Avoidance Reduction Therapy for Stuttering (ARTS®)

Avoidance Reduction Therapy for Stuttering (ARTS®): An Overview

Contributors:

Vivian Sisskin, University of Maryland, Maryland, USA; Sisskin Stuttering Center, Virginia, USA
Mark Baer, Sisskin Stuttering Center, Virginia, USA

Theory and Framework

Quote: "Basically, stuttering is not a speech disorder but a conflict revolving around self and role, an identity problem.” – Joseph Sheehan
Foundations of ARTS:
- Grounded in the work of Joseph Sheehan (psychologist) and Vivian Sheehan (speech pathologist).
- Utilizes concepts from conflict theory and role theory to understand stuttering.

Conflict Theory

Stuttering is viewed as an “approach-avoidance conflict”:
- Competing desires to speak versus fears that lead to holding back from speaking.
- This conflict creates maladaptive behaviors that interfere with communication.
- Results in “mental gymnastics” that limit social participation.
- Contributes to multiple types of avoidance:
  - Word/sound avoidance
  - Situational avoidance
  - Impact on relationships and life choices
- Avoidance Reduction:
  - Approaching feared situations helps resolve the conflict.

Role Theory

Individuals who stutter fluctuate between fluent and disfluent speech:
- “Sometimes I stutter, and sometimes I don’t.”
- Fluency leads individuals to mask their identity as a person who stutters.
- Role Behavior:
  - Individuals may act in ways that reflect a false identity as a fluent speaker.
  - Behaviors can include:
  - Pretending to think
  - Speaking in unnatural ways
  - Avoiding answering questions
- Role Conflict:
  - When stuttering occurs, shame arises from being unable to uphold the fluent persona.
- Role Congruency:
  - Achieved through self-acceptance as a person who stutters.

Understanding the Problem of Stuttering

Quote: "Successful suppression of stuttering is what maintains and perpetuates the problem.” – Joseph Sheehan
Learning Consequences of Stuttering:
- From a young age, individuals learn that stuttering is viewed negatively by listeners (e.g., disapproval, eye contact avoidance, interruptions).
- Negative feedback initiates a cycle of avoidance behaviors that reinforce stuttering.

Common Escape Behaviors Include:

Tapping a finger
Breaking eye contact
Using interjections (e.g., “um” or “uh”) before feared words
Repeating already spoken words/phrases fluently
Substituting words
Not speaking at all

Operant Conditioning:

Escape behavior serves as a reinforcement mechanism that alters speaking patterns, providing temporary fluency.
Example: Breaking eye contact to avoid stuttering during introductions. As these strategies become habitual, they lead to a never-ending search for new methods of suppression.

The Iceberg Analogy

Visible issues (e.g., disfluencies, physical struggle) are like the tip of an iceberg;
- The underlying issues (negative thoughts, feelings, attitudes) are submerged and larger.
Each instance of suppression increases the hidden problems, such as shame and fear.
Efforts to avoid stuttering lead to physical tension, disrupted speech patterns, and conditioned struggle.

Treatment Approaches in ARTS

Quote: "Every stutterer becomes in time a ‘walking museum’ of those crutches, devices, or mannerisms he has employed to conceal his stuttering.” – Joseph Sheehan

Identification and Monitoring

Initial step in therapy is to gain awareness of the various learned escape behaviors associated with stuttering.
Distinguishing between harmful behaviors (e.g., loss of eye contact) and helpful behaviors (open repetitions) is crucial.
Monitoring:
- Involves identifying escape behaviors in real-time, effectively reducing them indirectly.
Replacement Behavior:
- Openly stuttering replaces escape behaviors, allowing stuttering to be acknowledged without avoidance.

Open Stuttering Defined

It refers to "clean" stuttering, free of escape or avoidance behaviors.
Patterns may differ among patients; may involve initial struggles such as tension when revealing stuttering patterns.
Practice of open stuttering should begin in low-stress situations to encourage acceptance of feelings of shame.

Williams Normal Talking Model

Developed By: Dean Williams, former researcher and clinician at University of Iowa.
Parameters of Normal Speaking:
- 1) Air Flow: Needed for vocal cord vibration.
- 2) Voicing: Required for phonation.
- 3) Tension: Essential for normal speech.
- 4) Timing: Essential for coordination of speech.
- 5) Movement: Necessary for effective speech production.
Therapeutic Approach:
- Understand and explore the speech mechanism within these parameters to achieve fluent and smooth speech.

Desensitization and Reframing

Open stuttering leads to desensitization regarding the disfluency previously masked by escape behaviors.
Individuals must confront the shame and negative thoughts surrounding their stuttering.
Techniques from cognitive behavioral therapy (CBT) and mindfulness therapies (e.g., Acceptance and Commitment Therapy — ACT) are utilized to help with reframing and acceptance.
Goal: Gradual exposure reduces anxiety and reactivity, fostering acceptance of stuttering.

Self-Acceptance and Self-Advocacy

Years of avoidance and false role behavior can make individuals feel the need to achieve fluency for success.
Therapy promotes a cognitive shift in defining success:
- Value being able to express oneself, regardless of fluency.
Self-Advocacy:
- Individuals learn to be advocates for themselves, shedding the need to mask their stuttering.
- Utilizing self-disclosure provides permission to stutter and presents a positive view of their condition to others.

Culture of ARTS® and the Process of Change

Quote: "If you don’t like something, change it. If you can’t change it, change your attitude.” – Maya Angelou

Key Concepts and Values of ARTS®

Promotion of comfortable, forward-moving speech and struggle-free disfluency.
Emphasizing self-acceptance and exercising choice regarding stuttering.
Important shifts include:
- How one stutters is prioritized over if one stutters.
- Focus on conveying messages rather than concealing stuttering.
- Tolerance of shame considered a success.
- Expression over avoidance is encouraged.

Tools and Techniques

Avoid reliance on “tools” or techniques to manage stuttering; focus instead on natural communication processes.
Therapy emphasizes the significance of spontaneous communication and self-expression without barriers.

Outcomes and Recovery in ARTS®

Recovery is defined by outcomes such as:
- Self-acceptance as a person who stutters.
- Achievement of spontaneous and confident communication, with minimal life interference due to stuttering.
Patients resonate with the idea of recovery as being able to communicate freely without the baggage of shame or worry about listener reactions.
Quote: "I say exactly what I want to say, when I want to say it, comfortably, efficiently and spontaneously. I no longer carry around negative mental baggage or worry about listener reaction. I am free to be who I am."

References

Beilby, Byrnes, Yaruss (2012) Acceptance and Commitment Therapy for adults who stutter: Psychosocial adjustment and speech fluency.
Brutten, G.J. & Shoemaker, D.J. (1967). The Modification of Stuttering. Englewood Cliffs, NJ: Prentice Hall.
Reitzes, P. (Producer). (2015, March 27). “Use Your Tools!” And Other Ineffective Nagging: featuring Vivian Sisskin. Episode 507. Audio Podcast, Stutter Talk. Retrieved from http://stuttertalk.com/use-your-tools-and-other-ineffective-nagging-ep-507/
Sheehan J. G. (1953). Theory and treatment of stuttering as an approach-avoidance conflict. Journal of Psych, 36, 27-49.
Sheehan, J.G. (1968). Stuttering as a self-role conflict. In H.H. Gregory (Ed.) Learning theory and stuttering therapy. Evanston, IL: Northwestern University Press.
Sheehan, J.G. (1974). Stuttering: Research and treatment. New York: Harper and Row.
Sheehan, V.M., & Sisskin, V. (2001). The creative process in avoidance reduction therapy for stuttering. Perspectives on Fluency and Fluency Disorders, 11(1), 7-11.
Williams, D.E. (1959). A point of view about stuttering. JSHD, 22(3), 390-397.

Citation

Sisskin, V. & Baer, M. (2016, March-April). Treb: éliminer la lutte contre le bégaiment. Ortho Magazine (Elsevier). Vol. 22(123), 14-17.