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Psychology in Russia: State of the Art Volume 7, Issue 3, 2014
Russian Psychological Society
Lomonosov Moscow State University
Lev Vygotsky's ideas in family group logopsychotherapy
Nataliya L. Karpova
Psychological Institute of the Russian Academy of Education, Moscow, Russia
Corresponding author. E-mail: nlkarpova@mail.ru
According to Lev Vygotsky's theory, every bodily deficiency not only changes a person's attitude to the world but also entails social consequences, which makes its social and psychological rehabilitation so important. The way in which problems of deformity compensation and supercompensation are solved, is largely determined by a patient's motivation. The paper deals with stuttering (logoneurosis) as an extreme form of broken communication; it analyses the peculiarities of stutteres and their families, and the specific features of treating this defect; it also dwells on issues involving family co-participation in social rehabilitation. The multilayered system of family group logo psychotherapy - treatment of stuttering children, teenagers and adults - is based on Yu.B. Nekrasova's method of group logopsychotherapy. It also employs non-traditional techniques: Nekrasova's dynamic psycho-therapeutic diagnostics and biblio-, kinesi-, symbol-, video- and cinema therapies.
This system may serve as a model for forming motivational involvement and in-tragenic activity by patients and their relatives in social rehabilitation processes. The paper describes the levels and psychological structure of motivational involvement and mechanisms of its formation in logopsychotherapeutic processes. Motivational involvement is understood as a source of a subject's intragenic (inner) activity, the paper maps out strategies to form intragenic activity. The family group logopsychotherapeutic techniques may also help optimize communication between parent and child, doctor and patient, teacher and pupil, professor and student.
Keywords: logoneurosis, motivation, social rehabilitation, family group logopsychother-apy, supercompensation
Introduction
Lev Vygotsky noted that every physical deformity not only changes a person's attitude to the world but also has social consequences, which makes its social and psychological rehabilitation so important. 2.5-3.5% of the world's population suffers from speech disorders in the form of stuttering (logoneurosis). In most cases, stuttering leads to development of personality changes in a patient which makes the problem not only a medical issue, but also a psychological and social one.
ISSN 2074-6857 (Print) / ISSN 2307-2202 (Online) © Lomonosov Moscow State University, 2014 © Russian Psychological Society, 2014 doi: 10.11621/pir.2014.0308 http://psychologyinrussia.com
From the early 1960s Yulia Nekrasova, as a speech therapist and later on as a psychologist, began to elaborate a technique of group logopsychotherapy for stuttering adolescents and adults aged 14-40 on the basis of the emotional and stress therapy by Doctor K.M. Dubrovsky, who used a suffering person's internal psychological resources.
In addressing the problem of broken speech communication through organization of intensive multifaceted speech communication we base ourselves on Vy-gotsky's theory of supercompensation as the highest degree of compensating an individual's physical, psychological and personal deficiencies. It is a "paradoxic organic process which transforms disease into super-health, weakness into strength, poisoning into immunity.. vaccination of super health through disease, rising to a new height through overcoming dangers (Vygotsky, 1983, V.5, pp. 34-35).
Since the late 1980s we have been developing Nekrasova's technique in the direction of family group logopsychotherapy for stutterers aged 7-45. Alongside with patients every stage of social rehabilitation actively involves their parents and relatives who creatively acquire the biblio-, kinezy-, and art therapies. It corresponds to Vygotsky s idea that children with various health problems should not be brought up and taught solely in specialized institutions. An isolated environment only sharpens a child's focus on its deficiency and generates certain character traits that are bound to hamper its adaptation in an open social medium (ibid., p. 41).
Stuttering and stutteres
We understand stuttering as an extreme form of broken communication. Patients who come to us for treatment, can be described as individuals with a highly sensitive attitude towards the issues of communication and recovery, acute emotional suffering from their stutter and, as a result of it, they all display a high level of dissatisfaction with their self-actualization. Many of them blame their failures on their stutter (speech impediment) which only serves to emphasize the psychological aspect of stuttering.
The main psychological mechanism of stuttering is inability to change one's pathological psychic state in a speech communication situation. This pathological state includes the following three complex processes: firstly, a patient can hear his defective speech, secondly, he feels his muscular tension, and, thirdly, he sees himself as a failure through the eyes of people around him. As a result, the patient deprives himself of the opportunity to freely change his psychic state. An analysis of stutterers' self-reports about their perception of the disease showed them to resort to an iceberg metaphor, where speech is the tip of the iceberg, whereas the greater part of it, i.e. a stuttering individual's problems, remains hidden under the water (Nekrasova, 1992, 2006). With time these impediments come to be supported by their close family circle as they parents and relations tend only to exacerbate it.
A study by Polish psychologist B. Adamchyk suggests that a mere 10% of stutterers have a strong motivation for recovery and willingness to exert much effort during their treatment. Most patients rapidly discontinue their speech therapy lessons, and with time put up with their handicap, or tend to shift the burden of their own personal problems which they see related to their speech impediment, onto
their doctor's shoulder. As British psychotherapists L.Rustin and A. Kurn (ХХП World Congress, 1992) suggest in their study, some stutterers are convinced of their unresponsiveness to treatment while others use their speech impediment both for defense and offense to hurt others. While emphasizing the need to be constantly cognizant of a patient's true goal, Rustin and Kurn say that a stutterer wants his therapist to exhibit affection, consideration, understanding, confidentiality, and even expects their doctor to accept his problems as one's own. But the latter is only supposed to provide aid and support instead of making decisions on his patient's behalf.
The above specific features of this particular patient category point to the fact that before embarking upon a course of active treatment it is necessary to create in patients and his relatives a strong motivation for achieving success in an effort to overcome the deficiency, in other words, they should be brought to reconsider their attitude toward their impediment, treatment and self-awareness in the process to secure as much inclusion as possible.
First and foremost, speech disorders in logoneurosis manifest themselves in communication situations of great importance to the patient and in the majority of cases lead to profound personality changes. Research into the motivational aspect of logoneurosis suggests antagonism between a stutterer's level of aspiration and his adaptive capabilities, which leads to the justification of his low in-group and in-family status, since all his life problems get focused on his speech impairment.
Family members' participation in social rehabilitation
In viewing the social rehabilitation process as a whole it is necessary not only to rehabilitate a patient himself but also to include his immediate environment, i.e. his parents and relatives, in this process. To increase the effectiveness of a social rehabilitation process among stuttering patients we analyzed their interfamilial relationships and identified a number of the personality peculiarities and speech behaviors of the patients' parents; we singled out some of their characteristic features that support or aggravate their stuttering and we also analyzed the degree of their interest in the results of the treatment.
Many years of practice in speech neurosis therapy have shown that:
a) Disharmony in family relations (between parents and children, husband and wife, etc.), which has been normally left out of consideration, serves only to further aggravate the speech deficiency and a patient's subjective perception of it;
b) If allowed to go unchanged, the pathological nature of the family relations proves to be a brake on the remediation process during therapeutic group classes;
c) Completion of the treatment course is likely to trigger off a relapse of stuttering.
It is the profound motivational personality inclusion of both sides (patient and family members) in the ongoing therapy that constitutes a sine qua non condition for overcoming logoneurosis as a systemic disorder not only in speech but also in interpersonal communication.
System of family group logopsychotherapy
The system of family group logopsychotherapy consists of four stages: a propaedeutic one, a séance of emotion-stress psychotherapy, active family group logopsychotherapy and control supportive logopsychotherapy.
Stage I (propaedeutics) lasts at least six months and is built on dynamic psychotherapy diagnostics based on the bibliotherapeutic method. This type of non-traditional diagnostics was elaborated by Nekrasova to treat stutterers. But in our family group logopsychotherapy both patients and their close relatives read texts of fiction and make written comments about them. In his book The Psychology of Art Vygotsky analysed catharsis as a special personality effect produced by a work of art. We make use of this effect by offering patients and their families for reading specially selected books including those by Hans Christian Andersen, Anton Chekhov, Ivan Turgenev, Bernard Shaw, Alan Marshal, Ray Bradbury, Richard Bach, etc. Bibliotherapy is used in combination with specially selected psychological tests and questionnaires.
Traditional methods: Tests (Rosenzweig, Wesman-Ricks, Taylor, Kelly et al.) aimed at identifying such personality features as anxiety, aggressiveness, reactivity, ways of coping with critical situations, etc; questionnaires (self characterization, leadership qualities, speech diary, etc.) and picture tests that give us a most complete and comprehensive idea about the patient.
The tests were carried out in writing, which was not traumatic to our patients with speech communication disorders. Another feature of this diagnostics was carried out "at a distance", in the absence of a psychotherapist as many of our patients come from far away places. The tests are structured in the ascending order of psychological complexity. This fact, however, remains unnoticed by the participants as it enhances their motivational involvement in the unusual therapeutic process.
To identify interfamilial relations and motivation for communication and recovery we also used the Orlov and Thomas tests and specially designed tests and questionnaires and the essay My Family and I. This data was compared with that obtained in the bibliotherapy. This diagnostics was aimed not only to identify The Internal Picture of Health, (Nekrasova, 1992) but also to compose The Family Portrait.
Treatment Stage II is based on K.Dubrovsky's method of emotional stress psychotherapy aimed at "removing stuttering" within 1-1.5 hours. It is both individual and group hypnosis directed at a group of stuttering patients. The séance is conducted on stage in a frustrating situation in front of an audience. The psy-chotherapeutic encyclopedia edited by Karvasarsky (St Petersburg, 2000) describes this séance as "Dubrovsky's directive group impact in an awaken state". Our séance employs all the materials of the propaedeutic stage.
Treatment Stage III is active group family logopsychotherapy. Classes are conducted with patients involving active participation by their parents and relatives on a daily basis for a period of 1.5 months. We call this therapy intensive because its daily classes last 7-8 hours.
Vygotsky's idea about the zone of proximal development in child upbringing and education and the role of a teacher (an adult), without whose help the child will be unable to cope with new tasks and learn new skills, has also been implemented in
Nekrasova's logopsychotherapeutic system. Here the stuttering-removal session is followed by learning a new, hitherto unknown pleophonic speech style which is impossible to master without the help of a professional - a team leader.
This stage also employs non-traditional treatment methods in group form:
Bibliotherapy is a method of treatment through guided reading. This technique is designed to perform a dual function of psychotherapy and diagnostics. It makes it possible to reveal each patient's uniqueness, and get a portrait of his personality not shaded by his disability.
Kinesitherapy is a method of treatment by movement. It is designed to produce an effect on the patient's condition and personality through working with his body. It is also called dynamic relaxation. One of speech psychotherapeutic techniques, kinesitherapy employs paradoxical respiratory gymnastics elaborated by the Strelnikov mother and daughter, Günther Ammon's humanely-structured dance therapy and special speech and movement exercises.
Symbol therapy is a method which uses healing symbols for treatment. It is a process of group communication via healing symbols, created by patients themselves Defining art as "a social technology of feeling" Vygotsky emphasized that it was created by society in order to influence an individual's emotional sphere through inherently specific "tools". He introduced the concept of "an aesthetic sign" as a cultural element. Unlike animals, humans see sign systems as a means of cultural development of their psyche, and among human psychic functions the sign-mediated one has the highest level of organization. Based on Vygotsky's thesis we can explain the fact that in her system of logopsychotherapy Nekrasova has made a great use of the symbol therapeutic method.
Cinema therapy employs the therapeutic potential of specially selected films (for more see below). Active use of film and video recordings and broad employment of these techniques in our groups allow us to speak about developing a new cinema therapeutic method as well as its diagnostic capabilities.
These non-traditional methods of overcoming disordered speech communication enable patients to realize their hypercompensation potential according to Adler's and Vygotsky's theories. Individual and group biblio-, kinesi-, symbol-, video-, and cinema therapies are also used for fixating and developing patients' artistic potential. The work results not only in the restoration of normal speech but also in the formation of good communication abilities and skills.
Treatment stage IV is a control and supportive logopsychotherapy provided six months after the main treatment course, it lasts two weeks and repeats, on an new higher level, the chief elements, techniques and methods of the group family speech psychotherapy. It also features traditional diagnostics (tests, individual and group reflection, etc.) and non-traditional diagnostic methods including biblio-, kinesi-, symbol, video- and cinema therapies in group form.
Motivational inclusion of stutterers and their relatives in social rehabilitation
The main issue in social rehabilitation, as Vygotsky points out, is motivation. In his Thought and Language (1934) he emphasized the importance of studying motives that drive thought and those motives and emotions without which thought
cannot occur or evolve. Addressing the problem of effectively overcoming disordered verbal communication we examined motivational inclusion of stutterers and their families in all type of complex multidimensional social rehabilitation activities.
Practice shows the effectiveness of any personality transformations, be it in learning, training or remedial re-education (psychological correction or therapy), depends not so much on a student's, or client's or patient's IQ level, culture, or extent of the disease, and even not so much on the level of their abilities as on how much emotionally, intellectually and personally he is active and involved in the process.
In our study of the problem we arrived at a concept of motivational involvement in activity. We define motivational involvement as a special psychic state which characterizes a person's involvement in the process of an activity.
Motivational involvement consists of four components: a) the degree of one's awareness of a motive; b) the force and sustainability of this motive; c) a person's actions to realize the motive; d) the emotional aspect of the motive. There are four levels of motivational involvement.
Table I shows levels and psychological structure of motivational involvement in the process of social rehabilitation (Karpova, 1998, 2003).
Table 1. Levels and psychological structure of motivational involvement in the process of social rehabilitation
Psychological structure
Degree of Strength and Actions to realize Emotional aspect
lu > awareness stability of motive motive of motive
of motive
I Non-awareness Amorphous Absence of actions Positive, weak,
dissatisfaction and unstable,
desire for change short-lived,
field-dependent
II Partial Unstable motivation Situational activity to Positive, unstable,
awareness for change realize motive longer-lasting,
field-dependent
III Clear awareness Sustainable motive Active steps to Positive, stable,
for change realize motive both long-lasting,
as part of specially field-dependent
organized activity and
independently
IV Clear and full Motive turns into a Active actions directed Positive, strong,
awareness compelling need for at realizing the motive stable, long lasting,
change both in the framework field-independent
of specially arranged
activities and beyond it
The motivational involvement of the participants in the family logopsychotherapeutic groups was studied using a method of expert evaluations and Karpova's own method of motivational involvement assessment: the participants were to assess the level of their own motivational inclusion at each stage of social rehabilitation by using graphs where the vertical axis marked levels of motivational inclusion (0 - 4), and the horizontal one measured time (micro - and macro-) it took to pass each of the four stages.
Table 2 provides comparative results of a study we conducted among patients and their relatives at the propaedeutic stage of social rehabilitation (This study was carried out in groups of family logopsychotherapy in 1993-1997. The results and description of the methods used have been presented and published in the Doctor's thesis (Karpova, 1997, 1998, 2003)).
Table 2. Comparative results of patients' and their relatives' involvement in propaedeutic stage
Number of patients: 66 Involvement Parents and relatives: 64 families Involvement
HIGH High 30 (45.5%)
45 people (68.2%) Medium 10 (l5.2%)
Low 2 (3.0%)
N/A 3 (4.5%) 2 of them from orphanages
MEDIUM High 5 (7.6%)
18 people (27.3%) Medium 7 (10.7%)
Low 3 (4.5%)
N/A 3 (4.5%)
LOW High 0 (0%)
3 people (4.5%) Medium 1 (1.5%)
Llow 1 (1.5%)
N/A 1 (1.5%)
High involvement indicates fulfillment of all or more than 50 % of the tasks given. As can be seen in Table 2, over 70% of the patients registered high motivational involvement. All of them overcame their impediment with best results. Importantly enough, only 30-40% of the patients have stable results, however, all of them also demonstrated high motivational involvement at every stage of social rehabilitation.
Mechanisms of forming motivational involvement in social rehabilitation
Our continuous efforts to investigate and understand how patients and members of their close circle form high motivational involvement in a social rehabilitation process have made it possible to single out and describe some psychological mechanisms for formation of motivational involvement in a speech psychotherapeutic process.
1) A co-participation mechanism. We examined the specifics of this mechanism at different stages of social rehabilitation and demonstrated ways of creating "a co-participation environment", enabling each participant to attain a high motivational involvement and to concentrate their efforts on self-improvement. A.S. Makarenko was a master at creating such "a co-participation environment".
2) Adequacy Mechanism. A mechanism of adequate attitude towards one's impairment (shortcomings). The problem of a person's attitude toward one's impediment was analyzed from the point of view of motivational inclusiveness formation based on child-parent relations in stutterers' families. This is a most fundamental issue and is traditionally examined by psychologists as a level of aspiration and self-estimation, inadequacy affect and, in broader terms, at a level of self-concept formation. In social rehabilitation the formation of an adequate attitude helps attain a high level of self-rehabilitation.
3) Mechanism of forming an aspiration for "an ideal ego". We have identified it based on the A.Bodalev's thesis about the potentials difference between "the ideal" and " the casual" egos. If he lives his life at his "casual ego" level a person leaves much of his potential untapped. During his treatment the patient overcomes his "casual ego" and seeks to attain an ideal "super-ego" devoid of his handicap.
4) Mechanism of embodying one's goals in an ideal image. As a regulator of a state, the role of an image in an activity has been investigated in psychology by D.A. Oshanin, N.D. Zavalova, V.A. Ponomarenko et al. Family group speech psychotherapy singles out three main functions of an ideal image: a) an image as a regulator of a state; b) an image as "an initiator" of development; c) an image as a factor creating a common "semantic field" both for patients and their relatives. The propaedeutic stage creates a special imagerial world in patients by using main characters from bibliotherapeutic books and thus promoting their speech and communicative progress. The patients traverse a path from Andersen's Ugly Duckling to R. Bach's Jonathan Livingston Seagull.
Problems of intragenic activity
We consider motivational involvement to be a source of a person's intragenic (inner) activity. The analysis of motivational involvement as a "tiny cell" of intragenic activity has shown ways of forming a common semantic field for patients and their relatives as a major direction in the formation of motivational involvement in the social rehabilitation process. Our research team has determined several types of intragenic activity enabling it to propose a general classification of the strategies for its formation in patients. Three strategy types have been singled out: 1 — semantic, 2 — psychotherapeutic, 3 — specific methodological.
On social rehabilitation in general
After one of her visits to our group the famous theatre critic and theatrologist N. Krymova said: You have a theatre, too, but it's a special one. Here dramatics, stage direction and acting occur simultaneously". We highly appreciate the Master's concise and precise definition.
Similarly to using specially selected books in bibliotherapy we tap the therapeutic potential of specially selected films. In the first place, they are scientific documentaries describing our method: Human Abilities Unlimited (1986), directed by A. Shuvikov, and Human Abilities Unlimited - 2, or 15 Years Later (2001), directed by A. Shuvikov. The first film received a Grand Prix at a documentary film festival in Polezo (France) in 1987.
Today we are very happy to use the wonderful film The King's Speech (2010), directed by Tom Hooper. This film is also based on real facts and may serve as a good illustration of Vygotsky's theory of social rehabilitation and hypercompensa-tion. Albert, Duke of York, suffered from a grave form of stuttering. With the help of a former actor called Lionel Logue and his paradoxical methods the Duke overcame his stutter. Another important thing is that Albert's wife took an active part in his recovery. When he became King George VI, he made great public speeches. This is a good example of hypercompensatoin. Logue's methods seem very similar to ours.
We have worked with more than 70 groups of family speech psychotherapy in different cities from Moscow, Taganrog, and Samara to Vladivostok and the results have borne out the effectiveness of this system of social rehabilitation. These methods of family logopsychotherapy are not only beneficial in extreme cases of communication disorders of the stuttering type, they also serve as a model for optimizing effective communication between parent and child, doctor and patient, teacher and pupil, professor and student.
While considering stuttering as a model of a systemic disorder in speech communication we also regard the process of social rehabilitation of patients with this handicap as a model of restoring full-fledged dialog communication, a model for transforming an ailing, unsteady, communicatively limited personality into a healthy, sociable, stress-resistant and socially active one.
Conclusion
In conclusion, as emphasized by every scholar who studies Lev Vygotsky's works, none of the world's eminent psychologists has been able to enrich his science in a more profound and versatile way than Vygotsky did in his short 37 year long life. And we would like to thank the organizers of this wonderful International Conference, which has for many years been bringing together scientists from different countries, and thus preserving and enhancing the memory of our illustrious compatriot whose scientific discoveries are now an integral part of the world heritage.
References
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Original manuscript received June 11, 2014 Revised manuscript accepted August 28, 2014 First published online September 30, 2014
