Anne Marie Simon
Chargee de cours sur le begaiemenr a Paris VI
Ex-Attachee au Lahoratoire Pathologies du Langage INSERM Hopital de la Salpetriere 75013 Paris
4 rue Cecile Vallet 92 340 Bourg la Reine France
Many behaviours are altered when patients are in a situation of stuttering. Overcoming stuttering depends as much on the control of fluency and the modification of stuttering as on the inner building of a “ being able to communicate”. Building a link between his or her inner world and the inner world of the other speaker is the central therapeutic task for the stutterer. The means of such a change will be described here.
When one of my patients tells me he has taken or will take communication training, I know that what he will learn is only a small part of the work I am going to suggest to overcome the difficulties he has because of his stutter. He will work to improve his posture, voice, breathing, and eye-contact for more efficient communication. But other techniques exist that also involve the speaker. These are the social skills of communication, as defined by Lena Rustin, which are specific to a particular group or country. Everyone knows these skills and conforms to them as much as possible. In addition, unique talents exist for each person that allow the establishment of a link between the Various partners in an exchange. These talents allow for a "communication-communion”, the meeting with the other, the exchange between different inner worlds (i.e, this includes relating to the other but also relating to oneself). These talents are often faked or may even be non-existent in stuttering subjects.
It is in this context that stuttering can be seen more clearly as a communication disorder. Those difficulties, the lack of social skills and talents, and the problems communicating are, in my opinion, the negative outcome of all the traumatic and frustrating experiences that stutterers have had since childhood and consequently have gradually led to the construction of the self aa stutterer. Therapy will aim at making these patients people who “communicate better than average” (Gregory 2003) even if their speech remains impaired. Thanks to understanding their own communication and that of others, they will become more in touch with their feelings and thoughts, while at the same time learning to change some behaviours, including shams or pretense, negative thoughts, avoidance and retreats imposed by stuttering.
In France, we believe that it takes two to stutter. It is in this context that the treatment I recommend to my patients takes on a particular meaning. A large proportion of treatment focuses on the role of both speaker and listener in the interaction. Speech motor skills are not neglected in treatment. It is nevertheless believed that the improvement of fluency is directly dependent on the hidden part of the iceberg (i.e, the cognitive, affective and social construction of the individual that has been modified over time until he becomes an adult stutterer). Therefore, it is essential to understand the mechanisms which underlie conversational exchanges, from self-knowledge (what’s felt) to an awareness of others (intuition and empathy). The treatment includes three steps:
- Identify with the patient how he has altered some behaviours during interactions by using defense mechanisms to protect himself in the struggle against depreciation and humiliation.
- Suggest therapeutic methods for change, both as speaker and listener, that address all aspects of communication.
- Commence this change during the training course then transfer it to daily life.-
The behaviours and attitudes which most often underlie the stutterer’s trouble communicating in an authentic and genuine way are:
- Giving in to time pressure (this is a major stumbling block of unsuccessful therapy).
- Hurrying speech production, (i.e, not using the necessary control, whether motor or psychological) and saying everything in a rush.
- Preventing the listener from interrupting.
- Creating unnatural dialogue time, either by speaking too much or too little.
- Fearing silence and feeling pressure to break the silence as well as fearing an inability to restart speech..
Saying no, defending oneself, explaining one’s behaviour, attitudes or opinions: These are high risk situations, where the fear of stuttering results in the person not being himself and not being able to be assertive. This leads to a double whammy, not only does the person say what he doesn’t want to say, but he is also angry with the one who made this happen.
One must not forget the awkwardness felt by the listener who ends up playing the game of pretence while simultaneously smiling, which is of course distressing to the stutterer.
Relationship of the stutterer to the listener
Some patients explain and repeat until their listener understands, not letting that listener take the responsibility to ask for explanations if he has not understood the speech. The feeling of being alone in the conversation then becomes so strong that the ability to listen and observe are seriously 484 Theory, research and therapy in fluency disorders altered. “Two years ago I would have been able to spend a whole evening with someone, to speak for a long time with him, and the following day I would not even recognize him” says Guillaume. This difficulty was expressed by Le Huche (1988) as the inability to use the speech of others. The stutterer is no longer able to use his listener as a partner in the conversation and does not give himself enough time to formulate responses. He does not know how to use the other in order to achieve the message. Instead of following his feelings, the stutterer tends to be sucked in by the strong wish of the listener to hear a certain answer, the one that apologizes and causes the stutterer to put himself down by accepting the unacceptable and not saying what he should have said to be true to himself.
Most of the traits cited can be grouped as types of avoidance. One of the avoidance behaviours that all patients recognize well is to avoid speaking due to fear of stuttering, appearing ridiculous, being judged or considered unworthy. It can also be described as avoidance when the stutterer does not go with his feelings or with those of the listener. In the research literature, the stutterer is often described as someone said to have difficulty with his feelings.
A large part of the awkwardness in the stutterer’s communication is due to blocking of his feelings by rushing as well as to attitudes related to the disorder, leading to an inability to create a bridge between his world and that of the other.
Loss of spontaneity
As soon as the control of speech disappears, spontaneity is lost. Furthermore, the rushing and the tendency to be sucked in by the other’s wish for a reply (the expectation of the listener to hear a reply), along with the pretence; all mediate against spontaneity. Paradoxically, spontaneity requires some inner reflection and cognitive awareness to be truly the expression of oneself. All this cognitive awareness/identification work - the work of becoming sensitive to the processes of conversation - allows one to suggest other behavioural changes.
- Suggested therapeutic techniques
Using cartoon figures engaged in dialogue, we try to identify how people respond, for example, when faced with complimentary, aggressive or surprised comments. Thus, the patient’s tendency to apologize, justify himself or react aggressively is manifested in his reactions to the drawings.
We’ll try to find out together which types of replies could sometimes be better adapted to the context and better suit the listener. Listening is equally important. I agree with Yasmina Bensalah ( 1997 ) when she writes that some patients have so altered their own prosodic abilities - “the reason might be the loss of self listening” - in order to express themselves without stuttering that they do not always notice the intonation of their conversational partner’s speech.
At this stage in treatment, significant factors include the patient’s ability to listen as well as to observe and maintain eye contact, together with the aptitude to anticipate what a conversational partner will say as well as to put oneself in the place of and adjust to the listener.
Using flash cards with simple to complex questions that can be experienced as intrusive at times, the patient learns to respond in front of the mirror. First the therapist models the behaviour and then the patient tries it out using the following guidelines :
- I am learning to indicate politely but firmly that I do not wish to respond to certain questions for various personal reasons. Our patients often raise the issue of not being able to say no. They feel that it is uncomfortable and even rude not to respond. Don’t we all have the right to our own secrets ‘.7
- I am learning to reply only to the question asked, without enlarging on it. Nobody will be frustrated if the conversation stops there.
- I am learning to formulate a response which must relate in some way to the other person: I may allude to the context of the conversation, to the age of the respondent, or to his opinions if I know them; and thus I acknowledge his presence. This develops the ability to reinforce the other, whether I agree with him or not.
While working on fluency employing a simple picture card, we first ask the client to name what he sees, then to give a short description, and finally to state an opinion about the picture. The patient is invited to use different strategies to do this. These include ERASM, resisting time pressure, using pauses and grouping elements on the basis of meaning.
At this stage we introduce the presence of the other by asking the client, having stated his opinion, to add : « I like or I don’t like » and« what about you? ». Thus we enter into the world of associations of ideas, of analogies and the possibility for the patient to’ use mental representations, images and metaphors to open up a common mental space with the picture as support. Fluency is often difficult to maintain under the pressure imposed by a different point of view. Progress is seen in an opening up of feelings, connections or memories (similar to what happens in Scenotherapy: Guilhot, 1989) and enables the patient, by means of images, to communicate often painful feelings.
Using the basic attitudes of Porter, Roger’s disciple (1966), we engage in a conversation about, for example, a problem to solve. We will identify with our patient different attitudes which may be value judgements and interpretations or may show understanding..
This attitude of understanding is the only usable one whatever the circumstance. It shows openness and availability; in other words, an interest in other people and the desire to understand them. Other attitudes are often ambivalent and even to be rejected. Each of the replies given allows one to get closer to one’s own feelings and to anticipate the reaction of the respondent.
Remember it is necessary to respect hierarchy order for the treatment to progress. There will be two axes:
- The increasing complexity of the units during the training, at a phonological, semantic, syntactic and propositional level (load of the meaning ).
- The progressive involvement of the patient in his speech (themes, situations and conversational partners).
On the second axis, the subject will feel stronger at the end of the treatment. In situations where he has to search for his words or to explain his inner world, he will be more able to express himself in front of the other for true communication to occur. The thought process consists of asking the patient to flash back to difficult situations - the ones that made him feel badly, such as conflicts, frustrations, and negative anticipations - and to recall pleasant ones and reflect on his own feelings. He will have to try to understand what may have occurred and whether the listener reacted the way he expected or not. Then he will try the different communication behaviours suggested in the treatment.
In such a way the person who stutters can determine the replies of his conversational partners. It allows him to order them and decide with whom and when he can take the risk of change. To explain how the message is conveyed within himself and within the other, a method was adapted from Bizouard (2000) which enables one to determine how the different zones of communication are organized :
First, there are nonverbal zones between the speaker and the respondent before any words are recognized, analysed, discussed or understood. These zones will then give place to verbal zones which relate to the way the message is elaborated and arrives at the listener’s similar zone. Thus the difference between the intention of the message and the impact of the message can be taken into account. It is often necessary to request clarification in order not to be carried away into negative interpretations.
How to develop the mental space that helps a patient to anticipate nondefensively and to develop an appreciation of the other?
Role playing, discussion, recounting real life situations: All this is the backdrop of the treatment. It is also important to develop work in the subconscious and in the conscious mind by employing multiple forms of representation such as drawing, fantasy, humour, poetry (metaphors and proverbs) imagery, story telling, comparisons, associations and memories. This opens up the psychological work by freeing up affects, and speech thus becomes easier.
Overall this work makes our patient more sensitive to his inner world, to the affective echo of situations, and at the same time increases his ability to listen.
This work puts the conversational partner back into our patient’s mind, eliminates his rushing and restores the link between the two inner worlds where speaker and listener connect. Little by little this communication - communion is constructed. It is helped by mental processes that enable the patient to resist external distractions. This concept of mental processes was developed byMarvaud (2001).
Nothing in this work attempts to respect any particular standard. Standards, after all, vary from one culture to the next and from one socio-cultural group to another. It also does not attempt to make those patients into good communicators in all situations. Is it indeed possible? Are we not surrounded by many people who do not possess the skills that we would like our _patients to acquire? The treatment aims rather to awaken a specific sensibility. This sensibility already exists in stuttering subjects but includes some elements that are unfavourable to a good relationship to the self, including devaluation of the self and the feeling of a lack of respect on the part of others. Furthermore this flawed sensibility leads to difficulties in relationships with others due to the fear of being criticized, judged and other negative projections.
By sensibility, I am referring to a sensitivity to “the voice within” and at the same time a sensitivity to the other’s presence and to the other’s difference.
Then we are looking at a sort of chain reaction. The stutterer listens better, in the broadest sense of understanding and feeling, so his conversational partner hears him better, in turn bringing reassurance and Comfort.
Gains are made in listening, in empathy and -in autonomy. This is far beyond the patient’s initial request to stop stuttering. While there has been no research as yet into this treatment approach, many have testified ten years later that their gains have resulted in a permanent shift in their lives.
To be aware of the rich emotional tapestry that constitutes the self, to know that we are all made in different ways, to be able to anticipate the reaction of the other (having already absorbed his or her presence); all this inner work means that it is less distressing to have recognized that the other person is different and thinks and feels differently. The therapy for stuttering, which is a disorder for communication-interaction, must also include work on communion with the other. In order to do this a bridge must be built between the inner worlds of the two communicators. When the bridge is built, it is a better treatment for stuttering than all the other techniques put together, however necessary they may be.
BenSalah,,A( 1997). Pour une linguistique du bÃ©gaiement. Paris L’Harmattan
Bizouard, , C (2000).Wvre la communication. (pp 67-75) Lyon. Chronique sociale.
Breitenfeldt, D.H.(1989).Successful Stuttering Management Program. Cheny :Eastern Washington University
Cooper E.B. & Cooler, C.S. (l985).Cooper Personalized Fluency Control Therapy.Allen. TX: DLM
Cottraux, J. J .(l993).Les therapies comportementales et cognitives. Paris Masson
Guihot, J..(l989). Expression ScÃ©nique. Paris. ESF
Gregory, H.H.(2003).Stuttering therapy. Boston MA: Pearson Education.
Le Huche, F..(1998). Le bÃ©gaiement option guÃ©rison. Albin Michel : Paris
Marvaud, J ..(200l).Le be’gaiement: hypotheses actuelles. RÃ©Ã©ducation Orthophonique. 206,5-20 Rogers, C: (1966). Le dÃ©veloppernent de la personne. Paris. Dunod
Rustin,L.,& Kuhra,A.(l989). Social skills and the speech impaired. London : Taylor & Francis Simon ,AM.(l993). Attitudes cornrnunicatives gauchies chez le sujet begue. Glossa. 33, 8-13 Simon, AM.(l994).Therapeutic group for adult stutterers. 1 st World Congress on Fluency Disorders Proceedings.423-424. IFA Munich.
Simon, AM. (2003). BÃ©gaiement et communication. Actes du Hlerne Colloque de l ‘APB. Lyon.