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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 '^mmMmmimnmmmfA-\\B--i 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. BIBLIOGRAPHY Books Berry, Mildred F., and Eisenson, Jon. Speech Disorders: Principles and Practices of Therapy. New York: Appleton-Century-crofts, 195b. Eysenck, Hans J. "Learning Theory and Behavior Therapy," Behavior Therapy and the Neuroses. Edited by Hans J. Eysenck. New York; Pergamon Press, I960. Glauber, I. Peter. 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