A Trauma-Informed Opinion About Using Fluency Techniques Outside the Clinic

Background on Using Fluency Tools Outside the Clinic

It is common knowledge that speech fluency techniques, such as fluency shaping, are easily learned and implemented in the clinic but using those techniques outside of the clinic is difficult, sometimes impossible, and very seldom sustainable. One commonly reported experience by people who stutter (PWS) is that the speech therapist is frustrated or even angry at us since we did not use our “tools”.

Clarification before I continue: I am not promoting or supporting fluency shaping techniques in any way.

The question is asked as to why we find it so difficult, or impossible, to use the fluency tools outside the clinic. The common answer is that while the clinic is a safe, quiet space (mostly), once we leave the clinic, we again feel intense anxiety, fear, and shame regarding stuttering, and those emotions and experiences inhibit the use of fluency tools.

The reason for this is that the use of speech fluency techniques requires focused cognitive effort on the explicit control of various speech motor control mechanisms and organs, but focused cognitive effort is inhibited when we feel under threat. In the safe space of the clinic, we don’t feel threat, but outside the clinic we do. Fear, anxiety, and shame are all responses to threat. When we stutter when we are in the clinic, we might be criticized but we are not in a situation where we feel that we have to hide our stuttering. After all, we are at the clinic because we stutter. Outside the clinic, however, we feel, and in fact believe, that we have to hide our stuttering. We feel that we are under threat: we experience anxiety, fear in the moments of conversation, and shame. These emotions are not conducive to focused cognitive effort. Anxiety, fear, and shame also come up when we use the fluency tools since we sound weird to ourselves, and most likely to the listener, too.

Probing further, we ask why it is that focused cognitive effort is difficult or impossible to achieve when we feel that we are under theat. This, too, is easily explained by referring to the physiological fight-or-flight response to threat. The emotional part of our brain engages in protecting us when we feel threat, and the rational part of the brain – the part that we use for focused cognitive effort - is largely out of action during the fight-or-flight response to threat.

All this is quite well known. I think, however, that these processes cannot be completely understood without additionally understanding the trauma of stuttering and the physiological effects of trauma and of ongoing trauma.

The Physiology that Controls Reactions to Threat

Bessel van der Kolk, writing in The Body Keeps the Score, explains how the human brain is structured, how it reacts to threats, and how traumatic events affect the brain. In brief, the brain is divided into an emotional brain and a rational brain. The emotional brain, comprised of the reptilian brain and the limbic system, is at the heart of the central nervous system and it functions to take care of our welfare. The emotional brain is the first part of the brain to deal with sensory input and it reacts quickly and automatically to incoming information. While the incoming information is passed via the emotional brain to the rational brain, the rational processing of events takes longer than the automatic survival-drive responses to sensory input.

The emotional brain, being responsible for our welfare, is the part of the brain that initiates self-preservation actions in the face of threat. This is where the amygdala resides, and it is here that fight-or-flight reactions are initiated and from which automatic physiological reactions are set in motion, all without any rational or cognitive thought.

Van der Kolk explains that part of the experience of trauma is that there remains a strong response to threat and that there remains a weak connection between the emotional brain and the rational brain. The rational brain is responsible for cognition, and so if there is a weak connection between the emotional brain (responsible for the fight-or-flight response) and the rational brain, then of course we will not be able to use the fluency techniques that require cognitive effort.

Connecting Stuttering to Trauma

Bessel Van De Kolk writes that “Being traumatized means continuing to organize your life as if the trauma were still going on – unchanged and immutable – as every new encounter or event is contaminated by the past”.

As long as the PWS perceives and experiences stuttering (and the anticipation of stuttering) as traumatic, we will experience recurring traumatic events each day. So, the trauma is still going on, and organizing our lives continues with a focus on survival. This includes avoiding speaking and doing our utmost to avoid stuttering – for as long as we perceive and experience stuttering as traumatic events.

Additionally, consider this scenario. The PWS leaves the clinic with the training and directive to use fluency tools. Using these tools requires the rational brain (the neocortex). However, with recurring trauma, the rational brain is not available in situations of threat, and for the PWS every speaking situation is a situation of threat. Since the rational brain is not available, the cognitive effort required for the implementation of fluency tools is not accessible. The PWS finds themselves in a speaking situation that they find traumatic, but in an even more difficult situation since now the PWS has been taught techniques to avoid stuttering, but those techniques are not available in that traumatic situation in which the person needs those techniques.

As a result, the trauma is intensified. The feelings of helplessness, hopelessness, inferiority, and shame are intensified. Shame is intensified because we now believe in our inherent deficiency: we were taught tools for eliminating our stuttering but we were unable to use them and therefore we believe that we are deficient.

When the PWS returns to the clinic and reports that they were not able to use the fluency techniques, the therapist will be disappointed, and even frustrated and angry. After all, the therapist gave the PWS tools to use, but the PWS did not use them. How annoying! But there is a lack of understanding of the trauma of stuttering and the effect of that trauma on the ability to use fluency tools. The cycle of misery and suffering is perpetuated. This is one of the reasons why fluency-focused therapy can itself be traumatizing and can be abusive.

Van Der Kolk explains that being able to move and to do something to protect oneself is a critical factor in determining whether a horrible experience will leave long-lasting scars. In the light of this, consider the experience of stuttering where we are in what we perceive as a horrible experience – we are in a speaking situation, we are stuttering, we feel fear and shame, we feel threat – but we are unable to move away and out of this horrible experience. We are stuck, unless we give up trying to communicate and we walk away, but we seldom, if ever, do this. We feel trapped. We are unable to protect ourselves. This is traumatic, and it happens (or can happen) every time we speak.

All this, and more, is why the understanding of trauma is such a vital part of therapy for stuttering.

Healing and Thriving

The way out is, of course, through rejection of the stigma of stuttering and through unconditional acceptance of ourselves and of our stutter, and not though continued efforts to suppress our stutter by using fluency tools. The reason for this is that we are, by our physiology, PWS, and attempts to escape this result in continued suffering.

If we return to the clinic situation, we can think of therapy that empowers the PWS, that gives the PWS tools to understand stuttering, to understand the trauma response, to develop resilience, to learn how to advocate for ourselves, all while completely and unconditionally accepting ourselves and our stuttering as we are. We now have much better tools that fluency-focused techniques to use outside the clinic since these acceptance-based tools enable us to be who we are without hiding any part of us. As a result, we no longer have a problem with stuttering and we have much needed tools for living our lives in the way that we want to, irrespective of stuttering.

Of course, treating trauma requires expertise. Our brains have to be repaired, as it were; the connection between the emotional brain and the rational brain has to be restored. This can be done, and fluency tools are not needed and have no place in this process.

In my personal experience, cognitive approaches, philosophical attitudes, and mindfulness practices have helped me to largely overcome the struggle with stuttering and the shame that I had associated with stuttering. These attitudes and philosophies enable me, most of the time, to be mindful – present without judgment – in moments of stuttering. They enable me to observe my stuttering with curiosity instead of with judgment, and to thereby avoid the experience of stuttering being a traumatic experience.

Mindfulness meditation teaches us non-judgmental awareness and teaches us to be aware of mind and body. Mindfulness enables PWS to be present without judgement in the moment of stuttering, as opposed to experiencing dissociation and a flight-or-flight response. Mindfulness and stuttering, however, is a significant topic by itself, and will not be addressed further here.

More information on stuttering can be found in my book:

Stuttering: From Shame and Anxiety to Confident Authenticity

Information on the book and where to buy it on Amazon can be found here:

https://onstuttering.com/

Information on the book in Hebrew can be found here:

https://onstuttering.com/hebrew/