Last year, I went to a talk by Max Gattie on the therapies available to adults who stammer.
Max listed the core approaches most people opt for: City Lit, NHS therapy, McGuire and Starfish. I realised, whilst looking at the whiteboard he wrote them on, that they are all informed to some extent by the medical model. Max asked if he had missed any approaches. “What about an approach based on the social model? Why have you not included that?” I asked. Max wrote it on the whiteboard as an option.
For the rest of talk it sat on that board alongside other miscellaneous options, including hypnosis and delayed auditory feedback, as Max outlined how he felt these core approaches follow the same outline: Motivation, Identification, Desensitisation, Modification and Stabilisation.
It dawned on me that we do not have a form of stammering therapy for which the social model is the sole underlying ethos – the driving factor. Some stammering therapists have integrated social model principles into their practice, perhaps as part of a biopsychosocial model approach, but there is no guideline and no clear form of social model stammering therapy for people to choose. Max did not include it in his talk because it is not an option readily available to people who stammer at the moment.
So, I have written a few blogs that try to map out an Identification, Desensitisation, Modification and Stabilisation shape to social model therapy. I am using my own experience and reading of current ‘integrated’ stammering therapy as the starting point, to highlight where a social model approach may diverge from how some stammering therapists currently work (for some therapists who have integrated the social model into the heart of their practice it might not though, great!).
I do not want to suggest this is ‘the way to offer or do therapy’. This is one person who stammers opinion on how current stammering therapy could perhaps be reconfigured for someone who wants to have therapy informed by the social model. Take from it what you want…
Identification
Acknowledging and understanding ‘a problem’ are generally seen as the first steps to tackling it. And so, medical model stammering therapy typically begins with ‘identification’. Identification is often broken down into overt identification, of the mechanics of the stammering moment, and covert identification, of thoughts, feelings and behaviours around stammering.
Identification is informed by the medical model in that it locates the problems of stammering as within the person who stammers. But, I believe there are tentative shoots of social model thinking that, with a little bit of imagination, can enable identification to centre around identifying disabling barriers in society and discovering new positive meanings in stammering.
Overt identification
“You’ve got to examine and analyze the act of speaking to see what errors you’re making.
What are you doing wrong that makes your speech come out as stuttering?”
Harold Starbuck, speech and language pathologist
Overt identification was originally thought of as a pre-cursor to modifying the act of stammering. It was the ‘know thy enemy’ start of a medical model path. The locking of the throat was analysed, the smattering of the lips studied to the ends of understanding a pathological process requiring targeted treatment.
Thankfully, I think most therapists have moved identification away from this original purpose. Once we uncouple the identification process from later speech modification therapy, it can become so much more. If we encourage the person who stammers to look at their moment of stammering with curiosity rather than prejudice, it can be explored as an innate and natural biological act.
The moment of stammering can begin to be seen in a different light. Moments of tension, like smattering and locking, can still be explored to ease the physical effort of stammering, but perhaps other aspects of their stammering can begin to be positioned as part of that person’s unique speech pattern. The person who stammers can begin to see the stigma and struggle around stammering, and the act of stammering as separate entities. A new relationship with stammering can start and, perhaps, even a sense of personal stammering aesthetic may emerge.
Covert identification
Covert identification focuses on uncovering and identifying the negative thoughts and reactions the person who stammers has in relation to their own stammering. My concern with covert identification is that it typically locates these unhelpful responses as within the person who stammers and inherent to stammering. It tends not to explore the process by which these thoughts and reactions are part of a larger societal dynamic of stigmatization, and in the most part only connected to stammering through oppression.
Take for example, the iceberg, perhaps the most widely-used analogy of stammering. Generally, the iceberg is introduced to differentiate between the ‘overt’ features of stammering, pictured above the water level (e.g. blocking, repetition of sounds and words) and the negative ‘covert’ emotions related to the stammering (e.g. shame, embarrassment, fear) below. The iceberg is helpful to understand that the impact of stammering goes beyond the physical act. However, it provides a reductive understanding of these emotions. In isolation, it is arguably an unhelpful model to appreciate the powerful dynamics of public and self-stigma central to the experience of stammering.
The iceberg alone makes no attempt to place these negative feelings into the context of societal oppression of stammering in which they are born. Without this context, the person who stammers is left holding a list of perceived personal failures resulting from their stammering. From a social model perspective, we can shift the focus onto the freezing seas of societal prejudice and discrimination towards stammering that cause the formation of the iceberg, to highlight that the iceberg is not ‘the fault’ of the person who stammers but rather a natural by-product of societal- and self-oppression.
Societal identification
Identification, from a social model perspective, would place an emphasis on the widespread societal prejudice and discrimination towards stammering. Indeed, Josh St. Pierre has powerfully proposed that to begin to understand stammering in terms of disability, we must look beyond the individual who stammers’ speech mechanism, and onto the society and social situation in which the stammering occurs.
“Stuttering as a communicative action is a distinctly social phenomenon that
cannot properly be reduced to the physical difficulty of producing sounds,
but must be situated within its social fabric.”
Josh St. Pierre (2012, CJDS)
Such ‘societal identification’ would be an opportunity to open the eyes of people who stammer to the disabling and discriminative society in which they live. They could be encouraged to identify and reflect on the structural, physical and attitudinal barriers in this society, for example voice-automated telephones that fail to comprehend stammered speech, stigmatising television tropes of people who stammer and the general view that stammering is a lesser way to speak. People who stammer could usefully be asked to reflect on where the value society places on fluency has come from and whether it is valid.
To me, the social model calls for the identification process to become broader, richer and multi-dimensional. It asks therapists to encourage their clients to look deeper and further than their own ‘overt’ stammering behaviours and ‘covert’ feelings and attitudes, and onto the social landscape and self-stigmatisation processes from which these negative conceptions of stammering have emerged.
This transformed and expanded process of identification sets the groundwork for something more empowering than simply ‘desensitisation’ to follow: the chance to develop a robust political identity as a person who stammers. More on that in the next blog post in this series.
Patrick Campbell
Acknowledgements
I would like to thank Max Gattie for providing the framework to think about this topic and Nina G for her forthcoming chapter ‘Transforming the stuttering iceberg’ in Stammering Pride and Prejudice that sparked my own re-imagining of the iceberg. Thanks to slide hunter too for the image.