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Cluttering Treatment: Theoretical Considerations and
Yvonne van Zaalen
Institute of Applied Sciences, Fontys University
Eindhoven, the Netherlands
Isabella K. Reichel
Program in Speech and Language Pathology, Touro College
New York City, NY
Financial Disclosure: Yvonne van Zaaeln is an Associate Professor at Fontys University.
Isabella K. Reichel is an Associate Professor at Touro College.
Nonfinancial Disclosure: Yvonne van Zaalen has no nonfinancial interests related to the content of
this article. Isabella K. Reichel has no nonfinancial interests related to the content of this article.
This article presents a variety of treatment approaches based on an understanding of four
components of communication, and describes cluttering intervention focusing on problem
identification, speech rate reduction, appropriate pausing, appropriate monitoring, and
addressing story narrating skills. Therapeutic considerations, taking into account the
specific characteristics of cluttering, will also be presented. Finally, building clients’
confidence, emotional skills, and sense of accomplishment will turn the therapeutic process
into awareness of realistic expectations and motivation to pursue challenging goals.
Cluttering is a disorder of speech fluency in which people are not capable of adequately
adjusting their speech rate to the syntactical or phonological demands of the moment (van Zaalen,
2009). When language production is relatively easy, people with cluttering (PWC) are capable of
producing fluent and intelligible speech. When language production demands are more complex,
the speech rate should be adjusted to the language complexity. PWC tend to have difficulties doing
so. This reduced ability of PWC to control their speech rate results in either a higher than normal
frequency of disfluencies or multiple speech errors. This article presents various intervention
approaches based on an understanding of four components of communication: cognitive, emotional,
verbal-motor, and communicative. The article focuses on problem identification, speech rate
reduction, appropriate pausing, and addressing monitoring and story narrating skills. Therapeutic
considerations, taking into account the specific characteristics of cluttering, will also be presented.
The speech rate is influenced by two components: speech execution and pauses. Syllable
duration normally is rather consistent, while pause duration varies to a great extent between
speakers. Daly (1992) observed significant improvements in clients with cluttering when a
synergistic and multi-dimensional perspective in treatment was implemented. Myers and Bradley
(1992) introduced a widely followed synergistic perspective in treating clients with cluttering. This
perspective integrates different approaches in treating PWC who manifest various symptoms. It
may be noted that these symptoms interact, and affect each other in a variety of ways. Addressing
multifaceted interactions of these symptoms can be very challenging.
Subtyping of Cluttering
Differences in symptoms of cluttering led researchers to identify various subtypes of
cluttering, such as dysarthric, dysrhythmic, dysphasic, motor, and linguistic (Damsté, 1990;
Ward, 2006). van Zaalen (2009) described two types of cluttering: syntactic and phonological.
Similarly Reichel’s Brief Cluttering and Stuttering Questionnaire (BCSQ) sought to identify the
same types of cluttering based on clients’responses to a question: “What interferes more with
your communication? Planning and formulating thoughts or fast and unclear speech?”(Exum,
Absalon, Smith, & Reichel, 2010). Difficulties in planning and formulating thoughts would indicate
phonological cluttering, while fast and unclear speech would indicate syntactic cluttering. We will
now describe how these two types of cluttering can be differentiated.
Syntactic Cluttering. Syntactic cluttering refers to problems in grammatical encoding
and word retrieval at a fast speech rate. Such symptoms occur more frequently in linguistically
complex situations. The problems are manifested by normal disfluencies, such as word and
phrase repetitions, interjections, hesitations, and revisions (van Zaalen, 2009).
Phonological Cluttering. Phonological cluttering, according to van Zaalen (2009), refers to
problems in phonological encoding and is characterized by word structure errors (e.g., coarticulation,
telescoping, or syllable sequencing errors) at a fast speech rate, especially in multisyllabic words.
Similarly to syntactic cluttering, symptoms of phonological cluttering occur more frequently in
linguistically complex speaking situations. For a discussion as to how such subtyping can assist
in the treatment of cluttering, see van Zaalen and Reichel, in press).
Four Components of Communication
The four component model of Stourneras (in Bezemer, Bouwen, & Winkelman, 2006)
explores the interaction of different communication components in cluttering: cognitive, emotional,
verbal-motor, and communicative. Clinicians who work with PWC may use this model to improve
the performance of their clients in all four components of communication (van Zaalen & Winkelman,
2014; van Zaalen & Reichel, in press).
Cognitive Component in Cluttering Therapy
PWC often feel misunderstood and incompetent. Negative thoughts and feelings of PWC
are not as deep as such thoughts and feelings in people with stuttering, but they contribute to
doubts about the future, uncertainty about treatment, low self-esteem, and motivation (Daly,
1993, 1986; Reichel, 2010). While practicing a different manner of speech, most PWC will not feel
comfortable, in the beginning. Their speech does not feel “natural”to them. A clinician should
be aware of such clients’cognitions and negative self-appraisal. The clinician should play back
segments of the client’s speech, using audio and video recordings in order to demonstrate to the
client that the new speech pattern is much more intelligible.
Emotional Component in Cluttering Therapy
PWC may respond to their failure to speak clearly and to be understood by experiencing
anxiety and frustration (Dalton & Hardcastle, 1993), nervousness, sadness, and low self-esteem
(Reichel, 2010). Daly (1993, 1986) proposed a combination of cognitive training, counselling,
attitude changes, relaxation, affirmation training, and positive self-talk in working with PWC.
Reichel (2010) adapted Bar-On’s (2000) emotional intelligence (EI) competencies for the use of
clinicians who work with clients with a predominance of cluttering-like symptoms. The five EI
competencies are: (1) Emotional self-awareness, (2) Impulse control, (3) Reality testing, (4) Empathy,
and (5) Interpersonal relationships. The focus on such emotional competencies can help in
improving awareness of emotions and communication behaviors, facilitating the ability to
manage emotions for self-control, cognitively processing emotions, assessing events realistically,
considering the emotions of listeners, and increasing the ability of PWC to improve responsibility
for meeting expectations of others (Reichel & Draguns, 2011).
Verbal-Motor Component in Cluttering Therapy
In most cases, it is possible to address the fast articulatory rate by slowing down the
speech rate with syllable tapping. Such work on speech rate reduction needs to be performed in a
carefully structured manner, with both auditory and visual feedback. In addition to moderating
or tempering the speech rate, the clinician should consider the degree of motoric and linguistic
complexity involved in the speaking task, in order to facilitate better cohesiveness or synergy of
speech and language output (Myers, 2011). PWC are able to make all verbal-motor movements
adequately, but not when the speech rate is fast. They have a problem in the planning and not just
in the execution of oral-motor movements (e.g., jaw movements). It is important to address the
verbal-motor skills at the word level. Priority is given to working on correct sequencing of syllables,
especially in multisyllabic words at a fast speech rate. The next step is to practice such skills at
the sentence level and later in spontaneous speech.
Communicative Component in Cluttering Therapy
The literature on cluttering describes many of the stigmatizing characteristics of PWC, such
as not being interested in communication, not being a good listener, and exhibiting behavior that
is aggressive, expansive, explosive, extroverted, impulsive, uncontrolled, and/or hasty (Freund,
1966; Weiss, 1964). The abnormal communication skills of PWC such as poor listening, abnormal
turn-taking and verbosity and impulsivity, need to be addressed by clinicians who work with PWC.
A period of frequent and direct feedback from the environment (e.g., family members, colleagues)
can contribute to an increase in speech awareness. Partner-focused communication (adjusting the
message to the listener) is a skill which needs to be facilitated in PWC as one of the most important
goals of the clinical process (van Zaalen & Reichel, in press).
Phase I: Identification
Cluttering therapy always starts with identification, making the PWC aware of symptoms
at the time they occur. During the identification phase, social exchanges are encouraged by asking
clients to modify their communication patterns during the diagnostic and therapeutic exercises.
Listening to clients’own recordings is a very effective home assignment.
Phase II: Speech Rate Reduction: Syllable Tapping and Audio-visual Feedback Training
After clients become aware of their speech symptoms, articulatory rate reduction can be
initiated to improve fluency and intelligibility. Two particularly effective ways of slowing down the
articulatory rate are syllable tapping and audio-visual feedback training (AVF-training; van Zaalen,
2014, van Zaalen & Reichel, in press). With both approaches, the client’s syllable and rate awareness
are facilitated. Once syllable awareness is achieved at different levels of linguistic complexity, the
clinician may use AVF-training to work on rate, rhythm, pauses, and prosody. PWC are trained
to spell out every syllable, and to make adequate pauses or focus on prosody. Reducing the
articulatory rate has a positive effect on all communication related parameters.
Speech Rate Reduction: “A Conscious Decision”.PWC are not able to adjust their
speech rate appropriately in order to accommodate language complexity. Although clients can be
taught how to slow down their speech rate, it takes a significant amount of attention capacity to
achieve this objective. Therefore, most clients are not able to automatize speech rate reduction.
An attempt to do so requires a conscious decision and resolve, almost like deciding to learn
a second language. A distraction of any kind can interfere with clients’attempts to use their
technique, to the point where another conscious commitment must be made in order to start
working on the speech rate again. Clinicians should aim for the highest articulatory rate
(+/−0.5 syllables per second) at which the client is still fluent and intelligible.
Appropriate Pausing. Pauses in speech are of tremendous importance, both in the
production and understanding of speech. In order to be capable of monitoring speech at the
sentence level, a speaker needs sufficient pause time between sentences. Pauses between sentences
allow for normal breathing patterns. Appropriate pausing provides adequate time to plan the
structure of a new speech plan. Pauses are also needed for listeners’understanding of speech. If
the pause is too long, listeners can get the impression that the speaker stopped talking; when
pauses are too short, listeners may not have enough time to process what was just told to them.
Pause duration is correlated to speech rate; the faster the speech rate, the shorter the pause
duration. Normal pausing between sentences is usually an indication of a normal speech rate. A
normal pause has a duration of 0.5–1.0 second in most languages. Pause duration between sentences
is usually equal to pause duration between speakers (turn-taking behavior).
Phase III: Monitoring
Development of an internal feedback loop during conversation is essential for PWC in
order to detect moments of fast and/or variable articulatory rate, disfluency, or poor intelligibility.
The internal feedback loop consists of the elements of self-observation, self- judgment, and
self-correction. Regular recordings of conversations in daily life are made, listened to, and analyzed
in order to develop this internal feedback loop.
Phase IV: Narrative Skills
Speech output control in a secure environment is relatively easy. Adequate narrative skills
are necessary in order to communicate at different levels of language complexity within the fast
rate of human communication. Telling PWC to “take time to formulate your thoughts before you
talk”in running speech does not work. Exercises in formulation of thoughts can help to improve
the skills so that correct wording is ready in less time. Focusing on speech planning is helpful
rather than focusing on language planning alone.
The therapeutic considerations for treatment of cluttering include the following:
•It is important for the client to practice daily, beginning on the first day of therapy. It
is also crucial that the amount of exercise each day should be tailored to the symptoms,
skill level, and needs of each individual client.
•Treatment plans for cluttering should each start with identification exercises. After the
identification exercises, the clinician should discuss exercises that improve the client’s
speech, memory, and attention skills.
•As soon as the client is aware of the speech difficulties, it is essential to praise and
reinforce the client every time a goal is achieved. The sense of success and of mutual
journey will bring hope, pride, and courage to attempt to overcome the remaining
symptoms of cluttering (Reichel, 2010).
•A Speech Situation Checklist (Brutten & Shoemaker, 1974) adjusted for PWC can be
used to plan a hierarchy for practicing in various conversational situations. Exercises
will be implemented first in the situations that are known to pose little difficulty
(van Zaalen & Reichel, in press).
•In order for cluttering intervention to be successful, planning an intensive program of
therapy is recommended. Self-monitoring skills take time to develop and are acquired
with intensive practice (Bennett Lanouette, 2011).
•The short-term results of cluttering treatment are influenced by two main components:
a positive impact on speech behavior and a positive impact on cognitions and
emotions. Speaking clearly is particularly beneficial for PWC, even if it is only in a few
conversational settings (Miyamoto, 2011).
•When cluttering is accompanied by stuttering in adults, the specific symptoms of
cluttering need to be prioritized unless people have anxiety or fear of speech secondary
to stuttering. St. Louis, Raphael, and Myers (2003) and van Zaalen and Winkelman
(2009) suggest using fluency enhancing techniques for working with clients who have
both cluttering and stuttering.
•In children with a combination of cluttering and stuttering, it is better to start therapy
with stuttering modification approach because this is consistent with what children
expect to address in therapy and thereby helps to establish the needed client-clinician
rapport. After a couple of sessions, the clinician can let the child know that, at this
point, cluttering symptoms should be addressed as well.
This article has set forth a program of cluttering therapy, taking into consideration
cluttering subtyping and four components of communication. The present treatment planning
includes problem identification, speech rate reduction, appropriate pausing, monitoring and
focusing on story narrating skills. Therapeutic considerations take into account the specific
characteristics of cluttering, and explain the reasons for frequent and short home exercises.
Training PWC in self-awareness is of the highest priority. The acquired pattern of speech should
become the client’s habitual way of talking, which should become automatic and effortless.
Finally, building clients’confidence, emotional skills, and sense of accomplishment will turn the
therapeutic process into awareness of realistic expectations, motivation to pursue challenging
goals and, very importantly for every human being—the joy of successful communication.
Bar-On, R. (2000). Emotional and social intelligence: Insights from the emotional quotient inventory. In
R. Bar-On & J. D. A. Parker (Eds.), The handbook of emotional intelligence (pp. 363–388). San Francisco:
Bennett Lanouette, E. (2011). Intervention strategies for cluttering disorders. In D. Ward & K. Scaler-Scott
(Eds.), Cluttering: A handbook of research, intervention, and education (pp. 175–197). Sussex: Psychology Press.
Brutten, G., & Shoemaker, D. (1974). Speech Situation checklist. In the Southern Illinois Checklist.
Carbondale, IL: Southern Illinois University.
Bezemer, B.W., Bouwen, J., & Winkelman, C. (2006). Stotteren van theorie naar therapie. Bussum:
Dalton, P., & Hardcastle, W. (1993) Disorders of fluency and their effects on communication (2nd ed.).
Daly, D. (1986). The Clutterer. In K. St. Louis (Ed.), The Atypical Stutterer: Principles and Practice of
Rehabilitation (pp. 155–192). New York: Academic Press.
Daly, D. (1992). Helping the clutterer: Therapy considerations. In F. Myers & K. St. Louis (Eds.), Cluttering:
A Clinical Perspective (pp. 107–124). Leicester, England: FAR Communications. Reissued in 1996 by San
Diego, CA: Singular.
Daly, D. A. (1993). Cluttering: Another fluency syndrome. In R. Curlee (Ed.), Stuttering and Related
Disorders of Fluency. New York: Thieme Medical Publishers, Inc.
Damsté, P. H. (1990). Stotteren (4
druk.) Utrecht/Antwerp:Bohn, Scheltema en Holkema. (in Dutch).
Exum, T., Absalon, C., Smith, B., & Reichel, I. K. (2010). People with cluttering and stuttering have room for
success. International Cluttering Online Conference, 2010 [Minnesota State University, Mankato].
Freund, H. (1966). Psychopathology and the problems of stuttering. Springfield, IL: Charles C. Thomas.
Miyamoto, S. (2011). Assessment and intervention of Japanese children exhibiting possible cluttering.
In D. Ward & K. Scaler Scott (Eds.), Cluttering: A handbook of research, intervention, and education
(pp. 198–210). East Sussex: Psychology Press.
Myers, F. L., & Bradley, C. L. (1992). Clinical management of cluttering from a synergistic framework. In
F. L. Myers & K. O. St. Louis (Eds.), Cluttering: A clinical perspective (pp. 85–105). Kibworth, Great Britain:
Far Communications. Reissued in 1996 by Singular, San Diego, CA.
Myers, F. (2011). Treatment of cluttering: a cognitive-behavioral approach centered on rate control.
In D. Ward & K. Scaler Scott (Eds.), Cluttering: A handbook of research, intervention, and education
(pp. 152–174). East Sussex: Psychology Press.
Reichel, I. K. (2010). Treating the person who clutters and stutters. In K. Bakker, L. Raphael, & F. Myers
(Eds.), Proceedings of the First World Conference on Cluttering (pp. 99–108), Katarino, Bulgaria: International
Reichel, I., & Draguns, J. (2011). International perspectives on perceiving, identifying, and managing cluttering.
In D. Ward & K. Scaler Scott (Eds.), Cluttering: A handbook of research, intervention, and education
(pp. 263–279). East Sussex: Psychology Press.
St. Louis, K. O., Raphael, L. J., Myers, F. L., & Bakker, K. (2003). Cluttering updated. The ASHA Leader, 19,
van Zaalen, Y., & Winkelman, C. (2009). Broddelen, een (on) begrepen stoornis. Bussum: Coutinho.
van Zaalen, Y. (2009). Cluttering Identified. Differential diagnostics between cluttering, stuttering and learning
disability. Ph.D. thesis, Utrecht, Zuidam.
van Zaalen, Y., & Winkelman, C. (2014). Broddelen, een (on) begrepen stoornis. Bussum: Coutinho.
Van Zaalen, Y., & Reichel, I. Cluttering: Current views on its nature, assessment and treatment. iUniverse:
New York, Lincoln, Shanghai (in press).
Ward, D. (2006). Stuttering and cluttering, Framework for understanding and treatment. East Sussex:
Weiss, D. A. (1964). Cluttering. Englewood Cliffs, NJ: Prentice-Hall.