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"•^r^-TMiMMI ' "-iT I • iTi«
THE MODIFICATION OP STUTTERING BEHAVIOR
THROUGH SYSTEMATIC DESENSITIZATION
AND REACTIVE INHIBITION
by
KATHRYN ELAINE HALDY PATTERSON, B.A.
A THESIS
IN
SPEECH
Submitted to the Graduate Faculty
of Texas Technological College
in Partial Fulfillment of
the Requirements for
the Degree of
MASTER OF ARTS
August, 1967
i\v\
IKt
205'
T3
\9^o7
No. I5S'
Ca^3
ACKNOWLEDGMENTS
The author is grateful to those who have participated in the preparation of this thesis SLnd is deeply
indebted to the following:
Dr. William Keith Ickes, for his direction of this
thesis and for his encouragement throughout the author»s
graduate studies at Texas Technological College.
Dr. Eugene Brutten, for his time and suggestions
which aided in the development of this program.
Mr. William Marlin Patterson, the author's husband,
for his patience and understanding during the past year.
ii
TABLE OF CONTENTS
ACKNOWLEDGMENTS
ii
LIST OF TABLES
;
LIST OF ILLUSTRATIONS
I.
vi
INTRODUCTION
1
Review of Previous Research
2
Psychosomatic Theory
3
Psychoanalytic Theory
4
Learning Theory
6
Behavior Modification: Extinction
of Conditioned Behaviors
Behavior Modification: Clinical
Procedures
Evaluation of Behavior Modification
Therapy
11
13
l6
20
Purpose and Scope of the Thesis
III.
2
Neurological Theory
Various Learning Therapies
II.
v
METHODS AND PROCEDURES
22
23
Population
23
Evaluation of Stuttering
23
Therapeutic Procedures
24
CASE STUDIES
31
Case Study of J. H
31
Clinical Proceedings
32
Clinical Summary
42
iii
iv
Case Study of T. C
Clinical Proceedings
45
C l i n i c a l Siommary
46
Case Study of S. S
IV.
43
48
C l i n i c a l Proceedings
49
C l i n i c a l Siimmary
57
SUMMARY AND CONCLUSION
58
Summary
58
Conclusion
60
BIBLIOGRAPHY
62
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a imnfir-fcirr mMMti»]mt]imiMttimmtrma-Mmmmu
LIST OF TABLES
Table
1.
Page
Scale for the Degrees of Hypnotic State . . . .
27
mi -i I'miutmivk-
LIST OF ILLUSTRATIONS
Figure
1.
Page
Classically Conditioned Negative Emotion
in Stuttering
vi
10
CHAPTER I
INTRODUCTION
The phenomenon of stuttering has been an enigma to majikind for centuries. It has a history that dates back at
least to the ancient Egyptians. Stuttering has been mentioned
in the Bible, and Moses is reputed to have been a stutterer.
Aristotle, Aesop, Demosthenes, Vergil, Erasmus, Charles Lamb,
and Sir Winston Churchill are among the famous who have been
afflicted by this disorder.•'• The mystery of its conception
and maintenance has led to countless speculations, theories,
and therapies, many of which were as mysterious as the disorder itself. In early centuries, stuttering was believed
to be of a physical origin. Later theoreticians assumed that
there were deep psychological disturbances that caused stuttering. Modern theorists expound on the hjnpothesis that
stuttering is a learned behavior.
In accordance with the assumed genesis of stuttering,
therapies have been prescribed in an attempt to cure the
stutterer of his difficulty.
Hippocrates advised the appli-
cation of healing oils and medications to the throat and the
2
neck.
Nineteenth century surgeons performed operations on
^Dominick Barbara, Stuttering: A Psychodynamic Approach
:h to Its Understanding and T
Treatment (New York: The
rulian Press, Inc., 1954), p. 23.
^Ibid., p. 24.
the tongue to bring it nearer to the palate.^ Psychologists
have advocated treatment for neuroses. Learning and behavior
theorists have set forth procedures for the eliminating of
the undesirable behavior of stuttering and replacing it with
the desirable behavior of fluent speech. It is due to the
progressive sophistication and increased knowledge of the
behavior of humans that stuttering has been treated more as
a disadvantage than as an infirmity.
Review of Previous Research
Modern theorists have proposed innumerable concepts for
the stuttering behavior. Most significant of these includes
the neurological, psychosomatic, psychoanalytical, and learning theories.
Neurological Theory
h
The dominant gradient theory, asserted essentially by
Orton,-^ Travis,^ smd Bryngelson,' holds that lack of cerebral
3c. S. Bluemel, "Concepts of Stammering: A Century in
Review," Journal of Speech and Hearing Association, XXV,
No.l (February, 19^0}, p. 25.
^bid.
^Mildred F. Berry and Jon Eisenson, Speech Disorders:
Principles and Practices of Therapy (New York: AppletonCentury-Crofts, 195b), p. 2b4.
"Barbara, Stuttering . . ., p. 30.
7'lbid., p. 26.
dominance, or an interference of the development of dominajice associated with handedness, causes a failure of the
musculature employed in speech to receive properly timed
innervating impulses for the integrating centers of the
central nervous system.^
The factor of the inheritance
of stuttering has also been investigated, but, as yet,
this factor has little unequivocal evidence to support it.
Psychosomatic Theory
The psychosomatic concept basically concerns a variation in the physiological composition of an individual which
may be causally related to personality maladjustment.9
Karlin's theoretical assiamption of delayed or incompleted
myelination of the cortical speech area may be considered
exemplary.-^
The primary somatic, biological, factor of
this two-factor theory is the assximption that myelination
of the cortical speech areas is incomplete or delayed until
early adulthood.
The secondary, psychological, factor is
based upon undue emotional stress to which a child may be
exposed during a negativistic period.
This period is usually
encountered between three smd four years of age.
Should
°Berry and Eisenson, Speech Disorders . . ., p. 264.
^Ibid., p. 266.
l^lsaac Karlin, David Karlin, and Louise Durren,
Development and Disorders of Speech in Childhood (Spring•field, Illinois: Charles C. Thomas Co., 19^5)3 P- 96.
non-fluencies occur and unflavorable reactions be precipitated by the speech of the child, emotionality develops and
becomes an integrated component of stuttering. Habit strength
of the speech response is reinforced and stuttering behavior
is learned.
Psychoanalytic Theory
Stuttering, as conceived in a psychoanalytic framework,
is regarded broadly as a neurotic disorder in which personality maladjustment is reflected in part by a disturbance of
speech.12 The disorder has been accepted by psychologists as
a narassistic neurosis, a pregenital conversion neurosis, and
as an oral fixation. -^ To delve further into the realm of
psychoanalysis is unnecessary for this discussion. Import
should be attached to the therapy afforded by psychoanalysis
and psychotherapy in general. A simple yet important practice
in this area is relaxation therapy. The experience with relaxation has proved sufficiently satisfactory to make the
therapy empirically acceptable.l4 Of more concern to this
lllbid., p. 95.
•^%. Peter Glauber, "The Psychoanalysis of Stuttering,"
Stuttering: A Symposium, ed. Jon Eisenson (New York:
Harper and Brother, 195^), p. 73.
^3ibid., pp. 93-95.
^^Bluemel, Journal of Speech and Hearing Association,
XXV, No. 1, p. 2Ti
report is a specific tool of relaxation therapy: hypnosis.
The term hypnosis means sleep.-^^ As early as the sixteenth century, therapeutic value was found in the trancelike state induced under hypnosis.^" In its present application of function, the phenomenon of hypnosis was used by
Braid, an English physician, in l84l. ' Unfortunate connotative implications have shrouded hsrpnosis, causing modern
practioners in medical, psychological, and social fields to
be reluctant to utilize its full capacities.
The use of hypnosis and post-hypnotic suggestion has
been attempted as therapy for stuttering. Fluency, if
achieved at all, was short-lived and lasted no longer than
thirty minutes. It was concluded that fluency could be
achieved in some stutterers, but that it was not permanent.
Consequently, hypnosis should be visualized, not as a miraculous "cure" for stuttering, but merely as a valuable adjunct
18
to any system of therapy for stuttering.
Relating psychotherapy to stuttering behavior and
therapy. Dr. Eugene Brutten states:
•'-^William Heron, Clinical Applications of Suggestions
and Hypnosis (Springfield, Illinois: Charles C. Thomas, Co.,
1959)/p. 3.
l^Ibid.
^'^Ibid.
^^Wilbur E. Moore, "Hypnosis in a System of Therapy
for Stutterers," Journal of Speech Disorders, XI (1964),
pp. 120-121.
Psychotherapy is the basic treatment for
stutterers. This deeper means of therapeutic
intervention may involve the release of feeling, the development of satisfactory interpersonal relationships, and the adjustment to
increased fluency. Though psychotherapy alone
may improve ones adjustment it does not assure
a significant change in fluency. This lack of
change in the speech behavior indicates the
tenaciousness of the learned effects of stuttering. 19
Learning Theory
The above statement directs the discussion to the consideration of stuttering within a framework of learning.
Wendell Johnson investigated the various stimulus variables
of which stuttering was a function and arrived at the diagnosogenic theory of stuttering.
Essentially this theory is
based on the assumption that stuttering is a learned anxiety
system resulting from the evaluative behavior of parents,
teachers, and others close to the stutterer. The child becomes a stutterer after he has been labelled one.20 As Dr.
Johnson phrases it:
"The problem of stuttering, then, would
seem to start, not in the speaker's mouth, but in the listener's ear."^l
•^Eugene Brutten, "Stuttering: Behavior Theory ajid
Therapy." (unpublished manuscript), p. 31.
^^Joseph Sheehan, "The Modification of Stuttering
Through Non-Reinforcement," Journal of Abnormal and Social
Behavior, XLVI (1951). p. 52":
21
Wendell Johnson, "The Time, the Place, and the
Problem," Stuttering in Children and Adults, ed. Wendell
Johnson and Ralph Leutenegger (Minneapolis: University
of Minnesota Press, 1963), p. 11.
Wlschner attempted to interpret the original instigator
of stuttering behavior as any pain-producing, punishing state
of affairs that have been elicited by the environment as a
response to a child's behavioral pattern.
The response,
serving as a stimulus, evokes a state of anxiety vrtiich motivates the child to seek activity designed to avoid the noxious stimulus.
Stuttering develops after anxiety has been
learned, amd the disorganization of speech behavior consequent on anxiety is related to the speech act.^^
The re-
sponse has been labelled anxiety-motivated avoidstnce be24
havior.
The normal speech behavior which was associated
with the painful or punishing situation will be avoided and
a substitive speech behavior will result.
This behavior will
persist due to the maladaptive reinforcement preceding p\inishment. -^
Within a similar learning framework, Sheehan conceptualizes the stuttering pattern as a res\ilt of a double approach-avoidance conflict.
At work are four opposing forces:
the desire to speak and the desire not to speak; the fear of
speaking and the fear of not speaking.
Point of conflict
^Brutten, "Stuttering . . .," p. l6.
2^
~^George J. Wlschner, "Stuttering Behavior and Learning: A Preliminary Theoretical Formulation," JTournal of
Speech and Hearing Disorders, XV (1950), p. 32"5";
^^rutten, "Stuttering . . ." p. 17.
^Wlschner, Journal of Speech and Hearing Disorders,
XV, p. 332.
8
aroused by these forces results in stuttering.
Conflict
may develop at five distinct levels: words, situations,
emotional content, interpersonal relationships, and egoprotection levels. Interplay of approach-avoidance forces
at any of these levels determines the moment of stuttering.
Stuttering behavior is maladaptively reinforced due
to reduction of anxiety during and after the loci of stuttering. The reduction of anxiety becomes reinforcing; yet
at the same time this reduction advances the stutterer
closer to the goal of speaking which, in turn, creates an
increase in anxiety. Thus the anxiety is "bound" within
the stuttering behavior and a vicious cycle is perpetuated. '
A two-factor learning theory is presented by Brutten
and Shoemaker. They propose that learned emotionality and
instrumental learning are involved in the acquistion of
stuttering and its associated behaviors.28 This two factor
theory is explained concisely in the following statement:
(1) Stuttering is considered the disintegration
of speech fluency that results from classically
conditioned negative emotionality, and (2) responses of avoidance and escape are viewed as the
^^Joseph Sheehan, "Theory and Treatment of Stuttering
as an Approach-Avoidance Conflict," Journal of Psychology,
XXXVI (1953), p. 46.
^"^Ibid.
28
Donald Shoemaker, "A Two-Factor Approach to the
Modification of Stuttering," Abstract of a report to the
International Seminar in Stuttering and Behavior Therapy,
Cannel, California, November 1-4, 1966, p. 7.
instrumentally conditioned attempts at adjusting to anticipated or coping with the existent
noxious consequences that may be associated
with stuttering.^9
Classical conditioning may be explained as an emotional
response due to its momentary association with a noxious
stimulus that is capable of arousing emotion.^^
By assign-
ing operational definitions to the standard Pavlovian symbols, the development of classically conditioned negative
emotion producing stuttering may be seen more clearly.
The
unconditioned stimulus (UCS) would be a noxious stimulus
coming from the environment which elicits the unconditioned
response (UCR) of unlearned negative emotionality and disintegration of speech.
The noxious stimulus (UCS) becomes
associated with environmental cues, such as situations and
words, which develop into the conditioned stimulus (CS). The
environmental cues (CS) now produce learned negative emotionality and disfluency, which represent the conditioned response
(CR).
With the development of the relationship between the
environmental cues (CS) and the negative emotion eliciting
disfluency (CR), stimulus generalization will occur which will
evoke a similar emotional response.
This explains the onset
and development of stuttering behavior.31
29Eugene Brutten, "Stuttering: Reflections on a TwoFactor Approach to Behavior Modification," Report to the
International Seminar in Stuttering and Behavior Therapy,
Carmel, California, November 1-4, I966, p. 1.
30Brutten, "Stuttering . . .," p. 19.
^ b i d . , p. 20.
10
Noxious Stimulus
Disintegration of Speech
UCS
.
UCR
CS
.
CR
i
Situation
and/or
Word Cues
Fig. 1.
Negative Emotion
with
Disfluency
Classically conditioned negative emotion
in stuttering.
Instrumental learning is assumed to be responsible for
the development of speech-associated problems which result
due to the "stutterer's attempts to escape and avoid fluency
failures and the conditioned stimuli which tend to produce
32
them."
The adjustive behaviors may be both verbal and nonverbal. Examples of the verbal behaviors may be changes in
speech-rate, hesitations, or interjections. Examples of nonverbal behaviors are moving the feet and legs, blinking the
33
eyes, wringing the hands, or Jerking the head.
Brutten, Shoemaker,"^ and Eysenck-"-^ concur in assuming
that there is a particular relationship existing between the
32Eugene Brutten and Donald Shoemaker, "A Two-Factor
Approach to the Modification of Stuttering," Report to the
International Seminar in Stuttering and Behavior Therapy,
Carmel, California, November 1-4, I966, p. 2.
33ibid.
3^Ibid.
^^H. J. Eysenck, "Learning Theory and Behavior Therapy,"
Behavior Therapy and the Neuroses, ed. H. J. Eysenck (New
York: Pergamon Press, 19^0), p. 13.
11
classically conditioned emotional responses and the instrumentally conditioned adjustive behaviors. The emotional responses function as learned drives and tend to stimulate and
reinforce instrumental behavior.3*^ Likewise the occurrence
of instrumental behaviors appears to influence and activate
the emotional conditioning.3'^ 3
There is an interaction
occurring between these two factors. Negative emotion causes
stuttering; stuttering precipitates use of instrumental adjustive behaviors in order to avoid disfluencies. The adjustive behaviors are annoying to the environment, which
responds piinitively toward the stutterer. This punitive response reinforces and/or increases negative emotional conditioning. 3^
It is thus assumed that stuttering is a learned behavior
which results from classically conditioned negative emotion
and instrumentally conditioned adjustive behaviors which
interact to perpetuate the behavior.
Various Learning Therapies
The learning theorists reviewed concur that emotionality
is an essential factor in the onset, development, and
3°Brutten and Shoemaker, p. 2.
^'^Ibid.
3 Eysenck, p. 13.
39Brutten and Shoemaker, pp. 2-3.
12
maintenance of stuttering behavior. It should be assumed,
consequently, that learning therapy should be centered
squarely on this factor and its associated responses. Both
Brutten and Sheehan found that there had been little clinical
applications of the scientific methods of learning. Although
widely acknowledged by speech pathologists for his research
with stuttering, Wlschner reported to Brutten that he had
not formulated his theoretical position into specific therapeutic procedures.40 The Johnsonian approach, like other
traditional therapies, was not effective "because /Tt7 merely
tried to increase the number of normal speech attempts by
preventing anxiety through 'confidence' measures, but gave
the stutterer nothing to help deal with the anxiety when it
was elicited."
The therapy prescribed by Sheehan involves an integration of psychotherapy and speech therapy in order to reduce
emotionality associated with words, situations, interpersonal relationships, and ego defense and to reduce the
tendency to avoid these sources of conflict.42
^^Brutten, "Stuttering . . .," p. 30.
^•^Sheehan, Journal of Abnormal and Social Behavior,
XLVI, p. 53.
^^Sheehan, Journal of Psychology, XXXVI, p. 47.
13
Behavior Modification:
Extinction of Conditioned Behaviors
Brutten and Shoemaker have proposed a therapeutic program consistent with their two-factor conceptualization of
stuttering behavior. There are two sets of extinction
procedures:
the first, directed toward the extinction of
the classically conditioned emotional responses; and the
second, directed toward the extinction of the instrumentally conditioned adjustive behaviors.4^
-* The program is
based upon two hypotheses.
First, it is hypothesized that conditioned
emotional responses will extinguish with
repeated presentation of the conditioned
stimuli in the absence of unconditioned
stimuli or in the presence of stimuli which
lead to a competing dominant emotional response. Second, it is hypothesized that
extinction of instrumental behaviors will
occur with repetition of these behaviors
under conditions of non-reinforcement or
massed repetitions under conditions of
mild reinforcement.^
The first set of procedures is recognized as reciprocal inhibition, and the second set is conceptualized in terms of
reactive inhibition which results in learned conditioned
inhibition.^^
Reciprocal inhibition is basically a clinical means of
reducing anxiety. According to Wolpe, the general principle
^3shoemaker, p. 7.
^Brutten and Shoemaker, p. 4.
^5ibid.
14
of reciprocal inhibition is this:
If a response antagonistic to anxiety can be made
to occur in the presence of anxiety-evoking stimuli
so that it is accompanied by a complete or partial
suppression of the anxiety responses, the bond between these stimuli and the anxiety responses will
be weakened.46
Conditions must be established which will lead to the inhibition of the fear response in the presence of the conditioned stimulus; conditioned inhibition of the response will
47
result.
Not only does reciprocal inhibition produce a cessation of responding in the presence of the stimulus, but it
creates a situation for the development of a new stimulusresponse relationship.^^
The technique used to construct the new relationship
through reciprocal inhibition is Wolpe's systematic desensitization.^9
This technique produces a reduction of the
intensity of the conditioned response /negSitlve
emotion/
through manipulation of the conditioned stimulus /speaking
situations/. The critical conditioned stimulus is approached
by moving through a series of graduated steps. Theoretically,
46
Joseph Wolpe, Psychotherapy by Reciprocal Inhibition
(Stanford:
Stanford University Press, 195^), p. 71.
^'^Brutten and Shoemaker, p. 5^9joseph Wolpe, "Reciprocal Inhibition As the Main
Basis of Psychotherapeutic Effects," A.M.A. Archives of
Neurology and Psychiatry, LXXII (1954), p. 209.
15
extinction occurs at each of these steps, with generalization
of extinction reducing the intensity of responses to stimuli
closer to the critical stimulus.^^ Extinction of the classically conditioned emotional responses thus involves reciprocal
inhibition and stimulus modification achieved through systematic desensitization.^
The second procedure for extinction is that involving
inhibition of the instrumentally conditioned adjustive behaviors through reactive inhibition. Very simply, reactive
inhibition is a state which has an innate capacity to cause
a cessation of a response; but it can diminish with time.
After a response is repeatedly evoked with little or no
reinforcement, reactive inhibition acciimulates and summates
with the potential for total inhibition of the response.
•^2 Thus Brutten
This final result is conditioned inhibition.-^
and Shoemaker state that "when specific instrumental responses are delineated and subjected to massed evocation, a
learned tendency not to respond develops."-^-" Repeated production of an adjustive behavior increases inhibitory potentials which accumulate to cause the extinction of the behavior.
^^Brutten and Shoemaker, p. 6.
51ibid.
52John F. Hall, The Psychology of Learning (Philadelphia: J. B. Lippencott Company, 19bb), pp. 279-280,
53Brutten and Shoemaker, p. 8.
16
The therapy proposed by Brutten and Shoemaker involves
extinction of the conditioned emotional responses and a
direct attack on the instrumental escape and avoidance behaviors.
They feel that working directly with the instru-
mental behaviors is important because successful avoidance
behaviors tend to interfere with the extinction of emotional
responses instigating the avoidance.
In addition, they as-
sume that the punitive responses produced in the environment
as a result of the instrumental behaviors tend to reinforce
negative emotional conditioning.^^
In accordance with this
belief, Eysenck states that the removal of the motor conditioned response /adjustive behavio£/ by itself, without the
removal of the autonomic conditioned response y^egative
emotioi^T' is only a very partial kind of treatment and could
not be considered as being sufficient.^^
Behavior Modification:
Clinical Procedures
Behavior modification therapy, as advocated by Brutten
and Shoemaker, employs three phases:
(1) measurement of
emotionality, frequency of fluency failures, and self-rated
emotionality; (2)
systematic desensitization; (3)
^\bid. p. 10.
^^Eysenck, p. 13.
extinction
17
of adjustive behaviors.5^> 57, 58
The initial phase involves measuring the frequency of
the stuttering response while simultaneously measuring palmar sweating.
Brutten considers the Palmar Sweat Index
(P.S.I.) a valuable source of "information concerning the
intra-individual relationships between speech behavior and
eg
emotional reactions."-^^ Adaptation from massed oral reading,
anticipation of fluency failures, consistency with which
words are stuttered, and the adjacency effect are measured.
This phase assesses the magnitude of emotionality in the
stuttering and establishes a picture of the relationships
between fluency failure and speaking situations.
Before the second phase of therapy can begin, it is
necessary to determine what stimulus situations arouse
negative emotion in the stutterer and what escape and avoid6l
ance behaviors have developed.
These stimulus situations
are constructed into a hierarchy. Each situation is analyzed,
and graduated steps leading up to the critical stimulus are
5°Brutten and Shoemaker, pp. 10-11.
5'Brutten, "Stuttering: Reflections . . .," pp. 6-8.
58
Interview with Dr. Eugene Brutten, Director, Speech and
Hearing Pathology, Hunter College of the City University of
New York, March 28, I967.
50
-^Brutten and Shoemaker, p. 10.
60ibid.
^•^Tbid., p. 11.
18
determined.
The most disturbing item is placed nearest the
critical stimulus, while the least disturbing is placed at
62
the bottom of the list.
The hierarchy is compiled by the
client and should include all situations that produce emotion. The client then ranks the stimulus situations according to the degree of emotionality.
Concomitant with the
stimulus hierarchy, a hierarchy of adjustive behaviors which
are produced in each stimulus situation is composed. 3 The
result is a fairly accurate picture of the stuttering behavior in life situations.
The second phase of therapy is a procedure essentially
identical to Wolpe's systematic desensitization. The client
is trained in progressive relaxation or hypnosis, the latter
depending upon the willingness of the client. The purpose
is to induce as deep a state of relaxation as possible. The
client is then instructed to visualize as vividly as possible
a scene embodying the lowest member of the anxiety hierarchy.
It may be advisable to begin with a completely neutral scene
64
and gradually introduce the steps of each stimulus situation.
The client is instructed to signal by raising his hand if he
feels disturbed by any of the stimuli presented.
"^Wolpe, Psychotherapy . . ., p. 139*
^3interview with Dr. Brutten.
^\olpe, A.M.A. Archieves, LXXII, p. 210.
Should the
19
client indicate the presence of emotion, the therapist immediately curtails the scene -^ or presents a non-anxiety
provoking situation.^° The scene is repeated until the
client shows no sign of emotion in that scene. The presentation of subsequent scenes is continued, following the same
procedure, until no scene of the hierarchy evokes emotion.
It is considered that generalization will occur in the real
67
life situations. ' A question may arise concerning the
validity of the response elicited by visualization in hypnosis.
It is a basic assumption underlying this procedure
that the response elicited in the imagined situation is
quite similar to the response elicited in the real situation.
Wolpe found that through experience with clients this assumption is true.68
The third phase of therapy overlaps the second. After
a number of stimulus situations have been desensitized and
the emotional reactions have been inhibited, "therapy time
is spent in massed evocation of specific instrumental behaviors."^
Repeated evocation of the instrumental response
"5wolpe, Psychotherapy . . ., p. l40.
Dennis Friedman, "A New Technique for the Systematic
Desensitization of Phobic Symptoms," Behavior Research and
Therapy, IV, No. 2 (I966), p. 139.
^7john Paul Brady, "Brevital Relaxation Treatment of
Frigidity," Behavior Research and Therapy, IV, No. 2 (I966),
P. 72.
68
Wolpe, Psychotherapy . . . , p . 139.
6Q
•^Brutten and Shoemaker, p . 1 1 .
20
causes a summation of reactive inhibition for that response.
The result is the physical inability to reproduce the response due to fatigue.'
When this occurs, the client is
immediately instructed to imagine himself in the desenitized
stimulus situations. An association develops between the
desensitized stimulus situations and the inhibited adjustive
71
behaviors.'
During this phase of therapy, the client "actually
vocalizes if this does not interfere with the intensity
with which the imagined stimulus situation is experienced. "'^^
When a significant reduction in the emotional reactions and
instrumental behaviors is reported, the client is instructed
to follow the clinical procedures in the real life situations.
Subsequent therapy is a coordination of desensitization of
emotion and massed repetition of instrumental responses in
the clinic setting and controlled interaction with the stimulus situations outside the clinic.'-^
Evaluation of Behavior Modification Therapy
The application of reciprocal inhibition to disorders
in which anxiety plays a predominant role has met with
'^^Interview with Dr. Brutten.
71ibid.
'Brutten and Shoemaker, p. 12.
73it>i(i.
21
impressive success. Of specific concern to the speech
pathologist is the success of the therapeutic program with
elimination or modification of stuttering behavior. With
this in mind. Dr. Wolpe reports that the "deconditioning
has been followed by marked and lasting improvement in the
stuttering of the subjects to whom it /^esensitization/ has
74
~
been applied."'
in agreement, Brutten has found that the
therapeutic process has achieved behavior changes which are
maintained under environmental pressures and are not limited
to the clinical or experimental setting.'5
It could be feasible that the behavior therapy proposed
by Brutten and Shoemaker could be one of the most promising
contributions to the field of stuttering pathology and
therapy in years. It is in its infancy, so to speak, and
it must be utilized, modified, and refined by pathologists
in clinical research. There is a glaring shortage of research and practical application concerning the modification
of stuttering behavior through desensitization and reactive
inhibition.
"It is anticipated that therapeutic need and
74
' Joseph Wolpe, "Behavior Therapy of Stuttering:
Deconditioning of the Emotional Factor," Abstract of a
report to the International Seminar in Stuttering and
Behavior Therapy, Carmel, California, November 1-4,
1966, p. 1.
'^Eugene Brutten, "Stuttering: Reflections on a
Two-Factor Approach to Behavior Modification," Abstract
of a report to the International Seminar in Stuttering
and Behavior Therapy, Carmel, California, November 1-4,
1966, p. 13.
22
eaqperimental interest will lead to meaningful clinical and
76
clinically relevant research."
Purpose and Scope of the Thesis
It was, then, the therapeutic need and experimental
interest in the behavior therapy that prompted the author
to develop a therapeutic program for modification and/or
extinction of stuttering behavior based upon the extinction
of conditioned emotional responses and instrumental behaviors through systematic desensitization and reactive
inhibition.
Clinical research dealing with behavior modi-
fication of stuttering has been conducted essentially by
the original authors.
The proposed therapy discussed in
this report, therefore, is considered one of the primary
research studies developed by an experimenter not directly
associated with Brutten and Shoemaker; it is an attempt to
validate their basic assumptions.
It is the purpose of this
document to describe the procedures followed, the significant milestones reached, and to evaluate the positive or
negative results achieved from this program.
76Brutten, "Stuttering . . .," p. 42.
CHAPTER II
METHODS AND PROCEDURES
The purpose of this chapter is to examine the clinical
procedure used in developing a behavior modification program for the extinction of stuttering.
Examination of the
program will include a discussion of the instriiment used
for evaluating stuttering behavior and a description of the
therapeutic procedures that evolved.
Population
Three stutterers, two males and one female, voluntarily participated in the experimental therapy.
(Chapter III
will include a comprehensive case study of each subject.)
Evaluation of Stuttering Behavior
The Iowa Inventory for Stuttering was administered prior
to therapy to evaluate stuttering behavior and to obtain a
refined quantitative method of measuring the various dimensions of the stuttering problem for the purposes of diagnosis, prognosis, and assessment of results of therapy.
The
inventory is composed of six scales which concern themselves
with stuttering reactions and severity of stuttering, attitudes toward stuttering, self-ratings of severity of stuttering.
•^Eugene Brutten, "Stuttering: Behavior Theory and
Therapy, (unpublished manuscript), p. l6.
23
24
reactions to speech situations, and measurement of adaptation and consistency.
The adaptation effect is a tendency for a decrease in
the niomber of words stuttered during successive oral read2
ings.
The adaptation score may be viewed as a "miniature
'model of improvement'"3 for stuttering behavior. The adaptation score can be obtained by plotting the percentage of
words stuttered during the first of five repeated readings
and the percentage of words stuttered during the fifth reading on a chart of adaptation scores. The mean score is 50
with a standard deviation of 10.
The consistency effect is the tendency to stutter on
the same words from reading to reading. It may indicate
how strongly the stuttering responses are associated with
stimuli to which they have been conditioned.^
Therapeutic Procedures
The development of a therapeutic program for the extinction of conditioned emotional responses and adjustive behaviors involved much trial-and-error learning for the experimenter. The procedures developed in the initial stages
^Wendell Johnson, Frederic Darley, and D. C. Spriestersbach. Diagnostic Methods in Speech Pathology (New York:
Harper and Row, 19b3), p. 2b7.
3ibid., p. 268.
^Ibid., p. 271.
5ibid., pp. 272-273.
25
of therapy were modified extensively throughout the therapy
period iintil a satisfactory program evolved. The model of
behavior modification set forth by Brutten and Shoemaker
guided the author in establishing the program.
Following an evaluation of his stuttering behavior,
each subject developed a hierarchy of stimulus situations.
To aid the subjects in organizing the hierarchy, the author
suggested nine broad themes under which the subjects could
determine what critical stimulus situations were applicable
to their stuttering behavior. The suggested themes were:
(1) family, (2) school, (3) church, (4) Job, (5) social
activities, (6) recreational activities, (7) asking for
information, (8) telephone, and (9) ordering in a restaurant.
Each critical stimulus was divided into stimuli situa-
tions placed on a graduated continuum of emotionality, thus
developing a stimulus generalization phenomenon. Individual
stimuli situations, in turn, were composed of a number of
graduated steps, the one evoking the most emotion being
closest to the stimulus situation. Stimuli situations were
ranked in descending order (the first being the most difficult) under each critical stimulus. The critical stimuli
were similarly graded in relation to their over-all position
in the hierarchy. A list of adjustive behaviors used in each
situation was compiled.
The subjects were conditioned to hypnosis using two
techniques: visual and auditory fixation. Auditory fixation
26
was achieved by using a 1000 cycles per second tone presented at 55 db with a frequency modulated 5 percent.
Each
subject, while under hypnosis, was presented with a preparatory phrase and a key word which, when spoken by the therapist, would enable the subject to go into a hypnotic state
without using the visual and auditory fixation techniques.
The conditioning sessions nxmbered from three to five, depending on the suggestibility of the subject, and all were
supervised by Dr. William Ickes, director of the Speech and
Hearing Clinic of Texas Technological College.
No clinical data correlating the depth of the hypnotic
state and the extinction of conditioned emotional responses
could be foxind.
It was assumed, however, that a maximum
depth of hypnosis was desirable in order to facilitate complete relaxation.
To determine the degree of relaxation in
each client, a scale of the degrees of the hypnotic state
was used.
Five levels were delineated on a continuxim of
hypnosis.
They were as follows:
hypnoidal, (3)
deep state.
(1)
insusceptible, (2)
light state, (4) medium state, and (5)
In Table 1, a description of each level can
be found.
William Heron, Clinical Applications of Suggestions
and Hypnosis (Springfield, Illinois: Charles C. Thomas, Co.,
1959)rp. 45.
27
TABLE 1
SCALE FOR THE DEGREES OF HYPNOTIC STATE*
Degree
Symptom
Insusceptible
No response to suggestion
Hypnoidal
Relaxation
Fluttering and closing of eyelids
Profound physical relaxation
Light State
Inability to open eyes or move limbs
Medium State
Performance of simple motor tasks
without wakening
Performance of simple post-hypnotic
suggestion
Ability to forget a number or name
in the hypnotic state
Maintenance of forgetfulness after
awakening
Extended verbal discourse without
waking
Deep State
Ability to open eyes without affecting the hypnotic state
Positive hallucinations (misinterpretation of a stimulus because
of suggestion, e.g., a rumpled
handkerchief is seen as a kitten)
Negative hallucinations (inability
to sense something that is present)
•William Heron, Clinical Applications of Suggestions
and Hypnosis (Springfield, Illinois: Charles C. Thomas, Co.,
1959)/PP. 46-47.
28
After conditioning to hypnosis was completed, therapy
was begun. Under hypnosis, the subjects were instructed to
visualize a scene described by the therapist. The initial
scenes for each subject were those in which the clients could
speak fluently. The lowest stimulus situation on the hierarchy was then introduced.
Each subject was instructed to
raise his hand as soon as he felt the presence of negative
emotion. An attempt was made to effectively validate the
signaling of emotionality by the stutterers. Gray'^ felt that
some measurement of the ongoing anxiety state in stutterers
while receiving desensitization therapy was of significant
importance to the program.
Thus, the psychogalvanic re-
sponse (PGR) was used during each session. Wolpe found this
instrument to be effective in determining levels of emotiono
ality in different situations.
Similarly, Imaseki found
that PGR reflected anxiety-tension of stutterers. He concluded that it could serve as an indicator of the intensity
of stuttering as well as an evaluation of a therapeutic
9
effect.
"^Burl Gray, "Stuttering: The Measurement of Anxiety
During Reciprocal Inhibition," Abstract of a report to the
International Seminar in Stuttering and Behavior Therapy,
Carmel, California, November 1-4, I966, p. 11.
^Joseph Wolpe, "Reciprocal Inhibition as the Main Basis
of Psychotherapeutic Effects," A.M.A. Archives of Neurology
and Psychiatry, LXXII (1954), p. 20t5.
^Y. Imaseki, "Psychogalvanic Reflex of Stutterers,"
Folia Phoniatrica, XVI (1964), p. 35.
29
The subjects were instructed that vocal responses were
not necessary in the therapy. The only response vital to
the therapy was the indication of emotion in the situations.
The therapist presented the stimulus situations using a
cinematic approach.
ulus scene"
This "segmental unfolding of a stim-
had as its guide the graduated items of each
situation found on the stimulus hierarchy. According to
Brutten, the method "appears to be associated with an increased 'carry-over' of desensitization from the clinical
12
to the non-clinical setting."
When a subject indicated
the presense of emotion, the therapist immediately terminated the scene, suggested deep relaxation, and repeated
the items until the subject reported the absense of emotion.
When the majority of the items under a stimulus situation
was desensitized in the therapy room, the client was instructed to go into the real-life situation, following the
identical clinical procedure, and determine if desensitization had been successfully achieved.
If the client reported
no emotion in the situation, then therapy would continue
with presentation of more difficult situations. If the client
Eugene Brutten, "Stuttering: Reflections on a TwoFactor Approach to Behavior Modification," Report to the
International Seminar in Stuttering and Behavior Therapy,
Carmel, California, November 1-4, I966, p. 4.
l^Ibid.
l^lbid.
30
reported that emotion was still present, then desensitization of the same scene was repeated.
When the emotional reaction in a situation had been
successfully desensitized, massed evocation of the punitive
adjustive behaviors found in that situation was begun. When
fatigue caused inability to evoke the behavior, the client
was immediately placed in a hypnotic state and instructed
to visualize the desensitized scene. This procedure was
repeated several times to insure the development of the
association between the desensitized scene and the inhibited
adjustive behavior.
The length of each therapy session was approximately
one hour, and all sessions were conducted in an I.A.C.
Mfg. Company sound treated chamber with only the therapist
and the client present. Each session was tape recorded.
CHAPTER III
CASE STUDIES
The purpose of this chapter is to'present the case
studies of the three subjects who participated in the development of the behavior modification therapy. Events
during significant therapy sessions will be discussed in
order to evaluate the progress of each client and to observe the phases of the establishment of the therapy procedures.
Case Study of J. H.
J. H., a twenty-two year old male senior student at
Texas Technological College, reported the onset of stuttering behavior when he was four years old. There were intermittent periods of fluency between four and seven years of
age.
Following this period, complete fluency was non-existent
J. H. had received psychiatric counseling before entering
college and traditional speech therapy during elementary
school through college; neither had eliminated the stuttering behavior. When the behavior modification therapy was
explained to him, J. H. was most interested in participating
in the program.
The Iowa Inventory of Stuttering was administered to
the client, and the results indicated that his stuttering
behavior was characterized predominantly by clonic repetition
31
32
of initial, medial, and final sounds, irregular exhalation, protrusion of the tongue, movement of the head sideways, and movement of hands and legs in association with
stuttering blocks.
Conspicuous tension was noted when
speaking, the degree of tension depending upon the situation in which he was placed.
His disfluencies averaged
more than four seconds in duration.
Stuttering was present
on more than twenty-five percent of words.
An intense de-
gree of emotionality in speaking situations was indicated.
The adaptation score was well above the mean score of 50,
which indicated the probability of noticeable improvement.
Consistency of stuttering on the same words from reading to
reading was noted.
The measurement of attitude toward stut-
tering indicated tolerance toward the disorder.
The client was seen four hours a week and would rarely
miss an appointment.
Work on the stimulus hierarchy began in April, I966,
and was completed in October, 1966, after an intervening
period of three months.
Five conditioning sessions were
required to attain a light state of hypnosis.
Following
conditioning, regular therapy sessions began.
Clinical Proceedings
Session One:
It was felt that desensitization therapy
for J. H. should begin with a situation in which he could
be fluent.
The only fluent situation was singing.
33
Consequently, the first scene presented to the client while
\mder hypnosis was one in which he was alone auid was singing.
He was instructed to visualize himself singing then
speaking the words of the song in rhythm. He was able to
do so and progressed to speaking the words of the song without the rhythmic pattern. Next, the client was instructed
to visualize having a book from which he was to read silently.
After reading silently for a time, he began visualizing reading aloud, reading a few words at a time, until he could hear
fluent reading of complete paragraphs.
The following sessions were repetitions of the initial
one.
The purpose was to build confidence in his ability to
read aloud, thus establishing a basal level of fluency.
Session Four: The client reported that he had begun
reading aloud and that he had been fluent. Quite by accident, J. H.'s roommate had overheard him reading. The
client was very pleased with the occurrence and seemed to
be gaining confidence in the therapeutic program.
Session Seven: The lowest member of the hierarchy,
speaking with his mother, was presented.
Because the sub-
ject could read aloud confidently now, the experimenter hoped
that reading would aid in generalizing to speaking. The
general outline of the stimulus situation of reading in the
presence of his mother progressed from reading in the room
farthest from his mother to reading in the same room with her.
34
Session Eleven; The client was able to visualize himself reading in the same room with his mother for the first
time without an excessive amount of disturbing emotion. He
reported that he felt some uneasiness, but it was not as
intense as previous presentations. The PGR continued to
implement the client's subjective response to emotion.
Session Sixteen: The client continued to progress
through the steps of the stimulus situation, the frequency
of emotional response decreasing noticeably. The subject
was instructed to test the validity of the desensitized
levels, and to report the absence or presence of emotion.
He was instructed that he should not proceed beyond any
point at which he felt the slightest amount of emotion.
Session Seventeen: The client reported continued
fluency while reading aloud outside the therapy sessions.
He also stated that he had read at home following the steps
as they had been in therapy.
He was able to progress to the
level of reading with his mother in the next room, but he
began to feel uncertain about continuing and stopped. He
was pleased, however, that he had been able to achieve that
level of success.
During the therapy session, the client was able to move
rapidly from the level of reading in the room next to his
mother to reading in the same room with her. When no emotion
was indicated by the client and the PGR, another level on the
35
hierarchy was presented. This level was reading in the same
room with his brother. Upon initial presentation of this
level, the client indicated considerable emotion. The intensity diminished rapidly, and he was able to visualize
reading aloud after several repetitions of the steps involved.
It was assimied that generalization of the success in the
previous situation had occurred.
Session Twenty-four: During the seven preceeding sessions, the subject visually advanced through the levels of
reading to his father, making simple comments, and answering
questions requiring limited speech. He was able to visualize
himself conversing casually with the members of his family.
Serious discussion caused emotional responses.
Session Thirty: The progression of the client was extremely encouraging. During the last five sessions, the
client proceeded to the level of speaking casually with his
best friend. He expressed confidence in the clinical desensitization of current levels on the hierarchy and felt they
would be validated in the real situation during the Christmas
holidays. The client was reminded that if he began to notice
the presence of emotion during verification of desensitization, he should not advance beyond that point.
Session Thirty-one: The subject informed the experimenter that he had been able to read fluently, and with no
36
emotion, in the presence of his mother several times during
the Christmas holidays.
He attempted to read t£ her, but
after reading a few sentences, he felt uneasy and experienced
a non-fluency.
He attempted the level again and achieved
similar results.
He was encouraged that he was able to at-
tain success at one level, but could not understand why subsequent levels had not been fluent.
The experimenter ex-
plained that the presence of emotion indicated that the level
had not been thoroughly desensitized, and with emotion in the
situation, stuttering resulted.
The client was advised that
he should not have allowed himself to progress beyond the
point of an emotional reaction, and definitely not to have
repeated a situation in which he had heard stuttering.
Further questioning revealed that the client's grandfather had died during the Christmas holiday, and that his
death had caused a marked disturbance in the emotional state
of the client.
This incident could have affected the sen-
sitivity of the client's responses, causing him to mistakenly identify a normal disfluency as a learned disfluency,
consequently increasing emotion.
The differences between a normal disfluency and a learned
disfluency were discussed because it seemed that the client
had an idealized image of speech as being totally void of
non-fluencies.
The average speech pattern will contain many
hesitations and disfluencies and will never be an uninterrupted flow of sounds and words.
Therapy was resumed from
37
the level of fluency successfully attained in reality.
Session Thirty-seven; The client was able, once again,
to visualize reading and speaking casually with his family.
It was not possible, however, to test the validity of the
desensitized levels.
Consequently, it was decided to begin
desensitization of speaking with the experimenter, which was
the next level on the hierarchy. Reading was again the basal
of fluency.
Session Forty-six: Three sessions had been required to
desensitize the level of reading in the presence of the experimenter while under hypnosis; during the forty-fifth session, the client indicated the absence of emotion at the
level of speaking with her. The client continued to report
the absence of emotion for speakiing with the therapist, and
seemed to be eager to test the situation. It was agreed
that validation would begin. Again, the client was admonished not to attempt a step if he felt the slightest amount
of emotion.
Session Forty-seven: The client and experimenter constructed the test situation exactly as visualized in the
therapy sessions. The subject was able to read and describe
objects fluently in the room adjacent to the one in which
the therapist was typing, and on occassion, the therapist
was able to hear the client. The session was terminated
38
because the client experienced uneasiness before entering the
same room with the therapist.
Session Forty-eight: The test situation was reconstructed and begun again.
Shortly after beginning, the sub-
ject confronted the experimenter with the news that he could
no longer read aloud to himself without stuttering. He was
completely distraught over this turn of events, and the experimenter was puzzled as to the reason for the complete
regression. After thoroughly analyzing the situation and
seeking the consultation of her advisor, the experimenter
concluded that too much emphasis had been placed on moving
through the test situation before reinforcement of fluency
at each level had occurred. The fact that emotion persistently appeared in the test situations created some concern
on the part of the therapist. Obviously the emotion had not
been extinguished, but the question was, why? At that time,
the answer was not known. Because of the regression, therapy
with the subject had to resume with the initial phase of
establishing fluency while reading to himself.
Session Fifty-seven: After regaining his ability to
read and speak fluently when alone, the client was able to
retrace the steps involved in visualizing speaking with his
family with a minimum of time lost. A re-evaluation of the
hierarchy had placed the therapist on a more difficult level
of the continuum.
Consequently, desensitization was begun
39
on the situation of reading in the presence of his roommate.
Session Sixty-six: J. H. informed the therapist that
he had read fluently with his roommate listening. When asked
about the presence of emotion in the situation, the client
revealed that he had felt none as he began, but as he continued to read, emotion developed and intensified until he
stopped. The therapist was faced with the question of why
the emotion was present. If desensitization did not successfully inhibit the emotional reactions, what was the
reason?
Was there something in the therapy procedure that
was impeding proper inhibition?
constructed?
Was the hierarchy properly
Was the subject reporting every emotional re-
action, or was he so conditioned to the therapy situation
that he could no longer objectively determine the presence
of emotion?
These and many other questions led the experi-
menter to the conclusion that a re-evaluation of the therapeutic procedures was necessary.
(On March 28, I967, an interview with Dr. Eugene Brutten,
one of the co-authors of the behavior modification therapy
for stuttering, was conducted. From this interview, the
therapist was able to determine the needed modifications and
improvements for her program. The stimulus hierarchies were
re-organized.
A method of signaling and recording the degree
of the emotional response was devised.
The validation of the
desensitization of the levels approaching the critical stimulus
40
was to occur before reaching the actual stage of speaking.
This would enable the therapist to know at which level desensitization had not been successful, and thus prevent complete breakdown of the test situation when emotion appeared.
Desensitization of the emotion experienced during the act of
speaking was incorporated into the stimulus situations. Instructions were given to the clients that they were to signal at the slightest feeling of uneasiness, not to wait
until the intensity was disturbing.
No level of the hier-
arachy was to be passed until it had been tested outside
the therapy situation.)
Session Sixty-eight: Following the modification of the
therapy procedures and a re-organization of the stimulus
hierarchy, therapy was resumed.
It was established that the
easiest situation for the client, other than with his family,
was playing tennis with his roommate. The levels of communication in the situation were recognized as:
(1) asking
a question, (2) answering a question, (3) making a statement, stnd (4) uttering a spontaneous comment. Asking a question was the most difficult; uttering a spontaneous comment
was the least disturbing.
Consequently, the first step was
desensitization of making a spontaneous comment. The stimulus was approached through the following sequence: driving
to the court, arriving at the court, beginning to play, and
spontaneous comment.
Since "driving to the court" was the
41
least disturbing element of this situation, it was the first
step in desensitization of the stimulus. Each step was presented until the client could visualize making spontaneous
comments without experiencing an emotional response.
Session Sixty-nine: The client had tested the steps
involved and found no emotion in the actual situation. All
spontaneous comments had been fluent. The next level, making a statement to his roommate while playing tennis, was
introduced. This segment of the stimulus situation was constructed in the following manner:
Short and/or Long Statement
1. Think of statement
2. Both approach the net
3. Time to change courts
4. Second game ends
5. Begin second game
o. Play first game
7. Going to make statement
when changing courts
8. Begin playing tennis
Each of these steps represented a gradual increase in intensity of emotion, nimiber one being the most disturbing. Desensitization began with the presentation of number eight
and moved through the continuum to reach the stimulus situation.
Session Seventy-three: In the clinical setting, the
client reported that there was no emotional reaction elicited
by the events leading up to making a short comment; however,
there was uneasiness associated with the production of certain
42
words.
He could hear fluent speech, but expected to hear
stuttering after a number of words were spoken. He was instructed to signal when the uneasiness appeared and the scene
would be stopped.
Repeated presentations of the scene, al-
lowing time for the subject to listen to the statements,
created an increased latency of response which eventually
culminated in the extinction of the response.
Session Seventy-eight:
Short statements continued to
evoke no emotional response. Initial presentations of events
approaching longer statements elicited strong reactions;
several sessions were required to achieve desensitization.
The extinction of the emotion associated with words and
soTinds began to follow a pattern: the intensity of the response diminished; latency of response increased; responses
became intermittent; extinction of response was achieved.
Session Eighty-one: Repeated presentations of the stimtilus situation failed to evoke an emotional response. The
therapist encouraged the client to arrange for validation
of the desensitized situation; due to final examinations,
however, the client was unable to do so. Therapy was forced
to conclude without knowledge of the effectiveness of the
desensitization outside the therapy room.
Clinical Summary
J. H., a twenty-two year old stutterer, participated
in the development of a therapeutic program of behavior
43
modification. When therapy began, J. H. was fluent only when
singing. Although the client was not dramatically cured of
his stuttering during the course of the program he did attain significant levels of fluency. He achieved and maintained the ability to read and speak fluently when alone;
he successfully read in the presence of his mother and his
roommate; he was able to make spontaneous comments without
the presence of emotion.
Assessment of the program indicated that the weaknesses
in the initial stages of development significantly impeded
J. H.'s progress. The final set of procedures adopted by
the therapist were considerably more efficient and effective.
Application of these procedures conceivably could have resulted in extinction or modification of the stuttering behavior .
Case Study of T. C.
T. C , a male, nineteen-year-old, sophomore student at
Texas Technological College, reported that his stuttering
was noticed during the first year of elementary school. He
had not been aware of the disorder until he began receiving
speech therapy for stuttering. Years of traditional therapy
had succeeded in improving his attitude toward his difficulty,
yet had failed to eliminate the stuttering. T. C. was willing to participate in the new therapy, but did not appear to
be convinced of its merit.
44
The results of the Iowa Inventory for Stuttering indicated that T. C.'s stuttering behavior was typified by prolongation of sounds, repetition of parts of words, an
occasional eye blink, and pressure of lips before starting
certain words. Stuttering was Judged to occur on twelve to
twenty-five percent of words. Little perceptible tension
during speaking was noticed; his disfluencies were rated as
mostly simple and averaged about two seconds in duration.
A moderate degree of emotionality associated with speech
was indicated.
The adaptation score was the lowest of the
three subjects but was slightly above the mean adaptation
score.
Consistency was noted. A tolerant attitude toward
stuttering was indicated.
Three one hour appointments were scheduled for the client
each week; attendance was irregular, however, and was a significant factor in the final analysis of progress.
Creation of the stimulus hierarchy required approximately
one and a half months, after which time the client underwent
conditioning for hypnosis. T. C. was able to attain a medium
state of hypnosis after three sessions. Instructions concerning the signaling of emotion were given to the client, and
he responded that in many situations he did not believe he had
negative emotion. The PGR was tested with the client and was
veiy effective in reporting emotionality when T. C. did not.
45
Clinical Proceedings
Session One:
Procedures establishing a basal of fluency
for T. C. were patterned after the ones used with J. H. in
which the client was to visualize singing and reading while
alone.
Two sessions were employed to establish this basal.
Session Three:
Desensitization of the least disturb-
ing member of the stimulus hierarchy, speaking with T. C.'s
mother, was begun; reading was used as an introductory
level.
The client visualized a gradual process of moving
closer to the room where his mother was waiting and imagined
reading fluently in her presence.
T. G. did not indicate
an emotional reaction at any level, but the PGR signaled the
presence of emotion in the initial scene.
Repeated present-
ations failed to elicit a response from the client or the
PGR, thus the level of speaking with his mother was brought
into the proceedings.
An indication of anxiety was noted
by the PGR as the client visualized the scene the first time;
but desensitization occurred in a short time.
Session Five:
A review of reading and speaking with
T. C.'s mother did not elicit a response by the client or
the PGR.
Introduction of his girlfriend to the scene met
with identical results; many situations involving reading
and casual conversation with her failed to evoke any response.
The client was told that it would be permissible
to begin testing the validity of the desensitization of the
46
levels thus far achieved. In fact, due to the progressive
pace of therapy, validation was essential, because it was
probable that the levels were not receiving enough attention
for extinction of the emotional responses to result.
(The client failed to meet several of the subsequent
therapy sessions.
Consequently, the therapist believed
that a review of the previous levels was necessaiy before
progressing to more difficult stimuli. When the client
reported that he had not had an opportiinity to test the
therapeutic procedures, the therapist strongly advised him
that the step was vital to progress and that he must face
the situations in reality. He agreed to do so.)
Session Eleven: The client informed the experimenter
that he had tried reading aloud when alone; he described
his speech as being "remarkably fluent." He was discouraged
considerably when stuttering had persisted while speaking to
his mother.
It was pointed out to the subject that in his
eagerness to attain fluency he had by-passed levels which
had not been verified as being desensitized.
The test situa-
tion must follow the sequence of events proposed in therapy.
Session Sixteen: Intermittent attendance continued to
be a problem in the time between the reported sessions. During the fourteenth and fifteenth sessions, the client was
able to visualize fluency up to the level of speaking with
his father. He continued to avoid testing the situations
47
outside therapy.
Session Twenty-one: Although the client and the PGR
indicated no emotion associated with conversation with the
family, girlfriend, and best friend, the therapist could
not assume that emotion had been extinguished.
Perhaps the
client truly had no emotion associated with the speaking
situations thus far presented; but stuttering remained.
Session Twenty-two: To test the possibility that emotion did not exist in the previous situations, it was necessary to advance to the next level on the hierarchy in order
to observe the reaction. The stimulus situation was speaking to friends on campus. Initial introduction of the stimulus elicited a response of the PGR, but subsequent presentations failed to arouse any indication of disturbance.
(Following the above session, the interview with Dr.
Eugene Brutten was held, and the modification of the therapeutic procedures was undertaken. With re-organization of
the hierarchy, therapy was resumed.)
Session Twenty-three: A discussion of the theory and
therapy of the behavior modification program allowed the
therapist to question the client concerning his opinion of
the procedures as they appeared after reconstruction. T. C.
credited the theory as being basically sound, but he believed
that the same results could be accomplished "without all the
48
ritual" of the therapy room, the PGR, and even the therapist.
In effect, the client regarded the sessions as non-essential
and concluded that he should be able to desensitize his emotion without supervision. Both the client and the therapist
concurred that it was best to terminate therapy as he would
be unable to attend most of the remaining sessions.
Clinical Summary
T. C , a nineteen-year-old stutterer, began modification therapy doubting the merit of the program. This could
have been in part due to the lack of organization in its
early phases of development. Irregular attendance and lack
of verification for desensitization of emotion were assumed
to contribute significantly in preventing positive results.
Case Study of S. S.
S. S., a sixteen-year-old, female, high school student,
stated that she had been aware of stuttering since the third
grade.
She noticed that she would stutter more severely if
she were nervous or excited.
She had received very little
speech therapy because her parents refused to admit that she
had a stuttering problem.
The client was eager to learn
about the procedures being developed and volimteered to be
a participant in the research.
The results of the Iowa Inventory revealed that S. S.'s
stuttering behavior was characterized by disfluencies on
49
ten to twenty percent of her words, with the length of the
blocks lasting anywhere from two to five seconds. There was
perceivable tension around the lips and an associated eyeblink during a block.
The client indicated intense emotion
and avoidance behavior in speaking situations, and an intolerant attitude toward stuttering.
The adaptation score was
above the mean, and consistency was noted.
The client was seen by the therapist for the first
interview in early February of I967.
Due to the cooperative
attitude of the client, construction of the stimulus hierarchy was accomplished without delay.
Hypnotic conditioning
allowed the subject to attain a light state of relaxation
and suggestibility.
Three sessions a week were scheduled
for therapy, and the client met them faithfully.
Therapy
began February 24, I967.
Clinical Proceedings
Session One:
It was determined that, like the other
subjects, singing was the only situation in which S. S. was
completely fluent.
Reading and talking aloud when alone
had produced an occassional hesitation and/or repetition,
but the situations were regarded as easy for the client.
The initial desensitization session progressed from singing
to reading aloud at her home.
Session Three:
During session two and three, several
situations were encountered and passed after the emotional
50
reaction was extinguished.
S. S. was able to visualize
herself reading and describing aloud, and talking to animals
and small children without feeling anxious about her speech.
The client was instructed to begin applying the therapeutic
steps to the real-life situations. She was advised to follow the exact procedures outlined in the therapy room and
to report the presence of emotion if it appeared.
Session Seven; Therapy for the preceeding sessions
gradually moved toward the stimulus of speaking to older
children.
Close observation of the client provided a more
accurate indication of an emotional reaction than the PGR.
The client reported fluency while describing objects in her
room. After attaining this goal, she had begun reading
aloud.
She noticed no emotionality until she reached a word
that she could not produce.
She skipped over the word and
continued reading, noting that other words in the passage
evoked a similar reaction. The therapist concluded that
repetition of desensitization for that level was needed.
Incorporated into the reading were words that posed a threat
to the subject, and she was instructed to visualize reading
passages which contained many of these words.
Session Ten: Although the client continued to report
occassional difficulty with words while reading, she claimed
that it was occurring less frequently.
She could imagine
fluency and no associated emotion while speaking to children,
51
S. S. was told that the situation could be tested outside
the therapy room; the next level of the hierarchy was introduced.
This level represented the client's first inter-
action in a social setting. The stimulus was placing a short
order in a restaurant. Graduated levels of events advanced
the client into the stimulus situation where she was to
visualize a waitress taking her order. Repeated presentations of the levels appeared to have extinguished the emotion
associated with each step.
(Re-evaluation of the author's behavioral therapy resulted in modifications of the therapeutic procedures and
the stimulus hierarchies for the clients. S. S.'s hierarchy
was analyzed and re-organized, and explanations of the
modified techniques were given.)
Session Fifteen: Desensitization of the lowest member
of the new hierarchy was initiated.
Recreational activities
were grouped together to create the broad theme under which
the least disturbing situation was bicycling with her closest
friend. The stimulus scene involved four aspects of speaking:
(1) asking a question, (2) answering a question,
(3) making a statement, and (4) uttering a spontaneous
comment.
S. S. believed that asking a question was the most
difficult of the four, and assigned it the value of one.
The remaining three were rated as numbered above. Steps
were arranged in graduated order under each type of speech;
52
they were presented until an emotional response was given
by the client. The scene was halted at that point on the
continuum.
Beginning again with the first step, the scene
unfolded until another response was given.
Session Eighteen: The preceeding sessions achieved
desensitization in the therapy room of the emotional reactions evoked by the situation previously mentioned. Spontaneous recovery of the emotion did not occur when the stimulus was presented during the eighteenth session. The
therapist encouraged S. S. to test the validity of the desensitization as soon as possible.
Session Nineteen:
S. S. came into the therapy room
quite eager to report the results of her test situation.
She disclosed that the real-life situation had been void
of any emotion and that, with the exception of a few disfluencies "that didn't bother me," she had been completely
fluent. The client was asked to compare the situation before and after desensitization therapy.
She stated that it
had been an easy one but that there had been, on occasion,
several noticeable disfluencies which had caused slight
disturbance.
She was certain that her speech had been more
fluent following desensitization; she regarded the few disfluencies that she had as normal because they did not disturb
her.
53
The next situations under recreational activities were
those in which she participated with her family. Desensitization was begun on selected activities.
Session Twenty-one: Desensitization of the family
recreational activities was conducted and tested outside
the therapy room.
No negative emotion associated with the
speaking situation had been present. S. S. was "surprised
at myself" when she used sounds which had been difficult
for her. She was extremely eager to advance to the next
situation.
An examination of the hierarchy revealed that desensitization of one complete theme had been accomplished, and
that the next theme was comprised of speaking situations at
her church. The least threatening circiomstance was conversing with one of the nuns who had become a very close friend.
The client had never addressed the nun by her full name;
the thought of doing so created a strong emotional response.
Consequently, her full name was not used in initial stages
of desensitization.
Session Twenty-two: Although the client indicated that
she felt no emotion in the visualized scene during the previous session, when she approached the situation outside the
therapy room, she experienced \ineasiness. After analyzing
and discussing the event, the therapist and client agreed
that inhibition of emotion beyond a particular step had not
54
been achieved.
They were able to locate the step creating
the disturbance and returned to that level for further desensitization.
Session Twenty-three: The progress of S. S. was evidenced by her report of fluency while conversing with the
nun in the presence of other people. To desensitize the
emotion associated with saying the nun's full name, the
client visualized massed repetition of only the name. After
inhibition of emotion, the situations previously desensitized were reviewed to allow desensitization with the new
variable.
A new stimulus situation was presented; it required
attending a church affiliated meeting with friends. It
was divided into two sections:
and (2) during the meeting.
(1) before the meeting,
Only three presentations were
required for inhibition of emotion for the first section.
The meeting itself was approached by using the four aspects
of communication previously established.
Attempts at making
short statements were visualized without emotional responses,
The steps on the continuum leading to making longer statements elicited no responses; however, emotion associated
with the act of speaking and with certain words was present.
Session Twenty-five: The client was able to visualize
making short and long statements, expressing an opinion, and
answering questions with no speech associated disturbance.
55
She reported the maintenance of fluency experienced outside
the therapy room.
(A period of three weeks followed the twenty-fifth
desensitization session. During this time, the client was
instructed to reinforce successfully attained levels of
fluency and to validate desensitization of items recently
presented in therapy.)
Session Twenty-six:
S. S. was eager to report that
during the break in therapy she had addressed Sister
by her full name and had not experienced anxiety.
She had been confident that fluency would be attained. Not
only had she addressed her privately, but she had done so
in the presence of others. Another incident, asking another
nun to call Sister
, created emotion. Whatever
emotion was associated with the incident disappeared, however, and the client was able to produce the name. The
therapist considered that reinforcement of the situation
would be beneficial.
Session Twenty-seven:
For the first time in the thera-
peutic program, a client had advanced to the third phase of
behavior modification therapy: massed evocation of an adjustive behavior.
S. S. indicated that she would swing
her necklace back and forth while speaking to the sister or
to her best friend.
Thirty-five minutes were required to
inhibit the behavior initially, after which time the client
56
was placed under hjrpnosis and instructed to visualize the
desensitized scenes.
Session Twenty-eight: The client reported that she had
talked with her best friend and that she had no desire to
reach for her necklace; she stated, "I didn't even want to
show her what we were doing." Another behavior was selected
for evocation; coordination of inhibition and desensitization
followed. A demonstration of self-hypnosis and relaxation
was given for the client so that she might continue the third
phase of therapy outside the clinic.
Session Thirty-one: Application of self-hypnosis met
with positive results outside the therapy situation. She
found it useful in relieving tension not associated with
speech. Desensitization of the subsequent stimulus was
commenced and was progressing satisfactorily with the conclusion of this report.
Clinical Summary
The case of S. S., a sixteen-year-old, female stutter,
proved to be the only one in which all three phases of behavior modification therapy were attained.
In the opinion
of the author, the achievement was due primarily to the
application of the modified and more efficient procedures
which evolved after re-evaluation of the therapeutic program.
A comparison and evaluation of the results achieved by the
57
three subjects pointed to the assumption that this factor
was the significant variable influencing success.
Attainment of fluency in situations under the broad
theme of recreational activities was a significant milestone of success for the client. As a result of desensitization, she was able to say words which she had never
been able to say; she was able to accept occasional disfluencies in her speech pattern with no fear that they
would instigate the return of learned disfluencies.
The interaction of desensitization of emotion and
inhibition of adjustive behaviors was the most distinctive
aspect of this case study. As a definite association between the first two phases of therapy developed, the client
reported fluent speech and no desire to reproduce the adjustive behavior.
It was assumed that continued reinforce-
ment of the situation would strengthen the newly established
relationship.
Progressive reports from the client suggest
that the assiimption was valid.
CHAPTER IV
SUMMARY AND CONCLUSION
Summary
Because of the therapeutic need and the experimental
interest in behavior modification, the author of this
document developed a therapeutic program for modification
and/or extinction of stuttering behavior based upon the
extinction of conditioned emotional responses and instrumental behavior through systematic desensitization and
reactive inhibition. The three phases of therapy included:
(1)
systematic desensitization, (2) reactive inhibition,
and (3) coordination of the first two phases.
Three stutterers, two male and one female, participated
in the program.
Preceeding the first phase of therapy, the
stuttering behavior of each subject was measured and evaluated. A hierarchy of emotional stimuli situations was constructed for each subject. The critical stimulus evoking
the most intense emotion was placed at the top of the hierarchy; other stimuli were rated for intensity and placed
on a continuum with the least disturbing stimulus at the
end.
Each stimulus contained situations which were placed
on a similar continuum of difficulty.
The speaking situa-
tions under individual stimuli involved four aspects of communication that were application to every stimulus in the
58
59
hierarchy.
They were:
(1) asking a question, (2) answer-
ing a question, (3) making a statement, and (4) uttering
a spontaneous comment. Steps gradually approaching the stimulus were arranged under each aspect.
Conditioning to hypnosis followed construction of the
hierarchy, and the first phase of therapy was initiated.
Desensitization began with stimuli which were reported to
produce weak emotional responses. Graduated steps were
repeatedly presented until no emotional reaction was indicated; emotion associated with production of sounds and
with expectancy of stuttering was extinguished in a similar
manner. Validation of clinical desensitization outside the
therapy room was conducted after a situation was reportedly
void of emotion.
Massed evocation of adjustive behaviors found in the
situation caused inhibition of the response. Immediately
the client was instructed to visualize speaking in the desensitized scene. Interaction of desensitization and inhibition created a new stimulus-response relationship.
With successful modification of behavior in one situation, the procedures were applied to subsequent levels,
gradually approaching the stimulus of greatest intensity.
The program underwent constant modification and improvement before the procedures which were described above finally
evolved.
Two of the three subjects involved in the program
achieved levels of fluency which were significant in relation
60
to their stuttering behavior. One client did not appear
to benefit from the therapy.
Conclusion
In the opinion of the author, behavior modification
therapy should be credited as having considerable merit.
The theory behind learned behavior of any kind has been
validated through psychological research and experimentation. Modification and extinction of learning has become
an observable phenomenon. When viewed through a framework
of learning, then, stuttering behavior should benefit from
procedures directed toward its modification.
The procedures developed and described in this thesis
have met with encouraging results. The levels of fluency
attained by the subjects may have appeared to be of insignificant value to the non-stutterer, but to the stutterers,
they were monumental. The duration of therapy for extinction of all stuttering behavior would appear to be a much
longer time than the period reported in this document.
A question must be asked concerning the maintenance
of fluency: Will the effects of therapy assure longlasting results?
At present, there are few, if any, lon-
gitudinal studies of clients who have received behavior
modification therapy that would give an answer to the question. With the publication of procedures to establish
modification programs, it is hoped that more and more
61
clinicians will adopt the therapy, thereby enabling researchers to study the carry-over of extinction.
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Brutten, Eugene, and Shoemaker, Donald. "A Two-Factor
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