The Camperdown Program

Further support for the treatment comes from outcomes of Phase I and Phase II trials of the treatment adapted for telehealth delivery (Carey et al., 2010; O’Brian et al., 2008). Participants in those trials did not attend the clinic. Instead, the treatment was conducted remotely with contact occurring only by telephone and e-mail. We will present details of these studies in Chapter 10. However, these two trials, consisting of 53 participants, produced group mean reductions in stuttering of 66% and around 82%, respectively, with the number of clinician hours decreasing still further to an average of between 10–12.

Although designed to be used with the adult population, the programme has also been trialled with adolescents. Hearne et al. (2008) conducted a Phase I trial with three adolescents aged 13, 14 and 16 years. In this trial, no significant adaptations were made to accommodate the younger population. The oldest of the three children responded very well, reducing his stuttering to below 1% and maintaining this result for at least 12 months. However, the younger two children did not perform as well. Subsequent modifications have recently been made to the programme to make it more suitable for this age group. A recent Phase I trial of a Skype Internet version (Carey et al., in press) shows significantly improved outcomes for adolescents, with a group mean percent stuttering reduction of 92% at 6 months post-treatment.

Finally, a clinical trial of the treatment with adults but delivered by students under supervision (Cocomazzo et al., in press) has confirmed that similar results can be achieved under those conditions. The 12 participants in this trial achieved a mean 62% reduction in stuttering 12 months after treatment.

In summary, there is strong evidence from Phase I and Phase II clinical trials with adults and adolescents that the CP can produce significant reductions in stuttering regardless of the delivery format. That evidence is robust because outcomes have been collected from both objective and self-report measures, supported by speech naturalness data, in everyday speaking situations, independent of the treatment environment and for up to 12 months after treatment. Outcomes have been shown to be socially valid during this research.

Advantages and disadvantages

Advantages

The CP has a number of advantages over traditional speech restructuring programmes. The most obvious is the reduced clinician time required to achieve comparable outcomes. This programme requires a mean of around 10–20 clinic hours depending on the treatment delivery model. This is a substantial saving compared to the 50 or even 100 plus hours required for more traditional intensive group programmes that may even include a residential component.

The CP allows for flexibility of treatment delivery. For example, it can be administered entirely at a distance, using phone or webcam technology allowing equity of access particularly for remotely located people. It can also be offered in group or individual format, hence catering for different client preferences and infrastructure needs.

The programme has been manualised for implementation by generalist clinicians. It requires no specialist skills, no equipment and it can be delivered by whatever method is suited to a clinician’s caseload. Taking the service away from specialist centres again allows for greater access to treatment for the general population.

Disadvantages

The disadvantages of the programme are those that are inherent to all speech restructuring programmes. The learning of a new speech pattern requires effort and focus to maintain over long periods. Relapse is common and speech that sounds and feels unnatural to some extent seems inevitable. The limitations to the CP evidence also need to be acknowledged. There has been no replication of these findings independently of our research group. Further, there has been no investigation of the treatment against a ‘no treatment’ control group. As such, it is likely that the effect sizes have been overestimated (Kunz and Oxman, 1998). There have been no long-term follow-up studies past 12 months and given the well-acknowledged relapse rates with adult stuttering treatments, this is also a caveat to the findings.

Conclusions and future direction

In conclusion, the CP is a speech restructuring treatment for which there is reasonable empirical evidence for both its treatment processes and its efficacy. So what does the future hold for the programme? We are just completing a Phase I trial of a completely clinician-free, Internet-based version that clients complete in their own time, and in their own environments (Erickson et al., 2012). This version retains all the concepts of the original programme but clients work through the programme at their own pace. This will obviously not be the solution for all clients; however, preliminary data have shown that it is a viable model for some. Hopefully in the future, we will be able to report on a model that makes treatment accessible to anyone, wherever and whenever they need it. How satisfying that would be for both the stuttering population and for speech pathologists!

Discussion

Ann Packman
Our group was interested that you reported variable outcomes for clients in the trials.
Sue O’Brian
I don’t know whether many of you noticed that the outcomes for the earlier trials were better than the outcomes for the later trials. What happened from the first trials to the later trials is that we changed the way we measured outcomes. For the earlier trials, although outcomes were measured beyond the clinic, in three different situations – friend, telephone and family – all of those beyond-clinic outcome measures were client initiated and that obviously is a bit of a problem. If participants are able to initiate their own assessment situations, then they can potentially manipulate outcomes. In the later trials, they were still beyond-clinic measures, but we did not allow the participants to initiate the assessments – we had ‘surprise’ phone calls to participants. Surprise is a bit of a loose term. Obviously, they are not surprise calls in the sense that participants did not know they were coming, but they were surprise calls in the sense that they did not know when they would come. We always have to establish a convenient window of time for when the participants can take the calls so there is some known element. These surprise calls are from two strangers, who are researchers at the Australian Stuttering Research Centre. The procedure has the advantage that participants cannot rehearse before an assessment phone call and they cannot choose who the call will be from. And most importantly, they cannot remake a recording if they are not happy with the first recording. Now I don’t know if that has ever happened, but we sometimes wondered with the way we used to collect outcome recordings. So the way that we are now collecting objective stuttering-count assessments is a much more valid way of doing it. So for that reason I think probably the outcomes the later trials provide are a more valid effect size estimate than the earlier trials.
Ann Packman
I wonder if you could give some idea of predictors of those outcomes? How useful were severity or previous treatment, or other factors, as predictors?
Sue O’Brian
There have been no studies to date that have specifically explored predictors of outcome. However, for a number of the trials we have explored correlates of outcome. None of our studies so far have recruited enough subjects to allow statistically useful predictors of outcome, but we have at least looked at correlates. Nothing has come up. Severity, previous treatment and family history have not been correlates of outcome for our trials. But of course you need to take that as a preliminary finding only. Sophisticated regression modelling, when we have sufficient numbers, may provide a different result.
Sheena Reilly
Sue, I think the first comment our group made was what a great example it was of building evidence about a programme and approach, so congratulations from the group. During the Instatement Stage, how do you get from the imitation task during the Practice Phase to shaping speech naturalness during the Trial Phase? How do you decide which speech components you’re going to work on to make speech natural?
Sue O’Brian
The way it’s taught in the first place is just by exposure to the video model during the Practice Phase. What we do clinically is play the video or the audio for clients, get them to listen to it a few times and try to imitate it. Clinicians often ask how you give feedback about the speech pattern without using traditional terms to instruct clients such as ‘soft contacts’, ‘gentle onsets’, ‘continuous vocalisation’, and so on. It is easy to break the video model into small bits and compare that small bit with the attempted client production. Often, we will tape record the client and compare the two small bits of the model, asking, ‘How do you think it sounds? Can you make yourself sound more like that?’ What we find is that clients don’t have any problem with that, as long as the model is broken down into smaller bits and they copy it bit by bit. We don’t insist clinically that clients imitate the model exactly (unless they want to) because that would fly in the face of the underlying assumptions of the programme.
Joseph Attanasio
Is there a resistance to go into an unnatural speech pattern, and if so how do you overcome that?
Sue O’Brian
No, because what we want the clients to do during the Practice Phase is to develop their own individual pattern that completely controls their stuttering. So if in the Practice Phase of the programme they develop a technique or a pattern that seems to be completely controlling their stuttering, we will ask them, ‘Do you feel like you could stutter? At all?’ No. ‘Okay, then that’s the technique’ – the pattern, whatever you want to call it – ‘that’s the one that’s going to help you.’ Once clients get to that level during the Practice Phase, then that’s the first stage of the programme, where you have them at a very unnatural level using a speech restructuring technique where they feel they are completely in control of their stuttering, where there is no room for any stuttering whatsoever. If they are using a speech restructuring technique well they will not stutter at all. When we get that far then we go into the Trial Phase where the cycles happen and they start to shape more natural-sounding speech while retaining control of stuttering.
Sheena Reilly
Can you just clarify the procedures?
Sue O’Brian
Clients cycle through the three phases: Practice, Trial and Evaluation. During the Practice Phase, they are just imitating the video with speech naturalness 7–9, which is extremely unnatural. During Trial Phase they move from imitation of the video to monologue and conversation with the clinician, and they are told to use any features of the pattern that they think they need to control stuttering while attempting to make their speech sound more natural. There is no programmed instruction. In other words, we don’t use the traditional approach of starting at, say, 40 syllables a minute and moving to 70 syllables a minute to 100 syllables a minute, and so on, or starting at naturalness 9, and moving systematically from naturalness 8, to 7, to 6, and so on. Instead, we allow clients to just use the features as they please. They set their own speech naturalness targets. They know their goal in a Trial Phase is a severity of 1–2, so its got to be virtually no stuttering or no stuttering at all, and they set a naturalness target that they think they can achieve to meet that goal. So every client does it differently. You will get those clients who want to play it safe and they’ll stay at a very unnatural level for quite a long time. Such ‘play it safe’ clients have the same speech naturalness during the Trial Phase as they did in the Practice Phase, because they want to reinforce their speech technique. You’ll get others who are more adventurous and say: ‘Okay, if I’m allowed to set my naturalness, I want to sound really natural, so I’m going for a naturalness 3.’ Then what happens in such cases, nine out of ten times, is that they will stutter during the Trial Phase and during the subsequent Evaluation Phase, when they evaluate their speech from the recording, they will hear how little of the speech restructuring technique they are using and they will reset their strategies, aiming for less natural speech, with more technique, during the next Trial Phase so that they do not stutter. Then you get others who pace themselves evenly throughout the cycles and move progressively from higher to lower naturalness scores during the Trial Phases. And finally you get other kinds of clients who go up and down with their speech naturalness during the Trial Phases, and rely a lot on problem solving, saying: ‘Okay, this is what I did this time, my severity was this, my naturalness was that, I wasn’t happy with that; this time I’m going to set a goal and I’m going to do that.’
Joseph Attanasio
Now to a different issue. You mention in your presentation and in your publications that the CP is not based on any theoretical model and the group was wondering might it be incorrect to say that? Surely motor control theory underlies CP because after all you are slowing down speech, you are changing motoric aspects of speech, and might not that be at the core of this and so might it be theoretically driven?
Sue O’Brian
First of all, there is evidence for how speech restructuring might work. There’s evidence to show that, for example, the variability of vowel duration decreases with speech restructuring patterns. And if you consider theories such as those I mention, they would explain why the speech restructuring process works. The thing I am keen to promote is that it was not a theory that drove the development of the programme; empirical studies drove the development of the programme. We did so looking at the laboratory evidence I mentioned, in particular the Packman et al. (1994) study.
Ann Packman
Sue, our group was interested that you mentioned using cognitive behaviour therapy procedures during the Problem Solving Stage. Could you elaborate on what they are and do you think that an unskilled or an untrained therapist could do them?
Sue O’Brian
The first thing I need to say is that the primary CP goal is to reduce or eliminate stuttering. But of course that does not mean that speech-related anxiety should be overlooked. That would just be silly, considering the evidence about the number of adults who stutter and seek speech treatment that have speech-related anxiety. I imagine most speech pathologists would assess speech-related anxiety when they do an assessment.
We use a couple of different tools for assessing anxiety, one being the UTBAS scale that is an acronym for Unhelpful Thoughts and Beliefs about Stuttering (Iverach et al., 2011; St Clare et al., 2008). The UTBAS scale is a 60-item checklist, which was developed by psychologists working with adults who stutter. It was taken from a file audit of clinical cases and established the unhelpful thoughts and beliefs that adults who stutter typically present in a treatment environment. I think it is a useful tool, not for diagnosing anxiety but for finding out what sort of anxiety, the levels of anxiety and what sort of situations clients fear. It contains a series of statements and asks clients to indicate the extent to which each applies to them: for example, ‘I feel stupid when I stutter’ and ‘people will laugh at me when I stutter’. Those unhelpful cognitions are used during the Problem Solving Stage of the CP. The other tool that we often use is the fear of negative evaluation scale (Watson and Friend, 1969). So those tools give you a lot of information to use during the treatment process. I tend to find that anxiety becomes a problem most often during the problem-solving components of the programme – not always, but mostly, as that is when clients want to generalise their stutter-free speech into real world speaking situations.
A publication by Menzies et al. (2009) provides basic cognitive behaviour therapy strategies for use by those who feel professionally qualified to do so. But the caveat here is that cognitive behaviour therapy is the domain of clinical psychologists, not speech pathologists. That being said, I do think many adults who stutter who seek stuttering control would benefit from cognitive behaviour therapy. How speech pathologists might present those services is a topic to which I don’t think time will allow me to digress.
Sheena Reilly
Our group discussed the advantages of the CP flexibility for individual clients. Obviously you are an experienced clinician and your team developed the programme. But how suitable is it for generalist clinicians, particularly in the telehealth and Internet-based versions you mentioned.
Sue O’Brian
The short answer is that the manual has been written with generalist clinicians in mind, so it’s written as a simplistic step-by-step programme. The skills required are not those of a specialist clinician. First, there is no counting of stuttering moments. The CP just uses a severity rating scale. And second, because the video model is provided, it is possible for a clinician to do the treatment without having to constantly provide perfect demonstrations of the target speech pattern; the video model does that. I also think that telehealth is no problem, but we will get to that later (see Chapter 10).
Sheena Reilly
I think the question was more about if you didn’t have access to a clinician and you were simply doing a standalone Internet-based version.
Sue O’Brian
One of the reasons I am guessing – or hoping – that clinical trials will show a standalone Internet version to be viable is that there is a lot of drill with the programme. Our Phase I trial (Erickson et al., 2012) show that some clients can use the Internet version satisfactorily.
Joe Attanasio
Our group had a concern about your comment that the CP can be done without specialised training. And there was also a concern about how outcomes were judged. We queried the reliability and freedom from bias in the outcome assessment process and that is an issue that you might want to clarify at some point.
Sue O’Brian
Hopefully, at some time we will have an empirical response to your first concern. Regarding the second concern, all of us who conduct stuttering treatment research are tarred by that brush.

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