I was interviewing for assistant positions at our summer speech and language camp when I first met Ben Goldstein. Ben is a graduate of the University of Maryland and was in the midst of taking his pre-requisite courses to apply for graduate school to become a speech-language pathologist. Ben also happened to be a person who stutters (PWS). As the interview continued he shared that he was introduced to avoidance-reduction therapy by Vivian Sisskin at the College Park campus of UMD. I had already been applying aspects of avoidance reduction therapy with my clients, however Ben helped solidify my feelings on this approach. Ben was kind enough to answer some questions and walk me through his experience with avoidance-reduction therapy, which is included below.
Avoidance-reduction therapy is an approach to stuttering therapy that can be used with both school-aged and adult clients. This approach views stuttering as an approach-avoidance conflict; a theory that states that a PWS experiences the desire to speak and interact with others while simultaneously experiencing an urge to hide their stuttering. The result of these competing desires culminates in the maladaptive secondary behaviors that interfere with communication (ex. eye blinking, leaning forward, use of fillers, etc.). These competing desires also result in a feeling that one can not partake in certain activities and situations due to their speech.
Avoidance-reduction therapy works toward reducing these maladaptive behaviors, leaving in its place a more comfortable, forward moving form of stuttering. It also works toward reducing the handicap of stuttering, whereby increasing a person’s willingness to participate in various activities and situations, whether or not they show some stuttering. Unlike other approaches that focus on fluency, this particular approach views a person’s strong desire to be fluent as perpetuating the problem and ultimately what contributes to their word and situational avoidances, as well as much of the struggle behaviors you see in their speech. Avoidance-reduction therapy does not put an emphasis on fluency, but rather on improving a person’s ability to successfully communicate in the “real” world.
How do you incorporate avoidance-reduction therapy into your sessions? Start by helping your client to identify their own stuttering patterns and assist them in recognizing how much of their pattern is “true” stuttering and how much of what we see is actually habits they formed in an attempt to mask stuttering. Challenge clients to allow themselves to show true stuttering (or perhaps use voluntary stuttering), beginning in the safety of the therapy room and eventually branching out to different “real-life” situations. As you work through these challenges, clients will often discover ways in which their stuttering was holding them back that they may not have realized before. Read on to learn about Ben Goldstein’s first-hand experience with avoidance-reduction therapy.
Before jumping into avoidance reduction therapy, how would you describe your speech intervention experience leading up to it?
Ben: Prior to avoidance reduction therapy, I saw two SLPs as a private client. Both focused primarily on common fluency shaping techniques (easy onset, breath control, continuous phonation). My parents felt that the therapy helped me sound better, but I don’t remember sounding better. I also don’t remember feeling better about myself or my stuttering through therapy.
Can you describe your stuttering pattern prior to beginning avoidance reduction therapy? Do you feel like stuttering impacted your quality of life?
Ben: When I showed my stuttering I usually blocked for long periods of time, contorted my lips and mouth, tapped my leg to release a block, used fillers such as “umm” and “you know,” and closed my eyes. There was little actual stuttering going on. It was mostly secondary behaviors.
In particularly scary situations, I would avoid talking altogether if I felt that I was going to stutter. If somebody asked me a question and I felt a disfluency coming on, I would often pretend that I didn’t hear the person. I would constantly change words that I thought I was going to stutter on. I would not go to parties and avoid hanging out with friends sometimes.
All of that avoiding had a huge impact on my life. For one, I never showed my real personality. If I had a joke I wanted to tell or a comment I wanted to say, I usually wouldn’t say it. My mindset everyday was “Let’s get through today without showing stuttering. Say only what you absolutely have to say.” That kind of mindset suppresses one’s personality and it can lead to a lot of feelings of shame, guilt and feeling less than others.
How were you introduced to avoidance reduction therapy?
Ben: After my first semester freshman year at the University of Maryland, I found my way to the on-campus Hearing and Speech Clinic. It was there that I was introduced to avoidance reduction therapy.
How would you define avoidance reduction therapy and the rationale behind this approach?
Ben: I think the most basic definition of avoidance reduction therapy is to reduce one’s avoidances related to stuttering, speaking, and really, in life. In other words, the goal is to reduce how often one actively avoids stuttering, avoids various speaking situations, and avoids different opportunities in life. The rationale behind the therapy is that stuttering is perpetuated by habit and fear. If I have a fear of speaking in class, every time I keep silent in class, I reinforce that behavior and the fear of speaking in class grows. Avoidance reduction therapy is about reversing that process. If you face your fear head on and with a different attitude of what is a success and what is a failure, the fear eventually dissipates, and once the fear of speaking weakens, you can start to make choices to stutter in a more comfortable and effective way.
Most clients seek therapy to try and reduce or eliminate stuttering and may be initially concerned with the premise of avoidance reduction therapy. How long did it take for you to “buy in” to this approach?
Ben: Great question. For me, I bought in pretty quickly. No one before in my life had explained to me the cycle of avoiding stuttering, the feelings and thoughts that I had, and how those feelings and thoughts perpetuated and worsened my speech. Once these ideas were laid out for me it was almost like a lightbulb went off in my head. “Yes, finally what I’ve experienced my entire life makes a little sense.”
Can you explain what a typical therapy session would look like?
Ben: A typical therapy session usually begins with the client talking a bit about how their week went. The client might talk about a speaking-related success they had the previous week (talking about my successes helped me feel good about myself as a communicator), a situation that is really bothering them (these always helped me relieve some anxiety and develop a plan), or a topic unrelated to speech altogether. While the client is speaking, the SLP is taking note of the client’s speaking pattern and assessing how successfully they are hitting their target from the previous week.
After the client has spoken for a bit, he or she usually receives feedback from the SLP. This feedback can be related to the thoughts and feelings of the client (dependent on what the client was saying) and/or his /her motor pattern (dependent on how the client was saying it.) Following feedback, the client and SLP engage in some specific practice where the client has the opportunity to put the SLP’s suggestions into action in a safe speaking environment. This allows the client to play around with the new assignment (whether motor-based or cognitive-based) and allows the client to begin to reinforce the new behavior.
Following target practice, the client and SLP finalize the client’s assignment or plan for the week. The client is told what the rationale behind the assignment is, and how that target or goal fits into the client’s longer-term plan.
What aspects of avoidance reduction therapy do you think are most beneficial to you and to the individuals in your group?
Ben: I can’t speak for everyone in my group, but to me, the lessons I’ve taken from avoidance reduction therapy are that it’s OK to stutter, it’s OK to be vulnerable and it’s OK to not be perfect everyday. Contrary to what I used to think, stuttering is not some giant, evil monster that I need to run away from for the rest of my life. It’s a part of me and not a negative thing. Perhaps most importantly, my goals have changed since starting avoidance reduction therapy. In the past, my priority was to avoid stuttering at all costs regardless of how it affected the way I connected with others and how I felt about myself. Today, my goal is to be true to myself, connect with other people, say what I want to say, and enjoy life as much as I can. If stuttering wants to come along for the ride, that’s OK.
How do you think your stuttering has changed? Does stuttering affect your life in the same way it did prior to receiving avoidance reduction therapy?
Ben: A lot has changed since starting avoidance reduction therapy. For one, my stuttering pattern has definitely changed. Now, I keep eye contact during disfluencies. The habit of tapping my knee is gone. I no longer use interjections with the same degree of frequency. I still contort my lips and mouth sometimes, but hey, it’s my next goal to tackle.
In terms of life impact, it’s night and day. Now, I say most of what I want to say. I show my personality. I also have a completely different perspective of what constitutes a success for me at this point and time and what is a failure. I recently gave a short talk in front of 600 people and stuttered a great deal. Four years ago, I wouldn’t have even thought of doing it, and if I had been forced to, I would have viewed my immense amount of stuttering as a failure. Today, I recognize what an accomplishment it is for me to voluntarily speak in front of that many people. I’m slowly chipping away at avoidances and those are my successes.
Do you think that there are individuals who would not benefit from this approach?
Ben: I think one really has to be motivated to change to undertake avoidance reduction therapy. It’s not easy work. Doing things that petrify us is so counterintuitive. If one has never talked in class before, talking in class that first time is going to be really scary. But talking the second time is going to be a little easier.
My experience of diving right into the therapy isn’t the common one. (And my initial experiences with avoidance reduction therapy probably weren’t as smooth as I’m remembering them). It takes time to truly change one’s attitudes and beliefs. This isn’t an intensive, short-term kind of therapy. But in my experience, and the experience of many of my peers, it’s a therapy that leads to real, meaningful, long-term change. The motto “short-term pain, long-term gain” really applies here. I do think everyone is capable of receiving meaningful benefits from it, but they’ve got to put a lot in as well.
If you want to learn more about Avoidance Reduction therapy, I highly suggest Vivian Sisskin’s video Avoidance Reduction Therapy in a Group Setting, available through the Stuttering Foundation of America.
Brooke Leiman, MA, CCC-SLP, is the fluency clinic supervisor at the National Speech Language Therapy Center in Bethesda, Maryland. She is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency Disorders. This blog post is adapted from a post on her blog, www.stutteringsource.com, which focuses on fluency disorders and their treatment
Ben Goldstein is a graduate of the University of Maryland. He will begin work toward a master’s degree in speech-language pathology in the fall of 2014. Ben is a member of the Rockville Chapter of the National Stuttering Association and served as its co-chapter leader. email@example.com