Frequency of stuttering during challenging and supportive virtual reality job interviews

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Abstract

This paper seeks to demonstrate the possibility of manipulating the frequency of stuttering using virtual reality environments (VREs). If stuttering manifests itself in VREs similarly to the way it manifests itself in real world interactions, then VREs can provide a controlled, safe, and confidential method for treatment practice and generalization. Though many researchers and clinicians recognize the need for generalization activities in the treatment of stuttering, achieving generalization in a clinical setting poses challenges to client confidentiality, safety, and the efficient use of a professionals’ time. Virtual reality (VR) technology may allow professionals the opportunity to enhance and assess treatment generalization while protecting the safety and confidentiality of their clients. In this study, we developed a VR job interview environment which allowed experimental control over communication style and gender of interviewers. In this first trial, persons who stutter (PWS) experienced both challenging and supportive VR job interview conditions. The percentage of stuttered syllables was calculated for both interviews for each participant. Self-reported ratings of communication apprehension and confidence were also obtained, and were not significantly correlated with stuttering severity. Results indicated that interviewer communication style affected the amount of stuttering produced by participants, with more stuttering observed during challenging virtual interviews. Additionally, the amount of stuttering observed during the VR job interviews was significantly, positively correlated with the amount of stuttering observed during an interview with the investigator prior to VR exposure. Participants’ subjective reports of the VR experience indicate reactions similar to those they report experiencing in the real world. Possible implications for the use of VR in the assessment and treatment of stuttering are discussed.

Educational objectives: After reading this article, the reader will be able to—(1) list some of the challenges to treatment generalization; (2) describe how virtual reality technology can assist in alleviating some of these challenges; (3) describe how the frequency of stuttering varies across two different virtual environments.

Introduction

This paper seeks to demonstrate the possibility of manipulating the frequency of stuttering using virtual reality environments (VREs). If stuttering manifests itself in VREs similarly to the way it manifests itself in real world interactions, then VREs can provide a controlled, safe, and confidential method for treatment practice and generalization.

Generalization of treatment effects is one of the major challenges facing clinicians who work with persons who stutter (PWS). Finn (2003) noted that the jump between clinical and real world situations is often large and foreboding to PWS. This perceived difficulty can form a significant barrier to treatment success. To facilitate treatment generalization, clinicians are advised to vary the places where techniques are practiced, the people the PWS interact with, and the tasks involved (Culatta & Goldberg, 1995; Finn, 2003, Manning, 2001). While scheduling repeated visits to venues outside of the treatment room is often desirable during treatment to improve generalization, controlling what occurs during these situations can be difficult or impossible for clinicians. Additional challenges include time away from the clinic, potential for loss of confidentiality for patients if the same locations are visited multiple times, and client safety.

Generalization is “the occurrence of relevant behavior under different non-training conditions (i.e., across participants, settings, people, behaviors, and/or time) without the scheduling of the same events in those conditions as had been scheduled in the training conditions” (Stokes & Baer, 1977, p. 350). In essence, treatments cannot be considered effective if the techniques taught fail to generalize beyond the clinic room (Bloodstein, 1995, Gregory, 1995, Ingham, 1984). Finn (2003) suggested that the development of [unspecified] “interim steps” in the therapeutic process enhanced transfer of new behaviors from the clinical to the real world, regardless of the treatment approach employed.

VREs are one possible interim step. Virtual reality (VR) is a human computer interaction in which users are active participants in a computer generated three-dimensional world (Schultheis, Himelstein, & Rizzo, 2002). VR differs from typical computer displays in that display and input technologies are integrated to create a sense of presence or immersion in the VR space. One approach uses a head-mounted display (HMD), which has earphones and a display screen for each eye, together with a motion tracking system. The user views and hears a computer-generated VRE in the HMD, and the integrated tracking system tells the computer how to change the display and sound to reflect the orientation of the user's head. In some VRE's, users can also hold joysticks that allow them to interact with or navigate through the environment. Careful combination of hardware and programming features create convincing VRE's that allow patients to have experiences that mimic those of the real world. Thus, VR may be useful in meeting some of the challenges encountered during the generalization phase of stuttering treatment (Brundage & Graap, 2004).

Maintaining client confidentiality during treatment generalization is often challenging. Clients are often reticent to practice techniques and/or advertise that they stutter to strangers. This is especially true early in the treatment process, because it is precisely these types of feared situations in which “he was so grievously wounded” prior to treatment (Van Riper, 1973, p. 225). VREs allow clients to practice techniques in front of many different virtual people and in different situations, while a clinician controls the responses of the virtual people. In this way, VR may be useful in desensitizing clients to their stuttering.

Efficiency and cost effectiveness of treatment are also challenges during the generalization phase. It is often not economically feasible for clinicians to take clients outside the clinic to practice newly learned skills, or to create complex interactions within the clinic setting (Brundage & Graap, 2004). For example, most persons who stutter fear speaking in front of audiences, and while it is sometimes possible to create such an audience in a university setting, it is often difficult or impossible in private practice settings. Further, to assemble an audience of unfamiliar people for each client who needs to practice speaking to large audiences quickly becomes unfeasible. Additionally, confidentiality for clients, especially in small geographic areas, is likely to be compromised.

An alternative often employed is role playing. However, it may be awkward for clinicians to simply “role play” job interviews or other similar interactions, because in doing so a professional must assume two roles (clinician and interviewer) to both create the scenario and to control the therapeutic aspects. In addition, over the course of treatment the clinician may become a conditioned stimulus for fluency, making role playing less effective as a generalization tool. VRE's offer a technology that allows various sized audiences, social interactions, and impromptu encounters with unfamiliar people by simply choosing a different computer program. For example, the Virtual Audiences computer program contains large and small audiences, and has been used effectively in the treatment of social phobia, suggesting that people do perceive the virtual audiences as similar to real audiences (Anderson, Rothbaum, & Hodges, 2003, Anderson, Zimand, Hodges, & Rothbaum, 2005).

Another challenge is the lack of control over the external environment. Taking clients into the real world exposes both the client and clinician to increased risks that can negatively impact the therapeutic relationship. Clients may encounter aversive social interactions that undermine confidence in their ability to use newly acquired techniques for fluency. This can contaminate a therapeutic relationship in which clients may assume that the clinician can protect them from such harm. VR offers an opportunity to present unique stimuli to clients without risk of aversive outcomes at inappropriate times.

Treatment hierarchies are often used to facilitate client success in treatment and to reduce risk of failure (Culatta & Goldberg, 1995). Tasks that often lead to increased disfluency and speaking-related stress in adults who stutter, such as talking to persons in authority, addressing large audiences, and participating in group discussions, are targeted later in the generalization phase than those less challenging to fluency (Blood, Blood, Tellis, & Gabel, 2001; Mahr & Torosian, 1999; Ornstein & Manning, 1985). VR allows clinicians to arrange interactions in a hierarchical manner and to specify the salient aspects of the interaction for clients. With such control, early failures that interfere with treatment progress are minimized while challenging situations can be introduced at therapeutically appropriate times. It is important to note that VR is a clinical tool that depends wholly upon the skill and training of the clinician running it. VR extends the range of opportunities easily accessible to clinicians but in no way replaces the need for experienced clinical judgment.

Obviously, VR cannot model every possible aspect of the real world. However, recent research suggests practicing new motor tasks in VR may be “superior to that following real world practice” (Holden, 2005, pp. 191–192). This benefit of VR is likely due to the absence of distractions that make it difficult for clients to distinguish “key aspects of the task on which to focus” (Holden, 2005, pp. 191–192). Measurement and documentation of generalization effects has been difficult (Finn, 2003; Hillis & McHugh, 1998), perhaps in part due to the lack of control over many of the variables that influence the learning of treatment techniques. VR can assist with this challenge by allowing control over various aspects of the environment and unlimited repetition of the social interactions contained within the environments.

VR technology has been applied to the assessment and rehabilitation of disorders that affect communication, including: traumatic brain injury (Christiansen et al., 1998; Grealy, Johnson, & Rushton, 1999; Schultheis & Rizzo, 2001; Zhang et al., 2001), stroke (Merians et al., 2002), cerebral palsy (Reid, 2002), and autism (Max & Burke, 1997; Self, Scudder, & Weheba, 2003). VR has also been used in audiologic applications to assess sound localization in functional environments (Besing, Koehnke, & Abouchacra, 2003).

To date, VR technology has not been used to enhance the treatment of stuttering (Brundage & Graap, 2004). VR has been used to augment the assessment, treatment and generalization of disorders that share important characteristics with stuttering. VR has been used successfully in the behavioral treatment of anxiety disorders (see Glantz, Rizzo, & Graap, 2003; Krijn, Emmelcamp, Olafsson, & Biemond, 2004; Schultheis et al., 2002 for reviews). VR-assisted treatment of public speaking anxiety allows the clinician to control how the participant is introduced to the virtual audience, how long she/he is exposed to them, and the reaction of the audience, including questions and interruptions. A variety of scenarios have been developed, including a boardroom, lecture hall, and auditorium. Data from case reports and open clinical trials indicate that treatment using virtual reality for exposure to public speaking may reduce public speaking anxiety (Anderson et al., 2005, Jo et al., 2001; Pertaub, Slater, & Barker, 2001).

Challenges in implementing VR in a clinical setting include: the initial cost of the necessary hardware (e.g., computer, HMD, tracker, vibration platform, scent machine), in excess of US$ 5000; the scarcity of VREs and difficulty obtaining the desired stimulus; the high cost of developing new VREs; failure of some participants to become immersed; and a slight risk of nausea when immersed in VR for those prone to motion sickness. System costs will continue to decline, due to increased performance of desktop computers, mass production of high quality head-mounted displays, and scent machines. Increased use by professionals in speech, voice, psychology, psychiatry, and education will stimulate development of more VREs that can be used in conjunction with a variety of treatment programs.

The purpose of this study was to develop a virtual job interview environment (Brundage & Graap, 2005), and to test its effects on speech patterns of persons who stutter. Specifically, we wanted to know if the type of virtual job interview (challenging versus supportive) affected the percentage of stuttered syllables produced by PWS.

Section snippets

Participants

Twenty-three PWS (six females) were recruited from speech and hearing clinics and stuttering support groups in the Washington, DC area. Participants ranged in age from 20 to 52 years (M = 31 years, S.D. = 9.4 years). Fifteen of the participants self-identified themselves as Caucasian, five as African American, and three as Asian; each reported stuttering onset during childhood. Potential participants were excluded if they reported the presence of: speech-language disorders other than stuttering,

Presence in the virtual environment

We were interested in the correlation between stuttering severity and amount of presence in the virtual environment; previous research in other disorders suggests that more severely anxious participants report greater levels of presence in virtual environments than did participants without anxiety related to the environment (Robillard, Bouchard, Fournier, & Renaud 2003). Although all participants reported sufficient levels of presence in the virtual environment, correlations between stuttering

Discussion

In this study, PWS participated in one challenging and one supportive virtual reality job interview. The interviewer's communication style affected the amount of stuttered syllables produced by interviewees with mild-to-moderate stuttering. This finding was consistent with other literature linking perceived stress to increases in stuttering (Manning, 2001, Shapiro, 1999), and suggested that VR environments can elicit stuttering in similar ways to real world environments.

Heretofore, a

Acknowledgements

This research was supported in part by an NIH grant (R41 DC006970) to Virtually Better, Inc. (PI: Brundage). We thank Adrienne Hancock for her assistance with data analysis, and Nan Bernstein Ratner and Scott Yaruss for suggestions on earlier versions of this research.
CONTINUING EDUCATION
Frequency of stuttering during challenging and supportive virtual reality job interviews
QUESTIONS

  • 1.

    Virtual reality has been used in the research and/or treatment of all of the following except:

    • a.

      anxiety disorders

    • b.

Shelley B. Brundage is an associate professor at the George Washington University in Washington, DC. She teaches courses on stuttering, research methods, and neurogenic communication disorders. She is a board-recognized specialist and mentor in fluency disorders. She serves on the steering committee for ASHA's Special Interest Division 10: Issues in Higher Education. Her main areas of research interest are in stuttering and in evaluation of the treatment process.

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    Shelley B. Brundage is an associate professor at the George Washington University in Washington, DC. She teaches courses on stuttering, research methods, and neurogenic communication disorders. She is a board-recognized specialist and mentor in fluency disorders. She serves on the steering committee for ASHA's Special Interest Division 10: Issues in Higher Education. Her main areas of research interest are in stuttering and in evaluation of the treatment process.

    Kenneth Graap is president and CEO of Virtually Better, Inc. in Decatur, Georgia. His main areas of interest involve employing VR technology in support of professional work and research. Mr. Graap holds a master's degree in education psychology, and a BS in management and economics. He has spoken and published widely on the use of VR in anxiety, addictions, PTSD, and other research studies. He serves as co-investigator on many funded research studies and consults on research design in VR worldwide. His own research involves combat-related PTSD.

    Kathleen F. Gibbons is a recent graduate of the speech and hearing science master's program at the George Washington University. She is a CFY candidate and is currently affiliated with Communication Enrichment Services in Bethesda, MD, where she provides assessment and treatment to children with communication disorders and their families.

    Mirtha Ferrer is creative director in charge of program development at Virtually Better. Her specialties include 3D modeling and video production for virtual reality environments. Ms. Ferrer holds a BFA (University of New Orleans) and a MS (Georgia Institute of Technology). She is an accomplished artist whose paintings and installations have been featured in solo and group exhibitions internationally.

    Jeremy Brooks is a software engineer at Virtually Better, Inc., in Decatur, Georgia. He is also a graduate student and research assistant at Georgia State University in the Department of Computer Science. His main areas of research interest are in virtual reality environments and real-time interactive media.

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    Present address: Communication Enrichment Services, Bethesda, MD, United States.

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