Treatment of Stuttering With Rational Emotive Behavior Therapy

Rational Emotive Behavior Therapy (REBT)
Treatment of Chronic Perseverative

Stuttering Syndrome
A Dissertation by
Gunars K. Neiders, M.A. Psychology, Psy. D.
Candidate (Ph.D. Electrical Engineering)
Argosy University - Seattle Campus
September 11, 2009
1 © Gunars K. Neiders ALL RIGHTS RESERVED

Basic Facts about Stuttering
u Random House (1987) Definition
u 1. to speak in such a way that the rhythm is interrupted by
repetitions, blocks or spasms, or prolongations of sounds or
syllables, sometimes accompanied by contortions of the face and
body.
u Prevalence of stuttering
u The rate at which a condition can be seen in the general population,
has been established (see Bloodstein and Ratner, 2008) to be
somewhat less than 1 percent in the United States and somewhat
more than 1 percent in Europe.
u Assuming that the prevalence of stuttering is the same among all the
peoples of the world, and noting that the current population of the
world to be 6.6 billion inhabitants, there are currently 66 million
stutterers in the world! (3.03 million people in the United States
alone.)

Conventional Treatments (1 of 2)
u Based on retraining muscle groups used in speech
u Fluency shaping
u Based on retraining people to speak from the beginning using exaggerated
muscle movement patterns
u The focus is on the vocal tract, respiration rate, gentle onsets of sound,
combined with prolongations that are eventually reduced so as to resemble
normal speech
u Stuttering modification
u The expressed goals of stuttering modification are modification of stuttered
speech so that the outcome is forward moving speech with minimum
abnormality and minimum anxiety experienced by the speaker.
u Role of counseling
u “[C]ounseling is first and foremost about listening to and talking with our
clients, and in doing so, helping them understand how their emotions affect
their thoughts, and how their thoughts and beliefs motivate what they do.”
Zebrowski 2006, p. 6

Conventional Treatments (2 of 2)
u Assistive devices
u The devices such as SpeechEasy employ Delayed Audio Feedback
(DAF) as well as Frequency Altered Feedback (FAF).
u At this time the effectiveness of SpeechEasy and similar devices are
open to question because there are no long time independent
studies.
u Integrative therapies
u Based on all of the above
u Outcome Meta-Analysis
u Craig and Hancock (1995), in a self-report meta-study, found that 70
percent of clients receiving stuttering therapy even after they
achieved fluency could be considered relapsed. Conture (1996)
reports that “[a]cross the life span, treatment for stuttering appears to
result in improvement (not recovery-italics added), on the average,
for about 70 percent of all the cases…” (p. S24).

Statement of the Problem
u Life Span Context
u Cooper (1993) states that one in five children who stutter will
develop chronic perseverative stuttering that cannot be cured
by a speech therapist.
u The low success rates are related to the fact that SLPs only
address the phenomenon of stuttering by focusing on
changing the mechanical behavior of the vocal apparatus: a)
the vocal folds, b) mouth, c) breathing, d) lips, e) tongue, etc.
u The therapies do not focus on cognitions, emotions,
perceptions and traumatic environmental factors.
u Rational Emotive Behavior Therapy
u Mentioned in literature, but not systematically applied to the
stuttering problem.
u Need for more systematic integration of cognitive-
behavioral techniques indicated in the literature.

Purpose of the Study
u 1) To develop a theoretical model of developmental stuttering
etiology and evolution of the CPSS through the lifespan that will
incorporate current research with respect to all the
biopsychosocial factors; and
u 2) To create a detailed therapy protocol informed by the
theoretical model that can be used as the basis for manualized
therapy accessible both to SLPs and psychologists.
u Desired client outcome:
u Maximize unconditional self-acceptance;
u Maximize spontaneous fluency;
u Decrease communication interference;
u Provide for managed fluency as an option;
u Decrease shame, guilt, anxiety, and other dysfunctional
emotions;
u Minimize-self limiting general life choices

Limitations
u Study addresses adult clients and mature clients in
their late teens who have CPSS (overt and covert) due
to developmental stuttering who are average or above
average in intelligence.
u The study is theoretical. No experimental verification
of either the development of stuttering, the
propagation of stuttering or the success of the therapy
process will be provided.
u The design of the therapy is the first step toward
writing a manual which could be used to verify that the
proposed therapy goals indeed are achieved.

All-Inclusive Definition of CPSS (1 of 4)
u Visible or audible speech producing muscle anomalies
u Repetitions
u Voiced or unvoiced
u Blocks
u Voiced or unvoiced
u Contrasted to normal speakers
u Differences in frequency, duration, emotionality, and struggle
u Visible or audible non-speech producing muscle anomalies
u Eye blinks and averting eye contact
u Snapping of fingers
u Swinging of hands
u Twitching or tensing various facial muscles
u Jerking of the whole head
u Tapping of a foot
u Swinging back and forth, etc.

u Distortions of speech
u Rate of speech
u Tone
u Sing-song voice
u Unnatural prosody
u Talking as if simultaneously chewing
u Any other idiosyncratic/unnatural speaking manner
u Avoidance behaviors while speaking
u Avoidance of sounds
u Avoidance of words
u Use of starter phrases, words, sounds or pauses

u Self-defeating attitudes and unhealthy negative
emotions
u Self-defeating beliefs (irrational beliefs)
u Lead to being emotionally upset
u Conscious avoidance behaviors
u Poor life-style choices
u Unhealthy negative emotions

u Lead to stuttering
u Pre-conscious avoidance behaviors

u Self-limiting general life choices
u Situational avoidances
u Avoiding to talking to certain people
u Role avoidances
u Vocational delimitation
u Avocational delimitation

Etiological & Perseverance Stages of CPSS:
Genetic Make-Up Stage
u Based on epigenetic systems theory
u Aggravating factors:
u Predisposition to slower speech development & anxiety
u Predisposition low tolerance of frustration, demandingness,
awfulizing, people rating, absolutistic thinking
u Ameliorating factors:
u Predisposition to rational thinking (non-hysterical, goal
oriented, calm, cognitive—non-emotional thinking)
u Conclusions:
u Fewer females stutter than males due to earlier speech
acquisition
u Predisposition only

Pre-Natal Stage
u Based on epigenetic systems theory
u Some genes become weaker, some stronger, others cluster,
some stop functioning
u Lack of proper nutrition
u Excessive alcohol, nicotine, prescription and street drug
exposure
u Healthy habits by mother; rhythmic sound exposure
u Conclusions:
u Before birthing some genes have already clustered and
modified
u Trauma may cause neurological damage

Birthing Stage
u Birthing has inherent dangers
u Voluntary or involuntary prematurity
u Lack of oxygen due to umbilical cord being entangled
u Uneventful birth at optimal time
u Conclusions:
u Need studies on oxygen deprivation during birthing
u Need studies on prematurity

Early Language Acquisition Stage: 20-48 months
u Hyper vigilant parenting figures
u Internalized belief to be vigilant not playful
u Taking speech success/failures too seriously
u Parental figures model playful, calm demeanor
u Conclusions:
u Beware of associating speech with danger
u Should model spontaneous playfulness about speech

Language Development Difficulty Stage
u Defined by
u Parental figure observes more disruptions than for average
child
u Child may or may not become aware of others concern
u Parental figure handles child with sensitivity and does not
alarm him or her
u Conclusion:
u Therapy to be done with the parents not the child

Awareness of Speech Difficulty Stage
u Defined by
u Child becoming aware of speech difficulty from external and internal
factors
u Child labeled as stutterer
u Child forms beliefs: “I can’t stand my imperfect way of speaking”; “I
must speak perfectly fluently”; “I must be in total control of my
speech”
u Child uses starter phrases: “actually”, “um”, etc.
u Child views difficulty with passing curiosity
u Conclusion:
u Awareness by itself is not necessarily damaging

Comparison with Others Stage
u Defined by
u Child starts comparing himself or herself with others
u Parental figures places demands on the child’s speech
u Child forms beliefs: “I should talk like a normal person”
u Child develops a habit of comparing his or her-self to others
u Child is reassured that parental figures love him or her whether he
or she has speech difficulties or not
u Conclusion:
u Acknowledge that the child has a speech problem, but that it does
not make him or her lesser of a person

Something is Deficient about Me Stage (Labeling)
u Defined by
u Child defines himself or herself as a problem
u Parental figures labels child negatively (stutterer)
u Child forms beliefs: “It is horrible to stutter”; “Fluent speakers are
superior to people who stutter”
u Child develops a habit of avoiding stuttering
u Introducing to other children who stutter via NSA
u Conclusion:
u Although labeling is a convenient way to communicate it is fraught
with problems
© Gunars K. Neiders ALL RIGHTS RESERVED

Classical Conditioning Associating Speech with Danger Stage
u Defined by
u Child is classically conditioned to associate speech with danger and anxiety
u Parental figures and environment punishes child for stuttering
u Child forms beliefs: “It would be awful if others laughed at me”; “It is awful to
have less than perfect speech”
u Due to arousal of anxiety, the child is unable to perform normal speaking
u A wise parental figure could provide a threat free speaking environment
u Conclusion:
u The strong classically conditioned association has to be acknowledged in
therapy

Operant Conditioning of Forcing/Struggling Stage
u Defined by
u The child escapes the stuck condition by forcing/struggling; hence,
he or she becomes operantly conditioned to force and struggle
u The synapses in the brain associates escape from stuck condition
with forcing and struggling; being unstuck is a relief both for the
speaker and the listener
u Child forms beliefs: “I can’t stand being stuck”; “Anything is better
than not being able to get out immediately what I want to say”
u Whenever the child stutters he or she automatically starts to
force/struggle
u In rare instances the child cognitively understands that
forcing/struggling is counter productive
u Conclusion:
u Spontaneous remission is caused by the child’s being able to
uncouple being stuck from forcing/struggling

Operant Conditioning of Secondary Symptoms Stage
u Definition
u When the child coincidentally blinks, jerks his or her head, etc. and
the sound comes out hence, he or she becomes operantly
conditioned to perform these secondary symptom actions
u The synapses in the brain associates escape from stuck condition
with the secondary symptoms
u Child sometimes goes into a type of a shock called petit mort where
he or she is not aware of exactly what they are doing
u In rare instances the child does become aware of what he or she is
doing and can voluntarily pre-empt their occurrence
u Conclusion:
u Spontaneous remission suggests that in self- or formal therapy the
client can become aware of these symptoms and eliminate them

Speech Situation Choice, Avocational and Vocational Choice
Stage
u Definition
u When the stutterer selects to bypass speaking challenges by choosing to
avoid situations where they would exhibit what they consider too much
stuttering
u The stutterer avoids immediate pain
u The stutterer forms beliefs: “All people are completely turned off by my
stuttering”; “It is terrible that I can’t control my body movements”; “I can’t
stand criticism and rejection”; “Stutterers are losers”; “Nobody wants to hang
out with someone who stutters”; “I find business meetings and parties
unbearable”; “I must not inconvenience other people”
u Some stutterers fight for what they want conquering their short range
hedonism tendencies
u Conclusion:
u The stutterer needs to be convinced that he or she has a right to pursue
happiness

Iatrogenic Traumatization and Hopelessness Building Stage
u Definition
u Some failed therapies cause some stutterers to feel more hopeless and
helpless
u Therapies that concentrate in-the-clinic changing of speech production only
u The stutterer forms beliefs: “Only perfect speech is acceptable”; “Nobody
and no therapy can help me”; “In order to be worthwhile I must not stutter”; “I
can’t bear having others know that I stutter”; “I must avoid criticism and
rejection”
u Role models who have achieved cognitive reconstructuring
u Conclusion:
u Therapists should be aware not to create more anguish and desperation by
asking the impossible or using methods that are not suited for particular
clientele

Reaction Stage
u Definition
u When a stutterer reacts to failed therapy and becomes embittered and turns
to blaming the environment
u The expert the stutterer has hired appears to have failed him or her
u The stutterer nurtures beliefs: “Other people must not look down on me” ;
“People who put me down for stuttering are no good and deserve to be
severely punished”
u Role models who do not have blaming attitudes (usually found at NSA)
u Conclusion:
u Although blaming others may not be the best way to go, it is better than
blaming one self for being a failure. Putting too much pressure on ones own
self can prevent any opportunity for change.

Productive Therapy Stage
u Definition
u Results in reducing severity and frequency of stuttering to normal range;
reduces preoccupation with stuttering; minimizes emotional upset; allows the
person to pursue his or her own vocational and avocational goals
u Well meaning friends and family may discourage a person from taking risks
u The stutterer forms self-actualizing beliefs and develops discipline to pursue
goals
u Success usually breeds success. Human frailty and fallibility is taken into
account
u Conclusion:
u The stutterer with a help of a therapist becomes his or her own therapist.
u This is a life-long process
u Spontaneous fluency periods are increased and at the least managed
fluency is achieved

The REBT Directed Stuttering Therapy:
Listening to the Client Step
u Motivation
u The therapist needs to understand the client’s world view and
build upon it
u Engaging the client to become active participant in therapy
from the beginning
u Topics to be addressed
u Client’s expectation of outcome
u Client’s view of the therapy process
u Client’s view of his or her role in therapy
u Client’s view of therapist’s role

Reaching a Therapeutic Alliance with the Client Step
u Motivation
u Not only show genuine empathy
u Negotiate a reasonable understanding with the client of
following topics
u Topics (with desired outcome)
u Goals of therapy: 1) unconditional self-acceptance; 2)
managing emotions; 3) manage stuttering; 4) decrease
disfluency severity and frequency; 5) pursue vocation and
avocations of choice; 6) become self-therapist; and 7)
become creatively involved in life
u Process of therapy: based on homework outside of clinic
u Client role: to become his or her own therapist
u Therapist’s role: act as a teacher and consultant

Overview of REBT and Its Application to CPSS Step
u Motivation
u Teach the client basic REBT principles
u Thumbnail sketch of REBT
u Activating event x Belief => Consequent emotions & behaviors
u Some negative emotions are dysfunctional because they are
demotivating and cause unnecessary emotional disturbance.
u The goal of REBT is to change the dysfunctional negative emotions
to functional negative emotions: emotions that enhance change, that
move the person to achieve his or her goals
u This is done by challenging the basic self-defeating philosophies of
a) placing demands on self, others, and the world; b) “awfulizing; ” c)
low frustration tolerance; d) global rating of self, others and the
world and e) absolutistic thinking

Unconditional Self-Acceptance Step
u Motivation
u To build a foundation of not rating the whole self but only one’s
characteristics and deeds. To dismiss conditional self-esteem as
pernicious, because one cannot constantly perform outstandingly.
u Tasks to be accomplished
u Learn that rating of a whole human being is counterproductive.
u Homework
u Convince oneself that stuttering cannot make one a lesser human
being.
u Practice unconditional self-acceptance statements:
u I can enjoy things whether I stutter or not;
u I choose to keep living and enjoying life whether I stutter or not;
u I do not need to rate myself whether I stutter or not;
u I can maximize my enjoyment whether I stutter or not;
u There are many things I can do whether I stutter or not;
u Becoming fluent will not make me a better person, only more fluent; and
u I do not have to disrespect myself even if others laugh at my speech.

Motivational Step
u Motivation
u The real work on change is done outside the clinic; the client has to
be motivated and kept on being motivated to do this.
u Demotivational forces
u Change is hard/other therapies may have failed.
u Not allocating enough time and energy to task.
u Strongly held irrational beliefs.
u Homework
u Using speech when alone as a guiding light.
u Cost-benefit analysis.
u Disputing helplessness and hopelessness:
u Using voluntary stuttering;
u Metronome talk;
u Envisioning therapy process; and
u Joining list server Stutter_Less_with_REBT@yahoo.groups

Identification Step
u Motivation
u Client becoming aware of his or her beliefs and behaviors so
that these can be changed
u Irrational beliefs that propagate stuttering
u Client uses table 6.1 in dissertation to rate his or her beliefs.
u Stuttering behaviors
u Using conversation, phone calls, and video recording to rate
all the elements of stuttering behaviors catalogued in the
definition of CPPS.
u Discussing with therapist the self-observations

Disputation of Irrational Beliefs Step
u Motivation
u Teach the client to dispute his or her irrational
beliefs
u Techniques used
u Reading assignments
u Discussion of basic model
u In-depth conversation about disputation
u Introduction to on-line homework sheet
u Homework
u Revisit/dispute all the irrational ideas that were
noted in the identification stage

Overcoming Dire Need to Be Approved Step
u Motivation
u Without minimizing the dire need to be approved the client
will continue to be petrified by some speaking situations
u Techniques used
u Replacing the irrational idea with a more rational one
u Anti-shame exercises
u Practicing assertiveness
u Have the client try something new at which they might fail
u Homework
u Written examples to be discussed in the dissertation

Advertising and Voluntary Stuttering Step
u Motivation
u Modify synapses in the brain to disassociate classically
conditioned fear response to speaking situations
u Voluntary pseudo stuttering
u On words that normally would not be stuttered
u Iowa bounce
u Advertising examples
u Wearing buttons or T-shirts about stuttering
u Mention stuttering
u In-depth conversation about therapy and stuttering
u Hand out pamphlets about stuttering
u Leave materials about stuttering or post them at work (if
appropriate)
u On internet mention stuttering

Building Fluency Base Step
u Motivation
u Modify synapses in the brain to disassociate
classically conditioned fear response to speaking
situations
u Background
u Proposed by Wendell Johnson, General
Semanticist and one of the greats in stuttering
therapy
u Homework
u Practice massive talking while alone
u As more situations arise where the speech is
spontaneously fluent practice massive talking in
these situations
Rational Emotive Imagery Step
u Motivation
u Provide an efficient alternative to in vivo practice and a way
to override less than satisfactory homework outcomes
u Description of technique
u Imagine a difficult speaking situation and all the
environmental cues as vividly as possible
u Immerse yourself in the unhelpful negative feelings
u Then change the unhealthy negative feelings to healthy
counterpart—panic is changed to watchfulness and/or
concern
u Applications
u Flashbacks of traumatic bullying
u Preparation for a public speech or interview

Managing Secondary Stuttering Step (Movement & Tension
Substeps)
u Motivation
u Provide an means to counteract operant conditioned non-speech
associated muscle involuntary movements and tension in speech
producing muscles
u Description of technique
u Voluntarily introduce movements or tension identical to what one
has identified
u Exaggerate these movements or tension
u First in isolation
u Then in actual conversations
u Outcome
u At first, intellectual recognition that movements or tension can be
made voluntary
u Then the extinguishing of the secondary stuttering symptoms of
movement in non speech producing muscles or tension in speech
producing muscles

Managing Secondary Stuttering Step (Proprioceptive Feedback
Monitoring Substep)
u Motivation
u Provide an means to counteract operant conditioned non-
speech associated muscle activity via proprioceptive
feedback
u Two components
u Tactile feedback
u Kinesthetic feedback
u Technique
u Note: auditory feedback was painful, so all speech monitoring
stopped
u Become aware of feedback through exaggerated motions
when no voicing takes place
u Introduce voicing when alone
u Start monitoring in actual speech situations

Application of Adapted Conventional Stuttering Therapy
Techniques Step
u Motivation
u Convince the client he or she can moderate and manage his or her
own stuttering and provide means to do so when the occasion
demands to manage stuttering
u Techniques used
u Cancellation: Repetition of stuttered work in altered manner
u Holding a block and bubbling out of it: Keep the sound in a block to
make it more voluntary and less struggling
u Holding a block and pulling out of it: Keep the sound in a block to
make it more voluntary and smoothing out of it
u Easy onsets: Using proprioceptive feedback and easy airflow to start
a word
u Using low vibrant voice
u Elongating vowels
u Handling on-coming blocks (preparatory sets or easy repetitions)

Stabilization and Relapse Prevention Step
u Motivation
u To enhance spontaneous fluency and be able to manage speech
u Stabilizing
u Monitor unhealthy negative emotions
u Trace them back to irrational beliefs
u Disputing irrational beliefs
u Continue advertising
u Practice pre-empting on coming blocks
u Relapse prevention technique C-CHALE-ET
u Chasing down irrationalities
u Challenging and disputing the irrationalites
u Humor
u Advertising
u Low vibrant voice
u Excluding relaxed calmness
u Elongating vowels
u Tracking down tension and releasing it

Termination Step
u Motivation
u Instill confidence and assure that help is available if
necessary
u Handling termination-even if early
u Make sure that the client understands the therapy
steps yet to be accomplished
u Assure client that he or she has some tools and that
others are available on the internet
u Leave door open for consultation sessions
u Assure client that he or she can come anytime

Limitations and Caveats
u Therapists need proper background training
u When a client reports no significant
improvement when speaking alone more
emphasis needs to be placed on conventional
stuttering techniques
u Motivation, severity of genetic component,
intelligence, and self-reliance are important
factors
u Gender does not seem to play a big role
u Client may need social training skills
u Client may need remedial education to catch up
in building a career

What This Dissertation Has Accomplished
u Provided--for the first time--a complete definition of CPSS that includes
both observable and unobservable phenomena as well as avoidances and
making self-limiting life choices
u Provided a new, original, detailed and complete model of the etiology and
reasons for perseverance of CPSS enumerating stages in development
u Provided a new, original therapy step sequence for approach to resolving
CPSS
u Emphasized cognitions (beliefs) and emotions in contrast to conventional
therapies that try to re-teach how to talk
u It follows the neuropsychology evidence that indicates that the brain has to
be modified through massive desensitization and homework
u The therapy is driven by a theory of development that is based on widely
accepted epigenetic systems developmental model
u Includes both classical and operant conditioning both in developmental
stages and therapy steps
u Therapy steps are conducive to building a therapy manual to test out the
effectiveness and efficiency of therapy
u Details of therapy protocol make it available to both to psychologists and
SLPs

Current Zeitgeist Compatibility & Future
Directions
u Compatibility with current Zeitgeist
u Captures the current zeitgeist of Evidence Based
Practice
u Is compatible with current search for application of
psychology to the problem of stuttering
u Future Directions
u Write a therapy manual
u Test for effectiveness and efficiency
u Do horse race studies determining how it stacks up
against conventional therapies

Summary of Dissertation
1. From the holistic point of view exhaustively defined all aspects that
characterize a person with Chronic Perseverative Stuttering
Syndrome. This includes stuttering behaviors, emotions, irrational
beliefs, and self-limiting behaviors.
2. Proposed a new theory of how stuttering develops based on current

neuropsychological research and Rational Emotive Behavior
Therapy (REBT) listing all the stages that a person who stutters
goes through during his or her lifetime.
3. Built a step by step REBT based therapy which also includes as a

subset some of the conventional treatment techniques, but focusing
mainly on the emotions and beliefs of the person who stutters.
The outcome is expected to be, just like in my case, periods of

spontaneous fluency with a fallback of managed fluency. The main
technique for managing fluency is an easy re-repetition that is used
to pre-empt when a person “hears the footsteps of an oncoming
block” or bubbling out of a hard block.

Treatment of Stuttering With Rational Emotive Behavior Therapy

Caricato da

Informazioni sul documento

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Treatment of Stuttering With Rational Emotive Behavior Therapy

Caricato da

Copyright:

Formati disponibili

Rational Emotive Behavior Therapy (REBT)

Treatment of Chronic Perseverative

September 11, 2009

1 © Gunars K. Neiders ALL RIGHTS RESERVED

2 © Gunars K. Neiders ALL RIGHTS RESERVED

3 © Gunars K. Neiders ALL RIGHTS RESERVED

4 © Gunars K. Neiders ALL RIGHTS RESERVED

5 © Gunars K. Neiders ALL RIGHTS RESERVED

6 © Gunars K. Neiders ALL RIGHTS RESERVED

7 © Gunars K. Neiders ALL RIGHTS RESERVED

8 © Gunars K. Neiders ALL RIGHTS RESERVED

9 © Gunars K. Neiders ALL RIGHTS RESERVED

u Poor life-style choices

u Unhealthy negative emotions

10 © Gunars K. Neiders ALL RIGHTS RESERVED

11 © Gunars K. Neiders ALL RIGHTS RESERVED

12 © Gunars K. Neiders ALL RIGHTS RESERVED

13 © Gunars K. Neiders ALL RIGHTS RESERVED

14 © Gunars K. Neiders ALL RIGHTS RESERVED

15 © Gunars K. Neiders ALL RIGHTS RESERVED

16 © Gunars K. Neiders ALL RIGHTS RESERVED

17 © Gunars K. Neiders ALL RIGHTS RESERVED

18 © Gunars K. Neiders ALL RIGHTS RESERVED

© Gunars K. Neiders ALL RIGHTS RESERVED

20 © Gunars K. Neiders ALL RIGHTS RESERVED

21 © Gunars K. Neiders ALL RIGHTS RESERVED

22 © Gunars K. Neiders ALL RIGHTS RESERVED

23 © Gunars K. Neiders ALL RIGHTS RESERVED

24 © Gunars K. Neiders ALL RIGHTS RESERVED

25 © Gunars K. Neiders ALL RIGHTS RESERVED

26 © Gunars K. Neiders ALL RIGHTS RESERVED

27 © Gunars K. Neiders ALL RIGHTS RESERVED

28 © Gunars K. Neiders ALL RIGHTS RESERVED

29 © Gunars K. Neiders ALL RIGHTS RESERVED

30 © Gunars K. Neiders ALL RIGHTS RESERVED

31 © Gunars K. Neiders ALL RIGHTS RESERVED

32 © Gunars K. Neiders ALL RIGHTS RESERVED

33 © Gunars K. Neiders ALL RIGHTS RESERVED

34 © Gunars K. Neiders ALL RIGHTS RESERVED

35 © Gunars K. Neiders ALL RIGHTS RESERVED

37 © Gunars K. Neiders ALL RIGHTS RESERVED

38 © Gunars K. Neiders ALL RIGHTS RESERVED

39 © Gunars K. Neiders ALL RIGHTS RESERVED

40 © Gunars K. Neiders ALL RIGHTS RESERVED

41 © Gunars K. Neiders ALL RIGHTS RESERVED

u Assure client that he or she can come anytime

42 © Gunars K. Neiders ALL RIGHTS RESERVED

43 © Gunars K. Neiders ALL RIGHTS RESERVED

44 © Gunars K. Neiders ALL RIGHTS RESERVED

45 © Gunars K. Neiders ALL RIGHTS RESERVED

2. Proposed a new theory of how stuttering develops based on current

3. Built a step by step REBT based therapy which also includes as a

The outcome is expected to be, just like in my case, periods of

46 © Gunars K. Neiders ALL RIGHTS RESERVED

Potrebbero piacerti anche