About the presenter: Erika Shira, MA, MT-BC, LMHC, works as a music therapist at an early intervention center and works in private and contract practice on the side. She holds a bachelor's degree in music from Whitman College and a dual master's degree in music therapy and clinical mental health counseling from Lesley University. She lives in Boston with her spouse, Molly Shira, who is a Suzuki violin teacher.

You can post Questions/comments about the following paper to the author before October 22, 2008.

Music Therapy Interventions for Improving Fluency Among People Who Stutter

by Erika Shira
from Massachusetts, USA

Introduction and background on music therapy

This section will focus mainly on the music therapy field in the United States, simply because this is the locality with which the writer is familiar. The scope of music therapy practice as well as the training and certification protocols may vary in different countries, but the general methods used will be similar around the world.

In order to practice music therapy in the United States, a music therapist must complete a college music therapy curriculum, which includes a clinical internship, and then must pass the national examination for the MT-BC (music therapist, board certified) credential. The college curriculum includes practicum work with a variety of populations and settings, as well as coursework in clinical, musical, and music therapy foundations.

The MT-BC credential can be achieved at the bachelor's level. A music therapist holding a bachelor's degree cannot practice any type of work that is considered to be psychotherapy or counseling. A music therapist may also train at the master's or doctoral level, in which case the curriculum is often combined with the necessary coursework and practicum work for licensure as a professional counselor or psychologist. It is common for a music therapist to hold the MT-BC credential as well as a counseling or psychology credential issued by the state in which the music therapist practices (such as LMHC, LPC, LMFT, LICSW, licensed psychologist, etc.). A music therapist with one of these licenses is qualified to practice music therapy in a manner that constitutes psychotherapy, including independently applying diagnoses and engaging with a client in in-depth verbal processing of social and emotional issues.

Music therapists work with individuals on a variety of skills. Depending on the music therapist's training, the music therapist may work with clients on goals in areas such as motor skills and motor planning, social skills, language skills, orientation and awareness, relaxation and coping, self-expression, or emotional issues. The music therapist uses music interactively with the client in a manner that is tailored to the client's particular goals and needs. This usually involves the music therapist and the client making live music together. The client does not need to have any previous musical experience in order to benefit from participation in music therapy, and individuals with profound physical and/or cognitive disabilities are as able to participate in music therapy as individuals without disabilities.

It should be noted that there are other individuals practicing various types of musical healing that look quite different from the clinical practice of music therapy. These practices usually involve mass-produced CDs or instruments such as bells and chimes, which are sold to an individual who has not met personally with the provider. They may also involve ritual practices that do involve interaction with the provider, but are not individualized for each client. It is not possible to state definitively that these types of practices cannot provide healing, but it is certain that they differ drastically from the professional field of music therapy in that they are not regulated as a profession, they are not endorsed by any scientific literature, and they do not operate in conjunction with mainstream healthcare facilities and insurance companies.

Music therapy as a means of addressing multiple skills simultaneously

A very basic discussion of the neurological and psychological principles involved in music therapy is necessary in order to understand how music therapy can be effective in treating stuttering. To put it very simply, music therapy is an effective means of evoking neurological changes because of the way that participating in interactive music stimulates multiple areas of the brain simultaneously. The brain functions most optimally when multiple areas are working together, as areas that work particularly well can compensate for areas that work less efficiently, all the while "teaching" the less developed areas how to rework themselves to function better. When a person participates in live music, the brain must process sound, vibrations, movement, emotional states, and sequential patterns that are processed by the brain in the same way as language.

In the case of stuttering and related fluency disorders, two separate issues must be assessed and addressed. For some individuals, stuttering is mainly a manifestation of social anxiety, and the treatment will revolve around addressing and overcoming the social anxiety. For other individuals, stuttering is the result of motor difficulty, and the treatment needs to address learning to better coordinate the individual's vocal movements. It should be noted that for individuals who initially have difficulty with fluent speech due to motor issues, the individual generally will develop a degree of social anxiety as a result of being in the world with stigmatized speech patterns. It is therefore necessary to address the social and emotional aspect of stuttering, just as it is appropriate to offer this support to anyone who is dealing with illness or disability. Music therapy is one of the few treatment modalities in which motor skills and social/emotional issues may be addressed completely simultaneously.

Considerations for the music therapist when assessing individuals with fluency disorders

As touched on previously, it is important that the music therapist determine whether the individual's fluency disorder appears to be primarily motoric in nature or primarily psychological in nature.

If the music therapist is confident that the individual's primary issue is psychological, and s/he is independently licensed to practice psychotherapy, then the music therapist can appropriately offer treatment as an independent provider. The music therapist would naturally follow ethical guidelines in ensuring that the client is aware of the many different types of treatment available for increasing fluency and is exercising informed consent in choosing the type(s) of treatment to pursue.

If the music therapist determines that the individual seems to have motoric issues, the music therapist would then recommend that the individual also be evaluated by a speech-language pathologist to address motor and speech production issues. The music therapist and speech-language pathologist would, with the individual's consent, consult with one another to ensure coordinated treatment. The providers could also arrange to see the individual in a co-treatment setting in which both providers work together during a session.

West African folk cure

Even if some of these ideas tend to disappear in the larger cities, in many villages because of illiteracy, ignorance and absence of treatment possibilities, these ideas, some of them potentially harmful, will continue to persist for a long time. ...This idea is widespread in medium Senoufo (an ethnic group of Burkina Faso, Ivory Coast and Mali). According to this idea, song is a method to treat stuttering. Children who stutter are asked to sing songs that account tales, mainly in public, around a wood fire or during rites of initiation. [Dr. Moussa Dao, 2002, retrieved from http://www.mnsu.edu/comdis/isad5/papers/moussa.html on 03/09/08.]

This anecdote was the original inspiration for writing a paper specifically about music therapy techniques that can aid in reducing stuttering. The technique described by Dr. Dao seems remarkably similar to scientifically validated music therapy procedures used for addressing anxiety disorders and motor-planning difficulty (aside from the aspect of sitting around a wood fire). While the medical and speech-language pathology literature makes many mentions of using singing to address stuttering, the presumption seems to be that singing used by healthcare professionals would look more like a patient in a clinic singing syllables off of an index card with the production monitored by electronic equipment. In the medical and speech-language pathology fields, here is little if any mention of a client composing or improvising a personally meaningful song, of involving family or friends in treatment, or of using live musical accompaniment -- all of which are common practice in music therapy.

It is intriguing that the aforementioned West African practice is presented as a myth contrasted with legitimate healthcare procedures. This demonstrates an often-held bias that any treatment method that seems to involve a spiritual or artistic component cannot also be scientifically sound.

Music therapy techniques specific to the treatment of fluency disorders

As mentioned earlier, music therapy can be effective in simultaneously addressing issues in multiple domains given how participation in live music is processed by many areas of the brain at once. One of the most effective treatments for dysfluency addresses issues of confidence and motor skills simultaneously. In order to understand how music can be used to address motor skills, let us first look at a simpler example: gait training.

Gait training is used with individuals who are stroke survivors, have cerebral palsy, spinal cord injuries, or other conditions that cause the individual to walk in an uncoordinated manner. In the simplest form of gait training, a physical therapist sets a metronome (a device that beeps or clicks at a consistent rate and can be adjusted faster or slower) and encourages the individual to walk to the beat. The individual's walking becomes somewhat smoother because of the auditory feedback and the reference for what a steady pace feels like.

When done with a music therapist, this is taken a step further. The therapist accompanies the individual using a song with a steady beat. The therapist uses voice and either piano or guitar to accompany the individual's walking. The therapist chooses songs based on the client's expressed musical preferences. Rather than playing the song at a steady beat and asking the client to walk to the beat, the music therapist sets the initial pace (in consultation with a physical therapist who determines a safe and reasonable pace), then will follow the individual's steps, which results in the song initially being played with an uneven rhythm. While the individual is walking to a familiar song, the rhythm of the song is processed in the temporal lobe, the order of the melody is processed in the frontal lobe and language areas, the lyrics are processed in the language areas, the personal meaning of the song is processed in the emotional areas, and so forth. With these areas all working together, the individual is very aware of when he or she is walking unevenly, as this causes the song to be played with pauses and hesitation. The brain wishes to correct the song, and the other areas of the brain work together with the motor cortex to better coordinate the person's movements. The steadier music then reinforces this in all of these areas of the brain, since the person is now experiencing a preferred song played in a steadier, more flowing manner. The emotional and multisensory aspects of the experience can also lessen any pain or frustration the person is experiencing, which can also get in the way of coordinated movement.

Similarly, in treating a fluency disorder, the music therapist uses live music and chooses songs preferred by the client. Since the desired motor behavior in this instance is coordinated speech, the therapist asks the individual to sing. The therapist may also accompany the client with vocal support as appropriate. As discussed earlier, people who seek treatment for fluency disorders have generally experienced anxiety and distress around their speech, so the therapist will want to address self-expression and processing of emotions as well. The therapist may support the client in improvising or composing songs about personally meaningful topics, much like the West African healers are reported to do. Though the context is different from singing around a fire, the concept of singing one's own words from the first person is important; mainstream psychotherapy literature clearly supports the value of self-expression and confidence-building in treating anxiety disorders. Similarly, recounting a personal story involves drawing upon physical memories and going through sequences of events; an individual who at times has difficulty with executive functioning and/or with grounding oneself might find it easier to do this type of work with musical support.

While it is widely known that most individuals who stutter do not do so while singing, it would not be particularly beneficial to spend therapy sessions singing precomposed songs, particularly when the individual is already aware that he or she can sing in this manner without stuttering. The individual would not be gaining a new life skill by using music in this way. In the process involving improvising lyrics with musical support, the first skill that the individual gains is the awareness that he or she is able to convey first-person information vocally in a fluent manner. Some individuals might feel that this is sufficient treatment. If the individual has developed a constant fear that he or she might become completely stuck and unable to speak, the individual now knows that he or she could always resort to singing if this were to happen. He or she may then feel less pressure when speaking, and therefore might speak more confidently.

Ideally, the individual would participate in further sessions in which improvised singing is used. The therapist and client might engage in extended sung dialogues. The therapist would eventually work to fade the musical support out and to shift to musical styles that are more similar to speech, as the end goal is fluent speech, not fluent singing.

You can post Questions/comments about the above paper to the author before October 22, 2008.

SUBMITTED: September 1, 2008
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