Stuttering therapy can be thought of as a two component process. The first component consists of the modification of motor speech behaviors, the second of the modification of psychodynamic features that influence the course of treatment. This presentation will focus on the second, psychodynamic component of the model.
The term "psychodynamic" is used here in a general way to refer to feelings, attitudes, and personality characteristics that often adversely influence the treatment of stuttering. These influences typically take the form of inadequate motivation, resistance to therapeutic change, and relapse following treatment. In fact, these obstacles are not unique to stuttering, but confound most efforts to accomplish therapeutic change. Consequently, this psychodynamic model is not offered as a particular explanation for the cause of stuttering. Resistance to change, as I am describing it here, may be thought of as the psychological analog of biological homeostasis. The organism strives to maintain equilibrium, not only physiologically, but psychologically as well.
Transactional analysis is a system that helps to explain in an understandable way both the internal psychological processes and the interpersonal processes that underlie therapeutic resistance and therapeutic change. Transactional analysis is a dynamic psychological system that was described by Eric Berne (1961). The cornerstone of Bernes system is the description of three ego states; parent, adult, and child, which are active during both the therapeutic process and during interpersonal interactions that occur outside of treatment. These ego states bear a rough correspondence to those described by Freud (1962), the superego, ego, and id. The two systems differ, however, in that Freuds ego states are mainly structural entities, while Bernes are mainly dynamic. Consequently, during therapy the latter are clearly visible to the trained observer.
The adult ego state is recognized by emotionless exchanges of information. For example, "I am typing this paper on my computer. I have one hour to complete it." The child ego state, on the other hand, expresses emotion of two types. One is unrestrained joy, curiosity, love, fear, and anger, while the other reflects constrained adaptations. The latter expressions often sound like a complaining or overwhelmed child. For example, "I cant make this computer work right. It keeps changing the margins of my paper. Everything is going wrong. Ill never get it done on time". The parent ego state is also the source of two kinds of expressions; those which are caring and nurturing, and those which are critical and punitive. An example of the latter might be, "If you had read the instructions for your computer you would not be having so much trouble. You always wait to the last minute. Thats why your paper is not finished yet. Wont you ever learn? If you dont change your ways, you will never be successful."
This last statement, "If you dont change your ways, you will never be successful,"carries with it a particularly odious curse. Statements like this one seem to come from the parent ego state, but are actually constructed by the biological parents child ego state. However, they are interpreted by the biological child as a parental prescription, what Steiner(1974) calls an injunction. In this example, the actual injunction is "Dont succeed". If statements like this are repeatedly presented to a child with strong emotional force, they may become the substance of childhood decisions which shape later behavior.
Berne described the interactions between the ego states of two individuals as "transactions", which have both a social and a psychological component. A series of transactions between the various ego states of two individuals may constitute what Berne(1964) described as a game. A key feature of a game is the presence of an ulterior motive. For example, a patient might engage in a social level exchange with a therapist that would sound like this; "I have a problem and I need your help" (adult ego state). At the psychological level, however, the patient may simultaneously be saying, "I have no hope. Nothing that you tell me to do will help me" (child ego state). It is this latter sort of message that is of particular interest since, if unattended, it will compromise therapeutic intervention. In this particular game, which Berne called Yes, But, the therapist repeatedly offers suggestions to the patient, each of which is rejected by the patient as impossible or unworkable. Finally, the therapist throws up her hands in despair and the patient goes away, vindicated in the belief that the therapist cant help him. Thus the status quo is maintained and the patient does not need to confront the discomfort or pain of change.
The games which Berne(1964) describes serve the function of reinforcing the decisions which individuals make about themselves and the course that their lives will take. These life course decisions are called scripts (Steiner,1974). I am particularly interested in the script decisions made by young children about their stuttering and how those decisions influence the course of therapy. Since stuttering typically begins in early childhood, the force of script decisions made then is particularly strong and resistant to later change. Script decisions are typically made as responses to parental injunctions. Therefore, I am also interested in the scripts of parents and the specific injunctive messages that they transmit to their children.
During this brief mini-seminar, I will describe four case studies that illustrate different types and degrees of injunctive messages and their corresponding script decisions. These include direct injunctions, such as "Dont be fluent", as well as injunctions that operate indirectly, such as "Dont succeed" and "Dont think". A fifth case illustrates the shift in ego state that can accompany successful theapeutic intervention.
The first of these cases has been chosen particularly to illustrate the point that attention to script issues may be important even when the goal of establishing fluency is unsuccessful.
When I first met Steve, he was 4 years old. He was already showing clear signs of dysfluency and his parents were appropriately concerned. Both Steves father and paternal grandfather stuttered. Steve seemed to be a "legacy", destined to be a third generation stutterer. I wish that I could report that through some heroic effort, or just shear luck, that Steve was able to escape this destiny. That was not the case, however. Now, as an adult, Steve stutters severely despite having received intensive intervention and therapy from the time that he was 4 years old. Steves parents were prepared from the start that his stuttering was likely to be a persistent problem, and that management, not cure, was the more realistic pursuit.
Steves parents willingly explored their respective attitudes about stuttering. His father recalled that when he was a child, his mother told him repeatedly to speak slowly. She often coupled this admonition with a direct or implied question, "Do you want to speak like your father?". The implication was clear. It was not acceptable to stutter. His mother did not like the fact that his father stuttered and she did not want her son to stutter either. His inability to meet his mothers expectations resulted in increased tension, more stuttering and feelings of shame. As Steve's father expressed these feelings, Steves mother recognized that her own attitudes about stuttering were also somewhat negative and intolerant. She believed, for example, that stuttering had impeded her husbands career and feared that her sons experience would be the same. Steves father had successfully found and married a person who reflected the attitudes he had come to expect from his own mother.
The objective of counseling Steves parents was to break the cycle of communicating negative attitudes about stuttering. These negative attitudes included instilling a sense of shame in Steve about a behavior that he was unable to completely control and the premise that stuttering would interfere with Steves success in his adult life. We pursued this goal not only by counseling Steves parents, but also by actively communicating an attitude of acceptance to Steve about his speech. The latter was accomplished in part during his therapy with a succession of student clinicians.
In this case the measure of success is that, as a young adult, Steve is without shame and unconcerned about his stuttering, although he continues to stutter quite severely. He has attended college and has career plans that he has chosen without regard to his stuttering. I have discussed with him from time-to-time my belief that he could, with little effort, increase his fluency by applying rather typical modification techniques, such as the use of pull-outs. However, he has no particular interest in expending the effort to attain more fluent speech at this time. Nevertheless, that possibility is open to him if he chooses to pursue therapy at some future date.
The second example illustrates how parental scripts and injunctions can influence a childs response to therapy. John's mother brought him to the clinic when he was 10 years old. She was divorced from Johns father who she reported also stuttered. The positive family history and the severity of Johns dysfluency suggested a strong physiological predisposition. At best, this was destined to be a difficult and challenging case. The situation was further complicated by a strong symbiotic relationship between John and his mother.
From the beginning, it was unclear who was the patient. John demonstrated rather severe stuttering, with numerous head movements, eye-blinks, and obvious struggle. Nevertheless when I asked him why he was coming to the clinic, John told me that he had come because his mother wanted him to and because he wished to please her. He did not mention his stuttering as a particular problem and seemed strangely unmotivated to address it. On the other hand, when I spoke with Johns mother separately, she told me that she felt sorry for John and wanted to do every thing possible to help him. During a session with both of them, I asked John to tell me how he felt about his stuttering and what he wanted to do about it. He shrugged and looked pleadingly at his mother for help about how to respond to the question. A predictable pattern emerged. Every time I would ask either John or his mother a question, each would look at the other before attempting to reply. For several weeks, even when his mother was not present, John was singularly unable to focus on his stuttering as a problem and refused to make decisions regarding his own treatment. Because his persistent passivity was impeding treatment, I decided to spend several sessions with his mother in order to better understand their relationship and its influence on Johns treatment.
During my sessions with mother, she revealed that as a child she and her brother had been abused by their alcoholic father. She and her brother hid under the kitchen sink when they heard him coming home for fear that he would beat them. He repeatedly warned her that if she protested or ran away, he would kill her. Her powerlessness and passivity as a child carried over into her adult life. In some ways John reminded her of her younger brother who she was unable to protect. For example, she confided that she was afraid to send John to visit his father, who now lived out-of-state, because she feared that he would not send John back. Nevertheless, she felt that she could not refuse to permit the visit. She was unable to consider any possible safeguards or recourse if her "worst fears" occurred.
This theme of helplessness and powerlessness in her own life was the apparent source of a similar injunction directed to John. Translated to the specific problem of managing his own stuttering, we might interpret the injunction as "Dont take care of yourself (or your stuttering)". However, it is more likely that this was not a specific injunction about stuttering, but rather a prescription for how to respond to most life events and situations that are difficult.
The paradoxical aspect of this case is that the triumphant moment for John came when he made a quite clear decision to not continue therapy. His mother was not happy with this decision, but allowed it to stand. In some small way, John found a way to separate his own needs from those of his mother. John was 11 years old when he left therapy. He returned to the clinic voluntarily at the age of 19 and successfully learned several fluency enhancing procedures which seemed to satisfy him.
Sometimes the script issues of parents can predispose an otherwise fluent child to become increasingly dysfluent, as is illustrated by the following case. Ryan was a 9.5 year old boy with very mild dysfluencies consisting of occasional repetitions of initial syllables. There was no indication of struggle, no secondary characteristics, nor any self-consciousness about his speech. Ryans mother was beside herself, desperately worried that she had done something to cause these dysfluencies. From the outset it was evident that Ryans mother was far more concerned than the severity of the problem warranted. During the case history interview, Ryans mother revealed that there was a positive family history of stuttering. Her younger brother had stuttered as a child and was still stuttering as an adult. I spent several sessions with Ryans mother in order to better understand the source of her extreme concern.
During our third session together, Ryans mother revealed the following "shameful" story. When she was a child of about 7, she recalled an incident that had occurred. The family, including her 4 year old brother, had assembled at the table for a typical family dinner. During these occasions there was much spirited conversation and considerable competition between her brother and herself for the attention of their parents. She was already clearly aware that her brother stuttered, although she did not have any particular understanding about the problem. She was aware intuitively that her brothers dysfluent speech behavior was something that made her parents upset and uncomfortable. On the particular occasion that she remembered so vividly, there was more than the usual competition for talk-time, and she interrupted her brother frequently to get her parents attention. At one point her mother turned toward her, looked at her severely and said, "If you dont stop interrupting your brother you are going to make him stutter!" She recalled this incident tearfully. She had come to feel that she was somehow cursed as person who causes young boys to stutter. When her own son had produced some normal and unremarkable dysfluencies, she seized upon them immediately as evidence that she was again creating a stutterer.
As we pursued this theme over several sessions, it became clear that the prestige moment which established Ryans mother as a "creator of stutterers" was not really a single incident. It was a repeated theme, which when reinforced over an extended time, established her belief that she was the cause of her brothers stuttering. Now, armed with the critical understanding of an adult, she was able to comprehend what her mother had really meant. Merely to stop interrupting her brother. That realization coupled with specific information about stuttering, how it is transmitted and how it is not, allowed her to relieve herself of the burden of responsibility for both her brother and her son. Subsequently Ryans dysfluencies disappeared.
This particular case should make us mindful that when we counsel parents about how to react and respond to their childrens stuttering, we should also discuss their responses to other children in the family.
The next case illustrates the unusual occurrence of a direct injunction "Dont be fluent". I am indebted to Joelyn Ryan, a former clinical supervisor, for this interesting report.
David was a 7 year old male who had been receiving therapy for stuttering since shortly before his third birthday. During his early therapy he was taught the "bounce" technique in an effort to reduce the severity of his blocks. He used this technique extensively, but on his fluent rather than his dysfluent speech. When he came to our clinic this technique was discontinued. David had well-developed secondary characteristics, including head jerks, pitch changes, leg swinging, arm movements, eye aversion, and the habit of tearing tissue. His baseline dysfluency rate was as high as 50% of his talking time.
One day David arrived for his therapy session and he was completely fluent. At the end of the session the therapist asked David about his stuttering and he responded that he was forgetting how to stutter. When asked to demonstrate an aspect of his stuttering pattern, David told the therapist that she would have to come and see him on Saturday or Sunday because he was " only going to stutter on weekends." That evening he was speaking on the phone with a friend and was apparently still fluent. His mother overheard the conversation. Later she told David that his speech was so good that it did not sound like him! The next time that he came for therapy he was stuttering badly and told the therapist about the phone call and his mothers reaction.
In this example, Davids mother provided a direct injunction to not be fluent. Within the current framework, successful treatment would be undermined by the mothers injunction unless it was countermanded. That could be accomplished by her clear permission to her son that it is acceptable to be a person who is able to speak fluently. Parent counseling and direct parent intervention are called for to accomplish this objective.
The thesis of this paper is that successful intervention and resolution of injunctions and their associated script decisions clears the way for effective therapy in two ways. In the case of young children who are beginning to stutter, decisive intervention with parents may serve to short-circuit unintentional, but nevertheless damaging injunctions, and to replace them with "helpful" messages.
For adults who stutter the matter is a bit more complicated. There is a high probability that an adult who stutters is attempting to deal with his stuttering by using child ego state adaptations. That is because stuttering usually begins in early childhood before the adult ego state is fully developed. Consequently, the incipient stutterer is most responsive to the emotional content of the child ego state and that ego states interpretation of parental attitudes and injunctions. The child ego state becomes the repository of ineffective responses and actions. Therefore, a goal of therapy is to energize the patients adult ego state and to engage it as the primary ally in the therapeutic process. When that is accomplished, the patients energy becomes redirected toward a search for new and effective solutions to old problems.
A final case presentation will illustrate the shift of ego states in treatment. The subject is a young woman who participated in an eight week intensive therapy program conducted at a military speech and hearing center (Naylor & Rosenthal, 1968). Video tape recordings were made prior to the start of therapy and again at the end of the eight week program. These recordings included reading, a telephone call, and one-minute of spontaneous speech. The texts of the spontaneous speech portions of the recordings are presented here.
A comparison of these two transcripts indicates an increase in information content statements from 19 in the pre-therapy text to 24 in the post-therapy text , or an increase of 26%. At the same time, statements reflecting emotional content comprised 21-26% of the pre-therapy text, but only 4-8% of the post-therapy text. The reduction in emotional content reflects a reduction of statements made from child ego state, and an increase in factual information produced by the adult ego state. The differences in these two texts are more dramatic when viewing the actual video recording. The changes in ego state from pre-therapy to post-therapy are clearly indicated by changes in the subjects posture and facial expression.
The text and video recording of this final case was made over thirty years ago, when transactional analysis was in its infancy and script theory had not yet been invented. Neither I, nor anyone on the treatment team thought explicitly about altering ego states. Treatment was directed at stuttering modification and the approach used was mainly inspired by Van Ripers model. I am pointing this out because I believe that in many instances therapeutic changes are unwittingly associated with changes in ego state functions, even when the therapist does not directly address those objectives. However, explicit attention to ego state functions, as well as the script issues that intrude in therapy, may improve overall treatment success.