Stuttering Modification Using Hypnosis: A Case Study
by Dr David Oakley and Guy Moss
The study reported here examines hypnosis as an anxiety-reducing and confidence- building technique for stuttering modification. The fluency of a 29-year-old man with a moderate to severe overt stutter was recorded in controlled conditions over a baseline period, twelve hypnosis sessions and three follow-up sessions, using standardised reading material.
In hypnosis the subject was taught anxiety management and self-hypnosis techniques and used self-guided hypnotic imagery to rehearse coping well in stressful situations. Fluency improved immediately during hypnosis and a steady decrease in stuttering incidents was seen over sessions on the standardised materials when tested without hypnosis.
The subject was able to transfer these marked improvements in speech production from the laboratory to everyday situations. He also reported a considerable improvement in his general mental well-being. These results support the view that hypnosis can be of assistance in the modification of stuttering and should encourage its wider use by speech therapists alongside conventional stuttering therapies.
Hypnosis is a state of focused attention, intense absorption and heightened imagery, usually accompanied by deep physical relaxation. Light hypnotic states, or trances, occur commonly in our everyday lives - not only during relaxation exercises and meditation, but also when we are reading a good book, watching television or listening to music. Clinical hypnosis builds on our capacity to experience these everyday hypnotic trances and uses them to facilitate a variety of psychological therapies (Gibson & Heap, 1991; Kirsch, Montgomery & Sapirstein, 1995).
In clinical hypnosis the patient is able to concentrate on the therapy itself without distracting thoughts or feelings, to achieve physical and mental calm and to experience imagined situations as though they are real. Hypnotized individuals are also more able to accept positive suggestions of well-being and of change. Self-hypnosis is an important part of most clinical hypnosis treatments and is the ability to enter at will into a state of hypnotic trance. It is most commonly taught during hypnosis induced by the therapist, who then encourages the patient to practice self-hypnosis daily between clinic visits.
Individuals vary in their hypnotic susceptibility but the majority of us are able to experience a clinically useful level of hypnosis.
The use of hypnosis in the treatment of stuttering and communication disorders is not new and reports date back to the late 19th century (for a review see Dunnet & Williams, 1988). Hypnotic techniques have been used to establish deep relaxation, with self-hypnosis being taught to enable the stutterer to benefit from the effects of relaxation in the absence of the therapist. It is commonly found that the first time that patients are hypnotized, even before any therapeutic work has been done, their fluency improves significantly, at least for the duration of the trance experience.
An early demonstration of symptom relief of this sort can serve to increase the stutterer's belief in the treatment and strengthen his or her motivation to continue with it.
In addition to relaxation, direct suggestions of well-being, confidence and increased self-esteem (so-called "ego-strengthening" suggestions) may be given. These positive feelings may be linked in hypnosis to a word, an object or a gesture which may later be used by the patient to recreate the feelings when they are needed in everyday situations.
Suggestions given in hypnosis that are intended to promote responses, feelings or behaviours later in non-hypnotized state are usually referred to as post-hypnotic suggestions. Post-hypnotic suggestions may relate to feelings of well-being or confidence in certain situations or may consist of instructions to carry out traditional speech therapy techniques (ie, smooth, calm, slow and prolonged speech) at appropriate times.
Hypnosis can be used with stutterers to assist in stress management and the building of self-esteem where this is the sole means of therapy or alongside formal speech therapy exercises. A study by Lockhart and Robertson (1977) used both approaches. They claimed improvement to the point of fluency with a group of seven stutterers with mild symptoms (less than 6% of words stuttered) using ego-strengthening and anxiety
reduction techniques in hypnosis with self-hypnosis taught early in the treatment regime.
A second group of 23 stutterers with more severe symptoms had speech therapy exercises in addition to the hypnotic procedures. At the time of reporting ten of the severe group had achieved fluency with fluency stabilising within 30-40 weeks of the commencement of treatment. On the basis of their study Lockhart & Robertson recommended combined therapy in which clinical hypnosis supplements speech therapy techniques for severe stutterers.
Recognition of the potential usefulness of hypnosis in the context of disorders of communication led in the early 1980's to the foundation of the 'British Society for the Practice of Hypnosis in Speech and Language Therapy', which is recognised by the Royal College of Speech and Language Therapists.
A survey of speech therapists using hypnosis in the UK by Macfarlane and Duckworth (1990) suggested that the major use of hypnosis in fluency disorders is as a means of achieving rapid, deep relaxation, reducing physical tension and anxiety and encouraging self-esteem in the patient.
There is a general feeling then that hypnosis may be helpful for mild stutterers in conjunction with stress management and confidence building techniques and coupled with speech therapy techniques for the more severe cases. This view is based primarily on clinical studies and anecdotal reports. There is very little experimental evidence upon which to base a judgment. The present study uses a single case design to investigate the effectiveness of clinical hypnosis in the absence of specialised speech therapy techniques in the modification of fluency in an individual with a moderate to severe stutter.
The subject (S) was a 29-year-old post-doctoral research scientist. He had slightly above average hypnotic susceptibility, a moderate to severe overt stutter characterised by part-word and word repetitions, long prolongations and a very high stress component to his symptoms. S's most feared situations, in which his stutter was particularly severe were: public speaking, talking on the telephone and reading texts aloud.
He was not aware of the age at which he began to stutter. He believed that onset was gradual and was not triggered by any disturbing or distressing life events. He first went to a speech therapist at the age of six. This therapist concluded after a few meetings that S stuttered because he was 'lazy'. S's parents appeared to share that opinion and no therapy took place. At the age of 17 S went for three sessions to a hypnotherapist who attempted to treat him using progressive relaxation techniques. His fluency improved briefly but three week after the final session he suffered a relapse which brought the stutter back to its previous level. At the age of 22 he again visited a hypnotherapist. After one session, which worsened his stutter, he declined to return for further treatment. At the age of 26 he once more visited a speech therapist, whom he saw for several months at regular weekly intervals. The therapy concentrated on breathing and slowed, prolonged speech techniques. S felt that his fluency did not improve as a result of these sessions.
The experiment was conducted in a sound attenuation chamber to facilitate audio-recording and to standardise test conditions. On the first (pre-baseline) session S read from a prepared text (Text C) consisting of 40 sentences each of ten words. This text was then split into two 20-sentence texts (Texts A and B) matched for their difficulty for S. The next three sessions were baseline sessions on each of which S read Text A once. There followed twelve hypnosis sessions (described in more detail below) on each of which S read the text three times:- once just before, once during and once immediately after hypnosis.
For the first eight hypnosis sessions Text A was used and for the final four, Text B. During the baseline and hypnosis phases sessions took place regularly twice per week. At three, six and twelve weeks after the final hypnosis session there were single follow-up sessions on each of which S read the original Text C before, during and after hypnosis.
Recordings of all readings were analysed and the number of stuttering incidents (repetitions or prolongations) noted. S's feeling towards his stutter and its characteristics were monitored by questionnaires at regular intervals. His self-reports on fluency changes as well as his mental and physical well-being were recorded on each session.
On the first hypnosis session, prior to hypnosis, S was asked to describe a 'special place' in which he would feel at his most calm and relaxed. He was then seated comfortable and closed his eyes. A hypnotic induction involving a standardised muscle relaxation and regular breathing sequence was then carried out followed by a scripted visualisation of the 'special place'. Confidence building (ego-strengthening) suggestions were also given and the positive, relaxed and confident feelings experienced in the 'special place' were linked by suggestion to a short phrase and to a gesture (clenching of the right hand to form a fist). A post-hypnotic suggestion was given that the phrase and/or gesture could diminish anxiety and bring back the calm, confident feelings in everyday situations. S was then taught to repeat the same procedure for himself in self - hypnosis and was returned to the non-hypnotized state. He was instructed to practice self-hypnosis at least once per day. He was asked to imagine himself in self-hypnosis facing difficult and anxiety-provoking situations and succeeding in coping with them fluently using the hypnotic techniques he had been taught.
He also compiled a list of difficult situations, ones in which he was likely to stutter, and was asked to start with the least difficult one for his self- practice and to work his way through the list as he gained confidence.
The same standardised hypnosis intervention took place in all 12 hypnosis sessions and the three follow-up sessions, each of which lasted approximately one and a half hours including the three readings of the appropriate Text. At the end of the twelfth hypnosis session S was given an audio-cassette containing the hypnosis script. He was instructed to continue his self-hypnosis practice and to combine it with listening to the cassette.
Results and Conclusions:
The main results above show the total number of stuttering incidents per text reading with S not hypnotized. Text C revealed an initial level of stuttering of 20% (80 incidents from 400 words). Texts A and B, derived from Text C, had 39 and 41 incidents respectively. The level of stuttering incidents on Text A remained stable across the three baseline sessions and the pre-hypnosis reading on hypnosis session 1. Thereafter there is a steady drop in the number of incidents to session 8. The fact that Text B introduced on hypnosis session 9 immediately showed a considerable improvement compared to its pre-baseline level (taken 42 days previously) indicates that the improvement on Text A was not simply a matter of familiarity with a particular text and that the gain in fluency had become generalised.
There is a further drop in stuttering incidents on text B from session 9 to session 12. The three follow-up sessions were conducted using the combined Text C and it is clear that the gains in fluency have been maintained for at least 12 weeks (on the third follow-up session the level of stuttering on Text C was 0.5% compared to 20% at pre-baseline).
For clarity, measurements taken during and after hypnosis are not shown. However, it is worth commenting that on the first hypnosis session where the number of stuttering incidents before the hypnosis was 26, the number recorded during hypnosis was 6, and after hypnosis it was 7 - all with Text A. As the during-hypnosis reading occurred before any self-practice had been initiated it seems reasonable to conclude that this increase in fluency represents the frequently reported effect of hypnosis alone and that there is a carry-over effect to the immediate post-hypnotic period.
This pattern was repeated on all subsequent hypnosis sessions. The symptomatic improvement on the first hypnotic session provided S with a clear idea of the sort of fluency which was possible for him - in fact he went on to achieve higher levels of fluency even outside hypnosis.
S reported that he found both the gesture and the 'special place' phrase effective in diminishing anxiety and in creating a feeling of calmness and relaxation. He summarised the hypnosis intervention as "a resounding success" and commented further:-
"It has been instilled in me now that nothing I (have to) read or say can be a problem. I know that I can say it - so there is no problem. I found that the fear was soon gone ... using the techniques it had just become easier and easier. Now I don't mind reading things out - like reading people their star signs. I just know that there will be no problem and I have no problems. I am convinced of my improvement. It is working. I see the evidence of that constantly. I find that I can simply relax, use the techniques I have been shown and speak without stuttering. I am impressed with the rate of improvement. There were times when I was shocked by my own fluency - and that's nice. I'm almost home. I feel so much more confident about the future. I know inside that I've got what it takes - everything would be OK. I can do whatever I want to do!".
He also spoke about the situations in which he used the technique, such as giving a seminar in front of a research group:-
"It has always filled me with dread but I wasn't at all concerned this time. For previous seminars I prepared for hours. This time I just wrote a few key words on a piece of paper and just chatted for hours. Previously I used so many overheads - this time I only used one. I used the fist and 'special place' just prior to giving the talk and it was so easy. It just went so well - didn't stutter much at all. I don't think I did. That was excellent. It went really well".
The positive changes in S's feelings about his stutter revealed in the self-reports, such as those quoted above, were also reflected in the questionnaire data.
Despite a history of at least four unsuccessful attempts at therapy over a 23 year period, two of them involving hypnosis, the simple hypnotic intervention described in this experimental setting appears to have produced a stable improvement in fluency which has been extended to non-laboratory situations. Further follow-up sessions are planned at 6 months and one year to assess the longer-term outcome.
Clearly a great deal more experimental work is required to assess the reliability and generality of the findings reported here as well as to explore the role played by hypnosis. Nevertheless the results are consistent with the view that straightforward psychological techniques of anxiety management and confidence building delivered in a hypnotic context are effective in producing a significant and lasting modification in a long-term stuttering problem. Speech therapists and others involved in the treatment of communication disorders should perhaps be encouraged to acquire hypnotic techniques to supplement their existing clinical skills.
Acknowledgements: the authors are grateful to Professor Peter Howell for providing access to the Acoustic Laboratory's sound attenuation chamber at University College London and to S for his willingness to participate in this experiment.
Dr Oakley the Director of the Hypnosis Unit at University College London, and a member of the British Society of Experimental & Clinical Hypnosis.