Doctoral dissertation on the treatment of stuttering with Rational Emotive Behavior Therapy (REBT) by Gunars Neiders Ph.D.
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
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
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).
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.
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: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: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: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
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: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
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
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.