Handout from an ASHA Convention, 1959 presentation entitled "Stuttering: An Inquiry on Therapy and Therapeutic Approaches" featuring Joseph Sheehan, Peter Glauber, Oliver Bloodstein, Wendell Johnson, and Charles Bluemel

JOSEPH SHEEHAN: Participant in program entitled Stuttering: An Inquiry on Therapy and Therapeutic Approaches at ASHA Convention, 1959.

Stuttering is a conflict both of personal role and of interpretational relationship. Stuttering has its origins in the role uncertainties of the child. Guilt and anxiety over not measuring up to role expectations lie at the roots of stuttering. The ongoing process in the stutterer is understandable as approach-avoidance conflict operating at various levels. The basic aim of therapy is the reduction of avoidance at various levels through an integrated psychotherapy and speech therapy approach. Current speech therapy contains many unresolved anti-psychotherapeutic features. Since the stutterer does not differ in personality from the general population, for what does he need psychotherapy? He needs both psychotherapy and speech therapy because of the vulnerability of his speech to his emotional states. The stutterer cannot afford to be as maladjusted as the next person; he must handle his problems better. The stutterer can learn to handle feelings without speech upheaval. He can learn to stutter without anxiety and to handle anxiety without his old stuttering. Successive stages of therapy may involve difficult role changes. Guilt which the stutterer builds up during therapy from his self-expectations must be interpreted and handled or the stutterer will drop out. Finally, he can become fully integrated in a new role as a normal speaker, once he has become completely a stutterer. Role integration is an essential factor in all recoveries, both with therapy and without it.

PETER GLAUBER: Participant in program entitled Stuttering: An Inquiry on Therapy and Therapeutic Approaches at ASHA Convention, 1959.

I have stated that psychoanalysis regards stuttering broadly as a neurotic disorder in which personality disturbance is in part reflected in disturbance in speech. Other psychoanalysts, however, seeing far fewer stutterers than I do, report that occasionally a patient of theirs might have a stutter but that this disturbance is neither a presenting nor a secondary complaint; it is, indeed, not complained about at all. We refer to such a manifestation not as a symptom but as a character trait. Putting symptom and trait together, we may say that stuttering stems from difficulties arising at various psychic strata. Stuttering most often begins during the early phases of the evolution of the ego, when speech emerges as an expression of it as well as an instrument of its further development. At that stage the ego is differentiating itself from the undifferentiated reservoir of psychic energy from which also stems the id, or the primitive libidinal and aggressive impulses. As a result of fixations at these early levels speech becomes unconsciously equitable with these impulses, with magical attributes of thinking, and especially with archaic symbolic displacement. Furthermore, as speech is a function intermediate between thinking and neuromuscular action, it can substitute for either and for serious disturbances in thinking and action.

The pathology of this speech disorder caries reminders of the early phase of its origin, namely, in the more or less typical early methods of adaptation. These include:

(a) strong emotional ambivalences;
(b) great adhesiveness to early parental images and the transference of these into current life and to early modalities of pleasure and aggression;
(c) inhibitions and avoidances in relation to objects and flight from objects;
(d) flight tendencies from social situations;
(e) correspondingly in the mental sphere there is a strong tendency to adaptation through denial.
Two more characteristics are notable. First, alongside flight and avoidance reactions there are primitive attempts at restitution. The second characteristic is that the reactions are total personality reactions rather than merely defenses against particular conflict-producing instinctual aggressions. The various aspects here sketched constitute integrated phenomenological data and a theoretical position. The scope of this approach is made possible because it is based on an orientation which includes genetic, dynamic, economic, and topographic aspects.

WENDELL JOHNSON: Participant in program entitled Stuttering: An Inquiry on Therapy and Therapeutic Approaches at ASHA Convention, 1959.

The basic position defended was that the problem called stuttering involves an interaction between speaker and listener, and cannot be adequately described or explained by reference to the speaker only. In the usual case it is a listener who first reports the judgment that a problem exists; on the basis of the listener's report it is as a rule to be inferred that at the time when the listener first decided there was a problem the speaker did not share in this judgment. The speaker's feeling that he has a problem comes about as a function of the interaction between him and one or more listeners. Whether a listener decides that the speaker has a speech problem depends primarily upon the listener's judgmental system and incidentally upon the degree of fluency or other observable characteristics of the speaker's communicative behavior. The problem called stuttering, therefore, may be viewed appropriately as essentially a perceptual and evaluational problem, with behaviour effects, and is to be distinguished accordingly, from the problem of speech non-fluency, per se. The problem called stuttering is distinguished by three main variables:
(a) The listener's sensitivity to the speaker's nonfluency,
(b) The speaker's nonfluency, and
(c) The speaker's sensitivity to the listener's reactions to his nonfluency and to his nonfluency, as such.
The study of the problem may be fruitfully approached by identifying and investigating the factors functionally related to each of these variables and their significant interactions.

OLIVER BLOODSTEIN: Participant in program entitled Stuttering: An Inquiry on Therapy and Therapeutic Approaches at ASHA convention, 1959

Stuttering at all stages in its development appears to be an anticipatory struggle reaction characterized by tension and fragmentation in speech and reflecting the child's assumption that speech is a difficult process in which it is vitally important to succeed. In the earliest form it is vitally important to succeed. In the earliest form in which this behaviour is observed in the clinic it exhibits the consistency effect and does not seem to differ sharply or qualitatively from stuttering in its more advanced forms. On the other hand, the initial phase of stuttering is not to be differentiated in absolute way from certain types of normal childhood nonfluency. Most normal young children appear to exhibit, mildly and fleetingly, tensions and fragmentations in speech which reflect the ordinary difficulties which children have in acquiring language and the communicative pressures which are universal in our culture. What comes to be called "stuttering" by parents and speech clinicians in most cases is probably a more severe or chronic form of the same type of anticipatory struggle behaviour which may be observed to some degree in the speech of the majority of children. In stuttering, as in most other behaviour disorders, there appears to be no sharp line between the normal and the abnormal. The influences which lead to identifiable episodes of anticipatory struggle behaviour in children seem to be of essentially three types. First, these children frequently appear to be reacting to certain provocations in the form of delayed speech, articulatory errors, reading difficulties, cluttering, difficulties in phonating, or any other threat of failure which chronically evokes the suggestion that speech is difficult and requires effort and forethought. Second, there is often some reason for exaggerated concern on the part of the child about speaking well, for example parental pressures to live up to excessively high standards of speech, competition with siblings who are more advanced in speech development, excessive praise for unusually good speech, or identification with an adult who has a reputation for superior speech. Third, a child may possess personality traits which make him particularly vulnerable to the pressures and provocations which tend to make for anticipatory struggle behaviour. These traits include perfectionism, high aspirations, sensitiveness, dependence, fearfulness, insecurity, and poor tolerance for frustration.

CHARLES BLUEMEL: Participant in program entitled Stuttering: An Inquiry on Therapy and Therapeutic Approaches at ASHA Convention, 1959.

The speech therapist is in a unique position, for he has undertaken to deal with the most complex problem in psychiatry, and his task is stupendous. Nevertheless he is doing a better job than the psychiatrist, who has little to offer but the couch. There are many components in the riddle of stuttering:
1. There is a constitutional factor. The stutterer (stammerer) is poorly organized as an individual. He is tense and overactive. He is sensitive, excitable and easily confused.
2. Because of heredity, he is often born into a neurotic environment in which he is overstimulated and frequently frustrated.
3. The child who is a potential stammerer has a natural nonfluency, a speech deficit. This is a phase of the poor organization already mentioned.
4. Early in life and before the speech function is securely organized, the child encounters disorganizing stress. This may be acute stress in the form of shock, or continuing stress due to environmental factors, usually in the home. The speech, not yet organized, is now disorganized into stammering.
5. Secondary factors soon supervene. These are the speaker's reaction to his speech predicament and his frustration. (a) In his endeavor to speak the stammerer holds his breath, exhausts his breath, attempts to speak on inspiration rather than expiration, etc.; (b) He struggles physically to force the articulation of his words; (c) He uses "starters" and "wedges" in order to get going; (d) He uses synonyms and circumlocutions; (e) He develops aversion and avoidance; (f)He panics in speech situations; (g) He becomes conditioned against difficult words, and against difficult people and situations; (h) He becomes excited and confused in the stress of speech; (i) He may become morbid, introspective, and obsessive. (With respect to secondary stammering it should be noted that there are not two types of stammering - primary and secondary. Rather there are two phases in the development of stammering. The secondary phase may develop early or late in the course of the speech disorder. Meanwhile the primary phase persists.)

Here we have a complex problem which is not easily encompassed in its entirety. It is a difficult problem for research because of the multiplicity of factors, some relating to the personality and some to the speech. Fortunately, the therapy is much more simple than the etiology. The object in therapy is to reorganize the speech; or better still to organize the speech in the natural learning period. The ideal therapy situation is that of a mother reading a story to a child from a picture book, with the child quietly repeating the short, well-spoken phrases as the mother reads them. Effective therapy can be carried on in the kindergarten and the early grades in school. While reciting and singing in groups, and while engaging in speech games, the children hear and feel their fluency and thus they organize their speech. The adult stammerer is rarely cured of his speech disorder, though he may acquire a gratifying measure of fluency. The child, however, can learn fluency early in life and can retain it for life. In the broad view, it would seem that the treatment of stammering is still in the wrong hands. For a century or more it was in the hands of quacks. For a few decades it has been in the hands of colleges and universities. Rightly, however, the problem should move to the level of the kindergarten, where positive results are assured.