A BEHAVIORAL APPROACH TO SPEECH THERAPY

INTRODUCTION

In the past decade and a half the knowledge explosion has wrought many changes in psychology, just as that same explosion has changed much of the rest of science. Although psychology is still defined as the scientific study of behavior, and although the aims of psychology are still to understand, to predict and to control behavior, the way in which the work of psychology is accomplished - the way psychologists try to realize the aims of psychology - is now quite different.

For example, the use of drugs - many of which were still undiscovered a little over a decade ago - is now so prevalent in the treatment of behavior disorders that drug therapy has become one of the standard aspects of therapy. Likewise, the use of operant conditioning techniques, most of which were perfected in psychological laboratories where animals were used as subjects, has recently been successfully undertaken in the treatment of a host of human behavior disorders, including some of the most severe disorders.

As an example, operant conditioning was used to restore speech behavior in an adult psychotic who had remained mute for 19 years. The operant method was successful in spite of the fact that traditional psychotherapy has been tried on that particular individual a number of times during the years of his hospitalization.

Another factor of significance in this study was the fact that chewing gum, which the patient liked, was used as the principle reinforcement to induce the patient to re-assume verbal behavior.

Both the power of operant conditioning techniques and the availability of "commonplace" reinforcers are thus illustrated.

The operant learning methods have been developed in psychology within the broader framework of the behavioristic approach to psychology. The behavioristic view and operant conditioning could also be applied to describe speech pathology and the speech therapy session. Such a description might take the following form:

SPEECH PATHOLOGY AND SPEECH THERAPY

The behavioristic view of functional speech pathology is that the pathological speech behavior has been learned in the same way that normal speech behaviors are learned. In its broadest sense, the above statement means that the individual who exhibits a pathological speech pattern has been reinforced for emitting pathological responses and that, as a consequence of reinforcement, the pathological responses have become significant aspects of the individual's speech repertory. The above does not imply that the behaviors were intentionally reinforced. More often that not quite the opposite intention exists.

However, because of some quirk of understanding, communication or interaction on the part of the person or persons responsible for training a particular individual's speech behaviors, reinforcement is associated with the pathological rather than the normal speech responses. When this occurs, abnormal (pathological) speech develops.

Viewed in the above framework, the speech therapy situation becomes a condition wherein reinforcement (in the reward sense of reinforcement), must be transferred away from pathological speech production and toward normal speech production.

The therapist then becomes a behavior engineer, in the positive sense of this term, whose main task is to analyze the therapy situation in such a way that the controlling variables (i.e., those which reinforce pathological speech) are recognized and systematically manipulated so that they come to control normal speech.

Further, once the reinforcing conditions have been brought to bear on normal speech in the therapy setting, conditions that produce carry-over to the patient's world outside the therapy, setting must be formulated and successfully instituted.

The above objectives, though not always specified, have probably been the objectives of speech therapy, since its inception. The way in which the speech therapist views pathological speech and the approach to speech therapy has been reformulated.

OPERANT LEARNING DEFINITIONS AND APPLICATIONS

If the reader will bear in mind the above description of, and the accounting for functional pathological speech behavior and the objectives which inhere In the behavioristic approach to speech therapy, we can push on to a definition of terms and a further specification of the usefulness which operant methods hold for the speech therapy situation.

The basic datum of operant learning is the OPERANT or the "focal" response. An operant is any clearly defined, observable, measurable aspect of behavior. In the animal laboratories, the two most common operants (responses) measured were bar pressing by the white rat and disk pecking by pigeons. In the speech clinic stutters, lisps, clutters, various ataxic responses, and so forth could be used as focal responses.

The objective in applying the operant learning methods is to understand the relationship between response rate and reinforcers. A reinforcer is any aspect of the total environment that has a measurable effect on response rate. Positive reinforcers make the occurrence of a response more probable, or increase response rate. Negative reinforcers decrease the focal response probability or decrease response rate and/or increase the probability of alternative responses.

The crux of operant conditioning involves a careful analysis of the organism's behavior. The purpose of the analysis is an understanding of which reinforcers are in control of the behavior to be altered. If the controlling variables are discovered and understood, behavior can be predicted. When behavior can be predicted, it can be controlled.

It sometimes happens that the word control arouses a negative feeling. While this is a natural reaction on the part of many people in our culture, it must be realized that the control is to be exercised for the benefit of the patient and only until the patient can assume self-control or until the pathological behavior is no longer part of the patient's behavior.

You will recall that some measure of a specified response provides the basic datum of operant conditioning. In this regard, the notion of "base rates" is important. Prior to any attempt at understanding, prediction, or control, a base rate of the focal behavior should be taken.

Ideally, the base rate data should be gathered at random periods of time. The base rate data should be extensive enough to ensure an adequate sample and, hence, an adequate estimate of the "true" rate of occurrence of the behavior under a variety of circumstances.

The reason for obtaining base rate data is to provide a standard against which changes in the rate of the focal response can be precisely compared. In the absence of base rate data, only qualitative statements (usually of a vague nature) regarding changes in response rate can be made.

Within the speech clinic base rate data could be discreetly tabulated during the evaluation session(s), by the patient's therapist, from tapes of recorded interviews with the patient, and so forth. In most cases, an effort should be made to keep the patient unaware that focal responses are being counted and their use should likewise not be imparted to the patient.

Important deviations from the foregoing generalization occur when it seems wise to let the patient know how he is performing with relation to how he had been, as an incentive to speed up or sustain progress. Used in this way, response rates could be used as effective reinforcers.

One of the important reinforcers in the therapy session is social reinforcement. Social reinforcement, in the broadest sense, is any behavior by one individual that has an effect on another individual. Social reinforcement can take many forms. Its range extends from material reward, through verbal praise. It even includes such things as gestures, posture, eye contact (including pupil size), smiles, nods, time and the distance a person maintains between himself and others.

Whether a given social reinforcer is positive or negative depends on how it is used, by whom, under what circumstances, and many other factors. An awareness of social reinforcement may be especially crucial because of the highly personal and individual nature of most speech therapy sessions.

THERAPY AS BEHAVIOR MODIFICATION

In the most basic sense, becoming a successful speech therapist involves being able to evaluate a patient's problem, establishing the conditions by which the patient can overcome the problem, within the latter, helping the patient establish realistic therapy goals and finally, systematically helping the patient realize the nature of the problem, the course therapy must take, and how the goals of therapy can be realized.

In behavioristic terms, the job of evaluation becomes one of establishing whether or not the problem is primarily functional or physiological, and of obtaining base rates for the focal behavior(s). After this has been accomplished, the effective therapist begins to search for those aspects of the therapy situation - be they tape recorders, dolls, toys, or the therapist - which can be employed as controlling stimuli; that is, which can be used to help the patient realize the goals of therapy.

Controlling stimuli can be "routine" objects from the environment and still wield power as reinforcers as the example given in the introductory part of this paper demonstrated. As you may recall, in that report, chewing gum was used to restore verbal behavior in a psychotic male who had been mute for 19 years.

A dramatic example of the power of social reinforcers as controlling variables was demonstrated by Bachrach, Erwin and Mohr. They restored eating behavior in an adult female who was nearly starved to death because she did not eat or vomited food soon after ingesting it when she did eat.

This patient, who once weighed 120 pounds, weighed only 47 pounds when behavior therapy was commenced. All previous therapy efforts had failed. The successful therapy consisted of the therapist sitting beside the patient's bed after having brought in a tray of food that was set on the bed where the patient could easily reach the food.

The first time the patient moved as if to eat, the therapist spoke to her and smiled. As the patient took a bite of food, the therapist spoke a second time. Finally, the patient would commence to eat as soon as the therapist came in and set the tray down. While the patient was eating the therapist would talk to the patient in a lively and animated way. In this way, the therapist was socially reinforcing eating behavior.

Later, social reinforcement was only given if the patient showed weight gain, since the patient reverted to the habit of vomiting the food after the therapist left her room. Access to other controlling stimuli such as a radio, TV, and even visitors was then made dependent on weight gain. The results were so successful that the patient was discharged from the hospital, was able to complete a secretarial course and obtain and hold employment.

The patient's family was shown how their concern over her failure to eat and their attention to the vomiting had contributed to these behaviors becoming deeply ingrained habits from which the patient nearly died.

The above shows how subtle social reinforcers can be and how much power they can wield over behavior.

Likewise, in the speech therapy situation, the possibility exists for discovering and using social reinforcers in realizing the goals of therapy. The secret, of course, resides in discovering which reinforcers control the behavior of a given patient or in introducing reinforcers in such a way that they become controlling stimuli.

Such discoveries are made by systematically introducing various chosen stimuli and carefully noting their effects on response rate and by keeping alert to those things for which the patient displays interest. Once the controlling stimuli have been introduced, their effect on the elimination of pathological speech behavior (and on other behavior of interest) can be evaluated by comparing the response rate of the focal behavior from subsequent therapy sessions to the base rate data gathered prior to the introduction of the stimulus.

SUMMARY

The foregoing has been a discussion of speech pathology and speech therapy in behavioristic terms. Examples of the use of the behavioristic approach to certain areas of psychology were presented with the suggestion that operant learning methods might find useful application in the speech clinic.