1. Situation Stress. When I asked stutterers in what situation they found speaking most difficult, the most frequent response was, "On the telephone." Over 80 percent of adult stutterers reported some fear of using the phone. I saw a nineteen-year-old who exemplified this form of stress. A personable young man, he sat in my office and stuttered moderately in response to my questions.

As is customary in my diagnostic evaluations, I asked him to pick up the telephone, call the information operator, and request the telephone number of Macy's Department Store. He refused. I demanded that he do so, saying that this was an essential part of the evaluation. He pleaded with me not to force him to use the telephone. He confessed that he hadn't used it in years and had nightmares about it.

A most unusual situation stress was reported by a priest who was terrified at the thought of speaking in the pulpit. He had stuttered as a child, but thought he had outgrown it. After ordination, he assumed a position with a small congregation. A few years later he was given a new post and on his first Sunday entered the church to greet a congregation of 800. The audience size overwhelmed him, his vocal cords locked, and the feedback receptors in his cords triggered a stuttering response that had lain dormant for years.

He began to take tranquilizers, but the dosage required to be effective created undesirable side effects. He decided to leave the church when his physician told him to stop taking the drugs. He approached his bishop with his decision, saying that the stuttering was apparently a sign of his "unsuitability." The bishop, a practical man, suggested he try speech therapy first.

2. Word or Sound Stress. Most people who stutter tend to avoid specific words and frequently report they have difficulty with certain sounds. This form of stress, like almost all forms of stress, is learned. As such, it can show great variability - stutterers can learn to fear any of the sounds, and these fears can change periodically - that is, a person can fear "p" and "t" sounds one year and "b" and "k" sounds the next. Sometimes a person can lose all his fear of specific sounds only to have them return at a later date.

More common are word fears. Almost all adult stutterers have some of these, very often fearing only a few specific words. I treated a lawyer who stuttered on only about twenty words. He prepared a list and we practiced them. His problem was treated successfully in a few sessions.

Another patient had a problem saying his first name. He had had it legally changed to a name he had always been able to say easily - and then began to stutter on the new name. When he saw me he was unable to say it. I encouraged him to try and to continue to make the attempt in spite of the difficulty he was having. I timed his attempt. The block lasted two minutes and thirty-eight seconds - two minutes and thirty-eight seconds of totally silent and remarkably violent head-thrusting, punctuated only by the occasional need to take a breath. His convulsions finally terminated in the speaking of the name: David.

Another patient reported invariably lying when asked, "Where did you grow up?" because he could not say Westport. And many patients reported often giving wrong answers in class because they could not say the right ones - and they had to say something. One patient told me he was twenty-eight by saying, "the year after twenty-seven." And many patients bemoaned the fact that they were often required to eat what they did not want to eat in restaurants simply because they were unable to say what they wanted.

Word substitution is, at best, awkward and often frustrating and embarrassing. It is always the result of word or sound stress.

3. Authority Figure Stress. Many patients reported difficulty speaking before individuals best described as authority figures. They report having trouble talking to the boss or the teacher or when being interviewed.

One patient related that when he was stopped by a policeman for speeding he had to take a sobriety test because he was unable to answer the officer's questions.

And another reported that throughout school his questions and answers to teachers were written out and read aloud by fellow students.

Virtually all patients report they often stutter only with certain people, for example, with parents. Frequently, parents, noting their children's stuttering at home, request that the school speech therapist treat the problem. But when the child appears before the therapist there is no trace of a stutter. What the therapist is unaware of is the fact that for this child it is only in the presence of parental authoritarian stress that stuttering occurs and that in all other situations, it is absent.

One young man I encountered never stuttered with his fiance but only with her father, not her mother, just the father.

Another patient reported that he never stuttered with a colleague at work until that person was promoted and became his supervisor. He now assumed the role of authority and in that context became an object capable of provoking stress and consequent stuttering.

4. The Stress of Uncertainty. Patients often have difficulty speaking when uncertain about the proper way to behave - for example, in unfamiliar situations such as new neighborhoods or new jobs or meeting new people. This stress occurs also when one is uncertain about the correct way to pronounce a word.

Nowhere is uncertainty stress more manifest than in the difficulties encountered by stutterers attempting to learn a foreign language. There are a number of sources of uncertainty at work here. First an uncertainty about pronunciation, second, one of vocabulary, and third, grammar. It is no wonder that many patients report stuttering on almost every word in the new language.

5. Physical Stress. Stutterers sometimes report more difficulty when tired or ill. Indeed, in the nineteenth century in Europe a school of therapy contended that the primary cause of stuttering was lack of sleep. And so patients were often required to sleep as many as fourteen hours a day - as treatment. Some early therapists believed that only a certain part of the body, usually the tongue, was tired, and devices were constructed to hold up the "tired" tongue. Generally made of gold or ivory, and worn in the mouth, they functioned essentially as distractions and, as such, temporarily stopped the stuttering. But after a few days, at most, the stuttering returned with as much intensity as ever.

But one does not have to go back to the nineteenth century for unusual therapies which focus upon speech rest as the means for treating the problem.

I encountered several individuals who were treated by a therapist from Russia. His contention was that stuttering was an expression of an overworked speech apparatus, and so he required all his patients to refrain from speaking for six weeks. After this period of total silence they were to start speaking using single words only for the first several weeks, then to proceed to using short phrases and then finally to full sentences.

Needless to say, this technique invariably failed when the first real stress occurred and the vocal cords locked.

Illness is definitely a cause of stress. The Country & Western singer Mel Tillis started to stutter at the age of three after a bout with Malaria and Winston Churchill stuttering is attributed to an early severe fall.

6. External Stress. This form of stress can also be called "bad news." It is the stress of discovering that you have just been fired or that a relative has a terminal illness or that your car has been stolen. Patients frequently report that external stress figures prominently in their difficulty.

I treated a patient who responded beautifully to my techniques and after a few days of intensive therapy was symptom-free in virtually all situations. He left for his home in Ohio confident of his new skills and equally certain that the continuation of his program would strengthen these new habits and establish them permanently.

When he returned, however, he discovered that his house had been burglarized and burned. The external stress was so great that it took him fully six weeks to regain his ability to control his stuttering.

I have seen patients operating in the pressure cooker of the advertising world who, while fluent in most situations after treatment, cannot cope with the external stress of clients continuously contemplating agency changes. I recall seeing an Art Director whose speech deteriorated further with each subsequent rejection of his artwork by a major client.

7. Speed Stress. Probably the most common of all the stresses is speed stress. Speed stress is responsible for the onset of most stuttering in children. It is the product of speaking too rapidly.

Almost all patients were found to suffer from this to some degree. For very young children, speed stress was often the only form of stress experienced. When they spoke slowly, they became fluent. Adults, on the other hand, were under other forms of stress, and thus slow speaking did not result in immediate fluency for most.

As a matter of fact, most adults were not aware of speaking too rapidly. Indeed, when I measured the average number of words they spoke per minute, when fluent, it was well within normal limits, that is, approximately 130 words per minute; it was not a question of average speed but rather how quickly they spoke the first word of each sentence; that is, how quickly they started to speak.

When this was measured, they were found to be as much as four times faster than average. In other words, stutterers, instead of beginning speech in a slow and leisurely manner, attack their words.

One patient who invariably stuttered on the first word indicated that the reason he spoke so quickly was that he "wanted to get away from the scene of the crime as quickly as possible." What he did not realize, of course, was that this desire was resulting in speed stress and thereby helping to contribute to the very block he was seeking to escape.

8. Base Level Stress. There are sixteen muscles in and around the vocal cords, and if one were to put an electrode on any one of them one could easily record the tension developed within. This tension is present at all times and its magnitude can fluctuate widely. The fluctuation is the product of two major influences.

The first are brain hormones - which, through their chemical effects on certain cerebral centers, have been shown to have the capability of increasing muscle tensions dramatically. When patients report their speech has suddenly worsened, and can find no obvious reason for it, the usual explanation is an increased production of these hormones.

The second source of tension are persistent, longstanding subconscious conflicts which become exacerbated by a change in one's life circumstances. Perhaps a new job, with a boss whose demeanor parallels a parent's - sets off a sequence of underlying emotional reactions which go unrecognized but wreak havoc with speech. Or a spouse, whose decision to make a major life change, subtly upsets the well-defined structure of the relationship - producing forms of destabilization which provoke anxiety and subsequent negative effects upon speech. All this in spite of the fact that both parties consciously acknowledge the absolute desirability of the change.

When both factors are present simultaneously and are in combination with any of the other seven stresses, the total tension on the vocal cords can mount to the point where the patient is virtually incapable of speaking. This is seen often in young children whose Base Level Stress has been shown to vary widely over time. Parents are particularly frustrated by this and report that their child can often go for weeks without stuttering only to find that overnight the dysfluencies return with full force. Many such children are brought to my office during one of their fluent periods. The parents are quick to assure me that their child stutters and sometimes violently, and in a sense apologize for their child's lack of difficulty. They almost invariably say that they are unable to account for these fluctuations and experience much reduction of guilt when Base Level Stress is explained to them.