The Rise of Formal Therapy

The development of formal stuttering therapies

Until the 19th century, formal stuttering therapy was primarily left to doctors. An example of ‘treatment’ at the time was to operate on stutterers. The root of the tongue was sliced through and some tissue removed. As it happened people stopped stuttering for a while after such operations, probably because it was too painful to speak too much or too fast. Enthusiasm for this procedure declined soon after it was established that the benefits were temporary. In addition a number of patients died due to subsequent infection of the tongue.

The second half of the 19th century saw the start of the development of speech pathology as a field of study in Germany. Formal stuttering therapy as an independent school of thought took root in the first few decades of the 20th century. In America – currently considered by many as the leader in the field of stuttering therapy – the first university course in speech pathology was introduced in 1924. For the first time the search for the cause of this disability was conducted scientifically and approaches to treatment developed systematically.

The psychological approach

During these first decades the search for the cause and treatment of stuttering was to a large extent influenced by the emerging field of psychology. The psychological approach was supported by the rise of the theory of the subconscious, which by today has found general acceptance. According to this theory, man not only possesses conscious thinking processes. He also has an underlying consciousness, somewhat like the memory of a computer, storing every day’s experiences – including the unpleasant ones – in the brain.

The belief was that with the passing of years, all kinds of conflicting information or old traumatic experiences in this subconscious part of the mind could result in subconscious conflicts, which were revealed in stuttering behaviour. It was believed, for example, that the stutterer finds it difficult to say certain things such as his name because he cannot or does not want to say them on a subconscious level.

Stuttering was accordingly viewed as a symptom of more fundamental, deep-seated psychological problems from which the patient was suffering. The logical outcome of this approach was that the therapist should treat the patient psychologically to remove these underlying conflicts. Amongst other things therapists used psychoanalysis to search for old, frightening experiences from the past which were supposedly locked up in the depths of the subconscious mind. Some stutterers even received electric shock treatment for their problem, but without success.

It is easy to understand why the cause of stuttering could be studied psychoanalytically. Suppose you were a psychologist approached for help by a young man who told you that he only stutters in the presence of pretty girls, but never in the company of older women! Someone lacking a deeper insight into the functioning of tension and stress would perhaps think that this patient has a deep-seated problem with pretty girls ... the next step would be to reason that something had gone wrong with this person’s psycho-sexual development and that the theories of the founder of modern psychology, Sigmund Freund, could be applied to him.

It is however interesting that Freud himself had no success in treating stutterers. He later mentioned that psychoanalysis is not the correct treatment for this disorder. Unfortunately many of his followers disregarded his advice, in spite of the fact that, in general, psychoanalytical treatment failed to have the desired effect.

Standard psychological tests later indicated that the majority of stutterers are not at all more neurotic than the rest of the population. Most experts therefore currently accept that the psychological component of stuttering was overemphasised in the past and that the primary cause of stuttering should not be looked for on a psychological level.

This does not mean that psychological factors do not play a part in stuttering. Psychological factors can contribute to stress. This means that psychological factors can indeed be a contributing cause of stuttering. Moreover, stuttering may have psychological consequences, such as a poor self-image, neurotic behaviour, frustration, speech fears, shyness, etc.

In some respects the psychoanalytical approach was detrimental to the stutterer. He was branded as mentally abnormal – a stigma from which to this day he has not been able to escape completely.

Stuttering is not the only disorder that was formerly wrongly viewed as an ultimately psychological problem. Tourette’s syndrome, a neurological disorder characterised inter alia by involuntary swearing or other noises or convulsions, was originally also considered to be a psychological problem. Today many experts also view dyslexia as an organic, neurological defect rather than as an emotional one.

When one looks at a stutterer experiencing a serious block, it is easy to conclude that he is a bit peculiar. But the stutterer experiences it differently. To him a block is a dramatic event. He was after all in the process of saying something, and he wants to complete his sentence. Saying that difficult word becomes a personal challenge.

The ‘traditional’ approach

The psychoanalytical approach was accompanied by the so-called traditional approach. The traditionalists were more interested in the actual stuttering behaviour than the so-called ‘underlying psychological problems’ of the stutterer, and they tried to do something about the stuttering itself. These experts, including the aforementioned Dr Charles van Riper – himself a stutterer – emphasised that on a basic psychological level the stutterer was as ‘normal’ as fluent speakers and that symptoms such as speech fears, a poor self-image, etc were the result rather than the cause of stuttering. They asked: How can you develop a healthy self-image and self-confidence if your ability to speak may at any moment grind to an unexpected halt and result in embarrassment?

The behaviourist approach

A subsequent sub-approach to rise to prominence in the field of psychology was the study of behaviour, or behaviourism, which also presented new insights on stuttering. These experts were not interested in subconscious conflicts. They claimed that stuttering is learned behaviour and therefore a habit. Thanks to this approach we now know that a significant part of stuttering – much of the actual struggle behaviour as well as the many speech fears – does indeed consist of habits acquired in the course of time. The big question that nevertheless remained unanswered was: What exactly is the stutterer struggling against?

The organic approach

Nowadays the experts are also interested in a potential organic or physiological cause. This approach has its origin in the theory that was held to be valid for more than a thousand years, namely that it is the tongue that lies at the root of the problem. The infamous operations on the tongue as mentioned previously were based on this theory.

The organic approach also yielded important results. Experts point out that the incidence of stuttering is higher amongst identical twins than non-identical twins, and that the disability tends to occur in certain families. This does not mean that stuttering as such is hereditary – it rather indicates that the predisposition to stutter is genetically transferred. In other words, the potential to stutter is inherited, but this latent potential is not necessarily activated in everybody.

Some experts working in this field moreover indicate that the disorder is apparently activated during childhood by some or other form of pressure or stress, for instance the additional pressure on the child’s speech system when learning to speak. In this respect one can compare stuttering to epilepsy and the skin ailment psoriasis, both activated or aggravated by stress.

The theory of Prof Martin F. Schwartz, which is discussed in following chapters and on which this book is to a large extent based, is such an organic theory. Schwartz has combined the results of the different approaches. According to him, stuttering is struggle behaviour learned in response to an inherited predisposition to contract the vocal cords excessively in response to some kind of stress.

This means that the disorder is partly organic (hereditary) and partly psychological (learned and stress-related). According to Schwartz there are two reflexes: hereditary (where tension results in contraction of the vocal cords) and learned (where contraction of the vocal cords results in struggle behaviour). The latter reflex may follow the first. In some people the learned component is dominant (eg. the consistent word-stress stutterers who stutter irrespective of the situation), while the stress component features more strongly in others (eg. the situational stutterers). People also differ in respect of the intensity of their vocal cord closures.

Modern stuttering therapies

Current views on stuttering therapy are to a large extent based on the approaches discussed in the previous paragraphs. In general one can say that the conflict between the mentioned approaches has developed into two opposed approaches: the ‘stutter more fluently’ approach in contrast with the ‘speak more fluently’ approach.

The ‘stutter more fluently’ approach does not only consider the speech of the stutterer, it also looks at his inner life. These experts view stuttering as part of a larger group of problems. They focus on the fears, shyness and so forth that constitute part of the stuttering problem and aggravate it. Attempts are made to neutralise these anxious and negative feelings in order to reduce the stuttering. These experts claim that it is not really possible to cure the adult stutterer, and that improved adaptation to the disorder is more realistic and attainable. Rather than aim at completely fluent speech, the stutterer is taught ‘easier’ stuttering and how to overcome blocks. These experts are opposed to fluency techniques (see below). In their opinion fluency techniques only have superficial, temporary effects and fail to deal with the origin of the problem – the inner psychology of the stutterer.

In contrast with this we find the ‘speak more fluently’ approach. Stutter experts inclined in this direction attempt to replace the defective speech of the stutterer with fluent speech. They emphasise the fact that most stutterers do not stutter all the time and are often perfectly fluent. Their aim is to extend this fluent speech rather than change the psychology of the stutterer. In fact they believe that if the person’s speech improves, his psychological condition will also improve. To reach this objective, they attempt to teach the person some or other technique for fluent speech. These experts view the treatment as based on a series of clearly defined steps: 1) learning a fluent-speech technique, 2) transferring this fluent speech from the speech clinic to actual, everyday speaking situations, 3) maintaining the fluent speech so that it becomes permanent.

However, many experts believe that these two approaches merely represent extremes and that it is better to combine them; ie the stutterer is taught a speech technique or techniques that will help him to improve his speech, and at the same time his psychological attitude towards himself, his speech and the listener is also addressed. This is also the approach followed in this book.

This does not imply that there are no longer great differences in opinions on stuttering and its treatment. It is obvious that stuttering is neither an exclusively psychological nor physiological problem, but rather a complex combination of both. Consequently it becomes very difficult to prove any particular theory of stuttering.


1 comment:

Anonymous said...

Thanks for posting this (and all of your previous posts)! As a stutter I find your experiences insightful and interesting... also you're an engaging writer.