Controversies about stuttering therapy

Current controversies with respect to (1) the need to attend to the feelings and attitudes of stutterers; (2) the teaching of controlled stuttering as opposed to shaping fluency; (3) criteria for determining successful therapy; (4) the problem of relapse; and (5) therapy for the young stutterer are briefly discussed. It is noted that while there may be many controversies in the area of stuttering therapy, the author presently believes that the issue of whether or not to attent to the feelings and attitudes of stutterers is the most important and that the proliferation on the market of exclusively behavior-oriented therapy programs may be fostering the training of technicians without the skills necessary to assist others in identifying and handling feelings and attitudes.     

A comparison of alternative theoretical approaches to smoking cessation and relapse

Two theoretical approaches to smoking cessation were compared. Participants were randomly assigned either to (a) a traditional treatment program that used contingency contracting and that emphasized the necessity for absolute abstinence (AA) or to (b) a relapse-prevention (RP) treatment that focused on gradual acquisition of nonsmoking skills. It was hypothesized that participants in the RP treatment would be less successful initially but would have better maintenance skills and thus would relapse less during a 1-year follow-up period. Each program was evaluated in two formats: group-based treatment and self-help materials. Results indicated comparable 1-year abstinence rates for all treatments, although more participants dropped out of the self-help formats. Participants in the RP intervention were more likely to lapse sooner after quitting and were more likely to quit again during the 1-year maintenance period. Exploratory analyses of successful participants suggested that women were more successful in the RP program and that men had greater success with the AA approach.     

An evaluation of the effects of supplemental “fluency” training during maintenance

The voice onset time (VOT) of two groups of treated stutterers and a normal-speaking group was assessed by spectrographic analysis. Both groups of stutterers had significantly slower VOT than the normal speakers. The experimental group of stutterers was given 8 wk of “fluency” training designed to remediate characteristics of speech identified as related to “tenuous” fluency. The control group of stutterers received ongoing maintenance therapy. Posttreatment VOT was assessed. The experimental stuttering group had significantly decreased their VOT in the direction of the normal-speaking group, whereas the control group of stutterers had a greater VOT between pre- and posttreatment. The implication of these results for the maintenance of fluency are discussed.     

Collaboration and a Self-Help Orientation in Therapy with Suicidal Clients

Working with suicidal clients historically has placed a heavy burden of responsibility on the therapist for a successful outcome. This orientation generally has left clinicians feeling stressed and in need of controlling their clients' behavior; clients, in turn, often have developed unrealistic expectations of therapy or resistance of the therapist's interventions. In this context, the chance for a potentially valuable collaboration between client and therapist is often lost. This paper builds on previous work that has introduced the notion of a collaborative working relationship with suicidal clients. It is argued that the therapeutic process ideally should not only utilize the therapist's knowledge and skills in treating suicidal clients, but also cultivate self-efficacy by encouraging the client to adopt a self-help orientation to therapy. Several general principles of a collaborative/self-help orientation to working with suicidal clients are discussed and a variety of specific therapeutic strategies consistent with this orientation are described.     

Guided self-help versus pure self-help for perfectionism: a randomised controlled trial

Perfectionism is known to be a risk factor for the development and maintenance of obsessive-compulsive (OC) and depressive symptoms. The purpose of the present study was to test the effectiveness of a cognitive-behavioural self-help therapy for perfectionism, and to examine the effect of such treatment on OC and depressive symptomatology. The study compares the effectiveness of guided self-help (GSH, n=24) with pure self-help (PSH, n=25) therapy. Both GSH and PSH were found to be effective in reducing perfectionism, and also in reducing OC and depressive symptomatology. Overall, participants in the GSH condition experienced greater symptom improvement than participants in the PSH condition, and treatment gains for both groups were largely maintained at 3-month follow-up. Twenty percent of PSH participants experienced clinically significant increases in depressive symptoms over the treatment and follow-up period (compared to 0% in the GSH condition), suggesting that PSH may be a less suitable strategy than GSH in treating this population. Overall, the findings suggest that self-help for perfectionism is effective in reducing OC and depressive symptomatology in non-clinical individuals, with GSH being superior to PSH.     

Persistence and remission of incipient stuttering among high-risk children

This investigation concerns the persistence of stuttering and recovery from it among high-risk children. At the end of the second year of a 6-year prospective study, 26 of 93 preschool children with a parental history of stuttering were classified as stutterers. Four years later, seven of these children were classified as persistent stutterers, and 16 children were classified as recovered stutterers. The articulatory and linguistic skills of these two groups of children and the communicative and speaking behaviors of their mothers, were measured before and after the onset of stuttering. The analysis of these measures revealed that the articulatory skills of the children and the communicative style and language complexity of the mothers differentiated the incipient stutters whose stuttering subsequently became chronic from those who recovered.     

The voice problems of stutterers: A practical approach from clinical experience

Voice disorders, which may be caused by the stuttering problem, have been noted in at least one-third of stutterers seen. Basically, stutterers have false speech images that normal speech is perfect and without natural dysfluencies (repetitions, pauses, etc.). Many stutterers also have erroneous vocal images of how they should or should not sound. Both images control speech and voice. Clinical experience indicates that vocal rehabilitation should be used in conjunction with speech therapy for many stutterers.     

Cognitive and behavioral self-control strategies: Applications for the clinical management of adult stutterers

A model of therapy for adult stutterers which emphasizes the role of cognition in mediating the conditions for behavioral change is described. The philosophy of the program along with the specific forms and effects of several self-control strategies are discussed in relation to: (1) expectancy formation and the attainment of goals; (2) speech modification procedures; (3) transference of clinical gains; and (4) assessment of results. The use of cognitive restructuring procedures, self-instructional strategies, imagery and other coping skills for the management of speech-related stress is outlined. The importance of developing self-management and self-monitoring programs that clients may use in ongoing confrontations with real-life problems is emphasized in defining responsible behavior and the responsibility for change.     

Internet administered guided self-help versus individualized e-mail therapy: A randomized trial of two versions of CBT for major depression

Internet-delivered psychological treatment of major depression has been investigated in several trials, but the role of personalized treatment is less investigated. Studies suggest that guidance is important and that automated computerized programmes without therapist support are less effective. Individualized e-mail therapy for depression has not been studied in a controlled trial. Eighty-eight individuals with major depression were randomized to two different forms of Internet-delivered cognitive behaviour therapy (CBT), or to a waiting-list control group. One form of Internet treatment consisted of guided self-help, with weekly modules and homework assignments. Standard CBT components were presented and brief support was provided during the treatment. The other group received e-mail therapy, which was tailored and did not use the self-help texts i.e., all e-mails were written for the unique patient. Both treatments lasted for 8 weeks. In the guided self-help 93% completed (27/29) and in the e-mail therapy 96% (29/30) completed the posttreatment assessment. Results showed significant symptom reductions in both treatment groups with moderate to large effect sizes. At posttreatment 34.5% of the guided self-help group and 30% of the e-mail therapy group reached the criteria of high-end-state functioning (Beck Depression Inventory score below 9). At six-month follow-up the corresponding figures were 47.4% and 43.3%. Overall, the difference between guided self-help and e-mail therapy was small, but in favour of the latter. These findings indicate that both guided self-help and individualized e-mail therapy can be effective.     

Perceptual evaluation of the speech before and after fluency shaping stuttering therapy

An often-cited criterion for assessing the effect of a stuttering therapy is the ability of the stutterers to produce normally fluent speech. Many modern stuttering therapies use special techniques that may produce stutter-free speech that does not sound completely normal. The present study investigates this problem in the framework of the Dutch adaptation of the Precision Fluency Shaping Program.

Pre-, post-, and -year follow-up therapy speech samples of 32 severe stutterers who were treated in a four-week intensive therapy are compared with comparable samples of 20 nonstutterers. For that aim the samples were rated on 14 bipolar scales by groups of about 20 listeners. The results show that the speech of the stutterers in all three conditions differs significantly from the speech of the nonstutterers. The pretherapy speech takes an extreme position on a Distorted Speech dimension, due to the large proportion of disfluencies. The posttherapy speech has extremely low scores on a Dynamics/Prosody dimension, a‘1 while the follow-up therapy speech differs from the normal speech on both dimensions, but now the distances are smaller. These results are discussed in relation to the severity of the stuttering problem in the group of treated stutterers. Finally, implications for future research on therapy evaluation are discussed.     

A disfluency descriptor digest for clinical use

A clinical form to be used in identifying which of a set of fluency eliciting techniques might be used most advantageously in therapy with individual stutterers is described.     

The use of a portable delayed auditory feedback unit in stuttering therapy

A portable on-the-body delayed auditory feedback was used in the establishment and transfer modes of fluent speech in a stutterer while he was on the Monterey Fluency Program. The performance of the client was compared with a “standard” population of stutterers. The portable DAF was comparable to the larger DAF in establishment and superior in transfer with minimal behavioral and technical problems. Use and potential value of the portable DAF in transfer and maintenance phases of therapy are discussed.     

Prerequisite vs. in vivo acquisition of self-feeding skill

Separating the acquisition of prerequisite skills from the learning of skills in vivo may be a more efficacious procedure for self-help training of low functioning developmentally delayed children. Two procedures for training independent use of a fork at meals were compared using two equivalent groups of three subjects each, in multiple baseline design. Using previously accepted procedures, one group was trained during meals while the experimental group received prerequisite training making use of simulated food (styrofoam pieces). Data during training, generalization-to-meal, and follow-up were collected. For 6 months following training, the efficacy of prerequisite training was upheld. The complexity of individual responses to the singular or conjunctive use of social and edible reinforcement for the purpose of self-feeding skill generalization and maintenance, is discussed.     

Clinician attitudes toward stuttering: A decade of change (1973–1983)

The attitudes of 674 speech-language pathologists toward stuttering, stutterers, stuttering therapy, parents of stutterers, and related issues were studied during the years 1973–1983. During that period, clinician attitudes were found to shift away from support of the John-sonian concepts, which suggest parental causality and dangers in early intervention. In addition, clinicians became less likely to perceive stutterers as possessing psychologic disorders and misperceptions of their problem and of their interpersonal relationships. However, a significant number of clinician's were found to continue to hold unsubstantiated beliefs regarding the personality of stutterers, their parents, and the efficacy of early intervention with very young stutterers. The results of the study were interpreted as suggesting the need to educate fluency specialists.     

Cerebral lateralization of visual stimulus recognition in stutterers and fluent speakers

Cerebral lateralization of stutterers and nonstutterers was assessed in terms of choice reaction times to stimuli presented to either the left or right visual hemifield on letter recognition and figure recognition tasks. Reaction times on both tasks were determined before and after a behavioral speech therapy program. Stutterers demonstrated a significant reduction in mean reaction times in the letter recognition task over the course of the therapy program. This change differed significantly from that obtained from stutterers in the figure recognition task. The stutterers' responses were in contrast to the responses of the nonstutterers, who showed no reduction in mean reaction times for the letter or figure recognition tasks. The results were discussed in terms of alterations in aspects of central nervous system processing as a result of participation in the behavioral speech therapy.     

Differential impact of preschool models on development and early learning of inner-city children: a three-cohort study

Three different preschool models operating in an urban school district were identified through cluster analysis of teacher responses to the Pre-K Survey of Beliefs and Practices. The language, self-help, social, motor, and adaptive development, along with mastery of basic skills, of 721 4-year-olds randomly selected from these models were compared. Children in the child-initiated model demonstrated greater mastery of basic skills than did children in programs in which academics were emphasized and skills were taught. Children in the combination model did significantly poorer on all measures except self-help and development of social coping skills compared with children in either the child-initiated or academically directed models. Girls outperformed boys in all areas except gross motor development and play and leisure skills. Implications for educational policymakers are discussed.     

Changes in stutterers' fundamental frequency contours following therapy

The fundamental frequency (F_O) declination observed during the first 50 msec in vowels that follow voiced stop-consonant productions was examined in the fluent speech of 53 stutterers before and at the termination of an intensive therapy program. Results indicate that therapy has no effect on the F_O declination patterns. These results are interpreted with respect to research findings regarding fluent and disfluent speech productions of stutterers.     

Clinician attitudes toward stuttering in the United States and Great Britain: A cross-cultural study

The attitudes toward stutterers and stuttering of 702 speech-language clinicians in the United States and Great Britain were studied. Three hundred seventy-one clinicians from six states in the U.S. and 331 clinicians from England and Wales completed the Clinician Attitudes Toward Stuttering (CATS) Inventory. Results of the study were analyzed in terms of differences and similarities in attitudes between the two groups with respect to the etiology of stuttering, early intervention, the effectiveness of stuttering therapies, various therapy techniques, stutterers and their personality, parents of stutterers, clinicians, and reactions of others to stutterers.     

Men’s experience of a guided self-help intervention for hot flushes associated with prostate cancer treatment

Up to 80% of men who receive androgen deprivation therapy report hot flushes and for many these are associated with reduced quality of life. However it is recognised that there are a number of barriers to men’s engagement with support to manage symptoms and improve quality of life. This qualitative study was embedded within a larger randomised controlled trial (MANCAN) of a guided self-help cognitive behavioural intervention to manage hot flushes resulting among men receiving androgen deprivation therapy. The study aimed to explore the engagement and experiences with the guided self-help intervention. Twenty men recruited from the treatment arm of the MANCAN trial participated in a semi-structured interview exploring acceptability of the intervention, factors affecting engagement and perceived usefulness of the intervention. Interviews were audio-recorded, transcribed verbatim and analysed using a Framework approach. Over two thirds of respondents (69%) reported reading the intervention booklet in full and over 90% reporting practising the relaxation CD at least once a week. Analysis of the interviews identified three super-ordinate themes and these related to changes in hot flush symptomatology (learned to cope with hot flushes in new ways), the skills that participants had derived from the intervention (promoting relaxation and reducing stressors), and to a broader usefulness of the intervention (broader impact of the intervention and skills). The present study identified positive engagement with a guided self-help intervention and that men applied the skills developed through the intervention to help them undertake general lifestyle changes. Psycho-educational interventions (e.g. cognitive behaviour therapy, relaxation, and positive lifestyle elements) offer the potential to be both effective and well received by male cancer survivors.