Treatment of Stuttering With Rational Emotive Behavior Therapy

Rational Emotive Behavior Therapy (REBT) Treatment of Chronic Perseverative

Stuttering Syndrome

A Dissertation byGunars K. Neiders, M.A. Psychology, Psy. D.

Candidate (Ph.D. Electrical Engineering)Argosy University - Seattle Campus

September 11, 2009

1 © Gunars K. Neiders ALL RIGHTS RESERVED

Basic Facts about Stutteringu Random House (1987) Definition

u 1. to speak in such a way that the rhythm is interrupted by repetitions, blocks or spasms, or prolongations of sounds or syllables, sometimes accompanied by contortions of the face and body.

u Prevalence of stutteringu The rate at which a condition can be seen in the general population,

has been established (see Bloodstein and Ratner, 2008) to be somewhat less than 1 percent in the United States and somewhat more than 1 percent in Europe.

u Assuming that the prevalence of stuttering is the same among all the peoples of the world, and noting that the current population of the world to be 6.6 billion inhabitants, there are currently 66 millionstutterers in the world! (3.03 million people in the United States alone.)


Conventional Treatments (1 of 2)u Based on retraining muscle groups used in speechu Fluency shaping

u Based on retraining people to speak from the beginning using exaggerated muscle movement patterns

u The focus is on the vocal tract, respiration rate, gentle onsets of sound, combined with prolongations that are eventually reduced so as to resemble normal speech

u Stuttering modificationu The expressed goals of stuttering modification are modification of stuttered

speech so that the outcome is forward moving speech with minimum abnormality and minimum anxiety experienced by the speaker.

u Role of counselingu “[C]ounseling is first and foremost about listening to and talking with our

clients, and in doing so, helping them understand how their emotions affect their thoughts, and how their thoughts and beliefs motivate what they do.” Zebrowski 2006, p. 6


Conventional Treatments (2 of 2)u Assistive devices

u The devices such as SpeechEasy employ Delayed Audio Feedback (DAF) as well as Frequency Altered Feedback (FAF).

u At this time the effectiveness of SpeechEasy and similar devices are open to question because there are no long time independent studies.

u Integrative therapiesu Based on all of the above

u Outcome Meta-Analysis u Craig and Hancock (1995), in a self-report meta-study, found that 70

percent of clients receiving stuttering therapy even after they achieved fluency could be considered relapsed. Conture (1996) reports that “[a]cross the life span, treatment for stuttering appears to result in improvement (not recovery-italics added), on the average, for about 70 percent of all the cases…” (p. S24).


Statement of the Problemu Life Span Context

u Cooper (1993) states that one in five children who stutter will develop chronic perseverative stuttering that cannot be cured by a speech therapist.

u The low success rates are related to the fact that SLPs only address the phenomenon of stuttering by focusing on changing the mechanical behavior of the vocal apparatus: a) the vocal folds, b) mouth, c) breathing, d) lips, e) tongue, etc.

u The therapies do not focus on cognitions, emotions, perceptions and traumatic environmental factors.

u Rational Emotive Behavior Therapyu Mentioned in literature, but not systematically applied to the

stuttering problem.u Need for more systematic integration of cognitive-

behavioral techniques indicated in the literature.


Purpose of the Studyu 1) To develop a theoretical model of developmental stuttering

etiology and evolution of the CPSS through the lifespan that will incorporate current research with respect to all the biopsychosocial factors; and

u 2) To create a detailed therapy protocol informed by the theoretical model that can be used as the basis for manualized therapy accessible both to SLPs and psychologists.

u Desired client outcome:u Maximize unconditional self-acceptance;u Maximize spontaneous fluency;u Decrease communication interference;u Provide for managed fluency as an option;u Decrease shame, guilt, anxiety, and other dysfunctional

emotions;u Minimize-self limiting general life choices


Limitationsu Study addresses adult clients and mature clients in

their late teens who have CPSS (overt and covert) due to developmental stuttering who are average or above average in intelligence.

u The study is theoretical. No experimental verification of either the development of stuttering, the propagation of stuttering or the success of the therapy process will be provided.

u The design of the therapy is the first step toward writing a manual which could be used to verify that the proposed therapy goals indeed are achieved.


All-Inclusive Definition of CPSS (1 of 4)u Visible or audible speech producing muscle anomalies

u Repetitionsu Voiced or unvoiced

u Blocksu Voiced or unvoiced

u Contrasted to normal speakersu Differences in frequency, duration, emotionality, and struggle

u Visible or audible non-speech producing muscle anomaliesu Eye blinks and averting eye contactu Snapping of fingersu Swinging of handsu Twitching or tensing various facial musclesu Jerking of the whole headu Tapping of a footu Swinging back and forth, etc.


All-Inclusive Definition of CPSS (2 of 4)u Distortions of speech

u Rate of speechu Toneu Sing-song voiceu Unnatural prosodyu Talking as if simultaneously chewingu Any other idiosyncratic/unnatural speaking manner

u Avoidance behaviors while speakingu Avoidance of soundsu Avoidance of wordsu Use of starter phrases, words, sounds or pauses


All-Inclusive Definition of CPSS (3 of 4)u Self-defeating attitudes and unhealthy negative

emotionsu Self-defeating beliefs (irrational beliefs)

u Lead to being emotionally upsetuConscious avoidance behaviorsu Poor life-style choices

u Unhealthy negative emotionsu Lead to stutteringu Pre-conscious avoidance behaviors


All-Inclusive Definition of CPSS (4 of 4)u Self-limiting general life choices

u Situational avoidancesu Avoiding to talking to certain peopleu Role avoidancesu Vocational delimitationu Avocational delimitation


Etiological & Perseverance Stages of CPSS:Genetic Make-Up Stage

u Based on epigenetic systems theoryu Aggravating factors:

u Predisposition to slower speech development & anxietyu Predisposition low tolerance of frustration, demandingness,

awfulizing, people rating, absolutistic thinkingu Ameliorating factors:

u Predisposition to rational thinking (non-hysterical, goal oriented, calm, cognitive—non-emotional thinking)

u Conclusions:u Fewer females stutter than males due to earlier speech

acquisitionu Predisposition only


Etiological & Perseverance Stages of CPSS:Pre-Natal Stage

u Based on epigenetic systems theory u Some genes become weaker, some stronger, others cluster,

some stop functioningu Aggravating factors:

u Lack of proper nutritionu Excessive alcohol, nicotine, prescription and street drug

exposureu Ameliorating factors:

u Healthy habits by mother; rhythmic sound exposureu Conclusions:

u Before birthing some genes have already clustered and modified

u Trauma may cause neurological damage


Etiological & Perseverance Stages of CPSS:Birthing Stage

u Birthing has inherent dangers u Aggravating factors:

u Voluntary or involuntary prematurityu Lack of oxygen due to umbilical cord being entangled

u Ameliorating factors:u Uneventful birth at optimal time

u Conclusions:u Need studies on oxygen deprivation during birthingu Need studies on prematurity


Etiological & Perseverance Stages of CPSS:Early Language Acquisition Stage: 20-48 months

u Aggravating factors:u Hyper vigilant parenting figuresu Internalized belief to be vigilant not playfulu Taking speech success/failures too seriously

u Ameliorating factors:u Parental figures model playful, calm demeanor

u Conclusions:u Beware of associating speech with dangeru Should model spontaneous playfulness about speech


Etiological & Perseverance Stages of CPSS:Language Development Difficulty Stage

u Defined by u Parental figure observes more disruptions than for average

childu Aggravating factors:

u Child may or may not become aware of others concernu Ameliorating factors:

u Parental figure handles child with sensitivity and does not alarm him or her

u Conclusion:u Therapy to be done with the parents not the child


Etiological & Perseverance Stages of CPSS:Awareness of Speech Difficulty Stage

u Defined by u Child becoming aware of speech difficulty from external and internal

factorsu Aggravating factors:

u Child labeled as stuttereru Child forms beliefs: “I can’t stand my imperfect way of speaking”; “I

must speak perfectly fluently”; “I must be in total control of my speech”

u Child uses starter phrases: “actually”, “um”, etc.u Ameliorating factors:

u Child views difficulty with passing curiosityu Conclusion:

u Awareness by itself is not necessarily damaging


Etiological & Perseverance Stages of CPSS:Comparison with Others Stage

u Defined by u Child starts comparing himself or herself with others

u Aggravating factors:u Parental figures places demands on the child’s speechu Child forms beliefs: “I should talk like a normal person”u Child develops a habit of comparing his or her-self to others

u Ameliorating factors:u Child is reassured that parental figures love him or her whether he

or she has speech difficulties or notu Conclusion:

u Acknowledge that the child has a speech problem, but that it does not make him or her lesser of a person


Etiological & Perseverance Stages of CPSS:Something is Deficient about Me Stage (Labeling)

u Defined by u Child defines himself or herself as a problem

u Aggravating factors:u Parental figures labels child negatively (stutterer)u Child forms beliefs: “It is horrible to stutter”; “Fluent speakers are

superior to people who stutter” u Child develops a habit of avoiding stuttering

u Ameliorating factors:u Introducing to other children who stutter via NSA

u Conclusion:u Although labeling is a convenient way to communicate it is fraught

with problems

© Gunars K. Neiders ALL RIGHTS RESERVED

Etiological & Perseverance Stages of CPSS:Classical Conditioning Associating Speech with Danger Stageu Defined by

u Child is classically conditioned to associate speech with danger and anxietyu Aggravating factors:

u Parental figures and environment punishes child for stutteringu Child forms beliefs: “It would be awful if others laughed at me”; “It is awful to

have less than perfect speech” u Due to arousal of anxiety, the child is unable to perform normal speaking

u Ameliorating factors:u A wise parental figure could provide a threat free speaking environment

u Conclusion:u The strong classically conditioned association has to be acknowledged in

therapy


Etiological & Perseverance Stages of CPSS:Operant Conditioning of Forcing/Struggling Stage

u Defined by u The child escapes the stuck condition by forcing/struggling; hence,

he or she becomes operantly conditioned to force and struggleu Aggravating factors:

u The synapses in the brain associates escape from stuck condition with forcing and struggling; being unstuck is a relief both for the speaker and the listener

u Child forms beliefs: “I can’t stand being stuck”; “Anything is better than not being able to get out immediately what I want to say”

u Whenever the child stutters he or she automatically starts to force/struggle

u Ameliorating factors:u In rare instances the child cognitively understands that

forcing/struggling is counter productiveu Conclusion:

u Spontaneous remission is caused by the child’s being able to uncouple being stuck from forcing/struggling


Etiological & Perseverance Stages of CPSS:Operant Conditioning of Secondary Symptoms Stage

u Definition u When the child coincidentally blinks, jerks his or her head, etc. and

the sound comes out hence, he or she becomes operantly conditioned to perform these secondary symptom actions

u Aggravating factors:u The synapses in the brain associates escape from stuck condition

with the secondary symptomsu Child sometimes goes into a type of a shock called petit mort where

he or she is not aware of exactly what they are doingu Ameliorating factors:

u In rare instances the child does become aware of what he or she is doing and can voluntarily pre-empt their occurrence

u Conclusion:u Spontaneous remission suggests that in self- or formal therapy the

client can become aware of these symptoms and eliminate them


Etiological & Perseverance Stages of CPSS:Speech Situation Choice, Avocational and Vocational Choice

Stageu Definition

u When the stutterer selects to bypass speaking challenges by choosing to avoid situations where they would exhibit what they consider too much stuttering

u Aggravating factors:u The stutterer avoids immediate painu The stutterer forms beliefs: “All people are completely turned off by my

stuttering”; “It is terrible that I can’t control my body movements”; “I can’t stand criticism and rejection”; “Stutterers are losers”; “Nobody wants to hang out with someone who stutters”; “I find business meetings and parties unbearable”; “I must not inconvenience other people”

u Ameliorating factors:u Some stutterers fight for what they want conquering their short range

hedonism tendenciesu Conclusion:

u The stutterer needs to be convinced that he or she has a right to pursue happiness


Etiological & Perseverance Stages of CPSS:Iatrogenic Traumatization and Hopelessness Building Stageu Definition

u Some failed therapies cause some stutterers to feel more hopeless and helpless

u Aggravating factors:u Therapies that concentrate in-the-clinic changing of speech production onlyu The stutterer forms beliefs: “Only perfect speech is acceptable”; “Nobody

and no therapy can help me”; “In order to be worthwhile I must not stutter”; “I can’t bear having others know that I stutter”; “I must avoid criticism and rejection”

u Ameliorating factors:u Role models who have achieved cognitive reconstructuring

u Conclusion:u Therapists should be aware not to create more anguish and desperation by

asking the impossible or using methods that are not suited for particular clientele


Etiological & Perseverance Stages of CPSS:Reaction Stage

u Definition u When a stutterer reacts to failed therapy and becomes embittered and turns

to blaming the environmentu Aggravating factors:

u The expert the stutterer has hired appears to have failed him or heru The stutterer nurtures beliefs: “Other people must not look down on me” ;

“People who put me down for stuttering are no good and deserve to be severely punished”

u Ameliorating factors:u Role models who do not have blaming attitudes (usually found at NSA)

u Conclusion:u Although blaming others may not be the best way to go, it is better than

blaming one self for being a failure. Putting too much pressure on ones own self can prevent any opportunity for change.


Etiological & Perseverance Stages of CPSS:Productive Therapy Stage

u Definition u Results in reducing severity and frequency of stuttering to normal range;

reduces preoccupation with stuttering; minimizes emotional upset; allows the person to pursue his or her own vocational and avocational goals

u Aggravating factors:u Well meaning friends and family may discourage a person from taking risksu The stutterer forms self-actualizing beliefs and develops discipline to pursue

goalsu Ameliorating factors:

u Success usually breeds success. Human frailty and fallibility is taken into account

u Conclusion:u The stutterer with a help of a therapist becomes his or her own therapist.u This is a life-long processu Spontaneous fluency periods are increased and at the least managed

fluency is achieved


The REBT Directed Stuttering Therapy:Listening to the Client Step

u Motivation u The therapist needs to understand the client’s world view and

build upon itu Engaging the client to become active participant in therapy

from the beginningu Topics to be addressed

u Client’s expectation of outcome u Client’s view of the therapy processu Client’s view of his or her role in therapyu Client’s view of therapist’s role


The REBT Directed Stuttering Therapy:Reaching a Therapeutic Alliance with the Client Step

u Motivation u Not only show genuine empathyu Negotiate a reasonable understanding with the client of

following topicsu Topics (with desired outcome)

u Goals of therapy: 1) unconditional self-acceptance; 2) managing emotions; 3) manage stuttering; 4) decrease disfluency severity and frequency; 5) pursue vocation and avocations of choice; 6) become self-therapist; and 7) become creatively involved in life

u Process of therapy: based on homework outside of clinicu Client role: to become his or her own therapistu Therapist’s role: act as a teacher and consultant


The REBT Directed Stuttering Therapy:Overview of REBT and Its Application to CPSS Step

u Motivation u Teach the client basic REBT principles

u Thumbnail sketch of REBTu Activating event x Belief => Consequent emotions & behaviorsu Some negative emotions are dysfunctional because they are

demotivating and cause unnecessary emotional disturbance. u The goal of REBT is to change the dysfunctional negative emotions

to functional negative emotions: emotions that enhance change, that move the person to achieve his or her goals

u This is done by challenging the basic self-defeating philosophies of a) placing demands on self, others, and the world; b) “awfulizing; ” c) low frustration tolerance; d) global rating of self, others and the world and e) absolutistic thinking


The REBT Directed Stuttering Therapy:Unconditional Self-Acceptance Step

u Motivation u To build a foundation of not rating the whole self but only one’s

characteristics and deeds. To dismiss conditional self-esteem as pernicious, because one cannot constantly perform outstandingly.

u Tasks to be accomplishedu Learn that rating of a whole human being is counterproductive.

u Homeworku Convince oneself that stuttering cannot make one a lesser human

being. u Practice unconditional self-acceptance statements:

u I can enjoy things whether I stutter or not;u I choose to keep living and enjoying life whether I stutter or not;u I do not need to rate myself whether I stutter or not;u I can maximize my enjoyment whether I stutter or not;u There are many things I can do whether I stutter or not;u Becoming fluent will not make me a better person, only more fluent; andu I do not have to disrespect myself even if others laugh at my speech.


The REBT Directed Stuttering Therapy:Motivational Step

u Motivation u The real work on change is done outside the clinic; the client has to

be motivated and kept on being motivated to do this.u Demotivational forces

u Change is hard/other therapies may have failed.u Not allocating enough time and energy to task.u Strongly held irrational beliefs.

u Homeworku Using speech when alone as a guiding light.u Cost-benefit analysis.u Disputing helplessness and hopelessness:

u Using voluntary stuttering;u Metronome talk;u Envisioning therapy process; andu Joining list server [email protected]


The REBT Directed Stuttering Therapy:Identification Step

u Motivation u Client becoming aware of his or her beliefs and behaviors so

that these can be changedu Irrational beliefs that propagate stuttering

u Client uses table 6.1 in dissertation to rate his or her beliefs.u Stuttering behaviors

u Using conversation, phone calls, and video recording to rate all the elements of stuttering behaviors catalogued in the definition of CPPS.

u Discussing with therapist the self-observations


The REBT Directed Stuttering Therapy:Disputation of Irrational Beliefs Step

uMotivation u Teach the client to dispute his or her irrational

beliefs

uTechniques usedu Reading assignmentsu Discussion of basic modelu In-depth conversation about disputationu Introduction to on-line homework sheet

uHomeworku Revisit/dispute all the irrational ideas that were

noted in the identification stage


The REBT Directed Stuttering Therapy:Overcoming Dire Need to Be Approved Step

u Motivation u Without minimizing the dire need to be approved the client

will continue to be petrified by some speaking situationsu Techniques used

u Replacing the irrational idea with a more rational oneu Anti-shame exercisesu Practicing assertivenessu Have the client try something new at which they might fail

u Homeworku Written examples to be discussed in the dissertation


The REBT Directed Stuttering Therapy:Advertising and Voluntary Stuttering Step

u Motivation u Modify synapses in the brain to disassociate classically

conditioned fear response to speaking situations u Voluntary pseudo stuttering

u On words that normally would not be stutteredu Iowa bounce

u Advertising examplesu Wearing buttons or T-shirts about stutteringu Mention stutteringu In-depth conversation about therapy and stutteringu Hand out pamphlets about stutteringu Leave materials about stuttering or post them at work (if

appropriate)u On internet mention stuttering


The REBT Directed Stuttering Therapy:Building Fluency Base Step

uMotivation u Modify synapses in the brain to disassociate

classically conditioned fear response to speaking situations

uBackgroundu Proposed by Wendell Johnson, General

Semanticist and one of the greats in stuttering therapy

uHomeworku Practice massive talking while aloneu As more situations arise where the speech is

spontaneously fluent practice massive talking in these situations


The REBT Directed Stuttering Therapy:Rational Emotive Imagery Step

u Motivation u Provide an efficient alternative to in vivo practice and a way

to override less than satisfactory homework outcomes u Description of technique

u Imagine a difficult speaking situation and all the environmental cues as vividly as possible

u Immerse yourself in the unhelpful negative feelingsu Then change the unhealthy negative feelings to healthy

counterpart—panic is changed to watchfulness and/or concern

u Applicationsu Flashbacks of traumatic bullyingu Preparation for a public speech or interview


The REBT Directed Stuttering Therapy:Managing Secondary Stuttering Step (Movement & Tension

Substeps)u Motivation

u Provide an means to counteract operant conditioned non-speech associated muscle involuntary movements and tension in speech producing muscles

u Description of techniqueu Voluntarily introduce movements or tension identical to what one

has identifiedu Exaggerate these movements or tension

u First in isolationu Then in actual conversations

u Outcomeu At first, intellectual recognition that movements or tension can be

made voluntaryu Then the extinguishing of the secondary stuttering symptoms of

movement in non speech producing muscles or tension in speech producing muscles


The REBT Directed Stuttering Therapy:Managing Secondary Stuttering Step (Proprioceptive Feedback

Monitoring Substep)u Motivation

u Provide an means to counteract operant conditioned non-speech associated muscle activity via proprioceptive feedback

u Two componentsu Tactile feedbacku Kinesthetic feedback

u Techniqueu Note: auditory feedback was painful, so all speech monitoring

stoppedu Become aware of feedback through exaggerated motions

when no voicing takes placeu Introduce voicing when aloneu Start monitoring in actual speech situations


The REBT Directed Stuttering Therapy:Application of Adapted Conventional Stuttering Therapy

Techniques Stepu Motivation

u Convince the client he or she can moderate and manage his or her own stuttering and provide means to do so when the occasion demands to manage stuttering

u Techniques usedu Cancellation: Repetition of stuttered work in altered manneru Holding a block and bubbling out of it: Keep the sound in a block to

make it more voluntary and less struggling u Holding a block and pulling out of it: Keep the sound in a block to

make it more voluntary and smoothing out of itu Easy onsets: Using proprioceptive feedback and easy airflow to start

a wordu Using low vibrant voiceu Elongating vowelsu Handling on-coming blocks (preparatory sets or easy repetitions)


The REBT Directed Stuttering Therapy:Stabilization and Relapse Prevention Step

u Motivation u To enhance spontaneous fluency and be able to manage speech

u Stabilizingu Monitor unhealthy negative emotionsu Trace them back to irrational beliefsu Disputing irrational beliefsu Continue advertisingu Practice pre-empting on coming blocks

u Relapse prevention technique C-CHALE-ETu Chasing down irrationalitiesu Challenging and disputing the irrationalitesu Humoru Advertisingu Low vibrant voiceu Excluding relaxed calmnessu Elongating vowelsu Tracking down tension and releasing it


The REBT Directed Stuttering Therapy:Termination Step

u Motivation u Instill confidence and assure that help is available if

necessary u Handling termination-even if early

u Make sure that the client understands the therapy steps yet to be accomplished

u Assure client that he or she has some tools and that others are available on the internet

u Leave door open for consultation sessionsu Assure client that he or she can come anytime


The REBT Directed Stuttering Therapy:Limitations and Caveats

u Therapists need proper background trainingu When a client reports no significant

improvement when speaking alone more emphasis needs to be placed on conventional stuttering techniques

u Motivation, severity of genetic component, intelligence, and self-reliance are important factors

u Gender does not seem to play a big roleu Client may need social training skillsu Client may need remedial education to catch up

in building a career


What This Dissertation Has Accomplishedu Provided--for the first time--a complete definition of CPSS that includes

both observable and unobservable phenomena as well as avoidances and making self-limiting life choices

u Provided a new, original, detailed and complete model of the etiology and reasons for perseverance of CPSS enumerating stages in development

u Provided a new, original therapy step sequence for approach to resolving CPSS

u Emphasized cognitions (beliefs) and emotions in contrast to conventional therapies that try to re-teach how to talk

u It follows the neuropsychology evidence that indicates that the brain has to be modified through massive desensitization and homework

u The therapy is driven by a theory of development that is based on widely accepted epigenetic systems developmental model

u Includes both classical and operant conditioning both in developmental stages and therapy steps

u Therapy steps are conducive to building a therapy manual to test out the effectiveness and efficiency of therapy

u Details of therapy protocol make it available to both to psychologists and SLPs


Current Zeitgeist Compatibility & Future Directions

uCompatibility with current Zeitgeistu Captures the current zeitgeist of Evidence Based

Practiceu Is compatible with current search for application of

psychology to the problem of stuttering

uFuture Directionsu Write a therapy manualu Test for effectiveness and efficiencyu Do horse race studies determining how it stacks up

against conventional therapies


Summary of Dissertation1. From the holistic point of view exhaustively defined all aspects that

characterize a person with Chronic Perseverative Stuttering Syndrome. This includes stuttering behaviors, emotions, irrational beliefs, and self-limiting behaviors.

2. Proposed a new theory of how stuttering develops based on current neuropsychological research and Rational Emotive Behavior Therapy (REBT) listing all the stages that a person who stutters goes through during his or her lifetime.

3. Built a step by step REBT based therapy which also includes as a subset some of the conventional treatment techniques, but focusing mainly on the emotions and beliefs of the person who stutters.

The outcome is expected to be, just like in my case, periods of spontaneous fluency with a fallback of managed fluency. The main technique for managing fluency is an easy re-repetition that is used to pre-empt when a person “hears the footsteps of an oncoming block” or bubbling out of a hard block.


Treatment of Stuttering With Rational Emotive Behavior Therapy

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