Sarah James is a Research Post-graduate at the Department of Human Communication Sciences, University of Sheffield. She is currently completing her PhD, in which she has conducted a series of studies into investigate the personal and social impacts of the telephone for people with stuttering impairment. Sarah works under the supervision of Dr Shelagh Brumfitt.
Introduction
How many times have you read a book or article which states that, 'people with stuttering impairments have difficulty using the telephone?'
Although this statement is made frequently, we have very little information about the personal and social effects upon the individual and the ways in which therapy can help in telephone conversation.
Many of the behavioural approaches to using fluency techniques emphasise speech in a face to face conversation. Often just achieving fluency in a face to face conversation is such a huge challenge that success in this context may seem like the only therapeutic objective.
Yet, we have increasingly sophisticated ways of communicating, with a reported 63 percent of the population regularly using mobile telephones (Guardian Newspaper, 2001) and ownership of a home telephone being the norm. The Office for National Statistics reported that the number of household telephones owned in Great Britain had risen to 95% of the population by the year 1999 (Social trends, 2000). In addition we are expected to 'talk' to machines more routinely, such as speaking into security systems in order to gain entrance into offices or apartments.
All of this assumes an ability to use the telephone, but in reality we know that some people may find this difficult. In particular, people with hearing impairments, dysphasic speakers and people with stuttering impairments may experience great difficulty with this form of communication.
Speech and Language Therapy, using the telephone and having a stuttering impairment
Over the years people have told us about their feelings on using the telephone. Here are some examples below.
'I once made a telephone call to enquire about something and the person on the 'phone thought I was making a nuisance call because I blocked and couldn't get any words out'
'I just hate using the 'phone, particularly if someone else is in the room, I cant bear to have them hear me speaking'.
'I have to stand in a certain way at the bottom of the stairs, with one foot on the first step. If I do this, then I feel the conversation will go well'.
Our concern was that we often seem to implement telephone use in transfer programmes without a full understanding of what is involved in the communicative process in making a telephone call, and what attitudes people with stuttering problems actually have towards using the telephone. Although many books and papers refer to the use of the telephone and the special difficulties this may create, there remains a lack of an elaborated literature on this subject. Given the continually increasing prevalence of telephone use, it seems time to develop a further understanding.
What do we know about telephone use?
We know that the telephone plays an important role in the psychological well being of the individual.
Aronson (1971) suggested that, within an urban setting, the telephone reduces loneliness and anxiety, increases feelings of security and maintains cohesion with family and friendship groups. Ball (1968) notes that in societies where family and friends are increasingly dispersed, the telephone both facilitates and compensates for this dispersal. Dimmick, Sikand and Patterson (1994) looked at the use of the telephone and demonstrated sociability as a major factor in this. This included, 'socialising with family and friends', 'feeling closer to family and friends', and 'relieving boredom'. Additionally, instrumentality was identified as an important factor; where the telephone was used to find out information or serve some function such as, 'store hours', 'catalogue shopping', 'order things'. Reassurance was also identified as an important function of telephone calls.
Thus, the telephone can play a role in the social support network of an individual and thereby in their perception of their quality of life. If one of the ways in which people make links with each other is fragile, then this may impact upon their view of their quality of life and potentially upon their identity.
What are the special features of telephone conversations?
Although face to face speaking and telephone conversation share many features, we also recognise that there are differences. The most obvious of these is the actual physical difference between telephoning and face to face. Telephone conversations rely only on the auditory channel, thus visual cues in a conversation are missing. The visual clues might be paralinguistic; such as eye contact, which shows attention, is being paid to the speaker. Short, Christie and Williams (1976)also developed a theory which is relevant here; that of 'social presence' where warmth, sociability and sensibility can be communicated. For example, face to face communication has high social presence whereas a business letter has low social presence. Thus, the telephone as an auditory channel may not permit the influence of much 'social presence'.
Although obvious, (unless they are conference calls) there are only two people involved in a conversation. That may or may not put speaking pressure upon the individual speakers. There are greater implications from pauses in a telephone conversation when there are only two speakers. When one person stops talking, then the other person has to pick up the conversation, unless the pause is there to serve a purpose. Hopper (1992) discussed the role of pausing in turn taking signals during telephone conversation and suggested that inter turn pauses may mark disagreements or allow for repair time.
The structure of telephone conversations also requires a definite beginning strategy and an end strategy. Making and then ending a live connection creates this situation, but it also influences the pragmatic style of the conversation. The speaker who has initiated the call has to begin with an introduction, which may include giving a name and stating precisely why the call is being made. It may involve asking for someone else to speak to, again requiring some accuracy. Ending the phone call cannot rely on non-verbal signs, as in a face to face situation, where one of the speakers might begin to move away, or change body position. In a telephone call the end has to be achieved by verbal means, again, precision and formality is required.
Telephone conversations are more likely to be task oriented (Rutter, 1987) than face to face conversations. This may affect the amount of precise information to be communicated over the telephone. People may ring each other for details about social arrangements, or make calls requiring complex information that involves large numbers of turns including questions and answers. Traditionally they could be described as occurring in specific situations, but with the use of mobile telephones, this aspect is not so influential. There are special considerations which need to be given to telephone calls in 'public' places, for example on trains, buses, underground systems many people engage in making a call when other people can hear the conversation.
There is evidence that telephone calls include an understanding of rules of a special form of conversational interaction and a capacity to carry those out.
What do people with stuttering difficulties believe about the use of the telephone?
James, Brumfitt and Cudd (1999) surveyed 223 people with stuttering impairment in terms of their attitudes towards use of the telephone and their use of it. These people volunteered from the British Stammering Association, self help groups and via publicity in the local media. For comparison, 77 completed questionnaires by people without stuttering impairment were used. Data was collected from the PWS that required self analysis of severity of the impairment and also records of the age groups. 71% were aged 45 years or younger; of the total responses, 68% were male and 32% female. The self rating of the stuttering showed that 31% respondents considered themselves 'mild', 41% 'moderate' and 10% 'severe'. A great deal of information was gained from this study and a short report of it will be given below.
Results showed that making a telephone call was judged to be more problematic than answering a telephone call. Avoidance behaviours, such as writing or using alternatives to the telephone, or asking someone else to make a phone call, were reported more in younger than older stutterers. People who rated their stutter as 'severe' reported using the telephone least frequently. PWS were much more likely to plan a telephone conversation, than people who did not stutter. From a total of 223 questionnaires returned, 14 respondents stated they found no difference between telephone and face to face conversation. 30 reported that they found telephone conversations easier than face to face. 148 reported that they found telephone conversations more difficult than face to face. Analysis of their response to this open question is summarised below.
Reported reasons for the telephone being more difficult (James, 2001)
Those who reported the mobile to be less easy stated that it was because of; increased pressure due to feeling it was an expensive way to communicate, there was less likelihood of being heard, there was a chance of being cut off, there was a fear of being overheard, background noise was off-putting, the instrument was smaller and there were no wires to play with.
Out of the total group of respondents who were PWS, 15% reported that current or past Speech and Language Therapy had provided specific telephoning help; 39% reported it had been part of an overall therapy approach and the remaining 46% reported no help at all with telephoning.
What are the implications of this for therapy?
Clearly, there is plenty of evidence to show that PWS have special difficulties with using a telephone and that these fears associated with using the telephone can build up over time. It may be necessary to spend time with the individual talking through aspects of avoidance behaviours that may need to be changed before embarking on actual telephoning strategy and techniques. The younger group in the above study reported avoidance of telephoning and this evidence needs to be taken into account in the future. Cook and Fry (2000) also refer to the effects of attitudes upon responding to hearing the telephone ring. In their paper (Cook and Fry, 2000) they discuss the typical 'vicious circle' that adolescents may get into in relation to communication contexts such as telephoning.
Desensitisation is an approach to helping people cope more effectively with the telephone, with behavioural hierarchies developed on a case-by-case basis. For the PWS with very great fears about using the telephone, then work on holding the telephone without even attempting to speak, must be the first step in the process. It may be necessary for the individual to practise holding different types of telephones with no speaking attempts and practising this in different contexts, such as indoors, or outside with a mobile and so on. Thus any fears about the instrument itself may begin to reduce.
In addition, it may be useful to work out strategies which may help the individual feel fluent speech is more likely to occur, such as Kehoe's (1999) suggestion that using a mobile phone and walking around while talking may facilitate better fluency.
We do not have comparative information about the effectiveness of different fluency techniques for telephoning, so we need to advise the individual that the critical aspect lies in the ability to apply the technique to telephoning. Practise of technique as a separate activity is necessary before applying it to the telephone, as fluency proficiency is critical in a situation where speaking is the only channel for communication.
One of the most important findings from this survey is that there is a difference between initiating a telephone call and answering a call and that these activities require different communication skills. Initiating a call permits the PWS an opportunity to prepare at least part of the conversation, whereas answering the call is much less predictable. Kehoe (1999) advises planning before making a call on the premise that PWS are more fluent on planned speech than spontaneous speech. For people who find answering the telephone especially difficult then repeated practice in role-play activities may enable the individual to cope better. Repeated practising of answering the telephone can be constructed (asking a family member or the therapist to make a series of 10 calls asking the individual only to practise lifting the telephone and answering is a first stage task). Peins (1984) in a series of practise tasks created a tape-recorded telephone ring which the individual could practise responding to and the advice given here is that 'it may require many hours of patient practice'.
The British Stammering Association (www.stammering.org) runs self help groups by telephone allowing networking and support by this means, and also opportunities for practising telephone conversations in a supportive situation. Conferencing calls are made using small groups of people who can get to know each other over the telephone.
Finally, the survey noted the differences between people who were in the older age groups and the younger group. It is important to note that maturity appears to have an influence upon reactions to using the 'phone, which may have allowed the individual to cope better with the anxiety and also develop a personal strategy for speaking.
Final comment
We cannot underestimate the importance of telephone conversations. Even with email as an alternative communication route, the telephone is still essential for our daily lives. More research needs to be undertaken to explore factors which may contribute to successful and unsuccessful telephoning for PWS, so that applications can be made to current clinical practice.