2003 IFA Congress: Montreal, Canada

A New Proposal for Therapy: The “Empty Pause”

Volker Urban
Helmstedter Str. 14,, D-38102 Braunschweig, Germany

SUMMARY

The “Empty Pause” is a new method which consists in having the stutterer interrupt or postpone his attempt to say a “critical” word until he feels that he will succeed in continuing fluently. In doing so he has to tolerate the growing fear of stuttering and has to resist an intense urge to start the speaking attempt right away. There is a proposed hypothesis that this urge plays a crucial role in the explanation of stuttering. It triggers the stuttering events by provoking an acceleration of the articulation or its preparation.

1. Introduction
The following article consists of two parts. Firstly, a new therapy method is presented: the Empty Pause. It advises the stutterer to postpone his attempt of speaking when anticipating a stuttering event, until he gets the feeling that a fluent pronunciation of the word will be possible. The observations the method is based on lead to a theoretical conclusion which will be presented in the second part of this article. This conclusion contains the following: Before and during a stuttering event the stutterer experiences an urge to quickly start repeating his attempts at speaking. If this hypothesis should be corroborated some interesting inferences could be derived:
  1. On the one hand stuttering is based on a defect in speech processing still to be found, on the other hand it depends in a conspicuous way on characteristic features of the situation the stutterer is facing, and on his inner feeling. The urge to speak could prove to be the “missing link” between these aspects.
  2. The urge to speak could occasionally have the effect that a “normal” disfluency turns into a stuttering event.
  3. The effect of therapy techniques which slow down the efforts to articulate, could be interpreted in a new way: The stutterer has to withstand his urge to quickly start speaking.
2. The Empty Pause
The Empty Pause method requires that the stutterer is given a very simple instruction: “If you try to say a certain word and you start stuttering or you are afraid that you might stutter, make a pause and only continue speaking when you feel that you can pronounce the word without stuttering. Try to stay silent for a while even if you are experiencing fear.” Pauses are used in other therapy techniques as well; in the following some examples will be given. Van Riper (1973) makes use of them within the scope of his cancellation procedure (though he inserts the pauses after the stuttered word). Further approaches are made by Azrinn and Nunn (1974), Rojahn and Pesta (1977), Wendlandt (1979), Meltzer (1995) and Hayes and Christensen (1995). The new aspect with the Empty Pause is that the pause is not used to relax or to prepare for a specific activity (such as using a breathing technique or continuing to speak in an altered way). Instead, the stutterer waits until something happens by itself.

There is, however, a problem which often makes the practical application of this method very difficult: In the pause the fear of stuttering can increase considerably. The stutterer is more 150 Theory, research and therapy in fluency disorders and more afraid that he will not be able to avoid serious stuttering if he postpones his attempt to speak. Because of that it can get almost impossible to perform this simple experiment. The stutterer experiences an intense urge to immediately start his attempt to speak. That is even the case if there is no actual time pressure. Occasionally, a stutterer who tries to make use of this method does not succeed in waiting more than one second before trying to say a word which is difficult for him, even if he tries several times and even if he is in the save situation of therapy. As a record of the intensity of fear during the pause in the following a passage will be cited which can be found in Van Riper’s (1973) description of his cancellation procedure:

The gaps in their communication have always been anticipated with dread. The communicative delay inherent in the stuttering itself makes further delay almost seem intolerable for they feel they must get their message across before the listener interrupts or leaves. As Sheehan and others have pointed out, silence for the stutterer can even have overtones of impotence and death  All we are asking is that the stutterer stop for a moment after he stuttersl Why does he find this task so very difficult? Why all the emotional storm? (pp. 320-321)

The following hypothesis can be derived from these observations: By quickly starting his attempt at speaking, the stutterer avoids an increase of his fear. According to this the Empty Pause would have a therapeutic effect because it blocks the urge to avoid the increase of fear. Possibly the pause has the same effect as the exposure treatment and the response prevention, which are used in treatment of phobias or the obsessive-compulsive-disorder (Marks, 1987). People who suffer from compulsive disorder have to suppress their urge to perform an act of control (e. g. checking if a door is locked) by their own willpower, and phobics have to overcome their urge to leave a situation which they find dangerous, being in an elevator for example. If the patients succeed in preventing themselves from performing the critical (avoidance) behaviour they first experience a rise in agitation and in the urge to still perform the behaviour; if they keep this behaviour up long enough though, both, the rise in agitation and the urge to perform this behaviour, are going to diminish eventually.

Therapy methods which lead to a slowing down of articulation (e. g. easy voice onset, prolonging, see Ham, 1986) increase the stutterer’s control over his articulation. Possibly the therapy effects are additionally derived from the fact that they also counteract the urge to quickly start speaking. As support for this assumption, stuttering people have to suffer an increase of their agitation at the last moment before they try to insert such a technique (own clinical observation).

Experience shows that the fear does not always increase up to an extreme level when stutterers insert the pause. In most cases it remains at a level that the stutterer is able to tolerate if he uses his willpower. When doing so he often has an experience which surprises him at first: After a pause of between one and three seconds, the articulation is possible in a completely fluent manner.

We found that patients accept this method quite easily because they experienced pausing prior to an anticipated difficulty as a natural way to react. The goal of therapy is to collect as many success experiences as possible. Then through reward learning, the necessary pauses become shorter and eventually are not needed anymore. It is not necessary to learn a new technique which modifies the way of speaking. It becomes clear very quickly that building up and maintaining motivation is the main issue in the therapy work.

It has to be pointed out that to date there are no data to support the use of this procedure with people who stutter. The descriptions in this article are merely based on my personal experience in the therapeutic work with about 80 persons. Successes were varied of course, but I haven’t had a single case where the Empty Pause hasn’t worked at all. It has to be pointed out that it would not be useful in most cases to insert the Empty Pause as sole technique. In cases of severe stuttering the pauses - inserted with each anticipation of a stuttering event - would decelerate the course of speaking too much and the rate of failures would be too high. Inserting methods in the beginning of therapy, which demand less willpower than the pause, e.g. cancellations, pullouts (see Van Riper, 1973) and techniques which slow down the utterance (e.g. Runyan & Runyan, 1999) have been of value. The clients then are able to work with Empty Pause when the stuttering events decrease. The advantage of the Empty Pause compared to other methods is tha: in case of success the articulation takes place in a completely natural way.

3. The Urge to Quickly Start Speaking
The observations described above made while working with the Empty Pause led to the following hypothesis: Right before stuttering and during the course of the stuttering event the

stutterer feels an intensive urge to start his attempts to speak immediately and to quickly repeat them. Possible triggers for this behaviour are the fear of stuttering, a normal disfluency or a stuttering event that has already commenced, and properties of the word or the situation that remind the stutterer of previous stuttering events. The urge to quickly start speaking leads to an acceleration of the attempt of speaking or to an acceleration of its preparation. This acceleration causes the problems in the articulation which result in a stuttering event (Figure 1).

In the following some proof and observations reported in the literature which give support to the single components of this hypothesis, will be listed. Subsequently some proposals for experiments that might prove (or disprove) them, will be presented. Furthermore, a model will be presented elsewhere in order to demonstrate which learning processes maintain the unfavourable reaction pattern (Urban, this Volume).

  1. Whenever the stutterer postpones his attempt to speak when anticipating a stuttering event, his fear of stuttering increases. Wischner (1950, p. 326) reports the result of a study carried out by Goss (1947): “The longer the time interval between the presentation of the word and the sig Jal to speak, presumably the greater the anxiety and therefore the greater the probability that the word would be stuttered.”
  2. The fear triggers an intense urge to start the attempt of speaking immediately. Many stutterers show a fear of silence, and any dead stop in their communication spurs panicky efforts to release the block. Many of the irrelevant and apparently unintelligent symptoms of the stutterer can be understood as a filibustering, a measure taken against the fear of silence” (authors’s emphasis) (Sheehan, 1953, p. 32).
NPT_f1.png

Figure 1

  1. If the stutterer maintains the pause for some seconds in spite of the increasing fear of stutterng, he is often able to fluently speak the word afterwards. I don’t know any reference in literature which describes that an “empty” pause, i. e. a pause which is not used to practise further activities like changing the breath pattern or preparing the utterance, has a therapeutic effect. In the following the possible triggers of the urge to speak are described. It has to be pointed out that the cited authors refer to the triggers of stuttering but not of the urge to speak. These references will be relevant if the connection of urge to speak and stuttering can be proven. ' 152 Theory, research and therapy in fluency disorders
  2. Fear of stuttering is a possible trigger of the urge to start speaking. Numerous authors, e. g. Wischner (1952) and Bloodstein (1985) describe stuttering as a reaction to the anticipation of stuttering.
  3. The urge to start speaking can be triggered by properties of the situation or the word that remind the stutterer of previous stuttering events. Bloodstein (1985) makes the assumption that if a person who stutters could forget about stuttering, it would not happen. Wischner (1950) distinguishes properties of general situation anxiety and specific word anxiety.
  4. The urge to start speaking can be triggered or intensified by a disfluency or a stuttering event which has already commenced. Meltzer and MacKay (1995) found that stutterers show less “normal disfluencies” than non-stutterers. The hypothesis that with stuttering some of the normal disfluencies are turned to stuttering events by the urge to speak, could explain this result. Some known findings could be interpreted in a new way: masking reduces stuttering because its intensity is not experienced as clearly. DAF (delayed auditory feedback) suppresses the perception of stuttering as a result of that very moments effort of speaking. Prolonged speaking is efficient in therapy because the speaker doesn’t get the feedback that he stutters as soon as he starts his attempt of speaking.
4. Empirical Validation
In the following a number of suggestions for experiments that could show that there is an urge to start speaking and that it can end in stuttering, is presented. Since there is not much space these experiments are just going to be described briefly.
  1. Questioning and measurement of psycho physiological parameters could show if people who stutter actually do experience a rise in fear during the delay they undertake for a few seconds whenever they expect to stutter (Goss, 1947).
  2. People who stutter are instructed to try to pause for two seconds before they say certain words. One could measure if pauses are shortened in relation to the following parameters: Intensity of the fear to stutter when saying a certain word; intensity of the stuttering when saying the same word in a previous trial; intensity of the stuttering if (with variation of the experiment) a current stuttering event has to be interrupted by a pause. This way it could be shown that the urge to speak exists and that it is released by the listed variables.
  3. The subjects get the same instruction as in the experiment just described. It is to be measured if a following stuttering event turns out to be longer if the subjects have made a shorter pause. If so it would support the hypothesis that the urge to speak is a cause of stuttering.
  4. Search through imaging techniques for brain activation patterns which are typical for avoidance reactions (comparison group: compulsive disorder patients) and occur during stuttering. See whether they will occur in case of anticipation of stuttering during the pause as well.
  5. Record of spontaneous speech or texts that are read aloud: Is there a tendency towardsspeeding up speaking or towards shortening of pauses in passages of more intense stuttering?
  6. Making use of the Empty Pause in therapies as sole technique. This would not be adequate in cases of severe stuttering, because the time you have at your disposal for a pause in normal conversations (about three seconds) would not be enough in many cases; the number of disappointments would get too high. But this procedure would be justified in cases of low intensity. Success could be considered to be a proof for the presumption that the attempt to come to terms with the urge to speak tackles a fundamental cause of stuttering.
Acknowledgments

The author would like to thank the following people for the discussion of earlier versions of this work: Andreas Starke, Hamburg (Germany), Prof. Hans-Georg Bosshardt, Ruhr-Universitat Bochum (Germany), Prof. Dirk Vorberg und Dr. Jens Schwarzbach (both of them: Technische Universitat Braunschweig, Germany), Dr. Albrecht Schumacher, Hohenroth (Germany), and Prof. Wolfgang Wendlandt, Alice-Salomon-Fachhochschule Berlin (Germany).

References

Azrinn, N. H. & Nunn, R. G. (1974). A repid method of eliminating stuttering by a regulated breathing approach. Behavior Research & Therapy, 12, 279 - 286.

Bloodstein, O. (1985). Stuttering as an anticipatory struggle disorder. In R. F. Curlee & W. H. Perkins (Eds.), Nature and treatment of stuttering: New directions (pp. 1 7] - I 86). San Diego, CA: College-Hill Press.

Goss, A. (1947). An experimental study of an expectancy (anxiety) gradient in stuttering behavior M.A. Thesis, State University Iowa.

Ham, R.. (1986). Techniques of stuttering therapy. Eaglewood Cliffs, N.J.: Prentice Hall.

Hayes, E. & Christensen, S. (1995). The story is in the pause. In C. W. Starkweather & H. F. M. Peters (Eds.), Proceedings of the first world congress on fluency disorders, Munich, Germany, August 8-11, 1994 (pp. 608 - 612). Nijmegen: Nijmegen University Press.

Marks, 1. M. (1987). Fears, phobias, and rituals: Panic, anxiety, and their disorders. New York: Oxford University Press.

Meltzer, A. (1995). An innovative, integrated adult therapy program. In C.W. Starkweather & H. F. M. Peters (Eds.),. Proceedings of the first world congress on fluency disorders, Munich, Germany, August 8-11, 1994 (pp. 325 - 329). Nijmegen: Nijmegen University Press. .

Meltzer, A. & MacKay, I. (1995). Normal disfiuencies in stutterers. In C. W. Starkweather & H. F. M. Peters (Eds.),. Proceedings of the first world congress on fluency disorders, Munich, Germany, August 8-1], 1994 (pp. 613 - 616). Nijmegen: Nijmegen University Press.

Rojahn, J. & Pesta, T. (1977). Die Sprechpause als stotterinkompatible Reaktion: Therapeutische Abgrenzung und Einsatzmoglichkeit bei Stotternden. Zeitschrift fiir Klinische Psychologie 6, 281 - 302.

Runyan, C. M. & Runyan, S. E. (1999). Therapy for school-age stutterers: An update of the Fluency Rules Program. In: R.F. Curlee (Ed.), Stuttering and related disorders of fluency (p. 110 - 123). New York: Thieme.

Sheehan, J. G. (1953). Theory and treatment of stuttering as an approach-avoidance conflict. The Journal of Psychology, 36, 27 - 49.

Urban, V. (this vo1ume).A learning theory model of stuttering.

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

Wendlandt, W. (1979). Verhaltenstherapeutisches Sprechtrainingsprogramm filr stotternde Kinder und Jugendliche. Berlin: Marhold.

Wischner, G. J. (1950). Stuttering behavior and learning: A preliminary theoretical formulation. Journal of Speech and Hearing Disorders 15, 324 - 335.

Wischner, G. J. (1952). An experimental approach to expectancy and anxiety in stuttering behavior. Journal of Speech and Hearing Disorders 17, 139 - 154.

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