Dr Fluency is a computerised fluency shaping procedure designed to provide a home-based, programmed training facility for people who stutter. The programme gives instruction and feedback on:
reducing air pressure
control of volume
Dr Fluency can be installed on most IBM PCs or a compatible system which has a memory capacity of 8MB RAM or more. It also needs a high resolution monitor, a free serial port and one parallel port, a CD ROM drive and a sound Blaster voice card. Windows 95 is the package of choice for installing and using the programme.
We agreed to give the programme a try after being approached by one of the Dr Fluency originators.
This is a report on the use of the programme with one young adult who had recently re-entered therapy for his stuttering. The work on the Dr Fluency programme was seen as an adjunct to the speech and language therapy that was being offered.
S was referred for therapy in Leeds by his GP in March 1997. S attended St. James's Hospital in Leeds at the end of March 1997 when a case history was taken, a number of informal assessments carried out and various therapy options (including Dr Fluency) discussed with him.
At the time of the initial assessment, S felt that his stutter was at its worst and, because he had waited a long time for therapy, he appeared very motivated. It was agreed that therapy would begin immediately after the initial assessment. A programme was negotiated consisting of:
up to 10 individual appointments to begin work on identification and some speech modification including correct breathing patterns, reducing tension
attending an intensive speech and language therapy course (covering the principles of block modification, avoidance reduction, assertiveness)
attending a non intensive speech and language therapy group for continued follow up/maintenance and support
use of the Dr Fluency programme at a frequency convenient for him.
Use of the Dr Fluency programme
S experimented with the Dr Fluency programme during a six week period. He attended 12 times working for an average of 90 minutes per session. During this time he worked on four units of the programme.
Evaluation by Client
S was invited to comment on the programme and made a number of verbal and written comments on both specific areas of the programme and his personal experience of it.
a) prolonged syllables. S found this section clearly explained and the importance of self evaluation well emphasised.
b) Gentle onsets - reducing air pressure. S found this section very difficult and needed additional help from a clinician in order to grasp the technique. S found the instructions unclear. He commented that the combination of volume control and gentle onsets was too difficult to grasp together.
However, he did experience great satisfaction on eventually managing this part of the programme. The link between this and reducing air pressure was made naturally but S found the requirement to repeat each word a minimum of 15 times tedious. A customisation facility allowed the clinician to skip units, but could not modify the number of times practice was demanded. S felt that practise at the sentence and conversational level would have been of more benefit to him.
c) Gentle transitions. S found this fairly easy to grasp. He commented that the programme accepted some amount of slurring which could have affected the overall acceptability of the final speech outcome.
d) Rate control. The increase of rate of 120 syllables per minute seemed to be inflexible. Due to the severity of S's stutter, he found this imposed minimum rate compromised his speech control. He would have preferred practising at a slightly slower rate first. In fact he abandoned this section as a result.
Overall, our client commented on the fact that the programme gave him a sense of being in control, of knowing how to manage his speech production system better and what to do to overcome his problems of forward movement. He would have liked more practise at the question and answer format which he found particularly beneficial. This might have given him more confidence in the possibility of carry over.
Evaluation by Clinicians
The manuals are user friendly and comprehensive. The information on screen is also of a high quality but at times the amount of written information on the screen can be overwhelming and the content a bit dense.
The actual manipulation of the programme on screen demands a relatively high level of co-ordination, e.g. when the units are being attempted the user must activate the exercise and the stop watch and speak into the microphone at the same time. It took a while for S to manage it and might prove impossible for others with particular difficulties of motor co-ordination.
S found it frustrating at times to be required to produce targets over and over, especially when some of the 'errors' were generated by pressing the wrong button, rather than because he could not produce the required vocal behaviour! There is a customisation procedure which allows the clinician to tell the computer to skip over certain elements of the programme. However, this does not allow the speeding up or slowing down of acceptable limits of timing or the increase or decrease of the number of targets to be achieved.
At the end of each exercise, S had to evaluate his or her performance in terms of the accuracy of the time taken, the correctness of the loudness level and the overall fluency. The fact that this must be done after every attempt can become very irritating and stop the forward movement through the unit. More flexibility of choice as to whether to evaluate after every try or after 4 or 5 attempts would be more useful.
Dr Fluency is based on slowed, prolonged speech. The resulting speech does not sound 'normal'. There is an explanation in the introductory session that there is no expectation that the client will speak like this outside the confines of the work with the computer.
Our client enjoyed the 'conversations with Dr Fluency' and found himself able to maintain a reasonable level of fluency with these. This speech sounded more acceptable to S and additional practise at this level might have been beneficial.
Dr Fluency definitely increased S's feeling of ability to control his speech mechanism. This gave him a sense of achievement and positive self esteem. It did not teach him to speak without stuttering and maybe we should not expect it to.
The exercises were undertaken in a non-threatening, unobserved setting and the client could 'talk' to the computer and get feedback on his level of control. A whole programme devoted to a conversational approach where more normal speech use could be regularly practised may be a valuable step forward for the Dr Fluency team.
A computerised fluency control programme was used over twelve sessions by a client with a severe stutter. It was used in conjunction with other therapy as part of a more holistic programme. Use of the Dr Fluency programme was terminated because of a change of circumstances with the client being no longer available to come to the setting where the available hardware was lodged. Some aspects of the programme such as the transfer and maintenance units were therefore not utilised. The following conclusions are therefore based on approximately 18 hours of programme use:
Instructions and information were usually clearly and interestingly presented
Details such as the breathing mechanism were cleverly presented in graphic form
The programme engendered a feeling of control
Practise could be undertaken in a non-threatened and unobserved setting
Dr Fluency demanded repetition of aspects of speech that were being practised and no other - so it was precise and consistent
Question and answer and more 'conversational' units were of particular interest to our client
Dr Fluency is probably best used as an adjunct to other therapy as it does not provide the client with ways of addressing more holistic needs
Technical backup or very high levels of competence in the use of computers is needed as problems are bound to arise in the running and management of the programme
The programme will work best with a highly motivated person who can deal with the frustration of having to repeat activities over and over again
Individuals with poor motor skills or cognitive disabilities may find the programme too demanding.
Overall, this is a carefully considered and constructed programme. The outcomes for S of the use of Dr Fluency were useful but minimal change was made in his stuttering. The addition of the Dr Fluency work was beneficial but not essential to his progress.
|Dr Trudy Stewart
Speech and Language Therapy Dept
St James University Hospital
Speech and Language Sciences
School of Applied Social Sciences
Leeds Metropolitan Univerisity
LS1 3 HE
A demonstration copy of Dr Fluency is installed at our office. Any speech and language therapist or BSA member wishing to try the software for themselves is welcome to use our facilities. Please call 020-8983 1003 to make an appointment.
From Speaking Out, Summer 1998
For further information see the Dr Fluency website.
See also: Adult therapy and courses