Stuttering is a remarkable disorder. It's the easiest disease to treat, and the hardest to cure. On occasion, stutterers can talk fluently, when they're alone, by changing their manner of speaking, thinking differently, using an electronic device, or even just seeing their speech therapist walk into the room.

But stutterers can go right back to stuttering, even after weeks of the best therapy. Temporary "cures" are a dime a dozen, but a universal, permanent cure has never been found.

For many people, stuttering gets worse when we try not to do it. This paradox can be frustrating. Many stutterers are verbal, talkative people, coming from families that value speaking well. Communication is central to every aspect of civilized life.

Some stutterers have extreme physical symptoms, such as head jerks, facial grimaces, and even what listeners might think are seizures. Other stutterers hide their stuttering completely, by substituting or avoiding words. The latter can be just as disabling, because the stutterer is afraid that people will discover that he stutters. The stutterer may refuse promotions that require more talking, or avoid social interaction.

Despite the disabling effects of stuttering, the greatest orators have been stutterers. Demosthenes was the greatest orator of ancient Greece. Today, James Earl Jones is the most in-demand voice in Hollywood.

Dozens of stuttering causes have been hypothesized, but none have been proven. Suspected causes have ranged from Freudian anxieties, to parental demands, to poor vocal fold control, to neurological abnormalities.

Stutterers are both hyperaware and unaware of their stuttering. Before talking to a stranger, we have fear and anxiety that we will stutter. But when we stutter, we don't know what our lungs, vocal folds, lips, or tongues are doing. We lose awareness of our speech. Our minds seem to go "someplace else," and we lose awareness of even the passage of time.

Stuttering is one of few disabilities that gets better over time. Most children outgrow it. Even adults who stutter severely in their 20s usually learn to manage their stuttering in their 30s and 40s, and sometimes overcome stuttering completely. Your most severe stuttering is probably behind you.

Stutterers grow up humble, thinking we'll never get a job or marry. Later in life, when you realize you can do anything you want, regardless of your speech, you get what you need and appreciate what you have. Or you overcome stuttering and find pleasure in simply talking to people. Speech pathologists who treat adults who stutter say that we are the funnest, best-adjusted, most positive people they know.

• Avoidance of feared words, such as substitution of another word.

• Postponement of the feared word, with pauses or filler words.

• Starting tricks, such as an "uh" before the feared word.

• Escape tricks, such as head jerks, exhausting one's breath and speaking on residual air, "backing up and getting a running start," etc.

• "Anti-expectancy" speech behaviors to prevent stuttering such as speaking in a rapid monotone, or affecting an accent.

WHAT STUTTERING FEELS LIKE

Stutterers report three types of sensations:

• A sense of being frustrated in the attempt to talk. Stutterers know the word they are trying to say, but the word is stuck. The advice, "Think about what you are going to say before you say it" does not help stutterers.

• A feeling of muscle tension, usually in the speech-production muscles (breathing, throat, jaw, lips, and tongue), but sometimes in the arms or legs or shoulders.

• Emotions and anxiety before, during, or after stuttering.

Several studies have found that stutterers lose their ability to use their hands during stuttering. Other studies have found that stutterers lose sense of time during stuttering.

Because we don't perceive our stuttering, we can't alter our behavior. When we are not stuttering, we may be capable of any behavior anyone asks us to do, such as altering our breathing, relaxing certain muscles, making eye contact, etc. But during stuttering we lose awareness and control of our bodies.

We may be hyperaware that we are going to stutter before we talk to a stranger. We may experience great anxiety during stuttering. But when we stutter, we have little awareness of how long our blocks are, how many times we stuttered, secondary symptoms, etc.

ATTITUDES AND EMOTIONS OF STUTTERING

Stutterers believe that:

• Stuttering is shameful and embarrassing.

• Speech is threatening and difficult.

• Stuttering occurs for no apparent reason, and can't be controlled.

• Nonstutterers are believed to never experience speech hesitancy, anxiety, or fears.

• Stutterers may try to overcompensate or gain approval by working extra hours, doing favors for people, or excelling at non-speaking activities such as music or sports.

• Stutterers fear using telephones. On telephone calls, listeners can't see the stutterer struggle, and think there's a "bad connection." Also, telephone conversations have more time pressure. You are expected to talk immediately. In face-to-face conversations, a pause in replying is acceptable.

THE FLUENT SPEECH OF STUTTERERS

The "average" stutterer is disfluent of 10% on words. Stated conversely, we are fluent on 90% of words. But is our fluent speech normal, or are there abnormalities even in our fluent speech?

Some studies found that listeners could differentiate the fluent speech of stutterers from that of normal speakers. Other studies found that listeners could not hear a difference.

Spectrographic analysis did not find abnormal pitches in stutterers' fluent speech. But electromyographic and aerodynamic studies found abnormalities in stutterers' fluent speech.

The problem may be that in what each research team considered to be fluent speech. Some studies used mild stutterers, other studies used severe stutterers. Some stutterers may have used therapy techniques resulting in abnormal muscle activity in order to sound fluent.

DO STUTTERERS TALK TOO FAST?

Stutterers will tell you that they talk too fast, and this results in stuttering. We feel like our minds can produce speech "a mile a minute," and that our speech-production muscles can't keep up, and we stumble and fall over our words.

Several studies by Joy Armson and Joseph Kalinowski found that auditory feedback (DAF and FAF) enabled stutterers not only to talk fluently, but to talk extremely fast (averaging 6.5 words per second), while reading out loud.

Martin Schwartz suggests that a fast start on a sentence increases vocal fold tension before the first word of a phrase, which then leads to stuttering. He believes, however, that speaking fast on the rest of the sentence has much less effect on stuttering than starting the first word fast.

Studies of stutterers' fluent speech have found that our fluent speech is slower than nonstutterers. Early studies measured overall speaking rate of fluent speech (not counting disfluencies), and found that stutterers talk slower. Many other studies have found various results, sometimes faster, sometimes slower. Stutterers seem to do some speech movements faster, and other speech movements slower, which result in an overall slower speaking rate.

Variance in these studies may also be due to some stutterers having learned compensation techniques (from therapy or on their own) to produce fluent speech.

STAGE THREE - BEGINNING STUTTERING (AGES 2-6)

The symptoms of beginning stuttering are:

• Disfluency on more than 10% of words.

• Episodic disfluency. The child stutters for weeks or months, between long periods of fluency.

• Stuttering when excited or upset, when seeming to have a great deal to say, or under high environmental demands.

• Repetitions become rapid, tense, and irregular. A sound or word is repeated three or more times. The child is substituting the neutral vowel ("uh") for the appropriate one (e.g., "luh-luh-luh-like").

• Prolongations. Sounds are prolonged at least a half-second. Fixed articulatory postures occur, or freezing of speech-production muscles.

• Increased speech-production muscle tension. A rise in vocal pitch, caused by tensing the larynx. Blocking airflow and stopping the voice. Wide mouth opening or tongue protrusion. Irregular breathing patterns.

• Stuttering only on the first word of a sentence or phrase.

• Stuttering on both content words and functions words, such as "like," "but," "and," or "so".

• Secondary or escape behaviors, such as rapid eye blinking, nodding the head, facial grimacing, quivering lip, raising eye brows, flaring nostrils.

• Unconcern or unawareness of stuttering.

STAGE FOUR - INTERMEDIATE STUTTERING (AGES 6-13)

At these ages the child begins to fear and avoid stuttering.

• Usually this begins with fear and avoidance of certain sounds or words. Word substitution begins.

• Blocks become common, in addition to repetitions and prolongations.

• Escape behaviors are used.

• Stuttering becomes chronic, without periods of fluency.

• Stuttering occurs on content words -- the major nouns, verbs, and adjectives.

• Stuttering varies between situations, such as talking on the telephone, speaking to strangers, etc.

STAGE FIVE - ADVANCED STUTTERING (AGES 14 THROUGH ADULT)

• Vivid, fearful anticipation of stuttering.

• Feared words, sounds, and situations.

• Affects self-image -- thinks of himself as a stutterer. Chooses his friends, social activities, and jobs to avoid talking.

• Many advanced stutterers develop their substitutions and avoidance behaviors so well that you never know that they stutter.

A recent literature review by Marilyn Nippold and Mishelle Rudzinski found that the above advice doesn't do much good. They found "...little convincing evidence...that parents of children who stutter differ from parents of children who do not stutter in the way they talk with their children. Similarly, there is little objective support...that parents' speech behaviors contribute to children's stuttering or that modifying parents' speech behaviors facilitates children's fluency."

Nippold and Rudzinski caution against only changing the parents' speech, and not directly working on the child's speech. They believe that "...direct intervention should begin with the onset of stuttering..." Their article goes into depth on the scientific research on childhood stuttering therapies. ("Parents' Speech and Children's Stuttering: A Critique of the Literature", Marilyn Nippold and Mishelle Rudzinski, Journal of Speech and Hearing Research, 38:5, October 1995.)

The goal of stuttering modification therapy is not to eliminate stuttering, but to reduce its severity to an acceptable level, and to reduce the fears and anxieties associated with stuttering.

The therapy has four phases:

You begin by identifying the core behaviors, secondary behaviors, and feelings and attitudes that characterize your stuttering.

Your speech pathologist points out your "easy or effortless stuttering" first. The goal is to improve your awareness of what you do when you stutter.

Next, your speech pathologist trains you to identify and become aware of your avoidance behaviors, postponement behaviors, starting behaviors, word and sound fears, situation fears, core stuttering behaviors, and escape behaviors.

Finally, you learn to identify feelings of frustration, shame, and hostility associated with your speech.

DESENSITIZATION

Van Riper called this "toughening the stutterer to his stuttering." You do this in three stages. The goal is for you to become comfortable with all three of these aspects of your stuttering.

• Confrontation, or accepting that you stutter.

• Freezing your core behaviors -- repetitions, prolongations, and blocks. When you stutter, your speech pathologist raises a finger, and you have to hold what you are doing, until she drops her finger.

• Voluntary stuttering.

MODIFICATION

This is where you learn "easy stuttering" or "fluent stuttering", in 3 stages:

• Cancellations. When you stutter, you stop, pause for a few seconds, and say the word again. You say the word slowly, with reduced articulatory pressure, and blending the sounds together.

• Pull-outs. After you master freezing and cancellations, you use your "easy stuttering" while you are in a stutter, to pull yourself out of the stutter and say the word fluently.

• Preparatory sets. After mastering pull-outs, you look ahead to words you're going to stutter on, and you use "easy stuttering" on those words.

STABILIZATION

The last stage of stuttering modification therapy seeks to stabilize or solidify your speech gains.

The last fluency shaping speech motor skill improves your prosody, or rhythm. The slow-motion speech produces a monotonous, droning speaking style. Now you work on adding inflections, intonations, and emotions to make your slow speech sound more normal.

When you master these fluency shaping speech motor skills at the extremely slow speaking rate, you then work on increasing your speaking rate, while continuing to use your fluent speech skills.

At this point, your speech in the speech clinic should sound normal, and you should talk fluently. You are now ready to transfer this fluent speech to conversations outside the clinic.

PROBLEMS WITH FLUENCY SHAPING THERAPY

Fluency shaping has a number of problems:

• Fluency shaping is effective at producing fluency in the speech clinic, but too often the graduates relapse a few weeks or months after the program ends.

• Fluency shaping therapies train abnormal-sounding speech. It's so mentally-demanding that you can't pay attention to both the conversation and your speech. The idea is to use this abnormal-sounding speech only in the clinic, or only temporarily, in stressful situations, until your fluent speech skills become habitual. For many stutterers, the fluent speech skills never become habitual, or they are so embarrassed they never practice their fluency skills.

• Fluency shaping therapies are boring, repetitive, and expensive. You sit in a little room at the speech clinic, saying word lists over and over for hours. You do this for weeks or months before you see any results. A typical program costs about $2500, and taking several weeks off from work and flying across the country may cost you several thousand dollars more.

• Fluency shaping therapies are "one size fits all", but stutterers are all different. Fluency shaping therapies teach everyone the same skills, go through the same exercises, regardless of age, severity, or individual needs.

• Stuttering therapies (of all kinds) are based on little scientific research.