Principles of counseling people who stutter
This excerpt is from the book Effective Counseling in Stuttering Therapy
By Joseph G. Sheehan, Ph.D.
Editor's Note: Joseph Sheehan, a pioneer in the field of stuttering and person who stuttered, understood the reality of the "giant in chains"complex and its disabling impact on those who stutter. This complex relates to an unrealistic belief that any accomplishment in life would be possible if only stuttering were not present. Dr. Sheehan was ahead of his time in using counseling principles as a major force in treatment. His understanding of fear, guilt, and shame and their relationship to stuttering was unparalleled. He was a highly successful clinician and researcher who devoted himself to the study of stuttering and its impact on life.
All of us go through life meeting role expectations, or trying to meet them, sometimes succeeding, sometimes failing. When we fail publicly, we are shamed. When we fail privately in meeting our own self-expectations, we experience guilt.
Shame is an obvious occurrence in the disorder of stuttering, for the stutterer is expected to speak, and to speak fluently within normal limits, and fails to do so. In the process, he may exhibit behavior that listeners find mystifying and repellant, for talking always seems simple to those who have forgotten how complex the skill was to acquire in the first place. To understand the disorder as clinicians, we need to experience these audience reactions, often by acquiring the role of the person with whom we are working so that we can know a part of what he experiences as he tries to speak but blocks instead. In the process, we may also experience a reaction of having done something wrong, of failing to do justice to ourselves and to our listeners. Like the stutterer, we can experience guilt, the private anguish that stems from the feeling that we haven't done right or haven't measured up.
The part played by guilt in stuttering can hardly be over estimated. It is likely that feelings of guilt lie heavily in the back ground of the onset of stuttering, help to maintain the behavior once started, and tremendously complicate the whole process of therapy and counseling those who stutter.
The impact of guilt on fluency may be observed even in normal speakers. When confessing something, or defending our own actions, or offering explanation under threat, none of us is likely to remain smoothly fluent. In those who stutter, guilt heightens fear, or multiplies with fear to undermine fluent word production. We reduce fear for the stutterer by decreasing his feelings that he is doing something wrong every time he stutters. This is what we mean by acceptance of the problem, of the 'stutterer role,"to a sufficient degree that the problem may be discussed, analyzed, and worked on in a healthy and open atmosphere.
We may distinguish among several kinds and possible sources of guilt reactions in those who stutter. Some of these are relived each time the stutterer blocks on a word, and may contribute to the mixture of shame, relief, and guilt many experience upon release of the word.
Sources of Shame and Guilt
1. Primary guilt refers to the constellation of feelings that preceded and led to the appearance of blocking speech in the first instance. For example, a child of two may have been negated and shamed so often that he is profoundly uncertain about trying speech at all. Speech reflects attitude toward oneself, among other things. If a young child has been made to feel that he is often wrong in everything, he easily comes to feel that he is wrong in his fumbling efforts to acquire the speaker role.
2. Secondary guilt stems from not fulfilling expectations to speak, once the stuttering behavior has emerged. The constant suggestions of neighbors and strangers to the stutterer to take a deep breath, to think what he has to say, to slow down, to try some trick "all these imply that stuttering is a simple problem with an easy solution if the stutterer will just follow the proffered advice. But usually, the stutterer has tried them all, failed with them all, and each reiteration of the suggestions merely adds to his frustration and despair. Morever, there is a role expectation of immediate improvement tied to these bits of advice. When the stutterer has to reject them, he feels guilty. When he tries them and they fail, he feels guilty. "When I Say No, I Feel Guilty,"is the title of a popular book on assertion training. One of the book's suggestions for overcoming feelings of guilt and inadequacy is the technique of "Broken Record,"a courteous but firm and persistent statement of what you really want. It is far more therapeutic to fulfill your own aspirations and expectations rather than those of others.
3. Audience punishment guilt stems from the client's realization that his struggling and grimacing speech is distressing and punishing to his listeners "or to his projection that his stuttering behavior is punishing to others. This is qualitatively different from merely feeling that you didn't measure up to fluency demands. Although there seem to be a few people so neurotic as to derive sadistic satis faction from punishing audiences, they are not typical. Moreover, even those individuals can feel guilt along with the dubious satis faction of having pun ished their audience along with themselves.
Research has well established a positive relationship between threat or expectation of penalty, and frequency of stuttering. We tend to stutter most where it hurts most. Ironically, it is often the case that the audience isn't nearly as concerned or as punished as the stutterer assumes or projects. Discussion of the stuttering problem with the clinician and observational assignments may greatly reduce the stutterer's guilt and concern about punishing the audience. Most people in therapy come eventually to realize that the damage they imagine they have been doing to listeners is like the premature reports of Mark Twain's death "greatly exaggerated.
4. Therapy-induced guilt is the fourth discernible kind, and it has profound effects on the course of therapy and the counselor's relationship to the stutterer. The implied or explicit contract with the stutterer calls for greater fluency, at least eventually. Every clinician wants to help the stutterer speak better'that's the reason the client is there. But there is a great hazard in premature expectations. Many a promising client, in terms of response to therapy, has bogged down over the knowledge that he is expected to improve soon. Where the pressures for fluent performance are scheduled ahead of the time the stutterer can get ready to deliver clinical failure and consequent guilt may ensue.
Readiness for change is a central element in all therapies. But not every person who comes, is sent, or is brought into therapy has a readiness to change. For example, many stutterers have well-stabilized patterns of retreat and subterfuge and aren't about to give them up without hefty resistance. As clinicians or coun selors, we need to sharpen our ability to estimate the factor of readiness, so that we don't push when the client is not ready to move. At least, we don't push beyond his limits and receptive??ness, or he may become so frustrated and guilty that he drops out or regresses rather than progresses.
Some degree of therapy-induced guilt is built in to the whole venture of therapy. Nearly all therapies currently in use call for the person who stutters to be an active participant to some degree. He has to do something besides just talk. Under these conditions, it is easy for the stutterer to feel guilty over not doing enough. If the clinician has unwittingly encouraged the common belief on the part of the stutterer that perfect, stutter-free speech must be the goal, the burden of guilt can never go away. Speech need not be letter-perfect or fluency-perfect in order to be acceptable. Even accomplished actors will flub at times. In fluency as in many other things, perfectionism is a self-defeating goal. Any persisting feeling on the part of the stutterer that he has failed on any dimension of therapy will tend to undermine the self-worth upon which fluency must be based.
5. Clinician-induced guilt. We have been discussing therapy-induced guilt, that is, feelings in the stutterer that develop from his awareness that he has not done enough, that he did not meet role-expectations he had set up for himself. The client may have some underlying mistrust of the therapist and the procedure he offers "and the feeling is often mutual. In this atmosphere lurks ample opportunity for self-blame and for other-blame. We have called the self-blame kind, therapy-induced guilt; it develops naturally and inadvertently. But some clinicians, deliberately or otherwise, induce guilt and shame reactions more directly. As an excuse for a program or clinician failure, they choose to manipulate the client's already strong guilt and shame readiness. After weeks or months of therapy with repeated relapse, they put an ironic twist on the idea of acceptance. Finally they say or imply to the stutterer, "After all, remember that you're a stutterer, and you might as well accept that fact."
Acceptance of the problem belongs at the start of therapy, not at the finish. It is the role that the stutterer must accept, not the old stuttering pattern. That is what the stutterer entered therapy to eliminate! If he should be asked to accept the old pattern, then he should not have been asked to undertake therapy. To promote "acceptance"at the end of the venture to excuse clinician failure or method failure is an outrage. We need not accept what we can change "and the person who stutters can change. If he had wanted to "accept", not for the purpose of enabling change, but in order to remain as he was when he came in, then he would not have come. When a clinician heaps blame on the stutterer at the end of therapy, then the client's hopes have been abused.
6. Timing as a source of guilt. As in any counseling relationship, the mishandling of the factor of readiness for change can lead to guilt and a vague sense of failure. Timing is crucial, for it reflects the sensitivity and competence of the clinician. An expectation to perform at a certain level at one stage may be less appropriate at another. Perfectly good procedures may be inappropriate depending upon the readiness of the person. For example, some discussion of the problem is endemic to virtually all therapies, even if only to spell out the arrangements. Some clients are just not ready to tolerate even that much self-confrontation. Even the discussion of the problem with the counselor may be painful. Skill in counseling people who stutter requires an ability to recognize discomfort signs, and to make sure that therapy-induced guilt does not lead to discouragement, low morale and premature termination.
Stuttering Coexists with Other Problems
Many other problems may coexist with the problem of stuttering, and the clinician needs to be equipped to help the stutterer with these problems, within reasonable limits. Becoming a person who stutters does not exempt anyone from becoming a person with many other problems. It should not be assumed that the guilt and inadequacy feelings often shown by those who stutter are entirely the result of the stuttering. As one example, a stutterer may seem depressed, and it would be easy for him "and the clinician'to assume that he is depressed because he stutters, or that he stutters because he is depressed. But the relationship of these factors cannot be assumed'they may be connected or not, or they may be connected but only minimally.
As another example, a client may be either hostile or pervasively anxious; but might he not be either of those things whether he stuttered or not? Such feelings might easily not be associated with his stuttering. Because hostility might be evidently connected with stuttering does not mean that it must be psychodynamically related in each and every case. The relationship of stuttering to coexisting problems is largely unexplored territory, and this question is left unanswered by those studies merely comparing stutterers with control groups. In individual diagnosis, the relationship of other problems to the stuttering must often await their emergence during the course of therapy. Problems that will affect the later course of therapy often fail to surface during the initial interview.
As clinicians we sometimes need to remind ourselves that we are treating a person, not just a case of excess disfluency. In some clinics, the stuttering group is called the "fluency group,"apparently on the premise that fluency is the sole problem and the only goal worth mentioning. Many clinicians could facilitate the path toward fluent utterance more effectively by helping the person feel better about himself in all roles in his life, not just his speaking role.
A stutterer may feel ugly or lonely or unwanted or excluded from the mainstream of meaningful interactions with other human beings, and these feelings would all tend to contribute to the haltingness of his speech. But we cannot assume that he has these feelings only because he stutters. He might have them anyway. Nor can we assume that even a successful behavioral treatment of the stuttering would automatically remove all these feelings of self-doubt and inadequacy. By thinking only in terms of stuttering behavior, the clinician may overlook an opportunity to help those who stutter with other significant problems.
The "Giant in Chains"Complex
The client himself often thinks that if only he did not stutter, he would have no other problems, and there would be no end to his accomplishments. We have called this the "giant in chains"complex " the feelings that if only we did not have that problem, nothing else would be wrong. Awareness as clinicians of the overattribution of all problems to the stuttering may help us avoid the same illusion so frequently held by those who stutter, or by persons with any kind of handicap.
Nearly every stutterer has heard of the legend of Demosthenes, the Greek who overcame a speech impediment and became a great orator. It becomes almost a role-expectation. Yet we know that stutterers typically do not become great orators, even when they recover, with or without therapy. This is the "Demosthenes Complex."
The "giant in chains"idea is much broader. It refers to the overattribution on the part of the stutterer of all significant problems to the stuttering, to the handicap. If only he did not stutter, then there could be no limit to his accomplishments. Here is a defense function that can cause reactions of disappointment to the stutterer as he begins to improve. Unless we are aware of it, we may not realize that improvement brings many problems with it, and that there is a process of adjustment to fluency.
In stuttering we deal with both feelings and behavior, with both classically conditioned and instrumentally conditioned patterns of response. As clinicians we need to be aware of the distinction between these two classes of response, for they require some different handling in therapy. On the feeling level there must be no right or wrong. If a stutterer feels fear or shame or guilt, then help him to explore those feelings, for they may relate crucially to his stuttering and to his attitude toward himself and others, and toward speaking in the world. On the feeling level, the 'shoulds"and 'should nots"must not apply. Otherwise the person who stutters will tailor his disclosure of feelings and attitudes toward what he imagines the clinician wants to hear. Feelings have a validity of their own and should be respected.
Some Principles of Counseling Stutterers
Let us concentrate on the attitudinal or feeling level, for it is here that the role of counseling enters most prominently. We may profit from emerging trends in counseling and psychotherapy generally, for we share the same presenting problems and challenges as do counselors and psychotherapists working with other designated problems.
A few specific principles of counseling the client with emphasis on the feeling level, to relieve him of guilt associated with stuttering and other things, may be stated:
Create a relationship and an atmosphere in which he is able to express whatever he feels, without prior censorship. Help him understand that he is never wrong on the feeling level. In contrast, on the doing level, he has responsibility and choice.
Make the stutterer as a person the focus of therapy, not just the immediate suppression of stuttering frequency. Help her realize her potential for growth and development and self-realization.
Begin where the stutterer is, not where the clinician is. If he is fearful or overwhelmingly afraid to admit his fears, or feels guilty about them, give him running room enough to feel comfortable about what he feels.
Respect her feelings "guilt, shame, fear, or anger "as having an intrinsic validity, in terms of the kind of condi tioning she has experienced in life.
Help him discover that the more guilt, shame and hatred he attaches to his stuttering, the more he will hold back, and the more he will be likely to stutter. Help him explore and share and diminish these loads of negative emotionality.
Deal with the here and now. Emphasize the possibilities of the future, not the mistakes of the past. "Where do we go from here? What behavior choices are available? What can I do at this point?"Those are the questions that lead somewhere. Questions or statements like, "If only I hadn't done this,"or "I wish this had happened differently,"or "I am a failure,"or "Why do things always go wrong for me?"tend to lead to nowhere.
Let the stutterer know that you are interested in more than just the stuttering, that you are interested in her as a person. Get to know and understand her as a person as thoroughly as you can. She is better off if she feels you care about her and her feelings, that you are on her side whether she is a success or a failure in society's eyes, and that your emotional support doesn't have strings and conditions attached to it.
Be on the lookout for signs that he is trying to pretend more progress than he is actually experiencing, just to please you and retain your support.
As she reduces her load of shame, guilt, frustration and despair, help her prepare for the probability that progress and eventual recovery from the handicap of stuttering may still leave her with other problems with which she must cope. She may have to modify her view that stuttering has been the only impediment to her success; she may discover other problems, along with newly realized problems.
Beware of therapy-induced guilt, and at least be able to recognize it even if you can't entirely prevent some guilt development during the course of therapy. With a habit-based problem such as stuttering, it commonly happens that the stutterer finds, after coasting or wallowing in new-found fluency, he experiences an apparent return of the feelings and behaviors he thought he had conquered (Jost's Law of Habits). Unless continually practiced for a time, newly acquired responses drop out faster than older and more long-established response patterns. With relapse comes guilt "but the client can be prepared for the possibility, and can reestablish his improvement by the methods he used during therapy.
Every client should be encouraged to develop initiative and independence of the therapist, and can learn in time to become her own clinical resource. The therapist can help the stutterer shift from early dependence to later independence.
Fostering independence is not the same as abandonment, and the stutterer must always feel free to return to the clinician if new problems arise, or if he needs a refresher on dealing with the old ones.
Since some overlearning of newly acquired feelings and learned behavior patterns is desirable, the stutterer should not be dumped out of therapy the moment he becomes fluent, or more fluent than formerly. Stabilization for a considerable time after initial improvement is usually needed to protect the gains made during the therapy and to continue an abiding interest in the person and what he does with his life after improvement or recovery from the handicap of stuttering.