Navigating A Path Through the Stuttering Jungle – why a wider understanding of “stuttering” is necessary (Mark Irwin)

About the author: Mark Irwin is current Chair of the International Fluency Association’s Self Help and Advocacy Committee and National President of the Australian Speak Easy Association, Mark is a former Board Chair of the International Stuttering Association (2001-2007). He has made previous contributions to the understanding of stuttering through papers in the 2002 and 2008 ISAD online conferences, as well as the blog www.stutteredspeechsyndrome.com

Introduction

How to get through the stuttering jungle? With support, encouragement and inspiration from many sources I finally feel I’ve made it through. Now it’s my turn to help others. What’s more I know a few short cuts as well as turns to avoid, which will make the journey so much easier for anyone else.

These days stuttering no longer dominates my life or restricts my life choices like it once did.  I have successfully managed a busy professional career, an active social life and complex family interactions with an ease I once thought would never be available to me (even at age 40). Among numerous public speaking successes my most memorable achievements were a speech at my daughter’s wedding and my father’s eulogy. I no longer excessively monitor my speech, anticipate stuttering or ruminate over dysfluent experiences. I say what I want when I want.  Hey….it makes eating at a restaurant so much more enjoyable J

As a result of this experience I have gained insights which I firmly believe could be helpful to anyone feeling stuck or lost. In addition while I appreciate some people who stutter have chosen acceptance of stuttering as their path, it is my opinion this is a good starting point only; it doesn’t have to be a finishing point. I feel I have the insights now to confidently help anyone move beyond acceptance and to a more fluent future.

What!!!!! I hear some people say….“Don’t you know that stuttering is neurological and /or the result of a speech motor deficit”. “Don’t you know that nothing can be done and any successful management will be inevitably short term with relapse a continual reality.”  I know this has been the common sense view for many years but research now shows the brain continues to change throughout life and obviously, under the right conditions, the change can be directed. Certainly that has been my experience and that of many others who have also dealt successfully with stuttering. So if you have an open mind, read on. My intention is to discuss what worked for me, why certain strategies didn’t work and to stimulate a new way of seeing the “stuttering” condition. In brief I hope to provide information for long lasting successful therapy.

There were 3 necessary steps in my journey….1. Understand the Problem.  2. Develop an Action Plan.  3. Take Action

 

STEP 1.  Understand the problem

“To solve a problem first you must define it.”            Samuel Johnson

“You can’t change what you don’t acknowledge”       Phil McGraw

Stuttering is often (not always) a complex disorder with which to deal.  For most people it is much more than a behavioural speech problem. Research shows that between 40% to 75% of people who stutter have such significant emotional and attitudinal difficulties (Kraaimaat et al, 2002, Stein et al, 1996), they can be said to have the additional mental disability of Social Anxiety Disorder (SAD). SAD has its own negative impact on speech and ease of communication generally. The key first step in my recovery was to become aware that Social Anxiety Disorder was co-existing with my stuttering. I needed to take steps to overcome my SAD if my speech, and mindset, was to be improved.

In my mid-twenties I was aware my fluency would vary with the perceived social difficulty of any given interaction. While I believe others may have neurological limitations I had to acknowledge that my stuttering was not about my ability to speak but my ability to manage my emotional health when interacting with others. I had to acknowledge that I had a thinking problem which was showing up as a speaking problem. And in my case the thinking and speaking problems were more complex still. My thinking problem involved not only a fear response that I might stutter at any moment but also tension brought about by my unrealistic expectation that I should speak fluently, intelligently and diplomatically at all times. My speaking problem was complicated by entrenched patterns of behaviour, related to muscle memory and poor breathing habits. In addition, I realised I had formed an association between stuttering and the sound of my own voice. That is, my voice had become so linked (conditioned) with the stuttering experience that it was acting as a trigger for more stuttering.

I called my condition Stuttered Speech Syndrome to distinguish it from the speech event of stuttering. In my case the stuttering was interacting with my social anxiety in a positive feedback loop; each condition exacerbating the other. Not only was I suffering from the speech difficulty of stuttering (that bit of the iceberg above the water) but I was suffering from the emotional and attitudinal pathology of Social Anxiety Disorder (that section of the iceberg below the water). Furthermore I had developed specific phobias to telephone use and public speaking, to the extent I would react with dread just hearing a telephone ring or watching another person use the telephone or speak publically.  In addition I had another psychological disorder with which to deal. I had a fear of stuttering (known by the psychological term psellismophobia).

So the first step in my recovery was defining the full extent of the problem. In my case I was able to acknowledge that I needed to deal with Social Anxiety Disorder (related to performance anxiety and perfectionism) as well as my specific phobias to telephone use and public speaking . With regards to stuttering specifically, I recognised I had to overcome the fear of stuttering as well as the habituated stuttering behaviour of ingrained faulty speech muscle mechanics and breathing patterns.

Academic Note. The acknowledgement of Social Anxiety Disorder is significant. Effective psychological and pharmacological therapies for SAD exist (Holaway et al, 2004), but until now have not been accessed because of poor recognition, inadequate assessment, and limited awareness or availability of treatments. It is recognised that therapy for SAD is complicated by the formation of safety behaviours also known as safety-seeking behaviours. These behaviours are defined as behaviours which allow social success, without the need to re-evaluate threat belief (Lovibond et al, 2009). It is my view that improved awareness of the role of Social Anxiety Disorder in stuttering will lead to dramatic improvement in treatment outcomes. Already research shows that the presence of SAD will lead to relapse in speech restructuring (Iverach et al, 2009). Also speech pathologists, either unaware of the presence of SAD in their fluency client or uncertain how to treat it, are inadvertently encouraging the formation of safety behaviours (Helgadottir et al, 2014). In this case the goal of dysfluency reduction is met at the cost of social anxiety maintenance or enhancement.  Unfortunately this means that even though the client may be fluent the social anxiety disorder remains thereby negatively impacting on quality of life.

 

STEP 2.  Develop a Helpful Action Plan (and avoid an unhelpful one)

“Begin with the End in Mind.”           Stephen Covey

“The journey of a thousand miles begins with a single step”       Lao Tzu

Based on my experience I would encourage the following course of action (these items overlap).

  1. Develop a Positive Self –Image as a Speaker and Communicator. Visualise speaking well and certainly take confidence from the fact that in spite of stuttering there is no reason not to do well in the rest of the communication process by listening well, smiling and being relaxed.
  2. Deal with Social Anxiety Disorder. Take stock of perfectionistic standards and re-examine the reasons for them. This is easier to do with a realistic plan for life and a personal philosophical perspective. Begin to see each day as providing opportunities for growth and enjoyment rather than as providing difficult challenges to be endured or avoided. Learn to relax socially and the best way to do this is to focus on the other person.
  3. Deal with fear of stuttering. Voluntary stuttering (deliberate stuttering, VS) is a powerful tool for overcoming stuttering fear. Of course this refers to the speech event only. VS needs to be paired with a relaxed speech pattern and correct breath support. That is, when using VS it is obviously a counter-productive point to voluntarily repeat the old patterns of anxiety, tense facial muscles and lack of breath support which would thereby reinforce these.
  4. Deal with fear of telephone. The surprise for me was how small the steps of desensitisation needed to be. I went through the process of learning to relax in a chair, then relax in same chair while looking at phone, relax while holding the phone in my hand, relax while looking at myself holding the phone, relax while ringing a friend. Then I needed to flood the experience by making many phone calls in succession.
  5. Deal with fear of public speaking. There are many organisations offering courses in public speaking. My experience was with Toastmasters International. I found this to be extremely difficult at first resulting in sleepless nights before the meetings. But eventually the warm, welcoming attitude of fellow members, as well as their always positive feedback (remember as a result of my SAD I was my own worst critic), eased my tension and I began to finally enjoy public speaking opportunities.
  6. Deal with faulty muscle memory and breathing patterns. This was easier to do by observing closely people who spoke well and spending as much time as possible in their company. Practising reading aloud helped initially but interestingly, as I progressed, I found that simply visualising saying 3 linked phrases with pausing and breathing between each helped just as much.
  7. Deal with negative conditioned reflex from sound of own voice. The only way to manage this is to get used to hearing yourself speaking well. Speak aloud and fluently, pausing every 5-6 words with correct breath support. If this is done as a twice daily ritual then a new pattern of conditioning can develop. It did for me.

Why don’t some people improve in spite of their best effort? (How to avoid an unhelpful Action Plan)

  1. Overcome Self-limiting beliefs. Many people consider that stuttering has a fixed neurophysiological base and that it is not possible to overcome stuttering. All that can be done is to manage it by continual monitoring. With this belief it is impossible to summon the optimism to push through inevitable set backs on the road to recovery.
  2. Avoid safety behaviour formation (instead concentrate on remaining relaxed during social encounters even if being dysfluent). As discussed in the above academic note, safety behaviour formation is a significant complication to therapy for social anxiety. A safety behaviour is not defined by the behaviour itself but by whether the client uses it to achieve social success without dealing with erroneous perceptions of social threat. Examples of client developed safety behaviours are covert stuttering (word substitution, use of filler words, circumlocution), avoiding difficult words, talking quietly and mumbling. Examples of therapist suggested safety behaviours include recommendations to restrict verbal interaction to “safe” conversational partners and only ask questions during conversation. It is also noteworthy that a speech restructuring technique itself may become to be used by the client as a safety behaviour.

 

STEP 3. Take Action

“Life is an action game.”      James Rohn

“Let your dreams drive you across the bridge of discipline”.       James Rohn

I became intrigued by how people can become successful in any particular endeavour without necessarily having obvious natural ability. Certainly what they appeared to have was drive and determination which is much more about attitude than anything else. Anyone can have the right attitude. I applied what I read in the general area of self-help and encourage the following …

  1. Keep a journal (write down successes to remind yourself later and chart your own progress)
  2. Join a self-help group
  3. Join a public speaking group
  4. Gain support of friends to provide positive examples of correct speaking patterns delivered in a relaxed manner
  5. Seek speaking challenges which can be approached in a positive fashion with expectation of success.
  6. Celebrate achievements

 

In Summary.  Have fun taking your path through the stuttering jungle, however far you decide to go. Seek the company of supportive, encouraging and inspiring people. Lose old safety behaviours and avoid picking up new ones. At the very least you will be certain to overcome social anxiety and you may even go a lot further than you ever thought possible. Best wishes!

 

References

Kraaimaat, F.W., Vanryckeghem, M. & Van Dam-Baggen, R. (2002). Stuttering and Social Anxiety. Journal of Fluency Disorders. 27. 319-331.

Stein, M.B., Baird, A., & Walker, J.R. (1996). Social Phobia in Adults With Stuttering. American Journal of Psychiatry, 153(2), 278-280.

Helgadottir F.D., Menzies R. G., Onslow M., Packman A., O’Brian S., (2014) Safety Behaviors and Speech Treatment for Adults Who Stutter. Journal of Speech, Language, and Hearing Research, Vol. 57, 1308-1313.

Holaway R.M., and Heimberg R.G. (2004) In Bandelow, B. & Stein, D..J. (eds) Social Anxiety Disorder. N.Y. Marcel Dekker, Inc.

Iverach, L., Jones, M., O’Brian, S., Block, S., Lincoln, M., Harrison, E., et al. (2009). The relationship between mental health disorders and treatment outcomes among adults who stutter. Journal of Fluency Disorders, 34, 29–43.

Lovibond,P.F., Mitchell,C.J., Minard,E., Brady,A., Menzies,R.G. (2009). Safety behaviours preserve threat beliefs: Protection from extinction of human fear conditioning by avoidance response. Behaviour Research and Therapy, 47, 716-720.

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Comments

Navigating A Path Through the Stuttering Jungle – why a wider understanding of “stuttering” is necessary (Mark Irwin) — 24 Comments

  1. Hi Mark

    I enjoyed reading your excellent and inspiring article about your own journey of gaining a greater freedom of speaking. I particularly appreciate how you have clearly outlined specific paths which can be followed, to help other people who stutter move towards easier verbal communication. Thank you!

    Hazel

    • Hi Hazel,

      Thanks for taking the time to read, reply and encourage my efforts. (apologies for delay-I’ve been away travelling). I feel we are moving towards greater understanding of this condition/conditions as a result of people like you reading, and reflecting on, other people’s views and experiences.

      Mark

  2. Mark,

    What an informative and insightful article! I am a student studying speech-language pathology and stuttering is something I would like to learn more about. Honestly, I had never really considered the fact that people who stutter face so many internal struggles under the surface, such as social anxiety and fear of speaking on the phone. As a student, this is all very relevant and helpful information to know if I am ever to see a patient who stutters. Thank you for sharing about your behaviors and feelings before you learned ways to overcome your stuttering, and thank you for providing readers with practical, tangible ways to deal with their own stuttering behaviors through developing a well-structured action plan. I have learned a lot through this article! Thank you!

    Marilyn

    • Hi Hanan,

      As we both know….”the journey of 1000 miles starts with a single step” and “learning is changing what you do, not what you know”.

      While everyone’s view is to be respected, I feel it is necessary to challenge the idea that acceptance is the only possible end of the line position.

      Dare to dream, use intellect to formulate goals, have courage and discipline to take action.

      Mark

  3. Hello Mark;

    Its really cool the stages for change you set forth in this paper. Thanks for your insight.

    I want to add to your idea that acceptance is the only possible end of the line position–Wrote years back about stages of change on “stutterer to PWS.” Last year started to feel the next step for me was Pride. I have my office desk: “I stutter. And Proud.”

    Always,
    Michael

    Always,
    Michael

    • Hi Michael! Great to hear from you.

      I think you personally have a lot to be proud about in the way you have helped others accept themselves as people who stutter.
      My contribution is to suggest ways of understanding stuttering, overcome anxiety and communicate more easily. I’m proud of that effort too.
      Looking forward to our next catch up. Ghent 2001 was a real highlight.

      Best wishes,
      Mark

  4. Hi Mark,

    Thank you for sharing your experiences! You mentioned many fears that you had to overcome – As a speech language pathologist graduate student working with PWS who also have SAD- how can we best support our clients in overcoming these very personal fears (while avoiding encouraging the formation of safety behaviors?) What resources were most helpful to you during this journey?

    • Thanks for your questions.
      In my view the key point would be to help the client learn to be relaxed when speaking. That plus a slower rate will enable them to take on your specific speech therapy advice. Consider: Would you give a drowning man swimming lessons? NO.
      RE Helpful resources: Desensitization strategies, meditation course.

      Best wishes, Mark

  5. Hi Mark,

    Thank you so much for sharing your thoughts and experience with stuttering. I am a first year MS-SLP student at the University of North Carolina at Chapel Hill and I was a chapter leader for my local chapter of the National Stuttering Association for a year and a half.

    I love your optimism about therapeutic outcomes and I found your 3 step approach very interesting. I am currently enrolled in a Fluency Disorders course and one question I have for you is pertaining to therapeutic alliance. We’ve discussed in our class that sometimes having fluency as the end goal and indicator of ‘success’ may put strain on the alliance between the therapist and the client if it is not attained completely. Instead, we discussed that focusing on improved communication and increased autonomy (even if that includes stuttering) may lead to better resilience for our clients.

    My question is two-fold: Do you think that as a speech pathologist it’s appropriate to make fluency the end goal of therapy/is it realistic to expect that everyone has the ability to become fluent? Or should that be left to the client to decide?

    Best,
    Christine South

    • Hi Christine,

      Thanks for your positive comments.

      Related to your first question and interesting academic paper is Helgadottir 2014 JFD. The issue of fluency advice conflicting with social anxiety reduction advice is discussed.

      Perhaps not everyone has the ability or access to social support to become fluent (just as not everyone who takes up golf has the ability or access to support to play like Tiger Woods). Another huge variable is degree of motivation (not everyone sets out to play as well as Tiger Woods in the first instance). So my thought is that the qualities of a great speech pathologist would be similar to those of a great sports coach…. they would work with the client to achieve realistic goals of increasing complexity based on the client’s desires and ability. However, as I am inferring through my paper, the question of realistic goals is best determined with a broader understanding of all the possible issues involved.
      Please contact me if you would like to chat further.

      Best wishes,

      Mark

  6. Hi Mr. Irwin,

    Wow! I really enjoyed this article along with all the informative techniques you suggested. I am a current student in the Speech Language Pathology feild and am very interested in learning more about helpful strategies to utilize for successful therapy. In Step 2 of the article (Develop a Helpful Action Plan) you suggest “Deal with faulty muscle memory and breathing patterns.” Would you be able to provide a few more examples on how to do this?

    Thank you so much for your time and wonderful insights,

    Best regards,
    Lea

    • Hi Lea,

      Two ideas here are to have your client 1. practice reading aloud slowly with louder voice and clearer articulation (but always in a relaxed manner noting how relaxed are the facial muscles). 2. choral read the same passage with a fluent speaker and have the client copy the breathing pattern of the fluent speaker.

      Thanks for taking an interest,

      Mark

  7. Hi Mark,

    I really enjoyed reading your article and I appreciate the step-by-step instructions you proposed. I am a second year speech-language pathology graduate student and I am currently taking a fluency disorders course. In our class, we have learned a lot about the negative feelings, attitudes, and emotions that are commonly associated with stuttering. I haven’t considered these attitudes to be a psychological disorder of their own for some PWS, so I found this article particularly interesting.

    As SLPs, we are not trained nor qualified to treat psychological disorders such as SAD (or depression, anxiety, etc.). We are able to counsel clients and to address their attitudes and emotions as they pertain to stuttering in therapy, but not primarily if they are diagnosed as psychological disorders. Do you feel that SLPs should commonly refer stuttering clients to psychologists/psychiatrists/counselors to better help stuttering clients who may have SAD? Is there a way SLPs and psychological professionals can work together to better address the needs of PWS? Did you have any SLPs or psychological professionals who greatly influenced your journey through the stuttering jungle, or did you mostly navigate through the jungle on your own?

    Thank you,
    Alyssa

    • Hi Alyssa,

      Thanks for your questions which obviously reflect your deep thinking about the subject. The restricted training/qualifications of SLPs is a dilemma and one that I believe has restricted my ideas from progressing further. However I believe there is a solution……
      SLPs are able to use screens for SAD since popular screens are freely available on the internet as self report questionnaires eg LSAS, SPIN, mini-SPIN. That information can be used by the SLP to guide decision to refer for confirmation of SAD diagnosis and certainly it can be used by the SLP to give a diagnosis of Stuttered Speech Syndrome. (see my 2008 ISAD article)
      In this way the management of the care client remains with the SLP who ideally would work with a psychologist if the SAD is extreme and involves other areas of the clients life beyond speech.
      Your question on how SLPs and psychologists could better work together involves SLPs first being aware of safety behaviour formation in clients with SAD (Helgadottir JSHR 2014 -full reference in paper). Another awareness is of how small the steps in desensitization may need to be for extinction of fear.
      And with your last question: I think, as with most disorders the majority of the responsibility for overcoming the problem rests with the client. The clinician can only act as a motivator and guide. I have received motivation and guidance from many SLps and psychologists.
      Contact me again if you would like further expansion on any of these answers.

      Best wishes for your career,

      Mark

  8. Hi Mark,

    I enjoyed reading about your journey. I love that you mentioned the high percentage of PWS who also deal with emotional difficulties. As a graduate student and future clinician, the presence of emotional disorders/difficulties is a particular area of interest across all communication disorders. I think to be an effective clinician, one must also be aware of the potential emotional difficulties a PWS could possibly deal with. When you recognize an individual with SAD or another emotional difficulty, do you deem it appropriate to refer? Or do you think the level of counseling a SLP provides is sufficient?

    Best,
    Rachel

    • Hi Rachel,

      The particular interest in SAD relates to the fact that, unlike other psychological disorders, it has DIRECT negative impact on fluent speech. Therefore in my view it should be of prime interest to all SLPs and be part of their initial assessment of all fluency clients.
      The decision to refer should be seriously considered. In my view it would be based on potential degree of SAD indicated by screen, as well as expertise and experience of the clinician. Another factor, and perhaps ,the most significant, is the strength of the client/therapist relationship.

      Thanks for your question,

      Mark

  9. Hello Mark!

    I agree that accepting your stuttering is a good starting point. I am a firm believer that every person who stutters has the choice to become spontaneously fluent. I think it’s important to remember that everyone goes through different stages. I have been in multiple situations where I think I have met my highest potential, and then I realize there is so much more to accomplish. I think once someone who stutters is able to achieve the acceptance of stuttering, they realize there is so much more they can do if that’s what their goal is. I find your idea of accepting stuttering as a starting point refreshing.
    I also find your stuttered speech syndrome theory interesting. Do you think this is something that happens to all people who stutter, or was this specific to you? Have you heard of a system called Speech easy that uses delayed auditory feedback along with a different pitch? I am wondering what the advantages are of adding pitch change to a DAF system.

    Natalie Williams

    • Hello Natalie,

      Thanks very much for your positive comments. We seem to share a common experience.

      Yes I am familiar with DAF. My theory here is it works because it breaks the conditioning reflex between sound of voice and stuttering (obviously by making the voice sound different). Of course if the DAF is used under conditions too stressful for the speaker then stuttering will occur (my personal experience). Similarly if the DAF is used often enough in these situations then the DAF begins to sound familiar and therefore loses its effect. The only way to rectify this would be to change the pitch.
      Of course sooner or later this pitch may be associated with a stuttering experience and the speaker is back to square 1 ie needing to change pitch again.
      In my view the DAF is a great training tool for slowing speech rate, and it has some value as an aid in the social stress desensitisation process. However it is not a cure all. Its use can easily become a safety behaviour.

      Best wishes,

      Mark

  10. I am a Speech Language Pathologist student at Touro Graduate School for Speech Pathology. Your journey is very inspirational to read about. I was wondering who helped you most to work through your SAD issues related to stuttering. Was it a mental health professional, a speech pathologist or someone else? In the stuttering class I am currently enrolled in, we are learning that SLP’s need to take on more of a role in understanding our clients emotions especially when working with PWS. My professor is emphasizing the great emotional toll PWS experience.

  11. Hello Mark,

    Thank you for sharing your thoughts and experience with stuttering. Really, you should know that you are a huge inspiration to me. and you are amazing people. Seriously.
    I remember the days when you were the chairman of the board of the International Stuttering Association. I admired your perseverance and courage from afar.
    I try not to sound too creepy. But just know, you are an inspiration and I hope to affect others in my life as you have affected me. Thanks for motivating and driving me.

    Dieudonne

  12. Hello! I am a second year graduate student at University of Minnesota Duluth. I’m currently enrolled in an advanced fluency course, and we have discussed a lot of your themes in class.
    One thing we have not discussed is SAD. Given, as you said, that there are between 40-75% of people who stutter that can have this additional disability, have you had anyone reach out to you about how an SAD diagnosis change their life, too? I would think that if I was still feeling stuck and I suddenly became aware of another possible component to my disfluency, it would cause some relief!
    Thank you!

  13. Hello Mark, I am a graduate student studying to become a Speech-language Pathologist at Edinboro University. Thank you for sharing your experience. Before my fluency class I was unaware of the underlying emotional and social affects stuttering may have on an individual. I admire your positive attitude and commitment to spreading stuttering awareness. I imagine your story would be of great benefit to children or adults who are going through the same jungle. Although I am not sure what I would like to specialize in stuttering is very intriguing to me, and your post has strengthened my interest. If I were able to support individuals who stutter in becoming the best version of themselves then I feel I have made a difference. Thank you again for sharing, I am sure you have greatly influenced the lives of many.

    Julie R.

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