1 J O U R N A L OF T H E S O U T H A F R I C A N L O G O P E D I C SOCIETY MAY Experience of 41 children at the Pretoria School for Cerebral-palsy is described. Types of cerebral-palsy a n d speech defects found in these children a r e detailed. Methods a n d techniques in speech therapy a r e reviewed. Results a n d difficulties a r e discussed. My thanks are due to Dr. B. Epstein, chairman of the Board o! Management of the Pretoria Scnool for Cerebral-palsy, for his encouragement and assist- ance, and for allowing me cccess to files and recoras. REFERENCES. 1 Perlstein Μ A and B a m e ^ Η. E. (1952) : J. Amer. Med. Assoc., 148, 1389. 2 Pohl J. F. (1950) : Cerebral-Palsy. 2nd ed., p. 165- 167.' St. Paul, Minnesota: Bruce Publishing'Co. 3. Rutherford, B. R. (1948) : Give Them a Chance to Talk, 1st ed., p. 3. Minneapolis, Minnesota: Burgess Publishing Co. 4 Kastein, S. (1952) : Notes on Speech Therapy, 1st ed., p. 7. British Council for the V/elfcre of Spastics. 5 Eisenson, J. (1946): Examining ior Aphasia, 1st ed., p. 4. New York: The Psychological Corpora- tion. 6. Sittig, E. (1947) : J. Speech -Dis., 12, 194 (quoting Froeschells). 7. Evans, M. F. (1947): Ibid., 12, 97. 8 Ε wing I. R. and A. W. G. (1954) : Speech and the Deaf Child, 1st ed., p. 127. Manchester: University Press. 9. Leather, D. (1954): Int.-J. Phoniatry, 6, 38 (Separa- tum). 10' Clemons, E. S. (1953): J. S. Afr. Logopedic Soc., Special Congress ed., p. 48 (Johannesburg Univ. Witwatersrand). THE CONQUEST OF STUTTERING C. VAN RIPER Director, Speech Clinic, Western Michigan. College Kalamazoo, Michigan, U.S.A. Western Michigan College of Education. For centuries the treatment of stuttering h a s wrecked itself on the rock of symptom avoid- ance. The various therapeutic methods^ used, relaxation, rate control, unusual modes oi speech, h a v e b e e n focussed on the s a m e goal which h a s b e t r a y e d - e v e r y stutterer's own at- tempts to h e a l himself: the attempt to speaK without stuttering. Such c n effort carries with- in itself, even when successful, the seeds ot its own eventual failure. For a v o i d a n c e c r e e d s fear W h e n we flee from fear, w e magnify it. The situation a n d word fears so long condi- tioned in the adult stutterer c a n haralv ce e r a s e d by; such measures. According to modern Teaming theory, anxiety conditioned responses never extinguish completely. O n e pairing of the shock with the conditioned stimuli restores them to almost full strengtn. And so we find the discouraging frequency of r e l a p s e s in stuttering therapy. Moreover, much of the older methods did little more than to repress the symptoms. The powenul sug- gestion employed b y most therapists can in- d e e d produce such repression temporarily, ^ut stuttering, like murder, will out ! W e may b e a b l e to hold down the coiled spring of tne disorder for a time, but so long a s it is intact a n d a s strona a s ever, it will eventually e s c a p e from our grasp. W e a r e but mortals with no ability to sustain a repression for long. No matter how confident we b e c o m e , existence will sooner or later c a u s e morale to efco. No environment, however favourable, will b e without its moments of trauma. To build fluency upon an attitude a l o n e is to use fiux instead of mortar for the foundation. Ana. so at these i n e s c a p a b l e moments of e g o weakness, the fears invade our minds a g a i n , and the stuttering returns to haunt our lives. Is there no w a y to exorcise this evil ghost whose strength seems almost of the super- natural? The psychoanalysts have tried a n d most of them confess failure since speech, their · healing tool, is itself affected. The myriad de- vices, methods a n d tricks which have b e e n used upon stutterers since the dawn of history give us little hope of s u r c e a s e from that direc- tion. Witchcraft and surgery, vocal training a n d hypnosis, in none of these have we found consistent effectiveness. Our inability to c o p e with the severe stutterer after all these y e a r s still reflects discredit upon our profession. Perhaps we h a v e b e e n working in the wrong direction. The stutterer does not need to b e taught how to talk normally. He already h a s that skill, a s much of his speech attests. Sup- pose, instead of trying to k e e p him from stut- tering with all of its attendant evils, we try to train him to modify his symptoms in the direc- tion of fluency. The immense variety of stut- tering symptoms suggests that among them there might b e a few types which society would not Dunish. Among them there should R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) MAY J O U R N A L OF T H E S O U T H A F R I C A N L O G O P E D I C SOCIETY v,e certain forms which would not frustrate communication a n d which would b e tolercble both to the stutterer and his listener. The - u t h c r of this paper, once a severe stutterer, -Derating upon these principles, h c s learned to Gutter so fluently, so briefly a n d ecsily that neither he nor his auditors react to it. He o w e s his b a s i c concept to an old man, 82, whom ne met long a g o a n d who possessed a host of tiny blockings so small a s to b e almost unnotice- " b l e Queried a s to whether or not he had v̂ ad a l w a y s blocked in that fashion, the eld man said, " O h , no. Until ten y e a r s a g o or so, I s'uttered very b a d l y , jerked a n d fought my- self struggled a n d contorted my mouth. But I'm'too old a n d tired now to work that hard. So I stutter this w a y . " The development of stuttering m a k e s it clear that most of the abnormality of cduh stuttering is largely that of learned a v o i d a n c e reactions conditioned to phonetic or semantic cues or of struggle response conditioned to tremors m the articulatory, phonctory or respiratory struc- tures. O n e stutterer learns one set of symp- toms while another b e c o m e s the victim of a different set of learned responses. These ere constantly b e i n g reinforced in three w a y s : by anxiety reduction, by repression, a n d by escape from punishment. The stutterer expects a certain amount of abnormality ; the occur- rence of its satisfies the fear, and so the word is uttered only when the anxiety h a s fed upon enough abnormality to satiate its hunger. Secondly, the stutterer often d e t a c h e s himseh psychologically during the moment of stutter- ing. He almost " b l c c k s c u t . " He surrenders all responsibility for his behaviour. He gives up control. Ajs soon a s the word h a s b e e n uttered he convulsively hurries on to the rest of his communication. There is much repres- sion here. Thirdly, the struggle a n d a v o i d c n c e are themselves! highly punishing a n d unpleas- ant. The utterance of the word, therefore, is an e s c c p e from punishment. Therefore those struggle" reactions occurring just prior to the escape a r e strongly reinforced. The tremors themselves a r e punishing b e c a u s e of their irus- tration. They convince the stutterer of his incbility to move his recalcitrant tongue or mouth. Vibrating c s they do at very fast speeds and maintained b y tension, they pro- voke the stutterer to begin the random in- terrupter struggle which c r e a t e s so many bizarre symptoms. Unfortunately, tne more one struggles, the greater the tension grows and the fester run the tremors. Occasional s u c c e s s e s in jerking out of these tremors by some cut of p h a s e movement merely fixates the interrupter device used. The c a s e finds him- self confronted by three alternatives, all evil ; to stop e n d postpone, to let the block run on until the fear is satisfied and the tension a n d tremor die out, or to struggle blindly in the hope that b y chance he may b e a b l e to jerK himself, out c-f the tremor a n d proceed. There is also a fourth alternative : voluntarily to slow down and, b y decreasing the amplitude, to dampen cut the tremor, but the stutterer seldom discovers this by himself. During therapy, we e n c o u r a g e the ^stutterer to stutter cpeniy but experimentally. We stress the n e e d for varying the stereotyped reactions, for modifying them in the direction of normal utterance! ' W e reward all modifications in this direction a n d fail to reward all those which i n c r e a s e the abnormclity. W e teach our c a s e s to c e a s e reinforcing their disorder in the way mentioned a b o v e . W e train them to wrestle with their blockings, to learn to pull out cf their tremors voluntarily, to insert prior to the e m e r g e n c e of the word some voluntary control. W e get them to sally forth into the situations of real life hunting out their fears a n d then modifying the stuttering which they precipi- tate. " W e help them to maintain close con- tact with their stuttering rather than remain d e t a c h e d from it. W e facilitate their reality- testing so that their p a r a n o i a will not augment their true social penalties. In short we teach them to live with their stuttering easily so that instead of a curse it- b e c o m e s at worst a minor nuisance. In essence, what w e do is to t e a c h them to stutter fluently. When they can, the fears subside and so d c the blockings. Hidden in all of this is a potent psychotherapy leading io the understanding and a c c e p t a n c e of self a n d to self mastery. There a r e undoubtedly many possible routes up the formidable mountain of stuttering. Cer- tain of these paths m a n y therapists and stut- terers h a v e climbed, only to b e confronted by failure. Here is another, poorly charted c s vet, but one of "great premise. W e invite you to join our expedition. Sponsor: RADIO Μ ANNIE. 42 Kotze Street, J o h a n n e s b u r g , Phone 44-7055 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2)