Effects of the presence of a dog on the psychic content expression of a stuttering person: case report

ABSTRACT

Stuttering has negative impacts on an individual’s quality of life and is associated with higher risk of development of social and psychological problems. From this perspective, despite the diversity of etiological hypotheses for and treatments of stuttering, the interface between psychology and speech therapy in the approach to the biopsychic aspects involved in this clinical scenario stands out. Recent research indicates that the presence, specifically of dogs, can assist patients in symbolic elaboration of psychic content. From this perspective, the aim of this study is evaluate the effects of a dog's presence on the expression of the psychic content of a stuttering person, with the hypothesis that framing may reduce symptoms. The subject is M., female, 45 years old, married, without children, hairdressing assistant, with elementary school completed. She underwent the process of speech therapy in presence of a dog. A semidirected interview was conducted after this process. A co-therapist dog of Golden Retriever breed participated in all sessions. The relevant subjective content observed in the setting during the speech therapy process, which seems to have been mobilized by the framework established by the interaction among the therapist, the patient, and the dog, seems to demonstrate an association with the manifestation of disfluencies. The dog made physical contact with, supported, motivated and welcomed the subject in situations in which psychic conflicts were demonstrated. This clinical case study indicates that the dog's presence and interaction framework favored the reduction of stuttering symptoms, promoting welcoming environment that enabled the subject's psyche-soma integration.

Keywords
Language; Stuttering; Animal-Assisted Therapy; Treatment; Speech

RESUMO

A gagueira gera impactos negativos na qualidade de vida dos sujeitos e está associada a maior risco de desenvolvimento de problemas sociais e psíquicos. Nessa perspectiva, apesar da diversidade das hipóteses etiológicas e dos tratamentos da gagueira, destaca-se a interface entre psicologia e fonoaudiologia na abordagem dos aspectos bio-psíquicos envolvidos nesse quadro clínico. Pesquisas recentes indicam que a presença, especificamente de cães, pode auxiliar o paciente na elaboração simbólica de conteúdos psíquicos. Nessa perspectiva, o objetivo desse estudo é avaliar os efeitos da presença do cão na expressão de conteúdos psíquicos de um sujeito que gagueja, com a hipótese de que o enquadre pode reduzir o sintoma. O sujeito é M., sexo feminino, 45 anos, casada, sem filhos, cursou ensino fundamental completo e de auxiliar de cabeleireira. Passou pelo processo de terapia fonoaudiológica na presença do cão. Foi realizada uma entrevista semi-dirigida após o processo. Um cão coterapeuta, da raça Golden Retriever, participou de todas as sessões. Alguns conteúdos subjetivos relevantes observados no setting no decorrer do processo terapêutico fonoaudiológico, os quais parecem ter sido mobilizados pelo enquadre estabelecido pela interação entre terapeuta-paciente-cão, parecem demonstrar associação com a manifestação das disfluências. O cão fez contato físico, deu suporte, motivou e acolheu o sujeito em situações de demonstração de conflitos psíquicos. Assim, este estudo de caso clínico indica que o enquadre da presença e interação do cão favoreceu a redução do sintoma da gagueira, promovendo ambiente acolhedor possibilitando a integração psique-soma do sujeito.

Descritores
Linguagem; Gagueira; Terapia Assistida por Animais; Tratamento; Fala

INTRODUCTION

Stuttering generates negative impacts on the individuals' quality of life⁽¹⁾ and is associated with a higher risk of developing social and psychological problems⁽²⁾.

In this perspective, despite the diversity of etiological hypotheses and treatments for stuttering, we highlight the interface between psychology and speech-language therapy in addressing the biopsychic aspects involved in this clinical condition⁽³⁾.

In this study, we will reference such an interface by the psychoanalytic theory, which understands that the manifest symptoms (in this case, stuttering) result from conflicts between the unconscious and conscious dimensions of the psychic apparatus⁽⁴⁾.

It should be emphasized that this aspect of the symptom, that is, its symbolic nature, does not exclude or reduce its biological dimension (in this study, stuttering). It is a disorder that can manifest in people of different age groups, affecting the fluency of speech. It has been associated with differences in brain anatomy and functioning (dopamine regulation) associated with genetic factors. It is noteworthy that the pharmacological treatment has been investigated in recent researches, but its clinical evidence is still limited⁽⁵⁾.

After these considerations, we need to introduce the element that justifies the guiding question of this study, namely, Animal-Assisted Interventions (AAI).

Recent researches indicate that the presence of animals (specifically dogs) can help the patient in the symbolic elaboration of psychic contents, greater contact with anguish, and attempts at the internal reorganization of the studied individuals. Such results suggest that the AAI promoted greater contact with affectivity and consequent coping/elaboration of psychic contents at different levels⁽⁶⁾.

In this context – of the biopsychic approach in the treatment of stuttering - this study emerges from the following question: Does the presence of a dog in the speech-language therapeutic setting benefit the expression/elaboration of psychic contents involved in the symptoms manifested by individuals who stutter to promote this satisfactory environment?

From this perspective, this study aims to evaluate the effects of the dog's presence on the expression of psychic contents of an individual who stutters, with the hypothesis that the context may reduce the symptom.

PRESENTATION OF THE CASE

This research followed the guidelines and regulatory standards for research involving human beings of the National Health Council/resolution 466. It was approved by the Ethics Committee under number CAAE: 60647716.3.3001.0065, on December 8, 2016. We collected data from March to July 2017, at the Speech, Language and Hearing Research Laboratory of Fluency, Motricity and Orofacial Functions (SLHRL-FMOF) of the Speech-Language Therapy Course, Department of Physiotherapy, Speech-Language Therapy and Occupational Therapy, of the Faculdade de Medicina da Universidade de São Paulo. The participants signed the Informed Consent Form.

A co-therapist dog of the Golden Retriever breed participated in the study, following the health and behavior protocol already used in the routine⁽⁷⁾. The dog was led by the researcher who was present at all sessions.

The participant went through the Speech-Language Therapy Program for the Promotion of Fluency (SLTPPF)⁽⁸⁾ with the presence of the co-therapist dog. It consists of 12 sessions, of 30 minutes each, divided into 04 modules. The dog participated in all sessions and carried out different activities in each module such as drawing words and phrases for the patient to read, drawing objects to describe, and as an interlocutor. Besides, the dog was left loose in the room to interact freely when not performing specific activities. The dog was selected and trained for the function and adapted to the environment before the activities started. Both the patient and the speech therapist had an affinity with dogs. The researcher conducted a semi-directed interview after the process.

M., female, 45 years old, married, without children, with complete elementary school and hairdressing assistant (current profession).

M. is the seventh (in order of birth) of 09 children (06 women and 03 men). She does not remember having met/lived with her father. The family is of low socio-economic class. She did not attend school as a child.

She reported that no one in the family stutters. She does not remember when she started stuttering, considering that “she was born that way” because her mother had problems during childbirth, saying that “she was born purple”. She had meningitis as a baby and wonders whether this fact also influenced the appearance of stuttering.

From 8 to 9 years old, she tried not to speak so as not to stutter. When she was 15, she stuttered a lot. She reported that people have always laughed at her because of stuttering, which causes her a lot of suffering.

At the age of 20, she met a boy and a month later they got married, they have been married for 22 years. She said that this relationship is different from previous relationships, as she has always talked “sincerely” with her husband about stuttering.

She underwent medical treatment to get pregnant, but after some unsuccessful attempts, she gave up. Soon after, she had cancer in her womb and underwent chemotherapy. She tried an adoption process that also failed. She thinks that the disease arose because she had not resolved “something in life”, referring to past events.

She sought treatment for stuttering to speak well and make people not laugh at her anymore. She underwent speech-language therapy treatment in a private service in 2016 but did not get any better. She did not know for how long she went through therapy.

During the whole process, M. showed a lot of involvement to improve the stuttering symptom, even complaining about difficulties with the reading of words and phrases that were part of the treatment. The results of the evaluations showed that there was an improvement in the degree of severity of the stuttering symptom. The initial pre-therapy evaluation indicated a severe degree and, in the post-therapy, the patient obtained a mild degree.

M. reported and vented about moments and conflicts in her life when she was in physical contact with the dog. She said she was upset with her “boss” and her clients because of the teasing, but she never complained, because she needed the job to live. She never confronted colleagues at church who also laughed at stuttering. She also complained of being embarrassed to take a bus and ask for directions, or to go to the doctor’s and not to be able to speak the names of the tests.

M. reported that she felt very welcomed, something that did not occur in other health treatments during her life. In a previous process, the therapist emphasized that stuttering would have no cure, but for her, it was evident in this process that it would have: “my voice is different now”.

At several moments, M. addressed the dog and it was noticeable that she did not stutter. In all sessions, M. greeted the dog, asked how it was feeling, and “answered for him”, without stuttering.

We observed that M. has a great need for acceptance in front of others, which is associated with the negative marks that stuttering promotes in her self-esteem. It was observed a strong desire to please others, even if it causes her suffering. In other words: she seems to apologize for stuttering, which does not occur in the interaction with the dog that does not condition expressions of curiosity to her symptoms, since the first meeting.

The welcome received during treatment seemed to be remarkable in terms of reducing the feeling of rejection experienced so far.

DISCUSSION

Some relevant subjective contents observed in the setting during the speech-language therapeutic process, which seem to be mobilized by the framework established by the interaction between therapist-patient-dog, seem to show association with the manifestation of disfluencies.

The facts observed during the sessions will be highlighted in bold to be discussed.

In the moments when M. felt at ease to vent about her issues, the physical contact with the dog may have triggered psychic conflicts. The setting may have promoted a feeling of affection and acceptance for latent issues approached, favoring therapeutic listening. Physical contact with the dog may promote comfort and welcoming to patients in situations of vulnerability⁽⁹⁾, feeling connected, cared for, and with fewer feelings of loneliness⁽¹⁰⁾, corroborating the results of this study.

At the initial moment of the therapy, M. appeared to be in a state of non-integration. In Winnicott's psychosomatic theory, this is part of the healthy process of development. M. was in a position of total dependence on the caring environment. In this phase of absolute dependence, the individual instinctively seeks to fulfill some tasks such as integration and personalization (when the psyche lodges itself in the body)⁽¹¹⁾.

In the beginning, the individual is an unorganized set of sensorimotor phenomena in which the environment will provide support for this primitive stage to mature. The environment is the instance that sustains and responds to dependency. In this context, the dog may have acted as a holding company that makes the individual start to experience the beginning of integration. Physical care (contact) and a welcoming environment are fundamental for this healthy development of the individual⁽¹¹⁾.

The co-therapist dog played an affective support role in moments of difficulty when facing the activities proposed by the therapist, showing restlessness and agitation when M. complained “I didn't train”, “I can't”. M. recognized that the dog wanted to say something to her and interpreted it as “I need to stop complaining”, positively favoring the therapeutic setting. Some studies indicate that the dog can promote calm and comfort, reducing symptoms of anxiety and depression⁽¹⁰⁾, besides stimulating personal motivation and coping skills⁽¹²⁾, which may have occurred with M. in this process.

Another phenomenon of psychosomatic integration in Winnicott's theory is personalization (accommodation of the psyche in the body), which is also important for healthy development. This process depends on the environmental holding, which is the set of care that the individual receives from this environment. This contributes to the individual's feeling of being in his own body. Gradually, the body becomes a continent of self⁽¹¹⁾. When M. realized that she needed to stop complaining and encouraged herself, the action of the dog in the environment may have promoted the beginning of the phenomenon of personalization (accommodation of the psyche in the body).

Although she knows that stuttering has no “cure”, M. recognized that for her, it does, and realized that “her voice has changed” during the therapeutic process, suggesting the gradual construction of satisfactory personalization. Instinctive experience is important for this construction process. It encompasses⁽¹⁾ personal experience - skin sensations, impulses, excitations, and⁽²⁾ environmental experience - body care and meeting needs. The repetition of these experiences leads the individual to the construction of personalization⁽¹³⁾.

For M., the dog was fundamental for her improvement, as it left the environment more cheerful, without appearing to be under treatment. The therapist-patient-dog interaction suggests that it strengthened the therapeutic bond. In general, the presence of the dog made the environment more welcoming, favoring the therapist-patient bond and strengthening the demand for treatment. Some studies indicate that the dog provides positive feelings such as joy and well-being, demonstrating an important therapeutic potential for psychic aspects⁽⁹⁾.

The fact that M. did not stutter while talking to the dog may have been because M. did not feel judged, being able to be what she is in her essence⁽¹⁰⁾. Here it is possible to suggest that the presence of the dog potentiated verbal interaction experiences without criticism and judgments, often (and for a long time) experienced in different daily situations and also in the symptom of stuttering.

The decrease in M. stuttering symptoms may be due to the appropriate management and frameworks for her. The important thing is that there is not simply a unification of care (integration from outside to inside), nor to cure the somatic symptoms, but rather to provide the necessary conditions so that the individual does not experience dissociated psyche and soma⁽¹³⁾. The path is that there should be a follow-up full of patience so that the defenses are modified and that everyone can experience the integration process. In this case, the dog played a fundamental role so that M. could experience this process.

The dog did not show any strangeness in the face of M.'s symptom, corroborating the hypothesis that the animal has a depathologizing function before the patient, not highlighting the disease, but the relationship between them⁽¹⁴⁾.

Thus, in Winnicott's theory, nature is a matter of interrelated psyche and soma, and existence is essentially psychosomatic. There is an innate tendency to gradually integrate into a unit so that the psyche resides in the body, leading to psychosomatic cohesion⁽¹⁵⁾.

This cohesion is the result of some factors: (1) the available caregiver who allows the patient to explore the body; (2) the caregiver who supports physically firmly; (3) to recognize the need for the other's body; (4) not creating a feeling of abandonment; (5) to keep the environment safe, stable and predictable⁽¹⁵⁾. In this sense, we emphasize that the role of the therapist/speech-language therapist is also fundamental in therapeutic listening.

This setting promoted by the dog showed positive effects on the evolution of the clinical picture, as M. started to face the challenges and difficulties with commitment. She started to establish clear limits so that people would no longer make fun of her stuttering, stating that this was one of the results of the process: expressing dissatisfaction in the relationships that she considers abusive. Thus, there is a possibility to affirm that M. can gradually establish the psycho-soma connection, becoming a more integrated person in her biopsychic aspects.

FINAL COMMENTS

This clinical case study shows that the setting of the dog's presence and interaction favored the reduction of the stuttering symptom, promoting a welcoming environment allowing the individual's psycho-soma integration.

ACKNOWLEDGEMENTS

Nothing to declare.

• Study conducted at Faculdade de Medicina, Universidade de São Paulo – USP - São Paulo (SP), Brasil.
• Financial support: CNPq (142207/2016-0).

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Publication Dates

• Publication in this collection
  05 May 2021
• Date of issue
  2021

History

• Received
  12 Dec 2019
• Accepted
  06 May 2020