Walter Manning, Ph.D., CCC-SLP, is a professor and Associate Dean in the School of Audiology and Speech-Language Pathology at The University of Memphis. He teaches courses in fluency disorders and research methods. He has published more than 60 articles in a variety of professional journals and has presented on many occasions to regional, national, and international meetings. He is the author of a text titled "Clinical decision making in the diagnosis and treatment of fluency disorders." He is a fellow of ASHA and has received the honors of Tennessee Association of Audiologists and Speech-Language Pathologists. He holds Specialty Certification in fluency disorders from the Specialty Board on Fluency Disorders.
Miodrag Hodak was born in Sarajevo, Bosnia-Herzegovina, where he still lives. He is 24 years old and is studying economics at the University of Sarajevo. He spends most of his free time helping other people who stutter by telling them about self therapy. He recently created a first Bosnian web page dedicated to stuttering and self help (http://mucanje.fateback.com).
Laura Plexico is currently a doctoral student at the University of Memphis where she is focusing on studies concerning fluency disorders, speech acoustics, neurophysiological substrates of stuttering, and counseling. She received her undergraduate degree from the University of Montevallo, AL and her M.A. from the University of Memphis. She has presented research to the professional meetings of the American Speech-Language-Hearing Association and the International Fluency Association.

You can post Questions/comments about the following paper to the authors before October 22, 2005.


Letters from Sarajevo

by Walt Manning, Ph.D. (Memphis, Tennessee, USA), Miodrag Hodak (Sarajevo, Bosnia-Herzegovina) and Laura Plexico, M.A. (Memphis, Tennessee, USA)

Background

For the millions of people who stutter throughout the world, relatively few have the ability to seek help via the internet. When they do, their efforts to find help can be complicated by the fact that they must search through a collection of, sometimes conflicting, advice. This is a description of one individual's experience in seeking help and the nature of our correspondence.

Mickey, as he referred to himself in his initial emails, first wrote to me (Manning) in the Fall of 2002. He was a 21 year old college student majoring in economics who lived in Sarajevo, the capital of Bosnia-Herzegovina. He had come across something on the Stuttering Home Page that I had written for one of the ISAD conferences. My comments appeared to resonate with him and he had contacted me with some questions related to his stuttering. As we corresponded over several weeks Mickey and I quickly established a dialogue.

Mickey's internet searches had identified some sources of information, some good, some not so useful. Although I commented on some of the sites and the information he had discovered, I believe my primary role in our conversations was that of providing understanding, support and feedback. I also offered encouragement and acknowledgement of his many successes. We spent some time discussing possibilities for problem solving issues that were unique to his situation. We certainly were not conducting treatment in any formal sense in this long distance relationship. Mickey viewed our exchanges that took place every two to three months as self-therapy.

English is not Mickey's first language but it was obvious at the start that this young man was able to eloquently express himself as he described his experience with stuttering. As Mickey and I continued our correspondence it became clear that he was making important, often dramatic, changes in how he viewed himself and his ability to communicate. It occurred to us that the ISAD interactive computer conference would be an ideal venue for describing our internet experience and we began to document what had occurred. Fortunately, I kept a record of his letters.

Because of our experience with a content analysis procedure (see Plexico, Manning & DiLollo, 2005) we used this procedure as one indicator of change as we reviewed Mickey's letters. Mickey prepared a short story describing his journey through self-therapy and completed some measures that would indicate his changing reaction to his stuttering.

Pawns and Origins

The Pawns and Origins Scale developed by Westbrook and Viney (1980) indicates an individual's degree of internal and external locus of control (LOC). The Scale is designed to extract meaningful information from narrative responses to open-ended questions. In these scales, statements that are pawn in nature are related to an external locus of control. Statements that are origin in nature are related to an internal locus of control. Research using these scales (e.g., Viney & Westbrook, 1980) has reflected the dynamic, multidimensional nature of a person's locus of control suggesting that it would be more suitable to measure this pawns-origins construct by eliciting a spontaneously produced narrative rather than using a predetermined questionnaire.

We analyzed a total of 17 letters from Mickey, which he sent from the fall of 2002 through the spring of 2005. Two authors (Manning & Plexico) each identified Pawn and Origin statements and then compared their independent judgments. These individual judgments coincided an average of 82% of the time.

Two important points should be noted about the evaluation of Mickey's communications. Although the majority of the clauses in Mickey's communications had to do with Mickey's experience with stuttering, the entire content of the letters were included in the scoring process. For that reason, his narratives also included topics such as politics, travel, weather, and social and family interactions. It should also be noted that even at the outset of our correspondence Mickey was very likely in the early stages of making a transition in his relationship with stuttering as indicated by his efforts in seeing assistance on the internet.

The results of the pawns and origin analysis as shown in the above figure indicate a clear reduction in pawn statements and a corresponding increase in origin statements. A univariate ANOVA indicated that Pawn scores of 1.82 in 2002 significantly decreased in 2003 and remained significantly lower in 2004 (1.07) and 2005 1.03). Origin scores were not significantly different from 2002 (1.24) and 2003 (1.38) but significantly increased in during both 2003 (1.72) and 2005 (1.91). Reading Mickey's letters over the years gave one a sense of the progress he was making and this analysis helped to document the nature and extent of these changes. Two brief passages provide vivid examples of how Mickey was (re)interpreting himself and his situation.

Examples of Pawn statements (P): October 2003

. . .but sometimes it looks like progress is coming too slow and that demoralize me totally from time to time. (P) I am 22 years old now, and I don't know how much time I have left for overcoming stuttering in order to achieve normal life. (P) I feel like I'm spending best years of my life in the "mud", (P) not using all the available opportunities out there. (P) Despite the fact that I understand stuttering better now, some emerging fears are making progress difficult: (P) If I don't succeed in time I don't know how my life is gonna turn out. (P) Examples of Origin Statements (O): December 2004 But I am trying to enter them (stuttering blocks) without avoiding and using tricks. (O) But I am gaining more and more self-confidence, (O) and I think it is the most important thing in all this. Also I feel much more freedom (O) as I am accepting my stuttering (O) and decreasing emotional attachment and sensibility to it. I am now in position to feel and to see the full potential of the struggle free life (O) that I can achieve (O) if I put enough effort in this process of change. (O) Generally speaking I am now focusing more on reducing fear and emotional tension, (O) on improving the quality of my life, (O) than on techniques for improving fluency. I think it will be much easier to use those techniques (O) when I substantially improve my self-confidence and psychological health or life quality in general. I already achieved that in some extent (O) through facing feared situations, voluntary stuttering and changing negative attitudes, (O) but there is still a lot to be done in the coming weeks, months and years. (O) Also I am trying to increase physical activities (O) and to engage in some sport, (O) because I noticed such activities are contributing significantly to increasing my self-confidence. (O) OASES

In order to provide another indication of the global changes in Mickey's life, we chose a newly developed comprehensive self-assessment measure titled the Overall Assessment of the Speaker's Experience of Stuttering Scale (OASES, Yaruss & Quesal, 2004) in March of 2005. The OASES indicates the speaker's opinion about how stuttering influences communication, relationships, sense of confidence and well-being. Scores in each section range from a minimum of 20 to a maximum of 100 with higher scores indicating a greater degree of negative impact. Numerical scores from the OASES can be translated to ratings that can be used to reflect the degree of impact stuttering has on a speaker's life (mild, mild-to-moderate, moderate, moderate-to-severe, severe).

During March 2005, Mickey completed the OASES twice, once from the perspective of his experience with stuttering in 2002 when we began our correspondence, and once from the perspective of his current experience. Of course asking Mickey to retrospectively respond as he would have in 2002 was not the ideal option but it did provide an indication of his perception about the changes he has made. His scores from his 2002 perspective totaled 344 points (impact score of 79.1) and his impact scores for each of the four sections of the OASES ranged from 76.5 to 84. All of these impact scores were rated as Severe. The scores from his current (2005) perspective totaled 243 points (impact score of 56.5) and impact scores for each of the four sections of the OASES ranged from 49.0 63.5. Two sections reach Moderate levels of severity and the remaining two sections were moderate-to-severe, which resulted in a total impact score of Moderate.

My Journey Through Self-Therapy
By Miodrag Hodak
Sarajevo, Bosnia & Herzegovina

For many years, I've been relying on other people in a desperate belief that they will cure my stuttering and ease the emotional pain that I've been experiencing on a daily basis because of the way I talk. But visits to various charlatans, as well as ineffective formal therapy programs, didn't result in anything good. After every failed treatment my desperation grew stronger. My experiences reinforced the feeling that there was something terribly wrong with me and that I was never going to overcome my difficulty and live a normal life.

My stuttering occurred when I was just 3 years old, so as a child, I didn't think much about it and situation looked much brighter. I was attending speech therapy and everyone was saying that the stuttering would disappear over time. However, after entering adolescence I started to realize that my speech was worsening and that people were starting to view me as a weirdo. I was growing ashamed of my speech so I began developing a terrible habit of avoiding people altogether whenever it was possible. Such behavior culminated at the end of high school and after, when despair fed by crippling fear, shame, and anger, crawled into every bit of my being. My self-esteem plunged so low that I used to stay at home and avoid seeing people even for months. By the time I went to the university, the last of the fantasies that I could overcome my stuttering easily fell apart. I turned to the Internet as a last resort, in order to find help.

I found a lot of useless material on the Internet. But what caught my attention a few years ago was a paper called "A Process of Recovery" by a speech pathologist from Memphis, Tennessee. The article by Walt Manning gave me hope that I could do something as to how I feel about my stutter and life in general. I wrote to Walt and we started a successful and rewarding correspondence, something as an email speech therapy, during which he introduced me to a concept of self-help and provided me with guidance on how to slowly ease my stuttering. After experiencing a number of failed formal therapy attempts that were now behind me, this was a refreshing and promising idea.

First I learned that I had to find an easier way to stutter as well as to end all avoidance habits. Over time, I had developed a particularly hard and unpleasant way of stuttering with a lot of blockages, so easy stuttering was an abstract term for me. But, as soon as I started to pay more attention to how I stuttered, things started to get better. Gradually I realized that I could produce much more acceptable stuttering if I slowed my speech and established normal breathing along with openly entering and changing my blocks. Because I thought that I could probably never achieve total fluency I devoted all my efforts to improving my ability to communicate well and to change the old and frustrating way of stuttering. My self-esteem improved dramatically as I was making these changes and for the first time in my life I started to feel that something actually could be done about my difficulty.

Naturally, this wouldn't be possible if I had continued to give in to my fears and to avoid speaking challenges. Along with the positive changes in the way I stuttered came the confidence and resolution to confront the feared situations, in which I've experienced disappointment before. I used to avoid people, places and telephone calls, all in an attempt to spare myself from the emotional suffering. The only way to ease the fears was to force myself to confront them regardless of how I felt. This was a successful approach that resulted with reduction in general fear of speaking and overall level of anxiety. That also helped me to achieve a greater level of efficiency when using the fluency shaping techniques. I never had much success in using them before because the fear and tension were always so strong and I never achieved enough concentration to apply them in real life situations.

However, I think that the most important change I've made is in how I feel about myself. Stuttering is certainly becoming a less dominant theme in my life as I am learning to accept it and to let go all of the negative thoughts attached to it. While I am slowly gaining confidence in the way I talk, I am also creating a new image of myself, an image that includes a total acceptance of myself and my speech impediment. This provides a great relief for I am no longer wasting so much energy on feelings like despair, embarrassment and anger.

In a last couple of years I've come a long way from being hopeless and unable to help myself, to being much more honest about my speech impediment and making a firm progress toward recovery. I even created my own webpage (http://mucanje.fateback.com/) in order to help stutterers in my region to learn about self-help and to share my experiences.

Of course, there are still a lot of things I have to change in order to overcome all the negative effects of stuttering and to repair what was ruined in the past. A long process of healing is still ahead of me, but I have made the first step in this life long battle and I am determined to do some more.

Conclusion

The interactive nature of the correspondence between Sarajevo, Bosnia & Herzegovina and Memphis, Tennessee, USA, made possible by the internet provided a way for Mickey to find the understanding and support necessary to begin taking action and making changes in his life. Making use of his narratives, we were able to document some of the ways that Mickey is changing his experience with stuttering. These changes were evident in the evolution of his statements as indicated by his Pawn and Origin scores as well as the improvement in his OASES scores. These changes are also reflected in many aspects of Mickey's story of his ongoing journey with self-therapy. The authors of this paper are planning to meet in May, 2007 during the 8th World Congress for People who Stutter, in Dubrovnik, Croatia.

References

Plexico, L., Manning, W., & DiLollo, A. (2005). A phenomenological understanding of successful stuttering management, Journal of Fluency Disorders, 30 (1) 1-22.

Westbrook, M. T., & Viney, L. L. (1980). Scales measuring people's perception of themselves as origins and pawns, Journal of Personality Assessment, 44, 167-174.

Yaruss, J.S., & Quesal, R.W. (2004). Overall Assessment of the Speaker's Experience of Stuttering (OASES). In A. Packmann, A. Meltzer, & H.F.M. Peters (Eds.), Theory, Research, and Therapy in Fluency Disorders (Proceedings of the Fourth World Congress on Fluency Disorders) (pp. 237-240). Nijmegen, The Netherlands: Nijmegen University Press.


You can post Questions/comments about the above paper to the authors before October 22, 2005.


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