2003 IFA Congress: Montreal, Canada

The Bitter Sweet Tale of Empiricism in Stuttering Treatment Research

Mark Onslow
Australian Stuttering Research Centre, The University of Sydney, PO Box I 70, Lidcombe, Australia, NS W 1285

The honour of giving a plenary address at Congress of the International Fluency Association invokes certain responsibilities. One that came to mind repeatedly as I thought about my task is the responsibility to address not only those who formally study and teach about the disorder of stuttering in universities, but also those who treat it, and, in particular, those who experience its effects every day. Surely an IFA plenary speaker has a responsibility to be thought provoking for all those parties. Perhaps even a little controversial. Not so much as to give offence and to dissipate the good humour that delegates always bring to conferences in this field, but just enough that might stimulate productive debate.

Another responsibility for a plenary speaker at a scientific meeting such as this is to record something about the history of our field. Have you heard of time capsules? Things buried, often under buildings, during times thought to be of interest, with memorabilia of the day to be discovered by citizens who come across it eons hence? Well, in science, you don’t need a time capsule. Science is a time capsule. Any of us, in a library, can revisit the history of science. We can relive that moment, for example, when Galileo discovered that Aristotle was wrong, and that a heavy ball does not roll quicker down an inclined plane than a light ball. Surely, the study of our puzzling speech disorder is not so important to explore as that phenomenon known to the ancients, where things fell to earth.

But stuttering was known to the ancients. Indeed, Aristotle contemplated it. Surely there will come a time, as far in the future as Galileo is now in the past, when a historian of the study of this disorder will come across the proceedings of the 2003 IFA Congress, here in Montreal, gathering dust in a library somewhere. So, my responsibility is dire: To convey to our historian what was said at the head of this Congress, during August 2003, about this disorder. What I wish to do is lay out our time capsule for our historian of the future, in a story.

Then what story shall I tell? Well, I want to tell the story of empiricism in stuttering treatment research. Why? For two reasons. First, for what it is worth, because I am an empiricist. I had empiricist leanings at an early age. I was certain that I was one when I was four years old. At that age I denounced Santa Claus as a logical impossibility. For Heavens Sake, how could he leave presents at every house in the world in one night?

The second reason I wish to tell the story of empiricism in stuttering treatment research is because it is a story with intrigue, mystery, emotion, and, paradox too. Intrigue? Mystery? Emotion? Paradox? Are you in the correct convention hall? Oh yes indeed, you are.

Where, then, does such a story begin? Obviously, with Lee Edward Travis. Because most speech pathologists are women, I was recently invited at the The Univeristy of Sydney to give a lecture in the Department of Feminist Studies, during the course of which I found myself referring to Lee Edward Travis as the “father” of speech-language pathology in the United States, as is often done. I can tell you, I was vigorously taken to task on this point. They replied: “Who, then, is its mother?” Well, I am getting too old and clever to debate figurative birthing issues with 300 feminists, so I backed right off, and changed his appellation to “a parent” of speech-language pathology. It doesn’t sound right, though does, it? Never mind. This is he on the slide. Shame about the glasses.

In 1924, Travis was the first person to achieve a Doctoral qualification in the discipline that formally studies speech and language and its disorders. He was no fool, either, this Lee Edward Travis. He achieved a Bachelors Degree, a Masters Degree, and a PhD in ‘three years. He received a Fullbright to study the emerging technology of electro-encephalography. And 1928 he began a term as leader of the first American speech-language pathology program at the University of Iowa. And he 4 Theory, research and therapy in fluency disorders started the story of empiricism in stuttering treatment research. He was the first American researcher to record EEG waves. He was the first researcher to do EMGS on stuttering subjects. In his years at Iowa, his publication list fairly bristles with hard science. His research used equipment that is now long forgotten, but was ground breaking for its time. Instruments, such as the phonelescope and the kymograph.

And then something extraordinary happened. He went to California. That, of itself, is not so remarkable. Lots of people from Iowa have done it. He went there in 1938, to the University of Southern California. Well, Marilyn Monroe, who stuttered, is known figuratively as a candle in the wind. Iowa created a superstar, and he moved to California, and was, himself, a candle in the wind. Because, the extraordinary thing was that, from this time, he stopped his scientific publishing in stuttering. The record shows this to be true. From 1938, at the age of 42 onwards, he basically only published review articles and, of course, several editions of his landmark edited text “A handbook of speech pathology and audiology” (Travis, 1957). No EEGs no EMGS no phonelescopes, no kymographs. Virtually nothing.

Why was this‘? Forty two years of age is the adolescence of a life in science. It is most unusual for a young scientist to just stop like that. Even if he did go to California. I promised mystery, and there it is. We will go there in a while. But I promised intrigue also. So consider what he did when he got to California.

Speech pathology is not what you would call a “hard science” in the sense that we have been touched by the greatest, creative ideas in the history of humankind, as is any student of physics or biology. There have been many such great ideas, of course. Gravity, relativity. Evolution wasn’t bad. And democracy. There was a great idea (pity it never -really caught on in universities). But of all things, when he went to California, Travis gave our fledgling profession a brush with Freud’s great idea of psychoanalysis. He psychoanalysed 30 people who stutter, and published the results, for the world to see, in the early editions of the Handbook of Speech Pathology and Audiology.1 It was, of course, one of the texts I purchased when I enrolled in my first course in speech pathology. On the bus on the way home after enrolment, while flicking through that chapter, I thought that the bookshop had given me a pornographic novel by mistake. For Travis concluded, to use his words, that “stuttering is the speaker’s attempt to prevent the verbal expression of unacceptable feelings and thoughts” (1986, p. 121). And there they were, in the Handbook, a veritable tome of unacceptable thoughts and feelings. Astonishing.

This, from a man who, in a previous life, was researching the bodies of stutterers with the cutting edge tools of hard science. Now he had turned to explore their minds with psychoanalysis. Why did he do that? Well, one reason was that he was a clinical psychologist, and as such it was impossible to be immune from the effects of the revolution that Freud’s work brought to the field in those days.

But apart from these inevitable predilections from his background in psychology, I think that there is a more important reason why he did it. Naturally enough, because the leader of the first formal American speech pathology program was interested in stuttering, it attracted students who themselves stuttered. There were many such over the years, but, as we shall see, Travis had a special bond with his three first ones: John Knott, Charles Van Riper, and Wendell Johnson. To cut a long story short, when he was in his laboratory, doing his EEGS and EMGS on stuttering subjects, I think that they well and truly got in his ear, and told him that was not the full story of stuttering. And so he searched for the full story, as a scientist, with the best tool of the day in psychology, psychoanalysis. What a founding contribution to us, to be passionate about his own scientific approach to the study of stuttering, but to admit the validity of the approach of others. Surely a fine role model also, this parent.

And so it was early last century, a perfectly balanced beginning to our formal study of this disorder. We have to leave this part of the story now, this perfectly balanced, gently rocking cradle of our study of stuttering, that married the physical and psychological aspects of the disorder. For, I am bound to say, the baby in that cradle was a multifactorial approach. And what happened next? The behavior therapists arrived and spoiled everything! In the mid fifties. They threw out the cradle, and the baby too!

Remember the behavior therapists? My, they were a funny lot weren’t they? What happened to them? Was that one of them, that frail, ageing man in a white coat with horn rimmed glasses? The one who was taken away by hotel security for soliciting money for scientific research? Granted, they joined the ranks of many who have studied stuttering and had no sense of humour, and their work indeed assumed a unidimensional perspective.

I promised emotion, too. Well, the behavior therapists annoyed everyone. They had an astonishing capacity to annoy anyone who had taught, thought, researched, and/or suffered from stuttering, and then some. Joseph Sheehan, for example — who had his origins at Iowa, incidentally - often referred to their work in ascetic terms, severely admonishing, with strong language, it in one of his last publications (Sheehan & Sheehan, 1984). How didthey manage to give such offence? Simply, really. By saying that they cared neither whether the problem is in the body or the psyche. In fact, they cared nothing about the nature of stuttering. It was irrelevant. To them, stuttering was just an aberrant speech behavior that may — or may not be — manipulable. And whether that was the case or not would be discovered — by them of course — with a series of laboratory experiments. With electric shocks for openers. Understandably, this did not go down so well, particularly with those who stuttered and had entered our profession.

But the behavior therapists did not give up because they were criticised. In fact, it quite spurred them on. And once, after a hard day in the speech clinic in a white coat yelling “stop” whenever someone stuttered, one of them thought up a really interesting idea: That the resolution of this problem lay in the simple replacement of stuttered speech with a new way of speaking. What a terrific idea! Replace an undesirable behaviour with a less undesirable behavior. Should work well for stuttering. Certainly works well with smoking: Instead of smoking a cigarette, drink a glass of water (it’s not difficult to drink fifty glasses of water a day).

Anyway, we jump now from the mid 1950s in the United States to another time and place, the late 1970s in Australia. This was the time when I was a student in this profession, just when the effects of Goldiamond’s seminal work in the replacement of stuttering with the prolonged—speech technique had spread there, as well as to many other parts of the world. Smooth speech, precision fluency shaping, you know. As a student, I was entranced during my visits to intensive treatment programs, to see those who stuttered miraculously, in a fortnight, appear to lose their affliction. I must admit, one "of the reasons that I remained in this profession was the lasting effects that those exciting images had on me. Here was real science, originating in the laboratory just like the one Travis had at Iowa, and proliferating benefits to human kind through the speech clinic. Who would not be part of such a venture?

But it was not to be. Behavioral replacement of stuttered speech with prolonged—speech did not live up to its promise. For shortly after systematic research had established that it was possible in the short term, it became apparent that such treatment effects were not durable, and that they were often accompanied by unnatural sounding speech and unusual levels of attention to speech production.

All this is not to say that prolonged—speech as a treatment for stuttering is useless. Far from the case. It is just not all that we thought it was going to be, back in those heady days. It has helped many who stutter over the years. Did you know that this hotel is the very one in which John Lennon and Yoko Ono staged their “love in” in 1969. So, I should use a Lennon-McCartney phrase, “I’ve got to admit it’s getting better.” Clinical trials are showing better and better results for this method.

So, if we keep on getting better at this rate with prolonged—speech treatment, will it ever be enough for those who stutter? Will the bitter disappointment of the partial failure of this technique ever be reversed? I think not. Why? For one reason, and most obviously, many who stutter choose not to attempt to stop doing so. For many reasons I suppose. Stuttering does not impair someone’s capacity to communicate in all cases. In other cases it does, but the effort of attempting to stop stuttering is just not worth the benefits that it brings.

The other reason why prolonged-speech is not enough of a treatment for stuttering can be found in the stories of those who stutter and have received the treatment. I wonder what Travis would have thought of the current crop of behavioural, prolonged-speech treatments, had they emerged in his time? I don’t know, but I am certain that he would not have forgotten to ask those who stutter what it was like to receive the treatment. Well, my colleague Angela Cream and colleagues have used phenomenology — the study of how people experience things — to find out what it is like to stutter and to attempt to replace it with prolonged-speech (Cream et al., 2003). This research method systematically incorporates the experiences of those who stutter to find out important information. Of late, the stories of those who stutter are, more and more, being systematically harnessed and finding their way into our scientific literature.

It is common in phenomenological research to develop metaphorical explanations of findings. I suppose that you are all familiar with the metaphor of the glass ceiling to describe gender-based barriers to corporate promotion for women, and the glass escalator to describe the opposite effect for men? Those metaphors came from phenomenological research, and here is our metaphor for what it is like after treatment with Prolonged-Speech for stuttering, complements of Angela Cream. I suppose you have all seen children’s playground rockers like this one on the slide. This is what it is like to learn to speak with prolonged speech and to practice it every morning in the shower, in preparation for the day ahead. It is a one-way rocker. There is no-one else there, and you go at your own pace, and there is nothing at all that can make you feel different from other speakers or vulnerable to harm — simply, there are no other speakers.

And on this slide, here is the two-way rocker. This is what it is like with the caring, helpful clinician, or the “speech buddy” with whom you practice your prolonged-speech as a replacement for stuttering. Again, nothing threatening, potentially harmful, or unpredictable.

But on this slide, here we have the four—way rocker, and it’s a different story. Here, we have no control over who gets on or off the rocker, or how unpredictably, or in which direction they will rock, or when they will get on or off. Here, we feel terribly different. And if we use prolonged-speech that feeling of being different will not go away. In fact it may become worse. And we may experience harm on the rocker — maybe we will even fall off it — and being able to not stutter will never prevent that potential for harm. This is the communication of daily life. No matter how impeccably you are able to control your own speech and not stutter, it is simply impossible to control the daily communicative situations of life. They are always sources of potential harm, and they are always sources of feelings of being different.

And that is where the behavior therapists went wrong. No wonder hotel security took away that ageing, frail man in the white coat and horn-rimmed glasses. Hindsight is always 20-20, but why, oh why, did Israel Goldiamond, after his seminal prolonged-speech experiment (Goldiamond, 1965), not find out from those who stutter what it was like to replace stuttering with that novel speech pattern? Had he done so, I am certain that the story I am telling today would be much different.

So now, let us now jump from the late 1970s to the closing years of the last century. Now, in our story of empiricism in stuttering treatment research, we know enough about treatments to conduct clinical trials. Well, I promised you irony also. Then hear this. Roger Ingham has noted several times in papers over the years that, in clinical trials, as the posttreatment period increases, then there are an increasing number of uncontrolled variables. In other words, after treatment, those who stutter may go to self help groups, find religion, find true love, whatever. But what Ingham said was that the longer after treatment that someone does not stutter, the less confident we can be in the effects of the treatment.

Well technically, it is true. Indeed, there is little experimental control in a scenario where you have a treatment and a long follow up period. And to the horror of my colleagues and myself, we have discovered that the gatekeepers of our science, the editors of our scientific journals, are most sensitive to this irony (Onslow et al., in press).

My colleagues and myself recently published an outcome study of a prolonged-speech treatment (Onslow et al., 1996). There are the data, summarised for each subject over the three pretreatment assessments, one month apart. Each data point is a mean of percent syllables stuttered on six beyond clinic recordings. And here are the data, again summarised for each subject, over a 12 month posttreatment period. Not the best design in the world, but a long way from the worst. And this was published in a creditable journal, without much fuss. Now, here comes the good part. We followed—up these guys for 9-12 years after they received their treatment. We managed to obtain complete, long term outcome data of eight of the original 12 cases (Onslow et al., in press). Here are their data, presented against the pre—treatment data that we took years before. You can see that, except for one case, their stuttering rates were quite low at 9-12 years follow up. And they sounded really natural, too.

We were so pleased. Surely we had done well. We had managed to find out how these people were managing their stuttering a long period after they received the treatment. Unfortunately, the editors of our journals were not so enthusiastic, and we could not get it published. The problem was the long follow-up period.

The derogatory comments from editors and editorial consultants flooded in. In short, they said that, indeed we do desperately need to know the long term effects of the treatments that we develop — particularly those that we develop for small children — but following clients up for a long period after they have had the treatment is not the way to do it. Well, I can’t for the life of me think of how else you could know the long term effects of treatment. This is an amazing irony — a paradox, in fact, that I took the liberty of naming after its discoverer, Roger John Ingham (Onslow et al., in press). Medical science has established the lifelong effects of control of blood pressure, stopping smoking, reducing cholesterol, on so on. But such feats appear to be beyond.

As for the ultimate fate of our long—term outcome study, it was rejected by the Journal of Speech, Language and Hearing Research, the Journal of Fluency Disorders, the International Journal of Language and Communication Disorders, and Folia Phoniatrica. I am currently negotiating to have the paper as a poster presentation at the Annual Convention of the Antarctica Speech Pathology Association.

It is now time to turn to go beyond these ironic, paradoxical times, past today, and into the future. Why not? I wish to be daring and break one of my long standing rules. My mentor left me alone in Lidcombe, in 1983 and departed for — you guessed it — California. The last thing he said to me before leaving was “son, don’t go beyond your data.” Well, like all good rules, you need to know when to break them. So how about right now? Here goes caution to the wind, and here comes another Lennon-McCartney turn of phrase, coming right at you: “There will be an answer.” There will be a satisfactory treatment for stuttering.

How can I justify that? I have been involved in the development of the Lidcombe Program (Onslow et al., 2003). Surely I am not saying that will be the answer? No, in fact surely not. The Lidcombe Program is certainly the first treatment for early stuttering for which there are outcome data. But no, it is extremely unlikely that the first ‘evidence based treatment for early stuttering will be the best. As I have said before, an advantage of evidence based clinical practice is that things always improve: They are not handed down unchanged from generation to generation of clinicians. There probably will be other, better treatments for early stuttering developed in the future. But I do say that the evidence base for the Lidcombe Program has been extremely encouraging. My argument is this: If these are the results to hand with the first evidence based treatment for early stuttering, then things are looking good indeed. In fact, the data from a Phase III randomised controlled trial of the treatment, in New Zealand, is just now being analysed (Jones et al., 2001).

So, for perhaps the best part of my story, back to the future. As my colleagues Ann Packman and Joseph Attanasio have said recently (Packman & Attanasio, in press), the explicanda of stuttering — those things that must be made sense of — are intimidating. Bewildering. They have perplexed generations of us. They inspired the foundation of our profession itself.

And what pieces there are to put together. What explicanda! Why does this speech disorder begin with repeated movements and deteriorate to fixed, debilitating postures of the articulatory mechanism? Why does it not appear at the onset of speech but after considerable language development? Why do some children shake it off effortlessly — often without any therapy — and why do others go on to spend their lives with (thanks again, Lennon-McCartney) a shadow hanging over them, and over every syllable that they speak? Why is it that since the ancients it has it been perfectly obvious that stuttering disappears under rhythmic stimulation. How puzzling.

Well, it took a while, but the future looks good, because it all is really starting to make sense. It is starting to make sense. Not in a completely definitive fashion, but enough for us in science to be excited for what our scientific colleagues of the future will inherit.

William Webster has had a long program of research here in Canada, dealing with manual and finger coordination abilities of those who stutter. I have long admired Webster’s program of research, not only for its creative and scientific innovation and its immaculate rigour, but for what its results said about stuttering. Why should those who stutter have anomalies of finger movements? Indeed, why? Another rule my mentor gave me — and this one I shall never break — is to never really believe anything in science unless it is replicated by an independent group of researchers. And until this year the importance of Webster’s data had been diminished by the absence of a replication. So, it was particularly exciting to read recently in the Journal of Speech, Language, and Hearing Research that they have indeed been replicated by Ludo Max and colleagues. Another researcher, in another place, with a different method, has found anomalies in finger movements in those who stutter. There are now replicated findings of finger movement anomalies in those who stutter (Forster & Webster, 2001; Max et al., 2003). Finger movements? What is going on here?

The story was added to with a recent publication by Foundas and colleagues proclaiming anomalous gyral variants in grey matter in the left and right perisylvan areas of the brain in adults who stutter (Foundas et al., 2001). The speech areas. Of course, the literature on brain imaging is difficult to interpret. But a lot less difficult now, it must be said, after a further finding of neuroanatomical anomaly in a similar area. Martin Sommer and colleagues. used diffusion—tensor imaging to show relative problems between stuttering and control subjects in neurologic transmission through the white matter in the left rolandic operculum (Sommer et al., 2002). Another replication. Sure, it is too soon to be making too much of this. But we now have two independent reports of neurological anomalies in those who stutter.

If these findings are correct, as well they might be, then it all makes sense. Stuttering is a problem arising from unusual brain anatomy, located in the part of the brain that became important for humans long after their basic evolution. Our troglodyte ancestors developed a hybrid function from their bodies. They did so when the physiology for breathing and eating had evolved, and they added speech to all that. They combined the vegetative functions of breathing and eating into the volitional act of speech, in the latter stages of evolution of the human.

For an eternity thereafter, some humans would be born and would be destined to have brains marginally different in those areas that would be critical during language acquisition years later.

For those of humankind so affected, the problem of stuttering would arise after the start of speech development, when the complexity of speech motor activity required by language becomes taxing. Shortly after onset, children recover naturally or do well in therapy because it is easy for them to find a work-around for their problem, and learn to process speech effortlessly. When young, the brain is marvelously adaptive. But when humans are older, it is too late to adapt to the problem, and stuttering becomes chronic and may cause lasting problems with that defining feature of people, their capacity to speak. Little wonder that behavior therapy failed to do a great deal about it at that stage. And for those who care to look closely enough, such as Webster, Max, and colleagues have done, there are tiny problems with motor function that are neuro—anatomically related to speech, such as finger tapping. Now, at last, I understand the meaning of all those reports of people, who for want of a better word, “stutter” while playing wind instruments. Ann Meltzer, you were right (Meltzer, 1992). I have seen it myself (Packman & Onslow, 1999).

Gosh! What an end to the story! Is it true? I don’t know. It could all be wrong. Sure, anatomical brain anomalies may be caused by stuttering, rather than being the cause of stuttering. Sure, these findings may fail the critical test of verification in children shortly after onset. But for now, we empiricists have an exhilarating science for our next generation to inherit. It is exciting, it is based on data, it is elegant, and parsimonious. If it is correct, how cruel was history that the greatest evolutionist, Charles Darwin, did not spend some of his time on the Beagle contemplating why he stuttered. Had he done so, today’s story surely would be much different. 

You may have guessed by now, that I am still an empiricist after having lived through all this. But have I have lightened up in recent years? Well, when children ask me whether there is a Santa Claus, I give them the correct answer, that “yes there is one.” And just before leaving Australia, my wife and I were eating vegemite on toast, as we Australians do in the morning, when she turned to me and said “darling, do you love me?” I felt a strong urge to reply, “well, clear, I am not sure, there are no data to address the issue.” However, I quickly checked myself, and said, “of course I love you dear, more than empiricism itself.”

So, there is my story, of empiricism in stuttering treatment research after Travis’ time, in the latter years of the last and the emergent years of this century, and projected into the future. The Oxford dictionary defines “bitter-sweet,” in its figurative sense, as “agreeable or pleasant with an alloy of pain or unpleasantness.” This, to me, is the essence of the story that I have told you. The story of empiricsm in stuttering treament research since Travis’ time. It is a bitter-sweet tale. We have come to where we can believe that an effective treatment for the early stages of the disorder will be developed. Perhaps you teachers present today may imagine that the students of your students will teach a treatment for early stuttering that is marvellously effective. So effective that it stops the development of the disorder in its tracks, never to return. So effective that the chronic version of the condition, to which we have become so accustomed, can be prevented. Surely, that would be the sweetest thing. But it is bitter-sweet nonetheless. For it is too much to hope, really I think, that such a treatment will be developed for adults.

It is also bitter-sweet that since Travis’ time we have inched our way forward to the point where randomised clinical trials of the long-term effects of various treatments can be compared. For adults, incomplete as treatments will inevitably be, we are now poised to find the best one. And we are now poised to embark on a series of randomised controlled trials to find the best treatment for early stuttering. Yet, our journal editors seem resistant to publish long term data. Hopefully, sense will prevail there with recognition that variables that interpose between the treatment and the outcome measure will, of course be randomly distributed and not problematic. Hopefully, long term follow up of subjects in clinical trials will become an accepted methodology.

That frail, ageing man in a white coat and hom-rimmed glasses, who they took away. I must confess, I gave him twenty dollars. Also, I surreptitiously pressed into his other hand a slip of paper, with the following words inscribed: Behavior Therapy Lives! Certainly, its history in our field has been bitter-sweet. But how elegant a finish. When there is reason to hold out hope that something so fundamental as brain anatomy is at the cause of this disorder, and something so fundamental as the basic tool of parenthood, behavior modification, is a contender to one day be an effective treatment for it. How elegant is nature and the science that pursues it.

Well, after he cut short his career to leave our profession, Lee Edward Travis left the University of Southern California, and became a full time private psychotherapist in Beverly Hills from 1957. Practicing from Bedford Drive there, he lived the high life, with wealthy and famous clients. He was Anthony Quinn’s therapist, for example, and figured in that actor’s autobiography. Then, in 1965, he gave that away and began a term as founding Dean of Graduate Studies at Fuller Theological Seminary in Pasadena, with the express charter of integrating the study of psychology with that of the Christian faith. He lived out his working days there.

Remember I promised mystery. There is the mystery of why Lee Edward Travis touched our lives only briefly. Why he was a candle in the wind? What happened that he stopped his prodigious program of research and went to California, where he psychoanalysed stuttering clients, and, as an empiricist, we never heard from him again?. Well, no-one will ever know for certain. But here is my version. Perhaps there are those present who know facts that show that I am wrong. In which case, allow me my conceit.

Travis knew so much, so soon. He certainly knew a lot. Enough for it to be quite spooky. He knew there was a problem with inter—hemispheric functions in stuttering, and proposed his theory along those lines with Samuel Orton. And he was right. If modern brain imaging techniques have shown us anything, they have shown us that those who stutterer process speech across hemispheres in a different way than do those who do not stutter. And he seemed to know much more than that. Just before his death at 91, he turned back to the problem of stuttering to write a brief overview of his thoughts on the topic. Astonishingly, this document (Travis, 1986) says “the stutterer differs significantly from the normal speaker only in his neuro-anatornical organization for speaking” (p. 119) He knew, before we even brought ourselves to the threshold of knowing.

How did he know? I have no idea. How did he know that, to quote again from his 1986 article, that those who stutter have “a lack of proper development of the brain centres for speech” (p. 120)? It is a complete mystery. It certainly could not have been his archaic instruments that told him. I can only speculate. Judging by the glasses, he may have been from another planet. Do you believe in reincarnation? If you do, then perhaps he was Charles Darwin, who came to visit again for a year or two after his major work was done, to leave us a footnote that stuttering is a problem with the evolution of humans.

But why did he stop his program of research? Another mystery. Regardless of how he knew, perhaps he realised that it was too much to know, and that it was the wrong time and place to know it. Perhaps he was sensitive to the developing Iowa School of thought, being infused with the input of those who stuttered, and saw the importance of this to the development of the field that he began. Perhaps he did not want to undermine the complex input of those who stuttered to the new field, by disseminating What he knew about the simplicity of the origins of the disorder. He left a tantalising clue that this may be the case. Referring to his View of the cause of the condition, he wrote, in 1986, “I have expressed such feelings to three of my beloved and famous stuttering students, Wendell Johnson, Charles Van Riper, and John Knott. They have smiled and forgiven my implied evaluation of their explanations of why they stuttered” (Travis, 1986, p. 119) Perhaps the most bitter-sweet end to the story of empiricism in stuttering treatment research is that an old man knew the nature and cause of the condition long ago, but chose to keep it for another time and place, dropping it inconspicuously into some musings about stuttering at the end of his life.

Thank you. And now, with your indulgence, as plenary speaker today, I commit our proceedings — intrigue, mystery, paradox, along with my conceits — into a time capsule for our historian of the future.

1Shortly after giving this paper, the author benefited from a long conversation with a man who Travis had psychoanalysed for many hours, who was present in the audience. back to text

Cream, A., Onslow,. M., Packman, A., & Llewellyn, G. (2003). Protection from harm: The experience after prolonged-speech treatment for stuttering. International Journal of Language and Communication Disorders, 38, 379-395.

Forster,.D. C, & Webster, W. G. (2001). Speech-motor control and interhemispheric relations in recovered and persistent stuttering. Developmental Neuropsychology, 19, 125-145.

Foundas AL, Bollich AM, Corey DM, Hurley M, & Heilman KM. (2001). Anomalous anatomy of speech-language areas in adults with persistent developmental stuttering. Neurology, 57, 207- 215.

Goldiamond, I. (1965). Stuttering and fluency as manipulatable operant response classes. In L.

Krasner & L.P. Ullman (Eds.), Research in behavior modification. New York: Holt, Rinehart & Winston.

Jones, M., Gebski, V., Onslow, M., & Packman, A. (2001). Design of randomized controlled

trials: Principles and methods applied to a treatment for early stuttering. Journal of Fluency Disorders, 26, 247-267.

Max, L., Caruso, A.J., & Gracco, V. L. (2003). Kinematic analyses of speech, orofacial nonspeech, and finger movements in stuttering and onstuttering adults. Journal of Speech Language and Hearing Research, 46, 215-232.

Meltzer, A. (1992). Horn stuttering. Journal of Fluency Disorders, 17, 257-264.

Onslow, M., Costa, L., Andrews, C., Harrison, L., & Packman, A. (1996). Speech outcomes of a prolonged-speech treatment for stuttering. Journal of Speech and Hearing Research, 39, 734-749. Section I. Plenary Session, Invited Speakers 1]

Onslow, M., O’Brian, S. Packman, A., Rousseau l. (in press). Long term follow up of speech outcomes for a prol0nged—speech treatment for stuttering: The effects of paradox on stuttering treatment research. In A.K. Bothe (Ed.), Evidence—based treatment of stuttering: Empirical issues and clinical implications. Mahwah, NJ: Lawrence Erlbaum Associates.

Onslow, M., Packman, A. & Harrison, E. (2003). The Lidcornbe Program of early stuttering intervention: A clinician ’s guide. Austin, TX: Pro—Ed

Packman, A., & Attanasio, J.S. (in press). Theoretical issues in stuttering. London: Psychology Press.

Packman, A., & Onslow, M. (1999). Stuttering and disfluent wind instrument playing. Journal of Fluency Disorders, 24, 293-298.

Sheehan, J .G., & Sheehan, V.M. (1984) Avoidance-reduction therapy: A response—suppression hypothesis. In W.H. Perkins (Ed.), Current therapy of communication disorders: Stuttering disorders. New York: Thieme—Stratton.

Sommer M, Koch MA, Paulus W, Weiller C, & Biichel C. (2002). Disconnection of speech-relevant brain areas in persistent developmental stuttering. The Lancet, 360, 380-383.

Travis, L.E. (1957). Handbook of speech pathology. New York: Appleton—Century-Crofts.

Travis, L.E. (1986) Emotional factors. In G.H. Shames & H. Rubin (Eds.), Stuttering then and now. Columbus: Charles E. Merrill. 12 Theory, research and therapy in fluency disorders
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