Kahneman meets Van Riper

starkeAbout the author:  Andreas Starke, born 1944, holds an advanced degree in mathematics (Diplom-Mathematiker) from the Goethe University of Frankfurt, Germany. He has stuttered since he can remember but has been quite fluent for many years now. He is one of the founders of the PWS self-help organization in Germany. In 1982, he was awarded a master’s degree in speech language pathology from Western Michigan University and is a licensed SLP in Germany. He has translated a number of American books on stuttering into German, e.g. Van Riper’s “Treatment of Stuttering”. Since 1987 he has been conducting an intensive group therapy program with a block schedule – “Vier-mal-Fünf” (four segments of five days and a weekend) – for teens and adults who stutter. From 1995 to 2005, he was also teaching workshops on stuttering theory and therapy, in Austria, Switzerland and Belgium, as well as Germany.

Presentation in the Lecture Series “Fokus Stottern [Focus on Stuttering] at the 41st Stottern & Selbsthilfe [Stuttering and Self-help] Congress, Heidelberg, on October 2nd, 2014

by Andreas Starke, Hamburg, Germany

Kahneman and behavioral economics

Daniel Kahneman, born 1934, is one of the most important psychologists of our time. He received the Nobel Prize in 2002. It is quite unusual for a psychologist to be awarded this prize. Kahneman’s most significant contribution is his “Prospect Theory”. This is a theory of decision-making under uncertainty that can serve to explain economic decisions. Kahneman became one of the main proponents of behavioral economics, because his theory does not assume that a human always acts in a mathematically rational way, i.e. is not a “homo economicus”. In the model of behavioral economics deviations from rational behavior do not occur randomly, but in a systematic fashion.

Two classes of thinking – System 1 and System 2

In his scientific work that comprised both experiments and evaluations of real-life events, Kahneman proposed dividing the mental processes that a person experiences or executes into two classes. By “mental processes” we mean, more or less, everything that we consider to be thinking processes. The term “thinking”, as we will see, is taken very broadly. In order to avoid any unwanted connotations of terms, he called one class “System 1” and the other “System 2”.

System 1 is always “on” whenever System 2 is not. In this state everything is processed that is about to happen or actually happening. This could be more than one task, e.g. knitting and chatting at the same time.

Activation of System 2 requires a decision to execute a task.

Examples of mental activities in System 1 and System 2 (in random order)

System 1 System 2
to recall to reflect
to have an opinion to make a judgment
to react spontaneously to solve a problem
to have an idea to make a plan
quick action complicated operation
fast slow
it runs (its course) it succeeds
to receive sensory stimuli to process sensory stimuli
automatic flow of thoughts thinking about X / pondering on X
easy challenging
it happens you do it
to be off-guard /paying no attention to be on-guard / to be on the lookout

 

The following rules apply to mental processes:

  • System 1 is the default state, i.e. it is “on” as long as the person is not occupied with a task in System 2.
  • System 2 must be activated consciously.
  • If you don’t concentrate, System 1 reactivates itself.
  • System 1 and System 2 are disjoint, they cannot be active simultaneously.
  • System 2 is exclusive, i.e. at any given time it can only deal with one task or issue.
  • Skills that can be performed in System 2 also become available in System 1 with practice (sufficiently frequent repetition).

Stuttering when speaking in System 1 and System 2

If a person stutters, speaking in System 1 contains losses of control – the stuttering events. Speaking in System 1 also contains reactions to stuttering that have originated in a random manner and have been operantly conditioned. Reinforcement comes from succeeding to utter the next word (the stuttered word). This learning process takes place within System 1. Reactions to stuttering could also have been learned in System 2 by instruction (e.g. in therapy) or by trial-and-error.

Speaking in System 2 (with the intent of “speaking with as little stuttering as possible”) can also contain losses of control. However, they disappear completely after instruction and practice, if the way of speaking is consciously modified from the spontaneous way of speaking. This unnatural modification (alienation) may concern quite different characteristics of speech as

  1. speed and its variation,
  2. pitch and its variation,
  3. volume and its variation,
  4. the use of pauses, and
  5. voice quality.

The use of “soft / easy onsets”, i.e. fixed loudness patterns, and even the use of particular breathing patterns are also possible forms of alienation in this sense.

Traditional stuttering therapy (Fluency Shaping)

The first that comes to mind in the design of a therapy program is naturally the thought of introducing and practicing a stutter-free way of speaking in the hope that the automatization mentioned previously will occur. However, there is a danger that automatization does not happen and the person learns wrong elements of the speaking process. Reasons for the failure of automatization can be:

  • The patient does not apply the stutter-free way of speaking in System 2 (which is supposed to effect the shaping of fluency) often enough.
  • The patient uses the “speech technique” only in easy situations.
  • The patient refuses to use the “speech technique”, because of the substantial cost involved (the disadvantages of using it).

An additional risk consists of training wrong movement patterns so that they eventually become part of spontaneous speech (speaking in System 1). This happens, because a great deal of alienation is required to make speaking stutter-free, if the person stutters severely.

Speaking in System 2 without learning wrong things

One dimension of alienation does NOT carry the danger of unintentionally learning something wrong, namely deceleration (slowing-down) combined with a high degree of consciousness. All the characteristics of a natural spontaneous way of speaking can be kept by slowing down slightly or considerably – as much as necessary. Minor deviations from the pattern of natural spontaneous speech have to and can be tolerated. The deceleration has the advantage of reducing itself automatically when the speaker speaks in System 1.

Speaking in System 2 as a resource for local use

If automatization doesn’t occur (for any of the three reasons mentioned above) there is still the alternative of using System 2 speech at the stuttered word (at the very point in time, the location where stuttering occurs, the locus of stuttering). This is what I call a “local use” as opposed to “global use” meaning the alteration of the entire way of speaking.

If speaking in System 2 (decelerated and in a highly conscious manner) succeeds without stuttering, as it usually does, this way of speaking is used as a resource in order to “work” on losses of control in System 1, i.e. in natural and spontaneous speech. This “work” consists of switching to System 2 on the spot. Switching back to System 1 (automatic speech) happens automatically, i.e. does not have to be done deliberately and needs no practice, although it can be postponed (see below).

Cancellation as retroactively switching to System 2

A stuttering event comprising the whole utterance of the stuttered word (the word that was stuttered on) is spoken a second time in System 2 after a pause of 2 to 5 seconds. In order to reliably effect the switch to System 2, the pause is initially used to “rehearse” the repeated utterance of the word by performing the oral movements with a high degree of conscious awareness. Doing this, the pause may take well over 5 seconds. Van Riper called this maneuver “cancellation”; the German word “Nachbesserung” (my invention), literally “after-improvement”, means something like “subsequent repair”.

Pull-out as switching at the “point of inhibition”

Sometimes it is possible to halt an attempt to utter the stuttered word. With sufficient practice of using “Nachbesserungen” (cancellations) this turns out to be fairly easy. In such cases the stuttering event is supposed to act as a signal for immediately switching to System 2. At the start, this switch may take some time. With growing practice switching becomes faster and more reliable. This maneuver is called pull-out (Van Riper’s term). Like English words in many other fields, this word has been adopted into German in the context of Van Riper’s stuttering therapy, spelled as one word “Pullout”.

”Vorbesserung“ as switching before stuttering occurs

(“Vorbesserung” (literally “pre-improvement”) is a newly-coined word for the opposite of “Nachbesserung”. It means something like “predictive repair” or rather “predictive maintenance” (avoiding failure by replacing a part by an improved version, using the language of maintenance engineering). On par with a pull-out stutters can use a “Vorbesserung”, provided that they anticipate a stuttering event before it has occurred. Most, but not all, stutterers “know” some or many stuttered words in advance.  Doing a “Vorbesserung” means switching immediately to System 2 so that the anticipated (predicted) stuttering event actually does not take place.

What are the benefits of Kahneman to Van Riper’s therapy?

  • Kahneman’s classification of mental activities permits a clearer formulation of the differences between a fluency shaping therapy and a stuttering modification therapy like the one Van Riper has devised.
  • For me, a logical consequence of this model is that I now recommend my patients to remain in System 2 for a number of additional words (after a stuttered and modified word) and to resist the urge to continue spontaneously in System 1.

References

Kahneman, Daniel (1911): Thinking Fast and Slow. London: Penguin Group

Van Riper, Charles (1973): Treatment of Stuttering. Englewood Cliffs: Prentice Hall

 

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Kahneman meets Van Riper — 33 Comments

    • Thank you very much all you commenters and question askers. I wasn’t sure at all how this more technical approach to the question of stuttering therapy would be recepted. So this went pretty well for me. Thanks again.

  2. It would be interesting to use this model of thinking to explain covert stuttering or avoidance behaviors. I interpreted this paper as saying that a success is defined by increasing use of system 2, at least during stuttering moments. Perhaps you can take it a step further to say that success is defined as eventually automatizing helpful skills from system 2 to system 1, however this may be a lofty goal for some (or almost all in my opinion). However, in the case of avoidance behaviors or covert stuttering, the person is pretty much “stuck” in system 2, aren’t they? System 2 for them is actually having a negative impact. For them, reducing use of system 2 or using system 2 but changing the “plan” may actually allow for them to say more of what they want to say.

    • Of course I know the term “covert stuttering” (e.g. from Sheehan’s iceberg parable). To be able to apply the System 1 / System 2 scheme to it, a clear definition would be needed. “Avoidance” is much better defined. For me, it is not doing something that would be otherwise (without the “problem”) be done. Avoidance can have three forms, situation avoidance (not going to the birthday party or to an oral examination), speaking avoidance (not volunteering to speak in class or resisting to speak when called upon) and word avoidance (replacing a “difficult word” by an “easy” one.

      “Increasing use of System 2” is not possible, because practically there is not state in which System 1 and System 2 are on at the same time. That is what I meant when I wrote the S1 and S2 are disjoined. I may appear that they can be on simultaneously when the switching forth and back happens very fast / frequently. Yes, switching to System 2 after, during or, if possible, before a moment of stuttering. That is the “local use”. A global use would be, switching to System 2 before beginning to speak and stay in System 2 until the end of the entire speech act.

      The reason for my (and Van Riper’s) prefering the local use over the global use is of course that the full automatization of the stutter-free speech that can be attained by using an “alianated” way of speaking only very rarely happens and if, creates some unintended side-effects.

      Regarding being stuck in System 2 I can only say that this does not appear to be a problem in my therapy, because the time between (intentionally) switching to System 2 and letting the state (unintetionally) go back to System 1, with is the normal=default state, is bearably short.

      I your last sentence a defense for avoiding?

      • I believe this is a problem of semantics. What I meant by “increasing use of system 2” was increasing the times that a client “switches” to System 2 after, during or before a moment of stuttering. I understand they can not occur at the same time. I agree that “local use” is often more realistic and beneficial to the client. I was not arguing this.

        I’m not sure what you’re getting the idea that I was defending avoiding. Rather, quite the opposite. I think it is dangerous to speak about stuttering treatment while only speaking about eliminating or reducing the observable stuttering behaviors. I was wondering how you use your system1/system2 approach to target reducing avoidances (at all levels) and reducing potential adverse impact of stuttering on a person’s quality of life.

        • I agree to 100 percent of what you write. Switching to System 2 as a reaction to a moment of stuttering (after, during, before) would be the ideal and, because the rate of stuttering in many cases decreases dramatically, becomes feasible. For the cancellation which is aparticularily demanding task we usually set daily goals like 80 or 150.

          Re avoidance: Word avoidance (including sound avoidance) seems to be clearly a System 2 process if it is done deliberately and consciously, and it often is. But over a long period of stuttering is can become habitualized and also appears in spontaneous automatic speech (System 1) without the speaker recognizing it even when he knows the concept well. Speaking of other kinds of avoidance behaviors, working on avoidance reduction is not really the focus of the “modification phase” of our therapy program but rather of the “desensitization phase” which comes before (important!) the modification. Of course we attain a great deal of desensitization especially by doing cancellations.

          • “Shame forces the speaker to switch to System 2…” This was what I meant by being “stuck” in System 2. For this type of client, being in system 2 is not a sign of progress. This very idea was what I was trying to get at in my previous post. For this client, progress would either take the form of switching back to System 1 (if their default is talking without shame and therefore a reduction in avoidance) or altering their System 2 to a “plan” that helps them cope with shame so that it doesn’t lead to avoidance. I hope that this is more clear.

            • It’s an interesting question whether desensitization (overcoming avoidance and shame) in the therapy process can be decribed well using the classification of speaking in System 1 and System 2. I’m afraid it can not. Making a plan for shame-attacking activities belongs to System 2, of course. But that is as far as it gets. I could proceed to describing how we implement the counterconditioning required for relieve the emotional burdon of stuttering in our therapy. But I leave that to another discussion, maybe next year. (By the way, the plural first person is not a “pluralis majestatis” but refers to my colleague Robert Richter and me who do the therapy together.)

  3. Thank you for this article. It is very interesting. It seems to me that there may be an additional system related to stuttering. System 1 seems to be stuttering without awareness, shame, or avoidance. System 2 is when which the person is aware of and avoiding their stuttering behaviors and situations. Then there may be another part of System 2 in which the person is still aware, but feels like the locus of control has shifted inward so they are in control of their behaviors and feelings about stuttering. There seems to be an incredibly powerful psychological shift that occurs for people who stutter when they begin to be able to communicate fluently.What do you think about this?

    • I’m afraid that there is a fundamental misunderstanding. The separation of mental processes that Kahneman suggested was not devised to be applied to stuttering, but it can be used for describing the mental conditions under which stuttering happens since the two classes (System 1 and System 2) hold for all mental processes.

      Remember, System 1 performance is totally unaware like chatting, driving, walking. Stutterers talk also in System 1 like everybody else and in their System 1 talk a number of stuttering events (loss of control = motor control breakdowns and reactions to them) happen. By the way, most of what we see and hear are reactions to the stuttering itself, the core behavior of stuttering. These stuttering reactions are learned, the breakdowns do most probably have an organic basis.

      But there are also losses of control when a stutterer speaks in System 2 and there are reactions to those, too. That being said, I hope that you can reread by paper and find that I don’t talk about shame and avoidance. Depending of what you exactly mean by avoidance, avoidance and shame clearly are reactions to stuttering. Shame forces the speaker to switch to System 2 the same way a person would deliberately change is walking style if he fears a negative judgement of an oberserver. (I just remember Monty Python’s “Ministery of Silly Walks” where protagonists showed very perculiar ways of walking obviously in System 2 pretending it was their System 1 way of walking.) Some PWS have developed very peculiar ways of reacting to stuttering in terms of speech movements (as well as shame and avoidance) that show in System 1 and System 2 meaning that even in a conscious way of speaking cannot be suppressed or replaced by something better. To me, it appears quite obvious what that means for therapy.

      • Yes, on a second reading I understand more clearly. What I didn’t understand before is that people do not get stuck in either System 1 or 2, but that they can move back and forth between them. I love the analogy of Monty Python Silly Walks. That will always be what I think of now when secondary characteristics in relation to stuttering come up!
        Thank you for replying and for the work you do!

  4. Thank you for this article, it was very interesting. I will also take a look at your websites. I see you mentioned desensitization and modification as a part of a therapy program. Is this the program you follow?

  5. Thank you so much for sharing this article. I am a first-year graduate student studying to become an SLP, but my undergraduate work was in psychology. Having recently learned about Van Riper’s traditional therapy and having learned about Kahneman and Systems 1 and 2 in an undergraduate cognitive science class, this article appealed to me by merging my two fields of study thus far. The application of this theoretical psychology principle to stuttering therapy provides a new perspective that I have never considered.

    So, to make sure I understand how Kahneman’s principles further define the distinction between Fluency Shaping and Stuttering Modification, you feel that Fluency Shaping therapy teaches skills that are deliberately applied using System 2, with the hopes that with practice, those will be automatized and transfer to System 1; therefore, generalization would equal speaking fluently using System 1? Whereas in Stuttering Modification, fluent speech can be a continual process of switching between Systems, and that Van Riper’s methods for facilitating fluent speech can be defined in terms of when System 2 kicks in and takes control? Finally, how do you feel that Kahneman’s mental processing categorization of System 1 and System 2 applies to children who stutter, since they are often less aware of their own stuttering?

    Thank you again for sharing, and I look forward to further exploring your website and other work.
    Claire Richards

    • I find it interesting that you have heard something about stuttering and Kahneman’s classification without recognizing that there is a possible link. To detect this link was very surprising to me, too. As a SLP who is highly specialized on stuttering and its therapy, I am constanty (without being aware of it) looking for pictures / images / metaphors / parables to compare stuttering to for my patients and people around them. I stumbled upon Kahneman because I’m reading a lot on economics and finance now. I find Kahneman’s classification both simple and practical, much more than “generalization”, “automatization”, “volition”, “awareness”, “concentration” etc. Once you understand it, many things become simple and clear. (As a mathematician with some knowledge of physics I know that most of what we call explanations are merely decriptions with predictive value anyway.) In particular, it is clear why most of the usual therapy work addresses the patients’ behavior in System 2 which it which is mostly meaningless for them. What they want is speaking better in System 1.
      Yes, what you describe is about what I wanted to say. The term “generalization” might be a problem. If it means the consistent use of a behavior in all circumstances, as it is usually understood in stuttering therapy, the difference between deliberate use (performance of a skill) and automatic part of a behavior pattern (in this case speech) may not be really appreciated. Becoming fluent in System 1 cannot, by definition, be forced. (Nothing can be forced in System 1). It happens or it happens not. My point is that the local approach (i.e. Van Riper’s) is the better choice compared to the global approach (use of an alianated way of speaking thought a speech act as often as possible, i.e. Fluency Shaping), because the local approach is economical, because patients don’t like the global approach, and because the intended generalization of System 2 skills (becoming fluent in System 1) rarely happens, if ever.
      I’ll try to answer your question about children in my reply to LysandraS (next comment).

    • It made me smile that you call Van Riper’s therapy “traditional”, because my divide between “modern” and “traditional” is after and before the paradigm shift that Van Riper and others (what Bloodstein called the “Iowa School of Stuttering Therapy”) have effectuated. For instance, I consider Marc Onslow’s work with teen and adults (that’s only an example) to be “traditional”, i.e. not much different from what has been done for centuries in the old days. The paradigm there is “zero stuttering at any cost”. The fact that the paradigm shift happened around 80 years ago doesn’t qualify the Iowa School to be traditional, like the shift from the geocentric world model to the heliocentric that happened around 470 years ago (Copernicus) does not make the latter traditional.

      What’s important though is that the old stuff has reappeared again. The same happened in the 70-ies when the solution of the problem of stuttering seemed around the corner with the supposedly new “behavior modification techniques” and “learning technology”.

      • Thank you for your response! I am truly in awe of your multi-disciplinary knowledge and the connections you are able to make across many areas of study. It is definitely motivation for a student and future clinician like me. I understand the point you made about labeling stuttering modification as traditional; I suppose I used that because in many of my classes we have connected Van Riper with the term “traditional” in terms of therapy approaches used by clinicians. Van Riper’s work is part of that later paradigm focused on the goal of ‘stuttering more fluently’. I suppose terms like traditional and contemporary are all relative, but the important point for clinicians is to understand the various approaches out there and the theoretical basis on which they are founded. Thank you for your response below to approaches for children as well. Your work is very fascinating!

    • — “… therefore, generalization would equal speaking fluently using System 1?”

      Yes, that’s what proponents of the Fluency Shaping approach think and promise. But it rarely happens, if ever.

      — “Whereas in Stuttering Modification, fluent speech can be a continual process of switching between Systems, and that Van Riper’s methods for facilitating fluent speech can be defined in terms of when System 2 kicks in and takes control?”

      It is an interesting question what really happens in Van Riper’s “stutter fluently”. Certainly, locally switching to S2 in cases of real stuttering (actual and anticipated) is part of it. But we also find patients using minor voluntary disfluencies, voluntary in the sense of unforced, but not volitional (S2). Voluntary stuttering (pseudo stuttering / fake stuttering) which can be very demanding at first, sometimes becomes fairly easy and semi-automatic (the use can be stopped anytime) in System 1 once the patient is “in the flow”. We also use Van Riper’s pull-out batch (flooding one’s System 1 speech with fake pull-outs in order to strengthen the fluent speech gesture). That belongs to Van Riper’s stablization phase.

      I want to add that when we do cancellations the frequency of stuttering events drops remarkably, so patients just talk spontaneously and fluently. So in the end, these switches are not used very often, but the sheer knowledge that patients can use them as tools increases their confidence and changes their perception of seaking situations (the cheese vendor in a food store gets the same stimulus value as their kind grandmother). These are psychological effects, of course, which are truely fluency-enhancing.

      • I appreciate the connection between specific treatment methods and the underlying theoretical principles. Thank you so much for your responses!

  6. Thank you for such an interesting article! I really like the concept of the system one and system two. Since reading this article have been trying to notice when I am in “system 1” or “system 2”, not always an easy task.
    I was wondering if you use this type of therapy on children or mostly adults? If you used this approach of systems on children do you have any different ways of explaining it? I am a first year graduate student training to be an SLP and I am particularly interested in fluency work with children. I wish to explore this approach to therapy more, but wanted any feedback of how to better cater this type of therapy to a child, especially a pre-school age?
    Thank you again for sharing this essay, great food for thought!

    • I hope I made it clear that doing “this type of therapy” I follow Van Riper’s program for the most part. Participants in my intensive group therapies are aged 14 and up. That’s an age in which you can use theoretical concepts together with metaphors, parables and meaningful stories, even if some of these patients are not intellectual giants. With younger children I feel you can be more direct by (1) modeling with instruction (do what I do) or (2) modeling without instruction. I would recommend still keep the idea of a local approach.

      What you model is a kind of pull-out (decelerated conscious movement through the “dangerous spot”) demanding concentration is much less important than with teens and adult, imitation suffices in most instances and cases). I do not decrease tension below the normal level with extremly few exceptions. With older pre-teen children you can use an instruction, with younger children you don’t even do that. Preschoolers usually pick up your pullouts which you present randomly in your speech in a casual way without instruction. Imitation is the major avenue of learning for preschool children anyway. And if they don’t, tell them to, gently of course. I do not recommend to use the what I call “global approach” by using so many or so deviant “fluency skills” (soft onsets) that the stuttering disappears by alienation, i.e. by forcing the child to speak in System 2. I have heard some credible reports about very bizarre stuttering behaviors in an older teen or adult that have originated in a taught way of stutter-free speech by finger tapping on the upper leg and syllable-timed speaking. Read Carl Dell’s book “Therapy for the school-aged stutterer” that is hopefully still available at the Stuttering Foundation of America.

      If you have more questions, ask them here or, after Oct 22, write me a mail.

      • Dear Andreas,
        Thank you for your thorough response! You did make it clear this should be used for teens and adults, I was just curious if it could be modified for preschool age. I assumed talking about the more theoretical concepts would not be possible for young children.
        I will keep the concept of system 1 and 2 when dealing with teens and adults, and take a more direct approach when dealing with preschool age.
        Thanks again for your great article and introducing me to new ideas!

  7. Thank you for sharing this! I am a graduate student studying to be an SLP in the US and I have great interest in working with people who stutter. I really enjoyed reading your article, by applying this division of mental processes is a very helpful way of thinking about stuttering and a good way to understand that the process of speech production in connection with stuttering is very complex. Dividing behaviors into system 1 and system 2 has helped me to organize my own thoughts when considering explaining stuttering and approaches to therapy with my clients.

    From the links in previous comments I was able to look at the description of your intensive interval therapy program. Intensive therapy of this type over several weeks seems to be a very effective type of therapy for people who stutter. However, this type of intensive program is not always a feasible option for every client. Do you have any suggestions for implementing this Van Riper-style therapy when meeting with a client 1-2 times a week for maybe 60 minutes? Would you change the order in which the modification techniques are introduced?

    Again, Thank you for sharing. This article challenged me to dig a deeper into my own understanding of stuttering.

    TJ List

    • Understanding the process of speech production in connection with stuttering? Does the division the states of System 1 and System 2 help for that? It may be interesting to study the difference of brain function when speaking in S1 and S2. Perhaps that could explain why for a stutterer it is comparatively easy to speak without stuttering in S2. That speech production in connection with stuttering is very complex is something that we all knew even without considering the S1 / S2 distinction.

      My therapy as individual therapy in 1 or 2 weekly sessions? I try to avoid that whenever I can mostly because it is way less effective. Sometimes I can not, as with the 11 year old slighty autistic boy I just saw an hour ago.

      I don’t find it not feasible for the patients (I call them patients because the German health system pays for our therapy), at least in the German system. Our patients pay for travel and accomodation, and only a small fraction of therapy cost. If these costs are higher than a patient can bear, I have them pay in installments, interest-free with payments as little as they find possible for them. (And I have a former patient who works as a professional poker player who promised to incur the entire costs in extreme cases.) In our weekly program, patients lose 3 working days per week, i.e. 13 days for the entire program. Highschools generally agree to set their SWS (students who stutter) free for these 13 days, and adults who work on flexible hours compensate for the lost days by working overtime, most of them do. I quite sure that this con be done in the US as well, at least in the big cities. I would be willing to come.

      Years ago, a group of SLP in Frankfurt/M have adapted my therapy to the needs of a large private practice (with at least 2 larger rooms for the group) by doing one of my therapy weeks on two back-to-back weekends (Friday thru Sunday). Participants can sleep at home and therefore avoid the cost for accomodation and travel. For the last 7 years an SLP in Hamburg and I are using this format. We have just started the 15th of such group therapies. I still like the weekly program better, and it only partly because of the more enjoyable venue at the Baltic Sea, 300 meters from the beach.

      Changing the modification techniques (cancellation / pull-out / preparatory set / monitored speech)? This sequence has an intrinsic logic, and I (being a mathematician) insist that everything that I tell my patients makes sense. What would be your suggestion for changing the order?

      I suspect that only very few SLPs in Germany and the US use cancellations anymore. For me, that means giving away the single most powerful tool that we have in stuttering therapy and a stroke of a true genius, which Van Riper was. This I say gratefully stortly after the 20th anniversary of his death (September 25th).

  8. Dear Dr. Starke – Thank you for a lovely paper. My attention was particularly attracted by Dan Kahneman’s name in the title… I was fortunate to take a class jointly taught by Kahneman and Treisman when I was an undergraduate at Berkeley. It was just their second year there, IIRC. The course was on decision-making, and I remember enjoying every minute. (Part of my psych degree curriculum.) A funny thing – I remember that Dr. Kahneman always brought his own overhead projector to the lectures. There was one in the lecture hall, but he evidently liked his own better. (And back in those days, a portable overhead was sort of nifty!)

    Anyway, I appreciated your application of the work on classes of thinking to understanding how people approach and implement various types of stuttering treatment strategies. I believe that we can all gain a greater understanding and appreciation for whether and how these approaches might help only by better understanding the mechanisms that cause them to work, both in the short term and in the long term. The differences in thinking modes can potentially help us explain differences seen in different treatment approaches.

    Thank you for sharing your work on this forum…I’ll look forward to following your further thoughts on the topic!

    J Scott Yaruss, PhD
    University of Pittsburgh

    • Dr. Starke? Our former chancellor Helmut Schmidt, undoctored himself, once made the remark that there still are a few respectable Germans without a doctorate. Just call me Andreas.

      Yes, Kahneman is a joy to listen to. Fortunately, there are a number of his talks on Youtube. I’m glad and honored that you liked my paper.

  9. Thank you for sharing this information. As a current graduate student in speech pathology who has been learning about Van Riper’s therapy, I find your use of Kahneman’s views on mental processes to explain stuttering modification techniques insightful and helpful. I feel as though I now better understand the benefits of implementing stuttering modification therapy using this way of thinking. I would think that the basic idea of System 1 and System 2 could be relatable to many people. When you conduct intensive group therapy for adolescent and adult patients, do you focus much on this theoretical concept? The reason I am asking is because even though it is obviously a more theoretical than concrete way of thinking, I could see a discussion of System 1 and System 2 in general terms being a unique and helpful way for some to better understand the modification strategies they are learning to use. Could you expand on this? Thank you for your input.

    • No, it is not too difficult to explain. Try to explain the difference between S1 and S2 through an activity that the patient (e.g. a child) knows like walking. Have the child walk across the room in their usual unattended way of walking (S1) and have him or her walk on their heels (S2) which requires attention because it is more difficult and because it is new to the child. Talk to the child about how different it feels, S1-walking and S2-walking. You can even proceed to speaking in S1 with the stuttering for which the child is seeing you and an alienated way of speaking, i.e. a way that includes one (or more) of various unnatural alterations like talking word-by-word, talking with stretches syllables, talking with a “funny” voice (Mickey Mouse). This S2 speech should be stutter-free and if it is not, make the unnatural alterations even more unnatural. There is one degree of unnaturalness where the stuttering just goes away. Do you see how you can proceed from there? (You, of course, don’t tell the child that this kind of S2-speech will be the solution of his stuttering problem. Etc.)

      And well, I’m not afraid to talk to my patients about theoretical aspects of what we do. And this for several reasons.

      (1) I believe that a child, and every adult person, deserves to be spoken to in a clear and reasonable way and that their arguments are taken seriously.

      (2) I believe that “there isn’t anything more practical than a good theory”, as Kurt Lewin, a leading psychologist at his time (1890 to 1947), remarked.

      (3) I believe that slightly overcharging a person (esp. a child) is beneficial in that it can create curiosity, if done well, with that being a major factor in motivation. It has to potencially make sense, however, theoretical sounding nonsense wouldn’t work. (Since I’m not sure whether that’s well put in English, I include it in German. Perhaps there is someone who can translate it. Ich glaube, dass es nützlich ist, jemanden (bes. ein Kind) leicht zu überfordern, weil das den Menschen neugierig machen kann, und Neugier ist eine wichtiger Faktor der Motivation.)

      There is no real difference between theoretical and concrete thinking. Of course, you will use concrete examples for “explaining” a theory. Even the Maxwell Equations are not very convincing as such.

      Do I focus much on this theoretical concept? No, I explain it in the first phase of therapy (“Identification”) together with a theretical model of the Stuttering Event (difference between the core behavior and reactions to stuttering). In the course of therapy, I would at times ask the patient, “In which state have you been speaking the last two sentences?” With Kahneman’s terms I would now add: “System 1 or System 2?” You see, that’s not much focussing, because the concept is quite simple (and easy to understand). It just becomes part of the clinician-patient communication.

      More questions? Just write a comment or, after Oct 22, write me a mail. info@andreasstarke.de