By failing to acknowledge that fluent speech is an unrealistic goal for a significant number of people who stutter, speech-language pathologists provide a disservice when they enroll clients in therapy programs based on the simplistic notion that all people who stutter can be fluent and that success in therapy is dependent on the attainment of normal fluency.

One morning the director of admission at the university where I was teaching called. He said, "Gene, I've got a young man in my office who wants to come here. His test scores aren't that good and he has a real stutter. Could you see him for me this morning?" Twenty minutes later a slightly built, fair complexioned, dark haired, preppy-dressed, handsome young man appeared at my door. Todd was seventeen. After forty-five minutes I was convinced Todd could make it in college and that he was a moderately severe chronic stutterer. I referred him to the Vocational Rehabilitation Service and they agreed to assist him.

Todd entered the university that fall and began taking one hour of individual and one hour of group therapy each week. He joined a fraternity and tried out for the university's cheer leading team. Todd had an exceptionally high energy level and a recurring pattern of over-extending himself in making commitments. Todd is a charmer and he quickly became labeled as the "All American Boy Stutterer." by our stuttering group and its clinicians. In the fall of his sophomore year, Todd committed himself to concentrating on his stuttering and, as the reports in his file indicate and I recall, he earned the feeling of control and felt good about his ability to handle his speech. For the next 2 1/2 years, Todd was what we might call an irregular post-graduate of our therapy program. When we needed a sample of our success for public display, Todd was our man. In that period he appeared on TV talk shows, was featured on a TV program devoted to stuttering, received free luncheons for speaking at service club meetings and answered questions about stuttering on radio talk shows. Although disfluent at times in these situations, Todd explained to his audiences that his goal was to maintain the feeling of control rather than to focus on fluency. I saw less of Todd during his junior and senior years because he was no longer enrolled in therapy. However I knew he was becoming increasingly concerned about his chance of obtaining employment with a corporation because of his speech.

Todd completed an undergraduate degree in business and began to take additional coursework with the hope of being accepted into the Business School's graduate program. In the spring of his fifth year, Todd, realizing his test scores would keep him from being accepted into the MBA Program, withdrew from school. He returned home where worked for a construction firm as a laborer while seeking employment. The next time I heard about Todd was that fall when a colleague informed me his son, a member of Todd's fraternity, had learned Todd was enrolled in an out-o-state, three-week stuttering program and was being cured.

One Sunday afternoon Todd appeared at our home noting he had just returned that Friday from a three week intensive residential program for stuttering and wanted to share with me his success. I welcomed him in and we sat down to discuss it. Todd was fluent. As I listened and watched him, I could not help but think of the expression "walking on egg shells in a mine field." The enthusiasm and easy charm of the Todd I knew was replaced by an automaton. He exuded tension and fright even while verbalizing joy in his new found fluency. I expressed my pleasure. I reassured him of my continuing admiration for his determination and drive when he expressed fear that I might think ill of him for, as he phrased it, having gone behind my back. We chatted perhaps thirty minutes. Todd noted that with his new fluency he would now be able to get the kind of position he sought. He reported his clinician had warned him that he would need to work to keep his fluency, but Todd assured me he felt "great" because he now knew that he could be just as fluent as anyone. He left on that note, telling me he would be in touch. Five months later Todd appeared at my office in such a disfluent state that early in our meeting he gave up on a speech attempt, shook his head and said, "To hell with it, I can't even talk to you any more." He reminded me of a car's motor with the automatic choke stuck wide open and I told him so. I reached out, put my hands on his shoulders, and directed him to sit down. I got out an electric metronome I use for classroom demonstration purposes and had Todd begin speaking syllable by syllable at a very slow rate. With that, he was able to tell his story.

Todd had begun to job hunt the Monday after I had seen him fluent. He received a couple of job offers in banks but turned them down thinking he could do better. He continued his search for employment while living at home and working part-time in construction. By the end of six weeks he was once again experiencing disfluencies "even," he noted, "when I was hitting my targets." He noted that it was not long before his stuttering was more severe than he had ever known it to be and that any feeling of control was gone. In addition, he was overwhelmed with depression. He said he knew it was his own fault for not being able to maintain his fluency. He said he was deeply depressed at having let everyone in his family down and at having spent so much of his father's money on the cure. Todd noted that in the preceding six weeks, he had simply given up searching for employment and was on the verge of giving it all up because he was so down on himself. He wanted to know what he should do.

I told him the first thing he should do was to get medical help to get his "automatic choke unstuck" and the second thing he should do was to find a supportive counselor for rapid attitude adjustment. In addition, I said, "Todd, you don't need more speech therapy. You already have the skills to earn back the feeling of control" In his presence and with his permission, I called his vocational rehabilitation counselor explaining that Todd was in my office and needed immediate psychiatric attention. His counselor said there was nothing more he could do for Todd. I then learned the Vocational Rehabilitation Service had sponsored Todd's enrollment in the three-week cure and Todd, upon his return, had turned down a bank job arranged by his counselor believing he was cured of stuttering and could do better. Fortunately, his counselor was reasonable and compassionate. He quickly grasped the seriousness and the potentials inherent in the situation. Within two days, Todd was under the care of a psychiatrist and receiving medication. Within a week, Todd was being seen by a counselor. I met with Todd briefly two or three times to assist in making these arrangements. Each time we met I restated my belief that he already possessed the technical skills necessary to earn back the feeling of fluency control. The end of the story is that within two months Todd, with the help of his vocational counselor, was employed in a position appropriate for his educational level. Although continuing to experience disfluencies in many situations, Todd feels in control of his speech. He appreciates the extent to which he is able to control his speech and focuses on his effectiveness as a communicator rather than on the frequency of his disfluencies. Although he does not hold the individuals associated with the short-term intensive stuttering program directly responsible for the problems he experienced following his enrollment, he does express resentment toward them for not providing him adequate counseling while he was enrolled and for, by deed if not word, indicating his stuttering could be cured.

Todd's story is not unique. He is an example of the thousands of incurable stutterers subjected each year to treatment programs implicitly if not explicitly based on the erroneous assumption that all stutterers can be normally fluent. For a long time I was hesitant to write or speak publicly about the existence of incurable stuttering. I thought by focusing on the establishment of realistic treatment goals and by eliminating the primacy of the frequency fallacy, we might avoid the need to address the specter of incurable stuttering. I was wrong. While helping Todd put his life back together following his traumatizing experience with a whirlwind cure center, I decided a more direct approach is needed if we are to lessen the harm being done those for whom normal fluency is an unattainable goal. I am convinced there would be many fewer stories like Todd's if the existence of what I term the "Chronic Perseverative Stuttering (CPS) Syndrome" was acknowledged and studied.

I have defined the Chronic Perseverative Stuttering (CPS) Syndrome as an adolescent and adult disorder in the fluency of speech resulting from multiple coexisting physiological, psychological and environmental factors, distinguished by

(a) recurrence following periods of remission,
(b) characteristic cognitive, affective and behavioral response patterns and
(c) susceptibility to alleviation but, given the present state of the healing arts, not to eradication.

I began the development of a CPS Syndrome Inventory by simply listing factors that I and others observe to be associated with incurable stuttering. They are as follows:

• The individual's stuttering developed concomitantly with the development of language and speech.
• The individual's stuttering has persisted for ten or more years.
• The individual's moments of stuttering are, or have been, accompanied by fleeting but generalized feeling of loss of control.
• The individual has experienced periods of normal fluency accompanied by the feeling of control.
• The individual experiences a persistent fear of a catastrophic loss of fluency although such an occurrence in fact, may rarely if ever occur.
• The individual has identified one or more adjustments in speech production that generally, but not always, enhances fluency.
• While capable of predicting the level of fluency to be experienced in most situations, the individual continues to experience unpredictable fluency failures.
• The individual has experienced normal fluency following a heightened and sustained period of psychic and physical concentration on attaining fluency but has been unable to maintain that level of concentration or fluency.
• The individual's predominant self-perception is that of being a person who stutters.
• The individual experiences periods of obsessive absorption in striving for normal fluency.

Perhaps the factor most noticeably missing from this listing of identifying characteristics of CPS Syndrome is that of the frequency of stuttering. I find no meaningful relationship between reports of the frequency with which adolescents and adults experienced disfluencies and whether or not they are successful in overcoming the problem.

I use the "good news-bad news" scenario with most of the CPS Syndrome clients I have treated. Upon the completion of the diagnostic evaluation, I tell the client:

I have some good news and some bad news for you. The bad news is that you have the Chronic Perseverative Stuttering Syndrome which means there is no cure for your stuttering. The good news is that we can help you add to the enormous progress you have already made in controlling your stuttering. We can help you gain the feeling of control over you r speech by doing three things. First, we're going to make certain that you appreciate the fantastic job you have already done in coping with one of the most devastating and, above all else, frustrating disorders one can have. Secondly, we are going to help you earn and maintain the feeling of control over your speech by strengthening the things you already are doing so effectively to make your speech as fluent as it is today. Lastly, we are going to teach you to use those Fluency Initiating Gestures that you are not already using or that you are using ineffectively. When we finish, you most likely will still be disfluent, but you will be able to enter any situation knowing that no matter how tough it is, you have the skills to alter your speech and to communicate effectively. You will have the feeling of control.

I hope I don't hear any more stories like Todd's. Let's put an end to offering the quick fix for all. Let's acknowledge the fact that incurable stuttering is a reality, at least at present. In do doing and by setting realistic therapy goals, we can assist those with the Chronic Perseverative Stuttering Syndrome to enjoy a guilt-free quality existence.

-Discussion-

June 10, 2003