Articles

Vocal fold management – the way forward? Issue 27, Spring 2007
by Rachel Everard, The City Lit


After much soul-searching, extensive debate and a visit to Catherine Montgomery’s American Institute for Stuttering in New York, in 2005 we introduced a new intensive course ‘Stammering therapy: an integrated approach’ to our programme for adults who stammer.

For the past 20 years our approach has been predominantly avoidance reduction and stammering modification focused, strongly influenced by Sheehan and Van Riper (Gregory, 1979; Van Riper, 1972), so this was not an easy decision to take.

We were aware that some clients experience difficulty modifying moments of stammering, often due to the frequency of stammering, and some requested further help in directly working on fluency. The benefits of combining ‘stammer more fluently’ and ‘speak more fluently’ approaches have been extensively documented (Bernstein Ratner & Tetnowski, 2006; Guitar, 2006). For these reasons we invested significant time and effort into developing our own integrated course, with Catherine Montgomery as our mentor. The new three-week course initially focuses on block modification and desensitisation, before introducing vocal fold management (VFM), an effective fluency shaping technique. In addition, elements from cognitive therapy are now incorporated, ensuring that emotional, attitudinal and avoidance aspects of stammering are addressed. We also incorporate brief mindfulness practices. By the end of the course clients have a range of tools to choose from, depending on the situation. We continue to offer intensive and evening courses that focus on block modification only. Hence, are able to recommend a particular course to clients, according to their needs. For clients with experience of block modification, who want to learn a fluency technique, we now offer a one-week course on VFM.

What is VFM?
VFM is based on the premise that the physical core of stammering occurs most often at the level of the vocal folds and that all other stuttering phenomena are by-products of, or a compensation for, the physical struggle in the larynx (Webster, 1977, Montgomery, 2006). VFM helps reduce tension in the laryngeal area by teaching clients how to co-ordinate respiration, phonation and articulation – and a by-product is improved fluency.

The work is carefully structured; initially clients learn a four-part breathing sequence which they then combine with gentle voicing of vowel sounds. The next stages encompass co-ordination of breathing with voicing and articulation, at one syllable, two – three syllables and five – six syllables per breath, before moving to normal phrasing.

Results so far
Our integrated course has run six times and we and clients have been very encouraged by the outcomes. We analysed the results of one group in detail through the use of formal assessments (speech measures, S24 and WASSP), with qualitative feedback provided via a written questionnaire. From the latter it became clear that it is indeed feasible to integrate the different elements of the programme and that clients are not giving priority to fluency over desensitisation. This had been one of our concerns before working in this way.
In fact, in answer to the question ‘what was the most useful aspect of therapy?’, desensitisation and modification were the most frequently mentioned items.
When asked about the changes they have made as a result of attending the course, the majority talked about increased confidence and greater openness.
One client wrote:
Overall, I am considerably more at ease in speaking situations and the course contributed greatly to this (especially vocal fold management). Occasionally I do go into ‘hard’ blocks but I don’t beat myself up about it.’

When asked directly about their experiences of using VFM, the majority reported that it was helpful to some extent, but that it was a challenge to maintain practice levels so that they could use it every day.

In terms of speech measures, we obtained %SS for speaking and reading at the start and end of therapy and six months after therapy. Results indicated a significant reduction in both speaking and reading at the end of therapy, with the reduction remaining significant for reading and approaching significance for speaking six months later. S24 and WASSP results followed a similar pattern, in that there was a significant change in mean scores taken at the start/end of therapy, with a slight rise six months after but still remaining significant.
We are pleased that there have been significant changes in all areas which indicate that clients attending this type of course are not focusing on fluency only.

Challenges for the future
Whether clients attend this particular course or not is determined by client-therapist discussions and our perception of the clients’ needs.
In the long-term we would like to research which clients are best suited to which approach and develop a more formal decision-making tool.

We are constantly monitoring and developing our courses, in particular the integrated approach, as it includes so many elements. We hope, in the future, to balance the different strands optimally.

Follow-up therapy is essential for any course and specific ‘tune-up days’ for VFM are now on offer. It may be more convenient for clients to access follow-up therapy locally and therefore it is important that speech and language therapists UK-wide become better acquainted with the content of this particular course. For this reason, we will be running an annual two-day workshop focusing on VFM for speech and language therapists. The first will take place on 21/22 June this year (cost, £90).

Please contact us if you would like to find out more about VFM or any other aspect of our work.

speechtherapy@citylit.ac.uk
Tel: 020 7492 2578

References
Bernstein Ratner, N & Tetnowski, J (eds), (2006) ‘Current issues in stuttering research and practice’. Lawrence Erlbaum Associates.
Gregory, H (1979) ‘Controversies about stuttering therapy’. University Park Press.
Guitar, B (2006) ‘Stuttering: an integrated approach to its nature and treatment (3rd edition)’. Lippincott Williams and Wilkins.
Montgomery, C (2006) ‘The Treatment of stuttering: from the hub to the spoke’. N Bernstein Ratner & J A Tetnowksi (eds) – see above
Van Riper, C (1972) ‘The Treatment of stuttering’, Prentice Hall.
Webster, R (1977) ‘The Precision fluency shaping program: speech reconstruction for stutterers – clinician’s precision guide’. Roanoke, VA: Communications Development Corp.