Therapy guide
Introduction
Portions of the text below were taken from Wikibooks and aremade available here under GNU Free Documentation License.
The effect of "choral speech " — speaking or reading simultaneously with another person — has been known for years to promote fluency in individuals suffering from varying degrees and types of dysfluency, particularly effective in those afflicted by stuttering. In clinical setting or as used in the anti-stuttering devices such as SpeechEasy or Defstut, "choral speech" is simulated by various types of Altered Auditory Feedback (AAF).
Among the several types of Altered Auditory Feedback, the most effective for treating stuttering are Delayed Auditory Feedback (DAF) and Frequency-Shifted Auditory Feedback (FAF), both implemented in FluencyCoach. Simply put, the DAF allows you to hear your own voice delayed by a fraction of a second, like an echo, whereas FAF changes the pitch of your voice. FAF and DAF each reduce stuttering about 70%, immediately, without training, speech therapy, mental effort, or abnormal-sounding speech. Combining DAF and FAF reduces stuttering over 80%.
Owing to these remarkable immediate improvement rates, FluencyCoach can be used as a standalone speech aid when talking on the phone or making a call via your favorite VoIP program, for public speaking, or in virtually any other situation. See "Using FluencyCoach as speech aid for immediate improvement" section below for details.
The high carry-over fluency rate produced by combined DAF / FAF makes FluencyCoach a perfect tool for an autonomous at home therapy or in conjunction with several prominent stuttering therapies, such as Fluency-shaping Therapy, Stuttering Modification Therapy and Valsalva Control, as discussed in the corresponding sections below.
How Altered Auditory Feedback improves fluency
No brain scans have looked at stutterers' auditory processing while speaking with altered auditory feedback. However, one hypothesis is that introducing errors targeted at the area that integrates auditory and somatic processing increases blood flow to that area. In other words, hearing what you're saying out of sync with what you feel your muscles doing raises a red flag. The red flag is raised in the area that's abnormally underactive in stutterers. Increased blood flows to this area. The activity level increases to normal, and stuttering diminishes. DAF effectiveness has also been associated with planum temporale (PT) abnormality.
Another theory attributes the remarkable effect of DAF / FAF combination on stutterers' speech to the role of feedback in the associative stage of motor learning.
The associative stage of motor learning requires feedback. In sports this is called knowledge of results: in golf or tennis you see where the ball goes after you hit it. Observing the results (feedback), on the conscious level, you estimate the effort and technique required to make a better shot. On the subconscious level, after comprehensive practice, your body recognizes and retains the coordination patterns necessary to attain desired performance.
Feedback quality is affected by speed. If you hit ten golf balls on a dark, foggy night, then the next day find one of the balls 150 yards away, you'll have no memory of what you did right to hit it so far.
Feedback quality is also affected by accuracy. If you and your buddy each hit a golf ball, and one ball goes 150 yards but you don't know whose ball it was, you have inaccurate feedback.
When you're learning fluent speech motor skills, you need knowledge of results. Some skills are easy to observe: resting your hand on your stomach tells you whether you're using diaphragmatic (relaxed) breathing or thoracic (speech) breathing.
Your articulators (lips, jaw, and tongue) are a little harder to be aware of, as you can't see them. But you have good proprioceptive awareness of these muscles, so developing awareness and control isn't hard.
Your vocal folds are another story. These muscles are deep in your throat. You can't touch them or see them.
The most difficult feedback is with the timing of all this. Such is the case when your speech-language pathologist tells you to exhale a little air and then increase your vocal fold tension. You do this slowly and correctly. Then she tells you to increase the speed. You must execute these movements within hundredths of a second. You can't tell whether you're doing it right without a proper feedback. A fluency specialist who's helped hundreds of stutterers has better-trained ear and visual skills and gives better quality of feedback than a less experienced speech-language pathologist.
The delayed auditory feedback feature of FluencyCoach gives you an ongoing, instantaneous feedback of your efforts and performance, whereby a allowing you to adjust your speech pattern to achieve desired results. Using Speech Coach for improving fluency is similar to using a mirror, for a dancer or actor, when practicing facial expressions or gestures.
Moreover, with the "Save and Play" feature of FluencyCoach you can record your voice and play the recording afterwards to
analyze
in detail your major speech
difficulties
and problem areas, as well as note improvements. Listening and transcribing your recorded speech is a great way to single out particular sounds, syllables and words on which you stutter, and build your own reading
exercises
- texts and word lists - to target them.
Lastly, auditory processing abnormality, which can only be treated with the help of an altered auditory feedback software or device, has been identified as a major factor causing onset and development of stuttering. No speech therapy is known to correct this abnormality.
Many people overcome stuttering by treating the other factors. But using an altered auditory feedback device or software in conjunction with other therapies may make the other therapies easier, faster, and more effective. If so, you'll then need the software or device less and less, until achieving perfect fluency.
Using altered auditory feedback when making a phone call can be a great way to do autonomous speech therapy. If carryover fluency is produced, after a few calls your speech may be improved for the rest of the day.
Effects and uses of Delayed Auditory Feedback
Delayed Auditory Feedback (DAF) can be used two, very different ways. The delay can be set between 50 and 70 milliseconds to reduce stuttering about 70% at a normal speaking rate, without training, mental effort, or abnormal-sounding speech.
DAF can also be used to support the fluency shaping target of slow speech with stretched vowels . For this purpose the delay is usually set at 200 milliseconds and then reduced to shorter delays (as short as 75 milliseconds) over the course of the therapy program.
For this latter purpose, a speech-language pathologist must train the stutterer. When the stutterer can complete a simple speaking task, such as counting to ten, using the slow speech target correctly, then he can use a DAF device. DAF therapy then has two goals:
• To increase the length and complexity of the utterance, and increase the stress of the speaking situation, while using the DAF device to support on-target fluent speech.
• To reduce the need for the DAF device, until the stutterer no longer needs the device.
For the first goal, after the stutterer can count to ten using the slow-speech target correctly (e.g., all syllables stretched equally, all syllables stretched to one or two seconds, no pauses between words, and no dysfluencies) without the DAF device, then use the device to have a conversation at the same slow speaking rate. When the stutterer can achieve the slow speech target with 100% fluency using the DAF device for utterances with the length and complexity of normal conversations, then the stutterer should take the device out of the speech clinic and use it in increasingly stressful conversations. The first goal is speech that is 100% fluent and on-target (i.e., slow) in any conversation. For a severe stutterer, this may mean using one- or two-seconds per syllables speech with the device set at 200 milliseconds.
When the stutterer achieves the first goal, then he gradually reduces his dependence on the device. He decreases the delay and increases his speaking rate. But if he has any dysfluencies he should go back to the longer delay and slower speaking rate. He can also decrease the volume, and use the device in one ear instead of both ears. He can use the device at the beginning of conversations, and then turn it off when he feels capable of speaking on target with the support of the device. He can discontinue using the device in low-stress conversations. Then he can discontinue using the device in medium-stress conversations, reserving the device only for stressful conversations such as public speaking. Eventually he should need the device only occasionally.
In a study nine adult stutterers used DAF devices thirty minutes per day, for three months. The thirty minutes consisted of ten minutes reading aloud, a ten-minute conversation with a family member, and a ten-minute telephone call. The subjects received no speech therapy.
The devices were used with binaural (two ears) headsets. The subjects were allowed to set the delay where they wanted. Most selected delays around 100 milliseconds.
Before three months of DAF use, the subjects stuttered on 37% of words, on average. When they put on the DAF device their stuttering dropped to 10%. I.e., the device improved their speech about 70%.
Three months later the subjects stuttered on 17% of words, when not using the DAF device. When wearing the DAF device they stuttered on 13% of words.
This shows that, when not wearing the devices, the subjects' stuttering diminished from 37% of words to 17% of words, or a 55% improvement. This is "carryover fluency." Put another way, the devices trained the users to need the devices less.
The increase (from 10% to 13%) in stuttering when wearing the devices wasn't statistically significant. Examining this more closely, stuttering when wearing the device increased only for "automatic speech," such as reciting days of the week, and for repeating words and sentences after the examiner. No change in effectiveness was found in conversations or in a "picture description" task. This suggests that any "wearing off" effects occurred in less-important speaking situations.
The "carryover fluency" effect was the same across all speaking tasks.
In another study, an eleven-year-old boy received fourteen hours of structured therapy with mediated learning and a School DAF. His stuttering diminished from 9% dysfluencies to 4.8% dysfluencies (when speaking without the device, a 47% improvement). One year later he still had 4.8% dysfluencies. Another fourteen hours of treatment reduced his stuttering to 4.1% dysfluencies.
Two other studies combined speech therapy with a DAF device. One study was of adults, the other of children. Both studies found that combining DAF and stuttering therapy trained the subjects to speak fluently (less than 2% stuttering) and no longer need the devices.
Effects and uses of Frequency-shifted Auditory Feedback
Frequency-shifted auditory feedback (FAF) shifts the pitch of your voice in your earphones. A FAF upshift makes you hear your voice sounding like Mickey Mouse. A FAF downshift makes you hear your voice sounding like a gravel-voiced radio announcer.
A quarter-octave pitch shift reduces stuttering about 35%. A half-octave pitch shift reduces stuttering about 65-70%. A full-octave pitch shift reduces stuttering about 70-75%.
Effects of Frequency-Shifted Auditory Feedback
Shifting pitch up or down is equally effective in short-term studies. But there may be long-term differences between up- and downshifts. FAF causes non-stutterers to speak at a higher or lower vocal pitch, depending on whether the device is set for an up or down frequency shift. This higher or lower pitch vocal pitch results from changing vocal fold tension. In other words, FAF induces changes in vocal fold tension in non-stutterers.
Vocal fold relaxation is a primary target of fluency shaping therapy. A study found that a half-octave FAF downshift didn't cause a change in vocal pitch in stutterers. But, anecdotally, speech clinics have reported that FAF devices adjusted to one octave downshift, using newer headphones with better bass range, induce vocal fold relaxation in stutterers. A one-octave downshift has also been anecdotally reported to induce a slower speaking rate with stretched vowels. If these reports are true, then FAF downshifts appear to immediately induce, with little or no training or effort, the target behaviors that take weeks of fluency shaping therapy. And, if these anecdotal reports are true, then an FAF downshift should induce long-term carryover fluency.
Conversely, anecdotal reports suggest that an FAF upshift (the Mickey Mouse voice) induces vocal fold tension and faster speaking rates. If this is true, then a FAF upshift should result in poor long-term performance (e.g., no carryover fluency, and possibly "wearing off).
In a study, nine stutterers used a DAF/FAF device about seven hours per day. Their fluency was measured after four months and after twelve months. The delay was set at 60 milliseconds and the frequency compression FAF at 500 Hz up. The subjects received brief speech therapy, specifically to prolong vowels and use "starter sounds" such as "um" and "ah."
The two anti-stuttering devices had similar immediate effects. The DAF device reduced stuttered words about 70%. The DAF/FAF device reduced stuttered syllables about 80%.
Both devices show a small but statistically insignificant "wearing off" effect over time.
The difference between the two studies is the "carryover fluency," or the subjects' speech without the devices. The DAF users had more than 50% carryover fluency. The DAF / FAF users had no statistically significant carryover fluency.
Why did one anti-stuttering device produce carryover but another device didn't? Hypothetically, upward FAF has positive immediate effects but negative long-term effects. Hearing your voice shifted up (sounding like Mickey Mouse) may correct your auditory processing underactivity but make your speech motor activity worse (i.e., make you speak with a higher vocal pitch and tighter vocal folds). If the auditory processing effect goes away when the device is removed, but the speech motor changes are retained, then no carryover would result.
Another hypothesis is that using an anti-stuttering device for practice, rather than wearing it all day, may produce better long-term results.
Using FluencyCoach as speech aid for immediate improvement
For immediate improvement the delay can be set between 50 and 100 milliseconds and pitch shift between -0.5 and 0.5. Try experimenting with different Delay and Pitch on your settings on your FluencyCoach to find the optimal configuration that yields best improvement in your speech.
You can use FluencyCoach with the above configurations as a speech aid when talking on the phone or making a call with your favorite VoIP program, for public speaking, or in any other situation.
Due to the significant carryover fluency rates produced by the combined DAF / FAF, as described above, using FluencyCoach with the settings between 50 and 100 milliseconds can also be a great way to do an autonomous, at home speech therapy, or daily "warm-up" exercises, as in William Perkin's Fluency Shaping Therapy (see below).
You can begin by using FluencyCoach while doing basic reading exercises, such as reading a list of your problem words and sounds.
Reading a poem, a character's part from your favorite play, or a passage from your favorite book is a wonderful way to combine stuttering therapy with enhancing your appreciation of literary classics. A great collection of full-text online English literature can be found at the Gutenberg Project website.
Click here to preview a sample reading exercise program that we have prepared a sample exercise program to help you get started.
Another great way to exercise your speech is by making a phone call to your friends or family or doing so via your favorite VoIP application (such as Skype, Google Talk, Instant Messenger or Microsoft Live Messenger, all of which are compatible with and can be used parallel to FluencyCoach) or by participating in an online chat or conference regularly organized and announced online by speech-language pathologists and persons who stutter. If you are a part of a stuttering support group or participate and group speech therapy, you could schedule weekly online chat sessions with one or several of your peers.
If you do not currently use a softphone or "Voice over IP" programs, you can start with Skype, the most popular and user friendly internet calling software application that lets you talk through the Internet for free. You can talk to anyone else on Skype, wherever they are in the world, and it won't cost you a thing. If the people you want to talk to aren't on Skype yet, you can still make pretty cheap calls to landlines and mobile phones around the world using SkypeOut.
In addition, FluencyCoach is compatible with, and can be ran parallel to most other VoIP applications, including Instant Messenger, Google Talk, Yahoo! Messenger or Microsoft Live Messenger .
Using FluencyCoach as part of Fluency Shaping Therapy
Delayed Auditory Feedback (DAF) and Frequency-Shifted Auditory Feedback (FAF) features of FluencyCoach are used to provide feedback essential in associative stage of motor learning of several distinct skills identified as deficient or underdeveloped in persons who stutter and targeted by the fluency-shaping therapy.
Many speech language pathologists, fluency specialists and speech clinics use Delayed Auditory Feedback (DAF) in conjunction with Fluency-shaping therapy to establish fluency by helping a stutterer maintain perfectly paced, steady, mentally effortless, slow speaking rate, or slow closed-loop speech motor control.
The user's speaking rate can be adjusted via adjusting the auditory feedback delay. A typical protocol is to train a stutterer to use closed-loop speech motor control with a 200-millisecond delay and one to two seconds per syllable. The stutterer practices this until he is 100% fluent. That usually takes only one or two therapy sessions.
When the stutterer can speak 100% fluently, the speech-language pathologist then has the stutterer use one- or two-second stretched syllables without DAF; in increasingly stressful situations; and with DAF adjusted for faster speaking rates. The stutterer must stay on-target with 100% fluency, or go back to using DAF at 200 milliseconds and a slower speaking rate.
Typically, a 100-millisecond DAF delay is used with half-second per syllable stretched speech, a 75-millisecond delay is used with quarter-second per syllable "slow normal" speech, and a 50-millisecond delay with normal speaking rate.
The well documented Perkins' Fluency Shaping Therapy used Delayed Auditory Feedback for similar purposes.
William Perkins believes that stuttering is a discoordination of phonation (vocal fold vibration) with articulation (lips, jaw, and tongue) and respiration (breathing). He believes that stuttering is a disorder of timing.
Perkins' therapy develops compensatory skills that enable stutterers to talk fluently. Stutterers can't use all these fluency skills in every conversation. Using fluency skills demands attention and mental effort. He recommends that his clients use these fluency skills in difficult speaking situations. The rest of the time, they talk spontaneously. For some people the fluency skills become habitual and effortless. But for most people, only parts of the motor skills become habitual. Still, this produces improved, if not perfect speech.
Because Perkins believes that stuttering is a disorder of timing, his therapy emphasizes slow speech. The therapy uses delayed auditory feedback (DAF) to aid a very slow speaking rate of about two seconds per word, or 5-10 times slower than normal speech. You don't stutter when you talk this slowly. You start with reading out loud, then use slow speech in conversations in the speech clinic. You don't use this slow speech outside the speech clinic.
After establishing extremely slow, fluent speech, you work on five "breath flow" motor skills. These are:
1. Phrasing. You limit your phrases to 3-8 syllables. This is prevents running out of air.
2. Phrase initiation. You start each phrase with an easy vocal onset. In other words, you relax your vocal folds on the first sound of the first syllable.
3. Soft contact. You articulate consonants softly, keeping your lips, tongue, and jaw relaxed.
4. Breathy voice. This is a soft or breathy speaking style.
5. Blending. You maintain a continuous airflow from the beginning of each phrase to the end. You blend each syllable into the next.
This slow-motion speech produces a monotonous, droning speaking style. You then work on adding inflections, intonations, and emotions to make your slow speech sound normal.
When you master these fluent speech motor skills at the extremely slow speaking rate, you then work on increasing your speaking rate, while continuing to use your fluent speech skills. The DAF delay is reduced from 250 milliseconds (ms) to 200 ms, or about one second per word. Then the delay is reduced to 150 ms, or about two words per minute. Then the DAF volume is reduced, then one earphone is removed, and finally DAF use is discontinued.
At this point, your speech in the speech clinic is fluent and sounds normal. You are now ready to transfer this fluent speech to conversations outside the clinic. Perkins does this in four steps:
1. Evaluate your speech. You make tape recordings of your speech (or use Record and Playback feature of FluencyCoach), and rate your speech in terms of fluency, rate, breath flow, prosody, and self-con fidence. If you miss any of these targets, you are expected to practice the appropriate fluency shaping motor skills.
2. Speaking hierarchies. This includes rating of speaking situations from easy to difficult. This ranges from conversations in the speech clinic to conversations outside the speech clinic; one-to-one conversations to speaking to an audience; etc. When you can use your fluent speech in an easy situation, you move on to using it in more challenging situations.
3. Social and vocational changes. You are encouraged to take responsibilities at work that require talking, and to participate in social activities that require talking.
4. Prepare for relapse. There are times when your fluent speech will relapse, and your stuttering will return. To prepare for this, your speech therapist has you speak without each of the fluency shaping motor skills, until you stutter. For example, your talk as fast as you can, until you stutter. Then you start again, using your fluency shaping speech motor skills to regain your fluency.
Perkins found that when his clients tried to use fluency skills outside the speech clinic, the fluency skills demanded too much mental concentration and attention. They also found that their speech sounded monotonous and droning. They said, "I'd rather stutter than talk like this."
So his clients stopped controlling their rate and went back to speaking spontaneously. They felt and spoke like normal speakers—at least for a few hours, usually for a few days, sometimes for a few weeks, rarely for a few months, and only once for a few years. They had no control over this spontaneously fluent speech. They could not make it happen, and they could not prevent its disappearance. They called it "lucky fluency."
Perkins at first expected that this spontaneous, fluent speech would become habitual, but it didn't. Perkins concluded that fluency shaping speech motor skills can never become automatic or permanently habitual.
Perkins then changed his therapy goals:
"…those who were most satisfied with therapy were those who found that they could use their fluency skills to warm up each day, and also have them available for emergencies. The remainder of the time they forgot about controls and spoke naturally. This made them vulnerable to some stuttering, but by facing up to their avoidances, stuttering progressively lost its sting. These clients gained confidence in their ability to speak out freely, even though that included stuttering occasionally."
Perkins differentiates two types of speech:
1. "Warm up" or speech exercises.
2. Spontaneous speech.
The "warm up" speech can sound abnormal, or require mental concentration, or use of a DAF device, or software, such as FluencyCoach. None of these "downsides" matter if the "warm up" speech produces carryover fluency or improved spontaneous speech.
Perkins believes that no adult stutterer is ever cured. He concludes that you will have to practice "warm up" techniques every day, to continually improve your spontaneous speech.
To learn more about Fluency Shaping therapy, click here.
Using FluencyCoach as part of Valsalva Control Therapy
"The Valsalva Hypothesis postulates that excessively forceful closures of the mouth or larynx associated with certain types of stuttering, as well as difficulty in phonation, may involve a neurological confusion between speech and the human body's Valsalva mechanism.
Persons who stutter may have learned to activate the Valsalva mechanism in an effort to produce words, as if they were things to be forced out of the body. Such activation is most likely to occur when the stutterer anticipates difficulty or feels the need to use extra effort to speak properly. While this might instinctively feel like the right thing to do, it actually makes fluent speech impossible.
Valsalva Control is an experimental approach to reducing the frequency and severity of stuttering blocks by teaching the person who stutters to relax his or her Valsalva mechanism while speaking. Rather than teaching a new way to speak, Valsalva Control is aimed at recognizing and controlling the physiological forces that interfere with speech. Its goal is not artificial fluency, but freeing the stutterer's natural speaking ability and making speech easier and more enjoyable. No individual Valsalva Control exercise or technique is claimed to be a panacea or an instant ticket to fluency. Valsalva Control is holistic in nature, including a variety of exercises as well as changes in attitudes toward speech and stuttering. Rather than offering a quick fix, it seeks to provide tools for lasting improvement."
The author of "Understanding and Controlling Stuttering: A Comprehensive New Approach Based on the Valsalva Hypothesis" suggests in his book the several ways in which DAF and FAF, such as implemented in FluencyCoach, might promote fluency by affecting the "Valsalva-stuttering cycle."
Using FluencyCoach as part of Stuttering Modification Therapy
Stuttering modification therapy, primarily associated with Charles Van Riper, holds as its primary objective, rather than eliminating stuttering, the following goals: to modify your moments of stuttering, so that your stuttering is less severe; and to reduce your fear of stuttering, and eliminate avoidance behaviors associated with this fear.
The therapy has four phases: identification, desensitization, modification, and stabilization.
During Identification Phase you begin by identifying the core behaviors, secondary behaviors, and feelings and attitudes that characterize your stuttering. The goal is to improve your awareness of what you do when you stutter. To assist with the initial phase, the Recording and Playback feature of FluencyCoach lets you record your speech and play it back so that you may identify and thoroughly analyze your core and secondary behaviors.
During subsequent phases, FluencyCoach can be very useful in allowing you to recognize and freeze your core behaviours, learn and practice pullouts and cancellations, and to solidify your speech improvements.
Additional resources
We've assembled a short list of online resources to help persons who stutter, parents of children afflicted by dysfluency and speech language pathologists to better understand and treat stuttering. Please let us know if you have, or know of, a relevant website that we've missed. Click here to see our list of additional resources.