Do stutterers fear social interactions? How likely are stutterers likely to have mental illnesses? Should stutterers seek treatment from psychologists or from speech-language pathologists?

According to an old theory, stuttering is the “tip of an iceberg,” with 90% of the problem being fears and anxieties that listeners don’t see, and physical stuttering being only 10% of the problem.

I never believed that. I stuttered severely but I had little fear of listeners discovering that I stuttered. It was obvious every time I talked!

The Evidence

A study 1 of 25 adult participants in the Institute for Stuttering Treatment & Research (ISTAR) program, with one- and two-year follow-ups, found that:

  1. There was no relationship between stuttering severity and the severity of negative emotions and cognitions.
  2. The severe stuttering group had the largest treatment gains but also the highest level of regression.
  3. At post-treatment and both follow-up assessments the differences on measures of emotions between the mild and severe emotional group had disappeared, chiefly due to a large decrease in the latter group’s negative emotions and cognitions.

A study 2 of 32 adult stutterers found that 60% had social phobia. Some received 14 hours of fluency shaping; the others received 15 hours of cognitive-behavior therapy focused on reducing speech-related fears and anxieties followed by 14 hours of fluency shaping. The subjects who did only speech therapy had no change in social phobia. The cognitive-behavior therapy had no effect on the subjects’ speech. The subjects who did both had no social phobia after treatment.

A study 3 of 64 adults who stutter found that two-thirds had mental health disorders. Before treatment, “stuttering frequency and situation avoidance were significantly worse for those participants who had been identified as having mental health disorders.” Six months after treatment, the third of subjects without mental health disorders had maintained the benefits of treatment; the two-thirds with mental health disorders had not.

A study 4 of 94 adults who stutter and 920 non-stuttering adults found that stutterers are three times more likely to have personality disorders.

Examples

A woman called me about her husband, who stuttered. He had stopped talking. He asked for a demotion at work to a job that required only communicating by e-mail. He stopped speaking to his wife and children. He refused to see his friends. He refused to go to speech therapy. She was considering a divorce. She called me asking if there was anything he could do to talk fluently. I said yes, there are effective stuttering treatments, but if he didn’t want to talk then nothing could be done.

A man in his thirties has contacted me repeatedly for years asking for a free SmallTalk. He stutters severely. He has no job, few friends, and often tells me that he wants to kill himself. I gave him a free Basic Fluency System but he refuses to use it. He has never had speech therapy, even though several of the best stuttering clinics are within a few hours of his home. He called one day when Rick Huang was in my office. Rick stutters and is a Ph.D. candidate in speech-language pathology. Rick tried to get the man to do simple fluency shaping techniques over the telephone. He refused. I suggested that he try vitamin B-1. He refused. The man uses stuttering to mask a mental illness. I.e., when people meet him, their first impression is that he stutters severely, not that he has a mental illness. If he did something that resulted in fluency, people would see that he has a mental illness, and he would have to think about his mental illness. [Edit: I later gave him a free SmallTalk. Now he’s asking for another free Basic Fluency System.]

And then there are the French. Is the entire country mentally ill? I’ve sold several SmallTalks to stutterers in France, and each person returned the device for a refund. Each said the same thing: the device immediately made them talk fluently, which forced them to confront their psychological problems, and they’d rather stutter than deal with their psychological problems, so they returned the devices!

What It Means

About half of adult stutterers have speech-related fears and anxieties. About half don’t.

The adult stutterers who have speech-related fears and anxieties should be treated for social phobia. Teaching these adults fluent speech doesn’t work because they fear talking to people, minimize their social interactions, and the fluent speech motor skills are never learned on an autonomous (automatic, effortless) level.

The half of adult stutterers that don’t have speech-related fears and anxieties don’t need treatment for social phobia. Telling us to go to a shopping mall and do “voluntary stuttering” is a waste of our time. We want to learn to talk fluently.

No research has been done to see if children who stutter have social phobia. Among non-stutterers, social phobia is an adult disorder. Social phobia is ten times more prevalent among adults than among children. There’s no reason to assume that children who stutter have speech-related fears and anxieties, and no reason to tell children to accept their stuttering (i.e., to do stuttering modification therapy with children).

Stuttering is a problem for individuals with mental health disorders because psychological therapy requires talking. Speech therapy resulting in fluent speech can enable these individuals to get the counseling they need.

The use of evidence-based stuttering treatments could reduce the prevalence of stuttering in adults by 50% relatively easily, within five years. In other words, I believe that stutterers without mental illnesses can talk fluently, with treatments that are relatively simple and easy. But I also believe that stutterers with mental illnesses are much harder to treat. I doubt that the prevalence of stuttering could be reduced much more than 50%.

Some speech-language pathologists think they are capable of treating psychological disorders associated with stuttering. Most often these speech-language pathologists practice stuttering modification therapy. But speech-language pathologists aren’t any more qualified to treat psychological disorders than psychologists are qualified to treat speech disorders. Speech-language pathologists should teach stutterers to talk fluently. If a stutterer has a psychological disorder, the speech-language pathologist should refer the stutterer to a psychologist.

The way speech-language pathologists treat stutterers’ speech-related fears and anxieties (stuttering modification therapy) isn’t how psychologists treat social phobia. Psychologists using Cognitive Bias Modification (CBT) therapy don’t even treat social phobia, they have computer software that provides more effective treatment.

The way speech-language pathologists treat stutterers’ speech-related fears and anxieties (stuttering modification therapy) suggests that stutterers don’t have social phobia. Sending a stutterer to a shopping mall to do “voluntary stuttering” with strangers is like sending a soldier with PTSD back to the battlefield to voluntarily watch friends getting blown up. If a stutterer had social phobia, stuttering modification therapy would put the stutterer into the psychological ward of a hospital. Because thousands of stutterers have done stuttering modification therapy without apparent psychological damage, I suspect that stutterers’ speech-related fears and anxieties are something else. Social phobia is difficult to define, with large “gray areas,” especially in children who are naturally shy.

 

Notes:

  1. Huinck, W., Langevin, M., Kully, D., Graamansa, K., Peters, H., & Hulstijn, W. (2006) The relationship between pre-treatment clinical profile and treatment out-come in an integrated stuttering program. Journal of Fluency Disorders, 31, 1, 2006, 43–63. http://dx.doi.org/10.1016/j.jfludis.2005.12.001
  2. Ross G. Menzies, Sue O’Brian, Mark Onslow, Ann Packman, Tamsen St Clare, and Susan Block. (2008) An Experimental Clinical Trial of a Cognitive-Behavior Therapy Package for Chronic Stuttering. J Speech Lang Hear Res 2008 51: 1451-1464. doi:10.1044/1092-4388(2008/07-0070)
  3. Lisa Iverach, Mark Jones, Sue O’Brian, Susan Block, Michelle Lincoln, Elisabeth Harrison, Sally Hewat, Angela Cream, Ross G. Menzies, Ann Packman, Mark Onslow. (2009) The relationship between mental health disorders and treatment outcomes among adults who stutter. Journal of Fluency Disorders, 34, 1, March 2009, 29–43. http://dx.doi.org/10.1016/j.jfludis.2009.02.002
  4. Lisa Iverach, Mark Jones, Sue O’Brian, Susan Block, Michelle Lincoln, Elisabeth Harrison, Sally Hewat, Ross G. Menzies, Ann Packman, Mark Onslow. (2009) Screening for personality disorders among adults seeking speech treatment for stuttering. Journal of Fluency Disorders, Volume 34, Issue 3, September 2009, Pages 173–186. http://dx.doi.org/10.1016/j.jfludis.2009.09.001