|About the presenter: Tim Mackesey, SLP, Atlanta, GA. In addition to owning a full-time private practice dedicated to fluency disorders, Tim Mackesey has taught the graduate-level Fluency Disorders course at Georgia State University. An SLP since 1992, he travels internationally presenting workshops on early intervention, stuttering treatment, and cognitive therapy. Tim is published and has been interviewed on a number of television and radio programs related to stuttering. He has been selected as a Board Recognized Specialist in Fluency Disorders and Specialist Mentor by ASHA. As a certified master practitioner of Neuro Linguistic Programming, Tim integrates numerous unique strategies into therapy and teaching.|
Concealing and avoiding stuttering was once the most important thing in the world to me. During a television interview on CNN in 1989 I told a reporter that the first thing I thought about in the morning was where, when, and with whom I might stutter. Imagine you were undercover as a mole police officer in a prison and at any moment somebody might find out your identity and the inmates would all turn to attack you: that was my daily experience trying to hide my stutter. I have now interviewed several hundre people who have a similar phobia of stuttering as I once did. Instead of trying to be in control, people who stutter (pws) are often unwittingly doing the exact opposite of what will solve their problems.
What starts with conditioned muscular reactions to a blockage of speech production can quickly evolve into a very complicated phobia. Our greater understanding of the cognitive and psychological structure of stuttering is paramount in treating adolescent-adults who stutter. For a pws, why is it so important to not stutter?
Understanding classic conditioning and stuttering helps explain how stuttering progresses in severity. Stuttering may begin as a neutral stimulus (NS)- the child does not care when he is blatantly disfluent. The NS is paired with an event- an unconditioned response (UCS) - that elicits a tension response. This event might be a frown, mocking, or stern correction during a stutter. The formerly neutral stimulus becomes a conditioned stimulus (CS) and habituates. As conditioning takes place again and again, the stimulus becomes a complex of many things, including words and sounds, listeners, and physical surrounding, or situations (Guitar, 1998a). This chaining of stimuli is called higher-order conditioning (Zimbardo, 1985).
A preschooler might react to tension in the larynx, tongue, or lips in the same fashion they try to solve a sock stuck in a dresser drawer or a zipper that won't budge: force and frustration. The child just wants to spit a word out and he impulsively pushes and creates physical tension and stutters. Facial tension and strained glottal attacks (blocking) reflects extra muscular effort that emerges when the child anticipates difficulty (Bloodstein, 1987). As cognitive development progresses a child will begin to attach negative thoughts and feelings to the behavior we call stuttering. The identity of a stutterer- and the strong desire to conceal stuttering- may lie ahead for that youngster.
Some children rapidly develop stuttering symptoms due to their internal temperament: they might feel frustrated and angered by the blockage of their speech. Other children have external events- such as teasing or repeated questions as to why they talk that way- triggering struggle to not stutter. The Beginning Stutterer (Guitar, 1998b) displays signs of muscular tension, escape behaviors, and hurry. I have evaluated children less than three years of age who whisper, change words, use character voices, refuse to talk, and other habits proving a cognitive ability to form an intention to not stutter. They may have no word for it (stuttering or speech impediment) but avoidance is evidence of dislike. Blanket generalizations such as "don't worry he'll outgrow it" or "if it is still happening at age six, we'll consider helping your child" really chap me! Differential diagnosis by a stuttering specialist can ascertain the need for immediate treatment.
A pws punctuates his stuttering with deep-seated emotions that are called cognitive distortions (Burns, 1989). Mind reading (i.e., "He will think I am incompetent if I stutter") and personalization (i.e., "If I stutter, I will fail") are two of most common forms of "twisted thinking." I regularly hear similar statements ("the kids think I am weird") in second and third graders. Many of them have been subject to negative reactions to their stuttering.
Your attention follows your intentions. If your intention is to conceal stuttering from listeners, you will pay close attention to using tricks and crutches intended to avoid stuttering. The habits of word changing, eye contact aversion, inserting fillers (um) before a stutter, email/text specifically to avoid calling, avoiding talking, pointing to menus for the waiter to say it, avoiding introductions, and avoiding talking are all examples of dead ends to growth and improvements in speech fluency. These are all examples of attempted solutions that become problems (Mackesey, 2007). One of the more provocative quotes in stuttering literature is Wendell Johnson's one-liner: "Stuttering is everything you do trying not to stutter."
Every week I interview teens and adults who have vivid recollection of early stuttering events. A 55 year-old physician once told me he began stuttering at age six when his substitute teacher, Mr. Johnson, leaned over and barked "stop that stutter talk!" That 49 year-old memory was replete with cognitive distortions ("the kids thought I was weird"). That man was still word changing and avoiding in attempt to prevent the hurt from elementary school.
The time-line of memories is a very important target for cognitive behavioral therapy (CBT). Time Line Therapy (James & Woodsmall, 1988) is a very potent and liberating tool in my CBT repertoire. An adult pws can often feel an incident of stuttering in his soma several decades later. By associating into the memory (see, hear, and feel memory) he triggers somatic memory. If reading aloud was often embarrassing in childhood, it will likely provoke anticipatory anxiety for the adult pws. In time line therapy we can revisit the event (s), elicit the cognitive distortions embedded, and "edit" the memory. Cognitive reorganization, or reframing, eliminates the 'trauma' from these past experiences and reduces the likelihood that the same stimulus (i.e, phone, oral reading) will send a pws into panic.
As a fifth year senior at the University of Wisconsin- Madison an SLP named Flo Filley began my transformation. She introduced me to traditional stuttering modification and voluntary stuttering. I moved to Atlanta in 1987 as my own therapist. I am forever indebted to Flo.
Anxiety about stuttering made my speech targets unreliable. Many pws relapse after intensive programs due to anticipation of stuttering in specific situations from their time line. The use of CBT- specifically NLP- changed my life. I went from college student dropping classes to adjunct professor, Toastmasters competitor, expert witness, and public speaker. Until age 25 I had a better chance of winning the lottery than being fluent saying my name on the phone. For decades clinicians have been utilizing Gestalt therapy, REBT, CBT, transactional analysis, and Carl Roger's reframing; to name a few CBT options. Attending a support group can stimulate cognitive reorganization. Adults who stutter always have fear and anxiety reduction goals- not just talking goals.
Those pws who have programmed themselves to hide and conceal stuttering all day present like a phobic. I dropped many classes in college when oral participation was mandatory. It ended up being a blessing when my Italian teacher told me: "If you want to pass, you will talk." Cognitive anxiety is higher is pws than normally fluent speakers (DiLollo, 2003). According to Starkweather (2003) stuttering may be a variant of Post Traumatic Stress Disorder. He explains that pws have 'traumatic events' of stuttering and replay those memories in their mind. The pws begins to anticipate moments of stuttering and experiences disassociation. Many pws report that introducing themselves in front of an audience is terrifying. An example of disassociation would be: the pws hears the announcement of introductions and immediately feels panic in the soma (stomach or chest). The pws is going into a Meta State (Hall, 2009). The pws might think: "if I stutter they will all discover I stutter and they will judge me." The pws is disassociated as his turn approaches; he may largely forget others names and information due to panic. The pws may be scrambling to order his words (circumlocution), change words, or perhaps excuse himself to the restroom to avoid the introduction.
This panic and disassociation felt by pws may explain the ongoing experimentation with anti-anxiety medications. Many pws have reported that when consumed with anxiety they are overwhelmed and cannot attend to the auditory signal provided by in-the-ear prosthetic devices.
I once helped an engineer who had a mandatory Monday morning project meeting. Since introductions were done at the beginning of each meeting he would arrive late. His general contractor reprimanded him for the habitual tardiness. The engineer did not the contrition to admit: "Boss I have been late on purpose to not stutter. I have feared judgment from others." Remember that attention follows intention. The engineer had timed exactly what time he could arrive and not have to introduce himself.
Another adult pws shared that he would record his outgoing voicemail up to 25 times in an attempt to save one without a "big stutter." I asked how he measured a big stutter: stop watch, video, or just a hunch. I modeled a few pseudo stutters and asked which ones would be acceptable if left on his voicemail. He grinned as he sensed that we were headed deep into his cognitive distortions. I was probing to find his "internal rules" for acceptable stuttering. One irrational belief was: "if I leave a big stutter, someone will wonder how I got my Ph.D., and that I am not competent for my job." This mind reading of listeners was very toxic. CBT reduced his anxiety and then classic easy onsets and phrasing gave this man a method to habituate easy speech.
I say stuttering is what it means to you. The origin of the word meaning come from German and translates to "what you hold in mind." Profound, isn't it? If you associate shame, guilt, pity, embarrassment to stuttering you will likely be working very hard to conceal it. Many pws routinely stutter on the word stutter. I used to think: "if I stutter on stutter, people will explode in laughter." Interestingly, I find most pws attach no meaning to doing a fake stutter while looking into a mirror. But a real stutter might be traumatic to that pws. I let pws eaves drop as I call a business, stutter dramatically, and then we discuss the typical lack of reaction to it by the stranger. Who attaches meaning to the stutter?
Stuttering may begin as muscles reacting to obstruction and tension in early childhood. A child acts impulsively, hurries, pushes the word, and manifests a stutter. A child reacts to being stuck like he would a zipper caught on fabric or shoe lace: force and lack of patience. A child who continues to stutter into grade school will most surely face reactions to his stuttering (i.e., teasing). As soon as that pws attaches a negative meaning to the behavior he may rapidly establish a purpose/ intention of avoiding stuttering. Not stuttering is perceived as a protection from repeating the "trauma" of stuttering. Speech therapy from a stuttering specialist and support from parents and teachers can help stop this vicious cycle of avoidance. Another way to look at purpose is: a student who is trying not to fail classes is wired differently than one trying to get A-B grades Adults who stutter can still reverse these avoidance habits through integrated therapy with CBT, support groups, and a compelling reason to transform. A pws needs a purpose and intention of freedom and control to succeed.
Bloodstein, O. (1987). A handbook on Stuttering., 4th ed. Chicago: National Easter Seal Society
Burns, David (1989). The Feeling Good Handbook. NY, NY. Penguin Books. pp:8-11
DiLollo, Manning & Neimeyer (2003). Cognitive Anxiety as a Function of Speaker Role for Fluent Speakers and Persons who Stutter. Journal of Fluency Disorders. Volume 28, #3. Elsevier Publications.
Guitar, Barry (1998a) Stuttering: An Integrated Approach to its Nature and Treatment, 2nd ed. Baltimore, MD. Lippincott Williams & Wilkins. pp: 116-118
Guitar, Barry (1998b) Stuttering: An Integrated Approach to its Nature and Treatment, 2nd ed. Baltimore, MD. Lippincott Williams & Wilkins. pp: 89-101
Hall, L. Michael (2009). Meta States, 3rd ed. Grand Junction, CO. Neurosemantics Publications.
James, T. & Woodsmall, W. (1988). Time Line Therapy and the Basis of Personality. Felton, CA. Meta Publications.
Mackesey, T. (2007). Stuttering: When Attempted Solutions Become the Problem. http://www.stuttering-specialist.com/pdf/Solution.pdf
Starkweather, W. & Givens, J. (2003). Stuttering as a Variant of PTSD. ISAD on-line conference. www.stutteringhompage.com
Zimbardo, P.G. (1985). Psychology and Life, 11th ed. Glenview IL: Scott, Forsman & Company