From Communication Therapy Institute
Stuttering Online Therapy and Communication Therapy Institute Director Barbara Dahm will be featured in a televised interview in New York and North New Jersey. It will air at 6 PM, 7:30 and 11 PM on Thursday, January 27. In New York, as well as North Jersey, it will also air on 13/WNET at 6 PM, as well as on NJN. Please let Ariel know, too.
UPDATED: You can now watch the interview online here.
Several weeks ago I started a 3 part series in which I talked about whose fault it is that so many people who stutter are disappointed and dissatisfied with their treatment experiences. In part 1, I discussed that the approaches for treating stuttering need to be revised. In part 2, I talked about the inability of professionals to change the paradigms that they were taught and trained to believe are the best that can be. Today I am focusing on the people who are being treated, the people who stutter.
First I want to say that I strongly believe that everyone who comes to therapy wants to “get rid of the stuttering”. Furthermore, I think that most clients put their trust in their clinician and are willing to work hard to become fluent speakers. To some extent, while they are doing their absolute best to do what the clinician asks of them, it is this trust that is part of the problem. I believe that there are some clients who need to take a more proactive role in the therapy process. When they are asked to use a technique, they need to question how it is meant to help. Also, if they have honestly tried to do what was asked of them and found it to effortful or difficult to do, they have the responsibility to say that the technique is not working for them and, together with the clinician, explore where the problem lies.
Speech is one of the neurophysiologic systems of the human body that is meant to work automatically. It should not be an effort to speak. If it is an effort, something is wrong. Clients should not accept directives and goals that add layers of cumbersome controls. Clients who come to therapy without questioning what is being asked of them are at fault when they don’t get what they want.
It is very understandable that clients need to be encouraged to investigate the logic behind what they are being asked to do. This is why Dynamic Stuttering Therapy explains the process of normal speech production and is so centered on self exploration. I don’t want clients to do something because I say so; I want them to do what makes sense to them. Some clients do begin therapy thinking that I can make them fluent without their help. They do not want to be bothered with the details. Explanations and discussions are of little interest. During the initial intake it is normal to want to know results of therapy. However, during therapy clients who continue to believe that change comes by osmosis do not make the change that is necessary for a successful therapy experience.
Clients who expect that therapy is a quick fix cause their own disappointment. Therapy is a process of self-change. To be honest, speaking naturally is not a difficult process to learn. However, learning the process is only part of what therapy entails. I sometimes see clients who after 3-4 hours of treatment begin speaking with a degree of ease and fluency that is unfamiliar to them, even during their more fluent moments. In their joy, they expect to go off into their lives and their speech will remain fluent. This expectation is unrealistic. Developing a normal speech production system requires developing or at least strengthening the specific neurological network that results in fluent speech. This can only be done, with intention, mindfulness and repetitive experience.
I have discussed the three factors that are at fault for the failure of therapy to bring the understandably desired results. At the same time, I have touched on how these three factors can improve the situation. The poor outcomes that are traditionally associated with stuttering therapy need not be allowed to perpetuate. Open minds on the part of clinicians and clients will enable more people who stutter experience effective treatment and the ability to speak with ease and fluency.
A look at Stuttering Therapy Online – a seven-part series
Please join us next week on Wednesday as we examine the unique aspects of treating stuttering with online therapy.
This week’s focus – pros and cons of teletherapy
From my point of view, there are many benefits in online treatment, including flexibility in scheduling, the ability to present my perspective to people all over the world, and the client’s ease in contacting for short consultations between sessions if they are experiencing difficulty with their self-help assignments. I am really hard pressed to think of the detriments. However, it is more important to consider what clients feel. The following is a summary of clients’ perceptions.
Pros:
Cons:
Last week: Participation Procedures
Coming next week: What Clients Say About Teletherapy vs. Regular Therapy
A look at Stuttering Therapy Online – a seven-part series
Please join us every Wednesday for the next two weeks as we examine the unique aspects of treating stuttering with online therapy.
This week’s focus – participation procedures for teletherapy
The procedure for participating in online therapy is quite simple. People contact me through my website or email. Once they send me their skype name we set up an appointment for a free initial consultation. During this meeting we begin to get to know each other and can assess if online therapy is the right option for the individual. We also have an opportunity to sort out problems with the connection, cameras, microphones, headsets or even lighting conditions. If, after this consultation, the individual decides to begin treatment, we set a time for the first session.
Sessions are from 45 minutes to 1-½ hours depending on the stage of therapy and other personal criteria. All sessions are held by appointment only. Being prompt and available at the agreed time is a requirement. Since I am treating people in various time zones, I try to be as flexible as possible with my treatment schedule. Often the time zone differences work to everyone’s benefit, because I can keep fairly normal working hours while the client can participate in therapy either very early in the morning before going to work or during the quiet hours of the evening.
There is no magic number of sessions required. I have divided the treatment process into these four stages. Stage 1 focuses on understanding speech production, and doing activities to change the way you speak and relate to yourself as speaker. In Stage 2 the client gains heightened awareness of speech processes and does repetitive exercises in normal connected speech while creating new thoughts. During Stage 3, the client etches the process in procedural memory while gradually increasing use of new process at will in real life. In Stage 4 the client uses the new way of producing speech automatically in real life as part of the subconscious self.
Roughly speaking, Stage 1 & 2 take 3-6 sessions each, depending on the individual. Stage 3 takes from six months to a year of mainly self-practice and gradually incorporating changes into real-life situations. Sessions with the clinician in Stage 3 are optional and depend on the client’s feelings and personal need for support.
Clients do not have to commit to a certain number of sessions. Ideally, it is best to have clinical guidance at frequent intervals during stages 1 & 2, but progress can be made at a slower rate with less frequent sessions. Payment is made per session via PayPal. Some people have a very small budget for treatment so they suffice with only minimal direction and continue on their own. Others work through one stage with me, take a break while reinforcing what they have learned, then return for a few more sessions to work through the next stage. Still others prefer to have me guide them through treatment until they are well into stage 4.
Units of the Dynamic Stuttering Therapy workbook are sent to clients for their personal use as they progress through therapy. All people who participate in treatment work at giving up unnatural control of the speech production system and developing the normal automatic way of speaking. However, the content of the sessions are individualized to suit each client’s needs.
Last week: Appropriate Populations
Coming next week: Pros and Cons of Teletherapy
A look at Stuttering Therapy Online – a seven-part series
Please join us every Wednesday for the next three weeks as we examine the unique aspects of treating stuttering with online therapy.
This week’s focus – the appropriate population for teletherapy
At Stuttering Online Therapy, I treat people who stutter from approximately 14 years through adult. When treating children under age 18, I require an online consultation with parents or legal guardians before beginning therapy and at intervals during the therapy process. Parents are invited to sit in the room with their child to learn the treatment principles. This allows them to offer support and assistance between sessions and throughout the self-help phase of therapy.
People who participate in therapy must have a working knowledge of English or Hebrew. Some clients have a different native language. Therefore, some of the basic exercises are practiced in languages that I do not understand. This does not present a problem because achievement of the Dynamic Stuttering Therapy goals is not language dependent. I can identify speech processing in any language. Later in treatment clients often speak in their native language with family or friends who sit in on sessions.
Last week: Technical Requirements
Coming next week: Participation Procedures
A look at Stuttering Therapy Online – a seven-part series
Please join us every Wednesday for the next five weeks as we examine the unique aspects of treating stuttering with online therapy.
This week’s focus – technical requirements for teletherapy
The technology available for videoconferencing is constantly improving. The treatment platform must be reliable and easy to use. It is very important for the client and me to be able to see and hear each other clearly. The video streaming has to be natural and the lip and audio sync have to be good. Delays in either audio or video would make it difficult for me to evaluate what the client is doing and make it impossible to model differences in speech processing that are important to the treatment goals. Another requirement is file sharing. I send clients units of the Dynamic Stuttering Therapy Workbook and rely on diagrams, pictures and videos to clarify explanations. I also need to video and audio record clients with an option for immediate playback.
I tried out a handful of companies that are Mac compatible and offered white board and file sharing along with video streaming capabilities, but was disappointed with the quality of video streaming, the audio, or the synchronization of the two together. Also, I found that many platforms were difficult for new users to learn. As a last resort I tried Skype, the commonly used instant messaging platform that many people have or that can be easily downloaded at no cost. It works beautifully. The video and audio quality is usually good and has improved over the past two years. Incidentally, I have also used ichat/AIM, but have not been as happy with the video quality. Skype has options for sending files and screen sharing. It does not have a recording option, but I solved my recoding issues by purchasing both an audio recorder http://www.rogueamoeba.com/audiohijack/ and a video recorder http://ecamm.com/mac/callrecorder/. Together, I have all the recording functionality that I have in clinic.
Clients can record their practice between session on their personal MP3 or on computer recording software. For those who don’t have this software, a free personal recorder can be downloaded from Audacity http://audacity.sourceforge.net/ .
While most times the connection quality is good, there are interferences that need to be considered. Occasionally, the video freezes or the voice cuts out. Most of the time this can be resolved simply by hanging up and reconnecting. On occasion it is necessary to reboot the whole system. The video/audio quality can be greatly improved by using a decent web cam and headset with microphone. Each of these can be purchased for under $100 in most countries. I always use a headset with an attached microphone during treatment. However, some of my clients do not use one. The necessity depends on the quality of the built in hardware.
Last week: Ethical Considerations
Coming next week: Appropriate Populations for online therapy
Please join us every Wednesday for the next seven weeks as we examine the unique aspects of treating stuttering with online therapy.
This week’s focus – ethical considerations of providing therapy online
Telepractice must comply with the standards of in person therapy. Initial comparison of videoconferencing and conventional face-to-face speech language therapy has indicated that children made similar progress with both methods, and students and parents overwhelmingly supported the telemedicine service delivery model (Grogan et. al., 2010). I have not formally studied differences in treatment results, but my experience supports these findings.
Online assessment requires special consideration, because some assessment instruments are copyrighted and cannot be transferred to clients online without permission. For subjective assessment, I rely on information from the initial interview and the Speech Satisfaction Scales that are part of the Dynamic Stuttering Therapy protocol (Dahm, 2007). Assessing fluency, speech rate and length of blocks, can be easily done online by recording speech samples. That allows for quick assessment using the SSI-3 (Riley, 1994).
Care needs to be taken to ensure the client’s comfort, privacy and confidentiality. My clients electronically sign a statement agreeing to the terms of treatment and giving permission to record speech samples for training purposes. I am careful not share identifying information or recordings without explicit permission. Speech samples are saved in files on an external hard drive. Skype sessions are held in a private place and no one is allowed to observe sessions without the client’s permission.
When treating people in countries foreign to the provider, it is important to be sensitive to cultural, linguistic, religious and geopolitical issues so as not to cause discomfort to clients. I feel honored to be able to treat people who stutter who I would otherwise not have the opportunity to know. Sensitivity and respect for differences is imperative. This extends to topics for practicing conversational speech, modesty in dress, and other cultural differences. Having lived both in the Middle East and the United States, I have learned a lot about differing cultures. This understanding, and the bond we share of wanting the experience to be successful has a positive impact on service delivery.
Last week: Series Introduction
Coming next week: Technical Requirements for online therapy
Please join us every Wednesday for the next seven weeks as we examine the unique aspects of treating stuttering with online therapy.
This week’s focus – all about teletherapy
Time, place, the number of treatment hours are less important factors for the successful treatment of stuttering than the clinician’s depth of knowledge, experience and ability to lead clients through an exciting and adventurous process of changing their speaking experience. They are also secondary to the client’s willingness and ability to participate in the process of breaking away from the thoughts, feelings, and procedures that have interfered with satisfying communication through verbal self-expression.
Now let’s imagine that a person who stutters is ready for change, but does not know where to go to find that experienced clinician, or that he lives a great distance from a center that specializes in stuttering treatment. The constraints of time, place or accessibility no longer need to preclude receiving treatment from a clinician who specializes in stuttering. In this series of posts, I will explain how telepractice has broadened the scope of therapy for adolescents and adults.
I began using the Internet for treatment out of necessity. I am located in Israel, but travel to the USA several times a year to work in clinics in northern and central New Jersey. The in-person treatment that I administer involves one-on-one sessions for approximately 4-6 weeks with follow-up sessions. Once the technology became available, I used the Internet follow-up sessions. I soon realized that the ease, effectiveness, and functionality of this format make it possible to treat clients online from the start. That is how in 2008 I came to establish Stuttering Online Therapy. Now, after two years, I am traveling the globe from the comfort of my home office. To date, I have treated and/or held consultations with people in Australia, Bangalore, Bulgaria, Canada, China, Ecuador, Egypt, France, India, Israel, Kuwait, Malaysia, Mali, Mauritius, Nigeria, Norway, Pakistan, Russia, Slovakia, Sudan, Sweden, Turkey, the United Kingdom, and USA.
Teletherapy is not new to speech therapy. It is used in Aphasia-Apraxia treatment and for distance delivery of stuttering treatment (Harrison et. al.,1999; Kuly, 2000; Sicotte et. al., 2003; Wilson et. al., 2004). The American Speech Hearing and Language Association (ASHA) has studied its application since 1998 leading to position papers (2005; 2010).
The teletherapy model lends itself extremely well to stuttering therapy, because most approaches rely on auditory and visual communicative interaction. Treatment is non-invasive and does not require hands-on intervention. There is really little need for adapting therapeutic procedures for teletherapy.
Coming next week: Ethical Issues for online therapy
I often get emails from people who want me to give them a quick tip on how they can become fluent speakers. I certainly understand their desire. However, I’m also certain that no one really believes that there is a simple trick or one piece of advice that will instantly transform a person who stutters into a fluent speaker.
Nevertheless, people who stutter can go through a process of helping themselves to become fluent speakers. This process starts with discovering how fluent speech is produced and comparing this to what you do to produce speech. So for those of you who want to take an active role in this process, I thought that it would be a good idea to give you an activity to do.
The activity I am describing here is meant to show you that speaking does not involve thinking about what you want to say and then trying to get it out. So let’s explore….
Activity: Discovering how language develops in the brain i.e. developing internal (sub vocal) speech
Step 1: Write an email to some one. While you are doing this, become aware of how language automatically develops in your head. This is your internal or sub vocal speech.
Internal speech automatically develops in your head when you are writing, figuring out a math problem or simply talking silently to yourself. Language is meant to develop in the exact same way when you are talking to all people in all situations. Developing internal speech is speaking and there is really nothing else that you need to do. Doing anything less, or anything more, will very likely lead to speech blocks. I suggest you look at these fascinating links related to sub vocal speech. It will help you understand the power of this inner speech.
Step 2: Speak silently as you become aware of how language develops automatically when you are not thinking about the words that you are saying or planning to say.
For most of you, this will be natural under the condition of silent speech, but for others, you might find that even in silent speech you have a tendency to preplan your thoughts or choose your words. If this is the case, you can try giving up all control by experiencing automatic internal speech while counting or saying the ABCs. Later you can move on move on to spontaneous speech.
Step 3: Once you are speaking naturally in your head, continue to do this as your mouth simultaneously moves along with the internal speech.
Some of you might have been doing this already in steps 1 & 2. If not, do it now. If you are using automatic articulation, you will hardly feel that you mouth is moving, even though it is. Also you will be able to speak without any effort.
Step 4: Talk silently and then talk aloud. See if there is any difference at all in the way your internal speech develops and the way your mouth moves.
Being aware of whether the process of speaking silently and aloud is the same, or even slightly different, is the prerequisite for changing how the system works.
Have you been through a therapy program hoping to improve your speech fluency and in the end didn’t see much change? If you have, you are not alone. This is too often the case, even after years of treatment. Why? Who is at fault? Is it you, the client? Is it the clinician? Is it that fluency in real life is not possible? Or is the treatment approach that is not adequate? In my next few blogs I will discuss where I think the fault lies from the all these angels.
Before I begin, however, I want to say that looking for the responsible source i.e. “fault” is not the same as placing blame. There is a big difference between where the responsibility lies and the need for blame or guilt. For instance, once most people died from pneumonia. Was the doctor or patient guilty? No. Was the treatment at fault? Yes, and the reason was the lack of knowledge about bacteria and how to kill it. Therefore, at that time we could not blame or place guilt on the part of the people involved. Today, we have the knowledge of how to treat most cases of pneumonia, so a doctor could be blamed for not recognizing the signs of pneumonia (as my doctor failed to do 3 years ago when I had it); a patient could be blamed for not going to a doctor when feeling sick, or not demanding better tests and treatment when the condition is not improving (as I did when I wasn’t getting better), or not taking the medicine that was prescribed. Nevertheless, I would prefer to search for source, because blame and guilt are not constructive in a search for solutions.
So let’s get back to stuttering. If we are going to look for whose fault it is that so many people do not achieve the long-term ability to speak fluently, I think that the first place to look is the treatment approaches being used. Simply stated, I believe that the major cause for the failure of treatment is a lack of knowledge of how to treat it. Most treatment approaches focus on fluency or try to modify the moment of stuttering. However, it is obvious to anyone who has tried it that you don’t become a fluent speaker by treating the stuttered speech and trying to make your speech non-stuttered.
Speaking is a neurological activity in the brain of a person who has thoughts, feelings, intentions, genetic tendencies and memories. We have seen through various types of brain scans that the brain works differently in people who stutter. Therefore, changes in the brain need to be made in order to create fluent speech.
Not only is speaking is an activity of the brain but for the most part it is an unconscious activity. People are not meant to think about how to speak; how to get words out; which words should be said. People are not meant to preplan their speech before speaking. Why then should stuttering therapy train people to monitor and control how they breathe, how to hold or relax the muscles of the mouth, how to say sounds more gently and smoothly, how to change the way you stutter? Stuttering represents control of a system that is meant to function subconsciously, so why ask people who stutter to develop speech controls and “tools”? Tools and controls are not part of normally fluent speech.
Managing stuttering by way of speech controls has been the long-standing method of choice. It’s time to try a different approach, one that has eluded too many clinicians and clients for too long. We have to keep our minds open to a new perspective that incorporates research findings and clinical observations. This is the 21st century. Strides are being made in the understanding and treatment of human conditions that only a short time ago were not understood or treatable. The old paradigms that have been the driving force of stuttering treatment until now do not fall in line with current research and do not explain all that is known about the nature of stuttering. Until stuttering therapy helps people use their brain the way it is meant to function in order to produce speech, the ability to produce normally fluent speech will continue to elude clients and clinicians alike. Change is a reality of life. Now is the time to rid ourselves of the concepts that have not lead people who stutter in the direction that will give them a successful treatment experience. Now is the time for developing a treatment approach that will lead clients to speak with ease and freedom from control.
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