About the presenter: Peter R. Ramig, Ph.D., CCC-SLP is Professor and Associate Chair at the University of Colorado. He is also engaged in private practice with people who stutter in the Boulder, Denver and Fort Collins area. His primary research interest area is on issues pertaining to children and adults who stutter. He also regularly conducts treatment with children and adults who stutter, supervises therapy in the CU Speech, Language and Hearing Center, and teaches, among other things, graduate-level courses in stuttering. Peter has participated in the development of the SFA videotapes on child, teenage, and adult stuttering, and he and Darrell Dodge have written a comprehensive book on stuttering for clinicians. Peter is an ASHA Fellow and board recognized fluency specialist.
About the presenter: Darrell Dodge, M.A., CCC-SLP, graduated from the University of Colorado, Boulder, after leaving a career as a project manager at the National Renewable Energy Laboratory in 1996 to study the art, science and discipline of speech-language pathology. He is now a stuttering therapist in south metro Denver, where he operates the Greenwood Speech-Language Center as an associate of Dr. Peter Ramig, who was his speech therapist. This Fall (2004), he is serving as a lecturer and clinical supervisor at the CU Speech Language and Hearing Sciences Department. His primary clinical research interest is in the role of fear conditioning in stuttering development and fluency recovery, which is the focus of his Web site, "The Veils of Stuttering."

You can post Questions/comments about the following paper to the authors before October 22, 2004.


Fluency Shaping Intervention: Helpful, But Why It Is Important to Know More

by Peter R. Ramig and Darrell M. Dodge
from Colorado, USA

Today, the profession of speech-language pathology typically defines three types of intervention or "schools of thought" in addressing the treatment of those who stutter. They are 1) fluency shaping intervention (FSI,) (e.g., Shames & Florance, 1980 Ryan, 1974) 2) modification of stuttering intervention (MSI), (e.g., Guitar, 1998; Van Riper, 1973) and 3) a combination of fluency shaping and modification (FSI+MSI), also referred to as the " integrated approach" (e.g., Guitar, 1998). Of these, the majority of practicing speech-language clinicians are trained to primarily use fluency shaping techniques in working with persons who stutter. In contrast, far fewer have been exposed to the rationale and the techniques involved in the modification and integration of this approach and fluency shaping.

Fluency Shaping and Modification Briefly Described

The main focus of fluency shaping intervention is to increase fluent speech through teaching, for example, one or more of the following: easy onsets, loose contacts, changing breathing, prolonging sounds or words, pausing, as well as other methods that reduce speaking rate. The overall goal of most FSI advocates is to encourage spontaneous fluency where possible and controlled fluency when it is not. FSI advocates do not teach their clients techniques to confront stuttering and modify its form so as to produce an easier and less tense type of acceptable stuttering. In contrast, the goal of those advocating MSI, view acceptable stuttering through confrontation of their dysfluencies as more realistic, especially for those clients considered more chronic (Guitar, 1998). Clinicians who focus on MSI do so because they feel that FSI taught in isolation often does not hold up in more anticipated and possibly stress-producing speaking environments. Spontaneous fluency and controlled fluency is also a goal for many clinicians incorporating MSI, but they view such a goal as unrealistic as a sole answer for many of the more chronic stutterers they see (Ramig & Dodge, in press). As a result, many MSI advocates teach their clients to confront the stuttering moment through their implementation of pre-block, in-block, and/or post-block corrections, as well as through a change in how they perceive the stuttering experience. MSI proponents view these strategies as additional tools for the client to draw upon and use when spontaneous or controlled fluency does not work and the speech production system is tight and tense, which is often the experience of those clients with a longer history of stuttering.

Another difference between FSI and MSI is how each group addresses the impact that stuttering has in the everyday life of the dysfluent person. Specifically, many advocates of FSI do not directly target the often-invasive impact of feelings and attitudes resulting from the experience of stuttering. They suggest that negative feelings and attitude will improve as a normal outcome of their client becoming more fluent. Modification or MSI proponents on the other hand view their direct targeting of these as crucial if their clients are to become permanently more capable of living with and constructively managing their stuttering (Van Riper, 1973). In that regard, feelings are addressed with the client and significant practice using strategies to confront and change stuttering (e.g., pre-in-post block corrections) are practiced extensively in and out of the treatment room. The basic philosophy involves confronting what one fears over and over again through confrontation in order to learn to keep onešs " cool" enough to successfully implement their strategies in the face of impending stuttering. In this way, the client is said to be able to better key in to what he needs to do to produce acceptable stuttering, i.e. speech with less avoidance, forcing, and struggling.

For an excellent discussion and description of FSI, MSI and an integration of the two (FSI+MSI) the reader is encouraged to see Guitar's 1998 second edition text called, Stuttering: An Integrated Approach to Its Nature and Treatment.

Why Do We Need to Know FSI, MSI, and an Integration of FSI+MSI?

There is little doubt that programs focused only on fluency shaping strategies have significantly helped many who stutter. Similarly, however, there is little doubt that fluency shaping taught in isolation has failed many. This writer, as well as many of his colleagues, has worked with scores of such clients over the years. We can also say that using only MSI without the added benefit of fluency shaping knowledge has also failed a significant number of clients.

As is obvious by now, we are staunch proponent of clinicians having an understanding of both FSI, MSI and a comfort level that allows them to combine the two. Our logic is as follows: The more tools or "ingredients" we have at our disposal, the more likely it is we can help more people who stutter. Simply, we have more possibilities to draw from when what we have tried is not working well. Put even more simply, it's like making a cake that requires 8 ingredients in order to end up with a dessert that tastes good; yet, we only use four ingredients because that's all we have at our disposal. Without trying to sound trite, we see a similarity between needing enough ingredients to make a tasty cake, and needing to know more "ingredients" to offer our best to those who stutter. Knowing only FSI is having familiarity with some techniques, but those may not be enough for many classified as chronic stutterers. So knowing more techniques allows us to help a client manage his stutter by confronting and changing his dysfluencies when he is failing at his attempts to produce the fluency shaping goals of spontaneous or controlled stuttering.

Another way of looking at this is to view stuttering as being caused by stuttering triggers of sorts. For those who have been stuttering for some time, these elusive causes of stuttering are extremely difficult to extinguish, and it is safe to say they probably have not been erased for most through FSI, for the simple reason that FSI seeks to avoid these triggers rather than confronting them. As a result, they will continue to appear to some degree no matter how effectively a FSI regimen is able to implement spontaneous or controlled fluency. This is another reason for providing the client with knowledge about how to deal with the stuttering experiences of repeating, blocking and prolonging (MSI) when they may have unsuccessfully tried to use FSI strategies.

"Therapeutic Moments" of MSI

These stuttering triggers, which are most likely conditioned fear reactions and threat responses, are simply not treated by programs that use FSI alone. Quite often, clients who have relapsed following intensive FSI report that the gradual, unwelcome reappearance of old stuttering behaviors is what began to undermine confidence in their new "over-learned" fluency. During subsequent MSI, they may report that the experience of confronting the fear and emotional reactions they experience during the stuttering moment is a unique experience; one that is very different from their previous FSI. These "therapeutic moments" are often profoundly impactful, sometimes creating a feeling of confidence that facilitates meaningful changes in behavior and attitude; for example, vowing to use a certain modification technique more often, or to reduce word and/or situation avoidances.

The harbinger of these therapeutic moments is awareness of fear and of the effect of fear on specific speech movements. For example, this might involve feeling that fear is what is causing the person to unaccountably hold his mouth wide open when trying to say the word "boy," or that a sick feeling of dread occurs whenever the person's tongue comes near the alveolar ridge on a /t/ or /d/ sound. Coaching a client to welcome the opportunity to modify stuttering at such moments is an important part of therapy. It seems, as well, that not many of these moments are required to facilitate the change process. Although countless such moments may be required to extinguish most of the vestiges of fear and emotion.

What seems to be happening during these moments is that events such as increases in articulatory and laryngeal tension or perhaps even negative thoughts are triggering the activation of systemic fear and threat responses that are linked to speech gestures through conditioning. Because the attempt to increase awareness of fear and emotion and of their effect on speech gestures is not a normal feature of these responses, a novel situation is presented by MSI that provides an opportunity to change the system. Success in changing the result from "inevitable" stuttering to deliberately fluent speech provides a de-conditioning effect, whereby the elements of the stuttering system are de-coupled.

It is quite possible that some FSI clients experience such "therapeutic moments" when they are attempting to transfer their clinic fluency into real-life speech situations. In fact, this may explain why some people who have had only FSI do manage to overcome relapses and make permanent progress toward recovery. However, we would think ourselves irresponsible if we did not try to guide the client through such experiences to ensure that they have them and benefit from them, as well as providing assistance and assurance that the experiences are positive rather than negative. Some people report that they are concerned that lingering feelings of fear indicate that therapy isn't "working." And the large number of people who do relapse indicates that many clients need our support in confronting their fears and reactions and using them together with intentional speech modifications to break their conditioning down.

Benefits of FSI

At the same time, failing to incorporate experiences of fluency in therapy also leaves something out of the recipe. A model of speech that involves merely moving from block to block, working through dysfluencies as they are confronted may not provide an adequate replacement behavior. Gentle onsets of phonation, continuous voicing, and rhythmic phasing create feelings of pleasure during speech that provide an alternative model for which the client can strive. However, many clinicians who practice MSI add a critical ingredient to this mix: slightly exaggerated articulatory movements (stimulating increased proprioceptive and tactile monitoring) that associate the successes experienced during fluency-enhanced speech with the de-conditioning experiences of the clientšs " therapeutic moments." We often enforce or encourage continuous use of such speech (which Dr. Van Riper called " high stimulus speech" in his videotape series) during entire therapy sessions, once the client has made meaningful changes associated with de-conditioning. Of course, we do not delude ourselves into thinking that such clinic fluency means that MSI and confrontation of fear and emotion in transfer situations is not still required. The goal is to enable the person to create his own therapeutic, de-conditioning moments as he progresses through recovery.

Bibliography

Guitar, B. (1998). Stuttering: An integrated approach to its nature and treatment Ramig, P.R. & Dodge, D.M. (in press). The child and adolescent stuttering treatment and activity resource guide. Cliffton Park, NY: Delmar Learning.

Ryan, B. P. (1974). Programmed therapy of stuttering in children and adults.Springfield, IL: Charles C. Thomas.

Shames, G.H. & Florance, C.L. (1980). Stutter-free speech: A goal for therapy. Columbus, OH: Charles E. Merrill

Van Riper, C. (1973). The treatment of stuttering. Englewood Cliffs, NJ: Prentice-Hall.


You can post Questions/comments about the above paper to the authors before October 22, 2004.


September 8, 2004

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