At a recent Hypnotherapy supervision meeting the topic of stammering treatment came up. I joined the discussion as a result of my previous work as a Speech and Language Therapist (SLT) but I was cautious, deciding it would be worth my while refreshing my knowledge on the subject. Having done that I thought it might be useful to share this discursive essay although it must be said that my intention was a general update for myself rather than a thorough investigation. if you know someone who stammers I recommend The British Stammering Association's website (BSA).
What specifically is stammering?
At the Oxford Disfluency Conference (2008), Anne Smith produced this helpful statement: "Stuttering is a neuro-developmental disorder involving many different brain systems active for speech - including language, motor, and emotional networks. Each infant is born with a genetic makeup that contributes to his or her probability of stuttering, however whether stuttering will develop depends upon experience. To learn to speak fluently, a child's brain must develop many different neural circuits, and these circuits must interact in very precise and rapid ways. Stuttering emerges in childhood as a symptom that the brain's neural circuits for speech are being wired differently. For this reason, early intervention is critical, because by shaping the child's experience, we can affect the ongoing wiring process in the child's rapidly developing brain. The longer the stuttering symptoms persist in early childhood, the more difficult it is for us to change the brain's wiring, and stuttering becomes a chronic, usually lifelong issue."
Who is affected?
Stammering affects people in all countries and cultures, rich and poor, and those of all levels of intellectual ability. Most stammering begins in childhood and some spontaneously recover without any specialist intervention but about 1% of adults continue to do so. Incidentally, it is normal to have a degree of non-fluency when we speak - what that means is it is usual to have an occasional "um" and "er", small hesitations, minor revisions and corrections of what we've said. As is true for many speech and language problems, males are more often affected than females. Yairi (2005) cites Craig et al (2002) saying that in older children and adults the ratio is about 4:1 but less difference is evident in young children at 2 : 1 (Yairi & Ambrose 2005). Those who have stammered significantly for over three years are unlikely to become fluent (BSA). In my view later treatment may still help and is likely to focus on helping emotions, reducing fear and avoidance.
A genetic component?
Whilst not applying to the majority of children who stammer for a short time only, a genetic component has long been argued as it is evident in different family generations. Genetics research in 2010 found mutations in three related genes and gave additional insight as to the potential cause. They described it as an inherited disorder of metabolism and considered enzyme replacement therapy as a future possible treatment for those with a lifelong stammer. Reassuringly those with the mutated genes were not at risk of other more complex related disorders (Kang et al 2010 cited by Drayna 2010). I suspect that the group of adults who make their way to private hypnotherapy and less conventional therapy treatments beyond typical SLT (eg the McGuire programme breathing/belt technique) will include this group.
What does neuro-imaging tell us?
We can now study the "live" brain with the use of neuro-imaging. Indeed, neuro-imaging research has provided information about the neuro-physiological bases of this complex speech disorder. Subtle brain differences exist (eg reduced grey matter volume and white matter connectivity in these regions) however how to translate this understanding into beneficial everyday therapy is probably some years away (Chang 2014). Etchell et al (2017) reviewed neuro-imaging research between 1995 - 2016 and concluded that adults and children who stammer have widespread abnormalities in the structure and functional organisation of their brains which result in differences in speech tasks and non-speech tasks. This imaging does not give the "cause' of stammering but it does establish it has a neuro-developmental condition. The insights may lead to finding future treatments for modulating neuroplastic growth conducive to treating young children who stammer (Chang 2014). As we know, neuroplasticity reduces significantly (but does not stop) after childhood; therefore, early quality SLT intervention is key for children. I believe a collaborative approach between SLT and hypnotherapy could be worthwhile.
New biochemical research
In view of the gender bias, Bilal et al (2018) looked at hormonal factors. The findings supported that the GPER-1* levels of male patients were higher than females and of the control group. They concluded that it might be important in the diagnosis and treatment of stammering. From my reading G-protein coupled receptors help regulate a huge number of bodily functions from sensations to growth to hormone responses and many medicines target them. Links are included in the references for further explanation! (*G-Protein coupled membrane Estrogen Receptor-1)
Some treatment research, old and new
SLT research which included hypnosis and breathing was done by Eular et al (2014) on 98 patients. They concluded that "fluency shaping" and "modification" (standard SLT treatments) provided in an intensive time schedule were the most effective treatments and typically no further treatment was needed. Intensive group SLT was found to be recommended also. Extensive other S&L treatments including hypnosis and breathing exercises were found to be ineffective. Effectiveness was rated using a structured questionnaire by the participants and treatment was 1 - 7 sessions.
However, Kaya and Alladin (2011) found that hypnotically assisted diaphragmatic exercises were statistically significant for the management of stammering in a study of 74 people although they said further controlled trials were needed. Hypnotherapy was used to reduce anxiety, to lift self-confidence and increase motivation for the significant abdominal weight-lifting exercises lasting 2-hours a day for 8 consecutive days. (Note: whilst, as far as I know, no SLT was included in this study but, in my view, it is common for SLTs to target reducing anxiety and building confidence as part of their therapy. And likewise, if a patient's breathing pattern was considered problematic therapy would be given as speech is essentially a bi-product of breathing. (The air leaving our lungs gains sounds when it passes through the vocal folds in our larynx then the sounds are shaped into words by the mouth's movements. Hence shallow or irregular breathing does not support speech well.) Given that breathing therapy was not considered useful in the Euler et al (2014) research, perhaps hypnosis targeting anxiety and self-confidence was a crucial part of the significant result? It would be useful to look more closely at the study's methodology. I noted that Craig and Tran (2006) stated that emerging (psychiatric) evidence suggests people who stammer are more chronically and socially anxious to those who do not but it is considered the result of having a stammer rather than cause.
In a smaller study of 30 patients Lockhart and Robertson (1977) used a combination of hypnotherapy and speech therapy. They divided the group up into those patients whose stammer presented as 'mild' deciding that the etiological basis might have been an extension of normal non-fluency, and a second group whose symptoms were more stigmatising and severe. These respected SLT researchers of their time chose to use only hypnotherapy for the mild cases but a combination of SLT consolidated by hypnosis at all stages of the intervention to promote fluency in all situation in the second group. They concluded that an approach using both disciplines provided a unified and effective approach to treatment.
And it was no surprise to read that McCord (1955) reported that the material on stammering found in hypnosis literature had a more favourable tone about hypnosis/hypnotherapy outcomes than in SLT and Psychology literature! McCord also gave an anecdotal illustration of successful hypnotherapy but this was over a period of more than 30 appointments so one could argue uncontrolled factors could have brought about the recovery. Times have changed in our standards of research but it is still tricky to get comparable treatment groups and control groups together with the same treatment methodology being applied. We know that individualising treatment is essential which does not fit with Random Control Trials and we also know that the therapeutic relationship (rapport) and patient's belief are influential but not usually measured. I also wonder if more collaborative approaches are in practise today but, sadly, I can't say I found much evidence of that in my small search.
Hence my conjecture is that hypnotherapy is an appropriate approach, particularly to target the emotional responses and research indicates that visualising a changed future will alter/strengthen neural connectivity. Information from Stanford University (2016) of up-to-date information gained via brain scans during hypnosis, the brain's activity and connectivity is of interest. What effect hypnosis has on the brain when treating stammering is not mentioned in this article but it does mention treating anxiety and an effect of hypnosis being a dissociation between action and reflection which lets the patient engage in activities whether suggested by the therapist or self-suggested without being self-conscious about the activity. The Stanford medical scientists are curious about how to stimulate the brain to make a wider number of people more hypnotisable because its potential to help is recognised. In treating stammering I know that both hypnotherapists and SLTs aim to encourage a confident assertive attitude, develop a positive sense of identity and that they incorporate techniques to desensitise the person to the specific environmental situations that trigger their stammer responses regardless of the aetiology.
I hope this has been interesting and please get in touch if you have experience or case studies to discuss. The long list of references is available on request.
Audrey at Summit Life Coaching Ltd with NLP and Hypnotherapy
Audrey is a member of the British Society of Clinical Hypnosis and a non-practising member of the Royal College of Speech and Language Therapists