Stuttering Management: Psychological Therapy Effectiveness Case Study

Introduction

Joseph*¹, was a 38-year old medical officer and psychological and physiological therapist researcher attached to a healthcare facility that provided palliative care. Joseph was diagnosed with above-average hypnotic susceptibility (appendix 1) that was characterized by a severe overt stutter. Joseph’s stutter demonstrated part-word and word repetitions, and characteristic long prolongations. Joseph repeated syllables (appendix 1) that were secondary to “block” while speaking. Joseph didn’t exhibit control over his speech. Joseph stutter exhibited a high-stress language fluency disorder that was primary to psychological stress, sociological stress, emotional stress and physical stress. Joseph was diagnosed to exhibit fearing situations. During Joseph’s fear-stimulating situations, Joseph’s stutter was more severe (appendix 1). Some of the situations that Joseph’s stutter was severe included public speaking, conversations over the phone and scenarios characterized by the need to read texts aloud or to describe a situation or an event in his life. Joseph didn’t have awareness on when clinical signs of stutter manifested. Joseph suggested that his stutter was gradual and was suggested to have been triggered by his disturbing and distressing career in the palliative care department. Joseph’s stutter began twelve years ago when he was a medical student intern, a black-out occurred when he was on the night shift as a medical intern and many patients that were under the life support machines died while they were on duty and he had to explain the incident.

Speech-language pathologists evaluated Joseph’s stutter and proposed possible automatic over-learned social response that resulted in stuttering episodes during choral reading, singing in the church that was primary to impacts of white noise. Tests through delayed auditory feedback (DAF) arrived at a similar conclusion of possible relatedness of Joseph’s stutter to the over-learned social response. Three days post the initially assumed trigger for emotional and psychological stress, Joseph had complained of sore throat, advanced fever, and characteristic malaise. Streptococci antigen tests that were carried out determined Joseph was positive for g-enzyme strep A Test OSOM. However, Joseph was not cooperative on antibiotic medication and his family too was not cooperative towards streptococci tests and antibiotic management plan. Two months later, Joseph had developed acute stuttering that was evident through sound and syllable repetitions (appendix 1) and silent blocking of speech (appendix 1). This advanced into struggle behavior of stutter, facial grimaces and head twitches that was characterized by stutter. Joseph continued to test positive for streptococci. Hypnotherapy was initiated through use of progressive relation techniques that were meant to calm Joseph and improve language fluency. The therapy further integrated breathing exercises and prolonged speech approaches towards managing stutter.

Assessment procedure

The narrative analysis and recording was carried out in a sound attenuation chamber. Joseph was exposed to different scenarios to describe. This was meant to ensure Joseph speech fluency recovery was not associated with familiarity of events. This was performed towards facilitating audio-recording and to standardize the test conditions towards reducing opportunities for fear. Joseph was requested to describe a recent a special place that he visited where he felt relaxed and calm and at peace. Joseph was requested to close his eyes in order to reduce incidence or opportunities of watching the interviewee or speech pathologist that was present during the course of recording of the interview. Joseph was prepared for the narration through a hypnotic induction that had involved standardized muscle relation and regulation of sequence of breathing until it was ensured that breathing sequence was not varying. This was meant to build confidence on Joseph before he began narration of a special place that he had recently visited. The building of confidence was carried out through ego and self-strengthening measures. An environment was created towards achieving the state of environment of Joseph recent visit. A post hypnotic approach was initially suggested to achieve continuity of related and calm atmosphere. Joseph was then informed to be practicing self-hypnosis every day at least twice when exposed to anxiety provoking scenarios. Joseph underwent ten hypnosis sessions where his stutter was recorded. The results of the sixteen audio recording are presented by figure 1 below

NB: Joseph demonstrated higher speech fluency outside hypnosis at week 16.

Hypnosis intervention

Intervention for the Joseph stutter involved derivation of informed consent of procedures that were to be used towards managing the incident and documentation of expected outcomes (Van et al, 2003, pp.186-7). Participation of Joseph was achieved through understanding and education on rationale of the clinical intervention. Joseph was required to compile a list of difficult-speech interfering situations and scenarios where he was more likely to stutter. The stutter management involved Joseph management of scenarios that had least likelihood of causing stutter and advanced to other difficult situations that had likelihood of causing stutter (Jon, 1982, pp.302-3). This was meant to build Joseph speech fluency confidence.

Results

The incidents of stutter (figure 1) continued to decrease over the 16 weeks that the recording of Joseph stutter was recorded. The initial stuttering was high at 165 in 108 seconds and stabilized at 3 stutter at 108 seconds by 16^th week. This demonstrated improvement based on initial baseline session or pre-hypnosis reading session. The improvement of Joseph was not based on familiarity of scenes but through improvement of speech fluency. Joseph symptomatic improvement was clear evidence towards Joseph understanding of needs for fluency which were evident in Joseph higher levels of speech fluency outside his hypnosis. Joseph improvement involved change where every syllable was not contributing into a stuttering spasm. Joseph speech fluency improved in both gesture and body language. Joseph affirmed that use of special place description was effective towards reduction of anxiety, creation of confidence, developing sense of calm and relaxation that helped to manage social stress, emotional stress and psychological stress. It enhanced his feeling of acceptance to people. During an external hypnosis, Joseph demonstrated a clear speech fluency and indicated that “I have no problem of fear as I used before the session was commenced that had resulted into social isolation”. Joseph management was concluded with clear evidence that he could relax, use self-stuttering management techniques and speech fluency problem was fully managed. Joseph affirmed “inside, I am confident I am able to do whatever I desire and express myself clearly. Stuttering management is a form of internal healing of self, ego and personal interaction with the environment”

Conclusion

The results demonstrated that straightforward management of stuttering through use of psychological approaches was able to manage anxiety, fear and build confidence that was vital towards derivation of speech fluency (Molina et al, 2010, pp.560-1). The Joseph case represents needs for patient participation, education on rationale of stuttering management and communication of procedures and processes that would be involved towards improving speech fluency. Joseph stuttering case further helped to determine that secondary opportunistic infections that increase stuttering incidents should be medically managed in order to be able to manage stuttering incident as single problem through psychological approaches that have impact of restoring patient confidence (Van et al, 2001, pp.388-9). The study further established that family members’ participation help to improve on patient recovery through increased restoration of health by demonstrating acceptance of the patient condition (Packman & Onslow, 2003).

Recommendations

Future studies could be carried out on stuttering patients to determine impact that a device attached to the ear has on voice play back and how it could make the patient think that he is talking to listening people towards realization of a scenario where the patient brain could be kept occupied.

References

Jon L. Deal (1982) Sudden Onset of Stuttering: A Case Report , Journal of Speech and Hearing Disorders Vol.47 301-304 August 1982.

Molina Escudero R, Rodriguez Fernandez E, Lledo Garcia E, Tabares Jimenez J, Husillos Alonso A, Hernandez Fernandez C. (2010) Stuttering priapism: case report and bibliographic review. Arch Esp Urol. 2010 Sep; 63(7):559-62.

Packman A, and Onslow M. (2002) Searching for the cause of stuttering. Lancet 2002; 360:655-6

Van Borsel, J., Van Der Made, S., & Santens, P. (2003). Thalamic stuttering: A distinct clinical entity? Brain and Language, 85, 185-189.

Van Borsel, John and Taillieu, Caroline, (2001)Neurogenic stuttering versus developmental stuttering: An observer judgment study, Journal of Communication Disorders, 34 (2001) 385-395.

Appendix 1: Joseph first stutter

• Stuttering Rating Tool
• © 2005 La Trobe University
• Client Analysis
• 5/11/2011
• Client A
• Duration: 0:01:48
• Syllables: 165
• Stutters: 165
• SPM: 92
• %SS: 100.0
  • stutter 1 occured at 0:00:03
  • stutter 2 occured at 0:00:04
  • stutter 3 occured at 0:00:06
  • stutter 4 occured at 0:00:07
  • stutter 5 occured at 0:00:08
  • stutter 6 occured at 0:00:09
  • stutter 7 occured at 0:00:10
  • stutter 8 occured at 0:00:11
  • stutter 9 occured at 0:00:12
  • stutter 10 occured at 0:00:13
  • stutter 11 occured at 0:00:13
  • stutter 12 occured at 0:00:14
  • stutter 13 occured at 0:00:14
  • stutter 14 occured at 0:00:15
  • stutter 15 occured at 0:00:15
  • stutter 16 occured at 0:00:18
  • stutter 17 occured at 0:00:18
  • stutter 18 occured at 0:00:22
  • stutter 19 occured at 0:00:22
  • stutter 20 occured at 0:00:23
  • stutter 21 occured at 0:00:24
  • stutter 22 occured at 0:00:25
  • stutter 23 occured at 0:00:27
  • stutter 24 occured at 0:00:28
  • stutter 25 occured at 0:00:28
  • stutter 26 occured at 0:00:29
  • stutter 27 occured at 0:00:29
  • stutter 28 occured at 0:00:30
  • stutter 29 occured at 0:00:31
  • stutter 30 occured at 0:00:33
  • stutter 31 occured at 0:00:33
  • stutter 32 occured at 0:00:33
  • stutter 33 occured at 0:00:35
  • stutter 34 occured at 0:00:35
  • stutter 35 occured at 0:00:36
  • stutter 36 occured at 0:00:36
  • stutter 37 occured at 0:00:37
  • stutter 38 occured at 0:00:37
  • stutter 39 occured at 0:00:37
  • stutter 40 occured at 0:00:37
  • stutter 41 occured at 0:00:38
  • stutter 42 occured at 0:00:39
  • stutter 43 occured at 0:00:40
  • stutter 44 occured at 0:00:41
  • stutter 45 occured at 0:00:42
  • stutter 46 occured at 0:00:43
  • stutter 47 occured at 0:00:43
  • stutter 48 occured at 0:00:45
  • stutter 49 occured at 0:00:45
  • stutter 50 occured at 0:00:46
  • stutter 51 occured at 0:00:47
  • stutter 52 occured at 0:00:49
  • stutter 53 occured at 0:00:50
  • stutter 54 occured at 0:00:50
  • stutter 55 occured at 0:00:50
  • stutter 56 occured at 0:00:50
  • stutter 57 occured at 0:00:51
  • stutter 58 occured at 0:00:51
  • stutter 59 occured at 0:00:52
  • stutter 60 occured at 0:00:53
  • stutter 61 occured at 0:00:54
  • stutter 62 occured at 0:00:55
  • stutter 63 occured at 0:00:55
  • stutter 64 occured at 0:00:55
  • stutter 65 occured at 0:00:55
  • stutter 66 occured at 0:00:56
  • stutter 67 occured at 0:00:57
  • stutter 68 occured at 0:00:57
  • stutter 69 occured at 0:00:58
  • stutter 70 occured at 0:00:59
  • stutter 71 occured at 0:01:00
  • stutter 72 occured at 0:01:01
  • stutter 73 occured at 0:01:01
  • stutter 74 occured at 0:01:02
  • stutter 75 occured at 0:01:03
  • stutter 76 occured at 0:01:03
  • stutter 77 occured at 0:01:04
  • stutter 78 occured at 0:01:04
  • stutter 79 occured at 0:01:05
  • stutter 80 occured at 0:01:05
  • stutter 81 occured at 0:01:05
  • stutter 82 occured at 0:01:07
  • stutter 83 occured at 0:01:08
  • stutter 84 occured at 0:01:09
  • stutter 85 occured at 0:01:10
  • stutter 86 occured at 0:01:11
  • stutter 87 occured at 0:01:13
  • stutter 88 occured at 0:01:15
  • stutter 89 occured at 0:01:16
  • stutter 90 occured at 0:01:16
  • stutter 91 occured at 0:01:16
  • stutter 92 occured at 0:01:18
  • stutter 93 occured at 0:01:19
  • stutter 94 occured at 0:01:19
  • stutter 95 occured at 0:01:19
  • stutter 96 occured at 0:01:19
  • stutter 97 occured at 0:01:20
  • stutter 98 occured at 0:01:20
  • stutter 99 occured at 0:01:20
  • stutter 100 occured at 0:01:20
  • stutter 101 occured at 0:01:20
  • stutter 102 occured at 0:01:21
  • stutter 103 occured at 0:01:22
  • stutter 104 occured at 0:01:22
  • stutter 105 occured at 0:01:22
  • stutter 106 occured at 0:01:22
  • stutter 107 occured at 0:01:22
  • stutter 108 occured at 0:01:23
  • stutter 109 occured at 0:01:24
  • stutter 110 occured at 0:01:25
  • stutter 111 occured at 0:01:25
  • stutter 112 occured at 0:01:26
  • stutter 113 occured at 0:01:26
  • stutter 114 occured at 0:01:26
  • stutter 115 occured at 0:01:26
  • stutter 116 occured at 0:01:26
  • stutter 117 occured at 0:01:27
  • stutter 118 occured at 0:01:27
  • stutter 119 occured at 0:01:27
  • stutter 120 occured at 0:01:27
  • stutter 121 occured at 0:01:27
  • stutter 122 occured at 0:01:28
  • stutter 123 occured at 0:01:28
  • stutter 124 occured at 0:01:28
  • stutter 125 occured at 0:01:28
  • stutter 126 occured at 0:01:29
  • stutter 127 occured at 0:01:29
  • stutter 128 occured at 0:01:29
  • stutter 129 occured at 0:01:30
  • stutter 130 occured at 0:01:31
  • stutter 131 occured at 0:01:32
  • stutter 132 occured at 0:01:32
  • stutter 133 occured at 0:01:33
  • stutter 134 occured at 0:01:34
  • stutter 135 occured at 0:01:34
  • stutter 136 occured at 0:01:34
  • stutter 137 occured at 0:01:34
  • stutter 138 occured at 0:01:34
  • stutter 139 occured at 0:01:34
  • stutter 140 occured at 0:01:34
  • stutter 141 occured at 0:01:35
  • stutter 142 occured at 0:01:35
  • stutter 143 occured at 0:01:36
  • stutter 144 occured at 0:01:39
  • stutter 145 occured at 0:01:40
  • stutter 146 occured at 0:01:40
  • stutter 147 occured at 0:01:40
  • stutter 148 occured at 0:01:40
  • stutter 149 occured at 0:01:40
  • stutter 150 occured at 0:01:40
  • stutter 151 occured at 0:01:40
  • stutter 152 occured at 0:01:41
  • stutter 153 occured at 0:01:41
  • stutter 154 occured at 0:01:41
  • stutter 155 occured at 0:01:41
  • stutter 156 occured at 0:01:41
  • stutter 157 occured at 0:01:42
  • stutter 158 occured at 0:01:42
  • stutter 159 occured at 0:01:42
  • stutter 160 occured at 0:01:42
  • stutter 161 occured at 0:01:43
  • stutter 162 occured at 0:01:43
  • stutter 163 occured at 0:01:43
  • stutter 164 occured at 0:01:43
  • stutter 165 occured at 0:01:43

Footnotes

1. Joseph is not the real name of the patient.