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010. FAILING VOICE AND BLOCKED SPEECH

10.1 A kink in the link: distress causes tangled communication

In the introduction to the 6th edition of a well known book Speech Correction, principles and methods, its author Charles Van Riper writes: " If there is any real hope for mankind in these troubled times it is to be found in the ... belief that somehow we must change this planet from a polluted sphere into one where man can fulfill his destiny with some grace. We are sickened from the ugliness in which we live and die. We are appalled by the way we have raped the good earth and anointed its wounds with human waste. We protest the human cruelty and exploitation we see all about us. We are angry with those who preceded us for handing down to us this heritage, and we are utterly determined to reverse this evil course, for we see very clearly where it will end....There are many kinds of pollution, and some of the worst are those that reflect man's inhumanity to man."

Pain and avoidance belong together. Anticipation of pain calls for avoidance. People inflict pain on others to coerce them, to dominate, to control. An infant or child who suffers under domination and is threatened with pain, learns to fear the parent who forces his will upon the child. It also learns to avoid pain by dissociating from its body, by negating and repressing feelings. This may cause grave problems with communicating later in life.

Why have physicians, nurses and clergymen often averted their eyes and closed their ears to signs that betrayed the presence of family violence? They had access to the homes whose inhabitants were engaged in offensive struggles that often resulted in a child being physically and mentally bruised. Perhaps they thought it was not their business, perhaps they were too scared to take action, perhaps they were passive out of fear to be turned away. Novelists on the contrary have been keen to observe rough family situations: malice and hate developing, the more fierce when the members of a family are accomplices in a deadly game of humiliating each other. It has produced masterpieces of theatrical tragedy, cinema of the highest level, enjoyment and shuddering for the millions. This in itself is bizarre: several sectors in literature and art and the entertainment industry thrive on human oppression and suffering, satisfying curiosity and a passion for excitement. It is odd that novelists signal the entanglements of society and family life, that scientists write studies intended to understand and improve the situation, and that individual cases of mistreatment often go unnoticed.

Alice Miller (1980) has written about the harmful effects of cruelty and oppression, as exerted in normal education, at least what was still considered as normal in many families in the sixties. Absolute obedience was maintained by an occasional beating, humiliation was a daily practice. It includes: punishing by inflicting pain, locking up, verbal threats. When the child is older: sexual exploitation, incest and terrorisation. In a subtle form: the child is never allowed to choose, decisions are taken without explication or consent. In nature, and also in human nature, it is a law that the strong dominate the weak. This law tends to repeat itself over the generations. As the parents act out what they have experienced when they themselves were young, the practice is firmly established as a cultural heritage. Even though there have always been more enlightened educators, we can expect the practice to continue for many generations to come.

In this chapter we are concerned with the consequences later in life for victims of violence, especially with respect to their mode of communicating. The beatings and accompanying verbal abuse have established feelings of guilt that keep popping up later in life in situations that remind of similar situations in childhood. This undermines the self confidence of the victim and repeatedly prompts one to be apologetic and to shun responsibilities. Others will unconsciously try to liberate themselves from these negative feelings by energetically punishing themselves and others for their past sufferings: their spouses, their children, their therapists. A few examples of unexpected and absurd behaviour will suffice as a warning not to think lightly of the kinks in the communication lines linking humans.

10.2 The counterfeit victim

A not altogether rare presence in the doctor's office is the person who has a serious complaint, be it of repeated vomiting, or unexplained fever, a wound that never heals, blood in the urine or in the stools. After numerous consultations and laboratory tests, one of the specialists or nurses brings forward the question whether the patient her/himself plays an active part in self-administering the disorder and obstructing the healing process. If this happens in a non-incriminating and understanding way the counterfeit victim may be ready to disclose what has driven her/him to this sort of attention-getting behaviour. If it is done in a tactless or offensive way, the patient will likely move on to the next hospital, to repeat the procedures. It is also called the Münchhausen syndrome. A related form, called Münchhausen by proxy (MBP) is cited next.

A child is presented, seriously ill, and much to the concern of the hospital staff no explanation can be found and nothing seems to alleviate the illness. The mother, equally concerned, is around to look after and "protect" her child. In this case the mother has infected the child by injecting faecal matter or by nearly suffocating it, or by damaging it in another way that is life-threatening but hard to discover and hard to prove. The child is stripped of its identity by the mother, is refused any existence of its own, is wholly part of her maladjusted personality. The persons using this vicious coping style are usually intelligent and resourceful and victims of a personality disorder due to maltreatment in their own childhood. The fact that relatively often they have attempted some form of medical training in which they have failed, may facilitate as well as provoke their deceitful behaviour.

10.3 The dystonic syndromes

Equally bizarre, but less malicious are compulsive movements of facial muscles and/or eyelids (known as tics and blepharospasm), of the neck (torticollis), and of the laryngeal closing mechanism during speech (spastic dysphonia or voice stuttering). Although considered as an organic affliction with unknown substrate by many neurologists and laryngologists, more and more reports appear of cures by reeducational training. Behaviour therapy and cognitive therapy, especially when applied in an early stage of development of the disorder, have resulted in a complete disappearance of the dysfunction.

Functional pathology is a promising approach for dystonic syndromes and probably explains a part of the dystonic syndromes. When driving a car, most of us have experienced a ticklish feeling on the scalp, the face or the neck, caused by a moment of stress, e.g. after a tense moment at a road crossing. This is what tic-patients have reported about how the symptom began: when they were tense or annoyed, a pricking sensation would be felt in the cheek or brow. A quick contraction of the muscles of that part of the face would make an end to it. The muscle twitch had soon become an automatism to chase the skin sensation. Later, the twitch had become a familiar part of themselves, an indispensable companion, a distraction during annoying moments. As happens more often in life, a companion may become obtrusive. Even with the help of a therapist one may not succeed to free oneself. This is true also of torticollis. When the behaviour has freshly shot up it can, like a green sprout, be easily redressed. When it has been allowed to become a fully grown automatism, hardened into wood, it is inaccessible for change. The art of healing therefore begins with detecting the very first signs that announce distress and dysfunction.

Early detection of spastic dysphonia is an art mastered by few. Dystonia of the vocal apparatus announces itself by minute symptoms. They come and go, much like the symptoms of multiple sclerosis, with which the disorder has been confused in the past. A slight tickle in the throat giving rise to a dry cough, an unexpected interruption of the voice in the middle of a word are alarming enough to consult a doctor. Since most doctors have heard of spastic dysphonia but have no profound understanding of it, they will do the inappropriate thing and refer the patient to a laryngologist or a voice clinic. Many voice specialists are fond of gadgets, and the odds are that our spastic dysphonia patient will be subjected to videolaryngosopy, voice recording, analysis of vocal acoustics, electromyography of the laryngeal muscles, tests of respiratory function, all of which tend to provoke more ticklish sensations in the throat and to increase the patient's worries. Inapt attempts at treatment follow, medication and respiratory and voice training. The voice becomes progressively worse: the interruptions last longer and end in explosive bellowing sounds, alternating with normally spoken phrases. The loss of control over one's voice upsets these patients to a degree that it worsens their condition. They are now in a stage that they cannot be treated by reeducation. The usual procedure is then to inject botulinum toxin in the vocal muscles to prevent them to contract during the speech effort. Since the artificial paralysis lasts only a limited time, the procedure is repeated every three months.

In an appropriate management of incipient spastic dysphonia the damaging diagnostic procedures just described are omitted. The seasoned doctor or voice clinician will recognise the minute symptoms as being caused by incipient spastic dysphonia. Moreover he/she will notice small signs of a mental depression, a subdued anger, a smouldering discontent. These are the important signs to follow through. Even if the clinician recognises this, it requires in addition a lot of sensitivity and tact not to sever the thin line of communication that will eventually guide the patient to the solution of his brewing dilemma. The somatic signs (voice interruptions, wavering voice, burning throat) point to inhibited expression of strong emotions. The voice interruptions are a bizarre defence against an uncontrolled outburst of feelings such as the patient would not allow himself. A good therapist will walk the thin tight rope to reach the pent up feelings and help the patient out of his quandary. During therapy the patient will be lifted to his feet from were he can look at the conflict that has caused the turmoil and can work out a solution.

The personality that is inclined to get tangled up in functional disorder has been described as rigid and, when deeply touched by conflict, lacking flexible defence and adaptation.

10.4 Stuttering

There is reason to assume that early traumatic experience (ignoring of baby-signals, family fights, parental divorce) is one of the sources of chronic stuttering. However that applies to a small proportion of all stutterers. The reverse course is equally noteworthy: even in the presence of a hereditary disposition for stuttering, a supportive and encouraging upbringing will usually prevent stuttering from becoming chronic.

It is elucidating to compare some features of two bizarre communication dysfunctions that are still causing controversy between the specialists in the field: spastic dysphonia (also called voice stuttering) and stuttering, which has the official name dysphemia.

feature

spastic dysphonia

stuttering

onset

middle age

early childhood

usually develops

rapidly

slowly

symptoms at start

mildly blocked voice
  vocal tremor

articulatory and vocal tension

predisposition

punctual inflexible personality

hereditary disposition (cluttering, exacting or insecure personality?)

elicited by

injustice, mental injury

time pressure, guilt, over-demanding environment

management in "green" phase

early detection followed by behavioural and cognitive
therapy

parent-counselling for primary and secondary prevention are the best option

"woody" phase

locally injected botulin toxin to alleviate symptoms (no cure).

body-oriented reeducation to almost complete healing

Most cases of stuttering take years to develop, during which time the symptoms escalate and de-escalate. Thus there is plenty of time for secondary prevention, time which should not be passed in idleness. It has in many cases shown to be a reversible disorder, but once fully developed it usually takes years to become manageable. Some children need intensive treatment, others recover without treatment. Because life is unpredictable, we cannot know who will benefit from favourable life-events and who will be defeated by strains he cannot cope with. In the late stages of the developing disorder the principal features are: tense attempts to avoid or overcome interruptions in the speech flow.

The most striking fact however about stuttering is that all stutterers can speak fluently. This is the paradox of stuttering. In fact the fluently spoken utterances are more numerous than the stuttered ones. It means that the speech/language apparatus is intact and at least most of the timef unctioning properly. Stuttering is a conditional disorder. It is not a neurological speech disorder such as a dysarthria, since the symptoms in that case would be more constant. There are neurological patients whose speech is repetitious, halting or spastic, but that is not the kind of dysfluency that is here discussed. When a person who stutters is free from such emotional pressures or negative anticipations as usually elicit speech inhibitions, he is capable of speaking fluently. In one stutterer that occurs when he is talking to himself, to a small child or to a dog, in another when he whispers or sings or acts in a play, in a third when he is deeply relaxed or under hypnosis. Stuttering has therefore to be defined as a conditional speech disorder. Many stutterers have given evidence that the condition which elicits stuttering behaviour is time-pressure, and that it becomes worse when they feel they have lost control of their speech.

Another common feature of stuttered speech is that it sounds monotonous and dull. It lacks the appropriate intonation of normal speech. Because strong feelings disrupt the fluency of speech, it is possible that any expression of feeling is inhibited in order to prevent the disruption. During therapy for stuttering the clinician may ask the participants to concentrate on the sound of the voice and to express the intended feelings by intonation, but that is only in the final stages of therapy.

10.5 A double motivation conflict.

A plausible theory describes the conflict of motivations that explains the hesitation before and during a moment of stuttering (J.Sheehan 1970). When the moment is there to speak, the speaker prepares for the goal: go forward with speaking. The tendency to begin speaking increases as the goal approaches. There is however interference by a tendency to avoid taking the floor. This inclination is fed from a pool of frustrating experiences that induce fear of sounds, words or of speaking altogether. Because of the agonistic nature of the experience (it is a response to flee or to freeze) the tendency to avoid rises sharply as the feared goal approaches. When in the end avoidance wins, the system flips to a new goal: to freeze and stop speaking. As the goal to stop speaking is approached, fear inducing stimuli diminish and the tendency to stop speaking is rewarded. The tendency to stop speaking increases as the stutterer approaches this goal. However the social disapproval of not speaking interferes with reaching that goal. Avoidance of being silent gains in strength as the goal to stop speaking comes closer. When at last the tendency to avoid silence prevails, the system flips back to: go forward with speaking. From there the conflict will repeat itself. The whole episode, described in 200 words, has evolved in only 100 msec. A double avoidance conflict such as this can explain the seemingly endless series of sound repetitions that some stutterers engage in.

10.6 The dragon of stuttering: foe becomes friend.

Juvenile participants in a summer course for stutterers have created a sculpture. It is a dragon on a pedestal and one can easily imagine what the dragon stands for. The art-object has taken shape under the encouragement of the recreational staff of the two-week program. The participants spend their free time with healthy and creative activities while the therapy staff meets to discuss the plans for the following treatment session.

Self-expression starts the process towards knowing yourself. These youngsters have, at an early stage in their treatment, projected a part of their revulsion of stuttering in an ugly shaped object. The monster inside themselves that they have been fighting the greater part of their lives, now stands in front of them, ready to be challenged and to begin a dialogue with. It will take days, months or years of remedial experiences before they will be fully aware of some surprising facts:

1. the monster is a part of me, it is of my own making. It has been my way of responding to particular pressures in my early childhood.

2. my battle to slay the monster has been futile: the more I fight my dragon, the stronger it has grown.

3. since I have accepted that the dragon is a part of me of my own making, I can look at him more closely and without fear - he will loose his power over me. I will get to know him better and rename him: Avoidance (Map 10, 8), Agonism(6.5.2). Now I can restructure my life, venturing out of the old defence lines and working on new zones that serve adaptation as well as defence.

10.7 The iceberg of stuttering: 9/10ths of stuttering is below the surface.

There is no lack of maps that assist the traveller to find his way in the labyrinth of stuttering. The problem is that some are so sketchy as to be of no value. Others mutually contradict each other. Maps should be used with caution, and the user has to ask himself what part of the area is represented and on what scale in space and time. Is the area depicted the neuromotor event in the realm of milliseconds? Or is it the anxiety in the seconds before losing control over one's speech, or is it the (mal)adjustments to frustrations that have taken place over the years?

On this page is an early map that is still in use, designed by Dr Helen Fernau Horn in Germany around 1930. It shows the vicious circle that generates and maintains stuttering behaviour.

The same stuttering expert who introduced the model of "approach-avoidance conflict", J.Sheehan, thought of another powerful image, the "Iceberg of Stuttering". The symptoms of stuttering that are audible and visible are seen floating on the surface of the ocean of life; however they are just a small part of the whole stuttering complex. Under the waterline, unnoticed and ignored by many, are the persistent devious cognitions and emotions which uphold the disorder.

A therapist who is unaware of the damaging feelings and paralysing emotions below the waterline, and fails to work with these covert features of the stuttering complex, is bound to have disappointing results. The same is true for the stuttering person who, still lacking inner strength and courage, is not ready yet to face his inner dragons.

From the great variety of stuttering symptoms a few distinct behaviours stand out that occur in some, not all, stutterers. Rapidly repeated speech sounds are a form of agonistic behaviour that occurs under tense or threatening circumstances. What can be threatening for a stutterer? Speaking to a high ranking or dominant person, addressing a group meeting, conveying a "difficult" message. Above all, the apprehension for losing control of one's speech. These cues have obtained their threatening value by classical conditioning: it has happened before and was perceived as very embarrassing. When rapid repetitions occur signs of high arousal may be noticed, such as moist palms of the hands, dilated eye-pupils. Tenseness is a general condition that increases the probability of stuttering, a cue stimulus determines the particular moment that it will occur. The cue may consist of a feared word or sound which has caused problems in the past, or it may be a sign of impatience on the part of the listener.

Another symptom is speech inhibition or block. It consists of a tense constriction at the glottis or at an articulation point higher up in the vocal tract. There are many avoidance behaviours in stutterers: switching the sentence, choosing another word, allowing another person to do the shopping and to pick up the telephone, taking a train ticket to a farther destination when the actual destination begins with a feared sound. These avoidance behaviours are difficult to eliminate because they are part of a belief system that is continually being reinforced.

The behaviour-complex that maintains stuttering in a person has traits in common with superstitious and addictive behaviour. This aspect has remained underexposed. Recently some self-revelations on this point have been published by people who have been stutterers. The classification of stuttering as a neurosis has often been challenged. If one thinks of neurosis as a habitual regression to agonistic behaviour, it certainly fulfills the requirements:

These fears fuel a huge number of clever avoidance and escape devices. Fabricating these will consume a considerable portion of the person's economy in some, in others it will hardly affect the efficiency of the person. When a person engages in neurotic conflict only part of the time, it would be exaggerated to label that person as a neurotic. Still I find it appropriate to use the expression speech-neurosis, or a neurotic dysfunction of verbal communication. See 10.9 on lifestyle and life scripts. Besides elements of addiction, there are phobic and obsessive-compulsive elements to be found in varying proportions. Even when these characteristics have been correctly diagnosed, it has often been infeasible to bring about a successful treatment. Around the ocean of psychotherapy the beaches are littered with stranded stutterers.

10.8 Avoidance is addictive. The fatal attractor that leads to stuttering.

During a study-assignment in the US in the seventies, I became impressed by the rapid progress of the theory of behaviour-learning. The application of classical and operant conditioning models on the stuttering problem seemed to work towards a solution. C. Van Riper, in the fifth edition of his book Speech Correction has used a Map to illustrate the cascading evolution of a stuttering disorder. Conditioning events, reinforcing habits, were represented in the form of currents, straights and rapids; a mirroring pool of black thoughts was not omitted. The author, possibly disenchanted by his model, left it out of the succeeding editions. Inspired by the Van Riper model, I made a Map of the cascading process that ends in anticipation of failure and halting speech production.

emotional conditioning

instrumental (operant) conditioning

unassertiveness, time-pressure

halting rewarded by attention

motivation conflict, tension leading to >

inhibited speech

negative anticipation, speech-anxiety >

avoidance of sounds or situations sound-repetition, speech-block

autonomic arousal: tachycardia, sweating, high thoracic breathing

escape manoeuvres: facial grimaces, tremor, head- and limb-movements

10.9 The place of stuttering in a life-script.

Most explanations of moments of stuttering apply to short-term motives such as neurophysiological events, fears, avoidance etc. In the comprehensive view of Concentric Man the long-term motives are much more important. In contemporary research on stuttering the issue is rarely mentioned. For lasting results however the therapist should study also the long-term issues and acquire the skills to cope with them.

After laying the foundations of an intensive and comprehensive therapy program for stutterers in the Netherlands T.Schoenaker (1981, 2000) moved to Germany where he began the Adler-Dreikurs Institute for individual psychological counselling (www.Adler-Dreikurs.de) in Sinntal. In his view every child experiences key events before the age of six that will determine his life style. It stakes out a life strategy, for example

A lifestyle automatically confirms itself: the behaviour issuing from a lifestyle elicits responses by others for which one's own lifestyle supplies the fitting answer. That is why it hard to eradicate. It is a self-fulfilling prophesy, according to Watzlawick it is "begging the question". In most stutterers the way they stutter, the situations in which they stutter fit exactly in the life script they have laid out for themselves. They employ their stuttering for their ends, that is soliciting sympathy, shunning responsibility, keeping people at a distance, giving covert expression to aggression, to tax a person's patience. This approach is akin to that of Transactional Analysis (Berne 1964). In fact Berne writes: Of all those who preceded Transactional Analysis, Alfred Adler comes closest to talking like a script analyst. Berne also says that most neurotic persons are at least dimly aware of their hidden intent. Changing and replacing the ideas and concepts that keep the life script going is the key to therapy. More about this in the next chapter.

Most chronic stutterers recover from their disability sufficiently so that they feel not handicapped anymore. Some traces however may remain, as in the case of the author of the quotation at the beginning of this chapter. On the occasion of my inauguration as a professor in phoniatrics Charles Van Riper from Kalamazoo (Michigan) was in Utrecht as a guest of honour. There he met Theo Schoenaker, who demonstrated to him a group session with young people. They had received training in muscle relaxation and body awareness. Van Riper, who until advanced age has always remained a stutterer, commented: "What do you expect from lowering their defences in a world that is full of knives?" Schoenaker (in his book Ja ... aber, 2000) recalls the incident: "I wondered at the time what he meant by those knives, because I didn't see any. I knew nothing yet about lifestyles. Now I would have interpreted his remark as belonging to his lifestyle". Van Riper, who carried his residual stuttering openly as a token of vulnerability, has also written: "for the serious student of stuttering the box of Pandora opens, revealing all human vices: lust of power, egoism, the need to humiliate, to threaten, to torment". Clearly he opens for us the box containing the distress of his own childhood. And he shows to us a way to active prevention.

A general rule among today's therapists is that the parents are never at fault, so as not to lose their confidence. This of course is only partly true. When stuttering has developed on a basis of a genetic disposition, it is clear that one of the parents has a share in the cause. However the parent is not to be blamed for it. Just as when a parent is incapable to love his or her child and is unknowing of his shortcomings as an educator. A reproach won't bring you very far since his lifestyle has also taken form under circumstances that he has not chosen. You can work towards a solution by identifying the facts as they are without condemning the person who is involved.

What can you, as a teacher or a therapist, do when you suspect that a stuttering infant is from a home where it is witness or victim of violence? There is a dilemma: you fear to lose the parent's confidence when you mention it. It is the best policy to be frank about your thoughts since it provides the best chance for a frank answer, as long as your client feels that he is not being judged or condemned. Make clear that it is your common purpose to find a solution for the child in a difficult situation, and that you need one another to find that solution, even if it means calling in help from outside.

10.10 Battos meets his fate and becomes a stutterer: an escalation.

An ancient Greek vase reminds us that stuttering has troubled mankind since early history. It depicts the young and talented Battos, asking the Pythia (the oracle at Delphi) for advice in the matter of his stuttering. The story as described by Herodot is that he received the advice to leave the country with his group of followers and to found a new settlement overseas, in North Africa. Apparently the Pythia knew that a change of environment, independence from home and growth toward manhood are favourable conditions for a "spontaneous" cure. We call such a cure spontaneous, however "therapy" may in some cases have been implicitly administered by a nourishing friendship or attachment to a loving woman.

We understand the way in which young Battos has acquired his stutter. The son of an ambitious father, he was the object of great expectations. His learned instructors were tireless in stimulating and prompting the boy to do mental exercises far beyond the level of his peers. Anxious to comply with the demands he exerted himself to the utmost. Until at the age of 4, tired after an exhausting session with his teacher, he failed to come up with the correct answer. He had a moment of cramp in his vocal cords, an alarming feeling that no breath and no word would come out of his chest. His instructor, equally alarmed at the moment of apparent crisis, hastily brought him home. There he was comforted on the lap of his mother. Burying his head in her bosom he had a crying spell. Mama, he gasped, I couldn't speak... Something in his young life had changed: his confidence was shaken, he had become vulnerable. Not only had he become mistrustful of himself, but also of people around him: what would they think of him? The balance between encouragement and high demands had once tipped towards the latter, with an unfortunate result (Map 10.6).

Always since then, when he felt uncertain about something, he would hold his breath, prolong the speech-sound he was making so as to avoid getting stuck again. Sometimes when he got annoyed by the habit of prolonging sounds he tried to cut them short by force. This created a new habit of explosive interruptions, false starts and repetitions at the beginning of words. All this he brought upon himself by excessively

10.12 Habit or addiction?

In an abstract form (Map 10.12.1) we see the individual, Battos, represented as a sphere maintaining himself in his environment, and responding to contacts with this environment. The stimulation (S) can be perceived as painful, disagreeable or hostile, it can also be rewarding and friendly. Negative qualities in an environment will be avoided, a positive situation will elicit an approach- response.

alt

Map 10.12.1 Stuttering as a learned emotional and behavioural response

Reading from left to right we distinguish

Most of the behaviour associated with stuttering falls in the category of avoidance response or instrumental responses serving to relieve an immediate tension/anxiety. The emotional relief that immediately follows an avoidance-behaviour is the reward which maintains stuttering.

During therapy the stutterer should get to the point that he will not allow himself this type of short term rewards, and that he will prevent them from occurring (response prevention). There are now countless successful recoveries of stuttering on record. We have seen complete recoveries in stutterers whose affliction had received a neurological label "extra pyramidal disorder" or "focal pathology in the left temporal area". Such diagnostic errors are due to the fact that in the minds of neurologists and in the textbooks on neurology almost nothing is found on learning and conditioning. The study of conditioning and learning principles leads to convincing evidence that whatever "structural" changes there had been in a stutterer's central nervous system, they had lost their influence after a learning process that led to personal growth and healing.

Since we now know that most stuttering symptoms are the result of learning or conditioning we realize that other dyskinesia's have equally been acquired by learning. The principles illustrated by the example of stuttering have a wide significance. Dyskinesia's such as facial tics, ocular spasm, spastic dysphonia, can be treated with behaviour therapy combined with cognitive therapy, preferably in the early stages of their development. In the long run the faulty tracks are ingrained more or less permanently in the neural system, and in the personality structure.

10.13 Alalia scales the stairs out of the pit of doom: a de-escalation. Emotional and instrumental de-conditioning.

An equally easy to understand map is that of Alalia, a young stutterer who is climbing a stair, or rather she climbs up two ladders at the same time. With the left foot she attempts a higher rung in the hierarchy of increasing fluency, by decreasing the speech rate, using soft onset, legato speech etc. That procedure is called gradual approximation of a desired goal, a more fluent way of speaking. The learning principle involved is that of instrumental or operant learning of speech-motor abilities or habits.

With her right foot she will gain a higher level for tolerating emotional stress. The procedure is that of desensitisation by classical conditioning (respondent learning). It trains her not to be distracted by negative anticipations, to "believe in herself" when confronted by a dominant person, and to be less apprehensive of speech-failures. alt

A map such as this is a "figure of speech". Every stutterer dreams of a free ride by escalator to free, uninhibited speech. The best he can hope for, however, is a steep and unstable ladder, and he will need a lot of courage to climb it and so to free himself. The ladder is a metaphor that helps the student understand that:

(1) during therapy there are two learning principles at play. Type I: therapy and training of the individual changes emotions, cognitions, motivation, beliefs and attitudes. Type II: practising speech modifying techniques (instrumental learning) shapes the voluntary, partly automatic senso-motor control of the speech-act.

(2) for a stutterer, participating in therapy is an arduous task. The force of habit and the resistance to change are like the force of gravity. You have to work long and hard in order to obtain easy communication that remains easy under stressful circumstances. You have to work at two levels: at the involuntary level of emotions and attitudes, and at the voluntary level of senso-motor control of speech.



It is one of life's paradoxes that, in order to bring down highly strung emotions and tense habits its one has to make the effort of climbing up the ladder towards increased self-reliance and mental composure in order to let go of irrational fear and unnecessary tension. When the stutterer has discovered one or more conditions under which he can speak fluently this can be a point from which to start treatment. Suppose this is reading aloud slowly in a relaxed state of mind. It is certainly an encouraging experience to be fluent in the presence of somebody else. The surprise of experiencing this has made stutterers expect that they will soon overcome their stuttering. However: the greater the unrealistic expectation, the greater the fall when it appears that in other situations such as speaking under time-pressure their dragon is still undefeated. The margin for voluntarily changing conditioned behaviour is narrow, and numerous rungs of the ladder are needed to reach the avenue of freedom. Involuntary responses cannot be changed on short notice. Take for example the nervousness and tension, which is accompanied by moist hands, dilation of the pupils of the eye and rapid heart rate. Such a combination of autonomic reactions is provoked by certain circumstances and by the expectations associated with them. Unlearning emotionally conditioned responses can be achieved by body-oriented practice and other behaviour therapy procedures combined with cognitive therapy.

Between voluntary and involuntary behaviour there are gradations of partly (in)voluntary behaviours. You can move your fingers at will, but you cannot change your handwriting at will, because it is partly automatic. A stutterer cannot prevent at will that tension and moist hands occur under certain circumstances. He is however free to do his treatment assignments to gradually overcome the interference of involuntary and unwanted responses. It is a limited freedom, because the new behaviour has to compete with strong inclinations to stick to the habitual patterns of avoidance and flight reactions. Prolonging a sound, pushing against the vocal cords, pressing the tongue to avoid the dreaded repetitions, these habitual stuttering symptoms have had an avoidance function when they first established themselves.

The degree of voluntariness of behaviour decreases in the following order:

The response-times increase when we go from the sensomotor to the autonomous system. Changes in the lifestyle or life script at the cognitive level can only be implemented when certain conditions have been met: the patient should be sufficiently self-reliant, courageous and secure. The stutterer and his therapist face a great challenge when practising response modification and altering social relationships, mental attitudes and self-concept. Insight in behaviour associated with one's life-style opens the possibility to change it.

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