Saturday, February 27, 2010

Marilyn... Meet Winston

If you are a stutterer, you've seen the lists. Famous stutterers. Actors, singers, politicians and athletes. Here we have two who make every list, Marilyn Monroe and Winston Churchill. I'll leave aside the degree to which the two actually stuttered, and what this should mean to stutterers, and make another point.

Has anyone under the age of 40 actually sat through a Marilyn Monroe movie? The poor thing died in 1962 - I seriously doubt most post-baby-boomers know anything beyond the name and a few iconic photos. And Churchill? I fear that most recent American high school gratuates probably can't say what he's famous for.

If you're going to go the Famous Role Model route - which I see little sense in - I think you need to get off the historical figures bandwagon and find some more contemporary examples. As it is, I find this lists depressing in that with 3 million stutterers in the United States, so very few can be found as role models.

Wednesday, February 24, 2010

I dunno..... (really?)

I became familiar with Robert Quesal, Ph.D. through the podcasts. A quick search found his own web site, which linked me to the following article:

The Role of the Stutterer in Therapy

An examination of that article would extend far beyond a single blog post, so I'll start with one sentence.

"When we observe people who stutter, we have no way of knowing, for sure, which disfluencies that we are seeing are "stuttering," and which are the same types of disfluencies that anyone would exhibit."

First, let me point out that Dr Quesal sees the need to put the word stuttering in quotation marks, as if he were adding a parenthetical "so-called". Second, and rather more important, Dr Quesal tells us that as a Ph.D. in speech pathology, and over 25 years experience, he is incapable of recognizing stuttering when he sees and hears it.

Stop and think about that.

Now let's put on our common sense hats. I think it's fair to say that Dr. Quesal knows stuttering when he sees and hears it perfectly well. In fact, I think it's fair to say that you don't need a Ph.D. to recognize stuttering - any person taken off the street could do nearly as well as Dr. Quesal. People either stutter, or they don't. There was no qualification in the quote above for very mild stuttering, or for stuttering we get away with occasionally. The quote begins "When we observe people who stutter..." No qualifier here - this is meant as a statement of general principle.

So why would an "expert" in stuttering say that he can't recognize the fundamental fact of his field when we believe that that statement can't possibly be accurate? An answer, ironically (or not) comes from the late Marcel Wingate, who was paraphrased disapprovingly in the article cited above. Wingate railed against the tendency to obscure the nature of stuttering by some researchers, particularly Wendell Johnson of the University of Iowa.

This obscuring comes about through the introduction of the idea that stuttering is just another form of "disfluency." These days, it's hard to read a paragraph on stuttering without finding the words fluency or disfluency at least once. This focus - or misdirection - on disfluency just serves to take the spotlight off the matter at hand: stuttering.

This confounding of stuttering - a very special speech disruption - with what is called "normal disfluency" is at the heart of the problem. When stuttering becomes not just "stuttering," as it is understood by most people on the planet, but every hesitation, repeated word and slip of the tongue, then the quote above can be twisted into making sense. Yes, people who stutter do hesitate like normal speakers, and that hesitation cannot be separated out from the hesitation of a non-stutterer. So in that sense, the quote follows its own logic.

The problem with the quote above - the reason it fails so dramatically in a common-sense way - is that when Quesal uses the word stuttering, he doesn't mean stuttering. He means stuttering and all that other stuff that is not stuttering, but I'm putting it in the same bag with stuttering.

Wouldn't it make more sense to restrict the word stuttering for when people actually, you know, stutter? Have you ever listened to a person who didn't stutter speak and think to yourself "I wonder if those are stutters, or just stutter-like normal disfluencies?" I haven't. When someone stutters, I know it. When someone doesn't stutter, I know it. I claim no special knowledge, and I certainly don't have a Ph.D. in speech pathology. No one almost-stutters. A stutter is a unique product of speech pathology. It would be nice if experts in the field kept the definition of the essence of the condition to the actual thing itself, and not obscure it by adding a grab-bag of non-essential phenomena.

Tuesday, February 16, 2010

Stuttering and Social Anxiety Disorder

Please go read the following article on stuttering and social phobia, and come right back (it's better for you to read this short article than for me to quote liberally from it - and links are what the Internet is all about).

What is Stuttering? -- defining stuttering from the speaker's viewpoint, by Mark Irwin

So Mr Irwin is concerned about what he describes as social phobia, or Social Anxiety Disorder (SAD). Anyone who stutters knows that there is more to the experience than verbal disruptions. Irwin suggests a new term, Stuttered Speech Syndrome, to encompass both disfluency in speech and the negative emotional, behavioural and attitudinal reactions that can go along with it. I appreciate his intention, but question his method.

Personally, I'm in favor of having a term that encompasses all the symptoms of stuttering, including both the "stuttering moment" and any of the common but variable psychological baggage that goes along with it. I do, however, have a problem with terms like social phobia and social anxiety disorder. Let me explain why with an analogy to agoraphobia.

Agoraphobia is defined as a fear of public or unfamiliar places. While the exact definition may be disputed, I think that it is fair to say that people with agoraphobia do not suffer panic attacks in public places because they have been beaten bloody at the park. They suffer a generalized anxiety when confronted with a situation that is unfamiliar, out of their control, or where they would feel no where to hide or retreat. To say it another way, their anxiety is not rational in its basis or degree.

The negative emotional, behavioural and attitudinal reactions associated with stuttering, on the other hand, are of another class. They may become irrational in their degree, but they can hardly be said to without rational basis. There is a very real social stigma to stuttering, and I would hardly call the normal response to that stigma a phobia. It seems to me that there is a difference between a fear and a phobia. If I hang you off the edge of a 10-story roof by your ankles, your response is fear, If you won't look out a tenth-story window, that's a phobia.

This is not to deny that fear and anxiety can play a large part in the life of a stutterer - I know it myself. Yet many tests over the years have shown that stutterers are not different from non-stutterers in measures of psychological adjustment. Stutterers are not neurotic - or at least not more neurotic than non-stutterers. Attention to speech-related anxiety seems reasonable if not obvious. Even rational fears can be exaggerated over time until the outcome is far out of proportion to the cause. I just don't see the value in conflating fear produced by an objective, very real stimulus, with a general fear of being judged by others.

If the magic pill that cures stuttering were invented tomorrow, would we still need to talk about stutter-related social phobia?

Social anxiety disorder

Thursday, February 11, 2010

Stuttering Talk Makes My Head Explode!

I've taken the following paragraph from Straight Talk on Stuttering, by Lloyd M. Hulit. Please read it, and then I'll comment on it.

"Wendell Johnson popularized what is called the Anticipatory Struggle Hypothesis, which hypothesizes that the stutter stutters because he anticipates that he will have difficulty saying a particular word, and he tries very hard not to fail, as he believes he will. The struggle not to stutter results in the behaviors we recognize as stuttering. In trying to explain why anticipation is not perfect and why some stutterers seem not to anticipate at all, Johnson and others have suggested that anticipation may sometimes operate at a very low level of consciousness. That is, the stutterer might anticipate without being aware that he is anticipating. While this may seem a specious argument to some, I find it convincing. I suspect we have all experienced situations in which we think we are feeling little or no anxiety about something we must do, only to find ourselves relieved when the doing is completed. The relief is evidence of the anxiety we felt, anxiety we did not know we had. I am convinced, based on my own stuttering experiences and on the experiences of my clients, that stutters often anticipate when they are not acutely aware they are anticipating. One only needs to look at the stutterer's face to see signs of anticipation, signs that often appear before words are spoken. Eyes widen. Lips become rigid. Breathing stops. Whether or not the imperfections between anticipations and stuttering can be explained to every one's satisfaction, the Anticipatory Struggle Hypothesis is widely accepted as an explanation for why certain words are stuttered more often that others" (p. 41).

Sometimes, don't you feel like your head is just exploding? I do. Dr Hulit, Ph.D., is a fan of the late Wendell Johnson. In this case, he cites Johnson's proposal for the cause of stuttering. Johnson believed that stuttering wasn't stuttering until parents - and others - called it stuttering. That is, stuttering begins when parents misdiagnose their children's normal disfluency as deviant, thus provoking anxiety in the child, and setting off a chain of results that become persistent adult stuttering as we know it.

Johnson's Anticipatory Struggle Hypothesis, like any such general hypothesis of cause, has to explain all of our observations about the phenomenon. That is, the proposal has to be consistent with what we know for sure - it can't conflict with solid evidence. In this case, all agree that in many cases, stutterers do stutter exactly on words they fear, or when speaking to an authority figure, or when required to speak their names. All of this behavior is consistent with the anticipatory struggle hypothesis - the stutterer knows what is coming, and has opportunity to become anxious, and the anxiety can trigger the stuttering exactly as feared.

It is also known that many stutterers do not stutter when alone, or talking to pets, or in other situations in which there is no performance anxiety to trigger struggle behavior. This, too, supports Johnson's hypothesis. However.... there are problems. As Hultit acknowledges above, there are times when stutterers stutter in spite of no evidence of anticipation. Or as Hulit puts it, anticipation is "not perfect." Hulit cites Johnson and others proposal that "the stutterer might anticipate without being aware that he is anticipating."

This is where my head explodes!

There follows a twisting, backbreaking attempt to save the hypothesis. First, the word "anticipate" is redefined. The conscious experience of anticipation, which is the whole justification for the hypothesis, now works on a subconscious level. No evidence is presented to support such a suggestion, just rhetorical arm-flapping.

"I suspect we have all experienced situations in which we think we are feeling little or no anxiety about something we must do, only to find ourselves relieved when the doing is completed."

Actually, no. I don't know what he's talking about.

"One only needs to look at the stutterer's face to see signs of anticipation, signs that often appear before words are spoken. Eyes widen. Lips become rigid. Breathing stops."

Of course the signs often appear before words are spoken - the poor soul is anticipating - consciously!

"Whether or not the imperfections between anticipations and stuttering can be explained to everyone's satisfaction, the Anticipatory Struggle Hypothesis is widely accepted as an explanation for why certain words are stuttered more often that others"

First, we're not talking about "imperfections," It is a demonstrable fact that stuttering can and does occur when there is no opportunity or evidence for anticipation. Any general hypothesis for stuttering has to account for all the evidence, not just some of it. Second, widely accepted by whom? Is this an appeal to authority? Don't tell me that someone accepts it - prove it to me. Third, now the hypothesis is for why "certain words are stuttered more often that others." When the hell did a general hypothesis for stuttering become limited to "certain words?"

The worst part of the entire effort is this:

"While this may seem a specious argument to some, I find it convincing."

In other words, he knows exactly what he's doing, but he does it anyway. This was the precise point my head exploded. So you know what you're saying has no basis, but you're sticking with it? No doubt, I am not the first to make this point. I'm sure that Hulit acknowledges the obvious flaw in the hypothesis because it was pointed out by other long ago.

When students enter graduate school in the sciences, many are asked to read classic essays on the practice of science. One of these classics warms against falling in love with a favored hypothesis. Instead of developing - or learning - a favored explanation and defending it to the last, you are admonished to always be ready to allow the evidence to change your mind. There's a seductive danger in signing on to a particular hypothesis - once you invest yourself it its truth, it can be very difficult to say those three scary words - I - was - wrong. All evidence against the favored hypothesis is denied or explained away - like non-anticipated anticipation. Luckily for me, every time my head explodes, the pieces return to their proper place and I can return to thinking the next day.

Sunday, February 7, 2010

Book Talk - Understanding Stuttering

As I read to inform myself and gather material, I'd like to pass on my opinion of various books - a sort of a Consumer's Report for stuttering books, if you will. I'll start with Nathan Lavid M.D.'s small book Understanding Stuttering (2003). At 75 pages of text, plus appendix, glossary and bibliography, it's an easy read, and is written for a general audience. Chapters are: 1. Stuttering Defined, 2. Who Stutters, 3. The Biology of Stuttering, 4. Treatments of Stuttering, and 5. Searching for a Cure.

Such a small book has the virtue of getting to the point quickly, and the vice of not always making its point properly. The first two chapters do the job reasonably well for the general reader not familiar with stuttering or the stuttering literature. The third chapter, The Biology of Stuttering does rather well for its size, discussing relevant brain structure and language-generating areas, brain imaging research, pharmacology and genetics.

The fourth chapter, Treatments for Stuttering, is a disappointment. There is a discussion of brain plasticity and the much-discussed factors that induce fluency (choral speech, singing, adaptation, etc), but the only look at actual speech therapy we get is the author's own practice of Cognitive-behavioral therapy. Nothing on fluency shaping, Van Riper's stuttering modification or operant behavioral practice. After four and a half pages, he goes on to pharmacology and examines various drugs that have been used to treat stuttering. Rather a disappointment there.

The final chapter - Searching for a Cure - is all of seven pages long, and offers little of substance.

All in all, I'd rate it worth borrowing from the library - as I did. The content seems to be reliable as written, only suffering for what it lacks. For those with little time or lacking the inclination to dig into the stuttering literature, this would be a good start.

I'll give it Three Stars out of five. Some good content, but not not long enough to cover the topics properly. In the case of the therapy section, entirely unsatisfactory.

Wednesday, February 3, 2010

To Control or Not to Control.

Out of Control.

In an earlier entry, I cited the following quote from long-time speech therapist Barbara Dahm: "My firm belief is that people stutter when they are exercising control over speech processes that are meant to function on an automatic mode.” A long and fruitful discussion earlier this week has caused me to revisit this quote sooner than I would have expected. I'd like to suggest that the statement above is not only wrong, as in backwards, but it is inside-out as well, if such a thing is possible.

Let's look at a typical stuttering event. A stutterer says "My name is P-P-P-P-P-........P-P-P-P-P-P-P..... aul." Throughout the rapidly repeated "P" sounds, the speaker has shown tenseness in the facial muscles and an abnormally strong breath exhalation on each "P" effort. One could say that these tense, strained and unnatural efforts are part of the maladaptive "exercising control" that Ms Dahm speaks of above. This is a plausible explanation - let's see if it is the best explanation.

Stuttering is immediately recognized as wrong by the speaker at an early age. The stuttering literature gives many examples of young children straining in self-knowledge at their inability to speak works naturally and effortlessly. Certainly, adults are fully able to recognize their own disfluency, even if sometimes they can block it out.

In the example above, the stutterer begins to say his name, and falls into a stereotypical repeat pattern. We might say, for Ms Dahm (if we understand her correctly) that upon reaching his name, the stutterer has assigned to conscious volition a physical/mental process that can only be accomplished by sub-conscious, non-volitional control systems. Again, this is a plausible proposal. Now, let's look at it from another direction.

I will propose here that something very different has happened. The strain and other non-natural behavior seen in stuttering is not found in fluent, non-stuttered speech, and can be seen as - and may, in fact, sometimes be - volitional. But let's go back to the "stuttering moment" above and read it in a different way. The speaker begins his sentence, reaches his name, sounds the "P" and blocks. He knows from experience that this will lead to a series of repeats - the stereotyped stuttering. If he wanted to "take control," what would he do? He might push harder, in some sense, as stutterers so often do. This just increases the tension and anxiety level, and provides positive feedback to increase the stuttering, as Ms Dahm's model might suggest. Here is where I differ.

To gain control, the stutterer always has another choice. He or she can simply stop. Stopping is the ultimate control. If you don't want to stutter, you can always just stop, rather than falling into the stereotypical stuttering pattern. In the hypothetical sentence above, the speaker could say "My name is P-..... aul," or "My name is P-P-P-..... aul. In either case, as soon as the stuttering event is triggered and started, the speaker recognizes it as soon as possible and simply stops. This form of control would not stop the stuttering impulse from occurring, but it has the capability of lessening the symptom dramatically. So why don't stutterers do it? Why don't they even try to "exercise control" and remove themselves from stereotyped pattern or repeating or prolonging that is experienced as so painful?

So here is my counter-hypothesis to that of Ms Dahm. The stutterer doesn't stutter because he/she seeks to take control of the natural, sub-conscious speaking process; the stutterer stutters - in those stereotypical repeats and prolongations - because he or she instinctively seeks to give up control of the disfluency impulse to the (flawed) natural, automatic process. That is, the stutterer does the counter-intuitive - repeating the same letter-sound over and over, in an unsuccessful attempt to move on to the next sound - because he is under a natural compulsion to let the automatic process do its proper work.

Human speech evolved over hundreds and thousands of generations. We learn language and speech naturally, without any conscious effort of teaching, and without conscious effort on our own part to "learn." Our brains are wired to produce speech like they are wired to produce walking on two legs. Should be be surprised that impulse to speak without conscious effort would be a strong one? Wendell Johnson famously said "Stuttering is what stutterers do when they try not to stutter." Ms Dahm seems to fall comfortably into the Johnson school of stuttering theory.

Let me rephrase Johnson's much-cited quotation to my own liking: "Stuttering is what stutterers do, in spite of the fact that they don't want to do it." From that perspective, we can ask new questions. When stutterers know that their speech follows a pattern of long repeats and prolongations, why do they not take control and stop? It is the longest symptoms that are felt to be the most disruptive, and most noticed by listeners/observers. One might suggest that the stutterer is hoping to get through the dysfluency sooner rather than later. In fact, stutterers themselves may say that very thing. That doesn't stop us from pointing out that after years and literally thousands of failures to get it out "sooner rather than later," that reading of the situation doesn't impress.

The stuttering literature is full of citations of stutterers - and observers - describing a "loss of control" during stuttered speech. Are both stutterers and observers wrong in their interpretation? Let's take another tack on this subject. There are just a few basic schools of stuttering speech therapy today. The mainstream methods seem to agree on their basic approach - they seek to teach the stutterer skills to consciously control his or her speech. Slow speaking, controlled breathing, relaxation.... these are all exercising control. Which, of course, Ms Dahm believes is the cause of the problem in the first place.

Both fluency shaping and stuttering modification require the client to take control of his or her speech production in a careful, conscious way. And, interestingly, those who go through both of these therapy programs sometimes find that the effort to suppress their stuttering through such active control methods grows tiring to the point that they choose to give up the effort and revert to stuttering. How can that be?

If I am right, and stutterers stutter to the degree they do because of a natural impulse to allow speech to function automatically, then both of the above observations make sense. First, it requires conscious control of speech production (as taught in speech therapy) to increase fluency. Second, the impulse to allow the natural, sub-conscious generation of speech is so great that it can overcome an otherwise successful therapy program that relies on taking the speech generation away from its natural source and assigning it to constant, conscious monitoring and modification.

So there you have it. I can't prove I'm right, but my hypothesis is in concert with the observations I've noted above. I would argue that it is superior to the Dahm/Wendell Johnson hypothesis on multiple levels. It's a start.

*** Tip 'o the hat to Jamie R. for helping me clear my thoughts on this matter. All errors, misunderstandings and general BS are mine alone.