WHAT IS STUTTERING?
Stuttering is defined as a disorder of fluency, an involuntary and intermittent disruption in the flow of speech. The disruptions most frequently take the form of repetitions of sounds or syllables, abnormal prolongations of sounds, and unusual pauses within or between words. The pauses or hesitations are sometimes viewed as inaudible prolongations, especially if they occur within a word.
A general characteristic of most if not all stuttering behavior is some degree of stress or muscular tension. The stutterer seems to be having a hard time getting his words out, and is struggling to do so. The very fact of abnormal repetitions of sounds or syllables, and unduly prolonged sounds, would appear to indicate the presence of unusual tension. In the case of hesitations between and within words, which may occur for reasons other than stuttering, abnormal tension when present is nearly always indicated by the stutterer's behavior as he appears to be struggling to initiate a word or to complete a word already begun.
To the stutterer himself, the essential 'core' or basic feature of the problem is a sudden feeling of paralysis or blockage as he tries to begin a word or to complete a word already begun, or a loss of control as he suddenly finds himself repeating a sound or syllable over and over again before he is able to complete the word. Any of these events may occur on words that he has spoken many times before with no trouble whatsoever. Typically, the stutterer knows exactly what he wants to say and how to say it, but when stuttering occurs he fins himself abruptly and inexplicably unable to utter the word smoothly and fluently. These moments of stuttering may be of very short duration, extremely transient and fleeting, or on rare occasions they may last for a minute or more as the speaker tries to regain fluency.
STUTTERING AS PARTICULAR KINDS OF DISFLUENCIES
Fluent speech is defined as speech that flows or moves smoothly, easily and expressively, with few errors of any kind, and with no excess effort on the part of the speaker. Errors in fluency, or "disfluencies," include almost anything done verbally by the speaker that in any way detracts from the ongoing flow and continuity of his speech. Stuttering is classed as disorder of fluency, but this does not mean that all disfluencies are viewed as stuttering.
Some disfluency is an almost inevitable concomitant of spoken language. Even accomplished, experienced speakers will now and then exhibit some types of disfluencies. Young children, still in the process of learning the intricacies of spoken language, are normally quite disfluent, just as any adult will likely be when trying to master a foreign language. Disfluencies may be caused by such things as indecision in what to say or how to say it, almost any sort of stress or tension in the speaking situation caused by emotion (speaker feels angry, fearful, frustrated, etc.) or when trying to speak in competition with others ("Trying to get a word in edgewise"), or speaking in the presence of a distracting background noise, and there are also the types of disfluencies that are called stuttering, whose causes are still being debated.
Specific kinds of disfluencies have been classified as follows:
Where do we draw the line between 'normal' and 'abnormal' fluency? We have instruments to measure hearing acuity or the loudness and pitch of the voice, but we have no instruments to measure types or degrees of disfluency. Judgments of fluency must be made by listeners, which means that there will always be differences of opinion as to what is 'normal' versus 'abnormal.' Furthermore, there is obviously no sharp line between what is regarded as normal and abnormal; it is a matter of degree. The larger the number of people who judge a given speaker, the more variation in opinion there will be.
This is not to say, however, that obtaining agreement among listeners is impossible. Obviously, the greater the amount of disfluency shown by an individual, the more agreement there will be among listeners that he is disfluent. But we are chiefly interested here in what makes a listener say of a speaker, "He is stuttering" rather than "He is quite disfluent," or even "He is terribly disfluent." There has to be something about the amount or the specific types of disfluencies uttered by the speaker, or something about the manner in which the disfluencies are produced, the individual's "speaking style," to elicit a judgment of "stuttering".
Most languages have a word meaning "stuttering" (or "stammering"), and there are references to such a disorder throughout recorded history. What, then, constitutes the nature of the problem that all these people of diverse cultures have been reacting to since antiquity? What are the common denominators among their individual variations in defining the term "stuttering"?
In contemporary American culture at least, the amount (frequency) of disfluency per se that is shown by a speaker is not as important in determining a judgment of "stuttering" as are particular types of disfluency. The kinds of disfluency that are most likely to be heard as "stuttering," as already indicated, are part-word repetitions (sounds or syllables), prolonged sounds, and unusual pauses within or between words. The other types of disfluencies - interjections, repetitions of whole words or phrases, and revisions of wording - are more likely to be perceived as reflecting linguistic indecision on the part of the speaker.
Of as much, if not more, importance than type of disfluency, though, is the manner in which the speaker utters them. If the repetitions, hesitations and prolongations are performed with no more apparent tension or effort than that with which normal speech is performed, the listener will probably react to them as relatively mild stuttering. But if they are accompanied by noticeable tension, effort, and struggle behavior (indicated by facial grimaces especially around the mouth, eye closure, forehead wrinkling, head jerks or bobbing, fist clenching, foot tapping, and other behaviors), then almost any listener will feel that something quite abnormal is going on, and is very likely to call it "stuttering."
HOW DOES STUTTERING BEGIN AND DEVELOP?
Most adult stutterers cannot remember when they began to stutter; they feel they have done it all their lives. Data about onset must nearly always be obtained from parents, who generally report the onset to have been gradual. An inescapable problem in getting valid data on onset and early development of the problem is that parents differ widely among themselves in what they call "stuttering" and how it is to be distinguished from "nonstuttering" speech behavior. However, close questioning of parents by trained investigators has given a fairly accurate picture.
The most common age of onset is between three and four years, though parents have reported onset as early as 18 months and as late as 13 years. Very rarely it may be reported in adolescents or young adults, but this may not be typical stuttering behavior. In almost all cases, the child has been regarded as a normal or nonstuttering speaker for some time before the parents feel that he has developed a stuttering problem.
In most cases, an individual's overall stuttering problem appears to follow a pattern of development during childhood and adolescence. The overt stuttering behavior tends to progress from a simpler pattern with minimal tension to manifestly greater complexity and tension, while the degree of emotionality frequently changes from apparent indifference to strongly negative emotional reactions. It is possible that, as time goes on, the specific disfluencies that define stuttering become more frequent and severe, independent of whatever the stutterer does in reaction to them. On the other hand, progressive changes in the overall problem may consist only of the increasing repertoire of coping behaviors and emotional reactions that are learned in response to the basic fact of stuttering. A third possibility is that both factors - increasing disfluency and increasing reactions to the disfluency - may contribute to the increased severity of the problem.
It is possible to describe the typical beginning and development of the disorder, but there are many variations on this theme; many ifs, ands, and buts. However, keeping in mind how far and in what ways any individual stutterer may vary from this scenario, we shall now describe a more or less 'standard' pattern of stuttering development.
During the preschool years the child's stuttering behavior may at first be quite episodic, occurring for periods of weeks or months between lengthy interludes of nonstuttering speech, or it may be relatively continuous once it begins. The dominant characteristic is the repetition of initial syllables, though there is also frequent repetition of whole words. The child tends to stutter most on the first words of sentences, clauses, or phrases. Stuttering occurs on the function words (pronouns, conjunctions, articles, and prepositions) about as often as it does on content words (nouns, verbs, adverbs, and adjectives). The child tends to stutter most when excited or upset, when he has a great deal to say, and when speaking under any other type of communicative pressure. He usually shows little or no concern about his speech interruption, apparently having no expectation of trouble. He may, however, exhibit acute but temporary frustration in response to specific moments of stuttering; some exclaim "I can't say it!" In general, however, the child shows no negative emotion about his speech, and his self-concept is still unimpaired.
Later, as the problem becomes more chronic during the elementary school years, stuttering occurs less on the function words but more on content words. Whole word repetitions become much less common, and there is a much greater tendency to stutter on any word in a sentence rather than just initial words. Stuttering still increases when the child is excited or speaking rapidly, but otherwise may show little situational variability. The child is rather likely to have come to regard himself as a stutterer, but he still shows little or no real emotional concern about his difficulty and exhibits no fears, avoidance behaviors, or anticipation of trouble.
By late childhood and early adolescence the problem has become chronic, but now the frequency and severity of stuttering vary noticeably depending on the speaking situation. Situations involving stress, such as class recitation, speaking to strangers or people in authority, buying in stores, using the telephone, and so on, elicit more than usual stuttering. Also, certain sounds or words may now be regarded as more difficult to say than others, so that the child tends to substitute 'easy' words for 'hard' ones, and to employ circumlocutions as another method of avoiding stuttering. He tries to avoid stuttering because it is a frustrating experience, but he still has little or no feeling of anxiety and shame about it. He definitely regards himself as a stutterer, and he tries to avoid certain sounds or words, but generally he does not avoid speaking situation. Stuttering has not yet become a fearful and shameful thing. He is frustrated and irritated by it rather than scared of it, and though he may stutter severely at times he still participates in speaking situations in and out of school.
The most advanced stage in the development of stuttering occurs when the individual develops feelings of anxiety, shame and guilt about his speech behavior. This is most likely to take place in late adolescence, though it may happen as early as ten years of age. The individual now regards himself not only as a stutterer but also as a handicapped person who is obviously 'different' from other people. He may have much self pity along with his constant fear and embarrassment about stuttering. Only with reluctance does he enter any speaking situation in which he fears stuttering, and whenever possible he withdraws from or totally avoids such situations. He is acutely aware of other people's reactions toward him and his speech and he may imagine negative reactions from others when in reality there are none. He tends to become his own harshest judge. His social relationships are impaired. He now has many feared sounds, words, and situations, very frequent word substitutions and circumlocutions, vivid and fearful anticipation of stuttering, and many and varied types of coping, secondary behaviors. His overt stuttering behavior is not constant in severity, however; it may vary considerably depending on the degree of stress and tension he feels in a given situation. In some relaxed situations and interpersonal relationships, as when at a party or speaking with a close friend, he may be quite fluent, but he knows these times are just temporary interludes. He tries to pass as a normal speaker by employing all sorts of subterfuges and avoidance behaviors, at best with only partial success, and more often with total failure.
If the individual's stuttering problem has developed to this point, it can obviously have a profound effect on his life. It can adversely affect his social life, his choice of a mate, his vocation, and his overall emotional adjustment and self-image. Nearly all of his speaking situations, from the simplest and most trivial to the most complex and important, are colored by his anticipation of stuttering and his efforts to cope with it when it happens. Frequently he is more concerned with how he says something than with what he says.
Again, it is to be emphasized that the individual stutterer may vary considerably from the foregoing outline. He may acquire the various behaviors in a different sequence, may not acquire some of them at all, and may acquire some that are not described. His attitudes and feelings about himself and his stuttering problem may differ quantitatively and qualitatively from those outlines. Whatever the causes of the particular speech disfluencies that define stuttering, the overall problem consists largely if not entirely of learned behaviors and feelings, and so considerable variability is to be expected from person to person. Also, any individual stutterer will vary somewhat from time to time in the overt and covert aspects of his stuttering problem.
It should be emphasized that there is no necessary relationship between the overt severity of stuttering behavior and the intensity of the emotional reaction to the problem. Some mild stutterers have great anxiety about their speech, and some severe stutterers just don't seem to let it bother them a great deal.
A noteworthy aspect of the stuttering problem is that most children who exhibit stuttering behavior will cease to do so within varying lengths of time without speech therapy or other assistance. Stuttering, in other words, tends to disappear by itself, and the child recovers fluency spontaneously. Anywhere between the ages of about two to ten years, a child may stutter for a period of days, weeks, months, or even years, and then regain normal fluency. As a result, at any age level up through adolescence the number of active stutterers is probably matched by at least an equal number of people who formerly stuttered. The older the age group, however, the greater the proportion of recovered stutterers, so that by adulthood the percentage of ex-stutterers is probably quite large.
Spontaneous recovery can take place at any age, though the longer a person has stuttered the less likely will the problem disappear of its own accord. It appears that a very large group of children who recover fluency in their early years will have no memory of ever having stuttered by the time they reach adulthood. Of adults who do remember having stuttered and then recovered spontaneously, half or more still tend to stutter slightly at times. This is especially true of those whose recovery took place relatively late.
When questioned, adults who remember having formerly stuttered report that they recovered within a wide age range, although most of them say that their recovery took place between about 13 and 20 years of age. They nearly always report their recovery as having been gradual, and many have no idea why they recovered. Those who do offer an explanation, in the absence of any speech therapy, frequently attribute their recovery to such things as speaking more slowly, speaking more frequently (not being afraid to talk), relaxing, and acquiring new attitudes toward themselves and their speech problem.
The average nonstuttering individual, with his normal kinds and amount of disfluencies, may wonder why the stutterer is apt to be so emotionally upset over his stuttering. He will tell his stuttering acquaintance or friend, "Why does it bother you so much? Other people don't pay much attention to it. They may notice that you stutter, but then they tend to forget about it, and accept you as you are. Either they like you or they don't, but either way it isn't because you stutter.
The stutterer may see the reasonableness of this, but too often he cannot make himself really believe it. This is not to say that all stutterers have intensely negative feelings about themselves and their stuttering. Some fairly severe stutterers just seem to override the fact of their speech problem, with a sort of "Damn the torpedoes, full speed ahead" attitude. They regard their stuttering with frustration and irritation, perhaps, but they don't let it interfere significantly with their social and vocational activities. The degree to which a stuttering problem cripples an individual depends on many things other than just the overt severity of his stuttering. If a child receives love, respect, and realistic discipline from his parents, learning self-reliance and confidence, he will develop a healthy ego, have a basic liking for himself and for others, and be socially secure. With this personality structure, he will be better able to cope with any frustration or handicap, psychological or physical, that may come his way, including stuttering. On the other hand, a child who learns to feel threatened and insecure, who feels that the world is a rather dangerous and unpredictable place, and that he must be wary and defensive with other people, will be vulnerable to any event that threatens his fragile defenses and decreases his already low self-esteem. What one person perceives as a nuisance can be devastating to the next individual.
However, while people react in different ways to their stuttering, no one is happy about it. Stuttering, as much or more than other speech disorders that may actually have a more serious effect on intelligible communication, has a peculiarly frustrating effect on the speaker. The stutterer himself is baffled by it. He doesn't know why he does it ("Why me," he says, "and not the next guy?"). If someone has only one leg, or is blind or deaf, or mentally retarded, other people don't blame that person for his handicap. They can see what is wrong, and they don't offer advice designed to remove the handicap. They don't say, "Now if you'll just relax and concentrate on what you're doing and take it easy, you'll be able to walk as well as anyone, or see, or hear, or be smart." But they do offer this kind of advice to the stutterer, little or none of which proves helpful. For the most part it simply convinces the stutterer more than ever that he's really missing the boat somewhere, that everyone but him is an expert on stuttering. They all seem to know something he doesn't, or at least he can't seem to make any of it work. So he feels more inadequate and guilty and resentful.
A large part of the mystery of stuttering is due to its intermittent character. Physical handicaps are relatively constant: a blind person's vision doesn't come and go, a person with a hearing loss doesn't hear well one moment and not the next. But the stutterer is tantalized by the fact that for the most part he is fluent, and he wonders what goes wrong on occasional words. If he is an average adult stutterer, he stutters on only about one out of ten words that he speaks, though as a group stutterers vary widely in this respect. And to compound the mystery and frustration, he may stutter severely on a particular word that he has said many times earlier (perhaps only a few moments before) perfectly easily. In his quest for fluency he feels somewhat like the donkey trying to reach the carrot on the stick tied to his head and projecting out ahead of his nose. Fluency becomes precious, and he will do almost anything to achieve it.
The stutterer is likely to feel that he is viewed by others with a mixture of pity, scorn, or amusement. He feels that stuttering is degrading. It can't be done with dignity, in the way that blind or deaf or crippled person can be dignified. Advanced stuttering is apt to be accompanied by facial grimaces (the stock in trade of the clown throughout history), sputterings, strangled snorts, and other weird sounds. Except on relatively infrequent occasion, the nonstutterer is concerned chiefly with what he wants to say rather than how he will say it. The stutterer may become obsessed with how, and indeed, whether in a given situation he can utter any words at all without making a fool of himself. When a stressful speaking situation arises, he immediately plans how he will cope with it, choosing the words he will say that he may be able to say without stuttering, and dreading the words that he must say with no chance of substitutions. In school, when asked a question in class, he may pretend not to know the answer rather than to expose his stuttering. He may particularly dread having to read aloud when the other students have the same book and would know if he is skipping or substituting words. He will pretend to be ill on the day when he is scheduled to give an oral report, and may use other devices to avoid having to perform orally in class. He finds it almost impossible to believe that some nonstutterers have the same dread of public speaking; he feels that only he, with his humiliating handicap, has any reason to be scared. He feels that if only de didn't stutter, he would be happy and successful, perhaps even a golden tongued orator. He believes that all problems pale in comparison to his particular handicap. He may feel very sorry for himself.
When the stutterer knows that he must speak in an unavoidable situation and that he must say certain words, he may build up a great deal of anticipatory anxiety. This may vary from mild uneasiness to sheer panic. Based on past experience, he is very sure that he will stutter on certain words, such as his name, address, phone number or other specific factual information, or words that he must use in making specific requests of the listener. His anxiety is increased if he knows that other people will witness the situation, as when he is standing in line waiting to buy a ticket or obtain information, or to introduce himself in a group situation.
As the moment to speak approaches, his fear rises sharply. His mouth feels dry, his palms and underarms are sweaty, his heart pounds, his breathing is rapid and shallow. He feels trapped and panic-stricken. Then the instant arrives when he must speak. He tries to retain some degree of composure as he frantically casts about to find some way of getting out the feared words. He instantly and automatically goes into his repertoire of coping behaviors as he struggles desperately for fluency. He may hold his breath and try to squeeze out the words with sheer force, he may shut his eyes tightly, clench his fists, jerk or twist his head around, contort his face in grotesque grimaces. He knows he is making a horrible spectacle of himself but he feels out of control. He may utter weird croaking or gasping sounds as his speech mechanism seems to have gone berserk. He may feel as though he is blanking out, almost fainting, out of contact with reality. Then, finally, he manages to complete the utterance, mangled and distorted though it has been. He feels exhausted, worn-out for the moment. Worse, he feels shamed and degraded. He may attempt a show of bravado, of casualness, but he wonders what his listeners think of him for his weird behavior. He has made a complete fool of himself, and he wishes he could disappear. He is relieved to have gotten out the words, but he feels horribly embarrassed. He may then utter the remaining words quite fluently, hoping that somehow they will cancel out his failure and convince the listeners that somehow he is still human. But he can't convince himself of this, and he knows that the same thing will happen again many times in the future. His confidence and self-esteem are near zero.
If an individual's stuttering problem has developed to this degree of severity, it is no wonder that it constitutes a serious handicap, adversely affecting nearly all facets of his life that involves speaking with other people.
TREATMENT OF STUTTERING
The method of treatment of any problem will be determined by the cause that has been assumed or established.
The treatment of stuttering, like the treatment of any behavioral deviation whose essential nature and causes remain obscure, has always reflected the modes of theory and therapy of the age and the society in which it occurred. A society that believes in good and evil spirits as causes of behavior will tend to believe that evil spirits cause stuttering, and the therapy to be applied will naturally consist of efforts to exorcise the spirits. In the absence of factual knowledge about any problem, people will always make assumptions about the causes and treatment of the problem, based on popular contemporary viewpoints, then act on those assumptions.
Additionally, treatment may also be of an empirical nature, based on aspects of the abnormal behavior that are perceived to vary as a function of certain conditions. Thus, if a stutterer is observed to become more fluent when he talks in time to some established rhythm as when he taps his finger, the recommended treatment may be to learn to talk rhythmically, perhaps with the aid of a metronome or other timing device. Such a therapy may be advocated in the total absence of any understanding of why the stutterer becomes more fluent when he speaks with an imposed rhythm.
For the most part, the long history of thinking about the problem of stuttering has followed these patterns. We shall now review briefly some of this history.
Beginning with Aristotle, around 350 B.C., many writers down through the centuries assumed that stuttering resulted from some defect of the tongue, and recommended such treatments as division of the frenum, cauterization, tongue exercises, various devices to support the tongue, and, toward the middle of the 19th century, surgical mutilation of the tongue.
In the sixteenth and seventeenth centuries, in keeping with the 'humors' theory of physiology and behavior prevalent at the time, stuttering was frequently attributed to 'coldness' and 'moisture' of the tongue or brain, or occasionally to their 'dryness,' and treatment consisted of various gargles, cauterization, blistering salves, bleeding, and similar unpleasantries.
Although various physiological explanations for stuttering continued to be expounded - and still are - beginning in the early eighteenth century there were non-organic theories to the effect that stuttering was viewed as a "vicious habit", or due to imitation, or the result of the collision of many ideas flowing simultaneously from the brain. Treatment usually consisted of tongue exercises, practice in speaking and reading aloud slowly, softening the initial consonants of words, and similar activities.
It was observed that stuttering could be influenced by suggestion. A faith healer could exhort a stutterer to be glib of tongue, and at least for a short time the stutterer would become quite fluent. Autosuggestion gave the same results. A stutterer could tell himself that he had control of his speech mechanism and would not stutter, and if he really believed this, he would in fact be much more fluent than usual, even in difficult speaking situations - at least for a time, before his self-confidence began to fade. The use of suggestion in stuttering therapy became especially popular in the early 19th century, when hypnotism came into vogue. Many stutterers were hypnotized and given the post-hypnotic suggestion that when they "woke up" they would be able to talk freely and easily. And in fact, many of them did show remarkable fluency for a while - until the suggestive influence of the hypnotist wore off. In one way or another, by design or fortuitously, suggestion is still an integral part of most types of stuttering therapy, though it may take indirect forms. Direct hypnotism is also still employed occasionally.
Stuttering obviously involves muscular tension of the speech mechanism, so it was reasonable to assume that stutterers needed to relax as much as possible while speaking. Accordingly, techniques to induce greater relaxation became another popular method for treating stuttering. Stutterers were taught to practice general muscular relaxation, usually while lying down, and at the same time to assume a calm mental state, perhaps imagining a happy, peaceful scene. While in this condition they would practice speaking, trying to maintain the feeling of calmness. There was nearly always considerable difficulty in carrying over this relaxed feeling into real life speaking situations, however.
A variant of the relaxation technique was to try to change the stutterer's breathing pattern. It was observed that in severe stuttering the individual's breathing tended to be shallow, jerky, and irregular. On the assumption that there was something basically wrong with the stutterer's breathing habits or even with his breathing mechanism, attempts were made to have the stutterer breathe more deeply, slowly, calmly, and to begin to speak only on the outgoing breath. Apparently just about everyone who advocated "breathing exercises" seemed to overlook the possibility that the stutterer's disturbed breathing during speech was not the cause of his stuttering but the result of his disturbed emotional state and his tense, coping efforts to achieve fluency.
Other therapy efforts were directed toward having the stutterer change some feature of the way he spoke. Nearly all stutterers, sooner or later and in one way or another, discover that if they speak in some unusual manner their stuttering diminished, and in some cases disappears at least as long as they maintain the unusual speaking pattern. Changes in speaking pattern include such things as using a higher or lower pitch, speaking more loudly or softly, speaking more slowly or in some cases more rapidly, using a monotone, assuming a dialectal pattern or foreign accent, and above all speaking in time to a regular rhythm. If a stutterer paces his speech to the best of a metronome, or simply keeps time by tapping his finger, he nearly always achieves instant fluency even though his speech may sound quite monotonous. Some of the commercial "stuttering schools" or "stammering institutes" that flourished during the first half of the present century based their methods on the principle of an imposed rhythm of speech. In one such school, stutterers were first taught to swing Indian clubs as they spoke, and later to keep time by wiggling their fingers in prescribed patterns.
Shortly after the turn of the century, an entirely different approach to stuttering therapy came into being. Whereas always before it had been assumed that stuttering was due to some type of physiological disorganization or deficiency, or was simply a bad habit, the new approach assumed that stuttering behavior was the outward expression or symptom of an inner, unconscious emotional conflict. This was of course the view held by Sigmund Freud and his followers. The treatment of choice was psychoanalysis; a long, slow procedure in which the patient, through talking about details of his past and present life and describing his dreams, revealed to the analyst the nature of his unconscious or repressed personality conflicts that resulted in stuttering or other forms of neurotic behavior. The task of the analyst was then to 'educate' the patient, as non-traumatically as possible, as to the nature and reasons for his conflicts. The patient, having achieved insight into the true nature of his problems and having resolved his long-hidden conflicts, would no longer have any need to maintain his maladjustive overt behavior. It was theorized that if the inner causes were removed in this manner, the outward symptoms, such as stuttering, would simply wither away and disappear.
Psychoanalytic treatment for stuttering was never "speech therapy". Nothing was done about the stuttering per se, since it was regarded as merely a symptom that served a neurotic need and would automatically self-correct when the emotional conflicts that caused it were removed. Freud himself viewed stuttering as a neurotic symptom rooted in unconscious conflicts, but he admitted that it was a difficult problem to treat and that psychoanalysis did not always give good results. Other psychoanalysts of the early 20th century worked with many stutterers, but even the most ardent advocates of this treatment could express at best guarded optimism, and many felt that most cases of stuttering were unusually resistant to therapy.
On the assumption that stuttering has some sort of psychological etiology, it has continued to be treated by various kinds of psychotherapy other than classical psychoanalysis. Several neo-Freudian types of analysis have been employed, as well as group psychotherapy in its many forms, in addition to Rogerian non-directive or client-centered therapy, psychodrama, and other varieties of counseling and psychotherapy. None of these approaches have been outstandingly successful; all seem to give occasional good results which too frequently are of a temporary nature.
In the 1930's still another approach to the problem was developed. This approach was novel in that it attacked directly the emotional component of the problem as felt by the stutterer. No Freudian assumptions were made about unconscious, repressed, neurotic personality conflicts. Instead, it was assumed that stutterers were basically normal individuals, psychologically and physiologically, who had highly conscious anxieties about their stuttering in relation to specific sound, words, and social situations, as result of which they also had well-developed avoidance behaviors. Additionally, the new approach included the rigorous, scientific study of the nature of stuttering behavior itself and the personal and environmental variables to which it was functionally related. The therapy that was based on this approach stressed a direct attack on the fear and avoidance of stuttering, a gradual diminution of the severity and complexity of the overt stuttering behavior through self-analysis of feelings and behaviors, self-confrontation via mirror and voice recordings, and the development of an objective, relatively non-emotional and non-avoidant attitude. Emotional desensitization and the control or elimination of specific overt stuttering behaviors was attained in the context of everyday, real-life speaking situations.
The older methods of treatment had assumed that stuttering was caused by a specific organic defect (usually in the tongue) and fluency would result from a specific medical or surgical remedy, or that fluency was to be obtained immediately through suggestion, relaxation, or some unusual speaking pattern, or that stuttering was the outward symptom of unconscious emotional conflicts and fluency could be achieved only if these conflicts were removed. Except for psychoanalytic therapy, the emphasis had always been on the quick attainment of fluency by whatever means lay at hand, and it did not matter if was accomplished by some superficial method that would prove to be short-lived, or if the speech obtained was monotonous, breathy, or had other abnormal characteristics that were as bad as stuttering. These older methods were classed as "anti-stuttering" or "quick fluency" techniques, whereas the new approach was viewed as "anti-anxiety" or "anti-avoidance". It was felt that the anti-stuttering therapies employed methods that resulted in quick but temporary increases in fluency, whereas the anti-anxiety approach took longer and made more demands on the stutterer and his clinician, but resulted in more solid and permanent gains in fluency. The basic philosophy of the anti-anxiety school was that fluency was a by-product, that it "came in the back door," a natural result of the non-avoidant attitude of the efforts the stutterer made to avoid stuttering. Stuttering was seen as a self-fulfilling prophecy. Due to unfortunate conditioning experiences in early life, the stutterer had come to expect difficulty on certain sounds, words, or in certain speaking situations. He had learned to fear these events, and as one approached, he anticipated difficulty and began to tense up in preparation of having trouble. It was held that his anticipation of trouble and his defensive preparations for speaking fluently actually constituted his stuttering problem he might hold his breath, shut his eyes, jam his tongue against the roof of his mouth in an effort to say a word fluently, but these very things were what his listeners perceived as his stuttering. Therapy, therefore, was aimed at getting the stutterer to stop trying to avoid stuttering. The less he cared about whether he stuttered or not, the more willing he was to stutter, the less he would stutter. But in addition to this anti-avoidant attitude, the stutterer was also taught how to modify his stuttering when it did happen, to make it easier on himself and his listener, to reduce its degree of abnormality, to make it sound more like ordinary disfluency.
All this was done by such means as developing an "objective attitude," being deliberately disfluent to combat the fear and avoidance of stuttering, delaying, slowing down, and simplifying one's stuttering reaction, taking responsibility for one's own feelings and behaviors, approaching speaking situations with the correct preparatory set, and "stuttering fluently" with a smooth prolongation of sound rather than with staccato repetitions or tense blockages.
The foregoing approach to stuttering therapy was paramount in the United States from the late 1930's to the early 1960's. The record of success for this type of therapy appeared to be moderately good, although there was a scarcity of hard data. Its advocates believed that it produced far more stable gains than did earlier methods. On the other hand, it demanded considerable time, skill, insight , emotional maturity, and intelligence on the part of both stutterer and clinician.
Some people felt that, at worst, this approach did little more than teach the stutterer to live with his problem, producing what was sometimes sarcastically referred to as the "well-adjusted" or "happy" stutterer, but a stutterer nonetheless. It began to appear that stuttering theory and therapy had reached an impasse, a stalemate.
The time was ripe for a new development, and sure enough, one was forthcoming. It came in the form of what has become known as "behavior therapy" or "behavior modification". This new approach, gaining momentum in the early and mid-1960's, was a resurgence and extension of the hard-bitten Watsonian behaviorism of the 1920's, which had evolved form the earlier work of Pavlov and Thorndike and in turn was extended and made more respectable by Clark Hull. The behavioristic school of thought was still confined to the academic laboratory and classroom, however, until the sudden popularization of the operant methodology of B.F. skinner in the early 1960's. The summation of skinner with the earlier behaviorists produced a spectacular outburst of clinical and research endeavors that still continues.
Originally, behavior modification or behavior therapy was defined as the clinical application of the laboratory-developed, empirically derived and tested laws of conditioning and learning, stemming from the work of Pavlov, Thorndike, Hull, Skinner, and their followers. It was all very coolly scientific, objective, empirical, and irrefutable, with none of the mysticism, subjectivism, and untestable hypotheses and theories of psychoanalysis, or the vagueness and wishy-washiness of Rogerian non-directive psychotherapy.
Hull's work still seems abstruse, intellectual, and difficult to comprehend, but Skinner's operant methodology - at least as popularized - seems readily intelligible and appears to have immediate and almost universal applicability. The Skinnerian schema is deceptively simple. Any particular behavior is maintained by its rewarding or reinforcing consequences - a behavior that is followed by punishing consequences will soon cease to exist. To change an established behavior, therefore, all you need to do is to determine the reinforcing consequences, the schedule of reinforcement (how frequently the behavior is reinforced), and then eliminate or change the reinforcing event, or substitute a punishing consequence.
In such manipulations, it is obvious that only overt, observable behaviors can be dealt with. Subjective attitudes, feelings, or emotions are not amenable to systematic intervention. In behavior modification, only those "target behaviors" that are directly observable, countable, and repeatable, may be modified. In the case of a stutterer, for example, his feelings of anxiety about having to introduce himself or make telephone calls are not directly observable or countable, and cannot be manipulated directly. But the number of times that he introduces himself or makes telephone calls can be observed and counted, and can be followed by rewarding consequences. Thus, to the charge that the operant therapist is superficial, deals only with overt behaviors, and ignores important feelings and emotion, the therapist replies that feelings follow behavior, and that by helping the client to behave in a more adequate manner (increasing desired behaviors and decreasing undesired one), the client's reasons for feeling inadequate and anxious will wither away.
Operant technology is only one branch of behavior therapy, however. Some behavior therapists deal with negative emotions more directly, by systematic desensitization, assertive behavior training, role playing, and other techniques. Classical (Pavlovian) conditioning procedures play a large part in these procedures in deconditioning or counterconditioning anxiety responses.
From its original definition as the clinical application of laboratory-derived laws of conditioning and learning, behavior modification or therapy has come to include almost any technique or procedure that has empirically been shown to work. Some of these techniques have only an incidental relationship to "laws of learning", some have no discernible relationship whatsoever, and some appear to "work" for reasons that are not understood at all. For example, in the treatment of stuttering some techniques that are classed as "behavior therapy" include shadowing or echo-speech (repeating almost immediately what another speaker has said), speaking in time to a metronome, speaking under delayed auditory feedback, speaking in the presence of a loud masking noise that prevents self-hearing, speaking under the influence of tranquilizing drugs, and speaking after becoming thoroughly relaxed via ' progressive relaxation.' All of these procedures produce a decrease in stuttering, but efforts to explain this effect in conditioning and learning terms become tenuous, uncertain, and circular, and may end up as pure guesswork.
It is interesting that contemporary behavior modification has resurrected several of the older therapy procedures that had fallen largely in disuse, and occasionally into disrepute, since the advent of the "anti-avoidance" school of therapy just described, Nowadays, however, the procedures of relaxation, speaking in time to an imposed rhythm, breath control, deliberate prolongation of vowel sounds, and other fluency-inducing techniques, are investigated more systematically than before, quantitative measures of their effects are taken, and where possible they are discussed in the language of conditioning and learning - all of which conveys an impression of scientific rigor missing in earlier years.
HOW EFFECTIVE IS STUTTERING THERAPY?
It is apparent that a great diversity of opinion has existed, and still exists, with regard to the most effective way to treat stuttering. This is not surprising in view of the fact that the precise nature and causes of stuttering are still being debated. There are two commonly held ideas about stuttering therapy, based on clinical experience and on many attempts to measure the degree of success and the permanence of various types of therapy. One is that stuttering is extremely difficult to eradicate completely and permanently, especially in adults who have been stuttering for years, and the other is that almost any kind of therapy is likely to produce some degree of beneficial results for varying length of time. The latter fact has misled more than a few sincere but naive theorists and clinicians into making spectacular claims for the success of this or that type of therapy. Long term follow-up of their cases by disinterested observers all too often reveals that many of their clients began to stutter again at some later time.
The fact remains, however, that many stutterers - even those with a long history of stuttering - do recover normal fluency on a permanent basis, or at least reduce their problem to the point where it is hardly noticeable, and certainly not a handicap. The available data and clinical impressions suggest that the record in this respect is steadily improving. Furthermore, those who do make significant improvement have undergone any of a rather wide variety of therapies. The almost inescapable inference is that it doesn't matter so much what type of therapy was carried out as it is that therapy was administered at all. It would be extremely interesting to know how many adults recover from stuttering by reason of some form of self-therapy, and what the nature of that therapy is. Unfortunately, such individuals are not on record, and unless they come forward to tell their story they remain lost to scientific and clinical inquiry, and their contributions to knowledge about stuttering are never made.
The crucial point is that stuttering is remediable, and recovery from stuttering does happen. Stuttering is definitely not a hopeless proposition once it begins. The basic nature and causes of stuttering may already be known among our array of theories; perhaps we have not yet accumulated enough data to prove to ourselves that we really know what we think we know. Perhaps the most tantalizing question is, what is the common denominator, the necessary and irreducible factor among all the recoveries made from stuttering? And as a corollary, what is the basic element common to all forms of therapy that achieve significant results? If we knew how and why spontaneous recovery from stuttering takes place in so many children, we might then know how to achieve predictable and reliable results in treating adult stutterers.
Until that knowledge is achieved, we must continue the search and do the best we can with the knowledge we have.