management for adults with stuttering.pdf / kunnampallil gejo

KUNNAMPALLIL GEJO JOHN, MASLP

MANAGEMENT FOR ADULTS WITH STUTTERING

Introduction

Treatment for adolescents was recognized long before; in 1971 Van Riper commented

that adolescents are often the most difficult cases to treat. In 1995 Daly, Simon, and

Burnett-Stolnack suggested that this age group is particularly challenging, because

adolescent years are typically characterized by emotional conflicts, fears, and frustrations

that interact with the anxieties and negative feelings associated with stuttering.

Blood (1995) noted that the extensive treatment some adolescents experienced during

elementary school tends to reduce their motivation to continue working on the problem.

The 1997 survey of 287 school-based clinicians by Brisk, Healey, and Hux found that

school based clinicians felt that they had fewer successes with adolescents who stutter

than with any other student age group.

Finally, manning (1991) expressed the view that any clinician who is able to convince a

teenage speaker who stutters to enroll in treatment should probably receives a large

bonus. The main idea is that achieving success with this population requires

understanding at least as much about adolescence than it does about treating stuttering.

Relatively few adolescents are motivated enough to initiate and continue with treatment.

On the other hand, the handicap associated with stuttering sometimes becomes greater in

junior high/middle school as a result of academic and social pressures. Avoidance and

substitution often become more frequent during the early teenage years. Following

several years of adaptation to the handicap, the deep structure of the disorder- the

cognitive and affective feature- become further refined and sophisticated. This will be the

time to initiate treatment.

Treatment is more likely to be successful for adolescents if they are able to locate a

clinician who specializes in stuttering. Many people who stutter find that many things,

including fluency, improve considerably as they get older (Manning & Shirley, 1981).


Therapy for teenagers and adults is organized in terms of work in four areas of activity

according to Hugo H. Gregory 2003

1. Getting insight into attitude (thoughts and feelings) about stuttering- neglect

listener‟s reaction to his/her speech

2. Increasing awareness of muscular tension through the use of relaxation exercises

3. Speech analysis and modification- client himself/herself doing and mainly talk

about transferring level

4. Building new speech skills- use of variation in speech length, loudness, inflection,

rate, pause time, and so on

Objectives of therapy

Identifying Overt and Covert speech- with audio and video recording of

client‟s speech, he/she has to describe the stuttering like behaviors and

secondary behaviors

Negative practice- seen more in identification stage

More easy relaxed approach, smoother movement- cancellation is taught

Resisting time pressure (Delayed Response)

Voluntary Disfluencies and Voluntary Stuttering

Building Speech Skills and Increasing Flexibility

Choosing a treatment strategy

This is the first decision for the clinicians when initiating treatment. This has three

fundamental paths:

1). Fluency modification/shaping

2). Stuttering modification

3). Cognitive restructuring which is less commonly used.

1) Fluency shaping approaches tend to focus on the surface features of the syndromes.

That is, physical attributes of stuttering in terms of the normal or dysfunctional use of the

respiratory, phonatory, and articulatory systems are central to the treatment process. This

approach might be thought of as physical therapy for the speech production system. The


primary goal with this treatment strategy is to modify the surface features of the

syndrome and not (as Emerick, 1988, explains) to deal directly with such intrinsic

features as the client‟s cognitions about loss of control or attitudes of fear or anxiety

associated with stuttering. A basic assumption of the fluency-modification strategy is that

once the client has learned new ways of producing fluent speech, he will eventually

shows corresponding change in the cognitive and affective features of his problem.

Relatively little counseling in a traditional sense can take place. It‟s interesting to note, as

have others (McFarlane & Goldberg 1987; Ratner & Healey, 1999) that fluency shaping

approaches tend to be favored by clinicians with no personal history of stuttering.

Some specifics of fluency-modification strategies:

Bloodstein (1949, 1950) researched a variety of conditions where stuttering was reduced

or absent. He found that there were as many as 115 conditions that decreased stuttering

markedly. Such circumstances included activities such as speaking alone or during a

relaxed state; speaking in unison with others; talking to an animal or an infant or in time

to a rhythmic stimulus; singing; using a dialect; talking and simultaneously writing;

speaking during auditory masking, in a slow, prolonged manner under delayed auditory

feedback; and shadowing another speaker. Many of these fluency-producing activities

involve combinations of altered vocalization (Wingate, 1969) or enhancement of the

speaking rhythm (Van Riper, 1973). These treatments often results in more assertive

attitudes and a reduction of avoidance behavior as the speaker‟s fluency increases.

One of the best examples is the Precision Fluency Shaping Program (PESP) developed be

Webster (1975). Here stuttering is viewed as a physical phenomenon, little or no

discussion of emotional or affective features of the syndrome. Speaker should follow the

rules of speech mechanics, then his speech will be fluent otherwise it will not be fluent.

Here clients will be described with basic classes of sounds in English and the associated

vocal tract features associated with each sound. Clients are also taught with new classes

of sounds. Muscle movement targets related to respiration, phonation, and articulation are

provided to the client along with opportunity to practice the new movement skills.


2). Stuttering modification approaches, tend to be the treatment of choice by clinicians

who themselves have experienced stuttering. This strategy is, by nature, more cognitive

in nature in that the treatment requires the client not only to evaluate and change

behavioral characteristics, but to self-monitor and self-manage cognitive and attitudinal

features of the syndrome as well/ Informal counseling is some form is typically an

integral part of this approach.

Some specifics of stuttering-modification strategies:

This is also referred to as the traditional, VanRiperian, or nonavoidance approach. It‟s

based on the concept that a large part of the problem is the speaker‟s struggle, fear,

tension and avoidance of the core moment of stuttering. The primary goal involves the

reduction and management of fear and avoidance, typically via desensitization and

assertiveness training. This approach is more eclectic and counseling-based and requires

greater adjustment of the treatment to the individual clients.

Van Riper (1982) describe by taking the clients through the stages of

Identification,

Desensitization,

Variation,

Modification, and

Stabilization.

Identification- Identify both surface and intrinsic features of stuttering. With the

assistance of the clinician, client making a list of “things I do when I stutter” to identify

surface features of stuttering. These are the behaviors that can be observed in a mirror,

recorded, and identified on video and audiotapes. Another list, “things I do because I

stutter,” can include the less obvious, intrinsic features of the syndrome such as

avoidances, anxieties, feelings of fear and helplessness, and the decisions and choices the

speaker makes because of the possibility of stuttering. Thus identify the feature that

occurs frequently during treatment. (Ex- writing autobiography)


Desensitization- For both overt (surface) and covert (intrinsic) features of his stuttering.

This includes voluntary, intentional, or pseudostuttering. The clinician can often begin by

asking the client to follow her in producing easy one or two unit repetitions and brief 1-2

sec prolongations. In severe case one can include struggle behaviors and blocking of

airflow and voicing. Voluntary stuttering provides a way to break the link between the

experience of stuttering and being out of control.

Variation- Here the client is not asked to stop performing surface or secondary behavior

but rather to vary them in some preplanned manner. That is the client may select the

feature of producing a series of “ahs” prior to a feared word. Rather than attempting to

cease production of the „ah” as a postponement or timing device as he anticipates a feared

word, he could choose to systematically vary the rate, intensity, number, or vowel

segment.

Modification- Here the client is asked to begin varying some of his behaviors in even

more specific and appropriate ways. Here the goal is to replace the old, out of control

fluency breaks with a new, smoother utterance which he can completely control. But it‟s

not an easy process.

First step in this is often termed cancellation and has client approach the moment of

stuttering after the event. That is, the client is shown how to perform a post-event

modification of his stuttering. Immediately following a stuttered word, the speaker is

asked to stop and pause for approximately three seconds which serve as a mild form of

punishment for the speaker, since he can do longer continue communicating with the

listener. The client will be able to recognize the stuttering moment and consistently pause

following the event, he can now perform an analysis of his stuttered behavior.

Cancellation is usually done during reading, monologue, and conversation, both inside

and outside the treatment setting. The main purpose here is not to be fluent, but to replace

the old, automatic stuttering with a new form of fluent stuttering. This is usually difficult

to perform, particularly during the expectations and time pressure of real-life speaking

situations.


Second step, Para event modification, often called the pullout. Rather than waiting until

he makes it all the way through a stuttered word, the speaker will grab the word and

begin to “slide out of it” by enhancing his airflow, altering his vocal tract with

articulatory postures, and generally stuttering smoothly through the word. Clients find

that this technique is a natural progression from the cancellation technique and can begin

doing this spontaneously. This is less obvious than cancellation, and listener reactions

tend to be more favorable.

Final step, pre-event modification or preparatory set. This is intended to produce a

smooth form of easy stuttering. The speaker is preplanning, rather than reacting to, his

stuttering. The purpose is not to avoid stuttering and produce completely fluent speech.

Fluency-initiating gestures incorporated in fluency-shaping techniques like full breath, air

flow, gradual onset of constant phonation, and light articulatory contacts are helpful in

achieving a smooth preparatory set.

Stabilization- Newly learned modification skills are practiced under more stressful

conditions both within and outside of the treatment setting, with the goal of having the

speaker become resilient in response to stress and communicative pressure. Use of

delayed auditory feedback (DAF) or frequency altered feedback (FAF) can be used to

stabilize the behavior. Telephone calls, public speaking, and social introductions are

examples of particularly difficult speaking situations, which often need to be

systematically confronted. Most stabilization activities take place away from clinician

and treatment facility and will continue long after formal treatment is concluded.

3). Cognitive restructuring, here the intrinsic features of the syndrome become the major

focus of treatment. With this approach, relatively little effort is directed toward the direct

modification of surface behaviors and the speaking mechanism. The primary goal is to

change the way in which the client considers himself and his stuttering and how he

interprets the events of stuttering. By decreasing avoidance behavior and becoming more

assertive, the speaker is often able to make significant changes in the handicapping nature

of his stuttering. Rather than fighting his speech blocks, he may be asked to stutter more

openly. Although the frequency of stuttering moments will stay the same or even


increase, the quality of the fluency will improve. In addition, and most important, the

quality of the client‟s communication, as well as his lifestyle, will often change for the

better. Rational emotive behavioral therapy (REBT) (Ellis, 1977) may be the best known

of the cognitive psychotherapies (Emerick, 1988).

Each strategy dictates that the speaker systematically learns and practice techniques, first

within the treatment setting and then gradually outside the security of the clinic, in real-

world speaking situations.

St. Louis and Westbrook reports the results of a survey of 30 treatment intervention

studies that is published from 1980 through 1986. These authors found that the reported

treatment of choice for the majority of adults who stutter was a form of prolonged speech

or rate control procedure, both forms of fluency modification. Furthermore, same authors

pointed out that few of the authors of the studies listed activities such as the modification

of stuttering moments, client counseling, or desensitization (any systematic analysis and

subsequent self management of attitudes and speech behaviors) as a significant part of

treatment.

According to Emerick, the cognitive aspects of treatment involve at least four main

phases.

Phase 1 educating the client about the overall approach of the treatment.

Phase 2 involves having the client identify his self-defeating patterns of thinking

analyzing his thoughts before, during, and after speaking situations in general and

stuttering events in particular. The client can categorize his responses in terms of

dependency/helplessness (“I know I will relapse when therapy is over”), irresponsibility

(“I just cannot control my feelings”), dichotomizing (“There are good listeners and bad

listeners”), catastrophizing (“I know I will fall apart if I am asked to introduce myself”)

and fantasy (“Most of my problems would be solved if I didn‟t stutter”).

Phase 3 is one of reality testing. The clients‟ task is to evaluate his metal constructs by

asking:

-Does the construct deal with the reality of the situation?

-Does this construct make unreasonable demands on me?

-Does the construct help me accomplish the treatment goals?

Example-


“It is difficult to think of failing in a speaking situation while at the same time

concentrating on positive thoughts”.

Negative cognitions must become cues for the client tells himself, “Stop”. At this point,

the clinician can role-play for the client, alternating between the negative and positive

self-statements. This can be an ideal activity during group treatment sessions.

Phase 4 involves having the client substitute self-enhancing language for the traditional

negative thoughts.

Example-

“This may be a difficult situation, but I can deal with it”

One of the best examples of cognitive restructuring approach along with stuttering

modification approach is described by Maxwell (1982). He summarizes the program in

the following steps:

1. Information giving- client receives verbal preparation and instructions of the

treatment plan.

2. Cognitive appraisal- client summarizes in his own words the objectives and

methods of treatment plan.

3. Thought reversal- client begin to reduce and eliminate negative cognition. Here

client will be taught to tell himself “stop” when there is negative thinking of

speech in his mind. Initially say “stop” loudly later say silently.

4. Vicarious observation- once the client is able to experience some success at

disengaging negative cognitions, the clinician begins to model positive

cognitions.

5. Speech modification- the client begins to improve his information-processing,

decision-making, and problem-solving abilities. This comes as a initial stage of

behavioral change.

6. Identification- the client becomes proficient at identifying specific moments of

stuttering, beginning with ten-minute segments using short words and progressing

to reading and conversation.

7. Termination- this accomplish first following (as in a cancellation), then during (as

in a pullout), and finally before (as in a preparatory set) the stuttering moment.


8. Cognitive restructuring- the client is asked to restructure his thought in more

stressful extra-treatment speaking situations.

9. Coping skill

10. Self management- during this final stage of treatment, client becomes able to self-

manage without the assistance of the clinician.

As the field of fluency disorders continues to mature, there is the possibility that

clinicians are more likely to prefer a treatment approach that is eclectic, one that

incorporates elements from each of these three generic strategies according to the

capacities and needs of the clients.

The techniques used for the adult stutterers are:

a) Prolonged speech techniques:

Of the fluency management techniques prolonged speech techniques are the most

developed and researched. This technique involves the instatement, shaping

generalization and maintenance of fluent, prolonged speech. Initially, prolongations

referred to the slowing of speech by prolonging vowels. However, over the years the

terms prolonged speech has included combination of gentle onset of words, soft

articulatory contacts smooth transitions between sounds and exaggerated continuity of

speech. Goldiamond (1965) discovered that under DAF some stutterers used a prolonged

speech which reduced stuttering. Several modifications have been added to this by later

authors. The following are the prolonged speech techniques which have been developed

over two years.

1. Conversational rate control therapy and breath stream management therapy:

Curlee and Perkins (1969, 1973)

2. Intensive token economy therapy – Andrews and Ingham (1972)

3. Operant DAF therapy- Ryan (1974)

4. Precision fluency shaping program Webster (1974)

5. Prince Henry program :- Andrews Craig and Feyer (1983)


a). Conversation rate control and breath stream management therapy. The technique is

based on the fact that the duration of auditory feedback delay determines the rate of the

resulting speech. It involves consecutive acquisition of the following skill.

1. Show rate

2. Phrasing

3. Easy voice onset.

4. Soft contacts

5. Breathy voice

6. Blended words

7. Normal stress

Initially slow rate should be induced by DAF and gradually stutterers speech rate should

be increased to normal by stepwise decrease in feedback delay. At each stage, the

clinician should decide on the mastery of the skills by the stutterer.

b) Intensive taken economy therapy: - In this technique, initially slow rate is induced

using DAF. Stutterers have to speak at specific rates at each step of therapy. No DAF is

used during this stage. Penalties are provided for the stuttering and rewards for achieving

target speech rate and fluency. Transfer and maintenance are carried out in real life

situation.

c) Operant DAF therapy: - The program consists of several steps to teach the patient to

read, engage in monologue, and converse in slow, prolonged fluent pattern with the aid of

delayed auditory feedback apparatus. The first six steps are to teach the patient to

correctly identify stuttered words in reading and monologue. Criteria of one minute and

90% accuracy of identification are used in these stages. The next seven steps involve

reading and use DAF starting with 250 msec, of delay which is gradually reduced in 50

msec, steps until the patients can read in the prolonged fluent pattern without the DAF

equipment. The next seven steps are to use these in monologue and then the final seven

steps are the same except that these are in conversation.

The patient has to reach to a criterion of five minutes of fluency in each of the 21

steps to pass. Verbal reinforcement such as „good‟ are administered for the completion

of steps. The program also includes transfer of the technique.


d) Precision fluency shaping program: - The program is based on the premise that

stutterers‟ articulatory and phonatory gestures are disturbed and require reconstruction

through intensive over learning of appropriate speech targets. The skills to be achieved

are stretched syllables smooth transitions between syllables, slow change within syllable,

diaphragmatic breathing and gentle onsets. These skills are to be practiced first in simple

syllables and then in longer words and phrases. Prolongation is checked with a stop

watch and gentle onsets and continuity are acquired with the aid of feedback from a

computerized voice onset monitor.

In this program rigorous training is advised for these skills. However speech rate

increase is not systematically programmed and the transfer and maintenance of treatment

are less emphasized.

e) Prince Henry program: - The Prince Henry program represents the cumulative

developments of treating 50 adult stutterers each year since 1971 and grew out of the

original Andrews Ingham program.

The speech pattern taught is labeled smooth motion speech. The characteristics of

this pattern are gentle onset of phonation, continuous airflow, continuous movement of

articulators throughout each utterance, soft contacts and extension of vowel and

consonant duration.

During the first week, smooth motion speech is trained at a speech rate of 50 SPM

(1/4 th of normal speech rate). Speech rate is then increased to normal rate over the

course of the week in gradual increments of 5 SPM. Each step is considered to be

achieved when the patient exhibits „zero‟ stuttering and correct speech rate in a 45 minute

session.

A1 minute monologue is video recorded for each patient, who then evaluates his

speech for acceptable continuity, gentle onsets (less than three errors) and a speech rate

within 20 SPM of target. Later three other characteristics are also evaluated- Intonation

presentation (overall acceptability) and appropriate pause/less than three appropriate

pauses.

During the second and third week, patients transfer these skills to the real world.

They have to complete a graded hierarchy of 25 speech assignments, each recorded on

cassette tapes (phone calls, shopping etc). There are 15 standard assignments which must


be completed by all patients and 15 personal assignments which patients plan to cover

many aspects of their speaking life. Each assignment must contain at least 1,400

consecutive syllables of stutter free speaking at 200 + 40 SPM, otherwise it must be

reported. Patients must evaluate their speech quality and rate in each assignment before

submitting it for the therapist‟s evaluation. Each day of the transfer phase begins and this

with a 2 hour session of smooth speech practice at 100, 150, 200 and 220 SPM.

At three, six, nine weeks and at six months after intensive treatment, patients have

to attend a follow up clinic which involves participation in rating lessons and planning of

maintenance activities. If they are not satisfied with their progress, they have to continue

to attend to follow up clinic until they are fluent. Patients should be encourage to

perform formal practice and generalization assignments daily for at least nine weeks after

completion of intensive treatment. They should attend weekly self help meetings of

former patients. Booster treatment programs are also available.

Researches on the effectiveness of prolonged speech treatments suggest that they

are effective both in short and long term. The major value of prolonged speech

techniques is that they force a patient to slow his speech sufficiently to allow him to pay

attention to what he does when he is fluent and to reprogram his articulators accordingly.

It is not known how prolonged speech therapies work. Recent research on

abnormal laryngeal and articulatory behaviors and abnormal breathing patterns suggest

that some of these may be modified after prolonged speech therapy. However the basis

for the effectiveness of prolonged speech techniques remains unresolved.

f) Airflow therapies:-

Regulated breathing method (Azrin and Nuun 1974)

Flow and slow technique (Schwartz 1976)

Regulated breathing method: - this method is based on the belief that stuttering is a

habitual disorder of initiation and maintenance of airflow and hence should be eliminated

if the stutterer emits speech behaviors that are incompatible with these airflow anomalies.

Stutterers are trained to control a wide range of airflow aspects. These aspects involve

a) Smooth breathing

b) Exhalation prior to speech.

c) Blending words into exhalation pattern.


d) Continued exhalation after last sound of utterance

e) Pausing at natural juncturing points

f) Smooth inhalation during the perspeech pause and

g) Formulation of general speech content

A brief treatment of one or two sessions each of two to three hours involves breath

management practice. This is done initially in reading followed by spontaneous speech

gradually decreasing the frequency of pauses. Generalization is minimal and is restricted

to the clinic and its environments.

Flow and Slow method: - This method is based on the assumption that stuttering is the

result of excessive tensing of the vocal folds before speech, producing feedback that

triggers conditional struggle. To eliminate this malfunction, stutterers are made to relax

the vocal folds by maintaining passive airflow.

Initially the stutterer has to initiate passive airflow prior to speech and to slow the

first syllable of each utterance. These skills are to be practiced in increasingly length and

complex utterance and finally in generalization tasks. For a year after intensive

treatment, daily home assignments are carried out and audio taped sample are mailed to

the clinic.

It is found that the manipulation of airflow can reduce stuttering dramatically in

the short term. However data on the outcome of airflow therapies indicate that nothing

could be concluded about the lasting effect of these techniques. The outcome also

indicates that this technique is distinctly inferior to the prolonged speech therapies. In

summary it requires a better quantitative back up.

g) Rhythmic speech: - This technique is based on the assumption that packing words or

syllables to a rhythmic stimulus reduces or eliminates stuttering. A metronome is used

and initially the stutterer is made to speak a syllable for the metronome beat. Increasing

the number of beats/minute should depend on 100% fluency in the earlier rate of speech.

Once normal rate of speech is acquired, longer and longer units of speech are paced to

each metronome beat and unit lengths have varied to allow more normal speech cadence

and juncturing. Once the client achieves fluency with a metronome, then the patient is

given a portable hearing aid like metronome which he has to wear and complete the

transfer of fluency. The transfer is then repeated without the metronome.


h) Biofeedback: - this technique is based on the assumption that stuttering is associated

with excessive tension in speech muscles which interferes with speech production which

is supported by excessive EMG levels on speech related tasks in stutterers. To reduce the

tension, biofeedback is used. Clients are trained to use biofeedback to reduce masseter

muscle tension to a maximum of 5 mv. Then masseter muscle tension is reduced before

and during utterances of increasing length, first in reading and then in spontaneous

speech 95% fluency is required at each step before progress is permitted. This hierarchy

is completed first with direct EMG feedback and then with „indirect‟ feedback from the

clinician. The skills are then generalized.

The variability of outcome suggests that this method may be appropriate for a subgroup

of stutterers i.e., those with marked speech muscle tension symptoms.

i) Therapeutic packages: Individual therapy techniques are based on certain assumptions

which give more importance to and focus on limited dysfluencies presented by the

stutterers. To solve this problem, the present trend has moved from individual therapy to

a combination of several therapeutic techniques which are termed therapeutic packages.

Perking et al (1976) developed a therapeutic package. They consider stuttering as a

discoordination of the basic processes involved in the production of speech.

Treatment is aimed at teaching the stutterer to use respiratory, phonatory and

articulatory processes in a coordinated manner to produce and maintain fluent speech.

The initial goal of this program is to establish non stuttered oral reading with the help of

250 m secs of delayed auditory feedback. Prolongation of syllable is emphasized. In

gradual steps, the duration of the DAF is reduced. The real goal is to teach a normal

breath flow with easy vocal attacks. Speaking short phrases with sufficient air capacity

and continuous airflow is the specific target. Normal prosody is then taught. Finally, the

generalization procedures are implemented along with additional counseling

psychotherapeutic discussions are also considered of value in coping with the persistent

use of avoidance techniques.

The other therapeutic package is described by Azrin and his colleagues (1974),

the predominant feature of which is regulated breathing. This has been described under

airflow therapies.


j) Vocal control: The fluency of speech rhythm depends on smooth coordination of the

respiratory, phonatory and articulatory systems (Perkins et al 1976). Research indicates

the abnormal laryngeal activity is an important aspect of dysfluent speech. The results of

the study by Conture et al (1977) indicates the possibility of each type of stuttering

associated with a different pattern of laryngeal muscle action and that the difference is

related to many factors. Several treatment procedures have been suggested to attain vocal

control in stutters which are as follows:

- Conversational rate control and breath stream management therapy (Perkings 1973)

- Regulated breathing method (Azrin and Nunn 1974)

- Flow and slow technique (Schwartz 1976)

- Airflow and breath management therapy (Hasbrocuk 1983)

The first three of these have been explained under Airflow and prolonged speech

techniques. In Hasbrocuk‟s approach, the stutterer is trained to release a small amount of

air through the vocal folds prior to the on set of phonation, first with vowel sounds, then

with single words and moving on through systematic stages into connected speech. He

also suggests relaxation of tensed muscles, identification of tension and identification of

misuses of airflow. A structured transfer and maintenance program is also included

k) Masking: Since Cherry et al (1956) found that masking noise can reduce stuttering

attempts have been made to develop therapy techniques using masking noise. Initially

because of the bulkiness of the masking units, therapy was restricted to the clinician

situation. As the portable unit‟s cam in to existence, the treatment extended to social

situations also. However, there is not socially acceptable.

Though noise reduces stuttering when introduced, research on its long term use

does not suggest its applicability. Further, as the stutterer has to wear the unit it may not

be accepted by him.

l) Attitudinal therapy: Many of the therapeutic techniques are based on modifying

stutterers attitudes. A speech disorder like stuttering will evoke unusual reactions from

peers, parents etc. The most common reaction evoked is a negative reaction

As these reactions are unpleasant, the speaking situations may be traumatic and

the stutter may learn to avoid them. Stutterers may also feel less confident about

themselves because of repeated failures of speaking situations.


“Traditionally, it is believed that in order to achieve fluency, attitudes must be

changed. If the treatment focuses only on reducing stuttering and increasing on stuttered

speech, maladaptive attitudes do not change and these unchanged attitudes will soon wipe

out the temporary and shaky fluency generated by a treatment procedure who exclusive

concern was to moody the stuttering or nonstuttering rates (Hegde 1990).

The modification of attitudes is attempted mostly at the verbal level. The

clinician playing the role of a sympathetic listener, encourages the stutterers to talk about

attitudes, feelings and thoughts concerning themselves and their stuttering. Also, the

clinician interprets the stutterers‟ attitudes and feelings and provides new information on

stuttering. Finally the stutterers verbal expressions of appropriate attitude are improved

and inappropriate attitudes are ignored.

Attitudinal therapy can hardly be justified on the assumption that stutterings and

attitudes are two separate problems of a stutterer. In all likelihood, stutterers‟ verbal

statements and feelings concerning their stuttering are direct results of stuttering itself. In

this case, what needs treatment is stuttering and a successful treatment should eliminate

whatever consequences the speech problem generated. Indeed, the results of attitudinal

therapy and behavioral treatments that exclude it both support this contention (Hegde

1990)

m) Anxiety reduction techniques: Anxiety reduction procedures- systematic

desensitization and biofeedback: - have not been very effective as they are indirect form

of treatments. “In anxiety reduction procedures, the focus is on psychophysiological state

of the speaker, not stuttered speech. In systematic desensitization (also known as

reciprocal inhibition) he stutterers anxiety and fear responses relative to the act of

speaking and speaking situations are reduced. This is accomplished by teaching the

client deep muscle relaxation and having the person imagines himself or herself.

Speaking in difficult situations is presented. When this is done repeatedly, the relaxation

response is expected to reciprocally inhibit anxiety associated with speech tasks. The

assumption has been that if stutterers‟ anxiety is eliminated, stuttering will decrease. In

biofeedback various kinds of electronic instruments are used to display information

concerning psychophysiological function such as muscle function, blood pressure and

electromyographic activity. By and large, biofeedback as applied to stuttering is also


designed to reduce the stutterers‟ anxiety and muscle tension with assumption that a

relaxed stutterer can speak without stuttering (Hegde 1990).

Though positive findings are obtained for anxiety reduction procedures, data on

long term effects are lacking. Hegde (1990) opines that a relaxed neuromuscular state

may be a helpful background variable for fluency, but relaxation by itself does not teach

the stutterer the skills necessary to produce nonstuttered speech. Also, as more

successful techniques teach certain specific responses that lead to nonstuttered speech

and all these responses are speech related, the use and anxiety reduction techniques don‟t

appear to be on the increase.

n) Trial therapy: - Daly (1985) states that “the issue of trial therapy raises more questions

than answers”. Intensity of treatment, structure of the program, clinician competencies

and the number of trial sessions are only a few of the variables pertinent to such an

evaluation”.

Ingham (1982) proposes that a decision regarding the effectiveness or target

might reasonably be made after 12 sessions. He suggests a trial period of about four

weeks. However, guidelines for determining the length of trial therapy are needed.

Emerick and Hatten (1974) opine that “the longer a stutterers history Emerick and Hatten

(1974) opine that “the longer a stutterers history of therapeutic failure, the poorer the

prognosis for future improvement”.

THERAPY TECHNIQUES PROPOSED BY THE AUTHORS: -

Having been influenced by the concept of stuttering as a temporal disorder, the

authors would like to put forth a few new therapy methods which might be of use. Till

now, though these techniques have been tried on several stutterers, one cannot claim that

the fluency enhancement in them can be attributed to these techniques. Systematic

evaluation should be performed to make such claims. The authors would be extremely

happy if speech pathologists could use these and criticize, comment on the usefulness of

these techniques.

Before describing the proposed therapy techniques a brief description about the

concept of stuttering as a temporal disorder would be appropriate. The belief is that, the

muscles of the respiratory, laryngeal and articulatory system should be appropriately


times for the production of any speech sound. For example, to utter the word /ba:t/,

initially at „0‟ msec there should be lip closure (VPC) in the articulatory system. At the

laryngeal system, there should be lip closure (LC) and velopharyngeal port closure (VPC)

in the articulatory system. At the laryngeal system, there should be satisfactory condition

for the vocal fold vibration (V) and in the respiratory system, there should be appropriate

air pressure (AP) for the particular speech sound.

Thus, if LC, VPC, V and AP are ready at „0‟ msec and coordinate the first

phoneme of the word i.e. /b/ would be uttered. However if any one of these is not ready

of there is mis-coordination, the resultant speech sound will not be /b/, but will be

different (Mckay and McDonald 1985). If lip closure is inappropriate the end phoneme

would be /w/ and if velopharyngeal port is open it will be /m/. If VC vibrations not

maintained it would be /p/ and if air pressure is inappropriate articulatory release will not

be proper.

As these disruptions occur in the respiratory, laryngeal and the articulatory

system, tracking the movements of these systems would provide knowledge about the

location and the nature of disruption responsible for repetition or prolongation or any

other dysfluency. Thus, a tracking of these systems would necessitate the correction of

any of these disruptions. It is not necessary that sophisticated instruments are required

for this tracking. This could be roughly performed by carefully listening to the speech of

the stutterer. However, if instruments are available, this could be confirmed.

Depending on the location and the nature of disruption a stutterer presents

different techniques that could be used to correct these disruptions. A stutter may present

any of the following symptoms during the moment of stuttering, which suggest a mis

coordination of one of three systems. Sudden inspiratory air intakes especially in stop

release suggesting inadequate oral pressure to release the articulator of highly tensed.

Stuttering especially on the nasal sounds which sounds denasal indicating

velopharyngeal port opening difficulty at the instant.

Nasalization: Nasal/non nasals, especially voiced stops indicating open velopharyngeal

port in cases where closed velopharyngeal port is required.

Voicing for voiceless, where the vocal folds needs to be open.

Voiceless or/h/ for voiced, where the vocal folds needs to vibrate.


The first symptom suggests inappropriate airway dynamics or increased

articulatory tension, perceptually heard as articulatory fixations. Second and the third

indicate mis coordination in the articulatory system and the last two indicate mis

coordination in the laryngeal system. If these miscoordinations are set properly one

would expect enhancement in fluency. It is presumed that these can be coordinated

voluntarily which stands as the rationale for the techniques described herewith. By

isolating critical features one could help the stutterer to voluntarily with stand as the

rationale for the techniques described herewith. By isolating critical features one could

help the stutterer to voluntarily control the muscles concerned and then to transfer it to

the stuttering situation.

1. Airflow exercises:- when in appropriate air pressures are the critical features exhibited

by a stutterer one could establish a self control over the airflow for speech. This could be

achieved by taking in air through the nasal cavity and chanalizing it though the oral

cavity. Once the patient achieves this he could be taught to prolong vowels and fricatives

wherein he needs to maintain the air stream through the oral cavity.

2. Exercises for laryngeal coordination:- Voicing for voiceless or voiceless /h/ for voiced

indicates in appropriate laryngeal gesture. This gesture could be corrected voluntarily. If

one knows the gesture required. Patient could be first taught to feel tactually the

vibrations of the vocal fold during the prolongation of vowels. Once this is established,

he may be taught to feel the absence of vibrations of vocal folds during the production of

unvoiced sounds such as /s/ and /h/. After he learns these, he should be taught to say /a/

and /h/ alternatively, thus alternating voicing and devoicing.

In doing this at a faster rate he acquires voluntary control over the glottal gestures which

he can transfer to speech sounds while speaking/reading.

3. Exercises for articulatory coordination:- As for the velopharyngeal port is concerned,

initially the patient could be taught to tactually feel the nasal air escape for nasal

continuants and oral air escape for oral sounds. Once they are able to differentiate the

oral and the nasal sounds, they may be taught to alternate /m./ and /a/ or /i/ to shift from

open VP port to closed V.P. port. Voluntary control over V.P. gestures could be


achieved by alternately and rapidly uttering /m/ and /a/ or /i/ which would be transferred

to other speech sounds in speaking/reading.

Apart from these, for highly tensed articulations soft contact could be taught along with

the airflow exercises.

TRANSFER AND MAINTENANCE

Transfer techniques:- Transfer techniques commonly include the creation of hierarchies,

since the difficulties of establishing a desired response will increase with increased

complexity of speaking situation, as they affect each client. Hierarchies consider many

different types of speaker/listeners.

Transfer should always begin with the situation in which the client feels most

comfortable or stutters less. Treatment progresses systematically from most comfortable

to least comfortable situations and from lest amount of stuttering to maximum amount of

stuttering.

An important factor affecting change is the amount of self responsibility the client

will take. Florence and Shames (1980) created a four step procedure for training is self

monitoring. Those include (1) self instruction (2) self monitoring (3) self evaluation and

(4) self consequation.

The clinician can help the client to develop self instructions by using a signal,

such hand rising, to point out disfluent speech which occurs because the client has not

used the technique. To teach self monitoring, have the client deliberately be nonfluent

and correct the nonfluent speech with the facilitating technique. Later the client should

be able to monitor his dysfluencies on his own. They can evaluate their own fluency and

self consequation is the reward rein forcer that is built into this process.

Maintenance techniques: - Post treatment goals are crucial in helping to prevent relapse

into patterns of stuttering used before therapy. Some strategies the clinicians have used

include self monitoring checklists, outside clinic tape recordings, recorded phone

conversations, periodic visits to the clinicians, group therapy for self help etc.

The client could be given assignments such as short conversation with strangers

and self monitoring each day and the results of these activities should be documented in


some way such as tape recording or a self monitoring checklist. Personality problems

and adjustment difficulties often interfere with the maintenance of fluency. These

problems should be attended to without which maintenance is impossible.

Management of Adults with Stuttering- Recent advances

According to Cordes, A.K (1998) conference presentation a review was taken up.

Research subgroup and recommendation subgroup was investigated. The frequency with

which certain treatments were investigated varied widely.

Research Subgroup

1 Study each

Play therapy (Wakaba, 1983)

Acupuncture (Craig & Kearns, 1995)

Reinforcing fluency (Shaw & Shrum, 1972)

Self recording of stuttering (La Croix, 1973)

DAF (Martin & Haroldson, 1979)

EMG (Craig et al, 1996)

Recorded self-modelling of nonstuttered speech (Bray & Kiehle, 1996)

Programmed traditional treatment (Ryan & Ryan, 1983)

3-5 studies each

Precision Fluency Shaping

Prolonged speech plus cognition

Parent- administered operant

Parental change

Other packages

Masking

Punishment

GILCU/ELU

Rhythmic speech

7-13 studies each

Desensitization/cognitive

Airflow and regulated breathing


Response contingent time-out

Prolonged/smooth speech

These 4 is widely used and good prognosis is seen in clients with fluency problem.

Recommendations Subgroup

1-3 each

Parental change plus speech rate and utterance length

GILCU/ELU

Response contingent time-out

Parental change

5-9 each

Desensitization/cognition

Prolonged speech/related fluency skills

Prolonged speech plus cognition

Difference between these subgroups is, Research subgroup is more of operant: time-out

or other punishers or reinforcing fluency, or combinations of reinforcement and

punishment. Recommendation subgroup emphasis on cognitive or cognitive-emotional

treatment procedures. This doesn‟t involve airflow technique.

Effectiveness of researched and recommended treatments

Can be evaluated by any of the following measures

frequency of stuttering event

percent of syllables stuttered and

percent of words stuttered

Other, depends on individual researcher.

GROUP THERAPY

Backus (1947) first advocated the use of speech in social situation beyond the usual

speech production.

The experiences provided by group interaction are a valuable part of a comprehensive

treatment program. The group provides an ideal setting for “divergent thinking,” (e.g.


lateral thinking, thinking outside the box) as the client observes how others have dealt

with similar problems.

Luterman (1991) suggests two basic types of groups:

1. Therapy group

2. Counseling group

Group setting provides opportunities for enhancing as well as maintaining change in both

the surface and intrinsic aspects of the syndrome, client understand that he is not alone,

provide social setting where client can discuss his problem openly, become more

desensitized, members of the group provide an important source of motivation and

courage to speak, permits a greater variety of treatment choices and a more

comprehensive treatment approach than would be possible with individual treatment

alone. (Conture, 1990)

Determining group membership

This is the first step in assuring the success of the group. Each individual participant must

be committed, motivated, and willing to contribute to the group process. It can be

difficult to get adults who stutter to commit to a group setting. Luterman, 1970 suggest

that individuals must have “a willingness to examine their lives and to share their insights

with the group”, group should be dynamic, self-directed if members are motivated and

should share a common interest for introspection and contribute success of others in

attendance. For individual who resist being in group can be provided with videotapes of

group meeting.

Advantages of group treatment

Luterman (1991) indicate several characteristics of group treatment that are beneficial

1. The instillation of hope: Increase his belief that he is also capable of positive

changes.

2. The promotion of universality: Provision for coping with feelings of isolation and

loneliness.

3. The imparting of information: Not only clinician providing information, here all

the members of the group provide examples and advice based on their own,


unique experiences. Get an opportunity to know for the first time that

nonstuttering speakers also have same fear about speaking in public or formal

situations and risk taking in general.

4. The provision of altruism: Each group member provides not only information to

other members, but also support, reassurance, and insight. Furthermore, as the

group members are helping others, they also tend to experience an increase in

their own self-esteem.

5. The enhancement of group cohesiveness: Group develops its own history and

evolves through the stages of “forming,” “storming,” “norming,” and

“performing” (Tuckman, 1965). That is, group members discover and adjust to

the group protocol, find out how to identify roles and resolve conflicts, become

committed to working with each other, and eventually focus on group objectives

and goals. Group becomes self-directed and individual members experience an

increased desire to maintain their role in the group and look forward to group

meetings.

6. Possibility of catharsis: Group provides a safe place for individual members to

release and share feelings and attitudes concerning their own problems. Get an

idea to deal with feeling of embarrassment, shame, and social failure associate

with stuttering.

7. The development of existential issues: Gets an opportunity for individual clients

and clinician to deal with questions concerning anxiety associated with daily

living, such as feeling of loneliness and dependency. Thus improve the quality of

decision making, including the many interpersonal aspects of their lives.

Potential problems with group activities

Conture (1990) recommends a group size of approximately seven members, while

Luterman (1991) suggests an upper limit of 8 to 15 members.

It‟s been reported that it‟s difficult to find time and place to meet as a group.

Structuring group activities


Activities should be held in a large room with comfortable seating, area must be quiet.

Arranging the participants in a circle is useful in enhancing conversation as well as

promoting eye contact and allowing the clinicians and clients to read each other‟s body

language (Luterman, 1991).

Relaxation-Imagery Exercises- Usual relaxation exercise and imagine an event and

speak about that event Ex. Dental surgery.

Role-playing- Focus at feared moments he has previously encountered. Such situations

may include ordering food at a restaurant or drive-through window, training an oral exam

for certification, giving a formal oral presentation, exchanging marriage vows, or dealing

with threatening or confrontational situations at home, work, or school. It provides an

opportunity to become desensitized to past fluency failures future anxiety-provoking

situations.

Public speaking- Its highly feared situation for nearly anyone. Here client has to prepare

different types of presentations (informative, demonstration, storytelling) and to practice

responding to questions from the audience. Participants improve organizational skills and

learn to sequence and present their idea in front of a group. This can be done in the same

room where the group session normally takes place or in a more formal setting such as

classroom or auditorium; sometime can make use of microphone and amplification

system.

GROUP THERAPY

Backus (1947) first advocated the use of speech in social situation beyond the usual

speech production.

The experiences provided by group interaction are a valuable part of a comprehensive

treatment program. The group provides an ideal setting for “divergent thinking,” (e.g.

lateral thinking, thinking outside the box) as the client observes how others have dealt

with similar problems.

Luterman (1991) suggests two basic types of groups:

3. Therapy group

4. Counseling group


Group setting provides opportunities for enhancing as well as maintaining change in both

the surface and intrinsic aspects of the syndrome, client understand that he is not alone,

provide social setting where client can discuss his problem openly, become more

desensitized, members of the group provide an important source of motivation and

courage to speak, permits a greater variety of treatment choices and a more

comprehensive treatment approach than would be possible with individual treatment

alone. (Conture, 1990)

Determining group membership

This is the first step in assuring the success of the group. Each individual participant must

be committed, motivated, and willing to contribute to the group process. It can be

difficult to get adults who stutter to commit to a group setting. Luterman, 1970 suggest

that individuals must have “a willingness to examine their lives and to share their insights

with the group”, group should be dynamic, self-directed if members are motivated and

should share a common interest for introspection and contribute success of others in

attendance. For individual who resist being in group can be provided with videotapes of

group meeting.

Advantages of group treatment

Luterman (1991) indicate several characteristics of group treatment that are beneficial

1. The instillation of hope: Increase his belief that he is also capable of positive

changes.

2. The promotion of universality: Provision for coping with feelings of isolation and

loneliness.

3. The imparting of information: Not only clinician providing information, here all

the members of the group provide examples and advice based on their own,

unique experiences. Get an opportunity to know for the first time that

nonstuttering speakers also have same fear about speaking in public or formal

situations and risk taking in general.

4. The provision of altruism: Each group member provides not only information to

other members, but also support, reassurance, and insight. Furthermore, as the


group members are helping others, they also tend to experience an increase in

their own self-esteem.

5. The enhancement of group cohesiveness: Group develops its own history and

evolves through the stages of “forming,” “storming,” “norming,” and

“performing” (Tuckman, 1965). That is, group members discover and adjust to

the group protocol, find out how to identify roles and resolve conflicts, become

committed to working with each other, and eventually focus on group objectives

and goals. Group becomes self-directed and individual members experience an

increased desire to maintain their role in the group and look forward to group

meetings.

6. Possibility of catharsis: Group provides a safe place for individual members to

release and share feelings and attitudes concerning their own problems. Get an

idea to deal with feeling of embarrassment, shame, and social failure associate

with stuttering.

7. The development of existential issues: Gets an opportunity for individual clients

and clinician to deal with questions concerning anxiety associated with daily

living, such as feeling of loneliness and dependency. Thus improve the quality of

decision making, including the many interpersonal aspects of their lives.

Potential problems with group activities

Conture (1990) recommends a group size of approximately seven members, while

Luterman (1991) suggests an upper limit of 8 to 15 members.

It‟s been reported that it‟s difficult to find time and place to meet as a group.

Structuring group activities

Activities should be held in a large room with comfortable seating, area must be quiet.

Arranging the participants in a circle is useful in enhancing conversation as well as

promoting eye contact and allowing the clinicians and clients to read each other‟s body

language (Luterman, 1991).

Relaxation-Imagery Exercises- Usual relaxation exercise and imagine an event and

speak about that event Ex. Dental surgery.


Role-playing- Focus at feared moments he has previously encountered. Such situations

may include ordering food at a restaurant or drive-through window, training an oral exam

for certification, giving a formal oral presentation, exchanging marriage vows, or dealing

with threatening or confrontational situations at home, work, or school. It provides an

opportunity to become desensitized to past fluency failures future anxiety-provoking

situations.

Public speaking- Its highly feared situation for nearly anyone. Here client has to prepare

different types of presentations (informative, demonstration, storytelling) and to practice

responding to questions from the audience. Participants improve organizational skills and

learn to sequence and present their idea in front of a group. This can be done in the same

room where the group session normally takes place or in a more formal setting such as

classroom or auditorium; sometime can make use of microphone and amplification

system.

REFERENCES

1). Treatment Efficacy for Stuttering- A Search for Empirical Bases. By Cordes, A. K &

Ingham, R. J, 1998.

2). Stuttering Therapy- Rationale and Procedures. By Gregory, H. H, 2003.

3). Clinical decision-making in fluency disorders. By W. H. Manning, 2000.

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