(This foreword to THE STUTTERER'S SURVIVAL GUIDE by Nicholas
Tunbridge was written by 

Megan Neilson, PhD
Director of the Stuttering Treatment Program
CRUfAD, University of New South Wales at St Vincent's Hospital

It eloquently reflects her belief (and the belief of many others) that
the cause of stuttering is physiologically-based. It has been included
here with her permission. For those who are interested, information
about ordering the book, THE STUTTERER'S SURVIVAL GUIDE
is available in the Bookstore folder in the gopher. - JAK)

FOREWORD to The Stutterer's Survival Guide We know a lot about stuttering. In childhood it affects five people in every one hundred. We aren't sure of the exact rate of stuttering among adults but one in two hundred is probably a conservative estimate. Three times as many boys stutter than do girls, and this disproportion increases with age. This means that among adults who stutter we find many more men than women. While most studies of stuttering have been based in western countries, we know that the characteristic repetitions, prolongations and blocking of sounds have been observed to impede the smooth flow of speech in speakers right throughout the world. Wherever it has been sought, stuttering has been found in every language and among members of every race. It knows no societal or characterological barriers. It exists among the rich and the poor, the educated and the naive, the sophisticated and the primitive. Likewise it is found among the bold and the timid, the placid and the anxious, the gregarious and the retiring. Stuttering is not an emotional disorder. People who stutter, and for that matter their parents, have no greater tendency to be anxious or neurotic than the rest of the population. While psychological factors can influence the course of the disorder, the basic problem is a physical one. People who stutter do so because the complex part of the brain that controls the muscles we use to speak does not work as efficiently as it should in all circumstances. It's well known that stuttering runs in families and it was often suggested that the disorder was "learned" or environmentally generated. We now know that the disorder is largely inherited, with genetic factors more than twice as influential as environmental ones. Having a stutter is a bit like driving on ice when you're inexperienced. You know where you want to go and you try to make the car go there but it's easy to skid into disaster. Even if you do manage to stay on your chosen path, control is tenuous and you never quite know when you'll lose it. The more demanding the situation, the harder it is to maintain the control you have. So, if it's slippery and you're worrying about the appointment you're going to, or your passenger is being argumentative, or you're tired and cold, you're much more vulnerable to accident than in easier circumstances. It is the same for stuttering. Your brain doesn't have good, reliable control over the complex co-ordinated muscular movements that produce speech. When things are going comfortably, when you're at ease with your listener and saying something simple and straightforward, you're much more likely to be fluent than if you're talking on a difficult topic to an unfamiliar audience or when you're asking the boss for a raise. These demanding situations divert "brain power" away from your speech control and your fluency breaks down. Most people who stutter first do so in early childhood. For some the problem goes away during the natural course of maturation of the nervous system. Often the disfluency comes at a time when language acquisition or communication demands are outstripping the development of adequate speech control. When this catches up, the stuttering resolves. But for others this doesn't happen, or it happens too late. The longer the stutter persists, the less likely it is to remit naturally, and those still stuttering beyond puberty face a lifetime of chronic disfluency unless treatment intervenes. These days we don't wait to see which path a child's stuttering will take. If you are concerned that your child is abnormally disfluent, especially if there is a family history of stuttering, you should seek a professional assessment immediately, even if the child is only pre-school age. Early treatment is important as it allows changes to be made at a time when the nervous system is most flexible. If you're reading this as someone who has reached adulthood with a stutter, you may feel that you've missed the boat. This is definitely not the case because excellent adult treatment is available. Granted, it's much harder work than in childhood, a little like "teaching an old dog new tricks" but, unlike in the proverb, it *can* be done. Even a long lifetime of stuttering is no bar to gaining reliably fluent speech if you are willing to work hard at your therapy and to carry that commitment on into your everyday life. The strategy of maintaining your hard won fluency after treatment is what this valuable little book is all about. If you've already been through treatment you'll be keen to move on to that message. If you haven't, you'll want to know what treatment entails. There's no magic in treatment. You can't go along to a therapist, be given the secret of fluency and leave cured. And it's not like having a pacemaker put in or a gallstone taken out, where the surgeon does something clever and you walk away with the problem solved. While we're now sure we're dealing with a physical problem, it isn't one for which there is a satisfactory physical treatment. In rare circumstances there are people whose stuttering is associated with another problem, like a head injury, and here surgery or medication may have a role, but in general this isn't the case. We know there are physical interventions which have given some people who stutter temporary improvement in fluency, and these include certain powerful drugs, muscle relaxants and various electronic devices which alter the way the speaker hears himself. Unfortunately these tend to be fraught with unacceptable side effects or inconvenience, and nothing along this line has yet proved effective as a long term treatment. When you undertake good treatment for stuttering you have to be active, not passive. You have to put the treatment into practice yourself, getting your brain to do things it finds hard. It isn't something that someone or something does to you. It is this sort of treatment that this book presumes you've tackled. Good treatment means first learning a skill. Referring back to the analogy of driving on ice, good treatment teaches you how to become a reliable driver despite the unfavourable conditions. The exact technique that you learn varies with the treatment program that you enter, but skill in dealing with your inefficient speech control system is the important first step. Whatever technique you learn, it's also important that it's one which allows good, natural sounding speech when you've mastered it. Singing is usually a quick way to produce fluency but it isn't any use as a treatment unless you want to go around sounding like a Gilbert and Sullivan operetta. If you don't like the way you sound after therapy you're unlikely to get any lasting benefit. Initially you learn your new skills in the safe environment of a clinic. In terms of our analogy it's like learning to drive on a simulator. Then gradually you move what you have learned into the real world, without much traffic at first, slowly building up to greater challenges. Skill isn't the only component of good treatment. You also have to convince yourself that the skill will see you through even the most formidable situations. It's no use being the racing driver who can get around the empty track better than everyone else if you can't win the actual race. So it's also important for treatment to help you deal with things that hold you back in proving yourself. Such comprehensive treatment is known as cognitive-behavioural therapy and its effectiveness in stuttering is well established. Of course to undertake this sort of treatment, which is often offered intensively, you have to be prepared to invest real time and effort, which means you have to be really highly motivated to make a change in your fluency. And, more than that, you have to stay motivated if you want a good long term result. If you don't use the skills you've learned, you'll lose them. You can't keep them packed up in a carrybag like a Superman suit that you can jump into when danger looms. People have done that, only to find that the suit gets progressively moth-eaten until it's no good at all. You also can't afford to start avoiding old difficulties because they'll quickly resume their former status. You have to have the courage and conviction to take what you have learned in treatment and use it consistently in your everyday life. You can have the best therapist in the world, just as you can have the best coach, the best maestro, the best guide, but in the end it's you who has to win the game, play the concerto, climb the mountain. Similarly, with gaining and keeping reliable fluency, it's you who does the talking. And, more than that, it's you and only you who takes the ultimate responsibility for success, along with the credit that accompanies it. This book tells you how one very successful person has tackled that responsibility. It tells you about the process of becoming your own therapist, the ultimate goal of good treatment. Nick Tunbridge practices what he preaches. I can assure you that, if you were to meet Nick today and didn't know his story, you'd be unlikely to notice anything at all unusual about the way he talks, other than that he's a fine speaker who communicates exceptionally well. As you'll learn from the pages of this book, this mastery is hard won but the important message is - it is most definitely winnable.