Twenty-One Years of Audio-Psycho-Phonology in South Africa

Pieter E. Van Jaarsveld — Institute for Psychotherapy and Counselling, University of Potchefstroom, Republic of South Africa. French translation by Christian-Paul Delmas, audio-psycho-phonologist, Alfred Tomatis Training.

Translator’s note: We have chosen to translate the name of each psychological test, but to retain its acronym in its original form, given that this acronym constitutes an internationally referenced tool.

Abstract

The purpose of this article is to present an overview of the activities of the Potchefstroom APP centre from the standpoint of research. The very setting of the university favoured the creation of an APP centre. Not only did other departments of the university become involved in its activities, but the widespread interest in this new approach prompted the creation of other centres in South Africa. This overview of 10 studies conducted at the Institute for Psychotherapy and Counselling presents positive results, but the methodological shortcomings of some of them have raised questions about the interpretation of the findings. The need for studies demonstrating the intrinsic contribution of APP training to the achievement of favourable results had become a major issue. Two studies, designed so as to eliminate the design deficiencies and to carry out a more rigorous evaluation of the APP approach, are discussed. Their results highlight the improvement in personality functioning following APP training. This conclusion is discussed in line with a new line of research for the Department of Psychology, namely hemispheric functional asymmetry.

1. Introduction

This article briefly reviews the history of APP in South Africa, with an emphasis on the research conducted at the Institute for Psychotherapy and Counselling of the University of Potchefstroom, CHE. Operating in close collaboration with the Department of Psychology and possessing internships in clinical and counselling psychology, this Institute offered great opportunities for research thanks to both its staff members and its postgraduate students. The Institute also had access to the specialities of other university departments, such as Music, Electronics and various language departments. Apart from this versatility, the initial object of the Institute was to offer its services in psychology and education to the students of the university as well as to the general public; consequently APP soon found fertile ground and flourished. However, faced with a new technique founded on a revolutionary theory employing unique and original techniques present in no other therapy, the initial resistance was so strong that some time elapsed before other centres in South Africa incorporated APP into their psychotherapeutic and educational programmes. The members of future teams were trained and, ultimately, six centres, including a psychiatric hospital, special-education schools and university clinics, began to practise APP, while research programmes were also initiated by three other South African universities.

2. History

My first encounter with the Electronic Ear (then known under the name Aurelle) dates back to 1965, when a university student, Dr C.D. Rhoode, returned from Canada with two Electronic Ears. After he left the university, at the end of 1965, I seized the opportunity to absorb the available literature on APP, which consisted of Alfred Tomatis’s first publications, and I continued the treatment of stutterers. In 1969 a follow-up study was completed on a group of 43 adult stutterers, aimed at determining the effect of treatment by means of the Electronic Ear, from one to three years after treatment (Van Jaarsveld, 1973). These results and these clinical observations on the improvement of stutterers provided the motivation to go and study the technique with Professor Tomatis in Paris in 1970 and 1971. Alfred Tomatis’s subsequent visits to South Africa and his impact on the university authorities were greatly beneficial to the status of APP. In 1973 a fully equipped centre, with 12 Electronic Ears, was installed in the Institute. The centre immediately attracted a great deal of interest from a wide range of professionals, but also severe criticism and scepticism, especially from speech therapists who argued that their professional field was being encroached upon. At this stage, the lack of empirical backing made it very difficult to defend APP on theory alone, but in 1974 a doctoral thesis (Van Jaarsveld, 1974) was produced on the evaluation of the Tomatis approach in the treatment of stuttering, as well as a master’s thesis (Van Wyk, 1974), which tested the APP hypothesis concerning the effect of an auditory dominance in stutterers.

At that time (1974) the team of the Potchefstroom Centre was reinforced by Mr Paul Madaule, who proved to be of great help. He wrote an article on “Audio-Psycho-Phonology in Singers and Musicians” (Madaule, 1976), and numerous research plans followed.

The consequences of the outcome studies, as well as the successive visits of Alfred and Léna Tomatis to South Africa, opened the way to the establishment of new centres, such as the Witrand Centre (psychiatric hospital) and the centre of the School for Deaf Children of Worcester. The University of the Orange Free State sponsored a centre in the Marthie Du Plessis School (special education); in Pretoria a centre was installed in a school for autistic children; and most recently, in Cape Town, Mrs Beulah Levinson’s centre has just come into being.

When a new building was planned for the Department of Psychology, the Faculty of Education and the Institute for Psychotherapy and Counselling, we were at the stage of facilities specially designed for an APP centre, with 13 booths for the treatment of adults, a special room for the treatment of children, separate facilities for mothers listening to filtered music, two language laboratories and the facilities for the listening tests.

Meanwhile the interest of the Department of Music and the Department of French had been fully captured by the idea of stimulating a “musical ear” and a “French ear” in the students of these departments. These two departments therefore became keenly involved in the activities of the APP centre, with the consequence that two laboratories of these departments came to complete the Centre’s facilities.

The provision, by the university’s Division of Electronic Services, of an audiometry team proved salutary and a valuable time-saver for the daily management of the groups of students. Thanks to the head of this department for his enthusiastic interest in APP, Dr Cobus van der Walt; a very favourable cooperative relationship was established, ultimately culminating in a major research project aimed at developing a new Electronic Ear in close collaboration with Professor Tomatis. The new transistorised devices were ultimately assembled in Switzerland under the supervision of a staff from the Division of Electronic Services. The Potchefstroom Centre thus became the first centre equipped with the newly designed Electronic Ears.

3. Research

3.1 Introduction

According to a critical review of APP studies conducted in Canada by Stutt (1983), Canadian research seems to have been directed mainly at learning disorders and dyslexia. These studies, according to Stutt, indicate that the APP approach would provide benefits beyond what can be expected from maturation or from mere remedial education. The benefits mentioned include a significant progress in reading skills, in perceptual processes, in general adjustment, an improvement in communication skills and a greater capacity to verbally express thoughts and feelings. Stutt concludes that the results indicate that most children who followed the APP programme derive a benefit from it. However, because of underlying methodological problems noted in some of these studies, the question remains as to the specific contribution of APP to these favourable results. He concludes: “it would seem that cautious acceptance is the appropriate attitude” (Stutt, 1983: 15).

At Potchefstroom the research work followed a different line, since in these studies the emphasis was placed more strongly on fundamental and sound APP premises and techniques, with regard to stuttering and non-cognitive components such as anxiety and depression. These studies show other positive effects such as the improvement of self-control, self-awareness, interpersonal relationships and acting-out. But, given that the rigorous criteria and precautions for evaluating a specific therapeutic technique, such as those advocated by Rachman and Wilson (1980), Parloff (1986), Kazdin (1986) and others, were not, or could not be, all assembled in the first studies, investigations were organised so as to eliminate the design deficiencies in order to conduct a more rigorous evaluation of the APP approach. In this review particular attention will be given to two studies, with commendable methodological characteristics, dealing with anxiety.

In order to verify the specific contribution of the APP approach to the treatment of various disabilities, the mode of research that seems recommended is the one that is potentially the most instructive in comparing known alternative forms of treatment. Demonstrating that APP training is superior to any other treatment is certainly useful, but this must not rule out the possibility that non-specific effects such as the placebo or the contact with an enthusiastic and convinced therapeutic team account for the therapeutic change in place of APP training. On the other hand, the absence of treatment, the waiting list, and the placebo-care control conditions sometimes raise ethical questions, given that an acceptable treatment is refused or deferred (Kazdin, 1986).

The organisation of the research into comparative outcome studies should allow the analysis and comparison of the characteristic elements of the treatment. Ideally, according to Parloff (1986), the therapies to be compared should be compared on the basis of variables such as the patients’ credibility regarding the treatment, the duration of the treatment, as well as the attention, skill and enthusiasm of the therapist (Van Jaarsveld and Du Plessis, 1988).

Moreover, it is important that the differences in results between treatments do not reflect the differences in competence of the therapists. According to Kazdin (1986) it is desirable to “cross” the therapists during the treatment, that is to say that each therapist directs each of the treatment conditions during the investigation. The therapists can be treated as a “factor” among the data of the analysis.

Finally, the mode of recruitment of patients appears to be an important question. In the review of 14 studies comparing solicited patients and referred patients, Krupnick et al. (1986) discuss the disadvantages of recruiting or soliciting patients and warn that it would be methodologically wiser to rely on traditionally referred patients.

These are all crucial questions to take into consideration when evaluating the effects of the APP approach.

3.2 Studies on laterality

Two studies on laterality were conducted by Van Wyk (1974) and Badenhorst (1975). Van Wyk verified the hypothesis according to which there are more stutterers failing to develop right-ear dominance than fluent speakers. Using two different techniques, Kimura’s dichotic stimulation technique and Tomatis’s audiolaterometric technique, she studied the auditory dominance of a group of 20 stutterers and a group of 20 normally fluent speakers. No significant difference could be found between the two groups with the dichotic stimulation technique. The audiolaterometric results, on the other hand, demonstrated that the stutterers showed a significantly greater preference for the left ear, or a non-specific ear preference, while a significantly larger number of fluent speakers showed a significantly greater preference for the right ear.

Although Van Wyk took various precautions to control for contamination effects, the small size of the samples and the use of solicited subjects rather than the constitution of randomised groups call for a cautious interpretation of the results. Van Wyk also neglected Tomatis’s instrument, as a control technique, which consists of observing the extent of the mobility of the left and right facial muscles during speech exercise and which provides an additional indication of the right or left preference of listening to language.

Also using the techniques of Kimura and Tomatis, Badenhorst (1975) analysed more meticulously the nature and measure of auditory laterality. He formulated the hypothesis according to which left-handers form a heterogeneous group experiencing difficulty in realising their inner potential. The purpose of the investigation was to determine whether differences existed between the Rorschach responses of a group of female students completely right-lateralised, with a strong right preference for listening to language, and those of an equal group of female students having a reasonably general right lateral preference but with a left preference for listening to language. The right-preference group gave significantly more FC and M responses than the left-preference group. The left-language-listening group also tended to react with FM responses. Three commentators unfamiliar with the protocols concluded that the subjects with right-language listening showed a superior capacity to relate spontaneously and appropriately to emotional stimuli; that they showed a more extraverted orientation; that they were more sensitive to their emotional reactions, while controlling them; that they were less inclined or subject to anxiety, tension, frustration and aggressiveness. These conclusions were in direct line with the predictions of APP theory concerning laterality. Once again the small size of the sample does not allow any generalisation.

3.3 Studies on stuttering

Van Jaarsveld (1973, 1974) conducted two studies on stuttering. A follow-up study, aimed at determining the long-term effect of auditory training on 43 stutterers (mostly adults), was carried out during the pioneering years of APP in South Africa. All participants had experienced a relief of their symptom. For 82.5% of patients the symptom relief was significant and 54% of cases maintained their good progress one to three years after the training. Methodological restrictions made it difficult to isolate the specific contribution of APP training, since the comparison of the follow-up results with the results of the study remained to be done and there was no trace of a control group. However, taking into account the estimations of observers seems to confer greater objectivity since these estimations were based on the observation of the patients’ speech behaviour in “realistic” situations.

The second study (a doctoral thesis) (Van Jaarsveld, 1974) provides an in-depth analysis of Tomatis’s theory and of the APP approach to stuttering. The effect of auditory training on the speech behaviour of 30 young adult stutterers was the initial goal of the empirical study. The results were in favour of a positive assessment:

• The severity of stuttering measured on the Lanyon SS Scale was significantly less after the training.

• For a representative sample of speech and reading, the participants fared significantly better with respect to the number of their speech disfluencies.

• A significantly faster rate of speech and oral reading was recorded at the retest.

• The participants’ attitude towards their stuttering improved significantly.

• The audiometry results confirmed Tomatis’s observations, according to which stutterers tend to have a relative listening loss in the frequency range of the language zone, especially in the right ear, and according to which acuity progresses after re-education.

• A spectral analysis carried out on all subjects confirmed Tomatis’s observations, showing a significant gain of energy in the vocal emission after the training.

It may be argued that the results of this study could have been more convincing if a comparative outcome study, as well as the inclusion of a control group, had been possible. The methodological complexities of constituting such a group of unsolicited adult stutterers and of finding an acceptable alternative technique meeting all the controls and criteria listed by Kazdin (1986), nevertheless appeared insurmountable at this stage. On the other hand, an untreated control group raised ethical questions by the fact of a treatment that is prevented or deferred.

3.4 A study on the mentally retarded

Through a carefully controlled study, De Bruto (1983) tried to avoid certain methodological objections, mentioned above, in order to examine the specific effect of APP on a group of profoundly retarded children. Thirty residents of the Witrand Care and Rehabilitation Centre (psychiatric hospital), aged 4 to 14 years, previously diagnosed as mentally retarded but able to sit and walk, were randomly divided into three groups.

• group A was subjected to auditory training and, in addition, to a sensorimotor stimulation programme;
• group B was subjected to musical stimulation (but without the APP effect) and, in addition, to the same sensorimotor stimulation programme;
• group C was an untreated group.

The psychological tests used comprised the Bailey Scales of Infant Development as well as a measure of sensitivity. The results indicated that the two experimental groups A and B had recorded a progress in mental age, but the progress of group A with APP stimulation was greater than that of group B. No change appeared in group C. Whereas no significant difference concerning sensitivity had been observed between groups A and B prior to the stimulation programme, a statistically significant reduction of self-directed responses appeared after the APP training, together with a significant progress of object-directed responses. Taking into account the aspects of the methodology, this study demonstrates the positive effects obtained with the APP approach.

3.5 Studies on anxiety and depression

A number of studies on depression and anxiety illustrate the applicability of the APP approach to these disorders. Peché (1975) evaluated the effect of APP on 10 female students. The battery of tests conducted before and after the programme comprised: the IPAT anxiety scale, the 16 Personality Factors inventory, the Personal, Home, Social and Formal Relations Questionnaire (PHSF), the Rorschach Inkblot Test and the Listening Test. Peché found appreciable changes during and after the programme with respect to personality characteristics; these changes were confirmed by the results of various instruments.

1. Capacity to plan. The Rorschach test results suggested that after the therapy the group as a whole displayed a strong desire to organise and to plan towards the future. The subjects conducted their interpersonal relationships with a higher degree of spontaneity and vitality. As a consequence the integration of generally accepted norms and social norms also fell into place more easily.

2. Creativity and intellectual functioning. The subjects revealed after treatment a significantly better tendency to use their intellectual potential, as well as improved productivity and constructive action.

3. Will-power and ego control. A significant tendency to adopt a strengthened value system, under the influence of a well-developed system of ego control leading to an increased sense of self-esteem and self-confidence, was evident after the programme.

4. Emotional life. The results suggested that the programme had brought about a significant degree of anxiety reduction.

Once again, as impressive as these results may appear, the small size of the sample and the absence of a comparative outcome study give rise to criticism.

Lamprecht (1978) studied the psychological and physiological effects of filtered music on a group of high-anxiety subjects. The subjects were selected on the basis of high scores on the IPAT anxiety scale and subjected to a filtered-music programme. The psychological measures included the Personal, Home, Social and Formal Relations Questionnaire as well as the Listening Test. The physiological measures included the Electrocardiogram, the Rhonocardiogram, the Toe plethysmogram, the Ballistocardiogram and the Binary Choice Generator. Lamprecht argued that 60 half-hour sessions of filtered music would be sufficient, no hypnotherapeutic intervention being made. Statistically significant changes took place in the direction of a reduction of anxiety, an improvement in the level of adjustment and a better listening, but the differences in the physiological measures were not significant. This may be due to an incomplete application of the APP programme.

Botes (1979) adopted a different line of research. She argued that the evaluation of a therapeutic technique by means of statistical analysis entails limitations because statistics alone cannot really locate the course of a therapeutic process. She therefore embarked on an in-depth study of three patients suffering from neurotic depression (dysthymic disorder), with the aim of evaluating the effect of APP training. She illuminated the training process with the detailed description and discussion of a single case. The battery of tests consisted of: the SA Wechsler Intelligence Scale, the Thematic Apperception Test, the Rorschach Inkblot Test, the Beck Depression Inventory and the Listening Test. The results appear very favourable:

1. Higher retest scores on the intelligence test.

2. Reduced depression. In the case of patients A and C, the symptoms completely dissipated after the therapy. A masked depression emerged in patient B, but the treatment, although begun, proved positive. At the time when the therapy started, patient C was determined to give up her studies. After the completion of the APP training, she was so well motivated that she also succeeded in her studies.

3. Better interpersonal relationships. As insight into interpersonal relationships was improved, the release of affective anxiety as well as the better parent-child relationships were very evident.

4. Better self-control and self-image. In her final evaluation, Botes concluded that APP training deserved a positive appraisal particularly for the following aspects:

• the discovery of conflicts and traumas can be made more rapidly with the help of this approach than with the help of other therapeutic techniques, since the patients seem to develop a desire to communicate during the training itself;

• the emphasis placed on prenatal development implies a broadening of the notion of human development;

• the importance of the father-child relationship coming as a corrective to the traditional theories of human development focused mainly on the mother-child relationship;

• the fact that the technique activates the patient through the immediate awareness he has of energy constitutes a contribution absent from the other therapeutic approaches;

• the Listening Test, as a means of evaluation, proved to be a valuable instrument.

In 1979, this case study proved valuable because it constituted an objective clinical report of general-order observations gathered during APP training. The value of the results would have been of higher interest if a follow-up study had been undertaken. This was done in Du Plessis’s psychological exploration of a group of anxious and non-anxious first-year female students, in 1982.

The two following studies on anxiety deserve more attention because of their commendable methodological characteristics. Drawing the lesson from the methodological pitfalls of the previous studies, Du Plessis (1982) directed an exhaustive and very well documented study in the completion of a Ph.D. degree. The methodological characteristics comprised: the use of an experienced therapist during the experimental phase; the division of the patients into an experimental group and a control group; a follow-up over 14 months; practically no attrition of subjects; and the use of a broad range of specific outcome measures.

The initial purpose of the study was to seek the possible differences between a universe of anxious subjects and a sample of non-anxious subjects chosen at random among the first-year students at the University of Potchefstroom/CHE. A psychometric study was then conducted on 424 female students, using the following psychological tests: the SA Wechsler Adult Intelligence Scale, the IPAT anxiety scale, the Reactions to Everyday Situations (another anxiety scale), the Beck Depression Inventory, the Personal, Home, Social and Formal Relations Questionnaire, the Purpose in Life Test, the Personal Orientation Inventory (a measure of positive mental health), a measure of academic performance and a biographical inventory.

From the results it is evident that no difference appears with regard to the various biographical variables, the level of intellectual functioning and academic performance. The anxious group, however, displayed higher levels of depression, a more precarious adjustment, a lower level of positive mental health and a more fragile sense of purpose in life. It was thereby established that the anxious group was significantly the most hampered, by the inhibiting effect of its higher level of anxiety.

The second purpose of this study was an applied investigation, consisting of two therapeutic programmes, namely: an “anxiety-reduction” programme on a sample of volunteer anxious subjects, and a “stimulation” programme on a sample of volunteer non-anxious subjects drawn from the group of non-anxious subjects who had participated in the psychometric study. The two programmes were carried out by means of Audio-Psycho-Phonological training.

The anxiety-reduction programme was designed in light of the limitations of the previous study made in the same direction (see Peché, 1975, whose investigation confirmed the anxiety-reduction effect of APP). In the present study, provisions were made to include a control group of anxious subjects, which had not been done by Peché. The stimulation programme was launched for experimental motives only, since no information about earlier studies of this type could be detected (Van Jaarsveld & Du Plessis, 1983).

Ten subjects completed the anxiety-reduction programme with the control test. The anxious control group comprised 12 of them, also volunteer members of the initial anxious group composed of 40 subjects.

Given the number of subjects involved, the statistical estimations were carried out by means of the Wilcoxon test, a non-parametric technique.

The results — “anxiety-reduction” programme

Anxiety reduction.

Table 1. Scores obtained by the experimental anxious group and the control anxious group on the IPAT anxiety scale.

* statistically significant at the 0.05 level — ** statistically significant at the 0.01 level

As can be seen in Table 1, the anxiety level of the experimental group had decreased significantly, whereas no change took place in the control group.

Increase in the sense of purpose in life.

Table 2. Scores obtained by the experimental anxious group and the control anxious group on the Purpose in Life Test.

From the results of Table 2, it is clear that the experimental anxious group not only underwent a reduction of anxiety, but that it also increased its sense of purpose in life as measured by the Purpose in Life Test. By contrast, the control anxious group apparently underwent a decline in its sense of purpose in life.

Improved scores on the intelligence test.

Table 3. Scores obtained by the experimental anxious group and the control anxious group on the SA Wechsler Intelligence Test.

In the case of the two groups, the non-verbal and total IQ scores progressed significantly. The interpretation of these results requires caution, because the significant progress may, at least in part, be attributable to learning. However, the fact that only the anxious group achieved significantly higher verbal IQ scores could also be the result of the stimulating effect of APP, with the emphasis placed on the activation of the inherent communication potential.

Increase in the level of positive mental health.

Table 4. Scores obtained by the experimental anxious group on the Personal Orientation Inventory (IOP).

From the data of Table 4, it is evident that the experimental anxious group not only underwent a decline in anxiety, but that it also improved its level of positive mental health. The subjects of this group will subsequently use their time more constructively (significant progress in Time Management) and they will function more in accordance with their inner desires and motivations (significant progress in Inner Support). (For practical considerations it was not possible to include this test in the retest of the control anxious group.)

Non-measurable influence on academic performance.

Table 5. Mean scores on the mid-year and end-of-year examinations obtained by the experimental and control anxious groups.

Despite a decline in anxiety and an improvement in purpose in life, it is evident that academic performance was apparently not influenced by the anxiety-reduction programme, even though an improvement in memorisation was reported by some subjects.

Results of the “stimulation” programme with non-anxious subjects

Given that the non-anxious group presumably had no manifest psychological problems and that the stimulation programme constituted a purely experimental condition, the retest offered an opportunity to evaluate the extent to which the inherent potentials had been able to be activated by means of filtered music. An intelligence test and the measure of positive mental health (the IOP) were consequently used in the retest phase.

For practical considerations it was not possible to constitute a control non-anxious group, and the experimental non-anxious group was therefore compared only to itself.

The following results were noted:

Better scores on the intelligence test.

Table 6. Mean of the scores obtained by the experimental non-anxious group on the SA Wechsler Intelligence Test.

As in the case of the experimental and control anxious groups, the interpretation of these results calls for caution. Indeed, although a significant increase in the verbal, non-verbal and total IQ scores is evident, the influence of learning through the fact of retaking a test must not be underestimated.

Increased level of positive mental health.

Table 7. Scores obtained by the experimental non-anxious group on the Personal Orientation Inventory.

The most exciting finding of this part of the study was that even the group of non-anxious subjects had obtained a significantly high level of positive mental health.

The follow-up survey

Despite the positive results reported above, research-related and person-centred considerations subsequently led to a follow-up study, as if it were to enable the experimenter to evaluate the real significance of the presumed favourable results reported above. The period from the initial test to the follow-up evaluation was 14.3 months. All the subjects who took part in the anxiety-reduction programme were available for the follow-up. The control anxious group consisted of nine subjects from the original anxious group of the 40 students who volunteered to participate.

Results of the experimental and control anxious groups

Maintenance of the level of anxiety reduction.

Table 8. Scores obtained by the experimental anxious group and the control anxious group on the IPAT anxiety scale.

From the results, it would appear that both groups obtained a reduction in their level of anxiety. In the case of the experimental anxious group, the anxiety reduction as a consequence of the anxiety-reduction programme had been maintained.

Maintenance of the progression in the level of positive mental health for the experimental anxious group.

Table 9. Scores obtained by the experimental anxious group and the control anxious group on the Personal Orientation Inventory.

It is observed that the members of the experimental anxious group had maintained their level of positive mental health, while the control anxious group had not experienced any measurable personality development since the initial evaluation. These results were further confirmed by the additional information from a special follow-up questionnaire.

Results of the experimental and control non-anxious groups

The experimental non-anxious group comprised all the subjects who had taken part in the stimulation programme, except two of them who had finished their studies earlier. The control group consisted of volunteers from the original non-anxious group of 40 subjects and comprised 11 of them. Only the Personal Orientation Inventory was used as a follow-up test. The following results were obtained:

Table 10. Scores obtained by the experimental non-anxious group and the control non-anxious group on the Personal Orientation Inventory.

(Experimental non-anxious group: N = 13; control non-anxious group: N = 11.)

From Table 10 it is evident that the experimental non-anxious group had significantly improved its level of positive mental health, whereas the control non-anxious group had not significantly gained in personal development. Again the follow-up questionnaire brought a further confirmation through the evidence.

The significance of the two investigations put into practice

In summary the following statements apply:

• The results showed the value of Audio-Psycho-Phonology training in the therapeutic approach to anxious first-year female students.

• The results showed that apparently well-balanced non-anxious first-year female students could be stimulated by means of Audio-Psycho-Phonology and obtain a significant improvement in their level of positive mental health measured on the IOP.

• As a means of evaluating APP training, and as a starting point for the development of more appropriate instruments, the selection of psychological tests functioned relatively effectively.

• The procedures pertaining to the two therapeutic programmes brought to light certain deficiencies and also underlined the necessity of further research (Van Jaarsveld & Du Plessis, 1983).

4. A comparative outcome study on anxious primary school pupils

4.1 Introduction

Fully aware of the difficulty involved in demonstrating the exceptional effects of a particular type of therapeutic intervention, the researchers could not be entirely satisfied as long as all the rigorous criteria and precautions listed by Kazdin (1986), Parloff (1986), Krupnick et al. (1986), and others, had not been assembled satisfactorily in order to demonstrate the exceptional contribution of APP training to the positive results announced. Moreover, the results on anxiety had been obtained with female subjects only. No study had been conducted on anxious children. A comparative outcome study was undertaken with a group of anxious primary school pupils (Du Plessis & Van Jaarsveld, 1988). Our intention was to avoid the methodological deficiencies of the previous outcome studies by comparing the results of APP with those of a known alternative treatment approach and with those of an untreated control group, using unsolicited patients, ensuring that the treatment procedures were conducted as planned, carrying out a follow-up study and, finally, looking for possible differences due to the competence of the therapist as a contaminating factor.

4.2 Method

Subjects. After the agreement of the Transvaal Department of Education had been obtained for the project, subjects were gathered on the basis of non-solicitation. By means of a list of anxiety indicators derived from DSM III (1980), 40 Afrikaans-speaking pupils, from Std 1 to Std 3, were identified by their teachers as “tense”. The subjects came from five Afrikaans-medium primary schools in Potchefstroom. The subjects were divided into three groups. The selection of Group 1 (audio-psycho-phonology group) was established according to the daily availability of the children and their mothers for a period of three weeks during the mid-year school holidays. Twelve children and mothers were included in this group. Because of illness, Group 1 was finally reduced to 10 children. As six of the remaining 28 children could not be available for the duration of the project, Groups 2 and 3 were selected at random from the remaining 22. Owing to the attrition of three more subjects (two because of illness and one through dropping out of the Alternative Therapy programme) Groups 2 and 3 were finally composed of 9 and 10 members.

Measurement instruments. The psychometric evaluation was carried out individually. It targeted anxiety, personality factors, cognitive potential, family functioning and the listening ability defined by Tomatis (1972). Various authors have raised the question of the usefulness of outcome research in child psychotherapy insofar as sufficient information on child development was not established (Phillips, 1987; Werry & Aman, 1980). It was therefore decided to evaluate the clinical characteristics of the children with the help of structured interviews with their mothers.

The State-Trait Anxiety Inventory for Children (STAIC) (Spielberger, Edwards, Lushene, Montuori & Platzek, 1973) was used for the measurement of anxiety, because it is reputed to be among the best evaluation devices in the screening of the anxious child (Eason, Finch, Brasted & Saylor, 1985). A second and distinct measure of anxiety, the Child Anxiety Scale (CAS) (Gillis, 1980) was also included. This instrument gives a single score and, like the STAIC, proves adequate in its psychometric properties.

As a measure of personality factors, the South African version of the Porter and Cattell Children’s Personality Questionnaire, adapted and standardised by Du Toit and Madge (1981), was included. This instrument gives scores on 14 main personality factors, each presented as a bipolar continuum. The test is suitable for children aged 8 to 13.

Cognitive potential was evaluated by means of the Senior South African Individual Scale (SSAIS) (Madge, 1986). The listening ability, measured by the Tomatis Listening Test (Tomatis, 1973), was carried out by a qualified audiologist.

Family functioning was measured by the Family Assessment Device (FAD) (Epstein, Baldwin & Bishop, 1983). This instrument evaluates the properties of organisation and structuring within a family group, as well as the modes of transactions between members of the same family that have been found to distinguish healthy families from unhealthy ones. Six dimensions are identified, namely: problem-solving, communication, roles, affective responsiveness, affective involvement and behaviour control, as well as an overall measure of the health or pathology of the family, called General Functioning. When this was possible, this evaluation was completed by both parents.

4.3 The therapeutic programmes

Group 1: Audio-Psycho-Phonological programme (APP). The programme was structured according to Tomatis’s usual guidelines (Tomatis, 1978). The children and their mothers were exposed during a total of 103 half-hour sessions of auditory stimulation by means of the Electronic Ear, during three consecutive weeks during the mid-year school holidays. The mothers were gathered in a separate treatment room, and were stimulated during 100 sessions of filtered music. The similarity of presentation of the counselling to Groups 1 and 2 (except for the specific information applying to the members of Group 1) is discussed with the Alternative Therapy Programme.

Group 2: Alternative Therapy Programme (ATP). The decision was made to compare APP with a more conventional form of brief counselling for children and parents, such as that outlined by Weinberger (1971) and Leventhal and Weinberger (1975). Consequently the ATP was structured into joint mother-child sessions, into individual sessions with the children and into group counselling sessions for mothers and children together in order to enhance the effect of this short-term treatment programme.

The joint sessions consisted of discussions around the results of the evaluation, the problems reported by the parents and the mother-child relational dynamics observed during the sessions. In the individual sessions of the children, the problems were discussed openly. An anxiety-reduction technique, the Leuner Guided Affective Imagery (Leuner, Horn & Klessmann, 1983) was also applied when this was appropriate, both as a diagnostic and as a therapeutic. The group counselling for the children comprised exercises aimed at promoting the cohesion and communication of the group. The group counselling of the parents was focused on parent-child relationships.

To offset the intensive exposure of Group 1 to auditory stimulation, the number of counselling sessions was on average 28 for Group 2 and 23 for Group 1. In order to maintain the integrity of the treatment, an important condition for effective outcome research (Kazdin, 1986), the two therapists were involved in each therapeutic programme and consulted each other regularly, in turn, on the progress and conduct of the patients, so as to avoid the deviations between the established procedures of APP and the short-term strategies of the ATP.

Group 3: Control group. Between the test and the retest no intervention was carried out on this group. A course in reading techniques as well as a brief group counselling were offered after the retest.

Procedure. The children were identified at school. The consent and cooperation of the parents were obtained, followed by the individual evaluation, the assignment to the three groups and the administration of the therapeutic programmes. The retest followed the end of the programme. After three months a re-evaluation of the IQ was associated with a follow-up questionnaire completed by the mothers of Groups 1 and 2.

4.4 Equivalence of the group evaluations before treatment

A comparable functioning between the three groups, with respect to the level of anxiety, personality, cognitive and family functioning, and listening ability, was essential to evaluate the effect of the therapeutic programmes.

The two anxiety questionnaires reported negligible differences of sex and group. The mean scores, judged according to American norms, indicated that the children experienced at least an above-average level of anxiety. The mean scores, for all groups combined, totalled 9.8 (CAS), 40.0 (anxiety trait, STAIC) and 32.0 (anxiety state, STAIC).

The three groups achieved an average level of cognitive functioning (total IQ mean: 106.0). A single statistically significant difference emerged, namely the Drawing performance, on which Group 2 obtained a significantly lower score than Groups 1 and 3.

Group 2 obtained a significantly higher score than Groups 1 and 3 on the personality factors B, I, J and O, revealing that Group 2 was more intelligent, cool-headed, sceptical and calm. On Q4, Group 2 obtained a significantly higher score than Group 3, revealing that it tended to be more determined and more frustrated than Group 3, but no more than Group 1.

The family interaction did not indicate any differences between the groups.

The clinical characteristics are shown in Table 1. The group as a whole could be characterised as a group of latency-period children, Afrikaans-speaking, of an average age of 10.3 years, composed of 58.6% boys and 41.4% girls.

Table 1. Clinical characteristics of the subjects.

As Table 1 shows, the results highlight numerous aspects associated with the child’s anxiety. First, a striking finding revealed that many (41.3%) were first-borns. But, in keeping with the conclusions reported by Werry and Aman (1980), Gittelman (1986) insisted on the fact that the relationship between anxiety and birth order had not been well documented in clinical studies. Significant particularities in the developmental history represented: 37.7% having experienced difficulties at birth, from premature birth (17.2%) and birth complications (6.8%) to delivery by caesarean (13.7%). 41.3% of the mothers had had their affective bond delayed. Some 41.3% of the children had had substitute care during their very first years.

Most of the children presented a normal lateralisation as well as a normal development of language and motor skills, but 20.6% were hyperactive. Many had experienced developmental problems such as: fears (55.1%), lack of assurance (51.7%) and tendency to withdraw (48.2%). The family difficulties comprised 37.5% of divorced parents, whose disruptive effect is widely recognised (King and Kleemeier, 1983). In intact homes, over-protection was noted on the part of 68.9% of mothers, while father-child problems were reported by 62% of fathers. Given that latency-period children are especially closed to the parent of the same sex (Greenspoon, 1981), the child’s sense of security will be reduced accordingly in the event of excessive conflict. Stressful relationships with siblings were reported by 55.1% of the children.

School results below capabilities, due to learning difficulties such as reading, writing and perceptual problems, were reported by 44.8% of the children. Previous interventions represented remedial courses for 41.3%, occupational therapy for 22.2%, and reading-improvement courses for 20.6%.

Although probably influenced by the mother’s subjectivity and limited by the absence of information on the child’s emotional capital, the clinical characteristics confirmed that the developmental difficulties were distributed equitably among the three groups.

An audiometric investigation confirmed the listening equivalence of the groups before treatment. Only three scores among the 66 possible on the children’s Listening Test differed significantly: Group 1 scored more points than Group 3 on one frequency (8000 Hz, left ear, air conduction) and more than Group 2 (1500 Hz, left ear, bone conduction). Group 2 recorded more selectivity closures on one frequency (2000 Hz, right ear) than the two other groups.

The mothers’ Listening Test revealed only two significant inter-group differences: the mothers of Group 1 achieved higher acuity scores than Group 3 on one frequency (250 Hz, left ear, air conduction) and Group 2 scored higher on one frequency (750 Hz, left ear, air conduction). The group equivalence before treatment was thereby confirmed for all variables.

Table 2. Mean scores of the Test and the Retest, obtained on the CAS and the STAIC by Groups 1, 2 and 3.

* Two-tailed significance test — ** Significance threshold: 0.5

4.5 Results of the therapeutic programmes

The SAS computer program (1985) was used, first, to compute an analysis of variance in the determination of the group equivalence before treatment. When differences were found, the Tukey test was used to determine where these inter-group differences were located. Second, the intra-group differences, between test and retest, were evaluated by means of the t-test for competing groups. The intra-group differences were submitted to the Tukey test in order to determine how to compare them between groups. A maternal follow-up questionnaire and the therapist’s competence were analysed non-parametrically.

Anxiety reduction. The conclusions are reported in Table 2. From Table 2 it appears evident that a statistically significant reduction of anxiety was obtained by Group 1, both on the CAS and on the STAIC, by Group 2 on the anxiety trait only, and no anxiety reduction was evident in Group 3. Thus the main objective of the APP programme had been achieved with Group 1, whereas the alternative therapy programme had had a lesser impact.

Improved personality functioning. Group 1 effected four statistically significant changes in a positive direction. In keeping with the norms (Du Toit & Madge, 1981), it became genuinely phlegmatic (mean score: 2.8 on factor D), submissive (mean score: 2.1 on factor E), more closed to the point of “naïve” (mean score: 3.7 on factor N) and placid (mean score: 2.7 on factor G). The results indicated an improved mother-child relationship and an increased calm, confirming Tomatis’s hypotheses on the effects of stimulation with the help of the filtered maternal voice.

Group 2 scored significantly lower on factor O, thereby confirming the decrease in the anxiety trait on the STAIC. No change in relation to the treatment expectations took place in Group 3.

Improved cognitive functioning. The renewal of the test three months after the end of the programme indicated five statistically significant intra-group changes in Groups 1 and 2. For Group 1, Vocabulary, Drawing performance and non-verbal IQ increased significantly. For Group 2, Drawing performance and non-verbal IQ increased significantly. No change appeared in Group 3.

A general practice effect cannot be the only explanation for these advances, no more than for the change that took place only in Groups 1 and 2. It could thus be concluded that the two groups had derived a benefit from the programmes, since they had improved their visual orientation and their capacity to think logically (increased scores on Drawing performance). Moreover Group 1 manifested an increase in learning capacities and in the richness of ideation (increased scores on Vocabulary), perhaps as a consequence of the stimulation by music and language.

The curves of the Listening Test, test and retest, are shown in Figures 1 and 2. The left- and right-ear curves of the children and mothers of Group 1 are represented, and only the right-ear curves for Groups 2 and 3, since the functioning of the right ear is the most important in APP.

Figure 1: pre- and post-treatment acuity means, in air and bone conduction on the Listening Test for Groups 1, 2 and 3 — CHILDREN.

As Figure 1 shows, the children’s Listening Test indicates significant advances in the acuity scores on five frequencies and a significant shift of auditory laterality towards the right ear in Group 1. Gains were obtained in the direction announced by Tomatis, namely an increase in the capacity to distinguish the highest frequencies of the sound spectrum, indicating an increased receptivity in the sense of communication and perhaps explaining the increase in submissiveness on the CPQ.

Two inter-group differences were significant. Group 1 achieved higher acuity scores than Group 3 in air conduction, right ear, at 8000 Hz, and in bone conduction, right ear, at 4000 Hz, also exceeding Group 2 significantly on this frequency.

Figure 2: pre- and post-treatment acuity means, in air and bone conduction on the Listening Test for Groups 1, 2 and 3 — MOTHERS.

As Figure 2 shows, the post-treatment evaluation indicated that the mothers of Group 1 had their acuity scores significantly improved, which implies an increased perception of auditory stimuli, on 23 frequencies in air and bone conduction, particularly in the high-frequency zone. The post-treatment gains comprised ascending curves corresponding to the ideal audiometric curve of the “musical ear” described by Tomatis. The gains in the perception of high frequencies indicated an increased will to listen, perhaps explaining the increase in maternal affective involvement on the FAD. In Group 2, only three significant advances appeared in the acuity scores and only one in Group 3. With 13 significant inter-group differences, Group 1 regularly achieved higher auditory acuity scores than Groups 2 and 3.

Maternal follow-up questionnaire. The results of a three-month follow-up indicated consistent advances. Most mothers (88%) found that their own functioning was better or much better, while 94% noted that their child functioned better or much better. The entire group reported a better or much better understanding and handling of the child’s problem. The remaining problems comprised over-protection, in 26% of mothers, as well as fear (in 21%) of negative effects of having to give their child more freedom. Significantly, most of the mothers of Group 1 reported gains in the child on the level of communication.

Therapist’s observations. To make the implications of the results more explicit, observations on the children of Group 1 had been briefly noted. The children became more and more enthusiastic, particularly during the filtered maternal voice phase. Loquacity, kindness, more intense laughter and the taking into account of parental instructions were marked. During the musical sonic birth phase, one little girl regressed somewhat with infantile language and by sucking her thumb, but within a few days she recovered the behaviour in keeping with her age. In the audio-vocal stimulation phase the children became more and more resourceful; for example, they played more constructively among children of the same age, they joined the others and tried out new pursuits, such as jogging.

Therapist’s competence. The fact of having divided the children into groups directed by one therapist for each programme revealed that the group directed by therapist 1 had become significantly more extraverted, bold and self-controlled. The mothers of these children made significantly more progress in problem-solving, in affective responsiveness and in general functioning. The APP group of therapist 2 became significantly more “cool-headed”. For the ATP group only one significant difference appeared: the group directed by therapist 2 became significantly calmer.

4.6 Conclusions

Our results validated the basic premises of APP in several dimensions: auditory stimulation according to the prescribed mode led to the reduction of anxiety, to a cognitive refinement, to a better listening in mothers and children, to an enhanced mother-child communication, to an increased affective involvement and to a clarification of the mother’s role. Given that the verbal interaction between therapists and patients was the same via both methods, it appeared that the agent specifically responsible for the changes in Group 1 could be the filtered maternal voice, presumably acting in the reduction of anxiety and as a means of fostering communication. The effect of listening to filtered music also produced changes in the mothers’ listening curves, and increased the mothers’ propensity to communicate. Signs of improvement in age-appropriate behaviour, such as the increase in the willingness to listen and obey parental instructions, as well as increased signs of independence and self-confidence, were clinically significant.

The results extended to the latency-period child the anxiety-reduction effect of auditory stimulation demonstrated in adults (Van Jaarsveld & Du Plessis, 1988). However, the significance of the results may be limited by design deficiencies. First, APP was compared to an alternative therapy programme that did not have an adequate research track recorded for all its components. Second, the objectivity of the evaluation was limited by the absence of a standardised child behaviour checklist (e.g. Quay & Peterson, 1983) and of appropriate physiological measures such as those used by Zaichkovsky and Zaichkovsky (1984), of an inadequate and independent behaviour classification and of a limited time interval for the follow-up. Fortunately, these design deficiencies will be overcome in future studies with larger samples.

Nevertheless, the results are in favour of a new short-term approach to the reduction of anxiety, based on auditory training with the Electronic Ear. It is applicable to groups and is therefore of reasonable cost, which is important in an era of limited therapeutic resources and with a rise in stress and anxiety in the child (Du Plessis & Van Jaarsveld, 1988).

5. Discussion

The 10 studies discussed in this review comprise statistical studies, follow-up studies and a case study using as subjects: children, students and adults. The aspects examined comprise: laterality, stuttering, mental retardation, anxiety and depression. These studies reveal positive results even though rigorous methodological criteria and precautions were applied. The evidence has been established that not only anxious female students and schoolchildren but also non-anxious and well-balanced female students can be stimulated by APP training to obtain a significant improvement in the functioning of their personality.

The reactivation of “listening” (defined by Tomatis) makes, according to APP theory, a major contribution to this improvement. Listening means differentiation and integration of sensations into perceptions, that is to say the attribution of a meaning to sensory experiences that are at first raw and undefined. Listening requires the mobilisation of self-awareness; it is for Tomatis indispensable in order to attain self-actualisation. The key to the listening process, according to Tomatis, is motivation, the desire to communicate, taking its origin “in utero”. It is the desire to unite with the mother and, later, to integrate the father that serves as an incentive to attribute a meaning to the raw and undefined sensory experiences of hearing. By implication Tomatis therefore links the quality of the neuropsychological auditory process to the quality of the child’s differentiation and integration of his first models of learning, the mother and the father. The right ear, the directing ear, is designated to carry out most of the functions of control of listening and of precise language. The mother is perceived to the “left” and the father to the “right”. (In terms of neuropsychological processes the “left” implies the right hemisphere and the “right” implies the left hemisphere.)

Wissing’s research at the University of Potchefstroom (Wissing, 1978; Wissing and Guse, 1990; Wissing & Bothma, 1991; Wissing & Sander, 1991; Wissing, 1991) on hemispheric functional asymmetry (HFA) sheds light on these complex neuropsychological processes. She describes the ways in which the hemispheres are distinct or else cooperate in the processing of information by means of the concepts of differentiation and integration. Differentiation relates to the specialisation of the hemispheres as expressed by hemispheric functional asymmetry (HFA), while integration relates to the cooperation between the hemispheres. The differentiated pattern of hemispheric specialisation is well known. It is generally established that the left hemisphere serves as an intermediary for most aspects of the reception of language and its expression, in the same way that the right hemisphere serves as an intermediary for most aspects of emotional experiences and expression. Wissing (1991: 12) also notes that:

“although the right hemisphere is superior or has the meta-control of the emotional process, both hemispheres are capable of processing emotional information, the right hemisphere being rather associated with negative affect, and the left hemisphere with positive affect.”

Moreover, the processes of differentiation seem to be more strongly associated with the left hemisphere, while the right hemisphere is especially competent for integrative processes. For the experience of meaning (listening), however, the complementary functioning of both hemispheres is required, similarly to the necessity of integration of both parents in the psyche of the healthy child.

Discussing the hypothesis of balance and health, Wissing (1991) states that the complex processes and functions of analysis and synthesis, of differentiation and integration, of reason and imagery as well as of verbalisation are in harmony and develop in a balanced manner in the healthy and well-integrated individual, whereas in conditions of deterioration they may be discordant. Inhibition, repression or else maturational delays in nervous development may intervene in the integration of information between the hemispheres, and lead to a certain degree of functional disconnection. According to Cox & Theilgaard (in Wissing, 1991), this implies that if the left hemisphere, with its own ability to explain language, is disconnected from the right hemisphere, the person cannot self-articulate to themselves the loaded contents or non-rational, imaginal and emotional experiences, associated mainly with the processes of the right hemisphere. This implies that the person is unaware of these contents and incapable of developing a clear insight into their own behaviour. APP theory insists on the fact that a disturbing communication between parent and child entails psychic blockages, disturbing the integration processes between the two hemispheres and, therefore, “listening”. These blockages, which can be identified on the Listening Test, prevent the connection with the central determinants of functional efficiency.

So there seems to be a relationship between neuropsychological functioning and personality functioning. This hypothesis was explored in depth by Wissing and her collaborators (Wissing & Guse, 1990; Wissing & Sander, 1991; Wissing & Bothma, 1991; Wissing, 1991), and they found the indications of a relationship between the qualities of personality functioning on the one hand and the qualities of neuropsychological functioning on the other.

From these conclusions it can be argued that APP training, by which there is a simultaneous appeal to the verbal processes of the left hemisphere and to the imaginal, holistic and intuitive processes of the right hemisphere, leads to the improvement of neuropsychological functioning as well as to the improvement of personality functioning. This also explains why “listening”, as Tomatis defines and emphasises it, is of such importance in APP training. Finally, this sheds new light on Tomatis’s interpretation of the Listening Test, and it opens new avenues to research.

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Acknowledgements

The establishment and continued operation of the APP centre at the University of Potchefstroom/CHE were made possible thanks to the mediation of:

• Prof. H.J.J. Bingle, Rector and currently Chancellor;
• Prof. T.A. van Dyk, Head of the Department of Psychology, later Vice-Rector;
• Prof. L.A. Gouws, Dean of the Faculty of Arts and Philosophy;
• Dr A.J. van der Walt, Head of Electronic Services;
• Dr W.F. Du Plessis and the entire dedicated staff of the Institute for Psychotherapy and Counselling.

To Professor Alfred Ange Tomatis, honorary member of the Department of Psychology, and to Mrs Léna Tomatis, we are greatly indebted for their contribution.

Source: Pieter E. Van Jaarsveld, “Twenty-One Years of Audio-Psycho-Phonology in South Africa” (Institute for Psychotherapy and Counselling, University of Potchefstroom), translation by Christian-Paul Delmas. Transcription from the facsimile.