Stuttering is a disorder of the social presentation of the self. Basically, stuttering is not a speech disorder but a conflict revolving around self and role, an identity problem. The stutterer typically has no difficulty when alone -- a striking and significant feature of the disorder. He can speak freely then, for communication with other human beings is not demanded. Even when with others, he is a stutterer only when he talks -- an ancient joke that really tells us something important. For stuttering is role-specific behavior. It is specific to the speaker role and to the listener relationship. Just as it takes two to tango, it takes two to stutter. A listener, as well as a speaker, is required.
Compared to the extreme meagerness of Freud's references to stuttering, there is a fairly abundant proliferation of formulation stuttering from followers of Freud. The disciples have not hesitated to rush in where the master seemed reluctant to tread. Nor have they always agreed. Coriat has argued that the stutterer is primarily oral, while Fenichel argued that he is primarily anal, a discrepancy suggesting that these two may have been trying to peer into their subject from opposite ends.
Lest the majestic authority of Freud be invoked too readily to bolster what may actually be a current analytic view, it might be well to recall Freud's own apt disclaimer: "As for me, I am not a Freudian."
Stuttering is not a unitary disorder but a cluster of disorders of varying degrees of complexity and relatedness. Stuttering is a bog one can enter from many different pathways, and from which one may find a variety of exits. Many roads lead to Rome and to and from stuttering.
The handicap of stuttering is traditionally defined in terms of the blockings, repetitions, mouth posturings, and grimaces that the stutterer goes through in trying to utter a word, but it is much more than that.
A stutterer is one who does not know where his next word is coming from. Moreover, he does not know when the next situation will arise in which he will need that word. Even his fluency may give him little more than a feeling of thin ice. The to-be-or-not-to-be, to-speak-or-not -to-speak is always with the stutterer, and from this gnawing, pervasive uncertainty springs the major portion of his handicap.
Stuttering may be likened to an iceberg, with the major portion below the surface. What people see and hear is the smaller portion; far greater, and more dangerous and destructive, is that which lies below the surface, experienced as fear, guilt, and anticipation of shame. For an adult or an adolescent mature enough to tolerate it, public presentation of the self as a stutterer has major therapeutic effects. The portion of the iceberg exposed to the sunlight of public view melts away more quickly.
When the stutterer attempts to deny his stuttering behavior and to represent himself as a fluent speaker (which he is part of the time), he then creates tensions -relating to fear of failure of the role expectation. But by experiencing his stuttering, a stutterer can get over his shame. By getting more of the stuttering behavior above the surface, the total amount of fear and handicap may be reduced.
In terms of its simplest aspects, what we have to account for in stuttering is a momentary blocking. Almost mysteriously the stutterer is stuck on a word, and then, for reasons just as baffling, he is able to continue. An explanation of stuttering must account for these twin features of the stutterer's behavior. Most theories of stuttering have focused on the hesitancy, on what produces the blocking. But from the standpoint of systematic theory as well as therapy, it is just as important to explain termination of the block as the block itself. Two questions then become essential in the explanation of the stutterer's behavior: (1) What makes him stop? (2) What enables him to continue? In response to these twin questions, two central hypotheses may be stated:
The conflict in stuttering is not simply between speaking versus inhibiting expected stuttering. In the double approach-avoidance conflict situation, there is both a conflict between speaking and not speaking and between being silent or not being silent. The avoidance does not come primarily from the fear of stuttering as such but from the competition between the alternative possibilities of speech and silence, with the stuttering a resultant of this conflict.
Speaking holds the promise of communication but the threat of stuttering; silence eliminates temporarily the threat involved in speaking, but at a cost of abandonment of communication and consequent frustration. Many stutterers show a fear of silence, and filibuster furiously in their speech to keep any pause from becoming dangerously long. Since most stuttering occurs initially, silence plus initiation of speech becomes a conditioned cue for the painful experiences of anxiety and stuttering.
The listener, as well as the stutterer, is caught in a conflict. What should he do when the stutterer is struggling? Should he watch the debacle or avert his gaze? Should he help the stutterer with a painfully obvious word or let him flounder? Should he give some friendly recognition to the difficulty, or help the stutterer pretend it isn't there? Knowing little about the disorder, he gets his cue from the stutterer himself. Through the interplay of perceptions, the listener concludes that stuttering must be something shameful and joins the stutterer in pretending that nothing is out of the ordinary. By engaging in a false role, the stutterer draws his listener into an equally false role. In the manifest experience of his conflict between going ahead and holding back, the stutterer inadvertently places the listener in a conflict as well.
Two assertions frequent in the literature are that stuttering is attention-getting behavior (especially as it first appears in childhood), and that stuttering is perpetuated by the sympathy it arouses. Interestingly, neither assertion appears prominently in the writings of those who have gone through the experience of stuttering. Those who stutter report clinically that overprotection is the hardest to bear of all audience reactions, that it is experienced by them as a rejection, and that other forms of rejection are at least as frequent as sympathy. As for the thesis that stuttering is a negative bid for attention, why then doesn't the stutterer display his symptoms more freely and easily? Avoidance is characteristic of even the young child stutterer who develops the slightest awareness.
Stuttering involves a primary loss--a defeat of the ability to communicate. Whatever "gains" accrue to this loss are secondary indeed. With the onset of the problem called stuttering, the primary loss far outweighs anything that may later be rationalized as a secondary gain. An amputee veteran may experience some sympathy (most of it unwelcome) along with a multitude of frustrating social reactions. But does the gain exceed the loss? Would he trade back, given the opportunity? These are the questions that must be asked of the stutterer. Consider how eagerly the stutterer has grasped for every straw of distraction that yielded quick fluency and the temporary illusion of cure. In considering whether secondary gain is a "reinforcer" for stuttering, we must not overlook the primary loss.
Efforts to prevent a consequence can sometimes bring it about. We have used the plank-walking analogy. Anyone can easily walk across a 2-by-4 inch plank placed across the floor. But if it were placed between two tall buildings, or across a chasm, one would be in danger of falling off from the very effort engaged in trying to prevent it. For a stutterer, increased efforts to keep from falling off the fluency plank only increase avoidance behavior, associated conflict, and resultant stuttering.
Every stutterer becomes in time a "walking museum," or perhaps a "talking museum," of those crutches, devices or mannerisms he has employed to conceal his stuttering. The history of the stuttering pattern of any one individual is clustered in what he does each time he stutters. In the adult, unraveling the tangle of false behaviors is a major goal of therapy.
Stuttering is a complex problem whose nature forever tempts people to offer simplistic cures. Even intelligent people who should know better are taken in, or ensnare themselves in the unreasonable belief that a complex problem must have a quick and easy solution. But too much is known of the complexities of the disorder--and for that matter, of human nature--to entertain that hope intelligently. Self-presentation via speech is always going to be difficult for some, depending upon how they feel toward themselves and toward significant others. That kind of problem will and can never be "solved" by a simplistic gimmick--or even a complex gimmick.
The problem of stuttering cannot be adequately defined in terms of disfluency counts or speech interruptions. Stuttering is always the problem of a person. Unless we understand the person, we will not understand the problem. In many cases the frequency of stuttering is a trivial fact with reference to the totality of problems the person has. To understand the person, the stuttering behavior is not the only behavior in which we should be interested.
By far one of the most important statements we can make about the disorder is that the majority of stutterers are able to speak most of their words fluently. Fluency is a fair-weather friend that deserts the stutterer when he needs it most: to say some thing important to some one important. His speech is the tire that appears to be flat on only one side, but the condition means that he can't count on getting there.
All of us resist change, and the stutterer in therapy is no exception. Most stutterers have learned to be wary of efforts to help them, for so many useless suggestions are freely offered by anyone. Although such initial resistance is virtually a part of the presenting problem, the really substantial resistance is likely to come following a certain amount of progress. The stutterer who moves easily at one stage in therapy becomes unaccountably bogged down at another. Apparently, improvement and recovery in themselves involve role changes calling for difficult adjustments. The stutterer may become disappointed in the results of his new partial fluency, due to the loss of protective functions and secondary gains. He finds that he is not a "giant in chains" but an ordinary mortal who has many other limitations which had been obscured by his stuttering along with some of his capabilities. He discovers that there are two ways to be disappointed in life. One way is not to get what you wish for. The other way is to get it.
What a therapist offers a stutterer is much like the teaching a parent offers a child--part of it will be lost, and part may have great impact, but you cannot foresee which part will be which.
One school of clinicians asks the stutterer to accept for purposes of therapy the role of stutterer long enough to study, recognize, monitor, modify, and eventually eliminate the false-role behaviors that comprise the vast bulk of the stutterer's handicap.
The other school, and a much older one, is the. avoidance-cultivation, or distraction, method. It aims to prevent stuttering through active interventions to induce immediate fluency, to "establish" or nurture fluency in a sheltered "laboratory" environment, then to transfer the programmed fluency and to maintain it.
With therapies that aim at the prevention of moments of stuttering, and the stretching of fluency through the cultivation of avoidance of difficult situations, there is never an assurance of a method for meeting future fear and failure. By their very nature, such therapies increase the penalty on stuttering, the avoidance component, and the conflict. That they work for awhile at all is probably due to the novel-stimulus effect, or distraction principle. This means that their half-life is far less than the stutterer's full life.
The cultivation of fluency and suppression of stuttering behavior appeals to the worst in the stutterer: his tendency to deny the problem, to cover up, to conceal. And unless the cover-up is complete--in itself a fantastic and unlikely achievement--the stutterer will be worse off. His avoidance tendencies will have been strengthened.
The therapist needs to be on the side of the id, to accept the fears and failings of the client, not just demand more perfection in performance. The stutterer has already had plenty of that. If it worked, he would not be there for therapy. Aiming for perfect fluency and encouraging denial of the stutterer role is merely a way of ensuring that the behaviors will continue.
Competition in the marketplace of ideas and research findings is decidedly healthy; different ways of looking at the problem may be explored, and alternate hypotheses checked out. When we enter the matter of a competition on cure claims, or reported fluency "established' percentages, however, it is quite another matter. The crassness of the marketplace then enters in. Since commercial fame and publicity is heaped on those who report a new cure or an astoundingly high success percentage) a reinforcing state of affairs is thereby set up for success claims. The higher the better, the more sensational and attention-seeking. Although it is the victims of stuttering who are most frequently charged with attention-seeking, it is the experimentalists reporting spectacular results who are most often guilty of it.
We have come to believe that stuttering is perpetuated by successful avoidance, by the successful suppression of outward stuttering behavior and the substitution of false fluency, or by inner patterns of stuttering.
With some individual variability, stutterers appear to have the capacity to suppress the outward appearance of their stuttering, producing an apparent reduction in frequency. We assume that response suppression is a central continuing cause in maintaining stuttering behavior. This suppression of outward stuttering behavior may temporarily "make the stutterer seem better"; actually, it moves into a retreat position that makes ultimate recovery enormously more difficult.
The suppression of stuttering behavior has given rise in current literature to curves showing how much the stutterer has improved, or how much fluency has been "established." But at the end of this process, the stutterer is farther from a true recovery, not closer.
Though space does not permit us to develop it here, we hypothesize that stuttering becomes fixed or established in childhood when the stutterer learns successful suppression techniques. It is not so much that is a contributing factor--or the successful use of tricks or crutches, though that is enormously important. Rather, the basic step is the learning of a suppressive mechanism.
This formulation is quite different from previous theories to the effect that stuttering results from the unsuccessful attempt to avoid expected stuttering, and it is different from the anticipatory struggle hypothesis of Bloodstein. It is not the struggle, but the successful avoidance of struggle that perpetuates stuttering. How is this possible? Through successful learning of a suppressive mechanism.
The suppressive hypothesis is consonant with and is a new part of the double approach-avoidance conflict theory of stuttering. Avoidance reduction is even more basic as a vehicle of therapy, improvement, and recovery. Openness is a key to success; suppression is a toboggan ride to failure.
We have seen enough relapses of the suppressive therapies to be fairly sure that when response suppression is the basic vehicle of therapy, then relapse is inevitable. The consequences are that the stutterer is even more distant from a final solution to his problem.
sent by Vivian Sisskin and
added with permission of Vivian Sheehan
November 24, 1997