Therapists’ Issues in Understanding Stuttering

This article explores the issues with understanding stuttering. Stuttering is a multidimensional and multi-factorial (1) communication disorder that has eluded scientific understanding (2). Owing to the nature of stuttering, both therapists and patients struggle to grasp an understanding of stuttering. Quoting Sheehan's iceberg analogy, it is only the tip of the iceberg that has been understood about stuttering while a larger part of different aspects of stuttering is still largely unexplored. This poses challenges with defining, theorizing, measuring, diagnosing and understanding the nature of stuttering. The present article discusses the practical challenges faced by therapists in their practice with regards to stuttering.

Defining Stuttering

Many definitions of stuttering and proposed models explain the nature and aetiology of stuttering however there are few that are accepted as a standard (1). The primary cause of this confusion is that researchers tend to provide a different and novel approach to understand stuttering without a consistent conceptual frame. The lack of a standard definition of stuttering poses a challenge to therapists in understanding stuttering clinically. Based on the model that they subscribe to, the understanding and treatment approaches also show a significant diversity. The lack of a standardised definition and understanding hampers the confidence of therapists in handling stuttering cases in practice.

Diagnosing Stuttering

The diagnostic criteria listed in the Diagnostic and Statistical Manual of Mental Disorders for stammering, stuttering or the revised term Childhood-Onset Fluency Disorder highlights it as a “disturbance in the normal fluency and time patterning of speech inappropriate for the individual's age” and “the disturbance in fluency interferes with academic or occupational achievement or with social communication” (3). The presence of any of these characteristics like “sound and syllable repetitions, sound prolongations of consonants as well as vowels, broken words, audible or silent blocking, circumlocutions, words produced with an excess of physical tension and monosyllabic whole-word repetitions.” On probing deeper, it is reported that the experiences of stuttering are psychologically more significant than physical. Since only overt behaviours are the standard parameters for diagnosis, covert stuttering is missed out in diagnosis.

Although there are guidelines and diagnostic criteria available for therapists, theory and practical differ greatly. In theory, stuttering is reduced to a checklist of observable characteristics that a person displays while speaking. However the nonverbal behaviours of stuttering while speaking that hamper the smooth flow of speech form a major aspect of understanding stuttering (4). These nonverbal behaviours may be overt or covert in nature. In reality, stuttering can manifest in people very differently and show different characteristics at different times or in different situations.

Differential Diagnoses of Stuttering Disfluencies

Stuttering shares a resemblance with many clinical disorders like verbal apraxia, dysphasia, aphasia, spasmodic dysphonia, brain damage, cluttering, etc., (5) which makes it difficult to distinguish between them. This is a central problem in diagnosis. However, the aetiology of stuttering is not yet established. Disfluency can be caused by multiple factors like motor, neurological, cognitive, linguistic, psychological or organic reasons. As a result of which it becomes difficult to attribute the cause for the disfluency and whether it can be diagnosed as stuttering or not. Moreover, upto 2% disfluency while speaking is considered normal and in fact, normal spontaneous speech is never totally fluent. Further, the disfluencies of stuttering and normal disfluency overlap creating confusion (6). Stuttering is a speech disorder rather than a language disorder as the expression of speech is undisrupted in stuttering while the natural flow of speech production is affected (7). In stuttering, the nature, type and position of disfluency is noticeably different from other fluency disorders caused by sensori-motor, neuro-linguistic or organic deficits (5).

Understanding the Nature of Stuttering

Stuttering is a patterned and predictable interruption in the speech flow in the form of blockings, repetitions, prolongations, interjections, broken words, etc. It usually has an early start after fluent speech is developed, although the age of onset may be as late as adulthood. In the beginning it is episodic in nature and restarts after spontaneous recovery. Sometimes there is normal fluency even during stuttering episodes. Stuttering may reduce with increasing exposure and comfort level as a sign of adaptation. Different speech tasks show different degrees of disfluency in stuttering unlike other fluency disorders (5).

Stuttering behaviours change over time. The initial core behaviours give rise to secondary behaviours in the form of escape behaviours and avoidance behaviours to overcome the core behaviours which appear while speaking. It can be highly situation-specific or sound-specific as a result of which they may develop strategies to avoid or escape from the situation. The psychological impact of stuttering internalizes victimised self-belief and forms communication attitudes (8). Eventually, it develops in layers and progressively complicates.

The internalized self-schema in stuttering gives rise to certain emotional reactions and behavioural patterns. Denial, anxiety, fear, frustration, anger, isolation, hopelessness, shame, guilt, etc. become the predominant emotional reactions to stuttering (8). This predominance of negative emotional experiences further leads to negative self-perception and abnormal social behaviours. Eventually the progression of emotional arousal goes out of control leading to behavioural disorganization. Thus evaluating stuttering comprehensively as a factor of core behaviours, secondary behaviours and emotional reactions is essential to understanding stuttering (2, 8).

Training Therapists

The incidence rate of stuttering is 5–8% worldwide while around 1% is the prevalence rate (9). However every patient with stuttering has a unique set of symptoms which vary with time and situation. Heterogeneity, variability, individual differences, environmental influences, adaptation, spontaneous recovery, relapse, covert stuttering, psychosocial factors, etc. complicate the situation. Thus there is no consensus among therapists on the stuttering descriptors for assessment and diagnosis. Hence identifying and recognizing stuttering poses a challenge for even trained therapists.

With inadequate focus on fluency disorders in course work, curriculum, practicum, specialisation and training, therapists feel inadequate experience and confidence in handling stuttering cases. Insufficient knowledge and relevant clinical experience of faculty has resulted in the students struggling to assess and treat stuttering. This has led to low satisfaction levels, avoidance tendencies and a negative stereotype towards fluency disorders among therapists (10).

Thus, a specially designed training curriculum for stuttering is the need of the hour for therapists to cater to the needs of people with stuttering.

Conclusion

The key to solving any problem is to understand the problem. There is abundant research available on stuttering, but no consensus and clarity in the field which is the biggest challenge for therapists. To counter this, relevant practical training with actual cases of fluency disorders is required to help therapists feel better equipped. The gaps between research and academics, researchers and therapists, and theory and practice have to be bridged with a revised curriculum. To prevent the further loss of trust and credibility, standardised and precise guidelines should be provided to screen and assess stuttering. It needs to be kept in mind that stuttering consists of inconspicuous behaviours too. Thus all verbal and nonverbal should be evaluated to detect sub-perceptual processes. Once the understanding of stuttering is clear, therapy for stuttering will become more effective and accessible.