24 years with a stutter: a long guide with personal experience, advice and true stories

Jose Antonio Garcia Higuera

Born in Madrid in 1947.

Candidate of Sciences in Psychology. 1999 National University of Education (UNED). (Diploma with honors).

Licensed psychologist. 1979 Universitad Complutense de Madrid

Degree in Mathematics. 1969 Universitad Complutense de Madrid

Accredited psychotherapist. FEAP (Spanish Federation of Psychotherapists). ASETECCS (Spanish Association of Social Cognitive Behavioral Therapy).

Introduction

Most people who stutter have no psychological problems other than those associated with their stuttering. Most of the psychological problems that people who stutter have are related to their stuttering. In other words, if people who stutter could speak fluently and smoothly, they would not have any other problems. Van Riper (1973, pp. 211, 213) said, "The neurosis, if present, is usually the result of a traumatic experience of speaking...these stuttering people were unhappy only because they stuttered." This article, which focuses on the psychological problems associated with speech disorders, attempts to illustrate, by describing the treatment chosen in this particular case, some of the mechanisms and processes that may be involved in the development of psychological problems in people who stutter.

Stuttering can cause psychological problems, which in turn can impair speech. Solving psychological problems is not always a direct consequence of improving speech. The use of cognitive behavioral therapy techniques may be a fundamental principle for achieving better health in some cases.

Stuttering leads to the fact that a person gains the experience of losing control over his body in an extremely important situation - during interpersonal communication. Loss of control over one's own body can cause situations similar to those mentioned by Van Riper (1973, p. 330). In this case, the resulting blockage is so intense that external intervention is required to eliminate it. Van Riper compares this human experience with the results obtained in experiments with dogs, which were inevitably punished. These situations have given rise to the phenomenon of learned helplessness (Abramson, 1978), which is believed to play an important role in the onset of some types of depression.

Several years ago (1908), Yerkes and Dodson established a connection between the level of activation and performance indicators. If we are “too under-activated,” that is, in an almost sleepy state, our performance will be very low. As activity increases, our performance also increases to reach its optimal level. This optimal level of performance corresponds to a certain level of activation, which depends directly on the type of task and the individual characteristics of the individual. If the process of increasing activation continued, our performance would quickly deteriorate. A person who stutters, when he tries to speak, must make more efforts to formulate and express his thoughts correctly. Applying such efforts implies an increase in activation, and accordingly, a decline in performance can easily occur. When faced with failure, the subject experiences anxiety, which in turn further increases activation. This creates a feedback loop that sets up more and more blocks and finally leads to a feeling of loss of control over one's body, making stuttering inevitable. In psychology, loss of self-control has traditionally been recognized as a leading cause of depression. In recent years, the inability to control oneself has also been identified as an important culprit in the development of anxiety disorders (Zinbarg and Barlow, 1992).

Depression and anxiety are not the only experiences that can trigger psychological disorders that affect stuttering. Control of speech is of great importance in social relationships. Long-term failures in social relationships generate feelings of frustration, guilt, hostility, and high levels of anger (Van Riper, 1973, p. 264). In addition, improper management of the resulting feelings of guilt and disappointment can disrupt interpersonal relationships, provoking additional social problems that can lead to the formation of many psychological disorders. A person who stutters may have greater difficulty than a person who does not stutter when interacting socially. Avoidance, evasion, and flight from contacts can cause serious problems in social relationships, which give rise to psychological disorders. The effort a person who stutters puts into speaking can sometimes feel overwhelming and overwhelming, and he or she withdraws from social interaction, feeling frustrated, angry, and hostile, which in turn increases existing social problems.

Quite often, when speech problems are resolved, the person’s psychological state simultaneously improves. However, this is not always the case. Sometimes improving the ability to express one's thoughts leads to changes in a person's expectations and contributes to a change in the social environment, which, in turn, can create new psychological problems. For example, in a marital relationship, the ability to express oneself freely can lead to a redistribution of power within the couple, leading to problems that were not previously so obvious. In anxiety and depression, an important role is played by existing ancient patterns in a person's worldview (Beck, 1969), which continue to operate even when they are no longer needed and even in situations where they are harmful. It is necessary to deactivate the influence of such established patterns to solve psychological problems of the individual.

Producing etiological risk factors

Producing causes are understood as “triggers” that give impetus to the appearance of speech disorders . Factors are divided into 2 groups: mental/social and depending on the physiological and anatomical structure of the body.

Detailed information is presented in the table:

Rating of the most common producing causes:

1. Experienced horror - 67.5%.
2. Physical head trauma - 27.5%.
3. Diseases of an infectious nature - 2.5%.

Stuttering can also occur as a result of imitation. The stutterer also accounts for 2.5% of speech copying, but in these cases the hereditary factor also had an influence, since stuttering was observed in one of the child’s parents. It is impossible to determine in percentage terms what role the desire to imitate played.

Case R.

R., a man about forty years old, entered treatment with only one goal - to get rid of his stuttering. At the first session, he could not even say his name, and was able to form only a few coordinated phrases. He turned to this method of therapy after failures experienced with other treatment techniques. Van Riper's approach was a specific plan that had to be followed during therapy, since it was clear that other strategies simply would not be accepted by the patient.

Conclusion:

• Herbs are a burden for a child’s body. If there is no urgent need for herbs (they were not prescribed by a doctor), then it is better to refuse such self-medication.
• Carefully study the properties of the plants that you brew to treat any disease in general.
• Do not prescribe herbal decoctions yourself, especially for a child: take any medicine only after consulting a doctor!
• Do not rely entirely on information from sites on the Internet - even specific medical ones: consult specialists!
• In itself, herbal treatment without complex therapy is a pointless exercise.

And most importantly, while you are trying to cure your child of logoneurosis at home, with herbs, the disease enters a stage at which even real treatment will become difficult and lengthy.

Brief clinical information

R. is the second son in a family with average income. He has three siblings. When he was a year and a half old, he fell ill. To regain his health after his illness, his father had to carry out a recommended rehabilitation program that required great effort and dedication for two years. Following this program, R. achieved sufficient recovery of well-being.

He left school due to spontaneous panic that arose when he was faced with the possible need to talk during the educational process. He found a job in a profession that did not involve regular contact with other people.

Reasons for relapse

What causes relapses of stuttering, what are the reasons that a child begins to stutter again? Most often, relapses of stuttering occur when a child enters puberty. Preventive measures are selected based on the reason for the return of stuttering, so it is important to determine what influenced the teenager.

There are the following reasons why people start to stutter:

• overwork due to increased mental stress;
• general nervous environment;
• failure of sleep and wakefulness patterns;
• incorrectly selected diet;
• minimum support and lack of parental attention;
• poor consolidation of results while working with a speech therapist;
• incorrect work of the speech therapist: for example, the psychological reasons for the development of the disease were not completely eliminated and worked out;
• diseases that impair the functioning of the central nervous system;
• psychological trauma;
• disrespectful, offensive form of communication with a child;
• constant contact with a relative who stutters;
• stress caused by increased demands from parents.

Most often, relapses are observed if stuttering was provoked by an acquired disorder of nerve function or appeared without the influence of external factors.
The likelihood of the disease returning increases if the child forgets about prevention , stops doing exercises and is periodically examined by a speech therapist.

Functional diagnostics

Before starting treatment, functional diagnostics were carried out to determine the predominant behavior and factors influencing the behavioral pattern. This part of the procedure is similar to the identification phase in the approach used by Van Riper.

One day, when R. was an eight-year-old boy, he began to stutter while surrounded by his father and uncle, who also stuttered. Both men laughed at him, and his father, becoming very angry, shouted at the boy and demanded with severe reprimand that he immediately begin to speak normally. This incident determined his personality as a person who stutters. R.'s father is a powerful and authoritative person who established his own laws that apply to the whole family. The father continued to criticize the boy every time he stuttered. In other respects, R's father is a respected man who is loved by R and other family members.

When he sought treatment, his speech fluency was very poor. For example, he could not say his name. Moreover, his existing model of behavior - avoidance - made it difficult for any attempts to build a consistent discussion between the doctor and the patient.

Following the recommendations proposed by Van Riper, the treatment began with the identification phase, where we discovered the words that he was afraid of, avoided, and put off saying. Having determined which situations aggravated his stuttering, the patient discovered that lack of sleep, being too relaxed, vacations and holidays, and intimate contacts were precursors to the aggravation of his speech disorders. In order for R. to speak freely and fluently, he needed to make enormous efforts, which he was unable to do, being in an overly relaxed or tired state.

Another factor that aggravated the speech problem was the length of the phrase: pronunciation of long phrases was impossible for him. Other situations were identified that were problematic for the patient. These were: requests from other people, spoken in an aggressive tone; situations when he himself needed to make a request to other persons, the need to provide personal data, the requirement to repeat what had already been said. A problematic situation for him was the need to answer the phone, carry out a conversation in unfamiliar places, talk with unknown people. It was difficult, and often completely impossible, for the patient to carry on a conversation for more than an hour and a half.

The examined patient also had hypochondriacal syndrome and excessive aggressiveness, but getting rid of them was not accepted by R. as goals of therapy at this stage of treatment.

Treatment of stuttering in patient R.

Reducing Anxiety

The first goal of cognitive behavioral therapy, as in the approach proposed by Van Riper, is to eliminate the patient's excessive anxiety. R. had so many avoidance situations that it was impossible to reduce or eliminate his excessive anxiety in his real environment. This is why a technique that Van Riper called “adaptation” was employed (1973, p. 289). In other therapeutic approaches, this method is called “massive practice” or “flooding technique”. This is a fairly simple method, during which the patient is intensively and repeatedly exposed to factors that instill fear. After a long session, the client feels tired or relaxed. In R.'s case, after an hour and a half of adaptation, he calmed down. As a consequence, in a paradoxical reaction described by Borkovec and his colleagues, the patient became extremely anxious (Borkovec and Sides 1979; Heide and Borkovec 1983). The flood session continued, and R. began to adjust to the feeling of relaxation that came over him. Until the end of the session, a state of relative calm was achieved for the patient. Without such work, R.'s further treatment would have been a failure. An increase in anxiety before relaxation occurs is commonly observed in hypochondriacal individuals (Avia, 1993).

This step in therapy was decisive. R.'s enormous anxiety about his stuttering decreased significantly, and he noted that after the therapy session the improvement in his speech that occurred was impressive. The patient's motivation to continue treatment increased significantly, and the frequency of avoidance episodes decreased sharply. This allowed R. to confront problematic situations for him on his own. For example, he incorporated long phrases into his normal speech after working on them briefly in therapy sessions. Soon he was able to have long conversations that did not impair the quality of his speech. The therapy process allowed him to demonstrate blocking of fear in everyday situations and in front of outstanding people, meeting whom was not accompanied by high levels of anxiety.

At this stage of therapy, high-level fluency and fluency of speech was achieved. However, additional successes began to be achieved much more slowly, since other psychological problems previously discovered in the patient needed to be eliminated. Overcoming hypochondriacal syndrome was chosen as the next goal of therapy.

Other psychological problems of the patient and their overcoming

In cognitive behavioral therapy, treatment goals are clearly focused on problems that patients are able to resolve or are motivated enough to cope with. Other, equally important problems may also exist in the client, but work on eliminating them should be postponed until the course of therapy creates conditions when the client is ready to cope with them. This position does not interfere with therapy, because the patient understands that he is currently solving other problems and achieving other goals. Typically, success achieved in one problem area encourages the patient to confront the next problem and motivates him to continue therapy. If the patient interrupts treatment at a certain point, the results of therapy achieved up to that point are usually consolidated and even have an impact on other aspects of life.

Patient R. had some psychotic disorders that prevented effective and complete treatment of stuttering, primarily the hypochondriacal syndrome present in him. There were other problems, such as aggressive behavior, which came to the fore at a later stage of treatment, when the changes that had occurred in R.'s life, due mainly to the acquired fluency and fluency of speech, showed the importance of overcoming them.

Hypochondriacal syndrome

In this patient, a relaxed state, especially associated with sex, caused a significant increase in stuttering and associated anxiety. R. called his feelings “excruciating.”

In the religious education received by R., masturbation was considered a terrible sin and was seen as the cause of serious illnesses, including madness, tuberculosis, etc. When R. masturbated for the first time and experienced the relaxed state that usually follows sex, he began to fear that he would certainly acquire a terrible disease as punishment for his behavior. The fact that he realized years later that masturbation could not cause any disease, and he became a follower of agnosticism in his religious beliefs, could no longer solve anything. R. had already created and strengthened a conditioned connection between relaxation after sex and excessive anxiety, which had to be destroyed during therapy.

Treatment of hypochondriacal syndrome started with the recommendations given by Avia (1993). The main tool was the use of the body sensation exposure method. The goal of this technique is that the patient gives up his fear of his own sensations, which he interprets as illness. When these somatic symptoms of the body are perceived by the patient as normal, it is quite possible to rethink them and then interpret them as completely acceptable, normal, everyday sensations. The exposure method is used in conjunction with teaching the patient anxiety management techniques, which can quickly reduce anxiety caused by symptoms emanating from the body. Another effective way to reduce fear of your own physiological sensations is to rethink the bodily symptoms that arise and discover your body as a source of pleasure. In the case of R., this part of the treatment was completed completely, including the patient being able to accept other types of bodily sensations.

At this time, R. decided to suspend therapy. The goals of emergency treatment for his stuttering had been achieved, but the patient was not yet ready to confront other problems to get rid of the hypochondriacal syndrome.

As a result of the acquired fluency and fluency of speech, R. changed his place of work to a profession more consistent with his intellectual abilities. When changes occurred in his professional activities and other areas of life, R. had a desire to continue therapy. His efforts to implement changes in his life increased his stress, and the “torment” he felt increased in frequency and intensity. Treatment continued with the same strategies used to improve understanding and control of his own body. When R. felt that his “torment” had decreased and reached an acceptable level, he stopped therapy again.

Anger

At the beginning of therapy, the marital relationship was satisfactory, although there were episodes of violence on the part of R. with his loss of control over his own emotions and behavior. R. verbally attacked his wife, who defended herself by reproaching him for being overly restless, unclean and very aggressive. R's wife did not have sufficient tolerance for violence. From time to time, R.'s passionate and loud speech was interpreted by her as an attack.

Fluency in speech function, changing jobs, and the ability to manage anxiety provided balance in R.'s relationship with his wife. When R. began treatment, he was more dependent on his wife, a successful professional. At the time, his wife used guilt to stop R.'s attacks and reproach him after an outburst. The changes that occurred with R. increased the level of family income, and his social status became similar to that of his wife. Freedom helped him create stronger social relationships. Overall, his emerging tolerance for his own “torments” made him more resilient to his wife's reactions to violent outbursts. All these factors, as well as R.’s repeated therapy, contributed to the emergence of balance in the couple.

At this stage of treatment, R learned to deal with anger by following a program similar to that explained in Weisinger (1988). The abilities achieved in anger management allowed R. to significantly improve his relationship with his wife. R. left therapy without achieving all possible goals: the aggression was not completely controlled, and “torment” also continued to occupy the patient’s thinking. Reducing his own anger became such an important and priority for R that he sometimes neglected potential consequences in his relationships, such as divorce or the loss of the person whom he recognized as “the woman of his life.”

The problems that prompted R. to resume therapy did not affect his fluency and fluency of speech, which remained at a very high level.

Pathogenetic mechanism

There is no clear answer regarding the mechanism of the origin and development of stuttering, but the main cause of the disease in most cases is considered to be a violation of the communicative function of speech.

Difficulties in pronunciation, based on R. Levina’s assessment, depend on the following factors:

• conversational environment;
• type of nervous system;
• speech mode.

The study of the pathogenesis of stuttering made it possible to identify a number of changes in the autonomic nervous system in patients:

• dilated pupils during stuttering;
• increased intracranial pressure;
• extrapyramidal syndromes;
• sleep disturbance: nightmares, convulsive movements before falling asleep, easily interrupted dreams.

What is the mechanism of stuttering from the physiological approach? At the physiological level, a disruption in tempo and rhythm occurs due to a spasm of the muscles of the articulatory apparatus.

Return to treatment for hypochondriacal syndrome

Finally, after several years of good family relationships, R. returned to continue therapy due to stress caused by previously familiar circumstances that increased his “torment.”

After a short course of training aimed at more calmly overcoming his problems, a functional diagnosis established the relationship between interruptions in his rest, the ability to manage anger and the resulting suffering. This conclusion became the basis for continuing therapeutic work, focused on the patient’s acceptance of the emerging feeling of disappointment, gaining control over the emotion of anger and a calm attitude towards “suffering.” The consequences of the rest breaks were no longer interpreted by R. as negatively affecting his feelings that would arise the next day. However, the patient's anxiety was not completely eliminated. At this time we began a controlled resurrection of the original frustrations associated with his father's earlier attacks. In cognitive behavioral therapy, childhood memories are viewed with the understanding that they are likely to have established a set of behaviors that are triggered even when they are no longer functional. These mechanisms are similar to previous settings that were mentioned by Van Riper (Van Riper 1973, p. 337). R.'s automatic response to disappointment was such a previous installation, triggered when it is necessary to solve a problem, and caused “suffering.” Rethinking the old situation and the emotions that arise from it had the goal of finding an alternative solution to the problem in order to first select and implement a new model of behavior (Arnz and Weertman, 1999; Littrell, 1999).

Self-analysis and re-examination of R.’s “suffering” led to the emergence of a feeling of guilt, directly related to his father’s scream and strict demand that he speak normally. Such paternal violence gave rise to a feeling of guilt in R. He felt that he had done something to deserve what he called "God's punishment." His father had absolute power, and appealing his opinions and decisions was not possible. R. felt a total sense of guilt because he could not do the basic things that other people do - speak freely and fluently. This situation, in turn, caused anger directed both at his father and at himself, as well as feelings generated by guilt, which he called “suffering.” Remembering these situations with maximum intensity of emotions, the current R., with his current knowledge and abilities, could tell the previous R. that he deserves neither such enormous criticism nor “divine punishment.” When he realized this, his “suffering” and destructive emotions disappeared during the session. He also realized that the masturbation he was doing had created the same style of thinking. He felt enormous personal guilt for threatening himself with illness and rewarding himself with “divine punishment.” Having understood and accepted this fact, the patient’s “suffering” practically disappeared, and if it reappeared, he already had the ability to quickly change his thinking, accepting the feelings that arose.

Discussion

R.'s treatment, like the treatment of most other cases, is a work in progress. The sequence of his treatment was as follows: first, efforts were aimed at overcoming stuttering, then treatment of hypochondriacal syndrome was carried out (for two years), the issue of overcoming anger and stabilizing family relationships (6 months) and, finally, returning to the problem of hypochondria (3 months) . In R's situation there are still some unresolved issues that are addressed to address the anger, but it is possible that this patient no longer needs additional support in solving his own problems.

It is noteworthy that R. acquired his social identity as a person who stutters. This identity still exists today. Sometimes R. has some blocks that proceed without concern, even if he has a conversation with important people, for example, with the general director of his company. The role of his father is very significant in the patient’s life: it aggravates R.’s stuttering and contributes to the emergence of anger.

Specialists

Treatments for stuttering in children and adults are similar. Depending on the determination of the cause of the speech defect, the attending physician is appointed. There are several of them, sometimes two or more specialists deal with one patient.

• A neurologist and psychiatrist prescribe medication to solve the problem of stuttering.
• The psychotherapist prescribes psychotherapy depending on the characteristics of the person: hypnotization, training.
• A psychologist studies psychosomatics and human personality. First, the patient is removed from the psychological barrier. He is trained to be in society and make decisions in stressful situations.

A speech therapist is a specialist who corrects speech in parallel with the provision of assistance by another specialist. It helps improve speech, use breathing exercises, and pronounce letters and sounds.

The goal of his therapy is not to correct incorrect pronunciation, but to help in realizing that words can be constructed easily in a sentence, regardless of pathology. The patient reduces his fear of stuttering.

An acupuncturist works to improve blood circulation. The sessions used are responsible for a specific organ; in general, the technique helps with mild stages of stuttering. Stuttering is a fairly rare occurrence and can take a long time to correct. If you start to fight the pathology in time and diagnose the correct factor in the development of the problem, then the chances of getting rid of this speech disorder increase sharply.