Beyond the Visible: Helping Beyond the Visible: Helping Students to Look Beyond the Students to Look Beyond the DisfluencyDisfluency

ASHA -- SID 4ASHA -- SID 4

Leadership ConferenceLeadership Conference

May 18, 2001May 18, 2001

TorontoToronto

Stephen B. Hood, Ph. D.Stephen B. Hood, Ph. D.

Behavioral and Emotional Behavioral and Emotional DimensionsDimensions

R ep etit ion sS ou n d /S yllab le

P ro lon g a tion sV o ic ed

V o ic e les s

B loc ksH ard C on tac ts

s ta rte rs /s ta lle rsIn te rjec tion s

reco ils

Typ e

D u ra tion

E ffo rt/In ten s ity

F req u en cy

B eh avio rsO vert

D en ia lS h am e

G u ilt

V ic t imH e lp less

S cared /N ervou s

A n tic ip a tionE xp ec tan c y

A tt itu d es an d F ee lin g s

E m otion sC overt

S TU TTE R IN G

P re -D is ru ptio n F lue n c y D is rup tio n P o st D isr u pt io n

E m o t io n a l B e h a v io ra l B e h a v io ra l E m o t io n a l

A n t ic i p a t io n A v o id a n c e D is f l u en c y E m b a r ra s s m e n tE x p e c t a n c y P o s t p o n e m e n t F lu e n c y F a i lu re H u m il i a t io nF e a r W o rd S u b s t it u t io n S t u t t e r in g G u il tW o rry D is g u is e R e l i e fA p p re h e n s i o n A n t i e x p ec t a n c y A u d ib le - V o c a li z e d S h a m eA n x ie t y T i m e rs P a r t -W o rd R e p e t it i o n s W it h d ra w a lD re a d S t a r te rs W o rd R e p e t it io n s A n x i e tyW o rry P a u s e s P h ra s e R e p e t it io n s H o s t i l it yN e g a t iv e - C i rc u m lo c u t io n s S o u n d P ro lo n g a t io n s F ru s t ra t io n E m o t io n B o d y M o v e m e n ts A u d ib le -N o n v o c a l i ze d P e n a lt yA b u li a R e fu s a l P a r t -W o rd R e p e t it i o n s D e n ia l( e tc . ) (e t c .) S o u n d P ro lo n g a t io n s

D y s rh y t h m ic P h o n a t io n sIn a u d ib le - N o n v o c a li z e d

h a rd c o n ta c t st e n s e p a u s e ss il e n t b lo c k s

S t ru g g le - E s c a p eR e c o ilIn t e r ru p t e rsE f fo r t/ t re m o r / s t ru g g le( e tc .)

> > - - - - ra t e c h a n g e s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - > >> > - - - - - - - - s p e e d in g a n d t e n s in g - - - - - - - - - - - - > >> > - - - - - - - -h o ld in g b a c k - - - - - - - - - - - - - - - - - - - - > >

(A f t e r H o o d , 1 9 7 8 . A s s e s s m e n t o f F l u en c y D is o rd e rs )f il e : \ m o m en t o f .s t\ (9 9 )

Time Sequencing of Time Sequencing of EventsEvents

Project 1: Speech Rate, Articulation Project 1: Speech Rate, Articulation Rate and Normal Fluency Rate and Normal Fluency

1.1. Students are divided into groups of two or three. The Students are divided into groups of two or three. The assignment is to tape record a 200 word monologue assignment is to tape record a 200 word monologue or lecture of a faculty or staff member and to perform or lecture of a faculty or staff member and to perform analysis of speech rate, articulation rate and “normal analysis of speech rate, articulation rate and “normal nonfluency.”nonfluency.”

2.2. Each group submits the audio tape, and a descriptive Each group submits the audio tape, and a descriptive summary of the results.summary of the results.

Project 2.Project 2. Perform Rate & Perform Rate & Disfluency AnalysesDisfluency Analyses

1. Students tape record themselves in 200 word 1. Students tape record themselves in 200 word monologue where they realistically demonstrate monologue where they realistically demonstrate “moderately severe” pseudo-stuttering.“moderately severe” pseudo-stuttering.

2.2. Each student performs an analysis of his/her speech Each student performs an analysis of his/her speech and articulation rates, and completes an analysis of and articulation rates, and completes an analysis of both molar moments, and molecular types, of both molar moments, and molecular types, of disfluency.disfluency.

3. Each student submits the audio tape, analyses and 3. Each student submits the audio tape, analyses and narrative summary.narrative summary.

Project 3:Project 3: Learning to StutterLearning to Stutter

1.1. Stop three people on the street. Maintain eye contact, and Stop three people on the street. Maintain eye contact, and ask directions on how to get somewhere. For each different ask directions on how to get somewhere. For each different person demonstrate moderate tension/struggle along with:person demonstrate moderate tension/struggle along with:

– Sound and syllable repetitionsSound and syllable repetitions– Sound prolongationsSound prolongations– Tense pauses/hard contacts & silent blocks.Tense pauses/hard contacts & silent blocks.

2. Submit written report to summarize your experience. What 2. Submit written report to summarize your experience. What did you do? How did you feel?did you do? How did you feel?

Andrea and Jeanne ----Pseudo-Stuttering Andrea and Jeanne ----Pseudo-Stuttering with the Easter Bunny: Spring, 2001with the Easter Bunny: Spring, 2001

Project 4:Project 4: CancellationsCancellations

1.1. Along with partner, complete various practice Along with partner, complete various practice activities.activities.

2. Perform Cancellations2. Perform Cancellations• Select 3 common words, Cancel each of them at Select 3 common words, Cancel each of them at

least 5 times per day for 3 days.least 5 times per day for 3 days.• Perform predetermined quota of cancellations Perform predetermined quota of cancellations

during phone calls.during phone calls.• Perform three cancellations in each of three Perform three cancellations in each of three

different, realistic, speaking situations.different, realistic, speaking situations.

3. Submit a report to summarize your experiences.3. Submit a report to summarize your experiences.

Project 5:Project 5: Pull-OutsPull-Outs

1.1. Various practice activities to learn how to stutter, Various practice activities to learn how to stutter, “freeze,” and release slowly, deliberately, and with “freeze,” and release slowly, deliberately, and with voicing.voicing.

2.2. In realistic situations, collect 25 instances of In realistic situations, collect 25 instances of moderately severe stuttering where you briefly moderately severe stuttering where you briefly “freeze” and then release with a pull-out that is slow, “freeze” and then release with a pull-out that is slow, gradual, deliberate and vocalized.gradual, deliberate and vocalized.

3.3. Submit a report to summarize your experiences.Submit a report to summarize your experiences.

Project 6: Proprioceptive MonitoringProject 6: Proprioceptive Monitoring

This assignment is not easily summarized in limited This assignment is not easily summarized in limited space. Basically, the students are required to speak space. Basically, the students are required to speak in realistic situations where they engage in various in realistic situations where they engage in various degrees, and amounts, of “continuous phonation.” degrees, and amounts, of “continuous phonation.” Their task is to concentrate on feeling the Their task is to concentrate on feeling the proprioceptive movement of the speech mechanism. proprioceptive movement of the speech mechanism. Each student submits a written summary of the Each student submits a written summary of the experience.experience.

Final Exam Question: Spring, 2001Final Exam Question: Spring, 2001

Students came to my office, individually, to Students came to my office, individually, to make phone calls where they :make phone calls where they :• stuttered on approximately 20 % of words spokenstuttered on approximately 20 % of words spoken

• with moderate amount of effort/tension/struggle. with moderate amount of effort/tension/struggle. Their task was to:Their task was to:

• stutter and cancel three times. (finish the word, stop stutter and cancel three times. (finish the word, stop and pause 2 seconds, then repeat the word with and pause 2 seconds, then repeat the word with slow and deliberate co-articulated transition) slow and deliberate co-articulated transition)

• stutter, “freeze,” and then pull-out of three moments stutter, “freeze,” and then pull-out of three moments of stuttering. Pull-outs had to be gradual, voiced.of stuttering. Pull-outs had to be gradual, voiced.

Project 7:Project 7: Modeling Turtle TalkModeling Turtle Talk

1. Each student engages in a ten minute play situation 1. Each student engages in a ten minute play situation with a normally developing child between ages three with a normally developing child between ages three and seven. Each student tape records and analyzes and seven. Each student tape records and analyzes his/her speech and articulation rates, disfluencies, his/her speech and articulation rates, disfluencies, turn-taking, pausing and prosody.turn-taking, pausing and prosody.

2. Each student submits the audio tape, and a report 2. Each student submits the audio tape, and a report summarizing the experience.summarizing the experience.

Project 8:Project 8: Internet AssignmentsInternet Assignments

1.1. This project requires that each student visits Judy This project requires that each student visits Judy Kuster’s “STUTTERINGHOMEPAGE.” Kuster’s “STUTTERINGHOMEPAGE.”

http://stutteringhomepage.comhttp://stutteringhomepage.com

2. Each student is to select three papers, stories, or 2. Each student is to select three papers, stories, or other items of interest: one must pertain to a child, other items of interest: one must pertain to a child, one to a teen and one to an adult. Students must one to a teen and one to an adult. Students must submit a copy of the article, along with a one page submit a copy of the article, along with a one page abstract of it. abstract of it.

Additional (Optional) OpportunitiesAdditional (Optional) Opportunities

1.1. Visit the Home Page of the Stuttering Foundation of Visit the Home Page of the Stuttering Foundation of America: http://www.stuttersfa.orgAmerica: http://www.stuttersfa.org

2.2. Visit the Home Page of the National Stuttering Visit the Home Page of the National Stuttering Association: http://www.nsastutter.orgAssociation: http://www.nsastutter.org

3.3. Join one of the ListServs that deals with stuttering: Join one of the ListServs that deals with stuttering: STUTT-L, STUT-HLP, STUTT-XSTUTT-L, STUT-HLP, STUTT-X

Explore your OptionsExplore your Options

Components Components • FeelingsFeelings• AttitudesAttitudes• BehaviorsBehaviors

– AvoidanceAvoidance

– StutteringStuttering

– Escape Escape Goals/ObjectivesGoals/Objectives

• spontaneous fluencyspontaneous fluency• controlled fluencycontrolled fluency• fluent stutteringfluent stuttering• manageable stutteringmanageable stuttering

Effective CommunicationEffective Communication

Look For Clues

Study Your Options

I expose students to things above and I expose students to things above and beyond the textbook and journals.beyond the textbook and journals.

Students learn about Self-Help and Support Students learn about Self-Help and Support Groups: NSA, CAPS, Friends, Speak-EasyGroups: NSA, CAPS, Friends, Speak-Easy

Members of the Mobile NSA Chapter visit Members of the Mobile NSA Chapter visit class and share their experiencesclass and share their experiences

Students watch video tapes from SFA, NSA, Students watch video tapes from SFA, NSA, and other sources.and other sources.

Students learn about SID-4 and Specialty Students learn about SID-4 and Specialty Certification.Certification.

I expose students to things above and I expose students to things above and beyond the textbook and journals.beyond the textbook and journals.

Students learn about National Stuttering Awareness Students learn about National Stuttering Awareness Week, and International Stuttering Awareness day.Week, and International Stuttering Awareness day.

Students find they can learn more about stuttering from Students find they can learn more about stuttering from reading essays and autobiographies from PWS’s.reading essays and autobiographies from PWS’s.Fred Murray -- The Stutterer’s StoryFred Murray -- The Stutterer’s StoryMarty Jeser -- Stuttering: A Life Bound Up in WordsMarty Jeser -- Stuttering: A Life Bound Up in WordsKen St. Louis - Living With Stuttering: Stories, Ken St. Louis - Living With Stuttering: Stories,

Basics, Resources and Basics, Resources and Hope.Hope.

NSA -- To Say What Is Ours NSA -- To Say What Is Ours SFA -- Advice to Those Who StutterSFA -- Advice to Those Who Stutter

We need to help students We need to help students understand that: ----understand that: ----

PWS’s are better motivated if they view their PWS’s are better motivated if they view their clinical journey more as a challenge and less as a clinical journey more as a challenge and less as a threat.threat.

Accepting challenges requires giving up Accepting challenges requires giving up avoidance-motivated safety, and accepting avoidance-motivated safety, and accepting reasonable short-term risks.reasonable short-term risks.

It is difficult to maintain improvement when clients It is difficult to maintain improvement when clients attempt to superimpose fluency shaping and attempt to superimpose fluency shaping and stuttering modification techniques on top of fear, stuttering modification techniques on top of fear, expectancy and avoidance.expectancy and avoidance.

We need to help students We need to help students understand that: ----understand that: ----

Fluency is more than the absence of Fluency is more than the absence of stuttering.stuttering.

The conspiracy of silence heightens guilt, The conspiracy of silence heightens guilt, shame and denial, and increases attempts to shame and denial, and increases attempts to hide, conceal and interiorize the stuttering.hide, conceal and interiorize the stuttering.

Clients should be helped to get to the point Clients should be helped to get to the point where stuttering is not part of the decision where stuttering is not part of the decision making process. They can make personal making process. They can make personal decisions independent of the possibility of decisions independent of the possibility of stuttering.stuttering.

We need to help students We need to help students understand that: ----understand that: ----

We need to help clients make stuttering less We need to help clients make stuttering less mysterious, less awful and less terrible…. As mysterious, less awful and less terrible…. As Bill Murphy would say, we need to de-mystify, Bill Murphy would say, we need to de-mystify, de-awfulize and de-terribleize the stuttering.de-awfulize and de-terribleize the stuttering.

Clients need help understanding that Clients need help understanding that stuttering is something they do, not stuttering is something they do, not something that happens to them. something that happens to them.

The Client is paying to talk, and the clinician The Client is paying to talk, and the clinician is being paid to listen.is being paid to listen.

Realistic Outcomes: : for adults for whom stuttering has become for adults for whom stuttering has become

chronic and severechronic and severe

To be able to talk any time, any place To be able to talk any time, any place and to any body --and to any body --

And to be able to communicate And to be able to communicate effectively and efficiently --effectively and efficiently --

And to be able to do so with little more And to be able to do so with little more than a normal amount of negative than a normal amount of negative emotion.emotion.

Ideas from the InternetIdeas from the InternetAlong with other SourcesAlong with other Sources

I no longer need to chase the “Fluency God.”I no longer need to chase the “Fluency God.” I can live without constant fear.I can live without constant fear. I can speak well without scanning ahead for difficult words. I can speak well without scanning ahead for difficult words. I can speak for myself, rather than rely on others.I can speak for myself, rather than rely on others. I can explore and follow career opportunities that require talking.I can explore and follow career opportunities that require talking. I can make decisions in spite of stuttering, not because of it.I can make decisions in spite of stuttering, not because of it. I am not suffering or handicapped because of my stuttering.I am not suffering or handicapped because of my stuttering. I accept myself.I accept myself. I don’t feel guilty when I stutter, and I am not ashamed of myself. I don’t feel guilty when I stutter, and I am not ashamed of myself.

for when I do sometimes stutter.for when I do sometimes stutter. I have choices I can make that help me talk easily.I have choices I can make that help me talk easily. I communicate effectively, and feel comfortable doing so.I communicate effectively, and feel comfortable doing so. ““I’m really an o-k person” -- and I like being me.I’m really an o-k person” -- and I like being me.

Crucial Experiences: (Adapted Crucial Experiences: (Adapted from Van Riper and Czuchna)from Van Riper and Czuchna)

Stuttering can be deliberately endured, touched, maintained and Stuttering can be deliberately endured, touched, maintained and studied.studied.

Avoidance only increases fear, and must be reduced.Avoidance only increases fear, and must be reduced. Struggled, hurried escapes and recoils from stuttering make it worse Struggled, hurried escapes and recoils from stuttering make it worse

than it needs to be.than it needs to be. It is possible to build barriers to destructive listener reactions.It is possible to build barriers to destructive listener reactions. Society in general rewards the person who obviously confronts and Society in general rewards the person who obviously confronts and

attempts to deal positively and constructively with stuttering.attempts to deal positively and constructively with stuttering. Every effort must be made to build up your ego-strength, self-Every effort must be made to build up your ego-strength, self-

confidence and self-respect.confidence and self-respect. When the moment of stuttering occurs it can be studied, and its evil When the moment of stuttering occurs it can be studied, and its evil

effects erased as much as possible.effects erased as much as possible. It is personally more rewarding to stutter easily and stutter fluently than It is personally more rewarding to stutter easily and stutter fluently than

to stutter severely, and it is fun to be able to talk anywhere, even to stutter severely, and it is fun to be able to talk anywhere, even though you do stutter.though you do stutter.

Ways to Talk Easily -- (Which ImpliesWays to Talk Easily -- (Which Implieshelpful prerequisite attitudes)helpful prerequisite attitudes)

Post-It NotesPost-It NotesAVMAVM Air-Voice-MovementAir-Voice-MovementKYMRKYMR Keep Your (voice) Motor RunningKeep Your (voice) Motor RunningRTSERTSE Remember To Start EasilyRemember To Start EasilyNNTHNNTH No Need To HurryNo Need To Hurry

Speech Rate -vs- Articulation RateSpeech Rate -vs- Articulation Rate

““Slow it down -- to speed it up”Slow it down -- to speed it up”““Gearing down and gearing up”Gearing down and gearing up”

Speeding Tickets (car) -vs- Talking Tickets (mouth)Speeding Tickets (car) -vs- Talking Tickets (mouth)

Dealing With Time PressureDealing With Time Pressure

Ways to Talk Easily -- (Which Implies Ways to Talk Easily -- (Which Implies helpful prerequisite attitudes)helpful prerequisite attitudes)

Easy Onset / Gentle Onset.Easy Onset / Gentle Onset.

Light Articulatory Contact.Light Articulatory Contact.

Cancellations (If you are brave enough)Cancellations (If you are brave enough)

Pull-Out.Pull-Out.

Releases from stuttering moments must be easy, Releases from stuttering moments must be easy, gradual and voiced.gradual and voiced.

Preparatory SetsPreparatory Sets

Proprioceptive MonitoringProprioceptive Monitoring

Ways to Talk Easily -- (which impliesWays to Talk Easily -- (which implieshelpful prerequisite attitudes)helpful prerequisite attitudes)

Self Talk and the Use of Language: action oriented verbsSelf Talk and the Use of Language: action oriented verbs

““What Happened” -vs- “What am I doing”What Happened” -vs- “What am I doing”

““Having a block” and “Getting Stuck”Having a block” and “Getting Stuck”

““Little men are fighting in my throat”Little men are fighting in my throat”

NownessNowness

Superstitious BehaviorsSuperstitious Behaviors

Safety MarginsSafety Margins

Adjustment to easy talking and fluency. No more secondary gainsAdjustment to easy talking and fluency. No more secondary gains

Openness: Advertising, Voluntary Stuttering, Pseudo-StutteringOpenness: Advertising, Voluntary Stuttering, Pseudo-Stuttering

Hood’s Hopefully Helpful Hood’s Hopefully Helpful HintsHints

Although you may not have a choice as to WHETHER you stutter, you Although you may not have a choice as to WHETHER you stutter, you have a choice as to how you stutter.have a choice as to how you stutter.

Attempting to hide, repress, conceal, avoid stuttering makes it worse Attempting to hide, repress, conceal, avoid stuttering makes it worse than it needs to be.than it needs to be.

Stuttering is something you do, not something that happens to you.Stuttering is something you do, not something that happens to you. The things that may have originally caused stuttering are not the same The things that may have originally caused stuttering are not the same

as the things that influenced its development -- and are not the same as the things that influenced its development -- and are not the same as the things that are now serving to maintain the problem.as the things that are now serving to maintain the problem.

Fluency is more than the absence of stuttering.Fluency is more than the absence of stuttering. It is important to understand the process of talking.It is important to understand the process of talking. The process of desensitization is two fold: both emotional AND The process of desensitization is two fold: both emotional AND

behavioral.behavioral. It is better to do more and more things to talk easily, than more and It is better to do more and more things to talk easily, than more and

more thingsmore things to try not to stutter. to try not to stutter.

Preferred Client OutcomesPreferred Client OutcomesASHA -- SID-4: DraftASHA -- SID-4: Draft

1. I am satisfied with my therapy and its outcome.1. I am satisfied with my therapy and its outcome.

2. I have increased my ability to communicate effectively.2. I have increased my ability to communicate effectively.

3. I feel comfortable as a speaker.3. I feel comfortable as a speaker.

4. I like the way I sound.4. I like the way I sound.

5. I feel I have an increased sense of control over my speech, 5. I feel I have an increased sense of control over my speech, including stuttering.including stuttering.

6. My speaking skills have become more automatic.6. My speaking skills have become more automatic.

7. I have an increased ability to cope with variability of stuttering, 7. I have an increased ability to cope with variability of stuttering, including relapse.including relapse.

8. I am better able to reach social/education/vocational potential 8. I am better able to reach social/education/vocational potential and goals.and goals.

9. My knowledge of self-help/support groups has increased.9. My knowledge of self-help/support groups has increased.

Final Outcomes from Therapy: Final Outcomes from Therapy: Goals, Options and ChoicesGoals, Options and Choices

H ig h S tim u lu s S p eech

P u ll-O u ts , P rep ara to ry S e ts

P rio riocep tive M on ito rin g

"F lu en t S tu tte rin g "

M anaging Stuttering

B rea th s tream M an ag em en t

E asy O n sets

F lu en cy E n h an c in g B eh avio rs

P rec is ion F lu en cy S h ap in g

M anaging Fluency

Hom e Free

Norm al Spontaneus Fluency

F in a l Th erap y O u tcom es