Therapy Basic Skills: Adults

2 Types of skills

1. Fluency Enhancing Techniques

2. Stuttering Modification

Fluency Enhancing Techniques

• Increase fluent speech (e.g., easy onset); aka increasing proportion of client’s speech that is fluent

Stuttering Modification Techniques

• Target the stuttering behavior (e.g., cancellation, pull out); aka helping client have an easier time stuttering (bc stuttering can be hard on client; e.g., block is a harder type of stutter than part word repetition)

Specific Goals for Advanced Stuttering

In advanced stuttering the goals are:

1. Controlled Fluency: Conscious monitoring of speech and

2. Acceptable Stuttering: Noticeable stuttering, but speaker is comfortable despite of it.

Phases in Treating Stuttering (5)

1. Education

2. Identification (self-awareness)

3. Desensitization

4. Modification

5. Maintenance: maintaining skills over time.

Education

• Teaching clients about the basics of speech production.

• Dispelling myths of stuttering

• Information about stuttering (e.g., prevalence, factors that are associated with stuttering such as age, sex, etc.) also family history, who is at higher risk, etc.

• **Make sure you and your client are on the same page, i.e., using the same vocabulary to describe the same concepts. need to make sure clients know what SLDs vs typical disfluencies are!

Identification

• Client recognizes and examines the core behaviors, secondary behaviors, and feelings and attitudes associated with their individual nature of stuttering.

  • want to make sure the client understands the difference between physical concomitant and muscular tension, and what the core behaviors of stuttering are (core behaviors=SLDs**). Want to ask clients what it feels like when they stutter because want to know their level of muscular tension is (the more tension there is, the more likely they are to stutter)

    • maybe if they have a lot of tension, in therapy can think of ways to reduce overall tension they have (e.g., can reccomend yoga or do yoga with them)

• Therapy strategies used to identify behaviors are oral reading, discussion, modeling stuttered behaviors, and self-observation.

  • note: don’t do reading if adults can’t read, and make sure reading passages are equal to their reading level; difficult passages=more stuttering=not a true reflection of their stuttering. Self observation important** want to make sure the client is AWARE when they stutter so that they can report their stutter to you correctly

  • modeling stuttering behaviors: also when with clients, will psedustutter with them (e.g., this is what I mean when I say “block” and show them, or part word repetition (and show them) so that you and client are on same page and can help them identify their own type of stutter based on your modeling. You are modeling the type of stutter that they are exhibiting. Also model behaviors you want to SEE, e.g., use slow speech, walk slowly, sit down more slowly, to reduce time pressure on client which sets tone for their speech.

Identification helps clients identify and explore (2)

1. The Physiology of Speech: e.g., what happens when you talk? Talk about the vocal folds, muscles, and what happens during stuttering. Also asking what they feel when they stutter (e.g., if they say they feel stressed, ask them if they feel stressed around your chest, around your face, what do you feel? help client explore this to increase their self-awareness

2. What happens during stuttering

   1. Identify types of stuttering: all the SLDs but also teach them TDs (phrase repeitions, word revisions, filled pauses, etc) so that they know the distinction.

   2. Pseudostuttering: stutter for your client and also have the client pseudostutter so that they can tell you in that moment what stuttering feels like (hard to do during moments of actual stuttering)

   3. Identify moments of stuttering and what happens during stuttering

Identification: Discussion

for Advanced stuttering: aka adults; can also clients to

• Name 5 DIFFICULT speaking situations (aka when they stutter more, want to know when they stutter the most, want to know how to help clients become fluent in contexts that make them stutter a lot more e.g., presentations, etc)

• Name 5 EASY speaking situations (aka when they stutter less)

• Name 3 DIFFICULT people to talk to (aka maybe they stutter more when they feel like people are judging them and help them cope during those moments)

• Name 3 EASY people to talk to

For Early Stuttering: aka for children

• Clients may assume all types of disfluency is stuttering (aka parents of kids may assume all disfluencies (TDS) are SLDs. have to teach this distinction

• Less direct than in advanced stuttering. may not be able to use Word Stutter for kids, 3 year old may not understand, for example, (e.g., maybe say bumpy vs smooth speech and model different types of “bumpy” speech for them)

can also discuss with older/school age clients:

1. How do your client’s feel when they stutter?

2. What do your clients do (emotions and speech) when they stutter?

Desentization Phase

• Client learns strategies to reduce negative feelings and anxiety associated with stuttering.

  • For children, make sure parents are interacting with kids in a supportive way.

  • for adult clients: helps them confront the fear they have of stuttering.

• Therapy strategies are to confront the disorder and desensitize the individual to stutter behaviors and listener reactions.

Desensitization: 4 ways

Desensitization is mainly “the reduction of negative emotion” -Van Riper (1973)

1. Time pressure: Plan scenarios where clients feel rushed but have to resist the urge to rush through speech.

2. Stuttered speech Pseudostuttering. help them pseudostutter; will help give them a sense of control over their own speech. You will also pseudostutter and model that stuttering is okay.

3. Negative Emotion: Discuss the worst-case scenario and how to deal with the emotions. help client deal with emotions they have, a lot of it is just let client’s know you are a safe space to talk about it.

4. Eye contact: Depends/May be overrated. Do whatever helps you get over a moment of stuttering; you can look up, down, it doesn’t matter. Also, not all cultures is eye contact normalized; tell clients that in that moment of stuttering, do what is most comfortable for them.

General Guidelines for Teaching techniques (6)

TEACH in this sequence:

1. Clinician models and the client observes. First model the technique while the client observes.

2. Clinician and client practice together

3. Client practices technique (on own) with clinician

feedback

4. Client tries to teach the clinician how to use

the technique (if they are good with it, they can teach you)

5. Client practices and rates own production

with clinician guidance. (client does technique on own and rates themselves)

6. Client practices the behavior and self- monitors. (client practices at home/outside therapy and then monitors their own speech/how they used techniques (e.g., when you preducted you would block, did you then decide to do easy onset?); for pediatric clients, will have parents monitor their kids’ speech). Next time you see adult clients, ask them what did their fluency sound like, what was the frequency of their fluency (e.g., was it every day?).

Modification: Controlled Fluency Techniques-Fluency Shaping (3)

Controlled fluency or fluency shaping techniques include:

can be used for pediatric clients as well.

1. Slower rate

2. Soft starts/East Onset

3. Soft contact/light articulatory contact

1. Slower Speech rate (before stuttering occurs**)

Goals:

1. Overall slower speech, i.e., fewer words per minute; ask clients to slow their rate of speech, aka have fewer words in the same amount of time they take to speak

2. Smooth connected Speech. want speech to sound natural and not broken up

3. Increase fluency: 3 Techniques for slow speech***

   1. Stretching sounds and syllables (speaking really really slow!!!! as slow as they can) (allows speech plan to become complete before articulating) once they reach the slowest they can go (e.g., on a scale of 1-5 they reach a 5, will then ask them to pick a spot between 1 and 5 whwere it still feels natutal to them, but still slower than 1. for pediatric kids, turn it into a game (e.g., turtle talk- who can go the slowest! ask parents to be involved/play this game at home with them) and/or

   2. Pausing: help clients pause at natural points in their speech. help them think about how intentionally pausing is a way they can slow down in the natural areas of their speech (not after every word, and not just a really long pause, just wherever it feels natural).

   3. Proprioception (aka overarticulation): note: be careful doing this to preschool kids, may want to overarticulate all the time. model what overarticulation (basically sounds like over-enunciating your words) and help them find a place where it feels more natural for them in their speech but still overarticulating a bit. NOTE: want client to still sound natural!!

2. Soft Starts/Easy Onset

Before stutter→ helps you not stutter, ONLY USE When you think you are about to stutter, you use this; aka East Onsets

(most people who stutter can predict when it is going to happen)

This is a fluency shaping technique that includes:

1) Slower physically-relaxed speech starts (stretch)

2) Relaxed speech muscle

3) Smooth airflow and voicing

Usually used at the beginning of words, phrases, or

phrase boundaries.

Practice with single words → two words →

spontaneous speech

aka exhaling first or breathing out and THEN saying the first word→ this helps you get unstuck.

3. Light contact

before stutter; aka soft contacts; light articulatory contact

This is a fluency shaping technique that includes:

1) light tongue and lip movement (aka slightly moving tongue and lips as you speak, reduces tension)

2) continuous airflow

3) Smooth airflow and voicing

Usually used at the beginning of words, phrases, or

phrase boundaries.

Practice with single words → two words →spontaneous speech

a note on fluency enhancing/shaping techniques

When you have clients, going to teach them all of these and have them pick which one they want/mix and match what they want to use (e.g., stretching with pausing, slow speech/pausing with light contact, etc)

USE these techniques BEFORE client thinks they are about to stutter**** aka have to anticipate that you will stutter before implementing these techniques—> for light contact, easy onset,

For stretching or pausing, or over articulation, it does not matter if you anticipate or not do not have to anticpate

Difference between fluency enhancing and stuttering modification techniques: whether you anticpate: if you anticipate, fluency enhancing, if you don’t, stuttering modification (this is probably right)

Stuttering Modification (Acceptable Stuttering): 6 Techniques

1) Voluntary/Pseudostuttering

2) Holding & tolerating a moment of stuttering

3) In-block corrections/pullouts

4) Post-block corrections/cancellations

5) Bounce

6) preparatory set

1. Voluntary/Pseudostuttering

Purposeful stuttering (using repetitions, blocks,

prolongations) creates:

1) A sense of control

2) Increase awareness

3) Decreases fear and avoidance behaviors

4) Increases desensitization to stuttering

Practice with single words → spontaneous speech

2. Holding a moment of Stuttering

Why hold on to a moment of stuttering? (in a

clinical setting)

Aka keeping that moment of stuttering or disfluency

Helps to:

• Increase awareness of stuttering and areas of tension

• Increases desensitization

• Decreases avoidance behavior

Requires clients to:

1)Stay in a moment of stuttering

2)Keep the disfluency going

note: some clients will never be able to do this. same for

looking at self in mirror while stuttering. A lot of load on client.

3. Pull-outs (During stutter; aka slide-out)

Technique requires clients to:

1) Identify and focus on the moment of stuttering

2) Then decrease the tension (prolong sound) and

ease themselves out of the moment of stuttering

Helps to:

• Reinforce acceptable stuttering with decrease

tension

• decrease sense of loss of control

Practice with single words → spontaneous speech

deep breathing helps.

4. Cancellations (during/after stutter)

Typically used only in the clinic.

Technique requires client to:

1) Finish the stuttered word

2) Pause to plan

3) Pseudostutter (with any technique) on the

previously stuttered word

Helps to:

• decrease avoidance behavior.

In other words, Client will stutter and then after stutter, pause and plan type of psuedostutter on same word. Cancel and replace stutter with one they are in charge of trying to decrease avoidance

5. Bounce (During)

Technique requires clients to:

1) repeat the initial syllable of words

(so the general struggle behaviors evident during stuttering are reduced. )

Helps to:

• Decrease the sense of loss of control.

*Clients are told to vary the number of repetitions

of a syllable so that they do not create a habit of

the pattern. (e.g., the first time repeat 5 times and then after do 3 times to avoid creating a habit!!!!!)

Basically, like a part-word repetition, asking the client to do an easy stutter (part-word repetition) instead of a hard stutter.

Preparatory set (modification before stutter)

Technique requires clients to:

1) Anticipate moment of stuttering (we said that most people who stutter can anticipate when they can, but there are also times when they can’t)

2) Modify the tension before it builds up or reduce the tension

Basically, helping clients figure out when they are going to stutter so that they can use techniques before they get to that moment of stuttering. If you cannot anticipate, then you cannot use techniques like easy onset, light contact, etc. Asking client that when they anticipate they will stutter, to slow down, think about a technique they are going to use, and use it.

Note: this is still a stuttering modification technique because you are modifying the tension that you have, aka decreasing it

Helps to:

• Increase airflow

• Changes articulatory posture/reduces tension

Practice with single words → spontaneous speech

changes a hard stutter (e.g., a block) to a more easy stutter (e.g., part word repetition, or maybe not stutter at all, this reduction in tension helps achieve this.

Group therapy

• Therapy in a group ≠ support group (group therapy is not a support group; stutter support groups are usually not led by SLPs but just consist of other PWS)

• Led by SLP

• You (SLP) has a Treatment plan

• Goal and objectives for each client

(individual goals, group goal)***

Treatment in a group environment

• Intermediate between clinic and outside world

• Reduces isolation

• Place to practice strategies

• Community

Make sure therapy starts ONE ON ONE to build rapport first!

Practicing techniques is good for groups, but LEARNING techniques

should always be individual**

Counseling

• Counseling people who stutter

  • Informative (giving them information about stuttering and communties of people who stutter, etc)

  • Persuasive (e.g., persuading client to do something they may not want to do e.g., pseudostuttering)

  • Listening and valuing

Example of Questions to ask clients when counseling:

a) What do you hope to achieve as a result of our meeting?

b) When you use the word “stuttering” what do you mean ?

c) Describe when and how your stuttering began

d) What do you think caused your stuttering?

e) Have you had therapy for stuttering?

f) Does anyone else in your family stutter? Or have other communication challenges?

g) How is your stuttering affecting you at the

present time?

h) How would you describe yourself as a

communicator?

i) Where and with whom would you expect

your speech to be best? And worse?

j) Have your educational, social, goals been

affected by stuttering?

k) How do you see your communication skills

affecting your future?

l) What are your feelings about enrolling in

treatment?

m) Do you have any specific topics we would like

to address?

When to stop therapy? 4

1) When they can communicate effectively

2) When they can successfully transfer and maintain their skills in situations outside the clinic

3) When they become their “own clinicians”

4) Elimination of feared words and situations

Van Riper’s Definition of Success

Therapy is considered successful when the client

changes from a person who stutters to a

person who is in control and speaks fluently

with occasional moments of mild stuttering.

Therapy Goals-2

1. Ultimate goal is to become an effective communicator regardless of stuttering.

2. Motivation determines eventual success of therapy.

Clinician-client relationship

To form a good clinician-client relationship!!

• Preparation – outline of information you need

• Social greeting – talking, communicating,

express desire to learn more about the client

and their experience.

• Questions – direct, open-ended questions but

not an interrogation!