Monday, June 24, 1996

More on stuttering as "inappropriate control"

Excerpts from a discussion with therapist Barbara Dahm

I certainly agree that "paying attention to ones speech" contributes a lot to the syndrome. As a therapist I would also attack this aspect (as I have for myself). What I react to is the notion, implied at least by some, that this is the "essence" of the problem. I am worried that the pervasiveness of this notion has hampered serious research in stuttering.

"Therapies usually are about finding appropriate ways to pay attention"

Agreed. In the end the only "appropriate" thing to do is not to pay attention, but the best way to get there varies from person to person. What was appropriate for me was to bring the attention from the speech level to that of my overall "state" of being (tension etc.)

"motor processes like skiing, walking, dancing, playing tennis do disintegrate when under conscious control"

I think you are reinforcing my point here. The body typically "knows" how to establish the needed "unconscious" control. We have very sophisticated learning mechanisms that can tell the difference between fluent and non-fluent speech, and everyone has enough periods of fluency for the body to figure out how to do it right. In stuttering, our brain not only hasn't learned how to do it right consistently, it even learns how to make it worse. I cannot believe that after millions of years of evolution we are so maladapted to do that in the face of some initial "mistakes" (akin to falling as a baby) or environmental pressures.. UNLESS there is some fundamental mechanism that is not working right.

"we have to stop trying to look for the one and only cause. A whole system is involved in producing speech"

There are two separate issues here. If you are dealing with therapy you do have to somehow break down the "system" and, in this sense, I agree that looking for "one cause" would not be of immediate use. However, if your purpose is to really do research in stuttering and eventually find a "real" cure, I think "one cause" that might precipitate other concomitant factors is quite a worthwhile pursuit.

"The fact that you don't think about the words most probably contributes to the fact that your blocks are rare"

Yes, in my less humble moments I also attribute my great strides in fluency to my change in approach to speaking over time. Other times I wonder whether age alone would have done this anyhow and I am just fooling myself (and others...). This is a point I keep coming back to, but I seem to find no "takers". What I am asking in essence is: is there a form of chronic adult stuttering that tapers off in time? The analogy is with childhood stuttering... only it takes 40 years instead (I am now 51).

"Perhaps speaking is difficult at certain stages in (children's) development and this causes them to put more conscious effort into the task."

Perhaps... Yes, you make a good point. I would bet against it, but this could be researched if it hasn't already.

"People who stutter need to produce speech, not push words out. That means that all of the processes have to work correctly including not thinking about words"

... and including whatever neurological mishap set the whole system up in the first place. What I wasn't agreeing with was that thoughts or perception of inherent "difficulty" might cause the problem in the first place.

(about my point on stuttering as a "comunication disorder")
"Yes, the listener does influence PWS's to use more controlled speech processing so they stutter more when communicating with others."

Maybe, but what I was really saying is that the unconscious ways in which the brain gets set to "communicate" , neuron excitation, chemicals whatever... is in fact different from that of the brain "at rest".

"This is just another opinion as well but I came to it by learning from my clients and seeing what allows them to make gains in therapy."

Both your observations and your successes speak for themselves. I hope my musings about causes, and love for discussion, were not interpreted as doubts about your therapeutic approach.

Friday, June 21, 1996

Stuttering "because" of (unneeded) conscious control?

The question was posed as to "why people don't stutter when alone or with pets"

(My answer) I have stuttered talking to my dog during a nightly walk.. (and I consider myself "RECOVERED"!)

Barbara Dahm's answer was that "people stutter because they try to consciously control the way they speak".

I wish I had a dollar for every time I've tried to question this theory. We pay attention to our speech BECAUSE we have problems with it, we DON't have problems because we pay attention. It is certainly true that "paying attention" can in fact make things worse, on the other hand isn't much therapy about finding "appropriate ways" to pay attention?

Why don't we have 2% of the population falling all over the place because they somehow developed the bad habit of looking at their feet?

The (fortunately) rare times when I am still caught by a block, invariably come as a complete surprise. I absolutely do not pay attention to my speech and do not "fear" the word I block on (I did have such fears early on).

(Barbara:) "some possibilites are that this is learned behavior"

Some behavior is certainly learned and can add to the original problem

" a reaction to an inherited weakness in the speech system"

This is my belief (with inheritance and other factors playing varying roles)

"a reaction to the belief that speaking is a difficult task and must therefore require more than automatic processing"

I very much doubt this. Look at children... they just simply "do it". If they stumble it's because, for them, it is in fact difficult sometimes, not because they "think" it is difficult. Stutterers become frustrated precisely because they know it "isn't" difficult, as shown in their wonderful moments of fluency... yet they have problems. We PUSH and think "why isn't the damn word coming out???". Our problem is not in believing that speaking is difficult, it is in believing that stuttering is difficult (please forgive the slight paraphrasing of Van Riper - correct attribution? -).

" just to name a few. Maybe some of the PWS's on the list can come up with some other reasons."

well Barbara... one good reason is better that lots of bad ones, and you did have it. To answer specifically about the alone vs not alone business one simply has to understand that stuttering is not a "speech" disorder, it is a "communication" disorder that affects speech. The process of communicating original thoughts sets up the brain in a state that is different from that of the brain "at rest" or singing or reciting etc. Apparently it is in this state that our "breakdown" is most likely to occur.

Of course all of the above are merely opinions strongly held by me and many others. It would be great if they could be definitely proven right or wrong.

Wednesday, June 19, 1996

Stuttering in children of PWS's

I think we have a HUGE opportunity to do something here. The following points have come out loud and clear:

1. The idea that early intervention may be the best opportunity to prevent stuttering seems to be one that both "psycho-environmentals" and "organicists" (I am one) can agree on.

2. Most parents who don't have experience with stuttering tend to follow the advice of pediatricians and "just wait"... This makes pediatricians happy since being right 90% or so of the time is pretty good track record...

3. A small percentage of the same parents will bring a child to a stuttering clinic and simply trust that the treatment will be appropriate.

4. Ironically, parents who stutter aren't in the mood to either trust the pediatrician (we were the 10% that got stuck with stuttering) or the clinic (real competence with stuttering has seemed all too rare for adults - present list excluded - ... will it be easier to find for our children?).

Is it any wonder that parents who stutter(/ed) are tearing their hair off?

Just to relate my own experience: I have a 4 year old. About 1 or 2 years ago he started having occasional whole word repetitions, seemingly without effort or frustration. In one instance, however, the repetition seemed to go on forever... He still seemed to take it in stride, but my wife looked at me and my heart sank to my feet. I was bracing for a rough going from that point on, but instead he settled into his previous occasional effortless repetitions. I sought advice from an SLP on this list (to whom I will be eternally grateful).

His advice included things I could do (and which I did, although fortunately the need seemed to remain relatively rare) and the notion that the approaches different therapists will take to dealing with children indeed vary, and he could not endorse them all.

So here is the rub. It's not just a matter of PWS trusting or not trusting SLPs. If you put 10 SLPs in a room and asked how they would deal with your child your would get ...well probably not 10 substantially different answers, but at least a couple of "camps" with fairly intense disagreement. Now, this is only natural and should come to no one's surprise. As adults we have the "luxury" to try out what works for us and there are members of this list that would swear by one camp or the other. The problem is that with children, we are told, the "window of opportunity" closes rather quickly, and all therapy "camps" are buoyed by the high success rate due to spontaneous recovery.

By this time I have little hair left... SO WHERE IS THE OPPORTUNITY I mentioned at the beginning? These I my suggestions:

1. Stuttering organizations should conduct an "all out" educational outreach to parents and teachers.

2. SLPs should make their approaches and philosophy regarding treating children as explicit and clear as possible. If "labels" are possible all the better, but this information should be made available in a national directory. The idea is that parents should be able to look at this directory and make an informed decision on the type of therapy they want their children to undergo. Again, there is no time for trial and error here... so, we need to know as much as possible in advance. Of course if all SLPs could agree on what's best and possibly create a specialization area in childhood treatment, that would be great too!

Fundamentally parents ought to be told not only that it's a good idea to bring children to therapy ASAP, but also WHAT types of therapy are available, WHO is doing it and where (Ira would surely add "how good it is" but I am sure that would be too much to ask of any humans...).

To end on a happy note, my child continues to talk quite happily. At this point he shows some occasional very minor mid-word hesitancy (as if he needed to catch his breath to finish the word) and no repetitions. He talks non-stop sometimes even in Italian (which I speak to him constantly). I keep being alert, but my worry has considerably lessened.