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Gerbere Sanford E., Ed.The Family as Supportive Personnel in Speech andHearing Remediation.Social and Rehabilitation Service (DHEW), Washington,D.C. Rehabilitation Services Administration.71

84p.; Proceedings of the Post-Graduate Short Course,University of California, Santa Barbara, March 31,April 1 and 2, 1970Superintendent of Documents, U. S. GovernmentPrinting Office, Washington, D. C. 20402

MF-$0.65 HC-$3.29Aphasia; Aurally Handicapped; Conference Reports;*Family Influence; *Family Role; *Speech Handicapped;Stuttering; Voice DisordersLaryngectomees

ABSTRACTThe proceedings of the conference/short course on the

role of the family as supportive personnel in speech and hearingremediation focus upon the family and its relationship andinteraction with the speech, language, or hearing handicappedindividual. The purpose of the course was to emphasize the importanceof utilizing the family as a manpower resource in the fields ofspeech pathology and audiology. The five major papers concern voicedisorders and the family environment, the family of thelaryngectomee, family influences on stuttering and stutteringtherapy, family role in the management of the deaf child, and therole of the family in aphasia. Substantial discussions follow eachpresentation. (KW)

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DISCRIMINATION PROHII3ITED=Title VI of `the CiVilRights Act of:1964 states: "No person:in the UnitedStatesShall, on the ground :of tace,:cedor, or national origin, beexcluded from participation: in; be denied the benefits of,or be subjected: to dise.rimination under -any- programPrOgrain oractivity receiving Federal financial assistance."

LC1(tit

OOLL I

Proceedings of the Post-Graduate Short Course

THE FAMILY ASSUPPORTIVE PERSONNEL

IN SPEECH ANDHEARING REMEDIATION

at the University of California, Santa BarbaraMarch 31, April 1 and 2, 1970

L,IIEOnORE D. HANLEY, Pu. D., Program Chairman

SANFORD E. GERBER, PH. D., Proceedings Editor

Sponsored byTraining Division, Rehabilitation Services Administration,Social and Rehabilitative ServiceUnited States Department of Health, Education, and Welfare

Santa Barbara, 1971U.S, DEPARTMENT OF HEALTH,

EDUCATION & WELFAREOFFICE OF EDUCATION

THIS 00CUMENT HAS BEEN REPRO-DUCE() EXACTLY AS RECEIVED FROMTHE PERSON OR ORGANIZATION ORIG-INATING IT POINTS OF "EW OR OPiNIONS STATED DO NO' .4ECESSARILYREPRESENT OFFICIAL OFFICE OF EDUCATION POSITION OR POLICY

You have heard me ever since I was bornMy birth cry and my babbling

My first word and my first SentenceAnd that you have listened determined

that I have spokenAs my listener you are the soil for the

growth of my wordsI would not have them fall upon the barren

rocks of your unconcernOr into the noisy circuits of your distractionIt dots not matter only that I speak

It matters too that you listen

Lee Edward TravisSanta BarbaraApril 1, 1970

CONTENTSParticipants

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Acknowledgementv

Sanford E. Gerber, Ph.D.University of California, Santa Barbara

Prefacevi

Theodore D. Hanley, Ph.D.University of California, Santa Barbara

Introductionvii

Jamil Toubbelf, Ph.D.U.S. Department of Health, Education, and Welfare

Voice Disorders and the Family Environment1

Paul Moore, Ph.D.University of Florida

Discussion

The Family of the Laryngeetomee 12John C. Snideeor, Ph.D.University of California, Santa Barbara

Discussion

Family Influences on Stuttering and Stuttering Therapy 31Hugo H. Gregory, Ph.D.Northwestern University

Discussion

The Role of the Family in the Management of the Deaf Child 42Stephen P. Quigley, Ph.D.University of Illinois

Discussion

My Listener 57Lee E. Travis, Ph.D.Fuller Theological Seminary

The Role of the Family in AphasiaMartha Taylor Sarno, M.A.New York University

Discussion

61

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PARTICIPANTS

Theodore D. Hanley, Ph.D.University of California, Santa Barbara

Chairma rt

Bayard Allmond, M.D.University of California, San Francisco

Tina E. Bangs, Ph.D.Houston Speech and Hearing Center

Gene England, Ph.D.Monterey Institute of Speech and Hearing

Richard M. Flower, Ph.D.University of California, San Francisco

Hugo H. Gregory, Ph.D.Northwestern University

Paul Moore, Ph.D.University of Florida

Stephen P. Quigley, Ph.D.University of Illinois

Martha T. Sarno, M.A.New York University

James Sherman, Ph.D.University of Kansas

John C. Snidetor, Ph.D.University of California, Santa Barbara

Lee E. Travis, Ph.D.Fuller Theological Seminary

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ACKNOWLEDGEMENT

The editor is most grateful to Jamil Toubbeh, Ph.D. of the Rehabilitation Service:,Administration for his support, not only of the short course, but also of the publication ofthese Proceedings. The resident faculty at Santa Barbara is more than pleased to acknowledgethe participation of the contributors and discussants. I must thank them for putting up with myrepeated wheedling and needling for their manuscripts and discussions, and now I can apologizefor some of those letters which might have been kinder. We are very indebted to Miss MaryannCanatsey who listened to the recordings of the short course and typed the original draft of theProceedings. Of course, we also acknowledge the assistance of the Audio Visual Services ofIJCSB's Learning Resources for making those recordings. PersOna lly, as editor, I had the benefitof counsel with the program chairman, my friend and colleague; Ted Hanley. Also, the rest ofthe UCSB Speech and Hearing Faculty assisted all the way along; so thanks also to BarbaraThomas Bean, Janis Costello, and to Jack Snidecor.

Sanford E. GerberEditor

Santa Barbara, CaliforniaFebruary 1971

PREFACE

Manpower shortages in the human services (health, education, and welfar ,) are recognizedand reported to the extent that they are matters of common knowledge and concern in manydisciplines. The communicative disorders spccch pathologies and auditory impairmentshave come into focus in national, regional, and local conferences and have been the subject ofarticles and addresses by leaders in the profession.

Two trends are to be noted in efforts to alleviate shortages in personnel trained in speechpathology/audiology: federal support of graduate education in this field, and recognition ofsub-professional activities for which communication aides can be trained: For the present, atleast, the federal support appears to have plateaued, and even regressed somewhat as prioritieshave shifted at the national level. The communication aide concept is emerging, not everywhereaccepted, and like graduate education is a funding problem.

One manpower resource long acknowledged but minimally exploited is the family,spouses, parents, children, and siblings of the person who- has a communicative disorder. Inrecognition of the potential henefit to be realized by the inclusion of the family in the rehabili-tation process, the faculty of the Speech and Hearing Center at the University of California,Santa Barbara, sought support for a national conference/short course devoted to the subject.The support was forthcoming in the form of a grant from the Training Division, RehabilitationServices Administration, Social and Rehabilitative Services, Department of Health, Education,and Welfare.

With this encouragement, the resident faculty designed a three-day program, issuedinvitations to a distinguished short course faculty of lecturers and discussants and to a selectstudent body comprised of directors of RSA-supported speech and hearing training programs ortheir designees as well as a suggested list of Southern California Vocational RehabilitationCounsellors.

The conference/short course was held on the UCSB campus March 31, April 1 and 2,1970. The document that follows constitutes the Proceedings of this event. The resident facultywishes to express its appreciation to RSA for its support, to the invited faculty for their majorcontributions to the success of this undertaking, and to the select student hody for theirinterest and active participation.

Santa Barbara, CaliforniaNovember 1,1970

Theodore D. HanleyConference Chairman

IntroductionJamil I. Toubbeh, Ph.D.Department of Health, Education and Welf 'ireRehabilitation Services AdministrationWashington, D.C.

The conclusions embodied in these proceedingsshoal challenge rehabilitation personnel involved inspeech, language, and hearing remediatioe to developand evaluate innovative methods by which the familycan become actively involved in the therapeutic process.

No professional in the field of speech pathology andaudiology is likely to exclude the. family from the thera-peutic process; it would be incongruous with the natureof human communication and its disorders, and therehabilitation process. But such inclusion need not al-ways imply active involvement. The degree of involve-ment depends upon knowledge of the communicativeprocess and, its disorders, and the acquisition of certainskills for performance of specific, assigned tasks.

The importance of utilizing the family as a manpowerresource can best be appreciated in the light of thenational manpower needs in this field. At the presenttime, active manpower in speech pathology and audi-ology totals fewer than 14,000 professionals.

According to the most recent study of the prevalenceof communicative disorders in the United States, con-ducted by the National Institute of NeurologicalDiseases and Stroke (1969), more than 20,000,000persons have communicative handicaps worthy of con-cern! Clearly, the service needs of this large populationcan not be met by highly trained professionals alone.The implications of the NINDS study are quite obvious:unless new and innovative methods of delivery ofservices to these handicapped individuals are introduced,many potential rehabilitants will end up on welfare rolls;many more will pay the price in human suffering whichcommunication disorders inflict.

The concept of training and using supportive person-nel in speech, language and hearing remcdiation is notnew. The profession of speech pathology and audiologyhas been active in promoting training and utilization ofthese types of personnel for several years. In cooperation

with the Rehabilitation Services Administration, theAmerican Speech and Hearing Association has heldnumerous national conferences on this important topic.Guidelines for training and utilization of support person-nel have been developed. Further, several institutions invarious States have successfully trained and placedsupportive personnel in public schools, clinics, hospitals,and other rehabilitation settings.

The training and utilization of the family as support-ive personnel presents new challenges to professionals inthe field of Speech Pathology and Audiology. From theviewpoint of manpower resources, voluntary familycontributions to rehabilitation may be highly desirable.There are drawbacks, also. The personal involvement ofthe family in the communicative disorder may some-times hinder the therapeutic process and render profes-sional guidance and therapy ineffective. Exceptions tothe desirability of family involvement should not pre-clude greatly expanded efforts to devise programs forthe greater utilization of this resource. Experimentationwith the family in a supportive role could lead to identi-fication of tasks that can be performed without adverseeffects on the handicapped person.

The focal point of the discussions at the SantaBarbara conference was the family and its relationshipand interaction with the handicapped individual. Theprimary objective of this document is to stimulate thoseprofessionals concerned with communication disordersto act upon the urgent habilitation and rehabilitationneeds of the communicatively handicapped person. TheProceedings, therefore, do not constitute a documentwhich spells out step-by-step procedures in dealing withthe family as supportive personnel. To do so would be aquestionable undertaking when one considers the spec-trum of communication disorders and the complexity ofthe therapeutic processes. Nevertheless, the reader,professional or lay, can expect guidance from the Pro-ceedings, which may be helpful in structuring a programfor the training and utilization of the family as support-ive personnel.

The organization of this publication follows theformat of the conference at Santa Barbara. The reader is

vii

introduced to some of the most prevalent communi-cation disorders, discussed by luthorities in the areas ofvoice disorders, laryngectomy, stuttering, deafness, andaphasia. Each presentation is followed by a panel discus-sion which includes audience participation. By and large,the content of the Proceedings reflePt: research findingsand empirical observations not heretofore published.Speech pathologists, rehabilitation audiologists, rehabili-tation counselors, psych( logists, physicians, and otherallied health personnel will find the information useful.

viii

Those professionals who elect to transcend "laboratoryprecision" to look at the contemporary family through atelescope, are invited to read Lee Edward Travis' MYLISTENER: it should be required reading!

There is no doubt that the fmnily can serve thecommunicatively handicapped in another importantrole: it can act as a catalyst in alerting State and Federallegislators to the needs of millions of citizens handi-capped by speech, language, and hearing disorders.

Voice Disorders and the FamilyEnviron.mentPaul Moore, Ph.D., University of Florida

My assignment in this short course is to explore someof the ways in which voice disorders are relatea toenvironmental factors, particularly those enclosed withinthe concept "family." As I sec our environment, thisocean in which we live, it is composed of the cecable,hcarable, reelable, smellable, and tasteable creatures andthings that we call our physical world. This ocean alsoincorporates the circulating currents of attitudes,beliefsand customs that compose our social world. We reconizc, in addition, an inner world, a personal world. thatby definition is not part of the environment, yet is sointimately linked to out physical and social worlds thatthere is only a thin permeable film between them.

I picture the family as a segment of the environmentwith all of the usual physical and social elements, butdistinguished by specific biological and social relation.ships. Family also tends to imply a geographic location,or focus of activity, yet it is only loosely confined to theconcept "home." Ordinarily, location becomes decreas-ingly specific or becomes a multiple concept with in-creasing age. Family can be interpreted as that segmentof the environment in which the individual lives. Itincludes the places where he works, plays, eats, andsleeps; and the people with whom he works, plays, eats,and sleeps.

It is apparent from the title of this short ;curse, andthe material describing it, that the underlying philos-o'phy has at least four facets. First, speech is learned;second, some speech disorders may be caused by factorsin the family environment; third, remediation mayrequire modification of the environment to meet theindividual's needs; and fourth, change of the individual'svocal behavior may be necessary to meet the environ-mental demands. I subscribe to this philosophy and wishto discuss the environment, particularly the familyenvironment, as it relates to the recognition of voicedisorders, to the causes for some of these disorders, andto their remediation.

What are voice disorders, arid how are they deter-mined? The group assembled here recognizes that theterm voice disorders encompasses the basic sounds ofwhich speech is composed, i.: contrast with the linguis-tically significant sounds, tae phonetic elements oflanguage. Vocal deviations may be in pitch that is toohigh or too low, loudness that is too greet or too weak,or vocal quality that lacks c,.cellence by being hoarse(rough) or harsh or breathy or spasmod..c or hypernasalor hyponasal or mixtures of these and other factors.

Each person in the population has acquired a workingdefinition of voice disorders, and he has also de% eloped aconcept of normal voice on which he judges theabnormal. Yet it is obvious that there is no single vocalsou- d 'hat can h.% called "normal voice;" instead, ex-perience has taught us to recognize a normal forshildre'is' voices, girls' voices, boys' voices, womens'voices, mens' voices, voices of the aged, and so on. 'F helocation of the threshold that separates the abnormalfrom the normal is judged by each listener on the basisof his cultural standards, education, social concepts;vocal training, and similar environmental influences: butwherever the separation briween adequate arid inade-quate is placed, it is obvious that each individual hasacquired concepts of normalcy and defectiveness. Thisobservation should ales t all of us dealing w**h communi-cation problems to the fact that voice disorders are re-lated both to our cultures and our environments. A voicejudged to be defective by the clinician may be unnotimilby the parent, employer, or teacher. It follows that thesocial and cultural' factors provide the basis for the tradi-tional definition of voice problems as those deviations inpitch, loudness, and quality that are judged to be

*Modified from material presented by the author in Handbook of Speech Pathology and Audiology, Lee E. Travis, Editor,Revised edition. New York: Appleton Century Crofts, Inc.,1970 (In Pre), and in Organic Voice Disorders, Erigley.00dCliffs, NJ., Prentice-Hall, Inc. 1971 (in press).

atypical of thc vocal charactcristics of most personshaving the same age, sex, and cultural background.

Abnormalities of pitch establish significant relation-ships between the individual and his environment. Theman with a high-pitched voice who is addressed as"Mam" or "Miss" on the telephone is seriously handi-capped both economically and socially. In our culture,the pitch of thc adult -nalc voice is related to conceptsof masculinity; high pitch is often interpreted either as asign of delayed sexual development or as an evidence ofeffemininacy. A person with such a voice is usually re-jected by both men and women, and there arc few3ccupations in which he can obtain employment.

An equally distressing problem exists when awoman's voice has a masculine pitch. Various interpre-tations of masculinity-femininity confusions are madeby laymen, and there are certain jobs that are not avail-able to women with masculine-type voices. However,penalties for low- pitched voices in women do not appearto be as severe as those accompanying the oppositesituation in men. Part of this difference may reflect thepopularity of certain prominent actresses who havedeveloped low-pitched voices that tend to be admiredand imitated. Another probable reason for the socialacceptance of low-pitched female voices is that laryngitisand other laryngeal diseases almost always lower thepitch; consequently, the change can be associated withan "honorable" disease instead of with a "suspect"physical condition or personality.

The medical, social, and personality implication ofother pitch disorders such as vocal monotony, tremu-lousness, and atypical melody patterns, range fromneurological disorders to laryngeal disease, socialinadequacy, and fear. The layman rarely notices monot-ony, but tremulousness, except as it exist, in olderpersons and those experiencing stress, and atypicalmelody patterns may cause extensive economic andsocial penalties.

Voices that are too loud or not loud enough arefaulty because they do not satisfy the requirements ofthe environmental situation. These deviations are rarelyclassified as serious defects by the general public, but thcspeech pathologist must he alert to thcm and their impli-cations of potential social or personal problems. Individ-uals who speak too loudly or too quietly most of thetime, rarely do so all of the time; consequently, thevocal aspects are interpreted as evidence of, or sympto-matic of, a complex problem which itself needs remedialattention. On one hand, the person with a loud voicemay frequently be recognized by his posture and generalbehavior as an individual with a hearing loss; his voice isexplainable on a socially acceptable basis and there is nosocial penalty. In contrast, the person who oftcn speaks

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loudly as though he were excited or egotistical or angry'without obvious cause, will be considered odd, andsocial penalties will result. The individual who speakstoo quietly in the classroom or in a social situation andwho is not physically weak is considered to be shy orsocially retarded. However, in some social ; ''',p

groups, this "quiet voice" is fostered ar -ui,

women, but it is usually condemned in young ..... . us anevidence of weakness. It is probable, therefore, thatappropriate loudness of the voice constitutes one of theprincipal signs of personal adequacy within the familyenvironment.

Description and classification of discrete disorders,such as th.; pitch and loudness deviations mentionedpreviously, simplify presentations at meetings of thistype, but they tend to obscure the fact that such vocaldifferences often exist concurrently and -may vary inrelation to each other. Furthermore, pitch and loudnessare often intertwined with othcr types of speech andvoice disorders. The multiplicity of vocal factors andtheir complex combinations contribute to the varietiesof voice and consequently to the difficulty of descrip-tion and classification. Disordered voices are composedonly rarely of single types of deviation; usually theycontain mixtures of vocal elements that are themselvesvariable in degree.

Vocal quality refers to those tonal characteristics thatidentify voices even when they are being produced withidentical pitch and loudness. The disorders of voicequality are deviations from the normally expected vocalsound and are designated by such terms as hoarseness,breathiness, aphonia, nasality, and so on.

Pcrhaps the most commonly used term for voicequality disorders, is "hoarseness", a label that usuallyrefers to a group of phonatory deviations that arepopularly associated with "laryngitis" or "cold in thethroat." Most persons with otherwise normal voices haveexperienced hoarseness temporarily during the course ofa respiratory disease; or intermittently with the accumu-lation of mucus on the vocal cords which causes a rough-ness of voice that is relieved when the offending materialis removed by coughing or clearing the throat. This per-sonal experience with hoarseness enables individuals toassociate the problem with the larynx and to recognizethe disorder as phonatory. Hoarsencss has a roughnessand noisiness about it that contrasts with the smooth-ness of the normal voice.

The commonness of hoarscness reduces its socialstigma, yet persistent hoarseness may carry serious impli-cations about health, employability, or social adjust.ment. If the disorder is of recent origin, it may be asymptom of disease or structural change that requiresimmediate medical attention. On the other hand, if the

voice has been hoar: for some time and the laryngealcondition is stable, the health -lications becomesecondary to the social and ecor '3r .i.Jrations. A

hoarse voice may reduce the ind ' ersoial effec-tiveness by making him difficult to understand orunpleasant to hear and thereby restricts his choice ofoccupations.

Another term that is associated frequently withabnormal voice quality is "breathincss," a problemwhich, like hoarseness, has many varieties and degrees ofseverity. Its name suggests that the important, audiblecomponent of the sound is the noise that is produced bythe flow of breath, similar to that heard in whispering.Breathiness may indicate laryngeal disease, but fre-quently, particularly when it exists in high school andcollege girls, it signals imitation of some actress who hasadopted this quality as a sex symbol. In our currentsociety there is no social stigma for this type of voice.

A third phonatory quality disorder that is describedvariously in the literature is frequently called "harsh-ness." It has a ru; ing sound, and some clinicians recog-nize it primarily b, ,he presence of "vocal fry" or glotta-lization. It is often identified with hard-drivingbusinessmen who appear to work under great environ-mental pressure. However, a simple or uncomplicatedform of harshness is found commonly but intermittentlyin the spc of adolescent boys and young men whoattempt to force the pitch below the normal range in aneffort to sound mo:e masculine. The problem may resultfrom a laryngeal disorder, but it is usually linkedcausally to environmental conditions.

One other phonatory defect from among many, thatshould be introduced here is aphonia, a problem thatoften has a close relationship to family and environment.Aphonia is a disorder in which the individual who isafflicted speaks only in a whisper. The loss of voice canoccur at any age, but is more common in adults, and itmay develop either suddenly or over a period of time.

Most persons in our society have lost their voicestemporarily, either as the result of shouting at anathletic contest or in conjunction with "larynuitis." Inconsequence, the problem usually carries no real psycho-logical or social pcnality. However, persistent aphoniacan signal the presence of serious laryngeal disease oremotional disturbance. Aphonia as a vocal symptomlimits the patient's employment and his association withfriends; it can be frustrating and emotionally disturbing.However, its social acceptability makes it an ideal escapefrom competition and responsibility for those who wishsuch relief. The range of possible causes for aphonia,from organic impairment to hysterical reactions,emphasizes the importance of careful diagnosis and closecooperation between the medical profession, including

psychiatry, and speech pathology. The speech pathol-ogist usually assumes his rehabilitative role after themedical specialists have performed their therapies, buthe may have the initial responsibility for evaluation andreferral.

In the preceding comments, the entire emphasis wasplaced on the larynx and the phonatory deviationsoriginating there. However, when the sound that is

generated in the larynx passes through the pharynx,mouth, and nose, it is unavoidably modified by theresonance characteristics of the passageway. As thevolume and shape of the respiratory tract arc varied, aselective emphasis is exerted on the partials in thecomplex tones that are flowing through. Such adjust-ments create the vowels and consonants, and they alsocontribute to such paralinguistic factors as individual orpersonal voice characteristics. When the nasal passage-way is opened to the resonance system by the loweringof the soft palate, a so-called nasal component becomesprominent in the sound. This audible element is normalin the [m ], [n], and [d] consonants but is abnormal inall other English sounds except in certain regionaldialects.

Hypernasality is a term that includes several voicequalities that are associated with t} ,e excessive use of thenasal resonator when such use is not normal in theutterance. When one of these voice deviations is presentsingly or as the most prominent aspect of a complexvoice disorder, the voice is 4escribed as being hypernasal,and it may carry se; ions social and economic conse-quences for the person who possesses it. In some formsit interferes with the intelligibility of speech; in others itimplies either defective oral structures or an impov-erished family background. Usually, it is estheticallyunpleasant to hear. Hypernasality is frequently blendedwith disorders of phonation, thereby creating extremelycomplex vocal deviations in which the component partsare difficult to identify individually.

Another type of hypernasality is called nasal twangand represents a form of voice deviation that is usuallyfunctional. It is associated in various forms with certaindialects, and with hawker occupations such as auction-eer* and newspaper vending. However, a similarsounding voice disorder occasionally accompanies thepresence of polyps or other nasal obstructions situatedanteriorly in the nose.

It is etqtomary in discussions of voice disorders tocontrast excessive nasal resonance with the lack ofnormal nasal resonance, a quality referred to as hypo-nasality. Hyponasality is the quality that accompanies"cold in the head" or blockage of the nasopharynx b;enlarged adenoids, polyps, or other obstructions. Occa-sionally this problem may also have a dialectal base.

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What is the role of the environment in the cause andthe alleviation of voice disorders?

The environment contributes in three major ways tothe establishment of voice disorders: (1) the voices ofthe family serve as models that may be imitated; (2) theliving, playing and working situations may provide thestress of interference or competition causing vocal abuse:and (3) the environment may contain allergens amidirritating substances that adversely affect the mucosaand deeper structures of the vocal organs.

Imitation is observed most commonly in resonancedisorders, particularly hypernasality. These deviationsoften persist throughout life and are recognized asfamily vocal patterns. Obviously, these voices are defec-tive only when they are so judged by someone outside ofthe home. Occasionally a phonatory problem occurswhen a boy attempts to force the pitch of his voicedownward in an attempt to duplicate the masculinevoice of his father or brothers. Usually permanent vocaldisorders do not develop because the voice changes thatoccur normally at puberty solve the problem. However,where adequate voice change does not occur and acompensatory vocal-fry harshness is acquired, it maypersist into adulthood. Occasionally, tile opposite typeof adjustment appears in which the adolescent boy wholives largely in a female environment prevents the changeto a masculine pitch and maintains instead the high pitchof the juvenile.

When the environment in which an individual works,plays, and lives creates a need for excessively loud voiceor for extended periods of vigorous talking, the laryngealstructures are traumatized and chronic changes in thevocal organs often result. elildren in large families,where vocal competition is customary, boys who.shoutduring athletic contests, cheerleaders, employees whomust talk in the midst of loud industrial or other noiserepresent the kinds of persons and their activities thatlead to voice disorders.

A statement by Jackson and Jackson in 1942 hasbecome a classic and is as true today as it was 30 yearsago:

"Unquestionably the greatest of all causes oflaryngeal disease (and hence phonatory prohlems -

author) is the excessive use of one of its normalfunctions, phonation... The patient with chroniclary ngeal disease is ahnost always a person whoeither talks constantly or uses his voice profes-sionally, or often, both. There is little use askingthe patient if he talks much. For sonic curiousreason a patient who talks all the time he is awakewill insist he talks little. It is not only the singer,the lecturer, and the huckster who suffer fromoccupational abuse of the larynx, Teachers are

especially frequent sufferers and persons who talkin noisy places such as factories where machineryis running often develop chronic hoarseness...There is a great variation in the amount of abusethe larynx of different individuals will stand; butevery larynx has its limit. To go beyond this limitmeans thickening of the cords, and a thickenedcord means a hoarse voice. Not only is a thickenedcord a poor vibrator but it throws great additionalwork upon the thyroarytenoidci. These musclesinstead of growing stronger grow more and morefeeble, less and less able to cope with the increased

requirements. A vicious circle is established andthis renders cure a long tedious process."

The effects of vocal abuse were referred to by Ballen-ger (1969, 389-390) as hyperkenetie phonasthenia. Hesays,

"Phonastlienia or functional vocal fatigue is dueto vocal abuse. The amount of abuse necessary toproduce the condition is quite variable. Personsusing their voices professionally and the elderly aremore prone to develop intermittent vocal fatigue.

"The underlying disorder is weakness or fatigueof the vocalis or thyroarytenoid muscle. As aresult, the tension and form of the vocal foldscannot be maintained. This occurs most often insingers and public speakers as a result of overuse ofthe voice. With senility, the thyroarytcnoid muscleis subject to atrophy and loss of tone which mayprecipitate phonasthenia with normal voice use."

Vocal trauma often leads, also, to other types oflaryngeal disorder. Vigorous shouting and cheering maycause vascular engorgement, injury to the joints ormusculature, resulting in arthritis, myositis or, moreoften, hematoma. These subcpithelial hematoma "donot always become absorbed; often they become orga-nized into fibrous tumors that increase in size as theresult of irritation and inflammation." (Jackson car

Jackson, 1942, p. 378) They are often on the vocal foldedges, where they cause breathiness or hoarsenessaccording to associated conditions.

Prolonged vigorous use of the voice frequently causesvocal nodules. These lesions are by definition a type ofpolyp, but their unique relationship to vocal traumacauses them to be treated in the literature as an entity.In referring to the etiology of nodules Ballenger states:

"The factors important in the causation ofchronic laryngitis are influential here. However, itis probable the persistent vocal abuse of hyper-kinetic phonation is the tingle most importantprecipitating factor. As a result, the lesions areseen most commonly in professional voice users

and in nervous, hyperkinetie individuals. Thelesions occur at the center of the membranonscord because this area is the center of vibrator)motion of the cord."

Irritating substances such as dust, dry air, smoke, andpollens in the environment that can be breathed into therespilaton tract often cause hoarseness. The Mechanismby which these laryngeal irritants generate the mucosalchanges that cause the hoarseness is the production of... vasodilatation and hyperemia. This may in turn

precipitate submucosal hemorrhages, interstitial edemaand production of au inflammatory exudate consistingmainly of mononuclear cells. Eventually, the injuredarea is invaded by fibroblasts, causing fibrosis andhyalinization with thickening and deforming of struc-ture. The patho-physiologic cycle may be arrested at anypoint with a resulting-clinical entity." (Ballenger, 1969,p. 348)

The vocal folds appear pink, the small vessels on theirsurfaces are dilated and their glottal margins arc roundedwhen they arc approximated for phonation. Thethick'ening of the inneosa and alteration of the shapeModifies the mass of the vocal fold, its compliance, andthe manner of glottal closure..The result is atypicalvibration that can produce breathiness, hoarseness, oreven roughness if the changes are sufficiently advanced.

Therapy for vocal disorders is accomplished throughthree general procedures: (1) surgical and medical treat-ment of the organic problems; (2) vocal reeducation forthe direct modification of voice production: and (3)environmental or psycho-social therapy. Medical treat-ment and vocal reeducation rarely accomplish anylasting improvement in a defective voice so long as theclient lives or works in an environment that is respon-sible either directly or indirectly for vocal abuse orimpairment of the vocal organs. Vocal therapy is acontinuous 24 hour per day process that must include afavorable enviromnental setting.

The procedures that may be used for improving theenvironments of the- family, school, and work in theinterest of voice require time and may appear to be fardistant from vocal therapy. However, the efforts areusually extremely beneficial and may constitute thetotal therapy. Occasionally a patient modify hisspeaking requirements in his various environmentsthrough his own efforts, after he understands the rela-tionships between his voice and his surroundings. Morefrequently, however, it is necessary for the speecnpathologist, physician, social worker, or counselor tobecome involved with the individual in his environmentand to provide the actual leadership for seeking bene-ficial changes. This procedure requires interviews withparents and teachers, if the problem exists in a child, or

with employers and families when the disi,rder is presentin adults. Where sufficient insight and understandingexist, adjustments are usually not difficult to accom-plish, but when the patient considers his voice to berelatively unimportant or when the employment situa-tion cannot be altered, the chance for en% iromnentalchange is remote. The conscientious speech pathologistwill rarely feel justified in refusing to work with anindividual primarily on the basis of a detrimentalenvironmental situation, but he must realize that thetherapeutic process is more or less jeopardized.

There arc at least two objectives of interviews withmember:, of a patient's family. Basierlly, the purpose isto reduce both the amount and the loudness of thepatient's talking when he is at home. Ile should beencouraged to speak more softly and to speak lessfrequently. Sympathetic reminders by persons withinthe family about excessive use will help the patientcontrol his voice.

The second objective of conferences with the fandlyis related to and supplements the pnrpose of the first butinvolves the family more and the patient less. Wherepossible in a vocally noisy family, all members should beurged to reduce the amount and loudness of their owntalking. Lessening of vocal competition is of greatbenefit to the patient and where family cooperationoccurs, ipiovement is enhanced. Unfortunately, itmust be acknowledged that the psychological and socialfactors that create the noisy family are not apt to bechanged willingly or readily. One method that usuallyhelps a family realize the amount of speaking done andthereby contributes to improvement of the vocalenvironment. is the establishment of a period of 5-minutes during the evening meal (hiring which no one isallowed to say anything except in an emergency. Thosewho break the silence are required to pay a penalty. Thispractice causes many persons to become aware for thefirst time that they do indeed talk more than theythought they did.

;Modification of the environment of an adult who hasa voice problem is often accomplished through directwork with him. Discussions about laryngeal trauma andits consequences provide insight for the patient into suchvocal abuses as excessive speaking, shonting at sportingevents, loud singing, and loud talking in noisy workingsituations. ks a consequence, the individual arrives at anunderstanding of what he must do to improve his voice.If his employment environment cannot be modified, hemay be able to change his manner of speaking by usingan amplify aig system to compensate for the noise. liemay also be able to use ear wardens (stopples) to reducethe effeCts of the surrounding noise and thereby lessen

5

the tendency to shout when attempting to speak in thenoisy environment.

The place where an individual lives or works may bedetrimental to the voice, not only because it encouragesvocal abuse but also because the air in it contains pollen,dust, or other pollutants that irritate the linings of theairway. Frequently, the regular use of air conditioners,air filters, face masks, or humidifiers can lessen the detri-mental effects sufficiently to reduce or eliminate theproblem. In rare instances it may be necessary for anindividual to move his place of residence or occupationto escape from the environmental irritants.

Summary: An attempt has been made to point outthat many voice disorders are intimately related to thefamily and associated environmental factors. Thesedisorders are determined primarily by personal judg-ments that are environmentally and culturally based;many voice problems are precipitated by social andphysical factors in the environment; and therapy forvoice disorders may be accomplished entirely throughenvironmental modification, or with such auxiliarysupport. It is apparent that medical therapy and vocalreeducation cannot accomplish much unless the environ-ment is supportive.

References

Ballenger, J. and contributorsDiseases of the Nose, Throat and Ear (11th Ed.), Phila-delphia: Lea and Febiger. 1969.

Jackson, C., and Jackson, C. ....Diseases and Injuries of the Larynx, New York: Macmil-lan. 1942.

6

Moore, G. PaulOrganic Voice Disorders, Englewood Cliffs, N. J.: Prentice-Hall, Inc. 1971.

Moore, G. PaulVoice Disorders Organically Based, Chap. 21, Handbookof Speech Pathology and Audiology, Lcc Edward Travis(Ed.), New York: Appleton - Century - Crofts. 1971.

DiscussionMOORE: I hope this discussion, as well as those thatwill occur in the group sessions will imitate to somedegree the procedures used by our medical colleagues.Undoubtedly many of you have attended discussions ofmedical groups where the professional elements underconsideration were paramount. The individuals involvedin such discussions usually are not important as individ-uals. Consequently, I hope our questions and inquirieswill press relentlessly into concepts without worryingabout the person himself. There is no such thing asdelicacy when it comes to professional discussion. Nowwe of the panel may not have answers, but I believe thisfact will not keep the discussion from generating con-cepts and insights. With that kind of invitation to thepanel and the audience, I would like to ask Dr. Bangs, ona ladies first basis, to open the discussion.

BANGS: I have a question, but first I would like topreface it by saying that I believe counseling, in general,must deal with the intellectual level and thefeeling levelof the patient as well as his family. So, let's assume Dr.Moore that I, a speech pathologist, am working with ateenage boy diagnosed as having a voice disorder. Duringtherapy this boy tells me, "My dad says if I don't changemy voice, he'll cut off my allowance. I've been trying todo something about my voice but I just can't seem tochange, and I don't know whether it's best to leavehome or what I ought to do." My question is, "whoprovides counseling that deals with the feelings of theboy, and the feelings of the parents?" Should this be thesame person, i.e., the speech pathologist, who is also"intellectualizing" on the problem or should anotherdiscipline be represented?

MOORE: It seems to me that speech pathologistsshould he capable of making the initial approach withthis boy. I believe we have to make an evaluative judg-:nent of his vocal potential and to start him toward anunderstanding of his psyehosocial difficulties. He hasfocused his attention on voice and even though the causeof the disorder may be an environmental problem, hemust be approached initially on the vocal problem. Theinformation supplied and implied in Dr. Bang's state-

ment of the problem may be summarized as a basis formy point of view as follows: this boy is objecting to his

environment and the pressure exerted by his father; heisn't capable of leaving home despite his own beliefs.Consequently, he does not have a choice between leavingand staying; he is dependent upon his father. The fatherwill continue to exert pressure until there is sonic helpabout the voice. So what I'm trying to say is that thevoice problem should be approached directly in an effortto start the boy working on his voice. This action willsatisfy the father's demand that something be done.Concurrently an approach should be made to the fatherto help him understand the environmental factors. Ifpressures from the family can be idertified, then Ibelieve there could be some modifications in the familyattitudes through counselling procedures. However,some of us in speech pathology may not be trainedsufficiently to serve as both voice therapist and coun-selor. If it is possible to get help from a counselor, Ibelieve this should be done. On the other hand, manyfamilies will not admit to the need for professionalcounseling. In this situation we can develop their readi-ness for such service.

In summary: I believe that if this boy came to a speechpathologist, this person would have the responsibility forstarting the vocal rehabilitation and possibly, for

managing the total rehabilitation program.

Undoubtedly, other panel members have opinions onthis question.

ALLMOND: I'd like to ask, once you've started it off,then what happens? Who takes over or what takes overand where does it go from there? Let me just add inparentheses that as a pediatrician I'd be itching to get ahold of this boy and his father. I'd like to leave thetreatment of the voice disorder to you folkg, but I'dreally be interested in sitting down with the boy and hisfather. My initial question reflects that of Dr. Bangs: ifyou as speech and hearing professionals arc not trained

to do this, is it appropriate that you get the training andthat you become well-equipped in handling the kinds ofthings which she's bringing up?

MOORE:, If we had the pediatrician to help, then Iwould be more than happy to urge him to help with thefamily situation. Unfortunately, too often we don't havethis opportunity. How can we draw the pediatrician intothe rehabilitation of a voice disorder? We regularly seekthe help of the otolaryngologist for obvious reasons, butI think too often we don't involve the pediatrician. Whatcould the pediatrician do for this boy?

ALLMOND: I don't like to get hung up on the walls ofdisciplinary boundaries, because I don't know that it'sany more exclusively the pediatrician's province than itis, let's say, another discipline that's involved in thewhole business. Parenthetically, it's not all that easy toentice pediatricians to become interested in things ofthis nature, as you're well aware; we're trying this at UCMedical Center in a very direct way but the going istough. I'm wondering if there should be, and now I'moutside your discipline looking in, if there should be oralready is training within your field towards this kind ofcounseling.

MOORE: There is some training in counseling proce-dures but I believe there is not enough. The problemcomes back again to persons in our field who have aprofessional myopia. There seems to be a tendency tosee the tremendous values of those subjects and experi-ences that have been in our own training and to excludeothei areas. Unfortunately, there appears to be littleattention given to family counseling in the academicpreparation of speech pathologists.

BANGS: I have a question germane to yours. If there isto be a physician involved in the counseling, andcertainly I see a need for this, and if the speech pathol-ogist is to be involved in modifying this voice behavior,then should these two people meet with the patient ormeet with the family rather than meet individually? Ican see many problems cropping up if I, as a speechpathologist, talk to a person who has very had feelingsabout himself and about his family, and then he goes thenext week to somebody else who takes a different stand.We just may be tearing this person to shreds rather thanhelping to pull him together as an individual. Whatwould your com milts be?

FLOWER: This kind of joint session is a marvelous idea,but even working full time in a Medical Center, in closeassociation with the medical profession, it's frequentlyalmost impossible to arrange. We must also recognizethat, with the exception of children with voice disorderswho may be in the care of pediatricians, the medicalspecialty most concerned with voice disorders is otolar-

8

yngology. Most otolaryngologists admit their lack ofsecurity, concern, and perhaps interest, in anythingbeyond the possible surgical aspects of voice pathology.

I believe and 1 think we encounter this morefrequently in voice disorders than in any other place itis extremely important that we accept the concerns ofthe patient as he .,cites them, even though those con-cerns may not be the important concerns. If he's con-cerned about his voice, telling him on the first interviewyou don't need me, you need psychotherapy. is prob-ably going to send him home and not to the psycho-therapist. There must be a period of time in which wework with the patient on the symptom level hopefullytoward getting the kind of help that's actually needed. Ialso wonder about the father of your hypotheticalpatient. If it were riot the voice disorder, would it he thelength of the hair? I think maybe again that the com-plaints people conic in with, are not necessarily theirmajor concerns.

SHERMAN: I guess being a developmental psychologist Ihave a number of advantages over speech therapists and

physicians. The primary advantage is that my role is notdefined. Very few people really know what psychol-ogists do or are supposed to do and this gives usextraordinary freedom in doing whatever we want to do.Psychologists, particularly those working in behaviormodification, have another advantage they're veryarrogant. They assume that their province is behaviorand that they can deal with any kind of behaviorjustpresent them a problem. This is obviously false, I think,but nevertheless, it's a very common attitude amongbehavior modifiers which I share for the most part. Now,given the problem as you stated it, there is a number ofissues that I would be concerned with. One, I guess, issimply the definition of the problem. The fatherapparently is very upset about sonic characteristic of theboy's voice, and a very reasonable question might be, "Isit a problem?" Is it just something that's of concern tothe, father that's not of concern to the mother, that's notof concern to any of his teachers? If the boy's voice isjust of concern to the father, I might say, "Well, it lookslike we primarily have a problem with the father. He'sharassing the kid about his voice and we may need to dosomething about this". On the other hand, if a numberof people judge the boy's voice to be a problem, asocially important problem, then it would seeni likelythat some modification is necessary in the manner inwhich the boy speaks. Then it simply conies down to thequestion of, how is that modification to be made, and isthe family to be involved in this modification? In myopinion, it's absolutely necessary that the family beinvolved in the modification, for a variety of reasons. As

a behavior modifier and as an operant conditioner, oneof my primary goals is to control the consequences ofbehaviorto make some changes in the consequences ofthe behavior so as to produce a desirable change in theboy's voice. Some of the most important, powerfulconsequences in a child's life are those provided by thefamily members. The father's threat to do away witl theboy's allowance certainly is a consequence that could beused to modify the boy's voice. However, in my opinion,it's the wrong type of consequence. First, it's a threat.It's an aversive kind of contingency which I don't thinkis the best way to approach establishing new behaviors.

Secondly, it has an all-or-nothing characteristic. It saysto the boy, "If you don't change, all of a sudden onyour own, then I'm going to take away your allowance."The threat simply has no flexibility in terms of providingconsequences for small changes in a, desirable direction.As a behavior modifier, I would want to involve thefamily to define what the problem behavior is, to specifywhat a desirable change would be, hopefully to providesonic kind of measurement system for the behavior, andthen to try and involve family members in providingpositive social and other consequences for changes in the

behavior which are towards a desirable direction.Requiring the terminal behavior from the boy right tostart with, is, I think, a very unrealistic goal.

ALLMOND: I low would you do sonic of those things,Jim?

SHERMAN: Well, most of the work that I've done is withautistic children, retarded children, and mute psychoticadults; and it's a different problem involved in all those.Nevertheless, there are some similarities. Probably what Iwould do first of all is to bring the parents into thesituation and then try and get some definition of theproblem behavior. What is it about the boy's voice thatshould he changed and in what ways should it bechanged? Given that there is some agreement that thereis a problem, and on the basis of my ow n observation of

the boy's voice, I would probably bring the parents in andsimply lay out the problem, what are the characteristicsof the problem, and what are sonic of the approxi-mations towards a solution to that problem.

ALLMOND: Would you lay that out, or would they laythat out for you?

SHERMAN: I would probably lay that ont for them, onthe basis of what they said and what I have observed.personally am very directive about what I do. I wouldalso examine the characteristics of the boy's voice in avariety of situations. But I would probably lay out the

problem to the parents, at least as I saw it. At this pointthey would probably also bring up additional issues. Anytime you have a family in an interview situation and youstart talking about voice, a variety of other issues coniesup. For example, three minutes into the interview thefather may start complaining about the boy's long hair.As the wide variety of other problems comes up, youmay have to say, "Look folks. let's deal with voice firstand then we'll worry about long hair," if this is a prob-lem.

BANGS: I would like to interject a question. As a speechpathologist, let's say I've not had any of this training. Doyou think it's possible for a person like myself to be ableto take a short course, a semester's course, or to bring ina consultant to train me so that I can do these kinds ofthings? Or, will there be enough "behavior-modifier-type" people in the community to call upon, and if so,how expensive are their services? Cost can get in the wayof therapy.

SHERMAN: I don't know about the expense. Manybehavior !mu:Viers in cases like this do it for free,because the,i're interested in the research possibilities.Whether that's a satisfactory answer or not, I don'tknow. My primary interest is not in training the familymembers to be supportive personnel, but to be the thera-pists. Given that I'm making the assumption that I couldtrain family members to be therapists in that situation, Ithink it would be reasonable that anyone could betrained. It's not that complex in some ways, in terms ofthe basic concepts. In terms of the actual utilization ofprocedures and putting those procedures into effect, itbecomes very, very complex, but I don't think therewould be any difficulty in training speech therapists todo that. In fact, I think that many speech therapists thatI'm acquainted with, do enter into the family situationand try to restructure the interaction patterns and thesocial consequences to bring about some desirablechange in behavior.

BANGS: One more question: What kind of overlap isthere among these specialists; that is, you, as a psychol-ogist in behavior modification, the psychiatric socialworker, the psychological couselor? We, as speechpathologists, have many routes we can go, how wouldyou

SHERMAN: I really don't know.Typically, the paths ofinteraction are broken or paths of communication arebroken between various disciplines for a variety ofreasons, primarily theoretical. I've worked with medicaldoctors, with speech therapists, and with social workers,

9

and as long as we can agree on certain assumptions thereis very little difficulty in working together. We need toagree that we are primarily concernedwith changing thebehavior of the patient. If we will agree that that's a

primary concern, then we have a good start. We don'thave to agree that that's the only concern, but only theprimary concern for the moment. Secondly, if we agreethat changes in the environmental conditions are necessary to produce those behavioral changes, then we're inthe right ballpark together. We typically have littleproblem working together on that kind of basis. Butthose two agreements may be hard to arrive at becauseof my professional training and the professional trainingof other therapists. If we can't agree on these two issues,then we simply don't work together. There are noreasonable grounds for doing so.

FLOWER: I'd like to return to something you said earlier;I don't think its a question of being directive versusnondirective. I am concerned, however, at accepting tooreadily face statements of problems. I thoroughly agree

with you that we'should work toward clear definition ofthe behaviors to be modified.

I'd be concerned, however using Tina's exampleabout accepting at face value that the first complaintrepresents the most important behavior in this family tomodify at the moment, and recruiting the family aroundit. I can see where potentially this might feed intosomething that's not very good in this family system. Iwould rather work a little more slowly and help thisfamily define their problems a bit more exactly.

SHERMAN: Very often it's the case that the originalcomplaint that a family or an individual of a familycomes in with is very, very different from the complaintthat they bring up in subsequent sessions. You findyourself virtually with a snake's nest on your hands, thateverything is all intertwined. The only way that I'vetried to handle this is simply to get some agreement onwhat is the first problem that you want to work onsomething that most members of the family will agreeto. This, to me, is extremely important. Given that youarrive at some behavior definition of a problem anddevelop a therapy procedure to begin to ameliorate thatproblem then you can start on the next problem. But Iwould never attempt to handle all of the many problemsthat might exist simultaneously. I just don't think it's a

feasible procedure. It may be difficult to obtain coopera-tion from the family members since there's no reasonthat the family should believe that you can help themwith their problems. Psychologists are very often in theposition of being snake oil salesmen. They have notproduced evidence that their procedures are effective.

10

They have not produced evidence that they really knowwhat they are doing. A therapy procedure may involverather extensive changes in the present patterns offamily interaction. Why should a family coming in fortherapy, speech or otherwise, fully cooperate with youunless you can demonstrate some effect of your pro-cedures? That's one of the reasons why I emphasize a

measurement system for the problem behaviors andkeeping a daily record of what's happening so you cansee some kind of change in the behavior, Given that youLave a number of examples of behavior change within a

family, it seems to me you are in a relatively strongposition to enlist further cooperation. You have demon-strated your functional effect on the behaviors of thefamily or individuals thereof, and you now are out ofthe position of being a snake oil salesman. The measure-ment system is the only safeguard we have against that.

BANGS: How many times a week would you meet withthese people? Would you initially propose ten meetings,one day a week, for an hour? Would you meet in thefamily's home or in the therapist's office? Who comes tothese meetings? the mother and she father? Which agesiblings? Do you take them individually, or in specificgroups?

FLOWER: By's a much more experienced family thera-pist than I; would you comment?

ALLMOND: I'll say a little bit. My bias and vantage pointcome from the fact that I'm very interested in conjointfamily therapy a la Virginia Satir, Nathan Ackerman, JayHaley, Don Jackson. Those are some of the names whosetheoretical notions seem to fit what I likeand startingfrom that vantage point then my approach with thisfamily would be to have them all come in, includingsiblings, mother and father, and the identified patientand in much thc same way (although I'm not sure ourmethods would he the same, my end point would be thesame) I would want to arrive at some definition as towhat's the problem and what does the family want towork on. oat, along with Dick, I might go a little moreslowly and allow them to expand their views of thcproblem rather than too quickly putting it out on thetable, as I was seeing it.

SHERMAN: I guess my only response is that psychol-ogists typically don't have the prestige of a medicalinstitution behind them and the assumption that theyknow what they're doingvery often a psychologist hasa reputation of one who does not know what he isdoing. I'm really very concerned with this. If you'regoing to do effective family therapy then you have to

have a situation that's responsive to your requests tochange the present environmental conditions. So it'sabsolutely essential, for me at least, to have the coopera-tion of the parents. One of the best ways of getting thecooperation of both the parcnts and the children is byshowing them that this type of therapy works. That'sone of the reasons why I'm most interested in getting inas soon as possible and attempting wo achieve some sortof desirable outcome, whether it's on a very minorbehavior or not, it doesn't matter.

MOORE: It appears that the old adage which statesthat there usually is a good reason for a proposal andthen there's a real reason, may apply to this case. Thegood reason that the father focussed on initially may beonly the peak on the iceberg. I believe the discussion hasdemonstrated amply that there is need for furthcrexploration. The person or persons who should conductthis exploration has not been clearly set forth. It is

obvious that individuals in any of several professionalgroups could very well do it; and, I believe, that we asspeech' pathologists have a responsibility to acceptpatients of the type described in Dr. Bangs question. Ibelieve it is unprofessional, at the initial stages, to refersuch a problem immediately and say it belongs tosomebody else. On the other hand, I believe it is unethi-cal for us to attempt to carry a procedure beyond thepoint where another person could more adequatelyhandle the problem. I wish I knew how to determinewhere my inadequacy stops and his adequacy begins. Weall recognize thal the point of transfer must be deter-

mined in each case and where there is doubt, it is

probably wise to refer. Undoubtedly this particulargroup in the discussion sessions will have much to addon this point; you probably face the issue frequently. Isthere another question that should come into our discus.sion? Tina, do you wish to introduce another problem?

BANGS: This I'm sure you can dispell in a hurry. Youalluded in your presentation this morning to the factthat, in the dialect languages, we have children andadults whose phonologic features are diffcrcnt frompersons in other communitiestwangsthis kind ofthing. Let's say that wc have a child moving from onevicinity to another where voice qualities differ, and thespeech cliaician in the public school sces this child.Should there be a thcrapy program to change theprosodic features?

MOORE: I expect there are persons in this group whoare much closer to this problem than anyone of us hereon thc panel, but I have some beliefs about it. I am sureyou would agree that we probably would not definesuch a dialect deviation as a defect. However, it signals adifference in the speech and if thc dialect varies suffi-ciently to set a person apart from his associates in hisenvironment, thcn I believe we as speech pathologists areobligated to help develop an acceptable form of speech.Conversely, if the vocal characteristics are not impairinghim; if wc, as speech corrcctionists, arc the only oneswho judge the voice to be different, I question that weshould attempt to force a change.

,._

I i

The Family of the LaryngectomeeJohn C. Snidecor, Ph.D., University of California, Santa Barbara

HISTORY AND INTRODUCTION

The laryngectomec is a-substantially different personthan he was before his operation even though his handi-cap is not immediately as noticeable as it is for one whohas lost an eye, or an arm, or a leg. This fact is preciselystated by Diedrich (3), "The full impact of amputationof the larynx is not ordinarily apparent. A fully clothedlaryngectomee walking down the hall does not lookmuch different from anyone else. It is not until he isasked to speak, cough, breathe, eat, smell, bathe, lift,cry, or laugh that his differences become patent. Inother words, little is left unaffected in the laryngee-tom ee's physical, psychological, and social behavior."

As an individual, the laryngeetomee has been studiedin a number of different ways. Even his habits andpersonality prior to the operation have been studied byWebb and Irving (11) who conclude that many laryn-gectomees befog, cancer manifested the oral triad ofexcessive talking, smoking and drinking. These twowriters also point out that some laryngectomees areunstable in the direction of asociality rather than in thedirection of neuroticism. Stoll (10), among others, hasably described his fears:

1. The fear of the word cancer and the manysemantic implications involved in such a word. Thefear of death is probably the paramount fear. 2.The fear of operations in general. 3. The fear ofthe permanent loss of voice. The anxiety associ-ated with this fear results from the assumed con-sequences of permanent aphonia. The patient'sentire pattern of interpersonal relationships builtup through the years becomes threatened. Heworries about the probable loss of his job, hissecurity, his friends, etc.

The fears often experienced by patients post-operatively are as follows: 1. The fear of the recur-rence of the cancer, hence the continued fear ofdeath. 2. Fears due to the new physiological rela-

12

tionships resulting from the laryngeetomy. (Theinability to lift heavy objects, the breathing andcoughing from the tracheal stoma, the oftenimpaired sense of smell and taste, the cosmeticliabilities of the tneheal stoma, etc.). 3. The fearof old age which has been aggravated by the feel-ing of uselessness resulting from the loss of speech.The depression frequently observed often has itsroots in this specific fear. The loss of earningpower further contributes to this feeling of useless-ness. 4. Fear of being unable to re-establish oldpatterns of interpersonal relationships. 5. The fearsassociated with the anticipation of failing to learna new method of speaking.

Harrington (5) has stressed the complication of age. Itshould be noted, parenthetically, that 60 is the medianage for male laryngectomees so at least half of the grouphas entered into some of the problems of aging asidefrom laryngeal amputation and loss of voice.

Amster (I) has shown that conventional personalitytests indicate that laryngectomees are essentially thesame as a class when compared to others. In terms ofwhat these tests measure, this writer is sure that differ-ences do obtain based on methods of tail zion differentfrom those in standardized tests. One of the bases forsue' a judgment is stated by the writer (8) and based onthe review of case studies done in England by Hodsonand Oswald (6) as well as studies done by himself. Inbrief, the successful esophageal speaker is outgoing, the"best" in his trade, often devil- may -cart, and potentiallysociable even though he may have to struggle to be heardin social situations.

Most laryngeetomees, like most people in the generalpopulation, arc married and have children. If childrenare living at home, they will likely be in adolescence andwill often he rather especially sensitive to peculiarities intheir parents. The spouse will usually be of comparableage and will be experiencing at least the first signs ofprcsby cusis.

Statements of advice to laryngectomees have, in

general, been based on empirical data. The surgeon orspeech therapist or laryngectomee speaks or writesadvisory comments to the laryngectomee in regard todress, voice, personal hygiene' and so forth. Thesecomments will be realistic and useful only if the advisorhas adequately filtered some facts and made sound judg-ments. By way of example of advice based ou nonfactualdata, a few years ago many surgeons, speech therapistsand laryngectomees stated that one could learn if heonly tried. In other words, with "will power" odds were10 to zero. The facts, based on the A. C. S. survey,indicate that odds on a nation-wide basis are 7 to 3 infavor of learning speech. These are good opportunityodds, but not good enough to bury the artificial larynx-.

Another example, but a good guess this time, Mrs.Ann Lampher, of I. A. L., has for years insisted thatfemale laryngectomees retain and even stress thefeminine in their voice. Many have been skeptical of thelatter idea, for the superficial acoustical aspects of thefemale voice are masculine. However, in 1969, thiswriter with Knorr (9) found that the female laryngec-tomee voice can be identified because acoustic formantsarc similar to those in the normal female voice.

The most useful items of advice in regard to familiesof the laryngectomized have come from two studies.First is the study of Diedrich (2) from the Speech andHearing Department, University of Kansas MedicalCenter and the Veteran's Administration Hospital,Kansas City, Missouri, where 87 answered his question-naire. Second is the study of Warren Gardner (4) basedon laryngectomized women, three-fourths of whom weremarried at the time of the operation. Neither arc studiesof intra-marital relationships per se.

With inevitable injustice due to truncation, thesestudies make the following points. First the DiedrichStudy:

1. Speech, coughing, breathing, eating, smelling,bathing, lifting, crying, and laughing are altered.Most of these changes may be related to personalrelations in marriage. An example from thiswriter's experience is that of an out-going andemotionally expressive woman who had bothlaughed and cried a great deal. Subsequent to theoperation the husband judged from her silencethat his wife had undergone a marked change ofpersonality and he became depressed. Analysis ofthe situation indicated that little, if any, changehad taken place in the woman's psyche. Discussionand counseling bettered the situation. Many agood cook is not appreciated as she once was be-cause her husband has lost or in large part lost hisSr nse of sind1. (Seventy -seven per cent of

laryngeetomees have permanently lost their senseof smell.) Other examples abound.

2. With esophageal speech there is less speech afterthe operation than before. This could give positiveas well as negative responses.

3. Speech is at times tiring (57%).

4. If the individual has good speech he is more likelyto live with one or more persons. Those with fairor poor speech tended to live alone.

5. Speech is not as loud as before the operation.Consider, therefore, the effect upon the spousewith a hearing loss.

6. Speech is very much more difficult when emo-tionally disturbed, and much better when relaxed.However, how many marriages, even good ones,are always relaxed?

7. Speech is poorer in the morning.

8. Many have problems related to the drinking ofliquids and swallowing 'of foods. Comment: Thecook may have to learn to modify her cooking.Soup may be served in a cup.

Gardner Study:1. More than three-fourths of the women were

bolstered because their husbands were with themwhen the report of cancer was given them. Three-fourths of the men continued full support duringthe operative period.

2. A minority of husbands thought only of them-selves. A few actively rejected their wives duringthe operative period and later.

3. Eighty-five per cent of single women accepted fullresponsibility for their surgery, whereas almost allof the married women could share the responsi-bility.

4. Only 23% of all of the women said they believedthat surgery made them less feminine. However,16% had reservations about their ability to displayaffection.

5. Forty-six per cent of the wives thought they werebeing avoided or overly babied, whereas fifty-fourper cent wrote gladly of their husband's optimismand confidence.

6. More married patients (92%) than single (81.5%)who sought out their friends gained speech, Inother words, if the quality of being outgoing isheld more or less constant, the married womenexcelled in communication.

13

7. Sixty-six per cent of the husbands positivelyreinforced their wives' speech with forty-four percent disliking or even making fun of their wives'speech.

8. Sixty per cent of the single women were depressedbecause relatives or friends did not visit them.There is no statistical break down between friendsand relatives.

9. More married than single women had an unfavora-ble impression of their first esophageal speechsounds.

10. Many women felt that they were treated withindifference or even ridiculed about their speech.Fewer than one-half (44%) of married womenexperienced such treatment, whereas 67% of thesingle females felt so treated ("People wereashamed of me." "They were afraid of hurting myfeelings." "People throw up when I try to talk tothem." "They think I am deaf." "They are afraidof catching cancer."). People did not listen tothem, became impatient, and often filled in withwords that were not fitting to the thought thatthey were trying to express.

11. Sixty-six per cent of husbands were kind and help-ful with speech.

14

12. One woman with five sons and grandmother toeight said her Christmas present to all would be anew voice.

13. One woman learned to talk so she could continueto raise and train dogs.

14. As regards intelligibility, married women excelledin telephone speech (71%) and singles rated 54%.In dose conversation 81% of married women wereeffective with 66% of the singles effective.

There is much more to both the Diedrich and theGardner Studies. The writer has only gleaned them formaterial relevant to the laryngectomec and his family.

PROCEDURES FOR THE PRESENT STUDY

Two questionnaires were developed of both the "yesand no" and open-ended type. One questionnaire wasfor the laryngeetenice and one for the spouse. Theywere made out separately and mailed not to the writer,but to a departmental secretary. Upon being received,the results were tabulated and comments recorded.

The nature of the questionnaire and the results arerevealed in the following report.

LARYNGECTOMEE FORM

GENERAL

Sex Age Married Size of family living at home when operation per-

formed Employed If so, type of positions Retired

Housewife

N = 50

There were 124 male (80%) and thirty-one female (20%) laryngeetomees reporting as ofSeptember 1, 1970. Their age ranged from 43 to 90. The median age was 62 for females with arange of 44 to 8? . For males, th, median age was 62 with a range of 43 to 90. Seventy-nine(51%) were employed. The positions ranged from service station attendent to corporationpresident. Sixty-five (42%) were retir.d. Eleven (7 %) were housewives:

COMMENTS:

1. There are more females represented in this study than in a normal propulation of !armee-tomes. In viewing the positions held by both male and female one immediately gains theimpression that these individuals are middle-class ,,!acs, for a substantial number appear to be, or

were, successful business and professional people.

2. Seventy-six per cent of out sample was married, thus, were, as far as we can determine, infavorable circumstances for learning esophageal speech. Generally speaking, only the man andhis wife constituted the household which would be expected for most of the people in the agerange considered. However, the size of the family did range as high as thirteen, although thiswas not a typical figure.

Operation

How long since your operation(Example: 6 months, 21/2 years, etc.)

Was it total? Radical neck dissection (1 or 2 sides)

Asai operation? Radiation? before or after operation.

3. The median number of years after the operation was three years and six months. It has beenstated that laryngectomees seldom improve after a period of four years. Therefore, most ofthese individuals would have, in all probability, nearly reached a plateau as regards to speechdevelopment. Ninety-two per cent had a total laryngectomy with 47% also having a radical neckdissection. Fifty-five (76%) individuals of this 47% had one side and eighteen (24%) had bothsides. In other words, almost Otte-half of our individuals were handicapped in regard to reachingfor objects and other manipulations. With the females in this group, housekeeping would bevery difficult because dishes could not he placed high in the cupboards not could they, forexample, wash or dust anything with ease at a high level. There are directions that can be givento somewhat assist in reaching high objects, but these are seldom knon to laryngectomces. Itwould be unrealistic for a man to continue a vocation of housepainting, barbering, wallpaperhanging, or carpentry if he had had a neck dissection.

15

Seven per cent of the individuals in our sample had the Asai operations, and it's doubtful thatany population .ampled would produce 7% with Asai operations except in California andaround Osaka. Kobe and Kyoto, Japan, where Dr. Asai originated the operation. The writer canidentify the surgeons who performed the operation, but cannot relate these to the anonymousdata.

Irritants

.

I did not smoke I did smoke packs of cigarettes a day for_ years.

My job of caused irritation of my throat

with

(Example: dust, smoke, etc.)

I drank: socially occasionally heavily not at all

Ninety-two per cent of our population has smoked ai some time. Strangely enough, 1.3%started after the operation. Only eight per cent of our population has never smoked. A few usedcigars and pipes. Of those who smoked, the median was two packs or 30 cigarettes a day with arange from a few cigarettes to six packs a thy . The median is represented by 38 individuals whosmoked two packages of cigarettes a day.

Twenty-one per cent of our individuals previously held jobs under conditions which, from theirreport, caused irritation; for example: chalk dust for a teacher, engine smoke for an individualaboard ship, dust for a griin operator. chemicals for one in the oil industry, and plastic dust fora machinist.

Of those who drank, 50% stated that they drank socially, 36% only occasionally, 10% heavily,and 9% did not drink at all. Ninety-one per cent did some drinking. Some in the 10% groupmay have started drinking after the operation, perhaps even as a result of it. King Lowlks andPcirson (7) have figures which make ours look optimistic. They stated the "Laryngectomecs arepredominantly Caucasoid male smokers, in middle and later years, and 25 to 50% arealcoholics. Because of age distribution of veterans generally, patients in this series weresignificantly older at surgery than national averages." In contrast to the success rate in a normalpopulation the group studied by King 0 al succeeded in esophcgcal speech only 40% of thetime. It is quite obvious that the veteran's population in age and attitude is significantlydifferent from the norm. King also estimates that 4 ounces of whiskey and 30 cigarettes a daywill multiply the chances of laryngeal cancer by a factor of 10.

The Surgeon, Surgery, and the Hospital

Did your surgeon counsel you sufficiently?

At the right time? State briefly how the counseling could have

been improved:

How might nurses and other attendants have been more helpful?

16

Were you counseled by a speech therapist in the hospital?

Was this helpful? Briefly comment:

Were you counseled by another laryngeetomee while in the hospital?

Was this helpful? Briefly comment:

5. Eighty-five per cent of the population stated that their surgeon did counsel themsufficiently, and 88% of this 85% stated that counseling was at the right time. The majority ofthese typically commented that they would have like to have had for themselves and theirspouses more specific counseling by the surgeon in relation to the operation and to speechfollowing the operation. Sixty-seven per cent had no conflict about their nurses. In general, itwas felt that the chief criticism of the nursing care was concerned with lack of medicalknowledge on the part of the nurses; that is, knowledge related directly to the laryngeetomyoperation and its effects upon the laryngeetomee. For example, they should be taught to cleanout tubes, and not be afraid to use the suction machine properly. On the psychological side,they should be more honest and less optimistic.

In terms of percentage, 21% were counseled by a speech therapist. It is notable the 82% ofthose counseled by a speech therapist thought it was helpful. Fifty-nine per cent of our samplewas counseled by anther laryrgectomee. Of this group, 81% considered such counselinghelpful. The main benefit of counseling by another laryngectomee seemed to be in increasingmorale and giving a challenge to the laryngeetomee. However, females were depressed by visitsfrom male laryngectomees. This precisely coincides with Gardner. There is little doubt thatmale laryngeetomees should not counsel female laryngectomees in the hospital. The mostaffirmative statements are in regard to counseling by the speech therapist.

YOUR SPOUSE

Was your spouse with you when the diagnosis was mad. 9

What was his/her reaction?

Did your spouse give sufficient support prior to the operation?

and immediately afterward?

Were you "babied" or overly protected? When?

and by whom?

Did your spouse's attitude help you with speech?

Is your spouse hard-of-hearing?

Did your spouse seek employment? Continue to work?

If new employment was sought, did any difficulties arise in your family?

After leaving the hospital, was it difficult to readjust to a normal sex life?

17

How could your spouse have helped more with any aspect of your problems?

6. Seventy-two per cent of the spouses were with the laryngcctomec when the diagnosis wasmade. Over 59% commented that they were: shocked, anxious, and deeply concerned. Ninety-four per cent said that they had sufficient support before the operation and 89% immediatelyafterwards. These figbres are very high relative to other studies. It may well be that the Gardnerstudy has had an impact on those who counsel laryngeetomees. Seventy-four per cent (16% NC)denied that they were babied or over-protected. Seventynine per cent said their spouses'attitudes were helpful in learning speech. Only 8% admitted to a hearing loss. Only 8% felt thatthey needed to seek employment after their spouses' operations. Thirty-six per cent continuedto work. In view of the large number working, the 8% who sought employment does notconstitute a very meaningful figure. Of those who sought employment, 20% (2 out of 10) hadfamily difficulties arise. Twenty-one per cent of our population admitted difficulty with theirsex life subsequent to the operation. Twenty-seven per cent had no comment to make whichmay indicate a negative attitude about this question. Counseling appears to be needed in thisarea.

Fourteen per cent of our laryngectomces said that they could have had more help from theirspouses. The usual comment was that more patience, understanding, and listening were needed.Some commented that their spouses made them nervous. In one ease, the spouse knew of thecancer before the patient. Sadly, one laryngectomee said his wife could have been more helpfulif she had not deserted him. i

CHILDREN LIVING AT HOME

Ages: Sex:

How did they react or over-react to your operation?

How did adult offspring behave?

7. Twenty-eight per cent had children living at home and their ages ranged from one to 30years, with a median age of 15. It is no stretch of the imagination to assume that those of themedian age of 15, male or female, have some adjustment problems. It is surprising, then, that58% of the children living at home reacted cooperatively with the patient - typical commentswere that they took it in stride, helpful and very good, perfect, and very understanding. This isa surprising statistic in view of the fact that one would not expect a high per cent of adolescentchildren to react so very favorably to their parent's problems. Adult offspring generally reactedfavorably.

YOUR SPOUSE AND YOU AND YOUR SOCIAL LIFE

What were your major social, religious, and recreational activities before the operation?

8. Four per cent of our laryngectomees said that they had no social, religious or recreationalactivities before the operation, while 85% had activities. Of those who did have theseactivities,only 41% of the 85% said that their life had remained unchanged, or in other words, 49% hadchanged their lives socially and recreationally.

18

If these have changed, in what ways?

9. This requires analysis because much of th. change related to the fact that people could natswim, skin dive, or golf. Some had a loss of friends, one individual -aid he became very latentbecause nobody cared about him. Generally speaking, social life is substantially reduced.

If changes have occurred, have these caused you or your spouse unhappiness?

or greater happiness?

10. Forty per cent stated that changes, as a result of the laryngectomy operation, have causedthem and their spouses unhappiness. Eleven per cent of our population stated that the changeshad made an improvement in their lives and they have greater happiness now. We can onlysurmise with Gardner that some, at least a few, couples may be drawn closer together by thecrises of the operations.

OTHERS

Did you receive important help (other than speech) from psychiatrists, your minister, priest,

other laryngectornees, organizations, etc :

11, Of the total group, 53% received help other than speech, lca'ing 38% who did not receiveany general help. Of the 53% who did receive help, 43% of these received help from the LostChord Club and the New Voice Club,Typical sources of help other than those clubs mentionedare the American Cancer Society, other laryngectomees, people at work, and the church. Twopeople in our group of 155 sought help from a psychologist or a psychiatrist.

YOUR SPEECH

I use, esophageal Asai or the artificial larynx for speech.

How do you get along in the family group insofar as speech is concerned?

12. Esophageal speech, 68%, Asa' speech artificial lary nx, 20%. Nine used both esophagealspeech and the artifii ial larynx which makes these figures total over 100%. Seventy-nine percent of our population said they got along well in the family group as far as speech wasconcerned.

Who first told you about new forms of speei h?

Who was your teacher? your surgeon a speech clinician

another laryngectomee Were your IeSSOIP effectively presented?

Ilow could they have been improved?

19

13. Only 53% of our population learned about new forms of speech from their surgeons. Therest learned from various sources such as: laryngectomees, American Cancer Society, aridspeech therapists. Of our population, 8% were taught how to speak by their surgeons, 63% byspeech clinicians, and 24% by laryngeetomees. The figure of under 100% is accounted for bythose who felt they were essentially self taught. Some 62% c".'our population said their lessonswere effectively present d, whereas 5% said the lessons were riot, Sixty-two per cent effectivepedegogy is too low. Comments for improvement were: more sessions, more time in thesessions, and better explanations.

How long did it take you to learn to speak?

Is your speech hesitant? rather free arid easy?

automatic?

14. The learning period for first speech ranges from immediately as in the Asai operation tothree years. No median can be established from our information. Hesitant speech. 29%; free andeasy. 51%; automatic, 34%. Nineteen of our subjects answered the comments both "free andeasy" and "automatic," so apparently they felt this described the same kind of speech. At least61% of our population had easy and free-flowing speech.

What did family members do to help or hinder your learning of speech?

15. Approximately 59% of our population received positive reinforcement with members oftheir families, with 19% receiving negative responses or no rest, nise at all from their families.The actual comments are, of course, as important as the statistics. Comments in regard topositive attiLdes report their families being: cooperative, good listeners, helpful in using taperecorders and walkie-talkies while practicing speech, Negative responses were that members ofthe family pushed too much, gave no attention, were impatient, and not understanding.

ADDITIONAL AND RELATED PROBLEMS

16. The data on additional and related problems is open-ended, therefore, it is really notpossible nor appropriate to use statistics. However, some of the very common comments wereabout loss of sense of smell, depression, physical irritation, coughing and mucous, lack ofability to swim, thoughts of suicide, need to change occupations. or loss of employment,domestic quarrels, food arid drug allergies, church not being helpful, and total disability fortheir type of employment,

Considering yourself and your family, would you have another total laryngeetorny or would

you take the considerable risk of only radiation?

17 Sixty-nine per cent said they would have another total laryngeetomy Eleven per ventwouli have had radiation only, and this choice was stated with full knowledge of considerablerisk as we stated on the questionnaire, "take the considerable risk." Nineteen per cent did riotconvert, 1%rlected the operation or radiation.

20

SPOUSE OF LARYNGECTOMEE

(One hundred and one responses have been received from spouses, fifteen of whom are male.)

BACKGROUND INFORMATION

Sex (There were 86 females and 15 males.)

STATUS TODAY

Age last birthday (The median age is 59 female with a range from 41 to 78.The median age is 61 male with a range from 40 to 87.)

Married (Ninety-six were married, one separated, with one widowed and two divorced.)DivorcedSeparatedWidowed

Number in family living at home (Median is two, with a range from one to five.)

Number under age of 18 (Only fourteen families had from one to two children under 18.)

STATUS AT TIME OF SPOUSE'S LARYNGECTOMY

Age last birthday (The median age is 52 female with a range from 29 to 72.)(The median age is 51 male with a range from 37 to 74.)

Number in family living at home _(Twenty-two families had one to three children, in otherwords,

Number under age of 18

LAST GRADE COMPLETED Circle one:

Grade School1 2 3 4 5 6 7 8

High School1 2 3 4

College Post-Graduate Academic degree(s)1 2 3 4 1 2 3 4 earned (if any)

(The answers ranged from Grade Six through third year postgraduate. Sixty-three per cent wereat least high school graduates.)

FAMILY INCOME AT TIME OF SPOUSE'S LARYNGECTOMY Check one:

Under $5,000 per year$5,000 to $9,999 per year$10,000 to $14,999 per year$15,000 or over

(Twenty-one per cent reported having incomesunder $5,000; Thirty-five per cent reported in-comes from $5,000 to $9,999; Twenty-six percent reported incomes from $10.000 to $14,999;Seventeen per cent reported incomes over$15,000.)

Note: Some spouses had been widowed; we used them anyway.

21

GENERAL

Scx Age Married Sizc of family living at home

Employed if so, type of position

Retired Housewife

1. Responses indicated that thirty-two per cent were employed, with sixty-eight per cent re-tired and/or housewives.

OPERATION

How long ago was your spouse's operation'

2. The answers range from seventeen years to five months with the median being four years.

Were you present when the diagnosis of cancer was made to your spouse'

3. Seventy-nine per cent said yes, with twenty-one per cent saying no.

What was your reaction to the surgeon's presentation of the information?

4. Out of our population of 101, only 13 appeared to be optimistic in general. There wasshock, heartbreak, worry, fright. One couple was shocked because of being in the process ofadopting a child.

What was your spouse's reaction'

5. Most spouses were depressed, two wanted to die. Fifteen (or 15 %) were optimistic.

Did you receive satisfactory counseling at this time?

6. Satisfactory counseling was received by seventy-six per cent of our population.

How might this counseling have been improved'

7. Some spouses commented that more information would have been useful as to what to ex-pect after and during the operation, and many would have liked to have had the surgeon talk tothem, 's well at, their spouses, to help them anticipate some of the coming frustration theywould experience.

What did you do to support and help your spouse's attitudes?

8. Generally speaking, the spouses gave encouragement, love, understanding. Some kept thebusiness going, some encouraged speech by talking and reading and some also went to speechclasses with the laryngectomces. One woman accused her husband of feeling sorry for himself.She felt that her criticism helped him.

'Are you hard-of-hearing?

22

9. Ninety per cent said no, while ten per cent said yes. It is obvious that in this age group morethan ten per cent of the spouses had a hearing loss significant in limiting the reception of esoph-ageal speech.

Did you try to help with speech?

10. Those that said they tried to help numbered seventy-one per edit of our sample.

Did you seek or continue employment?

11. Forty per cent said yes.

Is your spouse retired? Did he or she go back to the former job?

or a new job.

12. Forty per cent said that their spouses were retired. Of those not retired, sixty-six per centwent back to the former job. Of those who were still employed, twenty-two per cent took newjobs.

What, if any, home situations proved difficult?

13. Thirty-seven per cent of the spouses said there were no home problems. Some interestinganswers were that there was difficulty in: communication, hard-of-hearing problems, finances,suicidal tendencies, nervous strain, speaking and eating problems.

Has anything related to the.stoma (appearance, noise, coughing, etc.) been disturbing to you?

If so, in what ways?

14. Forty-five per cent of our population felt that matters relating to the stoma were disturbingto them. The coughing and presence of mucous was a well-nigh universal complaint from thespouses.

As a result of the operation did you become more or less dominant is the family situation?

Please explain:

15. Dominance on the part of the spouses increased for twenty-four per cent. For seventy-twoper cent there was no reported change. Four per cent reported that they had less dominance.

Did your major social, religious, and recreational activities change?

If changed, in what ways?

16. Thirty-seven per cent admitted to a change. Sixty-three per cent said there was no changein activities. Generally speaking, those who had fewer activities sought small social groups orisolation. One woman felt sorry because her husband could no longer swim.

Aside from your spouse, who helped you most with your problems?

23

17. Twenty-five per cent of the spouses did not get help from anyone else. Of the seventy-fiveper cent who did get some help, it was mentioned that it came from: physicians, relatives,laryngectomccs, wives of laryngeetornms, employers of a laryngectoince, priests, and speechtherapists.

ADDITIONAL AND RELATED PROBLEMS

React to any of the following or other problems which may apply to you. Depression (self orothers), hear, condition, hearing loss, your boss, domestic quarrels, food problems, churchesor clubs, jealousy, stoma (care, noise, etc.), work, retirement, etc

18. These reactions were highly varied and some appear worthy of mentioning at this time:felt had, can't swim, jealous!: on the part of one wife (apparently of nurses and those whohelped her husband more than she could), depression, heartbreak, annoyance of bibs around thehouse, launderi ng of stoma napkins, drinking, difficult to cook for, difficulty when trying to getmucous from stoma, financial domestic quarrels, frustration because spouse cannot help more.

References

Amster,Walter, A Comparative Study of the Breathing andSpeech Coordination of Laryngectomized and NormalSubjects, and the Relationships Between the Breathingand Speech Coordistationi and Articulatory Errors ofLaryngectomized Subjects to they Speech Intel-ligibility. Unpublished Ph.D. dissertation, SyracuseUniversity, 1954.

Diedrich, William M., Study from the Speech and HearingDepartment, University of Kansas Medical, Center andthe Veterans Administration Hospital, Kansas City,Missouri.

Diedrich, William M., and Youngstrom, Karl A., AlaryngealSpeech. Illinois: Charles C. Thomas, 1966.

Gardner, W. H., Adjustment problems of laryngectomizedwomen. Arch Otolaryng. Chicago: 83:3142,1966.

Harrington, R., Problems Associated with the Developmentof Pseudo-voice in the Aged Laryngectomee. ASHAConvention Report, 1960.

24

Hodson, C. D., and Oswald, M. V. -0., Speech Recevery,After Total Laryngectomy. Baltimore: Williams &Wilkins, 1958.

King, P. S., Lowlks, E. W., and Peirson, G. A., Rehabilita-tion and adaptation of laryngectomy patients, Amer.J. Phyz Med., 97 (9), 192203, 1168.

Snidecor, John C., Speech Rehabilitation of the Laryngec-tomized. Illinois: Charles C. Thomas, 1968.

Snidecor, John. C., and Knorr, Sharon K., A Study on theAbility to Discriminate Between Recorded Female andMale Esophageal Voices. Unpublished Master's Thesis,University of California, Santa Barbara, 1969.

Stoll, B., Psychological factors determining the success orfailure of the rehabilitation program of laryngec-tomized patients. Ann Otol, 67:550-557, 1958.

Webb, M. W., and Irving, R. W., Psychologic and anamnesticpatterns characteristic of laryngectornees; relation tospeech rehabilitation.!. Amer. Geriat Soc.. 12:303-22,1964.

DiscussionSNIDECOR: My subject this morning was the family ofthe laryngectomce, but I'd like to stress something elsevery briefly because the question was asked and it needsto be answered right now. In learning to teach a laryn-gectomee to talk, you have a direct learning situationand you'd better know how to handle it directly andeffectively with the right kinds of reinforcement andcancellation. If you don't, you're not going to have aspeaker and you're not going to have rehabilitation; for,if this client cannot begin to speak, his whole vocationaland family relationships are inadequate. The battle islost before it began. I don't want to oversimplify nor doI wish to have you feel there is something very esotericabout the teaching process and that only a few of usknow how to teach for this is not true. But then againthere are many people who think they know somethingabout it and don't. Teaching esophageal speech is a verydirect and positive kind of thing; success breeds success,and just give you one example of how I wouldapproach it with a laryngeetomee. I want to see him asmany as three times the first day. I'm like WillyDicdrick, I want this client to phonate before the sunsets if he can do so without stress. And if he phonatesthe first time around, the firt hour, fine. lie goes on hisway, and he goes home, and I hope when his wife says,"How are you doing?" He says, "Okay" or somethinglike that. If at the second appointment he phonates.fine, then we don't sec him later that day. If he phonatesat the third lesson then his day is made and so is mine.In teaching laryngectomees you're laying it on the line.Remember you have got about a seventy per cent chanceof teaching this person how to talk if he's under sixty-five years of age; the odds are with you they aren'tperfectbut they are known so you can look over theyears and know whether you're a skilled clinician or not.Nobody has to tell you, you can cheek your own rate ofsuccess. Now let's get on with the family problem.

BANGS: If we're going to be working with the laryn-gectomce and his or her spouse, then I guess we canassume that people arc helpable at a time of crisis. Afterlistening to your statistics it seems that there arc tworeal crises in the life of the laryngcctomec and hisfamily. One is the pre-operative crisis, or learning abort

the problem, and the other is the post-operative crisis. Iam not clear regarding your statistics. Does the speechpathologist do the best job in conferencing pre-operatively or post-operatively?

SNIDECOR: That was pre-op, at least in the ease Imade. A meeting before the operation doesn't have thepurpose of teaching speech, but orients the client andmay cancel some of the fears prevailing at that moment.

BANGS: All right. I would like to know, then, whatthe speech pathologist does when he or she meets withthe laryngectomee for the first time. Does she meet withhim, or with him and his spouse? Does the speechpathologist start out with a question such as, "Well, howdo you feel about it? Tell me how you feel about it," ora question such as, "Lel me help you anticipate whatyou will be like post-operatively." Or, does he start outwith something like, "What questions do you have?" or"Row do you think I can help you"? Give us somespecific idea as to how we get started with our firstsession.

SNIDECOR: Before I even attempt to answer this, I'dlike to say that Jack Bangs, (who is Tina's husband, asmany of you know) bale. and Strother, produced thefirst article on the laryngectomized individual generallyavailable to speech pathologists. It was published inJournal of Speech and Hearing Disorders in about 1946.For all of my being talkative when I get in a situationsuch as we have here this afternoon, I usually am nottalkative in the counseling situation. Now, mind yon,our candidate is in the hospital, not yet operated, hisvoice is hoarse and breathy, }hut he can talk, and so I'minclined to let him lead off, except to say, "I'm a speechteacher as you know. Somebody's probably told youthat you can learn to talk either with your own voice orwith an artificial larynx after your operation. Now. whatcan I tell you about it?" An interesting c.o, I hadsometime ago was a man who had a strange look on hisface. I said there must be something I haven't answeredand he said, "Yes, you haven't. After I get through theoperation can I keep on drinking?" He was a very heavydrinker and I said, "Well, this is between you and your

25

physician and insofar as the ability to swallow is con-cerned, you're still going to have it." he was a very quietguy, a custodian, and he didn't have to talk, so he wrote,but an interesting thing happened. I had obtained, for aChicano client, a sweet old fellow of 80 years, anartificial larynx because that's what he wanted. Hedidn't want to learn esophageal speech. He wanted amachine and he got it and used it. Well, my first friend,from the hospital, who never learned esophageal speech,met a girl and wanted to take her on a weekend trip andhe couldn't talk to her so he tried to con the Chicanoout of the artificial larynx and the Chicano called me upand said, "Should I loan it to him?" Now that's a hell ofa spot to be in, isn't it? Are you for or against sin? Ianswered in a very practical way for the Chicano. I said,"This man has a reputation for drinking heavily and hemight break your `machina.' My suggestion is that youkeep it." Now, I cannot tell you whether our first manever got away for the weekend or not, I just don't know.But you see, all he wanted to know was that he couldkeep on drinking. He didn't want to know whether hecould speak again. This actually happened, it's not some-thing you can generalize on, but it seems to me thatpeople in trouble are full of questions. You answerquestions the way they give them to you, and then yougo ahead from there if you think you should fill in, andsometimes you need to. Now that's the way I would doit. I don't go in with anything very structured. I have anartificial larynx in my pocket and an available playbackso I can play samples of esophageal speech, or perhaps Isay a few words in esophageal speech myself. So I don'tstructure, I play it by ear. This man is in trouble. I wantto soothe him, answer his questions and honestly moti-vate him.

SHERMAN: I have a couple of questions I'd like toask about postoperative treatment. You talked abouttraining the laryngectomee to phonate for the, first time,and then sending him home. What I'm really curiousabout, particularly with the emphasis on family therapy,is what do you tell the family to do/ Or do you tellthem anything? Do you give them ta As on which totrain the patient? Do you tell them to respond differ-entially to his speech in any form or another? I'm reallyinterested in a specific outline of a programming pro-cedure by which a laryngectomec is taught to speak andhow this involves family members?

SNIDECOR: I consider this a very important question,but there is no quick answer. Usually you have to give alot of general information. Surgeons, generally speaking,arc not highly verbal people so you may have a bit ofcounseling on your hands. I had a repeated operation

26

last summer, and I had a very strange feeling across mygut and on the surgeon's second or third hospital visit Isaid, "You know, I have a feeling across here which isvery disturbing to me." "Oh," he said, "Yes, I did theoperation a different way. I forgot to tell you that youwere going to have this sensation for about six months."Good surgeon, but hell of a communicator! So, I think,one of the things we have to do is say that speech isgoing to take quite a while. If it comes quickly, so muchthe better, but generally speaking, it's going to take awhile, perhaps as long as four or five months. If hedoesn't learn, we'll teach him how to use an artificial.larynx. Delay may be normal. Like my twinge here wasnormal, but I didn't know it. People read a lot of junk inReaders' Digest or Good Housekeeping, or someplacelike that about the magic of this or that. Now, I'm oldenough to know there's damn little magic aroundanywhere, and most of you will agree.. We must buildrealistic views about speech and then we have to saysimple little things like this to the family members:"Now, when he trys to say something turn the televisionoff, don't have the radio going, don't be riding in a caror plane or bus. Let's have it quiet." Simple? Obvious?But just terribly important. And then encourage positiveyet patient responses on the part of the children, thewife, et cetera. and recall what I said about the hearingloss. When two elderly people sit down at the table toeat, they should sit close together. One particular couplemade quite an affair of dinner each evening. They had acandle on the table, a highball or martini before dinner,and sat at the ends of the table. She said, "I can't hearhim." I explained the inverse square law, I said, "You sithere close by, he sits here, put the candle here." Shereported, "Now I can hear him." So now they wereseparated by eighteen inches instead of three or fourfeet, and it made all the difference. These are the sortsof things you've to keep working on imply, directly,and thoughtfully. Take this idea of not talking in a ear.Esophagcals arc never going to be as loud as they were sodon't speak where it will frustrate them. We also have tobe patient about speed. A hundred and twenty words aminute is a median figure for good esophageal speakers.That's a rate at which a secretary, a rather good one,takes dictation, but far below the normal rate of speech.That's a good speaker! You're going to be impatient?Well, you'd better not be. You've got to know thestandards, and everybody in the family and the bosshave to know the standards. You have the responsibility,so far as I am concerned, to talk to the boss if this willhelp. And I would prefer to take him to lunch than justwalk into his office. I want him to know that hisemployee is just as good as he was before, and that I amtruly concerned with the employee's welfare.

In general, you've got to be flexible. People are rein-forced in different ways. In another study the wife said,"He didn't talk `til I got on his back. He didn't talk `til Ipushed him." I'm perfectly willing to believe her but,generally speaking, people react better to the carrot thanthe whip.

Over and over again, wives state that they becomemore dominant after the male has become operated; it'seasy. He can't holler at her, he can't say this, that, andthe other thing quickly and loudly so it is easy for thewife to become more dominant. She may be ashamed ofit, she may know that it's cracking up her marriage, butshell do it, she'll admit it, it's in this study and it'scommon behavior. You as a counselor may be able tohelp.

Dr. Sherman, I have taken quite a few words to saythat you can't really formulate a clear cut program forfamilies. They differ too much. Teaching of esophagealspeech, yes,families, no.

FLOWER: Jack, to pursue the last question, are therespecific speech-like productions, let's say buccal noise,or whatever that you would have a family discourage ormonitor?

SNIDECOR: In general, I'd give the wife a notion ofwhat good beginning esophageal speech is like and lether reinforce this. Sometimes, speech which sounds poorat the time is the beginning of good speech. Now, so faras buccal speech is concerned, it's poor on all accounts;and so there is one thing that I will tell any member ofthe familydon't let him whisperdon't let him whisper.Let him write, let him use the artificial larynxbut don'tlet him whisper or use buccal speech. This is very simpleand absolute and depend on it: if he becomes a whisperer,he's had it. Almost never can we teach esophageal speechto a person who has fixed the whisper habit or uses buccalspeech. And further, such sounds are just no good fromthe point of view of communication, just no good at all.Positive reinforcement for effective speech, from thefamily, by all means, if this is the kind of thing that isgoing to stimulate him, but no conning! There are somepeople, nurses for example, who say too optimistically,"Oh, you're going to learn how to talk, everything'sgoing to be all right." Well, this laryngectomee has tubesup his nose, he's lying there feeling sorry for himselfwith good reason, and I don't care how brave he is, heknows that things ate never going to be quite the sameagain. You know and he knows that some things willnever be perfect again, so let's face this, let's tell thesenurses and social workers to be a little more realistic,and this goes for the wife, too. If she now babies herhusband and this happens many times, and with good

intentions, he becomes resentful. This is a new kind ofactivity which is patronizing and makes many peopleangry. Who wants to be patronized? You know, most ofus, the people in this group, are making a decent kind ofa living someplace with a sense of pride about what wedo. You don't want to go to a hospital and have a nurseor a physician or a speech therapist or a wife or anybodypatronize you. You want them to teach you, love you;but you don't want to be patronized or conned orpitied.

ALLMOND: For somebody who is interested in familythings, your presentation is kind of a treasure trove. Onething I'm particularily lighting on is your feeling that thespeech therapist somehow needs to be appraised of andget into the family system and know how the familyenvironment is reacting to the individual who has lost hisspeech. You know, the social worker's traditional homevisit, which is a beautiful tool, is being revitalized inother disciplines; and particularily some of us in familytherapy now are going out and having an evening mealwith the family at which we get lots of things besidesindigestion. That might be a very elegant way to get intothe kinds of things you're talking about: to see physi-cally how the home is set up for communication andemotionally how is it set up as well. I'm wondering ifthis has been done or if you have any experience with it.

SNIDECOR: Well, certainly at the beginning stages, Iwould be inclined to work another way with the familybut not in the home. But I can tell you something thathappens. Those of you who have worked with laryngec-tomees know this: if you teach your client how to talk,he's likely to visit your home. If he's a farmer you mightget some vegetables; if he is a business man you mayget a damn good bottle of whiskey for Christmas; if he'sretired, and buys a new trailer or a camper, he and hiswife will drop by, because they want to show it to you.Ill tell you a story about a retired couple because Ithink it's especially interesting. They had a goodmarriage built on give-and-take, a certain amount ofscrappiness. Irish people, lovely people, but theyscrapped a lot. And they stopped by to show us a newcamper they had purchased. They knew that we wereinterested in camping and fishing, so they dropped by toshow it to us. We were having coffee and cake and thewoman made a statementa very strong statement andthe husband turned to her and said sharply, "Mary, itwasn't like that at all. It wasn't like that at all, Mary."and she turned to me and she said, "Thank God, Bobcan talk again." The husband with his new esopha realspeech was reacting in a very strong and customary .'ay,so everything was all right again.

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In the home or in the office I do want to talk withmembers of the family. Further, I'd like to suggest to alot of you, including people in rehabilitation, that someoffice hours should extend beyond 5:00, or be sched-uled in the evening, or on Saturday, or you're not goingto see all of the family, the boss, and the other import-ant people in the picture. Most important is the clientwho may be worried about his job and reluctant to askfor time off when he already has had a long period ofsick leave,

FLOWER: Jack, there was one finding in your ques-tionnaire that was different than I would have predicted.In general, the pre-operative and post-operative coun-seling by other laryngeetomecs faired better than Iwould have anticipated. I have great concern about someof the instances I have seen where laryngectomecs makea career of working out some of their own unresolvedproblems. They tend to make many generalizationsaround the theme that because you face this situation,you have the same problems I do. I'm wondering if ourown lack of skill and sometimes lack of interest in work-ing with this population hasn't led us to discharge ourresponsibilities to people that maybe aren't too well-equipped to handle it. I think that other laryngectomecsmay have a place in the total rehabilitation picture. Butfrequently we turn over to laryngeetomees as lay-teachers, or lay-counselors, too much responsibility,particularly in working with the entire family.

SNIDECOR: I couldn't agree more . I know a man whois the very opposite. I'm sure he's still alive because hellprobably never die. His name is Shorty Poor. He livesdown in Del Mar, California. If you're down there dropin and say I said you ought to meet him. He's this kindof a personaround the house, he leaves his shirt openso the stoma shows, and some kids came by and one ofthem said, "Shorty, what happened to your neck?" Hesaid, "I'll tell you, boys, you know I raised cattle up inMontana, some cattle rustlers shot a hole in my neck."So they went home and they told the story to theirparents and, you know, the parents weren't that amused.But I asked Shorty once, "Do you ever go to Lost Chorddubs, Lost Voice Clubs?" He said, "What the hell wouldI want to belong to a club for if they're all held togetherby misery?" Let me hasten to emphasize that I believethese clubs are great until a person learns to speak, andas a place to go to help others, but I think they ought tostop there and people ought to get back into theirformer groups with a five card stud game, the church,whatever their hangup is. In brief, most laryngeetomeesas counselors, have limitations, and yet we have a fewvery good counselor-laryngectomms in Southern Cali-

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fornia. I'm not going to distort my data, but I'm goingtostate it in writing with great caution because generallyspeaking a laryngectomee is not a good speech teacherfor at least two reasons. One is overcompensation andthe other is that he's going to tell some learner how to talkand the teacher may be fifty years of age and he is aninhaler and this client is seventy -five and if he's going tolearn, he's likely to do so as a plosive injector, but he'sunlikely to learn by the inhalation method. So even themethodology may be poor. Generally speaking, I'm forprofessional instruction. I was reporting what the studysaid. Now I'll tell you what I think, and I think thelaryngectomee should not usually he the person to visitin the hospital, unless perhaps he comes as an adjunctperhaps with me, so that I can say, "I want you to meetBill here, he's an old friend, he's been through this."Maybe that's the ideal way to do it, I'm not sure. But Idon't send the male to talk to the female, ever.

BANGS: I have a question for you. I believe you statedthat the spouse usually has difficulty in accepting suchthings as wheezing, coughing, the annoyance of the bibsaround the house and having to launder them. All of theseare petty, picky little things which can keep mountingand mounting. How do you handle this? Do you bringthe spouses in as a group and talk about it, or do you letthem talk about it? What is your procedure?

SNIDECOR: Well, first of all we don't deal with groupsherethis is not a large community and much of myresearch has been done outside of Santa Barbara, as youknow; but we still have a good many come here, and wehave over the years. This is a problem, and I try to bepretty direct about it. I try to tell the laryngectomee agood deal because he's the one who can help his wife.And let me suggest this, for physicians present inparticular, a lot of the wheezing comes from the factthat for laryngectonices, airborne allergies are nowintensified. This is very important. A lot of these peopleshould go see someone who specializes in allergies,immunologists, et cetera, so they can experience, ifpossible, some rdief from any allergenic factors. Nowthere's another little trick and it's really very simplealaryngectomee talking: "I get all clogged up and I leanover the side of the bed or a chair and gravity helps meget rid of the stuff." I would not, if I were a laryngec-tomee, knowing what I know, ever expect my wife tolaunder a bib. There are ways to make them so cheaplythat they can be discarded, or I'd launder them myself. Iwould not ask my wife to do it, and I have suggested tomore than one laryngectomee, "You knew how to runthe washing machine. Let these things stack up, putthem in a bag in the garage until you hale two or three

dozen of them, run them through the washing machineyourself." Important? Yes, it's a small thing, but it couldmake a big difference.

Eating garlic and onions can be bad. The wife's nosemay be at stoma level and get obnoxious breath standingup, or lying down. This could be just pretty damn revolt-ing unless the wife shares the same diet. So laryngec-tomecs should be told something about these kinds ofthings, you see, and be helped in getting over all kinds ofbig humps with small pieces of advice.

SHERMAN: The kinds of advice you've given to laryn-gectomees seem very, very reasonable. But, I mildlyobject to your idea of "playing it by ear" for each laryn-gectomy case. You mentioned, for example, thatphysicians often don't know that laryngectomees sufferfrom pollen irritations. You also mentioned that laryn-gectomees, because of the reduced loudness of theirvoices, should be told to be closer to another personwhen they want to talk with them and should not havethe television playing when they talk and should nottalk in an automobile. Should these very important bitsof information be left to a speech therapist to "play byear"? Shouldn't some kind of systematic program bespelled out for a laryngectomee to tell him about thekinds of physical constraints that have to be put on hisenvironment and what he can do to better handle theproblem? Also, you mentioned that the family had to betaught what to expect from a laryngectomee - what kindof speech was appropriate, what kind of speech wasgood. Do you actually, or would you, advocate trainingthem to do this? That is, playing tape recordings tothem to let them know how fast a laryngectomee cantalk, what kinds of speech forms they should expect andfurther teaching them to provide, let us say, social con-sequences for the laryngectomee coming closer andcloser to these forms?

SNIDECOR; I think these are very good questions, andI'll take the first one first if I understand it correctly andif I don't, tell me. I used the expression "play by ear"and I say this when I am talking to trained people. Inother words, I'm talking to good musicians, you know,who can really play by ear. And I'm not joking, I'm say-

ing this very seriously because if you don't know whatthe hell you're doing, you're not going to be able to playit by car. And what I try to avoid , as I know you do, sir,is putting unnecessary things in the salad. You know,you can give people a lot of information which they willmisuse. So this is why I try to limit, and this is what Imean by playing by ear. You and I have a little differentconnotation of what I mean hem So, you don't go

telling people something they don't need because thatsomething may be very discouraging to them. And itmay actually be bad from the sheer conditioning view-point. Now if I were to tell a client, "Look, you'll learnto talk in about four months," and this man learns totalk in four (lays and some do, why should I havesaid to him, "Maybe you'll learn to talk in fourmonths"? If he doesn't learn in four days or four weeksthen I tell him, "Well, it takes a lot of people fourmonths," but I'm not going to tell him this right away.Not at all. And by the way, I have answered a lot ofthese questions about programming in my book on thesubject. Now, as regards structuring for the family, thereis a variety of suggestions that might help. Now, anystudent who has been through my course in alaryngealspeech, and a number of you have, will know the kind ofstructure that you might use if you had to use the wholething. Now, it's pretty obvious that with a youngercouple, thirty-seven years of age, you don't have to talkabout sitting close together, you don't have to talkabout it because they can still hear each other. Because aman is fully employed, every minute has to countbecause you're working hard and he is too. You can'tcover all the territory so you have to really get in whereit count,. For efficiency I may use recordings, but Iseldom play a recording right away unless perhaps it's inthe hospital; and then I never pick the best example, justa passable one. When one records and plays back a begi::-ning client it's almost like playing the first recording of acerebral palsied child to that child. You must be prettycareful or the vocal image on the recording may be quitedevastatingquite demoralizing. But I do try to givepositive examples, and I try to explain what the personis working for and how he can get air down and up. It iseasier to get air down than up, at least at first, so thereprobably isn't a laryngeetomec in the world who has notbeen seriously disturbed by flatus though much of it is,of course, air. You just go around pooping all over theplace for days on end, and some people never get over it.And if you want to he the life of that kind of a party, Ican teach you how. It's very simple. You relax the topof the esophagus and you charge air. Now most normalspeakers can't get the air back up but almost everybodycan get it down, and then it's got to go sompleace, eitherup or down. Did you hear me charging air (over micro-phone)? It's going down here (points). I'll take it outthe top. It is easy to auditorily monitor a charge, youcan take a little plastic or aluminum funnel and a pieceof ordinary rubber or plastic tubing, preferably a littlelarger than enema tubing and put in on the small end ofthe funnel and put the other end in the client's ear andplace the larger end on your throat and say, "Now doyou hear the air go down?" Ile hears it. Now he can

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learn to duplicate the sound. Give him the funnel to takehomethey cost very little. However, emphasize that hemust immediately get the air up Charles Berlin hastalked about this very effectively. The latent periodeventually should be reduced to half a second. Berlin is avery good research worker; that is his findings areessentially the same as mine. The latent period in hisstudy and mine worked out to be a median of half asecond or so for successful esophageal speech. Berlinpoints out how important the reduction of this latentperiod is, but you can't have a latent period if you can'tget the air down; so this little funnel which anyone canuse is wry useful as monitor and reinforcer. When heonce hears the air go down he feels great because he':made the first step and proven to himself that he can doit.

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I wrote an article rather badl: years ago because I wasimpatient with the concept that most ills are psycho-logical and must be cured by therapy in depth. giveyou the title of it but not the reference becae I didn'twrite it the way it should have been written at all odds.The title of the article was "The Kills arc Adjustive."And I believe to this day that the skills are adjustivc antiesophageal speech is one area where, believe me, theyare, Most of what we do with the family of the laryngee-tomee is designed to cushion his failures and reinforcehis successes in speech. Gardiner pointed out so veryclearly that the very fact of having a family makes forsuccess in re-learning speech communication. A knowl-edgeable, patient, sympathetic, and positively stimulatingfamily will obviously accelerate and implement suchsuccess.

Family Influenc-_,As on Stutteringand Stuttering TherapyHugo H. Gregory, Ph.D. Northwestern University

There is general acceptance of the idea that environ-mental factors are of great significance in the develop-ment of speech. Among others Mowrcr (1952) hasdescribed the way in which identification positive

feelings between child and parent influence the earlyacquisition of oral language. Words are repeated if theyhave been associated with positive reinforcement.Throughout the literature on human behavior, the socialnatua .(1 speech is stressed. On the other hand, it is truethat geixtic endowment and maturation set the pace. Wewill no doubt refer to the contributions of these lattc.factors (luring the symposium, but the influence of theenvironment, and the person's family in particular, is ourmain concern.

Most of those who have studied stuttering clinicallyand experimentally, regardless of specific point of view,have concluded that just as environmental factors arecrucial in the acquisition of language and speech ingeneral, it is also necessary to include c!.vironmentalinfluences in an explanation of the. onset and develop-ment of stuttering. Therefore, modification of thereactions of those persons, family and others, in a child'senvironment is important in the prevention of stuttering,stemming the tide of development during an early stage,or in working directly with a child or adult with a stut-tering problem.

I think these remarks indicate that my presentationshould include a discussion of two topics: (1) Environ-mental conditions that have been related to the onsetand development of stuttering, and (2) The methodsused by those of us who deal with this problem tomodify the responses of the environment and hopefullyreduce or eliminate a subject's stuttering behavior.Obviously, the behavior of the family occupies a keyposition in both of these areas.

ENVIRONMENTAL CONDITIONS THAT HAVEBEEN RELATED TO THE ONSET AND

DEVELOPMENT OF STUTTERING

Although most stuttering theorists, even those whohave referred to the possibility of constitutional factors,have considered environmental influences as importantin the acquisition of stuttering, it was Johnson whostressed that the crucial differences between a child whobecomes a stutterer and one who does not is found inthe parents' and others' reactions. In Johnson's analysis,Davis' data (1939) and that of Branscom, Hughes, andOxtoby, (1955) showing that all children are disflue.t,those studied showing a wide range of variation, wascited as proving that statistically speaking disfluency isnormal. During and following the time these studies of'',fluency in the speech of children were being done,three major studies of the onset and development ofstuttering were conducted (Johnson, 1942: Harley,1955; Johnson, 1959) at the University of Iowa.

In all these investigations, a total of two hundred andforty-six children judged by their parents to be stutterersand their parents (the experimental group), and an equalnumber of children judged by their parents to be non-stutterers and their parents (the control group), werestudied. Research data were compiled from carefullyplanned interviews, clinical observations, and test pro-cedure. The experimental group children were seen, onthe average, two and one half years after the perceivedonset of stuttering. In general, 85 to 90% of the parentsagreed that the speech behavior originally diagnosed asstutteringiwas the effortless, brief repetition of syllables,whole words, or phrases. The studies of normal fluencydevelopment and the onset of stuttering led Johnson topropose and advocate that stuttering was a diagnosticproblem, i.e. it was not a problem until after a listenerevaluated normal disflueney as stuttering and began to

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react to it. A second step in the proces of normaldisfluent speech becoming a problem was the internali-zation of the parents' evaluation by the child. Signifi-cantly, Johnson (1959) pointed out that parents werenot to blame that they were only reflecting a culturalattitude toward the fluency of speech. Furthermore, thereason that stuttering tended to run in families was thata particular sensitivity about disflueney was present inthe families of stutterers. In addition to the previouslycited finding th' the parents of stuttering children hadmore demanding expectations regarding' the fluency oftheir children, the onset studies and related studies ofparental attitude (Darley, 1955; Johnson, 1959)appeared to show that the stuttering group's parents,especially the mothers, were more perfectionistie andstriving, and less satisfied with themselves and theirchildren. These latter findings, along with similar reportson the parents of stuttering children by Glasner (1949)and Moncur (1952), Johnson reasoned, added to a

picture of sensitive, hyperreactive parents. In the last ofthe three onset and development studies (Johnson,1959), findings relative to type of disflueney showedthat sound or syllable repetition and prolongation ofsounds occurred in significantly more of the stutteringchildren; whereas, phrase repetition, silent intervals, andinterjections such as "well" and "and uh" occurred moreoften in the non-stuttering children. These results, andfindings from listener reaction studies, that sound andsyllable repetitions arc more likely to be labeled as stut-tering, seem to have influenced Johnson (1959) tohypothesize in some of his last writing that stutteringwas the result of a general interaction between threemajor variables: (1) the listener's sensitivity to thechild's disfluency, (2) the child's degree of disflueney,and (3) the child's sensitivity to his own disflueney andhis sensitivity to his listener's evaluations.

Others such as Sheehan (1958, 1968) have stressedthe child's general feelings about himself in relating tohis environment in tracing the beginning of stutteringand in showing how the behavior is perpetuated.Sheehan believes that repetitions and prolongations inspeech represent approach-avoidance conflict (Miller1944, Dollard and Miller 1950) which can have its originon one of five levels and, in addition, can be generalizedfrom one of these levels to another. These levels ofconflict are: (1) Ego protective, i.e. how the child feelsabout himself, (2) Relationship, i.e. acceptance or rejec-tion of certain interpersonal relationships, (3) Emotionalloading of speech (expressing or inhibiting feelings), (4)Situation speech conflict, and (5) Word level conflict.Disfluent or stuttering behaviors are increased if con-flicts are not reduced. Moreover, fear and conflict reduc-tion which occurs simultaneously with and immediately

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following stuttering reinforces the behavior. Thus,approach-avoidance behavior causes stuttering, and fearreduction at the moment in time that the stutteringoccurs reinforces it. In this connection, Wischner (1950),in relating Johnson's diagnosogenie theory to learningtheory concepts, referred to the way in which behaviordesigned to avoid noxious environmental reactions todisfluency was reinforced by monetary anxiety reduc-tion.

Wyatt's (1969) multidisciplinary approach to thestudy of individual children who developed stutteringhas led to her interpretation of stuttering as a loss ofparental love, corrective feedback, or modeling ofappropriate language forms during the development of-language through the pre-symbolic (babbling), symbolic(naming, words), and relational (phrases, sentences)stages. The loss of corrective feedback is most detri-mental when the child is moving from one stage oflanguage development to the next. This causes compul-sive repetition of an earlier developmental form, e.g. ini-tial sounds and syllables, which are least characteristic oflater normal development, but which are characteristicof early speech development.

Skinner's (1953) behavioral principles have beenstressed by Shames and Sherriek (1963) in postulatingeffects of the environment producing stuttering. Disflu-ency and stuttering are considered operant responsesthat are similar and continuous. Disflueney results from,among other things, maturational factors and the stressthe child experiences in communication. Aversive stimulifrom a listener, which if response contingent would beexpected to reduce disflueney, do not, since social reac-tions are not that precise. In addition, the listener, thesituation, and other aspects of the stimulus-complexpresent become aversive through association and thusevoke more disfluency. The continuation of thisprocess degenerates the speech response into what wecall stuttering. The child feels punished for a new formof stuttering response, but at the same time there isnegative reinforcement because the new form terminatesthe preceding aversive form. If the stuttering gains atten-tion, and this may be very important in some eases, thispositive reinforcement increases the behavior. Parentaland sound negative and positive reinforecrs are presentedon a complex intermittant schedule; thu'; explainingwhat every clinician knows who tries to analyze the rein-forcing factors operating in a stuttering child's environ-ment.

Brutten and Shoemaker's recent theoretical explana-tion (1967) of stuttering, in which reference is made toindividual differences in autonomic reactivity and eon-ditionability, also emphasizes the role of the environ-ment. Their concept is that fluency, the predominant

characteristic of normal speech, is disrupted by learnedclassically conditioned emotionality which increases

fluency failures (repetitions and -:elongations). Uri-

adaptive instrumental behavior or operant responseswhich reduce emotional responses are reinforced, adding

to the. complexity of failure in fluency.

Whereas, Shames ?nd Sherrick (1963) begin with thehigh operant level of disfluency and consider the shapingof this behavior, Brutten and Shoemaker (1967) are alsointerested in the factors that occasion disruptions influency fluency failure as they refer to it.

Studies of the incidence of stuttering in differentcultures and socio-economic groups has additional impli-cations for our evaioation of environmental factors.Surveys of Indian tribes in America and other societies(Snidecor, 1947; Lemert, 1953, 1962; Stewart, 1960)have provided strong evidence that there is more stut-tering in competitive, status-conscious societies in whichhigher standards of behavior arc the rule. For example,Lemcrt (1962) inferred that the low incidence of stut-tering in Polynesian societies and the comparatively highincidence in Japan was due to the differences in prcssures to achieve and conform. Morgenstern (1956)concluded that socioeconomic upward mobility waspressure that increased stuttering in some occupational

classes.

In summary, environmental factors, reflecting eitherbroader cultural patterns or the specific adjustment ofthe parents or perhaps a combination of the two are

considered to be significant determinants of stuttering.Consequently, our clinical evaluations include a

thorough study of parental management, other familyreactions, educational factors and in the case ofadults, the wife's attitude and the person's interactionswith co-workers.

As I conclude this review of environmental factors,including parental reactions, that have been related tothe, development of stuttering, and before we discusstherapy, I would like to say a few things briefly aboutmy present point of view. Many cases of stuttering mayinvolve social learning only (social learning being definedas behavior influenced by the environment), but somecharacteristics of the subject, individual differenceswhich may be constitutional, can also occasion moredisfluency and possibly qualitatively different types ofdisfluency. Disruptions in the flow of speech may beoccasioned by subtle expressive language deficits or

problems of motor patterning for the, produc-tion of speech. Moreover, I believe that the preventionof stuttering or the management of stuttering in incip-ient or advanced stages requires a differential therapywhich is based on a careful differential case history andevaluation.

Stuttering Therapy and the Modificationof Environmental Responses

As we know, the way in which the family and otherenvironmental infleunees are involved in therapy differsin terms of two major variables: (1) the developmentalstage of the problem and (2) the chronological age of thesubject. In the discussion to follow I will considerdifferences i.. approach with reference to these twovariables.

In the young child (usually three to six years of age)speech clinicians have attempted to minimize thedevelopment of anxiety (unpleasant expectation) aboutspeech as a learned source of drive. If you prefer theterminology of operant conditioning, clinicians haveattempted to prevent speech, or to be more exact,disfluency in speech, from becoming a discriminatedaversive stimulus. As we enter into the process ofdevelopment, we hope to accomplish this by workingwith stimulus events (variables of the subject andenvironment) which occasion disfluency and parental orothers' reaction which may, by learning, become associ-ated with speaking. Said another way, we want to dealwith all of the sources of negative emotion or anxietywhich result in approach-avoidance conflict which isreflected in speech. Said yet another way, we warn tominimize the operant rate of disflinnicy and the shapingof a "normal" response into "abnormal" ones. Learningtheory helps us understand what a complicated situationof stimulus complexes, responses, and reinforcementswith which we are dealing. Our students are helped to bemore realistic and, in addition, these various learning

paradigms serve as a basis for analyzing and treating the

problem.Contact with the family of these young children is

usually through parent coup. ling. After initial evalua-tion, a judgment is made as to whether the child shouldbe seen for indirect speech and language activity therapyas a part of the therapy process. One advantage of seeing

the child, with reference to our present topic, is that wecan f,Ilow variations in the child's fluency and other

behavioral patterns as the parents report to us. Anotheradvantage is that we can model types of behavior thatwe want the parents to use in their interaction with the

child.

Specialists are agreed that parent counseling is

essential. Even if we visit the home situation to view forourselves the parent-child or child-child relationships, westill need to rely on the verbal reports of the parents toknow what stimulus conditions evoke negative emotion(Brutten and Shoemaker, 1967) or what stimulus condi-tions control disfluent or stuttering behavior (Shamesand Sherrick, 1963). In addition, the parents have their

33

thoughts which are related to various emotionsor whichcue certain emotions. One of these we commonly labelas guilt. They need an experience which is more iermis.sive and which rewards expression of ideas and feelingsabout their behavior and that of their child. They needinformation about speech development and how stut-tering might develop. New verbal labels (Dollard andMiller, 1950) can be supplied which help the parents tobecome less general and more discriminating in thedescription of their behavior and that of the child.Finally, the mother, father, and others associated withthe child need to understand what we are doing intherapy and how they can support our work.

As an illustration I will tell you about a youngster,Jim, and his parents and his grandparents! Jim wasbrought to the clinic for evaluation when he was 3 years11 months old. The mother and father said that he stut-tered. The condition was worse whcn Jim was "nervousor under pressure." Touching the main point briefly,birth was by high forceps, motor development was alittle slow, he spoke his first words at 2Y2 years, and usedword combinations at 3Y2 years. Both parents agreedthat the boy "stuttered" from the time he began to talk.The mother said that the first few words Jim said werestuttered and that his grandfather thought this wasfunny and teased him. When asked what they had doneto help their son, the mother said that she was trying tobe more patient and give him more love and understand-ing. She also said she was teaching him to read from theChicago Tribune series of articles on teaching pre-schoolchildren to read. Briefly, the results of testing revealedgeneral social immaturity, receptive language about sixmonths below age level, obvious retardation in expres-sive language, articulation at age level, and normalphysiological support for speech. Jim's speech wascharacterized by mild disfluencies. He repeated andprolonged initial sounds and syllables and occasionallyrepeated the entire word.

At the end of our out-patient examination it wasconcluded that Jim's disfluency may stem from a combi-nation of factor,. I quote, "His rapid rate of develop-ment after a long period of relatively slow development,may be creating pressures and putting more demands onhis speech and behavior than he is capable of handlingwell at this time. The parcnts' anxiety about Jim'sdevelopment, coupled with their attempts to teach him,may add additional pressures. It is felt that all thesepressures plus generally slow development of speech andlanguage may tend to increase disfluency."

Jim was brought to the clinic on Saturday morningsfor individual and group therapy in the Primary Disflu-eitcy Program. The mother and father joined the parentgroup.

34

Therapy was structured around Jim's language delay.Naming and matching games were employed. Basicconcepts were taught. The parents appeared over-whelmed by the problem and found it difficult tounderstand that we did not view, in their words, "thestuttering" as the basic problem. Our reports note thatat the end of the third quarter of therapy the parentswere finally beginning to comprehend the nature ofJim's problem and were able to cooperate in the activi-ties aimed at vocabulary and syntactical development.We showed the parents how to simplify their sentencestructure and diminish their speech rate when talking toJim. One day when the mother was playing with Jim atthe clinic while we watched from the observation room,he said, "You talking too fast for me."

In the parent group, the parents reported that theycould not get the grandparents to stop reacting to Jim'sfluency and to understand the nature of the problem.Perhaps we could have seen the grandparents I have insome cases but with the understanding and support ofthe group, the parents were finally able to tell the grand-parents that they were welcomed to their home andgreatly loved, but to leave the management of Jim tothem.

This is not a new story in speech pathology. but itillustrates how important al change of the parents'perception of the child and the change in their reactionscan be. Furthermore, these changes were brought aboutby reinforcing changes in their thinking or by usingreinforcement to shape their thinking. Also, after theyhad positive feelings toward us, we were able to modelbehavior for them which they found rewarding toimitate. In turn, they were reinforced to see changes inthe child come about as a result of cur working as ateam.

Speech clinicians employ a more direct approach witholder children in whom we are dealing with acquiredattitudes, learned behavioral patterns, and accessoryspeech mannerisms as well as factors which contributedto the development of stuttering. I have discussed else-where the difference in approach we use with elemen-tary school age children and older youngsters and adults;also the way in which procedures differ at various ages

depending on the developmental stage (Gregory, 1968,1971).

Experience has taught me that deciding how direct tobe in approaching the modification of inappropriate ormaladaptive stuttering behavior involves a careful judgment. With school age children, dealing with the types ofstimulus events I have discussed previously may besufficient, although, of course, persons in the schoolenvironment should he included in the therapeutic

process. A semi-direct approach of parent-teacher coun-seling plus communicative activit% therapy may be Ali,-able. For purpose of our discussion here, let us assumetherapy with a 10 year old boy that :s direct in that itincludes a direct analysis of the stuttering behavior andthe reinforcement of modified patterns. Such a ten yearold boy was Kurt. who had a moderately severe stutter-ing problem. He came to the clinic once a week forindividual and group therapy and his parents attendedthe parent counseling sessions. All involved, Kurt, hismother and father, understood and readily accepted ourideas which were as the parents said. "a new twist."Voluntary disfluency was one of the procedures in the"new twist" category. We gave Kurt and his parents therationale that when you used a modified disfluent pat-tern you were seeing that you could change your speechresponse and that you were doing on purpose the typeof thing of which you were afraid. Kurt came to havenew verbal formulas such as, "I am doing the thing 1fear" and "When in doubt, cancel." We rewarded thesestatements. The parents rewarded these attitudes. Theclinicians in the program modeled voluntary disfluencyfor Kurt and his parents. They all practiced this andother procedures together at home. We have found itvery rewarding to children to have reinforcing agentssuch as teachers and parents actually carrying out someof these same procedures we are asking the youngster todo. To reverse the situation, not much change can beexpected from a child when the parents do not under-stand, are uninterested, or, as in some cases, display apattern of behavior which shows disapproval of what theclinician is attempting., An interesting development in Kurt's case was aregression in progress during therapy., Seems that oneevening at home while lying in bed talking, Kurt's olderbrother, age 14, said to our subject, "Why are you doingthat stuttering on purpose? I thought you went toNorthwestern to stop stuttering." Kurt replied, "I guessI shouldn't." So, in spite of a rather strong new attitude,the statement by the brother was damaging. I decided tohave a few family counseling sessions attended by theparents, a younger sister age 7, the older brother, andKurt. As his therapist said, "Kurt was, King." We talkedabout speech, speech development, the development ofstuttering, and Kurt's therapy. I have counseled familiesin this way when I was able to predict a successfuloutcome. This procedure is effective after the parentshave been in the group counseling program for severalmonths and the child involved is making progress.Another procedure we have used is to invite a child'steacher or teachers for such a counseling session inwhich a youngster, like Kurt, displays his new attitudesand behavior and receives our approval.

6-74.C7-

Modifications of environmental responses and inclu-sion of the fAmil in the therapt process is of noimportance wit! adult stutterers. Nlotitation to actuallychange is a major factor. Sometimes such goals as doingbetter in school or getting a better position will producegeneral motivation, but more immediate support andreinforcement is needed as can be provided by a mother,a girl friend, or wife as the person makes certain desiredchanges in therapy. I recall a recent case who, althoughhe professed a desire to change his behavior, alsoexpressed a feeling of hesitation to change in some waysthat were suggested. As it is our procedure in the AdultStuttering Program to bring members of the family intothe group, this man brought his wife who turned out tobe a very attractive person. Her reaction was splendid!She was very fascinated with our techniqu. "loved"what her husband was doing including the use of volun-tary disfluency. That was a major turning point in thissubject's therapy. To add a light note, I might say that 1think a smile from her consequent upon some behaviorwas a strong generalized reinforcer for all of our clients.

In my recent report of a three year assessment of theresults of stuttering therapy, I described a failure case inwhich the mother's adjustment and previous pattern ofinteraction with our client made it highly improbablethat she could cooperate in therapy.

In my case summary, I stated:In some adult situations, of which the present client'smay be illustrative, we may want to control carefullythe information the parents or spouses have abouttherapy. Fred's main work in therapy may have to beto learn to react differently to the environment ratherthan hoping that along with his change there will bechange in environmental factors.The first part of this presentation was concerned with

a review of theory and research relating environmentalfactors, which usually operate through the family, to theproblem of stuttering. After that, I have shown howfamily reinforcements have been utilized in therapy orin tI'e last ease how it was not probable that familyreinforcement would be beneficial. In the last section,general principles already referred to will be expandedand summarized.

1. In working with pre-school age children, we dealwith stimulus events (characteristics of the child and theenvironment) that may be occasioning disfluency of anature that concerns us. We want to dissolve as much ofthe aversiveness that may be associated with speaking aswe possibly can. A minimal expressive language problem,viewed as a behavioral deficit, may need to be reduced asgeneral and specific language facilitation procedures areused. The parents cooperate by learning to reactdifferently e.g., not being aversive in their reactions to

35

the child's speech, and perhaps learning to be lesspunitive and more positive in their total relationshipwith the child. Modeling procedures, as described byBandura (1965, 1969) and Mowrer (1960, 1965) areutilized. As the clinician comes to be a positive rein-forcer to the child and the parents, i.e., his presence isassociated with comfort (positive feelings), they willimitate his behavior. He may model a slower, morerelaxed pattern of speech for the child. The parents mayobserve the clinicians interaction with the child as theclinician engages in language and fluency developingactivities. I could go on with examples. Bandura liststhree effects of odeling influences: (1) The observermay acquire new responses that did not exist in hisbehavioral repertoire, (2) Exposure to models maystrengthen or weaken inhibitory responses in theobserver as a function of rewarding or punishing re-sponse consequences to the model, (3) The behavior ofmodels may facilitate previously learned responses in theobserver that match precisely or bear some resemblanceto those of the model. Theories to explain imitative andmodeled behavior have been propounded by Miller andDollard (1941), Mowrer (1960) and Bandura (1965).According to Mowrcr, "B" learns from "A" because heexperiences reinforcement vicariously. Bandura dis-cussed the possibility that the acquisition of matchingresponses takes place through contiguity, and that rein-forcements administered to a model influence perform-ance. Speech pathologists need to devote more study tothis method of behavior modification. We have used it,but we can be more systematic in our applications.

2. In modifying a child's or adult's behavior we havelearned from Skinner and his students that one of thecrucial elements in the process is the contingencybetween certain positive and negative reinforcing stimuliand emitted responses. As referred to earlier in describ-ing the acquisition of sutttering, we analyze contingentrelationships between responses and reinforcements. As Ihave said in the last chapter of Learning Theory andStuttering Therapy, I think the emphasis on the carefulanalysis of behavior and the planning of action to betaken, measuring progress as precisely as possible, iscontributing to more efficient and effective therapy. Forexample, if we want to improve eye contact of a stut-terer, we first get a baseline measure of this behavior.Then, based on our observation of or acquaintance wit1-.the subject, we choose, a reinforcer. With one of oursubjects we used chips that could he exchanged for coinswhich this 12-year-old wanted to add to his coin collec-tion. At first, we gave one chip for each demonstrationof eye contort and only ten chips were needed for acoin. Later 20 chips were needed for a coin. Still, in latersessions, the schedule of reinforcement was changed

36

from a continuous to an intermittent schedule. Skinnerhas found, that intermittent reinforcement schedulesreduce extinction. Mowrer (1960) stated that inter-mittent reinforcement during acquisition producesgreater frustration tolerance when reinforcement occursirregularly as it does in real life. In addition, I speculatethat this allows self-reinforcement to begin becomingeffective. The parents obtained a baseline at home at thebeg.nning of the program. As our samples of eye contactbehavior in the clinic showed improvement, the rate ofeye contact responses at home also increased. Theparents were trained to carry out the response-reinforcercontingency at home during practice periods.

3. As we countereondition anxiety and modifybehavior in the clinic, the new attitudes and overt be-havior have to be generalized to other situations. I bringoutside real-life situations into the clinic as much aspossible. Roles representing real life situations arepracticed in the clinic, hopefully, to insure more successwhen attempted in the actual situation. A wife of anadult stutterer may be brought into a conversationalsituation at the clinic in which the husband uses a speechmodification before he is asked to use the modificationat home. These approaches take into consideration agradual desensitization approach in which responses arechanged, first in the presence of stimuli which evokeminimal stress, and then in situations that have a historyof producing higher levels of anxiety.

4. fn stuttering therapy we work with verbal"thought" behavior as well as the overt responses of theperson. Taking initially after Dollard and Miller I havespoken of labeling, thinking, and verbal formulas orcues. Those who took after the operant conditionersfirst, and I might say that verbal behavior as related toovert behavior is a more recent development for Skinner,speak of verbal self-instruction. The younger the subject,the more we stick to work on stimulus events and overtbehavior, but as the cognitive life of the child becomesmore important at eleven or twelve years of age. perhaps,we have to give this aspect of behavioral control moreattention. Furthermore, it wouki appear most importantto deal with the parents' behavior as it is mediated bylanguage and thought.

5. In this brief discussion of the onset, development,and treatment of stuttering the influence of the familyappears large. Advocates of family therapy in psychiatryand psychology have challenged the validity of seperateand individualized treatment of a child and parents orhusband who is the patient and his wife. In this discus-sion, I have emphasized the collaboration of others inthe environment and have mentioned briefly somecounseling I have done of family units when it was inr!ieated and a successful outcome could be predicted. As

we continue to increase our professional working rela-tionships with psychiatry and psychology, we shouldfollow carefully the developments in the area of familytreatment.

BIBLIOGRAPHY

Bandura, A. Behavioral modification through modeling proce-dures. In Krasner, L. and Ullman, L., Research in BehaviorModification. New York: Holt Rinehart (1965).

Bandura, A. Principles of Behavior Modification. New York:Holt Rinehart (1969).

Branscom, M. E., Hughes, J., and Oxtoby, E. T., Studies ofnonfluency in the speech of preschool children. In Johnson,W., and Leutenegger, R. R. (eds.), Stuttering in Children andAdults. Minneapolis: Univ. Minn. Press (1955).

Brutten, E. J., and Shoemaker, D. J., The Modification of Stut-tering. Englewood Cliffs, NJ.: Prentice-Hall (1967).

Darley, F. L., The relationship of parental attitudes and adjust.ments to the development of stuttering. In Johnson, W., andLeutenegger, R. R. (eds.), Stuttering in Children and Adults.Minneapolis: Univ. Minn. Press (1955).

Davis, D.M., The relation of repetitions in the speech of youngchildren to certain measures of language maturity and situa-tional factors: Part I. ./. Speech Dis.. 4, 303-18 (1939).

Dollard, J., and Milier, N., Personality and Psychotherapy. NewYork: McGraw Hill (1950).

Glassner, P. J., Personality characteristics and emotional prob-lems in stutterers under the age of five. J. Speech HearingDir.. 14, 135-38 (1949).

Gregory. H., Applications of learning theory concepts in themanagement of stuttering. In Gregory, H., Learning Theoryand Stuttering Therapy. Evanston: Northwestern UniversityPress (1968).

Gregory, H., Stuttering: differential evaluation and therapy. InHalpern, H., Communicative Disorders: An Introduction toSpeech Pathology, Audiology, and Speech Science. NewYork: Random House (1971).

Johnson, W., et al.. A study of the onset and development ofstuttering. J. Speech Drs.. 7,25157(1942).

Johnson, W., and Associates, The Onset of Stuttering. Minne-apolis: Univ. Minn. Press (1959).

Lemert, E. M., Some Indians who stutter. J. Speech Hearing Dis..18, 168.74 (1953).

Lemert. E. M., Stuttering and social structure in two Pacificsoc -ties. J. Speech Hearing Dis., 27,3-10 (1962).

Miller, N. E., Experimental studies of conflict. In Ilunt. J. McV.(ed.), Personality and the Behavior Disorders. New York:Ronald Press (1944).

Moncur, J. P., Symptoms of maladjustment differentiatingyoung stutterers from non-stutterers. Child Dev.. 26, 91-96(1955).

Morgenstern, J. J., Socio-economic factors in stuttering. J.Speech Hearing Dir., 21, 25-33 (1956).

Mowrer, 0. H., The autism theory of speech development andsome clinical applications. J. Speech and Hearing Dis.. 17,263-68 (1952).

Mowrer, 0. H., Learning Theory and Behavior. New York: JohnWiley (1960).

Mowrer, 0. H., Learning theory and behavior therapy. InWolman, B. B. (ed.), Handbook of Clinical Psychology. NewYork: McGraw Hill (1965).

Shames, G. H., and Sherrick, C. E., Jr., A discussion of nonflu-ency and stuttering as operant behavior. J. Speech HearingDis., 28,3-18(1963).

Sheehan, J., Conflict theory of stuttering. In Eisenson, J. (ed.),Stuttering: A Symposium. Ncw York: Harper & Row(1958a).

Sheehan, J., Stuttering as self-role conflict. In Gregory, H. (ed.),Learning Theory and Stuttering Therapy. Evanston: North-western University Press (1968).

Skinner, B. F., Science and Human Behavior. New York:Macmillan (1953).

Snidecor, J. C., Why the Indian does not stutter. Quart J.Speech, 33, 493-95 (1947).

Stewart, J. L., The problem of stuttering in certain North Ameri-can Indian societies. J. Speech Hearing Dis., Monogr. Suppl. 6(1960).

Wischner, G. J., Stuttering behavior and learning: a preliminarytheoretical formulation. J. Speech Hearing Dis.. 15, 324.35(1950).

Wyatt, G., Language Learning and Communication Disorders inChildren. New York: Free Press (1969).

:17

DiscussionBANGS: Yesterday Dr. Suidecor talked about laryngee-

toinees and who should and who should not work with

them. Ile feels strongly that a laryngeetomee should not

work with another laryngettomee. I would like to ask

you, lingo, do you feel that a speech clinician AI,o stut-

ters or who has renmants of stuttering should It ork with

stutterers?

GREGORY: This is a question that I have dealt with in

my own thinking. in talking with my students, and intalking with students who have been stutterers and arc

thinking about going into Speech Pathology. In addition,

yon will be pleased to know that I have talked to Dr.Van Riper about this. Therefore, I can bring you the

results of our discussion. I think that it is very important

in working clinically that the client feel you are very

interested in him and that you want to understand as

well as possible the way hue thinks or feels. It is all too

infrequent in life that we have this type of relationship.

Ilow many of you have had people with whom you can

talk, who you feel are genuinely interested in you? The

person with a problem of stuttering may feel that theclinician who has hoer a stutterer, or who may, as Dr.

Hangs stated, have remnants of stuttering, is able to

understand him in some special way. But, I know that all

of you are thinking that the person who has experienced

a particular difficulty has to be very careful to not per-

ceive the other person's problem in terms of his ownexperience. I agree that we have to be very careful about

tnis. In my work with laryngeetomees, I ha felt that

this is often a problem confronted by a laryngeetomee

who is-a layman instructor. When Dr. Van Riper and I

discussed this a number of years ago, we agreed that a

person who has not stuttered or who does not stutter

may have an advantage if, through his experience in the

clinic and in interacting witlt stutterers, he can gain

insight into the attitudes of stutterers. In this ease, the

stutterer realizes that here is a person who does not

stutter who understands. Here we have the situation of a

perS4111 who expresses keen insight, but it is not because

he has had to understand in order to mork with his own

problem. It is because he wanted to understand in order

to help others. Let one of our clinicians uorking on a

:18

Master's Degree be willing to go out and use voluntary

disfluency. Let her really show the stutterer that she has

the courage to do that. This type of a model demon-

strated by a non-stutterer can have very important,

challenging effects on the stutterer in therapy.

ALLMOND: A parallel to what you're saying, obtains

in the field in which I'm particularly interested, the

evaluation of children with learning and language prob-

lems; that is non-reading third graders are very effective

at teaching non-reading first graders how to read. This

has been shown in the research literature. I have a ques-

tion of my own, but before I ask it, I would like to give

you a positive reinforcer: and that isI was very im-pressed with your presentation this morning and feel

that it was a well-conceptualized and well-thought out

paper, and I commend you on it. Now my question is,

where did you learn your principles of fancily interven-

tion, and do you feel they are learnable by the members

of this audience?

GREGORY: Throughout my training, the importanceof the parents in working with children with speech and

hearing problems was emphasized. In working withalmost all speech, hearing, and language problems we aregoing to have to work with the mother and father.

Perhaps we have not included the father in counseling or

the therapeutic process as much as we should. When we

consider the ways in which we have learned about coun-

seling, I would say that the most important influence on

rite was the opportunity to watch a person like Dr.Moore, who spoke here yesterday, counsel a youngster

or his parents. I fed that this modeling of behaviortouse the concept I was employing in my remarksis oneof the most important ways of teaching. We can send our

studeutt, out to the Department of Psychology or the

School of Education to take courses in counseling and

interviewing. or we can offer academic courses ourselves.

Still, I think, more is going to be learned by watching

others. In terms of working with family units, I have

brought the various members of a family into a coun-

seling unit including siblings when I felt that the out-

come was going to be advantageous and successful. I

7

have not brought in a family unit together at thebeginning of the therapeutic process.

ALLMOND: You say you don't do it, but what youdescribed in your paper is that you were doing it.

GREGORY: Yes, I said that I do do it and that I havebeen doing it for the last ten years. I have used a varia-tion of the concept of family counseling as it may bediscussed in the literature. In working with a youngster.we always counsel with the parents from the beginning.Then, as the child is showing improvement and we havegained insight into the way that the behavior we arechanging is being effected by other members of thefamily unit, we may JCe them all together in a group fora number of sessions. I would not be comfortable to seeall of the family together from the ',Tinning. I wouldlike to have the opportunity to see that approachdemonstrated before I undertake it.

ALLMOND: Would you he comfortable incorporatinginto a teaching pnsgram for future speech and hearingclinicians some of the principles which you have come incontact with in your own experience?

GREGORY: Yes. I think we should give this seriousconsideration in the future. However, as I have expressedbefore, I would like to work with a person who has hadparticular experience in the area of family counseling. Itis my belief that there is a great deal for all of us tocomprehend and experience when we work with ahuman being. So, we are going to have to bring otherswith differing experiences, with whom we can work,into the therapy program. If I were in San Francisco, Iwould certainly want to get to know you better andexplore ways in which we could cooperate in this area offamily counseling.

FLOWER: Hugo, there's one thing I'd like you tocomment about. One of the things we have inheritedfrom the work on the onset of stuttering you alluded tois that during I'll use the "blab words" the primarystages (assuming there is such a thing) it is deleterious tothe child's welfare to meet the symptom head on. is itpossible then to deal with the problem in a familycontext? In other words, can we work with the youngpatient and parents together, or does the peculiar natureof stuttering during these early stages mean that wecannot help the family meet the problem head on anddeal with it directly?

GREGORY: Dr. Bangs, do you want to add anythingto Dr. Flower's question?

BANGS: If you do involve the child with the parents.do von ever have them liken individual or groupwork? Do you ever have the parent go into the class-room where he carries on the activities while y

observe? Do you ever video-tape with instant playback?

GREGORY: Let me deal with this last question. andthen go on to the broader one which Dr. Flower asked.We do model for parents the kinds of things that wewant them to do. Then we reinforce them for change:, intheir behavior. In my career I lime done a great deal ofparental counseling where 1 said. ''Now. this is the kindof thing we are doing in the clinic, and we would like foryou to do at home each day with Jolumv." Verbaldescription may he an effective beginner. but combinedwith a demonstration. the results are much better. Wehave used video-tapes of therapy session for our parentdiscussions. In addition, we have used video-tape record-ings to help school-age stutterers and adults begin theprocess of analyzing their stuttering behavior. The stut-terers may view a video-tape playback of another stut-terer and analyze the behavior observed before theybegin to analyze their own. Now, to get back to Dr.Flower's question. In stuttering therapy . we make ajudgment as to whether we work with stimulus condi-tions that elicit or control dysfluentstuttering behaviorin a child, or whether we help the person modify thedysfluent response itself. In general, with the youngerchild, we work with stimulus conditions. A carefuldecision is made about working with the speech responseitself as well as environmental factors or minimallanguage and motor patterning factors that may bestimulus conditions contributing to dysfluency. Callingattention to the dysfluent speech response itself may insome eases attach aversiveness to that response for the,first time. We have to he careful about this.

FLOWER: But how about attending to the dysfluencyitself; not teaching an alternative, but contacting thedysfluency itself?

GREGORY: In some eases, we must contact thedysfluency through working with stimulus conditionsassociated with it. These stimulus conditions may beonly environmental or they may be a combination ofenvironmental factors and maturational factors such as aminimal language deficit.

SHERMAN: I have a couple of que.stions. I'm really inagreement wu.ru your emphasis on learning theory andreinforcement procedures, as probably is evident frommy earlier comments. In many of the examples y on havetalked about, you've tried to give us an idea of the use of

:59

reinforcement procedures to shape the parents to dotherapy. Given that you can use social attention andvarious kinds of approval to shape the parents, what doyou shape the parents to do? Do you shape them. forexample. to differentially reinforce closer and closerapproximations to fluent speech in the home situation?Do you give the parents specific tasks to present to thechild in which he is to verbalize fluently or nonfluently?

GREGORY: If we begin by referring to the youngchild who demonstrates fluency characteristics aboutwhich we are concerned, we make a judgment abouttherapy goals based on a careful evaluation or study ofthe child and his environment. If a parent talks very fast,and if we come to believe that this may be related to thechild's dysfluency, I can model to the parents the way totalk more slowly and relaxed in the child's presence. Ican demonstrate in most cases, the time varying fromchild to child, that the youngster will become more calmand speak more fluently when this type of stimuluscondition is in effect. The parents can view this frombehind the observation mirror. We can gradually bringthe parent, or parents, into the therapy room with usand have them talk more slowly with the child. In thenext step, we can leave the room and observe the parentfrom behind the mirror. Once the mother is makingchanges in her behavior at the clinic, we can assign herspecific times to make these changes at home.

As we know, the way in which the family and otherenvironmental influences arc involved in therapy fordysfluentstuttering children differs in terms of twomajor variables: first, the developmental stage of theproblem using such a reference as Van Riper ;s fourstages of development; and, second, the chronologicalage of the child. Now, when it comes to the intermediateage stutterer in a later stage of development, we maydeal more specifically with the stuttering behavior itself,as well as stimulus conditions associated with it. We maydecide to modify the speech response somewhat, forexample, ask the child to speak somewhat slower andrelaxed or show him that he can change the amount oftension involved in the production of bilabial voicedsounds. We make certain reinforcement contingent onthat response. After we have been doing this for a whilein the clinic and the youngster is experiencing success,we demonstrate the target behavior and the reinforce-ment procedure to the parents or others in the home andhave them do the type of thing we have been doing inthe clinic during certain periods at home. We have themkeep records and report to the clinician.

FLOWER: Among the "certain behaviors", do youinclude speech fluency?

40

GREGORY: Well, in a way. if that were the objective.However, practically speaking, the target behavior orobjective is usually easy speech, relaxed speech, or to usean example I mentioned earlier, light contact on thebilabial voiced consonant-vowel combinations. Usuallywith the pre-school child, the kinds of actiities we arereinforcing in the parents will be conducive to morefluency in the child, and we tell the parents that as aresult of what they are doing their child is going to bemore fluent. We observe the child at least once weeklyand the parents report to us. individually or in theparent group.

FLOWER: What do you have the parents attend to?

GREGORY: As I mentioned previously, we made adecision about rewarding certain modified behaviors inthe child or certain modified behaviors in the parent.The older the child and the more advanced the develop.ment of the stuttering, the more likely it is that we willwork for both modifications in the parents' behavior andmodification of the child's speech responses.

SHERMAN: I'm curious about the laboratory studiesthat have been done to modify stuttering behavior -

those by Martin and Siegel (19) and by Goldianiond (19)and by a variety of other people. Do you see these kindsof laboratory procedures as being useful in actual thera-peutic practice?

GREGORY: I am glad to have the opportunity tocomment on this work. I have emphasized in my re-marks that in the problem of stuttering we are dealingwith a very complex stimulus-response-reinforcementsituation. We might take the approach that we have tobe very general in our research because this behavior isso complex. There is another approach which, as wewould expect is more characteristic of the laboratory, inwhich we try to take a specific aspect of the behaviorand be more specific in our study of it. As we know,these investigators have indicated that response con-tingent punishment decreases dysfluency in normals andstuttering behavior in those who stutter. A study byMartin and Siegel (19) has indicated that punishment ofdysfluency and reward of fluency increases fluency.Those of us in Speech Pathology know that we havebeen conditioned in our field to say punishment is bad,that punishment increases stuttering. Well, it depends onhow we look at punishment. If I say to you after youmake a response, "No, that's not quite right," that'swhat a psychologist in a learning tradition would say is a"punisher."

SHERMAN: If it decreases the behavior.

GREGORY: Dr. Sherman is emphasizing the operantdefinition of punishment in that a stimulus following aresponse is a "punisher" if it decreases the behavior. Mypresent point of view is that the laboratory studies byGo !diamond and Flanagan (19) and Martin and Siegel(19) indicate that we can use certain punishing conse-quences to diminish and disrupt stuttering behavior andcertain reinforcing consequences to reinforce modifi-cations. You can view this as counter-conditioning.

Where one stimulus condition sas present and a certainresponse was made, we are now enabling the person tomake another response which is reinforced. We are alsousing the punishing consequence to help the persondiminish the previous response. We are experimentingwith these procedures in therapy. When 1 experiment intherapy, I have to be very careful because I cannot doanything unless I think it can be rationally made a partof a constructive therapy program. I appreciate theseresearch results that Dr. Sherman has asked about. Theypave the way for our consideration of new constructiveapplications in the clinic.

41

The Role of the Family in theManagement of the Deaf ChildStephen P. Quigley, Ph.D. University of Illinois

Recent research in lingtristies and psycholinguisticsemphasizes that one of the most important aspects oflanguage acquisition is that it takes place in a very shortperiod of time. The child with normal hearing whomoves past the use of holophrastic utterances begins tocombine words sometime before the end of his secondyear and is a relatively fluent speaker of his language bythe age of four. By this age the child has mastered thebasic grammatical structure of his language, and thisprocess usually is complete by the age of eight years.Beyond this age, the typical child will learn to elaborateand consolidate certain grammatical structures toachieve greater maturity and economy of expression andwill continue to expand his vocabulary to meet theneeds of his environment, although for most peoplevocabulary shows little growth beyond the age of about18 years. It is obvious from the linguistic and psy-cholinguistic research, and indeed even from casualmonitoring of the speech of young normal children, thatthe first four years of life are crucial for languagedevelopment. This observation has been reinforced byresearch and experimental programs with culturallydisadvantaged children whose early impoverishedenvironments often result in serious retardation inlanguage development.

While generalizations to the language development ofdeaf children must be made with some caution, the over-whelming weight of the evidence from studies of normalhearing children makes it reasonable to assume that thefirst four years are also critical years in the life of thedeaf child. Not only are these years critical in thedevelopment of language and communication, they arealso critical in the development of emotional and socialattitudes and adjustment. Yet, these often are wastedyears in the lives of deaf children, many of whom do notreceive systematic training from professional personnelnor from their parents in developing the language and

42

communication necessary for future participation insociety. As one result, most deaf children in the UnitedStates finish 12 to 16 years of schooling by the age of 18to 20 years with poor oral id written skills, and educa-tional level below the six grade, and an even lowerreading level. If any signil ant breakthrough is to beachieved in improving the development of the deaf child,it would seem that it will have to occur during ti,c firstfew years of life with methods which will foster earlydevelopment of language and communication. And inthose early years the family must be the primary agentof development of the deaf child, as it is for the develop-ment of children who have normal hearing.

From these introductory remarks it will be obviousthat I have chosen to limit my topic to the deaf childwithout, for the moment, entering into any discussion ofthe term "deaf", and to further limit it to the vital rolethat the family plays in the deaf child's development. Itis my thesis that the family is almost indispensable indeveloping language and communication in the deafchild, and that our professional efforts should be di-rected toward equipping the family to provide thisdevelopment rather than toward direct work with thechild himself. Let me hasten to add this is not a newpoint of view. It was current in the education of deafchildren for many years before the recent emphasis onearly childhood education stimulated by federal interestand funds. However, the federal involvement now givesus for the first time the promise that funds may even-tually become available to extend early childhoodservices to all deaf children, as well as to other childrenwho may need them.

After having presented in some detail the findings oftwo studies wh.ch are pertinent to our purpose, Ipropose in my concluding remarks to relate them toseveral points which might serve as a basis for groupdiscussion.

1. The fir, four years of life are as critical for thedevelopment of language and communication and socialadjustment for the deaf child as they are for the childwith normal hearing.

2. The family is of primary importance in the deafchild's development during his early years, and weshould accept the responsibility for equipping the familywith the knowledge and skills to foster this develop-ment.

3. Since the audiologist is usually the first or secondperson to make the diagnosis of deafness, he must acceptthe responsibility for working with the family and theyoung child to develop a program of home management.

4. Since the training of audiologists presently leavesthem ill-equipped to function in this capacity, audio-logical training should be expanded to better equippractitioners for this role, or a specialty should bedeveloped within audiology and/or education to dealwith the home and clinic management of the young deafchild.

5. The public schools are not now, nor will they be inthe foreseeable future, prepared to function at the homeand infant level; and, therefore, speech and hearingcenters should accept leadership responsibility in

developing home and clinic management of the youngdeaf child and articulating those services with the educa-tional services provided by the schools.

Experimental Investigations of FamilyManagement of Young Deaf Children

While early childhood education has achieved wide-spread visibility in recent years because of the interestand programs of the Federal government, it is a develop-ment of considerable maturity in the education of deafchildren. 1 do not propose any detailed discussion of thehistory of this development, but would like to point outsome of the highlights of the development in this andother countries. Home and family management of theyoung deaf child is commonplace in several Europeancountries, including England, Sweden, Denmark, and theNetherlands. In this country the work at the John TracyClinic, Central Institute for the Deaf, and other places iswell known. Observation indicates there are few differ-ences in methods used in this country and in Europe in

instructing the family in the management of the child;however, there are three important socio-political differ-ences which result in early childhood education being

more widespread and systematic in several Europeancountries than in the United States. First, thosecountries are small by comparison to the United Statesand their populations are more concentrated; second.centralization of government responsibility permits theapplication of uniform social services; and third, andperhaps most important, socialized medicine makespossible adequate medical services for all people, withparticular emphasis being given to the early detection ofhandicaps in children. It is these factors, rather than anysuperiority in techniques of clinical and educationalmanagement, that make early childhood education morewidespread and systematic in some European countriesthan it is in the United States.

While a number of centers in this country haveemphasized the importance of early childhood educationfor deaf children, and the central importance of thefamily in that education, the work of the John TracyClink is perhaps the most widely known because of itscorrespondence come program. Since its founding in1942, the John Tracy Clinic has agressively promotedthe idea that the greatest influence in the deaf child'searly years should be the family and that the familymust be given the means to work with the child in thehome. One outgrowth of this philosophy was the corre-spondence course which has been used by thousands offamilies and which obviously recognizes the parentsthe child's early teachers. Another, and more recent.outgrowth was the idea that training of the parents inhome management of the deaf child should take place ina home-like setting rather than in a clinic. This idea hasspread to several other centers and one of the twoexperimental investigations I wish to discuss is a study ofthis approach to the home management of the youngdeaf child. Before proceeding to that task, let me pointout that the systematic programs of early childhoodeducation and home management that prevail 111 SOIlleEuropean countries have not eliminated the need forspecial educational facilities and programs for suchchildren when they reach school age. I will return to thispoint in my concluding remarks in trying to provide aproper perspective of what can he expected from familymanagement of young deaf children.

Home Management Program at the BillWilkerson Hearing and Speech Center

In February, 1966 the Bill Wilkerson Hearing andSpeech Center, with support from the U. S. 0171(1. ofEducation, began an investigation of the effects of earlyhome training on the developuumt of young hearingimpaired children. The final report on this project was

43

submitted by McConnell and Lorton to the U. S. Officeof Education in January, 1970. I plan to present onlypart of that report for our discussions, but recommend athorough staly of the project to anyone interested inthe home management of hearing impaired children. It isone of the very feu studies in this important area whichprovided data on the children and their families, on theprogram which was undertaken, and the results whichwere achieved.

The McConnell and Horton (1970) study was pat-terned after the home training program of the JohnTracy Clblic. It involved providing a home setting forparent training, invosive and continuing hearing evalua-tion of the children, provision of hearing aids for thechildren, informing the parents of the nature and effectsof hearing impairment, and instructing the parents howthe home setting could be used to provide opportunitiesfor developing language and communication in thehearing impaired child. The investigators listed the mainobjectives of the project as being:

1. To provide a parent oriented program appropriateto the needs of the very young child;

2. To provide a program which the skills basic toattainment of language could be practiced on anintensive basis in the child's home; and

3. To develop a manual of home teaching techniquesto be used for supplementing and facilitating theeffective management of the deaf child during hisfirst three years of life.

A population of 94 children was served during thethree-year period of the project and extensive data aregiven in the report on these children, their families, andthe results achieved. However, a number of uncontrol-lable factors resulted in lack of continuity of attendancefor many children, and the data I will present are basedon 28 children who had continuous attendance in theprogram for an instruction period with a mean length of27.8 months for the group. As the authors themselvesstate, it seemed reasonable to select a subgroup fr on thepopulation which would best represent the home teach-ing program on the basis of having spent a sufficientlength of time in it to permit come definitive conclusionsto be reached.

Table 1 shows some background data on the childrenand their parents. Of particular interest are the data onthe hearing levels of the children. The initial unaidedSpeech Awareness Level for the group had a mean of71.6 dB with a range of 40-109 dB. While the projectwas designed to deal with very young deaf children, thehearing level is not as severe as that usually associatedwith the term "deaf". This is more apparent in the initial

44

aided Speech Awareness Level where the group meanwas 48.6 dB with a range of 20.100 dB. These data raisesome questions concerning the degree and type of hear-ing impairment, as do the data for the final aided exami-nation where the mean was 27.1 dB and the range 8-65dB. This point is being emphasized only to cautionagainst overgeneralization of the results of the study tochildren with more severe degrees of hearing impair-ment.

Table 1. Summary description of 28 children with respect toparental occupational classification, amount of homeprogram instruction, and hearing level for speech.

MeanStand.

Dev. Range

Parent's occupationalclassification

3.9 1.8 1.7

No. homc visits 21.2 12.8 7-57

No. hr. instruction 27.2 16.1 7-68.5 hr.

HEARING LEVEL

Speech awareness level.1st Exam, unaided 71.6 dB 15.2 dB 40-100 dB

Specch awareness level,1st exam, aided 48.6 dB 21.3 dB 20-10r; dB

Speech awareness level,last exam, aided 27.1 dB 17.2 dB 9-25 dB

Table 2 shows the results which were obtained witnthe 28 children in language development. Language Agewas measured by the Communicative Evaluation Chart(Anderson, Miles, and Matheny 1963). On the basis ofthis evaluation, the children progressed 29.8 months inLanguage. Age during the 27.8 months of instruction athome and in the demonstration home setting, which isvery notable progress indeed.

Figure 1 shows the results obtained when the 28children were divided into three subgroups on the basisof Language Age gain in months - the one-third with thegreatest amount of gain, the middle third, and the one-third which made the least gain. It can be seen that theseparation ')f the groups in Language Age was accom-panied by separation in hearing level also, with thelowest language gain being made by the groups with themost, evcre hearing impairment. As a matter of interest,it can be seen from Figure 2 that the differences inLanguage Age (and also the differences in hearing level)were related to differences in mean Social Quotient onthe Vineland Social Maturity

These few data from the McConnell and Hortonstudy are sufficient to indicate that very early interven-tion through the auditory sense in a cooperative programbetween professionals and milies can be successful in

Table 2. Pre. and post-instruction comparisons for 28 children on Chronolog-ical, Language and Performance Age.

MeanStand.Dev. Range Diff.

Chronological Age

Pre-instruct. 27.5 trio. 8.2 10 . 40 mo.27.8 mo.

Post - instruct. 55.3 mo. 9.6 34 - 69 mo.

Language Age

Pre-instruct. 8.4 mo. 2.3 4.7 - 13.8 mo.20.8 mo.

Post.instruct. 29.2 mo. 13.0 12.7 - 57.0 mo.

Performance Age

Pre.instruct. 23.2 mo. 9.2 - 30.8 mo.24.7 mo.

Post-instruct. 47.9 mo. 26.6 - 60.0 mo.

improving language and communication development.As pointed out earlier, caution should be exercised ingeneralizing to children with more severe degrees ofhearing impairment than those in the study. For ourpurposes in this meeting, the point of interest in thisstudy is that the family played a major role in earlywork with the hearing impaired child. And this role wasnot merely a supportive one, for the family in a very realsense became the teacher of the young child.

Studies of Deaf Children of Deaf Parents

A few studies have been conducted in recent years ofdeaf children of deaf parents which have implications forthe role that the family can perform in the managementof deaf children. I propose to discuss one of thosestudies which was conducted by Meadow (1967, 1968).

Meadow's thesis was that the basic impoverishment ofdeafness is a result of lack of language rather than a lackof hearing (although the two arc obviously related), andthat the deficiencies in language, communication, educa-tional level, and personal and social adjustment that arecharacteristic of many deaf pc,. 'xis result from environ-mental factors involving the early horn*: management ofthe child rather than being an inevitable consequence ofdeafness, per se. In order to examine this thesis, Meadowcompared the performance of deaf chiidren of deafparents with the performance of deaf children of parentswith normal hearing on the assumption that the earlysocialization experiences of deaf children of deaf parents-.mild differ markedly from those of other deaf chil-dren. She reasoned that acceptance of a deaf child bydeaf parents should be comparatively easier than forhearing parents, and that most deaf children of deafparents have a ready means of communicati ,a from

early childhood, since most deaf adults use manualcommunication as a matter of course between them-selves and with their children.

Three hypotheses were formulated for the study:

Hypothesis 1. Deaf children of deaf parents, com-pared to deaf children of hearingparents, arc more likely to show ahigher level of intellectual func-tioning.

Hypothesis 2. Deaf children of deaf parents, com-pared to deaf children of hearingparents, are more likely to show ahigher level of social functioning,especially apparent in situations re-quiring "maturity" and "inde-pendence".

Hypothesis 3. Deaf children of deaf parents, com-pared to deaf children of hearingparents, are more likely to demon-strate a higher level of communicativecompetence, including competence inwritten and spoken, expressive andreceptive language.

The base population of the study consisted of 59children with deaf parents who were enrolled in theCalifornia School for the Deaf in Berkeley, California.These children were matched individually with 59 deafchildren enrolled in the same school whose parents hadnormal hearing. The two groups were matched on thebasis of sex, age, IQ, hearing level, and family size. Inaddition, children of hearing parents were eliminated

45

46

0

10203040.

5060708090

100

0o

Highest gain group (N-9)Midgain group (N-10)Lowest gain group (N-9)Total group (N-28)

0 35.44 Mo.

0,.e....:1___.., 18.76 Mo.8.31 Mo.

120-

100-

80-

60-

40-

20

I

First First Lasttest test test

unaided aided aidedFigure 1. Comparison of mean unaided and mean aided hearing levels (firstand last) for 28 childrei. divided into three subgroups on the basis of LanguageAge gain. (Figures at right indicate mean L A. gains for the three subgroups.)

MEANL.A.

GAIN8.2 Mo.(N-9)

MEANL.A.

GAIN19.5 Mo.(N-10)

MEANL.A.

GAIN35.4 Mo.

(N-9)

S.Q.RANGE

Lowestgain

groupFigure 2. Comparison ofgroups of children divided on

Middlegain

group

Highestgain

groupVineland Social Maturity Scale levels for threethe basis of Language Age gain.

from consideration if t hey had any of the followingcharacteristics:

I. (leaf siblings:2. racial or ethnic miority group membership;3. secondary handicap (e.g. physical condition in

addition to deafness which interfered with func-tioning);

4. deafened after the age of two years:5. deafness resulted from maternal rubella, Rh in-

corn pa tibility , or anoxia.

Table 3 from Meadow (1968) shows the matched-paircomparisons of Stanford Achievement Test scores for 32pairs of children for whom such scores were available in1966. It can he seen that differences in grade level, read-ing level, and arithmetic level, favoring the children withdeaf parents, were significant at or beyond the one percent level. The considerable difference of more than twoyears in reading level is of particular interest to personswho arc familiar with the education of deaf children.

Table 3. MatchedPair Comparisons of Stanford AchievementTest Scores: 1966 Grade Average, Reading, andArithmetic

Meandifference

(N)(pairs)

Gradc average + 1.28 years (31)* 2.84**

Reading + 2.10 years (31)* 2.56**

Arithmetic + 1.25 years (32) 3.67**

*one tied observation (bopped from the analysis.**p

< .01

An index of ratings by teachers and counselors famil-iar with the children in the study was used to comparethe two groups in the areas of social and personal adjust-ment. Table 4 from Meadow (1968) shows the results of

these comparisons. and it can be seen that pairby pairanalysis of the various items describing social func-tioning favored the children of deaf parents in all

instances.Table 5 from Meadow (1958) contains data on the

communicative functioning of the subjects. It will benoted there were no significant differences between thetwo groups on the ratings of speech and speechreadingability. On the other hand, there were significant differ-ences favoring the children of deaf parents on: (I) facili-ty in written language; (2) ability to finger-spell: (3)ability to read others' fingerspelling: (4) ability to usethe language of signs; (5) no apparent frustration fromability to communicate; and (6) willingness to attemptcommunication with strangers.

Meadow (1967, 1968) concluded that the results ofthe study confirmed her initial research In pothesesregarding the superior educational and social functioningof deaf children with deaf parents compared to deafchildren with hearing parents. Confirmation was ob-tained on the Stanford Achievement 'Pests, teacher-counselor ratings of educational functioning, social andpersonal adjustment, and language and communicationskills, with the exceptions noted for ratings of speechand specchreading ability where no significant differ-ences emerged between the two group..

Mudi of Meadow's interpretations of her findings isconcerned with the thesis that exposure to both manualand oral communication at an early age is likely toproduce better results than exposure to only one form.This is an interesting thesis, but it is not our concerti atthis meeting. The point of interest for our discussions isthat the studies by McConnell and Horton (1970) andby Meadow (1967, 1968), emphasize that early Inter-vention is essential to the improvement of language andcommunication and personal and social development ofthe deaf child, and that in such intervention the family

Table 4. Index Ratings of Social Adjustment Variables for Matched Pairs of Children withDeaf or !tearing Parents

Rating Scaleitem

No. ofPairs

No. whereChildren withDeaf ParentsRated Iligher

WileoxonT value z

Mature 56 39 (70%) 430.0 2.99**Responsible 55 38 (69%) 432.5 2.83**Independent 53 40 (75%) 281.0 3.85**Enjoys new experiences 55 36 (65%) 501.0 2.25*Friendly, Sociable 55 42 (76%) 405.0 3.06**Popular with classmates 55 40 (73%) 434.0 2.82**Popular with adults 52 34 (65%) 427.5 2.38**Responds to situations

with appropriate emotion 55 34 (62%) 535.5 1.97*Shows appropriate

sexrole behavior 54 33 (61%) 509.5 2.01*

**p< .01 *p< .05

47

Table 5. Matched-Pair Comparisons of Index Ratings for Communicative Functioning.Chil-dren with Deaf or Hearing Parents

Rating Scale No. ofItem Pairs

No. whereChildren withDeaf ParentsRated Higher

WilcoxonT value 2

Speechreading ability 46 22 (48%) 623.0 .10Speech aptitude and

performai ce 51 21 (41%) 758.0 .89Facility in writtenlanguage 49 35 (71%) 263.5 3.47**Ability to fingerspell 54 50 (93%) 18.5 6.23**Ability to read others'fingerspelling 52 49 (94%) 25.0 6.09**Ability to use thelanguage of signs 55 46 (87%) 117.0 5.474*No apparent frustrationfrom inability to communicate 56 39 (70%) 319.0 3.89**Willi..gness to attemptcommunication with strangers 45 30 (67%) 335.5 2.06*

**p< .01

plays a crucial role. Results of the two studies indicatethis to be the case, even though the studies were quitedifferent in philosophy, one being concerned with theeffects of early intervention through amplification andaudition and the other with the effects of early exposureto manual communication. Other studies could be citedto support these results, but these two are sufficient toprovide a basis of discussion of the importance of thefamily in the early development of the deaf child, andthe importance of such early development for the laterdevelopment of the child.

The Role of the Family, the Hearing andSpeech Center, and the School

Early in this paper I listed five points which mightserve as basis for discussion of the role of the family inthe management of the deaf child, and would like to

,discuss those points now in relation to the findings ofthe two studies which I have just presented. I will passover the first point on the importance of the first fouryears of life since it seems axiomatic.

Part of tht second point, that the family is of primaryimportance in the deaf child's development, probablymerits little debate, Linguistic and psicholinguistieresearch with hearing children has indicated the impor-tance of the first three or four years of life for thedevelopment of language and communication. Comparethe four-year-old hearing child, who usually has a

vocabulary of between two and three thousand wordsand a working knowledge of the basic syntactic structureof his language, with the profoundly deaf child of similarage who might have only a few words of vocabulary andlittle or no command o, syntactic structure, and theimportance of those cal ly years of life, the deaf child

48

lip < .05

suffers experiential deprivation which can retard hiseducational and personal development throughout therest of his life.

The second part of the second point, that profes-sional personnel should accept the responsibility forproviding the family with the knowledge and skills tofoster the deaf child's development, might produce somedisagreement. Professional individuals often are reluctantto accept the idea that the parents of a child can betrained to function as his teacher or clinician. Yet, thereis no reasonable alternative to this in the early develop-ment of the child. Many of the early childhood programsfor culturally disadvantaged children, which arc notbound by the traditions of education, operate on theassumption that as much effort should be expended ontraining the parent to train the child as on direct trainingof the child, himself. Since language and communicationdevelopment is a continuous process throughout thechild's waking hours, the parents are the only individualswho have sufficient contact with the child during theearly years of life to provide the continuous stimulationnecessary for language development. If the parents ofdeaf children are to perform this function adequately,they require training and education for the task.

Lowell (1967) has listed four stages of parental edu-cation which arc important to guidance of the learningof a deaf child: awareness, acceptance, information, andapplication. By awareness is meant realization by theparents that the child has a profound hearing impair-ment and the implications this has for his futuredevelopment, particularly his development of languageand communication. Since, again according to Lowell(1967), first the audiologist, and second medical person-nel, are responsible for the initial determination ofhearing impairment, it is on these persons that theparent must rely for initial advice in guiding his child's

development. Few public school programs accept (leafchildren before the age of three years, and not manybefore the age of five, so that in the foreseeable future(unless responsibility for early childhood educationspreads more rapidly throughout the public schoolsystem than seems likely) some other types of institu-tions will have to accept at least partial respongibility forthe management of the young deaf child, and one logicaltype of institution is the hearing and speech center.

The acceptance of this responsibility by hearing andspeech centers has some implications for the role andtraining of the audiologist which relates to the third andfourth points I listed earlier. 1 helieve it reasonable toassume that most audiologists are ill-equipped by train-ing to provide guidance to parents in managing a deafchild. Too frequently, their training is concentrated ondiagnostics with accompanying work in acoustics,anatomy and physiology, statistics, speech and hearingscience, and other areas which educate them in thehearing and speech process and its disorders. Too infre,quently is there any systematic preparation in familyand child development and guidance and practicum withvery young children and parents. If this kind of trainingcannot be included in all audiology programs, perhaps anew specialty needs to he developed in home and familymanagement of the young hearing impaired child toprepare individuals who can manage the stages of accept-ance, information, and application in parental education

'described by Lowell (1967). As McConnell and Horton(1970) have pointed out, "educational concepts for deafchildren of school-age cannot be applied as a simpledownward extension to include the infant and thenursery-age child. A completely new kind of orientationto her role will be needed by the teacher, first of all,who must be able to work effectively in a non-teacherkind of counselor approach. She must focus on theparents since their involvement is crucial to the successof any program with a child too young to enter into aformal educational experience."

Either the audiologist or the new type of teacher willhave primary responsibility for creating acceptance,information, and application on the part of the parents.As Lowell (1967) has stated, many parents are unable orunwilling to fully accept the fact that their child is deaf.The programs at the John Tracy Clinic, the Bill Wilker-son Center, and other institutions have found thatobserving other deaf children and talking with otherparents of deaf children who share the same problems,helps parents in the emotional acceptance of deafness.Such observation and discussion should, of course, beguided by professionally qualified personnel.

Realistic acceptance of the fact of deafness is impor-tant to the next stage of providing the parents with

information about the role they can play in their child'seducation. McConnell and Horton (1970) found thatseveral sessions were required to provide parents withbasic information on the effects of deafness and whatparents could do to promote auditory training, the useof hearing aid, and language and speech development. Inaddition, continuing periodic attendance was required ofthe parents at clinic sessions throughout their child'sattendance in the program. McConnell and Horton(1970) considered this continuing education of parentsto be an essential factor in success in the program. Onthe other hand, it should be remembered that the JohnTracy Clinic has conducted much of this type of workthrough correspondence courses for many years.

The final step described by Lowell (1967) in parentaleducation is application. Arid this essentially means thatthe parent must be trained to become his child's teachersIn several programs throughout the country, this trainingof parents is conducted within demonstration homesettings rather than in clinics, and the McConnell andHorton (1970) study was an investigation of this proce-dure. By training parents to use routine household activi-ties as the vehicle for teaching, they can be shown howto make maximum use of the many opportunities forlearning in everyday activities. It is believed that teach-ing in the simulated home situation will also increase thelikelihood of transfer and application in the real home.

The fifth point I listed earlier stated that the publicschools are riot now, nor will they he in the foreseeablefuture, prepared to function at the home and infantlevel; and therefore, hearing and speech centers shouldaccept some leadership responsibility in developinghome and clinic management of the young deaf childand in articulating those services with the educationalservices provided by the schools. Some of the programswhich have been developed are located in hearing andspeech centers while a few others are in schools for deafchildren. It would be a great service for deaf childrenand their parents if hearing and speech centers in generalwould accept this responsibility and activate programswhich would reach out to identify deaf infants in theirgeographic regions and provide training for the family onthe management of the child in the home.

McConnell and Horton's (1970) study, and otherdemonstration home programs around the country, haveindicated that parents can be trained to function asteachers in the early development of their deaf children.The study by Meadow (1968) indicated that deaf par-ents are able to play a vital role in their deaf children'sdevelopment without any outside help from professionalpersonnel in the field. What both studies indicate is thatearly intervention through the parents is one of our besthopes for future improvement in the development of the

49

child who is deaf, and that parents, in many instances,are perfectly capable of becoming successful teachers oftheir children. In order to provide parents with the skillsto function adequately in that role, the audiologist orsome new type of specialist must have the proper back-ground of training and experience, and hearing andspeech centers should become focal points for suchprograms. Hearing and speech centers and hearing andspeech personnel have had too narrow a concern, inmany eases, with the processes and disorders of speechand hearing, and too little concern often with the childand his family. It is in the area of the family. that suchcenters and personnel could make a significant contri-bution in the future.

REFERENCES

Anderson, R., et al, Communicative evaluation s. infancy tojive years. Cambridge, Mass.: Educators Publishing Service-Incorporated, 1963.

50

Lowell, E. L., et al. Survey of families enrolled in the JohnTracy Clinic correspondence course. Journal of Speechand Hearing Disorders, 1957, 22, 75.86.

McConnell, F. & Horton, K. B. A home teaching program forparents of very young deaf children. Vanderbilt Uni-versity School of Medicine, Project No. 6-1187, GrantNo. OEG 32-52-04506007 U. S. Office of Education,Final Report,January, 1970.

Meadow, K. P. The effect of early manual communicationand family climate on the deaf child's development.Unpublished doctoral dissertation, University of Cali-fornia, 1967.

Meadow, K. : . Early manual communication in relation tothe deaf child's intellectual, social, and communicativefunctioning. American Annals of the Deaf, 1968, 113,29.41.

DiscussionFLOWER: I was very interested in several of the thingsyou were reporting and agree that the Meadow study isone that requires a great deal of thought. I think thereare two emphases that have been placed on it. One is thenotion that the child is better accepted by the deafparents hence the better achievement among deaf chil-dren of deaf parents. On the other hand you note thatby the nature of the situation, they are getting earlierinstruction in a system of communication. I don't like toput anybody on the spot but I wondered if Dr. Shermanwould be willing to comment as a behavior modifier.From the standpoint of behavior modification, do yousee anything different in the deaf parent working with adeaf child?

SHERMAN: Yes, But I will make a couple of com-ments. Basically, in the study described, you have acorrelation. No matter what kind of behavioral measureyou want to take, whether it is a measure of the child'ssocial adjustment or language skills, you have a correla-tion between those measures and whether the parent ofthe child is deaf or whether the parent is hearing. itseems likely that, if you are ingenious enough, you couldprobably find maybe a thousand things on which hearingand deaf parents differ on personality dimensions, onthe way they handle the child, and on the way theyinteract with the child. No matter how carefully you'rematching groups you're going to find some differ noes.If the children of one type of parent do better than thechildren of another type of parent, the question thenbecomes, what is the crucial difference in the parents, ifany? Is it because one kind of parent accepts their chil-dren more than the other? Is that the crucial difference,or is there some other crucial difference out of the manydifferences that exist? NOW , the emphasis in the study isthat there are differences between these two groups ofparents, and it seems likely that one of those differencesmust account for the better social adjustment and thebetter language skills of the child of deaf parents. At onelevel, it is a reasonable starting hypothesis. But you stillhave the problem of which difference makes the differ-ence. In my opinion, the only way of systematicallyapproaching the problem is to take a deaf child, let's sayof a hearing parent, and expose him to those conditions

which you suspect are functional al producing betterlanguage skills and see whether his language skills arebetter than those of a child, or group of children, whowere comparable to begin with but who weren't exposedto these conditions. Is that in the general ballpark?

FLOWER: Yes, but is there. some reason why the deafparent is a more effective behavior modifier than thehearing parent, other than these things we've men-tioned?

SHERMAN: I really don't know. The first approachthat I would take is simply to observe what deaf parentsdo in terms of teaching their children to "communicate"on whatever level you're talking about. I would simplyobserve what do they do. What do they present to thechildren as tasks? What kinds of consequences, if any, dothey deliver to the children? On this basis, I'd begin toform some ideas about what a training procedure wouldconsist of for a deaf child. I would obviously subject mynotions to some sort of experimental verification. Thatis, I would want to have a measurement system for thelanguage skills of a deaf child. I would then attempt toput various training procedures into effect and observewhat happened to the child's behavior. I would thenremove those training procedures and see whether youstopped getting as much language gain, and then I wouldput those training procedures back into effect to see i;language skills again increased. As a result of this I woulddevelop a sequence of procedures which empirically, atleast, appeared to result in gains in language skills. I'mjust stating an approach that I would take. I'm notstating what I think it is about deaf parents that mightniake them more effective behavior modifiers. I'm reallysuggesting how I would go about looking for what makesthem more effective behavior modifiers, if, in fact, theyarc.

QUIGLEY: Am I suppose to respond to it? NowMeadow interpreted her findings by attributing thedifference to the manual communication that the par-ents had with the deaf child, but there arc a lot of otherways in which you could interpret that study. As it waspointed out, there could be a whole variety of factors in

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which the two types of parents differed. Might be thatjust the factor of acceptance of the deafness. not beingtraumatized b it, working with the child in any sys-tematic kvav from carp infancy would work out as wellas manual communication. But I think You do have tobe a little careful about the interpretation of it. She hasa right to interpret it as :he did. but other people mightwish to interpret it somewhat differently. I don't knowabout the operant conditioning: I'm not much of abeliever in behavior mmlifieation through operantconditioning. I think man is a rational animal not aconditioned (me: but it is big on our campus throughBijou, Engleman,13ceker and some others, and I've had adoctoral sentient do a thesis on it. but I couldn't com-ment on it because 1 don't have !midi belief in it. Ilowyou would apply it to working with deaf childrenthrough their parent? You multi. It's a mechanicalenough device for learning that it could be applied fairlyreadily.

SHERMAN: I think your characterization of operantconditioning b. fair. In my opinion. that's the exactbeauty of it. its mechanical nature. I would prefer to callit systematic and programatic, but we can have a se-mantic difference. However. I would maintain that itsexactly that characteristic about operant conditioning -

its systematic nature - which allow s you to use it dfce-tively to teach parents to teach their children. I thinkthat whether one believes in operant conditioningmethods is a slightly misunderstood issue. I have a beliefin these methods in a certain sense, but my belief isempirically based. I do have a belief in measurement ofbehavior as a valid way of approaching abnormal human

problem behaviors. That's really the belief stage of thegame. But given that belief, I am now willing to exploreany techinque which will make reliable changes in thosebehavioral measurements. It S happens that I use

operant conditioning procedures simply because I havefound very often that they are effective. On the otherham!, I'm willing to accept a variety of procedures whidtare not typically thought of as operant conditioningprocedures, if they arc effective. There has been anumber of very promising procedures suggested byothers during the short course. Some of them involvemanipulation of the stimulus condition antecedent tobehavior and some involve mechanical reatrangements ofthe environment. As far as I am concerned, they areperfectly valid procedures as long as you're producin::reliable changes in the problem behavior. So I don'tthink it's a matter of belief in the methods of operantconditioning or behavior modification. It's a belief inmethods of therapy which produce measurable chat,gcsin problem behaviors.

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FLOWER: You can find no better evidence of the needfor a more orderly look at the things we have been dis-cussing than the two studies you mentioned. Althoughboth :Iambi be reckoned with. we cant really sa% howclinicians should behave differenth because of theresults of these studies. As you say, the area remainsopen for disenssion.

QUIGLEY: Well. I don't know what the actual factorswere that led to the greater achievement on the part ofdeaf children of deaf parents. I personally would acceptMeadow's interpretation, but recognize that it is open tomany others. But the difference that was found, twoyears in reading level for a deaf child, is an awful lot. Ifyou've ever worked with deaf children you'll realizethat. The best normative data we have on deaf childrenand reading ability was a study done by three people inNew York (ref) on standardizing the MetropolitanAchievement Tests with deaf children. They fowl!' that,between the ages of eleven and sixteen, the reading levelof deaf children from schools and classes around thecountry, went from grade 2.7 to grade 3.5. That's eight-eenths of a grade in five years. So a difference of twoyears is a whopping difference. It's something you'll getin ten years of teaching. I said six to he conservative,because I think that at certain age levels you'll get adifference of about a third of a grade. Now that differ-ence is large enough so that I think some real attentionshould be paid to the study. What application you wouldmake of it I think would depend upon your interpre-tation of it. I would have the parents use manualcommunication with the child - that is the way I wouldinterpret it.

FLOWER: The sad part about it is, I think, this was an

answerable question to begin with and it's too had thatit has remained unanswered. Of course, it is still ananswerable question.

ALLMOND: I'm not having as much trouble with theMeadow study as I am with the prior McConnell andI lorton study. I like the conclusions very much. I'm notsure that they got there in the most appropriate way orthat the conclusions can be derived from the study itself.I am concerned that there were no controls for the studyso that we don't know what's happening in this par-ticular s udy to deaf children who are not exposed tothis experience for the three-year period. The otherthing which 1 found very interesting :flume theMcConnell and Horton study is that of the 94 childrenwhich they started with they ended up with only 28over the three-year period. And aside from this being a

rather confusing variable in the study itself. I'm wonder-ing if this obtains in the population of the deaf at large.is there difficulty in maintaining a three -'ear contactwith deaf children in any kind of an instructional pro-gram, and is this indtd a very real stumbling point forall of you people who arc involved with speech andhearing problems: is this a specific variable which couldbe looked at in and of itself? How come only 24 or 28out of 94?

QUIGLEY: Well, I would agree with your reservationsabout the study. I have many myself. primarily in thatfrom the data they gave on hearing threshold level I

would doubt that these w ere deaf children to beginwith certainly the aided threshold levels initially of 48decibels-- I've got a hearing loss that severe and I

wouldn't consider myself to be particularly deafbut Ibrought it out for two reasons. Uric. I think the study isgoing to be overgeneralized. In fart. the authors themeHelves have done so. They stated in their conclusion thatthis is what should be done with deaf children, whenthey really were probably not dealing with (leaf childrenat all. I wasn't so much concerned about the fact theylost a lot of the kidsthat's inevitable in that kind ofresearchbn what could be done to keep the parentscoming on a regular basis certainly is a matter for con-cern. They 'Were dealing with children from all overTennessee and several other states so that simpledistance very hkcly was one factor. But I combined itand the Meadows study, which are quite ( yosite inphilosophy, to point out that it's the early interventionthat we have to accomplish with deaf children. Languageis developed for a hearing child by the time he's fonryears of age. By then he has all the syntactic structure ofhis language. he'll elaborate a little bit from there on,but he knows how to use adverbs, though he doesn'tknow what adverbs areall that grammar in school doesis give him a name for it. But those first three or fouryears is where we have to get at deaf children. Theschools cannot get at them. They don't have themechanism, and I think that the one institution that earndo it is the hearing and speed] center, and I think thatthey should be looking at this. I think in order to do itthey're either going to have to train an anthologist differ-ently or they're going to b tve to train some kind of a

specialist to work with verb young deaf children, be-cause it's nut a simple do A.m. ard extension of the exist-ing teaching techniques by ny means. It's a wholedifferent kind of operation.

FLOWER.: There is another Try important factorwhich we haven't mentioned in the discussion thus far atthis meeting. here I speak as an administrator. By and

large. the speech and hearing renter is geared to relatively limited care. The financial base of operation. andparticularly for audiology service:.. Center:, on diagno.tii.sees ices. What von are suggesting requires a whole newlevel of support. One of the reasons why many audi-ology dillies have not functioned as effectively as theyshould relates to the cost of providing these services.

QUIGLEY: I wouldn't be overly t oneerned about that.I'm a member of the National Advisory Committee onthe Education of the Deaf which advises the secretary ofIIEW about programs and the education of the deaf.When that early childhood bill was first written, it wasnot written by our committee. it was written by theAdvisory Committee to the Bureau of Education for theHandicapped. When they first wrote that bill. they hadextended only to the age of three and we were givenadsanee notice of the bill. When we saw this, we had theage taken omit, :4) that it can go down to infaney. Themechanism exists through that act for the funding ofsuch programs.

BANGS: Could I speak to that question? Closely alliedto the question is the Early Childhood DevelopmentAssistant Act which was signed by the President in theFall of 1968. It provided monies for planning andoperational grants which will produce model programsfor handicapped children, ages birth through third grade.Of impntanee is the fact that this act has introducedinto special education a national shift of emphasis fromthe handicapping condition of the child to his edno-tional needs. There is no question that speech andhearing clinics have been pioneers in developing educa-tionally oriented programs for pre-school handicappedchildren. Man% of these clinics have assisted the child atbirth, and have involved families in a variety of ingeniousways.

I believe it is time that university departments ofEducation and Special Education also take a look at theneeds of these pre-school handicapped children, anddevelop curriculums that follow an outline similar to theone I have on the, blackboard. You will observe that thefirst four y ears (or more), are concerned with teachingthe regular classroom telteher. You will note, however,that the course content isquite different than that repre-sented in most College of Education degree plans: e.g.linguistics; phonology, semantics and syntax: psychol-ogy: behavior modification, learning theory.: etc. Now ifone of these teachers desired to go on into special educa-tion, she would take a fifth. possibly a sixth, year, ofon-the job-training plus course work. With the basicteaching background and her practical experience withhandicapped ("nicker!, irrespective of their labels, she

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would be graduated with a one-level teaching certificate.If her foundation was adequate, she could teach mostany child irrespective or his handicap... keeping in mindthe shift of emphasis from the handicapping conditionto the educational needs of the child.

What I am hoping for is a one level certificationwhich will qualify teachers to train children irrespectiveof their handicap. Except in rare instances, it can bedone. There will no longer, then, be a need for certifiedteachers of the hearing impaired (I dislike the termdeaf), teachers of the orthopedically handicapped,teachers of the multiply handicapped, etc. Furthermore,I am not concerned with who certifies these teachers. Itmay be state departments or it may be one or more of anu mber of university departments; i.e. Education,Speech Pathology-Audiology, Psychology. This, ofcourse, means a cooperative inter-play among universitydepartments that is not always in existence today.

So, in response to your question; yes, I do thinkSpeech and Hearing Clinics will continue to carry theball until they can promote genuine interest amongother profe:sions.

QUIGLEY: I think it's more than a matter, though, ofhaving the teachers trained, I agree with your idea oftraining a particular specialist. I don't think the audi-ologist training can be expanded to include this orcertainly should be expanded somewhat because it'spretty narrow as it is. But there is a good deal of talkabout the elimination of differences among the varioustypes of handicaps and I think this is a myth. Therereally isn't any such thing as special education otherthan in an administrative sense. I work in a Departmentof Special Education. It's only an area in an administra-tive sense, that's all. There is no relationship basicallyamong the different types of handicaps. But there aresome people on our campus, Bijou, for one, who feelsthat through the application of operant conditioningthat you can train all kinds of kids alike. You don't needto have specialists on the deaf and the handicapped andthe emotionally disturbed and so on. He feels that thetechniques of operant conditioning are applicable across'the board, and that all you would have to requirebeyond this perhaps would be programming of languagefor deaf children. I don't agree with it. It's a passing fadat the moment, to say that we're not going to call kidsdeaf or retarded or anything else as though the labelreally makes that much difference. I don't think it'sgoing to come about, although there are many peoplewho would agree with you and there are some on ourown campus who do.

BANGS: You don't think the label makes any differ-ence?

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QUIGLEY: Well, I know it's not good for them to usethe term deaf anymore, we arc not supposed to refer tothese children as being hearing impaired. That has a lotof problems associated with it, because you're thenlumping together under one label children who differradically not only in their degree of hearing impairmentbut in the behavioral effects of it. Hearing threshold is acontinuum, I agree. But somewhere along that con-tinuum a person ceases to be linked to the world pri-marily by his ears and becomes linked to it by his eyes.Now where that point is, is a matter of debate; but itexists. And once you've crossed that you're not talkingabout a difference of degree any more, you're talkingabout a difference in kind.

FLOWER: I think an even more important point,however, is that "deafness" implies that reduced hearingsensitivity is the dominant disability; but many young-sters we're working with these days have a whole spec-trum of disabilities. Generalizing about "the deaf" asthough they represent a single entity is extremely pre-carious.

BANGS: I have, I think, a pertinent comment here. Asone reads the research literature on the academicachievement of the deaf, he finds it is most often con-cerned with deaf children educated in schools for thedeaf by "deaf education methods." Flow often do youread in the literature about children who by audiometricand educational definition are deaf, but who haveachieved academically and socially on grade level? I havenot read many. We have such a study under way at theHouston Speech and Hearing Center. In the study wehave approximately thirty children who received pre-school training at our clinic which utilizes a naturallanguage approach to teaching. These children are

currently achieving in normal classrooms in the basicsubjects of reading and arithmetic. I mention this studynot because of the success story, but because there arestill many disbelievers. We have submitted a manuscripttwice for publication consideration and have had it re-jected twice. In general the editors stated, "It is commonknowledge that deaf children will not achieve on gradelevel through senior high school." So, we will continuethe reassessments in our longitudinal study and submitanother manuscript at a later date. We think the childrenwill graduate in a regular curriculum. Who will be right?We've got to wait until they're through junior highschool, but I think the, studies have all been gearedtoward deaf education.

QUIGLEY: No, that's not really so. I would like to seeyour study, by the way; I would very much like to have

a copy of it. But the whole education philosophy inworking with deaf children for the last 20 or 30 yearshas been the idea of integrating them within the regularschool system. That's why day classes have expanded sorapidly. You know, 50 per cent of hearing impairedchildren are in day classes now. Only half of them, Ithink somewhat less than half of them, are now inresidential schools. Now that's a radical change in thelast 30 years. It used to be about 80, 90 percent inresidential schools and 10 or 20 in what were then dayschools rather than day classes. The whole philosophyhas been geared to doing just whay you say, and it'sbeen rather unsuccessful. Although I agree very muchmyself with the philosophy, I think it's the onlyreasonable philosophy to have, the success of it, in myknowledge, like I said, has not been very great. But Iwould very much like to see your study. Now maybe ifwe were getting at these kids early enough, you know, ifyou were getting them by the time they were a year oldand working with them, sure it's possible. But you mustallow us who work with deaf children to be a littlecautious because we have some sweeping enthusiasmthrust upon us every other year or so. It was oralism,manualism, general amplification, low frequency ampli-fication, verbal-tonal audiometry, frequency compres-sion and transposition, each one of these was going toeliminate all of our problems and it hasn't yet eliminatedanything. So we are a little cautious when a new panaceaenters upon the scene.

ALLMOND: I'm a little concerned. What's happened tothe family? Where did they all go?

BANGS: I think the family is very close at hand. If youbelieve in starting training of children from birth (if feas-ible), then the family must become involved unless youare thinking of residential care.

QUIGLEY: I think you're right. But I still maintainthat since language and communication is a process ofcontinuous development, the only people who have thiscontact with the child during his first three or four yearsare the family. And you can teach a parent, you cantrain a parent to teach that child, it's not that difficult.It requires an awful lot of patience, an awful lot of timeand whether or not the parents can give this time awayfrom their other duties, I think is probably a majordifficulty. But the family is not far away. They have tobe the key, I think, in working with very young deafchildren.

SHERMAN: Exactly what would you like to see thefamily teach the child? How does a family member teach

the child, and possibly more important, how do youknow that it's doing any good? What kind of feedbacksystems do you envision so that you will know that whatyou're doing is effective, and how do you break downthe components to know that they are effective?

QUIGLEY: Well, I think this is one area in whichoperant conditioning has some merit. I'm saying itseriously, it really has provided a means whereby a taskcan be broken down into manipulable parts and the

effects of these studied, and they can do this in a verysystematic way. I think there would be some real appli-cations to this to working with the families of the deafchild. My reaction against it is simply that I feel thatman is a rational being and not a conditioned one.

BANGS: I'd like to speak to your question. Many of uswho arc working with pre-school hearing impaired chil-dren, or any handicapped children, have developed abattery of tests that purport to measure language andlearning skills. Periodic re-assessments tell us whether ornot a child has moved, for example, from the baseline ofbabbling to jargon, to echolalia or to the semantic level.

SHERMAN: I guess I wanted more specific informa-tion. Earlier, manuals for parents and a correspondencecourse were mentioned. That really interested me be-cause if you can do it by mail and produce quantifiableresults then it would seem that you have developed avery powerful and practical teaching tool. What do youteach parents to do, how do you evaluate whether theyare doing it, and how do you evaluate whether it's hav-

ing an effect on the child? You have already mentionedsome of the methods to evaluate whether the child's

behavior is changed.

BANGS: We attempt to assess our behavioral objec-tives. If we are starting with a basic comprehensionvocabulary of phrases, e.g. "pick it op." "close it," "giveit to me," "throw it away," then we use our specificallydesigned assessment tools to demonstrate if the childdoes comprehend these phrases in a functional environ-ment.

SHERMAN: That implies control conditions-that thechild wouldn't have done it unless you used these specialtraining procedures.

QUIGELY: That, though, is so obvious in working witha deaf child that I don't worry too much about the lackof controls in the McConnell and Horton study becausewe know enough about how little a deaf child has when

he's three, four, five years old, is nothing, probably his

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name, maybe. Ile doesn't have anything, usually, so thatthe difference u hen he goes through sonic kind of train.ing program is so glaring that controls arc, well, I don'tthink they are of any real relevance.

ALLMOND: , Well, my own feeling is that it doesn'texcuse the lack of controls with the Horton study.

My ListenerLee E. Travis

Ma) I be allowed to take a glance at our theme fromthe top of a high mountain rather than walk in thebottoms of the canyons? May I be excused fa m labora-tory precision in my utterances and instead be allowedgreat expanse of imagination, even poetic license?

You have heard me ever since I was bornMy birth cry and my babbling

My first word and my first sentenceAnd that you have listened determined

that I have spoken

As my listener you are the soil for thegrowth of my words

I would not have them fall upon the barrenrocks of your unconcern

Or into the noisy circuits of your distractionIt does not matter only that I speak

It matters too that you listen

May I look at our contemporary family scene througha telescope id allow others the use of a microscope?

Since the beginning man has reflected upon themeaning of his life. At one period in his thinking abouthimself he believed that he was governed by immutablelaws and in the next by chance. In one period angelsdelivered him to earth and in the following time he was aplanetary waif born of meaningless and ever alteringchemistry. One time God made man and the next timeman made God. Century after century man studies him.self, draws conclusions and makes plans only to changehis mind and his behavior the next timc around. Onecentury he was a reactive creature, the victim of controlby stimuli supplies by his inside and by his outside. Hiseyes, ears and nose moved him about in competition orin collaboration with an acht or a pain or a need. He wasthe pawn of his sense organs. More currently man isv;-wed as being ordered by a control center within, acenter that alerts not only the responding system toaction but the receiving system to receive. Both the

responding and the receiving are to acquire a supply ofstimuli to serve. the organism. Mainly this central regula-tory system maneuvers the organism so as to place thesense organs into position to register Possibly allthat man ever does is to seek stimulation and not at all,expression. Man is mainly a searching and not a reactingorganism, seeking always for food-stuff, from his accept-ance by another to the delicacies of the banquet table.He moves his receptors around in his environment thatthey might in their intake quench his thirst for realiza-tion. Man is most likely a realizing and not a reactingorganism. Instead of SOR (stimulus, organism, response)we have ORS (organism, response, stimulus).

Although one searches far and wide for answers to hismeaning, he searches mainly for another's appraisal.Constantly he reaches out in all ways, but especially inspeech, for a message of how he is standing withanother. I ask, is my life in your keeping? Is it in yoursafe keeping? Or must I be afraid? With inanimatenature, and to a large degree with living animals, I can beobjective and view the thing or the animal as an object.have a sovereign independence from the whole objectiveworld opposing me and I can treat it essentially as I will;measure it, alter it; even destroy it. The substantialworld has no share in my experiences. It is experiencedby mc, but it has no concern in the 'ratter.

But out there too, I encounter you and never againwill I be unexperienced. Now I will have to share mewith you. I have an awareness of being in the world ofyou and me, in a shared world, and I wonder about us.You seem as irrevocably welded to your position as I amto mine. You cannot shed your skin and I cannot shedmine. Existence now becomes completely coexistenceand I exist only in communication with you, the otherone of us. The world has two centers, yours and mine,two seeing points, your view and my view; and right herethere exists the bases for all the crises of human exist-ence. You and I alike will claim to be the correct centerof the universe. and coexistence will become not nceessadly a peaceful juxtaposition.

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I go about in the world transmitting signals to you,the other one. This is practically half of what I do duringmy entire earthly existence. I make sounds to you, Imotion to you, I hold you, I let you go, I come to you, Ileave you. My speech and my gestures and my comingand my going are my signals. Constantly I tell you aboutus. That's all I have to tell you, is about us.

My transmitting is unique. It is different. No otherOne transmits quite hi, 1 do. This will always cause ustrouble, and we will spend about half of our lives tryingto handle this trouble.

Also I go about the world receiving your signals. Thisis practically all I do the other half of my earthly exist-ence. So practically my entire lifetime is occupied withtransmitting signals to you and receiving signals fromyou. And also my receiving is unique. It is different. Noother one receives quite like I do. This also will cause us

both trouble, and we will spend the most of the rest ofour lives trying to handle this trouble.

So my life and its troubles will concern themselvcpractically entirely with communicating with you, myunique other on

When any one speaks, not only by what he says, butalso by the way he says it, he defines a relationship withhis listener. The listener may accept the speaker's defini-tion or counter with his own. In talking now I amdefining you as the student and me as the teacher. I amdefining the relationship. Yet you as the listener ;,an aisoeontTol the definition of our relationship because youdid invite mu here to speak and you are now letting mespeak.

Some sort of relationship is inevitable whenever twopeople meet. All verbal message s between them are notonly reports but also manipulations and commands. Apatient may say -hat he eannot make a decision. Bysaying this he is not only reporting but he is alsoconveying an order for the therapist to tell him what todo. As Jay Haley so aptly exprmes it, the patientcommunicates at two levels: "Tell me what to do" and"obey my commit(' to tell me what to do." Thehelpless person, as well as the authoritative one, maydetermine the other person behavior.

Communicative behavior which defines a relationshipmay be symmetrical or complimentary. If it symmetri-cal, the two people }Inge the same kind of messages.Each person wul command, reject or acquiesce on anequal :,axis with the other. "You are mean", "so areyou"; "I do't care", "neither do I"; "What you can do,I ca i do better". These are messages of competitionbetween the t messages of combat, defeat andvictory. The people nay help eael other a little, but thereal game is who will be the boss and who will be theslave, who will win and wh6 rill lose In society at large

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he who plays this game may be too insensitive to thewelfare of others. Union Oil, the Land Developer, thePharmaceutical House, the Political Dictator, all comequickly to mind. And this game is far too popular in theAmerican home: spare the rod and spoil the child comesdown from ancient times.

If the relationship is complimentary the two peoplewill exchange different types of behavior. One gives andthe other receives, one leads and the other follows. Theyalternate er_atively in bossing and serving, and in takingturns in all of the chores of the household: cleaning,washing, baby tending, marketing, and making andspending money.

These two types of relationships denote a simplescheme of interaction between people and may be con-sidered normal. May I point out, however, that a crucialaspect of a symptom is the advantage it may give thepatient in determining what is to happen between himand others. And further, nay I declare that a symptomis not only a way to deal with others but it is also a partof an arrangement worked out in implicit collaborationwith those very same others. Possibly always someoneelse joined the patient in the creation of the illness.

I do not think that it is pathological to control arelationship, either all the time or just part of the time.If relationships arc open and honest. and mutuallyunderstood, all may be well. But when one person triesto control another person while all the time denying it,then such a person is advertising his illness. When a childby his stuttering circumscribes his mother's living whiledenying that he is doing so, he is exhibiting symptomaticbehavior. If the stuttering child knows or awaits that heis annoying his mother in the face of her attempts tohelp him, then he is just a stubborn bullheaded lad. Butif he feels that he is controlling the family by behaviorover which he has no hold and no choice and no re-sponsibility he is a troubled boy. And the family shouldknow this. And they should know too how much of histrouble is organic and intrapsychic, and how much isfunctional and interpersonal. Maybe he does not havesufficient cerebral dominance, either perceptual ormotor, and cannot therefore, willfully control his stut-tering behavior. Maybe he has the soil for inverhalizedand unspeakable thoughts and feelings derived from thetumultuous interpersonal relationships of an earlier day.Regardless of neurology or intrapsychic forces the stut-terer and his listener must get along. They must liveconjointly.

May I repeat something here that i have said before:"To understand my speech it is necessary not only tounderstand my speech organs but to understand me, ti..;speaker, in relation to you, the listener. Neither my

speech organs nor I, nor You, have any separatistie signif-icance... I know that every listener originates what hehears. I know that each one of you as my other one liveshis own particular hermit's existence. I know that youwill live my words in your own way that is not tike anyone else's way, including my own way. When I speak mywords I live my words and when you hear my words youwill live them too as your words, meaning assuredly thatall language spoken or written is always given awayforever in becoming another's creation... I can talk wellonly in living you close to my heart. I can make speechsounds well or poorly only in terms of my living of you.lf. in the beginning, I could not live you as a safe one,and as a loving one, 1 might not talk at all, or clearly, orfluently, then, or even now. I have a beautiful andpleasing voice or a harsh and unpleasant one, dependingpartially at least on how it is with you and me. I mayhave great flexibility in volume and pitch if all is wellwith us. If I could not kiss you or bite you, taste you orsmell you, inhale you or blow you ? 'a y , swallow you orspit you out, I might not be able to talk to you well, ifat all, with my lips and teeth a-ul tongue and breath. Ilive you and my speech organs together in talking toyou. To change my talking I must change my living ofyou and my body together... for me to talk to youperfectly, I must live you perioetly. paleetly in trustand love. Mainly it is not for me to know the cause and

nature of my talking trouble, but mainly it is for me tomend the strands of love between us two..."

Not always have people thought this way. They havetreated the speaker and ignored the listener; they havetreated them as though they were separate. The speakerand his listener must be treated together. One just has nosignificance without the other. Not only might a listenerfeel better in the atmosphere of an improvement in thespeaker's speech but he might feel worse because he too'.as gaining satisfaction from the speech trouble.

Speech pathology in the individual is a p' Aid of theway he deals with the intimate relations betw .4n himand others, and between those others. In dealing wit:, a

speech defective child the whole family system mustchange before he can change. Speech pathology is theproduct of power struggles between members of a familyas well as the product of the power struggles betwcm,conflicting feelings within the child. Probably externalconflicts induce inner ones which reflect them. Realityas well as fantasy is related to troubie.

To handle a speech defective child one must alterresponses of the members of the family to his child andto each other. May we shift our gaze from the panoramabelow to see the scene from a slightly different angle.And do we see an ordered structure for the organizationof interpersonal behavior that will holl for all different

types of groups including the nuclear family?Apparently we see a circumplex (round network) struc-ture around two orthogonal axes of dominance-submis-sion and affection-hostility. Each axis is a continuum.For the dominance-submission axis one extreme or poleis self-confidence, assertion and achievement, and theother is passivity, submissiveness and acquiescence. Forthe affection-hostility axis one extreme is warmth,friendliness, kindness and love, while the other extremeis criticism, negativism, anger, and hate. An interpersonalact or feeling is to establish the person with himself andwith another. The dominance-submission axis definesthe degree 4 acceptance or rejection of the self, whilethe affection-hostility axis defines the degree of accept-ance or rejection of the other. 'f I dominate you, I thinkmore of me than I do of you. If I submit to you, I thinkmore of you than I do of me. if I love you, I love you;and if I hate you, I hate you. The chances are that if Ilove me, I love you; and that if I hate Inc, I hate you.The ideal feelings toward others and toward the selfwould place the person at the love end of the affection-hostility axis and at dead center on the dominance-submission axis. The second commandment wouldexpress perfectly these positions... love thy neighbor asthyself.

Today's society complains bitterly about the rebel-lion of its youth and the defiance of law and order.Parents and teachers alike voice their concern about thecurrent popularity of non-conformity and disobedience.Always there has been the problem of individualism andthe acceptance of authority. Utopia will come when theapparently contradictory aspirations of a culture arcreconciled. In the meantime, what do we do? How dowe impose the burdens of a civilized life in a reasonableand tolerable way? What is the true relation between theends of living and the conduct of the person in achievingthese ends? The assumption may be sound that theconsequences of pureiy individual behavior are fre-quently too serious to be permitted. We may assume,futther, then that the child's immaturity in both under-standing and in conduct-control will demand somedegree and kind of restraint, some substitutio of theadult's guidance and control for the child's self-direc-tion.

Probably dependence reactions have an innate basis.Certainly they have an experiential one For each of us,authority at first is mainly benign and friendly. Andwhen we' love we identify with the loved one. Ourcompliance with the authority who is loved does notbecome s,lf-abasement or a personal loss. Rather,yielding to a beloved authority shows the way to theattainment of enduring purposes and values. Disciplinebecomes a form of discipleship. But from the very first

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1

also, both innately and eillturely considered, resistanceto authority appears. Deprivations are inevitable: anddissatisfactions, displeasure, and anger arise. As compli-ance and resistance polarize, so do love and hate. But asdifferent as they are however, they spring from the samesource, the dependence of the child's life upon anauthority figure. How this dependence is handled deter-mines the child's personality and character for all time.

In a true sense, man is born separate and alienatedand acquires twoing. Prior to the rule of society was therule of self apart. All encounters are with a non-self. Andthe overwhelmingly important non-self is anotherperson. Not only is every one born separate and apart,but every human being is born the enemy of all others,to fight to the death if need be for his very existence.

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Split as we are by our fluctuating partisanship to loveand to hate, we live an eternal wrestling match with eachother. To hate is in some way to love. Quite easilyactually, we may pass from angry rage to tender affec-tion.

The child who would speak at all or better, mustlearn first that he is loved in order that he can risktell-tale words. He must learn to label his experiences.He must talk about them and be heard. What is notlabeled and verbalized in the early years cannot well bereported later. Only shadows and echoes of uneommuni-eated early and deep feelings can occur later on.

Speech is the great compromise between the need tobe heard and the purity of heart to risk it.

The Role of the Family in Aphasia:Martha Taylor Sarno, M.A. New York University

You arc 54 years old. Last month on the way backfrom the U. of T. class of 1940 reunion dinner, you andyour wife discussed how hard it was to believe that somany years had passed - so many milestones reached -

both of you noticed how tired and old some of yourclassmates looked. You were shocked to learn that thechap you remembered as the Big Man on Campus didn'tmake it to the dinner because he was in the hospital forobservation after a second coronary. He was always themost athletic of the group but your buddies say that ofrecent years lie had gained a good deal of weight -

probably a result of two martini business lunches. Old11m Chambers, you learned, passed away quietly in hissleep at the age of 82 - he worked for two hours at hisoffice that morning.

Both of you took comfort in the fact that you werein good health, happy, and had a good life together.Now you were living in a style which thirty years agoseemed out of reach. Except for Connie's last year atcollege coming up you had put both children throughschool and they were well launched. You waited forwhat seemed like a long time to reach your presentposition as Assistant Vice President of the Company butat Acme it was unusual to reach that post at 54. Maybeit was extravagant last year to go to Europe and to buysuch an expensive ear but after all a $50,000 nest-egg is a

good cushion and you had no large debts exceptmonthly ear payments and the mortgage. You were gladthat Betty stopped working a year after your marriage.Somehow you didn't like the idea of your wife workingand you can remember how upset you were whenConnie had her tenth birthday and Betty said she wasconsidering going back to teaching. But eleven years hadpassed since she last worked and she'd have to go hackto school for some credits before she'd be eligible toteach again. You were relieved when you talked her outof it.

It's all history now and you wouldn't remember itall except if reminded. The only important thing to you

at this moment is yourself and the nightmare you'reexperiencing.

Three weeks ago you had a stroke - you didn't reallyremember the details. All you're aware of nou is thatyou can't make yourself understood - not even to Betty -and your right arm and leg don't move. You've alsonoticed that you laugh much more easily than beforeand you cry a lot, sometimes without apparent provoca-tion. And once you start, you can't stop easily. On sonicoccasions it turns off as quickly as it turned on. It is as

though tears would well up without ally real reason. Youcan't understand it. You certainly feel like a differentperson. It must be happening to somebody else - notyou.

It seems unreal, but at least you're sure that it's justtemporary. One morning you'll wake up talking andyour limbs will move. The physical therapist will takethe sandbags and footboard away and she'll help you outof bed. You'll be weak at first but it won't be longbefore you'll he your old self again and you'll rememberit as a horrible dream; especially today with modernmedical techniques.

It's a blessing that nature helps you to deny. For ifyou knew the facts you might not have laughed withL last night when she visited over the distorted wayin which you pronounced her name. If you knew thetruth about the months and years that lay ahead youwould become paralyzed with fear* and be utterlydespondent.

One could make some obvious predictions of ourhypothetical patient on the basis of the little we knowof his pre-illness personality, social history, and lifestyle. Our patient was a college-educated, high achiever,and must, therefore, have been dependent to a greatdegree on verbal skills. We know that he representedwhat many consider the "American ideal." That is, hewas married with two children, lived in an expensivehome, was a high income earner, had put assay capitalfor his future, was healthy, and enjoyed good taste intravel and general life style.

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He assumed the role of the man and exclusive pro-vider of the family as it seemed appropriate for his agegroup, and his sole problems in this area were condi-tioned by social expectations militating against his wifeworking. This may have led to some unconscious ambi-valence and covert conflict. Yet both assumed their rolesas man and wife without any great difficulty. We don'tknow what deep seated emotional conflicts Betty mayhave suffered in view of the denial of her desire to returnto work.

After the stroke one would expect some severe con-flicts and confrontations revolving around the need forrole reversal in this particular family constellation. Theonce strong man of the house, now disabled, would haveto assume a more dependent role. His wife would beforced to take on more of the decision making thanpreviously, and would be obliged to assume a rot( ofgreater independence and assertion. In view of theirhistory, one might expect that she would enjoy hernew-found role and this could lead to temporary liabilityin family relationships due to a reversal of previouslyestablished ascendancy submissiveness patterns. Onestudy has dealt specifically with the effects in a marriageof aphasia in one of the partners (1).

The family had enjoyed a relatively high cconomicstandard during .he patient's years of good health. Sincehe is not eligible for retirement pension or Medicarebenefits because of age, there would necessarily be someimmediate changes in the family's economic status. Hiscompany, depending upon its size and benevolence,might carry him for a year or so waiting to see what theoutcome of his rehabilitation course, might be. At theend of that time, he would undoubtedly be retired on alimited pension and his wife would probably return towork in order to supplement his now limited income. Itis doubtful that our patient would ever accept workingat a lower level. Methods would have to be found tokeep him occupied for the remainder of his life in someuseful non-verbal activities which might not only givesome meaning to his life but would help to drain someof the anxiety and depression which will plague himindefinitely.

If our hypothetical patient is fortunate he will re-cover completely within the next few days. If this is tobe, he has probably already shown signs of recoveringfunction physically, emotionally, and in language. Forthe period of spontaneous recovery is most dramaticduring the first few weeks. Indeed, one recent studyreports that ,ntost improvement in language takes placein the first month post-CVA (2).

But if our patient is less fortunate, he will be left withresidual deficits - all of which will place significant limi-tations on his ability to lead a normal life. More impor-

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tant, perh. os, no matter how mild or severe his reallimitations might be, the majoriti of stroke patientswith residual dysfunction stiffer overwhelming feelingsof loss, alienation, and anxiety. These can be of suchintensity that they stand in the way of the patientrealizing his potential level of function or arriving at asatisfactory level of adjustment to his deficits and self.acceptance.

The broad spectrum of symptoms secondary to

stroke can be classified into four major categories:physical, intellectual, emotional, and verbal impair-ments. Let's quickly review some of the more commonresiduals:

The physical symptoms can include weakness orparalysis of one side of the body (hemiplegia), loss ofbalance (ataxia), deficits of sensation, particularlyposition sense, visual field defects, double vision, blind-ness of one eye, nystagmus, facial weakness or paralysis.Any of these might affect the patient's ability toambulate, to feed, dress, or toilet himself, and to moverapidly. He may fatigue easily, may have changed tastefor food and drink, may experience pain in the henti-plegic arm and leg, may suffer seizures, and have bladderand bowel incontinence.

The intellectual deficits associated %/Rh strokeinclude deficits in abstract thinking, judgment, losses inimmediate, recent, or even remote memory, orientationfor time, place, and person, and deficierit 1,:s in percep-tion. The personality changes characterist of strokeinclude depression, agitation, denial, anxiety, fear,inability to endure frustration, impulsivity, childish

behayior, lability, aggression, and deficits in attention.Perhaps the most important of all is the alteration of selfimage colored by a sense of loss akin to grief which thestroke victim suffers.

The communication disorders arc well known to you:aphasia with its characteristic impairments of deficits invocabulary and syntax; verbal apraxia with its mani-festations of slow, labored, and misarticulated speech;and dysarthria manifested in an or all of the acousticparameters of speech.

The impact of these changes on the patient and hisfamily cannot be overemphasized. They have been welldescribed and highlighted in personal accounts by strokevictims (3,4,5). As speech pathologists, we are com-mitted to the diagnosis and treatment of aphasia andhave accepted a professional responsibility for participating in the identification of these symptomsand their management. It is not a small or simpletask. But it is much less stressful, burdensome, orheartbreaking to us than to th,. patient's family whomust now constantly define the environment for thepatient and live with his problems for the remainder of

his life. Theirs is a lifetime role, and, as such, takes onmuch greater importance than our detailed fascinationwith the curious phenomena that characterize asphasia,the type of rehabilitation therapies applied, and the testscores the patient achieves.

Most of the literature focuses on the patient's, ratherthan the families', reactions (1). Yet, virtually all clini-cians who have reported on the management of strokepatients with communication disorders have also stressed

the importance of the family's contribution to therehabilitation process, and have recommended thatfamily contacts, support, and education should be anintegral part of the speech pathologist's role(6,7,8,9,10,11).

Douglass stressed the role of the family by stating:"of no less importance in the therapeutic program is theeducation of the immediate family whose cooperationmust be obtained. This is especially so when the familyconstellation reacts to the patient's limitations withfrank hostility or by an overprotective attitude. This isnot an infrequent Occurrence when the aphasic disturb-ance is not correctly understood and is thought of asgeneral mental deterioration. Often well-intentioned butmisguided efforts made to assist the patient prove to bea real detriment because demands are made of him at alevel to which it is impossible for him to respondadequately. The result can only be further withdrawal,social impoverishment, and isolation of the patient andreluctance to even attempt to fulfill a useful role insociety" (12).

Counselling has been suggested by many as the meansfor reducing the destructive effects of unfavorable atti-tudes on the family's part (6,8,10). Concern for thefamily's role is also manifest in the number of publica-tions which have appeared in the last two decadeswritten specifically for increasing family understanding(11,13,14,15).

One of the first published reports of a formal pro-gram designed to help the family of the aphasic patientwas based on work done at our Institute and publishedin 1952. This group discussion program, now in itseighteenth year, has been considered an important partof the total rehabilitation effor . provided for strokepatients. The primary purpose of the group is to educateand orient families of aphasic patients as to the nature ofstroke and aphasia. Further, to clarify the nature of therehabilitation process and in so doing to help themimprove their emotional adjustment and acceptance ofthe patient and his disability (16).

The group meets once weekly and is lcd by a psy-chiatrist, a psychologist, and a speech pathologist. Al-thow',h the meetings are kept informal and maximumgroup participation is encouraged, topics are presented

regularly by the staff as a means for stimulating discus-sion. The medical, physical, psychological, and speechaspects of stroke are presented in five to ten minute"lectures." In the context of the group, families sharemany of their experiences and ask questions. A tally ofquestions asked over the years in these group meetingscomprispd the basis for a question-and-answer bookwritten for families of stroke patients (11). The psycho-therapeutic benefits of this program include markedreduction in anxiety, opportunity for ventilation,renssurance, alleviation of guilt, and the adoption of aconstructive attitude, as well as a more realistic outlook.The staff members who have participated in the groupview the process as primarily educatir:, and have beenimpressed with the psychotherapeutic byproductsgenerated by providing the families with factual informa-tion.

Boone has described a family group program as partof a larger aphasia rehabilitation program which meetsonce or twice weekly. Participants watch patientsthrough observation windows in order to gain an under-standing of the uniqueness and complexities character-istic of each aphasic patient. He suggests that "there isno more useful device for understanding aphasia and thepatient than family group therapy as part of a totalrehabilitation program." Yet, he feels that the speechpathologist may be well advised to avoid personalinvolvement with the problems of the family, andsuggests enrollment of a social worker's or clinicalpsychologist's help in this area. It would appear thatwhile he appreciates the intensity and importance of thefamily's reaction to the patient's disability, he wouldprefer to leave this part of the rehabilitation manage-ment problem to other disciplines (7).

The late Hildred Schnell went to considerable lengthto describe the many aspects of family counselling whichshe considered important. In the context of her pro-gram, counselling is administered on an individual basis.She felt that a great deal of time should be taken tolisten to the family member so as to increase his aware-ness, to instruct him on the limitations of the disability,and to be honest with him about the limitations imposedby he disability. She outlined three important facts ofcounselling:

(1) First, one should strive for acceptance of the factthat no dramatic changes can be expected; there can be apositive consequence to such negative information. Itmeans that resources of time, energy, and money thatmight have been fruitlessly expended on unattainabletreatment goals for aphasia can be released for morefruitful ends (8).

(2) The second important facet concerns the impor-tance of clarifying that the aphasic: is neither feeble

63

minded nor nundallv deranged. This is perhaps a uni-versal concern of aphasics' families.

(3) The third facet of counselling is to help the lama%and the patient make the best possible adjustment to analtered situation, focusing on the importance of living asnormally as possible within the limitations imposed bythe disability. Schnell stressed that perhaps the mosteffective goal to be set for an aphasic patient involvesthe provision of a systematic and regular daik routine.This structures his day, gives him a feeling of confidenceand security , as well as something to get up for and lookforward to. She squarely places the responsibilits forthis structured daily living on the patient's family.

It is not easy for an individual who has been busy andactive all his life to alter his way of living, and to settlefor what he sometimes regards as trivial. Adjustmentscan be facilitated, however, if the family understands theimportance of kf!ening the patient active and stimulated,and of having a regular routine with which the patientcan cope.

In 1967 a report appeared whit In descram! an orga-nized, formal pro gran of family fowl:4:1141g with rela-tives of aphasic patients conducted at the SchwabRehabilitation Hospital in Chicago (17). This ! rojeet wasinitiated because no .services existed in the communityto which families could be referred. Yleetings were heldon a once weekly basis for periods of four consecutiveweeks am' families were invited to attend these sessionsimmediately upon admission of their relative as a

patient. A speech clinician and a psychologist acted asgroup co-leaders. After several Nears of experience withthis format. it was decided that more would be achievedif the format were open-ended and continuous. Theolder members them-elves could play a therapeutic rolewithin the context of the group's session. Furthermore,the open-ended format allowed participants to return tosessions long after the patient's discharge for furtherreassurance or discussion of problems or issues as theyarise. The auditors r eorted the same psychotherapeuticresults and benefits indicated earlier by others (16) forthis purpose. That is, the family's need for ventilation,for alleviation of guilt, for sharing a fear of theunknown, and fear of the patient being mentally de-raugml are coped with, and the relatives' perception ofthe patient and their own mode of relating to hintchange positively as a result.

Another experience of this sort with the families ofstroke patients was reported by two social workers (18)at Mt. Sinai Hospital in Cleveland. The group had as itspurpose to bring together the families of stroke patientsand to hopefully change some of their attitudes. fears.and anxieties through an educational group approach.The program was led by a physiatrist, a physical them-

64

pist. occupational therapist, speed) therapist, and anurse. The authors were encouraged by the !positiveresults of their experience and urged the adoption of thistechnique as part of regular rehabilitation services.

The rehabilitation team at the American Rehabilita-tion Foundation in Minneapolis acted as t Ile teachingstaff for a program which met two hours weekly for fourconsecutive sessions. Audio-visual aids, slides. trans-

parencies. films. and special displays giving participantsan opportunity to see clothing, kitchen aids. and othergadgets adapted for on-handed use were part of theproj.,rram. Sixt -three people registered for the course,and about half were professional workers who attendedon the same basis as family members. The format foreach session was carefully structured beginning with anhour of didactic presentation by members of theteaching team. A brief quiz and a group discussionfollowed each session. Questions were solicited in

written form both to encourage people to participateand to give the panel au opportunity to select for at-tention those inquiries of general interest. In addition,booklets and pamphlets were distributed. 0-I the basis ofan evaluation of the course by telephone interview, theteam intends to schedule additional offerings of thesane course (19).

In the speed] pathology program of a Visiting NurseAssociation which provides speech therapy services inthe patient's home, it is reported that "therapy is asoften centered as much on the fiunily as on the patient.The sp,ech pathologist's primary goal is often the totaladjustment of the patient and his family to the existingcommunication disorder this adjustment can comeonly when the patient can to his satisfaction, functionadequately within his own environment, Lc., a betterunderstanding of the many aspects of stroke makes eachfamily member's role clearer and more realistic." (20)

Malone (21) has pointed out that; in view of theincreased importance attached to the role of the familyin rehabilitation, it is interesting that the literature isbarren of information on how the family is affected byaphasia. Ile reports on int en iews with 25 peoplerepresenting the families of 20 aphasic patients in antattemPt 'a establit which reactions arc common to theentire group. The problems most frequently reportedincluded role change, irritability, guilt feelings, alteredsocial life, financial problems, health problems, over-solieitiousness and rejection, amt effects on children.Malone points out that the attitudes of families ofaphasic patients slowest the need for the speech

pathologist to recognize the necessity of providing acounselling program. "'liar family unit cannot functionas a collective partner of the rehabilitation teams Until allits members have become aware of the many and varied

problems associated with aphasia and until they havereceived sonic help in coping with these problems. Thedisruption which t»ay begin with a language andpersonality disorder of the patient, creates severe

problems for the family which in turn aggravate thecondition of the patient." By personality' disorderMalone undoubtedly refers to those behavioral changesassociated with central nervous system damage. There-fore. Malone suggests that a counseling program heinstituted as soon as possible after onset.

Wt, are all aware that many speech pathologists whowork with aphasic patients engage a member of thepatient's family to assist the patient with "homepractice.- There is a number of published materialsdesigned for this purpose. One recently published studyreported the application of operant conditioning wherethe wives of aphasic patients were trained to administeroperant conditioning trehniques in order to controltheir husband's verbal behavior (22).

In some settings it is standard practice to !prepare a"lime Program for a patient to follow with his familyafter discharge from an active speech therapy program oras a supplement during the weaning process. Such pro-gains are prescribed by some as a means of structuringthe patient's daily life. Others recommend a !Ionic Pro-gra because they feel that it will esmtribute specificallyto the patient 's language recovery. There is some generaldisagreement among those specialized in aphasia re.habilitation about the usefulness and desirability ofenrolling the assistance of the family in speech therapyat home. We have exercised some restraint in this matterin our program finding that very often speech therapyadministered by a family member serves as a device forthe family meinher to (I) be reassured that the profes-sionals believe that the patient will inipnne (or theHome Program would not have been prescribed), (2)assuage guilt ("everything is living done-), and (3) serveas a means for the angry family member to act out hishostility by controlling the patient's treattn,ai. We,therefore. only prescribe a "Mune Program on a

selective basis.

It is certamlY clear from the literature and fnun whatwe can observe clinically that the families of aphasicsplay a critical role in th,. patient's rehabilitation. Th;swe believe, a result of the fact that mudi of what iscalled "suevessful aphasia rehabilitation has little to dowith Mimi improvement in communication functionbut is dependent on the patient's overall adjustment tolife. An adequate and appropriate "speech therapy.regime, whether based on direct or indirect methods.may indeed be a proc,ss of assisting the patient in hisstruggle to live with a devastating disability.

In this regard. we need to ask oursel% es some unpopular and hard to answer questions. What are thespecific language changes that occur as a direct result ofspeech therapy once the condition is stabilized? W hickpatterns of aphasic impairment benefit from speechtherapy? What is the natural course of recovery fromaphasia? We will need rigorously designed research usinguntreated subjects in order to help answer thesequestions. .1t this time. there is strong support for thenotion that only a very limited number of patients. of a

particular type derive specific benefit in languageproficiency from direct speech therapy.

If future research corroborates the idea that mostaphasia rehabilitation is less a matter of itnprovinglanguage skills and more a matter of participating in thepatient's overall life adjustment. we must then take a

hard look vt the appropriate role for the speechpathologist.

In a setting where the speech pathologist is the onlyprofessionally trained indiYid WI I who is aware of thepatient's family's needs, he may be forced to do thew1101e job alone. If this is the ease, the unsophisticated.untrained, and self-appointed. "I)s eft:itherapist" shouldbeware that he may find himself confronted with a setof dynamics which arc beyond his II nderstanding ande(mtpetnce. Family counseling is a complex andtremendous responsibility. I feel strongly that no onewithout a considerable background of training andexperience should venture into this role. In the situationwhere the speech pathologist is alone, it might beadvisable to deal only with the facts related to thespecific patient's verbal impairment and his speechrehabilitation -- taking great care to avoid becomingim (dyed and enmeshed in dynamics which could bepsyvhologically harmful to the patient and his family.

Ideally, I befit:ye. that family counseling should (begin on the first contact with the patient, and (2) takeplace in the mute\ t of a multidiscipline setting wherethe speee pathologist. trained and experienced inaphasia, acts as educator to his colleagues including thephysician as to the nature of aplia-da, its symptoms,exfletations and realistic limitations, where a teamundertakes the responsibility for assisting the family inw,rking out and roping with their inn !tilde problems. Insuch a setting the psychiatrist, psychologist, caseworker,or other member of the tram. trainee, and experienced insuch matters, can carry the respon,dbilily while receivingspecific information relative to the patient's verbal

etc. horn the speech pathologist. The speechpathologist partiei!Pates with his colleaguespl.:. ill the overallgoal of educating the tamily. nut at this time I do notsee the feasibility or advisability of encouraging the

65

average speech pathologist, whose training and ex-perience is at best naive in such matters, to assume theresponsibility for helping the patient's family in its

psychosocial needs. What he can do is insist that hiscolleagues undertake the provision of such services in thecontext of a team approach and assist in the process byproviding them with the information they need to knowabout the nature of aphasia and the recovery process.

REFERENCES

1. Buxbaum, J. Effect of Nurturancc on Wives' Appraisals of,their Marital Satisfaction and the Degree of Their Husband'sAphasia. Journal of Counseling Psychology, Vol. 31, No. 3,pp. 240.243, 1967.

2. Culton, L. Spontaneous Recovery from Aphasia. Journal ofSpeech and Hearing Research, Vol. 12, No. 4, pp. 825.832,Dec. 1969.

3. Buck, M. Dysphasia: Professional Guidance for Family andPatient. Prentice-Hall, Inc., Englewood Cliffs, N.J., 1968.

4. Wint, G. The Third Killer: Meditations on a Stroke.Abelard-Schuman, Ltd., New York, 1967.

5. Ilodgins, E. Episode. Atheneum Publishers, New York,1964.

6. Godfrey, C.M., Douglass, E. Recovery in Aphasia. CanadianMedical Association Journal, Vol. 80, pp. 618-624, April15,1959.

7. Boone, R. A Plan for Rehabilitation of Aphasic Patients.Archives of Physical Medicine and Rehabilitation, Vol. 48,pp. 410414, Aug. 1967.

8. Schnell, H., Jenkins, J., Jimenez-Pabon, E. Aphasia inAdults. Harper and Row, New York, 1964.

9. Wepman, J.M. Recovery From Aphasia. New York, RonaldPress, 1951.10.

10. Wepman, J.M. Aphasia Therapy: Some Relative Commentsand Some Purely Perional Preludices. Proceedings of the

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Conference on Language Retraining for Aphasics, OhioState University, October, 1968.

11 Sarno, J .E., Sarno, M.T. Stroke- the Condition and thePatient. McGraw-Hill Book Cc., N.Y., 1969.

12. Douglass, E. Diagnostic Classification and Re-education inAphasia. Canadian Medical Association Journal. Vol. 69,pp. 376-381, Oct. 1953.

13. Taylor, M.L. Understanding Aphasia A Guide for Familyand Friends. Institute of Rehabilitation Medicine, PatientPublication # 2, New York University Medical Center.,1958.

14. Boone, D.R. An Adult Has Aphasia. The Interstate Printersand Publishers, Inc., Danville, Illinois., 1965.

15. Aphasia and the Family. American Heart Association,Publication #EM 359, 26 pages, 1965.

16. Turnblom, M.L., Myers, J.S. A Group Discussion Programwith the Families of Aphasic Patients. Journal of Speechand Hearing Disorders, Vol. 17, No. 4, pp. 393.396, Dec.1952.

17. Derman, S., Manaster, A. Family Counseling with Relativesof Aphasic Patients at Schwab Rehabilitation Hospital.Asha, Vol. 9, No. 5, pp. 175.177, May 1967.

18. Strauss, A.B., Burrucker, J.D., Cicero, J.A., Edwards, R.C.Groupwork with Stroke Patients. Rehabilitation Record.pp. 30-32, Nov.-Dec. 1967.

19. Crewe, M. Training Course: Stroke in Your Family. Re.habilitation Record, pp. 32-34, Jan.-Feb. 1969.

20. Rolnick, 1. Speech Pathology Services in a Home HealthAgency:, the Visiting Nurse Association of Detroit. Asha,Vol. 11, No. 10, pp. 462-463, Oct. 1969.

21. Malone, L. Expressed Attitudes of Families of Aphasics.Journal of Speech and Hearing Disorders. Vol. 34, No. 2,pp. 146-150, May 1969.

22. Goodkin, R. Procedure for Training Spouses to Improvethe Functional Speech of Aphasic Patients. Paper presentedAnnual Meeting, American Psychological Association,Washington, D.C., Sept. 1969.

DiscussionALLMOND: The first letter of my last name hasplagued me since first grade, but there is nothing I cando at this point. I'd like to, if I could, speak both formyself and Jim Sherman, although I didn't ask himabout it. I'll speak for him anywayI never let thingslike that get in my way. It seemed to me what I washearing him say throughout the discussions following thespeakers' presentations was this, "Okay, the family isimportant in the management of the person with thisparticular disorder, whatever it happens to be. Yes, thefamily's important. Now, what are you going to teachthem? what are you going to tell them? what are yougoing to do with the family now that you've recognizedthat they're important?" My question is really a

variation of that same theme, and it's a how question.His is, "What are you going to teach them?" and mine is"How are you going to teach them?" I don't feel thatwe've gotten to that in this conference. The specifics ofwhat and how have not yet been answered. I would liketo throw that out to the audience for some discussionback and forth as well as among the panel members.

And I now proceed to answer my own question withan amplification of what he began yesterday. I'm takingsomething that Dr. Quigley said in his talk: "Lowell, in1967, has listed four stages of parental education whichare important to the guidance of the learning of a deafchild." And then he goes on to list the four and I'll talkabout those shortly. What I would like you to do is justtake "deaf" out of that sentence and I'll read it again."Lowell has listed four stages of parental educationwhich are important to the guidance of a child." Thechild may be a normal child; the child may have aproblem. And then the four stages are these. awareness,acceptance, information, and application. It seems to mewe've cornered off various disciplines to tackle eachstage. At the present time, psychiatry has a corner onthe awareness market; if there's a problem with aware-ness in a family or awareness of parents towards a child,one goes to the psychiatrist. If there's a problem in afamily with acceptance, I'm not sure to whom one goes

Ill leave that one for last. Information, we're allpretty good at that; we really like to hand out informa-tion, and we all feel we're pretty expert at that. That's

one of the most easily learned skillshow to tell in-formation to someone. And then finally the application,I think we're all pretty good at that. But the stage that issurprisingly left out is acceptance; maybe that's because,carrying things to a logical extreme, none of us is in andof ourselves, walling to accept a patient with a disability.Our very professions speak against that, otherwise wewouldn't be trying so hard to take the disability or theillness or the abnormality away from the patient, if wewere really accepting. So our very lives are kind of adenial, if you will, that there is indeed something wrongwith the patient since we do all in our power to do awaywith it. And for that reason, and for others perhaps, inour training we skirted that issue to the point that now,and I'll say for me particularly, I'm very uncomfortablewith the notion of acceptance of a disability, an illnessor an abnormality in a child or within its family. Interms of our training for the future this is where we'veall got to do a lot of spade work. This, I guess, is mymessage to the group. Let's think less about how we'regoing to tell somebody something or how we're going toapply a principle or technique and Ices begin to thinkabout patient and family awareness, patient and familyacceptance of a child within his family.

BANGS: I'd like to present a few of my basic tenets aswell as those I have listened to during this conference.Although I am directing my summary to families ofhandicapped children, I believe that if we understandbasic principles of counseling that such principles canapply to an adult population. Number one, I fed thatparents want to become involved with the care and train-ing of their child, and we really should not rob them ofthe responsibility of planning for their child by ignoringthem during the course of action. Second, presumablyparents do not want to reinforce unwanted behavior.Hence, a planned course of action is indicated. It seemsapparent that, without a planned course of action,pa cnts would continue to experience just confusion andbewilderment. Third, counseling is directed toward twolevels, the feeling level and the intellectual level. If weexpet parents to intellectualize regarding the: course ofaction we must first cut through all the emotional

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problems and dilemmas that exist. Foruth, reality mustbe represented: that is, reality related to improvement oreven educational achievement. Parents should take anoccasional look at what has been, but should be en-couraged to really look down the road where changesand challenges will have to be met. Fifth, the counselormay work with a group of parents of vary ing educationaland socio-economic levels. Ilowever, it is best if there isa basic homogeneity within the group such as hearingimpairment, orthopedic problems, retardation, etc.Sixth, counselors must always indicate their interest andgive reassurance of their continued interest with thegroups of people with whom they're working.

Now I'd like to say something about the first fewmeetings with parents. I) Something we have f,undhelpful at the very first meeting is to have each parentwrite, in large letters, his name and the name of familymembers on a fold-over card. I think it is very importantin group counseling to know how many children are inthe family. Mrs. Holm may have eight children, thereforeher problems may be very different from the problemsof the family who have only one or two children. 2)During this first meeting we must discover what theparents want from us. They may not really want whatwe have planned for them, so we must listen, and becertain that we find out what is truly bothering them.Then, we write their needs on the blackboard. Takingpenciled notes during the meeting is a risk as it mayarouse suspicion. The notes may be copied from theblackboard for the second meeting. 3) It is important todirect to the parents as many questions and answers as isfeasible. We, as counselors should do very little talking.W. must listen to the parents as they express their feel-ing and their attituiles that often get in the way of theirtrying to achieve the goals being layed out for them. Forexample, it may be that a mother reveals that she needsto have her role as a wife improved before she can playthe role of a mother. 4) We should be aware that parentswih not agree on solutions to problems. What works forone may not work for another. 5) With regard to hometraining, mother's or the family's job will be to provide asomewhat structured environment for a very unstruc-tured child who is there to have fun. But remember, it isdifficult to get parents to accept new rule books whenthey have memorized the old. Training must be adaptedto the strengths of the child, not to his handicaps. Areverse of this may have been the basis of the problem athome. In conclusion, I can easily summarize my conceptof parent involvement. It's found in the title of AlineAuerbach's hook which is Parents Learn ThroughDiscussion (New York: John Wiley & Sons, 1968).

ENGLAND: First of all I'd like to point out that this isJim Sherman's chair. I'm not trying to fill his

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because I'm sure I cannot. I'm quite sure that mostcannot. Now this other chair is my chair. It has been uphere all week and I've shaped Dr. Hanle) not to makeme sit in it the first two days. Dr. Hanley asked meyesterday if I would sort of jot down sonic general re-action from the perspective not only of a panel member,not only as an audience member, but as a generalobserver of the scene. So I got up at six o'clock thismorning and went down to the beach, which is where Iget all my psychotherapy, and jotted down these things.When I got finished I had a group of words which are

not used by most behaviorists professionally but theyare familiar and useful, I think, to everyone else., As Ilook down through them they say things like"distressed," "humbled," "overwhehned," "startled,""pleased," "disappointed," "disturbed," "co,...ouraged,""warmed," "enthusiastic," and "stimulated." Now I'dlike to be a little more specific because I've been sayingall week that we must be more specific. I would like totell you the things that have caused each of theseresponses in my repertoire, here. I was very distressed, Ithink, and humbled, by the fact that very few of us, aswe got right down to it, have really done what theconference participants have been advocating. I do notthink that we really have very effectively developed pro-grams, systematic programs, for helping parents workwith their child's problems. I think we had a notableexception to that this morning in Mrs. Sarno's presenta-tion. For twenty years she has been systematicallyteaching spouses to help their spouses with the problemsof a CVA. But in general, as we listen in the groupsessions and when we asked people, "What are you doingin your center for systematically training the family?",we have continued to be more vague than we should be

content with. I think that's true of almost all of us. So Iwas distressed with that fact, and very humbled by it,because there was not too much data or practice alongthat line.

I was somewhat startled by what seemed to be a col-lective resistance on our part to specify behaviors. Thisis, I think, the most difficult task we have ahead of us.

Whenever a question was asked, "Witll, what do youmean specifically?", there was a lot of avoidancebehavior and then the question was asked again, "Well,what do you mean specifically?", and then some ap-proximations to a little more specific behavior was madeand finally we could see that really what we had so dowas sit down and become much, much more specificthan we have in the past. So this, I guess, startled me.

I was very pleased with our apparent knowledge ofthe gross sequencing or ordering of behaviors which arcinvolved. Almost every time you asked a person, any oneof us, "What should yon do clinically?", they could tell

you in general terms. Each one of you would lay out aplan, saying, "I should do this first, I should do thisnext," etc., in gross terms. So we do have that knowl-edge in our backgrounds; and its very, very pleasing tome that its there, because now all that needs to be done,it seems at least from my viewpoint, is to plug thisinformation into a better strategy perhaps or a moreefficient strategy.

I was very disappointed that we haven't heard morefrom Ed Garrett during the conference, and I wouldsuggest that some of you tackle him before he gets awaytoday and ask him what he's doing to train parents toteach their children, because even though he may nothave a lot of hard data on the parent training, much ofhis work over the past several years is directly applicableto making parents into teacheers, very effective teachers.

I was very impressed by the panel members duringthe two days previous to today, and their ability to raisethe significant issues for the panel discussions. I thinkthat's a very difficult task to do under the circumstancesand I was very impressed with that. The thing thatdisturbed me most was a philosophical point which cameup, which I think Jim Sherman handled very gently andit relates to training family members to be teachers oftheir children. The comment that disturbed me was "Idon't believe in operant conditioning." Now thatwouldn't disturb me terribly if that was one uniformedman, but what really discouraged me was that there wasa lot of reinforcement for that 'response from theaudience. In other words there was some applause where

I was, there was much affirmative nodding, there wassome smiling which meant you just conditioned thatman's comment to occur again. And though we maydeny that we are not eonditionable (i.e., can't learn), hewill more than likely make that response again. Un-fortunately for him, he really doesn't have the option ofbelief or disbelief.

I'm very encouraged by the presence of a verypowerful learning strategy and I think everyone hasrecognized this. Many of you are deeply involved withthat strategy. That strategy seems relatively simple inprinmple. I think it has become apparent how devasta-tingly difficult it is to apply that strategy, and to plug inthe necessary information to that strategy. The strategywhich I am referring to is choosing your target, specify-ing the small steps in behavior that you want to change,setting up a measurement system to keep track of yourprogress as a teacher, keeping track in some way so thatyou can continue to modify your programs in a betterway and continually evolve better and more efficientprograms. That strategy is extremely useful and power-ful if we are clever enough to utilize it well.

Jim Sherman garted out the whole, conference bysaying that behaviorists were arrogant. I was more

impressed and warmed by his humility, quite frankly,during the sessions and the fact that he was completelyopen and flexible in his approach. Many times you thinkof the behaviorist as being very mechanical de-

humanized, and very rigid. I saw the kinds of things hewas telling all of us as exceedingly flexible, human, andexceedingly humble; and in that sense I was warmed.

I'm enthusiastic, very enthusiastic, that we have conicto the recognition that the responsibility for teachingchildren and for teaching parents to be teachers ofchildren falls on us. We're starting to throw away the"resistant" child, the "ornery kid," the "laxy kid"-kindof labels and beginning to say there is something wrongwith the way I am teaching this child or he wouldn't beornery, he wouldn't be laxy, or resistant, and all theseterms that we use to describe our procedures andfailures. I saw many of us begin to say, 'Tin doing some-thing wrong and I can tell by watching the child."

I was very stimulated, Dr. Bangs, by your commentsyesterday, as 1 told you afterwards, that somv very basicchanges are going to have to be made in the traininginstitutions as to the kinds of ways we look at separatingout these disorders. We really have a lot of barriers here.Barriers between professions and between disorders weset up a whole course in one small piece of behaviorrather than the underlying discipline which will changemany of the behaviors and I was very impressed by yourcomments, and you're in a situation where you can domuch about it.

Then finally last night I guess my reactions weresurprise and that's where the "overwhelmed" came in.But there were three very strong statements that weremade by Dr. Travis which perhaps unintentionallyprovided a beautiful rationale for behaviorism and thefirst one really caught me off guard but is wonderful forthought for those who don't "believe" in operant condi-tions, Dr. Travis said, "He who controls behavior anddoes not admit it is in trouble and is sick." I wouldsubmit that there is not a person in this room who notcontrolling the behavior of yourself and others. Many ofyou are controlling mine right at this moment by yournods and smiles and shakes of the head and lookingdown at the floor and frowning and throwing vege-tables, etc. So I think it's critical, not only now incontrolling panel members, but it's very critical in thework we do with the kids in front of us and the parentsin front of us that we analyze and understand in whatways we are controlling them. It is important that weachieve the mutual objectives of our control rather thansome other random objectives that we are not awareofthat's when we are in trouble. I think that Dr. Travismade that point exceedingly well in one very straightforward statement. This psychoanalyst also said that "all

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behavior is the result of its consequences." He also saidthat "personality, how it is treated, determines itsnature." All of those are very strong behavioristic state-ments. I was very overwhelmed, and surprised by thesecomments from that source and very pleased. I thinkstop, thank you.

FLOWER: This conference, like every coderence thathas ever been conducted has, in a measure, revealed the"state of the art". As I have listened to the papers andthe various group discussions during these past threedays, it has seemed to me that we can identify threedifferent areas of discussion that have reflected the stateof our art in utilizing families as supportive personnel:First, we have talked at some length, and perhaps atinordinate k igth, about reporting information tofamilies so that they all understand better thepathologies and the problems with which we arc dealing.At. least when we clinicians are working with patientswho share our social, cultural, and linguistic systems, thisis probably the area in which we have been most success-ful.

A second area concerns helping families provide anenvironment that is more conducive to better com-munication. Here, we fare less well. The clinician mustfunction as a family therapist, dealing with communica-tion in a broader framework than specific disorderedspeech and language behaviors. Throughout thisconference I have heard protestations of our inability asspeech clinicians to play this broader role. Yet, if we areindeed concerned for comnmnication, surely the com-munication between our patients and their families is ofsupreme importance. I wonder if we can claimrespectability as the profession predominantlyconcerned with communication, and at the same timedeny our ability to deal with this particular aspect oFcommunication. Learning to work with families is surelyat least as important as learning the origin and insertionof the meths abdominus and being able to describe atgreat length the major surgical approaches to cleftpalate. I'm afraid, however, that this perspctive has notas yet reached many of our institutions of higher learn.ing.

The third area, and the one in which we fail mostmiserably, is teaching family members to work directlyon the modification of specific communicationbehaviors. Perhaps our inability to assist families in theteaching of communication behaviors says somethingabout some of our own professional problems, that is,we have been very laggardly in developing specific ap-proaches to the modification of communicationbehaviors that are objectively describable and ultimatelymeasurable, If we don't really know what we arc doing,

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how can we expect to train supportive personnel bethey family members or someone else to carry outsome specifically structured part of the behaviormodification process? In all honesty, therefore, inconcluding that this area of working with families is thearea of our least effectiveness, we are admitting somevery disquieting things about the overall state of our art.

SARNO: I agree with Dr. England's comment thatoften a patient's behavior is simply a reflection of whatour own behaviors are, and one asks one's self, "Whatam I doing that I shouldn't be doing?", or, "What am Inot doing that might help to reinforce particularbehaviors in a child in particular?" But I worry very,very much about this kind of philosophy when it comesto aphasic adults where indeed the behaviors that onecan do much about are quite limited, I often get phonecalls from young people who are out working, andwho've been working with aphasics for a period of time,and have gotten no results; and they become increasinglyguilty, and increasingly upset, and they're sure thatthey're the ones that are at fault, that they're simplyinexperienced and haven't seen enough aphasics, and soon. And sometimes it takes an enormous amount ofreassurance to reassure them that the patient is reallydoing all he can and you're doing all you can and this isas far as he can go for the moment. So when we'retalking about organic conditions and not functional con-ditions, I wonder if we don't have to modify that kindof an approach. In the same vein a lot of people havesaid, "If you can just stimulate the patient to be moreinterested in talking, indeed his language will change." Ihave rarely seen what I would consider a real honest-to-goodness poorly motivated aphasic. I think most of ouraphasics operate at their optimum considering theirbrain-damaged condition.

I appreciate being singled out as someone who hasdone something with the families of aphasics, but at thesame time I'd like to comment on what we have notdone. We are very fortunate to be operating an aphasiaprogram which happens to be within a rehabilitationmedicine center. This allows us the privilege of a largecounseling staff representing many disciplines. But wehave not yet designed a program which is more realis-tically designed to meet the aphasic's need for life ad-justment., Perhaps our focus has been in the wrong place.We're still focused on something called speech therapy,and we make an underlying assumption: that every oneof our patients can improve, which is not necessarilyture. I believe that these patients, many of them strokevictims, improve for the rest of their lives as a matter offact, but this may not necessarily be because of speechtherapy. What we need are structured programs. re-

creational, community, and hospital-based programsdesigned to help these pati.mts lead a more normal lifeeach day and which are not necessarily speech therapyfocused: not goal-oriented toward improving speech, but

goal-oriented toward improving living.

BANGS: May I ask one question? After what you havesaid about organizing a recreational-type program, doyou believe in having clubs or organizations for adultaphasics?

SARNO: Yes, very much so. I wish there were manymore stroke clubs. The only one I know of is the one inGalveston. These clubs arc in some ways like Lost ChordClubs. Aphasic patients often Can't fit into a Golden AgeClub milieu. They really need a club of their own wherethey can go on a regular basis. I wish we had themachinery for getting such clubs organized. They'll haveto be generated by the patients and their familiesthemselves and we might do some public relations in thisregard.

EARNEST:* In all of this discussion, no one has saidanything about financial problems; and when one visitsGreat Britain, for instance, a great deal is available

because it is a country of socialized medicine; and itseems to me, until we have some financial basis in all ofour various institutions, we cannot get a wide-spreadcoverage of the problem. It's done mostly on a "boot-strap" level or an experimental level, and I wonder whenit's going to be available everywhere in small villages aswell as in big cities and will be paid for in our country.

FLOWER: Could I respond to that Sue? I agree, againas somebody who has to worry about how you pay astaff at the end of the month, that what you say is verytrue. Too often members of our profession behave as,,though we are only serving the patient when we are"testing or teaching him", therefore fees should becharged for only these "testing and teaching" services.This philosophy is now being locked into third-partypayment programs Nevertheless the first changes mustoccur in the way we look at what we're doing. We mustrecognize that the time we spend with families may,indeed, be an even more important part of the programthan our "teaching" of the patient himself.

*Dr. Sue Earnest, San Diego State College.

EARNEST: Do you think this :,going to come?

FLOWER: I think we have to take the first step

because we have to be the prime movers.

SNIDECOR: I wanted to comment on something Dr.Allmond said, and add a few words. There is a %ery goodreason why we're sometimes so far ahead on informationand so behind in other ways. Now, for example. I

reported a study which was finished last Thursday. It's alittle difficult to read some of the applications, and I'mafraid that I can't read some of them; but I'd like to readsome right now because as some of my students knowvery good and well it is too easy to go way beyond thedata. Many, many times, when I think it desirable to doso, I identify that fact. I think of some things here thatapply to what I said the other day, and just sayingthat because we're here to take stuff home and workwith. One is that, no matter how well an individual iscounseled, the laryngectomy operation is a desexingkind of thing, and I am not speaking of Sigmund Freudby any manner or means. I'm just talking about thenitty-gritty of the fact that, even in this age of equality,it is usually the man who asks the question, usually hassome sex life, and the chances are pretty good he hasmuch more than fifty-fifty at the age of the operation.The second point in regard to the female laryngectomes,and there arc not so man of them, you will neverprobably wear a low neck dress again. Your neck verywell may be disfigured. You will never cry again, Thistakes some education and sometimes it takes a patternbook so that you can wear something that's beautiful. Ipersonally think that high neck dresses can be beautifulindeed.

FLOWER: Ted, May I direct a question to Mrs. Sarnothat occurred to me during her paper? Most of thefamily counseling situations that you were describingseemed to- exclude the patient Do you feel that thenature of the communication problem of the aphasic;in:eludes conjoint work with family and patienttogether?

SARNO: I never tried on any large scale to workwith the family and aphasic patient in the same sessionsso I have no real experience upon which to base anopinion. I wouldn't mind trying just to see what wouldhappen. But I suspect that the complications of thedynainics between the spouse and the patient would beextremely difficult to handle in a group setting. I never-theless recognize that these are the dynamics which aremost crucial.

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FLOWER: As a conjoint therapist, would you bewilling to comment, By even though you hat en't workedwith adults with aphasia?

ALLMOND: Sure, as I say, I never let myself bebothered by the facts; but what you're saying, Martha,at the end. I ringing into play the dynamics between thepatient and the ;wilily. would be specifically what I wasafter since those are the factors operating twenty-fourhours a day outside of my office and perhaps that's whatthe patient and his family need some help with. I'm justfinding as time goes on that there's less and less need tosegregate patient from family with anything I do. Thegame of secrecy that we as clinicians impose upon apatient versus family is really a game that we play. Thefa goes along with us, but in any number of condi-tions, the child with a fatal illness, for instance in-variably he knows whether he's been told or not. I don'tcare how old he is, his concepts of how sick he is may besophisticated or not sophisticated, but he knows fullwell when he's dangerously ill. The business about don'ttell him or don't deal with it is really an illusion andsomething that we work at. Then the family begins tofall into that, and play the same game. I just don't seemuch merit that anymore, a9,1 the more I do the lessI'm finding there is an appropriate opportunity toseparate the patient from hi; famil!. That's not to saythat it never happens but it's just not working out thatway for me. It's much better to have everybodytogether.

SARNO: I didn't mean to give th:. impressim thatthe' ought to be a secret relationship betwen profes-sional and fa-nily member or profLsjonal and patient.As a matter of fact, we urge families to carry back wha-t:ter, no matter how much they want to protect thepm' from knowi ig things like the fact that his shopwas just closed beca.ise they coz.ldn't keep it runningany longer or that a brother died or any other fact whichmight be difficult for the patient in his already devas-tated condition to comfort. This is life and these are thethings one has to lire with. The only thing that I meantwas that if you're not very skilled in hand!Ing bothspouse and patient, the dynamics are even more difficultand I've never tried it except in my office when I firstsee a patient but never as a group therapy process and soI rr ally haven't the experience.

HANLEY: Hugo Gregory, will you talk on the samei(nie?

GREGOR Wel' I think I commented on this yester-day and my experieuees have been very much like

Martha's that I have not initiated therapy with the entirefamily. I have been reading about this work and I'm veryinterested in it and ,:ither by working with a person whohas had experience with it and moving into this area orby, as Martha is commenting, beginning to move in onsort of an experimental basis, I think that this should beexamined tery carefully and this was the point that Iended on yesterday but I have had very good results at apoint in therapy where I have felt that it is indicated tobring in the family to help them now understand clearlyand to reinforce and support what we we're doing, whatwe'd already been talking about with the mother andfather, what we had already been talking about with theyoungster and what we'd already been talking aboutwith the husband now talk ;bout with the wife. At thepoint where I can predict that its going to be effectiveto do this.

Question from the floor:The benefits and the virtues of group sessions for the

families and the patients, I think, are pretty well realizedand the question I'm going to ask shouldn't be inter-preted as a negative implication. I think recently I read alittle script about someone, perhaps someone here, whoreported on some family groups with stroke patients.Some of the family members got so comfortable withaccepting the fact that their own dependency needs werevalid that they became less motivated to take care of thefamily ir ::mbers. I wonder Mrs. Sarno mentioned any-thing about it or if anyo-,e has any experience in thatregard It's a i'aseinatiry thing to me that otherpeople felt the same way. He no longer felt guilty thathe didn't want to take care of so and so; some of themactually withdrew from the chair of the family member.

SARNO: That wouldn't surprise mc. I don't know theparticular study you refer to but in certain familyconstellations one might expect this to happen

ALLMOND: like to pose the question back to you.Would you then feel it preferable to have this guilt-laden, angry individual still helping his husband, his wifeor what have you? You know, which is preferable?

Same questioner:That's why I prefaced the question with the sha'

remark. Now obviously this becomes whatever youwould like to call it, philosophical judgment, if you willand I don't mean to sit in that judgment. Obviously,you'd like the constellation to be as comfortable and beas lived with, whatever it is they happen to adapt to. Idon't mean to imply they should be Liking care of thisperson by virtu, of the guilt...I didn't mean to implythat.

FLOWER: Ted, could I return to something that Hugostated? All of us who work with patients work withfamilies. There seems to be an implication that workingwith these poeple separately is something different fromworking with them together, that is, it takes a differentset of skills to work with them together. What do youthink, By?

ALLMOND: I see what you're driving at, and yes andno. It does take some different skills, but my feeling isthe skills arc learnable by everybody in this room andcan be as integral a part of their training and theirexperience as any aspect of language training. But, well,I don't know, I would prefer that people not be scaredoff by the notion that seeing a family all together issuch a horribly different thing that I must never attemptit until I've at least had psychoanalysis myself. That justisn't the case, you know. If that were the ease I'd still be

DPP s to kids and seeing children for well-babycheckups. But I happea to feel that there's a spot for allof us in the handling of bLhavioral matters, for you aswell as for me. Yes there's a discipline and a skill and it'slearnable.

ENGLAND: Behaviorists rush in, too, where angels fearto tread. I probably don't do a very good job of raisingmy own children, but I'm always willing to tell otherparents how to train theirs. At the Monterey Institute, ifI may make a personal reference, we have attempted tolo, I think, what th" 4.onference is suggesting. We bringin groups of parents: parents who have children in ourcenter with specific kinds of problems, and we sit downand train them in the same kinds of principles of learn-ing theory that you've been hearing Dr. Sherman andothers talk about this week. We teach them to count, we,teach them to measure, we teach them to keep track, weteach them to chart. Now these are parents, some ofwhom are illiterate, some of whom speak otherlanguages, some wbo come from educated homes, etc.There are housewives who come in to a group sessionand within 5-six I hour sessions they are routinelychanging their own child's behavior in demonstrableways. Now that eicourages me to agree with what Dr.Allmond is saving, if a person can read or even if theycan't, they can be trained. In ether words, all of us earllearn these skills that I'm taN:ing about if we know whatthese skills are and we know how to program them--weknow how to sequence them. Then what makes it magicfor a man who enrolls in one department to learn theseskills, and illogical for a man who cn-olls in anotherdepartment to nvt. be able to learn these skills? Again inMonterey, we king in high school youngsters, house-

people from retirement homes, and people from

junior high. who also are trained to train children. Theyare trained in the basic principles of learning theory andthey can sit down and administer a program, sae., to

teach a child to read or to teach a child nett articulationor language or other kinds of skills. behavior eontrol.etc. These arc people off the street basically. We say to ahigh school, "Do you have any kids who want somevolunteer time?" So we know now that the person "offthe street" eau "he trained. (I was once a person off thestreet, too, but then some people say I can't be trained.)We do know that people can !earn new skills and there'snothing magic about the degree attached to it. What is"magic" are the underlying laws which govern that skill,I don't know if I've made myself clear on that point. Agood volunteer without formal training can easily out-.distance a M.D. without a learning theory discipline inteaching children new skills. TL,: secret is in the pro-gramming and appropriate training.

GERBER: Mrs. Sarno has suggested something thatmight be called a kind of a "lost words" club. I supposeyou get a lot of aphasics together. Dr. Snidecor hassuggested that the Lost Chord Club is sort of a society ofmutual suffering and perhaps not a good thing I'd liketo hear him react to her suggestion of "the lost wordclub."

SNIDECOR: Well, I think I'd first better clarify mythinking, because maybe I said what I really didn't meanto say, and that is that the Lost Chord Club is a veryimportant transition for most people between theSpeech and Hearing Center and getting back into anormal social life, in -my opinion. It's a place where youtalk, and not a place where you learn to talk because thelaryngeet is often a very bad teacher becaose he wants toteach people how he learned to talk which may not be atall right for the other guy. So I look at it as a transitionalkind of place where the wife and the guy, or the guy andthe wife (depending on who had his throat cut), canadjust to other people, and then stop and make thetransition to the bridge club, to the country dub, towherever it was they were having fun before and notbecome . professional laryngeetomee. I am in no sensecriticizing the function of the Lost Chord or the NewVoice Club. It's got to hate a revolving membership. Theperiod of time ;on belong to it depends upon your need.It may be two weeks, two months, six months: it's avariable and so I want to make this point very clearbecause somebody might go home and say, "Snidecorsays that Lost Chord Clubs are no good." They are verybt,od indeed, an. or got :1 rods cd, but they serve aneed that lasts for awhile. The ease of the laryngectomecwho learns how to talk, I assure you (and I'm sure that

73

you would agree with this) that between this person andthe individual who has had a stroke there are not toomany similarities, not too many. They're different birds.

HUBER:* Well, I can see a Lost Chord Club fordysphasies, but I would certainly like to see someonewho understands the language problems of all of themguiding them (as certainly Dr. Harrington does in theLost Chord Club), to have someone who really knowshow to draw lut individual members at a particular timeand make a unified group of them. Then I think it wouldcertainly function very well. But just for them alone toget together, I think it would be very much the samesort of thing that Dr. Snidecor envisioned as the LostChord Club could eventually just become a group of thesame members meeting constantly.

CATE:** Might I suggest something here and say aword. All of you've been aware that rehabilitationworkers have been here the last three days I'm sure. Andwe are trying to become more involved in the field ofspeech and training and this kind of thing, closer attach-ment, and yet an attempt in many, many speech andhearing meetings across the state is being involved. It's apretty tight discipline. A little bit of nonacceptance, youmight say. I'd like .o put a plug in, if I may, for rehab.And a little advertising if you please. May I have three

*Dr. Mary Huber, California State College, Los Angeles**Mr. Gene Cate, Calif. Dept. of Vocational Rehabilibs .an

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minutes? A lot of our counselors are highly skilledpeople, not only in family counseling, but in finances, invocational aspects, etc. Quite often we have people whocome in, who have problems, who say to us, "I'm sick ofthat, I never want to see the speech therapist again. Idon't want to go over there anymore," and he'sprobably telling the speech ther'apist the same thing, orother persons. But what happens quite often is that wetry to communicate with the therapist or the doctor orsomeone, and for some reason I get this feeling and I'msure a number of our other counselors do: We are con-sidered a step lower than the discipline, and I'd like tosay that the rehab people and the counselors have a lotto offer you people, a great deal to give you, and lidoyou with a lot of your patients in the transitional period.Quite often you have a person who has a laryngectomyand cannot move back into the environment, maybe theguy has been working at a ready-mix plant where he'sbreathing cement and sana and dirt, and s just impossible for him to go back into this tr.lie and really half ofhis preparation is "%Opt am I going to do for aliving?" Quite often ti'. doctor and the counselor willspend a lot of thee doping this out where a call to thecounselor atii! bringing the counselor in on the easealocal rekto counselor you can solve a lot of yourprohl._ins and a lot of the client's problems very readily.This is a little off the family counseling directly but wedo that also. Thanks for the plug.

HANLEY: Those words needed saying, Gene Cate. I'mglad they got said.

* U.S. GOVERNMENT PRINTING OFFICE. 1971 0 428.001

DEPARTMENT OF HEALTH,EDUCATION, AND WELFARE

Washington, D.C. 20201

Official Business

Rehabilitation Services AdministrationSocial and Rehabilitation Service

POSTAGE AND FEES PAIDU.S. DEPARTMENT OF H.E.W.

U.S.INAIL

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U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE SRS-RSA-202-1971