Rational Emotive Behavior Therapy (REBT) Based Preferred Stuttering Recovery Process

neidersAbout the author:  Gunars K. Neiders, Ph.D. Elec. Eng., Psy. D. He is the author of the dissertation entitled “Theoretical Development of a Proposed Rational Emotive Behavior Therapy Based Model to Treat Persons with Chronic Perseverative Stuttering Syndrome” and book “From Stuttering to Fluency: Manage Your Emotions and Live More Fully”. His experience as a person who stutters, a licensed psychologist in private practice in Washington State in U.S.A. and stuttering coach over Skype resulted in the paper “Rational Emotive Behavior Therapy of Stuttering via Skype: Case Series Studies” presented at the International Fluency Association 8th World Congress in Lisbon, Portugal, July 6-8, 2015. Dr. Neiders also works part time training Psychology Doctorate students.

Introduction

This paper describes stuttering therapy based on modern psychology principles of REBT, the grandfather of all the Cognitive Behavior Therapies. It describes the techniques I use with my  clients who have audible and inaudible blocks, part-word repetitions, and physical struggle (e.g., tension); communication avoidances characterized by insertion of pauses, substitution for certain words and sounds and using circumlocutions and fillers. They also have anticipatory anxiety, shame, guilt, and anger and unhelpful beliefs and self-talk that prevent them from pursuing suitable mates or satisfying careers.

Preferred Outcome

The preferred outcome of REBTS is recovery from stuttering. Recovery means that the client:

  1. No longer feels shame, fear, anticipatory anxiety, anger, and other unhealthy emotions about stuttering.
  2. May well have some disfluencies but generally the speech is effortless and forward moving.
  3. The outcome is operational fluency: natural sounding speech with easy bounces that are reminiscent of how the client talked before he started to stutter. The client has no need and does not monitor his speech.
  4. Understands that he is a complex person with many character traits and knows that he is not defined by his stutter.
  5. Can acknowledge to all people that in the future, he may occasionally stutter.
  6. Lives life to the fullest pursuing any career that he chooses and seeks romantic and social relationships that are to his liking.

Description of the Preferred REBTS Steps

The preferred sequence of steps—together with a short explanation—is given below. The effectiveness of REBT has been established by meta-studies. The one that is frequently quoted is by David and associates (David, D., et al, 2005).

Step 1: Establish a Good Therapeutic Relationship

The therapist strives for a good, transparent therapeutic relationship that culminates in the client being able to become his own therapist.

Step 2: REBT Formulation of Stuttering

Most clients talk fluently when alone but when they encounter an authority figure they stutter. In situation #1 (when there is no stress) a PWS does not stutter, but in situation #2 (when there is stress) he does stutter.

Suppose a PWS is in a type #2 situation where he has to attend a daily status meetings in his boss’s conference room in presence of his co-workers and executives that are higher up in the company. Here are the steps that the PWS undergoes:

  1. The sequence of events starts with the computer alarm that signals to the PWS that he needs to go and present his status.
  2. PWS’s conscious and subconscious mind becomes aware that he will have to talk.(A)
  3. This awareness evokes conscious and subconscious beliefs such as “It would be awful if I stuttered”, “I should not stutter!”, etc.(B)
  4. These beliefs in turn trigger a general anticipatory anxiety, self-deprecation, and possibly other unhealthy emotions such as shame, feeling of urgency, feeling of uncertainty, etc. (Ce)
  5. …later in the actual meeting when the PWS is forming sentences of what to say (A) a certain forthcoming sound may signal probable stutter and the anticipatory anxiety (Ce) concerning a sound or a word on which the PWS has a history of stuttering is raised.
  6. When the time comes to say this word or sound the PWS uses various avoidance techniques and/or has a block or tense stutter. (Cb)

When I explain these steps to the client at first he concludes that the situation #2 caused the PWS to go into the above chain reaction terminating in loss of control, and tense, struggling stutter. This is where I explain emphatically that the Activating Situation (A) did not directly cause stuttering. The following chain of events occurs: A triggers the Beliefs (B) (“It would be awful if I stuttered”, “I should not stutter!”) and the combination evokes the Consequent Emotions (Ce) resulting in the Consequent Behavior (Cb) the loss of control and tense, struggling stutter. This can be expressed by the following formula:

A x B => Ce => Cb   

Where the italicized phrase in step number 2 and first italicized phrase in 5 correspond to A, the italicized phrases in step number 3 corresponds to B, the last italicized phrase in step 5 and the italicized phrases in step 4 correspond to Ce, and the italicized phrase in step 6 correspond to Cb.

Now let us apply the formula #1 to a PWS when he is talking to himself:

A=Talking to oneself x B=I don’t care if I stutter=>Ce= Calm=> Cb =Relaxed Speech

Step 3: The Focus of Therapy

I explain that the focus of REBTS is to substitute the irrational Beliefs in Step 2 with rational belief such as “Although I might stutter, I am making good progress on my project” and “The boss only cares more about the schedule on the project, than my stuttering”. This might well lead to a relaxed emotional state and fairly fluent speech. Therefore, the focus of REBTS is on changing beliefs about the situation so that the beliefs that cause a PWS to stutter are replaced by beliefs that help him to communicate better. One of the methods to change beliefs is called disputing. In this method we the beliefs are subjected to three questions that mirror the scientific method:

  1. Is there evidence to support this belief?
  2. Is this belief logical?
  3. Does this belief help me to get my goals?

After some hard thinking neither of the above beliefs i) “It would be awful if I stuttered”, ii) “I should not stutter!” pass the gauntlet of these questions. One can readily dismiss both of them as being irrational. There is no evidence to support these beliefs. The beliefs are not logical. And, above all, neither of the beliefs help with achieving the goal recovering from stuttering.

Step 4: Explain What Rational Thinking Is

In order to recover from stuttering using REBT, I teach my clients what REBT considers rational or helpful. REBT research has concluded for a human to be non-neurotic he best not hold extreme absolutistic rigid beliefs. It is saner to be somewhat flexible when pursuing one’s goals.

Step 5: Why We As Humans Tend To Think Irrationally 

I tell my clients that we humans are born with healthy strong desires to belong to a group, communicate with members of this group, master various skills, avoid distress, and be in a good emotional state. Unfortunately, we also have the inborn tendency to take these healthy desires and turn them into destructive rigid demands and needs.

Step 6: What Magic Tool Does REBT Gives You To Solve Your Emotional Problems

In REBTS my role is to convince the client that the beliefs that we absolutely must have what we want only serve to raise anxiety, shame, guilt and feelings of urgency. Besides irrational ideas that start with musts there are irrational ideas based on evaluation that some situations are awful, unbearable, that self-deprecation and condemnation and damnation are justified and all or nothing thinking is valid. I teach the client how to detect and dispute these pernicious beliefs and, thus, provide him with an almost magical tool of turning a stuttering producing belief into a stuttering reducing belief.

Step 7: Using REBT To Facilitate Stuttering Homework Assignments

The client by this time understands that he has a very powerful tool that he can use to proceed in stuttering therapy.

Step 8: Operational Description of Stuttering

Operational definition of stuttering provides means for measuring and focusing on reducing stuttering. Operationally stuttering consists of distorted cognitive/thinking habits (e.g. must statements), unhealthy emoting habits (e.g. anxiety), habits of avoiding (e.g. substituting words) and habits of inappropriate tensing and forcing. REBTS provides means to measure these habits and focus on reducing them.

Step 9: Acknowledging Stuttering

In preparation of sending out a client to desensitize himself he first is encouraged to acknowledge his stuttering. Then REBTS builds up his tolerance for discomfort and frustration. The success of the assignment is measured by whether they carry out the assignment and their emotional reaction while carrying out this assignment.

Step 10: Conquering Shame and Fear

I have my clients study and discuss Chapter 6 of my book to conquer shame and fear. With proper guidance the clients can change their feelings by changing their thinking. Anti-shame homework exercises are assigned to solidify their anti-shame and anti-fear attitudes.

Step 11: Desensitization

The classically conditioned fears that are “stored” in limbic system, especially the amygdala, are reduced by direct exposure to the feared stimuli, which in case of stuttering are speaking situations that involve authority figures. Many methods are chosen from REBT, the main one being homework that exaggerates his stuttering with the additional instruction to observe that nothing catastrophic happens to him.

Step 12: Freedom From Irrational Beliefs

Chapter 7 in my book is used as guide to eliminate common irrational beliefs that prevent the client from doing the required homework efficiently.

Step 13: Acceptance of Self With or Without Stuttering

To teach the client to accept himself unconditionally I use my chapter 8 as a guide. I teach each of my clients that since we are human we are all imperfect; we all have our faults and flaws. We can work on self-improvement until cows the come home, but we will never be perfect. However, we are all lucky since there is no, nor ever can be, an absolute standard to measure human worth. Thus, we who stutter and other people with their own issues are no more and no less important or worthy than anyone else.

Step 15: Identification

I like to record my clients, with their permission, of course. Then we can discuss the various extra baggage such as avoidances, secondary stuttering, and forced, tense speech. Usually awareness is enough to inspire the client to drop many of these habits.

Step 16: Avoidances

As a consequence of understanding that avoidances sabotage long range recovery and that perfection in speech is not necessary, the client successfully eliminates his avoidances.

Step 17: Learning Easy Bounces

Easy bounces are introduced and used in voluntary stuttering, helping the stuttering to become forward moving, cancelling, and pre-empting hard blocks. All the speech management exercises are wrapped in the REBT context. It is really important to understand the speech management exercises are mainly used to change the emotions and beliefs — not to make the vocalization easier or smoother.

Step 18: Motivation

Motivation to continue therapy often depends on the ability to demonstrate to the client that progress is being made. Video recording can show progress with respect to severity of blocks, eliminating secondary behaviors, avoidances, and tenseness during stutters. The important changes in cognition can be assessed by periodically reviewing journal entries.

Step 19: Maintenance

The therapy usually ends when the client has significantly reduced the severity of his stuttering and has accepted stuttering as part of himself. This sounds paradoxical, but as Joseph Sheehan said, “Stuttering is what we do in order to avoid stuttering.” If the client truly focuses on his attitudes, emotions, and beliefs instead of chasing the witch goddess of fluency, he will stop obsessing about his speech and start living his life to the fullest. As he firms up his rational attitudes toward himself and his stuttering the disruptive stuttering patterns melt away. At termination the client is ready to maintain his own recovery.

Concluding Words

I hope that I have effectively communicated the main points of the REBTS therapy process. My experience with clients’ and my own stuttering has convinced me that recovery from stuttering is not only possible but very likely, if the therapy process is concentrated on changing beliefs, attitudes and emotions.

References

David D. et al. (2005). A Synopsis of Rational-Emotive Behavior Therapy: Fundamental and Applied Research. Journal of Rational-Emotive and Cognitive-Behavior Therapy 2005, vol. 23

Neiders, G. & Ross, W. (2013). From Stuttering to Fluency: Manage Your Emotions and Live More Fully. Neiders Press, Seattle, WA.

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Comments

Rational Emotive Behavior Therapy (REBT) Based Preferred Stuttering Recovery Process — 18 Comments

  1. Thanks, Gunars. Your outline of REBT principles is very helpful. It’s great to hear that you healed yourself from stuttering and that you’ve had positive outcomes with your clients. Changing beliefs, attitudes and emotions seem to be very important to achieve success in therapy. Is it still necessary to work on speech fluency shaping techniques to decrease disruptive stuttering patterns, according to REBT, or should there be a balance?

    • Thank you for your kind words. What I hear you ask is whether it is necessary to do also activities selected from traditional stuttering therapy. Permit me to open up your question to not limit these to “fluency shaping” but also include activities from “stuttering modification”. Usually these activities include learning direct speech manipulation tools and techniques (as compared to belief, attitude and emotion manipulation techniques of REBTS).
      REBTS hypothesizes that majority of the people do not have to be taught any new ways of sound formation, breathing, etc. What REBTS has in common with currently practiced stuttering therapy is: a) avoidance elimination; and b) reduction of the forcing, tensing, struggling, blocking and secondary stuttering. The one direct speech manipulation technique that REBTS uses is easy bounces: going back to the way of how PWSs talked before they started to stutter. Of course, all the therapeutic activities of REBTS have a strong cognitive/emotive component.
      Gunars

      • Thank you, Gunars. I appreciate your explanation of the REBTS cognitive/emotive focus on reducing avoidances, forcing, tensing, struggling, blocking, and secondary behaviors. Thanks for explaining the “easy bounces”, as well. Lourdes

  2. Dear Gunars,

    Good morning (or afternoon or evening)! I read your post and posted a reply on page with the ACT paper I wrote with Dan and Chat. I was going to post it here, but it was rather lengthy and I didn’t want take up space on your page.

    I wanted to say hi, and it is a pleasure to meet you, and I did reply back to you.
    With compassion and kindness,
    Scott

    • Scott,
      I enjoyed your comments. Starting to read “Stammering Therapy from the Inside: New Perspectives on Working with Young People and Adults”. I am especially eager to learn metaphors and parables taken from the area of literature. There are two ways of changing feelings: through dramatic and metaphoric images and through scientific reasoning. I hope most of us who do therapy learn both ways.
      My personal bias is that REBT employs more scientific, logic and empirical science based means, i.e. scientific method type of reasoning to change emotions, and ACT embraces more of the literary means.

      • Gunars,

        Like yourself, and thanks for bringing this up because it is vital to our field and to personal growth. I hope all practitioners develop a balance of embracing science along with metaphors and literary means to perform therapy. As you read and learn about ACT, you will see that the research performed by Contextual Behavioral Scientist around the world is extremely well done, and provides ample amounts of data across many disorders, mental, and personal challenges that a human can face.

        Like REBT, there are so many ways ACT can be applied to our lives to hopefully make them more fulfilling, so we strive for a life that is truly OURS, on our terms, and with a decreased sense of ego.

        I have so enjoyed our dialogue. Perhaps one day we will sit down and chat. It would be my pleasure.

        With compassion and great kindness,
        Scott

  3. Thanks, Gunars! It’s great to be reminded about the principles of REBT. It’s exciting to know that you were able to recover from stuttering and I truly enjoy reading your material. Thanks for all the contributions you make to the stuttering community.

    • Ruth, your compliments are greatly appreciated. Especially since it comes from a person who has done so much in the field of stuttering recovery.

  4. Thank you Dr. Neiders for sharing your expertise on REBT. My name is Katrina. I am a first year Communication Sciences and Disorders graduate student in North Carolina. Although I am not a PWS I myself have experienced chronic social anxiety that help me back in interpersonal relationships and in pursuing job opportunities, much like ideal candidates for REBT. Your methods for changing beliefs and desensitization are the tools I used to overcome my communication anxiety. This paper was very interesting and I look forward to reading your book!
    Best,
    Katrina

    • Katrina, the elegance of REBT approach is that it can be used to help with all types of problems that have emotional and cognitive aspects. I find that reading someone’s else’s version or application of REBT, gives me a great booster shot.
      Gunars

  5. Hi Dr. Neiders! I am a first-year SLP graduate student, and I find this paper helpful and interesting, and something that I will most likely keep in mind throughout my clinical experiences. I am wondering how long the timeline typically is for recovery while using the Rational Emotive Behavior Treatment techniques that you outlined in your paper for treatment of stuttering. Also, do you ever have to go back to a previous step that you’ve already worked on during treatment? For instance, if a client is somewhere around step 10 or step 11, and part of his/her homework involves having a conversation with someone else, and that conversation leaves the PWS feeling negative and disheartened, do you ever revert back to step 2 or step 3 to reemphasize the importance of the formulation of stuttering and the focus of therapy? If so, do you then continue back to step 10 or step 11, or do you instead go through all of the steps again in sequential pattern?
    Thank you so much for sharing your work!
    Teresa

    • Dear Ms. McDonald,

      You have asked some very good questions. First of all let me congratulate you on having focused on the steps 2 and 3 and 10 and 11. These are the crux of REBTS. Because of the length limitation I was not able to expand on these steps as much as I wanted to. However, in my upcoming book with the working title of “Stuttering To Recovery Guidebook: Rational Emotive Behavior Therapy Guided Stuttering Therapy” these and other steps will be written about in more detail.

      As for going back to steps 2 and 3 whenever there is an attitude setback, I certainly would do that. As for going back through all the in-between steps, that would be dependent on a case by case evaluation of where the client is at. As someone who is just picking up the steps I would lean toward quick review.

      As you go through your schooling and gain more experience in handling clients you will soon understand that what is being presented in papers and books is often the nominal path, that the experienced therapist is at will to alter.

      The decision whether to go light or thorough on steps being revisited is based on the concept of levels. Level designates a level of skill that a client supposedly arrives at when he is done with a step. This is a concept taken from gamification.

      (Gamification is the art and science of using motivational and other tools gathered from the addictive aspect of computer games. There are some marvelous YouTube videos on it, as well as the ordinary sources you can get from googling.)

      You as a therapist will quickly learn when a client has mastered a certain step and, hence, arrived at level x and is ready to move on to the next level.

  6. I am a graduate student who is currently taking a fluency course and we have learned about many treatments. I found this paper to be very informative and helpful in gaining a better understanding of REBT. I have enjoyed learning about this process and it is appealing to me that it can be used with various individuals who stutter. I really like how it focused on the client’s beliefs, attitudes and emotions. I also liked how recovery from stuttering was defined. The statement that stuck out to me the most was “Can acknowledge to all people in the future, he may occasionally stutter. I feel that this is crucial in the recovery process, it may happen but they move on. I am looking forward to utilizing this therapy in the future.

    • Peter,
      Remember that this therapy is based on acceptance of stuttering and unconditional acceptance of self. Everything else is built upon it.

  7. Hi Dr. Neiders,
    I am a speech pathology study and found this therapy approach to be very informative and easy to follow! I am currently in a fluency class and a lot of what my professor teaches us about therapy in stuttering is included in your approach! I was wondering what your thoughts were on PWS using past therapy approaches to avoid stuttering, while they are practicing this therapy approach? Do you believe that these past habits are a part of their stutter or do you believe that they should be avoided at this time while they are re-evaluating the way they perceive their stutter?
    Thank you,
    Molly Bates

    • The work on beliefs, attitudes, and emotions is basic. However, speech management techniques can be included to ease the tension and struggling in speech. I suggest that easy bounces be used as the main tool to do this.