Why Psychotherapy Doesn't Resolve Stuttering
study by L.M. Webster published in 1977 provided the following information: of a sample population of 648 people who were treated by psychotherapists specifically for stuttering, 597 showed either no improvement or only slight improvement. Although 51 (8%) of the patients experienced improvements in fluency, none was "corrected" (Webster 1977). Given the possibility that some of these people may have been trying to hide stuttering behavior to prove that their therapy was successful, these are truly abysmal results.
Psychotherapy (and other types of cognitive therapy) definitely has its place and can be a helpful -- and sometimes indispensible -- adjunct to stuttering therapy. But the experience of thousands of people who stutter has shown that psychotherapy by itself isn't concrete enough (on one hand), and doesn't go far enough (on the other hand) to help people who stutter permanently increase their fluency. Some psychologists, psychotherapists, and psychiatrists (while completely different in training and credentials), share profound misconceptions about the cause of stuttering. They may assume that stuttering is caused by some weakness or flaw in the ego or personality or by an oral fixation. Research has simply not borne out any of these purely psychological explanations.
If they assume that stuttering has no physical basis or correlate, psychiatrists may search for childhood abuse and traumas to explain how the person's ego structure could have been weakened to the extent that he/she attempts to repress feelings (such as anger) or fears that they theorize are reflected in an attempt to "hold back" or otherwise control speech. Not recognizing the importance of speech as a survival and reward mechanism in and of itself (a common oversight, shared by many people), they overlook the significant effect of even slight difficulties in speaking on the child. If the PWS mentions a feeling of shame and humiliation associated with severe stuttering in public, the natural response of the psychiatrist is to probe this for significance, as if the shame alone is the cause of stuttering. This not only discounts the person's experience, but leads to unhelpful speculations about neuroses that may underlie these feelings of shame -- while these feelings are really completely natural responses to speech difficulties.
The most unhelpful advice a therapist can give at this point is to encourage a person to plow ahead in spite of his stuttering without providing any adaptive speech techniques for doing this. It's been my thought that some stuttering children who actually stop talking (experiencing a silent block or remaining silent) might have a better prognosis for eventual recovery (assuming later speech therapy) than those who crash ahead and stutter severely. This is based on the observation that people who have so-called "silent" blocks tend to respond to speech therapy more rapidly and that such blocks are the stuttering behaviors that are helped most readily by fluency shaping techniques. In contrast, severe stuttering within the ongoing flow of speech that is accompanied by clonic tremors and violent motor movements might lead to more reactive learning, as tense or strained speech movements become physical cues that trigger stuttering reactions. (Note that I'd never advise an adult PWS to avoid speaking.)
A psychotherapist presented with an adult stutterer often sees a person who is depressed and upset. The unfortunate tendency is to see the depression and upset as the cause of the stuttering. But depression is a logical response for any human being faced with seemingly insurmountable speech difficulties which have become highly automated and seem to be totally out of control.
The psychotherapist or counselor may see the stutterer for many months. While considerable progress may be made on the other reasons for the initial visit (the end of a relationship, trouble at work, etc.) and the person's self esteem may be much higher, the stuttering persists -- largely resistant to anything either the client or the therapist can do. And why not? As the client's ego begins getting stronger, the super-ego (inner critic) will also get stronger. The super-ego's role is to maintain the existing personality and conditioning. As long as the super-ego, with its focus on the status quo, is in charge, the stuttering -- which was partly its creation in the first place -- will be resistant to change.
As the client's depression eases, there's a tendency to want to feel "better" and "normal." There's a danger that stuttering can seem controllable at this point, when it's just marginally beginning to be extinguished. At this point, a wise psychotherapist will usually refer the client to a speech-language pathologist or a stuttering support group. This is what happened to me many years ago and seems to be a fairly common experience.
There are obvious benefits of psychotherapy for anyone, including PWS. If the psychotherapist keeps seeing the stutterer, (s)he can work on building up the client's ego by doing compensatory activities or by encouraging the PWS to use "positive thinking" to replace negative thoughts. This can be a helpful first step. Old self-images are partially replaced with new self images that may involve the PWS as a newly fluent speaker (as a result of therapy or -- alas -- avoidances) or as someone who excels at a certain activity, hobby, or life situation. The stutterer now views herself as a "normal" person who happens to stutter, which is what (s)he was all along. But "normal" people are totally identified with their bodies and minds and persistent stuttering can become an aspect of the self-image. And there's a good chance that all that "positive thinking" has put the stutterer out of touch with what he really feels about his speech difficulty. Why? If being "cured" is being unaffected by "negative" emotions like anger, hate and fear, then the client will strive to submerge and control those feelings.
But, in the meantime, the client's speech has been totally neglected. Stuttering, because of the huge amount of conditioning involved, is a subversive disorder that will tend to undermine any positive strides the client can make in other areas. Psychotherapists are not trained in stuttering modification or fluency shaping techniques. And they are not trained in speech therapy techniques, which include 1) work to help the client identify and becoming desensitized to actual stuttering behavior, 2) actual repetitive de-conditioning practice producing modified or fluent speech in the presence of feared stimuli, (such as situations associated with speech failure, inappropriate articulatory postures, and "difficult" words or sounds), and 3) gradual and appropriate transfer of the modified responses into the client's life outside the clinic. The PWS has probably done a lot of talking in the therapy room and it may have become an island of spontaneous fluency, providing an illusion for both participants that progress has been made. But until this fluency is transferred to other situations, lasting progress is not likely to result.
Most medical insurance companies are happy to reimburse the stutterer (and pay his psychotherapist or psychiatrist) for spending his time in this manner. If the stutterer goes to a speech therapist, however, it's often very difficult to convince his insurance company to pay a penny for something that can really help him.
I haven't figured this out yet either ...
© 1994 - 2009 Darrell M. Dodge, MA, CCC-SLP
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Last Updated: Monday, November 09, 2009