Introduction

The majority of stutterers do not have psychological problems unassociated with their stuttering. The majority of psychological problems that stutterers have are associated with their stuttering. In other words, if the stutterers could speak fluently, they would not have any other problems. Van Riper (1973, page. 213) said, "neurosis, when it is present, is usually the result of traumatic speaking experiences.... these stutterers were miserable because they stuttered" (page. 211). This paper, which deals with psychological problems associated with speech problems, attempts to illustrate, by means of the description of the treatment followed in a particular case, some mechanisms and processes that may be involved in the development of psychological problems in people who stutterer.

Stuttering may generate psychological problems which in turn may worsen speech. The solution to this type of problem is not always a direct consequence of improvement in speech. The application of cognitive behavioral treatment techniques may be fundamental in obtaining better well-being in some cases.

Stuttering produces in the stutterer an experience of loss of control of his own body in an extraordinarily important situation -- interpersonal communication. The loss of control of one's body can lead to situations like those mentioned by Van Riper (1973, page. 330) in which the blocking is so intense that an external manual intervention is necessary to eliminate it. Van Riper compares this experience with those generated in experiments with dogs exposed to inescapable punishment. These situations produced learned helplessness (Abramson, et al, 1978) that has been considered as playing an important role in producing some types of depression.

Years ago, Yerkes and Dodson (1908) established a relationship between activation and performance. If we are "very little activated," i.e. almost sleeping, our performance will be very low. As activation increases, our performance also increases to reach its optimal level. This optimal level corresponds to a certain interval in the level of activation which depends on the type of task and the individual. If the increment of activation were to continue, the performance would deteriorate quickly. The stutterer, when he tries to speak must exert a higher effort to be able to articulate correctly. This effort supposes an increment of activation, and deterioration of performance may happen easily. As a consequence of failure, anxiety emerges which in turn further increases activation. This establishes a feedback loop that produces more and more blocking and finally results in a sense of loss of control, an inevitability of stuttering. In psychology, loss of control has been traditionally recognized as an important cause of depression, but more recently is also implicated in the appearance of anxiety disorders (Zinbarg, Barlow, et al, 1992).

Depression and anxiety are not the only emotions that may cause psychological disorders affecting stutterers. The control of speech has great importance in social relationships. Continued failures in social relationships produce feelings of frustration, guilt, hostility and high levels of anger (Van Riper, 1973, page. 264). Further, the incorrect management of feelings of guilt and frustration may disturb interpersonal relations causing additional social problems which may lead to many psychological disorders. The stutterer may have greater difficulty than non-stutterers in social interactions. Avoidances and flights may produce serious social problems that lead to psychological disorders. The effort that a stutterer exerts to speak may sometime s seem overwhelming to him and he gives up feeling frustrated, angry and hostile which in turn increase his social problems.

Many times, when speech problems are resolved, the psychological disorders improve in parallel. However this is not always the case. Sometimes improvement in expressive abilities produces changes in expectancies and in the social environment, that may in turn produce new psychological problems. For instance, in marital relationships fluent speech may cause changes in power relationships between the couple leading to problems that were not apparent before. In anxiety and depression disorders an important role is played by ancient schemes (Beck, 1969) that remain even when they are no longer necessary and even when they are damaging. It is necessary to deactivate them to solve the psychological problems.

The case of R.

R., a male close to age forty, entered therapy with only one objective -- to treat his stuttering. In the first session, he was unable to say his name and could complete few coherent phrases. He came to therapy after failure in other therapies. Van Riper's approach was determined as the plan to follow in therapy since it was felt other strategies would not be accepted by the patient.

Short clinical History

R. is the second son of a middle-class family. He has three brothers. When he was 1 1/2 years old he became ill. To recover from this illness it was necessary for his father to carry out a rehabilitation program, requiring great effort and dedication for two years. Following this program, R. reached an acceptable recuperation.

He left school due to the panic he felt facing the possibility of having to speak in class., and found work in a job that did not demand much relationship with other people.

Functional analysis.

At the beginning of treatment, a functional analysis was done to determine the target behavior and influential factors. This part is similar to the identification phase in Van Riper's approach.

Once, when R. was eight-years-old, he stuttered in front of his father and an uncle who was a stutterer. Both laughed at him, and his father, very angry, shouted and demanded with cruel reproaches that he speak well immediately. This incident established his identity as a stutterer. R's father is a violent and authoritative man that imposed his law on the whole family and continued his criticisms every time R. stuttered. In other aspects R's father is revered and beloved by R. and the family.

When he came to therapy, his speech fluency was very low. For example, he could not say his name. His avoidance behaviors impeded any effort to construct a coherent discourse.

Following guidelines proposed by Van Riper, treatment begun with the identification phase in which we identified his feared words, avoidance, postponement and timing behaviors. In identifying what situations worsened his stuttering, he revealed that lack of sleep, being too relaxed, holidays, and sex were the worst antecedents for his speech breakdown. For R to speak fluently required a tremendous effort that he could not do if he was either tired or too relaxed.

Another element that worsened his speech was the length of a phrase -- long phrases were impossible for him. Other problematic situations were identified such as aggressive requests by others, those where he needed to request something, providing personal data, when he needed to repeat something already said, talking on the telephone, and speaking in unknown places or to unknown persons. It was also impossible for him to have a conversation lasting more than an hour and a half.

Problems of hypocondriasis and aggressiveness were also identified, but they are not accepted by R. as therapeutic objectives at this point of therapy.

Treatment of R's stuttering

Reduction of anxiety

The first objective in cognitive behavior therapy, as in Van Riper's approach, was to deal with R's anxiety. R. had so many avoidances, that it was impossible to carry out desensitization in his actual environment. Because of this, the technique that Van Riper called adaptation (1973, page 289); and that in other approaches is called "massive practice" or "flooding" of his stuttering (Yates, 1970) was employed. After a long session of doing such flooding, a feeling of tiredness or relaxation arises. In the case of R. after an hour and a half of adaptation, he became relaxed while he stuttered, and as a consequence, a tremendous anxiety appeared in a paradoxical reaction described by Borkovec and associates, (Borkovec and Sides 1979; Heide and Borkovec 1983). Flooding continued and R. began to habituate to this feeling of relaxation. A situation of relative calm was reached before the end of the session. Without this work of massive practice, R. would have abandoned treatment with a failure. An increase of anxiety before relaxation typically happens in hypochondriacs (Avia, 1993).

This step in therapy was decisive. R's huge anxiety associated to stuttering decreased considerably, and he could see that after this session, improvement of his speech was spectacular. Motivation in treatment increased notably and frequency of avoidance behaviors decreased dramatically. This permitted R. to confront feared situations on his own. For instance, he included long phrases in his current speech after a short time of working on them in therapy sessions. Soon he could maintain long conversations without worsening his speech. The therapy process permitted him to show blocking in daily situations, and in front of significant people, without a high level of anxiety.

High levels of fluency were obtained at this point of therapy. Additional advances became slower and other psychological problems, previously detected needed to be confronted. Hypocondriasis was chosen as the next objective in therapy.

Other psychological problems and their treatment

In cognitive behavioral therapy, objectives are explicitly established around problems that patients may solve or are motivated to cope with. Other important problems may exist but its treatment must be delayed until the course of therapy permits dealing with them. This is not any impediment in therapy advances, because the patient is solving another problems and reaching another objectives. Normally success in one problem area motivates a patient to confront the next problem and to continue therapy. If the patient leaves treatment at a certain point, solutions to problems reached up to this point are normally consolidated and even generalized to other facets in life.

R. presented some psychological disorders that interfered in a remarkable way with treatment of his stuttering, primarily his hypocondriasis. There were other problems such as aggressive behaviors, that reached the foreground in therapy in a later phase of treatment, when changes in R's life, due mainly to the acquired fluency, increased its importance.

Hypocondriasis

In this patient, relaxed sensations, especially those related to sex, produced a remarkable increase in stuttering and associated anxiety. R. called it "anguishes".

In R's. religious training, masturbation was considered a terrible sin and the etiology of illness, including craziness, tuberculosis, etc. When R. masturbated the first time and experienced the relaxed sensation, that normally follows sex, he feared he would acquire a terrible illness as punishment for his behavior. The fact that he realized, many years ago, that masturbation does not produce any illness and he became agnostic in his religious beliefs, did not solve anything. A conditioning between sexual relaxation and anxiety was created and needed to be deconditioned.

Treatment of the hypocondriasis started following guidelines given by Avia (1993). Exposure to body sensations were the main tool employed. The aim of this technique is that the patient abandons his fear of his body symptoms which he interpreted as illness. When these feelings were accepted as normal, they could be reinterpreted as completely acceptable daily feelings. This exposure is done jointly with training in anxiety management techniques that permit a quick decline in anxiety levels produced by these symptoms. With success in decreasing fear of symptoms, the patient could reinterpret his body feelings and discover his body as a source of pleasure. With R. this part of treatment was completed including also acceptance of other types of body sensations.

At this point, R. decided to suspend therapy for a time. Immediate therapy objectives had been reached, and he was not yet ready to confront additional challenges to improve his hypocondriasis.

As a consequence of acquired fluency, R. changed his job to a profession more appropriate to his intellectual capacity. When the change in job was in progress, R. was ready to return to therapy. The effort in making changes had increased his stress; and his reported "anguishes" increased in frequency and intensity. Treatment continued following the same line of achieving a better relationship between R. and his body. When R felt his "anguishes" reached an acceptable level he again suspended therapy.

Anger

At the beginning of therapy, the marital relationships were satisfactory although there were episodes of violence with R. losing control. R. verbally attacked his wife, who defended herself by punishing him saying that he was disturbed, foul, and very aggressive. R.'s wife had little tolerance to violence. At times R's vehement and loud speaking was interpreted by her as an attack.

Fluency, changing his job and improvement in anxiety management produced a new equilibrium in R's relationship with his wife. When R. begun therapy he depended much more on his wife, a successful professional. At this time, his wife used guilt to stop R.'s attacks and to punish him after his aggression. Changes in R's. job modified the family income and his social position became similar to his wife's. Fluency had provided him with more reinforcing social relationships. Overall, tolerance to his own "anguishes" made him more resistant to his wife's reaction to violence. All these factors influenced the couple's equilibrium and increased violent episodes in frequency and intensity, and R re-entered therapy.

At this point of therapy, R. learned to deal with anger following a program similar to the one explained in Weisinger (1988). Abilities gained in anger management permitted R. to greatly improve his relationship with his wife. R. left therapy without reaching all possible objectives, aggression was not completely controlled and "anguishes" remain an important consideration. Dissipating the anger became so important for him that he sometimes neglected potential consequences in his relationship, such as divorce, and losing who he recognizes as "the woman of his life".

Problems that impelled R. to reinitiate therapy did not affect his speech fluency which continued at a very good level.

Re-addressing hypocondriasis

Finally, after several years of good family relationships, R. returned to therapy due to stress produced by some familiar circumstances which increment his "anguishes" .

After a short training to cope with his this problems with more distance and tranquillity, functional analysis revealed a relationship between interruptions in his resting, anger and "anguishes". This finding suggested additional therapeutic work for acceptance of frustration, anger management and acceptance of "anguishes". Consequences of resting interruptions were no longer interpreted as negatively influencing his feelings the following day. However, anxiety did not disappear completely. At this point we initiated a controlled revival of the original frustrations with his father's former attacks. In cognitive behavioral therapy, childhood memories are treated considering that they may have established a set of behaviors which are triggered even when they are no longer functional. They are similar to preparatory sets mentioned by Van Riper 1973, page 337). R's automatic response to frustration was a preparatory set to solve an unsolvable problem and caused "anguishes". Re-experiencing an old situation or emotion was made with the aim of finding an alternative solution to the one that established the behavior pattern in the first place (Arnz and Weertman, 1999; Littrell, 1999).

Analysis and re-experiencing R's. "anguishes" led to guilt feelings associated with his father's crying and violently demanding that he speak well. This violence produced in R a sense of guilt. He felt he had done something to deserve what he considered "divine" punishment. His father had the ultimate authority and no appeal was possible. R felt total guilt because he was unable to do something elemental that other people do -- speak fluently. This in turn caused mix of anger against his father and himself as well as the guilt-generated feelings ("anguishes"). Remembering those situations with high levels of emotion, the present R. with his actual knowledge and abilities, could say to little R. that he didn't merit either such tremendous criticism or the "divine" punishment. When he realized this, the "anguishes" and emotion disappeared in the session. He also realized that masturbation produced the same thinking. He felt tremendous guilt for putting himself in danger of getting an illness, and that he deserved "divine" punishment. After realizing this, the "anguishes" practically disappeared and if they reappeared he was able to change his thinking quickly, accepting his feelings.

Discussion

Therapy for R., as in most cases, is an uncompleted work. The sequence of his treatment was first stuttering followed by treating his hypocondriasis (over a period of two years), anger and his marital relationship (6 months), and finally re-addressing hypocondriasis (3 months). There still are some pending tasks that could be addressed in the treatment of anger, but it may be possible that R. does not need further support to deal with his problems.

It is remarkable how R. acquired his social identity as a stutterer. This identity still persists. Sometimes he has some blocks, without anxiety, even with important persons, such as the general director of his company. The role played by his father is quite remarkable, negatively influencing R's stuttering and modeling R's anger.

Conclusions

Stuttering may be associated with other psychological problems. In the case of R, these problems included anger management and hypocondriasis. Normally all psychological problems included in stuttering, form a stable process in which the relationships are well established. In the case of R,. stuttering produced guilt feelings and guilt increased the frequency of the stuttering. Fear of his anguishes influenced his speech and failure in speech produced anguishes. To obtain an increase in fluency it may first be necessary to solve some psychological problem. For R. it was necessary to start breaking relationship between his relaxed sensations and anxiety before he was able to obtain improvement in his speech.

Acquiring fluency does not necessarily imply the solution of al l psychological problems. Conditioning must be eliminated and schemes must be changed to obtain well-being. Another important aspect that is illustrated by R's. case is that insight is not necessarily the solution to problems. Desensitization and changes in response sets (schemes) are often necessary. Cognitive behavioral therapy has tools to deal efficiently with many of these problems.

Another aspect shown in R. case is that the solution to speech problems cause changes in the life of a stutterer which the patient must also learn to manage. If there were unsolved psychological problems that impeded the progress in speaking, these problems may become more evident or may impede the patient's progress. This happened with R. and anger management.

R's case is very unique in which psychological problems were very mixed with factors at the root of his stuttering. But it is also important to remember that most stutterers have no particular or unusual "psychological problem" not precipitated by the stuttering itself.

References