Below the Surface: Treating the Emotional Aspects of Stuttering
About the presenter: Woody Starkweather, Ph.D., CCC-SLP, received his Ph.D. in 1970 from Southern Illinois University. He is the author of over 50 articles and monographs and eight books on stuttering. His most recent book, Stuttering, with Janet Givens, was the first Speech Pathology book ever to make the "Best Academic Books of the Year" list. He was recipient of the National Stuttering Association's "Clinician of the Year" award in 1999. Since retiring from teaching at Temple University, Woody, along with Janet, devote their energies to the Birch Tree Foundation. One of the specific charges in the Birch Tree mission statement is to help stutterers deal with the emotional side of stuttering. Workshops are conducted for stutterers and training workshops are provided for SLP's who want to learn more about this important part of the disorder.
Below the Surface: Treating the Emotional Aspects of Stuttering
by C. Woody Starkweather,
from Pennsylvania, USA,
For most stutterers, the feelings associated with their disorder are an important part of the problem. For some, they are paramount. At the least, these feelings are powerfully disturbing, often painful. As the clinical specialists who deal with stuttering, speech-language pathologists are often taught little or nothing about emotion. Naturally, when a stutterer asks them for help in this area they feel inadequate and insecure. They can, and many do, form a professional relationship with a clinical psychologist and refer their clients to him or her, maintaining close cooperation and sharing of information. Such an arrangement can certainly work, but it is not easy for every SLP to find a psychotherapist willing to enter into it. And, invariably, some continuity of treatment is lost when more than one professional deals with the same individual.
This article will describe the emotions of stuttering and set forth, although sketchily, the elements of treatment strategies that are helpful in dealing with them.
It is commonly accepted, and what evidence there is seems to support the idea, that the earliest behaviors of stuttering begin as a result of some neurological weakness, flaw, or developmental shortcoming. Typically, these early behaviors are simple whole word or whole syllable repetitions in the majority of cases. In a minority of stutterers, the earliest behaviors are vocal blockages. Soon after these behaviors appear, they begin to change in ways that are individually distinct for each child, although a number of common themes have been identified (Bloodstein, 1960). These early changes are: (1) truncation of the repeated element, i.e. from "What, what, what is that?" to "Wha-, wha-, what is that," to "w-, w-, w-, what is that?"; (2) increased tempo of repeated elements, which is probably related to, or identical to, the truncation of repeated elements; (3) rising pitch of the voice during the stuttering, and (4) the appearance of tension, struggle, and avoidance. All of these early changes are most likely a result of reactions, most likely below the level of awareness, that the child is having to the experience of stuttering. Certainly, no other credible explanation of these early changes has been put forth.
The first reaction seems to be frustration. In the psychological literature, frustration is defined as a specific reaction to the experience of being unable to obtain reinforcement for a behavior which was previously reinforced regularly and reliably. The main behavioral characteristic of frustration is increased effort in the performance of the nonreinforced behavior (Amsel and Roussel, 1952). It isn't difficult to map these ideas onto stuttering. The child has been talking for a while and has become accustomed to the rewards of talking: His (or her) needs are met, adults are delighted to hear speech, and perhaps there is pleasure in these very early acts of communication. Then, usually slowly, the repeated elements or blockages begin to delay the child's receiving these rewards. During these delays there is no reinforcement and the necessary and sufficient conditions for frustration are present. The child begins to apply greater effort to the act of speaking. Typically, this greater effort would be in the form of trying to speed up the stuttering behaviors so as to get past them, and this could result in increased subglottal air pressure, increased articulatory pressure, glottal hypervalving, and extraneous body movements, all of which can be categorized as aspects of a frustration reaction to the experience of being delayed in speaking. Increased subglottal air pressure can lead to increased loudness, but if the loudness of the voice is restrained by parental or self-control, as would be natural, a rise in the pitch of the voice during the period of blocking would occur. So most of these early reactions seem to be aspects of frustration.
By putting additional effort into the act of speaking, the child does not succeed in removing or even reducing the stuttering, and in fact it increases the severity of individual blocks. The speech mechanism is too balanced and dynamic for these strategies to do anything but exacerbate stuttering. This of course redoubles the frustration reaction. This is why teaching a person an easier way to stutter relieves frustration.
With this increased form of stuttering, the child may encounter emotional reactions from peers, siblings and parents which may make him (or her) afraid to talk, certainly afraid to stutter. Later on, stutterers may become afraid of ever getting the word out, of not being able to breathe, of embarrassment. These fears will likely lead to two further developments: (1) the discovery of avoidance as a strategy for dealing with the difficulties of speaking, and (2) the tendency for stuttering to begin to occur in some situations more than in others.
The former is a strategy that is readily available to young children. They may simply not talk. Not talking, or acting shy, are very common in young children (Starkweather, Gottwald, and Halfond, 1990), and few parents would be concerned by this change in a preschool child. Other aspects of avoidance, such as large head, arm, or leg movements that can terminate the stuttering behavior, timing behaviors, starting behaviors etc., may also be discovered serendipitously by the child. The discovery of these tricks leads, as we all know, to the incorporation of them into the child's stuttering repertoire, where they lose their effectiveness as avoidance behaviors but retain a presence in the stuttering pattern. But they would not be acquired in the first place were it not for the child's frustration over, and fear of, stuttering.
The latter development, the attachment of stuttering to specific speech situations, is also a result of fear, specifically the apprehension that stuttering will occur. For example, a child who has stuttered when talking to his father, and experienced the frustration of it, and perhaps also a reaction of fear on the father's part, is likely to have an elevated apprehension of the same thing happening again, leading to an increase in muscular tension when in the same or a similar situation. In this way a fear of authority figures, and the occurrence of more frequent and/or more severe stuttering when talking to authority figures becomes established. The same thing is true for other situations. The simple experience of stuttering in a specific speech situation will lead to an increased level of fear when that speech situation re-presents itself, and the motoric act of talking will be made more difficult as a result of the muscular tension that the fear engenders. If the child tries to avoid a feared situation, his fear of the situation will increase. Avoidance always grows fear, as Bandura (1969) has demonstrated so clearly.
So frustration and fear are present during the early stages of stuttering and help to increase the severity of the disorder and to change its behavioral manifestation as the child continues to stutter.
Other emotional reactions can also occur, often later in the developmental sequence. Anger is a common part of frustration. In fact it could be said that frustration is a kind of anger turned in on oneself. So anger too can be one of the early reactions to stuttering. It also develops later on, at least in some stutterers, as a reaction to the real or imagined attitudes of listeners. Sometimes there is anger over stuttering when the person suspects or believes, erroneously of course, that a parent or some other specific person is responsible for the stuttering. The teasing of peers is another common factor in the development of anger. Teasing should always be taken seriously and dealt with effectively by parents and school officials.
As stuttering develops, there is sometimes growing fear, particularly when avoidance is a common strategy. Avoidance builds fear up and confrontation lowers it. The most obvious example of this is the covert stutterer, who has adopted avoidance as a central strategy for dealing with the stuttering. The covert stutterer lives in fear of being discovered, or of "slipping", that is, of stuttering overtly. In my experience, covert stutterers deal with more fear than other stutterers. Yet, one of the known characteristics of avoidance behavior is the decrease in fear that occurs when an avoidance behavior is regularly and reliably successful in avoiding the feared stimulus (Bandura, 1969). In some way, for the covert stutterer, the behaviors of avoidance must be less than regularly and reliably successful. In describing this phenomenon, Bandura is quick to point out that the fear is subdued, but is nevertheless just under the surface, and if there is reason for the person to believe that the avoidance strategy might fail in a given circumstance, the fear surges up rapidly. A good analogy of this concept can be seen in the application of car brakes as we approach a busy intersection. We do not feel afraid because the brakes have always stopped the car in the past. But if, as one applies the brakes while approaching an intersection, the brakes fail, there is a very noticeable surge of fear. I would guess that with covert stutterers, there are frequent times when they feel that they might be close to stuttering overtly, as if the brakes might soon fail. If so, then it is understandable why they remain afraid that they might stutter.
Later in life, many stutterers develop depression about their stuttering. They may grieve over lost opportunities - the many faces of what might have been. Stuttering itself is a loss of function, although partial and intermittent, and consequently can trigger the well known responses of the grief cycle. But exactly because stuttering is partial and intermittent, it can be very difficult for stutterers to get through the grief cycle to the comfort of resignation. They get stuck in the denial of futurizing (e.g., "some day it will just go away") or of minimizing ("it really isn't that bad") or of the purer denial of not wanting to think about stuttering when they are having a more fluent time of it. They may also get stuck in the anger or bargaining stages of the grief cycle, blaming themselves, blaming others, or blaming a mythical neurological or genetic cause, any of which can keep them from doing the necessary work of recovery. Playing the blame game is a sure way to keep the focus away from oneself and without a focus on oneself recovery is usually impossible.
Shame is, as we all know, often a major part of stuttering. Shame is not the same as embarrassment. When a person is embarrassed, he (or she) feels that the has made a mistake and done something wrong. They stop doing it, and the embarrassment quickly fades away. When a person feels shame, he feels as though he himself is a mistake. So shame in stutterers means a feeling of defectiveness. This is a terrible feeling to have. Many stutterers have told me that they don't feel completely human, that they are flawed in a major way and therefore not really members of the human race. Although to a person who does not stutter this may seem like an extreme reaction, I have heard it often enough to realize that it is not very uncommon. Charles Van Riper, Joseph Sheehan, and others have also, of course, written extensively about this feeling.
Rationale for Treating the Emotional Aspects of Stuttering
First and foremost, the emotional aspects of stuttering are worth treating in and of themselves. There is no reason why people who stutter need to suffer from frustration, internalized anger, depression, fear, or shame. The alleviation of these feelings can make a stutterer's life much more comfortable.
Second, many of these feelings lead to tension, additional struggle, and avoidance, which make the behavioral pattern of stuttering more severe, and by reducing them, therapists can make a stutterer's speech freer and more fluent.
Finally, it is clear to me and to many other speech pathologists that the emotional aspects of stuttering typically survive treatment that is directed at behavior alone. Even though the treatment might result in the person not stuttering at all, they are still likely to be afraid of the same situations they were afraid of when they stuttered, to be angry at listeners who look away or are themselves disfluent, to feel ashamed of their own perceived basic defectiveness, and to become depressed at the loss of their childhood because of their stuttering. The temporary fluency that results from purely behavioral treatments does create a euphoria, which may for a while cover over all these old emotional reactions, but in time the euphoria wears off and the old feelings resurface. When they do, they often lead to a recurrence of avoidance behavior, increased muscular and emotional tension, and a resurgence of stuttering behavior. Consequently, treating the emotional aspects of stuttering is one of the ways to prevent relapse.
In my opinion, no current therapy addresses the emotional aspects of stuttering satisfactorily. The fluency shaping therapies typically do not address them at all although a few give lip service to them. The stuttering modification therapies do address fear, and sometimes shame (but only partially), but rarely do authors who write on these topics mention any of the other emotional reactions that characterize the disorder. Of course, a psychotherapist is skilled in this kind of treatment, and when such a therapist listens carefully to what his or her client says about stuttering they can offer very effective treatment, as a number of anecdotes attest. But sadly psychotherapists learn next to nothing in their training about stuttering, and if they do read anything about it in the psychological journals, the information is very likely to be erroneous. So in many cases psychotherapists approach the treatment of stuttering with some false theoretical notion, which can override the information that their clients may be telling them. Although it does happen, successful treatment of stuttering in psychotherapy is probably even less common than it is in speech pathology.
Treating Specific Emotional Reactions
It goes without saying that this forum is too brief to allow anything more than a sketch of how to treat the emotional aspects of stuttering. As with all forms of therapy, hands on supervised practical experience is the best way to learn how to do it, and just reading about it is a poor substitute. What can be expressed here is the kind of activities that help stutterers to diminish the level of emotionality surrounding their disorder. Perhaps this will help clinicians realize that there is nothing mysterious about the process of working on feelings. All that is needed is a little training which can help in getting started. After that, clinicians will, as they always have, learn from their clients.
Frustration
The frustration that characterizes nearly all stuttering episodes is simply the increased effort the stutterer makes to continue talking. But increased effort leads to, or IS, more severe stuttering. Consequently, all clinicians need to do to help reduce a stutterer's frustration is teach the client how to stutter in an easier way, without the same levels of tension and struggle. This is common practice among SLP's and needs no further elaboration.
Fear
Just as fear is increased by avoidance, it is reduced by confrontation. So the treatment for fears related to stuttering involve confronting the feared situation and experiencing their full impact. Often, this treatment strategy is called "feel the fear and do it anyway." Too often, therapists overlook or do not give full importance to the first part of this slogan. It is important that the client let him(her)self feel the fear. There are a number of ways, based on denial processes, i.e., cognitive manipulation, that people can use to make themselves numb to fear. If a client employs one of these cognitive strategies and then enters a feared situation, he will not get the full benefit of the confrontation. So, therapists need to help the client, through support and reassurance, to be fully aware that they are afraid, before they help them confront a feared situation. With the fear fully experienced, the confrontation will be maximally effective in reducing it. It is sometimes difficult to get clients started on this path. They are, after all, afraid. But with support, most can get started, and once started the process is highly self-reinforcing, and fears are reduced substantially and quickly.
As clients become less afraid, the first change the clinician sees is a reduction in muscular tension, which typically manifests itself as a reduction in the severity of stuttering. There may also be a reduction in frequency as some of the milder episodes do not show enough muscular tension to be seen as obvious stuttering behaviors.
A valuable aid to working on fear reduction is the hierarchy of feared speech situations. It is almost always better to begin working on fear reduction in situations that are somewhat less fear-producing. Sometimes, one can begin a little farther up the hierarchy, but usually the most fear-provoking situations will not be amenable to change until the easier ones have been modified. The hierarchy is thus a powerful aid to reducing fear.
There are occasional clients whose stuttering manifests itself almost entirely as fear. They may not be entirely covert, but fear is their primary presenting problem. For these clients, working up the hierarchy to confront first the easiest and finally the most difficult of the situations is the main form of treatment, and it is highly effective.
Anger
Like fear, anger dissipates when felt, but there is the additional assistance of action. Anger can be more fully felt when it is expressed, either verbally or physically. Most of us have experienced this phenomenon. We feel anger, but when we actually yell at someone, the anger surges up. Then, it softens and dissipates. Clinicians can help stutterers discharge anger by creating an emotional and physical space where it is safe to do so. This means first that the client needs to feel trust and acceptance. They need to know that the clinician will not judge them for being angry. Then the clinician can help them express their anger by yelling, name calling, even screaming. It is also helpful to have the client hit something soft and yielding but not breakable. There are specific pieces of equipment for doing this work. Some clients need to learn also that they can discharge anger in relatively small quantities. For some people the experience of letting themselves get angry is frightening. They may feel out of control and afraid that they will hurt someone if they allow such a powerful feeling to be expressed. Clinicians can be very helpful with these clients in helping them see that they can discharge a small amount of anger, then a little more, then some more later. It doesn't have to be a cataclysmic eruption of feeling or a complete loss of control.
Nevertheless, it is the power of anger, and the possibility of losing control that create difficulties for the clinician. As the anger builds, clients occasionally try to hit nearby objects, the wall perhaps, even though they have been directed to hit something safer. In other words, they may lose some control and in the process hurt themselves or something valuable. As soon as any change in the client's behavior occurs that suggests this possibility, the clinician needs to stop them and redirect their anger at the preferred object. Anger is always on the edge of control, and clinicians need to protect the clients, and occasionally themselves, from this energy. Professional training is really necessary in learning how to help clients with anger.
Depression
We have all felt what Judith Viorst calls "necessary losses." We have something - a relationship or an ability - and something happens that takes it away. At first we deny that it could have happened to us, then we are angry, then we begin to blame and bargain with God or some other force. Finally, we are sad and accept the reality of the loss. After we have felt sad in this accepting way, the need to grieve the loss dies away. This pattern, described as the "grief cycle" by Elizabeth Kubler-Ross (1969), has been seen to occur in many types of losses. In some cases, and I believe very often with stuttering, a person becomes stuck in one of these stages and is unable to reach the peaceful conclusion. In these cases, clinicians who are familiar with the cycle can help their clients go through the stages and find relief.
It may be that stuttering, because it is only a partial loss, because it tends to diminish with maturity, and because it occurs only intermittently, may not be so easy to accept as a loss of function. Certainly, I have known many stutterers who were stuck in the denial, blame, bargaining, or anger phases of this cycle. Sometimes, therapeutic interventions that reach for simple fluency make it harder, through their rhetoric, for the person to see stuttering as a loss of function. Of course, it need not be a permanent loss. Effective therapeutic interventions can improve or remove stuttering so that relapse does not occur. Such a hope often makes it hard for clients to see stuttering as a loss of function. I like to help them see that it is a loss of function right now. At a later date, some or all of the loss can be recovered, but it is nevertheless important to be able to grieve for what is missing at the moment. It is like being a prisoner who wants to escape. Prisoners who do not recognize and accept that they are genuinely not free will not find the inclination to escape. But if a prisoner fully accepts that he has lost his freedom, he will then be in an emotional position to use his intelligence and skill to devise a method of escape. Probably the best example of this in stuttering is those clients - and I have seen this more than once - who do not want to go to a therapist because to do so will make it patently clear to them that they have a problem. Marty Jezer in his book Stuttering: A Life Bound Up in Words, (Jezer, 1997) describes this process quite precisely. In such a situation the person is stuck in the denial phase of the grief cycle and will not be able to progress in their recovery past that point until they come to see the problem for what it is, an intermittent, partial, and probably temporary loss of fluency.
Another loss that stutterers often have to grieve for is the lost childhood. Childhood should be a time of spontaneity, delight, and developing social skill. For all too many stuttering children, spontaneity is replaced by fear and intimidation, delight by dread and shame, and the development of social skill, by withdrawal and isolation. Later, when they look back as adults on such a childhood they feel a poignant sense of loss. Clinicians can help them grieve for this loss by creating an atmosphere in which they feel free to express their sadness by crying and other overt expressions of grief. In our work at the Birch Tree Foundation, Janet Givens and I have helped many stutterers feel this sadness, mourn the losses of childhood, and move on to the freedom of adult experience.
Shame
Because shame is a feeling of being less than others, recovery from shame takes place most effectively in the context of a group. Nothing could be more healing of the shame that stuttering produces than participation in a supportive group of other stutterers. Consequently, I always recommend that my clients who tell me about their feelings of shame participate in the National Stuttering Association, at whose meetings, local or national, shame over stuttering is reduced or absent. Many of those who attend these meetings come away with the feeling that their burden of shame has been lifted, at least for a while. And with repeated attendance at these meetings, many stutterers report that they begin not to feel ashamed, that they can see themselves as fully human, even though they have the particular difficulty called stuttering. It is not necessary to feel defective if you stutter. This is exactly what I read into the NSA's slogan, "if you stutter, you're not alone."
In addition to group meetings, clinicians can do much to reduce a stutterer's shame by simply listening to them in a fully humane way, accepting them as they are, and in this way helping them learn how to accept themselves, including their stuttering at the moment. There is no need to give up the idea of recovery in this acceptance. Indeed, in my experience, acceptance of oneself as a stutterer and as a complete person who stutters is a useful, probably a necessary, precursor to recovery from stuttering. When stutterers find it hard to accept themselves as fully human even though they stutter at this moment, I have found it helpful to employ the strategy known as "acting as if," or more colloquially "fake it 'til you make it." By acting as if they accept themselves as unashamed, full human beings, even though they stutter, clients can begin to get an appreciation of what it would feel like if they really did, indeed, feel this way. Once they see how comfortable this idea is, it becomes easier for the more genuine feeling to become part of their everyday self-concept.
Training Speech Language Pathologists to Deal with the Emotional Aspects of Stuttering
Training people to deal with the emotional aspects of stuttering is, as one might expect, a difficult proposition. The curriculum is already so crowded that most programs find it extremely difficult, if not impossible, to produce well-trained master's level students in two years. Many programs have adopted alternative methods of increasing training time so that students will be well prepared and aware of the extensive literature that comprises our field these days. At some point in the future, we will surely have to go to longer periods of training. In this atmosphere the idea of including a component that involves training in such a complex area as clinical psychology, even at the most superficial level, is essentially unthinkable. And, none of us wants that training to be superficial anyway.
What we can do is open students' eyes to the world of feelings and emotions that play such a central role in the lives of all human beings. This awareness does much to counter the prevailing medical model of education that most programs still follow, where the clinician is the "professional," the person with the special information and skills, and the client is the essentially passive recipient of the treatment based on that knowledge. It is ironic that this model is still prevalent in our field even though the field of medicine on which it is based has gone quite far in replacing it with models of treatment in which the patients play an important interactive and responsible role in their own treatment.
Probably the best way to open students' eyes to these possibilities is to help them see the importance of feelings in their own lives. Consequently, it was my practice when I was teaching at Temple University to begin each graduate course in stuttering with a number of sessions in which the students told a five-minute story of what it was like for them growing up. Within the first half hour of this exercise, the class would begin to become a more cohesive, supportive group, and the individual stories would become authentic and powerful. After two classes of this exercise, all students were fully aware of how their feelings impact on their relationships with others and with themselves. An additional benefit was that the students formed a much more cohesive bond with each other, much to the consternation at times of some of the other faculty members. In addition, a few other small exercises performed during the supervision sessions before clinical practicum were also helpful in teaching students how to look below the surface. Needless to say, students' performance in all areas of speech pathology, not just in stuttering, was enhanced. Many students have told me how the stuttering course helped them see speech pathology in an entirely different light and made the practice of this profession a continually fulfilling activity.
I have tried, in this brief article, to argue that SLP's need to take more seriously the emotional side of stuttering. I believe that they need more training in this area, and since it cannot be expected that the training programs will add such a large piece to the already overburdened curriculum, I have suggested that SLP's should seek this information and skill on their own. I have tried also to set forth, in the barest possible terms, what the emotional side of stuttering is, how it should be treated, and how SLP's can be, at least, introduced to it. I hope that this information is helpful to stutterers and to those who treat them.
References
Amsel, A., and Roussel, J. (1952). Motivational properties of frustration: I.. Effect on a running response of the addition of frustration to the motivational complex. Journal of Experimental Psychology, 43, 363-68.
Bandura, A. (1969). Principles of Behavior Modification. New York: Holt, Rinehart, and Winston, Inc.
Bloodstein, O. (1960). The development of stuttering: I.: Changes in nine basic features. Journal of Speech and Hearing Disorders, 25, 219-37.
Jezer, M. (1997). Stuttering: A Life Bound up in Words. New York: Basic Books.
Kubler-Ross, E. (1969). On Death and Dying. New York: Macmillan.
Starkweather, C., Gottwald, S., and Halfond, M. (1990). Stuttering Prevention: A Clinical Method. Englewood Cliffs, NJ: Prentice-Hall.
September 20, 2001
