I think most of us tend to approach stuttering therapy as we do any physical problem. That is, we follow the medical model. If you have a headache, you take aspirin and the headache "goes away." You may realize that the headache could be a symptom of some underlying cause, but probably, you hope that the underlying cause can itself be eliminated by some kind of medication. Our belief in medicine starts early in life. We want something to happen to us, with no effort on our part. Medicine does this. The aspirin takes care of the problem, with no responsibility laid on us. It's a drag to have to do something to change yourself. I once heard a four-year-old stutterer tell her mother, "Mommy, give me some medicine so I can talk." It tore my heart. Probably the ultimate in this type of belief happened in 1840-1841, when surgeons in Europe and America cut away part of the underside of stutterers' tongues to relieve the problem. Anesthetics had not yet :been discovered, but stutterers begged for the operation. Surgery was certainly more drastic than medicine, though some of the horrible concoctions recommended for stutterers in the Middle Ages were bad enough.

This is not to say that various drugs don't have direct or indirect effects on speech (including fluency), but these effects are always temporary, and frequently are accompanied by irrelevant and unwanted side effects. To date, there is no generally effective medical treatment for stuttering, and no such treatment appears to be in sight.

So, we are left with stuttering therapy consisting of a variety of techniques designed to produce changes in speaking behavior and attitude. It has been said that we don't curebehavior, we change it. This process of change can take a very long time before it becomes stabilized, with many ups and downs along the way The curve of learning is always bumpy.

We still have a tendency to view a program of speech therapy as we do a dose of medicine. We take a three-week, or three- month, "dose" of therapy and hope that it will have permanent effects. This is especially true of programs based on "behavior modification" (response shaping) or "behavior therapy"' procedures, in which cognitive and emotional change is minimized or ignored Indeed, these programs may be marketed in such a way as to engender the belief that attitude and feelings are not important in therapy.

We blithely overlook the fact that the "dose" of therapy is usually bucking many years of habit and attitude formation and reinforcement, many years of particular self-perceptions and life experiences. To expect the "dose" to permanently reduce or remove stuttering behavior (and all that goes with it) is like expecting to stop a charging bull elephant with a popgun. It may take a great many doses. Real, solid, long-term voluntary behavior and attitude change is slow, hard work -- far harder than many people are willing to do. You don't always get a pat on the head for doing the right thing.

All this is not to denigrate stuttering therapy of any type. As long as we don't know for sure just what stuttering is, or what the causes are, we can't be certain of the best way to treat it. So we have to use whatever methods come to hand, whatever seems to work; we have to be pragmatic. And we can't always worry too much about the degree of 'respectability' of the method, how well it has been accepted by the professional community. Stutterers have reported improvement, temporary or. seemingly permanent, stemming from all sorts of events and procedures. Sometimes these events and procedures have nothing to do with planned treatment; a therapist was never involved. The stutterer himself may not have been aware that anything was going on that directly affected his stuttering, until after some period of time he did begin to notice that he was stuttering less, or that what. stuttering he did continue to do bothered him much less than it used to,

Bloodstein (1) gives examples of some of these unplanned events that apparently eliminated stuttering:

Certainly the whole problem of stuttering, along with a great many other problems, would be vastly simplified if we had some kind of "stuttering aspirin" that would instantly and totally be effective with anyone of either sex, any age, any degree of stuttering, any personality, any background o life experience. Lacking any such medication, what can we say about the therapies that are available to us?

For stutterers, I think it is safe to say that no therapy will help everyone but that almost any therapy will help someone. In some cases recovery takes place with no therapy. The same therapy may help someone at some time in his life but riot at other times. Therapy may have no immediate effect, but may have a delayed effect when the stutterer finally begins (months or years later) to act on what he learned during the active therapy period. Effects of therapy are frequently unstable: the problem of relapse remains a crucial issue in dealing with stuttering. As any number of therapists have noted, it's no big deal to get a stutterer fluent -- the problem is to keep him that way.

One thing is apparent. Any decrease in stuttering means that something has happened. If a number of different therapies ail produce a decrease in stuttering, it would seem that there is some common factor among these therapies, a common denominator, operating to reduce stuttering. The alternative assumption would be that there is no common denominator, that the different therapies produced different effects all of which reduced stuttering. This possibility seems less likely; it is certainly less parsimonious. So, assuming there is some common denominator, just what is it? That is an intriguing question. If we knew the answer, we would probably have the answer to the entire riddle of stuttering. Perhaps we can speculate about this in a future discussion.

All things considered, I believe we are left with the inescapable realization that success in. stuttering therapy results from an incredibly complex interaction among a great many variables, some known, many unknown. Some of these are client variables: the stutterer's neurophysiological condition, his motivations, aspirations, emotional stability, insight, personality, life history, and God knows what else. Some are therapist variables: clinical experience and skill, knowledge of stuttering, personality, ability to motivate and empathize with client, flexibility, and so on. Some are methodological variables: type of therapy employed, therapy schedule, clinical environment, and whatever. We may reasonably assume that the weather is not a significant variable...but maybe we can't be too sure about that: I was once told by a Chinese student that in China there is an old superstition that, stutterers are born during stormy weather.

Obviously no therapist can control and manipulate all of these variables, since we don' t even know what all of them are. Quite probably only certain ones are significant in the therapy process. Would that we knew which are necessary and sufficient I've always had a sneaking suspicion that success in stuttering therapy may be due in part to clinical skill and in part to sheer luck. . .the therapist just happened to punch the right buttons, and the stutterer just. happened to have the right buttons to punch.

It has become almost axiomatic among therapists that the permanent elimination of stuttering is difficult to achieve, particularly in adults, but almost any kind of therapy is likely to bring about at least temporary reduction or elimination of stuttering.

Accurately measuring the effectiveness of therapy is extraordinarily difficult. There are so many factors involved. As Bloodstein points out (1, p. 385): "The assessment of results of therapy is a process fraught with opportunities for error and self-delusion." Wishful thinking so often plays a part. I have been academically and clinically involved with the stuttering problem since 1945, and I've heard and read countless papers and books and seen countless demonstrations on some "new" method of therapy, with countless claims for effectiveness. It would seem that in the treatment of stuttering there has always been and may always be an unending supply of Messiahs. Where are the results of all those claims now? Where are the snows of yesteryear?

In 1981, Bloodstein analyzed 116 published reports of stuttering therapy. These studies used a wide variety of therapy methods and they varied in methodology. Taking into account various ambiguities in comparing one study with another, Bloodstein inferred that substantial improvement as defined in these studies typically occurs as a result of almost any kind of therapy in about 60% to 80% of cases. He concluded: "It would seem that therapy itself, apart from what is done in therapy, has considerable capacity for effecting change." (1, p. 385).

While the permanent elimination of stuttering in adults with or without therapy happens too seldom, it does happen often enough to raise tantalizing questions. Why does it happen at all? Most of our thinking has always been directed toward the question of why people stutter. Of equal importance is the question: Why do people stop stuttering? There has been speculation about this, but in the absence of reliable data it remains speculation, with no definitive answers.

So we come to the inevitable question; What seems to be the best course of action for stutterers? Is all this buzzing confusion cause for dismay, frustration, pessimism, throwing in the towel, throwing up our hands, throwing up? I don't think so. If you wait until you have all the answers to your questions about yourself and your stuttering, you're going to wait until hell freezes over. The main point is: do something. Don't be frozen into impotent inactivity. A feeling of total helplessness in the face of any kind of threat, of not knowing anything to do, builds up tremendous fear and insecurity. Taking action of any kind tends to reduce anxiety and bring about change. Almost anything you do will help in some way and to some degree.

If you are involved in any kind of specific, planned, systematic therapy program, give it your best shot. Go at it wholeheartedly and optimistically, make a commitment to it, and stick with it long enough to get a real feeling about its usefulness to you. If you are working with a therapist, learn everything you can from him or her. Do what the therapist says and see what happens. Evaluate everything that goes on, and be aware of your own feelings. Don't hesitate to ask questions to get opinions or information. Try to be totally honest with yourself as well as with the therapist. To make any therapy effective, you've got to (1) know what to do, (2) understand and accept the reasons for doing those things, (3) be willing and able to do what you should, and (4) keep doing them until there is a real change in your feelings and behavior.

If you are not currently active in specific therapy, what can you do? You can simply do your best as you go along, handling each situation as it occurs. Try to stutter as easily and 'gracefully' as you can, and do your best to resist time pressure (the feeling that you must say something immediately and fluently). As you speak, don't try to talk abnormally slowly, but do try to stutter slowly, delaying and slowing down all your stuttering feelings and behaviors. This tends to counteract the panic and tension that are the essence of stuttering.

When you have a bad time of it, try to let that moment go -- it's history. Don't belittle yourself because you stutter. It's not your fault (it's too bad that words like "fault" and "guilt" become associated with stuttering in the first place). Enjoy life as much as you can; try to keep a sense of humor, of proportion and balance. There are other things to worry about besides stuttering, if you've got to worry. Abraham Lincoln said, "Most folks are about as happy as they make up their minds to be." I think the main thing is to learn not to be afraid of people, to realize that everyone has worries, fears, insecurities about all sorts of things, real or imagined. You are much more like other people than you are different from them, stuttering or no stuttering. We're all in the same boat.

At best, stuttering is a nuisance, at worst it can be a nightmarish, ego-shattering experience. It's never fun. And it's right there where everyone can see and hear it. You've spent tremendous amounts of time and energy trying to avoid and conceal it, and of course you really can't. Your efforts to do so have succeeded just enough (always temporarily) to keep you trying, though, and that's what causes the constant frustration. So, it helps a great deal if you can stop fighting your stuttering so desperately and fruitlessly. Instead, try to go along with it just a little more, ride it out, feel to h... with it. Be happy when you handle your blocks well or reasonably well, but don't feel guilty when you think you've screwed up. Be tolerant, patient with yourself, try to like yourself.

Your stuttering is an important and unwanted part of your life. It has caused you pain. It. has messed up interpersonal relationships. But think very carefully about this: of all the pain coming from your stuttering, how much has been caused directly by other people -- by their actual reactions to you -- and how much has been caused by yourself, by the way you feel about yourself in relation to others? It took me many years to realize that I was the source of nearly all of my pain.

Reference: 1. Bloodstein, 0., A Handbook on Stuttering 3rd ed., 1981.

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