"One Size Fits All (or: When the Only Tool You Have Is a Hammer...)"
About the presenter: Bob Quesal is a professor at Western Illinois University, where he serves as program director. He teaches courses in fluency disorders, anatomy, and speech and hearing science. He has presented papers at regional, national, and international meetings. He has served as newsletter editor for ASHA's Special Interest Division 4 - Fluency & Fluency Disorders, since 1997. He has been listowner of the STUT-HLP listserv since June of 1993.
"One size fits all (or: When the only tool you have is a hammer...)"
by Bob Quesal
from Ilinois USA
As I undertake writing this essay, I am not sure exactly what insights I will impart to the reader. In fact, this essay may be a selfish exercise on my part—an attempt to vent some frustration, perhaps. Or perhaps an exercise in self-exploration. Or perhaps a chance for me to try to organize my thoughts about some issues that have concerned me for quite some time. I believe that I am guilty of much of what I will talk about in this essay. I suppose I could pretend that I am the only totally objective person around, but I know that isn't true. So as I make my points, please realize that I am pointing a finger as much at myself as I am at any other individual(s).
The idea for this essay arose as I visited the various papers during the 1998 International Stuttering Awareness Day Internet Conference. At that time, many people visited the various papers and had left comments to the authors. Some of the comments (from a relatively small number of individuals) suggested, at least to me, that the writers were trying to force their views on a variety of perspectives—it seemed to be difficult for them to view stuttering in any broader context than their experience. Based on that, the original title for this essay was going to be "When the only tool you have is a hammer, everything looks like a nail." That's an old saying, probably a trite one. But that's what often comes to my mind when I read or hear what certain other people have to say about the disorder of stuttering. This essay will be a plea, of sorts, for us to all open our minds a bit more about stuttering.
Do you believe that all people who stutter are the same? Or, more specifically, do you believe that all people stutter for the same reason? I'd wager that most people would answer "no" to both of those questions. In fact, nearly any question that we would ask about stuttering: "Is there one best therapy for all people who stutter?" "Do all people who stutter have the same types of disfluencies?" "Are all stutterers' personal histories similar?" etc., would be answered "no" (at least by most people who have some knowledge of stuttering). It seems that there is considerable diversity among those of us who stutter, and those of us who study the disorder. This diversity should hold a lot of importance for our understanding of stuttering. It seems, however, that a lot of people want to disregard the diversity and focus on the commonalities of stuttering.
Looking for commonalities is not a bad thing. Certainly, any characteristic(s) that we can find that is common to any group helps point us in the right directions. My concern is when traits or attributes that are assumed to be commonalities are forced on those for whom they are not true. It is these overgeneralizations that I will address during the rest of this essay. My list of overgeneralizations is not meant to be exhaustive, but represents some of the statements I have read or heard from others. I will use some of my experiences and observations to expand upon some of the statements.
Let me say, in advance, that my intent here is not to disparage others or to diminish what they have to say. My views, like those of anyone else, contain a certain degree of bias and are subject to criticism. I hope, however, that they will provide some food for thought.
- Stuttering is a genetic disorder.
Many researchers have spent their lives looking for a genetic component to stuttering. There is no question that stuttering tends to run in families. Many people who stutter have a number of relatives who stutter. However, many other people who stutter have no relatives who stutter.
If stuttering is a genetic disorder, the pattern of transmission is not a simple one. A "faulty gene pool" explanation of stuttering may be a more accurate one. In my family, for example, I am the only person who stutters. I have many male relatives, however, who have "differences" ranging from ambidexterity to auditory processing difficulties and learning disabilities. My "faulty" genes manifested themselves as stuttering—in other cases, the faulty genes led to other.
Stuttering is not solely a genetic disorder, although many people who stutter may have a genetic component to their stuttering. I think it is safe to say, however (although others may disagree), that many people who stutter have no genetic factors that contribute to their stuttering. - Stutterers have faulty speech motor systems.
Other researchers (e.g., Caruso, Max, & McClowry, 1999) have spent their lives looking for a motor component to stuttering. Certainly, if one simply watches many stutterers "in action" the most obvious factor tends to be effort and struggle. Getting our speech structures moving and/or keeping them moving smoothly is a major part of the effort that we experience.
Motor skills manifest themselves in areas other than speech, of course. Handwriting, athletic skills, coordination, even dancing ability are "markers" of motor competence. If one uses those four factors to determine whether I am a "motor" stutterer or not, there is no question that I would fall under the "motor" heading. My handwriting is illegible, my athletic skills extend to being a superior channel surfer, I'm not very coordinated, and I won't even attempt to dance unless I've had a considerable amount of alcohol.
Yet, I've known many stutterers who had beautiful handwriting. Bob Love and Bo Jackson are just two examples of athletically gifted stutterers. Many of my friends who stutter are good dancers. So, once again, it would seem that not all stutterers have faulty motor systems.
In general, stutterers as a group tend to perform more poorly and more variably on various measures of speech and nonspeech motor performance. However, in nearly all of these "motor" studies, some of the stutterers perform better than their nonstuttering counterparts, and nonstutterers frequently perform more poorly than stutterers. Like genetics, if there is a motor component to stuttering, it is not a simple one. - There is only one cause of stuttering.
This may be true, but evidence continues to suggest that there are "subgroups" of stutterers. That is, the behavior that we see is similar (disfluency), but the reasons underlying the disfluency differ. This has been expressed as an analogy with the "cause" of sneezing—the overt behavior may be due to a cold, allergies, or some other irritant. We see the behavior, but cannot easily determine the underlying cause.
When we examine the ways in which people stutter, I feel it gives us some evidence of the subgroup notion. For example, some stutterers repeat parts of words. Others "block," tightening up their muscles and stopping movement. Others seem to have problems at the level of the larynx—starting voicing or keeping it going. Others seem quite fluent, but express considerable concern, perhaps fear, about their ability to speak fluently.
Eugene Cooper (1999) has said "Sixty years of research lead many of us to conclude that chronic stuttering results from the interactions of multiple coexisting physiological, psychological, and environmental factors." He goes on to say that there are "many interactions of affective, behavioral, and cognitive factors that result in a stuttering syndrome." (p. 10) My observations lead me to agree wholeheartedly with Cooper. - If you are not highly disfluent, you are not really a "stutterer."
Because I am a fairly fluent stutterer, one who "manages" my speech fairly well, some have suggested that I'm not really a stutterer, or that I can't understand what it's like to stutter severely. Many of my nonstuttering colleagues (who, in my opinion, really do understand the disorder and really care about people who stutter and their families) have been basically told that they will never understand what it's like to stutter.
I think these arguments have some merit, but not when carried to an extreme. I would wager that I have had a number of "episodes" in my life where I have been as disfluent, frustrated, annoyed, ashamed—you name it—as any other stutterer. I've been fortunate, I suppose, that these have not happened frequently, and as I've gotten older they've become less and less frequent. But I've had my share of "stuttering moments." Most other "fluent stutterers" have, too. My colleagues who do not stutter have not had the same types of experiences, but they have made it a point to talk to people who stutter and to gain insight from those interactions. They probably have had course work in counseling. They may be able to relate to stuttering because they have been through other painful life experiences. What my nonstuttering colleague who understand stuttering do have in common are good listening skills, natural empathy, and a strong desire to help others (that is not ego-driven).
What's most frustrating to me, I guess, is that this type of thinking tends to make us fight against each other when we should be working together. "Us against them" is always better than "us against us." - People who stutter are ashamed of their stuttering.
Stuttering can be shameful, no doubt about it. Bill Murphy (1999) writes eloquently about shame and guilt in stuttering. I don't think Bill is wrong—many stutterers have significant shame and guilt about their stuttering. But many other people, who by (at least) all observational measures would be considered to be "stutterers" seem unconcerned and unaffected by their stuttering. We've met many of these folks. At a party or some other setting, you start to talk to someone who is quite disfluent, who seems to be struggling with his speech, and you mention either speech therapy or a group like the National Stuttering Association (formerly the National Stuttering Project), and he tells you that he had therapy but is quite happy with the way he manages his speech. As you talk more, you find that he truly does seem to be content with his speech and his life. This person may stutter, but shame does not seem to be a part of his stuttering problem. Other individuals may have been ashamed of their stuttering at one time in their life, but have now come to grips with the problem so that they no longer feel shame.
I'm not trying to suggest that there are a large number of people who would fit into this category. Many of those people who are disfluent and seem unaffected by it may not be "stutterers" in the way we think about it—they are simply highly disfluent nonstutterers. Others, I suppose, may be in denial. But there are a number of stutterers for whom shame and embarrassment do not enter the equation. - This is what I do—if you do it, you can be fluent.
Or: This speech therapy approach is the best.
Oh, baby, let's see: hypnosis, electronic devices, costal diaphragmatic breathing, "not thinking about it," yoga, talking slower, talking faster, easy onsets, full breaths, drugs (legal and illegal), traumatic experiences, brain circuit reorganization, changes in thinking, correspondence therapy, etc., etc., etc.
Everything seems to work for some people who stutter. Nothing (so far) seems to work for everybody. To suggest a strategy is fine—we can all learn a lot from each other. But to imply (or express) that those who have not adopted our "pet" technique or strategy are somehow in denial, don't want to get better, have been co-opted by some "stuttering establishment" is pretty insulting.
The ones I find really amusing are those who believe themselves to be the iconoclasts. "My technique has to be good because it is not embraced by the 'stuttering establishment' which has a vested interest in the status quo." "My technique has to be good because it is so different from any other currently available treatments." When you ask these folks for some simple evidence to prove that their treatment is effective they either respond with testimonials from satisfied clients/customers, or they suggest that data collection is something Ph.D.'s should do. "I'm too busy helping people to collect data."
I believe that different people are helped by different therapies. People should try different things. When they find something that works, that's great. But what works for them is not necessarily going to work for everybody. And (in spite of the title of this paper), one size does not fit all. - Speech-Language Pathologists (SLPs) are not trained to work with clients who stutter. All speech therapy is bad. If you want to be helped, go elsewhere.
Once more, we are dealing in generalities that fail to capture the essence of the true state of affairs. It is true that a person can earn a Master's degree in Speech-Language Pathology without ever having worked with a stuttering client. It is also possible (but extremely unlikely) that a person can earn a Master's degree without taking a class in stuttering.
The vast majority of SLPs, however, have had coursework in stuttering. Most SLPs have probably had at least two courses in stuttering, in which they learned about theories, characteristics of people who stutter, and information about assessment and intervention for stuttering. Even if someone hasn't had a class in stuttering (or maybe didn't have a good class in stuttering), there is a lot in the speech-language pathology curriculum that one can use to work with stutterers. A typical SLP should know about speech physiology, counseling, voice science and other things that could prove useful in working with stutterers.
Not all SLPs realize that they can use that information. Many professionals may say, "I never had a good class in stuttering" or "I never had a stuttering client," as a way to rationalize their dislike of working with people who stutter, or their discomfort in providing therapy. It is best to avoid these individuals. We can be "savvy consumers," however (Quesal, Yaruss, & McClure, 1999). We ask questions about the qualifications of the person who puts a new roof on our house. We ask about the features of a car we want to buy. We need to learn to do the same with potential SLPs, to determine if they will provide the kind of treatment we want and need. There are many, many caring hard-working, competent, well-trained SLPs out there to help people who stutter. If someone has had a bad experience, that experience doesn't apply to all therapies or all SLPs. - This works for my other clients. You must be doing something wrong.
I am very troubled by the suggestion that the reason some people are unable to overcome their stuttering is because they don't work hard enough. This implication usually comes from two primary sources. One is SLPs who do not themselves stutter. Some (and I emphasize the word some) SLPs seem to have the attitude that any failure of their therapy results from some weakness on the part of the client. These nonstuttering individuals cannot fathom why a person cannot be fluent—after all, it is so easy for the nonstutterer. It reminds me of my high school math teachers who couldn't understand why the math concepts that they taught (and that came so easily to them) were difficult for someone like me to understand.
The second source of the "you're not trying hard enough" perspective is the person who stutters who has been helped by a particular therapy. Because this person has had success, they believe that success is attainable by all stutterers. "I did (fill in the blank) and now I am fluent. You just need to do the same thing." Nothing is worse, in my opinion, than the "recovered" stutterer who lords his fluency over those who have not been able to achieve fluency. - Because I have had therapy, I am an expert on stuttering treatment.
This ties in with many of the points I have made above. It is not uncommon to find a person who has had a few (or perhaps just one) therapy experiences come across as an expert on stuttering treatment and those who provide it. Based on their experiences, these people may have been encouraged to do a little bit of reading about stuttering therapy, and they combine their experiences and "research" into self-proclaimed "expert" status. Generally, what these people have to say is not wrong—it is simply incomplete. Because their experience is limited, their perspective is limited. They fail to see the "big picture" of stuttering treatment, how it has evolved, how many treatments are similar at certain basic levels, what factors may make therapy successful for one individual and not successful for another, etc. We should all beware of the "expert" who possesses limited knowledge. - People who stutter should be bothered by media portrayals of stuttering.
I was unsure about including this point, because I'll probably take some heat for it, but I felt it was important to include. Stated simply, it is too easy to demonize Porky Pig or the media for the problems that stutterers may experience. My question always is: In what ways does the media portray anyone accurately? About 20 years ago, I worked in a nursing home and one morning when I went to work, a lot of the staff members were talking about a show that had been on TV the previous night. In that show, a character had "gone undercover" in a nursing home to expose the many abuses that took place there. My colleagues were upset that the show would cause people to have negative attitudes about nursing homes, or to make their existing attitudes worse. One administrator seemed to feel that the show would have considerable impact on her nursing home. Just today, I read an article in which someone said that the movie "The Blair Witch Project" was unfair to witches because it portrayed them inaccurately and fostered stereotypes. My feeling is that anyone whose reality comes from the media probably is not going to be swayed by the real world very much.
If we are going to spend our time worrying about the media and stuttering, I think it would be healthy to examine how all people are portrayed in the media. Other cartoon characters have speech problems—not just Porky Pig. Other disabilities are used as plot device in many movies and TV shows. The ways in which these disabilities are portrayed are almost universally inaccurate—things are overstated, played for laughs, "poetic license" is taken, etc. Certainly, the media has some responsibility to be fair and attempt to be accurate (but a discussion of whether they assume that responsibility is way beyond this essay). But the important thing to remember is: it's just make-believe. (Maybe that's why I don't cry at movies.) - I speak for all people who stutter.
I guess I can be accused of this one, based on what I've written above. Basically, however, we all speak for ourselves, and usually no one else. Those who believe that they somehow represent a larger "stuttering community" are probably deceiving themselves. Certainly, we have a number of "leaders" in stuttering—officers in support organizations, leaders of groups that fund stuttering research and information, officers of professional organizations. But anything that anyone says has to at least be colored by some extent by his or her biases.
So, let's all speak up for ourselves and let others speak for themselves. Let's celebrate the things we have in common, but respect our differences.. International Stuttering Awareness Day is a great time to do that!
References
Caruso, A.J., Max, L., & McClowry, M.T. (1999). Perspectives on stuttering as a motor speech disorder. In: Caruso, A.J. & Strand, E.A. (Eds.) Clinical Management of Motor Speech Disorders in Children. New York: Thieme.
Cooper, E.B. (1999). Speaking Out - Is Stuttering a Speech Disorder? Asha, 41, 2, p. 10.
Murphy, B. (1999). A preliminary look at shame, guilt, and stuttering. In: Ratner, N.B. & Healey, E.C. (Eds.) Stuttering Research and Practice: Bridging the Gap. Mahwah, NJ: Lawrence Erlbaum Associates.
Quesal, R.W., Yaruss, J.S., & McClure, J. (1999, Jun.) What NSP members can teach speech-language pathologists about stuttering therapy. Workshop at the Annual Convention of the National Stuttering Project, Seattle, WA.
August 28, 1999
