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to the "Valsalva Hypothesis." (For further information, see Understanding and Controlling
Stuttering: A Comprehensive New Approach Based on the Valsalva Hypothesis. )
NOTE: This article discusses stuttering in its most common form, often called "persistent
developmental stuttering." It may not apply to other types of disfluencies.
I. Introduction
It is a great honor to be invited to speak at this World Congress in Sweden. As you know, I
come from the United States, where I lead the Philadelphia Area Chapter of the National
Stuttering Project. By profession, I am a lawyer. But the great obsession of my life has been
the mystery of stuttering - a condition with which I have struggled since I was four years old.
Over the years, I submitted to a wide range of therapies, without lasting success. Finally,
about fifteen years ago, I gave up on therapy altogether and began doing my own research
into the problem.
It seemed obvious that my speech mechanism was basically all right. Back in high school, I
had taken elocution lessons, and had learned to act out roles in front of an audience with
perfect fluency. However, in other situations, it seemed as if a powerful force clamped down
on my speech like a vise, causing me to block. My problem was not any lack of ability to
speak, but rather an interference with that ability. I suspected that the interference was
physiological in nature, but that it might be activated by psychological factors.
After extensive review of medical literature, consultations with professional researchers, and
personal experimentation, I believe that I have found the force behind that interference. It is
a normal bodily mechanism that we instinctively use every day, without even thinking about
it. It is called theValsalva mechanism. The Valsalva mechanism is a neurologically
coordinated team of muscles throughout the body which act together in the performance of
a Valsalva maneuver.
You were performing a Valsalva maneuver. It takes its name from Anton Maria Valsalva, an
Italian anatomist who lived from 1666 to 1723. Although it has been known to medical
science for more than 200 years, it has been almost totally ignored by speech pathologists.
lifting the weight. Otherwise, some of that energy would be wasted as his chest and
shoulders sagged.
The Valsalva maneuver also helps us to force
things out of the body. The most common
examples are defecation, urination, and childbirth.
In these activities, the air pressure helps to
stabilize the diaphragm, so that the abdominal
muscles can squeeze things out of the abdominal
cavity more efficiently. When defecation is
intended, the rectal and anal muscles relax,
permitting the bowel movement to be expelled.
However, when defecation is not intended - for
example, when we are lifting weights - these
muscles tighten up to prevent an accidental
evacuation of the bowels.
All these muscles comprise the Valsalva mechanism. They are linked together as a "team" by
our nervous system. They are neurologically coordinated to contract at the same time, and
with the same relative degree of force, during a Valsalva maneuver.
whom we feel we have to please or impress. When certain words must be said exactly right,
like saying our name or the punch line of a joke, stuttering usually hits the hardest.
In my own experience, I always found it easier to say the wrong word, whatever it was, than
the precise word that was most appropriate. In answering the telephone, I could not simply
say "Hello." In order to get it out, I would have to say "Yes, hello." But one day when I picked
up the telephone, the person on the other end immediately said, "Hello, is this Bill Parry?"
Suddenly I could not say "yes." Instead I had to say, "Hello, yes, this is Bill Parry."
The Valsalva mechanism may help to explain this. All these examples involve circumstances
in which we feel that the words themselves are especially important, or we anticipate that
speaking will be difficult. These are precisely the moments when we may feel that some kind
of extra effort will be needed. Therefore, these would be the times we would be most likely
to activate the Valsalva mechanism - which is instinctively used when we exert ourselves.
Another paradox of stuttering is the excessive amount of force and effort we use in trying to
speak. Fluent speech actually requires very little physical effort. The articulation of words is
accomplished by gentle movements of the lips and tongue, which touch lightly and then
relax quickly. In contrast, when we stutter, our lips, tongue, or larynx press much harder and
longer than speech requires. Paradoxically, our effort to get the words out becomes the very
obstacle that we are trying so hard to overcome.
I myself wrestled with this paradox for most of my life. For example, I knew that when I
wanted my car to go forward, I should step on the gas - not stomp on the brakes. But when it
came to speaking, that, in effect, is exactly what I was doing - pressing harder and harder
with my lips or tongue, and wondering why my speech wasn't going forward. No matter how
I tried intellectually to recognize the futility of such effort, I found myself at a loss to control
it. For some reason, using force and building up air pressure felt like the right thing - the only
thing - to do, even though it blocked my speech more than ever.
The Valsalva mechanism answers this riddle. It is a bodily mechanism designed to do exactly
what happened when I blocked. A Valsalva maneuver may feel like the right thing to do,
because it is our instinctive reaction when we exert physical effort or try to force things out
of the body.
A. Neuromotor Tuning
How might such confusion between speech and the Valsalva mechanism take place?
Scientific studies show that all physical activity, including speech, is preceded by
a neurological tuning of the motor neurons that control the muscles to be used in the
particular movement. The tuning makes some neurons more excitable, and others less
excitable, to the triggering impulse that actually starts the movement.
In effect, the brain says to some neurons, "Pay attention! Get ready to contract your muscles
when the next command comes!" To others it says, "Relax. Disregard the next command,
because it's not meant for you." A fraction of a second later, the triggering command comes
down the line. The neurons and their muscles either respond or don't respond, depending on
their level of excitability.
You can demonstrate this principle yourself, by playing this trick on your friends. First show
them how, by contracting different muscle groups, you can make your hand into a fist, or do
other things such as pointing a finger. Then till your friends to make a fist, as fast as they
can, when you say "Now!"
First alert them by saying, "Get ready to make a fist." (That is like the tuning signal.) Then
say "Now!" (which is like the triggering signal) as you make a fist yourself. "Not bad," you tell
them, "but you're not doing it fast enough. Let's try again."
Repeat this exercise a few times, so that everyone has gotten into the habit of making a fist
as fast as they can. Then, after again instructing them, "Get ready to make a fist," suddenly
say, "Point," and point your finger.
I have found that most people reflexively make a fist instead - because that is what their
nerves and muscles are neurologically prepared to do. Likewise, when we feel that speaking
will require extra effort, our body might become neurologically tuned for a Valsalva
maneuver rather than for speech.
built up, the brain would signal the lips to let go. That is what is supposed to happen. Now
let's see what might go wrong, according to the Valsalva Hypothesis.
First, let us assume that you have been blocking on your p's lately. When you see that
a p word is coming, your brain anticipates that saying the word will be difficult. It decides
that extra effort will be needed and tunes up the Valsalva mechanism. All the nerves and
muscles of the Valsalva mechanism are now geared up to perform a Valsalva maneuver the
instant a triggering stimulus comes down the line.
One kind of triggering stimulus could be the increase in air pressure that normally occurs
during articulation - for example, when you close your lips to say the p sound. Normally, this
increased air pressure would tell the lips to open. However, if the Valsalva mechanism is
overly excitable, it could have just the opposite effect. The increased air pressure could be
misinterpreted as the beginning of a Valsalva maneuver - triggering a reaction by the entire
Valsalva mechanism. This would stimulate the lips to close more tightly, to keep the air from
escaping. The more you contract your abdominal muscles and build up air pressure, the
tighter your lips will close. Suddenly, you find yourself in a stuttering block, which
automatically gets worse the more you try to force through it.
Similar types of blocking might be stimulated whenever articulation involves an obstruction
of airflow by the lips, tongue, or larynx, causing increased air pressure. The Valsalva
hypothesis might therefore explain why stuttering is often reduced when the speaker uses a
"gentle onset" of voice and "light contacts" in articulation, or starts speech with a stream of
"passive airflow." Such methods would tend to avoid abrupt increases in air pressure, and
thereby reduce the likelihood of a Valsalva maneuver.
This may also help us understand why we stutterers are usually fluent when we sing. Have
you ever wondered why that might be? When we sing, our mind concentrates on the
melody, rather than trying to force the words out. Therefore, our larynx is constantly tuned
for phonation, and is always ready to phonate at the proper time.
Step 3: Valsalva Tuning. The brain responds by neurologically preparing the larynx and
other parts of the body's Valsalva mechanism to perform a Valsalva maneuver (in which air
pressure is built up by forcefully closing the larynx or mouth while the chest and abdominal
muscles squeeze the chest cavity), in the mistaken belief that this may help to force the
words out.
Step 4: Vocal Delays and Forceful Closures. As we have just discussed, there may be
difficulty or delays in phonation, because the larynx is neurologically prepared to perform
effort closure rather than phonation. Valsalva tuning may also lead to excessively forceful
closures of the mouth or larynx during articulation, resulting in the blocking of speech.
Step 5: Avoidance Behavior. In an attempt to avoid, postpone, or hide our blocks, we may
resort to a wide variety of behaviors. These might include hesitations, repetitions, the use of
starters, fillers, and other unnecessary words and sounds, word substitutions, breathing
irregularities, teeth gnashing, and other tactics.
Step 6: Mental Reaction to Stuttering. We may interpret our stuttering as confirming
our original belief that speech is difficult, or that particular words are hard to say. We may
think, "I was right. That was difficult. If I didn't try hard, I probably never would have been
able to say it. The next time I'll have to try even harder." We may be left with the false
impression that Valsalva tuning, the use of force, and other stuttering behaviors were
eventually successful in getting the words out. This perception may reinforce the very
attitudes and behaviors that will promote stuttering in the future.
As we go round and round the Valsalva-Stuttering Cycle, we learn to force more and more,
and our rut becomes ever deeper and harder to escape. Using the Valsalva mechanism to
force out words instinctively feels like the right thing -- the conscientious thing,
the only thing -- to do, even though in reality it interferes with normal speech. We are
caught in the "Valsalva Trap."
Understanding the Valsalva mechanism may also help us find more effective ways to
improve our fluency. Today we are confronted by a wide range of competing therapies,
fluency devices, and techniques - many appearing to be totally different and even
contradictory to one another in their approaches.
However, when I analyzed all these approaches, I came to a startling conclusion: To the
extent that they were successful, they all could be explained in terms of the effect they had
in disrupting one or more of the steps in the Valsalva-Stuttering Cycle. In various ways, they
each reduced to some extent the stutterer's tendency to activate the Valsalva mechanism
during speech. Unfortunately, the existing therapies seemed relatively inefficient and
incomplete, because they failed to deal directly with the Valsalva mechanism itself.
I suspect that this failure to cope with the Valsalva mechanism may be one factor behind the
great tendency for people to relapse after successfully completing a fluency program. Such a
person might inadvertently activate his Valsalva mechanism while "trying hard" to use his
fluency technique. Once that happens, all attempts to use fluency techniques may prove
futile. Suddenly the person might find himself back in the grip of stuttering, without any idea
of how it happened.
Based on my research, I developed my own experimental, self-help therapy program, which I
call "Valsalva Control." Its objective is to control the Valsalva mechanism through both
psychological and physical means to reduce the likelihood that it will interfere with our
natural speaking ability. I developed or adapted a number of relaxation, breathing, and
speaking exercises designed to relax or "tune down" the Valsalva mechanism.
Among other things, I learned how to short-circuit stuttering blocks by relaxing my
abdominal muscles, so as to reduce the build-up of air pressure, rather than trying to force
the words out. In addition, I used certain phonation exercises to help "tune up" my larynx for
phonation.
Every morning, I began the day by spending one-half hour doing a special exercise routine,
to get myself properly tuned for speech. Over several weeks, my fluency gradually
improved. After a few months, the improvement was dramatic, and my gains have now
lasted for ten years.
This approach to Valsalva Control is described in detail in my book, Understanding and
Controlling Stuttering: A Comprehensive New Approach Based on the Valsalva Hypothesis.
VII. Conclusion
The ideas I have shared with you today, while promising, must still be subjected to
considerable research before they can be scientifically verified. Furthermore, I realize that
the approaches that worked for me may not be the "answer" for everyone. Because
stuttering is such a personal matter, the only "answer" that really counts must be discovered
Contact Information:
William D. Parry, Esquire, CCC-SLP
A licensed speech-language pathologist and trial lawyer, offering
stuttering therapy and counseling (including Valsalva Control
stuttering therapy) in person in Philadelphia and over the
Internet via webcam (subject to applicable law). For further
information, e-mail him at contact@valsalva.org.
Office: 1608 Walnut Street, Suite 900, Philadelphia, PA 19103
Office phone: 215-620-6792
E-mail: stutteringtherap@aol.com
Websites:
Stuttering Therapy and Counseling: www.stutteringtherapist.com
E-mail: stutteringtherap@aol.com
The Valsalva-Stuttering Network: www.valsalva.org
E-mail: contact@valsalva.org
Beating Stuttering Blocks: www.stutterblock.com
Stuttering and the Law: www.stutterlaw.com
The Second Edition (2000) (5th Printing updated in 2009) of Understanding and
Controlling Stuttering may be ordered from the National Stuttering
Association orAmazon.com.
For information concerning stuttering self-help and support, please
contact:
National Stuttering Association
119 West 40th Street, 14th Floor, New York, NY 10018
Telephone: (800) 364-1677 or (800) WE STUTTER
Fax: (212) 944-8244
e-mail: info@WeStutter.org