Stuttering  and psychotherapy

  Author: Dr. KAZAKOV   А.V.- the representation in Southern Federal District. Taganrog (RC for biocybernetics) 

The studying of stuttering as  one of the neurosis forms   was started with the publication in 1889 by I.A.Sikorsky of the results of the long-term researches of the problem of this kind of the speech disorder diagnostics and treatment called “logoneurosis” by the author, subsequently also called " Sikorsky's neurosis ". In his work the author for the first time  described in detail the external manifestations of different neurologic variants of logoneurosis. It is necessary to note, that the neurosis as a nosologic unit had been entered into the medical practice by the Scottish doctor William Cullen in 1776. To this very day we haven't observe the conceptual unity of opinions among the numerous researchers in the field of neurosis study. This, in turn, generates the distinctions in classification constructions and approaches to diagnostics and treatment of this  pathology. However, the versatile analysis of pathological changes of functional systems allows to establish pathophysiological mechanisms of dysfunctions and to define optimal methods of their correction. 

As a working hypothesis it is expedient to accept V.N.Myasischeva's statement (1960), that stuttering concerns to the system neuroses -  primary psychogenic disorders of the higher nervous activity of the local character, determined by  corticosubcortical cerebrum system, defining the primary defeat of the separate anatomico-physiological systems - respiratory, cardiovascular and others. System neurosis, as  I.M.Apter (1966) observes, - is a dynamic concept. Having arisen originally as a system disorder, it is transformed to the general neurosis, and, on the contrary, in the clinical picture of the general neurosis the dysfunction of any certain system in due course can get a defining value. At logoneurosis the speech functional system works as locus minoris resistentiae.

 In a syndrome of stuttering the speech-motor and psychopathological components are presented in different proportions.  If for children the speech-motor disorders prevail, for  adults the degree of decompensation of a  stammering person  depends on  emotional-affective shifts. Psychopathological changes with logophobia in the center promote the formation of such features in the character of a stammering person, as the increased anxiety, sensitivity, unsociability, which in turn result in even greater disorganization of  personal relations ( Shklovsky V.M., 1967,1985; Asatiani N.M., Kazakov V.G, 1974). In L.Y.Missulovin's work (1988)  85,9 % of the examined people, suffering from  stuttering, had got  the diagnosis “logoneurosis”  as one of the forms of neurotic disorder. High frequency of vegetative disorders both of general character in the form of a dystonia, and in the form of more delineated vegetative reactions of the sympathoadrenal  or  mixed type, accompanying logophobia, presence of the diffused organic neurologic semiology (Shklovsky V.М., 1975) also specify the leading part of neurophysiologic  mechanisms in pathogenesis of speech dysfunction. Diffusive  character of organic cerebral insufficiency proves to be true also by the results of  neuropsychologic researches. 

Consideration of logoneurosis as a special case of neuroses allows to approach the understanding of therapeutic methods essence from the point of view of their adequacy at this pathology.  

As B.D.Karvasarsky (1990) states, the basic method in the complicated therapeutic complex during neuroses is the psychotherapy, presented in the modern medical practice with  dozens of methods and forms, and the convincing  estimation of its efficiency  is extremely difficult  chiefly because of  insufficient readiness of the general theory of psychotherapy. 

According to S.Kratochvil (1978), the psychotherapy represents the regulation of  the damaged activity of an organism by psychological means. 

In 1998 the Ministry of Health of the Russian Federation  considered the list  of psychotherapy methods, recommended for RF. The following methods were included  into it: art therapy, autogenic training,  Gestalt-psychotherapy, hypnosuggestive  psychotherapy, group dynamic psychotherapy, dynamic short-term psychotherapy, cognitive-behavioural psychotherapy, the personal-focused reconstructive psychotherapy, logotherapy, non-directive psychotherapy of C.Rogers, neuro-linguistic programming, behavioural psychotherapy, psychodrama, classical psychoanalysis, rational psychotherapy, the family system psychotherapy, the corporeal-focused psychotherapy, therapy by creative self-expression, transactional analysis, transpersonal psychotherapy,  emotionally stressful psychotherapy, Ericsson’s hypnosis, clinical psychoanalysis, continuous psychotherapy, existential psychotherapy, social and psychological training. 

The efficiency of psychotherapy is determined by the patient’s expectations, the significance of   his treatment and recovery, the character of problems or diseases of the patient, the degree of his readiness for cooperation, expectations of the therapist, experience of the therapist, specific influence of concrete psychotherapeutic methods. 

Under the  existing variety of psychotherapeutic methods it is necessary to observe, that, with reference to treatment of neuroses, they are developed in K.I.Platonov (1962), S.S.Libikh (1974), D.V.Pankov (1979), A.M.Svyadosch (1982), B.D.Karvasarsky’s (1980,1985, 1990) researches. Their basis is the pathogenetic psychotherapy (Myasischev V.N., 1960), which provides the system change of the patient’s attitudes and correction of his behaviour as a result of the detailed studying of  the person’s characteristics and etiopathogenetic  mechanisms, causing a neurotic condition.

 V.M.Shklovsky, L.M.Krol, E.L.Mikhajlova's work (1985) is devoted specially to the question of application of various  group psychotherapy  methods  at treatment of stammering adults (discussion,  nonverbal communication, projective drawing, sociometrics). 

A very important point of  any of applied treatment methods  is the use of  rational psychotherapy techniques  already during  the first conversation of the doctor with the patient, which allows to come into necessary psychological contact, to form  the patient’s conception of the complete curability of his  disease. 

Different  variants of suggestive influence are applied for  the increase of psychotherapy efficiency. So, Dubrovsky K.M. (1958), P.I.Boulle (1974), V.M.Shklovsky (1966,1967,1979), YU.B.Nekrasov (1980) used suggestion during  a wakeful state at treatment of stuttering, which, in opinion of these researchers, promoted elimination of  speech fear in emotionally significant situations for patients. 

The analysis of essence of psychotherapeutic techniques and  factors, defining the efficiency of their application, shows, that none of ways of influence is  universal enough, the methods often depend on individual preferences and experience of the psychotherapist, mostly suggest long treatment with selection of the optimal individual therapeutic program, do not exclude relapses of disease. This can be explained.  In terms of already existing functional disorders in the central nervous system influence by a word as the carrier of the information, coded in it, originally can cause differently directed responses, but at the subsequent stabilization of bioelectric activity of the brain and the exchange of neuromediators positive dynamics of clinical symptoms is distinctly shown. In other words, in physiological sense the psychotherapy is the indirect, mediated method, which is based on the influence by means of function on its morphological substratum, at that opportunities of the direct objective control of physiological parameters are limited enough. 

Quite naturally the idea of search of the direct influence  method  with the opportunity of on-line monitoring occurs.  As is well known, the speech functional system includes the central neuron pool (neural network), the peripheral neuromuscular apparatus and visceral formations, synchronized interaction of which provides presence of normal speech function. The same system can be presented in the form of cybernetic model as a set of some multitudes of  objects, having the corresponding multitude of feedforwards and feedbacks, static and dynamical communications,  significant break of which leads to the occurrence of clinical manifestations of speech dysfunctions. This condition is confirmed by the researches of RDC of  biocybernetics, conducted on healthy military men with the normal speech, the scientists formed an artificial model of stuttering for them by  setting  of speech parameters,  which differed from normal for the concrete probationer. It  allowed to realize the idea of direct influence on the speech functional system in the form of  the corrective computer program. In it the testing module analyzes the parameters of the patient’s expressive speech and hands the control to the therapeutic module, which is carrying out the imposing of the proper rate and  rhythm of speech, necessary for formation of the normal individual pattern of speech. The double check  on the principle of  biological feedback, visual and acoustic, allows to carry out the monitoring of changing parameters of speech system functioning on-line, increases reliability of therapeutic influence both from the point of view of initial result, and in terms of treatment efficacy. The described way of stuttering correction  was called a "method of resonant speech production". Taking into consideration the degree of physiological validity, clinical efficiency, controllability and the absence of by-effects it is possible to consider the specified method optimal for treatment of logoneurosis. 

Thus, considering the important part of psychotherapy in the complex of therapeutic actions during logoneurosis as a special case of  neurosis, the validity of application of this kind of treatment as monotherapy looks rather doubtful. On the contrary, the methodically correct combination of the efficient psychotherapy methods at the different stages  of the complex medical program implementation promotes the increase of efficiency of the applied methods and improvement of results.