Approaches to the Treatment of Stuttering

Peggy Dalton

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429755040
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

In the years prior to publication 'cures' for stuttering seemed to appear constantly, but many were of limited value, were poorly evaluated and gave only a temporary alleviation that was not transferred to daily life. More responsible clinicians produced publications expounding one particular approach to therapy but less was available giving a balanced overview which was of practical help to therapists.

Originally published in 1983, this book aimed to provide such an overview, with a focus on practical intervention rather than on theory. The need for careful assessment is particularly stressed and also the need for flexibility in the choice of treatment for any one client. Changes in fluency are looked at in relation to the effects they might have on the person's life as a whole and factors involved in the maintenance of this change are discussed.

In addition, adjuncts to speech therapy, such as drugs, hypnosis and various forms of masking are evaluated. Issues of the training of therapists are raised and suggestions made as to the nature of the therapeutic relationship when working with people who stutter.

1  INTRODUCTION

Peggy Dalton

Theories and Therapy

This book is concerned with current approaches to the treatment of stuttering. No attempt will be made to cover the theoretical background related to its causes or development. These aspects are discussed fully in such volumes as Van Riper (1982) and Wingate (1976). Therapy is devised, however, on the basis of the clinician’s understanding of the nature of the problem. In this section, therefore, we shall look briefly at some of the ways in which contemporary workers define stuttering and the implications these definitions hold for the ways in which treatment is planned and executed.

Van Riper, for example (1971), states simply that ‘a stuttering behaviour consists of a word improperly patterned in time and speaker’s reactions thereto’ (p. 15). But his therapy, developed over many years, is founded on ‘learning theory, servotheory and the principles of psychotherapy’ (1973, p. 204). The steps involved in his complex treatment programme incorporate measures to deal with three major aspects of the problem as he sees them. The client is helped to unlearn old maladaptive responses to the threat and experience of fluency disruption and learn new and more adaptive ones. To counter the failure in the auditory processing system, which Van Riper proposes as the likely cause of the basic disruptions, stutterers are trained to monitor their speech by emphasising proprioception, thus by-passing the auditory feedback system. And psychotherapy, to bring relief from the psychopathology that he regards as so often surrounding the disorder in adulthood, is interwoven throughout all therapeutic interactions. Cheasman discusses Van Riper’s treatment approach in some detail in Chapter 4.

Ryan (1974), also describes stuttering in terms of three components: a speech act, an anxiety component and an attitude component. To him, however, it is the speech behaviour which produces the anxiety and attitude problems and he therefore focuses his attention in therapy on the improvement of speech fluency. Approaching stuttering as operant behaviour, which is ‘overt, has an impact on the environment and is controlled by its consequences’ (p. 7), he seeks to control disfluency by manipulating both the evoking stimuli and the consequences. The evoking stimuli take the form, for example, of instructions to ‘speak very slowly and as fluently as you can’, while the consequences may be ‘very good’, if the speaker is fluent, or ‘no, don’t do that’ if he stutters, both resulting in a decrease in disfluency. These procedures are programmed in very small steps from one-word utterances to lengthy conversations, as outlined by Rustin and Cook in Chapter 3. These authors evaluate the usefulness of such an approach in relation to work with children. In Chapter 4 Cheasman comments on its applicability to therapy with adults.

While Perkins (1979), also focuses on the speech act in his definition of stuttering as ‘dis-co-ordination of phonation with articulation and respiration’ (p. 105), his treatment programme is very different from that of Ryan. He works directly on achieving fluency through management of the breath-stream in order to initiate voice with a gentle onset and maintain airflow throughout the phrase. Though articulatory rate is slowed in the early stages to facilitate co-ordination with phonation, natural rhythmic patterns are introduced from the beginning as the key to developing normal-sounding speech without loss of control at faster rates. Unlike Ryan, Perkins does not see anxiety and negative attitudes as being automatically altered with changes in fluency, but unlike Van Riper, he does not include desensitisation or psychotherapeutic procedures in his programme. He estimates that ‘even the most diligent users of normal-sounding speech will likely require about five years to feel as normal as they sound’ (1979, p. 109).

A completely different view of stuttering from any of the above is taken by Sheehan in his later work. In an earlier attempt to define the problem (1958), he too included three components, similar to those presented by Ryan. One describes the disfluent speech behaviour, the second the fears and anticipations of speech failure and the third the self-concept the person develops as a stutterer. But by 1970 Sheehan had come to focus almost entirely on the psychological effects of stuttering and described it as ‘a disorder of the social presentation of the self … not a speech disorder but a conflict revolving around self and role, an identity problem’ (p. 4). Not surprisingly, therefore, his treatment is different again. He questions whether it should be referred to as speech therapy at all, since ‘the stutterer does not have to be taught how to speak, or anything about speech, per se’. He prefers the term ‘specialised psychotherapy’ to describe his approach, which includes the client accepting openly the role of stutterer, changing attitudes to effect a reduction of shame, hatred, embarrassment and even ‘stuttering on purpose’ (p. 19). Sheehan’s Avoidance-Reduction Therapy is discussed in some depth in Chapter 5.

It will be seen from these few examples that contemporary therapy for stuttering can take widely differing forms, both in the emphases and in the procedures used to bring about the alleviation of the problem. Each of the authorities referred to has made changes in the light of clinical experience and with the advancement of knowledge through research and technological progress. Yet though they and others who work with such thoroughness and concern to improve their methods of treatment can claim success with many who participate in their programmes, no one has developed an approach which can be universally applied to all who seek help. Stuttering is clearly not one single disorder. It is important, therefore, for the working clinician to assess what each therapeutic approach has to offer and to choose those treatment stategies which seem most appropriate to a particular client’s needs.

The Assessment of Stuttering

Throughout this volume it will be found that great emphasis is placed on the assessment of stuttering as a basis for such a choice. The next chapter is devoted to an exposition and evaluation of procedures for investigating both the nature of the disfluency and its effects on the speaker’s attitudes towards communication and concept of himself as a person. It is stressed that analysis of the speech pattern forms only a part of our preparation for treatment. If we are to decide on a course of action to alleviate stuttering we need also to understand how disfluency is experienced by a child or an adult, how parents or other significant people react to it, and what part it plays in governing the person’s behaviour as a whole. It is equally important to try to judge the extent to which changes in speech will demand other changes and take this into account before we launch into a fluency programme.

This exploratory stage is seen as going far beyond the gathering of information. Rustin and Cook in Chapter 3 show how, by means of their extensive interviews with children and their parents, they attempt to build up a picture of the young person they are dealing with and to understand fully the circumstances in which the child and those round him will have to work. They see this as a period when the rapport essential to a successful outcome is established with all concerned, and they base their choice of treatment as much on these factors as on the extent and severity of the child’s disfluency.

Similarly, in Chapter 4, Cheasman stresses the importance of the diagnostic phase of the intensive courses at the City Lit. Here, adult clients are fully assessed and given the opportunity to explore the overt and covert aspects of their problem. Trial therapy procedures are followed to allow them to test out not only the usefulness of various techniques but their own reactions to them. An approach is chosen as appropriate to each person on the basis of his or her attitudes towards what is involved, as well as an analysis of the stuttering behaviour.

Chapter 5 includes a discussion of personal construct procedures, which can be seen to be therapeutic in themselves, as well as forming part of the assessment in this particular approach to stuttering. As the client goes through the stages of setting up his own repertory grid (Kelly 1955) and writes a sketch of how he sees himself in his current position, he may already begin to look at people and events from a new angle. Sharing some part of his outlook on life with another forms the beginning of a relationship which will prove of considerable importance if real progress is to be made. Here, too, the therapist is gaining knowledge of how the client functions as a whole and her initial plans for treatment will be based on her understanding of him as a person and the circumstances in which any course of action will be framed.

Lees, in her chapter on adjuncts to speech therapy, sees diagnostic potential in some of the methods used to alleviate stuttering through external agencies – masking, biofeedback and drugs. Noting the recurrent finding that while some people who stutter become at least temporarily more fluent while using these means, others are unaffected by them, she suggests that further research might bring to light subgroups of disfluency. This could contribute both to our understanding of a particular client’s problem and our choice of the most appropriate procedures to mitigate it.

The Choice of Treatment

This book contains descriptions and evaluations of many techniques, programmes and approaches. These are, however, only a sample of the hundreds that are available. Responsible clinicians offering a specific course of treatment acknowledge that theirs is not the only method and that, while they have their successes, there are always those who cannot be helped through their programmes. Claims for instant and lasting ‘cure’, though attractive to the media and, understandably, to those who stutter or have disfluent children, are regarded with a distaste which comes from long experience and concern for the well-being of clients, rather than any threat to their own professional work.

An alternative to following one particular approach in treatment is for the clinician to equip herself with a wide range of skills and attempt through careful assessment to choose those procedures which seem relevant to the client in question. This is not a matter of dipping into what Sheehan (1970) has called ‘the Smørgasbørd of stuttering therapy’ (p.294). The clinician rather considers all aspects – the nature and severity of the disfluency, the psychological effects that the speech difficulty has produced, the context within which any improvement has to take place – and, with the client, sets up a balanced programme where due weight is given to each component. Eclecticism in one’s approach to treatment is advocated by a number of contributors to this volume and it will be seen that this does not imply the woolliness often associated with the term. It is urged that all procedures used should be integrated into a course of therapy which has both structure and relevance and its purposes clearly understood by those involved.

The Structure of this Book

Although, to a large extent, each chapter of this book is complete in itself, there is some interdependence where topics overlap. To save reiteration, for example, Hayhow (Chapter 2) has focused in her discussion of assessment on the differential diagnosis of disfluency in the very young child and then turned her attention to adults. Since Rustin and Cook (Chapter 3) present their assessment of the older child as an integral part of their therapy, it was felt unnecessary to cover this ground also in Hayhow’s chapter.

Cheasman and Levy (Chapters 4 and 6) include two aspects of the therapy carried out at the City Lit. In Chapter 4, techniques and programmes are discussed and in Chapter 6 the group context within which this work is undertaken is described. Levy, therefore, assumes that the reader will be familiar with any techniques to which she refers.

Grids and self-characterisations (Kelly 1955) are referred to both as aspects of assessment (in Chapter 2) and as part of therapy (Chapter 5). Again, to save duplication, Dalton has largely left the description of these procedures to Hayhow and it is important that those are read first, in order to make full sense of references to them in the later chapters.

The concluding chapter is in no way a summary of all that has gone before. Here, an attempt is made to address the major issues for the therapist who works with those who stutter. No single format is suggested as the answer to all treatment problems. There is no ideal clinician presented for workers in the field to model themselves upon. Only some suggestions are made with regard to training, the therapeutic relationship and the aims of therapy for stuttering.

References

Kelly, G.A. (1955) The Psychology of Personal Constructs, Norton, New York

Perkins, W.H. (1979) ‘From Psychoanalysis to Discoordination’ in H.H. Gregory (ed) Controversies about Stuttering Therapy, University Park Press, Baltimore, pp. 97–127

Ryan, B.P. (1974) Programmed Therapy for Stuttering in Children and Adults, Charles C. Thomas, Springfield, Illinois

Sheehan, J.G. (1958) ‘Conflict Theory of Stuttering’ in J. Eisenson (ed.), Stuttering: A Symposium, Harper and Row, New York, pp. 123–66

—— (1970) ‘Role-Conflict Theory’ in J.G. Sheehan (ed.), Stuttering: Research and Therapy, Harper and Row, New York, pp. 4–34

Van Riper, C. (1971) The Nature of Stuttering (1st edn), Prentice Hall, Englewood Cliffs, N.J.

—— (1973) The Treatment of Stuttering, Prentice Hall, Englewood Cliffs, N.J.

—— (1982) The Nature of Stuttering (2nd edn), Prentice Hall, Englewood Cliffs, N.J.

Wingate, M.E. (1976) Stuttering: Theory and Treatment, Wiley, New York

2 THE ASSESSMENT OF STUTTERING AND THE EVALUATION OF TREATMENT

Rosemarie Hayhow

The assessment procedures currently used with people who stutter are generally agreed to be inadequate. The aspects of the individual and his problem that are considered relevant to assessment are largely...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Contents
• Contributors
• Preface
• 1. Introduction: Peggy Dalton
• 2. The Assessment of Stuttering and the Evaluation of Treatment: Rosemarie Hay how
• 3. Intervention Procedures for the Disfluent Child: Lena Rustin and Frances Cook
• 4. Therapy for Adults: an Evaluation of Current Techniques for EstabHshing Fluency: Carolyn Cheasman
• 5. Psychological Approaches to the Treatment of Stuttering: Peggy Dalton
• 6. Group Therapy with Adults: CeliaLevy
• 7. Maintenance of Change: Towards the Integration of Behavioural and Psychological Procedures: Peggy Dalton
• 8. Adjuncts to Speech Therapy: Roberta Lees
• 9. Major Issues for the Therapist: Peggy Dalton
• Index