What Does Transactional Analysis Tell Us About Therapy for Stuttering?
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About the presenter: William S. Rosenthal, Ph.D. Professor Emeritus from the Department of Communicative Sciences and Disorders at Cal State East Bay, is "mostly retired from the University." He has a Ph.D. in Speech and Hearing Sciences and Psychology and is a member of the American Psychological Association, Division 29, Psychotherapy, and a member of the International Transactional Analysis Association. He has taught a graduate-level seminar in Counseling and Psychotherapy for Speech-Language Pathologists, as well as courses in fluency disorders. |
What Does Transactional Analysis Tell Us About Therapy for Stuttering?
by William Rosenthal
from California, USA
The exact mechanism of fluency breakdown in stuttering is not fully understood. Stuttering typically begins in early childhood and the pattern of disfluency among different children shows little variability. However, when stuttering persists into adolescence and adulthood, the patterns of disfluency become individualized, elaborated and often bizarre. The variability of patterns seen in adult stuttering reflects each individual's struggle against social, emotional, and linguistic stresses that are associated with fluency failure that began in childhood. Transactional analysis does not tell us about the cause of stuttering. The investigation of genetics, chromosome mapping, and brain function studies will most likely provide answers to that core question. Transactional analysis informs us, however, about the obstacles to treatment success that are associated with the individual's struggle against the social and emotional aspects of stuttering.
For example, when a young child first encounters fluency breakdown, he/she does not possess the necessary analytical and logical thought processes to accommodate or adjust effectively to the problem. Ineffective childhood strategies follow instead, including avoidance, struggle and denial. These strategies are carried into adolescence and adulthood. The adolescent and adult who stutters are capable of exerting more thoughtful and intentional control over episodes of fluency breakdown, but only if the appropriate mental capacities are energized. A complete model of stuttering therapy, therefore, becomes a combination of mechanical manipulation of speech and supportive counseling or psychotherapy that attends to the emotional component. Elsewhere, we have shown in a research project that both of these components are associated with treatment success (Rosenthal, Austermann Hula, and Rud, 2006).
Another part of the stuttering picture involves parents' reactions to their first encounter with their child's stuttering. Typical and normal responses include surprise, anxiety, concern, and helplessness. None of these are particularly good coping strategies for either parents or their children. Again, counseling and psychotherapy should be an available option to help parents shape effective responses.
Children carry these early attempts to cope, along with their parents' reactions, into adolescence and adulthood. By that time, however, well formed personality characteristics have an impact on success or lack of success with the treatment experience. Feelings, attitudes, and personality characteristics often adversely influence the treatment of stuttering. These influences may take the form of inadequate motivation, resistance to therapeutic change, and relapse following treatment. In fact, these obstacles are not unique to stuttering, but confound most efforts to accomplish therapeutic change.
Transactional analysis is a system that helps to explain in every day language, both the internal psychological processes and the interpersonal processes that underlie therapeutic resistance and therapeutic change. There are numerous psychological systems that attempt to describe the same processes involved in psychotherapy and counseling. They include cognitive behavioral, psychodynamic, interpersonal, and as highlighted in this paper, transactional models. There is no particular reason to assume that one or another of these approaches is more or less effective. It has been shown repeatedly that it is the therapist's skill rather than the particular psychological theory that they embrace that is at the heart of successful change. While I am emphasizing transactional analysis here, it is one of several effective approaches. If you are seeking this kind of help, you have many options and need to choose the path that makes most sense to you.
Transactional analysis (TA) is a dynamic psychological system that was described by Eric Berne (1961). The cornerstone of Berne's system is the description of three ego states; parent, adult, and child, which are active during both the therapeutic process and during interpersonal interactions that occur outside of treatment. These ego states bear a rough correspondence to those described by Freud (1962), the superego, ego, and id. The two systems differ, however, in that Freud's ego states are mainly structural entities, while Berne's are mainly dynamic. Consequently, during therapy the latter are clearly visible to the trained observer.
The adult ego state is recognized by emotionless exchanges of information. For example, "I am typing this paper on my computer. I have one hour to complete it." The child ego state, on the other hand, expresses emotion of two types. One is unrestrained joy, curiosity, love, fear, and anger, while the other reflects constrained adaptations. The latter expressions often sound like a complaining or overwhelmed child. For example, "I can't make this computer work right. It keeps changing the margins of my paper. Everything is going wrong. I'll never get it done in time" The parent ego state is also the source of two kinds of expressions; those which are caring and nurturing, and those which are critical and punitive. An example of the latter might be, "If you had read the instructions for your computer you would not be having so much trouble. You always wait to the last minute. That's why your paper is not finished yet. Won't you ever learn? If you don't change your ways, you will never be successful." This last statement, "If you don't change your ways, you will never be successful," carries with it a particularly odious curse. Statements like this one seem to come from the parent ego state, but are actually constructed by the biological parent's child ego state. However, they are interpreted by the biological child as a parental prescription, what Steiner (1974) calls an injunction. In this example, the actual injunction is "Don't succeed". If statements like this are repeatedly presented to a child with strong emotional force, they may become the substance of childhood decisions which shape later behavior.
Berne described the interactions between the ego states of two individuals as "transactions". A series of transactions between the various ego states of two individuals may constitute what Berne (1964) described as a game. A key feature of a game is the presence of an ulterior motive. For example, a person might engage in a social level exchange with their therapist that would sound like this; "I have a problem and I need your help" (adult ego state). At the psychological level, however, the client may simultaneously be saying, "I have no hope. Nothing that you tell me to do will help me" (child ego state). It is this latter sort of message that is of particular interest since, if not challenged, it will compromise therapeutic intervention. In this particular game, which Berne called Yes, but, the therapist repeatedly offers suggestions to the client, each of which is rejected by the client as impossible or unworkable. Finally, the therapist throws up her hands in despair and the client goes away, vindicated in the belief that the therapist can't help him. Thus the status quo is maintained and the client does not need to confront the discomfort or pain of change.
The game that Berne (1964) describes serve the function of reinforcing the decisions which individuals made about themselves as young children, and the course that their lives will take. These life course decisions are called scripts (Steiner, 1974). I am particularly interested in the script decisions made by young children about their stuttering and how those decisions influence the course of therapy. Since stuttering typically begins in early childhood, the force of script decisions made then is particularly strong and resistant to later change. Script decisions are typically made as responses to parental injunctions. Therefore, I am also interested in the scripts of parents and the specific injunctive messages that they transmit to their children.
Here is an example of just such a script.
When I first met Steve, he was 4 years old. He was already showing clear signs of disfluency and his parents were appropriately concerned. Both Steve's father and paternal grandfather stuttered. Steve seemed to be a "legacy", destined to be a third generation stutterer. I wish that I could report that through some heroic effort, or just shear luck, that Steve was able to escape this destiny. That was not the case, however. Now, as an adult, Steve stutters severely despite having received intensive intervention and therapy from the time that he was 4 years old. Steve's parents were prepared from the start that his stuttering was likely to be a persistent problem, and that management, not cure, was the more realistic pursuit.
Steve's parents willingly explored their respective attitudes about stuttering. His father recalled that when he, himself, was a child, his mother told him repeatedly to speak slowly. She often coupled this admonition with a direct or implied question, "Do you want to speak like your father?" The implication was clear. It was not acceptable to stutter. His mother did not like the fact that his father (her husband) stuttered and she did not want her son to stutter either. His inability to meet his mother's expectations resulted in increased tension, more stuttering and feelings of shame. As Steve's father expressed these feelings, Steve's mother recognized that her own attitudes about stuttering were also somewhat negative and intolerant. She believed, for example, that stuttering had impeded her husband's career and feared that her son's experience would be the same. Steve's father had successfully found and married a person who reflected the attitudes he had come to expect from his own mother.
The objective of counseling Steve's parents was to break the cycle of communicating negative attitudes about stuttering. These negative attitudes included instilling a sense of shame in Steve about a behavior that he was unable to completely control and the premise that stuttering would interfere with Steve's success in his adult life. We pursued this goal not only by counseling Steve's parents, but also by actively communicating an attitude of acceptance to Steve about his speech. The latter was accomplished in part during his therapy with a succession of student clinicians.
In this case the measure of success is that, as a young adult, Steve is without shame and unconcerned about his stuttering, although he continues to stutter quite severely. He has attended college and has career plans that he has chosen without regard to his stuttering. I have discussed with him from time-to-time my belief that he could, with little effort, increase his fluency by applying rather typical modification techniques. However, he has no particular interest in expending the effort to attain more fluent speech at this time. Nevertheless, that possibility is open to him if he chooses to pursue therapy at some future date.
This is but one example of how TA can help us understand the challenges to children and adults who stutter and their families. If you are at all intrigued by this approach, you can read a more detailed version of TA theory as it applies to stuttering, along with several additional examples of scripts (Rosenthal, 1997, 1998). One of those sources is also available on line and you can find the web address at the end of this paper.
Finally, I believe that one of the more important obstacles to effective treatment of stuttering is the tendency to underestimate the challenge to parents, children, and adults. Change is difficult and requires courage coupled with effective support. Transactional analysis provides a way of understanding and talking about these challenges to change in a relatively non technical fashion and with a minimum of jargon. Eric Berne once said that if a client can't understand what two professionals are talking about, the discussion is worthless. I hope that I have not violated that principle.
References
Berne, E. (1961) Transactional Analysis in Psychotherapy. New York: Grove Press
Berne, E. (1964) Games People Play: The Psychology of Human Relationships. New York: Grove Press
Freud, S. (1962) The Ego and the Id. (Tr. J. Riviere; Ed. J. Strachey) New York: W. W. Norton.
Rosenthal, W.S. (1997, August) Stuttering scripts: The transactional analysis of stuttering therapy. Paper presented at the Second World Congress on Fluency Disorders. San Francisco, CA. (On the web at, http://class.csueastbay.edu/commsci/stutteringscripts.htm)
Rosenthal, W.S. (1998) The transactional analysis of stuttering therapy: scripts and ego states. In E.C. Healy & H.F.M. Peters (Eds.) 2nd World Congress on Fluency Disorders Proceedings, San Francisco, California, 1997 (pp. 185-189). Nijmegen, The Netherlands: Nijmegen University Press.
Rosenthal, W.S., Austermann Hula, S. and Rud, L. (2006, August) Ego-States and Measures of Fluency: Unraveling Connections to Treatment Outcome. Paper presented at the Fifth World Congress on Fluency Disorders, Dublin, Ireland. (On the web at, http://class.csueastbay.edu/commsci/IFAWC06PubVersion.htm)
Steiner, C (1974) Scripts People Live. New York: Grove Press.
September 9, 2006
