A relearning technique for stuttering.
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. 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.
Early in the 19th century (1828) Colom-bat de l'lsere developed an instrument called a muthonome, known also as an or-thophonic lyre, 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 Brady, a psychiatrist at the time at the University of Pennsylvania, Philadelphia, who advocated the use of a metronome 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 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 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. 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 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 Medical Center and Lutheran Medical Center. He can be reached at firstname.lastname@example.org.
BY ROBERT T. LONDON. M.D.
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|Title Annotation:||THE PSYCHIATRIST'S TOOLBOX|
|Author:||London, Robert T.|
|Publication:||Clinical Psychiatry News|
|Date:||Sep 1, 2006|
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