PART II

TREATMENT


CHAPTER 8

ATTEMPTS AT CORRECTION

Approaches to the treatment of stuttering have been extensive. Hundreds of books and thousands of articles have been published on the subject in the last half century. Certain techniques occur repeatedly in the literature; they occur because they have been partially successful.

Relaxation Therapies. These have by far been the most prevalent set of approaches to treating stuttering. There are several varieties, but in all the aim is to reduce muscle tensions throughout the body, and thus elude the stutter reflex. In one approach, patients are encouraged to start by focusing on a specific muscle group (usually the toes), contract it maximally to heighten awareness of the tension, and then relax it as much as possible. Each muscle group is addressed separately until the entire body is relaxed. This procedure, known as Progressive Relaxation, was first described in 1923 by Edmund Jacobson, and has been employed frequently for the treatment of stuttering. The reported results indicate improvement but never total success in eliminating the problem.

Another type of relaxation involves yoga-derived stretching exercises. In these attention is drawn to increasing flexibility of the spine and involve twisting, rotating, and bending the torso. Performed slowly and in a deeply meditative state, these exercises gradually bring their practitioners a more tranquil demeanor - the result again being improvement, but not total arrestation.

Guided Imagery is another relaxation technique that has been employed to treat stuttering. Patients are trained to imagine a restful scene or tranquil activity and then encouraged to dwell on the image periodically throughout the day. This technique produces substantial relaxation in some patients, again with its attendant improvements in speech.

Finally, there are the biofeedback approaches. Electrodes are attached to various muscles (usually on the neck) and the degrees of tension developed during speech are registered on a meter. Patients are trained to lower tensions by attending to the meter as they attempt to make the level decrease. Unfortunately, the findings with biofeedback have been disappointing since the stuttering, following treatment, rarely improves.

In summary, it appears that relaxation approaches tend to improve or reduce stuttering, but not stop it. They simply do not subtract enough tension from the vocal cords.

Deep Breathing Exercises. It is felt that breathing deeply before speaking stops stuttering. Based on this premise, some therapies teach a variety of deep breathing exercises. A few of these techniques stress breathing from the diaphragm while others stress the ribcage. Some talk about the importance of nasal breathing, others, oral. The justification for the exercises is the often-noted observation that the breathing patterns of stutterers are disturbed. Unfortunately, most of the experimental studies have shown no improvement.

Speaking Exercises. Employing a novel way of speaking as a method for treating stuttering has been used frequently. For example, some therapists have advocated using speech timed to the rhythm of a metronome while others have suggested using what is best described as a sing-song voice. Some require their patients to speak softly while others require them to shout. Still others have suggested that the pitch be raised, while just as many are equally emphatic about the importance of lowering pitch. Some have insisted that speech with a foreign accent is a solution and others advocate speaking as they inhale. Some suggest hardly moving the mouth while speaking while others suggest whispering.

The outcome of the survey of these often contradictory approaches is a set of largely ineffective treatments. This is not to suggest that novel ways of speaking do not produce fluency, on the contrary, they often do. But they are ineffective as a form of therapy because patients reject them. They are perceived as alien; they are not normal. Patients may not like stuttering but at least they are used to it. They are not used to talking in a manner which they and others perceive as strange.

For example, it is known that every stutterer in the world will be fluent if he sings. But show me a stutterer who is willing to break into song every he wants to communicate. It is just not acceptable. The Country-Western singer, Mel Tillis, has made a career of juxtaposing a totally fluent singing voice against the difficulty he experiences whenever he tries to speak. He does this in a humorous vein and has his audience laughing along with him at the incongruity.

It has also been well documented that one can stop stuttering by speaking slowly. Proponents of this approach are known as the Controlled Rate Group. These therapists claim that the reason slow speech helps stuttering is that it allows the brain time to compensate for some presumed but unspecified incoordination among the respiratory, vocal cord and articulatory mechanisms.

One method commonly employed for slowing speech is called Delayed Auditory Feedback. Patients speak into a microphone which is attached to a tiny computer which records, delays, and sends amplified speech to earphones. The patient hears his speech delayed by approximately .2 second. Speaking under such conditions is difficult; one tries continuously to adjust or compensate for the delay.

It turns out that the only successful way to compensate is to slow the rate of speaking. While the slowing reduces or even eliminates stuttering, the price one pays, apart from the obvious slowness of the speech, is the obtrusiveness of having to speak into a microphone, wear a computer and have earphones on all the time.

In another method a tiny electronic metronome is inserted behind the ear. The speed of the metronome can be adjusted as the person speaks, so he is required to time his syllables to the rate he heard in his ear. Providing the beat is slow enough, this Syllable-Timed Speech, as it is called, produces fluency. But again, the price paid is unnatural sounding speech and dependency on an electronic device.

Proponents countered by saying that patients could gradually increase the speed of the metronome, and when it was sufficiently rapid, the speech would sound normal and the patient could then discard it. The experience of stutterers, however, contradicts this: as the rate is increased, stuttering reappears.

Punishment. As a form of treatment, punishment has a long history in the therapy for stuttering. For example, electric shocks have been and continue to be employed to create unpleasant stimuli. No one likes a shock, however mild it may be, and a patient will do anything to avoid one.

But the psychology of learning tells us that people learn because they are rewarded, and a shock is punishment, something to be avoided. Patients do whatever is necessary to avoid getting shocked, whether it means changing the pitch of their voice, swallowing, coughing, speaking slowly or sounding as unnatural as they can. But this does not mean that they learn these techniques. As soon as the shock is removed they quickly revert to stuttering.

Another form of punishment used with stutterers was carbon dioxide treatment. Breathing CO2 has been used to treat depression and other mental problems. It was often used as a substitute for electro-convulsive shock therapy. A patient in her early sixties reported being forced to breath CO2 as a child. She recalled being taken every morning by her father to a doctor who would administer pure CO2 through a face mask. After two breaths she would pass out and, when revived, be driven to school. This went on for a year and a half without any positive effect on her speech, and the memory of this daily torture has remained vividly etched in her mind for over half a century.

Surgery, while not necessarily punishment, had the same effect. Surgical approaches were employed in Europe in the middle of the nineteenth century and still continue today, albeit to a much lesser extent. For example, if one lived in Germany in 1842 there was a good likelihood that a stutterer would have had a portion or all of his tongue removed. (Bear in mind that this was before the advent of anesthesia). Surgeons pursued this course for almost fifteen years before they decided it was ineffective.

Even today, one sees well-meaning physicians suggesting that the cause of stuttering is tongue-tie and that the problem can be cured by the simple expedient of snipping the small piece of tissue they feel tethers the tongue to the floor of the mouth. Unfortunately, there is no evidence that this approach has any positive effects upon speech what-so-ever, and one can only hope that the practice will cease.

Drugs. The last area of treatment for stutterers has to do with the administration of drugs. There are three basic types. The first are the anti-convulsants. Neurologists see the violent struggle behaviors associated with stuttering and feel that they constitute a form of convulsive seizure. But lacking training in learning psychology, they fail to understand that such struggles are learned. The medical literature is filled with published reports of the merits of one anti-convulsant drug over another for the treatment of stuttering. The fact that the vast majority of patients do not stop stuttering and that the side effects of the drugs are often serious does not seem to dissuade neurologists from pursuing this treatment.

The second class are the tranquilizers. There are a number of these and all, in one way or another, have been tested. Many are useful in reducing overall stress. But again, they do not completely eliminate the problem and their side-effects can be substantial. Recently tested are a new family of tranquilizers called Beta-Blockers. These show promise and further research is under way.

The third group are the muscle relaxants. If tension is the ultimate source of stuttering, it makes good sense to investigate any approach that reduces tension. However, it appears that the amount of any drug necessary to reduce vocal cord tension is so great that the side effects are invariably unpleasant and unsafe.

It is clear that there has been great interest in methods for treating stuttering. Most bring at least some relief to a significant percentage of stutterers. But none solve the problem completely, and that ultimately creates their downfall. It's very much like cancer. You remove ninety percent of the cancer and the other ten percent does you in. Unless you can eliminate all of the stuttering, the residuum with eventually create the inevitable relapse. Also, if the price you have to pay for your improvement is speech which sounds strange or an involvement with obtrusive apparatus, the chance for fluency is virtually doomed from the start. 


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