# Speech-Language Pathology/Stuttering/Stuttering Modification

Stuttering modification therapy is primarily associated with Charles Van Riper.
The goal of stuttering modification therapy is not to eliminate stuttering. Instead, the goals are:
* Modify your moments of stuttering, so that your stuttering is less severe.
* Reduce your fear of stuttering, and eliminate avoidance behaviors associated with this fear.

## Four Phases of Stuttering Modification Therapy

The therapy has four phases: identification, desensitization, modification, and stabilization.

### Identification

You begin by identifying the core behaviors, secondary behaviors, and feelings and attitudes that characterize your stuttering.
Your speech-language pathologist points out your "easy or effortless stuttering." You learn to identify when you do these behaviors. The goal is to improve your awareness of what you do when you stutter.
Next, your speech pathologist trains you to identify and become aware of your avoidance behaviors, postponement behaviors, starting behaviors, word and sound fears, situation fears, core stuttering behaviors, and escape behaviors.
Finally, you identify feelings of frustration, shame, and hostility associated with your speech.
At first, identifying these behaviors is done in the speech clinic. Later, your speech pathologist takes you out of the clinic, to identify what you do in everyday conversations.

### Desensitization

Van Riper called this "toughening the stutterer to his stuttering." You do this in three stages:
* Confrontation, or accepting that you stutter. You're expected to tell people that you stutter, and talk about what you are doing in therapy to change your stuttering.
* Freeze your core behaviors&#151;repetitions, prolongations, and blocks. When you stutter, your speech pathologist raises a finger. You hold what you are doing, until she drops her finger. For example, if you were repeating a syllable, you have to continue to repeat that syllable. Your speech pathologist will make you freeze these core behaviors for longer and longer periods. The goal is for you to become less emotional or more tolerant of these behaviors.
* Voluntary stuttering, or stuttering on purpose. This helps you remain calm when you stutter.

### Modification

This is where you learn "easy stuttering" or "fluent stuttering," in 3 stages:
* Cancellations. When you stutter, you stop, pause for a few moments, and say the word again. You say the word slowly, with reduced articulatory pressure, and blending the sounds together.
* Pull-outs. After you master freezing and cancellations, you use your "easy stuttering" while you are in a stutter, to pull yourself out of the stutter and say the word fluently.
* Preparatory sets. After mastering pull-outs, you look ahead for words you're going to stutter on, and you use "easy stuttering" on those words.

### Stabilization

The last stage of stuttering modification therapy seeks to stabilize or solidify your speech gains. This is accomplished through sub-goals:
The first is for you to become your own speech therapist. You take responsibility for making your own assignments and prescribed therapy activities.
Another sub-goal is "the automatization of preparatory sets and pull-outs."
The last subgoal is for you to change your self-concept from being a person who stutters to being a person who speaks fluently most of the time but who occasionally stutters mildly.

## Efficacy Studies

A study indicated that naïve or nonprofessional listeners responded less well to stuttering combined with stuttering modification techniques than they did to stuttering (only). In other words, listeners may prefer to listen to untreated stuttering than to listen to a stutterer using stuttering modification therapy techniques.
Nineteen adult stutterers participated in the 3.5-week Successful Stuttering Management Program (SSMP, developed by Dorvan Breitenfeldt) program. Immediately post-treatment their speech had improved 10%. Six months later this modest gain had all but disappeared. Several measures of anxiety found a 10-15% psychological improvement. The researchers cautioned that six months isn't a long follow-up, and that this psychological improvement might not last, given the absence of improved speech. The researchers concluded, "&#133;the SSMP appears to be ineffective in producing durable improvements in stuttering behaviors."

## Stuttering Modification Programs
### Approach-Avoidance Therapy (Joseph Sheehan)

In the 1940s, behavioral psychologist Neal Miller tied strings to rats, and sent them scampering down a runway towards food. He measured how hard the rats pulled on the strings to get to the food. He called this force the "gradient of force."
He then put an electric shock at the end of the runway, instead of food. The rats scampered away from the electric shock, and Miller called this the "gradient of avoidance."
He put the food and the electric shock together at the end of the runway. The rats wanted to scamper to the food, but away from the electric shock. They ended up running back and forth in a narrow space somewhere in the middle of the runway. This was called the "approach-avoidance conflict."
This reminded psychologist Joseph Sheehan of stutterers' repetitions and prolongations. In 1953, Sheehan developed the theory that stutterers want to say a word, but also want to avoid the word.
Why would stutterers wish to avoid saying words? Sheehan suggested that stutterers dislike the listener, or fear certain words, or fear certain situations, or feel guilt or anxiety about the emotional content of our message.
Sheehan believed that "stuttering is not a speech disorder, but a conflict revolving around self and role, an identity problem." He based this view on the fact that most stutterers have difficulty saying their names, and that many stutterers are fluent when acting (Sheehan, 1970).
Sheehan developed a stuttering modification therapy program based the reduction of avoidance.first, in the "self-acceptance" phase, you are trained to accept yourself as a stutterer. You are encouraged to maintain eye contact with listeners, and discuss your stuttering with friends and acquaintances.
In the "monitoring" phase, you improve your awareness of what you do when you stutter.
In the "initiation" phase, you seek out feared situations, and feared words, and stutter openly.
In the "modification" phase, you stutter openly and easily. You let the listener know that you are having trouble with a word. You do a prolongation on the first sound of the word. You do a "smooth release" onto the next sound.
Lastly, in the "safety margin" phase, you develop a tolerance for disfluency.
Sheehan did not believe that stutterers could or should speak fluently. In his therapy, "No practicing of special techniques for achieving fluency are involved&#151;only openness and honesty and a changing role of self-acceptance as a stutterer will lead to overcoming the tyranny of stuttering."
Sheehan's stuttering therapy is practiced at the University of California&#151;Los Angeles (UCLA).

### Successful Stuttering Management Program (Breitenfeldt and Lorenz)

The "Successful Stuttering Management Program" (SSMP) is practiced by Dorvan Breitenfeldt and Dolores Rustad Lorenz at Eastern Washington University in Spokane, Washington. It's a three-week, intensive, residential group therapy program. The program is mainly stuttering modification therapy, emphasizing avoidance reduction.
The program begins with "confrontation of stuttering." The aim is to develop awareness of your stuttering, reduce use of avoidance techniques, and eliminate word and situation fears. The techniques are voluntary stuttering and stuttering surveys.
In a "stuttering survey," you go to a shopping mall, stop strangers, and ask them questions about their reactions to your stuttering. You stutter on purpose. You do 200-300 stuttering surveys in the program.
In the second phase, you learn the stuttering modification techniques: preparatory sets, cancellations, and pull-outs. This differs from other stuttering modification therapies, in which preparatory sets are learned after cancellations and pull-outs.
The second phase also includes changing your self-concept and lifestyle.
You also substitute continuents for plosives. You substitute /w/ for /b/, /s/ for /t/, and /z/ for /d/. For example, you say "wank" instead of "bank," and "zollar" instead of "dollar." You also add sounds with prolongations. For example, "water" becomes "oowater."
Other speech pathologists are skeptical of this technique:
   This type of substitution behavior seems to go against the original philosophy of nonavoidance&#133;the idea of teaching stutterers to substitute&#133;strikes us as [an avoidance "trick"]&#133;it may even strengthen clients' tendencies to scan ahead in anticipation of sounds that are feared and should be avoided.
In the third phase, you transfer your new skills to face-to-face and telephone conversations. You are also encouraged to do voluntary stuttering.

### "Self-Therapy for the Stutterer" (Malcolm Fraser)

The book "Self-Therapy For The Stutterer," by Malcolm Fraser, shows how to do stuttering modification can be done as self-therapy, as opposed to going to a speech clinic. The book is published by the Stuttering Foundation of America.

## Critiques of Stuttering Modification Therapy
### Assumptions

Stuttering modification therapy assumes that stutterers will never be able to talk fluently, and so the best a stutterer can hope for is to be a better communicator while still stuttering. The effectiveness of other, more recently developed stuttering therapies for producing fluent speech makes this assumption questionable.

### Identification Critiques

Improving self-awareness of stuttering behaviors, as well as psychological effects, is an excellent foundation for any speech therapy. The problem with this stage of stuttering modification therapy is that it was developed before the invention of video camcorders and biofeedback devices. Current technology can help you do this stage better and faster.

### Desensitization Critiques

Telling people that you stutter is good. But freezing core behaviors and voluntary stuttering could strengthen the neural pathways for these behaviors, making these undesirable motor programs even harder to change.

### Modification Critiques

"Cancellations" and "pull-outs" don't work if you have poor awareness of your stuttering. By the time you realize that you are stuttering your speech may be out of control. If stutterers' auditory processing underactivity results in poor awareness of one's speech, then stutterers who have a this neurological abnormality strongly can't be expected to modify their speech.
"Preparatory sets" teach stutterers to "scan ahead" for feared words, i.e., teach you another secondary behavior. In fact, the entire "modification" stage is arguably teaching you more secondary behaviors.
If modified stuttering sounds worse to listeners than untreated stuttering, increased listener discomfort may cause stress in the stutterer using stuttering modification techniques.

### Stabilization Critiques

But "becoming your own speech pathologist" doesn't mean reading books about stuttering, taking a class, going to conventions, or learning about new research and therapies. "Becoming your own speech pathologist" means motivating yourself to do therapy activities indefinitely. You wouldn't do these therapy activities on your own, because you don't perceive resulting benefits. You need a speech pathologist to get you to do the activities.
Another goal is "the automatization of preparatory sets and pull-outs." But you're just told you to practice, and not taught techniques or practice schedules to maximize autonomous motor learning.
The last goal is for you to change your self-concept from being a person who stutters to being a person who speaks fluently most of the time but who occasionally stutters mildly. This would be a good goal if stuttering modification therapy trained you to be a person who stutters mildly. But if stuttering modification therapy "&#133;appears to be ineffective in producing durable improvements in stuttering behaviors." then this self-concept may be difficult to maintain.

## Personal Experiences with Stuttering Modification Therapy

Please read Speech-Language Pathology/Stuttering/How to Participate in this Wikibook before adding material.

## References

* ^ Manning, W. H., Burlison, A. E., & Thaxton, D., (1999) "Listener response to stuttering modification techniques," Journal of Fluency Disorders, 24, 267-280.
* ^ Blomgren, M., Roy, N., Callister, T., Merrill, R. "Intensive Stuttering Modification Therapy: A Multidimensional Assessment of Treatment Outcomes," Journal of Speech and Hearing Research, 48:509-523, June 2005.
* ^ Culatta, R., Goldberg, S. Stuttering Therapy: An Integrated Approach to Theory and Practice. Boston: Allyn and Bacon, 1995.
* ^ DeNi, L., Kroll, R., & Ham, R. "Therapy Review," Journal of Fluency Disorders, 21, 1996, pages 61-67.