This is a version of Dr Rosemarie Hayhow's keynote speech at the BSA Cardiff Open Day in September 2008.

Dr Rosemarie Hayhow giving her keynote speech at the Cardiff Open Day.

What connects us
Stammering as a way of life
'Incremental' v 'entity' theorist
Solutions becoming part of problem
Thoughts on Lidcombe Program
Conclusions

The topic for the Cardiff Open Day was 'connections'. This got me reflecting on the things that connect people who stammer with people who do not. In my presentation I aimed to explore how ideas or models that have been developed to make sense of human behaviour can be applied to stammering, and so possibly increase our understanding.

What connects us

When I first learnt about stammering it was introduced as an area of speech pathology along with other communication problems in children and adults. When viewed from this perspective the focus is more on the differences between people who do and do not stammer rather than on the similarities between them. When we think of something as pathological we are alerted to what is wrong with someone or something rather than what is OK.

Over the last thirty years there has been a shift in thinking, with more people now questioning the usefulness of focusing on differences at the expense of understanding what connects us. When I was first learning about stammering, most treatments were rooted in the personal experiences of people who stammer (PWS) who then became academics, people like Van Riper and Sheehan. Later, in my early years of working with PWS there was an increasing interest in behavioural techniques and in teaching speech patterns that were incompatible with stammering, for example, syllable-timed and prolonged speech.

Working at the City Lit in London, and then researching the longer term effects of the courses, led me to question whether our ways of viewing stammering and stammering treatments were adequate to help people make the necessary changes to their speaking and their lives. At City Lit I was fortunate to be with Peggy Dalton and Renée Byrne, two very much more experienced and wise therapists. While we worked away trying to get a better understanding of stammering, Fay Fransella¹ was conducting some research that offered another way of thinking about this puzzling condition.

"Fransella found that people could become more fluent, not by consciously changing their speech patterns, but by changing the way they think about or construe themselves as speakers and also how they construe other people."

Fransella, a psychologist, was interested in Personal Construct Psychology (PCP). She believed that PCP provided a good explanation of how we all go about making sense of our worlds and that it offered new ways of understanding problems that people have. This in turn led to new ideas about how people can change. Fransella investigated the usefulness of PCP in relation to stammering and found that people could become more fluent, not by consciously changing their speech patterns, but by changing the way they think about or construe themselves as speakers and also how they construe other people. PCP considers people?s construct systems, not as separate independent constructs but as dimensions of meaning that interact and fit together.

Stammering as a way of life

Fransella was not alone in realising that stammering in adults was more than a symptom of some underlying dis-coordination of the cognitive and motoric aspects of speaking. She put it succinctly though when she suggested stammering was not so much a symptom but more a way of life.

What does a way of life imply in this context? It suggests among other things that stammering
Becomes central to the person's view of self
Influences how the person sees themselves in relation to others, and how they view others
Influences important decisions
Carries a lot of meaning, is often thought about or always in the back or forefront of a person's mind
Beliefs that are part of everyday thinking often go unquestioned or unchallenged.

If Fransella is right, her view raises questions about how stammering can become a way of life.

Early years

Stammering starts with repetitions and blocking in speech which may be symptomatic of an underlying difficulty in the co-ordination or timing of motor movements. This usually first occurs in young children during periods when speech and language are developing rapidly. It is often made worse by things like
increased cognitive, linguistic or memory load
heightened emotion
distractions e.g. background noise, competition to speak
a more intense need to talk, to communicate verbally.

We could argue that children become more and more proficient in stammering when it doesn't resolve naturally (as it does in around ¾ of the children who stammer at some point in their early years). They learn to stammer through practice and then gradually link some particular sorts of speaking situations or experiences with stammering.

They also develop more complex stammering behaviours by trying harder to speak at those times when they are feeling stuck. Heightened emotion can lead to quicker learning, so the more upset the child is by their speech disruptions the quicker they might learn complex stammering behaviours.

Negative evaluation

Children are good at comparing their speech with that of others around them. This is how they learn to talk and how they develop the cognitive, linguistic and articulatory skills that underpin verbal communication. When children realise all is not well with talking they may evaluate themselves in a negative way, which may lead to embarrassment and feelings of shame. They may also experience negative evaluations or responses from others, both adults and their peers.

The processes that might lead to stammering becoming a way of life are normal processes; evidence of self-evaluation and self-awareness are seen in all pre-school children. Embarrassment and shame can occur when there is too much attention from others focussed on children, or when children feel they are failing at something they think is easy

Developing truths

How might ideas or thoughts that we have about ourselves become beliefs? It is likely to be a slow process, and the beliefs that we develop about ourselves gradually influence how we see others. If stammering is central to our beliefs about ourselves, this will lead us to view people who we judge not to stammer in particular ways.

Over time beliefs can be viewed as truths. These truths may not be challenged, and so can come to influence a wide range of choices that we make in our every day lives. When stammering becomes a way of life, speaking and fear of stammering may provide a structure within which choices are made automatically.

For example, a range of career options or promotion may be ruled out because of a belief that you are not good enough at talking to do those things. If you believe stammering is the result of being a nervous person, you may avoid anything that triggers anxiety. In this way, life choices are limited to those that reduce the risk of more failure and stress. If you believe stammering to indicate inferiority then meeting new people who don't stammer will be a negative experience.

These ways of adjusting to and coping with stammering emphasise the differences between people who stammer and those who do not. This is in contrast to the more useful option of looking for similarities, looking for the things that unite or connect us.

'Incremental' v 'entity' theorist

I could talk for much longer about PCP but there are other areas of theorising and writing that I'd like to move on to. We can see how somebody's beliefs about their self-worth can be affected by making unfavourable comparisons between themselves as speakers and others. However, there is another level at which our beliefs can influence how we evaluate ourselves. Molden and Dweck² discuss this with reference to a tendency towards being an incremental theorist as opposed to an entity theorist:

An incremental theorist takes the view that we develop a mastery of skills through learning, trial and error etc. This happens over time - people with this view attend to process as well as the final outcome.

Entity theorists are more directed towards their goals or targets and may think more in terms of passing or failing, which in turn may encourage an 'all or nothing' way looking at things.

Being an entity theorist is OK when things go well, but may lead to feelings of vulnerability when setbacks occur. Entity theorists are more likely to feel they have failed and their sense of self-worth may be threatened when they don't achieve the goals they and others have set for them. Incremental theorists are better able to view setbacks as part of the learning process, which leaves their sense of self-worth intact when they encounter difficulties.

How might an emphasis on results rather than process tie in with stammering? It is possible that stammering might lend itself to an entity view - 'Can I say this word?' 'Can I be as fluent as I think others are?' 'Am I stammering?' These sorts of questions can lead to yes / no judgements. When feelings of self-worth get tied up with speaking performance the speaker is vulnerable during times of speaking difficulty. It may be more useful to ask questions like: 'did I get my message across?' 'Did my conversation partners have a chance to say what they wanted to say?' 'Was I able to think more positively before I started speaking?' These will still potentially have yes / no answers, but they encourage the speaker to reflect more on the interaction and not just pass judgement.

(Article on being entity or incremental theorist: 'What is your theory?')

Solutions becoming part of problem

I've talked a little about how we may develop particular ways of viewing ourselves and our speaking. I now want to make a bit of a jump to another view of how problems develop. The schools of Brief Therapy or Solution Focussed Therapy³ suggest how problems develop and are maintained. The process may go something like this:
We notice something that is not quite right
We try to fix it (¾ of children who stammer grow out of it)
If our fix works - fine
If our attempted solutions do not work, we begin to think we 'have a problem'
The attempted solutions become part of what keeps the problem going (tricks, avoidance etc)
The problem gets bigger as the attempted solutions become a part of it

This process can be applied to all sorts of potential problems, for example, weight problems, difficulties with sleeping, problems in settling down to tasks that need doing. Whether or not something is a problem to an individual depends partly on the nature and extent of the difficulties they experience, and also on whether or not they have identified it as a potential problem and failed in their attempts to deal with it. The more they have invested in solving the problem, and the less success they have achieved with this, then the bigger and more unsolvable the problem may feel. Stammering fits well into this model.

There are links between PCP, Brief Therapy and unhelpful theories and beliefs that influence our self-evaluations. One risk is that the person attends to the problem at the expense of other important aspects of the situation or event.

For example, in challenging speaking situations more time and mental energy might be spent on trying to reduce and avoid stammering than on preparation of content, research into the other people who will be present etc. After the event more energy may be directed towards reliving the sense of failure than from evaluating the achievements.

Gradually the problem gets bigger and unhelpful beliefs become part of everyday thinking, and so the person is more likely to notice what supports beliefs than what challenges them.

Thoughts on Lidcombe Program

The final area I want to consider is therapy for children, and in particular the Lidcombe Program, an approach that I have found helpful in recent years. In this treatment, parents give feedback about stammer-free speech and stammering during conversations with their children. Parents are trained by the speech and language therapist to do this safely and correctly

I am interested to know if a behavioural treatment like the Lidcombe Program does more than just reinforce the desired behaviour and discourage the 'problem' behaviour. Could it help children by giving them the space to find a 'workaround' for the momentary glitches in their speaking as Onslow⁴ has suggested?

Of course we can't be sure what the active mechanisms are in any treatment that has several components. However, in the Lidcombe Program there is an emphasis on stammer-free speech, thus helping children notice the speaking pattern they are aiming for rather than the problematic speaking. Also children are encouraged to find their own way of managing the glitches in their speaking. Adult ideas are not imposed but adult feedback helps the children know when their attempted solution is a good one - that is, not just a trick that will later become part of their stammering pattern.

Importantly Lidcombe is a treatment for children of less than 7 years, so it is being applied at a stage when new learning happens easily and emotional and psychological responses are not established. Their way of speaking is not yet a way of life, and the stammering is not hard wired.

Encouraging children to self-correct their errors is widely accepted in many areas of learning. The application of established principles of learning to a problem like stammering maybe helps children to view stammering and speaking as behaviours and skills rather than indicators of their worth or lack of worth as developing human beings.

Conclusions

I hope I've shown how looking at stammering from some perspectives offered by theories and ideas from outside the stammering field can help us look at it differently, and in the process offer the potential of new ways of managing speaking problems.

There's lots out there if we think about making connections rather than focusing on differences. I believe there has been a big shift in our thinking about stammering over the last thirty years and speech and language therapists and people who stammer are looking outside the stammering field to find more useful models and frameworks that help people live more comfortably with their speaking.

This open day is a wonderful example of this change, where contributors have independently and in different ways found connections between themselves and others -and in this process have changed their personal stammering stories.

Dr Rosemarie Hayhow is a Speech & Language Therapist and researcher at the Speech & Language Therapy Research Unit, North Bristol NHS Trust.

References
¹Fransella, F. (1970) Stuttering: Not a symptom but a way of life., British Journal of Communication Disorders, vol. 5, pp. 22-29.
Fransella, F. (1972) Personal change and reconstruction, Academic Press, London.
²Molden, D. & Dweck, C. (2000) Meaning and Motivation. in Intrinsic and Extrinsic Motivation: The Search for Optimal Motivation and Performance., eds. C. Sansone & J. Harakiewicz, Academic Press, San Diego, California, pp. 131-159.
³George, E., Iveson, C. & Ratner, H. (1999) Problem to solution: Brief therapy with individuals and families. Revised and expanded edition. Brief Therapy Press, London.
⁴Onslow, M. & Yaruss, J.S. (2007) Differing perspectives on what to do with a stuttering preschooler and why. American Journal of Speech-Language Pathology, vol. 16, no. 1, pp. 65-68.