Intensive Summer Program Helps Individuals Control Persistent Stuttering

Each summer, something truly transformative takes place for a select group of individuals at the USF Tampa campus. Teens and adults with a history of persistent stuttering discover that they can take control of their speech and find fluency. "This is not a summer camp", says Nathan Maxfield, Associate Professor and director of the Program for the Advanced Treatment of Stuttering (USF-PATS). "This is more like boot camp for stuttering. Clients work 6 to 7 hours a day, five days a week for three weeks, for a total of ~90 hours of intensive intervention. We deconstruct their old speech pattern, and then work with them to build a new speech pattern completely from scratch."

The program was originally directed by Pat Sacco, a now-retired Speech-Language Pathologist. Sacco ran the program for 20+ years at the State University of New York - Geneseo College campus, and then brought the program to USF in the early 1990s. One of Sacco's clients was Nancy Hogshead-Makar, winner of three gold medals and a silver medal on the 1984 US Olympic Swim Team. Nancy had a history of stuttering, which went from mild to severe following a traumatic event in college. Nancy remembers the therapeutic process as rigorous.  "Today I'd describe what I learned as mindfulness; moving myself into my mouth and strengthening the neural connections between brain and mouth."

The therapy begins by requiring clients to stuttering openly. "This seems counterintuitive because clients enter the program to learn 'not' to stutter", says Maxfield. "But you can't correct something that you can't fully observe. People who stutter are very adaptable, and typically learn to do things to mask or minimize their stuttering. The first step of the treatment process involves learning to stutter openly and freely without avoidance behaviors. Stuttering openly is like raising an iceberg out of the water in order to be able to see the entire thing."

After exposing the stuttering, clients deconstruct their stuttering patterns. "People who stutter often don't know why they stutter, mechanically, and feel helpless because of this. The 'stuttering dissection' process involves stuttering on a word, stopping, and then dissecting the stuttered word into 23 different components." Over the course of several days, the clients dissect several hundred stuttered words. After this process, any mystery clients may have had about what happens, physically, when they stutter is eliminated.

Finally, clients learn to correct their speech. They learn to initiate speech movements in a new way. They also learn to keep their speech moving forward after initiating an utterance. "The stuttering correction process we use is analogous to learning to walk again after crushing your leg in a car accident. A Physical Therapist might teach you to deliberately throw your leg and plant your foot with each step. Those actions may give the appearance of normal walking but may always require some degree of deliberate attention in planning and executing the movements. In our clinic, clients begin to correct their speech by road-mapping every gesture for the first and second sound of every word. They mentally rehearse the speech movements, and then say the word with total control by using a specific set of speech motor principles. The clients slowly progress from exaggerated one-word utterances ("sick-cow" speech), to lengthy utterances produced at a more normal speaking rate. The intervention also focuses on helping the clients sound as natural as possible, and on maintaining control under periods of stress."

This process helped Nancy Hogshead-Makar regain control of her speech and tackle significant speech challenges. In 1997, she earned a law degree from Georgetown University, and currently operates a foundation that advocates for women in sports called Champion Women. Her primary job involves giving policy talks to large audiences. This summer, Nancy had a chance to thank Pat Sacco for his help. Her son, Aaron, also stutters and participated in USF-PATS. "Aaron's commitment to the therapeutic process was awesome", says Maxfield.

Maxfield, too, is a client of the same program. He entered the program in 1993, and then worked as a member of Sacco's staff for five additional years. "The program was originally residential, lasting 5 weeks. You'd arrive on a Sunday, check-in to a dormitory on the USF campus, and five weeks later even the most severe stutterer was talking with controlled fluency. You learned to become your own Speech Pathologist."

Maxfield felt strongly about continuing the program. "I am primarily a researcher. But there is a constant need for services for teens and adults who stutter. The 'craft knowledge' involved in intensive stuttering treatment is complex, and very few people around the country are trained to do what we do." One of Maxfield's aims is to train a new generation of clinicians to do this type of intervention. Advanced Practicum students in the USF Speech-Language Pathology run the program under Maxfield's supervision. "These students have a passion for helping people who stutter. They go above and beyond the requirements for clinical training when they work with me. I'd love to be able to support these students with a training scholarship." Maxfield also wants to bring back the residential model. "Currently we run the program as a day-program, allowing clients to go home at night and on weekends. Having around-the-clock control over their activities in a residential model would produce even better results." But the cost of residential treatment is significantly greater, so Maxfield also wants to raise money to establish a scholarship program that will support client tuition and staffing needs.

Maxfield is also aiming to refine the treatment process in other ways through research. "We want to know how to prime clients for optimal learning, or plasticity, going into treatment. We want to know how to streamline the treatment process itself, so that treatment costs can be minimized. And we want to know how to help clients maintain gains after treatment ends. One tool that will help us is functional brain imaging." The Department of Communication Sciences and Disorders recently received a generous institutional investment to purchase functional brain imaging equipment. Among other projects, Maxfield plans to use that equipment to investigate neurophysiological changes that take place as a function of the intervention and how they can be enhanced. "There is evidence that behavioral interventions enhance activity in brain areas for speech that tend to be underactive in people who stutter. Brain imaging will help us identify those areas, and it may also be possible to augment the traditional behavioral intervention with medical interventions like brain stimulation and medications. For now, what we know works best is initially intensive behavioral intervention - training new speech patterns like an Olympic athlete would train for a medal race - followed-up by long-term maintenance therapy."

Maxfield is also interested in harnessing the role of compensatory neural mechanisms in people who stutter. "People who stutter often have periods of fluency in their speech, even without intervention. There is mounting evidence that the right hemisphere of the brain increases in activation during these periods of automatic fluency in people who stutter. One theory is that the right hemisphere compensates for decrements in left-hemisphere functioning. There are behavioral and medical interventions that can be used to further enhance right-hemisphere involvement in speech production." Maxfield is currently seeking approval and funding to investigate whether a right-brain intention training program produces gains in fluency, alone and in combination with traditional intervention. "In addition to supporting the USF-PATS program, private funding may also help us seed innovative pilot studies like this aimed at informing new interventions for stuttering. We have a growing number of thesis and dissertation students interested in this type of research. A local family recently provided scholarship money to support student research of this type. We want to continue building that fund for students."