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Using a grounded theory approach, four clusters were identified that represent patterns of coping by adults who stutter. In order to understand the complexities within the coping responses of speakers to the experience of stuttering, this first of two companion papers summarizes the literature on the human coping response to stress and the nature of two of the four main findings identified. These findings describe a coping process that emphasizes strategies of protecting both the speaker and the listener from experiencing discomfort associated with stuttering. The companion paper describes the remaining two main findings that emphasize the characteristics of self-focused and action oriented coping responses. Educational Objectives: The reader will be able to: (1) describe, from the perspective of a select group of adults who stutter, the themes associated with the process of coping with stuttering, (2) describe the basic rationale for the procedures associated with grounded theory methods, (3) describe the factors that influence the choice to use emotion-focused and problem-focused coping strategies, and (4) explain the factors that contribute to the use of methods of escape.

The literature describing therapeutic change for adults who stutter indicates that chronic stuttering is not likely to be eradicated but rather is managed or coped with to varying degrees. Some speakers manage the problem presented by their stuttering extremely well both with and without formal therapeutic experiences (Anderson and Felsenfeld, 2003, Finn, 1996 and Plexico et al., 2005). Some speakers are able to achieve mainstream, and in some instances, exceptional levels of fluency and communicative facility (Chmela et al., 1998, Daly et al., 1996, Hillis and Manning, 1996, Hood, 1998 and St. Louis, 2001). Other individuals are less adept at coping with their situation and continue to demonstrate obvious and often effortful stuttering as well as patterns of helplessness, hopelessness, shame, fear and avoidance (Corcoran and Stewart, 1998, Daniels et al., 2006 and Plexico et al., 2005). Numerous investigators have described the profoundly negative and restrictive impact of stuttering on person's lives prior to or at the outset of treatment (e.g., Crichton-Smith, 2002 and Corcoran and Stewart, 1998). In spite of the many detrimental consequences presented by stuttering, relatively few adolescents and adults who stutter seek treatment and many of those who initiate treatment drop out (Hearne et al., 2008 and Manning, 2006, chap. 9). For those who continue with therapy, some respond better than others regardless of the treatment protocol (Franken et al., 1992 and Huinck and Peters, 2004). The literature on models of human coping can provide insight into the variability of speakers in responding to the stressful circumstances presented by stuttering. 1.1. The process of coping Although there are several models and descriptions of the human coping response, there is some consensus regarding many of the fundamental concepts and essential features of this process (Carpenter, 1992). For example, the result of cognitive, affective or behavioral responses to exceptional demands or events that are perceived as harmful is often conceived of as stress. Lazarus and Folkman (1984) define stress as “a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” (p. 19). Whether or not a particular person–environment relationship will be judged as stressful is dependent on how the relationship is appraised and the coping resources available to the individual. Appraisal refers to the process of making a judgment about whether or not a particular encounter will significantly influence one's well-being. The process of coping is defined as “constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person” ( Lazarus & Folkman, 1984, p. 141). Accordingly, coping responses are likely to change over time to include responses that occur in anticipation of the stressor or as a result of the stressor. An important feature of this description is that coping is independent of outcome. That is, the process of coping is not dependent on the success or failure of the individual's response to the stressor. 1.2. The contextual model of coping One current way of conceptualizing the relationship between stress, appraisal and coping is the contextual model (Lazarus & Folkman, 1984). In contrast to models which view coping as an unconscious process or a stable trait of an individual's personality (e.g., the ego-psychological and trait/dispositional models; see Byrne, 1964, Haan, 1969, Menninger, 1963, Miller, 1987 and Valliant, 1977), the contextual model views the coping process in terms of how an individual actively engages in the management of a stressful situation (Folkman, 1992). Initially, the individual appraises the person–environment relationship, including both a primary appraisal of the personal significance of the stressful situation and a secondary appraisal of possible coping options (Folkman and Lazarus, 1990 and Lazarus and Folkman, 1984). Appraisal of the person–environment relationship is influenced by precursors such as a person's pattern of motivation, beliefs about himself or herself and the world, and recognition of personal resources. The variability observed among individual appraisals could be explained by individual differences in personal factors, which explains how something that is perceived as threatening by one person can be perceived with neutrality by another (Folkman & Lazarus, 1990). Environmental or situational factors such as the nature of the stressor, its proximity, its ambiguity and duration, and the existence of social support are likely to influence the appraisal process (Lazarus & Folkman, 1984). Within the contextual model, coping is viewed as having two functions. Problem-focused coping involves any effort to remove or reduce the impact of a threatening event, a response that is frequently employed in situations where an individual feels that something constructive can be done about a stressful situation ( Carver and Scheier, 1994, Carver et al., 1989 and Folkman, 1992). Problem-focused coping strategies can include but are not limited to defining the problem, generating alternative solutions, weighing alternatives in terms of cost and benefit, choosing among multiple solutions, and agentic behavior (i.e., thinking or acting differently than before; Van Inwagen, 1983). In order to reduce any negative emotions associated with the threatening event the individual may also employ emotion-focused coping. Emotion-focused coping is more likely to be used when individuals believe that they must endure a stressor ( Carver and Scheier, 1994, Carver et al., 1989 and Folkman, 1992). Emotion-focused coping strategies could include but are not limited to avoidance, minimization, distancing, selective attention, positive comparisons, and finding positive value in negative events ( Lazarus & Folkman, 1984). Using the contextual model, Folkman (1992) described two types of “fit” that should be considered when evaluating the effectiveness of a coping strategy. The first type of fit is between the reality of a situation and a person's appraisal of a situation. This relationship refers to the degree to which what is actually occurring corresponds to an individual's appraisal of the personal significance of a situation and his or her resources. For example, if individuals are overly pessimistic about their coping ability, coping efforts may be prematurely restricted. However, an overly optimistic appraisal of coping resources could result in self-blame and disappointment when the outcome of a coping strategy does not meet expectations (Folkman, 1992). The second type of fit is the correspondence between the individual's appraisal of the stressor and the coping strategy's usefulness. Folkman (1992) indicated that this refers to the degree with which an individual's appraisal of controllability of the situation matches his or her actual ability to cope. 1.3. Coping with stuttering One study has been conducted that addressed coping with the stress of being a person who stutters and it focused on the behavioral response to the problem. Vanryckeghem, Brutten, Uddin, and Van Borsel (2004) used a behavioral checklist to assess the types of speech associated coping (secondary) behaviors used by 42 adults who stuttered and 76 fluent adults in the presence or anticipation of a disfluency. The participants ranged from 17 to 50 yrs of age, and the adults who stuttered were receiving therapy at the time of the study. Vanryckeghem et al., construed coping as learned, behavioral responses that occur “secondary to the anticipation or occurrence of stuttering rather than a constituent of it” (p. 239). Using the Behavior Checklist ( Brutten & vanryckeghem, 2003) Vanryckeghem et al. (2004) found that individuals who stuttered indicated a significantly greater number of coping responses than their nonstuttering peers. The behavioral responses that differentiated the two groups were related primarily to general body movements (e.g., finger tapping and leg movements) and manner of speaking (e.g., using starter phrases and pretending not to know the answer to a question). Interpreting the human coping response within (only) a behavioral domain would seem to limit our comprehension of the coping process. Because coping behaviors are variable among individuals, even in the presence of the same stressor, it may not be useful to identify specific behaviors. Carpenter (1992) argues that highlighting only specific coping behaviors risks emphasizing only the idiosyncratic nature of coping, preventing any meaningful insight about the function of the coping behaviors. In addition, Carpenter suggests that it is likely that a particular coping behavior could have multiple functions. For example, avoidance behaviors may be utilized to escape from stuttering and/or to eliminate the possibility of embarrassment. It is well documented that there is considerably greater depth to the stuttering experience than the obvious surface behaviors (e.g. Manning, 2001, Sheehan and Martyn, 1970, Smith, 1999, Smith and Kelly, 1997 and Starkweather and Givens-Ackerman, 1997). For that reason, when evaluating the nature of an individual's coping response, emphasis should also be placed on the process and the quality of the coping strategy. The effectiveness of a coping strategy would be determined by considering whether or not the coping strategy is appropriate for meeting the demands of a specific situation. Currently, the self-derived coping responses acknowledged in the stuttering literature are often portrayed as maladaptive learned responses to the stuttering experience. It may be that the coping responses of people who stutter (if not always desirable) are natural and normal responses to the many forms of stress presented by stuttering ( Manning, 2001 and Manning and Dilollo, 2007). The literature suggests that successful coping and adjustment are characterized by the ability of the individual to take an active role in shaping one's life, acknowledging personal accomplishments, managing negative life experiences in a successful way, changing the environment to reduce limitations, and taking part in valued activities (Dembo, Leviton, & Wright, 1956, as cited in Livneh & Antonak, 1997). DeLoach and Greer (1981) added that adjustment is predicated on self-acceptance, responsible behavior, appropriate social techniques, and the use of successful coping strategies. Less successful adjustment is characterized by the inability to resolve or find functional or efficient ways to adjust to one's problems in living (Roessler and Bolton, 1978). The primary purpose of this study is to understand and describe the ways in which people who stutter cope more or less successfully with their situation and the impact of various coping responses. Our interest in coping centers around the idea that some ways of coping with a stressor like stuttering may be more effective or beneficial than others in terms of promoting emotional well-being and in terms of adjusting or modifying both the cognitive as well as the behavioral features of the problem. By evaluating coping responses and strategies it may become possible to understand why some people who stutter adjust better than others when faced with the stress of stuttering and the influence stuttering has on their lives. In order to develop a model of coping and a better understanding of the complexities within the coping responses of people who stutter, a qualitative methodology was selected as the most appropriate approach for this investigation. A qualitative analysis of the experience of coping with stuttering is an appropriate first step. It is appropriate because of the paucity of empirical literature evaluating the phenomenon of interest, the nature of coping for people who stutter, and the strengths of qualitative research in developing novel understandings of complex phenomena. The specific goals of this study were to: (1) develop an understanding of what people who stutter actually think or do to cope with stuttering, (2) develop an understanding of how the underlying meaning systems of people who stutter give coherence to the coping strategies being used, (3) develop a perspective on the functions that the coping strategies serve, and (4) develop a perspective on the impact that coping choices have on the lives of people who stutter.