|Joseph Sheehan (1918-1983)
(BSA note: this document does not necessarily represent BSA's views, or currently accepted views on stammering.)
Short Course in Diagnosis and Treatment of Stuttering: Conflict Theory and Avoidance-Reduction Therapy
Joseph G. Sheehan, Ph.D.
Professor of Psychology
University of California.
1. Stuttering is viewed as a double approach-avoidance conflict, having its origins in the role uncertainties of the child.
2. As a role conflict and an approach-avoidance conflict, stuttering behavior is a result of opposed urges to speak and to hold back from speaking.
3. In the double conflict, there are competing tendencies for approach and avoidance toward speaking, as well as approach and avoidance toward, silence. The stutterer fears silence, as well as speech.
4. Principal hypotheses concerning stuttering behavior spring from two fundamental questions: (a) What produces blocking? (b) what determines release?
5. The conflict hypothesis: The stutterer blocks or stops whenever conflicting approach and avoidance tendencies reach an equilibrium.
6. The fear-reduction hypothesis: The occurrence of stuttering reduces the fear that elicits it sufficiently to permit release of the blocked word, resolving the conflict momentarily and enabling the stutterer to continue.
7. The fixations and oscillations found in organisms caught in approach-avoidance conflict situations are strikingly similar to repetition and prolongation, often called the primary symptoms of stuttering.
8. Secondary stuttering behaviors appear chiefly to be instrumental response clusters adopted in a compensatory effort to go forward in the face of avoidance tendency or to reach the goal by a roudabout route. The stuttering pattern is reinforced as serial behavior, moves forward in the response sequence, and becomes overlearned, like a skilled act.
9. In this manner, stuttering behaviors are periodically reinforced, and anxiety is "bound". within them. Stuttering is perpetuated by instrumental escape and avoidance behaviors, but tends to disappear when approach behaviors are strengthened.
10. In 80 percent of the cases in which it begins, stuttering is not perpetuated, but disappears without treatment by the time the person reaches college, provided he has faced the problem.
11. Principal ingredients in the psychology of stuttering include the following: Self-esteem threat, excessive role demand, intellectual-achievement pressure, shame, guilt, anxiety about oneself, fear of failure in speaking, self-imposed time pressure, authority threat, compulsion to continue speaking once started, use of fluent asides and other false-role behaviors, maintaining flimsy pretense with the listener that nothing is out of the ordinary, frustration over primary loss of ability to communicate, occasional use of stuttering behavior as a power operation against the listener, and the ego-defensive function of the handicap in keeping tho possessor out of demanding role expectations.
12. Stuttering is not a unitary disorder, but a role-specific behavior that can be carried by individuals with widely differing personality dynamics. Possible subtypes of stutterers may be obscured by the group comparisons necessitated by statistical control.
13. Although no specific factor has ever been reliably isolated, the possibility remains that a physiological or genetic predisposing factor that vanishes or ceases before adulthood in 80 percent of the cases could be present. Though scientifically unsatisfactory, this conclusion is made inevitable by certain persistent census-type facts: (a) universality of occurrence, (b) universal age of onset across cultures, (c) significant tendency toward spontaneous recovery or remission at puberty, (d) 25 percent familial incidence, and (e) overwhelming predominance of maleness (four- or five-to-one).
14. Despite possible predisposing factors, nearly all of what is visibly and audibly observed as stuttering behavior is learned both by emotional (classical) conditioning and by instrumental, or motoric, conditioning. Just as speech is principally a learned skill, so is stuttering.
15. Stuttering may be considered as an example of homeostasis reversal, of antihomeostatic (positive) feedback
16. Therapies may be divided into two clases: (a) distraction, or avoidance-cultivation, and (b) avoidance-reduction. The first was rejected, for distraction therapies have the adverse effect of increasing the avoidance tendency responsible for the stutterer's conflict, while offering him no means of coping with future apprehension in relapse.
17. Stuttering makes its first appearance in childhood, at a time when the child is speaking upward to adult authority, upward on the status dimension. A status-gap hypothesis specifies that stuttering varies with the twin facjuors of speaker self -esteem or status compared to listener authority or status.
18. With young children, members of the family are members of the problem and must be worked with to alter the demand-support ratio in the direction of reduced demands and increased support.
19. With adolescents, it is often necessary to combine the family therapy used with children with an adaptation of adult avoidance-reduction therapy.
20. With adults, the basic goal of therapy is the total reduction of avoidance, including all tendencies to hide, conceal, use tricks or crutches, or deny the stutterer role. Paradoxically, rolo acceptance as a stutterer eliminates much of the false-role behavior that comprises stuttering, and leads toward more normal speech.
21. When stuttering is viewed as an approach-avoidance conflict, total avoidance-reduction is the basic and essential goal. Avoidance-reduction therapy for stuttering involves a role-taking therapy, a psychotherapy through action. Since psychotherapy and avoidance-reduction therapy both seek to reduce "holding-back" behavior, they are compatible, both in theory and in operation.
Reproduced with permission.
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