(Speech and Language Disorders) Zbigniew Tarkowski-A New Approach To Stuttering - Diagnosis and Therapy-Nova Biomedical (2017) PDF

SPEECH AND LANGUAGE DISORDERS
A NEW APPROACH TO
STUTTERING
DIAGNOSIS AND THERAPY
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A NEW APPROACH TO
STUTTERING
DIAGNOSIS AND THERAPY
ZBIGNIEW TARKOWSKI
New York
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Library of Congress Cataloging-in-Publication Data

Names: Tarkowski, Zbigniew, 1953- editor.
Title: A new approach to stuttering: diagnosis and therapy / editor,
Zbigniew Tarkowski (Head of Department of Pathology and Rehabilitation of Speech, Medical University of
Lublin, Poland).
Description: Hauppauge, New York: Nova Science Publisher's, Inc., [2016] |
Series: Speech and language disorders | Includes bibliographical references and index.
Identifiers: LCCN 2016036219 (print) | LCCN 2016037214 (ebook) | ISBN
9781634856409 (hardcover) | ISBN 9781536100143 (Ebook) | ISBN 9781536100143
Subjects: LCSH: Stuttering.
Classification: LCC RC424 .N49 2016 (print) | LCC RC424 (ebook) | DDC
616.85/54--dc23
LC record available at https://lccn.loc.gov/2016036219
Published by Nova Science Publishers, Inc. † New York

Contents
Preface vii
Chapter 1 Introduction to Diagnosis and Therapy of
Persons with Stuttering (PWS) 1
Chapter 2 Diagnosis of Persons with Stuttering (PWS) 25
Chapter 3 Systemic Therapy of Persons with Stuttering (PWS) 83
Chapter 4 Pharmacological Basis for Therapy of People
Who Stutter – Past, Present and Future
Dariusz Pawlak and Tomasz Kamiński 123
Chapter 5 Case Studies and Interviews 153
Appendix Methods for Diagnosing Persons with Stuttering 187
About the Author 209
Index 211
Preface
I have never stuttered and probably will never be a person who stutters
(PWS). However, at pre-school, my two sons experienced episodes of speech
disfluency which they have since recovered from. This piqued my interest in
stuttering, both as a researcher and a therapist. In raising my stepson who
began to stutter when he turned three, I conducted a therapy which led to his
recovery three years later. The boy has been speaking fluently since then.
Since then, I have developed professional and personal relationships with
people who stutter which have profoundly influenced the development of my
views on stuttering.
I am a non-stuttering speech pathologist from an Eastern European
country (Poland). In 2008, an article entitled Health and Human Services for
Persons Who Stutter and The Education of logopedists in Eastern European
Countries was published in the Journal of Fluency Disorders. The article,
which presented pathologies in Eastern European speech in an unfavourable
perspective, was written by Western authors based on the results of a research
which Eastern experts had not participated in. I felt offended and replied with
a polemic which, to my surprise, has not been published in the Journal of
Fluency Disorders. Thus, as a last resort, I decided to include it in an epilogue
to a book entitled Research on Stuttering in Preschoolers and Schoolchildren
(2009). In the summary, I stated that the problems that Eastern and Western
therapists experience are the same but they are dealt with in different ways.
Now the time has come for both sides to get to know each other and join our
efforts together to find a common solution.
Recently, a fundamental book entitled Advice to those who stutter: Expert
help from 28 therapists who stutter themselves (2015) has been translated into
Polish. In the foreword written by me, I pointed out the fact that there was no
viii Zbigniew Tarkowski
fluent experts among the authors of the publication. This was so probably
because a non-stuttering expert would seem less reliable than an expert who
stutters. However, therapists who are non-stuttering find it difficult to agree
with this view for an ornithologist does not necessarily need to be able to fly in
order to be considered an expert in bird behaviour. Therefore, I disagree with
the opinion propagated by some associations of people who stutter and self-
help committees that contend that their members are experts in stuttering. I
believe that they have only experienced their problems individually just like
other patients and that undergoing therapy successfully have not turned them
into specialists in the field of their disorder. Furthermore, the experiences of
experts do not automatically make them feel more empathy towards people
who stutter, nor improve their abilities to solve this speech problem. There is a
serious concern that they may end up transferring their own experiences onto
other people which may prove detrimental.
The foreword from 1972 refers to the authors of the abovementioned
monograph as ‘authorities and experts in the field of stuttering as a result of
their considerable experience in helping people with speech difficulties’. So it
appears difficult to argue with them. The work has since been reprinted many
times, which confirms the views it presents are still considered valid. At times,
the work sounds awkward as, for instance, one of its authors suggests reading
books written by people who stutter.
The experts’ monograph is basically a how-to type of a book and contains
plenty of advice on how to cope with speech disfluency, negative reactions,
emotions and attitudes. However, guidance and therapy are two separate
processes that should not be considered equal. Therapy should begin when
advice is hard to follow.
The authors of the book rely primarily on self-help and self-development
of adult people who stutter, and are critical of therapists. One can get the
impression that therapists are redundant. Although self-treatment is popular, I
doubt if it is effective as the self-therapy of stuttering requires self-analysis
and self-discipline and both skills are rare. A vast majority of people who
stutter, regardless of their age, need professional therapist’s support.
I was wondering why the stuttering experts focus on speech disfluency
and reactions connected with it, while completely omit the aetiology of the
disorder. The cause of stuttering remains undefined, nevertheless, it still exists
and one can attempt to identify predisposing factors, triggering factors as well
as factors which fix this speech disorder. If we do not make an attempt, even
by defining merely hypotheses, our therapy will only be aimed at modifying
symptoms. If the cause has not been treated, speech disfluency may relapse.
Preface ix
It is common knowledge that therapists tend to choose therapies which

they prefer most. It is no wonder that stuttering experts promote the
acceptance of stuttering on one hand, even while they attempt to convince
others that it should be converted into fluency at the same time. Such approach
is fundamental for their reliability. A stuttering therapist will rarely suggest
fluent speech to his/her patient if (s)he cannot produce it herself/himself and
will encourage accepting stuttering which (s)he has been unsuccessfully
fighting with.
Interestingly, L. Logue, a royal therapist and founder of the British
Society of Speech Therapists (1935), was not listed as a member of the group
of experts. We can learn about him from ‘The King’s Speech’, a film based on
a book which raised the prestige of speech pathologists, particularly those
dealing in the therapy of stuttering, in the eyes of both professionals and
society. Ignoring Logue’s achievements might have resulted from the fact that,
although well-educated in enunciation and pronunciation as well as having
considerable professional experience, he was self-taught in speech pathology.
However, the lack of appreciation of his achievements by professionals is
more likely to be due to his different approach to therapy of stuttering. Rather
than promoting acceptance, he encouraged others to fight against this speech
disorder. He promoted natural speech rather than fluent stuttering. He skilfully
combined speech exercise with psychotherapy, motivated appropriately and
defined therapeutic relations. His job was to prepare king George VI for public
speaking in, particularly during the Second World War. The king’s oratorical
successes made him become a symbol of resistance, and Logue, as their father,
is undoubtedly one of the most renowned and award-winning speech therapists
in the field.
Acceptance means approval, agreeing to something that cannot be
changed (e.g., stuttering). It is different from tolerance, which occurs when
one neither counteracts something, nor accepts it. In other words, one can
tolerate stuttering and not accept it at the same time. The difference is subtle,
albeit an important one. One can tolerate a person who stutters and not accept
his or her speech disfluency at the same time. Similarly, one can accept a
person who stutters and yet be unable to tolerate his or her speech disfluency.
Stuttering experts have made the acceptance of stuttering the basic
premise of stuttering therapy. This view has been developed based on their
own negative experiences related to dealing with this speech disorder, for
which, they claim, no effective method or medicines have been clearly
identified. In view of this claim, pathologists have undertaken stuttering
therapy in spite of the fact that they do not believe in it, and are more willing
x Zbigniew Tarkowski
to help patients accept it, which saves patients and therapists extra stress and
frustration. It is better if a patient accepts his stuttering, which does not
necessarily mean (s)he needs to like it. However, it is not that easy because the
acceptance of speech disfluency depends on a number of factors, including
age, attitude, approval, communicative barriers that need to be overcome, the
severity of the problem, school and professional career prospects.
Speech disfluency in preschoolers is commonly tolerated but a wise
therapist would never persuade anyone to accept a child stuttering for the rest
of his life. When the child comes of school age, this is the period when he
realizes that the stuttering which he had gotten used to at home is not accepted
in his school environment. This is why the acceptance of this disorder is most
often encouraged in adult people with chronic stuttering and who possess little
motivation to undergo therapy.
With time, one can get used to stuttering, which is comfortable as one is
no longer obliged to undertake and continue therapy. However, the process of
adapting to and accepting stuttering is long and comes at a price. At a certain
moment, stuttering can turn into a social stigma and a taboo.
Acceptance of stuttering depends on the degree and range of the disorder
being a communication barrier, which, in turn, is shaped not only by the
intensity of speech disfluency, but primarily by existing interpersonal
relationships. Stuttering may cause communicative stress in both the producer
and the recipient of the message. Some people who stutter think that if another
person holds something against their speech disfluency, it is not the problem
of a person who stutters. It is hard to support this view as the course of
communication is shaped by all its participants, including those with speech
disorders.
Views on the essence and the social importance of stuttering largely
influence its acceptance as speech disfluency as such is not a problem since
one can live with it and fail or succeed. The debate continues whether
stuttering should be regarded as a defect, a disorder or a disease. Accepting a
defect is easiest, while accepting a disease is most difficult.
The acceptance of stuttering is also conditioned by one’s quality of life.
The authors of the abovementioned monograph achieved professional success.
One may wonder how stuttering contributed to it and the answer is not
obvious. A vast majority of people still choose to speak of the problems, rather
than benefits, of stuttering.
Stuttering does not cause physical pain, nor is it a threat to one’s health or
life. Thus, one can recommend acceptance of stuttering without being accused
of negligence or risking negative legal consequences from. To put it
Preface xi
differently, one can make light of stuttering and not be punished for it. As a
result, it is common for a person who stutters to prefer to see a General
Physician to get different diseases diagnosed than to consult a speech
pathologist for speech disorders.
Let’s face it: accepting stuttering is an expression of therapeutic
helplessness that triggers nihilist attitudes. Moreover, the acceptance of it is
often ostensible. Compelled by a certain doctrine and in view of the
therapeutic failures experienced, a person who stutters may agree to his
stuttering, though deep in the heart he will want to speak fluently, just as
others do.
Acceptance of stuttering should not be the goal of the therapy. It can only
be a method applied in the initial stage when we tolerate speech disfluency in
order to facilitate change in negative emotions and attitudes. Rejection is the
next stage.
It seems that the idea of accepting fluent stuttering has hampered the
development of research over its therapy. Despite the fact that both therapists
and patients would find it beneficial, available research over therapy of
stuttering is relatively limited. It is observed that obtaining financial support to
conduct research studies on how the brain functions while stuttering is easier
than getting money to conduct experiments which would contribute to
developing therapies. This comes as no surprise especially since the
effectiveness of therapy is still being questioned by authorities in the field.
Acceptance of stuttering stems from a common disbelief in the
effectiveness of its therapy. There has not been sufficient research to verify
this opinion, but if we compare effectiveness of therapy of stuttering (which is
sometimes referred to as speech neurosis) with the effectiveness of therapies
of other neuroses, the results are similar. There are patients who have been
cured, there are those who have been partially cured and those who have not
observed any significant improvement. Thus, speech therapists should not feel
inferior because of low effectiveness. Some fields of medicine (e.g.,
psychiatry, neurology) have not fared better either and successes and failures
are observed even in didactics.
Much as I have tried, I have not managed to find studies which advocate
the acceptance of stuttering. For this reason, a question of who and when is
able to accept the disorder is hard to answer. It may be an option for some
people who stutter, but not for all of them. Surely, there are patients who will
not be able to accept their stuttering. It is worth noting here that there have not
been any studies which would prove the relationship between acceptance of
stuttering and the improvement of speech fluency, or the correlation between
xii Zbigniew Tarkowski
the rejection of stuttering and increased speech disfluency. Therefore, the

problem is an open one and any attempt to solve it requires making
controversial decisions.
The idea of acceptance of stuttering and making it fluent has not become
prevalent in Eastern Europe. Acceptance is regarded here as one of the stages
of therapy, and not its aim, while making stuttering fluent is a means of going
from tense disfluency (pathological) to non-tense (normal) one. Similarly to
many Eastern European therapists, I believe that stuttering should not be
accepted and as long as there are opportunities available to cure it, one should
try to fight it. Obviously, prognoses vary, but since they depend on a number
of stuttering-related factors, they are difficult to predict in particular cases.
Sometimes, even severe forms of stuttering may turn out to be treated very
quickly.
I question the acceptance of stuttering because if we look at it as an
expression of helplessness and therapeutic nihilism, it reduces motivation in
therapy which is the essential factor that determines the effectiveness of
therapy. The aim of therapy is not to promote acceptance, but to fight against
stuttering. Such an attitude may come only from a therapist who is convinced
of the purposefulness and success of the therapy. Otherwise, his or her doubts
can ‘infect’ the patient. The major problem faced here is that most speech
pathologists do not believe in the effectiveness of therapy in speech fluency
disorders and thus choose to avoid it. It has long been known that stuttering
itself is not resistant to therapy, but that real resistance comes from within the
person who stutters and the therapist whom he or she is working with.
Since various forms of stuttering are determined by different factors, there
is no single method of therapy. For this reason, the therapist should not force
one method to be applied on everyone, but rather try to find the one most
suitable for a particular patient. Scientific research does not unanimously state
that one approach is more effective than others. Determining the hierarchy of
methods, from best to worst, is equally difficult as each of them is worth
recommending if it brings positive effects in a particular case of stuttering.
Therefore, dividing the methods into old and new, traditional and modern or
professional and unprofessional is of little use. The most important indicator of
their value is effectiveness.
Stuttering therapy is an art with some scientific basis. Here, the difference
between art and science is fundamental. In science, development is made
through accumulation and elimination, with theses deduced from new
discoveries added to the existing ones. At the same time, theses once
considered scientific but not supported empirically are eliminated from this
Preface xiii
list. Developments in art comes from accumulation, i.e., new theses might be
added, but this does not mean that some of the existing ones have to be
eliminated. This is the case with therapy in general, not only in stuttering
therapy. Its scientific basis is usually not substantial enough due to the
relatively meagre research base in the field. Disputes over the effectiveness of
stuttering therapy are sometimes more marketing than scientific in nature as
they are not based on actual research results but on arguments verging on
promotion. However, this does not mean that the therapy cannot be successful.
In medicine, only some diseases are treated in a purely scientific way while
others are treated in accordance with the principles of medicine.
I propose that the entire therapy of a person who stutters should be aimed
at solving the person’s problem, which is not speech disfluency. Speech
disfluency becomes a problem when it hinders the accomplishment of certain
goals, in which case we may either modify the goal or remove the barrier.
Therapy aimed at solving a problem covers a complete structure of stuttering,
which consists of linguistic (e.g., speech disfluency), biological (e.g., tensions
during speech), psychological (e.g., logophobia) and social (reception of a
disfluent utterance) factors, as well as the relationships between those factors.
One can change particular elements (single-factor therapies) or form
relationships between them (multi-factor therapies).
According to the systems approach, the therapy of a person who stutters is
started by defining a problem, and not from selecting a method. Then, a
therapist needs to distinguish the problem from a pseudo problem, pose
diagnostic and therapeutic hypotheses, select a solution and verify it according
to the plan adopted. Only then are the methods selected. If they fail, they
should be replaced with other ones. Therapy is a natural experiment in which
different hypotheses about the relationships between various stuttering factors
are verified. Conducting this experiment requires a range of therapeutic skills
(primarily creative thinking and empathy) and is not limited to exercises only.
Selecting a method of diagnosis and therapy of a person who stutters
depends on our understanding of the essence or nature of stuttering. Most
often, it is associated with pathological speech disfluency, which is then
analysed and corrected. According to a system approach, disfluency is only
one of the factors for stuttering and takes the role of a symptom. It is caused
by muscle tension, whose source is to be found in the personality and
interpersonal relations of the person who stutters. Reaching this source is the
primary aim of the diagnostic and therapeutic process. The phenomenon of
stuttering lies in its changeability. It occurs in some communicative situations
while it does not in others. This suggests that stuttering might be treated as an
xiv Zbigniew Tarkowski
interpersonal communication disorder. Basically, a person who stutters is more

often fluent than disfluent. Although the reason for this remains unknown, it
proves that a person who stutters is potentially fluent, which justify favourable
prognoses and therapeutic optimism.
Combining training of speech fluency with psychotherapy has long been
called for. What remains undecided is which form of therapy should be chosen
and who ought to conduct it. Even S. Freud noticed that stuttering cannot be
cured merely with psychotherapy. Different directions and approaches of
psychotherapy are still being used in order to help solve
the problem of the stutterer. The most frequently applied approaches include
action psychotherapy (relaxation, desensitisation, hypnosis), psychodrama,
elements of psychoanalysis and play therapy.
The next question is who should conduct the therapy. Professional
psychotherapists hardly ever agree to treat people who stutter, and even if they
do, they are not focused on speech disfluency. They would rather leave this to
speech pathologists who, in turn, do not feel confident in psychotherapeutic
procedures. Even if a person who stutters is treated by both a speech therapist
and a psychotherapist, true cooperation between them is rarely observed. For
this reason, I have long suggested that a new discipline called Balbutology and
a specialisation as a balbutologist should be created. Balbutology is a branch
of speech pathology which deals with patients suffering from psychogenic
speech disorders (stuttering, mutism). A balbutologist is trained to conduct
both speech training and psychotherapy. Studies in this field have been
organised by the ‘Orator’ Foundation, which I set up in 1991.
Methods for improving speech fluency can be divided into the natural and
the unnatural. Natural methods reccommend that speech trainings conducted
as part of therapy should not be different from natural speech. In contrast,
cnnatural methods use slower speech, unnatural prolongations, mild stuttering,
singing, echo-corrections, unrhythmic or unnaturally rhythmicised speech,
which are often applied by a speech pathologist, but are rejected when
transferring to other situations. Applying an unnatural manner of speaking in a
natural communicative situation is the key problem here. In cases of most
people who stutter, a range of psychotherapeutic methods should be applied to
overcome resistance in the stutterer as recommendations based on mere
training are usually insufficient. For this reason, once the problem is defined
and a plan on how to solve it is drafted, I typically suggest starting the therapy
by teaching the stutterer methods of natural speech which prevents
communicative stress. If the results are not satisfying, I then employ a
technique using unnatural speech which is adapted to the patient’s abilities. I
Preface xv
do not suggest employing unnaturally rhythmicised speech if the patient has

no rhythm. I complement the training of speech fluency with
psychotherapeutic procedures based on the patient’s needs.
One of the primary aims of a therapy of a person who stutters is to teach
him how to cope with commonly observed communicative stresses in natural
speech. Since it cannot be eliminated from our lives, it is important that the
stutterer be trained to get used to coping with it in his or her daily life. This is
why I am against excusing stuttering students from taking oral tests and other
similar activities. The goal of therapy is to get them ready and confident
enough to speak in public. In the course of the therapy, I skilfully place the
patient in various situations or contexts where he has to deal with
communicative stress both during and after the appointment. I consider the
method effective as long as the person who stutters displays a task-based style
of coping with stress.
Stuttering therapy relies very much on the placebo effect which has been
proven effective and is widely applied both in pharmacotherapy and healing.
As commonly known, a cure to stuttering does not exist in spite of the
considerable demand for it. Making the patient hope that a given substance or
medicine may help him or her recover from stuttering is worthwhile as long as
it is ethical and legal. A positive placebo effect can result from a strong
relationship between the person who stutters and his or her therapist. This is a
very useful tool in treatment that can be used only by a reliable therapist whom
the patient trusts.
As mentioned before, motivation, which neither causes physical pain nor
is a threat to the patient’s health, is the primary factor in that determines the
success of stuttering therapy. Motivation is a complex process and its course is
determined by a number of factors. From my perspective the most crucial
factors that strengthen motivation include:
1. The rejection of stuttering,

2. The costs of therapy (financial, time-related and psychological),
3. The course of therapy so far and its effectiveness,
4. Personal belief and social support.
All of the above should be taken into account when shaping patient’s
motivation to therapy of stuttering. Therapy takes a long time and moments of
activation and effectiveness often interweave with those of inefficacy and
doubt. Successful and positive motivation stems closely from the therapeutic
relationship as the level of the patient’s motivation usually mirrors the
xvi Zbigniew Tarkowski
therapist’s. One can hardly imagine that an unmotivated therapist who does
not believe the therapy will bring positive results can effectively motivate a
patient to therapy of stuttering.
The person supporting the one who stutters plays a crucial role. Since
boys and men stutter most often, it is usually a woman (a mother or wife) who
supports them. It is also typically a woman who conducts the therapy. It can be
said that male supporting figures are usually absent in solving this ‘male
problem’. I believe that underestimating their role is a serious mistake. Speech
disfluency is a sensitive indicator of interpersonal relationships and it is
usually more severe when a stuttering boy talks to his father than when he
talks to his mother. I strongly insist that significant male figures related to the
person who stutters (such as fathers, stepfathers, caregivers, etc.) participate
actively in therapy. The course of therapy involving male figures is different
from one conducted for a mother and a son. In fact, if the therapy takes place
without the parents’ involvement (e.g., in a kindergarten or at school), one
should not expect spectacular results.
Only a small (5–10%) group of speech pathologists all over the world
offers stuttering therapy. The reasons for this vary but the most crucial appear
to be negative attitudes towards the process of treatment as well as distrust in
its overall effectiveness. Relapses of speech disfluency in the course of therapy
is a common cause of frustration that often discourages patients from making
further efforts. However, it is important to realise that relapses of symptoms
are observed in most diseases and disorders which are considered chronic and
that this is a natural process of development. When a patient returns to me
because his or her disfluency has relapsed or because of other problems, it
evidently shows that they have placed great trust in both me and the therapy
they have undergone so far. This has always provided me with a tremendous
source of along with a stronger motivation to continue further with the patient
in therapy.
I do believe and have evidence that therapy for people who stutter is
effective as long as it begins early enough and is conducted properly. It is my
hope that readers will be persuaded to my way of thinking and approach to this
problem.
Chapter 1
Introduction to Diagnosis
and Therapy of Persons with
Stuttering (PWS)
Abstract
Diagnosis and therapy of PWS should have solid theoretical and
methodological basis. Traditionally, stuttering has been identified with
speech disfluency. However, since disfluency accompanies a number of
different speech disorders, it is fundamental to establish a differential
diagnosis. Speech disfluency results from disorders within the process of
building an utterance, while stuttering is seen in a linear or systemic way.
From the systemic point of view, stuttering stems from biological,
linguistic, psychological and social factors and circular thinking is
required in order to better understand their inter-relationship. There is
evidence that supports the theory that stuttering is a psychosomatic
disorder and can be considered a special form of allergy to people which
disturb interpersonal communication and can constitute a communication
barrier of different severities.
2 Zbigniew Tarkowski
1. Utterance Planning and

Speech Disfluency
Speech fluency results from a skilful formulation of utterances, which, as
a process, has been presented with a few models. Tarkowski (1992) assumes
that it consists of 4 stages and 3 intermediary transitions:
Stage 1: Motivation
A proper level of motivation is required in order to begin an utterance and

this can be either conflicting or non-conflicting. In non-conflicting motivation,
the reason for the first utterance (or its segment) is in line with that of another
one (or its segment). The speaker remembers what the main reason for his or
her utterance is and adjusts particular segments of the utterance to it. In
conflicting motivation, the motif of the first utterance (or its segment)
contradicts that of another one (or its segment), or the motifs remain in a
random order, in which case speaking is stopped or suspended. The basic
conflict occurs even at the stage of motivation: to speak or to remain silent.
Transition 1: From Motivation to Thinking

This occurs when a speaker wants to speak and knows what he or she
wants to say, i.e., there is a reason and a corresponding thought, in which case
an utterance is likely to be fluent. However, there might be a case in which a
speaker needs to speak, but at a given moment does not know what to say (has
a reason, but lacks thoughts). This is reflected in such idiomatic expressions as
‘lose your tongue’ or ‘cat got your tongue’. In this instance, reason is
transformed into thought with a delay which causes speech breaks or
repetitions of the final element of the previous utterance. By doing so, the
speaker gains some additional time to think.
Stage 2: Thinking
This stage leads to creating information of a structure based on a semantic

and syntactic plan which selects linguistic means and determines their
function, with the so-called ‘private speech’. Efficiency of the process depends
Introduction to Diagnosis and Therapy of Persons with Stuttering (PWS) 3
on proper decisions concerning lexis and structure, and repetitions are one of
the symptoms of difficulties at this stage.
The stages and the transition presented above were primarily conscious
and intellectual in their nature, while the phases to follow are automated.
Transition 2: Transforming Thoughts into a Motor Programme

It consists of transforming the semantic and syntactic information into a
sequence of movements of muscles within the respiratory, phonatory and
articulatory systems. This stage is particularly important for fluent speaking as
it is a boundary which links the previous stages which happened in the
cerebral cortex and which involved consciousness with the next stages that are
more automatic and controlled by the subcortical structures. Transformation of
thoughts into a motor programme can be difficult because:
 thinking initiates the programming of muscles in the speech apparatus

(‘think before you speak’),
 motor planning begins before a thought is fully developed (‘speak
before you think’).
These disruptions are evident in irregular speech pace, elisions and sound
disturbances, consonant clusters and words, and consequently, result in
frequent self-corrections (Majewska-Tworek, 2014).
Stage 3: Motor Regulation
This stage initiates the programming of an utterance in which fluent

shifting from one sound to another is crucial. Thus, difficulties may occur
while pronuncing words and phrases of a complex articulatory structure (the
so-called ‘tongue twisters’).
Transition 3: Translating the Motor Program onto Movements of

Respiratory, Phonatory and Articulatory Organs
The process of translation works in the following order:
1) Breath,
2) Phonation,
3) Articulation.
According to classic theories, any disruption to this order causes

stuttering.
Stage 4: Myodynamic Performance
Keeping respiratory, phonatory and articulatory muscles in optimal

tension is vital at this stage as excessive tension is the cause of tense speech
disfluency of clonic, tonic or mixed seizures’ origin.
Utterance programming is performed in a particular emotional state and
controlled via hearing. In view of this, speech disfluency is triggered by
insufficient or excessive auditory control or too strong positive or negative
emotions.
While there is common agreement as to what the main stages of producing
and utterance are, the course of producing is debatable. Do these stages and
transitions occur in a fixed order or do they happen simultaneously with some
possible omissions? Whatever the decision is, it can be assumed that speech
disfluency is caused by disturbances at every stage, and splitting the process
into stages facilitates the development of therapeutic programmes aimed at
improving speech fluency.
Speech fluency as a term is easy to understand but difficult to define.
Grzybowska and Tarkowski (1987a, 1987b) claim that it consists of
maintaining appropriate pace and rhythm which results in the synchronisation
of the following three stages of producing an utterance: content, form and
phonic substance. They have identified the following:
 Semantic fluency, which is about skilful shifting from one thought to

another,
 Syntactic fluency, which is about skilful shifting from one sentence
structure to another,
 Phonetic fluency, which is about articulating consecutive sounds
easily.
In a similar way, one can distinguish three types of speech disfluency:
 Semantic disfluency stems from a temporary difficulty in moving

easily from one thought to another easily. In order to buy some time, a
person prolongs sounds, repeats sounds, syllables or words, or uses
pauses.
 Syntactic disfluency stems from a temporary difficulty in moving

easily from one grammatical structure to another and a repetition of
function words (prepositions and conjunctions) together with
revisions are its main symptoms.
 Phonetic (natural) disfluency consists in difficulty in moving easily
from one articulation to another. It happens when words of complex
phonetic structure are pronounced and is linked to the absence of
coordination in breathing, phonation and articulation. Its symptoms
manifest in the form of sound prolongations, tense pauses, blocks, as
well as respiratory and phonatory dysrhythmias.
Therefore, speech disfluency is a combination of psycholinguistic

(semantic and syntactic) and physiological disfluency and results from a
desynchronisation of the three levels of utterance structure: content, form and
phonic substance. It also indicates that the process of forming an utterance is
not fully automatic.
2. Typology of Speech Disfluency

Tarkowski (2010) developed a typology of speech fluency disorders and
identified the following types of disfluency:
 Pathological and natural (normal),

 Organic and functional,
 Tense and non-tense,
 Emotional and non-emotional.
Lechta’s typology (2004) differs slightly as disfluency is divided into the

following types:
1) Developmental,
2) Neurogenic,
3) Psychogenic,
4) Based on disturbed speech developments,
5) Accompaniment of disorganized speech,
6) A combination of the above types.
Natural Disfluency
Speech disfluency is a common phenomenon and as such it is normal –

every speaker happens to be disfluent, especially when angry or tired. Natural
speech disfluency is particularly visible when a child’s speech is developing. It
decreases with language development, reaches an optimal level in adulthood,
and increases again in advanced age.
Speech disfluency also occurs in the initial stage of learning a foreign
language. We speak disfluently because we lack words and find pronunciation
and sentence-building difficult. The more skilled we become in using the
language, the less frequent symptoms of speech fluency disorders become.
Natural speech disfluency (normal, acceptable) is observed when:
 the frequency of disfluency symptoms is low,

 disfluency happens rarely and occasionally,
 the dominant symptoms include interjections, pauses, revisions, word
repetition without excessive muscle tension,
 is random in a sense that a speaker can limit or control it,
 does not interfere with utterance reception and is basically acceptable.
Majewska-Tworek (2014) presented the following typology of natural

speech fluency based on an analysis of spontaneous speech samples:
‘1. Lexical self-corrections:

1.1. Ongoing lexical self-corrections
1.2. Lexical self-corrections with replaying parts of the utterance
2. Unfinished speech
2.1. Restarters
2.2. Unfinished thought with continued utterance
2.3. Unfinished thought and utterance
3. Self-correction of grammatical structure
3.1. Self-correction of syntactic structure
3.2. Morphological self-corrections
4. Phonetic self-corrections
4.1. Ongoing phonetical self-corrections
4.2. Phonetic self-corrections with replaying parts of the utterance
5. Pauses
6. Evidence of utterance continuity
6.1. Filled pauses
6.2. Sound prolongation

6.3. Repetition
6.4. Retarding words.’
As presented above, the model covers three types of speech disfluency

resulting from speaker’s self-control: self-correction (which may include
unfinished speech), pauses and evidence of utterance continuity. None of these
types of disfluency is a mistake. Instead, they are features of spontaneous
speech which occur naturally.
Correction always indicates intellectual efforts in building and refining a
text. ‘Noticing and correcting mistakes in others’ and a person’s own
utterances is a sign of linguistic competence.’ (Majewska-Tworek, 2014, p.
91).
Pathological Speech Disfluency: Organic and Functional
Organic speech disfluency accompanies diseases within the central

nervous system, such as: Parkinson’s disease, multiple sclerosis, amyotrophic
lateral sclerosis, stroke and brain and head injury. In these disorders Lechta
(2004) identified neurogenic disfluency which typically accompanies aphasia
or dysarthria. Góral-Półrola’s studies over organic speech disfluency showed
that:
 The frequency of disfluency symptoms in neurological patients is high

and reaches from 6.6% to 35.6%.
 The severity of speech disfluency in illnesses of the central nervous
system is not influenced by the type of an utterance (repeating,
reading, storytelling, structured of spontaneous conversation).
 In neurological diseases, all symptoms of speech disfluency are
present with varying levels of frequency. Pauses (26.6%) and embolo-
phrases (21.5%) are dominant in conditions resulting from stroke,
repetitions (38.7%) and pauses (25.4%) dominate in brain and head
injury, repetitions (43.1%) and pauses (26.7%) are dominant in
Parkinson’s disease, repetitions (34.2%) and prolongations (25.7%)
dominate in multiple sclerosis, while prolongations (62.5%) and
pauses (232%) are dominant in amyotrophic lateral sclerosis. In every
case, mental barriers were observed as marginal.
Functional speech disfluency does not result from damage but from
dysfunction of the central nervous system. It is present in stuttering, with its
basic symptoms being the blocking of an utterance as well as a tense
prolongation or repetition of sounds or syllables.
Tense and Non-Tense Speech Disfluency
Tense (pathological) speech disfluency is accompanied by increased

muscle tension defined in different ways, e.g., ‘Muscle tension is a complex
notion which, on one hand, describes the prolonged seizure of skeletal muscles
(i.e., tonus) and on the other hand, states that the flexibility of a muscle is
related to its structural properties whereas its passivity is related to its passive
stretching’(Grochmal, 1986, p. 155).
Apart from tonus, there is also clonus (i.e., quick, regular and rhythmic
seizures of a muscle which experiences sudden stretching). If a tension
persists, this state repeats itself continuously.
According to Grochmal (1986), muscle tension is regulated in the
following areas:
 The spinal cord in the so-called gamma system which is responsible

for basic tension,
 The cerebellum which merges and modulates tension,
 The cerebral cortex and motor areas which mainly regulate supporting
tension,
 The autonomic nervous system which can influence muscle tension by
modulating blood flow and changes in blood pressure.
The optimal level of muscle tension is referred to as eutonia, whereas

clonus and tonus are states found somewhere between eutonia and spasticity.
These states are fundamentally different from one another as spasticity is
permanent while clonus and tonus are changeable states that come and go.
Variations in muscle tension is the main cause of fluctuations in speech
fluency.
Tense speech disfluency results from excessive muscle tension and
examinations with EMG among PWS (Pruszewicz, 1992) have proven the
following results:
 An increased activity in the orbicularis oris muscles,

 An increased activity when flattening lips,
 A trembling of the tongue, soft palate and epiglottis during pauses in
phonation,
 A delay in emission,
 An increased tension in tongue and lip muscles while a person
imagines the verbal activity,
 A correlation between muscle tension and emotions (muscular-
emotional tension).
Emotional and Non-Emotional Speech Disfluency
Lechta (2004) identifies psychogenic disfluency as a consequence of a

trauma or an emotional breakdown unaccompanied by organic symptoms.
Psychogenic disfluency has a rare pattern as spontaneous speech includes
relatively much of changeable disfluency.
Speech disfluency can be caused by both positive and negative emotions
and what matters here is actually the intensity of those emotions as intense
thrills may block an utterance more than weak anger.
Results of the Test of Verbal Associations (Tarkowski, 2007) confirm that
words may express different strengths of emotional states from neutral to
intense and that words marked emotionally (e.g., stuttering, girl) trigger
speech disfluency more often than neutral ones (e.g., table, armchair).
Łuria’s research results (1976) suggest that speech disfluency may be
evoked not only by key words (e.g., speech), but also by semantically close
ones (e.g., I recite) as one’s reaction to a specific word activates a whole
system of semantic links. Semantic similarity is more influential that the
phonetic one. Based on results of experiments carried out thus far, Łuria has
identified three groups of words:
 Those which form the semantic root, i.e., the key word and the most
semantically related ones,
 Words which form the periphery of the semantic field,
 Neutral words.
 Speech disfluency is probably caused by meaningful words rather
than the neutral ones.
Traditionally, speech fluency disorders have been associated with

logophobia, stress and avoidance-based reactions.
According to Herzyk (2000):
‘In posttraumatic stress disorder an anxiety reaction spreads onto

situations which are similar to the original source of anxiety, e.g., a PWS
feels uncomfortable towards people who resemble individuals which
posed some threat in the past. The disorder is probably linked to
increased activity of subcortical structures between thalamus and
amygdala (…), and avoiding public speaking which is typical of
stuttering can be regulated by structures such as the amygdala, basal
ganglia, frontal cortex and hippocampus.’ (Herzyk, 2000, p. 76–77)
Permanent and Changeable Speech Disfluency
Speech disfluency is permanent if it occurs every day. Permanent speech

disfluency accompanies disfluent aphasia, dysarthria, cluttering and chronic
stuttering.
Speech disfluency is changeable if it comes and goes, is present for
several days, weeks or even months, and then abates partially or completely.
Periods of speech fluency and disfluency often intertwine and changeable
disfluency accompanies developmental speech disfluency and early childhood
stuttering.
Speech fluency disorders can occur in certain communication situations
only and its changeability is determined primarily by emotional and social
factors.
3. Stuttering and Its Types

Speech disfluency is typically associated with stuttering. To stutter means
to speak disfluently, and the nature of this state is expressed in the following
formulae:
J = NP
where: J – stuttering, NP – speech disfluency

Speech disfluency can occur naturally or pathologically but only the latter
type is characteristic of stuttering according to the following formulae:
J = PNM
where: J – stuttering, PNM – pathological speech disfluency

From the psychosocial perspective, stuttering is a reaction to natural
and/or pathological speech disfluency, and the essence of this approach is
expressed in the following formulae:
J=N+R
where: J – stuttering, N – speech disfluency, R – reactions to speech

disfluency.
Reactions to speech disfluency can be:
 Individual-specific (i.e., how a speaker reacts to his/her own speech

disfluency)
 Social-specific (i.e., how others react to a speaker’s speech
disfluency)
These are divided further into the following areas:
 Cognitive (i.e.,what the opinion is of speech disfluency),

 Emotional (i.e., which emotions trigger speech disfluency),
 Behavioural (i.e., which behaviours trigger speech disfluency).
The reactions mentioned above can be either positive or negative. In the

ontogenesis of stuttering, social reactions typically precede individual ones,
and negative reactions tend to dominate over positive ones.
Pathological speech disfluency may be accompanied by synkineses or
vegetative reactions (sweating, blushing, going pale etc.) according to the
following formulae:
J = PNM + W + RW
where: J – stuttering, PNM – pathological speech disfluency, W – synkineses,

RW – vegetative reactions.
From the systemic perspective (Tarkowski, 2007), the structure of

stuttering consists of linguistic, biological, psychological and social elements
(parts, factors) and the inter-relationship among those very elements follow the
structure below:
The explanation of the structure of stuttering should include a description

of each group of factors and, more importantly, the interrelationship between
those factors which appears to be a more challenging task.
A number of classifications and typologies of stuttering have been
developed over time. One of them, the systemic approach, applies a structure-
related criteria in which linguistic criterion allows us to distinguish the
following types of stuttering:
 Primary: Where the repetition of syllables or words is a dominant

symptom,
 Secondary: The most important symptoms include sound repetition,
blocks and prolongations,
 ‘At-start’: Where disfluency at the beginning of an utterance

dominates the speech,
 ‘In-course’: Where stuttering within the utterance is dominates the
speech.
The following types of stuttering can be identified in relation to biological

(or physiological) criterion:
 Clonic: Where clonic seizures are dominant,

 Tonic: When tonic seizures dominate,
 Clonic-tonic: When there is relative balance between clonic and tonic
seizures,
 Respiratory: For contractions located within the breathing apparatus,
 Phonatory: For seizures located in the phonatory apparatus,
 Articulatory: For seizures located in the articulatory apparatus),
 Mixed: For seizures located in different areas of the respiratory-
phonatory-articulatory system.
The psychological criterion enables one to identify the following types of

stuttering:
 Preneurotic (without logophobia and emotional disorders),

 Neurotic (accompanied by logophobia and emotional disorders).
 According to the social criterion, there exist the following types of
stuttering:
 Permanent (occurs in most communicative situations),
 Occasional (occurs less frequently).
The following types of stuttering are to be identified based on the

developmental criterion:
 Developmental (In the initial, early childhood and primary-school

years),
 Chronic (In advanced age).
The above-mentioned types can overlap each other and form various
combinations.
4. The Psychosomatics of Stuttering

Psychosomatics has been developed on the borders of medicine,
psychology and sociology, and refers to a comprehensive (holistic) approach
to a person. It focuses on psychosomatic disorders and diseases, one of which
may be stuttering, particularly in its chronic state (Tarkowski, 2007) as its
phenomenon lies in its volatility, situation or context, involuntariness and
multidimensional nature.
Stuttering is not fixed - it appears and disappears, it may occur in one
situation and yet is absent in another. It can occur while one is talking to some
people but it does not occur when talking to others. It either becomes fixed or
abates gradually. This changeability and involuntariness reflect the nature of
stuttering which has not been fully discovered yet. It still remains a mystery as
to why a PWS’s speech is more often fluent than disfluent. While speech
disfluency is not a fixed characteristic of an individual and may change
depending on the communicative situation involved, answering the question
on why a PWS speaks fluently is equally as interesting as answering the
question on why they happen to be disfluent.
Stuttering may be analysed from both a linear and a systemic perspective.
The former consists of identifying a clear link between a cause and a
symptom, with physiologically (e.g., increased muscle tension),
psychologically (e.g., fear of speaking) or socially (e.g., imitation) conditioned
speech disfluency being a primary symptom of stuttering. It is debatable which
cause is the most significant one here. The main drawback of the linear
approach to stuttering is that it provides explanations which frequently refer to
each other, e.g., logophobia is said to increase speech disfluency while speech
disfluency triggers the fear of speaking. As such, it can be difficult to
distinguish between the cause and the symptom.
Apparently, the systemic theory enables a better understanding of the
nature of stuttering as it assumes that stuttering consists of interrelated
biological, linguistic, psychological and social factors. The nature of this
interrelation is not linear (cause-effect) but circular, based on both positive and
negative feedback. Stuttering, understood as a system, displays features such
as dynamism (constantly undergoing transformations), variety (development
of subsystems), organisation (structure) and the ability to perform homeostasis
(self-regulatory mechanisms). To understand stuttering means not only to
describe its elements, but, more importantly, to explain relationships between
them, out of which the relationship between speech disfluency, increased
muscle tension, logophobia and the reception of the utterance plays a critical
role.
Humeniuk (2012) examined the structure of stuttering using a polygraph
and a battery of psychological tests. An analysis of the results calculated
statistically allowed her to formulate the following conclusions:
‘1. Adults with chronic stuttering display a higher level of reactivity,

which makes them react to stimuli more easily as well as develop greater
excitement and more intense reactions. This is evident in the following
observations:
a. Lower strength of the process of stimulation,
b. Higher amplitude, shorter latency and greater changeability of skin
conductance,
c. High emotional excitability.
2. Adults with chronic stuttering experience adaptation problems and may
display reactions which are different than expected. This is evident in the
following observations:
a. High level of neuroticism,
b. Moderate mobility of nervous processes,
c. Lower resistance to emotional stimuli.
3. Adults with chronic stuttering also find emotion control difficult, as
observed in:
a. Their profile of emotion control: high excitability, low resistance and
control of expression,
b. Low level of emotional suppression.
4. Adults with chronic stuttering display a specific model of physiological
reactions to emotional stimuli:
a. High frequency of skin conductance,
b. Increased pulse rate,
c. Increased amplitude of diaphragmatic breathing, lower frequency and
amplitude of chest breathing.
5. In some cases adults with chronic stuttering may experience problems
in interpersonal relationships which manifest in the following behavioural
symptoms:
a. Ambiversion,
b. High tendency to compromise,
c. Problems with controlling emotional expression.’ (Humeniuk, 2012, p.
186).’
Tarkowski and Paprzycki (2009) examined the reactions of the circulatory

system of adult people with and without stuttering when reading a text,
describing a picture of a naked woman and in direct conversation. While no
significant differences have been observed with regard to blood pressure and
pulse rate, the parameters increased significantly among PWS waiting to say
something, and gradually decreased during speaking (both fluent and disfluent
speakers). This implies that speech disfluency may reduce muscle tension.
Tarkowski (2007) presented the following hypotheses:
Hypothesis 1: PWS speak fluently most of the time because they speak
disfluently only momentarily. Paradoxically, speech disfluency contributes to
improvements in their speech fluency.
So far, researchers have concentrated merely on the negative phenomena
related to pathological speech disfluency but have chosen to ignore positive
functions performed such as:
 Signalling a problem,
 Sending an interpersonal message,
 Relieving muscle tension,
 Offering psychological benefits.
The most important function of speech disfluency is reducing muscle

tension. A PWS uses this method because he/she does not apply any other,
e.g., relaxing, appropriate breathing or releasing emotions. Speech disfluency
is for them the most natural, almost automatic (release) reducer of muscle and
emotional tension. The higher the tension, the longer period of speech
disfluency is required to release it. Repeating (clonus) or prolonging (tonus) a
movement gradually reduces tension, and by doing so, enables fluent speech.
Unnecessary synkineses functioning as reducers occur when speech
disfluency is not releasing tension efficiently, in which case muscle tension
shifts from speech apparatus to other parts of the body, e.g., head, neck, face,
upper and lower limbs. Synkineses precede or coincide with the act of speech,
are involuntary and different from gestures because they are not random.
Synkineses function as a reducer as long as they do not become automated, in
which case they are merely an unncessary motor habit. Limiting synkineses
leads to increase in muscle tension and speech disfluency.
Hypothesis 2: A PWS speaks more fluently if he/she relieves emotions.

While stuttering is most often associated with negative emotions (mainly
anxiety), it also accompanies the positive ones (e.g., happiness). Emotional
self-control has a serious impact on speech disfluency which transforms into
muscle tension and further triggers speech disfluency when the threshold of
emotional stimulation is crossed. A spontaneous relief of negative emotions
(e.g., by crying, swearing or taking a deep breath) reduces muscle tension and
increases speech fluency.
Hypothesis 3: PWS speak fluently when they do not control themselves

excessively.
Excessive control over an utterance decreases speech fluency as
disfluency disappears as long as a PWS does not hear himself/herself
speaking. Therefore, one should speak freely, without much preparation and
be a spontaneous and relaxed speaker.
Wolak (1988) assumed that PWS display disturbed emotional self-control
with the dominant attitude of being anxious that results from anticipating one’s
own disability and failure. This is accompanied by increased muscle and
emotional tension, which, as Wolak proved experimentally, can be reduced by
biofeedback rather than traditional relaxation exercises. Biofeedback helps
PWS control muscle tension and optimises emotional self-control.
Stuttering is associated with both physiological and psychological stress.
According to the physiological notion of stress, harmful factors (stressors)
trigger both specific (e.g., speech disfluency) and non-specific (e.g., breathing
and phonation disorders, ticks and neurovegetative symptoms) changes. On
the other hand, the psychological notion of stuttering assumes that stress
occurs in PWS mostly in communicative situations which are perceived as a
threat (e.g., fear of humiliating oneself or criticism). This triggers an increase
in activation (excitement), strong emotions and the motivation to overcome
stress. A PWS experiences anticipation stress because he or she expects speech
disfluency and its consequences. Permanent stress may lead to dysfunction or
damage within the speech organs which causes chronic stuttering (Lechta,
2004).
Stuttering is connected with a specific type of communication stress,
which combines physiological and psychological stress during spoken
communication. Development of stress in a PWS depends on the subjective
judgement of the threat which consists of three fundamental stages: alarm,
fight, and exhaustion. Stuttering is a stressful situation which has two basic
stages:
 Anticipating speaking (latent stuttering)

 Struggling for fluency (overt stuttering).
While waiting for an utterance, a PWS excessively motivates his or her

body in response to factors identified as threats. Speech disfluency then
becomes this sign of struggle which is closely followed by exhaustion that
increases fluency afterwards.
Szwed (1999) conducted an interesting research on the relationship
between stress, psychological costs and effects of speech therapy which led
her to draw the following conclusions:
1) 57% of stuttering adolescents and adults withdraw from therapy in its

initial stage.
2) PWS tend to display either a flexible or alert model of dealing with
stress where the more rigid one occurs less frequently.
3) People who prefer a fixed style, generally regarded as the least
efficient, incur the highest psychological costs related to the therapy.
4) Therapy was most effective for those who incurred average
psychological costs and the least effective for those who incurred high
costs. In this case patients’ opinions correlated with that of speech
therapists’.
There are interesting analogies between stuttering and an allergy

(Tarkowski, 2007) as both conditions manifest themselves when one has to
defend oneself against things which a person typically does not need to defend
himself or herself against. An allergen is basically a safe substance (e.g., a
cat’s hair) against which an individual starts to defend himself or herself
against. When it comes to stuttering, allergens may take the form of
individuals perceived as threats. This justifies a claim that stuttering is a form
of allergy to people.
It is common knowledge that the aetiology of stuttering has not been
thoroughly described and there exist numerous theories about it (Tarkowski,
2002). One of the theories assumes that the following types of factors of
stuttering can be identified:
 Predisposing, of a biological nature (e.g., heredity),

 Precipitating, of a psychological nature (e.g., trauma),
 Perpetuating, of a social nature (e.g., learning).
Although we do not know the cause of stuttering, it exists and hypotheses

about it should be adjusted based on the individual.
5. Conversation with a PWS

Stuttering is more frequent in dialogues than in monologues and in
spontaneous speech rather than a one prepared before. Góral-Półrola (2016)
conducted studies on random and stuttering-centred conversation among
adolescents and adults (120) as well as students of postgraduate studies in
speech therapy (120). The following results were observed:
1) Severity of speech disfluency was high and reached over 12%. It

turned out to be higher if a conversation touched upon the topic of
stuttering although the difference was not significant statistically. No
significant relationship was observed between severity of speech
disfluency, age and gender of the subjects. Results were similar for
adolescents and adults, as for men and women. However, it has been
observed that speech disfluency and its importance tend to decrease
with age which also results in a consequential decrease in motivation
for therapy.
2) On average, a PWS’s communicative input (i.e., the number of words
pronounced) was actually twice as much as their interlocutors which
contradicts the stereotype of PWS being men of few words. To some
extent this results from the fact that PWS assumed the role of
interviewees while their interlocutors took on the role of interviewers.
In addition, it showed that PWS’ communicative input increases with
age which contradicts the opinion of PWS becoming more reserved as
their age advance. Similar verbal activity was observed among
disfluent speakers of both genders.
3) It is interesting to note that, though controversial, speech fluency
increases with the increase of communicative input. It may result from
the following phenomena:
 ‘In the course of the conversation, participants get to know one

another better and this consequently serves to reduce the tension
between them.
 Reduced tension leads to a reduction in speech disfluency which is an

accurate indicator of interpersonal relations.
 Auditory control decreases in the course of a conversation as the PWS
stops controlling himself or herself and becomes more spontaneous
which leads to an improvement in speech fluency.’ (Góral-Półrola,
2016, p. 172).
4) During random talks, participants who had not known one another
before, discussed issues which are neutral, emotionally indifferent,
hardly original and typical small talk topics between strangers
(regarding the family, home, school, friends, weather etc.). They did
not present any actions or events, only opinions. Speakers kept
changing topics and treated them in a cursory way. Questioning and
answering (informing) was a dominant speech act among stuttering
logopaedic students which is typical in an interviewer-interviewee
relationship. Instead of a natural conversation, we observed them
making a diagnosis, which is considered a barrier to communication.
PWS were more open in dialogues than their partners.
5) The topic of therapy was most often touched upon in conversations
about stuttering. Most of the subjects received help from a speech
therapist with the therapy lasting for several (up to 10) years and
subjects being unaware of its aims and methods. The therapy was
focused on speech training which was typically separate from
psychotherapy. Such an approach had limited effectiveness and one
third of the subjects stated that although they saw some improvement,
stammering or quick speech prevailed. One-third of subjects observed
an improvement in speech fluency which was followed by a relapse of
stuttering after a period of time. Others did not observe any
improvement at all and the lack of success was justified by focusing
too much on exercises which were perceived as boring, stressful and
pointless. The subjects also found it difficult to see themselves in the
new role of a fluent speaker.
6) The conversation about stuttering was ordinary and, apart from
therapy, it concerned its aetiology, development, dynamics, self-
assessment, stereotype, reception, coping with stress, planning life
and its quality, and others.
7) The structure of both a random conversation and a conversation about
stuttering was similar and implied a directive-assertive style which is
an example of a non-partner and authoritative model of

communication.
8) The study showed that the higher one’s self-assessment of stuttering
was, the more likely one was to adopt compliant communication
barriers.
Stuttering may be a communication barrier (Tarkowski, 2007) whose

importance is determined by several factors found in:
 The sender,
 The recipient,
The relationship between the sender and the recipient.
The factors related to a PWS (i.e., sender) include:
 Severity of speech disfluency,

 Types of symptoms of speech disfluency,
 Duration of disfluency periods ,
 Location and severity of synkineses,
 Clarity of the utterance,
 Self-assessment,
 Social status.
 Severity of logophobia,
 Readiness to communicate.
The main factors related to the recipient of a disfluent utterance are:
 Attitude to the PWS ,

 Habit,
 Coping with communicative stress.
Interactions taking place in a conversation with a PWS are also important

for developing communication barriers.
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doktorska. Katowice: Uniwersytet Śląski (Styles of Coping with Stress,
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mówią płynnie. Lublin: Wydawnictwo Fundacji “Orator”. (The
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“Orator” Foundation Publishing).
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Chapter 2
Diagnosis of Persons
with Stuttering (PWS)
Abstract
Diagnosis (identification, assessment, measurement, examination) of
stuttering is multidimensional and most often considers fluency and pace
disorders in speech. In the course of diagnosis, types of disfluency
symptoms are identified and their location and intensity/frequency are
determined. In certain cases, utterance content and form are analysed as
well. In turn, the person with stuttering (PWS) is examined primarily on
his or her reactions to speech disfluency and selected personality traits he
or she displays, with particular attention paid to measuring
communicative skills and reception of a disfluent utterance. Although
diagnosticians are aware that biological factors play an important role,
these are considered only to a limited degree. Stuttering has been
diagnosed using a number of methods at different methodological levels.
Thus, in an effort to not repeat what is already known, the author has
focused on presenting his own proposition, which readers from Western
countries may not be familiar with.
1. Diagnosis: Types, Aims, Stages
Types of Diagnosis
In a medical sense, diagnosis means to identify a disease or disorder on

the basis of its symptoms. From a social perspective, though, a diagnosis is
understood as a description and explanation of a certain phenomenon. A
diagnosis can be made by a single specialist or a team and can be:
 Comprehensive,
 Hierarchical, or
 Problematic.
The diagnosis of a PWS may involve a General Practitioner, a

psychologist and a speech pathologist, each providing his or her own
diagnosis. If they do not cooperate openly, summative diagnosis is made,
which is a combination of opinions about a PWS as expressed by several
specialists. Although every one of them may be right, they do not necessarily
lead to the same conclusion. Therefore, a PWS diagnosis is made based on
medical, psychological and logopaedic approaches. Summative diagnosis does
not allow for discussion over a patient’s examination results and opinions are
exchanged in a formal way.
Teamwork may result in a hierarchical diagnosis in which the hierarchy
determines whose opinion is more important. In other words, the diagnosis
reflects professional status of the person involved. Typically, the GP’s
assessment is most important, followed by the psychological and logopaedic
diagnosis. Competence disputes may accompany the process of agreeing on
the hierarchy.
Problem diagnosis looks different as the starting point is the flagged
problem and not symptoms of a speech disorder. The problem occurs
(Tarkowski, 1999) when an obstacle is encountered on the way to the goal.
This is represented by the following equation:
P = C + Pr
where: P – problem, C – goal, Pr – obstacle.

Diagnosis of Persons with Stuttering (PWS) 27
Speech disfluency as such is not a problem. The problem occurs when

speech fluency disorder hinders goal achievement. The following questions are
posed during problem diagnosis:
 what is the problem and its nature?

 what causes the problem?
 why is the problem reported now?
 whose problem is it?
 where does the problem occur?
 who participates in the process of solving the problem and to what
extent?
 what will happen if the problem is not resolved?
 what will happen if the problem is resolved?
It is important not only to solve the problem but also to identify a person
who will be responsible for doing this.
Diagnosis as such (not only diagnosis of stuttering) is useful for both
science and practice. The following model shows the difference between them:
Differences between scientific and practical diagnosis
Criteria Scientific diagnosis Practical diagnosis

Aim understanding advice, help, intervention, therapy
Source knowledge patients, clients
Time longer shorter
Postdiagnostic actions publication diagnosis, therapy
Role scientist diagnostician
Object the examined patient
The primary aim of a scientific diagnosis is understanding as such. On the

other hand, the key goal of a practical diagnosis is to plan appropriate
intervention, advice, help or therapy. A scientific diagnosis may be the goal in
itself and may also be useful in practice.
While scientific assessment is based on knowledge and refers to an
overview of studies available, practical diagnosis is adjusted to the needs of
patients or clients. Hence, it is more limited than the scientific one which is
adjusted to a scientist’s aspirations and interests. A scientist has by far more
time for diagnostic procedures than a practitioner who works under the
pressure of his or her timetable. Furthermore, scientific diagnosis can be
repeated if the research project assumes so, whereas this is more troublesome
in daily practice due to extra costs involved.
Scientific diagnosis usually culminates in official publication, preferably
in a prestigious journal, whereas practical diagnosis leads to the issuing of an
opinion or diagnosis which then serves as a basis for post diagnostic
procedures which typically take the form of therapy.
Furthermore, the social role and professional career of a scientist and
practicing diagnostician are very different. The scientist is supposed to serve
science, represent certain standards of the profession and obtain scientific
degrees and titles. On the other hand, the diagnostician should be devoted to
his or her patients or clients who assess his or her actions. A good scientist can
be a good practitioner and the same applies vice versa as a practitioner may
sometimes undertake medical research which leads to obtaining a degree.
A scientists deals with subjects while a practitioner deals with patients and
clients. Both types of relationships are different. Doing a research project is
important for a scientist and the subjects, who are autonomous, may refuse to
participate in it. Working out an accurate diagnosis is important mainly for the
patient who, consequently, is more willing to accept it.
Aims of Practical Diagnosis
Practical diagnosis may be aimed at:
 Identifying speech disorder entity,

 Defining the problematic situation,
 Shaping the course and content of therapy,
 Assessing effects of the therapy.
Speech disorder should firstly be identified by a specialist. If a patient

claims that he or she stutters and an expert accepts this opinion, the diagnosis
here is in fact provided by the client and not by the expert. If we ask a patient
why he or she stutters, answers will vary and most often speech disfluency
symptoms are provided, which, as we know, are not typical of stuttering only.
Establishing a differential diagnosis is beyond the reach of any patient’s
common knowledge and provides a wealth of specialist information which he
or she does not possess. It can refer to a type of stuttering, its severity,
structure or supposed cause. Hence, determining speech disorder entity
according to the adopted classification is the primary responsibility of a speech

pathologist.
The diagnosis of stuttering often triggers stigma which is used to explain
or excuse most behaviours of a PWS. Obviously, this leads to
oversimplification such as the following: ‘he or she is like that because he or
she stutters’, ‘he or she stutters because he or she is like that’. A ‘stuttering’
label is used primarily for classification and administrative purposes but it can
also be the root of a stigma which distinguishes a PWS from others.
Determining what the actual problem is seems more difficult than simply
diagnosing a speech fluency disorder. If stuttering is to become a problem, it
needs to become an obstacle. Generally, it may:
 hinder one’s development,

 be a communication barrier,
 negatively influence interpersonal relations,
 make school or professional career more difficult,
 lower one’s quality of life.
Although stuttering may lead to developing a problematic situation, it

does not have to do so. As Adamczyk, a PWS himself, says, one can happily
live with it (1991, p. 15):
‘1. Stuttering as a disorder is not dangerous for other people.

2. Being a PWS, one can still graduate from school or university and
obtain scientific degrees and titles.
3. Being a PWS, one can earn top and well-paid positions in any field.
4. Being a PWS, one can have a good husband or wife and beautiful
children.
5. Being a PWS, one can lead a life which is equally good as the one led
without knowing a foreign language, without musical skills or without
successes in sports.’
However, this idyll happens to be interrupted by certain key events in

one’s life, e.g., when a PWS wants to say a wedding vow fluently. A problem
which occurs requires urgent action, after which a person typically starts to
stutter again until another important event happens.
Making a diagnosis for the sake of itself is like making art for art’s sake.
Diagnosis should be used primarily to shape the course and content of therapy
and the diagnostic and therapeutic processes used should be consistent.
Diagnosis is weakened when one specialist diagnoses and another one treats,
in which case cooperation between the two parties is formal and
communication is cursory at best. Hence, there is a strong argument to have
the diagnosis and therapy provided by the same person who can take
responsibility for both aspects of treatment.
Diagnosis is immersed in and constantly accompanied by therapy. Repeat
assessments enable a therapist to determine the degree to which goals have
been achieved and consequently, how effective the therapeutic procedures
have been. This applies to both therapy as a whole and its individual sessions.
Diagnosis remains vital as it influences medical practice and sets limits on
the competence and authority of the specialists involved. Although a therapist
is responsible for the success of the diagnostic and therapeutic process, his or
her social and professional position is inferior to that of a diagnostician.
Stages
The model of diagnosing a PWS (Tarkowski, 2007) assumes the following

stages:
Stage 1: Symptoms
At this stage, we record symptoms displayed by a PWS in the following
areas: linguistic (e.g., type and severity of disfluency), psychological (e.g., fear
of speaking, sense of guilt), biological (e.g., stronger muscle tension,
synkineses) and social (e.g., isolation, communication barriers).
Stage 2: Aetiology
Although the cause of stuttering has not yet been identified, it should be
looked for in an individual case. This undiscovered speech disorder probably
does not have one single cause, but rather a combination of predisposing (e.g.,
heredity), precipitating (e.g., trauma) and perpetuating (e.g., reinforcement)
factors. Each case of stuttering has its own individual formula and one should
attempt to discover it using a variety of linguistic, psychological, biological
and social theories.
Stage 3: Pathomechanism
Explaining pathomechanism consists of identifying the relationships
between elements of stuttering and, what is crucial, the interdependencies that
lie between speech disfluency, muscle tension, logophobia and utterance

reception.
Stage 4: Differential Diagnosis

Its aim is to differentiate between stuttering and other speech fluency
disorders, such as: disfluent aphasia, spastic dysarthria, cluttering and normal
speech disfluency.
Stage 5: Nosology
At this stage speech disorder is given a name according to the adopted
classification.
Stage 6: Opinion
The diagnostic process ends with an opinion being issued which is based
on examination results, the interpretation of those results and the prognosis. It
is then used as the basis of medical practice and postdiagnostic procedures.
A process that ends at stage 1 is a symptom diagnosis. At stage 2, it is a
symptom-and-cause diagnosis. At stage 3, a systemic diagnosis, and at stage 4,
a differential diagnosis.
2. Presentation of the Author’s

Own Diagnostic Methods
Questionnaire of Speech Fluency Disorders (Tarkowski, 2010)
Questionnaire of Speech Fluency Disorders (abbr.: KZPM) is a method of
quantitative assessment of speech disorders in children, adolescents and adults.
Its aim is to:
 identify a type of speech disfluency,
 assign a particular speech disorder entity accompanied by this type of
disfluency.
Such diagnostic procedure is expected to:
 determine the type of disfluency - a particular case is either organic or

functional, tense or non-tense, emotional or non-emotional, constant
or changeable, normal or pathological,
 identify the hypothetical causes of speech disfluency,
 correlate the identified type of disfluency with a particular speech

disorder,
 facilitate the planning of a therapeutic process adjusted to the type of
speech disorder.
Accomplishing these goals is possible provided that one is familiar with

the questionnaire guide based on the linguistic, biological, psychological,
social and developmental criteria described above. This has led to the
development of a method which consists of 8 parts referred to as:
1) Disfluency
2) Physiology
3) Emotions, self-awareness and behaviour
4) Social reactions
5) Dynamics
6) Aetiology
7) Type of speech disfluency
8) Type of speech disorder
9) Postdiagnostic procedure
Part 1 on ‘Disfluency’ analyses the subject’s utterances using parameters

of speech disfluency such as type, frequency and location of symptoms.
Part 2 on ‘Physiology’ is used to assess muscle tension, synkineses,
vegetative symptoms and neurotic reactions.
Part 3 on ‘Emotions, self-awareness and behaviour’ identifies the positive
and negative reactions linked to speech disfluency. The subjects’ awareness of
those reactions is also assessed and his or her typical behaviours are described.
Part 4 on ‘Social reactions’ examines the way the disfluently speaking
person is treated by his or her environment.
Part 5 on ‘Dynamics’ assesses the development of speech disorder from
its onset until the moment of examination.
Part 6 on ‘Aetiology’ is supposed to define the hypothetical cause of the
disfluency.
Part 7 on ‘Types of speech disfluency’ identifies the category of the
speech disfluency according to the typology provided.
Part 8 on ‘Type of speech disorder’ is aimed at identifying the nosological
entity which is accompanied by the observed type of speech disfluency.
Part 9 on ‘Postdiagnostic procedure’ proposes if the subject requires
therapy, consultation or advice.
Examination using KZPM should be prepared carefully, which refers to:
 Having access to a proper equipment necessary to record utterances,

 Selecting the place of examination,
 Creating an appropriate mood,
 The subject’s positive attitude towards the examination.
Although there is currently a wide variety of digital equipment used for

recording, storing and processing information, the device used should be rather
easy to operate and provide a high quality of recordings. Creating an
appropriate mood during examination is crucial and the diagnostician’s duty is
to establish good rapport with the subject. If he or she fails to do so during the
first meeting, another meeting should be arranged.
Some speech pathologists feel uneasy as diagnosticians and describe the
very context of examination as uncomfortable. However, a positive attitude to
diagnostic procedures and an appropriate theoretical background are
important.
The form is completed according to the following steps:
Part 1: Disfluency
Step 1: Selecting Communicative Context

A specialist’s surgery creates an artificial communicative situation. Since
more natural communication takes place at home, at work, at school or at
kindergarten, it seems better to record subjects’ utterances outside the
therapist’s clinic and after therapy.
Step 2: Recording an Utterance

Depending on a communicative situation, the recorded utterance should
take the form of:
 a dialogue between a disfluently speaking person and a diagnostician

or a family member, colleague, friend or some other important person,
 a subject’s monologue (description or story).
Also, it is better to record a conversation on a random topic rather than an

interview which often looks like an interrogation, as a subject should be
encouraged to produce spontaneous speech and not to merely answer

questions. An alternative to such a pseudo conversation is a conversation
without questions which encourages interlocutors to be more talkative and
stimulates the subject to open up.
Leading a conversation is challenging and this is particularly true when it
comes to conversations with young children. With these particular subjects,
conversations seem most natural in a thematic game as long as the game itself
is well-prepared and its participants are fully engaged.
When examining adolescents and adults, infantile behaviour or approaches
should be avoided. Thus, we do not use such resources as illustrations, books,
toys, etc., and avoid suggesting topics which are more appropriate for children
as they may confuse and embarrass older subjects. In a word, we should try to
be natural and adapt the course of the conversation to the subject’s age.
Affective communication has much more diagnostic value than task
communication as boring, impartial and uninvolved utterances do not provoke
speech disfluency. On the other hand, the more personal communication is, the
more likely speech fluency disorders are to occur.
A diagnostician may ask the subject’s family to record the utterance in a
more natural context outside of the therapist’s clinic. If speech is recorded at
home, performing everyday activities or participating in ritual meetings is the
best moment to do it. So, for example, the speech recorder can be switched on
during cooking or at meal times.
Since stuttering is changeable – it may occur today and and it may not
occur tomorrow - recording utterances requires a great deal of attention and
patience. Since it is sometimes difficult to record an appropriate moment, the
more speech samples are recorded, the more likely it is that there will be
disfluent utterances among them.
Step 3: Transcribing Utterances and Marking Symptoms of

Speech Disfluency
An analysis should be performed on a sample of spontaneous utterance of
over 200 words. The longer the text assessed, the more accurate indicators of
speech disfluency will be. One should not select only disfluent sentences.
Instead, all the dialogue, description or story available within the sample
should be analysed.
Traditional or phonetic transcription of the utterance can be provided.
While transcribing, we use the following codes and marks of speech
disfluency symptoms:
Symptom Code Mark

Sound repetition PG m-m-m-mama
Syllable repetition PS ma-ma-mama
Repetition of word/words PW mama-mama
Repetition of combination of words PK mama cleans-mama cleans
Block B` ___ mama or ma___mam
Prolongation P mmmmama
Interjection W mama no-no mama
Pause PN mama […] goes
Revision R mama goed […] went
The text analysed should be played back several times in order to capture
all the ‘subtle’ symptoms of disfluency and make appropriate notes.
Step 4: Calculating Indicators of Speech Disfluency

Speech disfluency indicators are calculated once for the whole dialogue,
description and monologue. In other words, we consider the whole body of
utterance and calculate in it:
 the number of words (LW)

 the number of syllables (LS)
 the number of speech disfluency symptoms (LO)
 a primary indicator of disfluency frequency:
(Formula 1)
 a secondary indicator of disfluency frequency:
(Formula 2)
 the number and percentage of disfluency symptoms is located in the

initial position in the utterance (LP)
middle of the utterance (LW)
 the number and percentage of disfluency symptoms is located outside
the word (NZ)

mid-word position (NW)
 the number and percentage of the following types of disfluency
symptoms:
Code Number %
PG ……. ……
PS …… ……
PW …… ……
PK …… ……
B …… ……
P …... ……
W …… ……
PN …… ……
R …… ……
Total ……. 100%
If calculations are correct, LP + LW = LO (100%) and NZ + NW = LO

(100%)
Part 2: Physiology
In this part the following elements should be assessed on the basis of

observation or an interview:
 muscle tension during speaking, and particularly occurrence of speech

disfluency,
 synkineses or ticks,
 neurovegetative symptoms (e.g., going red or pale, sweating, dry
throat, cold hands or feet etc.),
 neurotic behaviours (e.g., bed-wetting, sleep disorders, nail biting
etc.).
Some of these symptoms will be stronger and appear sooner in a situation

of communicative stress. This can be replicated by asking a subject to take
his/her upper clothes off during a conversation which is uncomfortable and
stressful for many people. Stress triggers speech disfluency, synkineses and
neurovegetative symptoms as well as increases muscle tension. They are easier

to notice when a subject is partially undressed.
Synkineses are most often located in the following parts of the body:
 the head (when turning or tilting forward);

 the face (when wrinkling the forehead, frowning, squinting the eyes,
cheek, chin, jaw and tongue tremor, clenching the lips etc.);
 the neck (when tensing the muscles),
 the arms (when hiding one’s face in one’s hands, shaking the arms,
clenching the fists, tapping or moving the fingers);
 legs (when moving the legs, jumping).
Generally, synkineses precede or coincide with speaking.
Part 3: Emotions, Self-Awareness and Behaviour
In this part one should identify emotions related to speech disfluency

based on observation and an interview. Although stuttering is most often
associated with negative emotions (e.g., fear, anxiety, stage fright, irritation,
annoyance, guilt), some positive ones are also observed (e.g., emotion control,
not caring too much).
The awareness of speech disfluency is derived from linguistic awareness
which starts to develop towards the end of preschool age. The development of
stuttering awareness is a complex process which takes time. Awareness of
pronunciation errors is usually higher than awareness of speech disfluency and
can be limited both in children and in adults, particularly in the elderly as it is
considered unimportant by them.
However, one should not focus merely on speech disfluency but rather try
to understand verbal and non-verbal behaviour as a whole. A typical model of
a disfluently speaking person’s behaviour can be worked out based on
observation, interview and a natural experiment.
Part 4: Social Reactions
Reactions to speech disfluency displayed by individuals important for a

speaker ought to be defined during observation or an interview. For children
and adolescents, the nearest relatives include their parents, siblings, relatives,
friends and teachers. For adults these relatives are their spouses, children,
parents, relatives, friends and colleagues. Observations or interviews should be
include all of the abovementioned parties who are in touch with the speaker
most often.
Part 5: Dynamics
In this section, we determine the duration of speech disfluency and decide:
 if its development was sudden or gradual,

 if it is constant or changeable,
 if disfluency periods tend to shorten or lengthen.
All in all, the aim is to determine whether the development of the

disfluency is successful or unsuccessful.
Part 6: Aetiology
There are many causes of speech disfluency and their setup is also
different. Hence, this section should propose hypotheses related to aetiology
which will be further verified later.
Part 7: Type of Speech Disfluency
Based on the criteria described in this manual, it should be decided if the

speech disfluency is:
 normal or pathological,
 organic or functional,
 emotional or non-emotional,
 permanent or changeable.
Typically, several types of disfluency co-exist and form a certain setup.

Part 8: Type of Speech Disorder
Following the rules of differential diagnosis as presented in the manual

(Tarkowski, 2010) it should be determined what speech disorder is
accompanied by the speech disfluency. In other words, it is decided whether
the speech disorder is a symptom of aphasia, functional dysarthria, cluttering,
stuttering or simply an evidence of natural speech disfluency.
Part 9: Postdiagnostic Procedures
Postdiagnostic procedures are then planned depending on the type of

speech disfluency identified and the speech disorder diagnosed. It is then
decided whether diagnosis should be followed by therapy, consultancy, advice
or any other form of support.
KZPM should be completed according to the order provided and one
should select the [x ] phenomena, symptoms and behaviours which have
occurred as well as complete the missing information.
Questionnaire of Speech Disfluency and Logophobia (Tarkowski, 2001)

The Questionnaire of Speech Disfluency and Logophobia (KNML) is
based on the assumption that stuttering is a combination of speech disfluency,
logophobia and synkineses in a communicative situation. KNML consistent of
three parts:
A – speech disfluency,
B – logophobia,
C – synkineses.
In the case of older children, adolescents and adults, each part can be
completed by the subject himself or herself to enable self-description. A
mother, father or caregiver can answer questions for a younger child.
Part A
1. How often does the child stutter when speaking to his/her mother:
never, rarely, often or almost always?
2. How often does the child stutter when speaking to his/her teacher:
3. How often does the child stutter when speaking to his/her friend:
4. How often does the child stutter when speaking to a shop assistant:
5. How often does the child stutter when speaking in class: never, rarely,
often or almost always?
6. How often does the child stutter when talking over the phone: never,
rarely, often or almost always?
7. How often does the child stutter when asking for or about something:
8. How often does the child stutter when speaking to his/her father:
9. How often does the child stutter when speaking at a name day party:
10. How often does the child stutter when speaking to strangers: never,
rarely, often or almost always?
11. Are there any other situations in which the child stutters? What are
they and how severe is stuttering?
Part B
1. How afraid is the child when speaking to his/her mother: not afraid, a
little afraid, afraid, very afraid?
2. How afraid is the child when speaking to his/her teacher: not afraid, a
3. How afraid is the child when speaking to his/her friend: not afraid, a
4. How afraid is the child when speaking to a shop assistant: not afraid, a
5. How afraid is the child when speaking in class: not afraid, a little
afraid, afraid, very afraid?
6. How afraid is the child when talking over the phone: not afraid, a little
7. How afraid is the child when asking for or about something: not
afraid, a little afraid, afraid, very afraid?
8. How afraid is the child when speaking to his/her father: not afraid, a
9. How afraid is the child when speaking at a name day party: not afraid,
a little afraid, afraid, very afraid?
10. How afraid is the child when speaking to a stranger: not afraid, a little
11. Are there any other situations in which the child is afraid of speaking?
What are they and how much is the child afraid?
Part C
In this part we ask which synkineses and vegetative symptoms listed in
KNML are displayed by the child.
Answers are marked [X] in appropriate columns and calculated according
to the following rules:
 Part A (Disfluency): never – 0 pt, rarely – 1 pt, often – 2 pt, almost

always – 3 pt.
 Part B (Logophobia): not afraid – 0 pt, a little afraid – 1 pt, afraid – 2
pt, very afraid – 3 pt
 Part C (Synkineses): 1 pt for each symptom.
The total score in a single part is 30pt, and the total score in KNML ranges
between 0 and 90 pt. Based on a comparison of answers in each part, the
following types of stuttering have been identified:
 physiological type is when logophobia is not as severe as speech

disfluency and is accompanied by synkineses,
 psychological type is when logophobia is more severe than speech
disfluency and is not accompanied by synkineses,
 mixed type is when logophobia and speech disfluency are equally
severe and both are accompanied by synkineses.
KNML dictates the type of therapy that should be followed as the

physiological type requires primarily speech training, the psychological type
needs primarily psychotherapy and the mixed type requires a combination of
speech training and psychotherapy.
Reaction to Speech Disfluency Scale (Tarkowski, 2011)
Theoretical Basis
Although reactions to speech disfluency vary, they can be classified as
individual or social.
Individual reactions are displayed by a disfluently speaking person and
mirror the way he or she reacts to their own disfluency. Social reactions come
from the environment (family, friends, acquaintances, teachers, head teachers,
carers) and show their reactions to speech disfluency.
From the ontogenetic perspective, social reactions precede the individual
ones. The mother, father, grandmother, grandfather, relatives and friends react
to speech disfluency earlier than the disfluently-speaking child itself.
Both types can be divided into the following reaction categories:
 cognitive,
 behavioural,
 emotional.
Cognitive reactions express one’s assessment or judgement of the speech

disfluency, specifically within the following areas:
 the concept of the nature of speech disfluency,

 the decision whether it is a normal or pathological state,
 the comparison between one’s own speech disfluency and somebody
else’s, or between the disfluency of one’s own child and somebody
else’s,
 the opinion whether the speech disfluency is likely to subside,
 focusing one’s thoughts on speech disfluency,
 hoping that the problem will resolve itself,
 assessment on the severity of the problem,
 knowledge of the cause of speech disfluency,
 the need and point of consulting a specialist,
 the assessment of others’ reactions to the speech disfluency.
Behavioural reactions are evident in such particular verbal and non-verbal

behaviours as:
 paying attention to speech disfluency,

 correcting symptoms of speech disfluency,
 reducing pace of speech,
 showing impatience,
 inconsistent behavioural patterns,
 avoiding eye contact,
 finishing a disfluent utterance for the speaker,
 reacting to every symptom of speech disfluency,
 listening to utterances overattentively,
 saying things for the speaker.
Emotional and physiological reactions mirror the emotions and conditions

of the body which accompany speech disfluency. The following emotions that
most often appear are:
 anger,
 increased tension,
 sense of guilt,
 shame,
 regret,
 anxiety,
 embarrassment,
 physiological changes,
 irritation,
 stress.
The cognitive, behavioural and emotional reactions listed above constitute

a person’s style of reaction to speech disfluency.
Structure
Reaction to Speech Disfluency Scale (SRNM) consists of 30 statements
divided equally into 3 subscales:
 cognitive (10 items),

 behavioural (10 items),
 emotional (10 items).
The Subscale of Cognitive Reactions includes the following items: 1, 4, 7,

10, 13, 16, 19, 22, 25, 28.
The Subscale of Behavioural Reactions includes the following items: 2, 5,
8, 11, 14, 17, 20, 23, 26, 29.
The Subscale of Emotional Reactions includes the following items: 3, 6, 9,
12, 15, 18, 21, 24, 27, 30.
There is an additional statement (31) at the end of the scale which refers to
assessment of speech disfluencv as a whole.
Two versions of SRNM (see: appendix) have been developed to examine
parents and teachers separately. Both versions are semantically identical and
grammatical structures are the only difference e.g., my child stutters – this
child stutters.
Examination
SRNM is applicable both to individual and to group examinations. It
consists of an instruction and 30 items which a respondent is supposed to
respond to by selecting one of the following options:
 yes,
 ? (hard to say),
 no.
Although the duration of the examination has not been determined

exactly, in most cases it takes approximately 10 minutes to complete.
Score Calculation and Interpretation

Subjects’ responses are scored according to the following model:
– yes: 2 pt,
– ?: 1 pt,
– no: 0 pt.
The total score in each subscale as well as in the whole scale is a raw
score which is then calculated into a sten one. Sten value informs about
intensity of a certain reaction in a way which is in line with or contrary to the
theoretical assumptions adopted. Results are interpreted in the following way:
Subscale of Cognitive Reactions

 if the score ranges between 1 and 4 stens, the subject has no or little
inclination towards considering his/her speech disfluency and
regarding it as a serious problem,
 if the score ranges between 5 and 7 stens, the subject displays some
inclination towards considering his/her speech disfluency and
regarding it as a serious problem,
 if the score ranges between 8 and 10 stens, the subject is highly
inclined towards considering his/her speech disfluency and regarding
it as a serious problem.
Subscale of Behavioural Reactions

 if the score ranges between 1 and 4 stens, the subject has no or little
inclination towards seeking intervention during disfluent speech,
inclination towards seeking intervention during disfluent speech,
 if the score ranges between 8 and 10 stens, the subject is highly
inclined towards seeking intervention during disfluent speech.
Subscale of Emotional Reactions

 if the score ranges between 1 and 4 stens, the subject displays little or
no negative emotional reaction towards speech disfluency,
negative emotional reaction towards speech disfluency,
 if the score ranges between 8 and 10 stens, the subject displays strong
negative emotional reaction towards speech disfluency.
Reaction to Speech Disfluency Scale

 if the score ranges between 1 and 4 stens, the subject displays little
negative reaction towards speech disfluency,
 if the score ranges between 5 and 7 stens, the subject displays
moderate negative reaction towards speech disfluency,
 if the score ranges between 8 and 10 stens, the subject displays severe
negative reaction towards speech disfluency.
Sten scores should be used to develop a person’s profile of reactions to

speech disfluency.
Normalisation
The reference group consisted of 856 parents and teachers of disfluently
speaking children, out of whom 342 were mothers, 240 were fathers and 274
were teachers.
Reliability
The reliability of SRNM was assessed using Alpha Cronbach’s coefficient
whose aim is to test correlations between answers selected for particular items
and the overall score. The stronger the correlation, the more likely it is that the
scale measures a given element reliably. The value of Alpha coefficient ranges
between 0 and 1, where 0 indicates the lack of correlation (i.e., an unreliable
scale) and 1 indicates ideal correlation (i.e., a 100℅ reliable scale). Statistical
analysis carried out has proven that the reliability of SRNM is high as the
Alpha Cronbach’s coefficient reached 0.74.
Scale of Self-Assessment and Assessment of Stuttering (Góral-Półrola,
Tarkowski, 2012)
Theoretical Basis
From the systemic point of view, stuttering consists of linguistic,
biological and psychological factors as well as relationships between them
(Tarkowski, 2007). These include:
Linguistic factors:
 the type (type and category) of speech disfluency symptoms,

 their severity (or frequency),
 their location,
 the length of an utterance,
 the grammatical structure of the text,
 the semantic cohesion of the utterance.
Biological factors:
 the type of excessive muscle tension within a person’s speech organs,

 the location of the tension,
 synkineses,
 vegetative symptoms,
 heredity issues,
 presence of left-handedness,
 breathing, vocal and articulatory discoordination.
Psychological factors:
 logophobia,
 self-awareness of one’s own stuttering,
 anger,
 sense of guilt,
 stress,
 frustration,
 self-esteem.
Social factors:
 contact with others,

 the number of interlocutors involved,
 the social position,
 members of the audience,
 reactions of others to speech disfluency,
 communication barriers.
The relationships which exist between these factors can be categorised as:
 Internal: If the relationships occur within a given group of factors,

e.g., between disfluency type and length of the utterance,
 External: If the relationships occurs between factors from different
groups e.g., frequency of speech disfluency and logophobia.
The abovementioned factors are assessed by both the PWS and his
environment.
Structure
The Scale of Self-assessment and Assessment of Stuttering (SSOJ) is a
Likert-type tool and consists of two parts:
 Scale of Self-assessment of Stuttering (SSJ),

 Scale of Assessment of Stuttering (SOJ)
SOJ includes 20 items related to the following factors:
 Linguistic: e.g., My speech disfluency is severe/considerable/

moderate/ mild/minimal (underline the option that is true for you).
 Biological: e.g., Mental blocks which make my speaking difficult
appear very often/often/sometimes/rarely/never.
 Psychological: e.g., I am very often/often/sometimes/rarely/never
afraid of speaking.
 Social: e.g., My stuttering hinders communication greatly/
considerably/quite/a little/ to a minimal degree.
Additionally, the subject provides the overall assessment of his/her own

stuttering:
 My stuttering is: minimal/mild/moderate/severe/very severe.
SSJ and SOJ are identical in meaning and differ only with regard to
grammatical form. Items in SOJ follow the pattern:
 His/Her speech disfluency is severe/considerable/moderate/

mild/minimal.
 Mental blocks which make his/her speaking difficult appear very
often/often/sometimes/rarely/never.
 He/She is very often/often/sometimes/rarely/never afraid of speaking.
 His/Her stuttering is: minimal/mild/moderate/severe/very severe.
The items are assigned to the following four subscales:
 Subscale of Linguistic Factors (items 1–5),

 Subscale of Biological Factors (items 6–10),
 Subscale of Psychological Factors (items 11–15),
 Subscale of Social Factors (items 16–20).
Items in both scales are arranged randomly. The SSJ is designed to be

completed by the PWS, whereas the SOJ is designed to be completed by an
observer who knows the PWS well e.g., mother, father, brother, sister, friend,
acquaintance.
Examination Procedure
The SSJ and SOJ can be used for both individual and group examination.
As explained in the instructions, the subject is expected to take a stance on the
items by selecting one option which he/she thinks is true for him/her.
Although the duration of the examination is not strictly limited, it typically
takes approximately 10 minutes to complete.

The subject’s answers are scored (from 1 to 5) according to the key
provided and scores are marked in a spreadsheet. The total score in each
subscale as well as in the whole scale is a raw score which is then calculated
into a sten one. Sten value informs the intensity of a certain reaction in a way
which is in line with or contrary to the theoretical assumptions adopted.
Consequently, results are interpreted in the following way:
Subscale of Biological Factors

 If the score ranges between 1 and 4 stens, it indicates little or no
occurrence of symptoms such as muscle tension, blocks, synkineses,
breathing difficulties, going red or sweating,
 If the score ranges between 5 and 7 stens, it indicates some occurrence
of symptoms such as increased muscle tension, synkineses, breathing
difficulties and vegetative symptoms,
 If the score ranges between 8 and 10 stens, it indicates frequent
occurrence of symptoms such as muscle tension, synkineses,
vegetative symptoms and breathing difficulties when speaking.
Subscale of Psychological Factors

 If the score ranges between 1 and 4 stens, it indicates little or no
inclination to experiencing logophobia, anger, apprehension, as well
as concealing stuttering symptoms,
 If the score ranges between 5 and 7 stens, it indicates some inclination
to experiencing logophobia, anger, apprehension, as well as
concealing stuttering symptoms,
 If the score ranges between 8 and 10 stens, it indicates high
inclination to experiencing logophobia, anger, apprehension, as well
as concealing stuttering symptoms.
Subscale of Linguistic Factors

 If the score ranges between 1 and 4 stens, it indicates that speech
disfluency is minimal, speech pace is natural, pauses are short and the
subject is ready to communicate,
 If the score ranges between 5 and 7 stens, it indicates moderate speech
disfluency, increased speech pace and the tendency to finish
utterances quickly.
 If the score ranges between 8 and 10 stens, it indicates severe speech
disfluency, fast speech pace, prolonged pauses and an unwillingness
to communicate.
Subscale of Social Factors

 If the sten score ranges between 1 and 4, it indicates effective
communication,
 If the sten score ranges between 5 and 7, it indicates that
communicative skills are at an average level,
 If the sten score ranges between 8 and 10, it indicates difficulties in
communicating and social disadaptation.
Scale of Self-Assessment of Stuttering

 If the sten score ranges between 1 and 4, it indicates low self-
assessment of stuttering,
 If the sten score ranges between 5 and 7, it indicates moderate self-
 If the sten score ranges between 8 and 10, it indicates low self-
assessment of stuttering.
Scale of Assessment of Stuttering

 If the sten score ranges between 1 and 4, it indicates low assessment
of stuttering,
 If the sten score ranges between 5 and 7, it indicates moderate
 If the sten score ranges between 8 and 10, it indicates high assessment
of stuttering.
Sten scores should then be used to develop profiles of one’s self-

assessment and assessment of stuttering, and compare them. The profile can
be:
 Compatible: Levels of self-assessment and assessment are equal,

 Incompatible: High level of self-assessment and low level of
assessment, or the other way round.
If incompatibility occurs, the cause and consequences of the therapy

should be explained.
Normalization
The norm group for SSJ consisted of 498 PWS aged 12–60, among whom
there were 127 women (26%) and 371 men (74%). For SOJ this was 298 PWS
aged 32–66, divided into 191 women (64%) and 108 men (36%). In most
cases they were the PWS’ family members 86%). Others were colleagues,
friends and acquaintances.
Reliability
The reliability of the Scale of Self-assessment and Assessment of
Stuttering was tested with Alpha Cronbach’s coefficient. The result was high:
0.846 for SSJ and 0.890 for SOJ.
The Scale of Motivation to Stuttering Therapy (Góral-Półrola,

Tarkowski, 2012)
Theoretical Model
Motivation to stuttering therapy is a process of undertaking and continuing
actions which lead to achieving certain results. It is initiated and maintained by
a PWS (internal motivation) or his/her environment (external motivation).
Three fundamental phases of the process can be identified with regard to time:
 Initial,
 Middle,
 Final.
The ‘initial’ motivation takes place while deciding to begin the therapy
and at the moment of actually starting it. Although often declared as strong,
initial motivation can eventually prove to be weak. Still, even weak motivation
is not good enough reason to deprive a patient of the opportunity to participate
in therapy. It is always to loss to the patient to be deprived of the opportunity
to do something constructive about this issue. At the same time, arousing the
need for treatment in an unmotivated PWS is no mean feat.
Middle’ motivation is observed in the course of a therapy and fluctuates
over time. Typically, it is highest at the beginning when activation and hopes
are high and decreases with time, especially when therapy results are below
expectations. Critical moments happen in every authentic therapeutic process
and the patient (or his/her carers) may continue or abandon his/her therapy
depending on how these critical moments are addressed as each session may
result in either boosting or reducing motivation.
The ‘final’ motivation occurs towards the end of the therapy and at the
control stage. In the case of stuttering, it can take at least one year for effects
of the therapy to be tested.
There are three fundamental stages of motivation to therapy:
1. Activation
It covers the decision-making process and the first moments when the
therapy is observed. According to Heaton (2004, p. 34), one can learn a lot
about their client’s motivation from his/her answers to the following questions:
‘What made you want to begin the therapy right now?’ The answers we have
come across vary and include:
 Stuttering was supposed to subside spontaneously but is still present.

 A teacher was asked to consult a speech therapist.
 We couldn’t stand listening to it any longer.
 Stuttering has become more severe.
 We were afraid that the younger child would start imitating the older
brother’s stuttering.
 They said they would fire me if I don’t improve my pronunciation.
 I finally have some spare time.
 I want to become a priest but PWS are not accepted at the seminary.
Therefore, stuttering in itself is not necessarily the cause of the problem

that motivates people to go on a therapy. The decision may be individual or
forced, spontaneous or well thought-out, hopeful and optimistic, or resigned
and pessimistic. In the initial stage of therapy, patients and their caregivers test
whether it is right, and a therapist’s task is to motivate the client by:
 defining clear goals which can be achieved in short term,

 developing positive interpersonal relations,
 offering prognostic diagnosis,
 agreeing to a written or oral therapeutic contract,
 instilling the belief of successful therapy in the patient,
 presenting patients who have succeeded,
 mastering techniques of fluent speech as a ‘therapeutic boost’ of a
kind.
If the involvement stage does not follow, this stage comes to an end
relatively quickly.
2. Involvement Stage
Effective therapy requires the involvement of both a patient and his/her
therapist, and their relationship develops in the course of a therapy. This is
referred to as ‘mutual feelings and attitudes in a client-therapist relationship
and ways of expressing them’ (Gelso, Hayes 2004, p. 17). A working alliance
understood as a coalition, cooperation or joint effort, is a main part of a
therapeutic relationship. According to the authors quoted above, this alliance:
 should reach a level that is considered acceptable quite early in the

course of therapy,
 weakens over time and requires additional support later even though it
might have been strong at the beginning,
 changes in the course of a therapy and is particularly important at the
crisis of the therapeutic relationship,
 has different strength levels depending on a type and difficulty of a
therapy,
 requires certain skills which are different both in a patient and a
therapist,
 interacts closely with the process of motivating.
This working alliance can be hindered by a patient’s reluctance.

Kottler (2004, p. 19–20) has outlined the following behavioural categories
of that demonstrate this:
‘When the patient refrains from communicating by:
 remaining silent,
 providing occasional and skimpy answers,
 referring to topics which are not related to the therapy.
When the patient avoids important information by:
 stimulating discussions on unimportant topics,

 having a tendency do intellectualize excessively,
 asking rhetorical questions,
 avoiding the topic persistently.
When the patient is being manipulating by:
 ignoring,
 flirting,
 ascribing one’s own problems to other people,
 forgetting.
When the patient breaks the rules by:
 not attending important meetings,

 delaying payment,
 making irrelevant requests,
 manifesting inappropriate behaviours.’
There are many reasons for a patient’s reluctance, among which the
following seem key:
 fear of the unknown, failure or judgments,

 sense of threat to the current status,
 fear of losing the things one regards as valuable,
 The ‘status quo’ attitude: “Things have been good so far so why
change it?”,
 the ‘waiting game’ strategy,
 costs of change,
 risk of change,
 disinformation,
 manipulation.
Resistance may be perceived as an opponent or a supporter. As Kottler

says (2004), it can be regarded as an obstacle and a distracter in a problem-
solving therapy, psychoanalysis and behavioural therapy. On the other hand,
its role can be neutral or supportive in cognitive-behavioural, systemic,
existential and strategic therapy.
If therapy results are noticed within a short period of time, the patient’s
engagement in therapy increases as success usually motivates one more
whereas failure usually weakens motivation. Hence, since even the most
engaged patient may run out of energy after some time, therapy should have a
time limit imposed on it.
3. Continuation
After stuttering therapy has formally ended, it is often continued in the
form of follow-up meetings or consultations for it is easier to achieve positive
change than it is to actually maintain it at the level achieved. Fluency improves
relatively quickly as long as appropriate techniques are applied but
maintaining it at that level in natural communicative settings after the therapy
has ended poses a serious challenge. Additionally, the end of therapy may
leave a patient feeling alienated or even abandoned. Thus, the patient’s
participation in follow-up meetings or consultation sessions confirms his/her
determination to maintain the fluency level achieved. It is very easy for the
patient to relapse into speech disfluency if its cause had not been removed
completely or he/she is not self-disciplined enough to continue the exercises
on his/her own.
The basic elements that motivate patients to engage in stuttering therapy
are:
 The patient’s non-acceptance of stuttering,

 The costs of therapy,
 The course of therapy chosen,
 Trust and support.
Obviously, the whole list is much longer and the four above-mentioned
elements were selected as crucial to making a quick assessment of the patient’s
level of motivation.
The Patient’s Non-Acceptance of Stuttering

Acceptance means approving of something and agreeing to things which
one cannot change. The term is different from tolerance, and the difference,
although subtle, is important. Acceptance means agreement whereas tolerance
refers to ‘not preventing’ and not necessarily accepting the situation or
condition. In the case of stuttering, it all boils down to whether one should
accept it or tolerate it.
Controversy/Dispute
Although the argument of whether to accept or non-accept stuttering
causes a heated debate, the predominant opinion is to accept the disfluent
speech of an individual. Although a number of arguments have been offered to
support it, no positive correlation has been proven scientifically between the
acceptance of stuttering and speech fluency, self-esteem, quality of life and
other key parameters. Hence, the problem remains unsolved and the
acceptance of stuttering may be perceived as an expression of therapist’s
helplessness and nihilist approach.
In the case of disorders which cause neither physical pain nor pose a threat
to a person’s life, motivation to therapy is a basic problem. If motivation is
insufficient, therapy results will be unsatisfactory or minimal. The motivation
to engage in therapy depends on a number of factors with non-acceptance of
the status quo as the leading cause. ‘Why bother to lose weight if one can
accept his/her weight and appearance?’ A similar attitude is observed towards
stuttering which once approved of, no longer poses a problem to the stutterer.
Only the non-acceptance of speech disfluency can motivate the stutterer to get
rid of it for one can accept a PWS and not approve of his/her stuttering at the
same time. This controversial issue will be discussed later in detail in the
chapter devoted to therapy.
The Costs of Therapy

‘Therapy that is free of charge is ineffective and the absence of fees makes
it invaluable.’ – the statement can arouse controversy and objections. It does
not refer to a mercenary approach to therapy but to further thought processes
as costs can be categorised as:
 Financial,
 Time-related,
 Psychological.
Financial costs include payments made in money or in other forms, e.g.,

gifts. There is no clear correlation between the value of payment for a therapy
and its effectiveness. However, it is important to note the source of payment
that covered the costs of therapy: the PWS’ or his parent’s (private medical
care) or the taxpayers (public health services). It is better when the patient
covers the costs on his/her own as it makes him/her value the therapy higher.
Therefore, adult patients are advised to find a job and pay for the therapy with
money personally earned. This matter is more complicated in children’s and
adolescents’ cases as it is the parents who cover therapy costs most often.
Apart from that, they offer their children a financial or non-financial reward
for participating in the therapy which seriously damages motivation levels.
Private treatment is also more likely to produce better results than therapy
offered in a public health centre.
It is often financial costs that are focused on while time-related and
psychological ones are omitted. This is in spite of the fact that they may
eventually accumulate to be higher than merely financial costs. It is a cliché to
say that therapy takes time. And yet, time can be hard to find. Parents usually
say that they would do anything for their stuttering child but later on it appears
that they have no time for regular exercise and it is impossible to find time to
go swimming together. ‘Time is money’ as they say and therapy is paid for
with both, only in different proportions.
The psychological costs of a therapy may appear high, especially if the
therapy combines psychotherapy with training in speech fluency. In the course
of both, one can have pleasant (e.g., relaxation and relief) or unpleasant (e.g.,
shame and apprehension) experiences. Speech training often causes boredom,
impatience, fatigue and ridiculousness. Psychotherapy, in turn, requires one to
be open-minded, to struggle against keeping silent, and to show weaknesses
and fears. Altogether, therapy of stuttering causes a lot of stress in the patient
and communicative stress in particular.
The Course of a Therapy

The results of a previous therapy undergone has a substantial impact on a
patient’s decision to take on another trial: the more unsuccessful they were
previously, the much weaker is their motivation in the present. Therefore it is
of great importance to look at which therapist a PWS goes to for only some of
them feel well-prepared to treat stuttering and truly believe that their therapy
will yield positive results. Finding a competent balbutologist is typically
difficult. However, once a therapist is found and effective therapy is provided,
the patient will return in case of of a relapse of speech disfluency. Therefore,
the higher the patient’s assessment of previous therapies, the higher is his/her
motivation to engage in further therapy.
Trust and Support

Kirenko (2002) states that the term is often understood as being helping,
caring, saving, being interested, sympathising, supporting, approving and
encouraging.
Support for PWS is offered in a variety of forms, including:
 financial support when someone else other than the patient covers the
costs of the therapy,
 a caregiver’s support or company during the visit to the specialist,
 concerns and care expressed regarding a PWS’s speech fluency and
his/her overall well-being,
 interest in a PWS and his/her life,
 empathy with regards to emotions that accompany disfluent speech,
 encouragements to begin or continue therapy,
 providing support for and approving of healthy behaviour of a PWS,
 accompanying a PWS in doing the tasks or exercises recommended
by the therapist.
The social support provided to a PWS can be:
 institutional when provided by a single or networks of organisations

providing logopaedic, medical or psychological help,
 interpersonal when it comes from specific interpersonal relationships
with other people, friends, acquaintances or neighbours.
The course of support for PWS depends primarily on the age of the PWS.
Children and adolescents rely heavily on family support and although it is
boys who typically stutter, it is the mothers’ help is more often sought after.
Adults often expect to receive support from their partners but are more likely
to be disappointed. As a taboo phenomenon, stuttering is often suffered in
solitude and silence.
One of the fundamental aims of a therapy is to arouse and maintain a
patient’s belief in the overall sense and success of it. This is actually difficult
to achieve due to common distrust and despair in the process. Only a reliable
therapist can foster confidence that the therapy will be successful so if the
therapist himself/herself does not believe in the method applied, therapy

becomes ineffective. A specific therapy may yield very different results
depending on the practitioner who uses it as the therapist’s confidence has a
strong influence on the patient and can strengthen his/her commitment to the
therapy.
To sum up, it should be highlighted that motivation to stuttering therapy is
improved if non-acceptance of stuttering is stronger, the patient is more
willing to bear its costs, previous therapies were more successful and
therapist’s optimism and social support received from caregivers and loved
ones are higher.
Structure
The Scale of Motivation to Stuttering Therapy (SMTJ) is a Likert-type of a
tool (see: Appendix) and consists of four subscales:
 Subscale of Non-acceptance of Stuttering (items 1–5), e.g., ‘I feel

happy with stuttering.’
 Subscale of Therapy Costs (items 6–10), e.g., ‘I will undertake
therapy of my stuttering even if it means stress and hard work.’
 Subscale of Therapy Course (items 11-15), e.g., ‘My previous
therapies of stuttering yielded positive results.’
 Subscale of Trust and Support (items 16-20), e.g., ‘I believe that there
is a treatment for stuttering.’
SMTJ consists of 20 items, which are provided in a random order. The

additional statement in item 21 assesses the overall motivation: ‘My
willingness to start a therapy is: very strong/strong/moderate/weak/very weak.’
SMTJ can be used to examine both individuals and groups. As explained
in the instruction, the subject is expected to take a stance on the 21 items by
selecting one option that he thinks is true for him. On average, the examination
takes approximately 10 minutes.

Subject’s answers are scored (on a scale of 1 to 5) according to the key
provided and scores are marked in a spreadsheet. The total score in each
subscale as well as in the whole scale is a raw score which is then calculated
into a sten one. The sten value shows the intensity of a certain reaction in a
way which is in line with or contrary to the theoretical assumptions adopted.
Consequently, results are interpreted in the following way:
Subscale of Non-acceptance of Stuttering

 if the score ranges between 1 and 4 stens, it indicates acceptance of
stuttering,
 if the score ranges between 5 and 7 stens, it indicates hesitation and
doubts on stuttering,
 if the score ranges between 8 and 10 stens, it indicates non-acceptance
of stuttering,
Subscale of Therapy Costs

 if the score ranges between 1 and 4 stens, it indicates that a person is
not ready to bear the financial, psychological and time-related costs of
the therapy,
 if the score ranges between 5 and 7 stens, it indicates that a person has
calculated the costs and chooses to bear them only partially,
willing to bear costs of the therapy.
Subscale of Therapy Course

not satisfied with the current therapy or has not undertaken any
therapy at all,
fairly satisfied with the course of therapy,
highly satisfied with the course of therapy.
Subscale of Trust and Support

 if the score ranges between 1 and 4 stens, it indicates considerable
pessimism and lack of support during therapy,
fairly convinced of the sense and success of the therapy and is
expecting to receive more social support,
 if the score ranges between 8 and 10 stens, it indicates optimism and
the availability of extensive social support.
Scale of Motivation to Stuttering Therapy

 if the score ranges between 1 and 4 stens, it indicates weak
motivation,
 if the score ranges between 5 and 7 stens, it indicates moderate
motivation,
 if the score ranges between 8 and 10 stens, it indicates strong
motivation.
Sten scores can be used to develop a person’s profile of motivation engage

in stuttering therapy.
Normalization
The norm group for SMTJ consisted of 456 PWS among whom were 81
women (18%) and 375 men (82%). Average age of the population examined
was 27.76 ± 13.01, which was 26.91 ± 14.02 for women and 27.95 ± 12.80 for
men. A group of subjects aged under included 145 (32%) people. The others –
311 people (68%) – were over 18.
Reliability
Reliability of SMTJ was tested with Alpha Cronbach’s coefficient. The
result reached 0.700, which proves relatively high reliability of the Scale.
Analysis of a Conversation with a PWS

Stuttering is an interpersonal speech disorder which becomes most evident
in a conversation (Tarkowski, 2007; Góral-Półrola, 2016). Although this is
more difficult to do than to evaluate a monologue, an analysis of a
conversation with a PWS is a vital part of the diagnostic process.
There are three indicators which can be used to describe a conversation:
 Conversational input,
 The ability to put oneself forward,
 Speech acts.
According to Nęcki (1996), one can assess how engaged the interlocutor is
based on his/her conversational input, i.e., number of words said in a dialogue
or poly dialogue, or by the number of topics raised in a conversation.
Distractions occur when a person is overactive or underactive, and this is how
individuals can be perceived as either talkative or taciturn. Conversational
input has nothing to do with IQ but is related to a person’s ability to present

himself/herself to others and sharing one’s own experiences, which is both a
form of self-therapy and a sign of balanced personality (Nęcki, 1996).
The ability to put oneself forward in a conversation is measured by the
percentage of topics discussed compared to topics suggested and this is further
influenced by the level of interest generated by the topic, the manner of
introducing it in a conversation and the status of the person suggesting it. The
ability to put oneself forward is considered low or weak if a topic suggested
has been rejected and the person does not insist on discussing it further (Nęcki,
1996).
A conversation is defined as a sequence of interlocutors’ alternating
speech acts. This theory was developed by two philosophers of language:
Austin (1962) and Searle, his student (1968). Searle identified five major
categories of speech acts:
1. Assertives, whose aim is to present facts and things as they are,

include stating, putting forward, suggesting, informing etc.
2. Directives, whose aim is to make the addressee perform an action,
include asking, requesting, inviting, advising, ordering, demanding
etc.
3. Comissives, whose aim is to commit the speaker to do something in
the future or take responsibility for something, include promising,
threatening, commissioning, vowing etc.
4. Expressives, whose aim is to express how a speaker feels, include
primarily polite acts such as welcoming, thanking, congratulating,
apologising etc.
5. Declarations, whose aim is to change the state of the world with a
speech act, such as appointing, announcing, ordering etc.
Based on samples of conversations, one can determine the model of

dominant verbal behaviours, also referred to as communication style. These
can be:
 Directive if the speaker uses directives most often,

 Assertive if the speaker tends to use assertives,
 Assertive-directive if directives and assertives overlap,
 Expressive if the speaker is willing to express his/her feelings and
emotions,
 Equal if suggestions and requests are predominant,
 Unequal if demands and orders are most frequent,

 Active if one displays readiness to communicate and speaks a lot,
 Passive if one does not need to speak and prefers listening to
speaking,
 Balanced if one both can listen actively and likes speaking.
Obviously, the typology of communication styles presented above is

rough, imprecise and inaccurate. Some styles overlap each other, e.g., a
directive style is unequal at the same time. The expressive style is not only
about using polite forms but it is highlighted as it is important to show one’s
feelings and emotions (particularly the positive ones) but this often proves
difficult to do. In summary, the typology facilitates the analysis of the
communicative style of a PWS and his interlocutors, as in the following
example:
A therapeutic session took approximately 40 minutes and involved a
stuttering child, his mother, father and brother. As presented in table 1, the
mother and the therapist were most the active participants and their
conversational input was 45% and 33% respectively. The stuttering child
spoke rarely (13%) and the father (5%) and the brother (4%) were completely
passive in this poly dialogue. While this situation is typical for communication
in which adults dominate over children, it is inappropriate as a therapeutic
conversation in which the verbal activity level of a stuttering child ought to be
much higher. In fact, this was primarily a dialogue between the therapist and
the mother that was passively observed by the father and the brother. In the
next session, the therapist should try to ‘quieten’ the mother, encourage the
father and the brother to speak and, most of all, raise the conversational
activity level of the stuttering child which may prove to be a difficult task.
The data in Table 1 suggests that the session was dominated by the
therapist and the mother. The former suggested 8 topics out of which 4 were
accepted (ability to put oneself forward: 62%), while the latter attempted to
introduce 4 topics and was successful in the case of 2 (ability to put oneself
forward: 50%). Other participants did not raise any other topic which may
indicate little interest in the course of the conversation. The therapist should
consider ways of improving the stuttering child’s ability to put oneself forward
in the next session.
Table 1. Conversational input of participants of the therapeutic session
Words pronounced
Participants
Number Percent
Therapist 935 33
Stuttering child 349 13
Mother 1281 45
Father 150 5
Brother 135 4
Total 2850 100
Table 2. Ability to put oneself forward as presented by participants of the

therapeutic session
Number of topics Ability to put oneself

Participants
accepted suggested forward (%)
Therapist 5 8 62
Stuttering child 0 0 0
Mother 2 4 50
Father 0 0 0
Brother 0 0 0
Table 2 lists the most important speech acts recorded during the
therapeutic session. Altogether, assertives (78%) and directives (15%)
dominate, expressives (4%) and comissives (4%) occur occasionally, while
declarations were absent. Such proportions of speech acts are typical of an
assertive-directive style which usually happens between a doctor and a patient,
a teacher and his/her student or a superior and his subordinate. These
relationships are unequal in nature and this influences communication in a way
that it is primarily instrumental with a limited usage of expressives.
The therapist in the session analysed mainly provided information (48%),
gave orders and asks questions (46%), makes promises only sometimes (2%)
and rarely showed emotions (4%). His style can be classified as assertive and
assertive-directive which is typical of instrumental communication focused on
task completion.
The mother used mainly assertives (74%) and directives (20%). She
presented the therapist with explanations, opinions and suppositions as well as
speaks for the child, repeats questions directed at him/her and encourages the
child to answer them. If she considered the answers to be insufficient, she
asked additional questions. To sum up, the mother was assertive towards the
therapist and directive towards the child, which placed her in the role of an
intermediary between them. Only sometimes did she consider the opinions of
her husband and the other child, who basically only answered questions.
Table 3. Speech acts during the therapeutic session
Speech acts
Participants Assertives Directives Expressives Commissives Declarations Total
L % L % L % L % L % L %
Therapist 44 48 42 46 4 4 1 2 0 0 91 100
Stuttering 32 94 1 3 1 3 0 0 0 0 34 100
child
Mother 83 74 22 20 5 5 1 1 0 0 111 100
Father 10 100 0 0 0 0 0 0 0 0 10 100
Brother 8 100 0 0 0 0 0 0 0 0 8 100
Total 204 78 38 15 10 4 2 3 0 0 262 100
Legend: L – number, % – proportion of speech acts
In this case, the role of a stuttering child was limited to answering

questions or carrying out orders (94%) by his/her mother and therapist. The
child asked only one question and expressed emotions only once, indicating
that he/she was passive and reserved. This posed a great difficulty for the
therapist to establish an emotional connection with the child even though it
was important in therapy.
Instead of being an authentic therapeutic conversation, the communicative
situation presented above is rather a pseudodialogue where one side (like the
therapist and mother) is active, and the other (the stuttering child, father,
brother) is passive. A proper conversation takes place between the therapist
and the mother while the child becomes a mere observer who is called in only
from time to time. It is unfortunate that therapeutic sessions are conducted in
this way quite frequently.
An analysis of the conversation with a PWS presents a clearer picture not
only of the individual itself but also of key suggestions on the direction that
further therapy should take. The goal of further therapy should be to increase
conversational input, strengthen one’s ability to put oneself forward as well as
improve verbal behaviour. As research by Góral-Półrola (2016) suggests, the
higher the conversational input of adult PWSs, the more fluent their speech is.
Scale of Interpersonal Communication (Tarkowski, 2007)
Theoretical Basis
Numerous scales of interpersonal communication have been developed on
the basis of different theoretical assumptions (Nęcki, 1996; Stewart, 1995).
However, the proposed scale refers to the concept of assertiveness (Król-
Fijewska, Fijewski, 2000), which takes into consideration the complete verbal
and non-verbal behaviour of a person. When it comes to utterances, it
primarily refers to the following skills:
 expressing opinion, criticism, needs, wishes, guilt,

 declining politely and tactfully,
 accepting criticism, judgements and praises,
 empathetic listening,
 expressing oneself.
Verbal assertiveness understood in the abovementioned way is different

from such unassertive behaviours as:
 shyness,
 difficulties in communicating,
 behavioural deficits,
 selective behaviour (Król-Fijewska, Fijewski, 2000)
Assertiveness was not discovered by psychologists as they only named

this specific form of behaviour and helped popularise it. This behaviour is
typically observed in people who are well-behaved, polite, self-confident and
linguistically skilled, self-accepting and offer reliable support to oneself and
others.
Assertive behaviours are different from the aggressive and compliant ones
which include, among others:
Aggression ↔ Assertiveness ↔ Compliance
An aggressive person is self-centred, tries to exert pressure on others,

cares only about his/her own rights. The verbal aggression is evident in:
 brutal utterances or aggressive tone of speech,

 forcing one’s opinion on others and not accepting any other opinion,
 using insults and swear words,
 sneering, humiliating, making fun of, mocking, offending, hurting and
being sarcastic.
Verbal aggression can be categorised as direct and indirect. Direct

aggression uses utterances in which the speaker has bad intentions and attacks
the interlocutor with vulgar, rude and offensive words. Indirect aggression
happens when the aggressor uses more subtle means, e.g., irony, sneering or
jokes.
A compliant person is focused on others and puts their needs first. He/she
respects others’ rights and accepts the fact that his/her own rights will be
neglected. Compliance is evident in:
 avoiding conversations,
 the inability to retort,
 remaining silent or reserved,
 over-apologising and using other polite forms excessively,
 using words which indicate docility, humility, pliancy,
submissiveness, obedience, resignation or helplessness.
It is easier to distinguish assertive behaviour from compliant behaviour

rather than from aggressive behaviour. Assertiveness is often confused with
aggression, particularly if a person has been compliant so far, in which case
cultural norms and relationships play significant roles here. In cultures where
social hierarchy is fixed, assertiveness is perceived as a form of aggression.
Thus, depending on the cultural context, an assertive subordinate may be
perceived by the superior as being aggressive.
Structure
The Scale of Interpersonal Communication (SKI) is applied to measure
assertive, aggressive and compliant verbal behaviour. It presents the
respondent with 20 typical communicative situations, each accompanied by 3
possible behaviours, such as:
1. A woman carrying a baby asks you for some money.

a. You say ‘You’d better go to work’,
b. You give her a few pennies,

c. You say: I’m sorry, I don’t give money to people.
Depending on the reaction chosen, one is seen as displaying aggressive,

assertive or compliant behaviour and conclusions can be drawn as to how one
will react in an actual communicative situation.
SKI consists of 3 subscales:
 Subscale of Aggressive Communication (answers: 1a, 2a, 3b, 4a, 5b,

6a, 7c, 8c, 9c, 10a, 11c, 12a, 13c, 14c, 15a, 16a, 17b, 18b, 19c, 20b),
 Subscale of Assertive Communication (answers: 1c, 2c, 3a, 4c, 5c, 6b,
7b, 8a, 9a, 10b, 11a, 12b, 13b, 14b, 15c, 16b, 17a, 18c, 19a, 20a),
 Subscale of Compliant Communication (answers: 1b, 2b, 3c, 4b, 5a,
6c, 7a, 8b, 9b, 10c, 11b, 12c, 13a, 14a, 15a, 16c, 17c, 18a, 19b, 20c).
Speech pathologists and students from different faculties took part in a

pilot research in which the appropriateness of SKI answers were assessed. The
options which have eventually been included as representative of aggressive,
assertive and compliant behaviours were regarded as such by at least 90% of
the respondents. The biggest doubts were raised when participants had to
differentiate between aggressive and assertive behaviours.
Procedure
SKI is applicable both to individual and to group tests. It consists of an
instruction and 20 descriptions of different situations, each accompanied by 3
possible reactions, out of which a respondent is supposed to select one. The
average duration of the test is 10 minutes.

Scores are calculated by counting the number and percent of behaviours
selected.
Interpretation of test results focuses on analysing the profile of answers,
which can be:
 even (non-dominant) if e.g., 25% of answers point to aggressive

communication, 40% to assertive and 35% to compliant,
 uneven (dominant) of e.g., aggressive communication represents 60%
of answers, assertive 35% and compliant 5%.
If a given type of answer is selected in more than 50% of cases, it points

to a preference for a given communication style (aggressive, assertive or
compliant).
Results obtained from SKI not only presents the communication style of
the PWS, it also enables the therapist to make adjustments to the therapy so as
to raise the PWS’ assertiveness level.
Scale of Interpersonal Communication Scores

Subscales Options selected (circle) Number Percent
Aggressive 1a, 2a, 3b, 4a, 5b, 6a, 7c, 8c, 9c, 10a, 11c,
communication 12a, 13c, 14c, 15a, 16a, 17b, 18b, 19c, 20b
Assertive 1c, 2c, 3a, 4c, 5c, 6b, 7b, 8a, 9a, 10b, 11a,
communication 12b, 13b, 14b, 15c, 16b, 17a, 18c, 19a, 20a
Compliant 1b, 2b, 3c, 4b, 5a, 6c, 7a, 8b, 9b, 10c, 11b,
communication 12c, 13a, 14a, 15a, 16c, 17c, 18a, 19b, 20c
Total 20 100
Scale of Attitudes towards Stuttering (Tarkowski, 2007)
Theoretical Basis
Although ‘attitude’ as a term is ambiguous (Brzeziński, 1978; Błachnio et
al., 2015), from the structural perspective, attitudes to stuttering consists of
three elements:
1) emotions and feelings, i.e., affections towards the PWS,

2) cognition, i.e., knowledge and judgements related to stuttering,
3) behaviour, i.e., specific behaviour towards the PWS.
Attitude defined this way is a relatively good basis for assessing stuttering
through the use of different scales and questionnaires. Tarkowski (2007)
developed a Scale of Attitudes Towards Stuttering (SPWJ), which consists of
41 items grouped into 8 modules that touch on the nature and aetiology of
stuttering, a PWS and contacts with him/her, the diagnosis and therapy of
stuttering as well as the education and job of a balbutologist. The method was
used on 1004 people, among whom were speech therapists (110), students of
logopaedics (179), neurologopaedics (51) and medicine (160), PWS (382) and
parents of stuttering children (122). The results obtained suggest that there are
as many as two stereotypes (A and B) which prevail in the society.
Stereotype A assumes that stuttering is a speech defect of a multilevel

aetiology and that a PWS is an individual with a speech dysfunction diagnosed
by a speech therapist whose therapy focuses on improving speech fluency.
Stereotype B states that stuttering is a speech neurosis which should be
diagnosed by a psychologist and treated in psychotherapy.
Most of the respondents found it difficult to choose between one of the
two stereotypes, accepted some elements from each of them and at the same
time, failed to notice contradictions in their decisions. Still, in spite of the
ambiguous character of stuttering stereotype being a multicultural
phenomenon (St. Louis, 2012), it is a convenient mechanism which makes it
easier to understand this complex phenomenon.
Recently, the POSHA-S method developed as part of an international
project led by St. Louis (2012) has been commonly applied in studies on
attitudes. The method consists of three parts in which the subject is supposed
to:
1) assess their physical and mental health, ability to speak and learn as
well as priorities in life,
2) contrast stuttering with the following 4 features: intelligence, left-
handedness, mental illness, obesity,
3) answer stuttering-related questions.
In Poland 4 research projects have been conducted using POSHA-S

(Błachnio et al., 2015) and the results obtained point to the fact that attitudes
within the Polish society are quite unanimous and similar to those in other
countries. Fear of stigmatisation and alienation of PWS is common in society.
Hence, Tarkowski (2009) attempted to change attitudes towards stuttering
during an experiment in which 4 methods were applied:
1) Scale of Attitudes Towards Stuttering,

2) A lecture was given,
3) An experiment on empathy was conducted,
4) A case study was created and presented.
The Scale (1) was used to contrast subjects’ attitudes before and after the
experiment. The author’s lecture (2) was delivered as a two-sided argument
comparing pedagogical and therapeutic support for a PWS. During the
experiment on empathy, subjects had to perform three tests: 1.
pseudostuttering, 2. melotherapy, 3. begging. Additionally, they were also

asked to work on two case studies which required them to contact a PWS.
87 students of logopaedics, mainly women, took part in the studies. When
results before and after the experiment were compared (the experiment lasted
for 4 months), only minor changes were observed. The most evident ones were
related to the assessment of the aetiology of stuttering, while others referred to
its nature, diagnosis and therapy. The smallest changes were observed with
reference to contacting a PWS and assessment of his/her characteristics. Still,
the changes do not extend far beyond the stereotype of stuttering and trigger
significant resistance, which, though natural and universal, that needs to be
coped with.
Assessment of individual and social attitudes to stuttering is an important
part of diagnosis and therapy, and a model of how to change them, presented
by Tarkowski (2009), assumes the modification of attitudes of the specialists,
the PWS as well as their families or caregivers.
Structure
SPWJ is a Likert-type of a tool (Brzeziński, 1978) which consists of 41
statements related to:
 The nature of stuttering (no. 3, 10, 13, 17),

 The aetiology of stuttering (no. 1, 5, 9, 20, 29, 37),
 The PWS (no 7, 11, 14, 22, 24, 34, 35, 36),
 Contacting the PWS (no. 4, 6, 15),
 The diagnosis of stuttering (no. 19, 25, 26, 28),
 The therapy of stuttering (no. 2, 12, 21, 23, 27, 30, 31, 32, 33),
 Educating the PWS (no. 16, 18)
Items no. 1, 7, 9, 18 are a modification of the model offered by
Grzybowska et al. (1991).
It is worth noting that SPWJ measures the cognitive component of
attitudes more deeply than the behavioural and emotional ones.
The subject is expected to take a stance on the statements provided by
selecting one of the 5 options which he/she thinks is true for him/her: 1. Yes (I
fully agree.), 2. Rather yes (I basically agree.), 3. Hard to say (I have no
opinion on this.), 4. Rather no (I basically disagree.), 5. No (I fully disagree.).
SPWJ can be used for both individual and group tests, and it usually takes
approximately 15 minutes.

In order to make calculations easier, the answers have been grouped into
the following categories:
 Approving (‘Yes’ + ‘Rather yes’) which have been marked as A,

 Neutral (‘Hard to say’) which have been marked as N,
 Disapproving ‘No’ + ‘Rather no’) which have been marked as D.
We use the abovementioned symbols to mark items in SPWJ records

which are then placed in the summary below.
The interpretation of the above summary of STWJ scores is based on
qualitative analysis, not quantitative. Obviously, one can try to give it scores.
However, it is sometimes difficult to decide which answers represent positive,
negative or neutral attitudes.
The SPWJ can be completed by all participants of the diagnostic and
therapeutic process, which allows for comparisons. However, the therapist
should first assess and analyse their own attitudes to stuttering. His/Her self-
awareness is crucial, irrespective of what he/she had been taught before and
what the current trends are because the therapist’s attitudes to stuttering will
exert an influence on his/her attitude to the PWS and will become evident in
the course of diagnosis and therapy. The research with SPWJ done by
Tarkowski (2007) indicates that most speech therapists regard stuttering as
both a speech defect and a speech neurosis but not a disease. Similarly, the
assessment of the aetiology of stuttering is also unanimous. The majority of
speech therapists are convinced that stuttering is either caused by
psychological problems or has a multidimensional background where the
presence of breathing disorders plays a vital role.
The stereotype of a PWS as a sensitive, shy, fearful and shy individual
showed up strongly in the group studied although few of the subjects noticed
the psychological and social benefits of stuttering.
The presence of relatively few speech therapists in the market limit the
options of the PWS and possibility to fill in responsible roles for the PWS. On
the other hand, the PWS was rarely expected to take the responsibility for their
disfluent speech and was sometimes even considered an expert in stuttering.
Quite a few of the subjects were unsure as to how to behave when somebody
else is stuttering and so they typically avoided conversations with such
persons. Also, they were more willing to refer the PWS to a psychologist than
to a GP, to not regard IQ testing as necessary and were more inclined to focus
on assessing speech disfluency instead.
Scale of Attitudes towards stuttering (score summary)
Item Answers
Modules
no. Therapist PWS Parents
Nature of stuttering :
Speech defect 10
Speech neurosis 13
Disease 17
Impediment 3
Aetiology of stuttering:
Psychological 1
Speech organ defect 5
Multi-dimensional 9
Learning 20
Dysfunctional family relationships 29
Breathing disorder 37
The PWS:
Sensitive, shy, quiet 7
Experiences limitations when looking for a job 11
Responsible for disfluent speaking 14
Cannot fulfil assigned responsibilities 22
Benefits from stuttering 24
Prefers stuttering to treating it 34
Should receive pension or subsidies 36
Contact with the PWS:
Not knowing how to behave 4
Avoided by people 6
Worry that their children will begin to stutter 15
The diagnosis of stuttering:
Based on a psychologist’s referral 19
Based on a doctor’s referral 25
Focus on describing speech disfluency 26
Intelligence test of the PWS 28
The therapy of stuttering:
Not encouraged to speak in public 2
Stuttering disappears automatically, no need for treatment 12
Is difficult 21
There is little chance of getting successfully treated 23
Medicines and herbal treatments are effective 27
It is a condition that should be accepted 30
Depends on regular exercises 31
The speech therapist conducts a therapy on his/her own 32
Based on a combination of speech training and psychotherapy 33
Educating the PWS (no. 16, 18)
Form special classes or schools 16
Do not bother with oral task 18
Marking: A – approving answer, N – neutral answer, D – disapproving answer
Speech therapists in the study regarded speech therapy as necessary, albeit

challenging, and very few of them were convinced that a speech disorder
could be treated with medicines and herbs. They believed that speech exercises
could bring more positive effects and almost all of the subjects were convinced
that speech exercises should be combined with psychotherapy. A majority of
them thought that stuttering should be accepted. Only a few of them were of
the opinion that the PWS should attend special schools and that they could be
helped by speech therapists if those therapists were not expected to take
responsibility for the therapy. A vast majority of the interviewees were
convinced that a cured PWS should not conduct therapy. Although the results
presented above refer to the therapist’s self-analysis of his/her own attitudes
towards stuttering, it is commonly understood that people are more willing to
assess others than themselves.
The SKWJ was used to examine individuals and groups of adolescents,
adults and children who were able to understand instructions as well as the
meaning of the items. Tarkowski (2007) presented results of 383 PWS aged
15-63 which showed that the PWS was more likely to regard non-chronic
stuttering as a speech defect than as a speech neurosis even while chronic
stuttering was considered a disease by half of the group studied. Even more
believed that the cause of stuttering was psychological or multidimensional in
its nature. Distorted family relationships and low educational backgrounds
showed a strong impact on a third of the group. A vast majority were
convinced that the PWS was sensitive, shy, fearful, quiet and therefore, the
PWS was not encouraged to speak. A third of the respondents thought that
stuttering resulted from negligence on the part of the PWS and thus they
should opt for jobs which involve speaking to a limited degree. Still, they
believed that the PWS should not avoid tasks and jobs which require
responsibility. A great majority of PWS did not perceive any psychological or
social benefits of their speech disorder while almost a quarter of them believed
that PWS preferred stuttering to therapy. Almost 50% of the respondents
agreed that the PWS knows most about the disorder. A majority were of the
opinion that the PWS should not receive any pension or subsidy and that no
major difficulties exist in the PWS’ communication with fluent speakers. Half
of the interviewees said that the speech therapist should refer the PWS to a
psychologist while fewer believed that a GP was still the best starting point.
Although the PWS typically regarded their disorder as difficult but highly
treatable, very few believed that the stuttering would abate if it remained
untreated. A vast majority of them thought that although stuttering should be
accepted, it could not excuse one from speaking. The essence of therapy lies,
as they say, in speaking exercises combined with psychotherapy, and not

necessarily in medicines and herbs. A great majority of the PWS questioned
said that speech therapists were able to help them speak fluently; and yet, only
a third of them gave cured PWS the right to conduct therapy and almost none
of the respondents considered it a good idea to have special schools for PWS.
Assessing the attitudes of the PWS’ parents was also important. The
research using SPWJ and conducted by Tarkowski (2007) showed that most of
PWS’ parents considered stuttering as a speech defect rather than a speech
neurosis or a disease. While opinions on the aetiology of stuttering differ, the
view that there is a multifactor cause of stuttering with a possible heredity, is
prevalent. Although parents were likely to repeat the stereotype of the PWS as
being sensitive, shy, fearful and quiet, they usually did not object to his/her
professional and social development nor did they see any psychological or
social benefits of stuttering. However, opinions were divided on whether to
offer pensions and subsidies to PWS. Parents were not willing to blame a PWS
for disfluent speech and only some claimed that the PWS preferred to stutter
than to undergo therapy. They did not regard stuttering as ‘contagious’ or as a
serious barrier to effective communication. While speech therapists are
expected to send a PWS to a psychologist than to a GP, some parents still did
not regard this as necessary. Most of them did not believe that the stuttering
may abate if it remained untreated, disregarded medicines and herbs and
considered potential therapy as difficult though potentially successful. Most of
the subjects supported the acceptance of stuttering and considered speech
fluency training combined with psychotherapy to be the primary solution.
More than 50% did not consider it necessary to excuse stuttering pupils from
speaking activities or create special schools or classes for them. A vast
majority of the parents examined believed in the therapist’s professionalism.
The results presented above, which can be a point of reference to
individual measurements and comparisons, show that attitudes to stuttering
differ considerably. Generally speaking, attitudes can be:
 unanimous,
 different.
Unanimous attitudes typically repeat the common stereotypes of

stuttering. Variances start to appear on the issue of the nature of stuttering and
the course of diagnosis and therapy. The difference became evident during the
first meeting of the therapist and the royal couple in the film entitled ‘King’s
Speech’ and referred to the nature of stuttering and the course of the therapy as
the Prince and his wife tried insisted on their view that stuttering was a
disorder in the very ‘mechanism’ of speech and that the therapy did not require
delving deeper into their private matters. Such an attitude can be summarised
as ‘take care of my speech, and not my life’ and to adopt it means one has to
give up psychotherapy. Therefore, a compromise was reached and the therapist
focused on speech fluency training in the first stage of the therapy. However,
after the death of his father, the Prince changed his attitude towards his own
stuttering and began to open up so much so that the therapist was able to
introduce certain elements of psychotherapy. In the meantime, the Prince’s
behaviour went through many dynamic changes.
The results of SPWJ examination are of great significance when agreeing
on the therapeutic contract as it is possible to do so only when the difference in
attitudes is minor and both sides are willing to negotiate and compromise.
Psychosomatic Interview (Tarkowski, 2007)
Theoretical Basis
In the ICD-10 Classification of Mental and Behavioural Disorders,
stuttering is marked as F.98.5. It is classified as a behavioural and emotional
disorder which starts in childhood or adolescence and regarded as a serious
disability of speech fluency as evidenced in frequent repetitions,
prolongations, hesitations and pauses. These actions can be accompanied by
movements on the face or body.
However, there are good reasons to classify stuttering as a psychosomatic
disorder as the term ‘psychosomatic’ means:
 a medical approach which considers aetiology, diagnosis and therapy
including a combination of biopsychosocial factors,
 a class of diseases and somatic disorder of psychogenic background,
 a holistic approach to human problems (Tylka, 2000; Scheir, 2005).
Tarkowski (2007) developed a Psychosomatic Interview (WP) and applied

it to examine 507 PWS. The subjects were gathered into two groups: children
and adolescents (aged 6–17, average age: 14), and adults (aged 18–63, average
age: 35). In total there were four times more men (81%) than women (19%).
The population was diagnosed with a high incidence of different disorders
with speech fluency disorders being the most common and observed in every
subject. They were accompanied by: 1. synkineses, 2. neurovegetative
symptoms, 3. breathing, phonation and articulation disorders, 4. negative
emotions, 5. disruptive interpersonal communication, 6. psychosomatic

disorders. The psychosomatic disorders have been divided into:
 Frequent: If it occurred in more than 10% of the subjects,

 Rare: If it occurred in 6–10% of the subjects,
 Occasional: If it occurred in 1–5% of the subjects.
The symptoms which often accompany pathological speech disfluency

include stomachaches, flatulence or wind, belching, knot, heartache or
stabbing pain near the heart, migraine, blocked nose, excessive fatigue when
making small effort, excessive sweating, trembling, heartaches, excessive
muscle tension.
Among the rare symptoms are nausea, bad taste in the mouth, whitish
coating on the tongue, peptic ulcer, frequent loose stools, paroxysmal cough,
dyspnea, changed skin colour or discoloured skin patches, a prickly sensation,
numbness, frequent urination, muscle ticks.
Pathological speech disfluency is occasionally accompanied by vomiting,
anorexia, inflammatory bowel disease, diarrhoea, ischaemic heart disease,
hypertension, hyperventilation, asthma, severe itching, spot baldness, wetting.
As presented above, stuttering is not an isolated speech fluency disorder
but a syndrome of psychosomatic background.
Structure
The WP consists of 11 modules:
I. Personal information: Basic information on the subject.

II. Onset and dynamics of stuttering: The occurrence of the first symptoms
of speech disfluency and comparison with the current situation.
III. Speech disfluency: Recording the current symptoms.
IV. Synkineses: Occurrence and location of symptoms.
V. Neurovegetative symptoms: Recording symptoms such as blushing,
going pale, sweating etc.
VI. Psychological symptoms: A description of the psychological side of
stuttering.
VII. Social symptoms: Symptoms of distorted interpersonal
communication.
VIII-X. Breathing, phonation and articulation: Symptoms of disorders.
XI. Psychosomatic disorders: Symptoms in the digestive, cardiovascular,
respiratory, musculoskeletal and skin systems.
XII. Past serious diseases: Names.
Generally, the WP focuses on recording behaviours observed and

emotional states experienced.
Interview Summary
Information gathered during WP should be interpreted based on a holistic
approach to stuttering and its accompanying factors, or, in other words, a
holistic approach to a PWS. In case some issues remain beyond the
competence of a speech pathologist, the PWS should be sent to an appropriate
specialist.
3. Procedure
Beginning therapy without a thorough diagnosis is a fundamental mistake
which happens when diagnosis cannot be done due to:
 A lack of time,
 Inappropriate place or location,
 Lack of diagnostic skills,
 Lack of an appropriate method,
 Lack of motivation to diagnose.
There is no diagnosis if there is not enough time for it. A speech

pathologist is supposed to perform diagnostic, therapeutic, consulting,
administrative and other tasks. Diagnosis requires a sufficient amount of time
in order to carefully arrange the test and then thoroughly analyse and produce
the results in the appropriate form. A rule which can be adopted here says that
a speech pathologist should have as much time to diagnose as a psychologist
has.
The examination can be performed only in a room which meets certain
standards. Ideally it should be a speech pathologist’s room equipped for
monitoring or with a one-way mirror. The room cannot be connected to
another or be selected randomly.
The diagnosis of speech disorders is based on both general and detailed
methodology of studies which every diagnostician is expected to master. The
fundamental skills include:
 Establishing contact with a PWS and his/her carers,

 Collecting and analysing speech samples,
 Continuous observation of the patient,
 Conducting an interview,
 Identifying the problem,
 Choosing the right diagnostic tools (tests, scales, questionnaires,
surveys) and using them according to the instruction provided,
 Planning and conducting a natural experiment with a PWS,
 Diagnosing,
 Assessing motivation to therapy,
 Issuing a statement or a certificate.
The first visit is crucial for consistent diagnosis and therapy. It is no

exaggeration to say that its goal is to establish a second visit, which in fact,
seldom happens. In order to increase the chances of having a second visit, a
therapist should: (PG.93)
 establish a rapport with the patient, make an agreement on therapy

and strengthen the patient’s motivation to undergo therapy,
 assess the patient’s speech disfluency, muscle tension and
coordination of breathing, phonation and articulation,
 interview, observe and examine the patient with a selected scale or
questionnaire,
 offer the patient a diagnosis and identify the problem.
When going to the first appointment (which is typically arranged over a

telephone), a PWS or his/her carers should bring with them a recording of a
speech sample with disfluency symptoms which pose a problem to them. On
one hand, this task assesses the patient’s level of motivation to undergo
therapy. But on the other hand, it provides evidence of symptoms regarded as
typical of stuttering. This is particularly important in the case of children who
rarely demonstrate symptoms of disfluent speech in the speech pathologist’s
clinic and thus annoying their parents who know that the child stutters at home
or in school. Instead of waiting for the child to start speaking disfluently, it is
easier to just play a recording with the speech sample prepared beforehand and
to register the symptoms and their frequency.
In order to assess the functioning of speech organs, a PWS should be
encouraged to strip to the waist. While such an instruction is common in
medical examination, it may cause some resistance among speech pathologist

as they typically limit their procedures to the head, which is visible and easily
accessible. When a PWS is half naked, it allows the pathologist to observe the
following:
 the work of respiratory, phonatory and articulatory muscles, as well as

the coordination of those muscles when the patient is silent and
speaking,
 tension in particular muscle groups,
 potential synkineses and vegetative symptoms.
A detailed examination of this kind is difficult for the speech pathologist

to do when a patient is fully dressed.
An interview, observation and analysis of speech samples allows a
therapist to distinguish between natural disfluency and a pathological one.
This is particularly important in the case of pre-schoolers and young children.
If parents claim that their child stutters, which, in fact, is a natural speech
disfluency, the therapist should agree with them and describe the phenomenon
as initial, primitive, mild and temporary. By doing so, we avoid a cognitive
dissonance which would otherwise occur because of the different opinions and
the need to reduce tension by choosing one of them. If parents continuously
insist on proving their diagnosis, they are likely to search for a specialist who
will confirm it, for example, by diagnosing physiological stuttering in the
child.
The therapist may conduct a structured (e.g., Psychosomatic Interview) or
an unstructured interview, each time struggling to find the ultimate cause of
stuttering which may not have been identified yet even though it exists. Thus,
the therapist can pose diagnostic hypotheses concerning the basis of aetiology
of stuttering i.e., predisposing (e.g., heredity), precipitating (e.g., physical or
mental trauma) or perpetuating factors (e.g., unconscious promoting speech
disfluency).
A number of methods used to examine the PWS are available (Tarkowski,
2001, 2007; Tarkowski, Humeniuk, Dunaj, 2012; Lechta, 2004) for a speech
pathologist choose the most suitable one from. It is vital that the therapist
makes a comparison between the self-assessment and the caregiver’s
assessment of stuttering as well as individual and social reactions to the speech
disfluency. Thus, while a speech pathologist is examining the stuttering child,
his/her parents may complete the Reaction to Speech Disfluency Scale or the
Scale of Assessment of Stuttering. Adolescents and adults may be asked to fill
in the Scale of Self-Assessment of Stuttering and the Scale of Motivation to

Stuttering Therapy.
The goal of the first appointment is to offer a preliminary diagnosis. A
mere statement that a person stutters is not sufficient enough as it only
confirms what is already known. The diagnosis should provide more detailed
information on the stuttering condition. For example, there should be details
on the level of severity (mild, moderate, severe, very severe), duration (initial,
chronic) and type (clonic, tonic, clonic and tonic or respiratory, phonatory,
articulatory, mixed). The diagnosis also plays a psychological role as it
reassures the patients and caregivers involved and gives them hope that
therapy is moving in the right direction.
The diagnosis of stuttering is different from identifying the problem of a
PWS in that the problem is not the stuttering as such, but rather, the inability
of the PWS to perceive that communication difficulties actually exist. , This
usually leads them to ignore those difficulties and sometimes, to grudgingly
accept them, which leads to low levels of motivation to undergo therapy, and
so on. The type of problem varies for every PWS.
Since diagnosis is immersed in therapy, which verifies its appropriateness,
the process of diagnosing does not come to an end in the first appointment.
The speech pathologist who diagnoses and conducts the therapy is a guarantee
that both parts of treatment will be consistent with each other.
References
Adamczyk B. (1991), Motywacja w terapii jąkania. “Logopedia,” 10, 15–19
(Motivation in Stuttering Therapy. Logopaedia).
Austin J.I. (1962), How To Do Things with Words. London: Clarendon Press.
Brzeziński J. (1978), Etapy konstruowania kwestionariusza osobowości. [W:]
W. Sanocki, Kwestionariusze osobowości w psychologii. Warszawa: PWN
(Stages of Developing a Personality Survey. [In:] W. Sanocki, Personality
Surveys in Psychology. Warsaw: PWN).
Gelso Ch. J., Hayes J.A. (2004), Relacja terapeutyczna. Gdańsk: Gdańskie
Wydawnictwo Psychologiczne (Therapeutic relation. Gdańsk: Gdańskie
Wydawnictwo Psychologiczne).
Góral-Półrola J., Tarkowski Z. (2012), Skala Motywacji do Terapii Jąkania.
Lublin: Wydawnictwo Fundacji “Orator” (Scale of Motivation to
Stuttering Therapy. Lublin: “Orator” Foundation Publishing).
Góral-Półrola J., Tarkowski Z. (2012), Skala Samooceny i Oceny Jąkania.

Lublin–Kielce: Wydawnictwo Fundacji “Orator” i Wydawnictwo Wyższej
Szkoły Ekonomii, Turystyki i Nauk Społecznych (Scale for Self-
Assessment and Assessment of Stuttering. Lublin–Kielce: “Orator”
Foundation Publishing and the Imprint of the School of Economics,
Tourism and Social Sciences in Kielce).
Grzybowska A., Łapińska I., Michalska R. (1991), Postawy nauczycieli wobec
jąkania. “Psychologia Wychowawcza,” 2, 139–149 (Teachers’ Attitudes
to Stuttering. Educational Psychology).
Heaton J. A. (2004), Podstawy umiejętności terapeutycznych Gdańsk:
Gdańskie Wydawnictwo Psychologiczne. (Fundamentals of Therapeutic
Skills. Gdańsk: Gdańskie Wydawnictwo Psychologiczne).
Kirenko J. (2002), Wsparcie społeczne osób z niepełnosprawnością. Ryki:
WSUPiZ (Social Support for the Disabled. Ryki: WSUPiZ).
Kottler J.A. (2004), Skuteczny terapeuta. Gdańsk: Gdańskie Wydawnictwo
Psychologiczne. (An Effective Therapist. Gdańsk: Gdańskie
Wydawnictwo Psychologiczne).
Lechta V. (2004), Koktavost. Komplexni pristup. Praha: Portal.
Nęcki Z. (1996), Komunikacja międzyludzka. Kraków: Wydawnictwo
Profesjonalnej Szkoły Biznesu. (Interpersonal Communication. Kraków:
Professional School of Business).
Searle J. (1969), Speech Acts. Cambridge: Cambridge University Press.
Tarkowski Z. (2001), Kwestionariusz Niepłynności Mówienia i Logofobii.
Lublin: Wydawnictwo Fundacji “Orator” (The Questionnaire of Speech
Disfluency and Logophobia. Lublin: “Orator” Foundation Publishing).
Tarkowski Z. (2007), Psychosomatyka jąkania. Lublin: Wydawnictwo
Fundacji “Orator” (The Psychosomatics of Stuttering. Lublin: “Orator”
Foundation Publishing).
Tarkowski Z. (2009), Changes in the attitudes towards stuttering. Cerveny
Kostelec: Published by Pavel Mervart.
Tarkowski Z. (2010), Kwestionariusz Zaburzeń Płynności Mówienia. Lublin:
Wydawnictwo Fundacji “Orator”. (The Questionnaire of Speech Fluency
Disorders. Lublin: “Orator” Foundation Publishing).
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Olsztyn: Wydawnictwo UWM (Stuttering in Preschool Age. Olsztyn:
University of Warmia and Mazury Publishing).
Chapter 3
Systemic Therapy of Persons

with Stuttering (PWS)
Abstract
Systemic therapy of PWS consists of selected elements of a speech
training, psychotherapy, pharmacotherapy and physiotherapy, as well as
links between them. Acceptance and fight are the attitudes which can be
identified in the systemic approach. The key factors which influence the
course of therapy include: type and severity of stuttering, the patient’s age
and motivation, as well as time, location, intensity and structure of the
therapy. Therapeutic methods are regarded as hypotheses to be verified in
a natural experiment. Working from a systemic perspective, a speech
pathologist adjusts his therapeutic techniques to a patient’s problem,
instead of forcing the patient to participate in a ready-made programme.
Effectiveness in a given case of stuttering counts most. The degree of
improvement of linguistic, biological and psychological parametres is an
indicator of therapy effectiveness.
1. Systemic View on Stuttering Therapy

Various types of therapeutic procedures have been created over the years
and currently one may even speak of ‘a culture of therapy’ while the meaning
of therapy as such has long diverted from the primary one referring to
treatment with drugs and measures. A clear definition of the role of the
therapist is also difficult to propose because the therapist used to be the doctor
as well, whereas in the present day, the therapist is the person who specialises
in a particular type of therapy, such as psychotherapy or speech therapy.
The systemic approach refers to the structure of stuttering and offers a
speech therapy that focuses on different tools or utilizes different treatments to
address specific factors that affect the speech. This means that the therapy can
focus on linguistic elements, pharmacotherapy, physiotherapy and herbal
medicine to address biological issues. The therapy can also focus on somatic
psychotherapy, behavioural and emotion-focused therapy to address
psychological issues. And to treat social issues, the therapy can utilize
psychodrama and communication training.
The systemic therapy of PWS starts from a wide range of suggestions
which is then narrowed and adjusted to the specific nature of stuttering and
focused on building interdisciplinary links. It is not multifaceted but systemic.
The integration of different therapeutic methods is difficult but it is possible.
Combining speech therapy with pharmacotherapy, herbal medicine,
hydrotherapy and communication in one’s natural environment is the easiest
method that has been practised for a long time. However, combining speech
therapy with psychotherapy is more challenging. Although it may seem to be
the natural solution for the PWS to consult both a speech pathologist and a
psychotherapist and to have treatments from both of them, this does not
happen often because psychotherapists regard PWS as problematic and are
unwilling to meet with them. Even if a psychotherapist does agree to conduct
the therapy, he/she usually does not deal with speech disfluency and
the stuttering then becomes a communication barrier which hinders
psychotherapy. In addition to this, persons with stuttering are not keen to begin
speech therapy when they believe that their problem is with speech and not
mental or psychological issues.
In practice, contact between a speech pathologist and a psychotherapist is
occasional and occurs in a highly formalized environment. These obstacles
then render them unable to communicate well with each other. While the
speech pathologist is eager to discuss the procedures he/she has followed with
the patient, the psychotherapist uses the doctor-patient privilege as an excuse
not to share information with the other because all information is confidential.
How then can they collaborate with each other without exchanging such
crucial information? A speech pathologist and a psychotherapist very rarely
conduct therapy together, possibly because such a solution is as challenging as
preparing or conducting a joint lecture or classes in a different field. So which
is the best solution then? Apparently, allowing one specialist – the speech
Systemic Therapy of Persons with Stuttering (PWS) 85
pathologist – to conduct both the speech therapy and the psychotherapy seems
most reasonable. However, such a setup is challenging and risky due to the
fact that in his/her procedures, the speech therapist usually takes on the role of
a teacher/trainer who focuses primarily on performing the exercises properly.
Combining this attitude with the role of a psychotherapist, who should
concentrate on listening, analysing and communicating, is not an easy task.
Bear in mind that speech therapy and psychotherapy are two completely
different worlds.
How can these two worlds then be combined? A reasonable way to do this
is to select the methods and techniques that match the structure of stuttering
and are common in both speech therapy and psychotherapy. For those reasons,
somatic and behavioural psychotherapy, as well as psychodrama, are most
likely to prove successful in treatment. And finally, the planning of the
therapeutic process should be considered. There are three possible scenarios:
 starting with speech therapy and gradually changing into

psychotherapy,
 starting with psychotherapy and including speech therapy gradually,
 conducting speech therapy and psychotherapy simultaneously.
When physiological stuttering is diagnosed (i.e., high severity of speech

disfluency and minor psychological problems), treatment should begin with
speech training. Similarly, if psychological stuttering is diagnosed (i.e., serious
psychological problems and low severity of speech disfluency), psychotherapy
treatment should be started first. And a mixed type of stuttering should be
treated with both speech training and psychotherapy simultaneously.
The course of therapy is strongly influenced by the method selected to
improve speech fluency, and techniques which rely on natural speech have
been proven to be most effective. Unnatural methods (singing, prolonging,
rhythmicizing) which slow down the pace of speech cannot be used
permanently during psychotherapy as they extend the duration of an utterance
and can cause resistance, discomfort and irritation. Focusing too much on the
technique of speaking makes it difficult for the patient to verbalise
judgements, opinions, emotions, attitudes and needs. This is why it is a good
solution to apply speech fluency improving techniques only in critical
moments when the stuttering patient is mentally blocked.
In psychotherapy, the PWS or patient is supposed to focus on
himself/herself and not on his/her speech apparatus. This causes the patient to
change his/her communicative style and enrich his/her communication with
personal details. Obviously, a speech pathologist is usually directive when

performing exercises. However, this style is inappropriate for psychotherapy
which is based on other speech acts (assertives and expressives). The purpose
of introducing psychotherapeutic techniques into the traditional speech therapy
is to make it more spiritual and this goal is achieved provided that:
 breathing exercises serve not only the purpose of regulating breathing

but also of expressing emotions,
 phonatory exercises are aimed at increasing not only vocal strength
but also self-confidence,
 articulatory exercises lead to improving not only pronunciation but
also one’s image.
From a systemic perspective, stuttering therapy is structured as follows:
Levels of stuttering Therapeutic methods

1. Speech disfluency Speech fluency training
2. Muscle tension Relaxation, desensitisation, physiotherapy
3. Negative emotions Bioenergotherapy, emotional vent
4. Social reception Communication training, psychodrama
The levels of stuttering and therapeutic methods presented above are

related to one another. Improving speech fluency requires the patient to reduce
muscle tension, which, in turn, requires him to change his emotional state and,
at the same time, increasing his readiness to communicate. The goal is attained
if several methods that work on different levels simultaneously are applied.
For instance, breathing training lets the patient reduce muscle tension, vent his
emotions and improve speech fluency, all at the same time. Voice emission
should be accompanied with emotional venting in the form of drama.
Views on the nature of stuttering impinge on the goals of therapy.
Stuttering is typically associated with speech fluency disorders and considered
a speech defect, so the primary aim of therapy in this case is to reduce the
severity of speech fluency symptoms. If one believes that the nature of
stuttering consists of speech disfluency and the negative reactions it brings,
then the goal of therapy will be to improve fluency or change a person’s verbal
behaviour. If one adopts the systemic approach to stuttering, therapy is then
aimed at: 1. improving speech fluency, 2. reducing logophobia, 3. reducing
muscle tension, and 4. improving interpersonal communication. Basically, the
goal of therapy is to cure stuttering and if that is impossible, then at the very
least, the patient should be placed on the road to recovery. This approach
attempts to combine a maximalist approach with a realistic one.
2. Stuttering – Should It Be Accepted

or Fought against?
There are two basic approaches to the therapy of PWS:
 To accept stuttering, or
 To fight against stuttering.
The attitude of accepting stuttering is typical of psychotherapy and

popular in the USA and Western Europe, whereas fighting against stuttering is
characteristic of speech trainings and common in Central and Eastern Europe.
At different stages of therapy, attempts are usually made to combine the two
approaches.
To accept something means to agree to something which otherwise cannot
be changed. This is different from tolerance in that tolerance means neither to
prevent nor to accept something. Hence, the tolerance of stuttering does not
mean that the stuttering is accepted.
The acceptance of stuttering depends on a number of factors and mainly
on age. The younger the child is, the more difficult it is to approve of speech
fluency disorders as parents object against it and hope for stuttering to be
cured. The situation of an adult PWS who is disappointed with previous
unsuccessful therapies is totally different as accepting stuttering means one has
resigned oneself to one’s fate. Therefore, encouraging a PWS to accept
stuttering in their school age is untimely as the chances of curing stuttering
increase in adolescence.
The degree of acceptance of pathological speech disfluency depends on
the severity of the disfluency. It is difficult to accept stuttering and expect a
similar attitude from others if stuttering is so severe that interpersonal
communication is largely distorted or even impossible. Furthermore, many
PWS regard suggestions to accept their speech disorder as simply
unacceptable. They do not wish to stutter and those wishes should be
respected.
American approaches to stuttering have been strongly influenced by
stuttering experts who earlier had personal experiences in fighting the speech
disorder and later introduced the paradigm of accepting stuttering. They regard
fighting against stuttering as a rather unsuccessful endeavour and have advised
others to focus instead on modifying reactions to speech disfluency. This has
been popularised by the self-help movement of stutterers.
Meanwhile, in the Central and Eastern European states, PWS have had
little influence on shaping approaches to stuttering therapy while the self-help
movement has not developed further in this field. Treatments for stuttering are
discussed by fluent specialists, mainly speech pathologists, who claim that
personal experiences with speech disorders (even the most severe ones) do not
make one an expert in the field of therapy. They find it disturbing when adult
PWS speak authoritatively about their disorder and even sometimes try to
conduct therapy without the necessary professional qualifications.
A number of charges can be levelled against the attitude of accepting
stuttering and they include the following:
1) The acceptance of stuttering is a sign of helplessness. We approve of

speech disfluency when we are unable to get rid of it. Thus, a helpless
speech pathologist would try to encourage a patient to accept
stuttering instead of treating it effectively.
2) The acceptance of stuttering weakens the patient’s motivation to seek
or undergo therapy. If stuttering is a state that will never fully
disappear, why bother treating it? As the acceptance of stuttering
weakens motivation levels in both the PWS and the therapist, it is no
wonder that so few of them deal with stuttering therapy.
3) The acceptance of stuttering is a sign of therapeutic nihilism. What is
the point of working on improving speech if one assumes that it will
never be fluent? If one does not believe that one will be successful, it
will be hard to achieve the desired effect.
4) The acceptance of stuttering can be a method but not the goal of
therapy. At certain stages, the acceptance of speech disfluency
reduces logophobia and muscle tension, while improving
communication skills of the patient. Once these positive changes are
observed, the therapist should work towards reaching a further goal of
curing the patient and not merely to remain at the level of acceptable
speech disfluency.
5) The acceptance of stuttering limits the goals of therapy and makes
therapy easier and ostensibly more effective.
6) It is easy to encourage the patient to accept his stuttering as
acceptance neither causes physical pain nor poses a threat to his well-
being, even though it may reduce his quality of life. The acceptance of
stuttering is thus one of the main reasons given to postpone or reject
therapy without being accused of negligence as the decision to not
treat speech disorders does not have legal consequences.
7) The acceptance of stuttering assumes that stuttering will relapse after
a period of remission. This is the reason why fluent speakers are
regarded as potential PWS. Stuttering may relapse at any time and this
is why the patient should simply accept it.
8) PWS expect others to approve of their speech disfluency. If other
people find speech disfluency a problem, it is their problem and not
the PWS.
9) If the declaration of the acceptance of stuttering is not accompanied
with actual behaviour to hide stuttering in a number of ways, we
observe an ostensible acceptance of stuttering.
10) The acceptance of stuttering leads to difficulty in identifying the
indicators of the effectiveness of therapy. Thus, the therapy can,
allegedly, be highly effective in spite of the fact that the patient is still
stuttering.
11) No tests have been conducted to confirm a correlation between the
acceptance of stuttering and a reduction in speech disfluency. Neither
has a difference been proven between people who approve of
stuttering and those who do not accept the disorder.
12) The acceptance of stuttering is one of the reasons for the impasse in
research on the effectiveness of stuttering therapy. If one can never be
fully cured from stuttering, why should anyone undertake such
research?
13) Although medicines and effective therapies may not yet have been
found for many illnesses and disorders, patients have not been
recommended to simply accept the condition they have.
In the current situation one can recall the attitude of fighting stuttering
which assumes that stuttering can be cured as long as a fighter’s attitude is
adopted by both the PWS and the therapist. The attitude is based on the
following assumptions:
 It is possible to achieve success ultimately,

 We are winners by nature,
 There is a strong will,
 There is hard work ahead,
 Problems can be solved.
The fighter’s attitude is observed in the relationship between a trainer and

a competitor who are both anticipating success. The attitude can be transferred
onto the therapeutic context as long as the therapist is reliable, fully-engaged
and professional. A speech pathologist who does not display these traits is
unable to motivate a PWS and his family to fight against stuttering. This
approach expects the PWS to imitate a fighter who:
o walks with his back straight,

o expresses emotions,
o maintains eye contact,
o is self-confident,
o speaks loudly,
o begins conversations,
o tries to speak fluently.
It has not been scientifically proven which of these two attitudes

(acceptance or fight) is better. Every one of them is acceptable though risky.
3. Therapy Elements
There are a number of elements that determine the course of the therapy.
The most significant ones include:
Time
Therapy of PWS takes time and a single appointment is expected to last

between half an hour and an hour, or even longer if it includes diagnostic
examination. The frequency of appointments is essential which is why
appointments should take place at least once a week. It is best to arrange daily
meetings for some time, and then continue with follow-up meetings. Short-
term (though intensive) therapy of stuttering is typically more effective than a
long-term one, and the sooner it begins, the better the results will be. Preschool
age and adolescence are two moments that are best for the patient to start
undergoing therapy. Although the minimal number of therapeutic
appointments has not yet been determined, there are typically no fewer than
eight sessions. A one-year long control period should follow the primary
therapy.
A lot of valuable information can be extracted by scrutinising the amount
of time spent on the various elements of therapy. To do this, one should
prepare a time balance sheet that includes the entire diagnostic, therapeutic,
consultancy and administrative list of procedures performed and the duration
spent on each of them. Once the time balance sheets of a speech pathologist
and a psychotherapist are compared, a fundamental difference will be noticed
as the former is focused on speech fluency training while the latter is focused
on therapeutic dialogue.
Place
The type of an institution in which the therapy is conducted has an

influence on the procedures as well as professional and social roles because
educational institutions utilize the teacher-student relationship whereas health
institutions use that of the therapist-patient.
Age
Speech pathologists have their own preferences as to the age of a PWS.

The majority of them (and these are usually women) prefer working with
children to working with adolescents or adults. However, in such cases, the
phenomenon whereby therapy is infantilized and the adult is treated like a
child is common and unfortunate.
Type and Severity of Stuttering
The therapy should be adjusted to the type and severity of stuttering. It is

important to determine the individual structure of a patient’s stuttering, and
since the structures are diverse, developing a single universal method is
difficult. Therefore, a PWS should be offered methods adjusted to his
individual problem instead of being forced to follow a ready-made program.
Motivation
Motivation is a fundamental element of therapy of stuttering as the results

of the therapy are close to zero without proper motivation. It should be
sufficiently high in a therapist, a patient as well as in other people who support
the PWS.
Therapeutic Relationship
The relationship between a speech pathologist and a PWS and his family
is important. Stuttering is typically a man’s problem which is solved mainly by
women. Mothers and female therapists may prefer a mother-like approach
based on sympathy and overprotectiveness. The father’s role in the therapy is
usually marginal even though it should be more significant, especially when it
comes to stuttering boys. Men should be involved in solving this ‘manly’
problem.
The situation becomes more complicated when stuttering parents send
their disfluent children to a therapy. The father asks the therapist to treat his
son while he himself refuses to participate in the therapeutic procedures
because he believes the therapy will be not be effective for him. By doing so,
he reduces his stuttering child’s level of motivation. Fortunately, there are
fathers who participate in the therapy together with their children which allows
both of them to benefit from it.
Proper therapeutic relationships bring new knowledge, emotional
experience and behaviour. They should also be symmetrical and engage each
side in a similar way. It is debatable, though, how close the relationship
between a speech pathologist and a PWS should be. Some people recommend
keeping each other at a distance, whereas others advocate maintaining a close
contact on three levels: 1. motivational (do we want to or do we have to spend
time with each other), 2. cognitive (we know each other more or less), 3.
emotional (we experience positive or negative feelings and emotions towards
each other). Having years of experience, a therapist can remain emotionally
neutral by controlling her involvement.
Training Intensity
The effectiveness of speech fluency training is determined by its intensity.

Although the exercises are not complicated, they happen to be tiresome. If
they are to bring the desired effect, they need to be performed perfectly, and
this requires a lot of repetition. A new proper and stress-resistant automatism
of speaking needs to be developed.
What does an appropriate selection of exercises mean? Firstly, there
should not be too many exercises because this would only lead to chaos and
sloppy performance. Secondly, exercises should be carefully adjusted to suit
the goals of the therapy. Thirdly, there is a rule of gradually increasing the
level of difficulty. Fourthly, we proceed to the next stages of an exercise only
when the initial part of it was done properly. Fifthly, the degree of completion
of a given exercise is tested and assessed. An intensive training requires
consistent effort and discipline, and once begun in a surgery, it should be
continued at home.
Communication
Communication is the basis of every type of therapy, and takes place on

three levels:
 Politeness (greetings, salutations, pleasantries),

 Instrumental (orders, requests, suggestions, threats),
 Emotional (expressions, opinions, affects)
Combining speech training with psychotherapy is difficult because it

requires instrumental and emotional communication to be combined as well.
When acting as a trainer, the speech pathologist has to be directive. However,
when in the role of a psychotherapist, she has to try to be non-directive.
Although the change of speaking styles during one session is possible, it
requires great communicative skills to be able to do this.
A therapeutic dialogue which involves the close cooperation between the
patient and the therapist is a basic technique. If a PWS prefers to listen than to
speak, the therapist is forced to become more active and cannot merely be an
analyst and an interpreter because such an approach may result in the patient
keeping silent. Therefore, she has to try to increase the PWS’ communicative
input and ability to put himself forward which is a challenging task.
Organisation
A good speech pathologist who uses well-recognised methods will not

achieve the desired results if the diagnostic and therapeutic process is
organised poorly. A speech pathologist is treated as a therapist in medical
institutions and as a teacher in educational ones. At the same time, the status of
a speech pathologist has an influence on her professional and interpersonal
relationships with others as well as her satisfaction in her work. The
therapeutic process is often adapted to the institution that determines the scope
of therapy and the level of autonomy of the therapist. Here, a private clinic or
institution generally offers significantly more autonomy than a public
institution.
Managing the diagnostic and therapeutic process is a challenge for the
speech pathologist in a managerial role. It should be highlighted that
therapeutic and managing skills do not overlap and a good therapist may be a
bad manager.
4. Stages of Therapy
Authentic therapy does not strictly follow the order of established therapy
stages which were developed more for didactic than practical purposes. The
following stages can be identified in the case of a combined speech training
and psychotherapy:
i. Establishing contact, diagnosing and motivating.

ii. Selecting the strategy and methods of therapy.
iii. Verifying the methods.
iv. Assessing the effects.
From a speech pathologist’s perspective, it is more comfortable when she

is looked for rather than when she offers her advice. The strength of
motivation to seek or undergo therapy can be assessed based on a phone
conversation. When there are problems agreeing on the date of the first
appointment, whose aim is, in fact, to arrange for the second session, it is a
bad sign for the future of the therapy. The goal of the therapy is achieved when
the speech pathologist is able to make herself credible in the patient’s eyes and
the potential patients start to believe in the need for and the sense of the
therapy. During the first appointment, a diagnosis should be made. Thus, the
patient should be interviewed, a speech sample should be recorded or
analysed, reactions to speech disfluency should be determined and breathing,
phonatory and articulatory coordination should be assessed. Results of these
examinations should be the basis for diagnosing the type and severity of
stuttering as well as the problem of the PWS. An accurate diagnosis serves to
strengthen the patient’s trust in the speech pathologist’s competences. The so-
called ‘therapeutic injection’ (i.e., showing the patient that he is able to speak
fluently during the first appointment) serves to boost the patient’s motivation
to undergo therapy. The first appointment should end with a therapeutic
contract in the form of a spoken or written agreement which includes the
agreed goals of the therapy, appointments and expected results. Here, it is
important to also define the consequences of defaulting on the conditions of
the contract.
If the second appointment takes place, its aim is to select the therapeutic
strategies and methods based on a number of factors, out of which the
diagnosis, the patient’s and his family’s expectations as well as skills and
abilities of the speech pathologist or the therapeutic team are significant. They
can adopt:
 single-factor strategies, or
 multi-factor strategies.
Single-factor strategies focus only on one element of the structure of

stuttering, e.g., speech disfluency (speech training), PWS (psychotherapy) or
his physical body (pharmacotherapy, physiotherapy). Multi-factor strategies
concentrate on several elements of stuttering and make various combinations
such as the following:
 Speech fluency training + interpersonal communication training,

 Speech fluency training + pharmacotherapy,
 Speech fluency training + psychotherapy,
 Psychotherapy + pharmacotherapy,
 Speech fluency training + psychotherapy + pharmacotherapy.
Speech fluency training is necessary in the case of severe stuttering,

irrespective of the type of stuttering. A low intensity of speech disfluency
together with an increased intensity of emotional reactions means that
psychotherapy is strongly required. Psychotherapy is unnecessary if there are

no problems of a psychological nature.
A comprehensive approach is recommended for chronic stuttering and this
approach offers the following strategies:
 Speech fluency training and pharmacotherapy are conducted

simultaneously,
 Psychotherapy and speech training take place at the same time,
 The therapist begins with speech training and introduces
psychotherapy gradually into the treatment program,
 The therapist begins with psychotherapy and introduces speech
training later on.
When choosing a strategy for stuttering therapy, it should be decided

whether it needs to be:
 individual or group,
 short-term or long-term.
One may begin with an individual therapy and encourage the PWS to join
a therapeutic group in order to enable interpersonal communication. It is
recommended to have a fluent speaker in the group, even if he or she would
merely play the role of an observer or a stressor.
It is best to begin with an intensive short-term therapy in order to see
speech fluency improve quickly and increase a patient’s readiness to
communicate. Psychotherapy typically takes more time than speech training. If
need be, a short-term therapy may turn into a long-term one.
Once all parties agree on a strategy, the therapist can then select
therapeutic methods/techniques to use from a wide range available, such as:
 Natural or unnatural speech,

 Breathing, phonatory or articulatory exercises,
 Psychotherapeutic or behavioural techniques,
 Psychodrama or role-plays,
 Passive or active relaxation,
 Desensitisation or aversive techniques,
 Modelling or social training,
 Hydrotherapy or classical massage,
 Manual therapy,
 Drugs or herbs.
The selection of techniques is determined by a number of factors.

Basically, it all comes down to adapting techniques to suit the individual needs
and abilities of a PWS instead of forcing a ready-made solution. Each method
is only a hypothesis that needs to be tested. If the results are not satisfactory,
one should introduce another technique and test it again with reliable methods
of measuring therapy effectiveness.
5. Motivating Patients to Stay in Therapy

The effectiveness of motivation depends on the subjectively perceived
likelihood of achieving the goal and this increases when the goal is
measurable, real and has a time limit. Improvement in speech fluency should
not be a goal in itself as teaching a PWS to solve problems is equally as
important. Motivation levels increase if therapeutic goals are combined with
personal ones. Some motivating techniques include:
Therapeutic Injection
It consists of showing the PWS that he can get over stuttering, that he is
potentially fluent (Engiel, 1977). It works best during the first appointment,
provided that an appropriately selected speaking technique is used.
Modelling
PWS who have completed their therapy with good results should be
invited to join the new PWS in the first stage of their therapy because they are
excellent role models who can also prove that the therapy is effective.
Education
A number of myths and stereotypes of stuttering have been created. One

of them says that stuttering is incurable, another states that one can grow out
of it. Both of them weaken motivation to undergo therapy. Therapy cannot be
replaced by merely learning about stuttering or joining training groups.
The Socratic Method
The Socratic Method is recommended for the PWS who dislikes to be

preached at. It consists of asking questions that direct a person’s thinking.
Ready-made answers are not provided but a person is guided to find it out on
his or her own.
The Selection Method
Adamczyk (1991) observed that the patient’s motivation to undergo

stuttering therapy very often weakens when the need to get help becomes real.
Thus, he has developed a method for initial selection which consists of:
 informing the PWS or his carers that one can live with this disorder
and that therapy is not necessary,
 explaining that the parents’ duty is limited to taking the child to
therapy,
 providing a PWS with the programme of the therapy and asking him
to read it,
 explaining that the therapy takes time and effort.
Adamczyk’s experience shows that 50% of potential patients did not come
to the second appointment and others typically did not make the effort to read
the description of the method. The latter were asked to read it. However, very
few of them would return. Those who would were then invited to begin
therapy.
The Method of Performing Tasks
Motivation can be tested by asking a person to do tasks which are

seemingly irrelevant to the stuttering. Since therapy is often based on physical
training, the PWS should be asked to do exercises, swim or jog. Only after
these tasks are done one can begin the therapy of stuttering.
The Method of Reward and Punishment
Frequently used in the process of motivation, punishment which is defined

as the consequences of one’s own actions is considered controversial. A
speech pathologist seeks to reward the patient, yet is not afraid of punishing as
well. And a fearful therapist is in need of therapy herself.
The Method of Editing
It consists of treating stuttering as a psychosomatic disease and not as a

speech defect or a speech fluency disorder. This change in classification has a
large significance as a disease is treated more seriously than a disorder or a
defect. Furthermore, treatment is more highly valued than correction,
rehabilitation or stimulation.
The Method of Encouraging to Fight
A person who accepts his stuttering is encouraged to demonstrate his

disfluency in difficult social situations. If he resists, we analyse the reasons
and propose that he adopts the attitude of a fighter.
The Method of Motivation by Fear
While a doctor is not afraid of accusing the parents of neglecting their ill
child, a speech pathologist and a psychologist are willing to make excuses for
parents who delay therapy for early childhood stuttering. However, they can
copy a doctor’s approach and hold the parents responsible for the development
of pathological disfluency and its consequences. In such cases, motivation by
fear is a negative tool that can be effectively used to reap positive benefits for
the patient.
The Method of Calculating the Cost of Therapy
The therapeutic process exerts burdens or costs on the patient and his
family in many ways. Thus, it is important for sake of motivational processes
that these burdens are assessed and made sure to be at a level that they are able
to cope with as a family unit. This is why the potential financial, psychological
and time-related costs should be explained to the patient and his family. These
costs are expected to be higher at the beginning of the therapy and decrease
with time.
The Method of Assessing Therapy Effects
The effects of therapy should be registered during each session and

presented to the patient. The refer not only to improvement in speech fluency,
but also to decreasing fear and tension, as well as increasing the person’s
readiness to communicate. Many PWS tend to ignore or marginalise the
effects of therapy. Thus, the more difficult it is to notice the effects, the more
they should be highlighted to the patient.
6. Therapeutic Methods
Speech Fluency Training
The numerous techniques aimed at improving speech fluency can be

classified as:
 Natural, or
 Unnatural.
Natural speech is characterised by speaking at a person’s natural pace,

rhythm and fluency during both stuttering and fluent speech. To help a patient
achieve more fluent stuttering is a method whose goal is to make a person
retain his or her disfluent speech as their inherent feature and to change tense
disfluency into a non-tense one. The method of fluent speech assumes that
fluency, which clearly dominates over disfluency, is a natural form of the
patient’s speech as it is assumed that the PWS is potentially fluent and his
fluency needs to be brought out.
Unnatural methods propose unnatural forms of speaking such as: 1)
prolonging, 2) singing, 3) rhythmicising, and 4) chanting. They damage the
prosodic structure of an utterance and slow down its pace. This results in an
exaggerated focus on the act of speech and makes thinking difficult. In sum,
the method of smooth but unnatural speech proves difficult for both the
speaker and the listener.
Examples of methods of natural and unnatural speaking during a stuttering
therapy:
Engiel’s Method
The aim and formula of this method is to produce proper speech and it
includes the following exercises:
 To begin speaking while focused on eliminating ‘stuttering at the

beginning of speech’,
 To speak while focused on eliminating ‘stuttering in the course of
speech’.
Exercises for Speech Opening
‘Version 1 (which makes use of leading movements of both hands).

The starting position: Put your hands and palms together in front of the
body (as if you wanted to pray). Move your hands apart and outwards (moving
your forearms only while your upper arms remain close to your body) and
breathe in with your mouth. The breathing should be easy, free and normal.
When both hands are stretched to the width of the body, stop breathing for a
while, do not move your phonatory or articulatory muscles and keep your
mouth open like when you were breathing in. When you start moving your
hands slowly back towards the body, begin your speech i.e., synchronise the
actions of breathing out, phonating and articulating while starting your speech.
Pronounce a simple 2 to 3-word sentence while putting your hands slowly

back together. The final word is stressed and pronounced exactly when the
hands are back together. Repeat the procedure several times.
Exhalation during the speech should be longer than inhalation, which
needs to be highlighted by slowing down the hand movement.
It is worth noting that this exercise regulates not only the beginning of
speech but also, to some extent, the course of speech as the hand movement
fluently ‘leads’ speech towards the final stress.
If this simple exercise is done precisely, no form of stuttering will appear.
Version 2: A small rubber bulb (size 2) is used for help. The starting
position: put your left hand close to your lower left ribs and stomach. Place the
rubber bulb in the right hand and press it with your fingers. The left-handed
should reverse the sides. Begin the exercise with no air in your lungs or in the
bulb. Release the pressure from the bulb slowly and let air get into the bulb
and into your lungs as well (control it with your left hand). When the bulb is
filled with the air, stop breathing. Say a sentence fluently while breathing out
and while pressing the bulb with your fingers. Repeat the procedure several
times.
This version of the exercise helps to make the free and natural pre-speech
inhalation automatic. Since, at first sight, this exercise seems more difficult
than the previous one, it is introduced as a way of improving the already
mastered skill of beginning speech.
Version 3 (move your thumb and index finger to imitate hand movements
from version 1 of the exercise). This ‘mini method’ is an emergency help in a
number of situations in which the stuttering patient is afraid of speaking.
Having described the exercises for speech opening, I would like to
highlight that their effectiveness depends on the precision of the ‘leading
movements’ (which represent the course of natural speech) and on the
precision of combining them with movements of speaking. If practised
regularly, the training leads to considerable improvement (disappearance of
severe stuttering) very quickly (after 2-4 weeks). Nevertheless, the training
should be performed towards the end of the course, at least in version 2, in
order to entrench the habits’ (Engiel, 1977, p. 84).
Exercises in the Middle of Speaking
‘I introduce exercises in the middle of speaking only after my patients

have overcome problems at the beginning of speaking.
In this case, a pendular movement of the right forearm is the leading one.
This rhythmical and fluent hand movement controls the speech which
accompanies it. The starting position: bend your right arm at the elbow and
rest your hand on an object (e.g., on your other fist or on a table). Raise your
forearm upwards. After inhaling (which by now has become coordinated with
speech) the patient starts to speak and ‘conducts’ with his hand by drawing
semicircles in the air. The hand falls down quickly while moving from the
right to the left and then moves upwards slowly. One rhythmical group is
pronounced steadily during this movement and the final accent occurs when
the hand slowly approaches the top left-hand-side position, marked as the
starting position. When moving back in the same way, the hand controls
another rhythmical group, whose final accent is, again, made when the hand is
up. The movement is repeated until the patient runs out of sentences.’ (Engiel,
1977, p. 71)
Wilczewski’s Method
The method of sound prolongation is an example of unnatural speaking in

which ‘each meeting begins with a child or adult PWS singing a verse of some
song which he knows. Then the patient says the verse again several times and
prolongs each vowel. The exercises should be done in front of a mirror for
some time. Later on, the patient can continue without supervision.’
(Wilczewski, 1967, p. 106).
During the exercises that follow, the therapist chooses words which begin
with consonants and the patient prolongs the vowels located after them in the
word with his mouth wide open to reduce lip tension. Vocal fold tension is
reduced because of the use of undertone and aspiration (hA). Even mere vowel
prolongation automatically regulates breathing. A technique of dialogue and
monologue prolongation is used to connect speech and thinking. The patient’s
tempo of speech increases gradually until it reaches a natural level.
This therapy demands a full commitment from everybody involved, so
children and parents do not go to school or work on the days when the therapy
is scheduled. The whole family participates in the therapy, learns to prolong
vowels and does so when talking to the PWS.
Adamczyk’s Method
The ‘Echo’ method was created by Adamczyk (1959), who was the first to
use Lee’s effect in therapy of PWS. It is common knowledge that Lee was
fluent when speaking to himself and his disfluency significantly lowered when
he spoke with other people, even if these were PWS. A group of PWS tend to
speak fluently among themselves. In addition, stuttering significantly
decreases or disappears during chorus speaking where echo or reverberation is
used. Hence, this phenomenon has become the idea behind the ‘echo’ method
of therapy of stuttering.
This method consists of three exercises:
1. In emotionally artificial conditions (e.g., in a surgery),

2. In emotionally friendly conditions (e.g., at home) while imitating echo
speaking (with echo remembered) and without an echo corrector,
3. In emotionally difficult conditions (e.g., frequent in-class speaking
tasks) without the help of echo but while imitating echo speaking.
Improvement of the echo-method is about determining the optimal echo

delay (0.1 second) and the optimal reverberation time (1 second). In such
conditions, stuttering decreases considerably and the tempo of speech becomes
similar to that of natural speech. As a result, experiencing success in public
speaking is the most natural form of psychotherapy.
Breathing
Breathing can be:
 automatic or controlled,
 mechanical or spiritualised
Breathing is an automatic activity which forms the basis of our existence.

Breathing is subconscious during speaking. A normal breath is easy, light,
calm, and pleasant and it makes fluent speech happen naturally.
If breathing is monitored, it becomes controlled. All breathing exercises
performed consciously is an attempt at intervention. Thus, breathing exercises
should be done with great care so as not to damage the natural automatism of
the process. The tendency is to make controlled breathing become an
automatic one, or, in other words, to develop the habit of conscious and
appropriate breathing. Many methods which have the same goal also have the
same limitations i.e., breathing is not accompanied by speaking. A PWS who
practises yoga will still speak disfluently because breathing exercises are not
related to utterances.
Breathing makes use of chest and stomach movements. If done calmly,
one breath pumps about 0.5 litre of air to lungs. However, the use of air
increases by 8 to 10 times during physical effort. The human body uses the
following patterns of breathing: chest (rib), stomach (diaphragm) and chest-
stomach. Chest breathing is thought to be too shallow and stomach breathing,
which is easier to do while we are silent than while we are speaking, is
recommended instead. Our breath becomes shallower, especially when we
speak in a stressful situation. Stomach breathing is not a prerequisite of fluent
speech, but it helps by calming down a person’s mind, reducing tension and
apprehension.
Lowen claimed that breathing is not mechanical but that it is a sign of the
spirituality of the body:
‘Breathing is linked directly to the excitement of the body. If we are
relaxed and calm, we breathe slowly and freely. However, it becomes fast and
intensive when we are excited. Our breathing is rapid and we often hold our
breath when we are afraid. When we feel tension, our breath is shallow. The
contrary may also be true. Deeper breath calms down the body. (… ) To
breathe deeply means to feel deeply. If we don’t breathe deeply, we suppress
sadness and regret because our stomach cries deeply. (… ) If we hold our
thoughts and feelings, we also hold our breath’ (Lowen, 1991, p. 44 and
further).
Lowen proceeds to explain that breathing disorders are characterised by
stiff and rather immobile chest as well as symptoms of hyperventilation
(tingling, stinging) which occur because our breathing is deeper than we are
used to. Breathing through the mouth is observed in moments of strong
excitement. Breathing improves when we reduce muscle tension in chest,
stomach and intercostal muscles. Bioenergetic analysis is one of the ways to
achieve deeper breaths (Lowen, 1991).
If a PWS’ breathing is shallow, we discuss it and are not affected by his
problems or refer to his emotions. The easiest technique is to allow breathing
to regulate itself by just sitting or lying down in a comfortable position,
closing the eyes, opening the mouth a little and just doing nothing. It is enough
to just wait until our breathing finds its natural rhythm. We may listen to the
heartbeat and with time, it will become slower just when breathing becomes
deeper. After several minutes, we will see that our chest widens and the
abdominal muscles stretch, which is a result of reduced muscle tension. We
may feel drowsy and relaxed and the more we feel so, the easier it will be for
us to get rid of negative thoughts and to focus on something pleasant. This
exercise can be continued in the Active Rest position or using other techniques
by Alexander (Kędzior, 1993).
Phonation
Mitrinowicz (1952) claims that doing breathing exercises is not enough

and that voice and articulation exercises should be included as well. She
developed the vocal method which utilizes appoggio. Two types of such
breathing have been identified:
‘1. The diaphragm stops in the breathing-in phase while the chest breathes
out (…). After 8-10 seconds the diaphragm slowly moves upwards and starts
working along with the respiratory muscles in the chest. This is called
appoggio.
2. The other type of support is when the chest adopts the breathing-in
position during sound emission and the diaphragm slowly moves upwards i.e.,
performs the breathing-out. This is supported by the chest, also known as a
chest support.’ (Mitrinowicz, 1952, p. 73)
In the vocal method, it is important to learn the soft voice attack. PWS
usually display hard voice attack because they tend to keep their vocal folds
too tense. Although this tension is reduced while whispering, in such a
context, it is equally as artificial as blowing onto things with warm air.
Excessive subglottal tension can be reduced by releasing small amounts of air
at the beginning of an utterance.
It is a common truth that the voice helps one express oneself and one’s
emotions. Although PWS often speak too quietly to conceal their disfluency,
this causes others to perceive them as being shy, fearful and weak. Therefore,
PWS should speak louder to be perceived as self-confident and try to shout out
emotions and anxieties that have been suppressed. To this end, throat muscles
can be activated by producing a moan while breathing.
Muscle Tension Reduction
The primary goal of the therapy is to reduce muscle tension, which blocks
the energy flow (Lowen, 1991) and hinders natural breathing, phonation,
phonation, articulation and spontaneous speech. The causes of the tension can
be located in:
 one’s physical body,

 one’s personality,
 one’s relationships.
The physiological causes of stuttering have already been discussed so now

the focus will be on tension in one’s personality as well as interpersonal
relationships. A PWS may feel tense because he may be expecting speech
disfluency, unresolved inner conflicts (e.g., to speak or not to speak) or
unfulfilled needs (e.g., that of safety and self-fulfilment). Relationships with
parents, siblings and other house tenants is also a source of tension which a
PWS experiences irrespective of his age. A tense mother transfers her tension
onto her child and chronic stress makes the tension become fixed.
Improvements in speech fluency might be difficult to achieve unless the cause
of tension and the ways to reduce it are identified. Grochmal (1986, p.196 )
names the following factors which help reduce tension:
‘I. Biochemical factors

1. Passive
a. Head, body and limb position
b. Body and topical massage
c. Exteroceptive stimulation
d. Proprioceptive stimulation
2. Active
a. Music and rhythm exercises
b. Resistance training
II. Physical factors

1. Warmth
a. Hydrotherapy (baths, compresses)
b. Paraffin compresses
c. Thermal treatments with light energy
d. Thermal treatments with electric energy
2. Cold
a. Ice
b. Cold water
III. Chemical factors

1. Drugs
a. Relaxants
b. Anxiolytics
2. Topical substances
a. Use of alcohol
b. Use of phenols
c. Procaine infiltration
IV. Relaxation training

1. Schultz’s Autogenic Training
2. Jacobson’s Progressive Relaxation Training
Manual therapy (Peninou, Tixa, 2012) and Wintrebert’s relaxation

techniques (Tarkowski, 1992) are also recommended. Tension can also be
reduced through crying, shouting, eating and having sex.
Gestures
Gestures accompany words and occur in a rhythmical manner. However,

this natural form of communication is disrupted by stuttering when facial
expressions and gestures often disappear, speech and body movements are
asynchronic, and speaking is stimulated by synkineses. These problems can be
overcome using the method of rhythmical gestures, which was described by
Bochniarz (1985) in the following way:
‘If a patient is able to follow the beats of a metronome, I check if he is
able to produce his utterance in a similar way and tap out the rhythm. (…)
I begin speech rhythmisation training by introducing simple hand gestures
(right hand for right-handed patients) which are synchronous with a word
pronounced. At the beginning, a single word becomes the basic single unit and
a patient does rhythmical gestures (clapping hands and laps) according to it.
(…). I use a poem of appropriate complexity to teach my patient how to do

gestures (…) and encourage him to do this training at home (…)
My patient and me use rhythmical gestures to read a random dialogue (…)
and then I ask him to practise at home using other types of utterances e.g.,
quarrel or outrage, while keeping its specific form in mind. (…) Movement
(gesture) can minimally precede the utterance. However, the utterance should
never precede movement. (...)
I also pay attention to the natural character, diversity and
multidimensional character of gestures as well as facial expression, body
movement and intonation.’ (Bochniarz, 1985, p. 83–85)
Therapy should also attempt to replace the involuntary synkineses with
different gestures. However, a PWS needs to be excited about this change.
Otherwise, these will only be movements which have little to do with verbal
expression.
Releasing Emotions
Releasing suppressed emotions (apprehension, anger, aggression, guilt) is

particularly important in the treatment of stuttering and is achieved through
therapies based on emotional release (Aleksandrowicz, 1996). Their aim is to
relieve the excitement to a degree where emotions can be controlled. The
exercises include:
 doing turning kicks,

 stretching arms to reach things,
 spreading lips,
 kicking a bed,
 pounding fists,
 fits of fury,
 twisting a towel.
A sample exercise aimed at expressing anger is as follows:

‘Stand with your feet next to each other and spread them so they are about
45 cm apart and then bend your knees slightly. Clench your fists and put your
hands above your head. Lean your elbows backwards as far as you possibly
can.
Relax yourself and start hitting the bed with both fists. Do not force
yourself to do anything. Say words which express anger, such as ‘I don’t want
it!’, ‘Leave me alone!’, ‘Go to hell!’, ‘I hate you!’ etc. You can also use a
tennis racket instead of fists.’ (Santorski, 1991, p. 138).
Coping with Stress
Stress is an inherent part of human life. There are different types of stress
and different styles of coping with it. Stress is bad if it is chronic, forced or
hard to control and it is harmful to our well-being. However, stress can be
good if it is temporary, motivating, controllable, accepted by the patient and
improves well-being. Although numerous styles of coping with stress have
been identified, the task-oriented and flexible ones are considered to be most
effective. Basically, they are similar in terms of the low level of emotionality,
attention and avoidance. Mastering these styles is very important due to the
fact that chronic stress may lead to impairment or dysfunction of a PWS’
speech apparatus (Lechta, 2004).
The parents and teachers of CWS (Children Who Stutter) are sometimes
advised to implement stress-free upbringing instead of teaching their children
how to cope with stress. Exempting a child from doing speaking exercises in a
kindergarten or at school as suggested by logopaedic or psychological advice
centres is an example of such ‘tolerant’ approach. However, this turns
stuttering into a specific selective mutism as the CWS does not need to worry
about being asked in class (whereas other less ambitious students would be
considered unprepared in a similar situation). Although there are obvious
benefits to stuttering, there is also a serious loss as the CWS is unable to speak
in public.
Stuttering drama takes place in school which is a natural context for
therapy. Students can be introduced to it by following the eight steps below:
1) Choose a lesson which causes moderate level of stress according to

the Questionnaire of Speech Disfluency and Logophobia (see
appendix).
2) Learn to relax with a technique which is adjusted to your (i.e., CWS’)
needs and abilities.
3) Learn to desensitise yourself by replacing reactions of fear with
reactions of relaxation.
4) Introduce a speech fluency improving technique which is adjusted to

your abilities.
5) Use psychodrama or drama to present a lesson iin which you
volunteer to answer questions and try to speak fluently.
6) Assess your abilities to cope with communicative stress in a
therapist’s office.
7) Try to volunteer to answer questions during a lesson with a therapist
sitting nearby.
8) Volunteer to answer questions in a lesson when the therapist is not
around and inform her (e.g., over a phone) later on about the effects
achieved.
Stuttering therapy performed in a kindergarten or at school should result

in teaching a CWS how to cope with stress which he experiences while he is
there. It is a good opportunity to transpose and test the effects of a therapy in
natural communicative situations which occur in educational and nursery
institutions.
Hart (1992) names the following basic methods of making children (and
CWS) resistant to stress:
 Having enough sleep,

 Keeping physically fit,
 Relaxation,
 Raising one’s self-esteem,
 ‘Vaccination against stress’ i.e., gradually exposing a child to
problems, filtering stressors and refraining oneself from the habit of
helping the child.
A therapy in which a child is exposed to controllable stress may produce

better results than a one without any stress.
Improving Self-Esteem
There are different opinions about the relationship between stuttering and
self-esteem. Some people claim that the experiences of pathological speech
disfluency have a negative impact on self-image. This is the reason why
improving self-esteem is a fundamental part of therapy for PWS (Fraser,
1993). However, researchers, who have proven the absence of a direct
relationship between stuttering and self-image, have offered polemical

opinions (Tarkowski, 2010) and claim that the two are autonomous structures
which may overlap, although they do not have to.
It is unclear how the self-esteem of PWS is influenced by the attitude of
accepting or fighting stuttering, as one may:
 have a high or low self-esteem and accept or reject stuttering,

 have a high or low self-esteem and fight or not fight against stuttering.
Since it is debatable which strategy offers better results, the choice should
depend on the therapeutic contract. One may assume that the acceptance of
stuttering often lowers a PWS’ self-esteem, while the attitude of fighting raises
it as the very fact of deciding to fight against it improves one’s self-image.
Although each authentic therapy leads to an improvement in self-image
and self-confidence, the effects depend on a number of factors and not only on
the type of disorder. There is no single ready-made method that would
improve the self-esteem of PWS (Volkova, 2007). Unless the psychosocial
factors of stuttering are modified, removing speech disfluency will not
improve self-image automatically, which is mainly about increasing self-
confidence and developing positive thinking. These goals are easier to achieve
when one goes beyond the borders of a therapeutic process and tries to
succeed in everyday life. If a shy stuttering teenage boy or man signs up for
therapy, we may ask him if he is single or not. If he is, the aim of the therapy
will be to improve speech fluency so that he can find a partner. Although very
few patients choose to take advantage of such an opportunity, success in this
area will improve self-esteem. After all, therapy should serve the needs of
daily life and cannot be a goal on its own.
Psychodrama or Drama Role-Play
Psychodrama and drama are used in different stages of PWS therapy and
the basic technique utilizes role-playing during individual or group meetings.
Role-playing is more restricted when roles are assigned and patients present
everyday scenes (e.g., a PWS at home, at school, at work or at a shop).
Improvisation is freer and bolder. Learning a role means repeating it until one
becomes fluent. Changing roles helps one understand the behaviour of another
person. It is advisable to introduce conflict into the play to stimulate the
development of feelings and imagination. Spontaneity training is important,

particularly for PWS who control themselves too much.
Aichinger and Holl (1999) presented the following lesson plan which uses
psychodrama in group therapy for children:
1. The initial phase (warming-up, deciding on the topic, agreeing on the

roles, preparing the scene),
2. The play phase (introducing the mood of fun and working on its
structure, instructors’ role models, the mirror technique, monologue,
understudying and look-alikes, interpretations),
3. The final phase (rounding up the task, stepping out of the roles,
summary, consideration).
Drama is used in PWS therapy to transpose the effects observed in a

surgery to everyday situations by acting out characteristic scenes which one
associates with communicative stress.
Placebo Effect
As Siwak-Kobayashi (2000) states, using a placebo is about using a

biologically neutral substance (e.g., water injection, sugar pills) or sham
procedures (e.g., sham surgery or procedure) to achieve a therapeutic effect
(e.g., relief, reduced pain, suffering or fear). Not long ago vast majority of
drugs were based on the placebo effect. The placebo is a ‘blessing’ (Siwak-
Kobayashi, 2000, p. 113) because ‘it constitutes 55% of the success of many,
if not all, therapeutic procedures’ (Rossi, 1995, p. 32).
The placebo effect can be achieved by selecting ‘herbs for stuttering’
which may reduce muscle tension or tranquilise. They are certainly not
harmful. Although herbs are available in herbal shops or in pharmacies,
purchasing them is too simple an activity to trigger the placebo effect. If the
effect is to be achieved, an appropriate atmosphere needs to be created by a
credible and trustworthy therapist. First, she needs to plant hope in the patient
that herbs which cure stuttering exist, but they need to be prepared or imported
and that takes time. As it is commonly known, people attribute particular value
to the inaccessible. Obviously, it is the therapist who buys, mixes and brings
the herbs to the patient without providing herb names (for mystery strengthens
the placebo effect). However, she tries to make the preparation and serving
seem complicated, e.g., by providing a particular time of the day when the
patient should take the mixture. Some healers go even further and order the
patient to set up a small field where the herbs need to be grown. All of this
done in an effort to raise motivation, determination, and, consequently, the
placebo effect. The effect will happen only if the PWS and his family believe
in the therapeutic power of herbs. It should be remembered, though, that
herbal medicine can only support speech training and does not replace it.
Another way to achieve the placebo effect is to apply acupressure, i.e.,
stimulating points on the body through topical massage. It is the oldest and the
most common therapeutic method which has been developed by the Chinese
(Bahr, 1988). In the case of stuttering, it is advised to massage points which
are responsible for relaxation and are located:
 in a tiny hollow between the lower lip and the chin,

 in a tiny hollow in the middle of the skull,
 on the surface of the forearm, in a row with the little finger,
 on the shin, near the knee,
 in the hollow of the ear and on the auricle.
Apart from the more traditional use, acupressure can also help achieve the
placebo effect and is particularly useful when talking to a PWS’ parents or
grandparents who doubt traditional medicine and trust healers. In such a case,
the number of appointments needs to be doubled as both parents and
grandparents need to be taught acupressure. In this way, they will feel that
they are participating actively in the therapy and will attribute positive
outcomes largely to acupressure. Of course, acupressure can be combined with
speech fluency training.
Learning to Solve Problems
According to Tarkowski (2007), PWS or their parents need to be taught

how to solve problems, and this process has several stages:
Stage 1: Noticing the Problem

Revealing the problem is often a problem in itself and this can be done by
asking appropriate questions or asking the patient to complete open-ended
sentences (Nęcki, 1994). Stuttering-related problems are usually discovered
too late and often underestimated. Moreover, real problems are not
distinguished from the ostensible ones.
Stage 2: Negotiating
A problem may be perceived differently by different people, in which case
negotiations among participants of the problematic situation are necessary.
This usually happens among parents who react differently to their child’s
stuttering. Sometimes stuttering is a problem for the mother and not for the
father. Cooperation with the therapist is ineffective and contradictory until
they can agree on a common approach.
Stage 3: Defining
Is the problem about stuttering as such or rather about its consequences?
Can a PWS be helped against his will or social support? If the problem is
defined wrongly, further therapy will only proceed in an unsuitable direction.
Stage 4: Seeking Solutions

At this stage, ideas on how to solve the problem are developed. Creative
thinking can be induced by brainstorming. All real and acceptable ideas need
to be noted down and then the best one should be selected. In case some
problems occur during the therapy, one may refer to the list and replace one
idea with another.
Stage 5: Assessment
The usefulness of ideas is assessed with the ‘questions to an expert’ or
‘lock’ techniques (Nęcki, 1994).
Stage 6: Implementation
The implementation of solutions to the problem requires the skills of
motivating people, managing time well and overcoming obstacles. It is also
important for both the therapist and the patient to have positive attitudes.
The process of PWS therapy requires creative thinking and effective
actions.
My Approach to PWS Therapy

I am convinced that PWS therapy is still more of an art which does not
have solid scientific basis and is developed in the process of accumulation
rather than elimination. New theories and methods co-exist with the old ones;
they do not replace them. Dividing the methods into the modern ones and the
dated ones is not scientifically based and sometimes results from the rules of
marketing and advertising. Each method deserves serious treatment as long as
it is effective and not harmful to the patient. Fortunately, tongue amputations

are no longer conducted and the tongue is no longer considered to be the cause
of stuttering. However, we may still follow Demosthenes, who changed his
environment to improve speech fluency by reducing communicative stress.
When the history of stuttering therapy in different parts of the world is written
down, many effective, though long forgotten or not popularised methods, will
be discovered.
I do not think there is one common method of treating PWS as there are
numerous forms of the disorder which are very much different from one
another. The condition of stuttering in every patient has its own individual
character and research on the effectiveness of stuttering therapy shows that
there is no single method which would be better than others. The scientific
status of all of them is still relatively low. In this case it is unjustified to
recommend one therapy and reject another. For what is a method of stuttering
therapy? It is merely a hypothesis that a positive change will be observed in
the patient after implementing a given method. Such an assumption needs to
be verified and in case no results are observed, one should select another
method instead of continuing with the unsuccessful one. It is not an easy thing
to do as it requires flexible thinking and action, whereas we usually get
accustomed to conventional solutions.
I try to adjust the therapeutic methods and techniques to the needs of a
particular PWS instead of forcing the person to a pre-agreed therapeutic
procedure. I prefer to conduct a systemic therapy aimed at solving an
individual problem that occurs when there is an obstacle on the way to
accomplishing the patient’s goals.
Stuttering in itself is not a problem as it neither causes physical pain, nor
is a threat to one’s life or well-being, so one can live with it one way or
another. However, it becomes a problem when it hinders the achievement of
goals which are important for the patient. The solution seems fairly easy:
remove the obstacle (i.e., stuttering) or change the goal (e.g., accept the
disfluency). It is easier, though, to change the goal than to remove the
obstacles (Tarkowski, 2002). When I hear an opinion that stuttering is
basically not a problem, I try to prove that, in fact, it is. If I describe the
unaccomplished goals in a certain way, stuttering will become an obstacle.
I regard therapeutic methods as hypotheses that need to be verified.
Verification is done in the course of a natural experiment free from scientific
requirements and takes place between a PWS and his therapist. It combines
speech, emotions and movement, so it basically changes a therapeutic
conversation into an action (Zinker, 1991).
From the methods and techniques presented above, I will choose the ones
that are most likely to solve the PWS’ problem and are adjusted to his
individual needs and abilities. Therefore, I do not recommend rhythmicising if
a person does not have a sense of rhythm. I do not offer prolongation methods
if the person can only perform it in the therapist’s office. I do not go for
psychotherapy if a patient refuses to participate in it. Neither do I advise the
patient to accept stuttering if he is not willing to do so. I look for a method
which is suitable for a given patient and do not hold on strictly to any specific
programme. I try to be flexible and creative.
I focus on the four basic elements of stuttering: 1. Speech disfluency, 2.
Muscle tension, 3. Emotions, and 4. Communicative skills. Depending on the
problem diagnosed, I use either all of them simultaneously, or gradually, one
at a time. In my therapeutic procedures, I usually begin with reducing muscle
tension and logophobia, and hope it will improve speech fluency and the
readiness to communicate. However, a completely different strategy is also
possible. The choice of appropriate methods and the order in which they are
utilised is determined by the result of the experiment.
I regard the social support of PWS who join a therapy as extremely
important, and I particularly care about the participation of the fathers. I
protest when people suggest that parents are the best therapists of their own
children. Let’s leave therapy to the therapists and allow parents to be parents.
To end with, here is an example of a systemic therapy of a 4-year-old girl
who was diagnosed with articulatory (clonic) stuttering, muscle tension in the
face, lips and tongue, with mild synkineses, although without logophobia or
awareness of a speech disorder:
Set a 2-week period of relative silence so as not to reveal speech
disfluency.
1) The parents took two weeks off and went to a village for the duration.
They limited verbal communication with the child to the minimum
and did their best to let the girl sleep a lot. Only non-verbal forms of
playing were acceptable.
2) Intervened whenever multiple sounds or syllable repetition occurred
in order to prevent the habit of speaking disfluently from becoming
ingrained. When the girl was unable to say some blocked word, the
parents were supposed to say it for her and say ‘Continue’.
3) Used herbal medicine and relaxation to reduce muscle tension. The
speech pathologist prepared herbs for stuttering based on the
prescription of a Polish monk, O. Klimuszko. Parents were supposed
to give the herbs to the girl and additionally engage in relaxation as

recommended by Wintrebert.
4) Changed parents’ reaction to speech disfluency to reduce family
tensions. The parents completed the Reaction to Speech Disfluency
Scale, which revealed significant differences between the mother and
the father. Changing the parents’ reactions became the leading topic
of appointments with the speech pathologist.
The therapy was given up after 5 months because the family moved to
another city. However, when talking to the therapist over the phone, the
parents admitted that the child’s speech had improved and that stuttering had
not relapsed.
7. Indicators of Therapy Effectiveness

The effectiveness of therapy is determined by its aims. The basic list of
aims and indicators of effectiveness is presented below.
Aim:
 Improved speech fluency
Indicators:
 Reduced severity of speech disfluency,
 Change of type of speech disfluency,
 Change of type of disfluency symptoms.
Aim:
 Change of reactions to speech disfluency,
Indicators:
 Change of cognitive reactions,
 Change of emotional reactions,
 Change of behavioural reactions.
Aim:
 Better somatic functioning
Indicators:
 Reduced muscle tension,
 Removal of synkineses and neurovegetative symptoms,
 Improved breathing, phonation, articulation and coordination of them.
Aim:
 Improve the ability to communicate
Indicators:
 Increased readiness to communicate,
 Increased communicative input,
 Better ability to put oneself forward,
 Change of the communicative style.
From the systemic perspective, indicators of therapy effectiveness are

linked to one another. Significant reduction of speech disfluency, which does
not happen without reducing muscle tension or fear and increasing
communicative skills, is the most essential parameter. If stuttering relapses,
the longer the periods of fluent speech, the better is the prognosis for the
patient. The age of PWS should also be taken into account when evaluating the
results of therapy as they are most successful among pre-schoolers. However,
differentiating natural speech disfluency from stuttering is difficult then as a
developmental phenomenon whereby stuttering disappears with age can be
mistaken as an effect of therapy. Because of this, the results of therapy
conducted among older school children or adults are more reliable, although
the consequences of natural recovery should also be considered even in those
cases.
Relatively scarce research on the effectiveness of PWS therapy has been
conducted and it has been discussed in several reviews (Thomas, Howell,
2001; Finn, 2003; Bothe, Davidow, Bramlett, Ingham, 2006; Nippold, 2011;
Humeniuk, Tarkowski, 2016). It appears that, although not spectacular, the
effectiveness is satisfactory and comparable to the effectiveness of
psychotherapy (Rakowska, 2005). In short, a third of patients observed
significant improvement, a third observed some improvement, while others did
not see any change at all. The earlier therapy is started, the better is its
effectiveness, and the best results are observed in the therapy for early
childhood stuttering.
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Neurology).
Tarkowski Z. (2001), Jąkanie. Warszawa: Wydawnictwo Naukowe PWN
(Stuttering. Warsaw: Wydawnictwo Naukowe PWN).
Tarkowski Z. (2007), Psychosomatyka jąkania. Dlaczego osoby jąkające się
mówią płynnie? Lublin: Wydaw. Fund.“Orator” (The Psychosomatics of
Stuttering. Why Do Stutterers Speak Fluently? Lublin: “Orator”

Foundation Publishing).
Tarkowski Z. (2010), Assessment and self-assesment of stuttering and self-
image. Olszytyn: University of Warmia and Mazury Publishing House.
Thomas C., Howell P. (2001), Assessing Efficacy of Stuttering Treatments. J.
Fluency Disord., 26(4): 311–333.
Wilczewski S. (1967), Teoretyczne założenia i metoda usuwania
jąkania.”Logopedia,” 7: 105–112 (Theoretical Basis and Method of
Removing Stuttering. Logopaedics).
Vołkova Ł. (ed.) (2007), Naruszenie tempa i ritma reczi. Zaikanie. Bradylalia.
Tachylalia. Moskwa: Vłados.
Zinker J. (1991): Proces twórczy w terapii Gestalt. Warszawa: Jacek Santorski
& CO Agencja Wydawnicza (The Creative Process in Gestalt Therapy.
Warsaw: Jacek Santorski & CO Publishing Agency).
Chapter 4
Pharmacological Basis for

Therapy of People Who Stutter –
Past, Present and Future
Dariusz Pawlak and Tomasz Kamiński
Department of Pharmacodynamics
Medical University of Białystok, Poland
Abstract
Information about nearly 70 million people all over the world
suffering from speech fluency disorders, including stuttering, is enough to
make one aware of how common the problem is (Carlson, 2013). From a
pharmacologist’s perspective, it is interesting to know whether
pharmacological therapy could be effective in the case. One cannot
remain indifferent to such a global problem, especially since it concerns
mainly children, who should be given special care from doctors,
pharmacists and everyone involved in their upbringing and shaping of
future generations. In view of the above, it is surprising that, in spite of
rapid developments, the treatment of stuttering is confined to
psychological and speech therapies.
124 Dariusz Pawlak and Tomasz Kamiński
1. Introduction
So far, pharmacological solutions aimed at eliminating stuttering are only
hypothetical and theoretical, as their use is limited to tests and experiments. In
2015, despite a number of promising projects, we still do not yet have a
medicinal substance approved by FDA (Food and Drug Administration) as a
treatment for stuttering. Given the size and impact of pharmaceutical industry,
it is important to reconsider the status quo and ask the following questions:
Why is it that treating stuttering with a commonly available medicinal
preparation is currently impossible? What is the reason? How is it to be
eliminated? When will a breakthrough occur?
There are many different problems that appear at every stage of research
and development of a medicine from developing the idea of a medicinal
substance to its launch on the market. A brief description of procedures which
lead to the launch of a potential medicinal substance, a panacea for speech
fluency dysfunctions will be based on problems which underlie the current
lack of safe, common and effective pharmacotherapy of stuttering.
Justification of undertaking actions that lead to research initiation –
Social, medical, scientific and economic indications that a given disease entity
and its possible treatment should be investigated are the first step towards
initiating the development of a new medication. The indications are strong in
the case of stuttering and call for the problem to be resolved by finding or
developing a medicine for this disorder. Both the number of potential target
group as well as benefits of developing medical sciences clearly suggest that
research on the pharmacotherapy of stuttering is necessary and current efforts
in this area have not been sufficient. It is most evident in the fact that no safe,
common and effective outline of pharmacotherapy is available to those
diagnosed with this dysfunction. Because of this, the financial outlay on
research is constantly rising and the greater activity of scientists, together with
a growing number of clinical tests being conducted, prove that there is true
willingness to provide proper pharmacotherapy of stuttering. So what is it that
is stopping this enormous machinery which combines industry, science and
medicine?
A thorough understanding of pathomechanisms which underlie a
given disorder or dysfunction – Even ancient Roman war strategies assumed
that one needs to know the enemy and their behaviour to win a battle, and
struggling with human diseases is a battle of a kind as well. From a
pharmacologist’s perspective, a deep and thorough understanding of
Pharmacological Basis for Therapy of People Who Stutter 125
mechanisms of a disease is a key stage which determines the future success of

finding a suitable medicine. Identification of areas where dysfunctions begin,
tracking changes in metabolic and neurological routes, as well as determining
the endogenous and exogenous substances that trigger these changes, enable
one to find the so-called ‘target points’ where a new medicine could work. The
aetiology of stuttering has still not been fully explained. Although, since the
1960s, a number of theories have been proposed to explain stuttering, there is
no unanimity as to its true causes. The latest reports point to the ‘dopamine
theory’ as potential explanation of speech disorders (Stager, Calis et al., 2005).
A shortage or insufficient activity of gamma-aminobutyric acid (GABA) in the
brain structures is another commonly discussed hypothesis (Craig-McQuaide,
Akram et al., 2014). Also, current techniques of brain imaging can identify
structural changes within a PWS’ brain (Salmelin, Schnitzler et al., 1998;
Sommer, Koch et al., 2002). On the other hand, a different approach should be
adopted towards patients whose speech disfluency result from developing
brain tumours or an unexpected injury (Lundgren, Helm-Estabrooks, Klein,
2010). Each of these theories is discussed further in subchapters 2, 3 and 4,
devoted to particular groups of medicines.
To sum up, currently it is impossible to identify the causes and
conditioning of stuttering, which makes it considerably more difficult or even
impossible to implement effective pharmacotherapy of the disorder. And yet,
substantial progress has been made in this field, which may increase the
knowledge of pathogenesis of the disorders discussed.
Chances of developing a medicinal substance of a given scope of
results – Identifying target points of a hypothetical medicine does not mean
that production will begin immediately. Being a highly complex biological
system, the human organism requires a precise and particular chemical setup
of a molecule in order to ensure a proper degree of similarity to target points’
structures. The possibilities of chemical synthesis are extensive, so, while
creating a given molecule is not a problem, making it possess adequate
biological features is a real challenge. A newly created compound needs to be
safe to use, as well as demonstrate appropriate pharmacodynamic,
pharmacokinetic and other features. This is why only a fraction of new
medicinal substances has been launched in the market. Apart from chemical
and pharmacological characteristics, the new substance needs to be stable
enough to be transported and its synthesis and sales need to be justified
financially. From a stuttering patient’s point of view, compounds commonly
regarded as medicines and used to treat other diseases offer the greatest hopes
because of their anti-stuttering properties which have recently, and most often
accidentally, been discovered.
Complex evaluation during clinical trials of a potential drug – If a
pharmaceutical company wants to introduce a new drug, they need to go
through proof-of-concept studies and clinical trials (Umscheid, Margolis et al.,
2011). In a four-stage clinical trial, the influence of the newly developed
substance on human body is evaluated with reference to hundreds of
parameters concerning its effectiveness, safety, interactions with other drugs,
as well as adverse and any unexpected reactions to the potential drug. In the
case of disorders which, to some extent, are conditioned by neurological
changes or have a psychological background, there is an additional difficulty
of the placebo effect which can influence a patient’s condition and,
consequently, change the perception of the disease and its therapy (Zubieta,
Stohler, 2009). It has been proven that symptoms gradually disappear when a
patient is given merely an excipient. The problem of the placebo phenomenon
has not been thoroughly explained. It is often observed in stuttering patients
partly due to the fact that neurological tension and stress trigger stuttering
episodes. Testing and monitoring drug reactions in children and adolescents
are particularly difficult as it is hard to compromise between medicine, ethics
and fundamental moral values. Consequently, despite frequent incidence of
stuttering among young people, this group has practically been excluded from
clinical trials for the potential medicine.
Paramedics’ point of view on the effectiveness of pharmacological
treatment of stuttering – Stuttering is now being researched by speech
therapists, psychologists, occupational therapists and people with similar
education, which offers hope? That a potential medicine to reduce symptoms
of speech disorder will be effective and reliable. Current therapeutic models do
not allow for the combination of a PWS’s own practice and occupational
therapy with pharmacological treatment. Parents of stuttering children may
have similar doubts, which points to the need for a modern education of people
working with a stuttering patient. Also, it should be noted that the direct
effectiveness of a given drug is hard to assess owing to the subject’s
simultaneous participation in therapy. It is widely believed that a different
form of therapy should co-exist in order to ensure, at least theoretically, the
high effectiveness of treatment.
Long-term effects of an innovative therapy for stuttering – The human
organism is an essence of order and inner balance, and as such, it is prone to
anything which can disturb this complex structure. Presumably, any substance
which interferes with the nervous system, neurotransmitters, hormones or
enzymes may lead to unpredictable negative consequences of therapy and it is

highly possible that a drug for stuttering, even when developed, will be of little
use due to the amount and intensity of adverse reactions. Researchers often
marginalise the issue of finding the ‘golden means’ and the right balance
between the expected results and adverse reactions in other parts of the body,
which is particularly evident in the treatment of speech disorders.
The above points to fundamental problems in this situation, as
paradoxically, all branches of medicine are experiencing rapid growth and
progress, while no safe and effective pharmacotherapy is yet available to
PWS.
The subchapters to follow and discuss groups of drugs and individual
substances which may be regarded as potential drugs for PWS, as well as
present a case which exemplifies scientists’ efforts to introduce
pharmacotherapy of stuttering and other speech disorders.
2. History of Pharmacotherapy of PWS
Vitamins and Minerals
Vitamins and minerals are micro- and macroelements which are essential
for life and metabolic processes. They serve a number of biological and
regulatory functions that are vital to practically every organ (Lieberman,
Bruning, 1990). One of the first theories for pathogenesis and therapy of
stuttering among school children was developed as early as in 1951, when Dr.
Hale et al. (1951) published a scientific paper on the influence of vitamin B1
implementation on reducing incidence of disfluency and unwanted pauses and
blocks. The subject of supplementing PWS with vitamin B1 reappeared after
50 years and was investigated by Schwartz et al. (2002). However, their results
did not support the previous study. And yet, PWS and their families are still
convinced of the positive impact of high dose of vitamin B1 (100–500 mg a
day) to reduce the incidence of disfluency-related syndromes, although this
has not yet been scientifically proven. Vitamin B1, also referred to as
thiamine, plays the role of a coenzyme in cellular respiration, performs a
regulatory function in protein and carbohydrate metabolism, and ensures the
proper functioning of the nervous system. Actually, the latter was quoted to
justify the scientifically unproven positive impact of vitamin B1 on patients
with speech disorders. Research results published in 2013 in Fluency and
Fluency Disorders Digest (Brocklehurst, 2013) came as a surprise as they

pointed to thiamine’s role in the biosynthesis of myelin, whose deficiency is
observed in many people with speech disorders, especially PWS. It should be
noted, though, that these are only premises and from a patient’s perspective, a
proper amount of vitamin B1 in the organism is more important than thiamine
supplementation that leads to hypervitaminosis. From a pharmacotherapeutic
point of view, an overdose of vitamin B1 may lead to a high risk of
hypervitaminosis evident in cardiac arhythmia, hyposthenia, sweating, and
death in extreme cases. However, this pertains only to intravenous
supplementation, as the absorption of vitamin B1 supplemented orally is
stopped automatically) (Lychko, Pentiuk, Lutsiuk, 1988). These observations
are similar in the case of another vitamin B called pyridoxine (vitamin B6),
which, as laymen believe, improves life quality and reduces the number of
syndromes of stuttering in PWS. The theory is based on research in which
Malouf et al. (2003) tested the impact of vitamin B6 on thinking processes.
However, there is no evidence of such therapy being successful. Vitamin C is
another vitamin believed to facilitate therapy of speech fluency disorders. It is
a strong antioxidant which is indispensable for collagen biosynthesis,
corticosteroids synthesis and iron assimilation. Vitamin C influences a number
of areas within the human body and despite many patients’ belief in its
therapeutic properties, its effectiveness has not been experimentally proven.
As evident in immediate improvement of speech fluency after supplementing
with a vitamin solution, the placebo effect appears to be important in a vitamin
‘therapy’ of stuttering since, in practice, the solution or suspension, did not
release a slightest amount of vitamin.
Research on minerals and their role in the development of speech
apparatus dysfunctions has been conducted for more than 60 years. In 1992
Pruszewicz et al. (1992), it was proven that the concentration of calcium and
magnesium ions in patients with speech fluency disorders is lower than
average. Schleier et al. (1991) pointed to the fact that the supplementation of
potassium ions stabilises the speech function. Interestingly, no statistically
significant correlations were observed in stuttering patients after
supplementation of the abovementioned elements. Still, it should be noted that
magnesium, calcium and potassium ions are necessary for the processes of
muscle fibres reactivity and maintaining proper function of the nervous and
urinary systems. Deficiency of these elements trigger the development of
stress and neurological disorders (Starobrat-Hermelin, 1998). Scientists
suggest that maintaining proper concentration of minerals is crucial for PWS
as they are part of systems which lead to the development of speech disorders.
Supplementation of mineral ions, just as supplementation of vitamins, should

cover the daily reference value, and avoid accumulation due to potential
adverse reactions. Despite individual relationships between stuttering,
minerals and vitamins, believing in them as a form of therapy of speech
disorder is too far-reaching. Still, their deficiency may intensify the negative
changes to the clinical image.
Pro-cognitive drugs is a group of functionally and structurally diverse
compounds which influence the stimulation of the processes of thinking and
association in the central nervous system, and are mostly prescribed to elderly
people with creeping dementia or consciousness disorders of
neurodegenerative or metabolic origin (Malik, Sangwan et al., 2007). Latest
trends point to an increasingly wider use of these drugs (memantine,
rivastigmine and galantamine) in treating such disease units as dementia
diseases, atherosclerosis, tinnitus, post-traumatic conditions of central nervous
system, and neurological diseases resulting from drug intake and creeping
depression. From the point of view of stuttering therapy, piracetam (Nootropil,
Lucetam) and Ginkgo Biloba deserve special attention. Structure-wise,
piracetam is a derivative of GABA, which would explain the theory of
disturbed GABA concentration in PWS. The mechanics of piracetam has not
been thoroughly explained yet. However, latest studies suggest that it reduces
the physical blood viscosity, increases flexibility of erythroid cell membrane
and improves flow of blood through brain’s blood vessels while not exerting
any influence on blood pressure. More efficient use of oxygen and glucose
within neurons and, consequently, and improvement in their function, is an
additional benefit (Winblad, 2005). Interestingly, the substance effect is much
weaker in a physiological state, which implies that the true effectiveness of
piracetam is observed only when disorders of concentration, concluding and
other cognitive processes occur. Although specialists had great hopes for using
piracetam in PWS, so far, no comprehensive clinical tests have been
conducted to test it. Current analyses are of a casuistic nature and their results
cannot be extrapolated to a larger group of patients. Still, there is a real ‘craze’
for taking 4 g–5 g a day dose of piracetam on one’s own account, especially in
the United States. According to those who follow the trend, it leads to
increased speech fluency and eliminates long pauses and unwanted syllable
and word repetitions. Considering the above mentioned placebo effect and
cognition-related effects of piracetam, it can be assumed that the improvement
observed does not result from the drug’s effects on the structures and
mechanisms of stuttering. Instead, it only masks the symptoms by increasing
the brain’s efficiency and self-confidence, as well as eliminating the stress
caused by the necessity to speak. Similarly, gingko biloba extract was thought
to have a positive effect on the communicative skills of PWS (Wesnes, Ward
et al., 2000). In view of the lack of evidence for the effectiveness of gingko
biloba, possibilities of achieving therapeutic results should be treated with
reservation as they may come merely from a conviction that a given drug is
effective. Among other nootropic substances there is taurine, which is a
biogenic amino-acid with a sulfo group in its structure. Taurine has long been
regarded as merely a metabolic transmitter linking bile acids in order to
eliminate them from the body (Ripps, Shen, 2012). Recent data point to
possible antagonism of taurine towards GABAA receptors, which is the basis
of neurotransmission inhibition in the nervous system, and consequently,
reduction in nervous tension, which correlates with the frequency of stress-
based symptoms of speech disfluency. Involving antagonist GABAA receptors
in reducing the frequency of symptoms typical of stuttering is described in
subchapter 3. Another effect taurine has in the central nervous system is it
increases the metabolism of glial cells, and, consequently, strengthens the
functioning of other neurons (Jia, Yue et al., 2008). Although there have been
single reports of effective supplementation of this biogenic amino-acid, no
research on the application of taurine as a potential drug for stuttering has ever
been conducted. In the 1980s and 1990s, there was a common belief that
taking the ‘old pro-cognitive drugs’ like vinpocetine, nimodipine and
cinnarizine was beneficial. However, apart from the oxygenation of brain
cells, no effect has been observed that could be directly linked to structures
which have a possible connection to the development of speech fluency
problems. In view of the above, a conclusion can be drawn that drugs from this
group can only supplement the primary pharmacotherapy of speech fluency
disorders and their effectiveness depends on the patient’s age and condition of
his or her nervous system. An advantage of nootropic drugs is that they are
tolerated well and adverse reactions are relatively rare.
Anti-Epileptic Drugs
Unlike stuttering, the aetiology of epilepsy has mostly been explained.

Still, current knowledge enables one to identify several features which these
disorder share. To go even further, some specialists consider stuttering a post-
epileptic complication. In both cases, therapists have great hopes for drugs
which react to GABAA receptors and enzymes which break down GABA, an
endogenous antagonist of these receptors. This indicates a possible common
background of these diseases i.e., increased nerve impulses (Banerjee, Filippi,

Allen Hause, 2009). Perinatal brain damages resulting from hypoxia are one of
the causes of epilepsy and lead to excessive bioelectric impulses of the brain at
an early stage.
Adulthood epilepsy is often caused by brain tumours, scleroses, brain
degeneration and alcoholism. Brain functioning disorders almost surely cause
speech fluency disorders as well. On this basis, efforts have been made to
adapt antiepileptic drugs to the treatment of speech apparatus dysfunctions,
and stuttering in particular, for over thirty years, and carbamazepine was tested
in therapy of stuttering as early as last century.
In 1987, Goldstein et al. (1987), and five years later, Harvey et al. (1992),
tested carbamazepine’s influence on the freedom and fluency of speech of
several volunteers. Despite the patients’ subjective positive opinions as to their
well-being and the declared improvement of speech apparatus functioning,
neither the number of words pronounced disfluently nor fluency of reading or
spontaneous expression changed. Harvey et al. (1992) used 400 mg of
carbamazepine a day, and such a dose may cause a number of adverse
reactions, including sleepiness, vertigo, hypotension, bradycardia, excessive
loss of bone tissue and disturbed vitamin D metabolism. Essentially,
carbamazepine is a psychotropic that regulates mood and partly prevents from
depression, which may cause the subjective feeling of improving a patient’s
health (Birkhimer, Curtis, Jann, 1985).
Valproic acid is another anti-epileptic drug used for treating stuttering. It
inhibits the breakdown of endogenous GABA and increases its reuptake,
which, in turn, leads to an increase in the level of endogenous GABA in the
body. Valproic acid is also a strong metabolic stimulant of GABA production
in the organism. Moreover, research has indicated significantly higher activity
of valproic acid towards the biosynthesis of GABA-ergic neurons (Laeng, Pitts
et al., 2004). On a separate note, valproic acid also influences
neurotransmission by blocking sodium and calcium channels within neurons.
Valproic acid interacts with a large number of medicines in the
pharmacokinetic phase, which may greatly limit its applicability. Literature
provides contradicting data regarding progress in speech fluency among PWS
who used valproic acid. There have been cases (the last one was described by
B. Aukst-Margetić [2008]) which imply that using valproic acid derivatives
induces stuttering. This rejects the compound as a potential medicine for PWS
for obvious reasons.
Verapamil, which is a calcium channel antagonist, has also been
mentioned in the context of the diminishing of speech disfluency in the course
of therapy of arrhythmia. However, the latest information about that has not
been confirmed in tests among PWS and no reports of it were available after
1983. Research results that finally confirmed the ineffectiveness of verapamil
in treating PWS were published in 1988 (Brumfitt, Peake, 1988). At the turn of
the 21st century, scientists focused on levetiracetam, another drug used in the
therapy of epilepsy. Although its mechanism has not been explained
thoroughly, it seems that the drug makes SV2A synaptic vesicle bond with
glycoprotein and inhibits presynaptic calcium channels, which reduces the
release of neurotransmitters into the presynaptic gap (Kaminski, Gillard,
Klitgaard, 2012). Based on that, levetiracetam can be regarded as a
neuromodulating type of medication. Interestingly, three unrelated cases of
considerable decrease in frequency of disfluency symptoms and forced
syllables and word repetitions were described in 2002. A detailed report by
MP Canevini et al., describing the complete recession of stuttering symptoms
after a 12-week therapy of permanent status epilepticus with levetiracetam, is
particularly worth reading (Paola Canevini et al., 2002). However, the absence
of randomised clinical tests which are aimed at correlating the drug with
improved speech fluency of PWS should be assessed critically and
levetiracetam sceptics point to the fact that the recession of speech disfluency
symptoms and status epilepticus may co-occur.
Vigabatrin inhibits the decomposition of gamma-aminobutyric acid by
inhibiting GABA-specific transaminase, and increases the concentration of
GABA in the central nervous system, which reduces the system’s excitability.
As supporters of the GABA theory claim, it leads to a decrease in the
frequency of disorders within the speech apparatus (Wang, Kammoul et al.,
2008). Unfortunately, vigabatrin, like other anti-epileptic drugs, causes a
number of adverse reactions, which questions its usefulness in therapy of
stuttering. To sum up, it is worth stressing that anti-epileptic drugs have a
potential for treating speech disorders. However, one should bear in mind that
these medications have strong and multidimensional effects on the human
nervous system and may trigger numerous adverse reactions and interactions
with other drugs, which considerably limits their usefulness.
Antispasmodic Drugs (Affecting Mainly Muscles within

the Face and Neck)
Some experts suggest that problems with the proper pronunciation of

words and syllables may be caused by articulatory disorders related to
excessive and prolonging spasticity and the trembling of lip and soft palate
muscles. Both clonic and tonic contractions have a negative influence on the
quality and fluency of speech. Excessive stress-related contractions of
respiratory muscles as well as increased tension in the face and neck muscles
have an equally negative effect (Hanna, Wilfling, McNeill, 1975). As this
leads to an inability to speak fluently and continuously, applying drugs aimed
at reducing excessive, unphysiological muscle tension appears reasonable.
However, it seems disputable to supplement with medicines which contain
diazepam as the drug displays a strong inhibitory effect on the hypothalamus
and the limbic system, and is typically used as an anxiolytic, a relaxant, an
anticonvulsant and a hypnotic medicine. It has been proven that diazepam
influences the transaminase which breaks down GABA, as well as increases
the permeability of ionic channels of GABA receptors within the hippocampus
(Eghbali, Curmi et al., 1997). The mechanisms behind diazepam are connected
with the receptors for GABA and while the supplemention of a drug of such
variety of effects which is potentially addictive seems controversial,
tolperisone might be an alternative which is typically tolerated well. Still, it
can also lead to considerable hypotension and excessive sedation (Quasthoff,
Möckel et al., 2008). This suggests that the drug could supplement the therapy
of PWS provided that there are no major contraindications for using it.
It is worth noting that American scientists are exploring baclofen, a
derivative of GABA and an antagonist of GABAB receptors, which implies
there can be numerous ways to utilise the compound in the therapy of
stuttering (Balerio, Rubio, 2002). The method of administration is the only
issue here as it is often administered by subarachnoid injection using an
intercalary pump. In many cases of PWS, depression of the respiratory system
and overall weakness also make it impossible to supplement baclofen. On the
other hand, the drug does not lead to tolerance and habit so it can be
supplemented for longer periods of time. Nevertheless, while antispasmodic
drugs can only supplement the primary therapy, the effects they cause can
substantially increase the effectiveness of the therapy.
Psychiatric Drugs Which Have Not Been Introduced into

Pharmacotherapy of Stuttering
Psychiatric drugs is a group which has appeared most promising in the

pharmacotherapy of stuttering. It includes anxiolytics, antipsychotics,
antidepressants as well as sedatives. Subchapter 3 focuses on substances which
are still being researched and theoretically, may be launched on the market as
medicine for stuttering so the subchapter will discuss key examples of the
abovementioned groups. Utilizing the drugs below in stuttering therapy is
impossible, pointless or irrational.
Anxiolytics and sedatives seem essential for patients with extremely
severe episodes of speech dysfunction to reduce the influence of stuttering on
their lives and social relationships. The mere fact of stuttering creates a
number of barriers, not only purely communicative, but also psychological and
social ones, in a patient’s life as he feels alienated and even the most basic
tasks which require interpersonal relationships cause stress and emotional
conditions that may lead to depression. Due to the above, anxiolytics and
sedatives often supplement logopaedic or group therapy. It would be
interesting to know whether they can also reduce or eliminate the everyday
symptoms experienced by PWS.
In view of the frequent use of anxiolytics in speech fluency therapy,
barbiturates were also introduced in 1950s. Beginning in the 1950s,
barbiturates were used as hypnotics, anesthetics and anticonvulsants for almost
four decades, and phenobarbital, pentobarbitone and hexobarbital are most
popular compounds in this group. However, based on research conducted in
1955 in Germany by Dr. Imre, the speech disorder reducing effects of
barbiturates should be called into question (Imre, 1955). It seems that all the
positive symptoms including improvement in speech fluency and easier
pronunciation resulted merely from sedation and relaxation after
supplementing with small doses of barbiturates. It should be emphasised that
the supplementation of barbiturates in the therapy of stuttering has long been
regarded as pointless due to the relatively high addictive properties, which
may lead to both physical and mental addiction.
The second half of 20th century was the time of medical experiments and
discoveries, one of which are benzodiazepines. Benzodiazepines display a
wide spectre of effects: seductive, anxiolytic, anti-epileptic, amnestic and
myorelaxant. Their mechanisms are based on compounding a certain
benzodiapine with an appropriate benzodiapine receptor (BZD), which is part
of GABA receptor complex, and seem particularly interesting from a
pharmacologist’s point of view. Benzodiazepines stimulate GABA reactions
with BZD by affecting the receptor, which leads to an accumulation of
chloride ions inside a cell, and consequently, hyperpolarisation that results in
reduced neuron excitability (Griffin et al., 2013). The effect caused by
benzodiazepines can be easily reverted with flumazenil, an antidote of a kind.
Along with development of medicine and chemical synthesis, the variety of
forms of benzodiazepines has increased as well. They could be different with

regard to effects, affinity to benzodiazepine receptor and lipophilic properties.
However, the number of patients addicted to benzodiazepines (which display
strong addictive properties, similarly to barbiturates) seems to be a serious
medical and social problem. Olanzapine, which is discussed in subchapter 3, is
the key component of the group. Other benzodiazepines are regarded as useful
for controlling depressive symptoms that accompany chronic stuttering, and
reducing excessive muscle tension in stress caused by the patient’s
interpersonal relationships.
Furthermore, numerous analyses (Brady et al., 1991; Lavid et al., 1999)
point to a hypothetical link between benzodiazepines mechanics and the place
where speech disfluency and discontinuity symptoms begin. Elliot’s 1985
double blind tests should also be mentioned as they refer to irreversible
stuttering episodes caused by the supplementation of alprazolam. This
confirms that there are fundamental misunderstandings of the biochemical and
molecular bases of brain changes which lead to the manifestation of symptoms
of stuttering and other speech disorders.
Apart from benzodiazepine, hydroxyzine is another sedative which can
eliminate stuttering-related stress. Although the substance per se neither makes
speech more fluent, nor eliminates the problem (Kent et al., 1963),
hydroxyzine enables the control of emotions which accompany speech
dysfunctions due to its affinity with D2 dopamine receptors and serotoninolitic
effects. In their research, Kent (1963) also examined the influence of reserpine
and meprobamate on patients with stuttering. However, since their results have
not presented thoroughly, it may suggest that they were not positive (Kent et
al., 1963).
Similarly to anxiolytics, antidepressants are used commonly and aim not
to eliminate the disorder, but to improve the quality of life of the patient. This
wide group includes drugs used in therapy of depression, anxiety and
obsessive–compulsive disorders, as well as phobias and disorders related to
everyday existence. In the case of patients with speech disorders,
antidepressants only supplement the primary speech therapy, with the
exception of the latest group of drugs referred to as selective serotonin
reuptake inhibitors (SSRI), which include: fluoxetine, escitalopram, sertraline,
citalopram and paroxetine. Their mechanism consists of inhibiting
neurotransmitter (serotonin) reuptake from the synaptic gap, which leads to an
increase in the duration of neural stimulation. Consequently, this leads to an
increased number of stimuli sent.
Interestingly, in 2009 a team of researchers led by P. Busan conducted an

initial study in which they proved that a single daily dose of 20 mg of
paroxetine supplemented during a period of 12 weeks led to a reduction of
both the unwanted pauses between words pronounced and facial muscle
tension, which, in turn, resulted in a reduction of stuttering symptoms (Busan
et al., 2009). This confirms the results of previous research (Murray, Newman,
1997; Schreiber, Pick, 1997; Boldrini et al., 2003), which point to the potential
use of paroxetine in stuttering therapy. Unfortunately, due to the insufficient
size of each research group, it was impossible to obtain statistically significant
results and the poor clinical quality of research may indicate that some other
factors had influenced the research results.
Researchers had similar hopes for sertraline, but contradictory research
results indicated that there was a need for in-depth analysis. However, the
analysis did not happen due to reports suggesting paradoxical stuttering was
induced in patients treated with sertraline (Christensen et al., 1996; McCall et
al., 1994). It is worth stressing that the target point of SSRI drugs is within the
serotonergic system, which, according to current knowledge, may be a
significant element of the initiation and development of speech dysfunctions.
Antipsychotics, also referred to as neuroleptics, complement therapy
aimed at eliminating emotional and mental disorders caused by stuttering.
Basically, drugs from this group are recommended in schizophrenia, manic
depressive episodes, psychoses with hallucinations and delusions, as well as
disorders of primary behaviours related to emotionality, mood and personality.
Neuroleptics differ substantially, and haloperidol is most often used in
therapy of stuttering. The drug is discussed in subchapter 3, along with
olanzapine. Antipsychotic drugs are used to sedate the patient in moments of
increased tension and stress which accompany a strong stimulus, e.g., public
speech, important exams or difficult life situations that intensify problems with
speech fluency and continuity. The mechanism of drugs from this group is
related to the neurons of the dopaminergic and serotonergic systems, which
suggests the drugs may supplement the therapy of a patient with stuttering.
However, reports (Yadav et al., 2010) which imply the possible onset of
stuttering in patients treated neurologically with risperidone, trifluoperazine,
levomepromazine and chlorpromazine cannot go unnoticed as, on the one
hand, they disqualify the drugs as pharmacotherapy supplementation, and on
the other, point to the potential role of dopamine and serotonin systems in
pathophysiological causes of stuttering (Murphy et al., 2015). Moreover, this
relationship confirms the need to examine the causes of imbalanced levels of
dopamine and serotonin neurotransmitters within the brain structures.
From the historical perspective, attempts to introduce narcotics into the

therapy of speech fluency and freedom disorders are also worth mentioning.
However, the data should be regarded merely as a source of information about
potential target points for effects that reduce symptoms of stuttering. Long-
term supplementation of forbidden and highly addictive substances with a
wide range of adverse reactions is not possible. In 1965, H. Fish published an
article in a magazine called ‘Californian Med.’ (not published anymore) in
which he pointed to the fact that D-amphetamine therapy combined with
trifluoperazine is effective for patients with stuttering caused by social
problems (Fish, Bwoling, 1965). However, the therapy did not work for post-
traumatic patients whose speech disfluency resulted from the physical damage
of brain structures. Research conducted in 2004 also pointed to a reduced
frequency of speech disorders in patients taking amphetamine in order to lose
body mass. However, taking amphetamine and its derivatives by PWS is
impossible due to the numerous adverse reactions within the cardiovascular
system, an imbalance of neurotransmitters and many other disorders. In 2007,
Linazasoro et al. published a report which linked cocaine intake with increased
dopaminergic processes within brain structures that may intensify
development speech disorders. However, there is still no clear information on
the potential improvement of speech fluency after supplementing with the
substance. Specialists have the greatest hopes for cannabinoids, which are
organic compounds that are present in some species of hemp and most often
associated with cannabis. Plant cannabinoids display an affinity with two
subtypes of cannabinoid receptors: CB1 and CB2. The former are located near
basal nucleus, hippocampus and cerebellum, and once stimulated, they reduce
the perception of pain and increase appetite. CB2 receptors are responsible for
modulating the response of the immune system. Borgelt et al. (2013) pointed
to a substantial reduction of face and neck muscle spasticity with
tetrahydrocannabinol (THC), which may help patients with speech
dysfunction.
Although a number of online services promote cannabis application as a
tool for separating fits of speech disfluency, it should be highlighted that the
method will remain debatable until standardised research results appear,
mainly due to the unknown composition of the substances taken by the patient.
Obtaining pure agonists of CB1 receptors by refining and standardising the
material appears to be a solution in this case. Though only momentary, the
reduction of emotional tension and removal of fear and stress in a way similar
to that which occurs during alcohol consumption seem to be the possible cause
of significant improvement in speech fluency of PWS (Iverach et al., 2010).
At the end of this overview of substances that people have tried to release
on the market as medications for stutterers, it seems critical to mention
numerous plant substances as well. Active ingredients obtained from plants
have been used in cases of excessive stimulation of the central nervous system,
stress, depression excessive emotions or insomnia for decades. Each of the
materials can only be used as an on-demand support in speech disorders, and
their direct impact on developing speech dysfunctions is highly questionable.
The list of plant drugs that have been used so far includes: maypop (Passiflora
incarnata), valerian herb (Valeriana officinalis), lemon balm (Melissa
officinalis), common hop (Humulus lupulus), Leonurus carnata (motherwort),
gingko biloba as mentioned above, as well as various herbs which appear in
natural medicine of different ethnic and culture groups and are taken in the
form of infusion, maceration, dry herbs or a tea add-on.
3. Current Knowledge and Development

of Pharmacotherapy of Patients
Who Stutter
Understanding of both speech disorders and their causes has considerably
increased at the beginning of the 21st century due to the dynamic development
of practically every single branch of medicine. According to the latest reports,
researchers have identified differences in brain structure in PWS and people
who do not suffer from any speech dysfunction. The use of brain structure
imaging technology has made it possible to identify significant differences in
the structure of: basal ganglia (BG), thalamus and left ventral premotor cortex
(vPMC), as well as the BG-vPMC loop in PWS (Civier et al., 2013). While
other discoveries are expected in the field, it should be highlighted that purely
structural differences may be the result, and not the cause, of speech apparatus
disorders observed. Nevertheless, further research seems reasonable and may
lead to a breakthrough in the struggle with stuttering.
From a pharmacological point of view, the hyperdopamine theory seems
crucial for understanding the pathogenesis and progression of speech disorders
as it skilfully combines the excessive concentration and expression of genetic
information of the neurotransmitter (dopamine) with the occurrence of speech
disorders (Lan, Song et al., 2009). A Gamma-aminobutyric acid system
(GABA) is a neurotransmitter which is directly linked to the dopaminergic
system within the brain structures. Potential therapeutic models and goals
which combine the latest discoveries of mechanisms that potentially underlie

the development of speech fluency disorders are discussed below. One may
assume that, as long as full safety is ensured, some of the presented therapeutic
methods will be introduced to the common model of therapy of speech
disorders in the near future.
Dopamine, Gamma-Aminobutyric Acid and the

Hyperdopamine Theory
At the turn of 20th and 21st century, several different groups of researchers
(Lan et al., 2010; Wu et al., 1997) began to point to an evident increase in the
activity of the dopaminergic system observed in vast majority of PWS.
Dopamine (DA) is catecholamine-type of a neurotransmitter which plays a
major role in the central nervous system and exerts an influence on the
organism via five types of dopamine receptors identified as D1-D5. Its
functions are diverse and include: motor driving, maintaining proper muscle
tension, directing higher-level thinking and associating, maintaining emotional
stability and finally, releasing the hormones of prolactin and gonadotropin
(Goberman, Blomgren, 2003).
Recent studies have pointed to dopamine’s role in developing addiction to
drugs, broadly defined pleasures and even eating (Jaber et al., 1996; Baik,
2013). Due to such a broad spectre of influence on an organism, dopamine
imbalance is observed in a number of diseases including: Parkinson’s disease,
ADHD, psychoses, Tourette’s syndrome, depression, pain pathology.
Dopamine is also closely related to the mechanism of deepening depressive
syndromes caused by addiction to psychoactive drugs. Recent reports indicate
that dopamine is also related to other disease units, including stuttering and
broadly defined speech disorders. Research on positron emission tomography
using a fluorinated derivative of dopamine (6-FDOPA) was conducted in 1997
to determine potential differences in dopamine level among PWS (with
moderately severe symptoms of stuttering) as opposed to the control group of
healthy patients. The results turned out to be of significant value as patients
with stuttering displayed a significantly higher level of 6-FDOPA retake and
had an increased concentration of it in the following brain structures: medial
cortex of the midbrain, extended amygdala, auditory cortex as well as minor
structures involved in creating and pronouncing speech (Wu et al., 1997). In
spite of the limited sample, results of this research laid the foundation for the
hyperdopamine theory. Interestingly, although much time has passed, the
theory has not been proven wrong and instead, it has become of interest to
researchers looking for effective therapy of stuttering. Gamma-aminobutyric
acid (GABA) is a neurotransmitter which, along with dopamine, can modulate
speech processes which are the basis of changes in speech fluency and
continuity. However, unlike dopamine, GABA is an inhibitor towards the
central nervous system and manifests itself in three subtypes of receptors:
GABAA-C (A,B,C). The biological effects of GABA include reduced muscle
tonus and muscle excitability, as well as stopping neurotransmission (Bettler et
al., 2004). Barbiturates and benzodiazepine derivatives are combined with the
benzodiazepine receptor and increase GABA affinity for their receptor. It
should be noted that these drug groups have been mentioned as potentially
useful in treating symptoms of disfluency as well as other speech disorders.
Researchers who work on developing a medication for stuttering are also
interested in drugs that directly (gabapentin) or indirectly (vigabatrin) increase
the level of endogenous gamma-aminobutyric acid.
Drugs Which Use Dopamine-Dependent Mechanism or GABA,

and Can Be Potentially Used in Pharmacotherapy of Stuttering
Pagoclone – a great hope for patients suffering from speech disorders, and
particularly stuttering, came at the beginning of 21st century, when a team of
Dr. Maguire and Dr. Riley (Maguire et al., 2010) published their research
paper on a new, potentially effective and safe new-generation drug for
stuttering in 2010. Pagoclone is a compound which has properties of a pure
enantiomer and a nonbenzodiazepine modulator of subtype A GABA
receptors, as well as their partial agonist. From the point of view of
pharmacology, that partial agonism is particularly important as it enables the
complete opening of ion channels, which leads to the sudden increase of
calcium ions and relatively low (approx. 5%) density of appropriate agonist in
the receptors (Caveney, Giordani, Haig, 2008).
Although pagoclone was initially supposed to be a sedative and treat
episodes of relapsing insomnia, it has never been widely used for this purpose.
Instead, its mechanism has inspired the idea of using the compound in the
therapy of stuttering.
The first trials displayed statistically significant improvement of speech
fluency and were followed by the idea to organise clinical trials on a much
broader scale. This led to the EXPRESS project (Examining Pagoclone for
Persistent Developmental Stuttering Study), whose aim was to determine the
drug’s safety, effectiveness and possible interactions in patients with

stuttering. The trial was registered as number NCT00216255 and conducted
between October 2005 and May 2006 in 16 medical centres across the United
States. The therapy involved the supplementation of a 0.3mg to 0.6mg dose of
pagoclone twice a day for 8 weeks, while the control group was given only the
excipient (https://clinicaltrias.gov/ ct2/show/NCT00216255 – accessed on
2016.03.01). Results of the research referred to 82 patients treated with
pagoclone and were gathered at 2 weeks, 3, 6, 9 and 12 months after the
therapy.
The results were very promising as the number of disfluently and
discontinuously pronounced syllables decreased by 19.4% straight after the
therapy and by 40% after 12 months. It is important to note that the drug was
tolerated well and had a positive influence on PWS’ emotional condition.
Incidental adverse reactions observed were related to the dose and manifested
themselves in the form of nausea, headaches and excessive sleepiness.
The scientific society has expressed some other objections towards the
research results, e.g., the insufficient number of patients treated with
pagoclone, no improvement in speech fluency observed in almost 30% of the
subjects and a spontaneous improvement of speech functions observed in 35%
of the patients from the control group. It points to the involvement of mental
and emotional spheres in treating speech apparatus disorders, which is another
suggestion for those who seek a drug for stuttering.
In 2013 it was stated laconically that research on pagoclone used to
control and reduce symptoms of stuttering had been abandoned and reasons
that decision are still not clear. In spite of this, one should not forget about this
drug as it has appeared to be the first substance which has been used
effectively in the therapy of PWS.
In 2010 researchers looking for a drug for stuttering focused on asenapine
(Asenapine, Saphris – Australia and the United States, Sycrest on the
European market), a new second generation antipsychotic (atypical) which is
used for treating schizophrenia and bipolar disorder. Initially, the mechanics of
asenapine effects was associated with its antagonist activity towards dopamine
receptors (D2) and 5-HT2A serotonin receptors. However, now, a wide range
of pharmacodynamic properties have also been demonstrated. Asenapine
displays a strong affinity for serotonin (type 1A–B, 2A-C, 5, 6, 7), adrenergic
(type α 1–2) and dopamine (type 1–4) receptors, as well as H1 receptors for
histamine. Furthermore, partial antagonist activity of asenapine towards 5-
HT1A receptor has also been observed, while anticholinergic effects of
asenapine have not been present at all (Potkin 2011; Shahid et al., 2009).
Potential therapy with asenapine has been significantly hindered by the

compound’s bioavailability-related pharmacokinetic properties. Asenapine
displays low (below 2%) bioavailability after per os administration, while
sublingual administration guarantees that the acceptable level of
bioavailability, i.e., 35%, is reached.
Liver metabolism is accompanied by UGT1A4 and CYP1A2 isozymes,
which may indicate potential interaction with other drugs that also undergo
coupling with glucuronic acid and oxidizing by the aforementioned isozymes
during cytochrome P450 metabolism (Citrome, 2014).
Clinical research on asenapine treatment in the therapy of schizophrenia
has proved that it is relatively effective and safe, and the most frequent adverse
reactions were excessive sedation, Parkinson-like symptoms, akathisia and
nausea. Unlike most antipsychotics, asenapine does not increase body mass
(Kane et al., 2011).
In November 2010, scientists from the University of California Irvine
included the drug in a research on the application of asenapine in PWS, and
the promising results obtained led to the initiation of the third phase of clinical
research in cooperation with Merck on the application of asenapine in therapy
of speech disorders. The research was given NCT01684657 as the reference
number and Gerald Maguire, who had tried to introduce pagoclone into speech
therapy, became its clinical research manager. The test assessed the change of
speech quality during a 5-minute reading session and a speaking session of
similar duration. The doses of asenapine supplemented varied from 5 mg to 20
mg a day, while the control group was given a placebo. Although certain
parameters depend on the patient’s emotional condition and thus are assessed
in a rather subjective way, it is possible to offer reliable evaluation of
asenapine’s influence on speech functions (https://clinicaltrials.gov/
ct2/show/NCT01684657 – accessed on 2016.03.01). The research is still
continuing and casuistic news of how asenapine impacts functions of the
speech apparatus and patients’ psyche gives one hope that at some point, the
substance will become a well-established drug for the disorders mentioned
(Maguire et al., 2011). It is likely that the potential success will be inextricably
linked to the antagonist activity towards dopamine receptors, which confirms
the so-called dopamine theory that links high activity of the dopaminergic
system with speech fluency disorders and hyper-excitement while creating and
analysing speech stimuli. PWS gathered at online forums have expressed great
hopes for the new drug.
Discussions on asenapine have naturally led to an analysis of tiapride,
which works in a similar way. Tiapride (Tiaprid) is a selective antagonist of
D2 and D3 receptors in the brain and was first described as a potential drug for
stuttering by dr Rothenberger et al. in 1994 (Rothenberger et al., 1994).
Currently, the drug is commonly used in therapy of mental and neurological
disorders such as dyskinesia, psychosis and fits of aggression, and supports
alcohol rehabilitation among alcohol addicts (Steele et al., 1993). Although the
mechanism has not been identified thoroughly, it appears to be linked to a high
affinity of tiapride for the limbic structures, which, according to latest reports,
may underlie speech fluency problems.
In 2012, researchers proved that therapy which uses tiapride has positive
results among PWS, which was directly linked to the anti-dopamine effect. It
should be noted, though, that currently, no clinical research on tiapride’s
influence on stuttering symptoms is available and the studies conducted
previously do not allow one to offer such far-reaching conclusions (Boyd et
al., 2011). Another problem refers to the possible adverse reactions, which,
although rare (1 per 1000 patients), may disqualify the drug from
pharmacotherapy of stuttering. They include increased prolactin level, sexual
disorders, orthostatic hypotension, increased risk of breast cancer, as well as
prolongation of the QT interval in electrocardiography of the heart muscle.
The above stands in contradiction to safety requirements that make the drug
appropriate for children as well.
Olanzapine (Zyprexa) is likely to be introduced to the market as element
of an effective pharmacotherapy of stuttering. It is an antipsychotic drug from
the thienobenzodiazepine class and its mechanism is related to its antagonistic
properties towards a number of receptors.
From the point of view of speech disorder therapy, blocking all subtypes
of dopamine receptors by olanzapine is essential. The mechanism is the basis
of supplementation of the compound during therapy of schizophrenia and
related mental disorders. It also allows for the classification of the substance as
a potential drug for stuttering, provided that the hyperdopamine theory is true.
Interestingly, olanzapine is also an antagonist of adrenergic, muscarinic,
histamine and serotonergic receptors, which, on one hand, proves the great
potential of the drug, but on the other hand, show that various general and
nonspecific actions may appear or result during therapy with this compound
(Callaghan et al., 1999). Reports which suggest olanzapine should be applied
in therapy of stuttering have been coming since the beginning of the twenty-
first century and in 2004, reports showed scientific evidence of not only
olanzapine’s effectiveness in treating stuttering symptoms, but also its
increased safety and tolerance compared to traditional antipsychotics.
Improvement of syllable fluency by nearly 50% and better results in SSI-3
(Stuttering Severity Instrument-3) test were demonstrated as well (Maguire et

al., 2004).
It should be highlighted that olanzapine is also recommended in
conditions such as emotional isolation, blunted affect, delusion and
hallucination. This indicates that the drug can potentially lead to emotional
stabilization of the patient and does not have a direct influence on the
dopaminergic system which would help develop and increase the severity of
stuttering symptoms. Since it is impossible to separate the two mechanisms, it
should be assumed that both theories of olanzapine’s positive effect on speech
disorder symptoms may coexist.
However, one should not ignore the possible adverse reactions to
olanzapine e.g., sudden increase in body mass, fatigue, excessive sleepiness
and drug-induced insulin resistance.
A team led by Dr. Dehghani et al. compared the effectiveness of
olanzapine- and haloperidol-based pharmacotherapy in a research paper
published in 2013 (Rosenberger et al., 1976). The results suggest that
olanzapine appears to currently be the most common drug for stuttering. Even
haloperidol (Haldol) as such is now being considered as a potential drug for
stuttering despite the fact that, from a pharmacologist’s perspective, it seems
too strong a medicine for the therapy of speech apparatus disorders. The
mechanism of haloperidol consists of inhibiting the constitutive activity
(inverse agonism) of D2, D3 and D4 dopamine receptors, while its influence
on other dopamine receptors remains unknown (potentially minimal antagonist
properties). It has also been proven that the compound reacts with serotonin
and adrenergic receptors. It should be noticed that, although researchers have
been constantly focused on it, unsuccessful attempts to adapt haloperidol to the
therapy of stuttering were observed as early as in 1976 (Rosenberger et al.,
1976). Adverse reactions are strong and significantly reduce the patient’s
comfort, and it seems unbelievable that one could think it is worth to
experience frequent adverse reactions such as anaemia, arrhythmia, obesity or
Parkinson-like symptoms in an effort to treat stuttering. On the other hand,
PWS’ desperate attempts to cure stuttering by taking haloperidol on their own,
without a doctor’s advice, cannot go unnoticed as it may pose a serious threat
to patients’ health and lives.
Undoubtedly, PWS have great hope for risperidone (Risperdal) as well,
which is a second generation antipsychotic widely used in treating psychoses,
psychotic episodes with positive and negative symptoms, anxiety disorders,
autism and Tourette syndrome. It displays weak extrapyramidal symptoms and
its effects are based on antagonism towards dopamine receptors of all the five
types. Apart from that, risperidone also exhibits antagonistic properties

towards some serotonergic, adrenergic and histamine receptors (this time as an
inverse agonist). Blocking dopamine receptors have made researchers examine
the compound’s influence on speech pathology processes. The high potential
of risperidone to treat disfluency symptoms was mentioned in an article
published in the Journal of Clinical Psychopharmacology in 2000 (Maguire et
al., 2000).
Researchers observed significant improvement in building fluent
sentences, speaking fluently as well as in the general well-being of patients
during a six-week therapy with 0.5 mg-to-2 mg doses of risperidone a day.
The medication was tolerated well and the results made the team repeat the
study on a larger group of patients.
Research results by Dr. Generali that proved the effectiveness of
risperidone in PWS were analysed with The Stuttering Severity Instrument for
Children and Adults - Third Edition (SSI-3) and published again in 2014.
Apart from improving the parameters of fluent speech, researchers also
observed a satisfactory level of the drug tolerance as only three patients
experienced excessive sedation (which abated when the daily dose was
reduced). However, there are cases in which adverse reactions to risperidone
have led to the development of stuttering symptoms, which appears contrary to
the theories listed above (Yadav, 2010). This mystery needs to be resolved as,
on one hand, there is a potential medication for PWS, which, on the other
hand, may trigger development of symptoms which it is supposed to reduce.
The problem seems serious as modern medicine is still unable to offer a
unanimous explanation.
4. New Horizons and the Future

of Pharmacotherapy of PWS
Many scientists claim that the future of therapy of stuttering will be
associated with molecular biology techniques. Recent scientific reports point
to the existence of specific genome changes which are correlated with the
incidence of stuttering symptoms.
In 2011, it was proven that chromosome 12 displays mutation in the
GNPTAB, GNPTG and NAGPA genes which are linked to the incidence of
stuttering within the family (Drayna, Kang, 2011). Molecular research pointed
to the role of FOXP2 and CNTNAP2 in development of speech disorders.
Research results published in 2014 indicated the possible influence of the

abovementioned mutations on the frequency of stuttering symptoms (Han et
al., 2014), which opens up a new way which can become a 21st century
solution. An increasingly wide spectre of diagnostic tests which aim at
identifying subtle changes in brain structure that underpin speech disorders is
another hypothesis that gives hope for finding a cure for stuttering. Results
obtained in this way make help one prevent symptoms of stuttering with
simple neurosurgical intervention. Widely available tools, including
EasySpeech, that modulate the duration and speed of auditory symptoms may
also turn into devices which can quickly edit a person’s pronounced sentence.
Alternatively, another way to find effective pharmacotherapy for stuttering is
to adapt current medication, which, as proven by history, seems real even
though it may require a little bit of coincidence and luck.
Conclusion
The 21st century has put the bravest and long-held visions into practice
and sees numerous and incredible discoveries change the world for good. How
to explain the fact that nearly 1% of the world population still suffer from
disorders that make their lives uncomfortable and cause problems that turn
into a number of other disorders? It is a permanent struggle for the
pharmaceutical industry who finds it difficult to correctly diagnose and
eliminate the cause as previous actions have turned out to be unsuccessful and
the nearest future does not offer any breakthrough. Fortunately, our history
shows that significant discoveries come unexpectedly and one should hope
that this will be the case in developing a ‘drug for stuttering’ that has already
been progressing for decades.
It should be highlighted that pharmacotherapy of PWS does not reject
logopedic and psychological therapy, but leads up to it, for it has long been
suggested that therapy could be comprehensive.
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Chapter 5
Case Studies and Interviews
Abstract
The case studies and interviews presented below come from my
publications: Stuttering. A Book of Questions and Answers. (2010) and
Stuttering in Preschool Age. (2012) and reprinted with the Publishers’ written
consent.
1. Developmental Speech Disfluency or

Early Childhood Stuttering
Differentiating between developmental speech disfluency and early
childhood stuttering may be troublesome, as confirmed in the letter below
written by a mother working as a speech therapist:
‘Dear Professor,
I am writing to you because my daughter began to repeat words a year
ago. There are periods of fluency and disfluency, during which she repeats
syllables, pronouns, conjunctions and prepositions. I have not observed any
tension, effort or synkineses. My daughter repeats words quickly and rather
unconsciously. She produced her first sentence at the age of one and a half
years old. Although she did not use to speak much, her sentences were well-
structured. She began to pronounce the ż, sz, cz, r sounds prior to her peers. No
radical changes have happened in her life which might cause the problem. She
has been going to a kindergarten since she was 3, and in three months she will
turn 6. While we, the parents have noticed the problem, her kindergarten
teachers have not. Her repetitions look as follows:
 E-enough for for this doggie (Wy-wystarczy dla dla tego pieska).
 These will be mine but but o-one will protect you (To będą moje ale
ale je-jeden będzie ciebie chronił).
 Ma-marcel co-come to the room (Ma-marcel cho-chodź do pokoju).
 O, this-this mo-mo-money is enough for 3 ice-creams (O, za za tyle
mo-mo-można kupić 3 lody).
Her worst utterences were:
 Jakby-by nie nie żył, to to nie nie byłoby bajki. (If-if he not not alive,
then then there wou-wouldn’t be a story).
 Cause cause cause Kubuś has has a red ja-ja-jacket (Bo bo bo Kubuś
ma ma czerwony fi-fi-firaczek).
 A-auntie, will you come later to the the stadium? (Cio-ciociu, a
przyjdziecie później na na na stadion?).
Moreover, she often repeats a a, ja ja ja, bo bo bo, no no no. Although she

speaks without tension, it is noticeable. She began to use the word ten to help
herself. She may say something first and does not repeat that word, but will
then say the word ten when thinking of what to say next (i.e., she patches her
utterance). This has only begun recently.
One cannot say when the disfluency will occur - sometimes it occurs and
lasts for half a day, sometimes it is only momentary and the girl starts to speak
fluently again. However, she does not repeat words when she:
 plays on her own or repeat my words,

 talks to strangers,
 talks to me in the evening,
 describes a picture to me.
Instead, she repeats words in spontaneous speech or when she wants to

say too many things at once and very quickly.
Case Studies and Interviews 155
She had preferred to listen and observe others until she turned four and a
half. Now she keeps talking all the time.
My daughter was diagnosed in a psychological and pedagogical
counselling centre and her IQ is normal. Her visual perception is similar to that
of a 7-year-old. She has very good manual skills and auditory analysis.
I live in (…) and may easily come to meet you. I would be grateful for
your advice or suggested therapy.
Dominika’s mother’
Several years later I received another letter (fragments below):
‘(…) Our daughter is shy, very sensitive and always obedient. She was our
darling and was growing well. I remember people being jealous of a 4-year-
old girl who spoke so beautifully. She articulated every sound and spoke
beautifully, though rarely, because of her shyness. She started kindergarten at
the age of 3.
When she was 4 years and 9 months old, she started repeating syllables
and the word się. I was worried about it and shared my thoughts with my
husband who had had similar observations. Our child’s utterances were fluent
for some time and disfluency periods occurred about every other week like a
bolt out of the blue. It lasted for several days and then disappeared.
Disfluency periods which occurred regularly made me worried that my
child was beginning to stutter. It was getting on my nerves, so I began to look
into it. I promised myself to borrow every single book on stuttering which was
available in our library. I knew that I could not make my daughter aware of the
problem (so I could neither correct her, nor ask her to speak more slowly or
stop stuttering).
The more I engaged in it, the more serious the problem appeared. I could
not eat, sleep or function normally. I was frustrated and depressed. When I
came back from work, I used to ask the grandmother who was taking care of
the child to give me a detailed account of my child’s speech during the day.
She never did so when my daughter was around.
My biggest worry concerned my friends’ reactions so we limited our
social life. My daughter’s teacher was surprised to see my nervousness and
explained that she had not observed anything alarming. I was relieved to learn
that many preschool children speak disfluently. Apparently, everything was
fine. And yet, the disfluency became more frequent. I comforted myself that it
was never accompanied by synkineses or blocks.
A speech therapist advised me to practise breathing with my child, so we

blew bubbles, competed with each other in blowing plastic balls, feathers and
so on, all to no avail.
I once got hold of a book entitled ‘Early childhood stuttering’ by Professor
Tarkowski, which made me concerned whether my child experiences
developmental speech disfluency or suffers from early childhood stuttering. I
wanted to believe that it was the former, and began to observe my child more
carefully in order to find evidence. I noted down nearly every disfluent
utterance (…) and it turned out that the girl tended to repeat a a a, o o o, i i i,
ja ja ja, bo bo bo or initial syllables. I purchased a tape recorder and started to
record, then play back and analyse my daughter’s utterance. I was obsessed
about it, but could not work out a proper diagnosis as the disfluency kept
changing. Although disfluency was not becoming more severe, it was
occurring every day. I said, “Enough! I will not be able to cope with it on my
own. I need to find a specialist.”
I contacted a speech therapist who did not deal with stuttering and he
referred me to a psychologist who had participated in workshops on childhood
stuttering. The psychologist spoke to us in a routine way and began the
procedures by examining my child’s intelligence. I knew this was not the
problem but felt too embarrassed to leave the surgery.
I then decided to contact Professor Tarkowski via the ‘Orator’ Foundation,
described the problem and asked for support or therapy. I was surprised to
receive an instant reply and offer to help. When he invited us for the first
appointment, my daughter was 5 years 9 months old.
During the meeting, I told him about my doubts and my daughter’s
problems, while he offered support and advised to change her closest
environment. I was happy that finally something is changing and believed that
Professor will be able to help us.
The next day I completed all formalities so that my daughter could leave
the kindergarten and start attending a different class. She settled in very
quickly, made new friends with her peers and was happy to go to school every
day. Her form teacher was delighted and was constantly saying that she was a
wonderful girl and everybody liked her. It was surprising as her kindergarten
teacher used to complain that my daughter did not want to speak or eat. (…)
Both my husband and me were invited to another appointment and
Professor talked to us both together and individually. I still have no idea what
he and my husband talked about (I have not insisted on learning that).
However, my husband, who had been tired of me talking about speech
disfluency over and over again, was delighted as Professor forbade us to talk
about the disfluency with each other and instructed us to focus on other
important information instead. This was a fairly easy thing to do as we were
about to move house and we were expecting a baby. (…)
I was often tempted to talk to my husband about Dominika’s speech
disfluency. Although the problem was gradually disappearing, when it would
reappear, old wounds and bad habits would come back as well. In critical
moments I used to go out and leave my husband with our daughter, or I would
stay home so they could go out on a trip without me. Our lives changed again.
We were able to forget about the topic of Dominika’s speech disfluency in our
everyday conversations. Although I kept waiting for Professor to invite our
daughter and talk to her, it actually never happened.
The third appointment left me confused as the Professor suggested that
Dominika should live with someone from our family for a fortnight and avoid
contacting us (we were allowed only to have telephone conversations). This
was the most difficult task but I wanted to help my daughter so I agreed. She
moved temporarily to her aunt, who had a daughter and two sons of
Dominika’s age. We were reassured that their family relations are healthy so
sending our daughter there was the best choice. We had considered if
Dominika should stay at her grandmother’s house instead, but we had a very
close relationship with the grandmother at that time and she was just as
immersed in the problem as we were.
Those ten days were the longest in my life. I phoned my daughter once
and promised myself I would never do that again as we burst into tears and
found it difficult to calm down. The longed-for meeting came after ten days
and was marked with great happiness. We hugged, cried and talked for a very
long time. Our daughter told us many interesting stories and I was happy that
she wass alive and with me again. It only mattered that we were together
again.
We soon moved to a new house and Dominika enjoyed her new room
while putting her things into the new cupboard.
In our last appointment, we told Professor about the 10-day separation and
the joy at being together again and he reassured us that Dominika’s speech
disfluency will abate. Two weeks later, our second daughter was born and
Dominika, as an elder sister, helped me a lot. The speech disfluency abated
without us even noticing it.
It has been four years now since those difficult days and today, Dominika
is a wonderful daughter, a conscientious pupil and a fluent speaker.
Dominika’s parents’
2. A Unique Case Study

I am the stepfather of a boy who used to speak disfluently. I began the
study when the boy was two years and seven months old, and its first stage
finished when the boy turned six years and four months. The child was
observed continuously for nearly four years and the speech samples recorded
at that time proved that average frequency of speech disfluency was 5.4%.
Repetition, which appeared as first, remained a dominant symptom, and
was later accompanied by blocks, i.e., the inability to begin or continue an
utterance due to excessive muscle tension of speech organs. This stage lasted
for about half a year and was followed by sound prolongation with occasional
starters (noi-noi, abo-abo), interjections (yyy, aaa) and non-tense
prolongations.
As indicated by the results of my Logopedic Screening Test (7th sten) and
Child’s Vocabulary Test (8th sten), the boy’s language skills were appropriate
for his age. Having analysed the boy’s utterances, it can be concluded that he
used to speak a lot and construct long utterances of a complex semantic and
grammatical structure. Only his articulation remained below the age norm as
he had a serious speech defect with substitutions and sound elisions being the
dominant symptoms.
Pregnancy and delivery were normal and the child began to walk at the
age of one. Although no neurological symptoms were observed, there were
some family predisposition to speech disfluency as the boy’s sister had
experienced it in preschool, but then the disfluency abated. The boy’s
articulatory skills were considerably retarded and he displayed cross
lateralisation (right hand – left eye – right leg). Increased muscle tension of the
face and synkineses were observed only during stuttering.
The boy is intelligent, reflective, sensitive, cheerful, careful and would
rather hide his emotions or show them later than expressing them immediately.
He is very disciplined and polite and avoids conflicts with other children. He
has never shown any signs of fear of speaking, on the contrary, he has seemed
very open when talking to other people, even with strangers. The boy’s
linguistic awareness was well-developed and when misunderstood because of
speech defects, he would notice it and correct the articulatory mistakes. He
could imitate speech disfluency and there were good reasons to assume that he
became aware of his speech disorder at the age of five, despite the fact that he
would not call it stuttering.
Other people’s reactions to the speech disfluency differed. I used my

Reaction to Speech Disfluency Scale to examine both the mother and the
kindergarten teacher, and observed that cognitive and emotional reactions had
changed more than just behaviour. This became evident in four examinations
of the mother conducted at different times.
During the first examination the boy was four and, according to his
mother, less fluent than his peers, although his stuttering was mild. She was
convinced that speech disfluency would not abate and she kept thinking about
it irrespective of its severity. Although she did not consider speech fluency
disorders a serious problem, she was willing to consult a specialist. She
claimed she knew the reason why her child stuttered and believed that people
react badly to stammering.
The first examination proved that the mother’s behavioural reactions were
basically positive and, although she found it difficult to ignore symptoms of
speech disfluency, she did not try to correct them, calm the child, slow down
or finish his utterance. This correctness in the sphere of behaviours did not go
along correctness in the emotional one, as the examination showed the mother
reacted with increased tension, relative anger, impatience and irritation.
Altogether, the first examination displayed most negative reactions within the
cognitive sphere, less in the emotional one and the least in the behavioural
one.
The second examination was conducted four months later and its results
were similar to that of the first test. The mother still regarded her son’s
stuttering as mild and she would think of his speech disfluency irrespective of
its severity. She believed she knew the reason for his stuttering but was
reluctant to name it. She listened to her son’s utterances too attentively,
reacted to every symptom of speech disfluency and when it occurred, she felt
increased tension, impatience, anger and irritation. She found her child’s
stammering stressful. However, some positive reactions also occurred, e.g.,
coping in a difficult situation and not interrupting a speech act.
During the third examination, the boy was 5 years and 4 months old and
the mother changed her opinion drastically. Although the boy was still more
disfluent than his peers, she claimed that he does not stutter and while the
problem was not regarded as serious, she kept thinking about it. She did not
display many of the negative emotions observed before and still claimed she
knew the cause of her child’s speech disfluency. She also believed people
reacted badly to stammering.
When the boy turned six, the mother’s reactions improved considerably.
Not only did she think that her child did not stutter, but also believed he was as
fluent as his peers. Although she no longer focused on her son’s speech
disfluency, she still felt increased tension and impatience when occasional
speech disfluency symptoms occurred.
The following five basic stages of developing speech disfluency can be
identified based on longitudinal studies conducted:
Stage 1: Basically Fluent Speech (1.0–2.5)
The boy started saying his first words when he was one and the first two-
word combinations occurred when he was one year and six months old. The
length and complexity of his utterances increased gradually. Occasional
syllable repetitions appeared towards the end of this stage and were regarded
by people as an element of child’s babble.
Stage 2: Developmental Speech Disfluency (2.6–3.3)
The frequency of syllable, and less often word, repetitions considerably

increased and reached between two and seven repeated elements. They
occurred every day and were easily noticed by other people. However, it was a
period of natural speech disfluency which was not accompanied by increased
muscle tension within the speech apparatus, synkineses or breathing
difficulties. Unaware of his speech disfluency, the boy spoke openly and a lot.
Both the mother and other people still believed the child was not stuttering but
that he was speaking in a form typical of children at this age. A typical
utterance at that stage was:
Mother (M): Maybe you’ve had enough of this water (Może starczy tej
wody).
Son (S): Enough, we’ll put together some presents for you (Śtajci, będziem
montować pjezienty dja ciebie).
M: Super (Super).
S: O-o-o, only-only-only loo-loo-look how I-I-I am playing a building site
(Ti-ti-ti, tijko-tijko-tijko, po-po-po-popatś jak ja ja ja się bawię w budowe).
M: You’re building a house. Can I help you? (Budujesz dom, może ci
pomóc?).
S: Yes, help (Tak, pomóć).
M: What are going to do here? (A tu co będziesz robił?).
S: P-pu-pu make presents (P-po-po, ziamontuje pjezienty).

M: Who are you making presents for? (Dla kogo montujesz prezenty?)
S: I-I-I will tell, I’m making presents for mum (Ja-ja-ja siam powiem,
montujem pjezienty dja mamy).
M: Good, I like getting presents very much (Dobrze, bardzo lubię
dostawać prezenty).
S: Me-me-me too, but Mikołaj will not get any present (Ja-ja-ja teś, aje
Mikołaj nie dośtanie ziadnego pjezientu).
M: Why? (Dlaczego?).
S: O-o-o-only me (Ti-ti-ti-tijko ja).
S: Car with a remote control (Siamochód ź pijotem).
M: What a nice drill, what do we do with a drill? (Ale świetna wiertarka,
co robimy wiertarką?).
S: This-this we do and-and-and I-I don’t know, may-may-maybe drill here,
here but not for me (Coś- coś jobimy a-a- a ja- ja niewm cio, mo- mo- mozieś
wiejcić tu, tutaj aje mi nie).
Stage 3: Stuttering (3.4–3.9)
A fit of real stuttering came in August 2008 after a 30-day separation from
the mother (the child had stayed with his father) and three days in a new group
in the kindergarten. The boy was unable to finish any utterance and would
hold his cheeks when a block would come in order to facilitate speaking.
Increased face muscle tension occurred during disfluent speech and the boy
moved his hands to make speaking easier. Sound and syllable repetition
became severe and reached as many as ten repeated elements. When the boy
was left home alone, the frequency of speech disfluency symptoms began to
decrease gradually. However, new symptoms occurred which were supposed
to make it easier to begin an utterance e.g., sound prolongation or starters (no i
– no i). The boy ignored his speech disfluency, and still spoke much and
openly. His disfluency was noticed at the kindergarten and described as
stuttering by his teacher and mother. Moreover, the boy experienced restless
sleep and bedtime wetting, so the mother introduced toilet training and took
the child to the potty at night. Although she feared it would increase speech
disfluency, in fact, the disfluency eventually decreased and bedtime wetting
abated over time.
A typical utterance at that stage was:
M: Maybe this would be a stick (Może to będzie patyczek).

S: Mo-mo____nnno, ‘cause this is for sawing (Mo-mo____nnnie, bo to
jeśt do piłowania).
M: I already have the stethoscope, doctor. What patients have we got
(Mam już słuchawki, panie doktorze. Jakich mamy pacjentów?).
S: Kubuś and the deer (Kubuś, łosiek).
M: What other patients are we going to have? Put on the stethoscope,
doctor. Good morning, doctor (Jakiego pacjenta jeszcze będziemy mieć?
Zakładaj słuchawki, panie doktorze. Dzień dobry, panie doktorze).
S: So (…) what happened? (No (…) cccio się śtało?).
M: Kubuś is ill, has a headache, sore throat and is sneezing (Kubuś jest
chory, boli go główka, gardełko, no i ma katar).
S: Open your mouth wide (Otwóś ssiejoko pyściek).
M: And he has to open his mouth wide, without a spatula (A pyszczek ma
szeroko otworzyć, bez patyczka).
S: We’ll manage without a spatula. The to-to-to-tongue is red. You have to
go to the doctor (Beź patyćka uda się. Je- jeśt ziaciejwieniony ję-ję–ję-jęzik.
Musicie iść do pana doćtoja).
M: To a laryngologist (Do laryngologa).
S: Yes, to do something, injections (Tak, zieby cioś tam źjobił ziaśtsiki).
M: Maybe we’ll manage without injections, maybe some syrup. Please
sound him again (Może bez zastrzyków się obędzie, może jakiś syrop. Proszę
go jeszcze osłuchać).
S: No (…) I have a syrup here, two syrops (Nie (…) mam tu sijop, dwa
sijopy.)
Stage 4: Return to Developmental Speech Disfluency (3.10–

5.8)
Tense physiological disfluency in the form of blocks and prolongations

practically abated and was replaced by semantic disfluency which consisted of
problems with shifting from one piece of information to another. The boy
spoke faster than he thought and started his utterances with interjections as he
wanted to keep his interlocutor’s (usually his mother’s) attention while not
knowing exactly what he wanted to say. This made the mother angry, so she
would demand he think before speaking. Although she used a message ‘Speak
without that no’, the boy ignored it. He spoke a lot, without any tension,
synkineses or logophobia. Sound repetitions happened occasionally and the
mother believed the boy did not stutter.
M: Maybe this will be a car park? (Może to będzie parking

samochodowy?)
S: No (…) cause this is a robot – this is a robot and this is a robot and
this is a sandman (…) like that (…) not this one (…) this is separate they have
to draw it (…) cause this is daddy’s son (…) this big and tall and sandman.
But you will also play. You will be a sandman and I will be a Spiderman (…)
like that (Ne (…) bo to jest jobot- to jest jobot i to jest jobot a to jest
piaskowiec (…) o tak (…) nie to (…) to odziejnie oni mają to najisować (…)
bo to jest sinek taty (…) ten duzi i hajego i piaskowiec. No aje ty tez się
będzies bawić. Ty będzies piaskowcem, a ja Spajdejmenem. Spajdejmen (…) o
tak).
M: So drink, I already feel better (To napij się, od razu mi lepiej).
S: So this is a good syrop. But you put it like that (…) this is a mug. Tudio,
you missed. Who wins? Maybe me and Ha-ha-harry is fighting with a lorry
(No to jest dobji sijop. No aje to tak się zakłada (…) to jeśt taki kubeciek.
Tudio, nie tjafiłeś, kto wigjiwa? Chyba ja, a ha- ha-haji wajci ź cięziajówą).
M: Is he fighting with a lorry? (Z ciężarówką walczy?).
S: But it has to stand like this (…) and here is a sandstone launcher. Now
don’t (No aje musi tak stać (...) a śtąd jest taka wyrzutnia do piaśkowca.
Najazie mi tu nioe).
At this stage the frequency of interjections and prolongations increased

and they would occur both at the beginning of an utterance and at the linking
between complex sentences. In a similar way, symptoms of disfluency
occurred at the beginning of an utterance and when moving from one sentence
to another. Speech disfluency would also increase when the boy joined a
conversation with a random topic in order to distract his mother’s attention
from another interlocutor and focus on himself. Typically the boy was able to
put himself forward better than other speakers. Although the child was likely
to be aware of his speech difficulties, this referred more to speech defects than
speech disfluency. Despite speaking a lot, he did not display any synkineses or
symptoms of logophobia. The mother claimed the boy did not stutter, while
the teacher noticed that he was often disfluent.
Stage 5: Relapse of Stuttering (5.9–6.0)
Stuttering relapsed when the boy came back after a month spent at his
father’s. It was a tense disfluency of increased intensity, visible and
accompanied by increased muscle tension, mainly within the facial area.
Dominant symptoms included tense syllable repetition and prolongation as
well as blocks lasting more than ten seconds. When a block came, facial
muscles are particularly tense, while a tongue is placed between the teeth and
performs tonic movements. Synkineses in the form of waving hands occurred
as well, but the block would not disappear despite him adopting this form of
coping. Instead, it took a while for the tension to disappear so that the boy
could continue his utterance. Often he would begin it and not end because of
the block.
S: It-it-it (…) it-it is my friend’s____ it-it-it is our friend-captain’s. All

those standing here are good (…) a-and this is also my friend (…) he-he-he
sleeps standing (…) so I took him. My friend, one more question: do-do you
know where Southern Warsaw is as I don’t know (To-to-to nas (…) to- to
mojego kolegi____ to- to-to nasego kolegi dowódcy. Wsyscy któji tu stoją są
dobij (…) a- a ten tez jest mój znajomy (…) on-on-on śpi na stojąco (…) więc
go zabjałem. Kolego jesce jedno pytanie cy- cy wies gdzie jest Wajsawa
południowa bo ja nie wiem).
M: So maybe you’ll come in to my house (To może wejdziesz do mnie do
domu).
S: Yyyy so maybe we’ll go to a swimming pool and-and we’ll play yy___
yu___ in shops up there yy maybe we’ll play at my house yy we’ll drink coffe
and tea and then we’ll go to my place and play computer games and then we’ll
go for a night walk (Yyyy to moze pójdziemy na basen i- i zagjamy na yy___ w
ju___ w gójnych sklepach yy może zagjamy w moim domu yy napijemy się
kawki i hejbaty potem pójdziemy do mnie i pogjamy sobie na komputeze a
potem pójdziemy na nocny spocej).
S: not give a fine. Sooo___ you need to watch out (nie wstawić mandatu.
Taaak ____ ze musis uważać).
When the boy was 5 years and 10 months old, he became fully aware of
his stuttering and logophobia appeared, as can be seen in the conversation
below:
S: Because I get excited (Bo ja się podniecam).
M: And what happens when you get excited? What has it started with? (I
co się dzieje, jak się podniecasz? A zaczęło się od czego?).
S: So yyy when he were sitting at a table and ea-eating breakfast Damian
told me that (No yyy jak siedzieliśmy przy stoliku i je-jedliśmy śniadanie to
Damian tak mi powiedział).
M: Damian told you that, and what did he tell you? (Damian tak ci
powiedział, no i co ci powiedział?).
S: That I get excited (No tak ze się podniecam).
M: So what happens when you get excited? (Jak się podniecasz, to co
wtedy się dzieje?).
S: Yyy that I just get excited (Yyy ze się po pjostu podniecam).
M: And what happens then? (I co wtedy się dzieje?).
S: Then I’m afraid that I will say wrongly (Wtedy się boje ze się, ze źle
powiem).
M: And it was like that today? (I dzisiaj tak było?).
S: Oh yes, but not yet when I was eating breakfast and lying today (O tak,
tylko dzisiaj jak jadłem śniadanie i jak leżałem to jesce nie).
M: And what did you answer Damian? (I co ty Damianowi
powiedziałeś?).
S: One word, that if I say like that then I don’t remember, and if I say like
that then I remember (Jedno słowo, ze jak powiem tak to nie pamiętam, a jak
tak to pamiętam).
M: So you don’t remember what you told Damian. And what happens
when you get excited like that? What are you afraid of? (Czyli nie pamiętasz,
co powiedziałeś Damianowi. I co się dzieje, jak się tak podniecasz? Czego się
boisz?).
S: About about I am afraid (O to-o to ze się-ze się boję).
M: What are you afraid of? (O co się boisz?).
S: That I will say badly (Ze źle powiem).
M: Badly meaning unclearly? (Źle, czyli niewyraźnie?).
S: Yyy that I get excited and start yyy____ a-a-_a, for example Adrian
(Yyy ze się podniecam to zacynam yyy____ a-a_a, na psykład Adrian).
M: That you begin to repeat? (Że zaczynasz powtarzać?).
S: For example like da-dad (Na psykład jak ta-tata).
M: So how do you say then? (To jak wtedy mówisz?).
S: T-t-t (T-t-t).
M: And Damian told you about that? (I Damian ci zwrócił na to uwagę?).
S: But only when we were at kindergarten (No (…) dopiejo jak byliśmy w
psedskolu).
M: Yes (No tak).

S: Wh-wh-why are you looking at me like that? (Ce-Ce-cemu wy tak się na
mnie patsycie?).
M: Because you’re a clever boy (Bo jesteś mądry chłopak).
S: And now I got excited whe-when I said you were looking at me (No i
tejaz się podniecałem ja-jak powiedziałem ze się na mnie patsycie).
M: What did you say to Damian when he asked why you spoke like that?
(Kiedy Damian pytał, czemu tak mówisz, to co mu powiedziałeś?).
S: That I get excited (…) but he- he I (…) he said that I get excited (…)
and I told him I only get excited (To ze się podniecam (…) tylko on-on mi (…)
on powiedział ze się podniecam (…) a ja mu powiedziałem ze się tylko
podniecam).
M: Do you get excited when you start speaking or when you are already
speaking? (Ty się podniecasz, jak zaczynasz mówić, czy jak już mówisz?).
S: Yyy so-sometimes when I sssstart _______ to speak (…) sometimes
when I don’t start (Yyy ca-casem jak zzzacynam _______ mówić (…) casami
jak nie zacynam).
M: Where does this excitement come from? You said you are afraid that
you will speak badly (Skąd się bierze to podniecenie w tobie? Mówiłeś, że się
boisz, że źle powiesz).
S: Yes (No tak).
M: And do you think before you say something? (A czy zastanawiasz się,
zanim coś powiesz?).
S: I simply speak. So-sometimes I think (…) sometimes I talk straight
away. It is a little easier when I think. That’s why I think ho-how to say (Po
pjostu mówie. Ca- casem się zastanawiam (…) casami zajaz mówie. Jak się
zastanawiam no to jest mi tjosecke łatwiej. Dlatego ze się zastanawiam ja-jak
powiedzieć).
M.: What a boy you are! (Ale ty jesteś).
S: Iii love you, mum (Jaa ciebie kocham, mamo).
Stage 6: Speech Fluency (6.1–6.5)
Speech fluency improved considerably when the boy turned six.

Symptoms of speech disfluency were rare and typically included interjections
and non-tense repetitions, which awee imperceptible for other people. The
mother claimed that her son stopped stuttering and hoped stuttering would
never relapse. The symptoms became slightly more intense before travelling to
the father, however, after coming back the boy still spoke fluently. He was still
under observation because speech fluency could relapse as the underlying
psychological conflicts had not been resolved.
The periodic presentation of early childhood stuttering partially supports
the stages of development of stuttering as presented by various authors. In the
initial stage natural speech disfluency typically precedes pathological
disfluency and interchanges with a tendency to abate and relapse. Such
instability confuses both parents and specialists.
The aetiology of early childhood disfluency identified three types of
factors: predisposing, precipitating and perpetuating.
In the case described above, family predisposition to speech fluency
disorders had been observed as the boy’s elder sister would speak disfluently.
Other predisposing factors include poor articulatory skills and cross-
lateralisation in the child.
The precipitating factors consist of separation from the mother, a change
of environment (moving to a different group in a kindergarten) as well as
family conflicts.
The following factors perpetuate the disfluent speech: tendency to
compete and the communicative stress it triggers, as well as developing a habit
of speaking disfluently. The boy competed with other important people for his
mother’s attention and this was particularly noticeable in the polydialogue in
which the boy wanted the mother to quit the conversation she has been having
by starting to speak (mainly disfluently) on a random topic. When the mother
ignored him, the severity of speech disfluency symptoms increased and the
mother started talking to the child, which was a reinforcement of the
momentary speech disfluency. Once mother’s attention was caught, the boy’s
anxiety temporarily decreases. Therefore, in that situation, speech disfluency
performed the function of a reducer.
Today the boy is eleven years old and speaks fluently without any speech
defects. He is a very good and well-behaved pupil. This is his mother’s
account:
‘The speech disfluency of my son abated when he was six and I haven’t
observed any symptoms of stuttering ever since. In moments of anxiety and
strong irritation, I have observed in my child muscle tension within the speech
apparatus, particularly the lips. He coped well with the new changes in his life
when he had to change his place of living and, consequently, school. He said
‘goodbye’ to his old friends and was making new friends. In the final grade,
his new teacher wrote: ‘A very polite, well-behaved and nice pupil. He is fully
engaged in his school duties, focuses on his work and performs it on his own.
He is able to establish good relationships with his peers. The boy behaves well
in public places and during school trips. He has achieved good results at
school.’
Our son is still a very sensitive and empathic child who is willing to help
others. The boy likes to spend time with his peers and seeks out their
company, though not at every cost. He does not like everybody and prefers to
have one good friend instead. He has good relationships with adults and is
confident in their company. When facing difficult situations, the boy remains
composed and calm, though he suppresses his emotions and feelings. He cares
about others, often to his own detriment and likes sports games and plays,
books, computer and good food. He does not like peas, bean and girls (yet).’
3. From a Student’s Diary

These are fragments of a diary written by a student of a top university in
Warsaw.
“It will be much easier if I begin with explaining my theories and
conclusions about my speech disfluency. My first problem is my inferiority
complex about where I come from compared to other people in the capital of
our country. (…) Another thing is the issue of money, and the fact that I do not
feel fully accepted by others because of my parents’ financial situation. I heard
a remark: “Rejected by the village. Unwanted in the city,” which describes my
attitude towards my acquaintances. It is fairly clear to me that I have such
inferiority complexes. I go off the deep end when I realise how much influence
they have on me and suppressing them is exhausting and somehow unnatural.
To continue this topic, let’s move on to the sphere of family relations – the
closest ones. We live in the village, they live in the city. We succeeded, but
they succeeded even more. When we meet up during holidays or celebrations,
we all sit around the table in the same setup. And hear the same success stories
of children who were sitting quietly beside them. At such meetings, parents
were boasting about our successes and I felt betrayed by them. I didn’t want
them to do it but knew that they found it really enjoyable to do so. In such
moments I would sit quietly and let them be at least a little proud of their sons.
My brother was not bringing them any honour, instead he was pushing
them in the obvious direction. I tried to behave differently and give my parents
at least small reasons to be proud.
And here we come to the trilateral relations of my parents, my brother and

me. Let’s call the parents-brother relation as sick, although I find it difficult to
agree to this adjective, but let it be. Their relationship was full of screaming,
aggression, tears, regret, guilt and gradually increasing distrust. At that
moment, I was just listening and learning how I should live and what I should
avoid. I tried to separate my regret from anger and helplessness. It was like
that for a long time.
Obviously, there was a peaceful relation between my parents and me, bred
with my successes which became natural as time passed. Although I used to
get everything I asked for and never thought of it like that, it turns out that my
parents were focused on my brother’s pranks more than on my successes. So
we have a deficiency of attention paid to my successes and an excess of it paid
to my brother’s problems.
However hard I try, I feel rejected and unimportant. I do understand that
my parents’ attitude was justified and purposeful as my brother has been given
another chance thanks to it. Still, the sense of neglect that I felt has had serious
effects and dominates over reasonable thinking.
In my case, it resulted in speech disfluency because of all that tension. The
disease became visible. (…) My stuttering was supposed to attract my parents’
attention. One may say I was lucky as others would probably turn to drugs or
alcohol, whereas I was only stuttering at times. But sometimes even I
underestimated it. My parents seemed to be starting to understand it all, but it
came slowly as at school everything was okay. However, I still feel that I’m
accusing them of causing it..
Conclusions: I can’t really accept this option, but acceptance will probably
come with time as I feel that I’m becoming more convinced of it. I don’t want
to overuse the general statement that unmet need to be noticed and not taking
care of it leads to serious negative consequences. I don’t want to abuse it,
otherwise I would justify many of my faults, stupid decisions and excesses by
simply saying that parents did not notice my successes. (…)
The saying that ‘time is money’ is appropriate here as, since I’m
dependent on my parents, they exchange their money for my time. And when
they send me money, I feel I owe them something. In this way, you can
connect the dots. I fear most that I’m losing the will to fight for myself as I
should limit the money I take from my parents if I want to free myself from it.
I have to choose what is more important to me: comfort and financial security,
or emotional freedom and the ability to become a responsible person. The
problem lies in being dependent on someone close and letting them make you
dependent.
My parents protect me from the evil of the world (or the things they
consider evil) driven by their parental love. They may think that if
experiencing happiness means experiencing evil as well, then it is not worth it.
However, life is becoming more and more attractive to me. They cannot
compete with it.
And I burst into tears. It took a while before I made myself cry and the
crying itself was short and, I guess, unsure. The reason for the tears was that I
recalled a number of events from my life and what was said at the table, but
the decisive moment was when I realised that I had never experienced greater
interest in myself than during the final days of my therapy. We were speaking
about me and what I am like. My parents never initiated such conversations. It
was the first time ever. However, they were not tears of joy. I do not feel
resentment towards my parents, just that the very awareness of it makes me
perceive our relationships and myself differently.
What about this attractive world? I feel it attracts me even more. They are
trying to keep me with their money. Obviously, they aren’t doing it on
purpose, but the effect is that it builds my sense of dependence on them. Just
as if they are buying themselves the right to some part of my life.
My reserved attitude when meeting women results from my fear of being
rejected. I fear that a woman will simply become disappointed and will break
up as soon as I show my real self. This is because I tried to open my heart to
my mum several times but was hurt by her lack of understanding. Usually
when I begin to talk, she bursts into tears instead of listening to me and
talking. I have never needed a person who cries when I need help, especially
when it comes to feelings and emotions.
As for my relationships with women, I often feel anxious about my older
friends’ reactions. If they’re present, I lose my confidence while speaking to
girls. Before I say anything, I always wonder what their reaction and response
will be.
On the previous page I wrote that cutting down on parents’ money is the
only way for me to get rid of the sense of dependence. So I think this is not
really the case. It’s more about getting addicted to their promises whivh are
fulfilled by the money they give me. That addiction to their belief that I’m not
mature and responsible enough to live my own life. To put it differently, they
should become independent of the subconscious control they have over my
life. Sadly, they do it by mixing love with a little bit of money. Sadly, they
want to control and advise instead of observing. And their advice is always
accompanied by tears and money. I hate it when my mother cries. It moves me
completely. But at least I know what to do then.
So why should I blame someone else for my discomfort in the presence of

people from the city? I feel ashamed that I feel ashamed for coming from the
village. I regard it as unimportant when I talk to my friends from the city.
There are so many different topics to talk about! They don’t bother me with
the topic of their parents either. That’s right! They are afraid of talking about
it. I think that deep down, they associate a person from the village with a dirty
and stinky moron, and they know nothing about life in the village. They are
afraid that someone may think I managed to get away thanks to my parents’
money only and that I don’t have any particular values whatsoever. But if
someone thinks like that and says it out loud, I’m done with him. He would
have no way to redeem himself, which I also think is a pitiful reaction of mine.
This is what you call obsession. I don’t want my parents to think that I have an
inferiority complex about my background and blame themselves for it. Your
background is unimportant in interpersonal relationships but I somehow
cannot stop thinking about it. I get the impression that I am mistaken and
cannot truly open up to others.
Now, when I’m a student, my parents want me to focus my attention on
them. They want me to go with them everywhere, talk to them on their
favourite topics, describe what I ate at my friend’s, what he has in his house,
what his parents and relations are, what the apprenticeship was like. They take
me everywhere and I agree just to make them happy. (…) My blood boils
when I think of going there again.
I’d like to be like my roommate who doesn’t care. He just went to the
States for the entire summer holidays. And at that time I was sitting with my
parents because they had asked me to come. Why do they transfer their need
of compensation onto me? They don’t want to travel with my brother despite
the fact that he finds it more pleasant than I do. I’m supposed to return what
they have never given to me - attention! Only the objects of attention are
different for them and me.
Suppressing emotion made my life miserable, especially during therapy. I
hadn’t felt such a shock with my parents.
My parents love me but, apparently, loving and feeling that you love
someone is far from making this person feel loved. A difficult thing to do,
probably the most difficult one. The conclusion is that my life was chaotic
when I was all alone. While my brother shared his problems with the whole
family, I was standing in the sideline. I have my own conclusion that maybe
my brother’s unwanted inclinations which caused him troubles were caused by
the fact that back in the past, my parents had focused more on me than on him.
It’s a pity that I don’t remember it. Of course I was and, I’m sure, will always
be loved by my parents, but apparently a child needs the parents to prove their
love. All my emotions developed at home but have were released there. I s
asking my parents to make up for all those important years a way to get rid of
this stigma? Or maybe I should look for evidence of their real love?
Sometimes, when I think that something terrible might happen to me, I feel
how greatly ashamed I would be when I see them. I think that they do not let
themselves think that I might make mistakes, so I’d rather not make them
because it might be difficult to get over them. I know it’s a bit sick but I can
see my parents coming to me and arguing because I let them know that I’m in
need. I sometimes feel sick to see how they behave because I feel that I’m
starting to behave in the same way.’
To what extent can a child and then an adolescent be responsible for their
emotions? Stuttering is a “disease of guilt”.
4. A Couple of PWS
After a free lecture I gave on stuttering I was approached by a student who
described herself as a PWS despite speaking fluently at the moment. She said
she needed therapy but was unsure whether this was even possible. When I
offered to help, she introduced her stuttering boyfriend, a student as well. They
were planning to get married and have children but fear their children will
stutter, too. This is how I met a pair of friendly, intelligent and determined
young people who stutter. Their opinions regarding the important topics are
written below:
1. Should Stuttering Be Accepted?
Woman: I think that stuttering should not be accepted as it does not

motivate one to fight with it effectively. Stuttering is a speech disorder which
should be eliminated and we need to perceive it as a problem in order to get rid
of it. If we accept stuttering, we will not be able to fight it successfully. I think
that neither should we accept stuttering in other people. I guess that if people
had commented on my stuttering more often, I would have started doing
something about it earlier. On the other hand, I could have felt rejected and
I’m not sure if I would have been able to cope with it. I believe other people’s
role is to make a PWS aware that he or she should fight his or her stuttering
but their remarks need to address stuttering and not the PWS. They should
motivate and not insult. I think that if other people don’t accept stuttering, the
PWS will also feel motivated to get rid of the disorder.
Man: One should accept a PWS but not his or her stuttering. There’s
nothing worse than accepting stuttering. Me and my friends and family have
been doing so for most of my life and it hasn’t done any good. After some
time I understood that it is an intrinsic defect, something which one has to live
with until the end of one’s life. And that is not the only point. One should do
their best to eliminate stuttering, prove that they can do it and be a role model
for others. It is a real test of our character. We will raise our own value and
become highly motivated to complete other goals. I’m sure that, after such an
experience, every other goal will be easier to attain. To sum up, if we accept
stuttering, we give up, we don’t believe, we take the easiest possible way. If
we fight against it, we succeed at the very beginning as we manage to begin
the fight and have 100% chances of winning. And this is what it is all about.
2. Can You Completely Recover from Stuttering?
Woman: I think you can cure stuttering. Obviously, it is not easy, it

requires a lot of effort and hard work, but if I perform all the tasks and do not
give up, I will achieve my goal. It is crucial to change present habits and apply
the new methods. I think that stuttering may relapse because of high stress, so
one should be careful and, when in stressful situations, focus even more on
appropriate speaking and relax more often. Since we are not able to eliminate
stress from our lives, it is important to learn the new rules and not return to old
habits. It is achievable.
Man: I have not heard of any other cases of stuttering apart from mine and
my girlfriend’s, but yes, I believe so, definitely. You need to spend a lot of
time and effort to improve your speech to perfection. Just like in training. You
first need to work by the sweat of your brow in order to shed less blood later
on. When you achieve your target effect, you should at least maintain it and
always remember about the training. The absence of training may lead to a
relapse of the disease later on and this will be the worst nightmare to anyone
who managed to recover from stuttering. You need to transform your old
speaking habits into new and effective ones, relax your body and treat your
speech as a natural form of interpersonal communication rather than a
punishment. Forget your old habits, which did no good and, most importantly,
keep repeating ‘I can speak fluently!’. Faith can work wonders. If we believe
in ourselves, we can move mountains. People get over various tumours,

diseases and live happily ever after, so why can’t you get over stuttering?
3. How Has Stuttering Influenced Your Life?
Woman: Typically stuttering had a negative influence on my life. It would

become particularly intense when I met new people. When I tried to speak
fluently, the effect was quite the opposite. This was really irritating and I felt
ashamed, which led to me limiting contact with other people to the minimum.
I asked different people to do things for me. This made me dependent on
others, which made my life even more difficult. Stuttering influenced by self-
esteem issues as well. The more I stuttered, the more inferior and less
attractive I felt. Blocks, which occurred in high stress, were the worst as I
couldn’t say a word then. I would make a long, involuntary break and feel
terribly ashamed of it. Thus, I rarely spoke, even if I wanted to say something.
The more reserved I became, the worse it got. It all led to a point where I was
afraid of speaking and delivering lectures. I would start wondering long before
and think of how to get out of it.
Spontaneous volunteering to answer teacher’s questions became a good
way to avoid blocks. It reduced my stuttering to some extent but did not
eliminate it completely. Instead, it made me focus only on how I spoke and
whether I stuttered rather than what I was speaking about. At that time my
utterances were chaotic and incomprehensible. When I recall the faces of some
people I spoke to while stuttering, I wonder if that strange expression on their
faces was their reaction to my stuttering or whether I made my utterance so
complex that they were trying hard to understand it.
Man: Stuttering had a serious impact on my life. I think it is a speech
disorder which becomes evident when you communicate with others. I
experienced that at the age of six.
I remember what I had been like before the surgery: I had been here, there
and everywhere, had been talkative and full of ideas and questions. After the
surgery I began to have problems communicating with my parents, my brother
and other people. My role as a lively and chatty child was reduced to nodding
and listening. At PE lessons, I would be the eleventh footballer or the seventh
volleyball player, always beyond the pitch. I felt really awful as I used to
dominate before and then everything changed completely. Besides,
appointments with the speech therapist would exhaust me. If you perform a
task for the first or second time, it is interesting, but if you are supposed to
repeat it ten or twenty times, you get fed up with it and do the task
perfunctorily.
At that time I was at a crossroads. On one hand, I wanted to speak like my
peers, on the other hand, I was hoping to visit the speech therapist for the very
last time. I tried to speak relatively fluently and practised my pronunciation on
my own. The playground or school was always the best test of my skills.
With time, I became part of the group and stopped doing the exercises,
which was my problem. I remember being humiliated by my teacher who put a
remark ‘problems with pronunciation’ into my Patient Summary Form. In my
class, there was a girl with a terribly deformed jaw, who spoke much worse
than I did. While the girl did not get any remarks, I was laughed at by my
peers.
My oral exam was the biggest tragedy. I prepared my presentation and,
while it was not the best I could have done, I had expected better results. The
first stammer came, followed by a block. No self-confidence. I wasn’t even
looking at the examiners. I just wanted to finish my utterance and run out of
the room.
I used to have more adventures that embarrassed me to a different extent.
However, with time, I became tougher, more patient and much more
composed. But I also experienced feelings such as shame, humiliation, a lack
of self-confidence and a sense of being lost. I would feel sorry for myself,
become reserved, be afraid of other people, have a complex about being
inferior, and many more.
Fortunately, that’s long gone. The less I stutter, the happier I am. I
sometimes wonder what I would do now if I hadn’t stuttered. It’s a very broad
subject and I could think of it endlessly. One thing I know is that life would be
much easier without stuttering. Would I be the same person I am now? I’m not
sure. After all, this has been my whole life.
4. What Benefits Can Stuttering Offer?
Woman: When I think of the benefits of stuttering, I actually see a lot

more drawbacks. In my case, I reaped some benefits during oral tasks as
teachers would typically assume that I know everything and would end my
utterance in order to prevent me from stress and stuttering. While they smiled
to me and offered me hints, other students would typically only get to see their
poker faces.
I think that learning to observe is another benefit of stuttering. Stuttering,

or rather the fear of stuttering, made me watch my interlocutor more
attentively, especially if we met or talked for the first time. If I hadn’t been
stuttering, most probably I wouldn’t have let anybody get a word in edgewise.
Man: In my humble opinion, stuttering does not offer any benefits, but
only drawbacks. I am aware of the fact that people are different and they like
different things. I have always liked competing and I have liked winning even
more. When you win, you can enjoy your success for years. But when you
compete with someone, for example, over a distance of 100m, but you start
after 50m and you win, then what is there to be happy about? With stuttering,
it is a similar story.
I have never expected to be given favours, mercy or the so-called
advantage. If you like it and accept it, that’s your business. You’ll have friends
who will be merciful to you. That would be terribly stupid.
My stuttering made me want to be just like others, not ‘exceptional in a
special way.’ My mum would spend more time with me than she would with
my brother but is that an advantage? He was running, jumping and playing
with his peers while I was sitting at a speech therapist’s, or with mum at home
and memorising the rules.
What about school? I would attempt to say a sentence while others would
make fun of me or gossip. And work? I haven’t experienced anything
unpleasant from my colleagues myself, but I have heard of PWS who have.
The only PWS I know is Owsiak (translator’s note: the President of Wielka
Orkiestra Świątecznej Pomocy, which is one of the largest NGOs in Poland).
BHe is liked and admired, not because he happens to be disfluent, but because
he works at Wielka Orkiestra Świątecznej Pomocy.
The only nice thing which happened to me in relation to stuttering was
that several girls said that my stuttering was ‘sweet.’ But I don’t perceive it as
a benefit. If you ask a PWS if he wants to speak fluently, he will always
answer ‘yes.’ If you ask a fluent speaker if he wants to stutter, he will always
answer ‘no.’
5. What Will My Life Be Like without Stuttering?
Woman: My life without stuttering will definitely be happier as I will not

waste time wondering what would happen if I started speaking fluently. I think
that I will regain much of my self-confidence, I hope my boyfriend can bear.
As a fluent speaker, it will be easier to I achieve my goals, most importantly, I
will not be dependent on other people. I will use my mobile phone more often
and will not waste time doing things on my own. I believe fluent speech will
facilitate my contact with others and I will meet many new and interesting
people. Surely, I will be more self-confident and spontaneous, which will
make me undertake greater challenges and achieve much more.
Man: My life without stuttering will surely be easier. When stuttering
disappears, other problems will disappear as well and I will forget about stress
and nervousness. My self-confidence will reach a high level and my manner of
communicating will become natural and will not annoy me anymore. I will
still pursue perfection in what I do, but I will have a wonderful proof that
things can be changed. This may not be important for others, but I consider it
significant. My self-assessment will also improve.
5. Professor Bogdan Adamczyk,

a Physicist and Therapist, the Author
of the ‘Echo’ Method
Did I stutter? Well, it depended on who I was speaking to. And not
only that.
For me stuttering is, and will still be, a fascinating mystery.
When I spoke to myself, I did not stutter.
My stuttering has fascinated me since I could remember, and the fact that I
was fully fluent when I was talking to myself was particularly amazing. I liked
to stand in front of a mirror and talk to myself, both slowly and quickly. I did
not find it difficult then. There used to be a huge three-part mirror at my
father’s tailor’s shop. Its main part was fixed and located in the middle, while
the side wings moved on the vertical axis. Thanks to this, the client or priest
who picked up his suit, coat or cassock could see how it fitted in the back. I
liked to stand in front of that mirror because, with wings bent in a certain way,
I could see a number of my reflections, which made me feel as if there were
many, or indefinitely many, of me. When I spoke, the reflections would speak
as well.
And I could speak like that endlessly, forgetting that I was a stuttering
child. But as soon as anybody, like my father, my dear father, asked me what I
was doing and who I was talking to, I would stutter and answer that I was just
playing.
When I grew older and attended school, my stuttering became more and
more tiresome, and even a nightmare. For example, when stuttering made me
fail while speaking in class, I would come back home, stand in front of the
mirror and ask myself ‘Why did you stutter back there if you are speaking
fluently now? Why don’t you stutter now?’ But, since I was unable to answer
this question and I knew than the next day or in a few days later I would make
a fool of myself again, I came to the optimistic conclusion that if I could speak
fluently when I was alone, I only needed to do ‘something’ which would
prevent me from stuttering in class. I only needed to find that ‘something.’
And I was becoming convinced that I would find that ‘something’ sooner or
later. Stuttering became a real adventure for me and, although I was already
attending the third grade of secondary school and stuttering was becoming
more and more severe, I was convinced that it would bring me huge success. I
did not stutter when I spoke in unison.
Our class, 3B, was supposed to recite some poem in unison. We went onto
the stage, and in the first row I saw our head teacher, a really good person, to
whom I would not mumble at all. There were also teachers, guests, parents and
all the others sitting next to him. I promised myself that I would pretend I was
reciting, I would simply move my lips and nobody would know that I was not
making any sound. This was because I was convinced that I would stutter and
distract other members of the team if I started to recite.
We started reciting and I can’t even recall the moment at which I joined
the class and recited the well-prepared text loudly and fluently. Joy
immediately turned into euphoria. I began to speak louder so that people could
hear me. I almost wanted to make a step forward so that people present could
see that it was me who was reciting so beautifully. Fortunately, the text came
to an end and I left the stage together with my classmates. So it turned out that
I could speak fluently not only in solitude, but also when accompanied by a
huge audience, which should have made me stressed. Hooray!
I did not stutter when I sang.
As early as in grade 5 of mainstream school (primary school according to
the present system of education), I used singing to do an oral task. I could do
so as this was a music lesson and the teacher only wanted to check if I had
learnt the lyrics of a song „Dni wiosenne zawitały, słonko coraz jaśniej świeci,
skowroneczek, ptaszek mały, z ciepłych krajów do nas leci….” (‘The days of
spring have come, the sun is shining brighter and brighter, a lark, a small bird,
is flying to us from warmer countries…’). I knew I was only supposed to
recite the lyrics but was aware that reciting will end up in gibberish and,
consequently, with embarrassment. Therefore, I pretended I thought the
teacher wanted me to sing the song. I sang the first verse fully fluently and the
joy of this success turned into euphoria. I ignored the teacher when she said
“Thank you, sit down,” and began the second verse, which was more directly
stopped by the teacher. However, I had another success after the lesson as the
teacher suggested I should join the school choir. I refused.
Severity of my stuttering depended on my interlocutor’s speech.
When I was talking to someone, I subconsciously tried to adjust to his or
her manner of speaking. Speaking to people who spoke forcefully, fast and
disfluently was for me much more difficult than speaking to people whose
speech was calm and even at a reduced pace. I liked talking to uncle Kazik
very much (I was 18 at the time) as he spoke at a reduced pace and in a
manner which is typical of people who live at the border. What is more, Uncle
Kazik liked to speak. When I was listening to him, I got the impression that he
was relishing in his own speech. Before the war, he used to be a member of
different organisations, including scouts. I tried to echo his manner of
speaking, which improved my own fluency.
Speaking at a slower pace was helpful. But not always.
Slowing down the pace of my speech was on the one hand helpful, but on
the other – stressful, and caused blocks for I was aware (or maybe this was just
my impression) that a listener was impatient with my slow speech. I think that
advising a PWS to speak more slowly is like advising people running out of a
burning cinema to stay calm and leave one room after another. The advice is
right, but is it doable?
Severity of stuttering depended on the stage fright which I
experienced towards a given listener.
Generally, it can be concluded that my stuttering results from some kind
of a stage fright. When I was speaking to myself, all alone, I was not feeling
any stage fright, therefore I was not stuttering. When I was speaking to Misiek,
our dog, I was not stuttering either. The problem did not exist when I was
telling invented fairy tales to Monika, a young daughter of mine. Speaking to a
shop assistant was easier if he or she looked harmless, good-natured or, even
better, absent-minded, than when he or she had a piercing or, even worse, was
impatient. Talking to teachers in class was similar. Obviously, this
conditioning influenced my speech fluency during family conversations as
well.
If people did not know I stuttered, I managed to keep my stuttering
secret for some time.
I still remember when I was a severely stuttering 17-year-old visiting
second-hand bookshops in search of ‘Mumbling and Stuttering’, a book by
Doctor Władysław Ołtuszewski, who was the father of Polish phoniatrics.

When asking about the book, I manifested very fluent speech with perfect
articulation. My motivation stemmed from the fact that my stuttering would
suggest that I needed this book for myself. And since I was ashamed of my
stuttering and wanted to keep it a secret, I pretended I need this book because
of ‘somebody else’s stuttering.’
I lived in such secrecy every time I met a new girl. Although none of thse
friendships lasted longer, I am sure I was remembered as a very fluent speaker.
Engagement with my present wife, Barbara, led to a record time in
concealing my stuttering. Fate was on my side. We had only known each other
for four months, two of which my fiancée, a pharmacist, spent away from me:
one month at a specialist training near Lublin, and the other one on a military
camp (at that time such trainings were obligatory for medicine and pharmacy
graduates as well). So we met occasionally, which helped me conceal my
secret. I started easing up after we got married and my wife soon realised that
she had married a man ‘with a hidden truth.’
Despite humiliation, I have never taken too much for granted. Quite
the opposite.
As soon as I found out that I could not communicate with others in a
natural way, I realised that my speech was tiring for the listener. Besides, my
interlocutors were more or less direct in letting me know about that. While
listening to me, they looked at me sympathetically, narrowed or closed their
eyes, looked into the sky or turned their head. I would often see impatience on
their faces and they sometimes finished single words or whole utterances for
me. I had the impression that they were suffering just as I was. At times and
driven by good intensions, they advised me to stop talking so that I would not
get tired.
Now and then, I have caused aggression in my listeners. I remember a
situation which happened in primary school. I was unfairly accused of being
involved in a scuffle and while listening to my excuses, my teacher said, “You
see, Adamczyk, you are stuttering because you are lying. If you weren’t lying,
you wouldn’t be stuttering.” I did not take offence. She may have reacted this
way in order to maintain control of the playful pupils.
During my speech in secondary school, a novice Polish teacher once said:
“My dear, please get your speech in order within the next two weeks.” Our
head teacher who taught German became so irritated by my stuttering that he
wrote ‘der Stotterer – stutterer’ on the blackboard and asked several students
to read it aloud one after another. I did not feel offended by the behaviour of
either the Polish teacher or the German teacher. Instead, I understood it as a

sign of their interest in my fluent speech.
Showing sympathy was most humiliating for me. One day my Geography
teacher asked me about the movement of Earth in the Solar System. I was well
prepared, but still, my reply ended in a terrible mumble. The teacher ordered
me to sit down and write my answer. I did so. Then he asked me to read it out
aloud. I started mumbling again. Then he asked my friend from the desk to
read it out and he turned out to be a very skilful speaker. He read out a very
good text. Complete silence filled the room. The teacher was standing silently
as well, and I could see compassion in his eyes. I felt I was being watched by
the entire class. A terrible humiliation, in spite of the best mark I received.
And here is a totally different case from a Polish lesson. We were
supposed to learn ‘Oda do młodości’ by heart (translator’s note: ‘Ode to
Youth’ is a poem by one of the most famous Polish writers, Adam
Mickiewicz). It was the same teacher who had given me two weeks to ‘get my
speech in order.’ He knew that I had not done it, so he asked me to recite the
poem because he wanted to help me. He ordered the class to stay silent and
announced that I was going to recite and that they would help me if they could
do what he had asked for. And, in fact, everyone was sitting in complete
silence and waiting for my recitation. “So Adamczyk, please begin,” said the
professor. So, stuttering as always, I said how very sorry I was and
remorsefully added that I… had not learnt the poem. The class burst into
laughter, the teacher spread his arms, angry that his attempt to help had turned
out to be a failure. Of course, I got a two (which was the lowest possible mark
at that time), and the professor kept telling the amused group to be quiet until
the end of the lesson and he was looking at me angrily and disappointedly. A
bell ring marked the end of the lesson, so we left the classroom and my
smiling friends were laughing and congratulating me in the corridor. This
episode became my huge social success.
So, on one hand, a good mark in Geography and humiliation, and at on the
other hand, a bad mark in Polish, but a social success.
Why do I speak fluently now? Because I wanted it a lot.
Well, I wanted to speak fluently very much. I have always been convinced
that I will get over stuttering, that this fascinating speech disorder will become
the subject of my, and my colleagues’, research, that I will travel around the
world and attend international congresses to talk about stuttering, that I will
publish, alone or with my colleagues, papers in international scientific and
specialist magazines.
6. How to Become a King’s Therapist?

‘The King’s Speech’, an Academy Award winning film by T. Hooper with
outstanding roles by C. Firth and G. Rush, is based on the diaries of Lionel
Logue, a king’s speech therapist. The diaries were edited by his grandson, M.
Logue, and a writer, P. Conradi (2011). While the film shows a multi-layered
story, speech pathologists will be particularly interested in the therapy which it
presents.
The prince, and who later becomes king, had been stuttering since early
childhood, and by the time he follows his wife’s advice and consulted a
therapist, he had already had several unsuccessful therapeutic attempts. He
decides to try once again because his public role obliges him to make public
speeches, which have turned into nightmares because of his chronic stuttering.
Thus, the problem is clear and stuttering is an obstacle to performing the tasks
of a king. The prince admitsthat if it had not been for stuttering, he would have
stayed with his family and not think of any therapy. Fortunately, he could not
escape therapy and did not have the chance to accept stuttering.
The first appointment is crucial as it could turn out to be the last one.
Although its course is appropriate, the therapist does not manage to convince
the patient to continue. The primary aim of the first appointment is to establish
contact, agree on the contract and boost motivation, so the therapist tries to
balance the social status of himself and his patient within the office,
considered as his territory, where he sets the rules and holds power. The prince
opposes to it firmly and refuses to be addressed by his first name. The
therapist is aware of the degree of his patient’s frustration, aggression and
disbelief in the success of another therapy offered by himself, a controversial
specialist. So to boost the prince’s motivation, the therapist introduces a
fluently speaking boy who used to stutter before he started therapy. Also, he
keeps stressing that since the prince is capable of speaking fluently, his speech
disorder is not permanent and there are chances of getting rid of the stuttering.
Still, despite attempts at bringing back the long lost hope, the patient remains
unconvinced and distrustful.
Before the end of the appointment, the therapist tries to apply the
technique based on drowning out one’s own utterances with music.
Unfortunately, the prince does not want to listen to the results, leaves the
surgery and says “It came to nothing!” to his wife who is waiting outside. The
therapist is left inside the room, feeling that he has just lost a perfect client.
Although he did not make any serious mistake, he had to face the
consequences of risk which is inherent in an authentic therapy.
Fortunately, the prince happens to play the therapist’s recording back and
it turns out that he is capable of speaking fluently as long as he does not hear
himself. Again, he hopes to improve his speech, so, accompanied by his
supportive wife, he decides to contact the therapist again.
Negotiations of the contract are restored in the second appointment and
the therapist agrees to focus first on the prince’s speech rather than on the
prince himself. And so they assume that psychological therapy will happen at
a more appropriate time and they begin with daily intensive speech training.
The prince turns out to be a devoted and disciplined patient, who eagerly does
typical exercises aimed at improving breathing, phonatory and articulatory
coordination, vocal emission, diction and speech fluency. Relaxation and
public speeches are of particular interest and the patient frequently gives
speeches, always accompanied by his wife. Since the therapist is aware of the
fact that unnatural manner of speaking is awkward, difficult to understand and
makes other people suspect that the patient suffers from mental disorders, it is
worth noting that the prince’s speech is always natural and the pace of his
speech does not need any prolongation or slow down techniques.
Since properly conducted speech fluency training includes a number of
elements of psychotherapy, it is difficult to actually separate it from
psychotherapy. In the case of the prince, psychotherapy as such begins at an
appointment which the prince arranges for spontaneously after his father’s
death. The therapist prepares soft drinks and listens to the prince’s story of
how he was dominated by his brother and competed with him for other
people’s favour. He learns that the prince was constantly afraid of his strict
father and that his mother employed a nanny to take care of the children
instead of supporting them. As a left-handed person, he was made to become a
right-handed one and sophisticated tools were used to straighten his legs in a
painful way. This resulted in the prince feeling insecure towards both his
dominating father and the favoured brother. His mother was always official
and cold. It turns out that the prince’s other brother was kept in isolation
because of his handicap and the therapist learns that the prince’s stuttering
resulted from the predisposing, precipitating and perpetuating factors revealed
during the conversation.
The therapist decides to move one step further and identify the primary
conflict which causes tension that leads to speech disfluency. He takes the
prince for a walk during which he explores the relationship with the older
brother who did not plan to become a king. The therapist sees an insight into
the complex situation and suggests that the prince, who has the potential and
feels responsible, should become the king. However, the prince understood
this as encouraging disloyalty or even a betrayal of his brother. His primary
conflict was based on the hidden need for power and the want to be loyal to
the brother and the king. This revelation makes the prince so angry, that he
instantly decides to give up the therapy once again. The therapist pays the
price for coming to an in-depth analysis of the situation and is accused by the
prince’s wife of using his prominent patient to fulfil his own ambitions.
When his older brother abdicates, the prince reluctantly becomes the king
of the United Kingdom and takes on the name of George VI. While the cause
of the prince’s stuttering has not been removed, his new duties related to
speaking becomes much broader, so he decides to contact the therapist, who,
though unconventional, offers him hope of curing his illness.
Both men apologise to each other and agree on an action plan. This
becomes the starting point for an interventional therapy that focuses on
preparing the new king to give speeches to his lieges during the Second World
War and motivate his nation and boost their morale. Both the prince and the
therapist do their best to complete this task and each speech is carefully
prepared. The therapist works on ready-made texts and implements rules of
phrasing, pausing, declamation and enunciation, while the king does numerous
rehearsals during which he learns to show strong emotions. Declamation of a
short, elevated and fluent appeal to the nation is the climax of the film. The
king becomes a perfect speaker, a symbol of fight and resistance, thanks to his
therapist’s support.
As we know, success has many fathers, and in this case, one of them is the
prince’s (and later on the king’s) wife, who is the role model as a supportive
person who influences the effectiveness of the therapy. She does not do things
for her husband, nor does she dominate. Instead, she helps, supports her
husband in his role and motivates him to undergo therapy despite the previous
unsuccessful attempts. She accompanies him during everyday therapy and
public speeches, hugs him in moments of doubt and despair, makes him
believe in the success of the therapy and enjoys it later on together with the
king. Such active engagement of a spouse in therapy is rare.
The relationship between the patient and his therapist was dynamic and
both had two different functions at the same time: the king was both a
monarch and a patient, while the therapist was his subject and a partner.
Although these roles changed depending on a situation, at times, they
overlapped each other. At the beginning of the therapy, the prince and his
therapist kept each other at a distance and changed their attitude into
friendship towards the end.
Who was this unconventional therapist? He was a self-taught, would-be
actor who did not have any formal education. However, he was also an
unparalleled specialist in enunciation and pronunciation, which was a good
trade at a time when rhetorical skills were particularly valued. Despite the lack
of a proper education, he became experienced in treating war neuroses just
because there was a demand for it. He was very creative, logical, well-read,
analytical, involved, decisive, consistent and took risky decisions. He was able
to motivate the patient to undertake and maintain therapy and, although he
charged a lot for it, he shared his money with the poor. As a non-professional
he acted very professionally and succeeded. And success attracts more clients.
Success was achieved both by the king and the therapist. The therapy had
clear goals, was very dynamic, full of ups and downs and its participants
believed in its positive effect. It released the potential of both the patient and
the therapist and, in a sense, each of them could solve his own problems: the
king solved problems with his monarchy, and the therapist decided on a career
in theatre. So joint therapy helped both of them individually.
Both the book and the film entitled ‘The King’s Speech’ improved the
social and professional image of speech pathologists and balbutologists in
particular (i.e., pathologists dealing with stuttering). Following this, the Orator
Foundation organised a training on ‘How to become a king’s therapist’.
However, there was little interest in it. Apparently, becoming the therapist of a
king or some other important person, is an ambitious task reserved only for
extraordinary speech pathologists.
References
Logue M., Conradi P. (2011), The King’s Speech. Warszawa: Świat Książki.
Tarkowski Z. (2010,) Stuttering. A book of questions and answers. Gdańsk:
Wydawnictwo Harmonia.
Tarkowski Z., Humeniuk E., Dunaj J. (2012), Stuttering in preschool age.
Olsztyn : Wydawnictwo UWM.
Appendix: Methods for
Diagnosing Persons with
Stuttering
Zbigniew Tarkowski
Psychosomatic Interview
I. Personal information
Interviewee’s name ………………..................... Gender ………. Age ………
Address (with a zip code) ………………….......................................................
Contact number ………………………………………………………………..
II. The onset and dynamics of stuttering

When did the first symptoms of disfluent speech occur? …………..……...
Under what circumstances did the first speech disfluency occur? .…..........
Please compare stuttering now with its initial stage and underline if it:
– has decreased
– has increased
– has not changed.
III. Speech disfluency and pace of speech

Currently, I have observed:
– sound, syllable or word repetitions
– sound prolongations
– blocks
– revisions
– pauses
– embolo-phrases/interjections
The pace of my speech is:
– too fast
– too slow
– unrhythmical
– natural
IV. Synkineses
Currently, I have observed the following:
– turning or tilting of the head
– wrinkling the forehead or frowning
– cheek tremors
– sticking out the tongue
– chin tremor
– clenching the lips
– nostril trembling
– squinting the eyes
– tongue tremor
– tensing the lips
– jaw trembling
– unnecessary movements of the torso
– covering the face with the hands
– clenching the fists
– shrugging the shoulders
– tapping the fingers
– rocking the body
– shifting weight from foot to foot
– stamping the feet
– other symptoms (what are they?) …………………………….
V. Neurovegetative symptoms
– face turning red
– face turning pale
– sweating
Appendix: Methods for Diagnosing Persons with Stuttering 189
– cold hands or feet

– heart beating faster
– other symptoms (what are they?) ……………………………….
VI. Psychological symptoms

– avoiding eye contact
– fear of speaking
– lack of sense of security
– increased emotional and muscle tension
– fear of pronouncing certain sounds or words
– sense of guilt
– shame-anger (irritation)
– aggression
– embarrassment
– anticipating the occurrence of stuttering
– other behaviours (what are they?) ……………………………..
VII. Social symptoms

– avoiding certain communicative situations
– isolating oneself from others
– minimal activity in conversation
– limited gestures
– other (what are they?) …………………………………………...
VIII. Breathing disorders

– excessive tension of the diaphragm muscles
– shallow breathing
– excessive contractions of the intercostal muscle
– cogwheel breathing
– apnea
– other disorders (what are they?) ………………………………….
IX. Voice and swallowing disorders

– difficulties in beginning to speak
– excessive muscle tension in the neck or larynx

– swallowing hard
– throat congestion
– throat clearing
– coughing
– excessive tension in the vocal cords
X. Articulation disorders
– increased tension of the articulatory muscles
– faulty articulation of some sounds
– trembling of the articulatory organs: lips, tongue
XI. Psychosomatic disorders

I used to observe, or still observe, the following symptoms:
Digestive system
– nausea and vomitting
– stomachache and anorexia
– peptic ulcer
– inflammatory bowel disease
– flatulence or wind
– frequent loose stools
– bad taste in the mouth or whitish coating on the tongue
– stomach knots or cramps
– belching
– diarrhoea
– other (what are they?) ………………………………….
Cardiovascular system
– paroxysmal tachycardia
– fainting
– stabbing pain near the heart
– ischaemic heart disease
– hypertensive heart disease
– migraine
Respiratory system
– paroxysmal cough
– blocked nose
– dyspnea and hyperventilation syndrome
– asthma
– breathing difficulties
– excessive fatigue from making little effort
Skin
– severe itching and excessive sweating
– frequent skin inflammation
– psoriasis
– spot baldness
– rosacea
– change in skin colour or discoloured skin patches
– a prickly sensation
– sweating
Urinary system
– wetting
– frequent urination
Musculosceletal system
– trembling
– nape spasms
– headaches
– excessive muscle tension
– muscle twitching
– lumbosacral region pain syndrome
–other (what are they?) ………………………………….
Other
– psychogenic pains located in different regions of the body
– obesity of psychogenic origin
– psychogenic vertigos
XII. Serious past diseases

……………………………………………………………….…
Date of examination: ………………………………………….
Name of the examiner: ……………………………………….
Source: Tarkowski Z. (2007), The Psychosomatics of Stuttering (op. cit.).

Zbigniew Tarkowski
The Questionnaire of Speech Disfluency and Logophobia
Part A. Speech disfluency
Speech Disfluency
Situations I don’t I stutter I often I almost

stutter at all a bit stutter always
stutter
1. Talking to the mother
2. Talking to the teacher during
the break
3. Talking to an acquaintance
4. Talking to an officer or a
shop assistant
5. Speaking in class (in a
kindergarten, at work)
6. Talking over the phone
7. Asking or making requests
8. Talking to the father
9. Speaking during a name day
party
10. Talking to strangers
Total: ……….. points

Additional information: ………………………………………………..
Part B. Logophobia
Situations I’m not I’m slightly I’m afraid of I am really

afraid of afraid of speaking afraid of
speaking speaking (I experience fear) speaking
1. Talking to the mother
2. Talking to the teacher
during the break
3. Talking to an
acquaintance
4. Talking to an officer or a
shop assistant
Situations I’m not I’m slightly I’m afraid of I am really

afraid of afraid of speaking afraid of
speaking speaking (I experience fear) speaking
5. Speaking in class (e.g.,
in a kindergarten, at work)
6. Talking over the phone
7. Asking or making
requests
8. Talking to the father
9. Speaking during a name
day party
10. Talking to strangers
Total: … points
Additional information: ………………………………………………….
Part C. Muscular, vegetative and psychological symptoms
MUSCULAR SYMPTOMS
HEAD:
□ turning □ moving the head forward
FACE:
□ wrinkling the forehead □ raising eyebrows
□ frowning □ squinting the eyes
□ clenching the lips □ opening and tensing the lips
□ sticking the tongue out □ tongue tremor
□ chin tremor □ trembling or cracking voice
NECK:
□ tensing neck muscles □ trembling or cracking voice
TORSO:
□ unnecessary torso movements
SHOULDERS:
□ covering the face with hands □ shrugging the shoulders
□ clenching the fists □ tapping the fingers
LEGS:
□ stamping the feet □ rocking the body
□ shifting weight from foot to foot
VEGETATIVE SYMPTOMS
□ faster heartbeat
□ blushing □ face turning pale
□ sweating □ hand cooling
PSYCHOLOGICAL SYMPTOMS:
□ avoiding eye contact □ lost eye contact
Number of muscular symptoms: ………………………………….

Number of vegetative symptoms…………………………………..
Number of psychological symptoms: ……………………………..
Total number of symptoms: ………………………………………
Diagnosis of the type of stuttering
The physiological type [ ] The psychological type [ ] The mixed type [ ]
Source: Tarkowski Z. (2001), Questionnaire of Speech Disfluency and Logophobia

(op.cit)
Zbigniew Tarkowski
Questionnaire of Speech Fluency Disorders
Name of person surveyed ……………………… Gender…. Age ……

Address ………………………………………….. Tel. ………………..
Part 1: speech disfluency
Conversation
Participants ……………………... Location …………………
A B
…………………………………. ………………………………….
Monologue
Story telling
…………………………………………………………………………..
…………………………………………………………………………...
…………………………………………………………………………..
Description
…………………………………………………………………………..
…………………………………………………………………………..
…………………………………………………………………………..
Speech disfluency indicators:

– type ……………………………….……………………………..……
– severity ……………………………….………………………………
– location ……………………………….………………………………
Part 2: Physiology
Muscle tension
Normal [ ] Excessive [ ]
Clonus [ ] Tonus [ ]
Spasticity [ ]
Synkineses
Head. …………………………………...
Neck …………………………………….
Face ………………………………….....
Torso …………………………………....
Shoulders. ………………………….……
Legs. ………………………………….....
Other .…………………………………...
Neurovegetative symptoms
Blushing [ ] Face turning pale [ ]
Sweating [ ] Cold hands [ ]
Cold feet [ ] Heart pounding [ ]
Dry throat [ ]
Other …………………………………..................
Neurotic symptoms
Bedtime wetting [ ] Daytime wetting [ ]
Sleep disorders [ ] Thumb sucking [ ]
Nail biting [ ] Trembling of hand or foot [ ]
Other: …………………………………..................
Part 3: Emotions and awareness

Emotions
Fear of speaking [ ] Anxiety [ ] Irritation [ ]
Regret [ ] Shame [ ] Guilt [ ]
Verbal aggression [ ] Physical aggression [ ]
Awareness
Awareness of speech disfluency:
Occurs [ ] Does not occur [ ]
Behaviour
Shyness [ ] Isolates oneself from others [ ]
Is coping well [ ] Is ignoring the situation [ ]
Other emotions and behaviours: ……………………………..................
Part 4: Social reactions

Reactions to speech disfluency
Cognitive reactions …………………………………...................
Emotional reactions …………………………………...................
Behavioural reactions …………………………………................
Part 5: Dynamics
Dynamics of speech disfluency
Duration:
Occurred suddenly [ ] Has developed gradually [ ]
Is permanent [ ] Appearing and disappearing [ ]
Prolonged periods of speech disfluency [ ]
Part 6: Etiology
Causes of speech disfluency
………………………………….................................................
………………………………….................................................
Part 7: Type of disfluency

Type of speech disfluency
Normal [ ] Pathological [ ]
Organic [ ] Functional [ ]
Emotional [ ] Non-emotional [ ]
Constant [ ] Changeable [ ]
Part 8: Type of speech disorder

Aphasia [ ] Dysarthria [ ] Cluttering [ ]
Stuttering [ ] Normal disfluency [ ]
Part 9: Postdiagnostic proceedings

Therapy [ ] Consultation [ ] Counselling [ ]
Other …………………………………..................
Date …………………………………....................
Examiner …………………………………............
Source: Tarkowski Z. (2010), Questionnaire of Speech Fluency Disorders (op. cit.)

Zbigniew Tarkowski
Scale of Attitudes towards Stuttering
Interviewee’s Name …………………………………..................

Sex ……………………… Age ……. Education ………………
Occupation …………………………………..................
1. In most cases, stuttering is caused by psychological problems.

True Rather true I don’t know Rather false False
2. PWS should not be encouraged to speak publicaly.
3. Stuttering is a barrier to success.
4. When a person stutters, others do not know how to behave.
5. In most cases stuttering is caused by a physical defect of the speech
apparatus.
6. People typically avoid contact with PWS.
7. Most PWS are sensitive, shy, fearful and quiet.
8. Speech pathologists can help a PWS learn to speak fluently.
9. In most cases, stuttering is caused by a combination of psychological,
physiological, linguistic and social factors.
10. Stuttering is a speech defect.
11. PWS should choose jobs that require minimal speaking.
12. In most cases, stuttering eventually disappears without special therapy.
13. Stuttering is a speech neurosis.
14. With a little more effort, a PWS can speak fluently.
15. If my child had contact with a PWS, I would be worried that he or she
may begin to stutter as well.
16. Special schools or classes should be provided for PWS.
17. Persistent stuttering is a disease.
18. Stuttering pupils or students should be exempt from speaking exercises.
19. A speech therapist should refer a PWS to a psychologist.
20. One can learn to stutter.
21. Stuttering therapy is difficult.
22. A PWS should not be delegated tasks or positions that involve high
responsibility.
23. There is little chance of curing stuttering.
24. PWS reap psychological and social benefits from their stuttering.
25. A speech pathologist should refer a PWS to a GP.
26. The diagnosis of stuttering should focus on describing speech disfluency.
27. Stuttering can be cured with medicines and herbs.
28. The intelligence level of PWS should be tested as well.
29. Stuttering results from dysfunctional family relations.
30. Stuttering should be accepted.
31. Stuttering therapy is based on doing exercises.
32. A speech therapist should conduct stuttering therapy on his or her own and
be responsible for its results.
33. Stuttering therapy is based on a combination of speech training with

psychotherapy.
34. PWS prefer to stutter than to treat it.
35. Adult PWS know the most about stuttering.
36. PWS or their families should receive pensions or subsidies.
37. PWS always experience breathing difficulties.
38. ‘Balbutologist’ as the name of a profession sounds strange and
pretentious.
39. A therapist should not be paid for treating stuttering as it is their duty to
do so.
40. Patients who have been cured of stuttering have the right to treat other
PWS.
41. I will get involved in working with PWS.
Source: Tarkowski Z. (2007), The Psychosomatics of Stuttering (op. cit.)
Jolanta Góral-Półrola, Zbigniew Tarkowski

Scale for Self-Assessment of Stuttering
Respondent’s name ………………………………….............................

Age ………………………........... Gender …………………………….
Date of examination …………………………………............................
The statements below refer to stuttering-related behaviours. Please

determine how true they are for you. There are no good or bad answers. You
can decide how honest you would like your answers to be. Please consider
behaviours that have occurred in the past year only. Please go through the
questions in the order they are given and do not skip any item. Underline the
answer selected.
19. I listen more often than I talk.

NO RATHER NO HARD TO SAY RATHER YES YES
11. My speech disfluency is:
VERY SEVERE SEVERE MODERATE MILD MINIMAL
16. I avoid contact with people because of my stuttering.
NEVER RARELY SOMETIMES OFTEN VERY OFTEN
6. Before I start speaking, I feel afraid.
VERY OFTEN OFTEN SOMETIMES RARELY NEVER
10. I prepare myself before speaking instead of speaking spontaneously.
1.I make unnecessary movements before or while speaking.
15. My utterances are structured incorrectly.
SOMETIMES OFTEN
NEVER RARELY VERY OFTEN
3. I have blocks which make speaking hard.
OFTEN SOMETIMES RARELY NEVER
VERY OFTEN
17. I wait until someone else starts the conversation.
VERY OFTEN
8. I feel angry.
13. I tend to finish my utterances quickly.
VERY OFTEN
2. When I speak, my breathing becomes irregular.
18. My stuttering makes communicating with others difficult.
VERY MUCH QUITE RELATIVELY HARDLY MINIMALLY
4. When stuttering I sweat, blush or turn pale.
14. Usually I speak:
VERY
VERY FAST FAST NATURALLY SLOWLY
SLOWLY
20. My life is hard because of stuttering.
RATHER RATHER
TRUE HARD TO SAY FALSE
TRUE FALSE
9. I try to conceal my stuttering.
12. Pauses in my speech are:

VERY SHORT SHORT AVERAGE LONG VERY LONG
7. I am less self-confident because of stuttering.
5. I am too tense.
VERY OFTEN OFTEN SOMETIMES RARELY VERY RARELY
21. My stuttering is:
MINIMAL MILD MODERATE SEVERE VERY SEVERE

Scale of Assessment of Stuttering
Who assesses the PWS (person with stuttering): speech therapist, mother,
father, brother, sister, husband, wife, friend (please underline or write the
answer) …………………………………............................................................
Respondent: …………………………………..............................................
Name ………………………. Age ……………Gender ………………......
PWS assessed: ………………………………….........................................
Name ………………………. Age ……………Gender ………………......
Date ………………………...

answer selected.
19. The PWS listens more often than he/she talks.

11. The PWS’ speech disfluency is:
VERY SEVERE SEVERE MODERATE MILD MINIMAL
16. The PWS avoids contact with people due to stuttering.
6. Before speaking, the PWS feels afraid.
10. The PWS prepares himself or herself for speaking instead of speaking spontaneously.
1. The PWS makes unnecessary movements before or while speaking.

15. The PWS’ utterances are structured incorrectly.
3. The PWS has blocks which make speaking hard.
17. The PWS waits until someone else starts the conversation.
8. The PWS feels angry.
13. The PWS tends to finish his or her utterances quickly.
2. When the PWS speaks, his or her breathing becomes irregular.
18. A PWS’ stuttering makes communicating with others difficult.
VERY MUCH QUITE RELATIVELY HARDLY MINIMALLY
4. When stuttering, the PWS starts to sweat, blush or turn pale.
14. Usually the PWS speaks:
VERY FAST FAST NATURALLY SLOWLY VERY
SLOWLY
20. The PWS’ life is hard because of stuttering.
TRUE RATHER TRUE HARD TO SAY RATHER FALSE FALSE
9. The PWS tries to conceal his or her stuttering.
12. Pauses in the PWS’ speech are:

VERY SHORT SHORT AVERAGE LONG VERY LONG
7. The PWS is less self-confident because of stuttering.

5. The PWS is too tense.

VERY OFTEN OFTEN SOMETIMES RARELY VERY
RARELY
21. The PWS’ stuttering is:
MINIMAL MILD MODERATE SEVERE VERY SEVERE
Source: Góral-Półrola J., Tarkowski Z. (2012), Scale for Self-Assessment and Assessment of Stuttering
(op. cit.).

Scale of Motivation to Undergo Stuttering Therapy
……………………………………………………………………………
Name of interviewee …………………….. Age ……….Gender ……….
Date of examination ……………………………………………………..

answer selected.
Underline the appropriate answer. If you fully agree, please underline Yes.
If you partially agree, please underline Rather yes. If you disagree fully, please
underline No, if you partially disagree, please underline Rather no. If you find
it difficult to decide, please underline Hard to say.
1. I accept my stuttering.
YES RATHER YES HARD TO SAY RATHER NO NO
14. Those who treat stuttering know little about it.
8. I will begin therapy even if it means stress and hard work for me.
13. A therapist should only be interested in my stuttering and not in me personally.
4. If somebody has an issue with my stuttering, it is their problem.
15. The stuttering therapy I am currently having has had good results.
20. Even if I get over stuttering, it will not change much in my life.
12. Stuttering will relapse after the therapy.
7. I can devote a lot of time to stuttering therapy.
16. Only a miracle can treat my stuttering.
9. I will abandon the therapy if the exercises are boring and the tasks are difficult.
2. I feel good about my stuttering.
17. My stuttering should eventually disappear on its own.

5. People have gotten used to my stuttering.
19. During therapy, I will be supported by my family and friends.
6. Stuttering therapy should be free-of-charge.
18. I believe there is a medicine for stuttering.
10. I will give up therapy if I feel ridiculed or hurt.
3. I will fight against my stuttering.
11. I will start the stuttering therapy immediately.
21. My will to treat stuttering is:
STRONG VERY STRONG MODERATE WEAK VERY
WEAK
Source: Góral-Półrola J., Tarkowski Z. (2012), Scale of Motivation to Stuttering Therapy (op.cit.).
Zbigniew Tarkowski in cooperation with Ewa Humeniuk

Scale of Interpersonal Communication
Name………………………….. Gender ……………….Age…………….

Education …………………… Address ………………………………….
Procedure:
Various situations are described below. Please choose one of the three
answers which you think best describes your reaction.
1. A woman carrying a baby asks you for some money.

a) You say, “You’d better go to work.”
b) You give her a few pennies.
c) You say, “I’m sorry, I don’t give money to people.”
2. You are being criticised for being late.
a) You say, “You are right.”
b) You say, “You are not very punctual either.”
c) You say, “My tardiness does not give you the right to criticise
me.”
3. You are watching an interesting film and suddenly hear loud music
playing from a room next door.
a) You say, “Turn off or turn down the music! I can’t hear
anything!”
b) You say, “Such awful people! They don’t let you watch
anything!”
c) You do not react.
4. Somebody on a bike bumps into you, but luckily he or she does not do
you much harm.
a) You say, “Learn to drive, man!”
b) You say, “That’s okay, nothing terrible happened.”
c) You say ‘Watch out when you’re cycling - you could cause an
accident!’
5. A doctor does not answer your question.
a) You leave without saying anything.
b) You say, “You are ignoring me.”
c) You say, “Please answer my question, because it is really
important to me.”
6. A man is pushing himself forward in a queue.
a) You say, “Stop pushing yourself forward!”
b) You say, “You weren’t standing here, please find a place
somewhere else”
c) You give up your place to the man.
7. Somebody is shouting at you.
a) You are listening without saying anything.
b) You also begin to shout.
c) You say, “Stop shouting and please explain what the problem is.”
8. An old woman tells you the same story again.
a) You say, “Let’s talk about something else.”
b) You listen without saying anything.
c) You say, “You have have told me this story a hundred times.”
9. A child is not listening to what you are saying.
a) You say, “Listen to what I’m saying.”
b) You ignore it.
c) You say, “How many times am I supposed to tell you this?”
10. People are swearing in your presence.

a) You say, “Who raised you?”
b) You say, “Please do not swear when I’m around because it
disturbs me”
c) You ignore it.
11. People are gossiping about your friend.
a) You say, “Stop gossiping! It’s inappropriate.”
b) You do not take sides,
c) You say, “Leave him alone.”
12. Somebody wants to interrupt you while you are working.
a) You say, “Can’t you see I’m working?”
b) You say, “I’ll talk to you when I finish doing this.”
c) You stop and ask what the matter is.
13. Your good friend asks you for a small loan, but you don’t feel like
helping him.
a) You say, “I can’t lend you money because I don’t have any.”
b) You say, “I have a rule that I do not lend or borrow anything.”
c) You say, “Leave me alone. Borrow from someone else.”
14. You are given too many tasks which you are unable to do.
a) You do them.
b) You say, “I won’t do it because it’s too much for me.”
c) You silently curse.
15. Your opinion is drastically different from that of other speakers’.
a) You say, “What do you know about it?”
b) You do not reveal your opinion.
c) You say, “I have a different opinion about it.”
16. You are not allowed to speak in a discussion.
a) You interrupt and speak in spite of it.
b) You say, “Listen to me, I have something important to say.”
c) You wait until you are allowed to speak.
17. You do not want to talk on a given subject.
a) You say, “Let’s change the subject.”
b) You say, “You keep talking about the same thing over and over
again.”
c) You do not protest.
18. Somebody speaks positive things about you.
a) You feel embarrassed and do not know what to say,
b) You say, “What do you really want?”
c) You say, “Thank you, it’s kind of you to say so.”
19. The atmosphere among your friends is tense.

a) You say, “Listen, I can’t stand it anymore.”
b) You say, “I need to leave now.”
c) You say, “You’re unbearable.”
20. Somebody is mean to you.
a) You say, “Don’t behave like that; it makes me sad.”
b) You say, “You’d better stop before I get mad.”
c) You feel sorry and ignore it.
About the Author
Zbigniew Tarkowski
Professor, Head of the Department of Pathology
and Rehabilitation of Speech,
Medical University of Lublin, Poland
Professor Zbigniew Tarkowski has been researching psychogenic speech

disorders (stuttering, mutism), institutional communication (in hospitals and
nursing homes) as well as logopaedic diagnostics. He has authored a number
of standardised and normalised tools, including the Screening Logopedics
Test, the Child’s Vocabulary Test and the Language Skills Test. He has been
conducting systemic therapy of patients with different disorders for years now,
and has authored several monographs, mostly on the topic of stuttering.
Recently he has published a book entitled Children with Behaviour, Emotion
and Speech Disorders, and reviewed a textbook entitled Speech Pathology for
print. His scientific research is inspired by his therapeutic experience.
Professor Tarkowski supports the systemic approach to disorders as such as
well as interdisciplinary studies, including their international aspects. His
hobbies include travelling and agritourism, and he loves St. Bernard dogs and
common cats.
Index
A C
aggression, 66, 67, 109, 143, 169, 180, 182, carbohydrate metabolism, 127
189, 195 cardiovascular system, 23, 137
anger, 9, 43, 47, 49, 109, 110, 159, 169, 189 caregivers, xvi, 52, 59, 71, 81
anxiety, 10, 17, 37, 43, 135, 144, 152, 167 central nervous system, 7, 8, 129, 132, 138,
articulation, 3, 5, 76, 77, 79, 106, 107, 119, 139, 140, 148
158, 180, 190 cerebellum, 8, 137
attitudes, viii, xi, 53, 69, 70, 71, 72, 74, 75, cerebral cortex, 3, 8
76, 82, 83, 85, 90 childhood, 10, 13, 23, 76, 99, 119, 153, 156,
auditory cortex, 139, 151 167, 182
children, 29, 31, 34, 37, 39, 46, 57, 63, 69,
73, 74, 76, 79, 80, 91, 92, 103, 110, 111,
B 113, 117, 119, 120, 121, 123, 126, 127,
143, 147, 151, 152, 158, 160, 168, 172,
bed-wetting, 36 183
benzodiazepine, 135, 140 communication, x, 1, 10, 17, 21, 29, 30, 33,
blood pressure, 8, 16, 129 34, 47, 48, 62, 63, 64, 68, 69, 74, 81, 84,
bradycardia, 131 85, 88, 93, 108, 117
brain, xi, 7, 125, 129, 131, 135, 136, 137, communication skills, 88
138, 139, 143, 146, 148, 149, 150, 152 conversations, 20, 34, 62, 67, 72, 90, 157,
brain activity, 149 170, 179
brain damage, 131 cure, xii, xv, 86, 113, 144, 146, 173
brain functions, xi
brain structure, 125, 136, 137, 138, 139, 146
breathing, 5, 13, 15, 16, 17, 47, 49, 72, 76, D
79, 86, 95, 101, 102, 103, 104, 105, 106,
107, 119, 156, 160, 183, 189, 191, 199, depression, 129, 131, 133, 134, 135, 138,
200, 202 139
212 Index
depressive symptoms, 135 epilepsy, 130, 131, 132, 147, 152

depth, 136, 184 excitability, 15, 132, 134, 140
despair, 58, 184 exercise(s), xiii, 17, 20, 22, 55, 57, 58, 73,
developing brain, 125 74, 75, 85, 86, 93, 96, 99, 101, 102, 103,
dialogues, 19, 20 104, 106, 107, 109, 110, 175, 183, 198,
diaphragm, 105, 106, 189 203
differential diagnosis, 1, 28, 31, 39
diseases, xi, xiii, xvi, 7, 14, 76, 78, 124,
125, 129, 131, 139, 174, 191 F
disfluency, vii, viii, ix, x, xi, xii, xiii, xiv,
xvi, 1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, fear(s), 14, 17, 30, 37, 54, 57, 100, 110, 113,
16, 17, 18, 19, 20, 21, 22, 25, 27, 28, 30, 119, 137, 158, 169, 170, 172, 176, 189,
31, 32, 33, 34, 35, 36, 37, 38, 39, 41, 42, 192, 193
43, 45, 46, 47, 48, 50, 55, 56, 57, 73, 77, fluency disorders, vii, xii, 5, 6, 10, 22, 23,
79, 80, 82, 84, 85, 86, 87, 88, 89, 95,99, 31, 34, 76, 82, 86, 87, 123, 128, 130,
101, 104, 106, 107, 110, 111, 112, 116, 131, 139, 142, 147, 159, 167, 194, 196
117, 118, 119, 125, 127, 130, 131, 135, fluoxetine, 135
137, 140, 145, 153, 154, 155, 156, 157,
158, 159, 160, 161, 162, 163, 164, 166, G
167, 168, 169, 183, 187, 192, 194, 195,
196, 198, 200, 201 GABA, 125, 129, 130, 131, 132, 133, 134,
dopamine, 125, 135, 136, 138, 139, 141, 138, 140, 147, 148, 149, 152
142, 143, 144, 147, 151, 152 genes, 145, 148, 149
dopaminergic, 136, 137, 138, 139, 142, 144, genetic information, 138
149, 152 gestures, 16, 108, 109, 189
drugs, 83, 113, 126, 127, 129, 130, 132, group therapy, 113, 120, 134
133, 135, 136, 138, 139, 142, 169 growth, 127
guilt, 30, 37, 43, 47, 66, 109, 169, 172, 189
E
H
education, 69, 126, 178, 185
educational background, 74 happiness, 17, 157, 170
educational institutions, 91 health, x, xv, 57, 91, 131, 144
emotional disorder, 13, 76 helplessness, xi, xii, 56, 67, 88, 169
emotional experience, 92 herbal medicine, 84, 114, 117
emotional reactions, 43, 95, 118, 147, 159 heredity, 18, 30, 46, 75, 80
emotional stability, 139 hippocampus, 10, 133, 137
emotional state, 4, 9, 78, 86 hormones, 126, 139
emotional stimuli, 15 hyperventilation, 77, 105, 191
emotionality, 110, 136
emotions, viii, xi, 4, 9, 11, 16, 17, 22, 32,
37, 43, 58, 62, 63, 64, 65, 69, 77, 85, 86, I
90, 92, 105, 106, 109, 116, 117, 135,
138, 158, 159, 168, 170, 172, 184, 195 inferiority, 168, 171
epiglottis, 9 insomnia, 138, 140
Index 213
intelligence, 70, 156, 198 neurotransmission, 130, 131, 140

interpersonal communication, xiv, 1, 66, 77, neurotransmitters, 126, 132, 135, 136, 137,
86, 87, 95, 96, 173 138, 139, 140
interpersonal relationships, x, xvi, 15, 20, non-stuttering, vii, viii
29, 53, 58, 94, 107, 134, 135, 171 non-stuttering expert, viii
K O
kindergarten, xvi, 33, 110, 111, 154, 155, obsessive-compulsive disorder, 151
156, 159, 161, 165, 167, 192, 193 occupational therapy, 126
olanzapine, 136, 143, 144, 150
organism, 125, 126, 128, 131, 139
L organs, 17, 46, 79, 158, 190
orthostatic hypotension, 143
language development, 6
language skills, 158
larynx, 190 P
learning, 6, 18, 98, 156, 169, 176
logopedists, vii Persons with Stuttering (PWS), v, vii, 1, 8,
10, 14, 16, 17, 18, 19, 20, 21, 25, 26, 29,
30, 47, 48, 51, 52, 56, 57, 58, 61, 63, 65,
M 69, 70, 71, 72, 73, 74, 75, 76, 78, 79, 80,
81, 83, 84, 85, 87, 88, 89, 90, 91, 92, 93,
machinery, 124 95, 96, 97, 98, 99, 100, 101, 103, 104,
medication, 124, 132, 140, 145, 146 105, 106, 107, 109, 110,111, 112, 113,
medicine, xi, xiii, xv, 14, 69, 114, 124, 125, 114, 115, 116, 117, 119, 125, 126, 127,
126, 127, 131, 133, 134, 138, 144, 145, 128, 129, 131, 132, 133, 134, 137, 138,
180, 204 139, 141, 142, 143, 144, 145, 146, 172,
mental disorder, 136, 143, 152, 183 173, 176, 179, 187, 197, 198, 199, 201,
motor planning, 3 202
motor tic, 150 pharmacokinetics, 148
multiple sclerosis, 7 pharmacological treatment, 126
muscle relaxant, 151 pharmacology, 140, 147, 148
muscles, 3, 4, 9, 37, 80, 101, 105, 106, 133, pharmacotherapy, xv, 83, 84, 95, 96, 124,
189, 190, 193 125, 127, 130, 133, 136, 143, 144, 146
phonation, 3, 5, 9, 17, 76, 77, 79, 106, 107,
N 119
phonetic fluency, 4
negative consequences, 127, 169 preschool, vii, 37, 80, 82, 119, 155, 158,
negative emotions, xi, 4, 9, 17, 37, 77, 159 185
negative experiences, ix preschoolers, vii, x
negative reactions, viii, 11, 32, 86, 159 primary school, 178, 180
nervous system, 126, 127, 129, 132 pronunciation, ix, 6, 37, 52, 86, 132, 134,
nervousness, 155, 177 175, 185
neuroleptics, 136 psychiatric disorders, 147
214 Index
psychological problems, 72, 85, 197 self-assessment, 20, 21, 50, 51, 80, 177
psychological stress, 17 self-awareness, 32, 47, 72
psychologist, 26, 70, 73, 74, 75, 78, 99, 156, self-confidence, 86, 112, 129, 175, 176, 177
198 self-control, 7, 17
psychoses, 136, 139, 143, 144 self-corrections, 3, 6
psychosocial factors, 112 self-development, viii
psychosomatic, 1, 14, 76, 77, 99 self-discipline, viii, 55
psychotherapy, ix, xiv, 20, 41, 57, 70, 73, self-esteem, 47, 56, 111, 112, 174
74, 75, 76, 83, 84, 85, 87, 93, 94, 95, 96, self-help, viii, 88
104, 117, 119, 120, 183, 199 self-image, 111, 112, 122
self-therapy, viii, 62, 120
self-treatment, viii
Q semantic disfluency, 4, 162
semantic fluency, 4
QT interval, 143 serotonin, 135, 136, 141, 144, 151
quality of life, x, 29, 56, 89, 135 sertraline, 135, 136, 148
speech disorder, viii, ix, x, xi, xiv, 1, 26, 28,
R 30, 31, 32, 39, 61, 74, 78, 87, 88, 89,
117, 125, 126, 127, 128, 132, 134, 135,
reactions, viii, 10, 11, 15, 16, 25, 32, 42, 43, 137, 138, 139, 140, 142, 143, 144, 145,
45, 47, 68, 80, 86, 88, 95, 110, 118, 126, 158, 172, 174, 181, 182, 196, 209
127, 129, 130, 131, 132, 134, 137, 141, speech pathologist, vii, ix, xi, xii, xiv, xvi,
142, 143, 144, 145, 155, 159, 170, 196 26, 29, 33, 78, 79, 80, 81, 83, 84, 86, 88,
receptors, 130, 133, 134, 135, 137, 139, 90, 91, 92, 93, 94, 95, 99, 117, 118, 182,
140, 141, 142, 143, 144, 147, 148, 149, 185, 198
151 speech problem, viii
relaxation, xiv, 17, 57, 96, 108, 110, 114, stuttering expert, viii, ix, 87
117, 134 symptoms, viii, xvi, 3, 5, 6, 7, 8, 9, 12, 15,
repetition(s), 2, 3, 5, 6, 7, 8, 12, 35, 76, 93, 17, 21, 25, 26, 28, 30, 32, 34, 35, 36, 39,
117, 129, 132, 154, 158, 160, 161, 163, 41, 43, 46, 49, 76, 77, 79, 80, 86, 105,
164, 166, 187 118, 119, 126, 129, 132, 134, 135, 136,
rhythm, xv, 4, 100, 105, 107, 108, 117 137, 139, 141, 142, 143, 144, 145, 146,
risperidone, 136, 144, 145 149, 158, 159, 160, 161, 163, 164, 166,
rules, 39, 41, 54, 115, 173, 176, 182, 184 167, 187, 188, 189, 190, 193, 194, 195
synaptic gap, 135
syndrome, 77, 139, 144, 191
S syntactic disfluency, 5
syntactic fluency, 4
safety, 107, 126, 139, 141, 143
schizophrenia, 136, 141, 142, 143, 149
school, vii, x, xvi, 13, 20, 29, 33, 73, 74, 75, T
79, 87, 103, 110, 111, 112, 119, 121,
127, 156, 167, 169, 175, 176, 178, 180, techniques, 53, 55, 83, 85, 86, 96, 97, 100,
198 106, 108, 115, 116, 117, 125, 145, 183
selective serotonin reuptake inhibitor, 135 therapeutic conversation, 63, 65, 116
self-analysis, viii, 74
Index 215
therapeutic process, xiii, 29, 30, 32, 52, 72, 182, 183, 184, 185, 197, 198, 199, 203,
85, 94, 100, 112 204
therapeutic relationship, xv, 53, 92 training, xiv, 20, 41, 57, 73, 75, 76, 83, 84,
therapist(s), vii, viii, ix, x, xii, xiii, xiv, xv, 85, 86, 91, 93, 94, 95, 96, 98, 99, 102,
xvi, 18, 20, 30, 33, 34, 52, 53, 56, 57, 58, 107, 108, 113, 114, 173, 180, 183, 185,
59, 63, 64, 65, 69, 70, 72, 73, 74, 75, 79, 199
80, 84, 85, 88, 89, 90, 91, 92, 93, 94, 96, treatment, viii, xv, xvi, 30, 52, 57, 59, 73,
99, 103, 111, 113, 115, 116, 117, 118, 81, 83, 85, 96, 99, 109, 115, 120, 123,
130, 153, 156, 174, 175, 176, 182, 183, 124, 126, 127, 131, 142, 147, 148, 149,
184, 185, 198, 199, 201, 203 150, 151
therapy, vii, viii, ix, x, xi, xii, xiii, xiv, xv, triggers, xi, 14, 17, 29, 36, 167
xvi, 1, 18, 19, 20, 27, 28, 29, 30, 32, 33,
39, 41, 51, 52, 53, 54, 55, 56, 57, 58, 59,
60, 61, 62, 65, 69, 70, 71, 72, 73, 74, 75, U
76, 78, 79, 81, 83, 84, 85, 86, 87, 88, 89,
90, 91, 92, 93, 94, 96, 97, 98, 99, 100, utterances, 2, 7, 32, 33, 34, 43, 50, 66, 67,
101, 103, 104, 107, 108, 110, 111, 112, 105, 109, 155, 158, 159, 160, 162, 174,
113, 114, 115, 116, 117, 118, 119, 120, 180, 182, 200, 202
123, 126, 127, 129, 131, 132, 133, 134,
135, 136, 137, 139, 140, 141, 142, 143, Y
144, 145, 146, 155, 156, 170, 171, 172,
young people, 126, 172

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SPEECH AND LANGUAGE DISORDERS

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Library of Congress Cataloging-in-Publication Data

Published by Nova Science Publishers, Inc. † New York

It is common knowledge that therapists tend to choose therapies which

the rejection of stuttering and increased speech disfluency. Therefore, the

interpersonal communication disorder. Basically, a person who stutters is more

do not suggest employing unnaturally rhythmicised speech if the patient has

1. The rejection of stuttering,

1. Utterance Planning and

A proper level of motivation is required in order to begin an utterance and

Transition 1: From Motivation to Thinking

This stage leads to creating information of a structure based on a semantic

Transition 2: Transforming Thoughts into a Motor Programme

 thinking initiates the programming of muscles in the speech apparatus

Stage 3: Motor Regulation

This stage initiates the programming of an utterance in which fluent

Transition 3: Translating the Motor Program onto Movements of

According to classic theories, any disruption to this order causes

Stage 4: Myodynamic Performance

Keeping respiratory, phonatory and articulatory muscles in optimal

 Semantic fluency, which is about skilful shifting from one thought to

In a similar way, one can distinguish three types of speech disfluency:

 Semantic disfluency stems from a temporary difficulty in moving

 Syntactic disfluency stems from a temporary difficulty in moving

Therefore, speech disfluency is a combination of psycholinguistic

2. Typology of Speech Disfluency

 Pathological and natural (normal),

Lechta’s typology (2004) differs slightly as disfluency is divided into the

Speech disfluency is a common phenomenon and as such it is normal –

 the frequency of disfluency symptoms is low,

Majewska-Tworek (2014) presented the following typology of natural

‘1. Lexical self-corrections:

6.2. Sound prolongation

As presented above, the model covers three types of speech disfluency

Pathological Speech Disfluency: Organic and Functional

Organic speech disfluency accompanies diseases within the central

 The frequency of disfluency symptoms in neurological patients is high

Tense and Non-Tense Speech Disfluency

Tense (pathological) speech disfluency is accompanied by increased

 The spinal cord in the so-called gamma system which is responsible

The optimal level of muscle tension is referred to as eutonia, whereas

 An increased activity in the orbicularis oris muscles,

Emotional and Non-Emotional Speech Disfluency

Lechta (2004) identifies psychogenic disfluency as a consequence of a

Traditionally, speech fluency disorders have been associated with

‘In posttraumatic stress disorder an anxiety reaction spreads onto

Permanent and Changeable Speech Disfluency

Speech disfluency is permanent if it occurs every day. Permanent speech

3. Stuttering and Its Types

where: J – stuttering, NP – speech disfluency

where: J – stuttering, PNM – pathological speech disfluency

where: J – stuttering, N – speech disfluency, R – reactions to speech

 Individual-specific (i.e., how a speaker reacts to his/her own speech

These are divided further into the following areas:

 Cognitive (i.e.,what the opinion is of speech disfluency),

The reactions mentioned above can be either positive or negative. In the

where: J – stuttering, PNM – pathological speech disfluency, W – synkineses,

From the systemic perspective (Tarkowski, 2007), the structure of

The explanation of the structure of stuttering should include a description

 Primary: Where the repetition of syllables or words is a dominant