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A relearning technique for stuttering.



Over the centuries, stuttering has caused children and adults serious psychological, social, and maladjustment maladjustment /mal·ad·just·ment/ (mal?ah-just´ment) in psychiatry, defective adaptation to the environment.

mal·ad·just·ment
n.
1. Faulty or inadequate adjustment.

2.
 problems. Numerous theories and concepts have been used in an attempt to explain the causes of the stuttering phenomenon.

Early psychoanalytic theorists jumped in to describe the conflictual situations that lead to stuttering. Stuttering certainly does lead to stress and anxiety, including maladaptations in childhood, adolescence, and adult life, but its origins, like those of many disorders we encounter, are certainly not rooted in psychoanalytic theory Psychoanalytic theory is a general term for approaches to psychoanalysis which attempt to provide a conceptual framework more-or-less independent of clinical practice rather than based on empirical analysis of clinical cases. . Even beyond psychoanalytic theory, I've heard so many psychological theories about stuttering that stutterers, if they heard about them, would be extremely disturbed.

Although psychological intervention is appropriate to help the emotional problems that may occur from stuttering, we should put some type of halt on attempts to explain this disorder psychologically. The more current thinking on the origins of stuttering rest in biologic models of cerebral dysfunctions or learning theory models. Neither model offers a fully satisfactory explanation.

Many current treatments focus on stuttering as a learned form of behavior and use various ways to correct speech through relearning techniques. I will describe a method I have used successfully with some very motivated patients.

Clinicians have known for many years that the paced speech of a rhythm is able to control speech in those who stutter stut·ter
n.
A phonatory or articulatory disorder characterized by difficult enunciation of words with frequent halting and repetition of the initial consonant or syllable.

v.
To utter with spasmodic repetition or prolongation of sounds.
.

Early in the 19th century (1828) Colom-bat de l'lsere developed an instrument called a muthonome, known also as an or-thophonic lyre lyre, generic term for stringed musical instruments having a sound box from which project curved arms joined by a crossbar. The strings are stretched between the crossbar and the sound box and are plucked with the fingers or with a plectrum. , to help add a rhythmic aspect to the speech of stutters (J. Fr. Otorhi-nolaryngol. Audiophonol. Chir. Maxillofac. 1981;30:281-3). The muthonome was a mechanical spring device giving off beats offering a rhythm to which a stutterer could speak. By the end of the 19th century, numerous schools to treat stutterers emerged using speaking techniques based on rhythm.

I had read years ago about the work of Dr. John Paul The name John Paul might refer to: Full name
  • John Paul (actor), who appeared in the two BBC television series
  • John Paul (field hockey), a field hockey player from South Africa
  • John Paul, Sr., former IndyCar driver
  • John Paul, Jr.
 Brady, a psychiatrist at the time at the University of Pennsylvania (body, education) University of Pennsylvania - The home of ENIAC and Machiavelli.

http://upenn.edu/.

Address: Philadelphia, PA, USA.
, Philadelphia, who advocated the use of a metronome metronome (mĕ`trənōm'), in music, originally pyramid-shaped clockwork mechanism to indicate the exact tempo in which a work is to be performed. It has a double pendulum whose pace can be altered by sliding the upper weight up or down.  to help pace speech in stutterers. Over the years, Dr. Brady helped create more portable metronomes, even one that would rest behind the ear like a hearing aid, so as to be portable and not evident (Am. J. Psychiatry 1968;125:843-8).

When a young businessman was referred to me to acquire some skills to treat his stuttering, I was prepared to use the metronome technique to offer a relearning/behavioral approach based on my experience with behavior modification behavior modification
n.
1. The use of basic learning techniques, such as conditioning, biofeedback, reinforcement, or aversion therapy, to teach simple skills or alter undesirable behavior.

2. See behavior therapy.
 techniques and the knowledge that I had acquired from my readings on stuttering.

First, I went to a music store and purchased several metronomes--the big boxy box·y  
adj. box·i·er, box·i·est
Resembling a box, especially in simplicity or rectangularity.



boxi·ness n.
 type that can sit on top of a piano. Why more than one? My plan was to give the patient a metronome at the end of the therapeutic visit to keep him involved in the treatment and avoid having to shop for one. Also, I believe showing commitment to the patient is positive reinforcement positive reinforcement,
n a technique used to encourage a desirable behavior. Also called
positive feedback, in which the patient or subject receives encouraging and favorable communication from another person.
. Moreover, my enthusiasm for a treatment can be transmitted to the patient.

While at the music store, I did notice that several metronome devices were available that were small and portable, including some that used a flashing light Flashing Light is a rhythmic light in which the total duration of the light in each period is clearly shorter than the total duration of the darkness and in which the flashes of light are all of equal duration.  to keep a beat or rhythm. In an office or in business setting, then, as a patient spoke, he or she could visualize beats and rhythms and not be distracted or embraced by a sound--not unlike Dr. Brady's ear piece.

When the patient arrived, medical and psychiatric histories were taken. Both were noncontributory. The man was 32 years old and in sales. He did well, but the stuttering was a handicap. It had been with him since childhood and, as he reported, his friends and family had grown accustomed to it. He did well on a previous occasion when treated for this problem--his family actually thought he spoke "funny" when he didn't stutter--but the stuttering did recur. The patient was motivated to learn a new technique, which is always a good sign in behavior modification or psychotherapy.

I explained the approach I would use and showed the patient the metronome. To begin, I was the one who would speak to the beat of the metronome. I ... would ... speak ... very ... very ... slowly ... to ... the ... beat. I would then speed it up to my normal speech. Afterward, Iwouldreally-speeditup, speakingtothebeat. After this 10-minute demonstration, we began the same process with the patient doing the speaking and me controlling the metronome.

After a half hour, the patient was essentially speaking to the beat and rarely stuttering. Then it was his turn to control the metronome. This was effective, and the gentleman was able to speak in a non-stuttering fashion. The drawback was that he was speaking to the beat, which sounded artificial.

The plan was to use the metronome as an aid to incorporate the natural beat or rhythm into his thinking in the hope that he would not always be dependent on it or simply use it as a reinforcer. Over time, a more natural flow of speaking would follow as the stuttering was controlled, and he kept the beat in his head. This first visit went on for 1 1/2 hours. At the end of it, the patient was not stuttering, but was staccatolike in his speech.

We made another appointment to review our results and continue the formal practice sessions. I suggested that, if he wished, he should visit a music store to investigate smaller, portable metronome variants, and then I gave him a metronome to keep. This was a very positive end to our first visit.

Two weeks later, we had our second visit and the patient's speech was much less structured and far more spontaneous. He did report that his family missed the "old stutter." He had bought a pulsating device for his pocket, which he said was a great reminder to keep up the beat. He had a metronome on a far shelf in his office that had no sound but a flashing light. He liked this. We practiced a few times and after an hour, the visit ended. This patient continued to practice and was successful for the 6 months we kept in touch.

As time went on, I did treat other stuttering patients with the same model with varying success. In my experience, it's the lifelong or long-term practice effect that contributes to the success. As with diets or going to the gym, those who continue in a program do better.

At this time, it appears that our knowledge of stuttering is somewhat limited. Many behavioral and linguistic/communications theories exist. There are, however, several good and successful behavioral techniques that can help with stuttering, and it may be that long-term treatment and reinforcement programs will meet with the best success.

As psychiatrists, we can actively participate in the treatment of stuttering through the use of behavior modification and relearning techniques. As leaders in the delivery of mental heath care, it's important that we find one or two stuttering treatments that we know well and can offer to our patients.

Let me know what you think and your experience in working with and treating people who stutter. I will try to pass this along to my readers.

DR. LONDON is a psychiatrist with the New York University New York University, mainly in New York City; coeducational; chartered 1831, opened 1832 as the Univ. of the City of New York, renamed 1896. It comprises 13 schools and colleges, maintaining 4 main centers (including the Medical Center) in the city, as well as the  Medical Center and Lutheran Medical Center. He can be reached at cpnews@elsevier.com.

BY ROBERT T. LONDON. M.D.
COPYRIGHT 2006 International Medical News Group
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Title Annotation:THE PSYCHIATRIST'S TOOLBOX
Author:London, Robert T.
Publication:Clinical Psychiatry News
Geographic Code:1USA
Date:Sep 1, 2006
Words:1226
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