11.4 Stages in the rehabilitation of voice- and speech disorders

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Most voice and speech disorders have a non-organic origin, they are caused by inappropriate usage. In other words, if you look for a damaged or defective part of the speech organs you may find one, but it is more likely the consequence than the cause of a dysfunction. A vocal nodule may be the "causa proxima" that prevents a teacher to speak with a clear voice, but the remote cause is the dyskinetic use of her voice. This has put an extra load on the vocal folds and the tissues show the consequences. The question is: can she acquire a new and better habit of using her voice, can she learn to cope with difficult days in the classroom, and become less tense under adverse circumstances? Similar questions can be asked in the case of a stutterer who would like to free himself from his speech habits and automatisms.

One of the great founders of communication pathology was Charles Van Riper (Kalamazoo, Michigan). We have already met him in Chapt. 10. He was an educational writer of great merit and originality. In his works on the treatment of voice- and speech disorders he introduced a systematic order of treatment, summed up in MIDVAS, a mnemonic device consisting of the first letters of the following sequence.

Motivation is the decisive factor in the treatment process. Many a patient who consults a clinician or a doctor hopes that he will be relieved of his problem in a simple way, a shot of an antibiotic, perhaps a little less smoking, or, if it must be, a minor operation. When the clinician proposes an intensive course of reeducation, implying that he will have to practice daily and will have to change some precious old habits, this may be more than he is willing to do. Much depends on the competence of the therapist to motivate the patient to venture into unknown territory. When the patient gives the therapist his trust he expects to get this credit repaid in results. After the first obstacles have been overcome motivation is fed by the drive to attain lasting results and an attitude of positive expectation that in turn is fostered by initial successes. Motivation-credit does not last indefinitely, results will have to show up soon to keep motivation going. A clear outline of the therapy in steps that are within reach of the patient will help to keep the spirits up.

By Identification the patient discovers that the dysfunction is part of himself and that the only way to improve the situation is by coming to terms with the treatment plan and by assuming co-responsibility for it. This is a large step. Patients with a voice or speech complaint have a tendency to ascribe the problem to external causes: predisposition, a virus, or just nerves. In the first treatment sessions the patient should explore the ways he uses his voice, the rate of his verbal output and other relevant details. This is to overcome the feeling of helplessness, of being powerless and at the mercy of his dysfunction.

During the Desensitisation phase the client frees himself of the fears and avoidance tendencies that inhibit him to touch the painful subjects that relate to his dysfunction. He loses his shyness and finds the courage to face the issues to be worked on during therapy. It is important in some stutterers whose symptoms are induced by negative feelings, such as an aversion to a situation in which speech inhibition tends to occur. Also patients having a voice disorder may have strong emotions: anger about being incapacitated, worries about the future, annoyance about being unable to change the situation. A strong emotion may in itself cause voice dysfunction. Anger or anxiety, causing agonistic moments, impinge upon the smooth automatism of speech, resulting in ugly interruptions, moments of roughness and other dyskinetic symptoms. When repressed feelings are not allowed to come to the surface, the tenseness to keep them down will stay as long as the patient has no other way of coping with his anger, dislike or hatred. Note the paradox: stuttering and dysphonia may be part of the defence system and anything, treatment included, that is aimed at breaking down the defences will invite resistance.

Variation is the procedure to let the client experiment freely with changes in his usual behaviour that has caused the problem, try out alternative ways to interpret his environment, if some misconception was at the base of his communication disorder; in short to break out of his former confines. This stage passes into the next:

Approximation: focussing on desirable behaviours and attitudes by response substitution, sensomotor practice, role playing to learn to give adequate expression to feelings of approval, anger or disapproval. All new possibilities need to be practised. By trial and error the patient will learn to come closer to the goals he has set in his life and had not been able to realise.

Stabilisation is the final phase in which the newly acquired behaviours and attitudes are introduced in situations of daily life and practised until they are strong enough to take the place of the former habitual behaviour. As long as the new voice or speech behaviour feels "strange" it can be easily lost. The old habit will take it's habitual old place. This is likely to happen if the new behaviour has been imposed on from outside, not grown from within. When the identification phase of treatment has been successful, the patient has taken on his own treatment and can work on his problem independent of the therapist.

The MIDVAS sequence is not as simple as would appear at the first glance. Each of the phases in the process of change can become an obstacle, leading to stagnation. In order to proceed, any single phase may in itself need a complete work-over with the MIDVAS cycle. When during the stabilisation phase the new behaviour (voice or speech habit) is not carried over into daily life, it is likely that the process of identification has not been successfully completed. This , in turn, can only be attained after the client has acquired sufficient self-confidence (basic trust) so that he can maintain a radical change in attitude and let go those he used to depend on. Thus MIDVAS is a recursive procedure and as such a veritable enzyme for growth.

11.5 Requirements for the therapist.