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:
an inappropriate sensitivity for signals pointing to trouble in speaking
excessive premonitions of potential loss of control
a pervading fear that somewhere along their speech performance a trap will be sprung and catch them
fear of being exposed as a stutterer
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.