Stuttering Intervention 3 PDF

STUTTERING Presented by: INTERVENTION 3 Dr Shabnam Abdoola  Affective (feelings and emotions) Anxiety, fear, avoidance and anticipation Behavior (core ADDRESSING behaviors) THE ABC’S OF Fluency Shaping...

STUTTERING Presented by: INTERVENTION 3 Dr Shabnam Abdoola  Affective (feelings and emotions) Anxiety, fear, avoidance and anticipation Behavior (core ADDRESSING behaviors) THE ABC’S OF Fluency Shaping Stuttering Modification (SSMP) STUTTERING Cognition (Attitudes) Reframing and reorganizing our thoughts and ideas about stuttering and ourselves 2  Impairment Fluency Shaping (FS) Approach - Shaping is about relaxation and motor skills, emphasizing what happens during fluent speech. However, working on modifications and motor skills alone is not enough. Therapy must also address attitudes and emotions, which we’ll discuss last. Stuttering Modification (SM) Approach - is about stuttering more fluently - modifying, changing, or APPROACHES smoothing out a stuttering moment. Students need to look at and work with the moment of stuttering. This may involve negative practice and stuttering on TO THERAPY purpose. The integrated approach Both fluency and stuttering should be honored in therapy. Since most people who stutter will always stutter to some degree, recognizing and targeting fluency alone can be dangerous to self-esteem. Besides, no stuttering therapy approach is 100% successful. All people who stutter should be helped to feel that it’s OK to stutter. 3  SYNERGISTIC STUTTERING THERAPY: A HOLISTIC APPROACH (Bloom and Cooperman) – provides a good summary The synergistic model: ⬥Neuro-physiological demands – reduced speech motor control and language formulation ⬥Physical factors – genetics and possible brain activity ⬥Psycholinguistics – the interplay between language and disfluency ⬥Behaviour - learned ⬥Attitude and environment –self esteem, confidence = how readily they will express ideas and opinions ⬥Locus of control – inner self or external events. The therapist and client should strive to – identify needs especially the debilitating negative emotions  Discuss the normal communication process. Motivate the client – show videos or play tapes. INTERVENTION/ MANAGEMENT Refer to websites. OF THE ADULT Keep note book or journal. Audio or video tape sessions regularly. THE PROCESS Combine modification with fluency shaping - an integrated approach (spontaneous controlled speech) Desensitise Vary and obtain control Use control techniques and modify the stuttering Cancellations Proprioception Transfer to outside situations as soon as possible Encourage to attend groups Must monitor self RELAPSES Discuss what these are Prepare Revisit fears Fake stutters Positive thoughts Discuss and use fears Help set realistic goals Therapy can be quite time consuming The therapist assists and supports the client in reality testing Conture (2001, p 293) “we are guides not magicians” Person- and Family-Centered Practice Consistent with a person- and family-centered approach to stuttering treatment, the SLP educates the individual who stutters and their family members about stuttering and communication and facilitates conversations between the individual and their family about the experience of stuttering, the individual’s communication expectations, their life goals, and how to holistically support communication  CHANGING COGNITION “Our chief want in life is someone who will make us do what we can.” Emerson Motivational interviewing Techniques: ▪ Open-ended questions ▪ Feedback ▪ Reflective listening ▪ Affirmations ▪ Summarizing Basic principles to encourage positive self talk and emotions and attitudes ⬥create a safe house ⬥client and therapist establish objectives for therapy ⬥create opportunities for success ⬥heighten awareness of fluency ⬥encourage the use of techniques ⬥working on maintenance and carryover ⬥prepare for the outside world ⬥establish good communication skills (pragmatics?) ⬥in order to get a better understanding – therapist to “walk in PWS shoes” Clients need to know ⬥Stuttering is a point of view ⬥DISability or disABILITY? ⬥Have the paradigm of a stuttering – fluency can include stutter ⬥Focus on positive goals and behaviours WHAT MATTERS MOST IS HOW YOU SEE YOURSELF! Clients view stuttering as a barrier to life ⬥“Disorder of the spirit” ⬥Need to access new beliefs – find role models ⬥Against all odds ⬥Take control ⬥Stuttering creates more pain than the pain of therapy. ⬥Build a positive self image – feeling of competence ⬥Find other areas to achieve ⬥Ability to influence others Use the talents you possess. The woods would be very silent if no birds sang there except those who sang best. Henry van Dyke The individual who has low esteem reacts by “I can’t” Thus: ⬥we demean our own talents, ⬥feel others don’t value us, ⬥we are powerless and lack self confidence. In turn easily manipulated by others, becomes sensitive, easily frustrated and tends to blame others for own weaknesses. If the therapist (environment) can build up high self esteem and praise the action: the client will act independently in making choices, assume responsibility act promptly and confidently be proud of accomplishments approach new challenges with enthusiasm exhibit emotions and feelings without self consciousness tolerate frustration feel special to those they love, play with or work with feel capable of influencing others. Extent of impact Social aspects Vocational aspects Clinical process Themes of successful stuttering management RET (rational emotional therapy) or CBT (cognitive behaviour therapy). The client has a long history of loss of control – “fight or flight” Indoctrination of illogical, inconsistent unworkable values Attitudes from false interpretation of events  A. Activating event E. Changing B. Person’s belief system irrational belief C. Emotional D. Irrational consequence belief A something unpleasant happens B we interpret the event C consequences – we get upset or “awfulize” the situation D you question and change your thinking about the event E irrational to rational TEACH POSITIVE AND NEW VALUES: Maslow quotes: “no psychological health is possible unless the essential care of the person is fundamentally accepted, loved and respected by others and himself.” Negative irrational self talk can also been seen as Bill Murphy (1997): The “stinkin thikin” which involves three levels of thinking/perception the descriptive level – I get the message making inference – I decide that the word are demeaning my cognition evaluates the comment and appraises. These beliefs can determine emotional health and in turn negative disturbed emotions so I start “awfulizing” “I’m bugged because I’m plugged” – a magical belief that becomes overly exaggerated (Emerick) Leads to F - false E - evidence A - appears R - real The aim is to control the products of primal processing (fear, self criticisms) → to learn more adaptive flexible behaviours. For example: You stutter→ the negative reinforcement → “I will never speak right” (this is an over generalization). A positive thought – “this was a momentary lapse on a good day what could I have done” or “I am making progress”. THE THERAPIST AND CLIENT SHOULD STRIVE TO – IDENTIFY NEEDS ESPECIALLY THE DEBILITATING NEGATIVE EMOTIONS. Break out New experience and positive Fear and anticipation Prediction and negative feedback Incident Stronger Getting Stuck Bogged Down Environmental feedback: Self fulfilling prophecy School – teachers Comparing with Work previsions – repeated Home – parents, history siblings A few simple tips: ▪ teach the client that he is not a bad person if he does not always achieve his goal ▪ perfection is not required to be a worthwhile person ▪ popularity and achievement are not necessarily related to being worthwhile nor is 100% ▪ teach the client that minor setbacks are not catastrophes. CBT steps: (See Emerick (1988), Bloom and Cooperman (1999) and Manning (2001) for an easy to follow programme). Information giving – a map of the therapy process and involve client to help set up objectives. Cognitive appraisal - the client summarizes in his own words the contents of the therapy programme and makes sure it suits his needs. Identify the self defeating thought patterns (identify the repertoire of negative thoughts). Thought reversal – reduce and eliminate the negative thoughts, “thought stopping”. Subject these “old” hypotheses to reality testing – the therapist helps by modelling, or role play. Substitute with self-enhancing language Coping skills Gerald Johnson (1985) 10 Commandments for long- term maintenance” uses the following 10 helpful steps: engage in an objective self analysis develop rational thinking work for philosophic change achieve spontaneity keep yourself healthy do not fall victim to the guru complex do not procrastinate achieve independence your choice – is positive self talk (Mental Health week task) MAP – monitor action and performance → your way to fluency. (similarly to sport = changing motor patterns) STARTING SELF-HELP GROUPS Rationale: The value of groups: ▪ support ▪ offer information and advice ▪ service delivery ▪ alternative therapy programme ▪ group activities FRAMEWORK OF A PROGRAMME Needs assessment Composition of the group Eliciting communication Choice of activities and topics 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: 1. 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. 2. Freeze your core behaviors—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. 3. Voluntary stuttering, or stuttering on purpose. This helps you remain calm when you stutter. U. Zsilavecz/S. Abdoola 2019 Modification This is where you learn "easy stuttering" or "fluent stuttering," in 3 stages: 1. 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. 2. 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. 3. 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. U. Zsilavecz/S. Abdoola 2019 Treatment Approaches: School-Age Children And Adolescents Who Stutter S. Abdoola 2019 Below is a list of approaches most commonly used with school-age children and adolescents who stutter. Approaches may vary for children and adolescents. Many clinicians use an integration of approaches in order to achieve optimal outcomes. All approaches should include a plan for generalization and maintenance of skills involved in activities of daily living. APPROACH/STRATEGY WHAT DOES IT ENTAIL? HOW DOES IT WORK? Increasing Speech Efficiency Increasing spontaneity in May initially exhibit more (Reducing Word Avoidance) communication surface-level stuttering Strategies For Reducing Desensitization: systematically Use of voluntary stuttering Negative Reactions (Personal desensitize themselves to their (sometimes called And Environmental Context) fears about speaking and "pseudostuttering," if the stuttering by facing those fears initiation of the activity involves in structured, supportive fake stuttering behaviors) environments Cognitive Restructuring: Identifying the assumptions designed to help speakers underlying their thoughts, they change the way they think can evaluate whether those about themselves and their thoughts are helpful (or valid) speaking situations and ultimately adopt different assumptions or thoughts. Self-Disclosure: involves communicating to others information that reveals one's identity as a person who stutters Support: valuable for improving Provide venues to practice attitudes, boosting self- learned strategies in a safe confidence, and reducing environment, promoting feelings of isolation generalization. Support activities can be incorporated into group treatment Strategies For Reducing Activity Generalization Activities Begin in supportive, low-fear Limitations And Participation situations and slowly evolve to Restrictions more challenging situations and settings as the child demonstrates the ability to accept or tolerate potential negative reactions. Accommodations At School and Reasonable accommodations In the Community include using audio/video recording, increasing the time provided for an oral reading or presentation, providing an alternative assignment to oral reading, altering the size of the group or audience. Treatment Approaches: School-Age Children And Adolescents Who Stutter S. Abdoola 2019 Fluency shaping Controlled Fluency Techniques include: Cognitive Reframing Rate Control Breathing (pausing and phrasing) Easy Onset Light Contact Continuous Phonation, linking Stuttering modification Modifying Stuttering Four Phases: Reducing Fear 1. Identification 2. Desensitization 3. Modification 4. Stabilization