The presenter of this paper has consented to have a personal email address posted here if you wish raise further questions and/or comments. Contact Josˇ Antonio Garc’a Higuera at firstname.lastname@example.org treatment of the PWS with psychological problems From: Jessica Schneider Date: 10/4/99 Time: 10:06:56 PM Remote Name: 18.104.22.168 Comments I learned a lot from your article about the variety of psychological problems that can coexist with stuttering. My question is, in cases which the client openly acknowledges both psychological and fluency problems and wishes to address them both in therapy, is it more beneficial to put the primary focus on the psychological disorder, fluency disorder, or both concurrently? Re: treatment of the PWS with psychological problems From: Josˇ Antonio Garc’a Higuera Date: 10/6/99 Time: 2:41:54 PM Remote Name: 22.214.171.124 Comments In our approximation to psychotherapy, normally, the client chooses the therapeutical target. In general he (she) chooses the one that most disturbs him (her), that normally is related with anxiety. Then, fluency is involved in it, because anxiety has direct influence in speech. If the chosen target is fluency, it is necessary to address contextual factors that influence fluency. In consequence psychological problems (if they exist) appear. Therefore, when we treat psychological problems client improves fluency; and when therapy work is directed to fluency we are approaching psychological problems. In the case of R., he chose fluency as his therapeutical target and only when he was motivated he was able to address hypocondriasis and violence. At this moment R. had sufficient confidence in therapy to expect some changes and improvements. relaxation paradox From: Judy Kuster Date: 10/5/99 Time: 6:33:34 PM Remote Name: 126.96.36.199 Comments In your article you shared that "problems of hypocondriasis . . . were also identified" and that it is recognized that "an increase of anxiety before relaxation typically happens in hypochondriacs (Avia, 1993)." You also reported that R's relaxed sensations . . . produced a remarkable increase in stuttering. . . ." I find that fascinating, and the understanding of this seeming paradox to be potentially vital in his treatment program. My understanding of hypocondriasis is that the individual is preoccupied with bodily functions and interprets normal sensations or minor problems like a runny nose, minor aches, etc., as something that needs medical attention, and that reassurance by a doctor only increases the patient's concerns about his health. It sounds to me that this was a very important discovery and insight on your part. There are some therapy programs for stuttering that have a relaxation component, which may have been very counterproductive in R's case. How did you determine that hypocondriasis was a problem in this case? Simply self-reporting from R? Could treatment for such an individual be done in a group setting effectively? or might it have been detrimental before this issue was resolved? Re: relaxation paradox From: Josˇ Antonio Garc’a Higuera Date: 10/6/99 Time: 5:49:41 PM Remote Name: 188.8.131.52 Comments Judy, you are really posing challenge questions. I have also found this paradoxical response in other cases of stuttering; but I don't know percentage of stutterers affected. I have also treated another stutterers without this problem. If some consequence may be derived from my experience, it is that therapist must be aware of this problem when relaxation techniques are applied. In general, relaxation response implies to feel a lot of sensations without any control. Normally, we interpret them as pleasant, but for hypochondriacs they are strange, uncontrollable and threatening feelings and they think that it is due to the fact that they have relaxed his vigilance and attention. Hypochondriacs have a special way of perceiving his body. They check it continuously to verify that everything is right. If there is a minimal sign that something may be wrong, they try to control it, they increase checking activity and initiate responses to mask and to eliminate this feeling, so they can obtain some security that everything is not wrong. These processes are reinforcements because sometimes they are successful. This explains its frequency and importance. These responses are performed under a high level of anxiety, and this anxiety acquires a safety meaning, if it exists he (she) is doing something to control the body, to assure that nothing bad will happen. In some cases, stutterers check their bodies to verify that they are ready to speak fluently. This process may be similar to the one I have described in the case of hypochondriacs. A state of excitation indicates that they are ready to react to any clue of become blocked. A relaxation state is interpreted as being unable to react and in consequence as threatening. The first time I have found this paradoxical response, I was monitoring psychogalvanic response of a woman who stutters during a session of training in relaxation. Apparently nothing happens but apparatus displayed a sudden increase of sweat in finger indicating the appearance of high levels of anxiety. In case of R. I have already learned to identify some minor body changes that indicates an increase in anxiety, and I was able to identify them when they appeared in session of R. exposure to his own stuttering. R's paradoxical response indicated me that something wrong existed in the relationship of R. and his body. This permit me to understand some vague statements of R. as "I am apprehensive" and finally, when the level of fluency was acceptable, R. told me that he interpreted certain sensations as frequents "heart attacks". Group treatment of hypochondriacs presents a problem that is the contagious. If a patient share his symptoms others look at their bodies to check if they are present. R. participates in some group sessions in which he spoken to other, but treatment of hypocondriasis was carried individually. Thank you for your questions Judy. Re: relaxation paradox From: agnello Date: 10/16/99 Time: 6:20:45 PM Remote Name: 184.108.40.206 Comments Higuera--Kuster great article...great question...I remember Van's comments concerning relaxation with PWS.".Sucess brings on relaxation/tension reduction(speech-stutter anxiety reduction) Sucess with controls(cognitve/motoric) is the path to 'relaxation" Re: relaxation paradox From: Josˇ Antonio Garc’a Higuera Date: 10/17/99 Time: 1:57:45 PM Remote Name: 220.127.116.11 Comments Thank you for this interesting citation. Sense of control is one of the most important things to maintain mental health. Studies have shown that lost of control originates anxiety and depression. Normally we control our behavior learning how to do it and increasing our effort to obtain success. When we increase effort, our activation increases and may lead to a behavior breakdown. Motoric tasks are especially sensible to the uncontrolled increment in activation. Problems also arise when we try to control our sensations and emotions. It is not through increasing effort as we can deal with our feelings. We must be open to accept unpleasant emotions and feelings and we must concentrate in the task not in the control of our sensations. If somebody directs his attention and effort to control the emotion, failure in this control becomes very probable, consequently anxiety increases and his task performance may also breakdown. Research on Spanish PWS From: James Au-Yeung Date: 10/7/99 Time: 3:34:48 AM Remote Name: 18.104.22.168 Comments It is wonderful to have researcher outside the English speaking world working on stuttering. We at UCL are currently collecting and analyzing Spanish stuttering speech and wonder if you have any recording that can be shared with us. In a recent discussion with Nan Bernstein Ratner, we wish to set up a database of speech recording of stuttering speech of various languages for research purpose. James Au-Yeung email@example.com Re: Research on Spanish PWS From: Josˇ Antonio Garc’a Higuera Date: 10/8/99 Time: 5:31:17 PM Remote Name: 22.214.171.124 Comments I have received a mail from Isabel Vallejo Gomez, Department of Phonetics and Linguistics University College London, suggesting to collaborate with your research. But unfortunately at present it is not possible for me. Sorry very much. Psychological problems in a case of stuttering From: Mary Ahlers SLP Date: 10/15/99 Time: 11:44:55 AM Remote Name: 126.96.36.199 Comments I focused on your statement that stuttering may generate psychological problems which in turn may worsen speech, and that the solution to this type of problem isn't always a direct consequence of the speech pattern improving. I had a student who would do extremely well with controlling his fluency, only to fall back again...and again...He openly stated concerns involving his mother...she was constantly trying to control him. I knew the only way his speech would improve, was if he was receiving counseling outside of the school setting to help him deal with family issues. I encouraged the entire family to seek counseling services. Once some of the underlying issues were brought to the surface and faced, his speech began to improve. (Although he still has a long way to go.) The counselor employed hypnosis in the therapy to help this child reveal these deeply rooted emotions. I think it is very important in my profession as a speech therapist to know when my services alone are not going to meet the needs of the student. I think we need to keep an open mind about calling in "outside help" for the benefit of the child. Thank you for your article...it was extremely interesting. Re: Psychological problems in a case of stuttering From: Josˇ Antonio Garc’a Higuera Date: 10/17/99 Time: 1:51:49 PM Remote Name: 188.8.131.52 Comments Thank you for your encouraging words. Really sometimes psychological problems may perpetuate speech troubles. I had a patient, referred to me by a language therapist, who resisted all attempts to improve his speech. Psychological therapy might be very short because he ought to incorporate to army in two months. Problems were focused in his relationship with his father. I trained him in therapy sessions to say his father what he thought about his relationship. However, he did not say anything to his father. Finally I joined both in a therapy session. Along that, he said, with a great effort, all he was thinking and he established an assertive conversation asking his father to change some concrete behaviors. Immediately after this session he improved notably his fluency. Unfortunately therapy was discontinued due to his incorporation to army. Several years later I contacted newly with this patient and I realized that improvements obtained in his short therapy are maintained. Psychological Problems... From: Karen Rockwell Date: 10/19/99 Time: 11:25:42 PM Remote Name: 184.108.40.206 Comments As a graduate student in SLP, I recently worked with a man (in a hospital setting) who stuttered since childhood (per patient interview), but was being treated in the hospital for depression and psychotic paranoia. Upon reviewing this man's charts, there was no reference to his stuttering anywhere in his history. However, after spending some time working with this man, I came to the personal (not professional, as I am not a psychiatrist or psychologist) opinion that his depression and paranoid behaviors seemed to stem from his stuttering--he was overly aware of his mouth, afraid that he offended people every time he spoke, and was afraid to eat in front of others, for example. Because I was "only" a grad student at this facility, I didn't feel I had the authority to make a statement about what I felt was a connection between his life-long stuttering and his psychological problems. After reading your article, I will feel more secure in following my "gut-instincts" in the future. Could you give some advice on how to present such a case, when a SLP feels there may be a causal relationship between stuttering and psychological disorders, especially when the physicians have not acknowledged the patient's stuttering? Also, do you know of many cases in which debilitating mental illness (not just mild-to-moderate depression) was judged to be related to stuttering? Thank you for your time! Re: Psychological Problems... From: Josˇ Antonio Garc’a Higuera Date: 10/22/99 Time: 4:48:31 PM Remote Name: 220.127.116.11 Comments It is clear that there exists a relationship between the stuttering and psychological problems in the patient and, even more, surely if you treat his stuttering his psychological problems would improve. Anyway, the diagnostic may be correct, this man has hallucinations. It may be that the cause of his illness begins in his stuttering but it is necessary to take into account his present state. At this momment there is an attempt to treat hallucinations and delusions with psychological methods and results are very promising. You may see the article: Haddock and al. (1998). Individual cognitive- behavior therapy in the treatment of hallucinations an delusions: a review. Clinical Psychology Review, 18, 821-838. I think that this type of treatment is beginning and that it is necessary a long time to become kwon in the health community. I think that you must be confident in your "gut-instincts" because you have perceived a relationship that is not so clear for many professionals with a lot of experience. Moving forward From: Ed Feuer Date: 10/20/99 Time: 2:27:30 PM Remote Name: 18.104.22.168 Comments Your views remind me of what John Harrison says in his analogy of stuttering therapy to putting a new stone in an old setting in jewelry. I would say that it is to be expected that our experience has given many of us a maladaptive way of dealing with the world. Helping the PWS change the setting and learn better interpersonal communication skills should be part of any real stuttering therapy. My view is that stuttering is too big for SLPs, alone, in terms of knowledge and time. Their key area is speech mechanics but most lack expertise in interpersonal communications, systematic desensitization, other areas of psychology, assertiveness training, anxiety and stress management, and human performance. That is why I have proposed collaborative teams including SLPs and people who possess this other expertise in treating adult stuttering clients. Ed Feuer firstname.lastname@example.org Re: Moving forward From: Josˇ Antonio Garc’a Higuera Date: 10/21/99 Time: 11:45:34 AM Remote Name: 22.214.171.124 Comments I completely agree with your proposition. Psychologists lack knowledge of speech mechanic, and most SLP lack expertise in how to deal with psychological problems provoked by stuttering. Working in an interdisciplinary team is a more suitable solution. I am very confident in human capabilities, and I think that human being is able to manage by himself most difficult situations. Then some assistance in any direction may contribute decisively to solve any psychological problem. This point of view is very optimistic for my profession because I think we work in the same direction that the patient and failure is not very probable. Def. of massive flooding From: L. Gustafson Date: 10/22/99 Time: 4:23:56 PM Remote Name: 126.96.36.199 Comments Could you please give a short description of what Van Riper's adaptations approach is that you used(ie. massive practice/flooding)? Re: Def. of massive flooding From: Josˇ Antonio Garc’a Higuera Date: 10/22/99 Time: 5:01:24 PM Remote Name: 188.8.131.52 Comments In this case I ask R. to repeat difficult words in which he probably will stutter (in his case those beginning with P or B) and I ask him to enter in blocking and maintain it without any attempt to avoid or fly. This may be considered massive practice of stuttering. From the point of view of anxiety treatment it is exposure to feared stimulus (his own stuttering). Exposure is also known as flooding, mainly when you situated the patient in the most terrible situation even if this have little probability to happen in the reality. It is necessary in these techniques to finish the session achieving an important relaxation level in the patient to be effective.