Maintaining fluency – The Risk of Relapse

After a busy week, with three days at the hospital and two at the fluency clinic, I must admit I’ve missed out on a few posts. However, after a conversation with a Clinical Educator, I felt like investigating the ‘dark side’ of stuttering treatments: Relapse.

I was told that relapse rates were enormously high (>50%), and that the risk factors were contested. Here’s a smattering of the literature

  • Andrews and Craig [1] identified three factors:
    • “Skill mastery as evidenced by no stuttering”
    • “normal attitudes to communication”
    • “internalisation of the locus of control”
    • They found pre-treatment severity to be only a small predictor.
  • A 1996 study [2] claimed “that 12 subjects who remained with the entire 2-3-year program achieved zero or near-zero stuttering”
    • Since I’ve only got the abstract, it’s impossible to say how many subjects were in the trial at its beginning, and therefore how many may have dropped out because it didn’t work.
  • Dayalu and Kalinowski [3] supposed that therapy only provides ‘pseudofluency’, masking rather than removing the stuttering; and suggested that this explains high rates of relapse.
  • A detailed study [4] into the experiences of people after they received prolonged speech treatment found:
    • Risk of stuttering continues, even after therapy.
    • “the maximum benefits of prolonged speech are attained when clients use a strategic approach to control stuttered speech and daily communication.”
  • A few years later, researchers from La Trobe and Sydney Uni found [5] that only stuttering severity predicted short or long-term outcomes for people who stuttered who sought therapy.

Colin-Firth-in-The-Kings--007My experience

I saw a client at a review day on Friday that had been through an intensive Smooth Speech program, and attended many review days. Upon arrival I noted they were quite severe, with many blocks exceeding 5 seconds in duration. However, within an hour of therapy they ‘miraculously’ became fluent ā€” well not miraculously, as I was creating a fluency-inducing environment. Why couldn’t they do this at the beginning of the session.

I thought they needed to be able to self-cue at home and work to create their own fluency-inducements. I asked them to practice in the mirror, before high-stakes interactions and just for the hell of it, to maintain the pattern. I also told them to record themselves during our session being fluent, and to play it back when they were having trouble with fluency: a reminder that they could be fluent. This approach (I later discovered) has preliminary evidence, and is very time/cost effective for both clinician and client [6]. As I explained to them, they needed to develop strategies to maintain their fluency actively, and couldn’t rely on the odd review day to do it for them.

The previous night, another client said they couldn’t wait until the smooth speech became second-nature, and they could talk freely without monitoring what they were doing. Unfortunately, this will probably never happen. They will always need to monitor their speech and actively use the pattern, and this will probably require greater effort than someone who does not stutter. I felt awful delivering this news (in the form of a pep-talk) ā€” if only there were a pill!

This raised interesting questions about whether cognitive constructs like executive-function and attention could be considered prognostic indicators for this type of therapy – a topic for another day.


  1. Andrews, G., & Craig, A. (1988). Prediction of outcome after treatment for stuttering. British Journal of Psychiatry, 153(2), 236-240.
  2. Onslow, M., Costa, L., Andrews, C., Harrison, E., & Packman, A. (1996). Speech outcomes of a prolonged-speech treatment for stuttering. Journal of Speech, Language, and Hearing Research, 39(4), 734-749.
  3. Dayalu, V. N., & Kalinowski, J. (2002). Pseudofluency in adults who stutter: The illusory outcome of therapy. Perceptual and Motor Skills, 94(1), 87-96.
  4. Cream, A., Onslow, M., Packman, A., & Llewellyn, G. (2003). Protection from harm: The experience of adults after therapy with prolonged-speech. International Journal of Language and Communication Disorders, 38(4), 379-395. doi: 10.1080/13682820310001598166
  5. Block, S., Onslow, M., Packman, A., & Dacakis, G. (2006). Connecting stuttering management and measurement: IV. Predictors of outcome for a behavioural treatment for stuttering. International Journal of Language and Communication Disorders, 41(4), 395-406. doi: 10.1080/13682820600623853
  6. Cream, A., O’Brian, S., Onslow, M., Packman, A., & Menzies, R. (2009). Self-modelling as a relapse intervention following speech-restructuring treatment for stuttering. International Journal of Language and Communication Disorders, 44(5), 587-599. doi: 10.1080/13682820802256973

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