CONTENTS This is a threaded discussion page for the International Stuttering Awareness Day Online Conference paper, Relapse: A Misnomer?, by C. Woody Starkweather (Pennsylvania, USA). Relapse, Unfinished Business, Lapse and Displacement From: Gunars K. Neiders, Ph.D. Date: 10/1/98 Time: 7:49:19 PM Remote Name: 188.8.131.52 Comments Dr. Starkweather, Thank you for the well thought out paper on relapse. As you know I am more into cognitive behavioral therapy approach than gestalt, although I consider experiental therapy as a valid tool in therapy. I quite agree with most of your conclusions. I only wanted to add a thought that besides "unfinished business" at times there is a tremendous displacement of the "negative energy" (for lack of better term) that takes place during therapy. One such instance would be when a neophyte fluency shaper clinician builds up a perfectionistic attitude in the client. Then a small lapse, i.e. inconsequential disfluency, can start a snowball effect. Do you agree that displacement as simple as that above or in some other perverted form is something that can play a role in so called "relapses"? Re: Relapse, Unfinished Business, Lapse and Displacement From: Woody Starkweather Date: 10/22/98 Time: 1:12:49 PM Remote Name: 184.108.40.206 Comments Hi Gunars: I replied to this much earlier, but apparently messed up the details and it didn't get on. Yes, of course, and it happens often that fluency shapers use a very hard sell, telling the clients that this is the ONLY way stuttering can be helped. Clients who give up on the technique often feel ashamed and as though it was their fault that they aren't able to talk perfectly. In my view this is the most unethical kind of treatment. Many clients are damaged by this practice. I see half a dozen like this each year. It is a practice that ought to be stopped. Sometimes, they are so "brainwashed" by all the hype that they tell me how wonderful it is that they aren't stuttering any more, and yet, even as they tell me this, their stuttering is as severe as it was before they went for the miracle cure. clients year after Relapse From: John Harrison Date: 10/9/98 Time: 1:38:33 AM Remote Name: 220.127.116.11 Comments Woody -- nice article! It fits right in with my experience of stuttering. I've said this before, but for a guy who never grew up with a stuttering problem, you certainly have developed a good handle on what it's all about. But I wonder if this holistic perspective will ever get through to the people who suffer from tunnel vision. They don't understand that constantly focusing on fluency enhancing techniques is like trying to keep a beach ball under water. At some point it just takes too much effort, and people give up without looking for alternatives such as (to continue the metaphor) finding a way to let the air out of the ball. What will it take to have them step back and see the bigger picture? Regards, John H. Re: Relapse From: Woody Starkweather Date: 10/22/98 Time: 1:15:20 PM Remote Name: 18.104.22.168 Comments Thanks John. I don't know what it will take. People have to stop being taken in by the false claims, I think. Suing is very difficult because then suddenly they get very technical. Fluency shaping and clinicians who don't stutter From: Andy Floyd╩╩ email@example.com Date: 10/9/98 Time: 5:38:45 PM Remote Name: 22.214.171.124 Comments Dr. Starkweather, First - excellent article! I enjoyed bumping into you at the last NSP convention when we had a little room mix-up. My comments mostly address Mr. Harrison's last comments - but they apply to all of us. I stutter and I am a second year SLP grad student. It seems to me that taken as a percentage, a lot more clinicians who stutter tend to use a more stuttering modification or combined approach and clinicians who don't stutter use more of a fluency shaping approach. What I deduct from this and my personal experiences as a grad student and as a PWS is that many clinicians who don't stutter are afraid or at the least very uncomfortable with stuttering. Now, to look realistically at the future - even with the specialty recognition program (which is great and was long in coming) the vast majority of PWS will be treated by clinicians who do not know much about stuttering and who are afraid of it. How do we attempt to alleviate this problem? I could think of 3 things off the top of my head that I'm sure others are already attempting to do - (1) For those grad programs that have a Stuttering course, have your grad students do a pseudo-stuttering assignment of some sort. (2) Let's try our best to try to get ASHA to reimplement the required stuttering course for all accredited programs. I know this is easier said than done, but I think it is essential to success. (3) It has been documented that the vast majority of SLP grad programs around the country do not have a clinical psych/counseling requirement. I believe this should be changed and the training could aid not only stuttering clients, but bascially every client that SLP's have. Any other suggestions? Re: Fluency shaping and clinicians who don't stutter From: Woody Starkweather Date: 10/12/98 Time: 1:12:49 PM Remote Name: 126.96.36.199 Comments Thanks Andy for your comments. I am afraid that I don't think ASHA is going to put back the requirements the way they were without some very powerful force. I huge suit from a person who stutters or from a parent charging malfeasance or some- thing is what it is going to take. I would be happy to testify. I think ASHA has done a terrible thing and has abandoned its own code of ethics. But, unfortunately, ASHA is not moved by my opinions, which they have heard. Your second suggestion is also an excellent one. You are way too young to remember that there was a time when courses in counseling psych or in abnormal psych. were part of most curricula in Speech and Hearing. Probably there are still some curricula that have these courses. But I don't think it is likely that we will see these courses added to the graduate curriculum. A curriculum is one of the least movable objects in the universe. Currently, the curriculum for speech pathology students is stuffed to the gills with courses that seem, in the opinion of most faculty members, to be absolutely necessary. Nor is it likely that SLP training will be expanded to three years, although it is inching in that direction. I think our only hope is through specialty recognition. The Board has now been elected, and the specialty recog- nition program is going forward. I am pretty sure the first applicants will be heard from within a year. One excellent way to become specialized is to demonstrate that one has expanded one's education in the counseling or psychotherapeutic direction. Several forms of psychotherapy seem particularly well suited to treating the baggage that accompanies stuttering, and I am sure that many applicants for specialization will find them and expand their clinical skill by getting trained in these techniques. So, I don't think it will be too long before there will be more well-trained clinicians. Once that happens, it will put pressure on the training programs, and then we may see them change too. ASHA members too may soon see that the people with specialty recognition are getting all the clients, and that may lead to some further regulation on ASHA's part. So, I am hopeful for the future, via the specialty recognition route. Woody Experiental therapy resource From: Andy Floyd Date: 10/9/98 Time: 9:16:27 PM Remote Name: 188.8.131.52 Comments Dr. Starkweather, Could you give the name and possibly the publisher of the one book (if you had to pick one) that explains the experiental therapy that you use that works on "relapse?" Re: Experiental therapy resource From: Woody Starkweather Date: 10/12/98 Time: 1:17:29 PM Remote Name: 184.108.40.206 Comments Andy: I am working on a book now that will lay it out in enough detail for a clinician to understand what it is, but I think it is not so easy to learn from a book. There are, however, Gestalt Institutes in most major cities where you can get the training over a three year period. The best book on Gestalt therapy is Erving and Miriam Polsters' book called Gestalt Therapy Integrated. It is available from the Cleveland Gestalt Institute. Woody Relapse From: Sarah Henderson Date: 10/13/98 Time: 6:57:50 PM Remote Name: 220.127.116.11 Comments Woody, I enjoyed reading your article. I have stuttered since I was a child, and currently, I would say I have a mild-moderate stutter. I have had relapses, occasionally, very severe. Most of the time these are due to situations in which I am very ambivalent or frustrated. I can see the point you make that I have not totally dealt with how to handle situations like these. However, as I get older the relapses don't seem as long. It was refreshing to read an article from someone who does not blame the person who stutters for the relapse. Re: Relapse From: Woody Starkweather Date: 10/22/98 Time: 1:16:44 PM Remote Name: 18.104.22.168 Comments Thanks Sarah. I appreciate your comments. Newsletter From: Speak Easy Inc. Date: 10/14/98 Time: 8:05:07 AM Remote Name: 22.214.171.124 Comments Your paper is very interesting and would also be of interest to those stutterers not participating in this online conference. As Canada's organization for people who stutter, may we publish a copy of your paper in a future issue of our monthly magazine, "Speaking Out"? Re: Newsletter From: Woody Starkweather Date: 10/22/98 Time: 1:18:02 PM Remote Name: 126.96.36.199 Comments Yes of course you can publish it. I replied to this earlier, but I must have failed to follow the directions, and my answer was lost. Woody Starkweather psychotherapy for stuttering treatment From: Les Anderson Date: 10/16/98 Time: 1:28:50 PM Remote Name: 188.8.131.52 Comments Mr. Starkweather The importance of psychotherapy has been mentioned over and over again in many of the papers and comments and question areas of this conference. It seems that over the past two or three years, there has been a very strong movement to deal with the emotional baggage that many stutterers carry around with them before, during or after intensive programs. I am one of those who agree very strongly that what we carry around from the past has a great deal to do with how we deal with realizing fluency. My question is, psychotherapy is generally a long term program that must be taken one step at a time so how does a clinical program gear its self to combining fluency skill usage and psychotherapy over a three week period? Dr Boberg, Deborah Kully, of ISTAR, and I have discussed this many times and the same stumbling block always appears. The time factor. It his difficult enough to learn to use fluency skills successfully over a three week period. Could it be said that a stuttering treatment program might be better suited for those who stutter if it were a two tier process? And, which process comes first: fluency skill usage or psychotherapy? I realize this is a loaded question but one that many will be asking. Les Anderson Re: psychotherapy for stuttering treatment From: Woody Starkweather Date: 10/22/98 Time: 1:24:33 PM Remote Name: 184.108.40.206 Comments Hi: It is difficult to do anything meaningful in a three week period, and the research shows clearly that the more intensive the program is the more likely that there will be a relapse. The real skills that one needs, not just to speak fluently -- that's pretty easy -- but to go on speaking fluently and easily, to go on taking care of yourself, growing, dealing with unfinished business, learning how to kill fear permanently, learning how to deal with anger and frustration, and most important, learning how to recover from toxic shame, it takes time. I wouldn't try to incorporate it into an intensive program. I do realize the practical value of doing intensive work, but what is done during the intensive work should not be work on speech at all, it should be work on self, work that will give the person the emotional skills to deal with all the issues that are going to come up. Better speech follows if the emotional issues are dealt with effectively. The problem in the past has been that the psychotherapists knew little or nothing about stuttering. What I am trying to do is develop psychotherapeutic techniques that are specifically for stutterers, tuned to their particular needs and issues, yet flexible enough to be useful for many different individuals. Relapse From: Chuck Goldman Date: 10/18/98 Time: 10:44:23 AM Remote Name: 220.127.116.11 Comments Firstly I'd like to say thanks for the 1997 book "Stuttering". I've used it successfully with graduate students this past summer. I too have gone to the "dental" school of stuttering therapy with regard to relapse. I've found that in addition to this model I offer the client a specific way of dealing with the lack of naturalness a fluency-shaping element in therapy may afford. My client and I usually acknowledge that use of an artificial fluency shaping device no matter how well learned, may never be natural. In accepting this we realize that as much as we try to utilze such a technique we may often "forget". Rather than fighting this apparent truth we acknowledge our lapse back to old speech patterns but we also acknowledge that because of our non-avoidance and desensitization therapy some of our old pattern may indeed be more fluent than originally encountered. In this way the fluency shaping techniques have served to generalize fluency even in utilizing older speech patterns. Undoubtedly however this generalized fluency cannot last so the real challenge to relapse is to self monitor your speech so well that when a disfluency or potential anxiety occurs you can "shift" into the more exaggerated use of the successful fluencing enhancing technique. One would then have to maintain this technique in its supercharged form until the feeling of control returns. It may then again be assumed that use of old paterns may again emerge only to be monitored again in much the same way as described. In such a paradigm true integration of stuttering modification and fluency shaping is achieved. Re: Relapse From: Woody Starkweather Date: 10/22/98 Time: 1:28:32 PM Remote Name: 18.104.22.168 Comments Hi Chuck: Thank you for your kind words about our book. I have to disagree with you however. We need less monitoring, not more. It is already too difficult for stutterers to monitor their production of behavioral targets. We need a treatment that changes the way they think and feel about speech and about fluency and disfluency. When these attitudes are changed, or when the person is given the understanding and skills to change those attitudes, their behavior changes automatically, without the need for intensive monitoring. Some small reflection on events that may have just occurred is necessary however. Relapse And Cycles of Stuttering From: Bernie Weiner Date: 10/18/98 Time: 9:42:11 PM Remote Name: 22.214.171.124 Comments It was really refreshing to read a paper that does not place blame on either the stutterer or the therapist. In my case, like many stutterers, relapse is not a very good term. I tend to have cycles where my stuttering is much more severe. Is this really a relapse, or something that would occur even if I am using every tecqnique at my disposal. Now , I just tend to let it happen and keep plugging away. I have tried to document when my stuttering is more severe, but it really doesn't seem to follow much of a pattern. Once again, thanks for a refreshing view on therapy for the stutterer. Re: Relapse And Cycles of Stuttering From: Woody Starkweather Date: 10/22/98 Time: 1:35:00 PM Remote Name: 126.96.36.199 Comments Cycles of severity are, in my opinion, unrelated to what is usually called relapse. Cycles of severity seem to be related to the stutterer's anticipation of difficulty and the confirmation or deconfirmation that his expectancy receives when he produces the stuttering. If the deconfirmation is negative, that is, he feels that he did worse than expected, it introduces an increased tendency to stutter in the future, given the same circumstances. This then causes further negative deconfirmations, until the person is talking as badly as he ever has. At that point, he can only have positive deconfirmations, that is, he will tend to stutter better than he expects to because he expects the worst. These positive deconfirmations introduce a tendency for the stuttering to be better, which increases the likelihood \of more positive deconfirmations and speech gets better and better until the person reaches a point where he is talking as well as he ever has. Then of course, he can only have negative deconfirmations, and the cycle starts over again. I have no way of knowing if this is actually what happens, of course, but interviews with many stutterers who have cycles of severity convince me that it is a process somewhat like this.