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Communication therapy
"/ournal of Adolescence z98z, 5, 285-299
Communication therapy TINA LUCAS* This paper describes my method of working with delinquent adolescent boys in a psychiatrie Borstal who have been referred with problems concerning communication. I concentrate here on work with boys who stammer, and give a case history of one such boy. INTRODUCTION I am a speech therapist who has also had some group analysis and family therapy training. M y paper describes a method I have devised of working with disturbed delinquent adolescent boys who stammer, in the setting of a psychiatric Borstal. Just before starting work at Feltham Borstal, where I felt sure I would be meeting people who stammer, I attended a refresher course on stammering in London. This gave me the opportunity to sit and observe on video many people afflicted with a variety of stammers of considerable severity, in fact crippling disorders of communication. As I watched I wondered how they had maintained their sanity after years of such stress--and then I asked myself whether the stammer could actually be a way of avoiding stress, a maladaptive way of coping perhaps, and that at some time in some way the stammer was a survival technique albeit an unconscious one. It is widely understood that stress can lead to disorders of speech and voice such as mutism and dysphonia. Thus a hen and egg situation arises, and as with any symptom-orientated way of coping, symptom and stress become symbiotic. It is also seen with physical symptoms such as ulcers, hypertension and the like. In my other job, at a centre for group and family therapy, I work with people who have become seriously incapacitated with such conditions as withdrawal from reality, agoraphobia, obsessional behaviours, etc. Here we find that various group techniques offer the best opportunity to get behind and then beyond the symptom, thereby making it redundant. I thought that this also might be the case with people who stammer. The point of these introductory comments is to show that it is far from * S p e e c h therapist at H M Borstal, B e d f o n t Road, F e l t h a m , M i d d l e s e x . E d i t o r ' s note : T h i s p a p e r is c o n c e r n e d w i t h t h e p r o b l e m s o f c o m m u n i c a t i o n . It is a personal a c c o u n t o f a m e t h o d o f w o r k i n g a n d itself c o m m u n i c a t e s in t h e first person. ox4o-z97x/8zlo3oa85 + xS $o3.oo/o
9 198z The Association for the Psychiatric Study of Adolescents
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absurd to suggest that a stammer can provide a function for the individual: others have as strange or evcn stranger ways of "coping". In other words there are ways of coping on one level that are non-coping at other levels. A stammer is a handicap to verbal communication, but it could be regarded as an effective avoidance tcchnique--it could be a way of "disarming the opposition" for example--so a stammer, though seeminglyso dreadful on the face of it, might be less dreadful than being fluent. Somebody who is aware that his stammer has Some advantages writes in SJ)eakhzg Out*; "It (the stammer) has become my pet, I wouldn't be without it now it's me". At a conscious level each person who stammers perceives his symptom differently; the mildest of hesitators can feel as crippled as the severest of blockers. The feeling side, or subjcctive response, which can range from denial of any feelings to acute embarrassment and misery, has to be taken into account as an important aspect of assessment. I have talked about levels, and started this introduction describing stammering as a crippling disorder of communication, but it needs to be acknowledged that on one level, the stammer is the communication; though unconscious, it might be described by some people as manipulative, because it creates a diversion onto itself. It has a purpose, such as concealment, but for each person that purpose may be different. By its very essence it involves other people---and it keeps them at bay. It communicates vulnerability and will elicit a response in others varying from sympathy to irritation, from protectiveness to flight. It thus creates an obstruction to natural social intercourse between people and this, for one reason or another, may be a great source of anxiety to the person who stammers. Although it is unlikely that a symptom will persist unless there is some use for it in the here and now, I would like to say a word about what I call the "fossilized response". By this I mean a response that is no longer appropriate although it has been effective for some purpose at another time, and now persists for want of experiencing that there is a more appropriate response which could make the habit redundant. This can apply to stammering. The aim of the therapy is to provide an environment where enough trust can develop to allow the person to discover whether he does, or does not want to change, and if he does, to enable the required internal changes to take place, and new modes of operating to be discovered, to replace the unsatisfactory ones. It is my experience that this can best be done in a group. People who stammer have found it difficult to work in analytic groups--putting this down to the disadvantage of their stammer (not getting a word in). So it is ideal to be introduced to group work with others who stammer, the diversion is less effective when others use the same technique. Thus each individual begins to * The Magazine of the Association for Stammerers, Vol. III (I), p. 4.
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:xperience his own, and others', modes of operating, apart from the stammer. I will now describe the methods I use in my attempts to achieve change at Feltham Borstal with delinquent adolescent boys, aged 15-2o years, who 'stammer. METHODS
The therapy This is an evolving process full of compromise because it is dependent on the length of Borstal sentence, early referral and so on. It consists of a mixture of individual and group sessions and can be divided into these main stages: (I) Assessment. (2) Individual sessions. (3) Introductory group. (4) Group work. Eight weekly meetings lasting one and a half hours with the possibility of a further group. (S) Follow-up individual sessions. (6) Family therapy session (when possible). This would be followed by a questionnaire to probation officers, six months after discharge from Borstal.
(I) Assessment This takes two forms: Objective (i) Tape recording. Repeated at intervals, during and at the end of work together. (ii) Basic vocabulary test. (Useful when selecting for groups.) Subjective (iii) Jacobsen Questionnaire. This assesses an individual's attitude towards his own communication skills. It requires a true or false response to such questions as, "A person who is my teacher or my boss is hard to talk to", "I am a good mixer" etc. (iv) A more detailed questionnaire of the "case history" type which leads into the individual therapy. (2) Individual sessions These last from a few weeks to several months--depending on the boy's readiness for a group, and the availability of others to form a group.
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Tile main feature of this is that we sit side by side and I write a running record of all that is passing between us. I work on the principle that everything that is said is important and shouldn't be lost. Non-verbal communications may also be recorded, e.g. "You say you are O.K., but you don't look it". The individual work is a combination of times past and present. I follow and reflect his lead, and respond and develop what he brings, with queries, suggestions, associations and some formulae--and it all goes down on paper, nothing being considered unimportant. Naturally a shorthand develops which we both understand, as with any diary. I use a fat pad of rough paper and as each sheet is finished it is pushed across the desk. By the end of the session we have a sequential record of all that has taken place. Misunderstandings and mistakes on my part or his are corrected there and then. We can see at a glance inconsistencies, new ideas, awful thoughts--and it enables us to start from where we left offeach week, as, after hellos and burning issues of the week, we always recap by looking at the previous week's session, and often pull bits out of it that seem important for further exploration. Also, the longer-term changes can be seen as we can recap to any point. Generally, a remarkable level of trust is developed using this method. For a start, there is proof that I am listening, and prepared to stand corrected. The boys know that the folders stay with me although they can have copies of the work if they want. My style is not that of the expert. Each boy needs to learn to recognise that he is the expert on himself. I am there to reflect and focus on what he really is, and maybe when he sees some of his own coping side he can start to explore areas in which he is not getting the best for himself by the way he operates. The attention of these sessions is entirely directed at getting the best for him. After this intimate start there is almost always a reluctance to join a group. However, I regard group work as a key part of the therapy, so the introductory group session is vital. The individual work which can be cosy for both boy and therapist is temporarily at an end. (3) Introductory group This is atypical in that it is shorter than the others and I take afirm lead and structure it throughout. The goal is to engage each individual. (i) Introductions. Right from the start the importance of listening is stressed. After each person has introduced himself each of us then introduces the person on his left--prompted when necessary. (ii) The advantages and disadvantages of having a stammer. The discussion on this theme is a vital part of the introductory group: it needs to be acknowl-
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~dged at this stage that the disadvantages outweigh the advantages for each ?otential group member. This is needed as a reminder when later stresses =ause members to wish to leave the group. (iii) Commitment to attend. Following this I state that in my experience group work, although by no means easy, is a help to those who take part. If anyone wishes to leave now they can do so, but otherwise we are committed t o meet together for the next eight weeks. (iv) The format of future sessions. I describe how the groups will be structured (see below). (4) Group work Each session comprises three distinct stages: Part one : Unstructured time. The therapist keeps as low a profile as possible, to give the adolescents the opportunity to be in control of what happens. The less anxious, troubled, disturbed the boys and the therapist are, the less structure they need. Although I will have explained this in our introductory group, it still comes as rather a shock when I start the session by saying nothing. This period can be the hardest time for the therapist as it can be for the boys. It throws each boy back onto himself. There can be a great deal of anxiety, anger and resistance to this, which may include a period of "ganging-up" against the therapist. As the group "grows up" Part one expands from as little as ten minutes to over an hour of the session. Part two : Structured time. I take control and introduce directed activity which is geared to getting to "know oneself and others. We talk around set themes such as one thing that you like/dislike about yourself; that you fear[ makes you laugh/sad etc. We are still stressing the listening. This is needed when, for instance, they are asked to remember what one other person has said. I have a pack of incomplete sentences which are helpful early on in a group's life such as: "When I'm inside what I miss most i s . . . " , "I w i s h . . . " , "Fathers should...", "I hate people w h o . . . " . At times I write down their responses and have them typed out to hand them the following week, this is particularly valuable; silliness looks even sillier when written down--and is more likely to be discarded as a way of responding in the group. The variety shows the individuality of each member and strengthens each person's sense of identity. Part three : Group activity. This involves each person making a contribution and being in step with the others, or out of step and putting up with the
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consequences. For example, going round the circle telling a story but only being allowed one word each at a time; or having a sentence to say towards a story but each boy starting alternately "Fortunately...", "Unfortunately...", "Fortunately . . .", "Unfortunately . . .", and so on. I will give an actual example of this here, as I did not use this technique in the detailed case history which follows. This is a group with four boys and myself. "Fortunately it was sunny when I woke up and I decided to go out. Unfortunately when I got out it started to rain. Fortunately I went to bed with my girl friend and my mum came back, unfortunately she had a fit. Fortunately she was understanding though unfortunately later when my clad got back I heard them talking downstairs and his voice got louder and angrier, I locked myself in the bathroom. Fortunately I said to myself 'be a man' and stand up to my dad, he will understand after all he probably did the same thing himself when he was my age. I went downstairs to talk to him. Unfortunately he did not understand at all. Fortunately when he lost his temper I hit him first and had him laid out on the floor, unfortunately I had to run away". (To be continued.) The story was continued the following week, but I hope this excerpt speaks for itself in the value such exercises can be. For example, one of the boys who spent the greater part of the eight weeks hiding under his jacket---emerged agitatedly at his turn and asked "Whose mother is this?"--to be told by me "It's yours, the story is with you now", he was horrified but was able to contribute in round one "Unfortunately she had a fit", and in round two regarding "his" dad "Fortunately when he lost his temper I hit him first and had him laid out on the floor". The boys in this group all had stammers and were committed to Borstal for offences of rape, grievous bodily harm, car theft and burglary. If the group can develop trust then the boys will begin to share their fears, anger, depression, problems as they see them, and through the action of the group can literally discard things they have been preserving for years--or at least take back and own things about themselves in an accepting way. This process has the effect of freeing the speech--and improved fluency is the result. (5) Follow-up individual sessions With the new experience of working in a group, and the insights and information this has brought to each of us, we then continue working on an individual basis--until discharge or further group work or, preferably, until he no longer needs to come, and would like to finish his time without the support of the sessions.
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) Family therapy This is invaluable, but is unfortunately only possible with a very few of the eople I see. There is often a strong resistance to it from the boys, but a sense "relief and achievement if it actually takes place. The style of the session is athreatening and is designed to observe, reflect and focus on what all mem~rs of the family bring into the room. The aim of the family therapy session is to continue the unscrambling of the tuation which will have been underway during our work together. It allows le family to be involved and to gain insights too--it is an important bridge Jr both sides as the release date approaches. Just as the boy, if he has achieved aything, will have made changes, so the family needs to recognize this, and eeds support in understanding their own reactions, attitudes and beaviours, and those of this family member. CASE
STUDY
'his approach becomes clearer in the description of the case of Ted, with ~me details from the assessment, followed by two individual sessions. I then mlude some excerpts from his group, dwelling on Ted's work in it; then ldividual sessions 3-Io; the family meeting a final session and some details "'om the follow-up questionnaire to Ted's probation officer. Ted, aged i8, was first seen on 23 January and discharged on x7 June. He ad been sentenced to Borstal for criminal damage, theft, taking and driving way a motor vehicle. His wrist was so severely cut that the tendons were ermanently damaged, a self inflicted injury with a bottle, after a family ledding. He also had a limp caused by a TB hip. At about I3 or 14 Ted had reviously had a month's intensive course of speech therapy learning pro9nged speech.
Assessments These showed: (a) Moderately severe stammer. (b) Vocabulary age of about ten and a half years. (c) A very poor opinion of his own communication skills (Jacobsen Questionnaire). The following are excerpts taken from the detailed assessment questionmire: "Q. What was the reaction of teachers to your stammer? A. Bad, I was what they call a trouble maker because of my stammer. The headmaster had a go at me to behave, he threatened me, it made the stammer worse. I would muck about to avoid having to read out.
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I used to hang around with blokes--they pinched cars and then I used to do it to prove myself. Q. What was your worst moment? A. In court, all these questions... I couldn't speak at a l l . . , in the end my father had to answer them for me. I was very embarrassed. Q. Which people are important in your life ? A. Parents, they help you all the time, they help you through life . . . I've disappointed them. Q. Do you feel you've done what you want in life so far ? A. No, I've always been in trouble and I don't want to be in trouble. I just want to be happy." Ted had two individual sessions following his assessment, before being admitted to a group. In the first he revealed his mixed feelings towards his parents, his indebtedness, and his inability to follow their advice and keep out of trouble. Trouble gets him attention which is what he wants, starring in the newspapers. In the second session Ted resentfully described how all his relatives cared about his parents rather than him. He was warned: " T h e y would get a divorce if I didn't pull myself out of i t . . . mind you, I am to blame". He enlarges on how he has to prove himself with his mates: "People are always proving themselves, especially people with some disadvantage". Towards the end of the session he states: " I must be stupid, everyone tells me I'm s t u p i d . . , brother, sister, m u m . . . " .
The group For extraneous reasons Ted was put into a group earlier than most. The group only had two other members, one having dropped out on release. Normally, I have four plus myself--and that is a squash in my tiny room. The group members were: Ted. Alan, aged 20. Moderate stammer. In regular work. Common-law wife and two children. Rory, aged 18. Severe stammer. Second Borstal sentence. Second group.
Introductory group Introductions in Ted's group ineluded one thing you like/dislike about yourself, and one thing that frightens you.
Excerptsfrom the group Ted. "I'm a friendly person who gets on with others, including those I don't
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like. I don't like my speech. I'm frightened of what will happen when I get out of this place".
Seed sentences I asked them all to take a journey back in time, and remember one thing that was said to them as a child. Alan: " G o out and get the shopping". Ted" "Grow up!" (said straight out, no thought necessary). Rory: "You are a right ghastly boy". T e d found the group embarrassing and said so. He strongly recommended to the others, particularly to Row, that relaxation classes are the best thing for stammering.
aro.p 2 (excerpts) Part I Ted. "This place is boring". Alan nodded agreement. Ted. Long silence. "This is out of order". Laughing and shifting. More silence. Therapist. I reiterate the "boring" phrase. Ted. "Well, it is, isn't it, we're here to practise our speech". Therapist. "Perhaps you expect someone else to start things off a l w a y s . . . " .
Part II. We recall last week's seed sentences. Ted." 'Grow up'--I should growup, they were right, Dad was right to beat me, I would have done the same in his place--but it made me go out and get into more trouble. It's my own fault, now it will be difficult to go out and get a job".
Group 3 (excerptsfrom Part I) Ted, biting nails hard, "What are we going to talk about?" Therapist. "Anything." Silence, approximately five minutes. Ted. "This is hard, it's out of order, I can't cope with it." Alan. Opens his closed eyes, glances anxiously at me. This seemed hopeful, but he went back to previous posture. Rory. Looking miserable. Ted. Talked of the help of relaxation saying his stammer is nerves. Rory nods. The others should have relaxation (he is having a course of this elsewhere). Therapist. I point out Ted's tense look and nail-biting.
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Alan and Rory. Agree. Ted. "It's just a habit." Therapist. I say that I hear that he is finding relaxation classes a help--good. But in here perhaps we could look at the nerves and what they are about . . . . Ted. "Rory looks tense and nervy and heavy as if he's got worries." Rory. Hot denial. Therapist. "It seems difficult for Rory to accept concern shown by another." Rory. Agrees this is so. Therapist. Stresses the caring nature of Ted's remark. Rory. Tells us that he has changed since being in here, he didn't used to be able to speak at all and now he can.
Group 6 (excerptfrom Part II) T h e y were asked to "role-play" another family member's view of t h e m - going back in time---or now. Ted chose first his Mum: "He's a tearaway, always trying to prove himself all the time, and he always ends up the worse for it. If only he'd listen to me. I love him a lot, but I loved him best when he was in nappies, and I was in complete control--I wish they didn't have to grow." Then his Dad: "Well, he ain't a bad lad, he just gets easily led--one day he'll learn either the hard way, or the easier way. I myself learned the hard way, and it isn't an easy life. He seems to be like me and it's going to be the hard way, like father, like son."
Group 7 (excerptfrom Part I) Ted. "Last week on Monday I saw the specialist--we were talking about my hip and all the pain I was having with it. Eventually he told me that I couldn't have an operation as it would open up all the poison. I was really annoyed about this and it kept coming into my mind. I was just talking to him and that, but I felt like getting up and hitting h i m . . , knowing that I would be like this for the rest of my life. Pin him up against the wall and kick the shit out of him."
At the end of group N o n e stated that it had helped their speech, but all agreed that talking of the " p r o b l e m s " helped. Actually T e d ' s speech was more fluent, and Rory's too. Alan's was not, it had become clear that he was sitting on something which had led to a drinking bout. H e was able to look at this in his subsequent individual sessions and found this such a help that he determined to continue speech therapy after discharge.
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Ted's individual sessions continue I will demonstrate the diary form of working using session 3, which followed straight after the group. Explanations to the reader are contained in brackets. There are none in the excerpt. The numbers on the extracts indicate the sheet number of the session which can be anything from four to 2o sheets in any one session.
hldividual session 3 [four sheets] (I) Ted. "Boredom--boring--get out to Finnamore" [open Borstal where he has applied to go]. Therapist. "Will the boredom go with you?" Ted. "I feel 8o in here. I feel really old." Therapist. "Grow up I" [recall seed sentence.] Ted. "I feel I'm passing away." (z) Ted. "I'm sick, slobby, unhealthy all the time. Bodily old. I'm hemmed in]enclosed]banged up."
D 3 J - 1 tI draw prison window with bars.] Ted. "In a box fading away." Ted. "Stupid really." Therapist. "Oh ?" Therapist. "You are describing the facts--how this prison is making you feel." (3) Therapist. "But you are a prisoner in more ways than one and one way you'll carry with you till you are 8o." [I'm referring to the hip. He had been under the impression an operation could cure it--these hopes had been dashed in the last few weeks.] Ted. "I didn't want to go all depressed." (4) Therapist. "Prison Borstal is boring. Prison Hip is boring."
Session 4 Ted's first statement is that he has decided against going to the open Borstal--as he might run away. This leads us to look at how his own actions harm him, and we take an actual example that has happened in the past week. Feeling frustrated by a rule, he abused an officer. He worked out an alternative strategy on a formula I often use--situation/your response/result for y o u - should such a situation arise again.
Session 5 Things are going better, he has a new job in the Borstal. I expand on his theme of letting others down. I ask if he has been let down.
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(2) Ted. "It's all my fault for being in here because I had heaps of warnings." Therapist. "So ?" Ted. "I didn't listen to the warnings." Ted. "Warned by parents, police, judges, uncles and aunties." (3) Ted. "The other day someone asked me to hold his burn*--in the past I would have taken it--this time I didn't because I know he had earned it." Therapist. " I ' m beginning to trust myself." Ted. "In here (this room) it's like being in a boat with my own food, not like out there where everybody is hogging it." (4) Ted. "After each session there is a feeling of satisfaction--as if I've done something really good--like as if I'm Barry Sheene and just won a big race." (5) Therapist. "In this room you are number one." Session 5 continued with us looking at the different ways people have of dealing with stress, and then we switched to his seemingly senseless/bad behaviour. (II) Therapist. "Punish me, I am bad. There's a pay off. You had to do wrong to prove you weren't a cripple." Ted. "They kept letting me off (the courts). But I was in court two more times and I proved I was capable--." Therapist. "I got what I was asking for--Borstal." (x2) Ted. "I know I did wrong first time." Therapist. "But I chose to do more." Ted. "On my third one, parents and relatives thought I'd get Borstal, Solicitor doubted it. I said why? He thought I wouldn't be capable." Session 6 T e d reports that everything is going O.K. There has been no aggravation and his speech is fluent. We explore the reasons for this. T e d states that it is more encouragement. I extract the courage part of that word and suggest that it is to do with finding out what is in you. I suggest that he used to see only the bad in himself, and ask him how important it is for him to see the rest of his family as perfect. I add that I don't think anyone is perfect. I hark back to letting down, and being let down, I mention the hip. (8) Therapist. "Hip. Since about I2 years you had pinned your hopes on an operation at I6. How disappointed and guilty your parents were at having a child with a wonky hip." * Cigarette.
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Ted. Interrupts. "I've blamed them--after all, they brought me into the world." Therapist. "Angry with them." (9) Therapist. "Hope." Ted. "Hope [for cure] has become less important." Ted. "In a way it's a relief to be able to throw that out." Therapist. "And know where you stand." Ted. "My future is now." Session 7
He has had a visit from his parents at the weekend--"I was nervous, but not stammering". Both he and they were surprised. Session 8
I suggest we have a session together with his parents. He is resistant, " I think you are trying to blame my parents", "They won't come", etc. (I5) Therapist. "Why shouldn't your parents get some help ? They've obviously found it quite difficult bringing up a terrible chap like you." (i6) Ted. "They used to have arguments over me." Therapist. "You?" Ted. "They've done everything on the earth to help me." Therapist. "How?" Ted. "Paid my fines." Therapist. [Here I draw a head and hands just visible, hiding behind a wall.] Session 9
Preparing for his return home, the session is geared to the difficulties of holding onto the changes he has made back in the environment in whieh he got into difficulties. We continue to explore his resistance towards the meeting with his parents--he is feeling very wound up. (I3) Ted. "Everybody winds me up." Therapist. "Bring three examples of your getting wound up in the house, next week." Session io
(Q Ted. "No wind ups." He did not even rise to being called a spastic. Ted's home leave is in two weeks. He says he is worried about something and he doesn't know what it is.
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I inform him that I am going to invite his parents to a meeting. The parents responded at once to the opportunity of a session, and although at short notice came on the earlier of the two dates offered. They greeted Ted warmly. They were an attractive couple, mother English, father Irish.
Excerpt from session with parents It wasn't long before Dad "got going" talking of his own difficult early start (leaving Ireland aged 14 alone, to find work); the iniquities of the police, etc. As this was going on Mum and Ted started to exchange looks and quiet talk; cigarettes and sweets were handed over. I drew attention to this and asked if this often happened, that Dad was ignored, all three agreed that it did. Dad (much to Ted's surprise) said that he felt "left o u t " - - T e d said that he felt left out as if they didn't love him. Ted agreed that he did find it difficult to talk to Dad and preferred to go through Mum, and Mum agreed that this was so, that she didn't discourage it--but that it might be better if Ted and Dad could communicate more directly.
Final session Ted reports with delight and surprise, how much he got out of the session with his parents. We end by making a recording of his now fluent speech and compare it to the first recording he made.
Some information from the questionnaire to the probation officer-six months post discharge Ted is attending monthly, and the probation officer occasionally does home visits. He has a job. Ted no longer finds his speech a problem and the probation officer no longer perceives it as a problem. He is not receiving further speech therapy. " . . . I would assess there has been no long-term regression since discharge, although there has been the odd stressful interview beginning with difficulty in communication. He has quickly coped with this rare event." Probation Officer CONCLUSION The purpose of this paper has been to demonstrate that stammering can be a symptom of stress. I have described a style of working which contains an individual, group, and family therapy "package" which I find is particularly effective, not only for work with adolescents who stammer but also, with minor modifications, for other adolescent groups in need of therapy.
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The main feature of the individual sessionwhich has proved most useful, is the keeping of a shared running record or diary of the individual sessions, which acknowledges and focuses on the importanee of all communications, maps the therapeutic journey, pin-points particular repeated difficulties and provides evidence of real change and progress. A feature of the group work is that it has a definite structure, boundaries, etc., but it also contains unstructured time which allows the adolescent to get a sense of being in control of what happens. It also has structured time where the therapist directs the activities and takes a definite lead. At least one family session should be held to enable the changes that have been achieved to be maintained.
Communication therapy TINA LUCAS* This paper describes my method of working with delinquent adolescent boys in a psychiatrie Borstal who have been referred with problems concerning communication. I concentrate here on work with boys who stammer, and give a case history of one such boy. INTRODUCTION I am a speech therapist who has also had some group analysis and family therapy training. M y paper describes a method I have devised of working with disturbed delinquent adolescent boys who stammer, in the setting of a psychiatric Borstal. Just before starting work at Feltham Borstal, where I felt sure I would be meeting people who stammer, I attended a refresher course on stammering in London. This gave me the opportunity to sit and observe on video many people afflicted with a variety of stammers of considerable severity, in fact crippling disorders of communication. As I watched I wondered how they had maintained their sanity after years of such stress--and then I asked myself whether the stammer could actually be a way of avoiding stress, a maladaptive way of coping perhaps, and that at some time in some way the stammer was a survival technique albeit an unconscious one. It is widely understood that stress can lead to disorders of speech and voice such as mutism and dysphonia. Thus a hen and egg situation arises, and as with any symptom-orientated way of coping, symptom and stress become symbiotic. It is also seen with physical symptoms such as ulcers, hypertension and the like. In my other job, at a centre for group and family therapy, I work with people who have become seriously incapacitated with such conditions as withdrawal from reality, agoraphobia, obsessional behaviours, etc. Here we find that various group techniques offer the best opportunity to get behind and then beyond the symptom, thereby making it redundant. I thought that this also might be the case with people who stammer. The point of these introductory comments is to show that it is far from * S p e e c h therapist at H M Borstal, B e d f o n t Road, F e l t h a m , M i d d l e s e x . E d i t o r ' s note : T h i s p a p e r is c o n c e r n e d w i t h t h e p r o b l e m s o f c o m m u n i c a t i o n . It is a personal a c c o u n t o f a m e t h o d o f w o r k i n g a n d itself c o m m u n i c a t e s in t h e first person. ox4o-z97x/8zlo3oa85 + xS $o3.oo/o
9 198z The Association for the Psychiatric Study of Adolescents
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absurd to suggest that a stammer can provide a function for the individual: others have as strange or evcn stranger ways of "coping". In other words there are ways of coping on one level that are non-coping at other levels. A stammer is a handicap to verbal communication, but it could be regarded as an effective avoidance tcchnique--it could be a way of "disarming the opposition" for example--so a stammer, though seeminglyso dreadful on the face of it, might be less dreadful than being fluent. Somebody who is aware that his stammer has Some advantages writes in SJ)eakhzg Out*; "It (the stammer) has become my pet, I wouldn't be without it now it's me". At a conscious level each person who stammers perceives his symptom differently; the mildest of hesitators can feel as crippled as the severest of blockers. The feeling side, or subjcctive response, which can range from denial of any feelings to acute embarrassment and misery, has to be taken into account as an important aspect of assessment. I have talked about levels, and started this introduction describing stammering as a crippling disorder of communication, but it needs to be acknowledged that on one level, the stammer is the communication; though unconscious, it might be described by some people as manipulative, because it creates a diversion onto itself. It has a purpose, such as concealment, but for each person that purpose may be different. By its very essence it involves other people---and it keeps them at bay. It communicates vulnerability and will elicit a response in others varying from sympathy to irritation, from protectiveness to flight. It thus creates an obstruction to natural social intercourse between people and this, for one reason or another, may be a great source of anxiety to the person who stammers. Although it is unlikely that a symptom will persist unless there is some use for it in the here and now, I would like to say a word about what I call the "fossilized response". By this I mean a response that is no longer appropriate although it has been effective for some purpose at another time, and now persists for want of experiencing that there is a more appropriate response which could make the habit redundant. This can apply to stammering. The aim of the therapy is to provide an environment where enough trust can develop to allow the person to discover whether he does, or does not want to change, and if he does, to enable the required internal changes to take place, and new modes of operating to be discovered, to replace the unsatisfactory ones. It is my experience that this can best be done in a group. People who stammer have found it difficult to work in analytic groups--putting this down to the disadvantage of their stammer (not getting a word in). So it is ideal to be introduced to group work with others who stammer, the diversion is less effective when others use the same technique. Thus each individual begins to * The Magazine of the Association for Stammerers, Vol. III (I), p. 4.
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:xperience his own, and others', modes of operating, apart from the stammer. I will now describe the methods I use in my attempts to achieve change at Feltham Borstal with delinquent adolescent boys, aged 15-2o years, who 'stammer. METHODS
The therapy This is an evolving process full of compromise because it is dependent on the length of Borstal sentence, early referral and so on. It consists of a mixture of individual and group sessions and can be divided into these main stages: (I) Assessment. (2) Individual sessions. (3) Introductory group. (4) Group work. Eight weekly meetings lasting one and a half hours with the possibility of a further group. (S) Follow-up individual sessions. (6) Family therapy session (when possible). This would be followed by a questionnaire to probation officers, six months after discharge from Borstal.
(I) Assessment This takes two forms: Objective (i) Tape recording. Repeated at intervals, during and at the end of work together. (ii) Basic vocabulary test. (Useful when selecting for groups.) Subjective (iii) Jacobsen Questionnaire. This assesses an individual's attitude towards his own communication skills. It requires a true or false response to such questions as, "A person who is my teacher or my boss is hard to talk to", "I am a good mixer" etc. (iv) A more detailed questionnaire of the "case history" type which leads into the individual therapy. (2) Individual sessions These last from a few weeks to several months--depending on the boy's readiness for a group, and the availability of others to form a group.
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Tile main feature of this is that we sit side by side and I write a running record of all that is passing between us. I work on the principle that everything that is said is important and shouldn't be lost. Non-verbal communications may also be recorded, e.g. "You say you are O.K., but you don't look it". The individual work is a combination of times past and present. I follow and reflect his lead, and respond and develop what he brings, with queries, suggestions, associations and some formulae--and it all goes down on paper, nothing being considered unimportant. Naturally a shorthand develops which we both understand, as with any diary. I use a fat pad of rough paper and as each sheet is finished it is pushed across the desk. By the end of the session we have a sequential record of all that has taken place. Misunderstandings and mistakes on my part or his are corrected there and then. We can see at a glance inconsistencies, new ideas, awful thoughts--and it enables us to start from where we left offeach week, as, after hellos and burning issues of the week, we always recap by looking at the previous week's session, and often pull bits out of it that seem important for further exploration. Also, the longer-term changes can be seen as we can recap to any point. Generally, a remarkable level of trust is developed using this method. For a start, there is proof that I am listening, and prepared to stand corrected. The boys know that the folders stay with me although they can have copies of the work if they want. My style is not that of the expert. Each boy needs to learn to recognise that he is the expert on himself. I am there to reflect and focus on what he really is, and maybe when he sees some of his own coping side he can start to explore areas in which he is not getting the best for himself by the way he operates. The attention of these sessions is entirely directed at getting the best for him. After this intimate start there is almost always a reluctance to join a group. However, I regard group work as a key part of the therapy, so the introductory group session is vital. The individual work which can be cosy for both boy and therapist is temporarily at an end. (3) Introductory group This is atypical in that it is shorter than the others and I take afirm lead and structure it throughout. The goal is to engage each individual. (i) Introductions. Right from the start the importance of listening is stressed. After each person has introduced himself each of us then introduces the person on his left--prompted when necessary. (ii) The advantages and disadvantages of having a stammer. The discussion on this theme is a vital part of the introductory group: it needs to be acknowl-
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~dged at this stage that the disadvantages outweigh the advantages for each ?otential group member. This is needed as a reminder when later stresses =ause members to wish to leave the group. (iii) Commitment to attend. Following this I state that in my experience group work, although by no means easy, is a help to those who take part. If anyone wishes to leave now they can do so, but otherwise we are committed t o meet together for the next eight weeks. (iv) The format of future sessions. I describe how the groups will be structured (see below). (4) Group work Each session comprises three distinct stages: Part one : Unstructured time. The therapist keeps as low a profile as possible, to give the adolescents the opportunity to be in control of what happens. The less anxious, troubled, disturbed the boys and the therapist are, the less structure they need. Although I will have explained this in our introductory group, it still comes as rather a shock when I start the session by saying nothing. This period can be the hardest time for the therapist as it can be for the boys. It throws each boy back onto himself. There can be a great deal of anxiety, anger and resistance to this, which may include a period of "ganging-up" against the therapist. As the group "grows up" Part one expands from as little as ten minutes to over an hour of the session. Part two : Structured time. I take control and introduce directed activity which is geared to getting to "know oneself and others. We talk around set themes such as one thing that you like/dislike about yourself; that you fear[ makes you laugh/sad etc. We are still stressing the listening. This is needed when, for instance, they are asked to remember what one other person has said. I have a pack of incomplete sentences which are helpful early on in a group's life such as: "When I'm inside what I miss most i s . . . " , "I w i s h . . . " , "Fathers should...", "I hate people w h o . . . " . At times I write down their responses and have them typed out to hand them the following week, this is particularly valuable; silliness looks even sillier when written down--and is more likely to be discarded as a way of responding in the group. The variety shows the individuality of each member and strengthens each person's sense of identity. Part three : Group activity. This involves each person making a contribution and being in step with the others, or out of step and putting up with the
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consequences. For example, going round the circle telling a story but only being allowed one word each at a time; or having a sentence to say towards a story but each boy starting alternately "Fortunately...", "Unfortunately...", "Fortunately . . .", "Unfortunately . . .", and so on. I will give an actual example of this here, as I did not use this technique in the detailed case history which follows. This is a group with four boys and myself. "Fortunately it was sunny when I woke up and I decided to go out. Unfortunately when I got out it started to rain. Fortunately I went to bed with my girl friend and my mum came back, unfortunately she had a fit. Fortunately she was understanding though unfortunately later when my clad got back I heard them talking downstairs and his voice got louder and angrier, I locked myself in the bathroom. Fortunately I said to myself 'be a man' and stand up to my dad, he will understand after all he probably did the same thing himself when he was my age. I went downstairs to talk to him. Unfortunately he did not understand at all. Fortunately when he lost his temper I hit him first and had him laid out on the floor, unfortunately I had to run away". (To be continued.) The story was continued the following week, but I hope this excerpt speaks for itself in the value such exercises can be. For example, one of the boys who spent the greater part of the eight weeks hiding under his jacket---emerged agitatedly at his turn and asked "Whose mother is this?"--to be told by me "It's yours, the story is with you now", he was horrified but was able to contribute in round one "Unfortunately she had a fit", and in round two regarding "his" dad "Fortunately when he lost his temper I hit him first and had him laid out on the floor". The boys in this group all had stammers and were committed to Borstal for offences of rape, grievous bodily harm, car theft and burglary. If the group can develop trust then the boys will begin to share their fears, anger, depression, problems as they see them, and through the action of the group can literally discard things they have been preserving for years--or at least take back and own things about themselves in an accepting way. This process has the effect of freeing the speech--and improved fluency is the result. (5) Follow-up individual sessions With the new experience of working in a group, and the insights and information this has brought to each of us, we then continue working on an individual basis--until discharge or further group work or, preferably, until he no longer needs to come, and would like to finish his time without the support of the sessions.
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) Family therapy This is invaluable, but is unfortunately only possible with a very few of the eople I see. There is often a strong resistance to it from the boys, but a sense "relief and achievement if it actually takes place. The style of the session is athreatening and is designed to observe, reflect and focus on what all mem~rs of the family bring into the room. The aim of the family therapy session is to continue the unscrambling of the tuation which will have been underway during our work together. It allows le family to be involved and to gain insights too--it is an important bridge Jr both sides as the release date approaches. Just as the boy, if he has achieved aything, will have made changes, so the family needs to recognize this, and eeds support in understanding their own reactions, attitudes and beaviours, and those of this family member. CASE
STUDY
'his approach becomes clearer in the description of the case of Ted, with ~me details from the assessment, followed by two individual sessions. I then mlude some excerpts from his group, dwelling on Ted's work in it; then ldividual sessions 3-Io; the family meeting a final session and some details "'om the follow-up questionnaire to Ted's probation officer. Ted, aged i8, was first seen on 23 January and discharged on x7 June. He ad been sentenced to Borstal for criminal damage, theft, taking and driving way a motor vehicle. His wrist was so severely cut that the tendons were ermanently damaged, a self inflicted injury with a bottle, after a family ledding. He also had a limp caused by a TB hip. At about I3 or 14 Ted had reviously had a month's intensive course of speech therapy learning pro9nged speech.
Assessments These showed: (a) Moderately severe stammer. (b) Vocabulary age of about ten and a half years. (c) A very poor opinion of his own communication skills (Jacobsen Questionnaire). The following are excerpts taken from the detailed assessment questionmire: "Q. What was the reaction of teachers to your stammer? A. Bad, I was what they call a trouble maker because of my stammer. The headmaster had a go at me to behave, he threatened me, it made the stammer worse. I would muck about to avoid having to read out.
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I used to hang around with blokes--they pinched cars and then I used to do it to prove myself. Q. What was your worst moment? A. In court, all these questions... I couldn't speak at a l l . . , in the end my father had to answer them for me. I was very embarrassed. Q. Which people are important in your life ? A. Parents, they help you all the time, they help you through life . . . I've disappointed them. Q. Do you feel you've done what you want in life so far ? A. No, I've always been in trouble and I don't want to be in trouble. I just want to be happy." Ted had two individual sessions following his assessment, before being admitted to a group. In the first he revealed his mixed feelings towards his parents, his indebtedness, and his inability to follow their advice and keep out of trouble. Trouble gets him attention which is what he wants, starring in the newspapers. In the second session Ted resentfully described how all his relatives cared about his parents rather than him. He was warned: " T h e y would get a divorce if I didn't pull myself out of i t . . . mind you, I am to blame". He enlarges on how he has to prove himself with his mates: "People are always proving themselves, especially people with some disadvantage". Towards the end of the session he states: " I must be stupid, everyone tells me I'm s t u p i d . . , brother, sister, m u m . . . " .
The group For extraneous reasons Ted was put into a group earlier than most. The group only had two other members, one having dropped out on release. Normally, I have four plus myself--and that is a squash in my tiny room. The group members were: Ted. Alan, aged 20. Moderate stammer. In regular work. Common-law wife and two children. Rory, aged 18. Severe stammer. Second Borstal sentence. Second group.
Introductory group Introductions in Ted's group ineluded one thing you like/dislike about yourself, and one thing that frightens you.
Excerptsfrom the group Ted. "I'm a friendly person who gets on with others, including those I don't
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like. I don't like my speech. I'm frightened of what will happen when I get out of this place".
Seed sentences I asked them all to take a journey back in time, and remember one thing that was said to them as a child. Alan: " G o out and get the shopping". Ted" "Grow up!" (said straight out, no thought necessary). Rory: "You are a right ghastly boy". T e d found the group embarrassing and said so. He strongly recommended to the others, particularly to Row, that relaxation classes are the best thing for stammering.
aro.p 2 (excerpts) Part I Ted. "This place is boring". Alan nodded agreement. Ted. Long silence. "This is out of order". Laughing and shifting. More silence. Therapist. I reiterate the "boring" phrase. Ted. "Well, it is, isn't it, we're here to practise our speech". Therapist. "Perhaps you expect someone else to start things off a l w a y s . . . " .
Part II. We recall last week's seed sentences. Ted." 'Grow up'--I should growup, they were right, Dad was right to beat me, I would have done the same in his place--but it made me go out and get into more trouble. It's my own fault, now it will be difficult to go out and get a job".
Group 3 (excerptsfrom Part I) Ted, biting nails hard, "What are we going to talk about?" Therapist. "Anything." Silence, approximately five minutes. Ted. "This is hard, it's out of order, I can't cope with it." Alan. Opens his closed eyes, glances anxiously at me. This seemed hopeful, but he went back to previous posture. Rory. Looking miserable. Ted. Talked of the help of relaxation saying his stammer is nerves. Rory nods. The others should have relaxation (he is having a course of this elsewhere). Therapist. I point out Ted's tense look and nail-biting.
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Alan and Rory. Agree. Ted. "It's just a habit." Therapist. I say that I hear that he is finding relaxation classes a help--good. But in here perhaps we could look at the nerves and what they are about . . . . Ted. "Rory looks tense and nervy and heavy as if he's got worries." Rory. Hot denial. Therapist. "It seems difficult for Rory to accept concern shown by another." Rory. Agrees this is so. Therapist. Stresses the caring nature of Ted's remark. Rory. Tells us that he has changed since being in here, he didn't used to be able to speak at all and now he can.
Group 6 (excerptfrom Part II) T h e y were asked to "role-play" another family member's view of t h e m - going back in time---or now. Ted chose first his Mum: "He's a tearaway, always trying to prove himself all the time, and he always ends up the worse for it. If only he'd listen to me. I love him a lot, but I loved him best when he was in nappies, and I was in complete control--I wish they didn't have to grow." Then his Dad: "Well, he ain't a bad lad, he just gets easily led--one day he'll learn either the hard way, or the easier way. I myself learned the hard way, and it isn't an easy life. He seems to be like me and it's going to be the hard way, like father, like son."
Group 7 (excerptfrom Part I) Ted. "Last week on Monday I saw the specialist--we were talking about my hip and all the pain I was having with it. Eventually he told me that I couldn't have an operation as it would open up all the poison. I was really annoyed about this and it kept coming into my mind. I was just talking to him and that, but I felt like getting up and hitting h i m . . , knowing that I would be like this for the rest of my life. Pin him up against the wall and kick the shit out of him."
At the end of group N o n e stated that it had helped their speech, but all agreed that talking of the " p r o b l e m s " helped. Actually T e d ' s speech was more fluent, and Rory's too. Alan's was not, it had become clear that he was sitting on something which had led to a drinking bout. H e was able to look at this in his subsequent individual sessions and found this such a help that he determined to continue speech therapy after discharge.
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Ted's individual sessions continue I will demonstrate the diary form of working using session 3, which followed straight after the group. Explanations to the reader are contained in brackets. There are none in the excerpt. The numbers on the extracts indicate the sheet number of the session which can be anything from four to 2o sheets in any one session.
hldividual session 3 [four sheets] (I) Ted. "Boredom--boring--get out to Finnamore" [open Borstal where he has applied to go]. Therapist. "Will the boredom go with you?" Ted. "I feel 8o in here. I feel really old." Therapist. "Grow up I" [recall seed sentence.] Ted. "I feel I'm passing away." (z) Ted. "I'm sick, slobby, unhealthy all the time. Bodily old. I'm hemmed in]enclosed]banged up."
D 3 J - 1 tI draw prison window with bars.] Ted. "In a box fading away." Ted. "Stupid really." Therapist. "Oh ?" Therapist. "You are describing the facts--how this prison is making you feel." (3) Therapist. "But you are a prisoner in more ways than one and one way you'll carry with you till you are 8o." [I'm referring to the hip. He had been under the impression an operation could cure it--these hopes had been dashed in the last few weeks.] Ted. "I didn't want to go all depressed." (4) Therapist. "Prison Borstal is boring. Prison Hip is boring."
Session 4 Ted's first statement is that he has decided against going to the open Borstal--as he might run away. This leads us to look at how his own actions harm him, and we take an actual example that has happened in the past week. Feeling frustrated by a rule, he abused an officer. He worked out an alternative strategy on a formula I often use--situation/your response/result for y o u - should such a situation arise again.
Session 5 Things are going better, he has a new job in the Borstal. I expand on his theme of letting others down. I ask if he has been let down.
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(2) Ted. "It's all my fault for being in here because I had heaps of warnings." Therapist. "So ?" Ted. "I didn't listen to the warnings." Ted. "Warned by parents, police, judges, uncles and aunties." (3) Ted. "The other day someone asked me to hold his burn*--in the past I would have taken it--this time I didn't because I know he had earned it." Therapist. " I ' m beginning to trust myself." Ted. "In here (this room) it's like being in a boat with my own food, not like out there where everybody is hogging it." (4) Ted. "After each session there is a feeling of satisfaction--as if I've done something really good--like as if I'm Barry Sheene and just won a big race." (5) Therapist. "In this room you are number one." Session 5 continued with us looking at the different ways people have of dealing with stress, and then we switched to his seemingly senseless/bad behaviour. (II) Therapist. "Punish me, I am bad. There's a pay off. You had to do wrong to prove you weren't a cripple." Ted. "They kept letting me off (the courts). But I was in court two more times and I proved I was capable--." Therapist. "I got what I was asking for--Borstal." (x2) Ted. "I know I did wrong first time." Therapist. "But I chose to do more." Ted. "On my third one, parents and relatives thought I'd get Borstal, Solicitor doubted it. I said why? He thought I wouldn't be capable." Session 6 T e d reports that everything is going O.K. There has been no aggravation and his speech is fluent. We explore the reasons for this. T e d states that it is more encouragement. I extract the courage part of that word and suggest that it is to do with finding out what is in you. I suggest that he used to see only the bad in himself, and ask him how important it is for him to see the rest of his family as perfect. I add that I don't think anyone is perfect. I hark back to letting down, and being let down, I mention the hip. (8) Therapist. "Hip. Since about I2 years you had pinned your hopes on an operation at I6. How disappointed and guilty your parents were at having a child with a wonky hip." * Cigarette.
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Ted. Interrupts. "I've blamed them--after all, they brought me into the world." Therapist. "Angry with them." (9) Therapist. "Hope." Ted. "Hope [for cure] has become less important." Ted. "In a way it's a relief to be able to throw that out." Therapist. "And know where you stand." Ted. "My future is now." Session 7
He has had a visit from his parents at the weekend--"I was nervous, but not stammering". Both he and they were surprised. Session 8
I suggest we have a session together with his parents. He is resistant, " I think you are trying to blame my parents", "They won't come", etc. (I5) Therapist. "Why shouldn't your parents get some help ? They've obviously found it quite difficult bringing up a terrible chap like you." (i6) Ted. "They used to have arguments over me." Therapist. "You?" Ted. "They've done everything on the earth to help me." Therapist. "How?" Ted. "Paid my fines." Therapist. [Here I draw a head and hands just visible, hiding behind a wall.] Session 9
Preparing for his return home, the session is geared to the difficulties of holding onto the changes he has made back in the environment in whieh he got into difficulties. We continue to explore his resistance towards the meeting with his parents--he is feeling very wound up. (I3) Ted. "Everybody winds me up." Therapist. "Bring three examples of your getting wound up in the house, next week." Session io
(Q Ted. "No wind ups." He did not even rise to being called a spastic. Ted's home leave is in two weeks. He says he is worried about something and he doesn't know what it is.
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I inform him that I am going to invite his parents to a meeting. The parents responded at once to the opportunity of a session, and although at short notice came on the earlier of the two dates offered. They greeted Ted warmly. They were an attractive couple, mother English, father Irish.
Excerpt from session with parents It wasn't long before Dad "got going" talking of his own difficult early start (leaving Ireland aged 14 alone, to find work); the iniquities of the police, etc. As this was going on Mum and Ted started to exchange looks and quiet talk; cigarettes and sweets were handed over. I drew attention to this and asked if this often happened, that Dad was ignored, all three agreed that it did. Dad (much to Ted's surprise) said that he felt "left o u t " - - T e d said that he felt left out as if they didn't love him. Ted agreed that he did find it difficult to talk to Dad and preferred to go through Mum, and Mum agreed that this was so, that she didn't discourage it--but that it might be better if Ted and Dad could communicate more directly.
Final session Ted reports with delight and surprise, how much he got out of the session with his parents. We end by making a recording of his now fluent speech and compare it to the first recording he made.
Some information from the questionnaire to the probation officer-six months post discharge Ted is attending monthly, and the probation officer occasionally does home visits. He has a job. Ted no longer finds his speech a problem and the probation officer no longer perceives it as a problem. He is not receiving further speech therapy. " . . . I would assess there has been no long-term regression since discharge, although there has been the odd stressful interview beginning with difficulty in communication. He has quickly coped with this rare event." Probation Officer CONCLUSION The purpose of this paper has been to demonstrate that stammering can be a symptom of stress. I have described a style of working which contains an individual, group, and family therapy "package" which I find is particularly effective, not only for work with adolescents who stammer but also, with minor modifications, for other adolescent groups in need of therapy.
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The main feature of the individual sessionwhich has proved most useful, is the keeping of a shared running record or diary of the individual sessions, which acknowledges and focuses on the importanee of all communications, maps the therapeutic journey, pin-points particular repeated difficulties and provides evidence of real change and progress. A feature of the group work is that it has a definite structure, boundaries, etc., but it also contains unstructured time which allows the adolescent to get a sense of being in control of what happens. It also has structured time where the therapist directs the activities and takes a definite lead. At least one family session should be held to enable the changes that have been achieved to be maintained.