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Understanding Stuttering and Counseling Clients Who Stutter.

Stuttering is a complex and prevalent disorder that involves not only speech disfluency but also challenging psychological and interpersonal experiences for those who stutter. Difficulties are exacerbated by fluent speakers' misconceptions about stuttering and negative attitudes toward people who stutter. As counseling techniques have been found to be effective in the treatment of stuttering, counselors must be better educated about stuttering and how to work effectively with clients who stutter. This article presents counselors with a model of stuttering that highlights three primary aspects of stuttering from a client-centered perspective. These three components of stuttering--struggle in speaking, avoidance of cues associated with speech difficulty, and the expectancy of speech difficulty--are each described with theoretical, empirical, and anecdotal support. Evidence of the effectiveness of counseling for stuttering is provided along with general guidelines for counselors working with clients who stutter.

Studies have continually reported that the general public, and even speech pathologists and teachers, tend to have inaccurate knowledge about stuttering and often hold negative attitudes toward people who stutter (Ginsberg, 2000; Lass, Ruscello, Pannbacker, Schmitt, & Everly-Myers, 1989; Wirtz, 1992; Yeakle & Cooper, 1986). This uninformed and frequently negative view of stuttering has itself contributed to the problems faced by those who stutter. Although people who stutter are, on average, no different from the general population in terms of psychological health and personality (Bloodstein, 1993), stuttering is a condition that is often accompanied by emotional distress (Manning, 1999), which is exacerbated by the incorrect and unflattering assumptions generally held by the public.

When the individuals possessing negative perceptions are mental health professionals from whom those who stutter may receive counseling, the consequences can be devastating. Unfortunately, it is not uncommon for people who stutter to have had experiences with counselors who possessed little knowledge about stuttering, and in the worst case scenarios, were wedded to outdated theories and stereotypic assumptions. People who stutter have been labeled by their (typically well-intentioned) counselors as nervous, uptight, unintelligent, socially inept, and maladjusted. As the prevalence of stuttering is approximately one percent of the adult population, with higher numbers in childhood (Bloodstein, 1993), it is likely that at some point in their careers counselors will encounter a client who stutters. Accordingly, counselors should be well prepared to assist those who stutter rather than add to their difficulties. Moreover, the value of a well-informed counselor can go beyond the emotional well-being of the person who stutters. The self-perception of an individual who stutters is thought to be a critical influence in the perpetuation of a cycle that either maintains disfluency or promotes greater facility in speaking (Harrison, 1993). Indeed, in one recent study, feelings of shame and self-consciousness among people who stutter were found to be related to more severe stuttering behaviors (Patraka, 1998). Thus, if properly prepared, counselors can not only contribute to their clients' emotional well-being, but they can also assist their clients in achieving greater fluency. To accomplish this, counselors need to better understand the stuttering phenomenon, with particular attention to the perspective that their individual client has of his or her stuttering problem.

Although much about stuttering, including its etiology, continues to be debated by experts in the field, certain components of stuttering are generally accepted and can elucidate the experience of stuttering considerably. Accordingly, in this article, a prominent model of stuttering based on principles of learning theory is presented with a focus upon areas relevant to the counseling process. Three primary behavioral components of stuttering -- struggle, avoidance, and expectancy--are discussed in terms of how each tends to be manifested in people who stutter. After setting forth these foundational concepts about stuttering, we present research regarding the effectiveness of counseling for stuttering. We then discuss how counselors can incorporate this understanding of stuttering into their work with clients, and we provide some general guidelines for fostering a positive therapeutic relationship with clients who stutter.

A MODEL OF STRUGGLE, AVOIDANCE, AND EXPECTANCY AS PRIMARY COMPONENTS OF STUTTERING

Three primary components of stuttering shed light on the experience of stuttering from the perspective of the individual who stutters: Struggle in speaking is frequently preceded by the expectation of the impending difficulty and an attempt to avoid it (Bloodstein, 1959,1997). Each of these components (struggle, avoidance, and expectancy) is explained briefly in this section.

Struggle

With regard to stuttering, the term struggle refers to one's speaking with undue physical strain, tension, and effort. Along with the assessment of frequency and duration of disfluencies, struggle in speaking is the primary means by which clinicians and people who stutter tend to characterize the severity of stuttering. Moreover, struggle is the primary focus of speech therapies for stuttering. Specific types of struggle behaviors can occur at the articulatory, phonatory, and respiratory levels (Wexler, 1996). As the experience of struggle is multifaceted, it is appropriate and beneficial to attend to the various manifestations of struggle in an individual.

This phenomenon is described by people who stutter according to specific behaviors, which vary from one individual to the next and also vary across time for any given individual. Whereas one person's struggle might manifest itself as tension in the arms and legs, another person might hold his breath or breathe forcefully. Moreover, whereas one sound (e.g., words that begin with the letter "t") might be accompanied by considerable struggle for someone for a period of time, another sound (e.g., words that begin with the letter "s") might become more troublesome at a later date. Other individuals may view their struggle through a figurative lens, using metaphors to describe the powerful experience of struggle in stuttering.

The variation in the experience of struggle is illustrated by the following: In listening to E.B. (1997, p. 6), we learn of his individualized experience of struggle:
 I just go on until I practically choke. The words just won't come out. My
 worst problem is with the sound "s," hard "c," sound "d," "k," "b," and
 "r," sometimes.


A more metaphorical example is that of Dell (1994, p. 160), who views stuttering as a devil that creates in him a variety of physical behaviors:
 There are now many times when I'm determined to face my listener and
 control my spasms only to find my jaw jerking and my mouth frozen in
 despair. I had intended to grab the devil by the throat and ring its bloody
 neck, but instead I'm defeated again.


Avoidance

Avoidance in the stuttering context is characterized by an effort to avoid situations, words, sounds, or anything else that one anticipates will result in stuttering. Some people who stutter are so adept at the use of avoidance that they rarely, if ever, exhibit any disfluency (Wexler, 1996). Avoidance may be manifested in a variety of ways, from avoidance of a specific sound to a general denial of one's identity as a person who stutters. A five-level avoidance classification system--including sound, word, situation, relationship, and self--has been delineated by Sheehan (1970), who viewed stuttering as a result of conflicting approach and avoidance tendencies. The person who stuters fears both speech and silence and associates the consequence of negative emotion with either choice.

Researchers, theorists, and clinicians generally view avoidance as a critical dimension of stuttering (e.g., Murphy, 1999; Starkweather, 1999), having found that stuttering tends to increase when people most want to avoid speaking; and, conversely, stuttering tends to decrease when people feel more free in approaching a speaking situation (Sheehan, Hadley, & Gould, 1967; Williams, 1982). Individuals have even found themselves unable to stutter when they actually want to stutter. In contrast, those who stutter tend to do so more consistently when forced to say particular words without substitute such as their names (Bloodstein, 1987), the punch line of a joke (Van Riper, 1982), and during introductions of particular people.

As with struggle, avoidance is a dynamic, ever-changing phenomenon, signifying different periods of development in an individual challenged by stuttering. Young children rarely avoid speaking, but as individuals get older and become more self-consciousness. Especially during the teen years, they exhibit greater avoidance. Lemon (1997, p. 50) remembers adolescence:
 At times as a teen, I rarely answered the phone as I couldn't always say
 "Hello." I attempted to hide my problem as much as possible and pretend
 that I was normal in speech by word substitution, avoidance of stressful
 situations, and talking as infrequently as possible.


The depth of the avoidance phenomenon can be profound. While one person avoids certain words in specific instances with particular people, another person may be reflecting deeply on how avoidance has shaped his entire identity, as exhibited in the following:
 As we avoid words and situations, as we try to project the image of a
 fluent speaker, we are denying who we really are. Because of the negative
 emotions we have come to associate with stuttering, we try in many
 different and ingenious ways to not experience that part of ourselves, and,
 in doing so, we severely limit our ability to experience life fully and
 grow as individuals (Young, 1994, p. 55).


Avoidance is also perceived by some to pierce their ability to engage in certain relationships.
 Me, the young man with the stern face that does not invite conversation
 with a stranger, more afraid of the pain this may bring than the dull ache
 of loneliness (Dawainis 1994, p. 115).


Although the avoidance of speaking situations may exacerbate the handicap of stuttering, it is nonetheless an expected reaction of those who often fail to speak fluently. Silverman (1996) stated this point plainly (p. 68):
 It is normal to try to avoid pain--both psychological and physical! Since
 persons who stutter are likely to experience negative reactions to their
 stuttering as pain, and since most of them probably are not masochists,
 their attempts to reduce the pain in their life by avoiding talking (and
 hence stuttering) whenever possible are understandable. The problem is that
 the price they pay for avoiding this source of pain may be too high.


Expectancy

Expectancy with regard to stuttering refers to the individual's assumptions about his ability to communicate verbally (Bloodstein, 1959). As people who stutter typically approach speaking with doubts, anxieties, and fears, their thoughts and actions become geared toward averting or postponing the anticipated difficulty. Expectancy, or anticipatory struggle, has been viewed by some as the defining factor in stuttering (Woolf, 1967). Stuttering is maintained by a debilitating cycle in which the failure to speak fluently is followed by the anticipation of the recurrence of the dreaded failure in fluency, which is followed by fluency failure.

Reed (1994, p. 108) described his experience as follows:
 My anxiety gave way to panic and my thinking raced and spun with tapes of
 old devastating experiences when my stuttering was way out of control. The
 harder I tried not to think about it, the more preoccupied and compulsive
 my thinking became.


The significance of one's expectations regarding stuttering is apparent in a variety of ways that are discernible through careful listening to the person who stutters. For instance, in the following quote, it is seen how detailed and calculating one's expectancy can be, even during the seemingly mundane task of ordering at a fast-food restaurant.
 So I try. Let's say I'm the third in line. I know I have to say that word
 relish. I can feel my heartbeat picking up speed. Thump. Thump. Thump. The
 first person in line calmly, fluently says what he wants on his hamburger.
 A voice in the back of my head repeats, "You aren't going to say it right."
 Fear starts to build. My heart beats faster. My throat starts to tense and
 close. Inside me, panic begins to set. Outwardly, I try to pretend that I'm
 just like everyone else. I try to appear normal, hiding the turmoil that's
 beginning to bubble inside (Moore, 1997, p. 60).


People who stutter also provide insight into how early memories can shape later difficulties in one's expectations regarding stuttering:
 I started to stutter in Grade one. I remember clearly. I was reading aloud
 in class. I tried to sound out a word, I even remember the word. It took a
 while to get the right pronunciation. I stumbled over it and all the
 children (it seemed) in the classroom began to laugh. It began there. When
 I came to that word again or one beginning with the same letter, I became
 nervous and conscious of what happened before and from there it got worse.
 I lost the little bit of confidence I did have (Bulger, 1997, p. 14).


The expectation to stutter also becomes apparent in associated symptoms that precede or accompany the struggle behaviors. When stuttering, reduced eye contact with the listener is a common occurrence among individuals who stutter (Atkins, 1988). Other behaviors may include jerking of the head; eye blinking; the inclusion of extra sounds, syllables, words, or phrases as starters before the expected difficult so,and; abnormal variations in loudness or pitch of voice; and abnormal variations of speaking rate (Silverman, 1996). These behaviors may initially occur as the individual attempts to avoid or reduce the severity of the stuttering moment. Such devices may continue to be used even as the individual no longer finds them beneficial because they have become a habitual accompaniment to the stuttering behavior.

THE EFFICACY OF COUNSELING IN TREATMENT FOR STUTTERING

Counseling and psychotherapy have been found to be effective in the treatment of stuttering, with effectiveness being measured in a variety of ways. Blood (1995b) described a cognitive-behavioral treatment program for relapse management in adolescents who stutter. Clients who were trained in problem solving, general communication skill,;, assertiveness, coping with stuttering episodes, and realistic expectations for fluency were found not only to exhibit a significant decrease in disfluencies, but also positive attitudes and feelings 12 months later. In evaluating the efficacy of a cognitive-behavioral treatment program with adults, a program utilizing both biofeedback and relapse management training, Blood (1995a) found similar results in decreased disfluencies and positive attitudes and feelings a year later. Zibelman (1982) described avoidance-reduction therapy for stuttering, emphasizing the intrapsychic and interpersonal conflicts of stutterers. Through practice assignments and heightened awareness of defense mechanisms, greater self-confidence and the ability to speak and live more freely resulted.

Therapy focusing on the covert symptoms of stuttering, including an introspective examination of the anticipation of stuttering along with other counseling and desensitization techniques, was reported to be successful in the clinical management of such symptoms (Moore & Rigo, 1983). Group therapy for stuttering has also been found to result in an improvement in fluency, a positive effect on personal behavior, and the facilitation of transfer and maintenance of speech gains (Leahy & Collins, 1991). Also, investigating group psychotherapy with stutterers, Ojha & Bettagere (1982) reported that six stutterers who met for 2 and one-half hours per week for 6 months were largely helped by the group process, five showing much improvement in their speech or becoming fluent. These clients also showed improved attitudes toward stuttering, speaking situations, and listeners. When examining variables likely to predict individuals at risk of relapse after successful behavioral or dynamic psychotherapy for stutterers, Andrews and Craig (1988) found that skill mastery as evidenced by no stuttering coupled with normal attitudes toward communication and an internalization of locus of control, predicted long-term maintenance of speech improvement.

A PRACTICAL APPROACH TO COUNSELING

Stuttering is a complex phenomenon that varies tremendously from one person to the next, both in the way that it manifests itself and in the effect that it has on the life of the person who stutters. Consequently, in effective counseling, each client's stuttering is explored from the unique perspective of that individual. It is important for the counselor to find out what kinds of speaking difficulties a person has and the struggle, avoidance, and expectancy behaviors that predominate. An individual's identity as a person who stutters, the experience of living a life with this particular difficulty, can become pervasive in one's overall self-concept. As the experiences of living with stuttering combine with other life experiences and relationships, a unique constellation of psychological issues or difficulties is created in an individual who stutters.

The task of the counselor, then, is to explore with the client his or her experience of stuttering in the context of other issues and problems that may exist. For example, the earlier quote by Dell, in which stuttering is viewed as an uncontrollable devil, brings forth issues of attempted control and defeat that might be explored in counseling. The counselor could ask Dell what the devil does to him, physically, when he is trying to speak. Empathy is often described as the ability to walk in a client's shoes. In working with clients who stutter, the task of the counselor is to talk from the client's mouth, or, more precisely, to understand what it is not to be able to communicate fluently. A counselor will then be more able to relate to the client's thoughts and feelings when stuttering.

Similarly, it is helpful for counselors to explore the specific sounds that are difficult for clients at any given time. E. B. provided an example earlier of sounds that "just won't come out." Counselors can explore how current struggles differ from past struggles and can then tap into whatever associations to the different sounds may be apparent. For instance, a teenage girl who stutters may tend to have difficulty with the sounds of letters that begin the first names of boys to whom she is attracted, or girls of whom she is envious. Exploring the physical behaviors that accompany a client's disfluent speech may also be valuable, as the client's self-awareness of concrete behaviors will be increased. By exposing the struggle that the client experiences, the mystical and uncontrollable phenomenon is made tangible. From this shared understanding, counselors can talk with clients about their thoughts and feelings related to struggle in speaking.

By addressing the particular struggles in speaking that are experienced by people who stutter, counselors demonstrate their desire to understand about their clients' experiences of stuttering. Counselors who take this direct approach toward understanding and confronting stuttering break the cycle of avoidance, first by encouraging clients to talk about what they do when they stutter, and how they think and feel about it. From here, counselors can help clients come to terms with their fears and anxieties about speaking and stuttering.

Counselors will serve clients well by not only being aware of their avoidances but also by encouraging open discussion about them, such that the therapy room becomes a place in which clients do not hide their faulty speech and their fear of it. Counselors will want to inquire about the specific sounds, words, situations, and/or people that their clients try to avoid. Similarly, it may be useful for counselors to explore any changes that have occurred over time in their clients' avoidance patterns. In this regard, support for clients' attempts to be open about and confront their stuttering is critical.

With regard to avoidance, it is important for counselors to be aware of the fact that individuals who stutter mildly may nonetheless exhibit significant avoidance behaviors, perhaps even more so than people who are severely disfluent. Communication anxiety, which not surprisingly has been found to be prevalent among those who stutter (Craig, 1990; Miller & Watson, 1992), may be higher among those who stutter mildly because they may be more successful in concealing their stuttering (Van Riper, 1982). They may be plagued by constant concern that others will discover that they stutter and, subsequently, reject them. Those who stutter severely, in contrast, are unable to conceal their stuttering and thus do not suffer the fear of their secret being revealed (Van Riper, 1982). Thus, the necessity in inquiring about one's selfperception as a communicator and one's anxieties and fears about stuttering is clear.

Some stutterers experience limited occupational choice and social relationships, as they have felt or been crippled by disability (Carlisle, 1985). Dawainis, who was quoted earlier, spoke of choosing loneliness over the pain that he anticipated would result from attempting to communicate with strangers. Others who stutter have chosen careers that they did not genuinely desire, but that they selected due to limited speaking or social requirements. In school, some people who stutter register or withdraw from courses based on whether class presentations are assigned. In order to understand their clients' experiences of stuttering and to help with associated difficulties, counselors will want to encourage clients to speak about how their lives have been influenced by avoidance, in general as well as in specific areas such as education, employment, and social relationships. As illustrated by Young's statement earlier, avoidance can most profoundly influence the lives of people who stutter.

Related to the topic of avoidance is the expectation that people who stutter have of their impending difficulty in speaking. The disfluency itself may be predicated, at least in part, by the anticipation of it. Thus, the exploration of clients' beliefs about their ability to communicate effectively, and their thoughts and feelings when approaching speaking situations, can be beneficial. In this regard, we think of Reed who spoke of the preoccupied and compulsive thinking that resulted from speaking experiences that were continually devastating.

Similarly, insight can be gained from discussing with clients what happens to them physically when anticipating that they will stutter. Moore, quoted earlier, described his heartbeat picking up speed and his throat tensing and closing as he told himself that he would not be able to communicate effectively. Finally, counselors will want to help clients explore their past experiences with stuttering that shape current assumptions about their speaking abilities, as Bulger provided a memory of his confidence as a speaker being challenged as early as the first grade. From here, self-defeating convictions can be exposed, confronted, and replaced with self-affirming and more productive beliefs.

FOSTERING A POSITIVE COUNSELING RELATIONSHIP

Although much about stuttering remains debatable, there are generally accepted recommendations for interacting with people who stutter. Moreover, the conditions that have been found to facilitate a productive counseling relationship with clients in general hold true when working with clients who stutter. That is, counselors who show empathy, genuineness, and positive regard for their clients create an environment that welcomes positive change (Rogers, 1957). These facilitative conditions should be coupled with skilled listening, in which the counselor understands that clients' stories tell how they have constructed their identities and how they have made meaning of events in their lives (Cormier & Cormier, 1998). Furthermore, clients who stutter may find great emotional relief in telling their stories, particularly if they have been hiding their feelings from others or even from themselves. Briefly, the following general suggestions are offered to counselors working with clients who stutter.

While listening to clients who stutter, counselors should pay particular attention to their own nonverbal behaviors at different levels of clients' fluency, noticing perhaps signs of discomfort such as loss of eye contact or body fidgeting. Similarly, it would be helpful for counselors to be aware of what they think and how they feel when a person stutters. Counselors who find themselves uneasy, impatient, or judgmental might want to think further about their assumptions about stuttering. Also, counselors (especially those who have had little interaction with people who stutter) will want to consider if they hold any biases toward people who stutter. For example, some might incorrectly assume that stutterers are less intelligent or more anxious than others. Others might mistakenly believe that stuttering results from speaking too quickly, wanting the speaker to just slow down and relax. Finally, counselors working with people who stutter will want to be educated about nonverbal and verbal behaviors that would be more helpful when working with people who stutter.

As when working with most clients, counselors should strive to maintain naturally attentive eye contact, demonstrating to clients who stutter that they are listening closely to the message being conveyed, regardless of how fluent the speaker is in communicating it. Although counselors might feel the normal tendency to interrupt or complete clients' sentences for them when they are having trouble, counselors who remain quietly attentive and give their clients all the time they need will be sending a message of interest and acceptance. It is also helpful for counselors to attend to their own speech when working with clients who stutter. Speaking at a relaxed pace and pausing when turn-taking create a speaking environment without pressure. It would also be advantageous if distractions from other stimuli (e.g., the phone and outside noise) could be avoided as much as possible, creating a place in which clients who stutter do not have to compete to be heard.

In counseling, clients who stutter benefit enormously from sharing their experiences and having them understood, as they are accustomed to others being impatient or uncomfortable with hearing disfluency or the pain accompanying it. Finally, it is helpful for counselors to know about good resources for people who stutter (e.g., self-help organizations, materials published by the Stuttering Foundation of America), which can be provided to clients as warranted. Research has shown that self-help affiliation with others who stutter is related to less psychological distress, less struggle in speaking, and less avoidance of verbal interaction (Patraka, 1998). Sharing age-appropriate materials such as stories written by others who stutter, may also help clients in working on their stuttering and their thoughts and feeling about it.

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Amy Patraka Ginsberg, Ph.D., is a professor, Department of Human Development and Leadership, Scholl of Education, Long Island University, Brooklyn, NY. Email: apatraka@liu.edu. Karin B. Wexter, Ph.D., is a professor with Teachers College, Columbia University, NY.
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Date:Jul 1, 2000
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