Speech-Language Pathology/Stuttering/Fluency-Shaping Therapy/Fluency-Shaping Protocols

William Perkins believes that stuttering is a discoordination of phonation (vocal fold vibration) with articulation (lips, jaw, and tongue) and respiration (breathing). He believes that stuttering is a disorder of timing.

Perkins' therapy develops compensatory skills that enable stutterers to talk fluently. Stutterers can't use all these fluency skills in every conversation. Using fluency skills demands attention and mental effort. He recommends that his clients use these fluency skills in difficult speaking situations. The rest of the time, they talk spontaneously. For some people the fluency skills become habitual and effortless. But for most people, only parts of the motor skills become habitual. Still, this produces improved, if not perfect speech.

Establishing Fluency
Because Perkins believes that stuttering is a disorder of timing, his therapy emphasizes slow speech. The therapy uses delayed auditory feedback (DAF) to aid a very slow speaking rate of about two seconds per word, or 5-10 times slower than normal speech. You don't stutter when you talk this slowly. You start with reading out loud, then use slow speech in conversations in the speech clinic. You don't use this slow speech outside the speech clinic.

After establishing extremely slow, fluent speech, you work on five "breath flow" motor skills. These are:

 Phrasing. You limit your phrases to 3-8 syllables. This is prevents running out of air. Phrase initiation. You start each phrase with an easy vocal onset. In other words, you relax your vocal folds on the first sound of the first syllable. Soft contact. You articulate consonants softly, keeping your lips, tongue, and jaw relaxed. Breathy voice. This is a soft or breathy speaking style. Blending. You maintain a continuous airflow from the beginning of each phrase to the end. You blend each syllable into the next. 

This slow-motion speech produces a monotonous, droning speaking style. You then work on adding inflections, intonations, and emotions to make your slow speech sound normal.

When you master these fluent 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. The DAF delay is reduced from 250 milliseconds (ms) to 200 ms, or about one second per word. Then the delay is reduced to 150 ms, or about two words per minute. Then the DAF volume is reduced, then one earphone is removed, and finally DAF use is discontinued.

Transfer
At this point, your speech in the speech clinic is fluent and sounds normal. You are now ready to transfer this fluent speech to conversations outside the clinic. Perkins does this in four steps:

 Evaluate your speech. You make tape recordings of your speech, and rate your speech in terms of fluency, rate, breath flow, prosody, and self-con fidence. If you miss any of these targets, you are expected to practice the appropriate fluency shaping motor skills. Speaking hierarchies. This a rating of speaking situations from easy to dif ficult. This ranges from conversations in the speech clinic to conversations outside the speech clinic; one-to-one conversations to speaking to an audience; etc. When you can use your fluent speech in an easy situation, you move on to using it in more challenging situations.</li> <li>Social and vocational changes. You are encouraged to take responsibilities at work that require talking, and to participate in social activities that require talking.</li> <li>Prepare for relapse. There are times when your fluent speech will relapse, and your stuttering will return. To prepare for this, your speech therapist has you speak without each of the fluency shaping motor skills, until you stutter. For example, your talk as fast as you can, until you stutter. Then you start again, using your fluency shaping speech motor skills to regain your fluency.</li> </ol>

"Fluency Controls and Automatic Fluency"
Perkins found that when his clients tried to use fluency skills outside the speech clinic, the fluency skills demanded too much mental concentration and attention. They also found that their speech sounded monotonous and droning. They said, "I'd rather stutter than talk like this."

So his clients stopped controlling their rate and went back to speaking spontaneously. They felt and spoke like normal speakers&#151;at least for a few hours, usually for a few days, sometimes for a few weeks, rarely for a few months, and only once for a few years. They had no control over this spontaneously fluent speech. They could not make it happen, and they could not prevent its disappearance. They called it "lucky fluency."

Perkins at first expected that this spontaneous, fluent speech would become habitual, but it didn't. Perkins concluded that fluency shaping speech motor skills can never become automatic or permanently habitual.

Perkins then changed his therapy goals:

&#133;those who were most satisfied with therapy were thse who found that they could use their fluency skills to warm up each day, and also have them available for emergencies. The remainder of the time they forgot about controls and spoke naturally. This made them vulnerable to some stuttering, but by facing up to their avoidances, stuttering progressively lost its sting. These clients gained confidence in their ability to speak out freely, even though that included stuttering occasionally.

Perkins differentiates two types of speech:

<ol> <li>"Warm up" or speech exercises.</li> <li>Spontaneous speech.</li> </ol>

The "warm up" speech can sound abnormal, or require mental concentration, or use a DAF device. None of these "downsides" matter if the "warm up" speech produces carryover fluency or improved spontaneous speech.

Perkins believes that no adult stutterer is ever cured. He concludes that you will have to practice "warm up" techniques every day, to continually improve your spontaneous speech.

Perkins believes that the key issue in fluency shaping is why fluent speech too often doesn't become habitual and automatic.