The presenter of this paper, A long term evaluation of a computerized biofeedback therapy has consented to have a personal email address posted here if you wish raise further questions and/or comments. Alexander Wolff von Gudenberg - AWvGudenberg@kasseler-stottertherapie.de Welcome From: Alexander Wolff von Gudenberg Date: 10/1/98 Time: 2:11:58 PM Remote Name: 18.104.22.168 Comments Hello to everybody, I hope you like this paper and give some comments or questions. With warm regards Alexander Wolff von Gudenberg Psychological element introduction, home follow-up, etc. From: Gunars K. Neiders, Ph.D. Date: 10/2/98 Time: 4:50:22 PM Remote Name: 22.214.171.124 Comments Dr. von Gudenberg, I really enjoyed reading your paper. I liked the visual feed back provision of your type of therapy. I am also intrigued by the aspect of giving the individual the follow up therapy. Now a few questions: 1) Inclusion of cognitive behavioral psychology: You state that: "It is interesting to note that the clients, who attribute their stuttering to physical causes have better long term results than the clients who attribute their stuttering to psychological causes." Assuming that the client knows what he or she is talking about, are you trying to introduce more psychological counseling for those clients that self- report that they believe their stuttering is caused by psychological factors. Granted that searching for a cause a la psychoanalysis is counterindicated, don't you think that cognitive behavioral therapy, such as rational emotive behavior therapy would by highly beneficial for these clients? 2) Cost of treatment: How expensive is your treatment? Maybe we could get the American Insurance Companies pay for a European vacation, eh? :-) On the serious side, is the software commercially available? 3) Who has developed the treatment software? Where can I find out what elements are measured? tension? speed? abruptness of onset? 4) What is the length of follow up that you expect to do on these people? 5) Do I understand right that the software, after initial payment, can be used by the client indefinetely at little or not cost? 6) In your own opinion judging from your experience, how many hours of practice per week would the client have to need in order to keep his relative fluency? In the first year? In the second? In the third? 7) After reading Dr. Starkweather's paper on the myth of relapse in this same forum, do you believe that the therapy voice of your clients is obnoxious enough or too stressful to be continued indefinetely? 8) Do you think that learning your system of speaking the client would go through the classical stages of learning 1) unconscious incompetence, 2) conscious incompetence, 3) conscious competence, and 4) unconscious competence? Or do you think that the client will always have to consciously employ the technique? Re: Psychological element introduction, home follow-up, etc. From: Alexander Wolff von Gudenberg Date: 10/4/98 Time: 7:03:01 AM Remote Name: 126.96.36.199 Comments Dr. Mr. Neiders Thank you very much for your interest in our work. I am looking foreward to get to know to you very soon to discuss all these issues in more detail. 1. At this point of the study we don`t use the data generated from the questionaires used in the study for differential diagnosis in order to treat the clients more individually. Maybe we will get more criterions in the future in the ongoing study, so we can think about this. Besides this I am convinced that even the clients who distributes their stuttering prior to therapy to psychological factors benefit more when working directly on the speaking behaviors in the first place instead of doing psychotherapy. About 1/3 of them had all sorts of psychotherapy before, some - just like me - even psychoanalysis. It did not change their stuttering at all. I have no experience with cognitive behavioral therapy so we donęt use it. I strongly believe that even a very good psychotherapy will not change the clients attitude so completely as the breakthrough of gaining speech control. That is what we see in our clients and what I experienced myself. The challenge is to keep this speech control on a high level. I had the devastating experience of relapse three times after a PFSP course. It was because of this that I started working with the software. In this visual biofeedback approach I saw the chance to improve the maintance substantially. Firstly by long term exercising at home and secondly by offering refreshers as part of the therapy on a regular basis. We donęt see in our clients that the tendency to go back to stuttering is mainly because of the burdon of sounding unnatural. It is more because they are loosing the motor skills due to lack of practice after relying too much on spontanous fluency. We stress from the very beginning and especially in the enthusiastical period at the end of the intensive program that setbacks are part of the therapy process and that this is no reason for panic. After these setbacks the crucial parts of the therapy really starts, because only the experience of regaining control after these periods is the basis for long term success. This is the major difference to the known fluency shaping programs which I mainly distribute to the new possibilties the software offers. To support this development in the clients we already integrate desensitizing elements in the intensive course. The clients have to use the new speech pattern very exaggerated on the phone on the streets and at home over and over again in many situations. They use tape recorders to evaluate their perfomance in these situations and to get used to their new speech. Most of them understand that the more they risk to sound conspicuous voluntarily in some situations the more they can vary the new speech pattern and the more they can sound natural in other situations. 2 ,3 and 5. Right now the Kasseler Stuttering Therapy is a university study, so we donęt take much money from the clients ( 500 DM). According to the German distributor Bioservices the software is available in an english version very soon. For more information about the software please contact firstname.lastname@example.org. They will also give you technical information. As far as I know you can get a demoversion very soon. When I come to Seattle next months I will demonstrate for you the program on a laptop. Maybe I can even bring the demoversion with me. I will ask the distributor. Than you can see end evaluate yourself the possibilities of the program and what elements are measured. With warm regards Alexander Wolff von Gudenberg (I will come to the US this month between the 23 rd of October and the 7th of November to visit people in different places like Chicago, Norfolk, Alabama, Boulder, San Francisco. If other people are interested in our study please contact me, maybe we can arrange a meeting). 4. We donęt know the best lenght of follow up exactly yet. We will take data for at least two years. My guess is nevertheless that one year of strucured maintance is enough. After this period it is up to the clients how they organize their maintance. It is important that they have a network of self organized self help groups in their regions at the option to participate in a refresher whenever they need it. Even "successful" clients tend to come to refreshers, because they feel they are on the safe side then. 6. In the first six months the clients agree to practice half an hour a day. In the next six months about twenty minutes most days of the week but not everyday. In the second year the client have to decide how much time he spend exercising per day. Some use the new speechpattern so constantly that they only need very few exercising on the PC. These are mean data of the whole group of all clients. Of course there are single clients who do not practice at all from the very beginning, but there are also clients who practice 2 hours (!!!) a day. Both are rare exceptions. We introduced a contractsystem on a token basis to support the home training. The clients send us their data of home exercising on a floppy disk, which worked quite good. So we really get a good overview how the clients are working at home and what we see is encouraging. This data and the objective and subjective data strenghten our believe, that the concept is working. 7. and 8. As already said above it is not the aim of our therapy to achieve normal sounding speech. Some clients with mild or moderate stuttering can achieve this. But the more severe stutterers like me always need to use the new speech pattern in a more exaggerated manner. This includes that it will always require a certain level of conscious efforts to stay in control. It is not realistic to reach the level of unconscious compentence. I believe a chronic adult stutterer will always remain a stutterer and even if he sounds normal this always needs a constant effort. Let me add two final personal statments: If the investment /gain ratio is okay most stutterers are more than willing to do bring this investment of practicing on the PC and speaking in a new obviuos speech pattern, because getting rid of the devastating unexpected control losses is a gain all stutterers are striving for. My personal belief as a stutterer who had a dozen uneffectice programs is that all stutterer are desperately wanting better control of their speech. They don ęt want to stutter differently or more controlled they simply want to speak more fluently with a feeling of control. Very few dare to say this due to their repeated failings in therapy and the therapeutic climate at least in Germany. Differential Diagnosis From: Judy Kuster Date: 10/15/98 Time: 8:58:47 AM Remote Name: 188.8.131.52 Comments I appreciated the reinforcement that a diagnostic interview with a client should include much more than an interview in the therapy room. I like your ideas of extending the diagnostic to more real-life situations such as interviewing people on the street and telephoning strangers. I also appreciate the differential diagnosis clues you shared to help determine which clients might profit more from a precision fluency shaping approach. Would you say those differences you discovered could be used to determine from the outset the client who did not profit at all and the 8 who did not make as much progress as the other 23? Re: Differential Diagnosis From: Harald A. Euler, University of Kassel Date: 10/20/98 Time: 3:46:02 AM Remote Name: 184.108.40.206 Comments Judy: Clients who assumed a physical cause for their stuttering (N=12) had better fluency results than those assuming a psychological cause (N=14), with a p=.048 in the t-test and a d (effect size) of .83. This is a strong effect and could thus be a good prognostic criterion. With respect to subjectively evaluated therapy effect the differences were not as great (p=.17, d=.57). The sample sizes are too small and not all data in yet, so I wait with further judgement. However, the variable of assumed cause for stuttering is confounded with amount of disfluencies: Strong stutteres tend more to assume physical causes than than less strong stutterers. We need to disentagle these effects (e.g. with a regression and a t-test on the remaining Y-intercept). So much I can say: If the client stuttters heavily and assumes a physical cause for his stuttering, (and if he is male), he is most likely to profit from our precision fluency program. (For sex the effect sizes were thus: d=.59 for objective and .48 for subjective success, but not significant due to small number of woman (N=6) in the program. Client's motivation From: Heidi Thorson Date: 10/19/98 Time: 12:13:16 PM Remote Name: 220.127.116.11 Comments Dr.von Gudenberg, Your study and results on computerized biofeedback therapy was exciting and encouraging to read. I was curious to know if there was a correlation between the client's motivation (which was determined during the diagnostic procedures) and their success with your program. Re: Client's motivation From: Harald A. Euler, University of Kassel Date: 10/20/98 Time: 3:56:14 AM Remote Name: 18.104.22.168 Comments Heidi: We did not assess pre-therapy motivation in the sense of asking which hurdles the client would be willing to overcome to get therapy, or to assess his 'determination' in any sense. We did, however, find positive correlations between amount of disfluency at onset, attribution of own stuttering to physical instead of psychological cause, and sex (male) on objective and subjective therapy effect. (See my answer to Judy Kuster for a few more details).