Monday, January 23, 2012

Neurogenic or Acquired Stutter?

Even CNN knows!

I happened to find this clip after I wrote the text for this entry.

Just when you thought there couldn't possibly be any more stutter word police, I'm back with more! This one only came up because I met a man with a neurogenic case of stutter last week. Neurogenic stutter describes a condition that comes on due to either physical damage to the brain, through injury or stroke, or secondary to a disease like Parkinson's. Neurogenic stutter can also be caused by prescription drugs, and may disappear when the drug or dosage are changed.

Until now, it hadn't occurred to me, but using neurogenic in opposition to developmental stuttering is not proper usage. And in fact, there is another, correct term used: acquired stuttering. These two terms correctly differentiate between a condition that comes on during development and one that is not development-related, but is 'acquired' regardless of the developmental process.

The Stuttering Foundation has an informational web page for neurogenic stuttering here. Interestingly enough, in the reference section, they cite multiple papers that use the term 'acquired stuttering,' and two using 'acquired neurologic(al).' So obviously, the profession hasn't made up its mind on this subject.

My preference goes beyond wanting to align the rationale for the two terms along logical, developmental/non-developmental lines. The reason is that I believe that the evidence is clear (to me, at least), that developmental stutter is neurogenic. The only difference between the two conditions is that one results from existing neurological abnormalities and is expressed during development, and the other is expressed when damage is done to an otherwise healthy neural speech system.

As a practical matter, the shift away from using the term neurogenic stuttering would require pointing out to people in the field that no, developmental stutter is not 'learned.' It has an organic, neurological basis, just like acquired stuttering. This is another effort on my part to stick a fork in the effort to save learning theory and sneak it past the door. Stuttering is not learned. Whether it is always an inherited condition or not is not proven, but I am confident that it is organic, and distinction not made often enough. There are those in this field who give lip service to acknowledging the evidence for the organic basis of stuttering, and then sneak behaviorist learning theory in the back door. The less places they have to hide, the better.

Take-home message: Acquired stutter, good, neurogenic stutter, bad.

Monday, January 16, 2012

A Proper Name: (Part II)

So now that we've nailed down what the condition known as stutter 'is' (to may satisfaction, at least), isn't it reasonable to ask that the condition have a technical name that reflects its nature? The profession saw cause to go all technical when it came up with persistent developmental stuttering (how's that for a mouthful?), so I don't think I'm asking too much. Stutter is fine for casual use. But can we not do better? I think we can.

As I've pointed out, stutter is not a random disordering of speech. When untrained people hear it, they know it. And although professionals have claimed to be unable to pin it down(!), we know better. Stutter is a failure of coarticulation, so coarticulation must be a part of any accurate name. The failure of coarticulation that occurs in a stutter block is located inside, not between, syllables. This could be described as an intra-syllabic coarticulation failure, but that would be redundant. The syllable is the smallest natural unit of speech, and syllables are by definition a coarticulated series of phonemes. While being specific, technical names should also be as simple as possible, so let's not add unnecessary jargon.

These coarticulatory blocks we've described occur in a specific manner. First, they occur intermittently. Not only are coarticulation failures actually rare, but they are not consistent. In spite of the point made in the literature of stutter that stutterers tend to block on the same words, in fact this is a statistical construct. Even 'most stuttered words' are not necessarliy stuttered; there is simply an increased likelihood that the speaker will block during that word. The intermittency, or irregularity of stutter block occurrences is, in fact, universal to the condition

As coarticulation blocks are intermittent, they are also temporary. As I described the stutter block as a dynamic paralysis, it is also a paralysis of lasting but limited duration. As with intermittency, the extended-but-transitory expression of the block is fundamental to the nature of the condition. Let me make this point. When non-stutterers make errors in their speech, as often happens, they typically correct them immediately, such that the errors are often not even noticed, much less remembered, by listeners. If the stutter block was simply a failure to coarticulate upon first attempt, then the condition would consist of the failure, followed by an immediate correction. We can imagine that such a condition could exist in a world of hypothetical speech pathologies. Those who had such a condition might be recognized to the degree that the rate of occurrence was high enough, but it would be a subtle disordering of speech, and would be a profoundly different condition than the stutter that we deal with.

At best, a technical name for the condition would recognize its core pathology and its defining factors of execution. That would be nice, but can we fit it all in? How about intermittent transient coarticulation block disorder? Nah, too much. In spite of the fact that the profession is happy to use two qualifiers in persistent developmental stuttering. Unless you follow the habit of speech pathology professionals and immediately squash it down to ITCBD, or perhaps TICBD, it's just too unwieldy. The object here was to come up with a better name, not write a book.

The fact is that there is only one speech pathology defined by coarticulation blocking. Clutterers may also suffer from coarticulation blocks, but they add their own unique disording to their speech. I think that by keeping to that which is necessary to define stutter, we can sort the two conditons out. Thus, stutter, whether childhood or persistent, could be accurately labeled as coarticulation block disorder (or CBD for all you speech pathology professionals). So it's taken 22 paragraphs, but there you are!

And what is the benefit of making such a change? The same sort of benefit that comes from sorting out chronic stuttering (persistent developmental) from childhood and injury-generated. Precision of language is crucial to rigorous thought, and rigorous thought is crucial to understanding. Stuttering is that funny thing people do. "He has a stutter" is the equivalent of "He has a tapeworm." They tell you nothing other than the two are somehow associated. Coarticulation block (or blocking, take your pick) disorder tells you in three words, once you familiarize yourself with them, exactly what is wrong here. This person doesn't have 'a' speech disorder, and they aren't 'disfluent.' They are subject to a very specific breakdown in their ability to produce normal speech.

The speech pathology community benefits from being forced to confront the core of the condition. One can read entire books written by the 'experts' and never see the word coarticulation. Of if it does occur, it is only in passing, and not tied specifically to the core of the disorder. The fact that this is true is mind-boggling. Within the therapy community, the mind-set seems to be a paint-by-numbers 'now do your easy onset,' rather than an effort to deal with the pathology from the inside out. I'll add here that I learned about coarticulation from the work of long-time therapist Courtney Stromsta, so clearly this information is available to anyone who chooses to pay attention to it. To the degree that SLP's do incorporate an understanding of the role of coarticulation failure into their therapeutic program, good for them.

There is a benefit to stutterers as well. Currently, when a stutterer asks 'what is wrong with me?' the answer is 'you stutter.' Well thanks loads. Stutterers know that they stutter - it's the nature of stutter. Few stutterers, however, have the slightest idea exactly what the nature of their speech disorder is. As with non-stutterers, they focus on the superficial mangling of speech, and add their affective reactions to their maladaptive speech. What you get is a knowledge of the obvious, with an added element of subjective confusion.

When you tell a stutterer that he/she has coarticulation blocking disorder, you do two things. First, you let them know they 'have' something, as opposed to their likely belief that they 'do' something. It is the nature of the stutterer to be in confusion, to not be able to explain oneself to oneself. This sense that 'I do something, I don't know what it is, and I don't know why' can only make the development and maintenance of a healthy identity extremely difficult. By giving the condition a name beyond 'that which it does' (stutter), the person who deals with the condition is given a place to assign the symptoms of, and responses to the condition outside of his/her essential self. Stutter does not do this. Nor does persistent developmental stuttering, which only separates out three classes of the condition.

There are many stories of people who have spent years being misdiagnosed (or undiagnosed). Typically, the story ends with the sufferer having a great weight lifted off his or her shoulders when they finally learn what is wrong with them. Even when they learn they have a serious disease, that knowledge is considered better than not having an answer to their questions. I don't think I stretch an analogy too far to say that stutterers are in a similar situation. A stutterer being told 'you are a stutterer' is little better than a person with multiple disconnected symptoms being told they suffer from a 'multiple symptom syndrome.'

And there is a benefit to the general public knowing (to the degree that the name would get to them) that stutterers are not people who happen to talk funny. Stutterers have a unique condition that results in a specific disordering of speech, which results from a specific failure of motor plan execution. The public now understands that the people who were once considered 'retarded' have a particular condition, called Down syndrome. 'Retarded' was (and still is) synonymous with 'stupid.' Down syndrome is not synonymous with stupid; it points to an underlying condition to which the person is subject to. As such, it makes no sense to 'blame' such a person for 'being stupid.' A person with Down syndrome lives their life within the limits of their condition, and are today judged within those limits. If the speech of stutterers were judged in a similar manner, rather than against the speech of those who do not have the condition, we would all be far better off.

And finally, all; professionals, stutterers, and maybe even the general public would benefit from the education that would be provided by the introduction of the new term. A change to coarticulation blocking disorder would invite the questions 'what the hell is that?' and 'why are they changing the name?' Which is exactly what I would want. The central fact of stutter is essentially ignored in the speech pathology profession and unknown by those who deal every day with the condition. A dramatic (re)education on this matter would benefit us all.

Monday, January 9, 2012

A Proper Name: Part I

In the previous entry, I made an argument for the use of stutter rather than stuttering as a name for the condition. By using a noun, we communicate that this speech disorder is the result of an underlying condition, and is not simply a learned behavior, as stuttering, a verb, implies. Stuttering, then, is what a person with stutter does. Thus, when using the term stutter in this way (he has stutter) we tell the listener that the speaker is not just talking funny; he/she has a condition that causes their speech to be disordered in this particular way.

I allowed in the previous entry that the relatively new term persistent developmental stuttering has its place, though preferably as persistent developmental stutter. However, while the two modifiers do serve a valuable purpose in making a distinction among the different types of stutter (non-persistent and non-developmental), I am still not satisfied with even this more technical name.

Persistent developmental stutter works because when we see the word stutter, we know to what is being referred. In that sense, the name works perfectly well. However, while the two qualifiers (persistent, developmental) distinguish the life-long condition that develops in childhood from the passing childhood and neurogenic (injury-induced) versions, there is still a problem with the base name - stutter.

While the terms persistent and developmental were applied to serve the need of the speech pathology community for specificity and clarity, they retained the base name stutter. This word, of course, is onomatopoeic, coming from they stereotypical phonetic repeats that are common to the condition, and is typical of names used for the condition in many languages. It is not, however, a scientific name, and does not, as is the case with persistent and developmental, specify anything. It is simply an agreed upon label that points to the condition if one already knows what stutter is.

I'd like to suggest that what is needed is another, more precise term for the condition. We need a name that specifies in itself exactly what is being referred to, in rigorous language. Just as there is value in separating out persistent developmental stutter from non-persistent developmental stutter and neurogenic stutter, there is at least as much (if not more) value in specifying in a name exactly what the condition, whether persistent or not, is by nature.

So what does it take to provide a concise name that is necessary and sufficient to define what the condition commonly known as stuttering actually is? Many definitions of the condition include the phrase 'is characterized by' (as in 'stuttering is characterized by repeats and prolongations'). This may be so, but it does not tell us what the condition 'is.' To do so, we have to go beyond what the naive observer sees, the so-called stuttering, and tease out the essence of the disorder. The fact that the field of speech pathology considers this effort so rarely is remarkable to me in the extreme.

As I have pointed out elsewhere, discussion of 'disfluency' only serves to obscure understanding of the condition. The disorder of speech observed in stutter is the result of a pathology of the speech process, and is specific to that pathology. Stutter is not just a speech disorder; it is a unique speech disorder. In spite of decades of effort on the part of researchers to deny it or obscure it, the simple fact is that stutterers stutter, and no one else does. There is no scale of disfluency on which stuttered speech can be located.

If the above sounds like strong language, the reader is invited to explore the literature of this field. Entire books are written on the topic of stutter without ever locating rigorously what has been called the 'moment of stutter.' In fact, again and again, you will find leading names in the profession describe stutter as 'repeats of phrases, words, syllables or part words.' This is so common that quoting a particular 'expert' would be unfair (Woody Starkweather, hint hint).

In fact, there is nothing in the repeating of phrases or words that is unique to stutter. Nothing. And in fact, repeating of whole words (much less phrases) is only trivially connected to the fundamental pathology of stutter. Such verbal behavior is analogous to the person who hold his hand to his jaw when he has a toothache. One follows on the other, but the core fact of a toothache is not that one holds one hand to one's jaw to deal with the pain. The essential fact of toothache is tooth decay, a particular biological process that results in the stimulation of a nerve.

Just as a toothache has an essential fact, so does the speech pathology of stutter. There is the essence of the pathology, and there is 'the rest.' While the profession of speech pathology (I'm thinking of research and theory here) has long been obsessed with 'the rest,' I am focused here on the core of the condition, and will allow other to concern themselves with the rest.

This core pathology of the condition stutter is found in a failure of coarticulation. To discuss this much-ignored fact, we need to define our term. When we assemble words from sounds during speech, we do not simply voice the different sounds, or phonemes, in sequence, like beads on a string. In you try to voice separately the individual sounds that make up your words, you will quickly find out what a slow process it is. In fact, even with practice, words spoken by sounding out the individual phonemes in sequence will always be much slower than simply saying the words naturally. The reason for the difference in natural speech and one-at-a-time phoneme speech is the process called coartiulation.

Coarticulation is such a subtle and natural process that it is unknown to those who use it. It is best described by an example. Think of a playground see-saw, and say the word. 'See-saw.' Now say it again, slowly, listening very carefully to the two 's' sounds you produce. If you listen carefully, you will hear that your two 's' sounds are different. This is because when you began the 's' in 'see,' your mouth (your 'articulators') was already prepared to sound the 'e.' And in the same way, when you began the 's' in 'saw,' your articulators were already in place to produce the following 'aw.' This is coarticulation, the modification of one phoneme to allow the rapid articulation of the next phoneme.

For those not familiar with the concept of coarticulation, think about it now. You have been doing this every day of your speaking life, without knowing it. There is no one 's' sound; there are different 's' sounds for coarticulating with different vowels. We all do similar modifications of phonemes every time we speak, but we all agree that however modified, an 's' is an 's,' and we don't notice the subtle distinction.

As coarticulation is the blending of two consecutive phonemes, a failure of coarticulation must be a failure to proceed naturally from one to the next. And since we coarticulate phonemes within syllables, a failure of coarticulation is more broadly a failure to properly execute a syllable in speech. This is why the essence of the stutter pathology can have nothing to do with repeating words. The failure of stutter is a failure within syllables. Anything else, however obvious to the listener, is superfluous to the essential nature of the pathology.

This failure of coarticulation, the failure to integrate two phonemes into a blended construct, occurs when the speaker is temporarily incapable of carrying out the motor process necessary to execute the intended smooth sequential transition from one to the other. I have called this failure (for want of a better term) a dynamic paralysis. It is dynamic in that occurs during a sequence of actions. It is a paralysis in that when a transition point in an intended coarticulation sequence is reached, the muscles involved in speech production stop executing the intended motor plan.

This failure to coarticulate, what I have described as a dynamic paralysis, is what is known as the stutter block. And the stutter block is the essential fact of the condition. All other observed behaviors, from the stereotypical repeats and prolongations to the 'other' of observed maladaptive speech behaviors, plus the unobserved avoidance, anxiety and fear are all the consequence of the coarticulation block. The temporary inability to coarticulate is stutter. as the inability to regulate blood sugar level is diabetes.

Continued, next entry.

Monday, January 2, 2012

Knowledge > Empathy

Within the speech therapy community, there is a wing that actively promotes the virtue of empathy. That is, therapists are told the value of empathizing with their clients. I think it is reasonable to say that the empathy-based practice is being contrasted to the 'speech correction' emphasis of the fluency shaping school of stutter therapy. So the empathy-based practice is rooted in a primary concern for the psycho-social elements of stutter, while the fluency shaping seeks to eliminate all stuttering, and in doing so, eliminate the cause of any psycho-social disturbance.

Now speech therapy is a helping profession, and in such fields it is always good for the clinician to be a people person. If one is going to help people deal with their problems, a misanthropic or uncaring personality is going to struggle to enjoy the work. I am, however, wary of a special emphasis being put on empathy.

Empathy is not a (cognitive) understanding of the feelings of others. Empathy is the ability to recognize the feelings of others, and to feel with them. In five minutes, I can tell anyone in dramatic terms what it is like to be a stutterer. I can share the usual suspects of the stutterer's inner life; the childhood traumas, the self-doubt, etc. And once I tell them, they know what they need to know. I have no interest in their 'feeling my pain,' although I do see the value in their understanding it. And that understanding is not empathy.

If I went to a speech therapist, I would want her/him to know what works and what doesn't. I would want them to be able to personalize their particular method of therapy to fit my situation. And I would want them to know what to expect from me as I attempt to follow their direction. In other words, I would want knowledge and experience. I would not want hugs, of any other such touchy-feely-ism. My problem is not a lack of love - my problem is a speech pathology. That's why they're called speech pathologists, no?

The affective aspects of stutter play a huge role in the condition. Stutter is a pathology of speech communication that has a major role in social relations and in personal identity. Put simply, being a stutterer is a bitch. But I would far rather have a therapist totally lacking in empathy, but with a deep understanding of both the objective and subjective experience of stutter, than a deeply empathetic clinician who followed a therapeutic script without understanding of the condition.

There may be times when it is advantageous for therapists to play the 'I feel your pain' card, but that could be done based on the practical value of doing so, without any particular empathy-based feelings. What is needed, in such cases, is not a sharing of feelings, but an understanding of how the client's feelings are getting in the way of therapeutic progress.

I have no doubt that the negative baggage we stutterers carry is the single greatest barrier to long-term success in therapy. My efforts on this blog have been focused almost entirely on stutter as a pathology of speech, in reaction to the non-speech emphasis I've found so often in discussions of stutter. That does not mean that I don't see value in understanding and coming to grips with the affective, reactive elements of the condition. But I see no reason to raise empathy to anything beyond a starting point for those in the helping professions.

Knowledge is power; empathy is not. Ultimately, there is something wrong with a person who stutter, and that something needs to be dealt with as far as is possible. Doing so requires understanding on the part of the therapist and the client as well. The more stutterers understand of their condition, and how they react to it, the less you will see anything to be empathetic about.