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The role of role avoidance

BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7341.857 (Published 06 April 2002) Cite this as: BMJ 2002;324:857
  1. Paul Reynolds, general practitioner.
  1. Hanwell, West London

    I've only recently heard of the term “role avoidance.” Looking back I realise that it's a strategy I've been using for a long time but one which has remained nameless until now. Perhaps I should explain. I am a doctor who stammers and have just embarked on a course at the City Literary Institute in London in what is called “block modification.” Those of you who are familiar with stammering therapy will know what this entails. For those of you who aren't, it is based on the work of a number of American speech pathologists, including Charles Van Riper and Joseph Sheehan, and basically comprises three stages—identification, desensitisation, and modification.

    The identification stage involves looking at both the overt and covert aspects of stammering, and the “iceberg model” described by Joseph Sheehan is useful for this purpose. Just visible above the waterline are the overt aspects of the stammer—the outward struggle, as it were. However, below the waterline lurks the often much larger covert component—the feelings of anger, resentment, frustration, and poor self image. It is these that result in avoidance strategies to lessen the discomfort associated with speaking situations, and right at the top of the hierarchy of avoidance is role avoidance. Although something of an abstract concept, the essence of role avoidance is the use of tricks or techniques to achieve fluency and thereby avoid taking the role of a stammerer, which as a doctor would be unacceptable.


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    From the moment I entered medical school and throughout my career it has been apparent to me that medicine favours outwardly “flawless” individuals. The embarrassed looks of the panel as I struggled my way through medical school interviews. The nervous laughs of my colleagues as I did presentations. The “do something about your speech” comment from the surgical senior house officer when all I wanted was an opinion on a patient. And perhaps most galling of all, being turned down for a GP rotation at a hospital at which I had worked previously and from which I had good references, just because I stammered. All these experiences fostered in me the belief that somehow I wasn't a “proper” doctor, that it would be far easier to avoid being a stammerer at all.

    To do this I've created a doctor persona—authoritative, knowledgeable, perhaps slightly brusque even, and usually avoiding eye contact for fear of seeing a reaction in my listener. In this role I can be considerably more fluent than I normally am. I can't deny that this strategy has served me well in the short term. It has enabled me to function effectively as a doctor for several years despite having a stammer. So why change it, you may ask?

    Well, I believe that block modification therapy is only going to be truly successful if I can disassemble my role avoidance strategy and be more open and honest about the fact that I stammer. This is the difficult part—old habits die hard. Coupled with this is a need to work on some of my beliefs, and I have made some headway already in this respect. Attending a self advocacy course for people who stammer at the City Lit last year and more recently going to the British Stammering Association's annual conference in Liverpool have both had a profound impact. Meeting other stammerers who are both eloquent and intelligent, and listening to their often inspirational stories, has filled me with the sense that I can be an excellent doctor who, by the way, just happens to stammer.

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