The Importance of Being Aware
PROFESSIONAL'S CORNER
by C W. Starkweather, Ph.D.
The following piece is derived from the STUTT-L discussion list on the Internet. It grew from some questions on the awareness, acceptance and change model that is the philosophical foundation of tire Birch Tree Foundation.
Acceptance is important, but there is something that has to precede it, and that is awareness. Many stutterers are hurt, shamed and frightened by their stuttering and they adopt defenses to minimize the pain. A common one is denial. People find relief from pain by pretending it doesn't exist, by distracting themselves with competing thoughts or emotions, or by mentally absenting themselves.
The problem is that denial, while it offers protection from pain, makes you lose touch with the problem. I believe that before one can accept a particular behavior, coping strategy, feeling, or belief, one has to become aware of it, and not just vaguely. Janet Ackerman [codirector of the Birch Tree Foundation] and I have adopted techniques for increasing awareness as a step preceding acceptance. We are just starting to develop and refine this approach for people who stutter, so claims for its successfulness are inappropriate; but it has been used with great success with other problems for many years.
The Individual Nature of Stuttering
In evaluating treatments, it is difficult to say "what works." We know that what works for one stutterer does not necessarily work for another. I don't claim to have the answers, but many stutterers have been helped by nonavoidance therapy, some by fluency shaping, and there are a few who have recovered on their own.
In my experience, the people who have succeeded in recovering from stuttering on their own have a more complete recovery than those who have recovered through therapy of any kind. This may be because they have taken responsibility for their recovery, which we know is important, or it may be because of the extraordinary individuality of the disorder. It isn't clear which of these two explanations is the right one, perhaps because each stutterer is the one best qualified to learn about his or her particular problem. The best quality of recovery seems to lie in designing one's own therapy. However, this must be hard to do, because many more people have recovered in therapy than have on their own.
Nevertheless, therapists can improve the quality of their work by listening to their clients, and with the client's "story" as the primary data, designing therapies that are tailored directly to the client's unique problem.
Good therapists also see the problem in all its complexity. This is an important factor. The Guidelines for the Treatment of Stuttering (ASHA, 1995) state that approaches that limit themselves to one or a few elements of the problem do not constitute acceptable practice. Simplistic approaches are just not acceptable. Van Riper, Sheehan, and other early experts identified these elements. Van Riper describes all the elements that are in John Harrison's hexagon [a conceptual model for stuttering] and recognized too, as someone recently noted, that those different elements may be weighted differently for different people. He didn't present these ideas as clearly as John has, but the ideas themselves are not new.
Age is certainly an important factor in assessing "what works" The preschool child may already have developed some coping strategies, but they are childlike and often not strongly habituated. The children are also still growing rapidly, and that helps recovery. Better yet, their parents are motivated to help and still remain in control of the child's environment, so preschool children can usually be reached by training their parents in how to make the child's environment more conducive to the development of normal fluency. It is the universal experience of practicing clinicians using appropriate methods that preschool children recover more easily than school aged children and adults.
School-aged children are quite different. For one thing, they think fluency is more important than anything. They are delighted with anything that works, as one boy was, when he had "found the cure" by squeezing his fingers together in his pocket. Clinicians can't approach a person in this state with a technique like voluntary stuttering. Also, school age children can't easily be reached through their parents. Their friends are now more important, even if they are teasing and cruel.
When you consider the factors of individuality and age alone, it is difficult to see how therapy can be assessed quantitatively. The scientist is limited to what is observable, probably the least important aspects of the disorder-the frequency of repetitions, prolongations, etc. Assessments of efficacy based on observable aspects of stuttering tell us that the tip of the iceberg has melted. Unfortunately, it may roll over and show a new face. Of course, attitudes, beliefs, and thoughts can be measured too, but only indirectly, and this limits conclusions.
Forums like STUTT-L, Letting GO, and NSP conventions are the best way to figure out what works for whom and when. We should do the science too, but it will always deal with the most trivial parts of the problem.
Denial
Stutterers (like most people, actually) seem rarely to have an accurate sense of what they are doing. This could be, of course, because their protective coat of denial filters out the unpleasant part of experience. One of the important things about denial, as I have heard Janet say many times, is that it is like being asleep; you don't know you have been doing it until you wake up.
Denial can be global or partial. For example, a member of the Stutt-L discussion list who lives in the Netherlands posted a long time ago that when she was blocking severely she felt as though she was outside of her body and "flying" above the conversational scene. Many stutterers have experienced something like this, where they are partly out of touch with their surroundings during severe blocking. This may worry the person, but it is just the mind protecting itself from pain by going off some where for a while where it is safer, not much different really from day dreaming when you are bored, although in this case the escape is from something more unpleasant than boredom, and the escape is correspondingly more complete. This is "global" denial.
But denial also has more subtle forms. Just saying to yourself, "Well, I stuttered a little today, but it wasn't really so bad" can be a form of denial called minimizing. "It didn't really hurt. Not that much" (Somehow this sounds like a Saturday Night Live skit where the guy drops a knife and it sticks in his foot, and he says something like "Ooh, that's annoying. Good thing it wasn't an ax")
Some people deny by living in the past or in the future. Others by being so angry at or concerned with someone else that they don't have time or energy to face themselves. There are many forms of it, and they influence the stutterer's perception of self, of the stuttering, of feelings and thoughts, how others see him or her, just about anything that might be painful. In denial, it is difficult to see the problem as it really is. In spite of this, I believe that most stutterers have the information about themselves and about their speech to find the solutions that will work best for them. Getting past denial is an important first step. That's how to get to all that information. But it is hard and sometimes complicated.
I think this is what Van Riper was aiming for when he worked, early in therapy, on "identification." But this was too limited. Identifying when stuttering occurs is just the beginning. Hal Starbuck, another fine clinician, took it further and had stutterers identify more of the details of their behavior in a step he called "analysis" But I think there is much more than behavior to become aware of. The sequence of events may begin with the apprehension that in a few words you are going to stutter, then sudden feelings of panic, thoughts of other words to say, time passing, try to postpone a little, take a quick stab at the word, uh oh it's going to be a doozy, try it, it's not working, bigger panic, try a trick, it doesn't work, more time passing, push hard, block hard, force it out, and then afterward trying to talk fast to make up for the time lost, reflecting back on what happened ("I was lucky to get out of that one alive"). All thoughts and feelings are important to be aware of, to acknowledge as real, even get to know them a little better, "embrace" them, as Janet says. But that is the beginning of acceptance, so l will end here.
Woody Starkweather is a professor at Temple University and Co-Director, with Janet Givens Ackerman, of the Birch Tree Foundation, which is dedicated to the support of people who stutter. Their book, Stuttering will be published by Pro-Ed in the Spring.
