Evidence-Based Treatment and
Purpose: To illustrate the way in which both fluency shaping (FS) and stuttering
management (SM) treatments for developmental stuttering in adults are evidence
Method: A brief review of the history and development of FS and SM is provided. It
illustrates that both can be justified as evidence-based treatments, each treatment
seeking evidence of a different kind: FS seeks evidence concerning treatment outcome,
and SM seeks evidence concerning the nature of the stutter event.
Conclusion: Although outcome evidence provides the principal support for FS, support
for SM comes principally from a cognitive learning model of defensive behavior as
applied to the nature of the stutter event. Neither approach can claim anything like
uniform success with adults who stutter. However, self-management and modeling are
strategies common to both approaches and have shown consistently positive effects on
outcome. It is argued that both strategies merit additional treatment efficacy study.
Cognitive behavior theory may provide a useful framework for this research.
KEY WORDS: stuttering, treatment, evidence-based practice
he purpose of this article is to illustrate, through a historical pers-
pective, how both stuttering management (SM) and fluency shaping
(FS) are evidence-based treatments. They share treatment proce-
dures that not only have shown consistent positive effects on outcome but
that suggest the causal processes involved and a direction for future treat-
ment efficacy studies.
The modern era for research and treatment of stuttering began about
1925 with the establishment at the University of Iowa of the first truly
academic program for the study of speech disorders (Johnson, 1955b).
Since that time, two basic behavioral management approaches for treat-
ing older children and adults who stutter have been practiced. Both focus
on altering behavior associated with the occurrence of stutter events—
but in quite different ways. One has come to be identified as fluency shap-
ing (FS). It seeks to reduce or eliminate the occurrence of stutter events.
The other, usually identified as stuttering management (SM), seeks to nor-
malizereactionstotheoccurrence of those events.
More specifically, FS teaches the person who stutters to produce
fluent speech in a manner that prevents the fluency disruptions that
trigger stuttering reactions. Its goal is stutter-free speech. SM, on the other
hand, teaches the person who stutters to react to fluency disruptions
calmly, without unnecessary tension or struggle. Rather than stutter-free
speech, its goal is speech that, although disfluent, is free of unnecessary
University of Washington
Roger J. Ingham
University of California, Santa Barbara
Journal of Speech, Language, and Hearing Research • Vol. 52 • 254–263 • February 2009 • D American Speech-Language-Hearing Association
effort. It is not uncommon for treatment programs to
combine the two approaches (Guitar, 2006).
FS and SM have come to be distinguished in the lit-
erature as evidence-based (FS) and assertion-based (SM)
treatments (see Blomgren, Roy, Callister, & Merrill, 2005;
Onslow, 2003; Ryan, 2006).
The effect o f th is distinc-
tion clouds the essence of the two treatments as well as
a meaningful discussion of e ach in relation to the na-
ture of, and future research concerning, evidence-based
FS and SM are essentially products of the eras in
which they gained stature and of learning theories then
in vogue. From that perspective, both conform to Sacket,
Rosenberg, Gray, Haynes, and Richardson’s (1996) def-
inition of EBP: “Evidenced based medicine is the con-
scientious, explicit, and judicious use of current best
evidence in making decisions about the care of individ-
ual patients. The practice of evidence based medicine
means integrating individual clinical expertise with the
best available external clinical evidence from systematic
research” (p. 71).
Each approach, pertinent to its concepts of nature
and treatment of stuttering, has sought support from a
different kind of evidence. FS, an outcome-driven treat-
ment, has sought outcome evidence even as it eschewed
theory. SM, a theory-driven treatment, has done the op-
posite. Accordingly, FS has asked what procedures re-
duce the occurrence of stutter events, whereas SM comes
from a tradition that has asked what procedures are jus-
tified by the nature of those events. A closer look at each
reveals these characteristics.
Stuttering Management (SM)
Nature of Stutter Events
For about 20 years beginning in the 1930s, theory of
learning was dominated by the ideas of Clark Hull and
Kenneth Spence (see Hergenhan & Olson, 2004). From
their research, they concluded that behavior was rein-
forced due to drive reduction (i.e., need satisfaction) and,
further, that anxiety reduction, in particular, served as a
powerful reinforcer. This was the climate into which
Wendell Johnson introduced ideas about stuttering that
were, quite simply, revolutionary. Among them was his
concept of the “moment of stuttering”—what we speak of
today as the stutter event (Johnson, 1933; Johnson &
According to Johnson (1955b), “the concept of the
moment of stuttering almost immediately suggested the
feasibility of measuring the amount of stuttering and
the variations in it by the rather obvious means of count-
ing the moments of stuttering in systematically obtained
samples of speech” (p.14).Thenatureof the“the moment,”
he believed, would reveal the nature of the disorder and
the pathway to appropriate treatment. Thereupon, he
and his colleagues launched an unprecedented program
of research; make no mistake about it—Johnson was a
data collector (see Johnson & Leutenegger, 1955).
The research consisted, to a large extent, of studies
concerning the variation in stutter event occurrence un-
der different experimental conditions involving oral read-
ing and spontaneous speech. Results led to discoveries
concerning stutter event distribution in sentences and on
different parts of speech; the increase in their occurrence
in response to threat of punishment; and the adapta-
tion, spontaneous recovery, and consistency phenomena
(Johnson & Leutenegger, 1955).
From this work, Johnson (1955b) found that “stut-
teringI behaves like a response made to identifiable
stimuli or cues with a very considerable degree of con-
sistency and predictability” (p. 16). He concluded that
“such cues I function as reminders, and so as ‘storm sig-
nals,’ warning of danger ahead” (p. 23). In other words,
stuttering was a reaction to cues contained in the act of
speech—cues that, as a result of environmental conse-
quences, had acquired the capacity to threaten.
Influenced by, and in harmony with, the ideas of
Hull and Spence, Johnson (1955b) came to view stut-
tering as an “anxiety-motivated avoidant response that
becomes conditioned to the cues or stimuli associated
with its occurrence” (p. 23). He maintained that what
these stimuli meant to the speaker, the threat of stut-
tering to follow, was the key to sustaining the behavior.
In Johnson’s words, there is “something peculiarly lack-
ing in those concepts of habit or conditioning which fail
to stress dulyIthe meaningful aspects of the stimuli”
(Johnson, 1955a, p. 441).
Johnson believed that “neither of the traditional
theories of stuttering—one which attributed it to a phys-
ical fault and the other which viewed it as a symptom of
an unstable or turbulent personality—was based on suf-
ficient information about the ways in which stuttering
behaves,” prompting him “to regard stuttering as learned
behavior, and to investigate it, theorize about it, and treat
it clinically, as such” (Johnson, 1955b, p. 18). With that
conclusion, Johnson had contributed the first true behav-
ioral model of stuttering—a model, according to Bandura
(1969), that defines behavior as the result of t he way
“the individual has learned to cope with environmental
and self-imposed demands” (p. 10).
During the Johnson era, research concerning stut-
tering was dominated by interest in theory and, more
specifically, in his ideas concerning the nature of the
stutter event. Even studies of treatment were concerned
Stuttering management has sometimes been referred to as tradition-
based or the Iowa tradition, and fluency shaping as research-based or the
behavioral tradition (Bothe, 2003).
Prins et al.:
Stuttering Treatment History 255
less about outcome, per se, than about whether outcome
evidence supported theory—and, hence, provided justi-
fication for the SM approach to treatment (see, e.g., Oxtoby ,
1955; Sheehan, 1951; Sheehan & Voas, 1954). Sheehan and
Voas’s conclusion from an experiment comparing treat-
ment techniques is typical: “I the obtained experimental
data support the theory of stuttering as an approach-
avoidance conflict ” (Sheehan & Voas, 1954, p. 279).
Likewise, Johnson (1939) was more concerned about
the “ ideas” of treatment, those based on the nature of the
stutter event, than he was about the techniques for
changing speaking performance: “One need not be too
concerned over the question of how one is to change overt
behavior,” he said (p. 172); and later, he said, “ It is as a
listener, a perceiver, an evaluator, quite as much—
probably, in fact, far more than—as a speaker that the
person who stutters is to be treated” (Johnson, 1957,
p. 913). In that sense, Johnson anticipated a tenet of
cognitive behavior therapy: “[O]utcomes change behav-
ior in humans largely through the intervening influence
of thought” (Bandura, 1977b, p. 18).
To Johnson, the critical factor in stuttering was not
what he regarded as normal disruptions of fluency, but
what these disruptions had come to mean to the speaker
that, in turn, motivated his reactions (i.e., stuttering)
to the expectation or experience of their occurrence. With
this idea, Johnson gave birth to the two-component view
of stutter events: (a) an anticipation or experience of
fluency disruption and (b) the speaker’sreaction.Al-
though the sources of fluency disruption have been a
matter of research a nd spec ulation sin ce th e Johnson
era (see, e.g., Brown, Ingham, Ingham, Laird, & Fox,
2005; Ludlow & Loucks, 2003; Perkins, Kent, & Curlee,
1991; Postma & Kolk,1993; Smith & Kelly, 1997;
Wingate, 1988; Zimmermann, 1980), it remains widely
believed that what we observe as “stuttering” results
from the nature of speaker reactions to the sensation of
disrupted fluency (Bloodstein, 1997; Nudelman, Herbrich,
Hoyt, & Rosenfield, 1991; Perkins et al., 1991; Postma &
Kolk, 1993; Prins, 1997; Van Riper, 1990; Wingate, 1988,
Evidence gradually accumulated that did not sup-
port a relationship between anxiety and stuttering (see,
e.g., Gray & Brutten, 1965; Reed & Lingwall, 1976;
Ritterman & Reidenbach, 1975), and Oliver Bloodstein,
taking this into account, modified the two-component
concept. He defined stuttering as an “anticipatory strug-
gle reaction” (Bloodstein, 1995, p. 404). The anticipatory
struggle, according to Bloodstein, is a response to cues
that have come to arouse the expectation of fluency
failure—in other words, a response to what the cues mean
(Bloodstein, 1997). The struggle reaction is learned and
may occur in response to fluency failures that arise from
a variety of different sources, but, in contrast to findings
by Johnson, does not require anxiety and is not nec-
essarily an avoidance act. As viewed by Bloodstein, the
observable reactions of stuttering are essentially what
contemporary cognitive learning theory calls defensive
behavior—“activated by events which become threatening
through association with painful experiences” (Bandura,
1977b, p. 60). What the cues mean motivat es and sustains
defensive reactions. Reflex-like in their quickness, they
may come to seem involuntary (Bandura, 1977b, 1986).
Bloodstein’s version of the two-component explanation
of stutter events preserves Johnson’s idea about fluency
disruptions as “storm signals—warning of danger ahead,”
and it undergirds SM treatments today (Prins, 1984, 1997).
Nature of Treatment
It remained for Van Riper, based on a revised con-
cept of the first component of the stutter event, to de-
velop the treatment procedures we now associate with
SM. Although Johnson maintained that stuttering speak-
ers learned to react abnormally to the kind of fluency dis-
ruptions all speakers experience, Van Riper believed the
fluency disruptions that preceded stuttering reactions
resulted from a breakdown of the speech motor system.
In his words, “ a stuttering behavior consists of a word
improperly patterned in time and the speaker’s reaction
thereto” (Van Riper, 1971, p. 15).
Van Riper shunned the idea of treatments based on
fluency enhancement procedures that measure success
in terms of “the decreased number of spasms in the stut-
terer’s speech” (Van Riper, 1937b, p. 149). Such treat-
ment, he maintained, fails to target what accounts for
“most of the abnormality” in stuttering, the learned and
modifiable struggle or avoidance behavior. Moreover,
fluency disruptions, though they might be masked tem-
porarily by fluency-inducing procedures, are not (because
they result from inherent failures of the speech motor
system) amenable to permanent elimination (Van Riper,
1937b, 1957, 1990). In a similar vein, Johnson decried the
notion of teaching the stutterer to talk without stutter-
ing, or to speak “perfectly,” believing that this would lead
to speech that was “ grotesque” due to its artificiality
From the beginning, Van Riper based SM procedures
quite specifically on findings from his own research:
(a) anticipatory breathing patterns, rehearsal movements,
and levels of tension appeared to pre-model behavior
during actual stutter events (Van Riper, 1936); ( b) threat
of penalty for stuttering increased its occurrence (Van
Riper, 1937a); (c) stuttering speakers could predict the
duration of stutter events (Milisen & Van Riper, 1934);
and (d) they could perform new preparatory sets at the
outset of stutter events that seemed to generalize to
other similar, though not identical, occurrences (Van Riper,
256 Journal of Speech, Language, and Hearing Research • Vol. 52 • 254–263 • February 2009
1937b). In fact, a new preparatory set became the goal
for Van Riper’s SM approach. It was to replace old stut-
tering reactions with a new response, one that would
start from a state of “quiescence,” initiate “ air flow sim-
ultaneously with the speech attempt,” and produce the
first sound with “ movement leading directly into the
succeeding soundI a speech attempt such as a nonstut-
terer might make” (Van Riper, 1947, p. 359).
For more than half a century, Van Riper worked to
develop, evaluate, and justify a system of procedures to
teach adults who stutter to explore, calm, and modify
their abnormal reactions to fluency failure (see Van Riper,
1937b, 1947, 1954, 1957, 1958, 1973, 1990). More so than
Johnson, Van Riper emphasized performance change
through the mastery of motor reactions during the stutter
event. In turn, this would lead to necessary changes in
attitude and beliefs. In this way, Van Riper presaged the
view of cognitive behavior therapy: “Change is mediated
through cognitive processes, but the cognitive events are
induced and altered most readily by experiences of mas-
tery arising from successful performance” (Bandura,
1977b, p. 79).
In all this time Van Riper, and others who espoused
SM treatment, paid little attention to developing ex-
plicitly replicable procedures or quantitative measures
of outcome (Van Riper, 1973). In fact, as noted, the very
nature of SM caused its proponents to distrust outcome
evidence based on stuttering frequency counts.
Fluency Shaping (FS)
Nature of Stutter Events
As the 1950s drew to a close, Hull and Spence’s ideas
about learning fell out of favor. They were replaced by
the ideas of B. F. Skinner that would become the founda-
tion for designing and interpreting behavioral experiments
during the next decade. According to Skinner , “It is possi-
ble that the most rapid progress toward an understanding
of learning may be made by research that is not de-
signed to test theories. An adequate impetus is supplied by
the inclination to obtain data showing orderly changes char-
acteristic of the learning process” (Skinner, 1950, p. 215).
Precisely in this spirit, Flanagan, Goldiamond, and
Azrin (1958, 1959) conducted and interpreted two ex-
periments in which an aversive stimulus ( loud noise or
shock), or its termination, was a consequence for stut-
tering or nonfluency . They concluded that “breaks, pauses,
repetitions and other nonfluencies can be considered op-
erant responses I controlled by ensuing consequences”
(1959, pp. 979–980). In this paradigm, there was no need
for theory concerning the nature of stutter events—it was
enough to show that their occurrence could be brought
under stimulus control. These early studies provided,
though indirectly, the foundation for FS as it is practiced
today (see Ingham, 1984). For stuttering, a new behav-
ioral revolution was on its way: the era of radical be-
haviorism (Bandura, 1977b).
Nature of Treatment
After Flanagan, Goldiamond, and Azrin (1958, 1959),
the occurrence of stutter events was considered sufficient
to define the disorder, and elimination of those events—
the treatment goal of stutter-free speech—was validated.
Outcome evidence, not evidence to support theory, would
justify FS treatments. If certain procedures reliably re-
duced or eliminated the occurrence of stuttering in the
laboratory, they were legitimate candidates for clinical
application. Accordingly, scores of studies followed to eval-
uate the effects on stuttering frequency of consequential
stimuli (Ingham, 1984). Far more important, however,
was the shift toward applying the principles of scientific
method to treatment—the development of replicable pro-
cedures that could be tested for their efficacy using re-
liable and valid measures of the problem behavior. An
additional and important contribution was the use of
experimental time-series treatment formats that lent
themselves to ongoing—even real-time—treatment eval-
uation (see Yates, 1970).
In a pivotal study, Goldiamond (1965b) discovered,
almost by accident, that prolonged, stutter-free speech
was a natural accompaniment to delayed auditory feed-
back (DAF) and, further, that the prolonged speech pat-
tern, while remaining stutter-free, could be shaped into
more normal-sounding fluency. As Goldiamond (1965b)
described it, “Where the new prolonged behavior is main-
tained without the delayed feedback, the reading rate
may now be speeded up, by machine control of the pre-
sentations, through appropriately programmed steps to
normal and supernormal rates” (p. 142). Goldiamond’s
laboratory studies appeared to give scientific credibility
to an age-old fluency-inducing technique, variations of
which have become the cornerstone of FS treatments.
Referred to collectively as prolonged speech, these tech-
niques include, among others, prolonged, continuous
phonation, slow articulatory movements, easy voice, and
articulatory onsets. However, what then emerged from
this pivotal study was unfortunate: There appeared a
virtual plethora of variants of “prolonged speech” strat-
egies that were mainly unreplicable and were subjected
to questionable investigations for their efficacy (see
Ingham, 1984, 1990). Remarkably, only recently have
serious attempts been made to translate the hypothesized
critical components of prolonged speech into replicable
and testable therapy procedures (Hillis, 1993; Hillis &
McHugh, 1998; Ingham et al., 2001).
Goldiamond’s (1965b) study was noteworthy in an-
other way: It was the first to introduce a self-control (or
Prins et al.: Stuttering Treatment History 257
self-management) procedure to stuttering treatment.
“This consists in training S to recognize those behaviors
of his which he wants to modify. Rather than telling him
to modify themI he is trained in the experimental ana-
lysis of behavior, and also in the variables which main-
tain it, or which he can recruit to modify it” (Goldiamond,
1965b, p. 153). As we point out in the paragraphs that fol-
low, Goldiamond’s introduction of self-management an-
ticipated the discovery of what we are coming to view as a
strategy that might be critical to the success of both FS
and SM approaches.
The ultimate concern of FS was with process and out-
come, not theory. As a consequence, FS has been charac-
terized by a clearly stated treatment goal—stutter-free,
natural-sounding speech; carefully described and repli-
cable procedures; performance-contingent progress during
treatment; and the quantitative measurement of process
and outcome. Like SM, FS grew from laboratory studies of
the effect on stuttering frequency of different experimental
conditions. But, unlike SM, it was based on an approach
to treatment that relied on the application of experimen-
tal method to the treatment process (Ingham & Andrews,
1973a). This important paradigm shift placed new empha-
sis on the development of measurement and measurement
procedures (Cordes & Ingham, 1994). These characteris-
tics were a perfect fit for the age of accountability—anat-
ural outgrowth of the new behaviorism.
FS and SM Today
FS and SM remain the principal behavioral ap-
proaches for the treatment of stuttering. Both are evi-
dence based—one on treatment process and outcome, the
other on a behavioral model for the nature of the stutter
event. Each relies primarily on the evidence it has always
sought and accepted. What does that evidence show?
In comparison with SM, outcome studies of FS treat-
ments (including those based on response-contingent
stimulation principles) abound in the literature (Bothe,
Davidow, Bramlett, & Ingham, 2006). On balance, they
show that FS, although it may be an effective treatment
for some adults who stutter, is clearly not for all. The age-
old problems re main : post-t reatment relapse and high
treatment dropout rates (Bothe et al., 2006; Perkins,
1992). At the same time, though, it has revolutionized
treatments for children who stutter. In this respect, it has
replaced one of the sad legacies of Johnson’s commitment
to theory—that direct treatment of stuttering in children
was to be discouraged.
SM, on the other hand, offers scant outcome evi-
dence to support its effectiveness (Blomgren et al., 2005;
Bothe et al., 2006) that must be adduced largely from
studies of defensive behavior treatments reported in the
cognitive learning literature (Bandura, 1977a, 1986). As
a consequence, SM’s justification relies today, as it has
since the beginning, on the widely accepted two-component
model of the stutter event and the belief that modifica-
tion of second-component behavior, the defensive reac-
tions to perceived fluency disruption, is the appropriate
objective of treatment (Prins, 1997). It is in this sense
that SM conforms to Bandura’s (1969) dictum: “The de-
velopment of principles and procedures of behavioral
change is largely determined by the model of causality to
which one subscribes” (p. 1).
Van Riper’s (1990) final words on the subject not
only capture the essential difference between SM and FS
treatments but restate a hypothesis that he held from
the beginning: “The goal of therapy for the confirmed
stutterer should not be a reduction in the number of dys-
fluencies or zero stuttering. Fluency-enhancing proce-
dures can easily result in stutter-free speech temporarily
but maintaining it is almost impossible” (Van Riper, 1990,
p. 318). So is it better, as Van Riper opined, to accept the
inherent inevitability of fluency disruptions that trig-
ger stutter reactions and teach the speaker to react
“normally” (SM) or to try to prevent their occurrence al-
together ( F S)? Frankly, we don’t know the answer—his
hypothesis has never been tested.
We do know, however, that two treatment strategies,
modeling and self-management, are being used increas-
ingly as adjuvants for SM (Guitar, 2006; Prins, 1997) and
FS (O’Brian, Onslow, Cream, & Packman, 2003). Both
strategies have been shown repeatedly, in the laboratory
and in the clinic, to have a positive influence on the gen-
eralization and maintenance of behavior change, two of
the most vexing problems that plague both SM and FS
Modeling and Self-Management
Modeling is a procedure for learning by observing an-
other person’sorone’s own performance. It is assumed
that individuals will acquire a desired behavior without
having to perform it. In his excellent review of the history
of behavior modification, Kazdin (1978) notes that early
therapeutic applications of modeling were essentially fo-
cused on fear reduction. Evidence accrued that the most
powerful effects relied on “similarity between the model
and the observer, competence, prestige, and status of the
model, the number of models, characteristics of the ob-
server, and consequences following emulated behavior”
(p. 227). Ultimately, the procedure evolved into covert
or imagined modeling and, later, carefully structured
It was experimen tal treatment evidence that directly challenged the retro-
grade effects of that theory ’s stranglehold on clinical practice (Martin, Kuhl,
& Haroldson, 1972; Reed & Godden, 1977) and ushered in the principal cur-
rent direct therapies for stuttering in children (Onslow, Packman, & Harrison,
2003; Prins & Ingham, 1983).
258 Journal of Speech, Language, and Hearing Research • Vol. 52 • 254–263 • February 2009
imitation strategies that focus on much more than just
fear reduction (Miller, 2006).
Beginning in the early 1960s, experiments in the be-
havior modification literature had already demonstrat-
ed clearly that observation of models could induce new
responses that were not previously in a participant’s rep-
ertoire, strengthen or weaken inhibitory responses, and
elicit previously learned responses in new environments
(Bandura, 1965). More than a decade later, Martin and
Haroldson (1977) reported their landmark experiment
concerning application of modeling to the treatment of
stuttering. Twenty stutterers showed a significant de-
crease in stuttering frequency as a result o f “ observing
another client responding dramatically to a treatment
Van Riper had informally employed modeling as an in-
tegral part of his SM program (Van Riper, 1958, 1973),
experimental evaluation of its effects on the treatment of
stuttering languished following Martin and Haroldson’s
report. In fact, almost 20 years passed before recent
studies by Bray and Kehle (1996, 1998, 2001) showed the
positive influence of self-modeling on the generalization
and maintenance of treatment effects. Since then, we
have only the report by O’Brian et al. (2003) suggesting
how modeling might be used in treatment to induce pro-
In the meantime, modeling of a target behavior had
been a well-established clinical strategy within many
areas of speech-language pathology. Indeed, tape-recorded
target models of prolonged speech were used in early FS
programs (e.g., Ingham & Andrews, 1973b). Yet there have
been no recent experimental investigations into how such
model recordings—of client or clinician—could be used
in a systematic way to increase the probability of gener-
alization and maintenance.
Self-management procedures are believed to influ-
ence the modification of behavior because they help to
establish the self-regulatory systems that “ provide the
very basis for purposeful action” (Bandura, 1991, p. 248).
Through self-observation, self-judgment, and self-reaction,
people learn to exercise and maintain control over their
behavior. Further, according to social cognitive theory,
self-regulatory systems are ultimately enabled by the es-
tablishment of self-efficacy, “people’s beliefs about their
capabilities to exercise control over their own level of func-
tioning and over events that affect their lives” (Bandura,
1991, p. 257).
Concerning stuttering, as noted earlier, pioneering
work in self-management was done by Goldiamond
(1965a), who advocated using self-control strategies
in conjunction with prolonged speech treatment
(Goldiamond, 1965b). Later, a single-subject study by
La Croix (1973) drew attention to the positive reactivity
of self-recording on stuttering. However, it was two
groundbreaking experimental studies—James (1981a)
and Martin and Haroldson (1982)—that had important
implications for the application of self-management pro-
cedures in treatment. James (1981a) clarified the ben-
eficial effects of self-monitoring on stuttering as well as
the latitude of monitoring accuracy within the procedure.
And then Martin and Haroldson (1982) showed that par-
ticipants who provided their own time-out for stuttering
events had less recovery of stuttering frequency fol-
lowing the time-out condition and, even more important,
showed significantly greater generalization to an un-
treated telephone situation than participants who re-
ceived experimenter-delivered time-out.
Additional clinical investigations by James (1981b)
and Ingham (1982) showed that self-managed time-out
and self-evaluation of performance are capable of produc-
ing sustained reductions in stuttering in young adults—
arguably the most relapse-prone type of patient. James
and colleagues (James, 1983; James, Ricciardelli, Rogers,
& Hunter, 1989) then went on to demonstrate that self-
managed time-out could be employed to increase the ef-
ficacy of FS treatments with adolescents and adults who
One later extension of those findings to stutter-
ing therapy occurred in a study reported by the second
author (Ingham et al., 2001). This showed that training
adult stuttering speakers to self-manage reduced frequen-
cies of short phonated int ervals ( PIs), whereas speaking
resulted in sustained reductions in stuttering, and that
this reduction in PIs tended to generalize across a variety
of speaking tasks.
There are covert aspects of SM and FS treatments
that lend themselves to systematic investigations into
how they might best be combined with self-management
strategies. In the case of SM, the focus is often directed
toward reducing sensations of apprehension of pending
stuttering. This type of sensation lends itself to quanti-
fication, if only via self-monitoring for frequency of oc-
currence in order to determine if those sensations during
speech are reduced by self-recording. In the case of FS, it
is already apparent that the quantification of the most
problematic features of prolonged speech might be ame-
nable to self-management strategies. For instance, stud-
ies have shown that speech naturalness can be measured
and modified using self-judgments (Finn & Ingham, 1994).
Those same self-judgments of naturalness are now being
Recent claims made by Hewat, Onslow, Packman, and O’Brian (2006) to
have developed a “new treatment program for persistent developmental
stuttering in adolescents and adults” using self-delivered timeout turns
out to describe a program that is almost identical to that developed more
than 20 years earlier by James (see James, 2007). Such claims serve to
illustrate not only the importance of just attribution but also the importance
of highlighting the discipline ’s extant knowledge base—one purpose of this
Currently, this treatment is being investigated within the framework
of neuroscience in order to determine the extent to which this strategy
promotes neural plasticity (Ingham et al., 2007).
Prins et al.:
Stuttering Treatment History 259
used as performance criteria in a program-based PI mod-
ification (Ingham et al., 2001). Similarly, the private sen-
sation of speech effort, one of the critical dimensions of
normally fluent speech, is also being measured by self-
ratings (Ingham, Warner, Byrd, & Cotton, 2006). And in
turn, the ratings may be used as performance criteria for
progress in FS treatments. These are but some of the
potentially rich areas of clinical research made possible
by investigating how self-management strategies can be
employed to maximize the durability of changes that are
a consequence of the core components of SM and FS.
Self-management in its p urest sens e implies no
clinician-directed constraints on the process, which of
course is essentially never true in practice. Nevertheless,
it is possible to consider levels of self-managed control
over the treatment process as a worthy topic of research
and to test whether self-established targets for treatment
are more effective—that is, show more durable change—
than clinician-established targets.
The Internet and other technical advances now offer
clinicians and researchers a powerful medium for de-
livering clinical services, including strategies for aiding
generalization and maintenance. There is evidence that
many Web sites are taking advantage of this, but there is
little evidence of research into methods that might be
particularly amenable to Web use. Relevant here are
ways in which the Web makes it possible to implement
modeling and self-management strategies. For example,
self-recorded audiovisual speech samples during treat-
ment can be used to make performance comparisons with
target models of normally fluent speech produced by the
participant. Similarly, the Web can provide access for
observing others using methods that help them with SM
or FS techniques. The new generation of cell phones makes
it is possible to produce and deliver performance tasks to
select sites for both self and clinician evaluation. The
possibilities for such research seem endless.
Finally, there is a rather obvious link between
(a) the concepts of modeling and self-management and
(b) the concepts of efference copy (Blakemore, Frith,
& Wolpert, 2001; von Holst & Mittelstaedt, 1950) and
self-efficacy (Bandura, 1977a). As mentioned earlier,
modeling has gradually evolved into imitation and an as-
sociation with neural structures that support an efference
copy of the neural system prior to behavior performance
(see Hurley & Chater, 2005). In turn, this relates to stud-
ies with direct connections to self-efficacy theory show-
ing that imagining behaviors prior to their performance
may increase the probability that the behavior will be
performed successfully (Gentili, Papaxthansis, & Pozzo,
2006; Mulder, Zijlstra, Zijlstra, & Hochstenbach, 2004).
Evidence shows that the aberrant neural region activa-
tions associated with both real and imagined stuttered
speech are normalized when adults who stutter imagine
speaking fluently (Ingham, Fox, Ingham, & Zamarripa,
2000). This process, too, might be investigated for its
The time is ripe for testing the effects of modeling
and self-management on FS and SM procedures. It is a
time to ask efficacy questions—to learn whether model-
ing and self-management are differentially effective when
applied to FS versus SM approaches. It is a time to deter-
mine which behavior associated with the occurrence of
stutter events, the fluency disruptions or the reactions to
them, is more amenable to permanent change. It is quite
possible, of course, that what is crucial to treatment’s
long-term effectiveness has nothing to do with the FS or
SM approach, per se. Rather, successful outcome may be
a function of the employment of self-management, mod-
eling, or other strategies not yet identified. Efficacy stud-
ies will be required to provide the answer—studies that
isolate treatment parameters in order to illustrate their
These potentially rich treatment parameters may
be identified in both behavioral and cognitive domains
by carefully elucidating the numerous strategies that
those who recover from stuttering in adulthood have found
to be effective (see Finn, 2004). Recent trends in cogni-
tive neuroscience are also fertile sources. The role played
by mirror neurons in modeling is especially interesting
given recent findings suggesting that it might be pos-
sible to control their role in learning a new behavior (see
Catmur, Walsh, & Heyes, 2007). Another interesting
possibility is the investigation of self-management through
the use of real-time fMRI (de Charms et al., 2005); self-
control over feedback from regional activity may increase
the probability of neuroplasticity in regions known to be
functionally related to reduced stuttering using FS pro-
cedures (see Ingham, Finn, & Bothe, 2005).
It is also a time to re-evaluate the role of theory in
treatment and ensure that we have theories that are
able to drive the development of more effective thera-
pies. The understanding and treatment of stuttering
need not await the appearance of an all-encompassing
theory—it is certainly not clear that past theories of
stuttering have done much to advance its treatment. Some
of the great advances in science have emerged from the
judicious use of less encompassing theory/models that
build on parameters that are related to powerful inter-
vention effects. For instance, in a recent review of the
enormous contributions made by the late Nobel Prize
winner, Pierre-Gilles de Gennes (Brochard-Wyart, 2007,
p. 149), it was noted that many were derived by isolat-
ing “the few essential parameters to derive minimalist
260 Journal of Speech, Language, and Hearing Research • Vol. 52 • 254–263 • February 2009
theories that could be used and tested” (p. 149). Iso-
lating the essential parameters that control stuttering
behavior—such as may be the case within modeling and
self-management methods—may well provide the small-
scale theory/models that can be used to advance treat-
ment. An d, as m entione d above, such mod els may help
build a stronger link with current advances in cognitive
neuroscience, especially with respect to neuroplasti-
the therapy arena (Ingham,Cykowski,Ingham,&Fox,
These observations on historic trends in stuttering
therapy are offered by two individuals with very differ-
ent backgrounds. Our hope is that they encourage fresh
approaches to stuttering treatment research.
Parts of this article were written with the support Grant
R01 DC007893 from the National Institute on Deafness and
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Received May 23, 2007
Revision received October 2, 2007
Accepted April 7, 2008
Contact author: Roger J. Ingham, Department of Speech and
Hearing Sciences, University of California, Santa Barbara,
Santa Barbara, CA 93106.
Prins et al.: Stuttering Treatment History 263