A Closer Look at Avoidance Reduction Therapy

Avoidance Reduction Therapy for Stuttering (ARTS®): An Overview

Vivian Sisskin, University of Maryland, Maryland, USA; Sisskin Stuttering Center; Virginia, USA

Mark Baer, Sisskin Stuttering Center, Virginia, USA

Theory and Framework

“Basically, stuttering is not a speech disorder but a conflict revolving around self and role, an identity problem.” – Joseph Sheehan

The roots of Avoidance Reduction Therapy for Stuttering (ARTS) are found in the pioneering work of the late Joseph Sheehan, a professor of psychology at the University of California, Los Angeles, and his wife Vivian Sheehan, a speech pathologist. The Sheehans applied concepts from conflict theory and role theory to formulate an explanation for the behaviors and paradoxes observed among those who stutter.

Conflict Theory: The daily experience of stuttering is viewed as an “approach-avoidance conflict,” whereby competing desires to both speak and hold back from speaking result not only in maladaptive reactive behaviors that interfere with communication, but also in “mental gymnastics” that limit participation in daily life. Negative thoughts of what others will think combine with fear of speaking and/or stuttering, and lead to avoidance at many levels; word/sound avoidance, situational avoidance, and avoidance impacting relationships and life choices. Avoidance reduction (approaching feared situations), on the other hand, resolves the conflict.

Role Theory: People who stutter experience periods of fluency: “Sometimes I stutter, and sometimes I don’t”. The allure of fluency leads those who stutter to hide one’s identity as a person who stutters. “Playing the role” of someone who is fluent requires false role behavior, for example, pretending to think, speaking in odd ways, pretending to not know an answer to a question. When stuttering is revealed, role conflict ensues, resulting in shame, that is, negative feelings about “self”. Role congruency, on the other hand, requires self-acceptance as a person who stutters.

The Problem of Stuttering

“Successful suppression of stuttering is what maintains and perpetuates the problem.” – Joseph Sheehan

Those who stutter learn the consequences of stuttering from a young age. Whether a listener looks on with disapproval, breaks eye contact, interrupts, or finishes the one’s sentences, or whether the child’s own frustration and self-criticism is at work, one quickly realizes that stuttering is not “OK”. This subtle, and often unintended, negative feedback begins the cycle of avoidance. Consequently, one swiftly discovers ways to suppress stuttering: Tapping a finger, breaking eye account, using interjections (e.g.
saying “um” or “uh” before a feared word), repeating words or phrases already spoken fluently, substituting words, or simply not speaking. These “tricks” induce temporary fluency because they are novel behaviors that alter the normalcy of one’s speaking pattern, and perhaps may be considered distractions. They can be understood through the learning paradigm of operant conditioning, where a behavior (the “trick”) that allows one to escape a negative stimulus (disfluency) is reinforced and becomes a part of the stuttering pattern. In a world where we are often told to fit in and please others, these tricks may appear to be an effective coping mechanism; however, they are anything but. Using them may provide temporary relief while escaping a potentially embarrassing situation, but the novelty soon wears off and the speaker is forced to discover new methods to suppress stuttering. For example, breaking eye contact helps to escape the moment of stuttering during an introduction (saying one’s name). However, after some time, the novelty wears off and they discover breaking eye contact no longer helps. As a result, they break eye contact (habitually) and add a new escape behavior, for example, saying “um” before saying their name, allowing them once again to escape. Soon, stuttering has evolved from a pattern of easy disfluencies to a pattern of struggled escape behaviors and inefficient and convoluted communication. At the same time, the fear of stuttering grows because it is perpetually avoided.

The problem of stuttering can be compared to an iceberg. Similar to an iceberg, the smaller component of the problem is visible (e.g. the disfluency and physical struggle), while the larger component of the problem is below the surface (e.g. negative thoughts, feelings, and attitudes related to stuttering). Each time that the person who stutters succeeds in suppressing stuttering, the problem grows below the surface. The desire to suppress the feelings (not wanting to feel shame) and suppress thoughts (not wanting to think about stuttering) fuels avoidance, and false role behavior.

Even in the absence of escape behaviors, efforts to push ahead (say the word) and hold back (hide disfluency) lead to tension and breaks in speech continuity. Normal respiration and timing patterns become disrupted. Physical struggle becomes habituated and reinforced as part of the stuttering pattern. Anticipation of struggle leads to negative thoughts regarding potential listener reactions, as well as dread and anxiety. The problem of stuttering is actually a problem of struggle, not a problem of stuttering, as easy disfluency without struggle would be a desired outcome for many people who stutter.

Treatment

“Every stutterer becomes in time a ‘walking museum,’ or perhaps a ‘talking museum,’ of those crutches, devices or mannerisms he has employed to conceal his stuttering.” – Joseph Sheehan

Identification and Monitoring

When beginning therapy, one may not be aware of the variety of learned escape behavior attached to the stuttering pattern. It is common to characterize all such behaviors as “stuttering”. The first step in therapy is to become an expert on one’s own stuttering pattern. After all, having awareness of a behavior is necessary in order to modify or reduce it. This involves making decisions about behaviors which are harmful or helpful
for comfortable, forward-moving speech. Avoidance behaviors that need to be reduced (loss of eye contact; use of phrase repetitions to avoid stuttering) are distinguished from open repetitions on intended words. The act of “monitoring” an escape behavior involves identifying it in real time, as it occurs. Monitoring will reduce the behavior without direct attempts to reduce it. What replaces the escape behavior? A person who stutters can easily guess this; it is replaced by “the thing he does not want to do”… stutter! Stuttering directly on the “feared” or intended word/sound is the success at this stage of therapy. This can be called “open stuttering”.

Open Stuttering

What is open stuttering? Essentially, it is “clean” stuttering – stuttering without using escape/avoidance behaviors. Open stuttering will vary among patients. Some open stuttering patterns may start with blocks due to the heightened reactivity to showing what one has previously been hidden. Open stuttering may be struggled at first, as increased tension and holding back would be natural when doing something that is highly feared. We recommend that open stuttering be practiced only in low-feared situations, where the patient is prepared to feel shame and still count open stuttering as a success. Once a patient is stuttering openly (again, the major milestone in Avoidance Reduction Therapy), he or she can begin to make choices to modify the stuttering pattern in order to achieve comfortable, forward-moving speech.

Williams Normal Talking Model

Dean Williams, a former researcher and clinician at University of Iowa, developed parameters for “normal speaking” and suggested that in order to produce forward- moving, smooth speech, one must speak within these parameters. The five parameters of Williams’ model are: 1) air flow: air flow is needed to produce vibration in the vocal cords; 2) voicing: vibration is needed to produce voicing/phonation; 3) tension: adequate tension is needed for normal speech; 4) timing: proper timing is needed for coordination of the system; 5) movement: proper movement of the speech mechanism is necessary for normal speech.

William’s suggested that when we speak, we are doing something, and thus, we can do something differently to promote forward-moving, smooth speech. As stuttering involves doing something that interferes with the parameters of normal speaking, those who stutter can modify the parameters to be more in line with “normal talking”. Before working with this model, the person who stutters should become knowledgeable about the speech mechanism and become familiar with each of the five parameters. The patient and clinician should explore these parameters, “play with them”, so to speak, as the patient learns to make choices that lead to comfortable disfluency.

Desensitization and Reframing

Open stuttering involves the process of desensitization, as the person who stutters is adapting slowly to hearing and feeling the disfluency that he or she previously concealed through escape behaviors. Desensitization is also taking place with regard to feelings and thoughts about stuttering. The person who stutters first must expect or plan to experience feelings of shame and potential thoughts of listeners. This may start as tolerance of those
feelings and thoughts, but with the help of exercises borrowed from cognitive behavioral therapy (i.e., CBT) as well as mindfulness therapies (i.e., ACT), acceptance can be achieved. The process involves reframing thoughts and feelings in a positive manner by planning and carrying out challenges to feel shame and accept potential thoughts of others. Gradual and repeated exposure will result in reduced reactivity, making it easier to stutter openly with less reactivity in a broad range of situations.

Self-acceptance, and Self-advocacy

A long history of avoidance and false role behavior leads those who stutter to “chase fluency” at all costs. They view fluency as success and stuttering as failure, and therefore constantly experience feelings of defeat. Redefining one’s idea of success and failure is a natural cognitive shift in avoidance reduction therapy. Instead of valuing fluency, they begin to value saying everything they want to say, despite stuttering. They begin to understand that stuttering doesn’t hurt them and fluency doesn’t help them.

Self-advocacy is vital for people who stutter. Through the process of therapy, they learn to be their own biggest advocates and ensure stuttering does not prevent them from taking part in life. Self-advertising (self-disclosure as a person who stutters) is a useful tool for self-advocacy, enabling those who stutter to present stuttering in the way they choose. It gives those who stutter “permission to stutter”, reducing the temptation to hide it, and it offers listeners a positive message about how to view their stuttering.

The Culture of ARTS® and the Process of Change

“If you don’t like something, change it. If you can’t change it, change your attitude.” – Maya Angelou

Living in a new culture may require rethinking basic beliefs, reassigning labels of “good” and “bad”, and redefining success and failure. In therapy, the person who stutters will be moving from a culture of suppression of stuttering to one of openness and acceptance, with the goal of comfortable, spontaneous, and joyful communication. This change takes time for the person who stutters and is reinforced with support from the clinician and other members of the therapy group.

What are the concepts and values of the culture of ARTS®? While goals and outcomes in some treatment approaches may include increased fluency (percentage of fluency words), control of stuttering, hiding stuttering well, “practice”, and protecting others from stuttering. In contrast, concepts that are valued in ARTS® lead to openness and acceptance and include comfortable, forward-moving speech, struggle-free disfluency, exercising choice, self-acceptance as someone who stutters, and ability to risk and change. Effective interpersonal communication and connecting with others is central.

The process of therapy involves a number of cultural shifts. Here are some examples:

  1. How one stutters is more important than if they stutter. Someone who stutters has no control over whether or not they will stutter, and thus, no importance should be placed on frequency. What they do have control over is how they stutter. With increased self-awareness, they can learn to stutter in a more comfortable and forward-moving way.
  2. Becoming comfortable showing stuttering, rather than concealing it; tolerating shame, rather than protecting oneself from it. Accepting oneself and taking the role of someone who stutters is a vital concept in the culture of ARTS®. If one expects to stutter, one naturally reduces frequency and struggle. It is a byproduct of therapy, not a goal. Approaching feared situations and tolerating any accompanying shame is valued, and considered a success.
  3. Communicating and connecting with others is more important than protecting others and themselves from stuttering. It is all-too-common for people who stutter to limit their participation on life’s stage, due to stuttering: they may not order exactly what they want at a restaurant or decide not to talk to a “cute” classmate after school. Expressing oneself and saying exactly what one wants is encouraged, along with stuttering. Sometimes just “showing up” is a success!

No Tools Required!

The use of “tools”, “techniques” and “strategies” to MANAGE stuttering are not a focus of therapy. If stuttering becomes something to be controlled or managed, there is a cost to pay in both joy and spontaneity. While behavior change is important in early stages of therapy (to reduce escape/avoidance that is maladaptive to forward moving speech), we move quickly to focusing on the natural process of desensitization, and subsequent reduction in reactivity. When the patient is free to say all that he or she wants, AND stutter, anticipatory reactions to hold back are eliminated – personality shows through. Spontaneous communication is joyful.

Outcomes and Recovery

The outcome of ARTS® include self-acceptance as someone who stutters, and efficient, spontaneous, confident, and joyful communication. In other words, experiencing minimal life impact due to stuttering. While recovery from stuttering may be different for each person who stutters, we believe that these outcomes play an important role in the definition of recovery.

We find that our patients resonate with this idea of recovery: I say exactly what I want to say, when I want to say it, comfortably, efficiently and spontaneously. I no longer carry around negative mental baggage or worry about listener reaction. I am free to be who I am.

Resources

  • Beilby, Byrnes, Yaruss (2012) Acceptance and Commitment Therapy for adults who stutter: Psychosocial adjustment and speech fluency.
  • Brutten, G.J. & Shoemaker, D.J. (1967). The Modification of Stuttering. Englewood Cliffs, NJ: Prentice Hall.
  • Reitzes, P. (Producer). (2015, March 27). “Use Your Tools!” And Other Ineffective Nagging: featuring Vivian Sisskin. Episode 507. Audio Podcast, Stutter Talk. Retrieved from http://stuttertalk.com/use-your-tools-and-other-ineffective-nagging-ep-507/
  • Sheehan J. G. (1953). Theory and treatment of stuttering as an approach-avoidance conflict. Journal of Psych, 36, 27-49.
  • Sheehan, J.G. (1968). Stuttering as a self-role conflict. In H.H. Gregory (Ed.) Learning theory and stuttering therapy. Evanston, IL: Northwestern University Press.
  • Sheehan, J. G. (1974). Stuttering: Research and treatment. New York: Harper and Row.
  • Sheehan, V.M., & Sisskin, V. (2001). The creative process in avoidance reduction therapy for
    stuttering. Perspectives on Fluency and Fluency Disorders, 11(1), 7-11.
  • Williams, D.E. (1959). A point of view about stuttering. JSHD, 22(3), 390-397.

A portion of this article is in press (French publication):

  • Sisskin, V. & Baer, M. (2016, accepted). La Thérapie de Réduction de l’Evitement Pour le
    Bégaiement: Une vue d’ensemble. Ortho Magazine (Elsevier).