.g., doesn’t learn fluency shaping skills, doesn’t work with a SLP or otherwise get immediate feedback, and doesn’t push his or her comfort zone.

Most stuttering therapy programs do one or two practice techniques well and ignore other practice techniques. Practicing without pushing your comfort zone doesn’t work. Pushing your comfort zone without immediate feedback doesn’t work. Feedback without conceptual models doesn’t work. Deliberate practice requires all of the above.