Study Guide for Charles Van Riper's
The Treatment of Stuttering
Following are my study notes for pages 203 - 368 of The Treatment of Stuttering, by Dr. Charles Van Riper (1973). Englewood Cliffs: Prentice Hall. Although out of print, the contents of this book are still copyrighted. These notes are provided to assist students and to interest others in exploring this classic work, in the hope that it will one day be refurbished and republished. While steeped in mid-20th century behavior modification therapy, Van Riper's work truly indicates a holistic approach to therapy for stuttering, giving it continued relevance. - Darrell Dodge.
CONTENTS
The Design of Therapy | Diagnosis: Initial Evaluation | Motivation
Identification | Desensitization | Modification | Stabilization
THE DESIGN OF THERAPY
The Bases of Our Therapy
The Therapeutic Schedule
- Learning Theory - new responses
- Servo therapy - proprioception
- Psychotherapy - for secondary expectancy neurosis (refer for primary)
The Therapeutic Sequence
- Intensive program for 3-4 months
- Minimum: 1 hr 3 days/wk, 1 hr group 3 days/wk, & daily self therapy
Identification Phase
Desensitization Phase
- Explore, analyze & classify overt and covert behaviors
Modification Phase
- Decrease speech anxieties and other negative emotions
- Toughen to threat, confrontation & experience of fluency failure
Stabilization Phase
- First vary and then unlearn habitual avoidance and struggle responses
- Learning, through counterconditioning, a new, fluent, less abnormal way of stuttering
Provision for Individual Differences
- Consolidate gains
- Create generalized sets to automatize new speech behaviors
- Develop proprioceptive monitoring of normal speech
Learning Theory
- Vary stress and time spent on stages or steps within stages
Stuttering Therapy as Unlearning and New Learning
The Targets of Learning and Unlearning
- Learning better ways of coping with stuttering when threatened or occurs
- Unlearn avoidance and escape behaviors
The Learning Process
- Each PWS has unique set of coping reactions
- Prevent reinforcement of fear and abnormality that maintains stuttering
- Habitual responses
- Goal should not be zero stuttering, this just reinforces avoidance behavior
- Reward open stuttering behaviors to extinguish shame
- Modify stuttering
- Learn "Easy Stuttering"
- Treat appearance of stuttering and fears as opportunities to learn new responses
- Extinguish false role conflict (i.e., contradiction of "disfluent normal speaker")
Learning of stuttering behavior
Learning in Therapy
- Classically conditioned fears of words, sounds, listeners, conditions and situations
- Learned emotional reactions
Servo therapy
- Expose PWS to conditional stimuli while extinguishing the conditioned response
- Counter condition new responses
- Use flooding, negative practice, reinforcement and limited punishment
- Modeling of behavior by therapist
Psychotherapy
- Replace auditory monitoring with proprioceptive feedback
- Use masking noise & DAF, varying application to individual responses
- Attend to motor aspects of utterance
[ Contents ]
- Most PWS are emotionally normal
- Normal PWS neuroses are secondary in nature (as the result of stuttering)
- Psychotherapy without speech therapy shows the lowest fluency improvement
- Use of group therapy beneficial
Diagnosis - Initial Examination
Obtain Speech Sample
- Demonstrate knowledge of stuttering
- Verbalize stutterer's feelings
- Demonstrate knowledge of range of overt and covert behaviors
Explore Client's Stuttering Behavior
- Use audio and video recorder
- Upon stuttering, ask PWS if this is typical
Assess Client's Normal Speech
- Comment on stuttering as it arises
- Invite PWS to comment on strategic function
- Identify prominent and consistent stuttering behaviors
- Note hierarchical sequences (coping & release strategies, etc.)
- Characteristics of syllabic repetitions (number, length, intensity, sounds etc.)
- Presence/absence of fixation phenomena
- Disruptions of timing, phonation and articulation
- Loci of stuttering moments (sounds, words, position in sentence)
- Presence of airflow impedance
- Occlusion locations (larynx, tongue, lips, etc.)
- Variability and consistency of behaviors
Anticipatory Characteristics
- Characteristics of rate, pitch, intensity, and quality
- How much talking does he/she do?
Explore PWS's Life History
- Ability to predict moment of stuttering (Underline feared words or ask to signal expectancy during speech)
- Ask to recount experiences when stuttering was traumatic or severe
- Get impression of hierarchies of situation difficulty
Clinical Procedures
- Explore stuttering onset and development history
- Discuss penalties and listener rejections
- Discuss possible profits and secondary gains
- Discuss previous therapy
- Evaluate body presentation (tensions, etc.)
- Emotional feelings about stuttering
Trial Therapy
- Response to masking noise and DAF
- Fluency in singing, whispering, unison speech, and shadowing
- Test breathing abnormalities (polygraphic recording)
- Allow PWS to hear/see recorded speech samples and ask about reactions
- Explore response to simulated communication stress
Provide Sum Up
- Skill at behavior modification
- Appraise client motivation
- Appraise severity of the behavior
Severity of Stuttering in Terms of Prospective Therapy (Prognosis)
- Provide summary of therapist's impressions
- Ask for autobiography at next meeting
- Invite PWS to participate in the therapy process
PFAGH + Sf Wf + Cs Ss = ---------------------------------- M + Fl Where:[ Contents ]
P = vulnerability to penalties of stuttering
F = frustration
A = anxiety
G = guilt or shame
H = hostility
Sf = situation fears
Wf = word fears
Cs = communication stress
M = morale or ego strength + motivation
Fl = fluency client already possesses
MOTIVATION
The Stutterer's Motives
- Determines eventual success of therapy
- Key is to get client involved in the design of therapy as well as its performance
The Costs of Therapy
- Cannot be assumed
- Must be discovered, nurtured and sometimes created
Varying Levels of Motivation During the Course of Therapy
- Costs of confrontation, work and stress of change
- Clients will not work without promise of payoff
- Key is ability to create perception of higher payoff than cost
Motivation Difficulties in Therapy
- Must be evaluated continuously in terms of cost-payoff ratio
- Acknowledge reasons for decreased motivation ("honeymoon" effect, early/partial success, passivity, need to vent or intellectualize, denial, fear of stuttering behavior, increased or decreased fluency)
Goal-Setting Difficulties
The Aversiveness of Stuttering
- cumulative effect of past failures
- unrealistically high goals
- distorted self-concepts ("giants in chains," or "Jekyll & Hyde" lack of integration)
- handling of denial and need to allow maintenance of needed defenses
Lack of Trust in the Therapist
- unpleasantness of facing stuttering behavior
- strongly reinforced conditioned avoidance responses
- avoidance must be expected until client is ready to confront
Reluctance to Surrender Secondary Gains
- past experience with token or unwise therapy
- therapist needs to establish competency
Problem When Stuttering as Only a Minor Nuisance
- acknowledge reality of secondary gains
- sufficient to explain all motivation problems in normal PWS
- may not explain all motivation problems in neurotic PWS
Revealing the Therapist's Competence and Commitment
- Behavior may not be sufficiently painful to motivate change
- Avoidances may be working
The Inevitable Challenge
- Show understanding
- Lead initial discussion of diagnostic goals
- Describe experience with large number of PWS & behaviors
- Show ability to analyze and imitate his behaviors
- Reveal understanding of, and sympathy for, covert behaviors & avoidances
Providing Hope that Stuttering is Modifiable
- How therapist responds to "can you cure me?" can determine failure of success of treatment
- Therapist as experienced guide
- Some will doubt competence of therapist who claims quick cure is possible
- Verbalize his doubts and his need to be certain of therapist's dedication & concern
Motivational Arousal Through Planning
- Demonstrate proof of change in past clients
- Demonstrate client's own ability to modify speech behavior
- Long range goal of acquiring behaviors which characterize an adequate human being
- Model behavior
- Reward for socially-rewarded behaviors (honesty, courage, etc.)
- Increase positive self-statements through operant conditioning
Subgoals and Motivation
- Provide sketch of a sequential course of therapy
- Put plan in concrete terms
- Ensure client you have a map of therapy course
Reinforcement
- This therapy is a psychotherapeutically-oriented activity therapy
- Counteract learned helplessness by involving client as active partner in therapy
- Discuss probable reactions during performance of agreed-to activities
- Emphasize that therapy is an interaction between the client and therapist
Therapist needs to constantly reinforce learning and behavior change
Available Reinforcers
Self Reinforcement
- Humans differ in how they respond to difference reinforcements
- Therapist's approval or disapproval is major reinforcer (But must be used with care to avoid passivity and dependency)
Approval for What?
- Transfer from therapist approval to self-approval
- "Premack's Principle" - in any pair of responses, the more probable will reinforce the other (defer pleasant activities or "work before pleasure.")
- Encourage self rewards for behaviors
Other Positive Reinforcers
- Reward progress, not single performances
- Identify gains as progress toward goal
- Reward open stuttering and other modifications of behavior
Negative Reinforcement
- Tokens
- Social reinforcement
- Be open to client preferences (provide meaningful rewards)
- Reward for stuttering
- "Embed" difficult tasks in pleasant or rewarding activities
Escape from punishment or unpleasant activities by changing behavior or accomplishing difficult tasks
Punishment
[ Contents ]
- Use very rarely and with discretion
- Help reduce "invisible self-beating" common to confirmed PWS
- Usually restrict to "counterconditioning" (punish old behavior as new is rewarded)
- Punish behavior, not person
- Explain rationale behind use of punishment
- "Time outs" - withholding attention as long as a desirable behavior was not produced.
IDENTIFICATION
Identification of overt and covert behaviors
Opportunity to establish client-therapist relationship
Therapist's Role
Role in Therapy course
- Give PWS responsibility & make part of therapy
- No demand for modification
- Strengthen approach gradient
Identification procedures
- Demonstrates that stuttering will not be punished
- PWS usually totally unaware of actual behavior
- Provides opportunity for early desensitization
The Hierarchy of Identification Therapy
- Collect categories of stuttering behaviors (as they reflect dynamics of coping reactions)
- Behaviors originated in purposeful actions
- Progress in this phase is anxiety reducing
Provide guidance in addressing progressively more difficult behaviors
Identifying the Target Behaviors: The Fluent Stuttering
- Fluent words
- Short easy stutterings
- Avoidance behaviors
- Postponements, timing tricks, and verbal cues
Identifying Avoidance Behaviors
Collecting Postponement Behaviors
- When PWS collects and classifies these he brings confronting stuttering & himself on a deeper level
- Less severe PWS are usually best at avoiding
- May provoke emotionality
Identifying Timing Behaviors
- Postponement is an avoidance in time
- Use of starter words
- Stereotypes sequences of postponement activities (speech & body movements)
Modifying the Verbal Cues
- Starter behaviors
- Attempt to terminate delay and begin speaking
- Can include head jerks, arm movements and breaths
- These provoke the most listener penalty
Identifying the Situational Cues
- Phonemic and positional cues that signal approaching stuttering & word fear
- Ask PWS to collect samples
- Ask questions about his behavior and its cause
- Fear of fear itself important in this area
Identifying the Core Behaviors
- Involves direct confrontation of self images
- PWS has huge collection of bad memories, traumas & fears
- Provide feared speaking situations with therapist present
- Therapist can model pseudo stuttering in these situations
Use triads to show contrast between fluent and stuttered utterance
Begin proprioceptive training
Allow self corrections to happen
Encourage active exploration by PWS
Model and discuss tremors and loss of control
- Use videotapes and mirrors
- Isolate and analyze specific stuttering sounds/events
Identifying Foci of Tension
Identifying Repetitive Recoil Behavior
- Each PWS has unique set of tension foci
- Make aware of detachment from actions & blackouts
- Have PWS feel facial area during stutters to heighten awareness
Identification of Post Stuttering Reactions
- Explore runaway blocks (often contain "schwa" vowel)
Identifying Feelings of Frustration
- Explore feelings which result from stuttering (Frustration, shame, hostility)
Identifying Feelings of Shame
- Both during and after speech
- Allow sharing and venting
Identifying Feelings of Hostility
- Often associated with listener penalties
- Some PWS will expect/need great amount of support in this area
- Some PWS will need to wallow, which must be allowed
[ Contents ]
- Wide variations
- Usually more anger associated with speech stoppages
- Frustration leads to blowups
- Hostility due to resentment of listener penalty
- Therapist may become target of anger
DESENSITIZATION:
THE REDUCTION OF NEGATIVE EMOTION
PWS fears are not irrational; they are based on the stigma of stuttering
Need to reduce strength of attendant emotional upheaval
Aimed at three targets:
The Therapist's Role
- Confronting abnormality of stuttering
- Tolerating fixations and oscillations
- Communication stress & listener penalty
How to Desensitize
- Create Zone of safety and security
- Control conditions of communication to explore limits of stress tolerance
- Allow and encourage stuttering
- Develop therapeutic relationship that allows therapist to exert control over covert behavior
Recognizing Negative Emotionality
Constructing Hierarchies
- Look for overt sings of emotionality
- Examine fluent and stuttered speech for signs of tension and emotion (eye movements, "mask like" appearance.)
Targets of Desensitization Therapy
- Create hierarchies of stimulus sets
- Allow PWS to experience each item repeatedly to decondition reaction
Confrontation of the Disorder (dealt with in Identification Phase)
Confronting Core Behaviors or moments of stuttering (fixations & oscillations)
Desensitization to Listener Reaction
Counterconditioning
- Build resistance to communication pressures (Hurry, sudden challenge, interruptions, noise, questions and doubting)
- Devise hierarchies of listener reaction to experience/confront in clinic
Link an anxiety-inhibiting response to a stimulus that formerly evoked anxiety
The Therapist as a Counter conditioner
Assertive Responses
- Provide acceptance of stuttering and emotionality through every phase of hierarchy
Disinhibition
- Practice assertive responses as modification of usual role
Systematic Desensitization Using Relaxation
- Release inhibitions by starting with low stress and working up
Pseudo stuttering in Desensitization
- Relaxation alone usually won't affect stuttering
- Success in therapy is best relaxant
Pseudo stuttering as Self Disclosure
- Demonstrate and experience stuttering without excessive emotionality
- First experiences must use a kind of stuttering that is not traumatic
- Learn in therapy room
- Therapist models stuttering to an observer as PWS watches until listener gives negative response
- Therapist models easy repetitions gradually modeling PWS's behavior, showing no reaction to it.
- PWS imitates these steps while therapist watches
- Ignore real stuttering in this stage
- Only ask to remain calm on fake stutters
Misuses of Pseudo stuttering
- PWS hides stuttering to hide deviancy
- Relief is experienced by stuttering openly
Adaptation
- Should not be used indiscriminately; only purposely
- Should not be used to punish listener or himself
"The Bath of Stuttering"
Nonreinforcement
- Fill life with planned stuttering behaviors or read long passage, stuttering on every word;
- Constant stuttering can create reduction in anxiety (combine real and faked stuttering)
- Exaggeration of consequences of stuttering are revealed
- Reduction in stuttering indicates it is not an instrumental or operant response
Negative Suggestion and Flooding
- Say stuttered words over and over, from pantomime to loud
- Return to earlier step if unsuccessful
Response Prevention
- Flood PWS (while speaking) with statements that he is going to fail
- Externalizes inner message
- Learns to doubt his own self-suggestions
Adaptation with Negative Suggestion
- Escape responses are stimuli for conditioning
- Encourage PWS to throw himself into stuttering blocks
Adaptation to Stress
- Prolong pseudo stuttering while therapist vocalizes negative suggestions
- PWS rejects negative commentary and starts to distrust his own
- Reduce conditioning of stuttering as a stimulus in itself
Eliminating Other Sources of Anxiety
- Works better for interiorized PWS
(Address other personality problems that may contribute to stuttering)
Reassurance
The Anxiety Reduction Effect of Modifying Stuttering
- Best reassurance is success
- Don't provide false reassurance. It will backfire.
[ Contents ]
- Best technique to do this is to confront
MODIFICATION
Hold out vision it is possible to stutter fluently
Avoidance and escape behaviors do not extinguish easily
Stutterer must change as well as stuttering
Variation
- Revise self-perceptions & ways of coping with stuttering
The Exploration of Self
- Beliefs are organized into a consistent system that supports stuttering
- Try to introduce changes in PWS' way of living
Varying Behaviors
- Identify idiosyncratic patterns of thinking, feeling & acting
- Promote an analytical self-awareness of what PWS can alter
Role Playing
- Self assigned "rut-breaker" tasks
Attitudinal Change
- Break up behavioral rigidity by trying out other points of view
- Role enactment to free PWS (often more fluent when playing a part)
Varying the Stuttering Behaviors
- Rational psychotherapeutic procedures may facilitate
- Try on new attitudes
Anticipatory Behaviors
Varying the Escape Behaviors
- Postponement & avoidance reactions easiest to change
- Assignments to vary reactions & postponements
- Change starter words
- Use with people outside clinic
Modification: Teaching of Fluent Form of Stuttering
- Model escape behaviors (head jerks, etc.) & show how they can be varied
- Alter ritualistic behaviors by reversing their order, omission, or insertion
Goal is to modify and shape the form of stuttering
Sequence ordering produced - as close as possible to normal utterance
- without impairing PWS communication
- without contributing to maintenance of disorder
Change articulatory postures and speech habits in some way
Behavior inappropriate to normal sound/word/utterance production should be error signal for altering
Clarifying the Motor Model
Proprioceptive Monitoring: Masking
- PWS insulates self from hurt by buffering proprioceptive & tactile awareness of speech
- Need to increase awareness of motor movements (let servo system do job of automating speech)
Enhancing Proprioceptive Awareness by DAF
- Intensive training in proprioception and tactile monitoring
- Mask auditory input to enhance awareness of proprioceptive/tactile feedback
- Try pseudo stuttering/speaking with masking noise
Proprioceptive Monitoring Through Pantomiming
- Have PWS watch speech under delay
- Use to increase proprioception, not to control rate
- desensitize to increasing volume
- record DAF speech and play back
- goal is to sound same in normal speech as under DAF
- Use electrolarynx (?)
Program rewards to reinforce specified performances
- Creates carryover from DAF to normal speech
- Mouth words in stressful situations (concentrate on movement and feel of speech)
- Intensive learning process involved
Cancellation
- By seeking out previously avoided situations, secondary gains fall away
Cancellation as a Preventative of Stuttering Reinforcement
- Basic form of therapeutic confrontation
- More than repetition of a stuttered word
- Use as a vehicle for learning new responses to situations that trigger abnormal speech
The Pause
- Delay reinforcement of stuttering so it loses effectiveness
- PWS usually flees dysfluency and moves forward to escape (until another is encountered)
Resistance to Contingent Pausing
- Deliberate delay rather than plunging forward (breaks reinforcement cycle)
Necessity for Completing the Stuttered Word Before Canceling
- Silence is aversive to PWS (assignment will cause resistance)
- Therapist should model pauses
- Use groups to demonstrate how others do it
- All other therapy omitted/suspended
Using the Pause for Calming
- PWS needs to learn how to unify word
- Don't use a bounce (reinforces word disunity)
- Use slow motion, prolonged sequencing
- Use in normal conversation whenever possible
Filling the pause
- Needs to be long (3 sec or more) to have calming effect
- May have difficulty due to subjective time distortion and fear
- Use after stuttering - calming is easier
- PWS may receive positive feedback from listeners when pauses inserted (Shows he is in control; less scary to them)
Cybernetic Aspects of Canceling
- After pause, reduplicate stuttering in pantomime
- Rehearse a revised/modified version of the stuttering
- Then can continue with cancellation
- Listeners regard this with respect
- Reinforces revisions of stuttering
- Repeat in a small whisper
Overt Cancellation
- Gives PWS chance to scrutinize dominant features of dysfluency
- Silence emphasizes pantomime rather than auditory monitoring
Shaping
- PWS says word again in strong, deliberate, slow motion manner, highly sequenced
- In beginning, some features of stuttered word can be present
Modification of Stuttering During Its Occurrence
- Vary manner of articulation and vocalization
- PWS learns other, better ways of stuttering
Pull-Outs - Apply modifications during moment of stuttering
Pulling out of Fixations
Pulling out of Tremors
- Prolong fixations & find way to slowly sequence transitional movements
Release from Laryngeal Closures
- Slow down frequency and smooth them out
- Voluntarily throw jaw, lips and tongue into similar tremors
- Explore how tremors begin
Release from Clonic (Spastic Muscular) Behaviors
- use "vocal fry" as transition from blockage to airflow
- Have PWS experiment with how to perform this voluntarily and deliberately
Getting Control of the Uncontrollable
- Slow down repetitions; change recycled syllable from schwa to appropriate vowel
- Encourage PWS to experiment with voluntary variations
- Prolongation should not become invested with tremor
Pull-Outs as the Consequence of Cancellation
- Voluntary searching for proper coarticulation and sequencing
Motor Planning and Preparatory Sets
- Use of cancellation technique may lead some PWS right into pull-outs
Motor plan breaks down because articulators are in unnatural position for utterance
"Set" is plan to begin word in a more normal fashion
Plan includes slower sequencing, all sounds and transitions slowed proportionately
Need to raise awareness if PWS not conscious of motor activities
Motor Planning: Normal and Abnormal
[ Contents ]
- Distraction techniques just replace sets with new ones; don't touch abnormal articulation
- Need to develop competing sets which modify the abnormal ones
- Establish clear motoric model of new variation (repeat stutter in pantomime and then revise)
- Hunt for "trophies" - feared words to modify (begin with pantomime to establish proprioception)
- Omit pantomiming once success has been achieved
- Don't let set-developing pauses become postponements
STABILIZATION
The Need for a Stabilization Stage in Therapy
Resist temptation to terminate therapy prematurely
Activities of the Stabilization Period
- If two learned responses are equal today, the older will be stronger tomorrow (Jost's law)
- Old latent stuttering behavior has been reinforced for many years, but may reappear under stress
- New personality may be disruptive, difficult to integrate & cause stress
- Speech rate can increase
- Client's "normal" speech is not yet natural (presence of gaps and holes)
Reconfiguring Fluency
- Therapist as consultant
- Client acts as his own therapist
Shadowing in Stabilization
- Speak in longer segments, eliminating gaps and holes in speech
Prosody and Formulation
- Simultaneously echo another person's speech to get feel for prosody
Continuous Speaking
- Learn to use cancellation on whole phrases and sentences
- Employ immediate oral paraphrasing of written passages
Increasing the Rate
- Create experiences in continuous extemporaneous speaking
Reflecting
- Increase maximum rate to automate preparatory sets
- Insert fluent stuttering to facilitate creation of "generalized sets" (see below)
Automatization of Sets And Strategies
- Reflect or mirror back thoughts of others in conversations
Generalized set creation by:
Preparing for Contingencies
- Repetitive reading of formerly feared words
- Repeat fluency-enhancing techniques (e.g., loose contacts) at varied rate
- Train self to focus on proprioception
Generalization
- Attach new generalizations to as many behaviors as possible
- Massed practicing of new behaviors
- Develop specific contingency strategies to addressed possible problems with formerly feared sounds
Extinguishing Fears
- Attach new responses to large number & wide range of stimuli
- Seek out communication situations & touch them with new learning and fluency.
Nucleus Situation in Stabilization
- Massed practice of formerly feared sounds and words
- "Wipe out" sessions for old fears.
Buffering
- Continue to use pseudostuttering, pull-outs, cancellations and proprioception in targeted "nucleus situations"
Resistance Therapy
- Use groups to create flooding with high stress situations/conditions
- Use people who cause PWS special stress
Other Resistance Activities
- Resist suggestion that stuttering is inevitable in presence of certain situations or phonemic cues
- Practice saying words normally despite presence of cues.
- Develop ability to consciously "will" self not to stutter
Reintegrating the Self Concept
- Resist modeled stuttering
- Resist conscious self-suggestions of impending stuttering
- Use DAF in "beat the delay" fashion to create stress
- Stop intentional syllabic repetitions on command
Terminating Therapy
- Concept of "fluent stutterer"
- Accept self-concept as "stutterer" to achieve desensitization to it
Therapist should learn when to terminate therapy (read signs from client)
Therapist should learn how to terminate therapy
- boredom with stuttering
- missed appointments
[ Contents ]
- Reduce frequency of appointments as termination approaches
- Schedule conference during which therapist and client-as-therapist explore and jointly agree to terminate therapy.