You have accessAmerican Journal of Speech-Language PathologyResearch Article19 Oct 2018

Covert Stuttering: Investigation of the Paradigm Shift From Covertly Stuttering to Overtly Stuttering

    Abstract

    Purpose

    Covert stuttering is a type of stuttering experience that occurs when a person who stutters conceals his or her stutter from others, attempting to be perceived as a nonstuttering individual. A person who covertly stutters experiences the cognitive and emotional elements of stuttering with minimum overt behavioral symptoms. Individuals who covertly stutter are able to provide insight into their experiences in attempting to be perceived as nonstuttering individuals. Covert stuttering is a topic that continues to be in need of a formal definition. The current investigation is utilizing thematic analysis to provide a detail-rich investigation of the paradigm shift from covertly stuttering to overtly stuttering.

    Method

    The current investigation is a qualitative analysis of individuals' transition process from covertly stuttering to overtly stuttering. Real-time video interviews were conducted with the use of open-ended phenomenological interview questions. Interviews were transcribed, and thematic analysis of interview transcripts was conducted to investigate the covertly to overtly stuttering process for participants.

    Results

    The findings provide insight into a paradigm shift that occurs when individuals who covertly stutter begin to outwardly identify themselves and allow for overt stuttering. The primary theme was a paradigm shift in the 6 participants' mindset regarding stuttering; additional details are provided in the subthemes: attending speech therapy, meeting other people who stutter, and a psychological low point. The details of the covert-to-overt stuttering conversion are documented with the use of direct quotations.

    Conclusion

    The evidence suggests the various intricacies of the experiences of persons who are covert. Clinical implications of these findings for assessing and treating individuals who covertly stutter are discussed.

    The Encyclopedia of Communication Sciences and Disorders (J. Douglass, in press) provides a working definition of covert stuttering as the disproportionate use of secondary behaviors to hide a stutter. The common understanding is with the increased awareness of a primary stutter (i.e., the core behaviors) comes the likelihood of an escape response of attempting to cope with the discomfort of the stutter. The discomfort of the stutter may come in the form of a negative listener response (e.g., teasing), sensing tension of the listener (e.g., body language of others), feeling of physical discomfort within self (e.g., articulatory tension), or the loss of control of speech (Perkins, 1990). With discomfort before, during, or after the moment of stuttering, the individual who stutters may create an escape behavior. These escape behavior responses are known under different terms but are all similar in meaning. These include secondary behaviors, accessory behaviors, escape behaviors, and coping behaviors (Manning & DiLollo, 2017).

    Early escape or secondary behaviors come in many forms, all of which are dependent on the individual. These may include using verbal starters (e.g., “um…”), creating distracting noises (e.g., clicking the tongue), abandoning the stuttered utterance, or a physical response (e.g., blinking eyes, moving the head, writhing the hands). With the persistent accumulation of experiences and the increasing level of discomfort with stuttering, persons who stutter (PWS) have an increase in avoidances, anxiety, and frustrations (Bloodstein & Bernstein Ratner, 2008; Manning & DiLollo, 2017; Tran, Blumgart, & Craig, 2011) as well as a greater impact on the individual's freedom of verbal expression. For example, individuals who are attempting to hide their stutter may take on personality traits that are not true to themselves (e.g., acting “flakey”) to avoid a moment of stuttering or be identified as a person who stutters (Bleek et al., 2012).

    Covert stuttering literature is in its infancy, thus requiring the development of a foundation rich with details and a descriptive understanding of the covert stuttering experience, which is best found via qualitative inquiry. For larger studies to develop, the literature must guide our strategic development of the most appropriate research questions via rich description (Damico & Simmons-Mackie, 2003). In addition, individuals who are covert are in hiding, passing in society (Goffman, 1986) as fluent. Unless an individual begins identifying as a person who stutters or in any way is seeking help, the general population of persons who covertly stutter (PWCS) is quite a challenge to recruit as research participants. Finding qualified participants who identify as someone who was formerly covert allows for a greater number of participants.

    The J. Douglass (2011) study was the first to provide qualitative evidence describing how six individuals who were previously covert describe their experience with covert stuttering. In addition, the study provided insight into the paradigm shift participants made when they went through a mental shift in their way of thinking about stuttering, which led them from covertly stuttering to overtly stuttering.

    Covert Stuttering

    In Bloodstein and Bernstein Ratner's (2008) seminal text The Handbook on Stuttering, the researchers make passing reference of the limited understanding of covert stuttering when they remark in a footnote that covert stuttering is “a well-recognized clinical phenomenon with sparse research documentation” (p. 2). The earliest researchers of covert stuttering discuss it as “interiorized stammering” with individuals being in a state of “constancy,” that is, being constantly aware of speech, surroundings, audience, word choice, self, and so forth (E. Douglass & Quarrington, 1952). Perkins (1990) acknowledges covert stuttering once in his article defining stuttering and considers the negative impact of listener perception evaluations of stuttering for covert stuttering. As part of the clinical observations of covert stuttering by Murphy, Quesal, and Gulker (2007), the grounds were laid for PWCS to receive stuttering therapy based on the potential severe psychological, emotional, and social impact their stutter may have on the individual.

    The J. Douglass (2011) study documented the narratives of six individuals who identified themselves as former PWCS who, at the time of the investigation, were deemed to formerly be PWCS and socially identified as PWS. The findings indicated six major themes that connected the narratives of the six participants. They included (a) justifying covert status, (b) feelings related to overtly stuttering, (c) realization that hiding is unproductive, (d) a changing event that leads to transition, (e) empowering experiences that aid in overcoming covert ways, and (f) commitment to change. The dissertation was the first to empirically document the transition of an individual from covert stuttering to overt stuttering.

    J. Douglass and Tetnowski (2015) investigated further into the J. Douglass (2011) study. Their new study revealed how the mental constancy of covert stuttering impacted the participants' workplace experiences. In an effort to save face and maintain one's professional reputation, individuals justified using covert strategies in the workplace. These strategies often impacted work performance and overall personal experience in the workplace (J. Douglass & Tetnowski, 2015).

    Today, the topic of covert stuttering has gained traction within the stuttering community. These grassroots efforts are noted via podcasts (e.g., stuttertalk.com; Stutter Talk, n.d.), blogs (e.g., Stutter Rockstar, n.d.), comics (e.g., stutteringiscool.com; Stuttering is Cool, n.d.), and stuttering support groups (e.g., National Stuttering Association [NSA], n.d.; Friends, n.d.).

    The most recent empirical research publication on covert stuttering (Constantino, Manning, & Nordstrom, 2017) identifies an element of the complexity of covert stuttering by theoretically delving into the concepts of “technologies of communication” used by PWCS. The in-depth philosophical research validates the “active manipulations” of the speaking situation and their speech that ultimately aids individuals who stutter to take on the identity of a fluent person (Constantino et al., 2017).

    Anxiety and Stuttering

    Fear and anxiety stimulate coping behaviors to respond to threats appropriately; however, fear and anxiety also have the ability to disrupt functioning. A disruption in the functioning of the speech motor system may disrupt speech processing and adaptive behaviors (Alm & Risberg, 2007; Attanasio, 2000; Folkman & Lazarus, 1988; Neilson & Neilson, 1987; Scherer, 1994). The levels of anxiety in adult PWS are significantly elevated in comparison with the anxiety in nonstuttering groups (Craig & Tran, 2014). Reportedly, anxiety potentially increases stuttering frequency and the likelihood of maladaptive coping, and PWS may experience negative emotional reactions socially because of anticipated embarrassment; further research is warranted to suggest generalizability (Attanasio, 2000).

    As previously stated, the accumulation of these negative experiences and emotional reactions often leads to an increase in anxiety and avoidance of social settings (Bloodstein & Bernstein Ratner, 2008; Craig & Tran, 2006; Manning & DiLollo, 2017; Tran et al., 2011). Negative life experiences, including stuttering-related bullying, may impact employment-seeking outcomes and self-perception and may have an overall impact on one's personality (Bleek et al., 2012; Craig & Calver, 1991; Davis, Howell, & Cooke, 2002; Klein & Hood, 2004; McAllister, Collier, & Shepstone, 2012; Van Borsel, Brepoels, & De Coene, 2011). Evidence suggests that stuttering treatments promoting self-efficacy and support groups positively influence anxiety, mood states, resilience, and social affiliation (Craig, Blumgart, & Tran, 2011).

    Concealment

    Marginalized populations have the risk of concealing their difference, potentially due to shame, stigma, societal misunderstanding, and misrepresentation of the difference. An individual who attempts to conceal his or her difference is, to some extent, self-perpetuating a stigma, giving in to the societal misunderstanding of a difference that he or she has (Boyle & Fearon, 2018; Goffman, 1986). Shame and the response of concealment can decrease with diversity education to raise awareness of the differences and a community support system (e.g., diversity training, diversity campaigns; Griffith & Hebl, 2002).

    The predominant concealment discussion is seen in the literature of the lesbian, gay, bisexual, transgender, and/or queer population. The lesbian, gay, bisexual, transgender, and/or queer literature is currently used to benefit the understanding of other populations with nonvisible disabilities. “Coming out of the closet” has been referred to as a process that persons with epilepsy (Schneider & Conrad, 1980), persons with disabilities (Samuels, 2003), and persons with psychiatric disorders (Corrigan & Matthews, 2003) may experience.

    Purpose

    Research on the perspective of individuals who covertly stutter is warranted to further expand the literature base and provide appropriate clinical interventions and clinician training. The current study will contribute to the few systematic investigations of covert stuttering (e.g., Constantino et al., 2017) and continue to develop the clinical definition of covert stuttering with the use of evidence-based research findings.

    The purpose of the study is to investigate and develop a detailed understanding of the transition process of individuals who transition from covert stuttering to overt stuttering.

    Method

    Participants

    The current study included five participants all over the age of 18 years (three male and two female) who self-reported a shift from covertly stuttering to overtly stuttering. The five participants included, under pseudonym, Annette, Bonnie, Chris, Doug, and Frank; descriptions of participants and their interview times are found in Table 1. Participant recruitment study was by word of mouth through the stuttering support group community. The selection process included participants verbally acknowledging that they were once covert and now consider themselves overt with their stuttering. Because of the small sample size, the findings form the framework for further understanding of this underrepresented population. In addition, all participants were at some point actively involved in the NSA support groups and/or national conferences.

    Table 1. Participant description.

    Pseudonym Age Gender Region, country Approximate # years to convert Interview length (H:M:S)
    Annette 40s F North, United States 30+ 1:39:40
    Bonnie Early 20s F East coast, United States 10+ 1:04:27
    Chris Mid-20s M Midwest, United States 4 1:12:58
    Doug Late 30s M East coast, United States 20+ 1:01:41
    Frank Late 30s M East coast, United States 10+ 1:27:59

    Note. H:M:S = hours:minutes:seconds; F = female; M = male.

    Procedure

    In accordance with the University of Louisiana at Lafayette and Sacred Heart University's institutional review boards, research approval was granted. In addition, confidentiality was maintained in accordance with the guidelines and regulations provided by the institutional review board's standards. As a way of observing confidentiality, names of all participants were changed including online identities (e.g., personal blogs), which may reveal a participant's identity, and they were given acknowledgment without stating the specific online name. Likewise, all dates of interviews are noted by the month and year rather than the exact date.

    Six audio-recorded interviews were conducted via Skype with the first author, and participant follow-up with the investigator was offered if the participant or investigator deemed it necessary. One participant e-mailed the investigator postinterview with additional information, which was considered within the data. The semistructured ethnographic interviews included open-ended questions (e.g., “Tell me about your stuttering.”) and a loosely guided plan (e.g., “Describe your earliest memory of your speech,” “Expand on those covert behaviors that you mentioned”), focusing on the broad question of their covert stuttering experience and allowing the participants to guide the details of the plan. Average interview length was approximately 1 hr 16 min, with a range of 1 hr to 1 hr 30 min (see Table 1).

    The audio recordings of interview data were orthographically transcribed and then reviewed and analyzed with interpretive phenomenological analysis (Smith & Osborn, 2003). The current authors reviewed the participant narratives to delve deeper into understanding and revising the purpose, which was to explore “the transition from covertly to overtly stuttering.” Use of thematic analysis provided flexibility to explore the details of the transition, which developed into the specific theme regarding a paradigm shift from covertly to overtly stuttering that was woven as a consistent underpinning to the narratives, although the theme did not take up large portions of the transcripts.

    Validity and reliability measures were conducted with the use of a number of techniques. To ensure reliability, all of the authors maintained a consistency of the approach via reading, understanding, and discussing the Smith and Osborn (2003) chapter regarding interpretive phenomenological analysis and thematic procedures. The authors reflected upon and discussed any biases they had or felt while first reading the transcripts; these biases were acknowledged and documented to ensure biases were clear before continuing the data analysis. The authors consistently checked the transcript for accuracy of the audio recordings. Regular meetings were held between the three authors who independently coded the transcripts and then came together to ensure the interpretation and meaning of the coding was maintained and focused on the “changing event that leads to a transition” theme. In the final stages of compiling the themes from the codes, intercoder agreement was conducted by cross-checking codes and comparing the results that were independently interpreted. The primary theme and subthemes were based on rich, thick description consistent throughout five of the participants' narratives; the themes were based on frequently occurring concepts throughout the narratives (Creswell, 2014; Damico & Simmons-Mackie, 2003).

    Results

    Direct quotations from the interview manuscripts are used to ground the themes in the data; all conclusions are based on the words of the participants. The data of the individuals' narratives are reported through their stream of consciousness during their interviews, with the linguistic disfluencies present, enhancing the authenticity of their responses. The stuttering-like disfluencies are not included as they were not part of the original (J. Douglass, 2011) transcripts. Regardless, the purpose of the thematic analysis is content-based and broadly focused (i.e., the message of the participant) rather than focused on how the participant spoke.

    Theme: Paradigm Shift

    The interviews revealed internal and external events that motivated the participants to change their perception of their covert stuttering. Five participants reported a paradigm shift in their way of thinking about stuttering. The shift was realized for some during the interview while recalling their past experiences; the paradigm shift was not a preplanned question for the interview—it was an organic part of five participants' narratives. The main theme of a paradigm shift was supported by three subthemes: (a) attending speech-language therapy, (b) meeting other PWS, and (c) experiencing psychological low point.

    Subtheme: Attending Speech Therapy

    Two participants, Bonnie and Doug, described their experiences attending speech therapy and the role the speech therapy played in their paradigm shift from covertly stuttering to overtly stuttering. Participants reported the speech therapy experience was mentally uncomfortable, although their regular attendance suggested they were ready for change.

    Bonnie shared the positive outcome she experienced after confronting her fear of overtly stuttering during a speech-intensive program. The following two quotations recount Bonnie's experiences during the program:

    I found out about another speech intensive program when I was there, so I went to that. And that was a lot of awful experiences wrapped up into one. Making me do these things I had been trying to hide for so long and all the things that I feared the most and, but at the end of it, it was really, like, what I needed all along. Once I finally let myself, um, confront my stuttering and let people hear my stuttering and me, become more comfortable with my stuttering, then it didn't seem quite as bad.

    Doug reported various negative experiences with speech therapy before his paradigm shift. Growing up, Doug avoided revealing his stutter at all costs. During school, he avoided public speaking and waited to talk until he felt like he would not stutter. These covert strategies continuously created awkward situations, eventually leading to Doug attending speech therapy. The following is a summary of his positive speech therapy experience that resulted in increased comfortability with his stutter:

    I ended up in the speech therapist's office and I remember not wanting to look at the people in the waiting room and just sitting down and not stuttering. And I remember [the speech therapist] saying, “It's okay you're allowed to stutter here.” And I remember him being the first one to say that and I remember him distinctly saying, “I understand,” and I remember telling him, “I've tried not to stutter my whole life,” and he said, “I understand.” He was very calm and I remember him telling me, “You are going to be not a good communicator you are going to be an extraordinary communicator. And you already are.” I remember feeling totally relieved and I remember for the first time feeling it was going to be okay.

    Bonnie and Doug reported positive speech therapy experiences as part of their paradigm shift from covertly stuttering to overtly stuttering. It is noted that they both found the beginning of therapy as a young adult a somewhat confrontational experience.

    Subtheme: Meeting Other PWS

    Three participants experienced a change in how they thought about their stutter. Meeting another person who stutters played a part in their paradigm shift. This affected their identity, and decreased emotional and cognitive impact of their stutter.

    Annette experienced a major unexpected career change that led her to psychological therapy. During her time of seeking psychological help, Annette learned about the NSA and began attending support group meetings. Annette faced challenges during these meetings and struggled to adjust to the overt lifestyle. Annette recalls her experiences during the NSA meetings:

    My first couple of [stuttering support group] meetings were a joke: the first meeting I cried the whole time, the second meeting I had to leave early. It took me about six months to say at a meeting that “I stutter,” and, you know, it took me a while for me to be able to say that but all of that I think has actually been a blessing in the covert journey that I've been on. Because I'm not sure if [being fired for stuttering] hadn't happened that I'd be where I'm at now.

    Bonnie had attended speech therapy growing up but felt that the therapy did not help her address her covert ways. When she began college, she realized that stuttering was holding her back from communicating with others and entering social situations. Bonnie found out about the NSA and joined the local support group. Bonnie experienced a paradigm shift during her first encounter with people who openly stuttered. She describes how being a part of this open environment impacted her life:

    So I found out about the [stuttering support group] and I went to that. And I met a bunch of people who were just, like, crazy open about their stuttering. And that was the first time I ever really heard anybody stutter and not really care. They were just so proud to speak the way they did and it really inspired me to want to be more like them.

    Chris, like Bonnie, had a similar experience in meeting and hearing the experiences of other PWS. He delved into the stuttering support group and self-education via podcasts. His experience is detailed with the following:

    And just talking about it and realizing that I'm not alone, like self-education, like really just changed my life. Like NSA conferences and [stutter podcasts], realizing that there's there's normal, well-adjusted, cool people who stutter. It's not, it's not any kind of a…it's not any kind of a deficiency about who I am. It's just something about me that's challenging, you know?

    We see similar experiences between Chris and Doug in that meeting other PWS changed their stereotype of other PWS as being “not cool” or somehow not normal. With much hesitation and numerous attempts at avoiding meeting other PWS, Doug went to his first support group meeting for PWS. Doug shares how his stereotype of stuttering vanished:

    Jack [my speech-language pathologist (SLP)] encouraged me for a long time to meet other stutterers and I would not do it. I remember he drove to my house on a Saturday or a Sunday, this was before the days of cell phones, so he said, “I'm coming over. Be ready in half an hour.” I didn't want to go but he was like, “You need to do this,” he was not a pushy guy, Jack. He knew to push me pretty hard on this one after about a year…. I met stutterers and I realized that they were really cool people, but I was expecting to meet people who were not really cool. I was expecting to meet people that were uncool and I had the stereotypes in my head that people who stutter are not hip, are not cool and I met people who I am still friends with today.

    Continuing the subtheme of meeting others and self-education, Frank had similar experiences to Chris. Throughout his years in elementary, middle, and high school, Frank concealed his stutter. Frank experienced his change in thought toward stuttering during his time as an undergraduate student. Frank disclosed his stutter to his university advisor, and she “was really supportive in it.” Frank and his advisor discussed potential graduate programs that focused on stuttering; he chose to pursue a master's degree in speech-language pathology. He describes how he felt during this time:

    It took me to the age of 22 to meet another person who was, you know, like a successful, like, person who stuttered and it was so neat just to hear them stutter and it was almost like indirect speech therapy. I was never a client. But these, these people that I was around, you know, um, I felt like I did my own kind of self-therapy with like observational learning, watching them do the things that they do. Me learning about speech therapy, learning about stuttering, applying these techniques that I'm learning to my stuttering, and I felt like I became my own self.

    The theme “meeting other people who stutter” proved to be a time of an identity shift in the narratives of Bonnie, Chris, and Doug; their preconceptions about what it means to be a person who stutters were challenged.

    Subtheme: Psychological Low Point

    Three participants experienced their paradigm shift during a personal dark period in their lives resulting in a psychological low point. Annette began her path to change after the dramatic firing from her job. Since her firing from the job was associated with her stuttering, she found herself helpless on her covert stuttering journey. The following recounts her experience:

    The guilt of honestly believing that [the firing] was my fault. I had myself convinced that if I had just told them that I stuttered they would have understood and I wouldn't have been fired. Which, of course, probably had not been the case. But I was living with that guilt and that fear of, “oh my god, what am I going to do? I don't have a job. I'm not going to have health insurance in a couple of weeks!” I was in that dark place. Um, and somehow I am here today and everything has completely changed. And I think it probably is, I mean, that moment was definitely my defining moment.

    For most of Annette's life, she was able to manage her stuttering until she hit rock bottom when she was fired from her decade-long career position. This defining moment caused her to make changes in her life and find services to help with her covert stuttering. Annette attributes that psychological low point to propelling her toward helping her develop and with the developments and empowering experiences she has in her current life.

    Similarly, Doug underwent a process of physical and mental turmoil before his reported paradigm shift. In his 20s, he was experiencing health issues for the first time, which included insomnia for 48 hr at a time, migraines, and intense stomach pains. These health issues were occurring simultaneously with his feeling of losing control of his covert tactics. While Doug was searching for a way out of his covert lifestyle, he disclosed his stuttering identity to university professors who undermined his feelings and dismissed his reports of stuttering. Doug reached out to a hospital health phone line that provided a reference to an SLP. During this search for help, Doug also revealed his struggle with his stutter to his mother. Doug's deteriorating health found him in the emergency room where he received intravenous injections to aid his migraines. Despite medical intervention, the health issues persisted. In desperation, Doug decided to contact the SLP. He immediately experienced physical relief from the insomnia, migraines, and stomach pains after his first meeting with the SLP. Doug spoke of how he felt during this low point:

    Within days of meeting [my SLP] my headaches and intense stomach pains went away. All that pain just stopped and I knew immediately that it was because I was talking about my stuttering. It may not be the most scientific thing to say but talking about my stuttering stopped the physical pain and I began sleeping better.

    Chris reported a desire for environmental change, which allowed him to commit to fully understanding his stutter. He decided to quit his job and relocate. Chris describes how he felt during this need for change:

    I was so, so miserable at the job that I had and I just needed to do something. I needed to do something, you know. Just, like, get out of town. Oh, and then my girlfriend at two and a half years broke up with me, too. It's just like, I just wanted to get out of town kinda. And I wanted to quit my job.

    Chris relocated and researched various types of stuttering therapy and chose to attend an intensive therapy week, which had a multidimensional approach to stuttering therapy. The psychological low point related to career and relationships propelled him to change his environment and address his stuttering.

    Discussion

    The phenomenological study provides a thorough investigation and an in-depth thematic analysis of the transition process from covertly to overtly stuttering. The current finding adds to the literature in creating a qualitative definition of covert stuttering (e.g., E. Douglass & Quarrington, 1952; Constantino et al., 2017), with the description of a paradigm shift that occurs when an individual is shifting to a more overt way of stuttering. The paradigm shift theme and subthemes—(a) attending speech therapy, (b) meeting other PWS, and (c) psychological low point—document the changes in the reported social, emotional, cognitive, and identity impact of covert stuttering.

    Stuttering support groups play a significant role as an intrinsic motivation (Trichon & Tetnowski, 2011) in shifting from covertly to overtly stuttering. When an individual discriminates or stigmatizes a marginalized group, he or she is likely to decrease his or her discriminatory beliefs after making contact with an individual of that marginalized group (Flynn & St. Louis, 2011; Jones, Lynch, Tenglund, & Gaertner, 2000). Upon meeting other PWS, individuals who are covert will experience a paradigm shift if they have a prior stereotype of stuttering or conceal their own stutter to avoid the stereotype of stuttering. Individuals experience a positive regard for self after physically encountering others who stutter, within a structured environment such as a stuttering support group.

    The successful outcomes of support group attendance are individualized, depending on what the individual deems as progress and what he or she deems he or she is capable of. Participants' definition of successful participation in the stuttering support group ranged from showing up and being present to bonding and engaging with others. Attending the stuttering support group was a positive part of the covert-to-overt stuttering process for the participants. A clinician endorsing his or her client's attendance at a stuttering support group should be mindful of the potential anticipation and hesitation that may be affiliated with the idea of support group attendance. As seen in the current findings, attendance at the stuttering support group meetings initially came with marked hesitations.

    The self-stigma and cultural stigma surrounding stuttering play a role in the participants' hesitations in attending a stuttering support group. Boyle and Fearon (2018) discuss a self-stigma model created by Corrigan, Rafacz, and Rusch (2011) as a process of internalizing negative public beliefs among individuals with stigmatized conditions. Within this model, individuals are aware of negative public attitudes, eventually agreeing and applying those perspectives to themselves. This process may impact psychological well-being, leading to negative self-perception and avoidance, as supported by the narratives of the current participants. Participants noted that they were unenthusiastic about meeting people who stuttered, with the stereotype that PWS would be “not cool” and “not hip.” After an initial meeting took place, participants came to the conclusion that there are “well-adjusted,” “cool” PWS. Participants found that stuttering is “not any kind of a deficiency about who I am… just something about me that's challenging.”

    Anxiety and stuttering are documented in the literature (Craig & Tran, 2014). The current study reveals the participants were addressing their anxiety as a part of their paradigm shift process such as reporting their levels of discomfort in attending speech therapy, the anxiety that they experienced leading up to and while meeting other PWS, and the psychological low point many faced due to the effects of anxiety. The findings reinforce that anxiety is intertwined in the overall stuttering experience.

    SLPs play an integral role in the process of an individual transitioning from covertly stuttering to overtly stuttering. Boyle and Fearon (2018) discuss the SLP role in the reappraisal of life events or situations to encourage self-efficacy and empowerment. Individuals experiencing high levels of self-stigma may benefit from regaining a sense of power and control regarding the ability to manage stress and helplessness, which often accompany stuttering. Positive statements made by clinicians during therapy, such as “it's okay, you're allowed to stutter here,” created a sense of hope. Increased perceptions of personal control over the helplessness and stress related to stuttering correlate to lower levels of self-stigma and higher levels of hope, self-esteem, and self-efficacy (Boyle & Fearon, 2018).

    Another component impacting the transition process from covert to overt stuttering is the clinician's perspective and knowledge of stuttering. The background of the clinician sets a tone for the client's relationship with their stuttering. Coalson, Byrd, and Rives (2016) discuss that individuals who stutter consistently rate clinician competency as a critical component for successful therapy. Findings of the current study suggest a direct relationship between the tone set by the clinician and how successful speech therapy was, as perceived by participants.

    The findings of the current research regarding the paradigm shift could be integrated to other marginalized populations who go through a transition popularly referred to as “coming out of the closet” (e.g., Corrigan & Matthews, 2003; Samuels, 2003; Schneider & Conrad, 1980). Albeit, the “closet” part of the reference implies the analogy of “skeletons in the closet” and suggests that a dark and shameful side of oneself is being revealed. In addition, the “coming out” element of the popular term refers to debutants having their coming out to society at a ball. The use of the popular term “coming out of the closet” with stuttering is in need of further review, as the origin of the term is multifaceted and without a systematic definition of the reference.

    Caveats

    As stated previously, each participant was involved in the stuttering community, specifically the NSA. All of the participants have experienced being in the majority as a PWS by attending either stuttering support groups or the annual NSA conference. The participants have had prior participation in dialogue about stuttering and identified with the term “covert stuttering” at NSA conferences. The NSA conference is attended by hundreds of PWS, a small fraction of the 1% of the American population who stutter (i.e., approximately three million Americans stutter; Bloodstein, 1995). The experiences, knowledge, and social encounters of the study's participants are atypical and exceptional in comparison with the general population of individuals who stutter who do not participate in the stuttering community.

    Implications

    Implications arise from the current study regarding the vulnerability of PWCS upon entering into speech-language therapy. The depth and focus on counseling a PWCS are warranted and are within the scope of the field of speech-language pathology. Knowledgeable counseling practices and graduate training in counseling are essential to provide best services for clients who covertly stutter. On the basis of the current findings, individuals who are covertly stuttering are managing high anxiety and significant cognitive impacts before and during their shift from covertly stuttering to overtly stuttering.

    Individuals who are covertly stuttering should seek the help of a certified SLP. More specifically, individuals seeking services for covert stuttering symptoms should refer to online resources such as the American Speech-Language-Hearing Association website to investigate board-recognized fluency specialists (asha.org); the Stuttering Foundation, which is organized by state self-identified fluency specialists (stutteringhelp.org); or clinicians who have fluency special interest group membership via the American Speech-Language-Hearing Association. Coalson et al. (2016) report that most SLPs note discomfort when providing services to individuals who stutter due to insufficient academic and clinical preparation in this area, as a student. Locating a clinician who is board-recognized or self-identified as a fluency specialist would enhance the individualized therapy experience for individuals who covertly stutter as the clinician may be more aware of the intricacies of stuttering (Coalson et al., 2016).

    SLPs are encouraged to endorse or develop a local stuttering support group for individuals who stutter. The stuttering support group environment is conducive for engaging with others who overtly stutter, who have overcome or continue to work through covert stuttering challenges, develop friendships, increase socialization, and provide freedom to be themselves. National stuttering support organizations often provide free resources, guidelines, and affiliation for creating a stuttering support group chapter (e.g., NSA, n.d.).

    In addition, SLPs should provide their client with educational information regarding stuttering, increasing their client's knowledge base of the topic in general and specifically to the client's needs. By doing so, the clinician is aiding in the client's autonomy and ability to self-advocate. In addition to increasing content-based knowledge with the client, the clinician should provide therapy time to explore online materials and aid the client in becoming analytical of free online resources and subscribing to appropriate stuttering-focused blogs and podcasts. When the clinician focuses on knowledge and valid resources, the clinician is investing in his or her client's needs beyond the allotted treatment time.

    The clinician and client should transparently set therapy goals at the onset of therapy based on assessment results, client values, and the clinician's expertise. For a client to be motivated to attend therapy, the client values for therapy goals may be the priority. Within therapy, as the client explores stuttering literature, blogs, podcasts, and stuttering self-help, the clinician and client should regularly revisit therapy goals as the client's self-concept continues to evolve.

    Future Directions

    Further studies should base their research on the current findings that individuals who were once covertly stuttering went through a paradigm shift as they began attempting to overtly stutter and identify themselves as a person who overtly stutters. Appropriate follow-up questions to consider include investigating the speech-language pathology experiences of individuals who covertly stutter, the positive and negative experiences, and the logistics of the therapy sessions such as the therapeutic approaches used. In addition, were there common contexts in which individuals who covertly stuttered had similar covert encounters? For example, when or where did an individual who covertly stuttered first realize he or she stuttered or first experienced shame in relation to stuttering? Further investigation of the study's findings and the continuation of in-depth thematic investigation of the broad themes would serve to provide greater insight into covert stuttering and beneficial therapeutic treatment. With the current research as the basis, application and integration of the stages of change (Floyd, Zebrowski, & Flamme, 2007) could be applied to the transition process from covertly to overtly stuttering.

    In addition to broad interviews, further qualitative research should incorporate mixed methods with measuring the current impact of stuttering on the participant's life via means of a standardized test such as the Overall Assessment of the Speaker's Experience of Stuttering (Yaruss & Quesal, 2016). Using the mixed method approach would develop robust findings with the use of triangulation of data.

    References

    • Alm, P. A., & Risberg, J. (2007). Stuttering in adults: The acoustic startle response, temperamental traits, and biological factors.Journal of Communication Disorders, 40, 1–41.
    • Attanasio, J. S. (2000). A meta-analysis of selected studies in anxiety and stuttering: Response to Menzies et al. (1999).American Journal of Speech-Language Pathology, 9, 89–91.
    • Bleek, B., Reuter, M., Yaruss, J. S., Cook, S., Faber, J., & Montag, C. (2012). Relationships between personality characteristics of people who stutter and the impact of stuttering on everyday life.Journal of Fluency Disorders, 37, 325–333.
    • Bloodstein, O. (1995). A handbook on stuttering (5th ed.). San Diego, CA: Singular.
    • Bloodstein, O., & Bernstein Ratner, N. (2008). A handbook on stuttering (6th ed.). New York, NY: Delmar.
    • Boyle, M. P., & Fearon, A. N. (2018). Self-stigma and its associations with stress, physical health, and health care satisfaction in adults who stutter.Journal of Fluency Disorders, 56, 112–121.
    • Coalson, G. A., Byrd, C. T., & Rives, E. (2016). Academic, clinical, and educational experiences of self-identified fluency specialists.Perspectives of the ASHA Special Interest Groups, 1(4), 16–43.
    • Constantino, C., Manning, W., & Nordstrom, S. (2017). Rethinking covert stuttering.Journal of Fluency Disorders, 53, 36–40.
    • Corrigan, P. W., & Matthews, A. K. (2003). Stigma and disclosure: Implications for coming out of the closet.Journal of Mental Health, 12(3), 235–248.
    • Corrigan, P., Rafacz, J., & Rusch, N. (2011). Examining a progressive model of self-stigma and its impact on people with serious mental illness.Psychiatry Research, 189(3), 339–343.
    • Craig, A., Blumgart, E., & Tran, Y. (2011). Resilience and stuttering: Factors that protect people from the adversity of chronic stuttering.Journal of Speech, Language, and Hearing Research, 54, 1485–1496.
    • Craig, A., & Calver, P. (1991). Following up on treated stutterers: Studies of perceptions of fluency and job status.Journal of Speech and Hearing Research, 34, 279–284.
    • Craig, A., & Tran, Y. (2006). Chronic and social anxiety in people who stutter.Advances in Psychiatric Treatment, 12, 63–68.
    • Craig, A., & Tran, Y. (2014). Trait and social anxiety in adults with chronic stuttering: Conclusions following meta-analysis.Journal of Fluency Disorders, 40, 35–43.
    • Creswell, J. W. (2014). Research design: Qualitative, quantitative and mixed methods approaches (4th ed.). Thousand Oaks, CA: Sage.
    • Damico, J. S., & Simmons-Mackie, N. N. (2003). Qualitative research and speech language pathology: A tutorial for the clinical realm.American Journal of Speech-Language Pathology, 12(2), 131–143.
    • Davis, S., Howell, P., & Cooke, F. (2002). Sociodynamic relationships between children who stutter and their non-stuttering classmates.Journal of Child Psychology and Psychiatry, 43, 939–947.
    • Douglass, E., & Quarrington, B. (1952). The differentiation of interiorized and exteriorized secondary stuttering.Journal of Speech and Hearing Disorders, 17, 377–385.
    • Douglass, J. (2011). An investigation of the transition process from covert stuttering to overt stuttering: An interpretive phenomenological analysis of individuals who stutter (Unpublished doctoral dissertation). University of Louisiana, Lafayette, LA.
    • Douglass, J. (in press). Covert stuttering.In J. S. Damico & M. J. Ball (Eds.), The Sage encyclopedia of human communication sciences and disorders. Thousand Oaks, CA: Sage Publications.
    • Douglass, J., & Tetnowski, J. (2015). Qualitative analysis of covert stuttering: Workplace implications and saving face.In K. O. St. Louis (Ed.), Stuttering meets stereotype, stigma and discrimination: An overview of attitude research. Morgantown, WV: West Virginia University Press.
    • Floyd, J., Zebrowski, P. M., & Flamme, G. A. (2007). Stages of change and stuttering: A preliminary view.Journal of Fluency Disorders, 32(2), 95–120.
    • Flynn, T. W., & St. Louis, K. O. (2011). Changing adolescent attitudes toward stuttering.Journal of Fluency Disorders, 36(2), 110–121.
    • Folkman, S., & Lazarus, S. (1988). The relationship between coping and emotion: Implications for theory and research.Social Science and Medicine, 26, 309–317.
    • Friends. (n.d.). Retrieved from http://www.friendswhostutter.org
    • Goffman, E. (1986). Stigma: Notes on management of spoiled identity. New York, NY: Simon & Schuster.
    • Griffith, K. H., & Hebl, M. R. (2002). The disclosure dilemma for gay men and lesbians: “Coming out” at work.Journal of Applied Psychology, 87(6), 1191–1199.
    • Jones, J. M., Lynch, P. D., Tenglund, A. A., & Gaertner, S. L. (2000). Toward a diversity hypothesis: Multidimensional effects of intergroup contact.Applied & Preventive Psychology, 9, 53–62.
    • Klein, J. F., & Hood, S. B. (2004). The impact of stuttering on employment opportunities and job performance.Journal of Fluency Disorders, 29, 255–273.
    • Make Room For The Stuttering. (n.d.). Retrieved from https://stutterrockstar.com/
    • Manning, H. W., & DiLollo, D. (2017). Clinical decision making in fluency disorders (4th ed.). San Diego, CA: Plural.
    • McAllister, J., Collier, J., & Shepstone, L. (2012). The impact of adolescent stuttering on educational and employment outcomes: Evidence from a birth cohort study.Journal of Fluency Disorders, 37, 106–121.
    • Murphy, B., Quesal, R. W., & Gulker, H. (2007). Covert stuttering.SIG 4 Perspectives on Fluency and Fluency Disorders, 17, 4–9.
    • National Stuttering Association. (n.d.). Retrieved from http://www.westutter.org
    • Neilson, M., & Neilson, D. P. (1987). Speech motor control and stuttering: A computational model of adaptive sensory-motor processing.Speech Communication, 6, 325–333.
    • Perkins, W. H. (1990). What is stuttering?.Journal of Speech and Hearing Disorders, 55, 370–382.
    • Samuels, E. (2003). My body, my closet: Invisible disability and the limits of coming-out discourse.Journal of Lesbian and Gay Studies, 9(1–2), 233–255.
    • Scherer, K. R. (1994). Emotions serve to decouple stimulus and response.In P. Ekman & R. J. Davidson (Eds.), The nature of emotion: Fundamental questions (pp. 127–130). London, United Kingdom: Oxford University Press.
    • Schneider, J. W., & Conrad, P. (1980). In the closet with illness: Epilepsy, stigma potential and information control.Social Problems, 2(1), 32–44.
    • Smith, J. A., & Osborn, M. (2003). Interpretive phenomenology analysis.In J. A. Smith (Ed.), Qualitative psychology: A practical guide to research methods (pp. 51–80). Thousand Oaks, CA: Sage Publications.
    • Stutter Rockstar. (n.d.). Retrieved from http://www.stutterrockstar.wordpress.com
    • Stutter Talk. (n.d.). Retrieved from http://stuttertalk.com
    • Stuttering is Cool. (n.d.). Retrieved from http://www.stutteringiscool.com
    • Tran, Y., Blumgart, E., & Craig, A. (2011). Subjective distress associated with chronic stuttering.Journal of Fluency Disorders, 36, 17–26.
    • Trichon, M., & Tetnowski, J. (2011). Self-help conferences for people who stutter: A qualitative investigation.Journal of Fluency Disorders, 36, 290–295.
    • Van Borsel, J., Brepoels, M., & De Coene, J. (2011). Stuttering, attractiveness and romantic relationships: The perception of adolescents and young adults.Journal of Fluency Disorders, 36, 41–50.
    • Yaruss, J. S., & Quesal, R. W. (2016). Overall assessment of the speaker's experience of stuttering (OASES). McKinney, TX: Stuttering Therapy Resources.

    Author Notes

    Disclosure:The authors have declared that no competing interests existed at the time of publication.

    Correspondence to Jill E. Douglass:

    Editor-in-Chief: Sharon Millard

    Publisher Note: This article is part of the Special Issue: The 11th Oxford Dysfluency Conference.

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