Wednesday, February 04, 2009

Don't believe in IPhone

IPhone is definitely a very cool device, but is it useful in stuttering treatment? The Hollins Center has a press release out: see here. They claim that they use the IPhone successfully to monitor speech targets. StutterTalk has an interview with Prof Webster: see here. They have asked very good questions (some from myself! :-) and Prof Webster did a good job in answering. 

I am convinced Hollins will drop or limit the use after a while even though I agree with them that in principle it is not a bad idea to get more objective feedback. I have seen the phenomena time and time again. Failing to get high tech working in real life. Here are the facts: it is very difficult to record in noisy environment unless you spend a lot of time to fine-tune to an environment, but you have to do it for all environments. And you have to hold up the IPhone to record, which is very artificial. So you need to work with microphones. And then the measurements. I am sure that is not very stable as well with significant error bars. The costs of using the technology far outweights the benefits. So at the end of the day, they might use it as a recording tool and listen to the recorded speech! Trust me: I always prefer low tech whenever possible. Why? Because I understand high tech! Every time I tell hyper excited people to stop using or developing high tech and go for low tech whenever possible, they do not listen. So I must let them waste their time, and every single time I ask them a few months later, they have stopped using it...

On the other hand, it is a brillant marketing campaign; attaching it to the icon of the day the IPhone. The press release is all over the internet and I am sure their web traffic will benefit for a long time. It is not about the device but about attracting attention to the center. I am also concerned by the statement they make on the main page.
98% of HCRI program graduates say they would recommend this advanced stuttering therapy to others who stutter. 93% of clients attain normal levels of speech fluency by the end of our 12-day day program.
Isn't it a bit misleading because the relevant measure is long-term success not the short-term? First, it is obvious that people would recommend a therapy. They are fluent and have seen the Hollins therapists working hard and honestly. Second, based on my own outcome research, I know of another fluency shaping therapy, the Kassel Stuttering Therapy, with similar numbers after 3 weeks. Virtually everyone was virtually fluent. Unfortunately they dramatically worsen after one year. And we should not forget that they knew that they were recorded, imagine how the results are if you are recorded secretly. So they should go for long-term measures. I am not saying the therapy is not helping. I am just saying that long-term is what they should talk about.

19 comments:

Anonymous said...

Does anyone use text to voice device (TTD-Telecommunications for the deaf)? It seems that it could solve some of the practical difficulties with using a phone?
Lynne

Greg said...

The core issue w/ fluency shaping has been, and will always be, that it attempts to modify the symptoms of an unknown pathology. It's trying to shape the output, without knowing or caring what is creating the output in the first place.

It's a nifty prosthetic implementation, and I expect that a bluetooth headset would make it usable in daily living. But with that said, it'll take a whole lotta dedication and effort--and will likely require constant attention (for the rest of one's life) to shape a variable & dysfunctional output.

Greg
http://Stuttering.me

Ora said...

Greg wrote "The core issue w/ fluency shaping has been, and will always be, that it attempts to modify the symptoms of an unknown pathology."

I don't see how that's a problem. There are plenty of effective remedies for maladies whose pathology is unknown or partially unknown. It's not necessary to fully understand the etiology or the mechanisms of a pathology in order to be able to remedy its effects.

This is true in many realms of medicine. If you look at the prescribing information for drugs for example, you often see a statement like "the underlying causes of this condition are poorly understood". Yet the drug works.

Treatment for symptoms can often be effective even without knowing or understanding the underlying disease process that's causing the symptoms.

Greg said...

Hi Ora,

Thanks for your questions--I may not have been clear.

Fluency shaping is behavioral. In other words, it only acts when we purposefully perform the behavior. Our biology is stuttered; we--by nature--produced stuttered speech. So in order for fluency shaping to work, it will result in a lifetime of purposefully performing a conscious behavior.

Your analogy of a drug working when we don't know the mechanism doesn't exactly hold in that regard. First, drugs will have side effects. Second, drugs can work entirely unconscious of purposeful effort.

Thanks for the opportunity to clarify.

Ora said...

Greg - you wrote "So in order for fluency shaping to work, it will result in a lifetime of purposefully performing a conscious behavior."

I don't agree. Consider any learned behavior. At first it's deliberate and conscious, and requires effort. But then it can become more and more second-nature and automatic and unconscious.

In my own case, as an amateur pianist, I reach for an example regarding playing piano. A pianist first will have to concentrate hard to play a scale, or to play a piece of music. Then he will get better, and better, and better, and at each step there will be less and less conscious effort. It's similar to learning a sport: at first it requires conscious effort, but gradually it becomes unconscious and less effortful.

In fact - I'm speculating here, but it's plausible - it's quite possible that motor-behavioral skills (such as fluency shaping, playing a scale, or playing tennis) induce some neurological changes so that they become truly automatic.

I don't accept the proposition that fluency shaping requires conscious effort througout one's life. It's tough at first. It requires concentration. But with sufficient practice and effort, it can become automatic and unconscious. It's not easy, but it's quite possible.

Greg said...

Hi Ora,

You're more than welcome to believe what you want to believe. SLPs and others have believed exactly what you cite for decades, so you're in good company. The problem is that there has been no change or improvement relative to long-term success rates. So in this case, your beliefs are not in agreement with the data. If these treatments were so effective, then nobody would stutter. It's that simple.

William Perkins even published a mea-culpa in the National Stuttering Association's "Letting Go" newsletter, where he admits that while these fluency shaping techniques may work, they never seemed to become automatic.

But let's not let data or reality get in the way of our beliefs. Things just get messy when that happens.

Greg
http://Stuttering.me

Anonymous said...

Greg -
http://Stuttering.me

It appears you believe you are quite the expert on fluency shaping and its effectiveness (lack of). I understand you have your PhD in speech, and I took a little time to listen to part of a podcast recently.

I'd be interested in your sharing of definitive data, research and studies regarding the effectiveness of stuttering modification techniques with adults and, even more importantly, children who stutter.

As well, in the articles you reference in the NSA, Perkins also indicates the professional experts "don't have a clue about what causes stuttering." Is that what you teach in classes?

Don't mind the mess. After the mess, it's easier to get rid of all the BS produced.

Greg said...

I'm not sure what it is that you're saying, so it's hard to really reply...

But in a word--yes. I am utterly convinced that most "stuttering research" is lost. And the tragic thing about it is that the 'lost researchers' (so to speak) don't know that they're lost.

Perfect example--the vast majority of SLPs and "stuttering researchers" still seem to believe that stuttering is solely a speech disorder. ...When there is a century of data that apparently confirms otherwise.

But under the misbelief that stuttering is a speech disorder, it leads people to create false definitions and false understandings of the pathology. And when you ask the wrong (or invalid) scientific questions, you get false & invalid (i.e., uninterpretable) results.

And that's what we've been getting for decades.

If you read the Bloodstein text, you'll read that there have been hundreds of stuttering therapies that all claim success. Yet--clearly, they all have failed. The continued prevalence of the disorder speaks to the invalidity of these results.

At a recent ASHA convention, I sat in a lecture where a very well respected stuttering researcher cited that 15% of treatment outcomes can be attributed to the actual speech therapy used. Think about that for a second--one can use stuttering modification, fluency shaping, hypnosis, whatever--and they can all get similar results. Tom just posted as such the other day on his Lidcombe post.

Neuroimaging sure is neat. But it's only another facet (or characteristic) of the phenomenon. And trying to interpret what's actually going on (even with our best functional imaging techniques) is akin to trying to decipher satellite photography. The soviets thought there was a secret bunker in the center of the Pentagon (it was a hotdog stand), and the world thought that Sadam had nukes. The data seems contrary in both examples.

James said...

Greg said:
"And the tragic thing about it is that the 'lost researchers' (so to speak) don't know that they're lost.

Perfect example--the vast majority of SLPs and "stuttering researchers" still seem to believe that stuttering is solely a speech disorder. ...When there is a century of data that apparently confirms otherwise."

so Greg...if you are an SLP/speech professor...what do you teach in your classes, do you teach the truth (because that would be blasphemy). That Stuttering research is BS and everyone is lost.

And if stuttering is not a speech disorder, what is it? We know that stuttering is not psychological, is it neurological?

Also, what about stuttering caused by "forced left hand to right hand switch"

I have a serious headache reading all the comments. Help!

Who are the lost researchers? Any researcher out there who is not lost....

Greg said...

I'm podcasting both my undergrad and grad stuttering courses. Go to http://stuttering.me for the XML files. :)

Anonymous said...

Ora,

You said:
"I don't agree. Consider any learned behavior. At first it's deliberate and conscious, and requires effort. But then it can become more and more second-nature and automatic and unconscious."

This is true for your amateur piano-playing, and for things like riding a bicycle, but with fluency-shaping techniques, the situation is not so simple. Consider this extreme example: A stutterer practices his fluency-shaping technique for 12 hours a day, 7 days a week for 1 month - but he does it in privacy of his own home and with nobody to listen. At the end of that month, his technique will have become second nature. But as soon as he goes out into the real world, and uses his technique to talk to his boss or make a phone call, the fear of stuttering will take over and he will stutter. This is why fluency-shaping techniques are usually accompanied by transfer tasks - i.e. use the technique in real-life situations. At the end of an intensive therapy which includes fluency-shaping and transfer tasks, a stutterer will become fluent. But why do so many of these "cured" stutterers relapse in the medium to long term - even though the technique may become "second nature"?

I believe it's because these fluency techniques are a kind of avoidance strategy. Sure, the right-hemisphere of the brain is recruited to help the left-side (which usually contains the speech centres), but you are actually avoiding speaking in your normal way. So you are not adequately coping with the fear of stuttering, and the stuttering fear lies latent in your subconscious. Life is full of situations that provide cues that can trigger the old response pattern called stuttering and, one day, such a situation may trigger the stutter and you will relapse. I've seen it before (it happened to me); people may internalise the technique, but the stutter returns with a vengeance, and the recovering stutterer will need "maintenance".

I believe that the most effective way to deal with a stutter is to treat is as a phobia. Speak as much as possible and in as many challenging situations as possible, using your normal speech. Use a technique, but only to "smooth out" any large block you may have. You won't get the instant fluency that you get from a fluency-shaping technique; in fact, this method is extremely difficult. But if you manage to stick with it (and not everybody can), you will attain a good level of fluency, and with no maintenance required.

George

James said...

To Greg, I tried to listen to it. But I had trouble hearing, and the quality can hopefully be improved.

Pretty sure I am not the only one who wants to hear, but have trouble. Why not Youtube like Gary R. at Duq. Univ. Thanks

Adrian said...

Ora/Greg,

As a Hollins graduate, I'll simplify this argument. Ora, I agree with your arguments in principle, but in my experience these techniques simply don't work very well. I attended the original three-week session and I kept up with all but two of my original group of ten after the course. I believe all but one of this group was considered fluent after the end of the course, yet all were stuttering at pre-course levels speaking with me on the phone a few weeks after we left the safety of the clinic. For me personally I was 100% fluent in the clinic following therapy, but I was still stuttering severely across the street at Hardee's ordering a cheeseburger.

Tom is correct to question these misleading success rates. It is very easy to produce fluent speech and have positive viewpoints immediately following therapy. It is another to have continued fluency in all situations after being away from the clinic for a length of time. Hollins has used these misleading statistics as the cornerstone of it's marketing and it's economic success for decades.

Adrian

ig88sir said...

I am a Hollins graduate as well. I took the 3 week intensive course and I honestly feel that it is a joke. Most stutterers can be relatively fluent inside the clinic. Even doing outside contacts with other stutterers is easier than alone. The fluency shaping sounds abnormal as well. I am a Mcguire gradate as well and am friends with many Mcguire people but I have to say that the technique does not hold up in the real world at all. Last Hope? Zeprexa Zydis prescribed by Dr. Gerald Mcguire. Should be on it in 2 weeks...BTW I was on the pagaclone trial 2 study for 1 year with no perceivable speech gains..

Eric said...

ig88sir: You say that Dr. Maguire is prescribing Zyprexa Zydis for you.

I'm curious why he chose that drug. I believe there are several drugs that he sometimes prescribes: Geodon (ziprasidone), Abilify (aripiprazole), Selexa, and Zyprexa (olanzapine).

In your consultation with him, did you and he explore the relative merits and side-effects of the various drugs? How did you settle on Zyprexa?

I'm very interested in hearing more about the drugs that are being used for stuttering treatment, and what factors Dr. Maguire (and other doctors?) use in determine which to prescribe.

Ora said...

Greg - I'm trying to grasp your points, and it may be that I'm confused because I don't have the concepts and terminology straight in my own mind.

If you believe that fluency shaping is largely ineffective, then presumably you don't use it in your own work. This suggests that you use stuttering modification techniques plus supportive psychological / behaviorial issues (avoiding avoidance, desensitization, etc.)? Is that right.

My first reaction was - he's an SLP but doesn't use fluency shaping? So what DOES he do as an SLP? Are you merely saying that you don't use fluency shaping but you do use stuttering mod + psychological/emotional/behavioral work?

(To avoid misunderstanding, I'm not trying to make any point here, or to contest your assertions in any way. I'm simply and honestly trying to understand.)

Thanks, Greg

Greg said...

Hi Ora,

All behavioral/motor stuttering therapies are limited. And the data suggests that whichever motor technique is used, it only accounts for a fraction of the overall therapeutic "success".

As a result, I've advocated the approach that the client/clinician make long term objectives together. Write out the desires/goals of the client, and then pick the stuttering techniques that best meet those client values. So for many a client, it may include techniques out of both SM and FS camps. If you're thinking that the two can't coexist in a therapy environment, then you're limiting yourself. Both are equally ineffective, to a very large and real-life extent. Much of it really comes down to the cognitive/emotional perspective of the client.

As far as myself--once I become convinced that I am an effective communicator (both cognitively and emotionally), then my active use of stuttering controls went pretty much out the window. So I'll use controls on a bad day; whichever ones seem to work the best and are most appropriate for that day/environment.

Hope this helps,

ig88sir said...

To Eric: Yes Dr. Maguire did tell me about the merits and side effects of different medications. For my case, in a stuttering moment I have terrible anxiety even when not talking and tension around my mouth. He claimed that the Zyprexa can help with that. I should be on it in about 1 week and the effects won't start for about 1 month I was told. I will post on here with my updated status. I will go to the gym more to gaurd off any weight gain as well..

Eric said...

ig88sir: I'm considering drug therapy myself, possible consulting Dr. Maguire, and I'll be very interested in hearing of your experiences as they develop.

I understand that Maguire himself was on Zyprexa for 10 years, though he's since moved on to different medications.