Avoidance Reduction Therapy

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Avoidance Reduction Therapy

• Vivian Sisskin

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Premises of Avoidance Reduction Therapy (Joseph
Sheehan, UCLA 1949-1983)

• Definition of stuttering
• Interruptions in the forward flow of speech
  (repetitions, prolongations, blocks, hesitations)
• Fear of speaking or of stuttering
• Self-concept as someone who has difficulty
  speaking

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Terminology

• Stuttering a disorder of fluency
• Disfluency interruptions in the forward flow of
  speech. May include core stuttering behaviors,
  open stuttering, voluntary stuttering.
• Trick/crutch something one does to avoid
  showing oneself as a stutterer.
• Open stuttering a stage in therapy. The
  behavior that results from moving forward into a
  feared word rather than using an avoidance.
• Voluntary stuttering stuttering on purpose on
  nonfeared words in order to show yourself as a
  stutterer.

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Premises

• Physiological/genetic factors play a role in
  stuttering.
• The desire to conceal disfluency or hide
  identification as a person who stutters leads to
  avoidance behavior. Avoidance behaviors create
  much of the handicap of stuttering struggle,
  fear of stuttering/speaking, shame/guilt,
  embarrassment, low self-esteem, etc.
• Avoidance behaviors may be physical, linguistic
  or attitudinal.

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Premises (continued)

• Avoidances may be at the sound, word, situational
  or relationship level.
• Avoidance behaviors serve to maintain and
  perpetuate the problem through principles of
  learning
• Avoidance behaviors can mask disfluency, causing
  the problem to resemble an iceberg.

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The iceberg of stuttering
Public shame (can be reconditioned or
extinguished)
Private guilt
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Avoidance behavior explained in terms of conflict
theory

• Approach-avoidance conflict
• The Conflict Hypothesis the organism stops when
  competing approach and avoidance gradients reach
  an equilibrium
• The Fear Reduction Hypothesis The occurrence of
  stuttering reduces the fear that elicited it,
  resulting in the release of the block. Increasing
  the approach drive will reduce the conflict.

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• Role Conflict
• The Self-Role Conflict stuttering varies
  according to how the stutterer views himself in
  his role as a speaker and how the listener is
  perceived.
• The Role-Role Conflict Experience of speaking
  fluently some of the time leads to expectations
  for fluency, leading to more stuttering. Enacting
  the role of a stutterer reduces the conflict.

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Goals of therapy

• To eliminate struggle, avoidance and fear of
  speaking.
• To develop a comfortable, forward-moving speech
  pattern, which may include some disfluency.
• To be able to spontaneously say what you want,
  when you want to say it, without the negative
  feelings associated with revealing yourself as a
  stutterer.

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Positive outcomes are measured in the following
areas

• Increase in fluency (Fluency is achieved as a
  by-product of reducing avoidance).
• Decrease in fear of speaking or of stuttering.
• Improved oral communication skills.
• Increase in self-acceptance.

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Therapy concepts

• Behavior
• Identifying avoidance behaviors and negative
  attitudes
• Monitoring and reducing avoidance behaviors
• Open stuttering
• Voluntary stuttering
• Stuttering modification
• Oral communication skills
• Managing relapse
• Adjusting to fluency

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Therapy concepts (continued)

• Attitudes
• Understanding the nature of stuttering and the
  factors that maintain and perpetuate it
• Fear reduction Establishing a hierarchy
  approaching feared situations revealing oneself
  as a stutterer taking the role of a stutterer.
• Accepting oneself as a stutterer confronting
  tolerating welcoming embracing accepting.

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By-products of therapy

• Fluency
• By-product of lack of avoidance, conflict,
  holding back, struggle
• Control
• Choosing the way you stutter smooth,
  comfortable, forward-moving.
• Breathing
• Struggle and fear interfere with ability to
  breathe normally
• Relaxation
• Fear reduction increases relaxation