A clinical study of nine stuttering children in group pscyhotherapy

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A CLINICAL STUDY OF NINE STUTTERING CHILDREN IN GROUP PSYCHOTHERAPY

A Dissertation Presented to the Faculty of the Graduate School University of Southern California

In Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy

toy Lester Lee Harris July 1950

UMI Number: DP31980

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T h is d is s e rta tio n , w r itte n by

u n d e r th e g u id a n c e o f h .ls ... F a c u lty C o m m itte e on S tu d ie s , a n d a p p ro v e d by a l l its m em b ers, has been p re se n te d to a n d acce p te d by the C o u n c il on G ra d u a te S tu d y a n d R e search, in p a r t ia l f u l ­ fillm e n t o f re q u ire m e n ts f o r the degree o f DOCTOR

OF

P H IL O S O P H Y

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D a t ^ % L 3 ± . > J 3 $>.....

C om m ittee on Studies

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TABLE OF CONTENTS CHAPTER i*

PAGE

the Problem and definitions of terms used . . The problem

.

1

Statement of the p r o b l e m ........... . .

1

Hypotheses

B

• • • • • . • • • • • • • • .

Importance ofthe problem...........

4

Definitions ofterms u s e d ................ Stuttering



• • • • •

Group psychotherapy

..................

Changes....................... Introjection • • II.

1

5 6 9

..................

10

SUBJECTS STUDIED AND MATERIALS U S E D ........

IB

The s u b j e c t s ............................

IB

Selection of the subjects..............

IB

Description of the subjects............

IB

Materials

.

5

.............................

16

Play m a t e r i a l s ........................

16

Tests u s e d .............

19

The Rorschach Psycho diagnostic Test • .

BO

Description........................

80

Administration...............

21

The Thematic Apperception Test • •

• •

S3

Description........................

B3

Administration

B4

. . . . . .

........

iv

CHIP TER

PAGE The Travis-lohnston Projection Test

. .

25

.

25

Description . ................... Administration III.

PROCEDURE................................. Plan for procedure

IT.



26 27

. . . . . . ..........

27

Approach, to therapy • ....................

28

Role of therapist........................

30

INDIVIDUAL CASE STUDIES AND FINDINGS

....

Plan for reporting of therapy sessions Case A

32

. •

.............

37

Report of therapy sessions

............

Test-retest findings and comparisons Summary of findings .

32

37

• •

................

43 50

Case £

53

Report of therapy s e s s i o n s ............

53

Test-retest findings and comparisons

63

• .

Summary of findings.................... Case C

70

.................................

Report of therapy sessions



........

Test-retest findings and comparisons

Report of therapy sessions

73

. •

80

.

88

Summary of findings................. Case D

73

..............

90

............

90

Test-retest findings and comparisons

• •

97

V

CHAPTER

PAGE Summary of findings.................... Case E

.........

Report of therapy sessions

107 • . • . . • .

Test-retest findings and comparisons

• •

Summary of findings • . • * ............ Case F

.................................

Report of therapy sessions

• • • • • • •

Test-retest findings and comparisons

• ♦

Summary of findings • • • • • • • • • • • Case G

107 111 118 120 120 124 129 151

Report of therapy s e s s i o n s ............

131

Test-retest findings and comparisons

137

Case H

.

. .

........

Summary of findings ...............

Report of therapy sessions

• • • • • • • . .

Summary of findings • • • • • • • • • • • Case J

...........

Report of therapy sessions

145 152 157 159

............

Test-retest findings and comparisons Summary of findings ........

. •

• * . . * .

SUMMARY AND CONCLUSIONS.................... Summary • • • • • • * • • • •

143 145

Test-retest findings and comparisons

y.

106

............

Conclusions • • • • • • • • • • • • • • • •

159 169 173 176 176 181

vi

CHAPTER

PAGE

BIBLIOGRAPHY...................................

184

A P P E N D I X E S ....................................

187

APPENDIX A. Test-retest Comparisons..........

188

APPENDIX B. Scoring Scheme for Thematic Apperception T e s t ..............

198

APPENDIX C» Record of a Complete Therapy Session.........

800

LIST OF TABLES TABLE I*

PAGE

Comparisons of Rorschach Test-retest R e s p o n s e s ............ . .................

II.

189

Per Cent Increase or Decrease in Amount of Certain Factors Expressed in Responses to TAT as Determined by the Test-retest Comparisons

....................

191

CHAPTER I

THE PROBLEM AND DEFINITION OF TERMS USED The purpose of this study was to explore possible changes in the stuttering child during the process of group — psychotherapy.

Particular reference was made to the thera­

peutical process and to a comparison of the results of pro- jective techniques administered before and after therapy* This study may be considered a preliminary investi­ gation of personality development as it relates to the stuttering child*

It is not a definitive study of person­

ality but an investigation of some of the longitudinal



behavior ©f nine stuttering children in group psychotherapy*' It is, as far as is known, a pioneer study of this particu­ lar type for the stuttering child. I*

THE PROBLEM

Statement of the problem.

The primary problem to be

studied may be stated as follows: Do changes occur in the behavior of the stuttering child during group psychotherapy, as judged by responses to the projection tests: (1) the ' Thematic Apperception Test (TAT), (2) the Rorschach Psychodiagnostic Test (Rorschach), and (3) the Travis-Johnston Projection Test (TJPT)?

Further, does the characteristic

behavior of the child in therapy correspond with the results

2

of the projection tests? The secondary problems may be stated also: (1) Does the stuttering child ^Ln therapy show any relationship between changes in behavior and changes in the symptom?

(£) Is there

any evidence from test-retest findings to substantuate this possible relationship?

(3) Do parents* reports of each

child’s behavior nine months after therapy indicate any relationship.between general adjustment and the stuttering symptom? These are questions which seemed critical to a better understanding of the clinical treatment of the stuttering child. Hypotheses.

The hypotheses which formed the basis

for the investigation refer to both the individual and to therapy as follows: (1) The stuttering child has not re­ solved the conflicts which result from his attempts tp satisfy his own needs or drives and at the same time meet the demands I* of the physical and social world. Part of his adjustment to the frustration is through the stuttering symptom*

(2) Through

the medium of group psychotherapy he should be able to expe­ rience a readjustment which will

enable him to meet and react

to his own needs and the demands of his environment in ways to decrease the needs for his. stuttering. The theoretical basis for the hypotheses may be stated

as follows: (1) Stuttering represents a defense against socially unacceptable attitudes of a person and represents a compromise between two opposing forces in that person, i.e., first, the seeking for honest expression of socially unacceptable impulses, such as hostility, and second, the force of introjected parental attitudes, of social standards and demands.

These forces operating in the person, both at

the same time, produce the conflicts of which stuttering is one symptom.

*(2) Yfhat has been said of the objectives or

aims of group psychotherapy represents the basis for the second hypothesis.

It is the belief of psychoanalytic

writers that the functional speech disorders are, or may be, conversion symptoms.arising out of a conflict between antago­ nistic-tendencies within the individual.-*-

Further, the

"description by,Levy2 of the clinical treatment by individual release: therapy of thirty-five cases of children showing conversion symptoms of night terrors, tics, stuttering, and temper tantrums suggested the possibility of employing group psychotherapy with a number of stuttering children. In actual practice, of course, it was felt that what might, be applicable as an individual therapeutic process ~ 1 Otto Fenichel, The Psychoanalytic Theory of Neurosis (New York: W. W. Norton and Company, Inc., 1945), PP* 311-25. 2 David M. Levy, "Release Therapy" (S. S. Tomkins, editor, Contemporary Psychopathology. Cambridge, Massachu­ setts: Harvard University Press, 1947), pp. 63-90.

4

need not be successful as a therapy with groups, even in the event of the same symptom in both instances.

Thus, the

second hypothesis was stated as a question: Does group psy­ chotherapy offer the stuttering child opportunity to exper­ ience a readjustment which will enable him to meet and react to his needs and the demands of his environment in ways to decrease the needs for his stuttering?/ Importance of the problem. The incidence of stutter­ ing is estimated at about 0.8 per cent of the public school population.

The estimate of incidence for the population as

a whole is well over one million in the United States.

This

large group of individuals who stutter constitutes a real problem in therapy for speech clinics.

Stuttering is a

handicap in speech which is recognized as a social problem in communication and environmental adjustment. The magnitude of the problem and the difficulties encountered in therapy have led to a tremendous amount of study and research which deals directly or indirectly with stuttering. In recent years there has been a definite change of emphasis in the research and therapy dealing with stuttering. These changes may be seen as trends toward the study of the — developmental personality and behavior of the stutterer and away from a study of the manifest speech and physical char-

5

acteristics.

The trend in management has been toward forms

of psychotherapy rather than attempts to control directly or modify the speech pattern. Any critical review of the voluminous writings relat­ ing to stuttering would he cumbersome and outside the purpose of this study; moreover, the literature dealing with a longitudinal study of the stuttering child in therapy is very meager.

Clinically, the stuttering child has been ob­

served to be an anxious, emotionally hostile, and aggressive child who actively inhibits these emotional expressions. Despert found that a group of fifty stuttering children, at one time, showed predominant obsessive, compulsive traits with anxiety and more or less inhibited hostility present.3 II. Stuttering.

DEFINITIONS OF TERMS USED In this paper the word, "stuttering,11

in accordance with common usage, was employed synonymously with and in preference to 11stammering.11 Most so-called t

definitions' of stuttering are descriptions of the observed speech pattern which, in a general sense, describe a dis­ order in the rhythm of speech, manifested in repetitions of syllables or words or phrases, prolonged sounds, pauses, 3 J. Louis Despert, "Psychosomatic Study of Fifty Stuttering Children," American Journal of Orthopsychiatry, 16:100-13, January, 1946.

and blocks*

A clinical definition of stuttering in terms of

possible etiology and personality development subsequent to the causes may be set forth in terms of psychoanalytic theory wherein the symptom of stuttering is defined as: "• . . the result of a conflict between antagonistic tendencies; the patient shows that he wishes to say something and yet does not wish to*114 Group psychotherapy*

The term, group psychotherapy,

was first used* according to Meiers,5 about 1951*

Group

therapy or group activities for therapeutic gain is, of course, much older*

The practice of group psychotherapy is,

in a sense, an outgrowth of individual treatment applied to two or more persons simultaneously*

It is not conceived of

as a substitute for individual therapy, although one of the obvious advantages- is that more individuals may be treated simultaneously. References which describe group psychotherapy with stuttering children are few or nonexistent; therefore, the type of therapy employed for this study was to some extent a compromise or combination of techniques*

The following

statements regarding group psychotherapy reflect the charac4 Fenichel, op* cit*, p. 311. 5 Joseph I. Meiers, "Origins and Development of Group Psychotherapy," Group Psychotherapy— A Symposium (New York: Beacon House, 1945), p. 3.

7

teristics common to most psychotherapy groups for children. A group of children, usually four to eight in number, within an age range of a year and a half to two years and demonstrating a symptom of maladjustment are placed together in a room with suitable toys and equipment.

The adult

therapist allows a completely permissive environment at first, and restrictions are later imposed only out of neces­ sity.

The manner in which the child plays and relates himself

to the therapist and other members of the group is the basis for interpretation by the therapist. The purpose of this type group is described by Slavson: . . . to give substitute satisfactions through the free acting out of impulses, opportunity for sublimative activity, gratifying experiences, group status, recog­ nition of achievement, and unconditional love and accep­ tance from an adult.6 The dynamics of such a group, as is true of all other forms of psychotherapy, are: (1) the relationship established between the individual and the therapist which is called the transference relationship; (2) catharsis or acting out of emotional experiences; (3) support from other members of the group and empathic release of their aggression; (4) insight into some of the problems of the behavior of the* individual; and (5) reality testing. 6 S . R . Slavs on, editor, The Practice of G-roup Therapy (New York: International University Press, 1947), p. 32.

8

The specific objectives of group psychotherapy em­ ployed in the present study were: (1) to help the child experience or act out and discharge aggressive and hostile impulses in a supportive and permissive environment; (2) to decrease the real or imagined pressure of restrictions and prohibitions which the child might feel; (3) to decrease the tension and anxiety of the child through physical and emo­ tional activity in the group setting; and (4) to help the child find ways of reshaping attitudes toward himself and others which would decrease the needs for the defensive and ■ v

self-punishing symptom, stuttering* In discussing the values of group therapy Slavson makes the statement: "One must remember that where there is no discharge of hostility there is no t h e r a p y T h i s statement does not imply that the child must indulge in gross, overt, hostile, or aggressive physical behavior*

The

discharge may be much more subtle and still constitute an emotional energy discharge.

It is known also that a partial

discharge or a further repression of a conflict may effect a seeming release from a symptom.

One must judge whether

the aggression and hostility exhibited as part of the therapy process has effected a release of energy and a diminution of anxiety and conflict.

The empirical judgment here employed

^ Slavson, op* cit•, p. 38.

9

consisted of evaluation of changes, if any, in the dynamic personality picture as obtained from projective techniques including the play.

The reduction of the stuttering was a

basis for judgment with the reservation in mind that the symptom might be further repressed and show a subsequent reduction in the symptom through added emotional control* There might even be aggression of a high level in the pas­ sive, quiet, docile individual*

This very passivity may be

the best control technique possible and at the same time the best expression of aggression of which he is capable. Slavson reflects what seems to be*general agreement regard­ ing group therapy when he says: •