2003 IFA Congress: Montreal, Canada

The Successful Stuttering Management Program: Assessment of Stuttering and Speech Rate

Michael Blomgren, Nelson Roy, Tom Callister
Department of Communication Sciences and Disorders
The University of Utah, Salt Lake City, Utah, 84112, USA

SUMMARY

Nineteen adult stuttering speakers participated in a three-week intensive stuttering modification treatment program (the Successful Stuttering Management Program). Stuttering rate and speech durations were assessed immediately pre-treatment and immediately post-treatment. Stuttering rate was calculated as a percentage of stuttering on an oral reading task and a spontaneous monologue task. Speech durations were calculated as speech rate and articulatory rate. Speech rate was measured as the overall duration of a reading passage and articulatory rate was measured as the average /i/ vowel duration during the reading passage. Based on mean scores, clinically positive trends in decreased stuttering rate were observed post-treatment, however these decreases did not reach statistical significance. Total reading passage duration and vowel durations did not change significantly. Discussion focuses on the possible interplay between stuttering rate "and speech rate and articulatory durations.

  1. Introduction
Calls for “evidence-based” clinical practice have become commonplace in the stuttering literature in recent years. However, providing evidence-based therapy to individuals who stutter is difficult given that relatively little objective evidence exists to support the various clinical methodologies. Treatment outcomes and efficacy research are needed for all types of stuttering treatment, however, objective assessment of stuttering modification approaches is especially lacking.

A dichotomy has long existed between fluency shaping and stuttering modification approaches. Fluency shaping aims to teach the stuttering speaker to talk more fluently, while stuttering modification aims to help the stuttering speaker to stutter less severely. Fluency shaping procedures tend to use some form of prolonged speech combined with specific breathing, voicing, and speech articulation strategies to reduce or eliminate stuttering. Yaruss & Quesal (1999) stated that due to the empirical nature of fluency shaping therapies, confidence is usually high that stated goals will be achieved and that clients, consumer groups, and insurance companies will know what to expect from these treatments. The outcomes of stuttering modification procedures, on the other hand, tend to be more difficult to evaluate, considering that they focus on reducing the broad spectrum of negative consequences that stuttering can have within the speaker, such as low self-esteem, shame, fear of speaking, avoidance of words, sounds, or speaking situations, and problems performing activities necessary for their career. While fluency shaping therapy focuses on improving speech motor control to enhance speech fluency, stuttering modification therapy appears to be more anxiolytic (i.e., anxiety reducing) in emphasis.

The Successful Stuttering Management Program (SSMP; Breitenfeldt & Lorenz, 1989) is a stereotypic example of a stuttering modification based treatment program. The SSMP is an intensive residential program that originated at Eastern Washington University in Cheney, Washington, in 1962. A second SSMP was offered at the University of Utah from 1998 to 2003. Since inception 40 years ago, close to 400 stuttering speakers have attended SSMP workshops. The philosophy that underlies the SSMP is a combination of Sheehan’s avoidance reduction therapy (1970) and the application of stuttering modification techniques advocated by Van Riper (1973). For example, the program emphasizes the importance of addressing feelings and attitudes as they contribute to stuttering severity, specifically desensitization and disclosure of stuttering in outside environments, acceptance of stuttering, and acceptance of oneself as a person who stutters. Typically, six to ten individuals who stutter attend each 3 1/2-week program, which takes place once a year during the summer. The program involves approximately five hours of therapy per day. A three-day “refresher” session is offered 6-months post-therapy. The aims of the SSMP are (1) taking responsibility for one’s stuttering, (2) not avoiding stuttering, (3) decreasing word and situation fears, (4) improving self-image, and (5) increasing knowledge of stuttering.

Two reviews (De-Nil & Kroll, 1996; Ham, 1996) discuss the structure and some weaknesses of the SSMP, and Manning (1990) wrote a review of the SSMP manual. However, rigorously evaluated treatment effects data on the SSMP are virtually non-existent. Breitenfeldt & Lorenz (1989) do not provide any evidence in their manual concerning fluency measures, attitude changes, self-report data, or any other data that demonstrate treatment effectiveness. Specifically referring to rate of stuttering, Breitenfeldt & Lorenz state, “the stuttering disorder is too variable and too influenced by many internal or external circumstances for frequency counts to be of any value at all. The number or percentage of words stuttered per number of words said is of no value in measuring severity or improvement of stuttering.” (p. 10). Still, such measures appear essential since, as De Nil & Kroll (1996) observed, evaluating the effectiveness of the SSMP is impossible without any empirical data. The complexity of evaluating the multi-dimensional aspects of stuttering and stuttering treatment outcomes leads to difficulty in the evaluation of the effectiveness of stuttering treatment programs. In spite of the challenges, it is necessary to make accurate assessments of the effectiveness of the treatments that are available for individuals who stutter. Accurate evaluation is critical to identify the specific aspects of therapy that are responsible for the success or failure of stuttering treatment.

Although an overall slowed rate of articulation was not a focus of the SSMP, it appears possible that participants will reduce their articulation rate as an indirect result of participation in the program. The SSMP implements specific management techniques to help control stuttering. One of these techniques, prolongation, is a speech rate slowing technique. Participants of the SSMP use prolongation only intermittently and only on utterance-initial phonemes; however, because participants do prolong the length of these phonemes occasionally, this technique has the potential to affect the participants’ overall speech and articulation rates. Onslow and Ingham (1987) stated that many treatment programs produce a decrease in speaking rate either directly or indirectly to improve fluency. Wingate (1976) believed that the common element in all fluency-enhancing conditions is extended syllable durations. Therefore, it appears important to assess speech rate changes, as any change in speech rate may contribute to possible changes in stuttering rate. Thus,_ the purpose of this investigation was to examine possible changes in stuttering rate and speaking rate secondary to participation in an intensive stuttering modification program. The preliminary speech-related data (percentage of stuttering and speech durations) presented in this paper are related to a larger ongoing multi-method study evaluating a series of fluency and affective-based treatment outcomes of the SSMP.

  1. Method
Participants Nineteen participants (15 males, 4 females) who stutter were assessed as part of a 35-week intensive summer stuttering modification treatment programs offered at the University of Utah. The participants were selected from two consecutive offerings of the program. The participants consisted of 3 adolescents and 16 adults ranging in ages from 16 to 52 years of age (M=27).

Treatment

Treatment was based on the Successful Stuttering Management Program (Breitenfeldt & Lorenz, 1989). The treatment was directed by an ASHA certified Speech-Language Pathologist who had received training in administration of the SSMP by the originator of the program. Neither the SSMP director nor the clinical instructors were involved in the data collection, data analyses, or authoring of this study. The program was organized around three phases of treatment. The first phase dealt with a series of activities designed to promote desensitization to one’s stuttering, disclosure of stuttering, and “letting the stuttering out.” The second phase focused on specific management techniques to control stuttering consisting of l) prolongation of utterance initial phonemes 2) pullouts of severe stuttering moments 3) cancellations of stuttering moments, and 4) negative practice. The third phase of treatment focused on maintenance of learned techniques.

Data Collection

Assessment of Stuttering Rate: The participants were audio and videotaped reading a version of the grandfather passage prior to and at the conclusion of treatment. Additionally, a two hundred- word spontaneous speech sample was recorded during each pre- and post-treatment session. Topics could be related to work, school, or leisure-time interests. Percentage of stuttering was calculated to assess change in rate of stuttering over the course of treatment. Participants were instructed to speak at their normal rate and loudness. For assessment of stuttering rate, video and audio signals were colleted using a digital video camera (Cannon Elura). Recordings were conducted with only the interviewer and the participant present in the room. In an attempt to minimize possible familiarity effects, interviewers were individuals not serving in a clinical capacity during the treatment phases of the study. Drawing on the stuttering taxonomy of Teesson, Packman, & Onslow (2003), words were coded as disfluent if they contained any type of repeated movement (whole syllable repetitions, incomplete syllable repetitions, or multi-syllable unit repetitions) or any type of fixed articulatory posture (with or without audible airflow). Each word was coded disfluent only once, regardless of the number of disfluencies present within the word. Interjections such as “ah” or “um,” were not counted or analyzed.

Assessment of Speech Durations: For assessment of speech durations, audio signals were colleted using a Digital Audio Tape (DAT) recorder (Tascam DA-Pl) and a stand mounted microphone (AKG-C5 35 EB). Two durational analyses were conducted on the Grandfather Passage. Duration of the entire Grandfather Passage was measured to assess overall speech rate. Specific /i/ vowel durations were measured to assess articulatory rate. For vowel duration measures, an average for each participant was calculated from up to six fluent /i/ vowels per sample. The six token words included five instances of the word “he” and one instance of the word “each.” Acoustic analysis of was performed using Computerized Speech Lab 4300B (CSL; Kay Elemetrics Corp., Lincoln Park, NJ). Segments were analyzed using a wide band spectrogram displayed on the computer monitor. Speech segments were demarcated using spectral display markings and auditory-perceptual confirmation. Vowel durations were measured from the first glottal pulse to the last glottal pulse in the wideband spectrogram displaying the target word.

  1. Results
Stuttering Rate.

Reading. Percentage of stuttering for the reading passage ranged from 0% to 60% pre-treatment and 0% to 37% post-treatment. Eleven participant’s reading stuttering rate decreased post-treatment, two remained the same, and six increased. Group means are presented in Table l. A correlated groups t test revealed no significant pre-/post-treatment differences with respect to stuttering rate 011 the reading passage (t(l8) : 1.44, p = .17).

Monologue. Percentage of stuttering for the spontaneous monologue ranged from 2.5% to 57% pre-treatment and .5% to 44% post-treatment. Thirteen participants’ monologue stuttering  decreased post-treatment and six increased. Group means are presented in Table l. A correlated groups t test revealed pre-/post-treatment differences approaching, but not reaching, significance for the monologue sample (t(l8) = 1.95, p = .07).

Reading Passage Durational Analysis

Whole Passage.: Durations for the whole passage ranged from 37.7 seconds to 280.6 seconds pre-treatment and 47.0 seconds to 166.2 seconds post-treatment. Twelve participants’ whole passage duration decreased post-treatment and seven increased. Groups means are presented in Table 1. A correlated groups t test revealed that the decrease in post-treatment whole passage duration approached, but did not reach, statistical significance (t(l8) = 1.89, p = .07).

Vowel Durations. Average /i/ vowel durations in the reading passage ranged from 55 msec to 177 msec pre-treatment and 60 msec to 179 msec post-treatment. Twelve participants’ ï¬ uent /i/ duration increased post-therapy, two remained the same, and five decreased. Group means are presented in Table 1. A correlated groups t test revealed no significant pre-/post-treatment differences with respect to vowel duration (t(18) = .13, p = .90).

SSM_t1.png

Table 1. Mean Scores for the 19 Participants on Stuttering Percentage, Speech Rate on the Reading Passage, and Vowel Duration Measures. Standard deviations are shown in parentheses.

  1. Discussion
This investigation examined changes in stuttering rate and speech and articulatory durations in 19 individuals who participated in an intensive stuttering modification program. There were no statistically significant improvements in stuttering rate following treatment during oral reading (p=. 17), however, reduced stuttering rate during the monologue speaking task approached significance (p=.07). Reductions in speech rate (as measured by total reading passage duration) also approached significance (p=.07), however there were no differences observed in articulatory rate (as measured by /i/ vowel durations) between pre- and post-treatment recordings (p=.90). The underlying rationale of the SSMP was to teach the stutterer “to manage his stuttering and his speech so that he can communicate as a stutterer in any situation without undue stress and strain to himself or his listener.” (Breitenfeldt & Lorenz, 1989, p. 5). It is reiterated that decreasing the rate of stuttering was not an overt goal of the SSMP. However, in the absence of substantial decreases in the rate of stuttering, it is not clear whether the SSMP goal of communication free of undue “stress and strain” is a Viable long-term outcome of this particular program. It is our hope that additional data will aid in shedding further light on the long-term treatment effects of the SSMP.

It was deemed important to assess speech rate in order to help rule out possible motoric contributions to potential decreases in stuttering rate. If stuttering rate had decreased significantly, it would have been useful to determine if the decreases might have been attributable to decreased post- treatment speech rate, or (in the absence of decreased speech rate) the assumed anxiolytic effects of stuttering modification therapy.

Since articulatory rate appeared to be unaffected by participation in the SSMP, participants who complete the SSMP program are likely to speak at a rate they perceive to be comfortable and normal. A more natural rate of speaking may be appealing to individuals who want only to modify their reactions and attitudes toward stuttering without affecting their perceptible speaking characteristics. This finding is consistent with other stuttering modification programs, which instruct participants to speak at their habitual rate while incorporating methods of reacting to stuttering behavior to improve communication.

References

Breitenfeldt, D. H., & Lorenz, D. R. (1989). Successful Stuttering Management Program (SSMP) for adolescent and adult stutterers. School of Health Sciences, Eastern Washington University, Cheney, WA.

De Nil, L. F., & Ifioll, R. M. (1996). Therapy review: Successful Stuttering Management Program (SSMP). Journal of Fluency Disorders, 2], 61-64.

Ham, R. E. (1996). Therapy review: Successful Stuttering Management Program (SSMP). Journal of Fluency Disorders, 21, 64-67.

Manning, W. H. (1990). Media review: Successful Stuttering Management Program (SSMP) for adolescent and adult stutterers. ASHA, December, 87-88.

Onslow, M. & Ingham, RJ. (1987) Speech quality measurement and the management of stuttering. Journal of Speech and Hearing Disorders, 52, 2-17.

Sheehan, J. G. (1970). Stuttering research and therapy. New York: Harper & Row.

Teesson, K., Packman, A., & Onslow, M. (2003). The Lidcombe behavioral data language of stuttering. Journal of Speech, Language, and Hearing Research, 46, 1009-15.

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

Wingate, M. E. (1976). Stuttering: Theory and treatment. New York: Irvington.

Yaruss, J. S. & Quesal, R. (1999). Preliminaries to treatment outcomes research for adults who stutter. Second Annual International Stuttering Awareness Day 0n-line Conference. October 1-22. Available: http://www.mankato.msus.edu/dept/cmdis/isad2/papers/yaruss2.htm1 [2002 May 28]

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