The Treatment of Stuttering-- Van Riper (ZT)

Study Guide for Charles Van Riper's
The Treatment of Stuttering

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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.

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CONTENTS

The Design of Therapy | Diagnosis: Initial Evaluation | Motivation
Identification | Desensitization | Modification | Stabilization

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THE DESIGN OF THERAPY

The Bases of Our Therapy

• Learning Theory - new responses
• Servo therapy - proprioception
• Psychotherapy - for secondary expectancy neurosis (refer for primary)

The Therapeutic Schedule

• Intensive program for 3-4 months
• Minimum: 1 hr 3 days/wk, 1 hr group 3 days/wk, & daily self therapy

The Therapeutic Sequence

Identification Phase

• Explore, analyze & classify overt and covert behaviors

Desensitization Phase

• Decrease speech anxieties and other negative emotions
• Toughen to threat, confrontation & experience of fluency failure

Modification Phase

• First vary and then unlearn habitual avoidance and struggle responses
• Learning, through counterconditioning, a new, fluent, less abnormal way of stuttering

Stabilization Phase

• Consolidate gains
• Create generalized sets to automatize new speech behaviors
• Develop proprioceptive monitoring of normal speech

Provision for Individual Differences

• Vary stress and time spent on stages or steps within stages

Learning Theory

Stuttering Therapy as Unlearning and New Learning

• Learning better ways of coping with stuttering when threatened or occurs
• Unlearn avoidance and escape behaviors

The Targets of Learning and Unlearning

• 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")

The Learning Process

Learning of stuttering behavior

• Classically conditioned fears of words, sounds, listeners, conditions and situations
• Learned emotional reactions

Learning in 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

Servo therapy

• Replace auditory monitoring with proprioceptive feedback
• Use masking noise & DAF, varying application to individual responses
• Attend to motor aspects of utterance

Psychotherapy

• 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

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Diagnosis - Initial Examination

• Demonstrate knowledge of stuttering
• Verbalize stutterer's feelings
• Demonstrate knowledge of range of overt and covert behaviors

Obtain Speech Sample

• Use audio and video recorder
• Upon stuttering, ask PWS if this is typical

Explore Client's Stuttering Behavior

• 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

Assess Client's Normal Speech

• Characteristics of rate, pitch, intensity, and quality
• How much talking does he/she do?

Anticipatory Characteristics

• 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

Explore PWS's Life History

• 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

Clinical Procedures

• 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

Trial Therapy

• Skill at behavior modification
• Appraise client motivation
• Appraise severity of the behavior

Provide Sum Up

• Provide summary of therapist's impressions
• Ask for autobiography at next meeting
• Invite PWS to participate in the therapy process

Severity of Stuttering in Terms of Prospective Therapy (Prognosis)

	PFAGH  +  Sf Wf  +  Cs
Ss  =	----------------------------------
	M  +  Fl

Where:

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

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MOTIVATION

• Determines eventual success of therapy
• Key is to get client involved in the design of therapy as well as its performance

The Stutterer's Motives

• Cannot be assumed
• Must be discovered, nurtured and sometimes created

The Costs 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

Varying Levels of Motivation During the Course of 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)

Motivation Difficulties in Therapy

Goal-Setting Difficulties

• 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

The Aversiveness of Stuttering

• unpleasantness of facing stuttering behavior
• strongly reinforced conditioned avoidance responses
• avoidance must be expected until client is ready to confront

Lack of Trust in the Therapist

• past experience with token or unwise therapy
• therapist needs to establish competency

Reluctance to Surrender Secondary Gains

• acknowledge reality of secondary gains
• sufficient to explain all motivation problems in normal PWS
• may not explain all motivation problems in neurotic PWS

Problem When Stuttering as Only a Minor Nuisance

• Behavior may not be sufficiently painful to motivate change
• Avoidances may be working

Revealing the Therapist's Competence and Commitment

• 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

The Inevitable Challenge

• 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

Providing Hope that Stuttering is Modifiable

• 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

Motivational Arousal Through Planning

• Provide sketch of a sequential course of therapy
• Put plan in concrete terms
• Ensure client you have a map of therapy course

Subgoals and Motivation

• 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

Reinforcement

Therapist needs to constantly reinforce learning and behavior change

Available Reinforcers

• 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)

Self Reinforcement

• 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

Approval for What?

• Reward progress, not single performances
• Identify gains as progress toward goal
• Reward open stuttering and other modifications of behavior

Other Positive Reinforcers

• Tokens
• Social reinforcement
• Be open to client preferences (provide meaningful rewards)
• Reward for stuttering
• "Embed" difficult tasks in pleasant or rewarding activities

Negative Reinforcement

Escape from punishment or unpleasant activities by changing behavior or accomplishing difficult tasks

Punishment

• 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.

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IDENTIFICATION

Identification of overt and covert behaviors

Opportunity to establish client-therapist relationship

Therapist's Role

• Give PWS responsibility & make part of therapy
• No demand for modification
• Strengthen approach gradient

Role in Therapy course

• Demonstrates that stuttering will not be punished
• PWS usually totally unaware of actual behavior
• Provides opportunity for early desensitization

Identification procedures

• Collect categories of stuttering behaviors (as they reflect dynamics of coping reactions)
• Behaviors originated in purposeful actions
• Progress in this phase is anxiety reducing

The Hierarchy of Identification Therapy

Provide guidance in addressing progressively more difficult behaviors

• Fluent words
• Short easy stutterings
• Avoidance behaviors
• Postponements, timing tricks, and verbal cues

Identifying the Target Behaviors: The Fluent Stuttering

Identifying Avoidance 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

Collecting Postponement Behaviors

• Postponement is an avoidance in time
• Use of starter words
• Stereotypes sequences of postponement activities (speech & body movements)

Identifying Timing Behaviors

• Starter behaviors
• Attempt to terminate delay and begin speaking
• Can include head jerks, arm movements and breaths
• These provoke the most listener penalty

Modifying the Verbal 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 Situational Cues

• 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

Identifying the Core Behaviors

Use triads to show contrast between fluent and stuttered utterance

Begin proprioceptive training

Allow self corrections to happen

Encourage active exploration by PWS

• Use videotapes and mirrors
• Isolate and analyze specific stuttering sounds/events

Model and discuss tremors and loss of control

Identifying Foci of Tension

• 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

Identifying Repetitive Recoil Behavior

• Explore runaway blocks (often contain "schwa" vowel)

Identification of Post Stuttering Reactions

• Explore feelings which result from stuttering (Frustration, shame, hostility)

Identifying Feelings of Frustration

• Both during and after speech
• Allow sharing and venting

Identifying Feelings of Shame

• 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

Identifying Feelings of Hostility

• 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

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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:

1. Confronting abnormality of stuttering
2. Tolerating fixations and oscillations
3. Communication stress & listener penalty

The Therapist's Role

• 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

How to Desensitize

Recognizing Negative Emotionality

• Look for overt sings of emotionality
• Examine fluent and stuttered speech for signs of tension and emotion (eye movements, "mask like" appearance.)

Constructing Hierarchies

• Create hierarchies of stimulus sets
• Allow PWS to experience each item repeatedly to decondition reaction

Targets of Desensitization Therapy

Confrontation of the Disorder (dealt with in Identification Phase)

Confronting Core Behaviors or moments of stuttering (fixations & oscillations)

Desensitization to Listener Reaction

• Build resistance to communication pressures (Hurry, sudden challenge, interruptions, noise, questions and doubting)
• Devise hierarchies of listener reaction to experience/confront in clinic

Counterconditioning

Link an anxiety-inhibiting response to a stimulus that formerly evoked anxiety

The Therapist as a Counter conditioner

• Provide acceptance of stuttering and emotionality through every phase of hierarchy

Assertive Responses

• Practice assertive responses as modification of usual role

Disinhibition

• Release inhibitions by starting with low stress and working up

Systematic Desensitization Using Relaxation

• Relaxation alone usually won't affect stuttering
• Success in therapy is best relaxant

Pseudo stuttering in Desensitization

• 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

Pseudo stuttering as Self Disclosure

• PWS hides stuttering to hide deviancy
• Relief is experienced by stuttering openly

Misuses of Pseudo stuttering

• Should not be used indiscriminately; only purposely
• Should not be used to punish listener or himself

Adaptation

"The Bath of Stuttering"

• 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

Nonreinforcement

• Say stuttered words over and over, from pantomime to loud
• Return to earlier step if unsuccessful

Negative Suggestion and Flooding

• Flood PWS (while speaking) with statements that he is going to fail
• Externalizes inner message
• Learns to doubt his own self-suggestions

Response Prevention

• Escape responses are stimuli for conditioning
• Encourage PWS to throw himself into stuttering blocks

Adaptation with Negative Suggestion

• 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

Adaptation to Stress

• Works better for interiorized PWS

Eliminating Other Sources of Anxiety

(Address other personality problems that may contribute to stuttering)

Reassurance

• Best reassurance is success
• Don't provide false reassurance. It will backfire.

The Anxiety Reduction Effect of Modifying Stuttering

• Best technique to do this is to confront

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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

• Revise self-perceptions & ways of coping with stuttering

Variation

• Beliefs are organized into a consistent system that supports stuttering
• Try to introduce changes in PWS' way of living

The Exploration of Self

• Identify idiosyncratic patterns of thinking, feeling & acting
• Promote an analytical self-awareness of what PWS can alter

Varying Behaviors

• Self assigned "rut-breaker" tasks

Role Playing

• Break up behavioral rigidity by trying out other points of view
• Role enactment to free PWS (often more fluent when playing a part)

Attitudinal Change

• Rational psychotherapeutic procedures may facilitate
• Try on new attitudes

Varying the Stuttering Behaviors

Anticipatory Behaviors

• Postponement & avoidance reactions easiest to change
• Assignments to vary reactions & postponements
• Change starter words
• Use with people outside clinic

Varying the Escape Behaviors

• Model escape behaviors (head jerks, etc.) & show how they can be varied
• Alter ritualistic behaviors by reversing their order, omission, or insertion

Modification: Teaching of Fluent Form of Stuttering

Goal is to modify and shape the form of stuttering

• without impairing PWS communication
• without contributing to maintenance of disorder

Sequence ordering produced - as close as possible to normal utterance

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

• 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)

Proprioceptive Monitoring: Masking

• Intensive training in proprioception and tactile monitoring
• Mask auditory input to enhance awareness of proprioceptive/tactile feedback
• Try pseudo stuttering/speaking with masking noise

Enhancing Proprioceptive Awareness by DAF

• 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 (?)

Proprioceptive Monitoring Through Pantomiming

• Creates carryover from DAF to normal speech
• Mouth words in stressful situations (concentrate on movement and feel of speech)
• Intensive learning process involved

Program rewards to reinforce specified performances

• By seeking out previously avoided situations, secondary gains fall away

Cancellation

• 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

Cancellation as a Preventative of Stuttering Reinforcement

• Delay reinforcement of stuttering so it loses effectiveness
• PWS usually flees dysfluency and moves forward to escape (until another is encountered)

The Pause

• Deliberate delay rather than plunging forward (breaks reinforcement cycle)

Resistance to Contingent Pausing

• 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

Necessity for Completing the Stuttered Word Before Canceling

• 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

Using the Pause for Calming

• 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)

Filling the pause

• 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

Cybernetic Aspects of Canceling

• Gives PWS chance to scrutinize dominant features of dysfluency
• Silence emphasizes pantomime rather than auditory monitoring

Overt Cancellation

• PWS says word again in strong, deliberate, slow motion manner, highly sequenced
• In beginning, some features of stuttered word can be present

Shaping

• Vary manner of articulation and vocalization
• PWS learns other, better ways of stuttering

Modification of Stuttering During Its Occurrence

Pull-Outs - Apply modifications during moment of stuttering

Pulling out of Fixations

• Prolong fixations & find way to slowly sequence transitional movements

Pulling out of Tremors

• Slow down frequency and smooth them out
• Voluntarily throw jaw, lips and tongue into similar tremors
• Explore how tremors begin

Release from Laryngeal Closures

• use "vocal fry" as transition from blockage to airflow
• Have PWS experiment with how to perform this voluntarily and deliberately

Release from Clonic (Spastic Muscular) Behaviors

• 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

Getting Control of the Uncontrollable

• Voluntary searching for proper coarticulation and sequencing

Pull-Outs as the Consequence of Cancellation

• Use of cancellation technique may lead some PWS right into pull-outs

Motor Planning and Preparatory Sets

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

• 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

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STABILIZATION

The Need for a Stabilization Stage in Therapy

Resist temptation to terminate therapy prematurely

• 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)

Activities of the Stabilization Period

• Therapist as consultant
• Client acts as his own therapist

Reconfiguring Fluency

• Speak in longer segments, eliminating gaps and holes in speech

Shadowing in Stabilization

• Simultaneously echo another person's speech to get feel for prosody

Prosody and Formulation

• Learn to use cancellation on whole phrases and sentences
• Employ immediate oral paraphrasing of written passages

Continuous Speaking

• Create experiences in continuous extemporaneous speaking

Increasing the Rate

• Increase maximum rate to automate preparatory sets
• Insert fluent stuttering to facilitate creation of "generalized sets" (see below)

Reflecting

• Reflect or mirror back thoughts of others in conversations

Automatization of Sets And Strategies

Generalized set creation by:

• Repetitive reading of formerly feared words
• Repeat fluency-enhancing techniques (e.g., loose contacts) at varied rate
• Train self to focus on proprioception

Preparing for Contingencies

• 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

Generalization

• Attach new responses to large number & wide range of stimuli
• Seek out communication situations & touch them with new learning and fluency.

Extinguishing Fears

• Massed practice of formerly feared sounds and words
• "Wipe out" sessions for old fears.

Nucleus Situation in Stabilization

• Continue to use pseudostuttering, pull-outs, cancellations and proprioception in targeted "nucleus situations"

Buffering

• Use groups to create flooding with high stress situations/conditions
• Use people who cause PWS special stress

Resistance Therapy

• 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

Other Resistance Activities

• 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

Reintegrating the Self Concept

• Concept of "fluent stutterer"
• Accept self-concept as "stutterer" to achieve desensitization to it

Terminating Therapy

Therapist should learn when to terminate therapy (read signs from client)

• boredom with stuttering
• missed appointments

Therapist should learn how to terminate therapy

• Reduce frequency of appointments as termination approaches
• Schedule conference during which therapist and client-as-therapist explore and jointly agree to terminate therapy.

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