Secondary Behaviors

What are some ways to help people minimize secondary behaviors when in a stuttering moment? It seems that the secondary behavior can be more frustrating or concerning than the actual block or stuttered speech.

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Secondary Behaviors — 14 Comments

  1. What an interesting question! I think the way of working on secondary behaviors will vary with the individual person who stutters. That being said, I have found that the use of voluntary stuttering (VS) can be useful. Along with the desensitizing effects, VS can help to reduce the accompanying tension. Byrd, Gkalitsiou, Donaher, and Stergiou (2016) found that when individuals who employed VS that was similar to their real stutters there was a decrease of physical tension in stuttering and it helped reduce stuttering severity. The authors also suggested that VS was more effective in reducing accompanying fear and avoidance associated with the stuttered moment when it was practiced outside the therapy environment. There is an excellent discussion on the use of VS in the article, and while there remains a need for further evidence to support the use of VS, the reported effects are promising.

    Byrd, C.T., Gkalitsiou, Z., Donaher, J., & Stergiou, E. (2016). The client’s perspective on voluntary stuttering. American Journal of Speech-Language Pathology, 1-16.

  2. Very often, people who stutter are not aware of their own secondary behaviors at the moment of stuttering so that activities that increases self awareness can be helpful in reducing secondary behaviors. Some clinicians review videos with their clients. Some clinicians have their clients identify their secondaries in the moment through self monitoring and identifying the sensation of physical tension. Van Riper’s stuttering modification strategies can be very helpful to identify and reduce the physical tension and struggle.

  3. Just a short response, often I experience that if we deal properly with the primary stuttering, the secondary behaviours are often reduced – or in some cases disappear totally.

  4. Hello, Pam,

    The approach I have come to favor is that of “leaning into the stutter.” Another way of saying that is “to relax into the stutter.” Not to fight it. Not to try to master it and “win.” Not to hate it. But to accept it. Welcoming it as a friend, which may sound impossible, but, believe me, it is not. By welcoming it, it starts to soften.

    Relating to actual stuttering this way is part of the mindfulness meditation technique I use called “Working With Shenpa.” (I presented a paper at an ISAD Online Conference Some time ago entitled, “Stuttering, Shenpa, and Me,” which is probably archived on The Stuttering Homepage by Judy Kuster and is included in my recent book, “Relief From Stuttering” along with some further thoughts on the practice.)

    Welcoming rather than trying to change a stutter is a perfect counter to resisting stuttering, which, as we know, tends to intensify and may prolong it.

    Feel free to ask a follow-up question or two.

    Best,

    Ellen-Marie

    • Thanks Ellen-Marie. As you note, it’s hard to lean into a behavior or movement that you don’t want. When I squeeze my eyes shut due to a block, I feel the tension and the instinct to try to push through the block. I hate that I squeeze my eyes shut (sometimes only one eye) as I feel it breaks the connection I have with my listener.

      When you say “lean into it,” are you suggesting doing voluntary eye closure?

      -Pam

      • Dear Pam,

        I can imagine how upsetting it can be to have one or both of your eyes close tight when you’re talking with someone and lead you to believe your link with that person is broken at least momentarily.

        An established shenpa practice can help maintain a better sense of continuity and ease of communication and minimize and, occasionally, eliminate the frightening sense of being out-of-control with the subsequent feeling of shame and/or guilt that can trigger.

        It can help you realize you are not frozen in time-space even for a fraction of a second because, at other times, you have released at least some of the muscular tension involved with squeezing your eye(s) shut and some of the emotional discomfort of feeling separated from the person you’re talking with. It can help you feel more powerful than powerless in that circumstance.

        That’s what I have personally discovered. BUT, and this is a big BUT: You really need to have a strong mind-body connection to do that.

        I could not do that if I did not have a mindfulness meditation practice that has helped me sense changes in muscular tension and the ability to relax and release that energy rather than accentuate it by the forcing associated with struggle to escape. The basic practice I have cultivated to attend to my body (and thoughts and emotions – but not necessarily all at once) is shamatha-vipassana, which I have written about at some length in the book, “Mindfulness & Stuttering. Using Eastern Strategies to Speak with Greater Ease.” It settles the mind down (and body) – shamatha – and then allows you to see more clearly what is going on inside and around you – vipassana. AND, and this is a big AND: It helps you learn to observe without judgment, which leads to just observing what is and not trying to change what is, which is a most powerful way to be.

        Well, the point is “leaning into the stutter/relaxing into the stutter” is possible by laying the necessary groundwork.
        And part of that is thinking deeply about what it means to stutter in general. Once you experience that you can “relax into the stutter,” you will feel more capable and, therefore, less tense, which, as you know, helps, and you will reinforce the idea that you already may be cultivating, namely – it is OK for me to stutter. I can deal with that

        About “voluntary eye closure:” No. I wasn’t directly suggesting Viktor Frank’s paradoxical intention technique, although there is a connection, I think, since that method of telling yourself to do what it is that you don’t want to do, is essentially giving yourself permission to squeeze your eye or eyes shut. That can remove at least some of the resistance to doing it. Then, lacking the felt need to resist shutting your eye/eyes tightly, you may do that less intensely, fewer times, and eventually not at all.

        I hope this has been of some help. Your awareness of what you are doing and what you may need to do to stop doing what you don’t wish to continue doing deserves a thoughtful response.

        – Ellen-Marie

    • Dear Pam & Ellen-Marie,

      This has been our tact as well. If a client (or myself–for that matter!) really buys into (and owns) the act of volitional stuttering, then that seems to undermine the power of the uncontrolled secondary. Doing this in a highly focused/deliberate 3-week period of time seems to allow the body to create new (more productive habits). Clincally, I’ve given up on trying to extinguish bad habits; instead, I try to replace bad habits with deliberate/better ones. Tangentially, I’ve also seen success using some D2 antagonists for a relatively short period of time, as this (behavioral detox) takes place, which also seems to help take the edge off.

      However–once this “detox” has taken place, the PWS is still going to have to play “whack-a-mole” with new uncontrolled stuttering behaviors as they pop up. It’s just that they’ll be easier to manage, as they’re less automated.

      Hope this helps,

      Greg Snyder, PhD CCC-SLP
      Associate Professor
      The Wheat Laboratory for the Voice, Speech, and Hearing Sciences
      Department of Communication Sciences & Disorders
      George Hall, Office 310
      P.O. Box 1848
      University, Mississippi
      38677-1848

      GoogleVoice 662.259.0123 / Office: 662.915.1202 / Fax: 662.915.5717
      GSnyder@OleMiss.edu / Greg.Snyder@SpeechandHearingCenter.org

      • Hello, Greg, and Hello, Pam,

        Based on my experience, doing what it is that you want to do rather than trying to stop doing what you don’t want to do is more likely to help you be as you wish.

        First, that way you won’t waste energy in squabbles and warfare as you try to outwit or beat down thought patterns and behaviors that likely are very strong and unwilling to be released, metaphorically and actually and, quite likely, lead to becoming tired and discouraged enough to tell yourself you can’t change.

        I’ve found it’s all-around better to take a direct route to establish desirable thought patterns/beliefs and behaviors. And that is by taking small, sometimes very small, steps and doing so with curiosity and with kindness and by being patient as your nervous system becomes acclimated to doing things differently, such as learning to face the unpleasant instead of running from it If you do all that, it is likely you will be reinforcing your motivation to continuing. A clear intent, empathy and kindness toward yourself, and patience are key.

        That is easier than you may think. When you don’t do what you wish you had, which will happen, you, in time, will learn to be proud of yourself for your intention to do for yourself what it is you wish to do. In fact, measuring change by considering to what extent you live your intention is the yardstick of improvement I favor.

        All that may translate to enjoying what you are newly doing that is different and that you recognize is for your benefit.

        Best wishes,

        Ellen-Marie

  5. When working with a person who stutters, an essential part of therapy is education – learning more about communication and especially about stuttering. Knowing more about stuttering in general and about the person’s own stuttering supports the client in being more desensitized towards it. Desensitizing the client to stuttering requires delicacy and empathy from the SLP – for many young people this is not an easy process. However, if we are able to empower the client and set that person in the position of an expert – it will really help. When the client is aware of his own stuttering symptoms and/or of potential secondary behaviors and what is more he is able to talk about it naturally it is a good idea to propose that they teach others about his/her stuttering. SLP students or family members or even the client’s teacher could be good volunteers to work with. Swapping roles – particularly with children and adolescents, when the client is an expert and the SLP, parent or teacher learns from him greatly supports the process of change.
    Useful examples of practical exercises (like mirror work) can be found in the Stuttering Foundation DVD: “Stuttering: Basic Clinical Skills”.

  6. Pam,

    What a great question you ask, and thanks for asking it. Also, thanks for you continued advocacy for yourself and for PWS.

    You have heard some wonderful responses above, which are great options. It is important to think about “options” as we talk about stuttering treatment in any way. With your question, asking specifically about secondary behaviors, the first thing I do is provide education about stuttering to the client (types of stuttering behaviors, some myths, some basic theories, and demographics). We also talk about secondary behaviors and at that point I allow the client to perhaps indicate which he/she might perform. From there we talk about the usefulness (this is a continuum for most PWS from not useful to very useful) with respect to their stuttering. From there we can talk about whether they want to keep using them, or try to reduce. This practice takes into account many of the options above with increasing awareness and desensitizing the client. We then relate their speech to what they value and what matters to them, and talk about whether or not these behaviors reflect how they wish to communicate a message, which ties into public speaking skills (which Pam I know you are a Toast Master, so you understand what that means).

    Anyway, that is one example of a progression (there are many). The nice thing about what you are reading here are there are many ways to address secondaries. It is really about figuring out how you (the person who stutters) want to express him or herself. As a person who stutters myself, my secondaries have evolved over time and years, and I’m very aware of when they happen. This awareness used to bother me, but now my awareness is helpful in the fact I can choose whether to address them in that moment or not. I choose to feel bad about them, or not. I can make choices that are linked to me and how I want to be heard.

    Pam, great to hear from you! Enjoy the conference and thanks for the great questions!
    With compassion and kindness,
    Scott

    • Scott – thanks for the great reply. You’re right, as a Toastmaster, I’ve often thought about how my occasional secondaries may interfere with the message I’m trying to convey. My secondary behavior is squeezing one or both eyes shut when I’m caught in a block. I worry that it interferes with my usually good eye contact when speaking, to a group or one on one to a communication partner. I usually feel bad when I do it, as if I’m letting stuttering win in that moment. I like your reminder that I can choose how to feel about it. Thanks! -Pam

  7. I know that we usually separate blocks, repetitions, prolongations, interjections (primary behaviors) from secondary behaviors such as head jerks, facial and body tension, loss of eye contact, etc. However, I relate to all of these behaviors as being secondary to the neurological processes that create speech. I have had many clients who had previously tried to eliminate one secondary symptom only to develop a different one. In fact, many of these symptoms are a normal outcome of the way they are creating speech.

    I therefore, do not bring attention to the “secondaries” or the “primaries” when treating my clients. Instead we make changes related to inner focus, attention and intention when talking. When the person is speaking naturally, the secondaries and primaries disappear.

    I like to compare it to having an infection. The symptoms disappear when the inner cause is eliminated.

    An example of secondaries being a natural reaction is the loss of eye contact that many people who stutter have at least some of the time. Every speaker once in a while thinks about the words they are going to say and momentarily their eyes move up or down or to one side. This is natural. People who stutter are very word oriented therefore they lose eye contact. The solution is not to work on eye contact but to work on not paying attention to words.

  8. Hi Pam,
    I am guessing you might already know this, but I am going to go ahead and post for those who have never tried serious monitoring…

    In some cases, most of the overt stuttering pattern is a collection of the secondary behaviors (escape/avoidance behaviors) people have used over the years in an effort to conceal or minimize showing stuttering or revealing their identify as a person who stutters. We often can’t see how much actual disfluency is present because of the habit-based behaviors, once learned in reaction to disfluency and the shame or frustration it produced.

    I find that by initially addressing escape/avoidance behaviors by reducing them significantly, it is much easier to modify disfluency to achieve easier stuttering and eventually increase in fluent speech.

    Here are some steps:
    1. Have the client become an expert on his/her own stuttering pattern. This involves identifying all escape/avoidance behaviors (and for the time being, let the easy repetitions and prolongations go). Escape behaviors can be physical (loss of eye contact; head movements; limb movements, etc.), linguistic (repeating previous words/syllables with the intent of hiding struggle; fillers; word avoidance), or attitudinal (pretending to think; taking on an attitude). I prefer to have the client identify without a video because the proprioceptive awareness is more effective in this process than visual awareness. I want the client to be able to catch themselves in the midst of using this behavior.
    2. Select one of the behaviors (usually loss of eye contact or the most prominent or debilitating in terms of struggle), and do exercises where the client is identifying use of that behavior in real time. This “monitoring” exercises reduces a good deal of the behavior itself. Move to other behaviors.
    3. The client then makes a conscious effort to stutter directly on the intended sound/word instead of using the escape (secondary) behavior. This is the step that requires not only counseling to tolerate the disfluency, but cognitive work to understand that this kind of clean or open stuttering will lead to less struggled speech, even though it feels more struggled (and more shameful) for the client in the moment.
    4. Once the client is allowing himself or herself to show the stuttering, gives oneself permission to stutter (instead of using the escape behavior), desensitization will begin to kick in and over time, reactivity will reduce, as will the desire to escape/conceal with the secondary behavior.
    5. At this point, strategies such as voluntary stuttering and Van Riper modifications, as well as fluency enhancing strategies can have lasting benefit and will have half a chance of generalizing.

    Hope this gives you something structured to try!

    Vivian

    • Hi Vivian – thanks so much for the very thoughtful
      response and the steps for self monitoring. Intellectually, I know many of these things but I have a hard time putting practicing them. I have never really self monitored because I believe I am
      stuck in the conundrum of acceptance. I accept my stuttering, most times even embrace it, but there are times when I really hate that I squeeze my eye (or both eyes) shut when blocking. And there are times when I’m really uncomfortable if I’m caught in a block and someone reacts. I’m going to re-read these and see if I can perhaps self monitoring an honest try. Thanks again! -Pam