Wednesday, December 28, 2011

The Genetics of Stutter - A Review

I've just found a very nice review of the 'Genetic Bases of Stuttering: The State of the Art, 2011,' written by S.J. Kraft and E. Yairi. This paper is a nice summary of the historical work on the subject, with an up-to-date look at the most recent work. In it, you will find no wooly-headed thinking, no Just-So stories, and no perverse clinging to long-dead 'theories.' Thank God, they stick to science.

I suspect you'd need at least a college biology course to follow the different discussions, but the paper is not written for geneticists, so it is not burdened with too much jargon, and it's not a research paper, so it's not filled with graphs and charts. Give it a try. The link to the full, free version is at the top right of the page.

Get it here.

Monday, December 19, 2011

Fear of What?

If you do an Internet search on stutter, you'll find that among the most common terms associated with the condition are fear, anxiety, shame and the like. If you read stutter message boards, you'll find stutterers discussing their frustration, embarrassment and anger at having to deal with their condition. Clearly, negative feelings, however expressed, are a very real part of the life of stutterers.

If you dig further into the literature on stutter, you'll find a common claim from therapists and researchers that stutterers overestimate the degree of negative attitudes held by their listeners. Commonly, it is said that stutterers 'project' their own feelings on to their listeners. No doubt, there are some people who harbor negative attitudes towards stuttering, and some express them openly when they encounter it.

In order to justify putting the onus for causing the stutterer's fear/shame/anxiety/etc. on the listener (given that this fear is typically felt before the stutterer even begins speaking ), we have to reach past the actual behavior and attitudes of listeners and speculate. One can argue that the fear comes from past experience, in which listeners did show hostility or ridicule, or simply impatience. This is a reasonable speculation, to a degree. How often, and to what degree does it apply, however?

Our experiences are all different, but how many stutterers suffer repeated, long-lasting persecution for their speech? For those who have suffered ridicule and bullying from schoolmates over time, it would be understandable that they should think the worst of non-stutterers. I suspect, however, that such cases are the exception rather than the rule. And given the natural cruelty children are capable of, I doubt most stutterers have suffered any more than many other children at the hands of their peers.

I would suggest that 'past experience' is only a partial answer. If eight out of ten non-stutterers treated stuttered speech with ridicule or disdain, it would be reasonable. I can only speculate, but I believe that the true proportion of people stutterers interact with who respond negatively is far smaller than four out of five. If positive - or at least neutral - experiences are the rule rather than the exception, then why the emphasis on the negative? Why is the evidence of fear and anxiety so much greater than the evidence for a rational basis for such feelings?

Let me make a suggestion as to the origin of the famous stutter-anxiety - one that might explain both the consistency and the degree of the phenomenon better than the 'listener reaction' hypothesis. It was William Perkins who suggested that stuttering be defined as a loss of control over the speech process. My hero in the field of stuttering, Marcel Wingate, derided this idea, but in this case I think he was wrong to do so.

The difference between stuttered speech and the normal flaws of speech by non-stuttering speakers is exactly the loss of control over the speaking process that is experienced by the stutterer. This is related to my antipathy to the rat-bag term 'disfluency,' which includes stuttering, as well as every imperfection of speech by those who do not stutter. A non-stutterer can be trained to clean up their speech to perfection, as professional public speakers like television and radio announcers, and (some) college professors do. Removal of interjections like 'umm' and 'uhh' are just a matter of paying attention and practice. That is, while they slipped into the speakers manner of speaking casually, they can be removed volitionally

The disordering of speech produced by stutter are another matter entirely. The blocks that generate the stereotypical prolongations, repeats and the assorted rest are not a bad habit; the blocks are generated beyond (under, within?) the level of voluntary control, and as such are only subject to conscious decision to a slight degree. Perkins was right in his assertion; what separates the stutter block(and the tics of Tourette syndrome, for instance) from other 'behaviors' is that they are generated at a sub-conscious, sub-voluntary level, and are not subject to what we commonly think of as 'will power.'

It has taken my multiple paragraphs, but I can (begin to) get to the point now. I'd like to propose that much of the fear, embarrassment, etc., of stuttering is not so much the fear of negative judgements by others. Rather, it may be the fear of experiencing the lack of control over one's own body that occurs during a stutter block, projected on to others.

You can read books and articles on stutter for hours and barely see a word about the core of the condition: the physical inability to proceed through the normal production of a spoken syllable. Stutterers are not bad at speech, as I might be bad at hitting tennis ball or painting a portrait. Stutterers suffer a temporary fault of speech production, in which the expected motor process cannot be carried out. This is in spite of the fact that in other cases, the stutterer is perfectly capable of saying the same word perfectly. Stutter can be described as a dynamic paralysis (although I've never seen it put that way), in which a typical series of physical movements is stopped in mid-sequence.

Imagine that you decide to write something down. You see a pen on your desk, and reach for it. Your elbow extends, your upper arm raises in your shoulder joint slightly, your wrist turns to face the palm of your hand down, and just as your fingers begin coming together in preparation to grip the pen, your entire arm locks up and will go no further. What's going on? Your arm comes back to your body, you raise your hand to look at it, you shake your hand at the wrist, and then you repeat the above process.

You reach down, get to the same point as last time, and again, just as you prepare to grip the pen with your fingers, your hand and arm lock up. Now you strain to force your hand down to reach the pen, but in spite of your arm muscles quivering, you can't get your fingers any closer to the pen. You pull your arm back, rub it with your other hand, shake your whole arm this time, and start over once more. And the same thing happens. After 5-6 attempts, you finally find yourself able to grab the pen roughly off the desk. How would you feel?

What I've done here is to model the stutter block with hand and arm movements. I've also eliminated any observer effect. How would you react to being suddenly incapable of controlling your own body in what has always been a natural - and necessary - series of motions? How would you think of your own arm if it suddenly seemed to be disconnected from your will? What does it mean to say 'this is my hand' when the hand won't respond to sub-conscious level control as it always has? It seems to me that this kind of dynamic paralysis of normal motor function would be terribly disconcerting.

Now add another element to this phenomenon. Make it intermittent. Sometimes you can pick up the pen, and sometimes you can't. Sometimes it's bringing a fork to your mouth while eating. Sometimes turning the ignition key when you want to start your car. And sometimes it's getting your penis out of your fly when you need to urinate (use your imagination, ladies). I think you can see how this sort of intermittent loss of control of one's body could easily be traumatic to the psyche - independent of any 'listener effect.'

I am proposing here, that a significant part of the fear/anxiety/shame that is discusses so often around stuttering originates not in the stutterer's understanding of how they will be perceived by others, but in the stutterer's own body. I am proposing the existence of a quite natural sense of dread that comes out of the loss of control over the stutterers's body during a block. That such a sense of wrongness should be directed outward to listeners is also quite natural. How many stutterers stop and analyze their own condition during those moments of blocking? Who calmly and rationally studies the nature of their stutterings, and considers the origins of their anxiety?

The nature of stutter directs us to look outwards when we examine our own physical and psychic responses to moments of stuttering. When do we stutter? When we talk. When do we talk? When there is someone to talk to. It is easy to take the next step and say that our listener causes us to stutter. Of course, here we must note the maxim from statistics: correlation is not causation. A good deal of science goes into supporting that statement against 'common sense.'

So to 'deconstruct' the 'listener effect' in stuttering anxiety, we could say that just because a listener is in front of us when we feel anxiety during speech, that doesn't mean the listener is causing the anxiety. Listeners, and any perceived negative attitudes held by then, could just be the hook we hang our anxiety on when we haven't looked inwards to find the source.

This is not to say that bad attitude on the part of non-stutterers isn't real. Any stutterer knows that. To a greater or less degree, we've all experienced the insults and various degrees of negativity, from being ignored to being beaten. My effort here has been to account for the difference between the degree to which real harm that can be inflicted on us (limited, and generally less than we think) and our internalized level of negative feelings.

So once again, the reader might ask 'what's the point?' In this case, I would argue that the point is a big one. Stutterers are notoriously resistant to speaking openly, and to the therapeutic path. Stutterers are even resistant to dealing with other stutterers. The first time I saw a stutterer on television as an adult, I was shocked. I found it hard to keep watching, it was so painfully uncomfortable for me. My native Boston metropolitan area has 1.8 million residents and two National Stuttering Association support groups. When I attend my local group meetings, we get from two to five stutterers. That's one stutterer at the meeting for every 1800-4000 stutterers.

Why is this? Why are stutterers so averse to their own condition that we are so resistant to acknowledging it and dealing with it? You can say fear and shame, but those words just raise the question 'why?' Why is the distaste for our stuttering so great that so many of us can't even begin to attempt to deal with it? My suggestion is that the source of our anxiety is deeper than has been acknowledged in the past.

Even if we understand cognitively that listeners won't point and laugh at us in public if we stutter, the interior source of anxiety remains. That feeling, experienced thousands and thousands of times over by the time we reach adulthood, that our body is not our own. The feeling that we are, in a sense, possessed during the moment of speech block, and have had our bodies severed from out intentions. Something not 'us,' not our thinking, volitional selves, is getting between our intentions and our most human of behaviors. When that which makes up our inner self is divorced from our physical self, should we be surprised at the outcome?

Monday, December 12, 2011

Scanning : Stutter-Style

Horror fans not familiar with his work should check out the movies of director David Cronenberg, including the 1981 creep-out Scanners.

It is commonly said (by stutterers and others) that while speaking, a stutterer will scan ahead to look out for 'difficult' words. An Internet search for [stutter + "scan ahead"] will verify the popularity of the idea. The word scan, taken literally, implies looking. We scan text on a page. We are able to do so because the text is, in fact, already on the page and available to be scanned. While we can take the word scan figuratively, as might be argued by some, the fact is that the word scan implies sight, and sight implies written text. This sort of confusion between spoken and written language shows up repeatedly in the stuttering literature. I'd like to question the degree to which such scanning actually occurs, and to what degree the analogy to a visual process (scanning) obscures rather then elucidates whatever it is that is actually happening.

First, let's look at the claim. Upon recognizing a difficult word coming up, the stutterer may insert a synonym, rephrase to avoid the word, or start an entirely new sentence in mid-speech. We need not rely on the word of stutterers for such mid-sentence changes. A recording of a stutterer talking studied closely will often reveal a pause, mid-sentence, followed by a grammatical mash-up that produces a new finish to the sentence that is divorced from what came before. A very similar kind of sentence breakdown is actually common in the casual speech of non-stutterers, and is often unnoticed by the listener. Transcripts of the extemporaneous speech of politicians that include such verbal inconsistencies have, however, been used (unfairly) to embarrass them by their opponents in the media. What is ignored (and acceptable) during speech becomes obvious on the page.

The fact this sort of word avoidance and sentence restructuring by stutterers occurs does not, however, necessarily support the idea of scanning. That is, if the decision to avoid a 'difficult' word doesn't come until the word is arrived at, then there was no scanning. Scanning implies looking ahead multiple words in a serial sense, and the behaviors of word replacement or sentence restructuring does not prove that scanning has occurred.

So how far 'down the page' (figuratively) can a speaker scan when he or she doesn't normally know exactly what they will say until they say it? Speech is a subtle and complex process by which vague, unformed ideas become words in grammatically ordered sentences at a rapid rate without conscious effort. So how much scanning of upcoming speech can a stutterer actually do?

Surely we cannot imagine that anyone can know in any but the rarest cases what is coming two sentences ahead during spontaneous conversation. The best one can say for words outside the current sentence is that if one is discussing Abraham Lincoln, there will be a time when one is going to have to say the name Abraham Lincoln, the word President, and other such terms necessary to the topic. We may perceive that while we speak on sentence, the next sentence will logically have to include Lincoln's name, or 'the President,' but that is not 'scanning,' in any non-stuttering sense of the word.

Putting aside such cases in which it becomes obvious that a word will have to be spoken some time soon, what can we say about the realistic possibility of 'scanning' ahead in speech? When we begin a spontaneous sentence, we do not have in our conscious mind how it will end. Sentence construction is done on a subconscious level, while we observe our listener, wait for the coffee machine to finish cycling, and wonder what that unpleasant smell is in the office lunch room.

The actual work of scanning, so-called, can only occur when a decision has been made to use that word in a particular sentence, in a particular grammatical construct. And given that in spontaneous speech one sentence cannot be logically constructed until the previous sentence is already known, we have to assume that the horizon for knowing upcoming words is very short.

What it comes down to is that it is difficult to imagine how one could scan for a word in the second half of a sentence until already engaged in speaking the first half. One could say that we need to know where our subconscious speech production center is taking us before we can know what our next steps will be.

Let's look at some examples. In a simple sentence of a single clause, the final words of the sentence may come to our conscious mind after we have said the first few words. This is not a matter of scanning ahead; we simple know where the logic of the sentence is going before we finish speaking it.

In a longer, more complex sentence, we may perceive the words that will begin a second clause as we approach speaking the end of a first clause. This may also be true of sentences. We may know as we finish one sentence how the next sentence will begin. This is less a matter of scanning that of gaining consciousness of the next few words in a package immediately before we speak them. We could make an analogy to walking in the woods. We do not scan up the path to prepare for rocks and roots on the ground. Rather, we keep an eye on the path immediately in front of us, and adjust our footfalls only as we reach the obstacle.

We can now ask whether this process, whatever we call it, is unique in any way to stutterers? Does it really require a life-long experience with a speech pathology to be occasionally conscious of the next few words to come as we speak? Being a stutterer, I can't speak for non-stutterers, but I suspect the answer is no. A reasonable assumption is that everyone becomes aware of upcoming words as they become 'next in line' for speech. For the normal speaker, this awareness is ephemeral and trivial. They might use it to edit themselves, but the operation would be a barely conscious one.

To sum up: I believe that what is being described by the term 'scanning ahead' is not scanning at all. The fear of saying certain words - and of stuttering while doing so - is not scanning. The consciousness of immediately upcoming words during speech could only be called scanning by stretching the word to its breaking point. A page of text can be scanned down a few (several?) lines while reading. Paragraphs of speech yet to be formed in the mind cannot be scanned under any effort of the imagination. The knowledge that certain words are associated with particular subject is not scanning - it is a static state rather than an active process. So while the term 'scanning ahead' points to a very real phenomenon - an effort of circumlocution to avoid a stutter block - the word can only suggest to non-stutterers something far beyond what actually occurs.

And why does it matter? It matters because this field is so full of obscurantist language that it is difficult to discuss the pathology using the standard jargon without necessarily being led astray by the very terms themselves. Word fear is very real, and can interfere with communication when it results in meaning-destructive circumlocutions. And that process of generating any such circumlocutions can, in itself, reinforce the fear that began the cycle.

I would suggest that rather than scanning ahead for difficult words, stutterers are simply alert to the occurrence of such words in their speech as they bubble up in consciousness. Anxious alertness would be a better descriptor than the 'scanning ahead' cliche found so often in the literature of stutter.

Monday, December 5, 2011

Role Models Revisited

In an earlier entry, I discussed the standard list of 'famous stutterers' that we see so often. While re-reading that entry before writing a new post, I was reaquainted with the following comment:

"Hi Mark, I think there is huge benefit in studying those who have managed to improve their fluency or have cured themselves. In many cases it would seem that career success has improved their confidence, so weakening the stutter to a point where it is no longer an impediment. Confidence seems to be a major ingredient in improvement. I believe this is due to the fact that confidence reduces tension levels, so improving fluency. Regards.

I'll use this response to my more critical take on stuttering role models to amplify on my concerns. Let's start with the list provided by The Stuttering Foundation. The list is too long to copy and paste here, so I'll refer to it and encourage you to read it for yourself.

I'll put these people into categories other than the ones listed on the web site. First, there are the professional speakers: actors and politicians. Their relevancy to stutterers is that when they do speak in public, they never stutter. These would be the people refered to in the quote above.

The professional speakers actually fall into two sub-categories - those who have experienced effective recovery (they don't stutter any more), and those who have gained what might be called a 'situational' recovery. The first group are part of a very rare minority of persistant stutterers who simply stop stuttering. Whether this is because of their acting or public speaking experience, or whether they were bound to recover in any case cannot be said for sure. What we know is that they are rare exceptions to the rule of persistant developmental stuttering.

So what do stutterers learn from those who have recovered? Is drama class the cure for stuttering? I see no suggestion in the stuttering therapy literature that it is. I would speculate that those who do recover are likely to come from the mild range of the condition, and are probably more amenable to the powers of suggestion and 'confidence.' It is difficult to gain such confidence when the first attempted word is mangled by a seconds-long struggle. For most stutterers, surely this is not a reasonable path to follow.

The second sub-category of professional pubilc speakers fall under the heading of situational or performance recovery. I believe that actor James Earl Jones belongs in this group. As well noted in the literature, some stutterers can speak without blocking when adopting a 'different' voice. This can be an accent or a caricature voice, or through adopting the role of another person, as in acting.

This sort of stage 'cure' for stuttering is certainly interesting in an academic sense, but what does it do for stutterers? There are only so many acting jobs available, so actor is hardly a profession to which stutterers can reasonably aspire. The performance 'cure' is really a sort of trick - a dramatic (pun intended) one, but a trick none the less. The fact that some stutterers can pull it off while still stuttering in 'normal' life is interesting only in the sense that it is a curiousity. If it was any more than a curiousity, then we could all use the same 'trick' in school or in our jobs. We can't.

Also in the first group are singers. Of course, we know that many stutterers can sing without any sign of stuttering block. This is one of those curious facts of the condition. What does it tell us that Carly Simon and Marc Anthony and John Lee Hooker stuttered? They are successful through their voice, but not through their speaking. And stuttering is a speech pathology, not a voice pathology. These are/were very successful people, but their success did not come from 'overcoming' their speech disorder. Their success came from sidestepping it. I don't know how severely the singers on this list stutter, but as far as I know only Mel Tillis was known by his audience as a stutterer. And it is Mel Tillis who makes my (very) short list as true role models. More about that later.

Next on the list is athletes. These are people who are rarely if ever called upon to speak during their day-to-day jobs. I'll note here that I live near Boston. Damien Woody played at Boston College, and then spent five years with the local New England Patriots. In all the time he was here, I never heard a mention of his stuttering. To what purpose is his name put on this list? If you are 6' 3" tall, weigh 320 lbs, and can move like a cat, and stutter, you too can be a professional athlete? I've seen Tiger Woods interviewed, and I've seen no evidence of stuttering. If I wasn't told, I wouldn't know. Again, if you have freakish skills hitting a little ball into a coffee cup, you too can be rich and famous.

I'll add to my short list by citing Johnny Damon. As a Boston resident, I learned that during his time with the Boston Red Sox, Damon successfully dealt with his significant stuttering to the point where he could do radio interviews. It was clear during these interviews that Damon stuttered, but he was willing to put himself on the spot, and was able to communicate clearly and without obvious stress or serious blocking.

The writers? The best that you can say is that the writers prove that you can be successful in life and even famous if you find a career in which you never have to talk. I think we already knew that. Maybe for children this could show that stutterers are as smart as anyone else, but how many children will be impressed by John Updike and Somerset Maugham?

The short list of journalists include the recovered like John Stossel, and tycoon Henry Luce, of whom we know nothing related to his stuttering. Was it mild or severe, or did he recover as well?

The politicians include people like Joe Biden, Frank Wolf and Tom Kean, who don't appear to stutter at all. Their cases can be looked at in two ways. First, their example holds out the hope that you, too can be one of the tiny minority of the 'cured,' and go on to success. To what degree lottery winners should be role models for investors is open to debate - to say the least. On the other hand, given that there are no stuttering (as opposed to formerly stuttering) politicians today that I am aware of should tell you that if you do stutter, there is no evidence that you have an icicle's chance in Hades of being successful in American electoral politics.

Then there are the business tycoons. Like the politicans, I suspect we're dealing entirely with the recovered. I've heard Jack Welch and Stephen Brill speak, and neither stuttered. A quick trip to YouTube shows that John Sculley intersperses his speech with momentary pauses that could, theoretically, be the remnants of a former stutter. On the other hand, let's face it - he doesn't stutter. The same two possiblities as above hold here: either you can use these people under the 'you may be one of the lucky few' banner, or you can accept that if you're going to be successful in business at a high level, you can't stutter.

The Moses and Demosthenes thing? Please - don't embarrass yourself. They may as well be King Arthur and Hercules. They are there just to pad the list.

So let's summarize my take on 'Famous Stutterers' lists. They are grab-bags of those who don't stutter and are successful, those whose careers depend on their not having to talk and are successful, and those whose careers depend on their not having to talk and are successful while also talking to the media. The latter consists, as far as I know, of Mel Tillis, Johnny Damon and Bill Walton. And Bill Walton may be a case of situational recovery, with his television appearances being done in 'performance' voice.

The best I can do is to say that these lists show children - and adults who don't stop and think - that they are not inevitably doomed to failure in life. This is true, in a literal sense. Unfortunately, it is also true that Mel Tillis is the only person on the list that I know of who became famous on a national level while being known - and observed - as a stutterer. And his stuttering was incidental to the performance of his profession. I know of no other person successful on a national level who stuttered openly on national television. The only other person who comes close to fitting the bill is Johnny Damon, and he spoke rarely and only to a local media market.

Tillis and Damon are people you could point to and tell your children "see, they stutter and they don't let it stop them." They were not only successful, they were successful while being stutterers. I think that is a far more powerful message, given what we know about success rates of speech therapy, than "if you can stop stuttering entirely- somehow - you can be successful like (fill in the blank) too!" Giving stutterers hope by way of the 'cure lottery' surely must end in tears for most stutterers.

Now that I've been thoroughly negative (again), I'll take some responsibility and suggest how it could be done better. The list we need is not basketball players and singers and recovery freaks. Far better would be to find stutterers who are successful in their professions, and still stutter. That would include those who have their condition mostly under control, but are still subject to some speech disordering.

A stuttering engineer from New Jersey who has received three promotions at his workplace would be a far better 'role model' to my mind than a long list of 'Famous People,' most of whom do not, in fact stutter. A stuttering pizza shop owner, or a stuttering plumber would be more comforting to the average stutterer than a Hollywood actor who makes a living out of perfectly controlled speech. Most stutterers will be far more concerned with getting and holding a job that will cover a mortgage and pay for a child's dance lessons than being 'famous.'

The replacement of 'famous' (mostly former) stutterers with stories of successful stutterers who are just 'normal people' is what stutterers - particularly young stutterers - need. Not Moses and a Hollywood actress you've never seen stutter. And while I'm at it, a photo gallery of the hot wives (and husbands) of stutterers would serve a valuable purpose as well. Think about it - do teenage stuttterers dream of being Joe Biden? I don't think so. On the other hand, attractive companions are rarely far from their minds.

I'm serious about this - a single 'hot spouse' photo could do more for teenage morale than one hundred captains of industry or professional athletes and all their money and fame. Can someone get on this?

Friday, December 2, 2011