Supporting patients (and colleagues) who stammer

Ben Farmer is an Honorary Assistant Psychologist (Rheumatology) at Guy’s and St Thomas’ NHS Foundation Trust and supports the management committee for the NHS Stammering Network (for staff).

Vaughan Parsons is a Senior Research Fellow at the UK Medical Research Council Versus Arthritis Centre for Musculoskeletal Health and Work, University of Southampton; Research Manager in the Occupational Health Service at Guy’s and St Thomas’ NHS Foundation Trust; and is on the management committee for the NHS Stammering Network (for staff).

Lorraine Maher-Edwards is the Deputy Lead (Psycho-oncology Support Team) at Guy’s and St Thomas’ NHS Foundation Trust and is on the management committee for the NHS Stammering Network (for staff); she also has a private practice.

Stammering (stuttering) is a speech condition with high heterogeneity. Approximately 1%–2% of the adult population experience lifelong stammering at a ratio of 4:1 (males to females). Aetiology of stammering is yet to be established; however, evolving evidence points to neurobiological, genetic, and situational factors.^1–3

Generally stammering begins in childhood as language skills are developing, but for some it develops later due to brain injury or infection. It leads to unpredictable smooth forward execution of speech, often characterised by repetitions and extraneous sounds (‘um, um, um’), behaviours (prolonged eye blinking), or prolonged pauses/blocking on certain sounds.⁴ People who stammer may avoid situations where they are expected to speak, for example, using a telephone and meetings.

Stammering is associated with significant impact on other life domains (such as education and employment), much of which is likely due to negative perceptions of stammering and associated stigma, and may discourage people who stammer from accessing health care.⁵ These effects can impact quality of life and wellbeing.^6–8

Common myths

• Anxiety/stress causes stammering: stammering isn’t caused by anxiety, however, speaking with a stammer and the challenging reactions of others can heighten anxiety during speaking situations.

• Indicates lower IQ: stammering is unrelated to intelligence. This myth may arise due to stammering sometimes being mistaken for hesitation when speaking and appearing unsure of what a person wants to say.

• Self-conscious and shy: people who stammer may become nervous of speaking in public due to difficult experiences and self-stigma about stammering. People who stammer can be extrovert and assertive.

• History of trauma: research has found that in the majority of cases, it is not the cause of stammering.

Why is this important for primary care clinicians?

Clinicians should have an understanding of stammering and how to interact with people who stammer in a supportive manner in order to optimise clinical consultations. This will minimise the risk of misdiagnosis and poor care. Clinicians also play an important ‘early intervention’ role if they suspect a child is experiencing a stammer by referring them to speech and language therapy for diagnosis and treatment rather than say ‘ignore it, it’ll go away’.

‘I often struggle to impart information to my GP because of my stammer. I use words that I don’t find difficult to say, which often makes it difficult for me to describe my symptoms in detail’.*

Tips for interactions with people who stammer

• Eye contact: maintain natural eye contact. Provide an environment that does not feel rushed and give patients time to express themselves. Try to focus on what the person is saying, not how they are speaking.

• Don’t jump in or finish sentences: although done with the best of intentions, finishing a person who stammers sentences can feel disempowering and cause embarrassment and shame. Wait until the patient has finished their sentence and expressed themselves.

• Don’t offer advice about speech: avoid use of ‘take a breath’ or ‘slow down’, for example, as this increases the expectation to not stammer.

• Monitor your own (non-verbal) reactions: people who stammer are very aware of negative listener reactions and it can trigger feelings of shame or embarrassment.

• Be open to talking about stammering: some people who stammer feel they have to hide their natural way of speaking, often at great cost to them. For some people, being able to be open and talk about stammering is empowering and helpful. Ask the person who stammers if there is anything you can do to help and if they wish to talk – be curious and open.

‘I feel I am very well supported by my GP, they wait for me to finish speaking. Their patience and awareness of my stammer is much appreciated’.*

• Managing virtual consultations and face masks: these may present challenges for some due to the lack of non-verbal cues and the pressure to speak without delay.

Additional support and resources

• British Stammering Association and support groups: https://stamma.org

• Cit Lit. Funding to access this support could be provided by the NHS: https://www.citylit.ac.uk/courses/specialist-learning/speech-therapy

• Michael Palin Centre: https://michaelpalincentreforstammering.org

• NHS Stammering Network (for staff): www.nhsstammeringnetwork.uk

• Airedale NHS. Online speech therapy to anyone who can’t access NHS therapy locally: https://airedalestammeringtherapy.wordpress.com

• Speech therapists: https://asltip.com

* quote is fictitious and included for illustrative purposes only.

Acknowledgement

The authors would like to acknowledge Carolyn Chew-Graham (GP Principal and Professor of General Practice Research at Keele University) for providing feedback on this article.

References

1. Mawson AR, Radford NT, Jacob B. Toward a theory of stuttering. Eur Neurol 2016; 76(5–6): 244–251.
2. Smith A, Weber C. How stuttering develops: the multifactorial dynamic pathways theory. J Speech Lang Hear Res 2017; 60(9): 2483–2505.
3. Onslow M. Stuttering and its treatment. Eleven lectures. 2020. https://www.uts.edu.au/sites/default/files/2020-07/Stuttering%20and%20its%20Treatment-Eleven%20Lectures%20%28May%202020%29.pdf (accessed 5 Jul 2022).
4. Teesson K, Packman A, Onslow M. The Lidcombe Behavioral Data Language of stuttering. J Speech Lang Hear Res 2003; 46(4): 1009–1015.
5. Bricker-Katz G, Lincoln M, Cumming S. Stuttering and work life: an interpretative phenomenological analysis. J Fluency Disord 2013; 38(4): 342–355.
6. Parsons V, Ntani G, Muiry R, et al. Assessing the psychosocial impact of stammering on work. Occup Med (Lond) 2022; 72(2): 125–131.
7. McAllister J, Collier J, Shepstone L. The impact of adolescent stuttering and other speech problems on psychological well-being in adulthood: evidence from a birth cohort study. Int J Lang Commun Disord 2013; 48(4): 458–468.
8. Constantino C, Campbell P, Simpson S. Stuttering and the social model. J Commun Disord 2022; 96: 106200.

Featured photo by Michael Dziedzic on Unsplash.