About the presenter: Dr. Ren Zhiqiang, is a speech therapist at the stuttering treatment center of the ENT Hospital of Fudan University. Dr. Ren graduated from the Air Force Aeronautical Engineering School in 1968, and the department of metal material of Qinghua University in 1979. He was engaged in the research of hydraulic control systems for aircraft jet engines and related technologies for many years, and then in the research and design of mechanical engineering. During the time he won a number of awards for his achievements. However, being a severe stutterer, he was unable to communicate effectively his ability was not given due recognition. He started stuttering as a child and sought a remedy many times, but did not produce satisfactory results. For long time, he lost hope for recovery until he found his son was a severe stutterer, too. He then was determined to explore a new way for treating stuttering through his own efforts. His technical background and long-term research experience proved beneficial to this exploration. After years of painstaking research, he developed the "fluencer", a device which helped him and for which he won a range of Science and Technology Invention Awards from Shanghai and China. How does the "Fluencer" treat stuttering
About the presenter: Yao Xinshan, born in 1938 is a researcher at the Shanghai Xuhui teacher training college, an academic leader, and a senior secondary school teacher. He started to study psychological counseling in 1986. He also led the research of "psychological counseling in primary and secondary schools", which won the second prize of the achievements in educational science research conferred by Shanghai municipal government. He is the first author or co-author of over 10 books including Individual Psychological Counseling. Having been the vice chairman of the Association for psychological counseling in primary and secondary schools of Shanghai for many years, he is now the deputy director of the Committee of Experts of the association. In the field of stuttering, he is the head of the Stuttering Treatment Center of Shanghai Xuhui Educational Institute. Based on his years of clinical experience, Yao published a monograph on the treatment of stuttering--The Treatment of Stuttering by Psychological Therapy (Shanghai Science and Technology Literature Publishing House, May, 2003) Stuttering Treatment from a Psychological Perpective
About the translator: Dr. Huang Haiyin is a doctor of internal medicine, currently at Yueyang hospital in Shanghai, China. He is a PWS. In the past ten years, he published two papers on stuttering, and 12 papers on his own academic field in authoritative Chinese periodicals. He is instrumental in starting the Shanghai Stuttering Association and is currently the chairman of the Shanghai Stuttering Association and the vice Chairman of the Chinese Stuttering Association.

I was privileged to meet with several professionals and people who stutter in Shanghai, China, in the summer of 2006. Spending an afternoon with Dr. Ren and Teacher Yao, with the able translation of Dr. Haiyin provided interesting insight in current thinking about stuttering treatment by the professional community in Shanghai, China, a city of over 23 million people. They were invited to share their treatment ideas for the online conference. Judy Kuster

How does the "Fluencer" treat stuttering

by Ren Zhiquiang from China and translated by
Huang Haiyin from China

Stuttering in China brings about enormous difficulty in the patient's education, employment, and daily life -- for instance: making a phone call, speaking in a meeting, conversing, shopping and so on. A relatively easy thing often becomes very difficult for a stutterer. Some young people lose the opportunity to go to the university or to get a job as a result of their stuttering. A lot of departments in colleges and universities in China, such as business trade, foreign language, politics and law, normal school, public security (police), and military all refuse to accept students with stuttering. In the interview for employment, a stutterer cannot compete against a person who does not stutter. Moreover, stutterers often fail to seek a relationship with the opposite sex or to married.

At the present time, the treatment of stuttering in China follows two forms: speech training and psychological adjustment. These methods may alleviate the patient's symptoms in a short-term, but the effect is usually not permanent. After a period of time, the overwhelming majority suffer a relapse. The stuttering returns and remains unchanged. Therefore, many experts believe that adult stutterers cannot be cured.

It is well known that speech is an extremely complex process. In order to produce air flow, the lungs, the trachea, the chest, the diaphragm and the anterior abdomen muscles all must have appropriate movements. In order to make the sound, the glottis and the vocal cord also must maintain a suitable position. In order to cause the sound to appear sonorous and pleasant, the nose, the mouth, the pharynx and larynx, and the lungs and the trachea must resonant adequately. In order to change the original throat sound into the uniquely human language, the tongue, the lips the teeth, the lower jaw and the soft palate must coordinate well. The whole speech process is completed through perfect coordination of these breathing and speaking organs. All these relationship and coordinations are controlled by the central nervous through two crisscrossing interweaving processes which excite (activate) and suppress. In this entire process, slight incoordination is not allowed.

Commonly, the two processes (excite and suppress) in the brain maintain balance and intercoordination. However, organs in the human body, including the brain, all have their certain physiological limit. In addition, excessive stimulus from the outside world can also surpass the psychological limit which the person can withstand. Breaking the balance between excite and suppress can also affect the central nervous system causing malfunction of its subordinated organs. This kind of imbalance in the function of speech is stuttering.

In my opinion stuttering is a speech-language disorder that is perpetuated by psychological barriers. A strong stimulus often makes such a deep memory in the brain of the stutterer that a conditioned reflex has been formed. This conditioned reflex is continuously reinforced. Consequently, it is extremely difficult for a stutterer to change the situation by his own will. In those specific situations, a stutterer's speech function inevitably emerges from conditioning and he stutters.

By avoiding the specific intense environmental stimulus, "Fluencer" can gradually decrease the stimulus-provoked conditioned reflex in the language center of the brain, thus realizing the balance and coordination, restoring fluent speech.

It is widely known that, regardless of the severity of stuttering, stutterers seldom stutter when singing or speaking to him(her)self. To most stutterers, stuttering appears only in specific environments. However, they often stutter at the very moment when fluent speech is needed. The overwhelming majority of those who stutter have the following clinical manifestations in common:

  1. He doesn't stutter when he talks to himself (when he is alone), but he stutters immediately once he finds that someone else is listening to him.
  2. He has less stuttering in a noisy environment, but more stuttering in a quiet environment with many people.
  3. In the same environment with a lot of people, he has less stuttering when other people are speaking simultaneously, but more stuttering when he is asked to speak alone..
  4. In a tense or frightening situation, he stutters when speaking with normal volume, but doesn't stutter when whispering or speaking softly.
These phenomena display that most stutterers have not lost the ability for fluent speech. Instead, when stuttering occurs, it appears that the language centers of the stutterer come under a condition of suppression when stimulated by some external factors. The problem is, this kind of conditioned reflex is so strong that common approaches cannot overcome it. Therefore, it is generally believed that the adult stutterer cannot be cured.

How the Fluencer works

It would be a mistake to think that the "Fluencer" can get results quickly just by putting it on. On the contrary, one cannot succeed without following instruction and extensive practice. It is something like learning to drive -- one cannot drive a car without a lot of careful and continuous training and practice. Therefore, the stutterer first has 5 days of special training in pronunciation skills from a speech therapist before using the "Fluencer". After this training, the stutterer practices with the "Fluencer" for an hour a day for six months, especially at work and in daily life. We are confident that if the stutterer follows this guidance, his speech will be fluent when using the "Fluencer."

What is the difference between the "Fluencer" and other kinds of DAF? The difference lies in the length of the delay time. Regardless of the length of the sentences said by a stutterer, the "Fluencer" delays the sentences as long as 3 seconds. This delay is much longer than other DAF devices which typically cause a delay measured in milliseconds. From our experience, the longer the delay time, the better the technique. During the extended delay produced by the "Fluencer", the stutterer can calmly send what he wants to say into the phone by whispering fluently using pronunciation skills practiced in the clinic.

The whispered sound is delayed and sent into the stutterer's ear through digitized processing producing a more than 3 second gap between what the stutterer "hears" and what he "says". This makes the stutterer feel as if what he "hears" and what he "says" are separated entirely in time and space which in turn creates a feeling of isolation from the outside world. Our clinical practice demonstrates that this effect decreases or eliminates the stimulus which previously provoked the conditioned reflex and produced stuttering and seems to protect the stutterer's language center from intense stimulation from the specific environment he finds himself in. Thus the continuously reinforced negative conditioned reflex is weakened, eliminating the former impact on the stutterer's speech-related organs, and restoring fluent speech.

Other apparent advantages of the "Fluencer" are that the somewhat noisy artificial sound field made by the "Fluencer" seems to relax the tense state of the stutterer. Furthermore, the delay of the sound by the "Fluencer" causes the stutterer to feel that someone is guiding and accompanying him to speak, making the speech easier (the choral speaking effect). Finally, even if the stutterer is in an extremely frightening situation, the "Fluencer" may help him speak when whispering or speaking softly as he begins to speak.

After more than 10 years of clinical practice, we believe that the "Fluencer", a kind of delayed auditory feedback (DAF) system invented by the Chinese, may open a path to fluency for adult stutterers.

You can post Questions/comments about the above section of this paper to Dr. Ren before October 22, 2006.

Submitted September 16, 2006

Stuttering Treatment from a Psychological Perpective

by Yao Xinshan from China and translated by
Huang Haiyin from China

Stuttering is a relatively common disorder, affecting about 1 percent of the world's population. It affects young and old, has been known about since ancient times, and occurs not only in China, but is a universal problem. There are many questions asked about stuttering including: Is Stuttering contagious or not? How can stuttering be treated effectively?

This paper will explain the philosophy of stuttering treatment in the Stuttering Treatment Center of Shanghai Xuhui Educational Institute, China.

People share different opinions about the cause of stuttering. Is it caused by physical reasons or by psychological reasons? Some people think stuttering means something is wrong with your tongue and recommend that a stutterer should have an operation to shorten the tongue. Other people think there is something wrong with bones in one's body which should be corrected by massage and manipulation.

We believe stuttering is no one's fault. A person who stutters can do anything he/she wants to do. No one is perfect. Feeling tight while talking is common for all people in different speaking situations. In my personal opinion, although there are some physical aspects to stuttering, such as disordered breathing and facial tics, when stuttering persists it is the result of a strong psychological/emotional element. People may enhance their psychological strength. When a stutterer does not feel anxious and embarrassed they decrease physical tension during speaking.

People can take medicine when they are sick, but there are no specific medicines that are effective in treating the physical symptoms of stuttering. When you take medicine to cure or treat the physical symptoms of an illness, it does not matter if you take the medicine at home, at work, alone, in a crowd, when you are relaxed or when you are in a stressful situation. The medicine will still treat the illness. For example, when you have a bad cold, there will be sneezing, watery eyes, and coughing no matter when and where you are. If you have a cold, the effects of the cold will be visible. But, a stutterer reacts differently in different situations. Some people stutter when talking to strangers and some stutter when they meet acquaintances; some stutter when they speak in front of a group and others don't. Why does this happen? In our opinion it is because of the individual's psychology/emotions. When they feel stress while talking, stuttering occurs. Physical diseases are usually caused by damage of some organs, the influence of a virus, etc. while stuttering is caused by imitation, teasing, being frightened and the speaking environment.

Treatment of stuttering in the Stuttering Treatment Center of Shanghai Xuhui Educational Institute in Shanghai

There are several components to successful treatment of stuttering. We combine treating the physical symptoms of stuttering, addressing the underlying feelings/emotion which we call "psychological helping", and also helping people change their knowledge and definition of stuttering.

Our program consists of ten-day's treatment, a month's consolidation and three years' follow-up.

During the initial 10 days of the training course class, the stutterer is taught skills and methods. In combination with teaching techniques, troubles and problems met in daily life are explored. The client returns home each day to practice. Training does not mean be away from society and their family. On the contrary, training encourages stutterers experience more contact with other people.

We use six strategies based on the theories of psychoanalysis, behaviorism, humanism, and cognitivism.

  1. Skills of pronunciation. Using new ways to talk; changing the habits of speech production such as teaching a stutterer to use a way of soft gentle and full of abduction, rather than speak too rapidly, heavy and anxious.
  2. Relaxation. Using breathing relaxation, meditation, muscle relaxation, and change the thought process to a relaxed state.
  3. Breathing skills. Harmonize the stutterers' speech, thought and breath by special training. Harmony among the three, reduces serious stuttering considerably.
  4. Positive thinking. Persuade the stutterers to accept positive thinking, and learn to give positive messages to himself. Helping develop an "I can!" attitude thus increasing the stutter's self-esteem and self-confidence.
  5. Hypnosis. Apply hypnosis in cases of severe stuttering to demonstrate, if possible that he has the physical ability to speak more fluently.
  6. Desensitization. Individualizing to the stutterers' personal situation, training is from easy levels to difficult ones, from simple steps to complex ones, from low systems to high ones, gradually desensitizing them to the worry of stuttering.
Our therapy combines the strategies of group treatment with individual treatment based on the individual's needs. For some, group treatment may offer a comfortable and better psychological environment where the stutterer will be brave enough to talk freely. On the other hand, individual treatment may be more beneficial for others.

After the ten-day of treatment, there is a one-month consolidation period. People who attended the course are asked to return to the institute, reporting the situation of the consolidation. At this time, we establish a network of contact, offering them a free telephone number they may use to consult with me anytime when they meet new problems. We also organize a "free talking" club, a kind of support group, encouraging every member of the training course to take part in activities every month. This offers a platform, for members to increase their ability of talking and make more friends. Finally, we do a follow-up survey after one year and again in three years.

Results of our treatment program

Our treatment has been successful with 95 percent of the people we have seen for therapy. We have been successful with 767 people from February 1996 to May 2006. That number reflects 616 males and 151 females. The oldest stutterer was 71 years old and the youngest was only five. They came from different professional fields, such as, professor, presidents, manager, doctor, nurse, engineer, teacher, students, PLA men, athletes, workers, farmers.

An engineer said: "Doctor Yao helped me to rebuild my self-esteem and overcome my lack of self-confidence. I feel good now, and I have enough courage to face the difficulties and pursue my dream in my life."

A female university student said: "I realized my long-term dream."

A seven year old boy wrote a letter to his teacher when his stuttering was cured. He said, "It is a turning point in my life. I will study hard and will be a top student in my class. And I will help more people when I grow up."

A famous real estate agent always stuttering when he talked to his colleagues and leaders. After treatment, he overcame his stuttering and celebrated by having a banquet to honor his Speech language therapist.

There were many such success stories.

In years of practice in treating stuttering, I have found some stutterers achieve great improvement during the treatment course, but may relapse, stuttering as badly as before. When relapse occurs, our institute offers free treatment one more time.

All above is my personal experience from working as a speech language therapist for ten years. I hope to share my ideas with you and get more suggestions and help in this field.

You can post Questions/comments about the above section of this paper to Psychologist Yao before October 22, 2006.

Submitted September 20, 2006
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