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Johnson's diagnosogenic theory of stuttering: an update. (Refereed Paper).

SPEECH THERAPY TODAY has suffered because many speech-language pathologists misunderstand Wendell Johnson's teachings on "stuttering." They believe that Johnson taught that assigning the label stuttering to a speaker's repetitions of sounds and syllables and other hesitancies actually caused the disorder. They could not be more mistaken.

Johnson examined how human responses to an event can reinforce it; he did not specify labeling as a cause. As a general semanticist, Johnson hated such word magic (the belief that we can speak things into existence); for correct evaluation, the event or thing had to precede the word.

Johnson faced a world that believed what many people believe today, that stuttering is a speech disease. Popular wisdom says that everybody can recognize the symptoms, because all repetitions of sounds or syllables that occur frequently in a child's speech are "stuttering" and these indicate that the child has the disease as certainly as the presence of blisters indicate the presence of chicken pox.

What Johnson Believed

In contrast with the popular superstitions of his day, Johnson believed that instrumental conditioning caused problematic "stuttering."

Parental responses to their children's early speech efforts were mediated by their "diagnoses" of this speech as the disorder "stuttering," and this led to chronic "stuttering." (1) It was not the word stuttering that caused "stuttering": it was reactions to the word that created the undesirable reinforcement of stuttering. While Johnson may not have discovered why all children begin to "stutter," he certainly understood how stuttering, whether "organic" or normal, becomes chronic. (2)

One of today's most widely used speech pathology texts (Guitar, 1998) reports that around 80% of all children who begin stuttering overcome it spontaneously. Guitar asserts that only those children who fail to adjust to what he calls "core stuttering" (repetitions of sounds and syllables) go on to become chronic stutterers. This suggests that chronic stutterers were taught (by themselves or others) to become frightened, ashamed, and guilt ridden when they stuttered and as a result attempted to avoid these feelings by avoiding stuttering, creating the vicious cycle called "stuttering." Stuttering, as Johnson maintained, became an "anticipatory, apprehensive, hypertonic avoidance reaction."

When persons behave in this way, they have "maladjusted" to their stuttering. However, if they do not fear their stuttering, if they accept it, do not anticipate it, do not try to avoid it (and therefore create it), they have "adjusted" to it.

The anticipation of making a series of repeated sounds that stutterers experience as stuttering does not always involve a specific word. It can be a feeling of anxiety associated with certain speaking situations. Stutterers cannot always predict the specific words on which they will stutter; however, a generalized feeling of fearful expectancy exists.

Many experts today attribute chronic stuttering to speakers' efforts to avoid painful emotions created by their evaluations of stuttering: fear of guilt, fear of shame, fear of fear, etc. Attempts to avoid these feelings result in efforts to avoid stuttering, and these efforts, along with repetitions of sounds and syllables and prolongations of sounds, appear as stuttering. The British call these reactions stammering and evidently regard the repetition of sounds or syllables as just one symptom of the disorder. This seems like a useful approach to me.

The Map is Not the Territory

Some young children who begin to repeat sounds and syllables at the beginning of words will adjust to this by making it a non-issue and disregarding it or by considering it normal, not shameful, disgusting, or wrong. Most importantly, they never become self-doubters because of it.

Johnson taught that false belief causes irrational conduct. It is our maps that disturb us, not the territory. Parents' beliefs that their children had a speech disease ("stuttering") were false and their effort to correct the "disease" led parents to create in their children a fear of stuttering. (3) Johnson did not think that people would jump to the conclusion that he meant using the word caused the disorder. If the results were not so unfortunate, it might be amusing to hear claims that Johnson was wrong because some parents report that their children no longer stutter and that they did call it "stuttering."

The Effectiveness of Johnson's Theory

The tendency to discount Johnson's work appears widespread. This is a great loss because use of his type of parental counseling to stop parents tinkering with their children's hesitancies has prevented thousands of children from becoming chronic stutterers.

At Baylor University, for years we have called stuttering in children "normal," and have cautioned parents against punishing it or disturbing themselves over it. We have told parents to reduce their demands on their children about other things as well as speech, to distract them when they "stuttered," and to keep them talking when they were fluent etc. So far we have failed with two children in over thirty years of practice, as far as I have been able to tell.

Other clinicians (Rubin, 1986, p.483) have claimed 100% recovery of stuttering children when they or their parents were seen early enough. Dr. Rubin states that "... every pathologist I have talked to reports the same success."

Johnson's Theory and Lidcombe Therapy

I recently attended the ASHA [American Speech-Language-Hearing Association] convention in Atlanta, and I was fortunate enough to see some sessions of what they called "Lidcombe" therapy for early childhood stuttering. I was quite impressed with the method, and I am certain that Wendell Johnson would have applauded what I saw.

I believe that Johnson's Diagnosogenic theory and resulting therapy, whether he intended it or not, was a roundabout way of treating early childhood stuttering with symptom-removal psychotherapy. He taught parents to ignore the symptom by convincing them it was normal, so this prevented reinforcement of stuttering. No matter how much Junior appeared to stutter, it was normal and he would stop doing it if you ignored it. Like thumb sucking, nail biting, and other attention-getting and controlling behavior, when parents stop feeding the habit, it often dies.

If parents can use the word stuttering without becoming disturbed by its meaning, and thereby misled into punishing or criticizing or otherwise advising their children when they do some "stuttering," the word stuttering (whatever they mean by it) is as harmless as any other word.

What the Lidcombe clinicians use when they work with children who stutter I would call symptom-removal psychotherapy for children that makes stuttering a non-issue (nobody is disturbed by it when it happens, so it is not reinforced; patients get no special attention for stuttering, so they cannot use it to control). When young patients get stuck, clinicians note this and sometimes gently ask patients to speak again without getting stuck. Clinicians increase the children's confidence in their ability to speak normally and exert normal audience control. Clinicians make the children the center of attention and put them in productive control of the sessions, increasing their sense of equality or superiority, a move that often reduces hostility. Moreover, clinicians teach parents to do the therapy and everything is done in the spirit of fun and play. No doubt the treatment is effective, but I think similar results have also come from treating parents without providing direct therapy for the children.

General Semantics and Psychotherapy Today

No doubt most chronic stutterers feel terrible when they stutter. They likely create these bad feelings by their evaluations of what they have done, something that they consider dangerous, disgusting, etc. They believe that they should not have so behaved and that they must not do it again. Where did they get these ideas? Johnson said that others had such ideas first and passed them on through their language-inspired instrumental (operant) conditioning.

The more you study Johnson, and also cognitive behavior therapy, especially Rational Emotive Behavior Therapy, the more valuable the Diagnosogenic theory of stuttering appears. The most popular psychotherapies today often consist of techniques for applying general semantics (Christopher, 1998).

Regardless of why children begin stuttering, how you respond to it has to be mediated by what you say to yourself about it, and what you say will be influenced by what the word stuttering means to you.

Before consigning Johnson to the trash bin, we need to do a lot of reading about what is going on today in the world of psychotherapy, and examine what we do in our therapy sessions. What has happened is this: While our field of speech-language pathology has nearly abandoned the fact that our evaluations, what we believe and say about real or imaginary events, accounts for how we feel and behave, the field of psychology has taken over the idea and has made it the very center of many systems of psychotherapy. Much of what we do in therapy I call "semantic" because we actively change beliefs. Peter Christopher summarized our influence on psychology in an article published in ETC, Summer, 1998, entitled "They're Stealing Our General Semantics!"

The Anatomy of Emotional Reactions

Emotional reactions involve at least three steps:

1. an event occurs or one imagines that an event might occur.

2. one evaluates this, usually without being aware of doing so, as hostile, neutral, or friendly.

3. this evaluation produces feelings that can lead to responses that fit the feeling.

Therapy involves working with clients at point 2, a position Johnson elaborated in his book People in Quandaries (p.428). We change behavior by changing beliefs about events. Most stutterers I have interviewed believe that all stuttering is the same and that all of it is dangerous. They also tend to believe that stuttering causes how they feel about it, and that listener responses make them feel a certain way about themselves and/or about their listeners. In other words, they jump from step 1 to step 3 without being aware of step 2. Too many speech pathologists agree with this misevaluation, and this makes it difficult or impossible for them to help stutterers become realistic about their problem feelings.

For improvement to occur, clinicians working with stutterers must discover what beliefs their clients need to change to make their beliefs more consistent with the facts. We have to correct these without losing the patient. No doubt, patients will resist, because stuttering therapy does not occur in a vacuum, and the insights gained will spill over into other important areas of their lives.

Alive But Not Kicking Too High

There is some evidence that Johnson's theories are still alive. Guitar (1998, p.4) states that some stutterers don't want to be called "stutterers" but instead called "persons who stutter." Guitar also says that "Adults who stutter often say that changing the way they think of themselves -- as people that happen to stutter but with many more important attributes -- was one of the most significant things they did to break the bondage of stuttering." Johnson would approve, but he would probably change it to "persons who repeat sounds and syllables more frequently than they want to, etc." This change could make a greater difference. For example, I may have once enabled a school-aged "stutterer" to cure himself. He lived in a distant city and I saw him for one session during which I told him that he did not stutter, but he unnecessarily repeated some sounds and syllables now and then. I told him that such repetitions were not needed, and that saying them once would suffice. He never returned. Later, his mother wr ote me a letter about how well he was doing.

Conclusion

Much that goes on in a typical session of stuttering therapy involves applied general semantics. We cannot always change the territory but we can change the map and patients will feel better, live more productively, and speak more fluently.

NOTES

(1.) Johnson did believe that all hesitancies misdiagnosed as stuttering were instead "normal," but he regarded the word "normal" as what is "normal" for a given patient. It would be "normal" for an alcoholic to drink, and "abnormal" if he did not do so. General semanticists use the word "normal" as an engineer would use it and not as a statistician would use the word. If an automobile performs as it should, given a certain car, it is "normal."

(2.) With reference to the possibility of an organic cause of stuttering, Gregory (2003, p.20) says, "A very simple, meaningful statement that I always made while teaching was to say that whatever the physiological difference in a child who stutters, it has to be very small considering: (1) the minimal nature of the speech disruption-repetition and prolongation; (2) the cyclic nature of these behaviors; and (3) the probability that up to 80 percent of those who stutter at one time do regain normal fluency."

(3.) Even if the diagnosis was not a misdiagnosis, it still stimulated irrational treatment of the children because of dangerous emotions attached to the word. Johnson's theory could have been called the "misdiagnosis" theory of stuttering.

REFERENCES

Guitar, Barry. Stuttering: An Integrated Approach. Baltimore: William and Wilkins, 1998.

Johnson, Wendell. People in Quandaries. New York: Harper & Brothers 1946.

Rubin, Herbert. Cognitive Therapy in George H. Shames and Herbert Rubin, Stuttering Then and Now. Charles E. Merrill Publishing Company: Columbus Ohio, 1986.

Christopher, Peter. "They're Stealing Our General Semantics!" ETC (Summer, 1998).

Gregory, Hugo H. Stuttering Therapy: Rationale and Procedures. Boston: Allyn and Bacon, 2003.

Onslow, Mark. "The Lidcombe Programme: Treatment of early stuttering: the Lidcombe Program." Australian Stuttering Research Centre, University of Sydney. http://www.stammering.org./lidcombe_info.html

GARDNER GATELEY, PH.D. *

* Dr. Gateley is Professor Emeritus at Baylor University, Waco, TX, in the Department of Communication Sciences and Disorders. He teaches two courses in stuttering and stuttering therapy each year. He holds Specialty Recognition in Fluency Disorders from the American Speech-Language-Hearing Association.

The Editors thank the anonymous referees for their helpful comments and suggestions on earlier drafts of this paper.
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Title Annotation:Wendell Johnson
Author:Gateley, Gardner
Publication:ETC.: A Review of General Semantics
Date:Mar 22, 2003
Words:2305
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