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 behaviors 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 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 paper I will explain how teletherapy can broaden the scope of therapy for adolescents and adults who stutter.

Background

Teletherapy is not new to speech therapy. It is used in Aphasia-Apraxia treatment (Connors, 2010) and for distance delivery of stuttering treatment (Lewis, et. al., 2008; Wilson et. al., 2004; Sicotte et. al., 2003; Kuly, 2000; Harrison et. al., 1999). The American Speech Hearing and Language Association (ASHA) has been studying its application since 1998 leading to position papers (2005; 2010). Teletherapy was discussed by Janet Brown, Director at ASHA Health Care Services at the ASHA Conference in 2007(http://presencetelecare.com/speech-therapy-telepractice/janet-brown-of- asha-on-telepractice) .

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 changing therapeutic procedures for teletherapy. I began using teletherapy 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 for 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, Bulgaria, Canada, China, Ecuador, Egypt, France, India, Israel, Kuwait, Malaysia, Mali, Mauritius, Nigeria, Norway, Pakistan, Romania, Russia, Slovakia, Sudan, Sweden, Turkey, the United Kingdom, and USA.

Issues of Ethics

Teletherapy must comply with standards equal to 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 to 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 location 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 or religious 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 my clients and I share of wanting the experience to be successful has a positive impact on service delivery.

Technical Requirements

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 make it difficult for me to evaluate what the client is doing and 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 the ability to video and audio record clients with an option for immediate playback.

I tried out a handful of companies that offer video conferencing solutions with white board and file sharing that are Mac compatible, 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 online 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. 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 personally prefer using a headset with an attached microphone during treatment. However, some of my clients do not use one. The necessity depends on the quality of their built in hardware.

Appropriate Population

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 speak 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 can speak in their native language with family or friends who sit in on sessions.

Participation Procedures

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 technical 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 1/2 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 for both clinician and client. 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. Stuttering Online Therapy is divided into four stages:

Stage 1 - Focus on understanding speech production, and doing activities to change the way you speak and relate to yourself as speaker
Stage 2 - Heightening awareness of speech processes with repetitive exercises in normal connected speech while creating new thoughts and setting goals
Stage 3 - Etching the process of the new way of producing speech in procedural memory while gradually increasing use of new process at will in real life.
Stage 4 - Using the new way of producing speech automatically in real life as part of the subconscious self.

Roughly speaking, Stage 1 & 2 takes 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 minimal direction and continue on their own. Others work through a particular 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.

Pros and cons

I recently asked over 30 clients to write what they think are the pros and cons of online treatment. The following is a summary of clients' perceptions:

Pros:

• Extremely convenient - #1
• Don't have to travel
• More open and casual then the formality of going to an office
• Practicing in a familiar place feels relaxed, makes easier to continue self-practice and make changes
• Easy access to the instructor
• The best therapy I've had is available from all over the world
• Gives a feeling as if the other person is in the same room
• Easier to have frequent therapy sessions if needed
• Saves travel expenses
• Feels immediate, and is like being face to face
• Feels identical to when we met in the same room
• Therapy is structured with exercises and goals I can do alone
• Good hours for people who work
• Payment online with credit card

• Glitches with the technology - #1
• Expensive in some countries
• English should be very good
• Initially hard to trust course presented online
• Personal interaction is missing

Summary

Teletherapy is new delivery option for stuttering treatment. While the technology is still not always reliable, it is already being used with high client satisfaction. As advances are being made in how to successfully treat stuttering, teletherapy is an important option to ensure that people all over the world can receive high quality treatment from a clinician who has vast experience and knowledge in this field.

References

American Speech-Language-Hearing Association. (2010). Professional Issues in Telepractice for Speech-Language Pathologists [Professional Issues Statement]. Available from www.asha.org/policy.

American Speech-Language-Hearing Association (ASHA). (2005). Speech-language pathologists providing clinical services via telepractice [Position Statement]. Available from http://www.asha.org/policy

Connors, W.A. (2010). Changing the Landscapes of Aphasia, presented at Maryland Speech Language Hearing Association Annual Convention, Towson, MD.

Dahm, B. (2007) Dynamic Stuttering Therapy. Glen Rock, NJ: CTI Publications.

Grogan-Johnson, S., Alvares, R., Rowan, L., & Creaghead, N. (2010). A pilot study comparing the effectiveness of speech-language therapy provided by telemedicine with conventional on-site therapy. Journal of Telemedicine and Telecare, 16(3):134-9.

Harrison, E., Wilson, L. & Onslow, M. (1999). Distance Intervention for Early Stuttering with the Lidcombe Programme, International Journal of Speech-Language Pathology, 1, 31-36

Kully, D. (2000). Telehealth in speech pathology: Applications to the treatment of stuttering. Journal of Telemedicine and Telecare, 6, 51-58.

Lewis, C., Packman, A., Onslow, M., Simpson, J., & Jones, M. (2008). A phase II trial of telehealth delivery of the Lidcombe Program of early stuttering intervention. American Journal of Speech-Language Pathology, 17, 139-149.

Riley, G. (1994) Stuttering severity instrument for children and adult: 3rd ed., Austin, TX: Pro-Ed.

Sicotte, C., Lehoux, P., Fortier-Blanc, J., & Leblanc, Y. (2003). Feasibility and outcome evaluation of a telemedicine application in speech-language pathology. Journal of Telemedicine and Telecare, 9, 253-258.

Wilson, L., Onslow, M., & Lincoln, M. (2004). Telehealth adaptation of the Lidcombe Program of Early Stuttering Intervention: Preliminary data. American Journal of Speech-Language Pathology, 13, 81-93.

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