12 points on SSS

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As Chair of International Stuttering Association I struggled for years to convey accurate public awareness messages about stuttering. I also was frustrated to see the conflict within the SLP profession as they too struggled to define exactly what it was they were researching, treating and discussing. Providing a solution to all this has occupied my mind for some time. I see it as the most valuable thing that can be done for the welfare of PWS.

I believe the same difficulties would have faced the condition known as coughing if we were not able to use words like asthma, emphysema, tuberculosis TB, and inhalation etc…

That is, our understanding will only develop if we create more words around stuttering and agree on common understanding. At the moment the word stuttering means different things to different people. Is it a) speech behaviour , b) a syndrome or c) the symptom of a syndrome? What is your answer? Is it the same after reading the rest of this mail. (If short of time please be sure to read point 6.)

  1. Stuttering is a speech behaviour which, like all other conscious human behaviour, is related to intentions, perceptions, beliefs, emotions and responses. This can be conceptualized as inter-relating parts of a hexagon.
  2. Not all stuttering is associated with anxiety or psychiatric ill health.
  3. To say all stuttering is a social anxiety disorder is as much a generalisation as saying all stuttering is genetic.
  4. Stuttering is the behaviour of dysfluent speech which may or may not be related to genetic factors and/or Social Anxiety Disorder (SAD) and/or physical trauma etc.
  5. Where stuttering is related to Social Anxiety Disorder then both conditions interweave to make it impossible to tell where one ends and the other begins. Therefore a specific term is needed for this condition. That term is Stuttered Speech Syndrome (SSS).
  6. Stuttering is not a social anxiety disorder. SSS is a social anxiety disorder. Stuttering is a symptom of this disorder (and stuttering may exist independently of SSS.)
    (Example. Coughing is not an infectious disease. TB is an infectious disease. Coughing is a symptom of this disease. Coughing may exist independently of TB)
  7. SSS allows distinction between the severity of impact and the severity of stuttering. (research has shown there is no direct correlation between severity of stuttering and severity of its impact on the life of the person stuttering. A person with an almost inperceptible stutter may be severely affected by it. Therefore, without the term SSS it is impossible to accurately link stuttering with disability)
  8. SSS gives a direct link to the psychology/psychiatry professions because it links stuttering to the disability of Social Anxiety Disorder which is a DSMIV listed disorder.
  9. Social Anxiety Disorder is also known as Social Phobia. It refers to an arbitrary level of social anxiety, determined by nominated surveys (eg LSAS) or clinical interviews, beyond which is regarded by the American Psychiatric Association as pathological.
  10. The presence of SAD infers significant emotional ill-health and indicates it is impossible for the sufferer to think logically in stressful social situations. This has an impact on therapy. Rational advice about what to think and what to do is relatively useless to the phobic brain. Instead therapies aimed at removing the phobia are necessary. (eg CBT, desensitisation, role play and relaxation therapy are of more use).
  11. Stuttering without co-existing SAD can be lessened, and sometimes eliminated, by a combination of CBT and speech therapy advice.
  12. A covert stutterer is someone who uses the strategy of covert stuttering (word substitution and word and situation avoidance.) They may not necessarily have SSS. SSS would be an appropriate diagnosis only if their covert stuttering was associated with diagnosable SAD.

Review of The King’s Speech as it relates to stuttering

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kings speech

Harrowing, funny, and instructive are an unusual combination of adjectives, but they aptly apply to Tom Hooper’s “The King’s Speech”. Colin Firth as the socially anxious George VI and Geoffrey Rush as the insightful speech trainer Lionel Logue, both give sensitive, commanding and convincing performances.

In this film stuttering, known by the British term stammering, is almost on full display. The verbal behaviours of repetitions, prolongations and blocks plus the secondary struggle behaviours of eye twitching, head jerking and mouth/facial contortions, are all portrayed. Also shown is stammering’s situational specificity as George’s difficulties vary with the social context in which he is placed. He is at relative ease with his supportive wife and children, has obvious difficulty with his demanding father and public speaking, and depending on the emotional demands of the conversation, has varying dysfluency with his brother. Furthermore, all the stuttering clichés for therapy and cause are presented, often humorously. Learning to speak with a mouth full of marbles, surgery, voice masking, diaphragmatic breathing, muscle relaxation, emotional release, conditioning and perseverance are all mentioned or shown. Possible causes such as emotional trauma, physical abuse and correction of left handedness are also brought up.

The film portrays stammering with sympathy and accuracy (as expected given the writer David Seidler stammered) and will no doubt do much for stuttering awareness. However current understanding, research and therapy would make at least three additions for an updated public awareness message. First amongst these is recognition of covert stuttering, the situation where the speaker avoids or substitutes words so as to avoid an overt stutter. People who are covert stutterers give enormous energy to speaking as they monitor ahead all words and sentence structures. Second is the likelihood that the predisposition to stutter is genetic. A relative minor incident, or series of incidents, may prove to be significant for a person with a stuttering predisposition so that they are then “tripped” into stuttering behaviour. Thirdly the newly appreciated brain plasticity stresses the need for early intervention and suggests meditation and pharmaceuticals can be part of modern therapeutic practice.

However the film’s strength is that the true nature of stuttering as a disability is obvious for all to see. Apart from the physical difficulty of speaking, stuttering was clearly impacting on George’s emotional health and on his relationships. George then is seen coping with both a physical disability as well as a mental disability.

Unfortunately words are still not in common use to directly define this double disability. This new definition is necessary as not all people who stutter will be so affected, or remain so throughout their lives.

This has an impact on understanding of dysfluent speech and on the provision of appropriate therapy. To correct this situation a new term has been proposed – Stuttered Speech Syndrome which links the physical act of stuttering with the mental disability of Social Anxiety Disorder. That is, George’s concern about his stuttering caused him to stutter more and to suffer clinically significant emotional ill –health. It also made it impossible for him to respond positively to rational advice. If it was available as a label then, a diagnosis of Social Anxiety Disorder could have been made to describe his psychiatric condition. The combination of stuttering and Social Anxiety Disorder, where one condition compounds the other, is to be known as Stuttered Speech Syndrome.

The film “The King’s Speech” sets up Stuttered Speech Syndrome very well. ie SSS – a situationally specific anxiety disorder related to the compounding effect of stuttering and social phobia. Unfortunately reviewers here in Australia are saying the film shows how Logue cured George VI of stuttering. However George continued to stutter all his life and, as all in the stuttering world know, current language prevents correction of this misinterpretation succinctly. But by using “additional” language provided by the term Stuttered Speech Syndrome, we could say the following:” Logue’s therapy reduced the symptoms of George VI’s Stuttered Speech Syndrome which allowed him to manage his stuttering and communicate effectively”.

This film gives the stuttering community a wonderful opportunity to discuss and develop their public awareness message. In this way a disorder which until now has led sufferers to bear the brunt of ridicule and discrimination might be more sympathetically and more accurately regarded. “The King’s Speech” has the potential to join the classics of cinema by being emotionally engaging, historically interesting and socially relevant.

Retreat

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“The best scientists, like military generals, are always ready to retreat from a position that can no longer be defended, no matter how much of their personal reputation has been invested in the enterprise.” ~ Peter Doherty, 1996 Nobel Prize winner

New website!

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I hope PEOPLE WHO STUTTER will find the perspective offered in the feature article, and advice offered specifically in the section “for people who stutter”, to be extremely useful in helping them deal with therapy for stuttering and its associated psychosocial pathology.

I also hope ACADEMICS and CLINICIANS will find the expanded terminology to be extremely useful to their efforts as well as it clearly points the way for use of differential diagnosis.

I realise new ideas can appear confrontational to some. However I hope the value of the proposed concepts will be seen to outweigh the stress of adjustment, and that everyone will soon benefit  from the introduction of the term Stuttered Speech Syndrome, and thereby more accurately discuss, research and treat the condition previously just known as stuttering.