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: 141.51.15.7
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: 199.238.253.14
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: 141.51.15.58
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 info@bioservices.com. 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: 134.29.30.79
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: 141.51.92.7
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: 207.109.214.2
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: 141.51.92.7
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).