Providing Distance Stuttering Therapy to Rwanda (Dale Williams)

About the Author: Dale F. Williams, Ph.D., CCC-SLP, BRS-FD is a Professor of Communication Sciences and Disorders and Director of the Fluency Clinic at Florida Atlantic University. In addition, he is a consultant for Language Learning Intervention and Professional Speech Services.  A board certified specialist in fluency, Dr. Williams served as Chair of the Specialty Board on Fluency Disorders from 2008 to 2010. He has coordinated the Boca Raton chapter of the National Stuttering Association since 1996. His publications include the books Stuttering Recovery: Personal and Empirical Perspectives (Psychology Press), Communication Sciences and Disorders: An Introduction to the Professions (Psychology Press), and Shining a Light on Stuttering: How One Man Used Comedy to Turn his Impairment into Applause (The Brainary), co-authored with comedian Jaik Campbell.

Note from author: Understanding of stuttering and its treatment is limited in Rwanda. The hope is that this work with the African Stuttering Centre, from which we get the referrals for the program described below, will improve this understanding and show people that help is available.

In 2009, my brother Andy was directing the Koinonia Corporation, which worked with local industries to provide solar power to Rwanda. One problem with this arrangement was that Rwandese1 businessmen often had difficulty understanding and being understood by Americans. If only, someone speculated, there was a profession that helped with that sort of predicament.

“You know,” said Andy. “I think my brother does something like that.”

I thanked him for having a general idea of what I do for a living and said I’d give it a shot. Because Rwanda has no speech-language pathology services (Hutchins, 2015; Munyankindi, E., personal correspondence), my idea was to establish a distance therapy program with Florida Atlantic University.

Because of Koinonia’s connections within the government of Rwanda, word of the proposed service spread quickly. When I visited the country, there was much interest in an English communication program. Officials from the Minister of Education to the National Director of Schools, introduced to me as, respectively, Theoneste Mutsindashyaka and Emma, were willing to meet about it. Representatives of the Rwanda Information Technology Agency (RITA) agreed to discuss the use of their space and computers.

The attentiveness to the idea was grounded in large part on its English language basis. Recent history has triggered a relatively urgent need for English instruction in Rwanda. In 1994, the country added English as an official language, along with French and Kinyarwanda, the latter being by far the language used by most of the population (McGreal, 2009). French was dropped as an official language in 2008 (Steflja, 2012) and, in time, much of the country’s education system was switched from French to English (Plonski, Teferra, & Brady, 2013). The result is an English-language country in which many young adults (that is, those requesting the aforementioned therapy), grew up speaking Kinyarwanda and being educated in French. In other words, English is their third language, but the one overtaking their country. From a practical standpoint then, speech-language clinicians from the United States had to interact with clients who were speaking their third most (and often least) proficient language.

But first there were issues of licensing and security to work out. The former turned out to be easy, as Rwanda had no laws restricting distance therapy. As for security, the potential clients were accustomed to Skype, but there were questions of HIPAA compliance because of Skype’s capacity to store data. That is, it is uncertain whether client confidentiality can be assured when data are potentially accessible, an issue still debated within the field (e.g., see Zur, 2016). In order to avoid even the possibility of non-compliance, in 2016 the FAU Communication Disorders Clinic changed its distance therapy program from Skype to ConnectUS which, unlike Skype, is purely a conduit service. That is, there is no processing or storage of the data between the two endpoints.

Visiting a local school in Rwanda

Stuttering Evaluations

The distance therapy language program was in place for about a year when the clinic was contacted by Dieudonne Nsabimana of the African Stuttering Centre. Mr. Nsabimana read an internet story about FAU’s efforts (“Department of Communication Sciences…, 2010) and asked if the program could be extended to people who stutter. Given that I primarily supervise stuttering clients anyway, this request was welcomed. Mr. Nsabimana soon sent a list of people who stutter and were interested in being evaluated.

The FAU clinic staff emailed all potential clients, but only heard back from a few. Evaluations were conducted via webcam, with materials sent by email. They consisted of accumulating history information, surveying attitude and secondary behaviors, taking speech samples, and various reading tasks.

Stuttering Therapy

The subsequent treatment was fairly standard in its objectives, if not its delivery. Goals such as education about speech and stuttering, speech modification, desensitization, counseling, and generalization of skills to everyday life were addressed and, at this writing, clients are all making progress.

Still, there are unique challenges presented by distance stuttering therapy. For one, there are speech targets for which loudness must be monitored. However, perception of this particular voice parameter can change with variations in microphone placement and movements of the client. Clinicians had to determine when the client’s loudness was appropriate despite only hearing the client’s voice transduced through a webcam speaker.

In addition, secondary behaviors, those actions designed to hide or escape from stuttering, can create a potential problem via distance therapy. As these behaviors can literally involve muscle movements anywhere on one’s body, treatment in which the clinician sees only the client’s face and torso can result in missed movements. However, we could still teach the problems with the use of these behaviors—namely, that their effects are temporary and they can increase stuttering in the long-term (see Williams & Campbell, 2016 for a detailed explanation). Thus, observing every instance of secondary behavior is not necessarily crucial to treating behavioral aspects of stuttering.

The electronic image of the client could be a barrier in other ways too. The client’s eye contact is difficult to monitor without knowing where the web cam is placed in relation to the monitor. In addition, non-verbal cues can also be missed when so much of the other person is unseen (i.e., posture may not be as apparent or perhaps there is an impatient foot tap that goes unnoticed).

Generalizing skills beyond the treatment room was another challenging aspect of distance therapy. One of the ways in which clinicians attempt to extend therapeutic gains to different settings is by leaving the treatment room and forcing clients to employ new skills with a variety of listeners. With present distance therapy technology, such a practice would be awkward at best. Fortunately, generalization techniques such as home programs, increasing the number of listeners, and role-play are all possible via telehealth therapy.

In addition to the treatment drawbacks, there were also barriers strictly related to technology. Rwanda is landlocked and thus has limited access to submarine fiber optic cables (Nyirenda-Jere & Biru, 2015). Currently, the internal network is good, but the connection to the internet is slowed by its dependence on satellite or microwave transmission (Pottier, 2010). As a result, connections are too often interrupted and video images frozen. Also, the videocam microphones used by clients seem to pick up interference or background noise.

Based on interviews with past and present students and clients, there were additional challenges that arose with the administration of distance therapy:

  • A 7-hour time difference can make cancellation or late notices difficult.
  • Holidays and other events celebrated in one country but not the other can result in client or clinician absences and thus scheduling must be an ongoing discussion.
  • On a similar note, Rwanda has no daylight savings time, and clinicians who have forgotten that particular difference have begun sessions either an hour early (in the spring) or an hour late (in the fall).

Distance Therapy Session

Benefits

The aforementioned challenges have been more than balanced by the benefit of providing therapy to an area with no SLPs and limited understanding of stuttering. As one client noted, “I knew something was wrong, but no one would listen. The CDC took the time to evaluate my supposedly superficial disability and listen to my complaints.”

Other benefits were noted as well. Distance treatment means that anyone can be seen by a therapist, as long as he or she has access to a computer. And most of the students agreed that once the clinician and client both became accustomed to conversing via video communication, the experience was just as personal as face-to-face therapy.

Many of the clients make contact from their computers at work, so there is not the inconvenience of having to change locales. The sessions are often longer than face-to-face meetings in the FAU clinic, as the student clinicians treat in the mornings—when the clinic is not busy and there is little competition for rooms—and clients are seen at the end of their work days, when their schedules are often less restricted. As one client explained, “The treatment is perfect for me and helping me to improve my speech — it’s also easy to take part in since I don’t need to move. We are using video calls and sharing documents through email.”

A final benefit, albeit one unrelated to stuttering, is that students get a feel for language as a shared experience. That is, people communicate not only via learned vocabularies, but also utilizing a familiarity that comes from pooled understandings (Liebal et al., 2009). By way of example, here is an exchange that would be understood by any American:

“Peppering down out there?”

“Oh man. Does the phrase ‘Cats and dogs’ mean anything to you?”

A listener who knows every English word but no common idioms would not understand that the topic of conversation is rain, namely because the word is never used.

In another context, I recently heard a man exclaim that an athlete ran a forty yard dash in 4.4 seconds. His listener’s response was, “Man, that’s picking it up and laying it down!” This is a particularly useful example because the response is not a common idiom and does not really even make sense (unless “it” is referring to the runner’s feet, perhaps). Nevertheless, everyone around understood that he was expressing agreement. Shared experience history allows for common understanding.

Of course, comprehension based on mutual language history is not present with clients who acquired English in completely different settings and contexts. Thus, the clinicians have to learn how to adjust communication and make their language more literal, a process which helps them become more focused therapists who are forced to think about language.

Future Considerations

Informal evidence suggests that distance therapy will continue to grow. The African Stuttering Centre has already enlisted another university CSD program for distance therapy. Moreover, FAU’s department has been contacted by three different universities for more information about the teletherapy program described here.

Finally, word of the FAU program has stretched beyond Rwanda. Inquiries have come in from Great Britain, Egypt, Brazil, and the Caribbean. Additional telehealth clients are scheduled for evaluations, at least some of which will undoubtedly begin treatment shortly.

Note this related submission from Dieudonne Nsabimana.

Footnote

1According to the first client I evaluated, “only Americans say ‘Rwandan’” and everyone else—including those in Rwanda—use “Rwandese.” Thus the use of the latter term here.

Sources

Department of Communication Sciences & Disorders – Distance Therapy Program with Rwanda(2010). Retrieved from http://www.coe.fau.edu/academicdepartments/csd/rwanda/

Hutchins, S.D. (2015). SLP Grad Takes His Skills Back to Rwanda. The ASHA Leader, Vol. 20, 24-25. doi:10.1044/leader.LML.20102015.24

Liebal, K., Behne, T., Carpenter, M., & Tomasello, M. (2009). Infants use shared experience to interpret pointing gestures. Developmental Science, 12(2), 264-271. doi:10.1111/j.1467-7687.2008.00758.x

McGreal, C. (2009). Why Rwanda said adieu to French. The Guardian. Retrieved from https://www.theguardian.com/education/2009/jan/16/rwanda-english-genocide.

Nyirenda-Jere, T., & Biru, T. (2015, May 22). Internet development and Internet governance in Africa. Retrieved from https://www.internetsociety.org/doc/internet-development-and-internet-governance-africa

Plonski, P., Teferra, A., & Brady, R. (2013, November). Why are more African countries adopting English as an official language? Conference Paper Presented at African Studies Association Annual Conference. Baltimore, Maryland. (November 23) Available at: http://www.booksforafrica.org/assets/documents/2013-ASA-Conference—EnglishLanguage-in-Africa-PAPER.pdf.

Pottier, N. (2010, July 20). Why Rwanda’s internet isn’t the third fastest in Africa [Web log post]. Retrieved from http://blog.nyaruka.com/stuff-0

Steflja, I. (2012). The Costs and Consequences of Rwanda’s Shift in Language Policy. African Portal, 30, 1-10.

Williams, D. F., & Campbell, J. (2016). Shining a Light on Stuttering: How One Man Used Comedy to Turn his Impairment into Applause. Geelong, Victoria, Australia: The Brainary.

Zur, O. (2016). Reviewing the Debate on Skype & HIPAA Compliance and Introducing the Alternative Option. Retrieved from http://www.zurinstitute.com/skype_telehealth.html

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Comments

Providing Distance Stuttering Therapy to Rwanda (Dale Williams) — 24 Comments

  1. I am an SLP graduate student at the University of Redlands in Southern California. First of all, I would like to commend FAU’s efforts to reach out to remote communities who are in desperate need of speech and language services. I, myself, grew up in a rural area in the mountains of Lebanon in the Middle East where SLPs do not exist and therefore would like at some point in my career to provide my services via telepractice to the local community there. As a graduate clinician here, I have had the opportunity to use telepractice with one of our adult clients in the fluency clinic. While it was an overall positive experience, I can relate to some of the challenges you mentioned above. Given that telepractice is such a new form of delivery that has not been exhaustively researched yet, I was wondering whether your program is collecting data for the purpose of conducting research that would inform clinicians who are interested in telepractice. Additionally, if you were to expand the telepractice program to countries where English is not commonly spoken, how would you go about bridging the language gap? Will the use of interpreters be feasible?
    Best regards,
    Suzy

    • Hi Suzy. I lived near Redlands (Loma Linda) for a short time way back when. Beautiful area. Thank you for your nice comments. We are not formally collecting data for a research study, although we regularly do interviews with clients and clinicians in attempts to improve the service. RE treating in different languages, I would have to think about that. Interpreters are difficult to incorporate into therapy under the best of circumstances. Everything from selecting words for the initial tasks to high-level conversational goals is affected. And counseling would no longer be the client confiding in just one person. I suppose it could be done, but it would essentially require setting up a program with an entirely different set of rules.

      Thanks for your interest.

  2. Thank you for sharing about the services that FAU has been providing for the people in Africa. I enjoyed reading your article and hope FAU will continue to bring more awareness of stuttering to not only Rwanda but also other parts of Africa. As you have mentioned various challenges of distant therapy, have there been ways that have been done to address these challenges?

    • Thanks for your comment, Cindy. For technology barriers, there is not much we can currently do. Rwanda has the capability for better internet, but needs the cooperation of bordering countries. Re clinical concerns, sometimes we can find alternate ways of addressing them (e.g., bringing another listener into therapy instead of leaving the treatment room), sometimes not (like if we wanted to give a PPVT, I don’t think we could do so validly). Was there a particular barrier you were wondering about?

  3. Thank you so much for sharing! I am a speech pathology graduate student and I am inspired by FAU’s determination to provide SLP services to people who would otherwise not have access to it. I really enjoyed reading about the journey and development of the distance therapy program. Does FAU ever work with any children who stutter in Rwanda or other parts of Africa or is it typically only with adults? In class we have read about the counseling piece of stuttering therapy and I am curious to know if counseling is incorporated into the telehealth therapy sessions and if the individual’s family members are ever included in the sessions?
    Thanks so much!
    Sophie

    • Sophie—so far we have only treated adults, probably because they are the ones who find the African Stuttering Centre. One member wished to have his daughter evaluated, but she had recovered by the time we contacted him. We do counseling tasks nearly every session, although including family members is somewhat problematic given that the clients are so often seen at their places of work.

  4. Hey Dr. Williams,
    I really enjoyed reading about your research! As a future Speech Language Pathologist, I have considered traveling to various countries where the need for speech therapy is high. With technology this day and age distance can be overcome without travel as you have shown through your study and the utilization of distance therapy. As you stated, you can only see the face of the client you work with and this can have some limitations. What are some ways that you may overcome these limitations, for example how might you address avoidance behaviors that happen outside the screen? Additionally, I was wondering what your thoughts are in regards to group therapy with distance therapy. Several individuals who stutter have noted that support groups and interactions with other people who stutter positively influence their life and view on stuttering. Do you think that group therapy in conjunction with distance therapy could be a possibility in the future?
    Thanks so much,
    Mary

    • I’m glad you liked the article, Mary. With respect to identifying secondary behaviors, often we just ask. Hopefully, rapport is good enough that the client understands the importance of answering honestly. But even if a client lied about avoiding, at least we’d send a reminder that we those are no-no’s. As for group tx, we did a lot of that with the accent reduction program and it was a great learning experience for the students to see how the clients interacted and the humor they used with one another. Once our stuttering clients have the basic skills, we’ll see if their schedules allow for occasional group meetings.

  5. I am a SLP graduate student at UNC Chapel HIll. I really enjoyed learning about the work you are doing to reach those in need in Rwanda. I am considering working with populations that are currently not reached or are under-served in my future career. I had a similar question to Mary about whether a support group has been considered. Also, I was wondering if any of the people you have worked with have shown an interest in seeking out therapy in one of their first languages? I understand that finding someone to provide this service may be a challenge, but I was just wondering if they had expressed an interest or if they have expressed frustration or challenges with trying to address their stuttering through English.

    • So far no requests for therapy in another language. In fact, basically the opposite has occurred several times: Clients who want therapy expanded to include English vocabulary, articulation, and other features. A support group is a good idea. One problem will be finding another available morning, but if the meetings are once a month, that seems solvable. Thanks.

  6. Hi Dale – great paper. I am really impressed with the work that you are doing in Rwanda, and the obvious benefits of distance therapy. What a win-win situation for your students and the Rwanda clients benefitting from therapy. I did not know this was happening. I am currently sitting on the board of the International Stuttering Association and we have struggled with how to provide outreach to African countries and other countries as well. This is heartening that this is already going on. And as a Stutter Social host, maybe consider Google Hangouts for the support group mentioned by a previous commenter. Thank you for sharing your work. It is touching many lives.

  7. Hi Dale. This was such an interesting an unique paper, thanks for sharing! I am a SLP graduate student from the University of Minnesota-Duluth and am currently taking an advanced fluency disorders course. One question I had for you is if you have any advice or recommendations for providing stuttering therapy in this form of service delivery? I have always been interested in this specific disorder and in the future would love to work more with it and with tele practice becoming more and more common it could be a future possibility. Thanks!

    • Thanks for the comment, Kelsey. I think the students surveyed were spot on about what the problems are. Many of them can be helped by the clinician simply putting his or her cards on the table. By that I mean, for example, letting the client know that the reason we’re asking about potentially unseen secondary behaviors is that there are problems with their use. Or that we are getting a quick sample of conversation so that we can compare the loudness level to how the target words are being produced.

  8. Hi Dale,
    I really enjoyed reading this post. I am a SLP graduate student at the University of Minnesota Duluth. I am currently taking an advanced fluency disorder course. One question I have is, have you noticed any cultural barriers when providing stuttering therapy that is not typically seen in the Western culture?

    • Hi Megan. When I was in Kigali, one difference that I thought might impact distance therapy was scheduling. If, for example, I was asked to attend a meeting at 6 pm, all that meant was that the meeting would begin some time after dark. I learned that I did not even have to start getting ready until after 6. Obviously, that way of looking at time wouldn’t work in a clinic. We do carefully explain why all sessions have to begin and end at set times, but there really haven’t been any misunderstandings about that. On a separate (but somewhat related) note, once after a client did not understand a Standard American English idiom, the clinician asked for some Rwandese idioms. It was interesting to be on the other side of that sort of exchange; to hear expressions that are second nature to the speaker yet didn’t really register to our ears .

  9. What a joy to read! It’s so beautiful how a coincidence (“Oh I think my brother can help”) can lead to helping many in another country.

  10. Dr. Williams,
    I thoroughly enjoyed reading the success of the distance therapy program that you founded in Rwanda. I’m currently a first year graduate student at Western Carolina University and some of our students visit another underserved African country, Botswana. I would love to see your model established in other countries. It is hard for me to imagine not having access to the services speech-language pathologists provide. Until programs are established outside of the United States and Australia, I agree that distance therapy is a great option. I was interested in what types of approaches the your student clinicians are utilizing with clients in Rwanda? In my fluency disorders class, we have discussed many aspects and approaches to treatment including stuttering modification and fluency shaping as well as a hybrid of the two. I imagine it may be a hybrid, individualized approach. Best wishes,
    Laura

    • I think you’ve got a pretty good handle on it, Laura. Hybrid is the best label for what we’ve done so far. The clients have needed to manage both the stuttering and speech in general, so targets originating in stuttering mod & f-s have been utilized.

  11. Hello Dr. Williams,

    I enjoyed reading through your article and about the process that had to be gone through to make this program work. I am currently a second-year graduate student in a Speech-Language Pathology program, and I think that what the students at FAU are accomplishing is incredibly impressive. You mentioned that there were security concerns because of Skype’s capacity to store data, so ConnectUS was selected as the therapy program because there is no storage of data. Does this mean that the students had no way of going back and watching or reviewing their sessions? What if a response or something significant was missed during an assessment and had to be looked back at? Was there an alternative way of recording, like a camera in the room, so if something were in question either the clinician or supervisor would be able to go back and look at the recording?

    Thank you very much,
    Maria N.

    • Good question, Maria. I could write a whole other paper on Skype, ConnectUS, HIPAA, confidentiality agreements, etc. Security/confidentiality issues get messy. But to answer your question, there is no recording feature on our ConnectUS program. An add-on or a more expensive version of the program would likely be needed. If a student wants to record a session, the easiest way would be, as you say, to use the camera in the room. For the most part, however, clinicians operate as they would in schools, home health, and various other settings: collect the data in real time.

  12. Hello Dr. Williams,
    I appreciate your interest in reaching out to provide services for those who don’t have them. I am curious as to how social media is prevalent there? Could it be beneficial to use social media to form groups these people can communicate with for support? Including this with the distant therapy may give them more outlets to reach their goals.

    Thanks,
    Kate

  13. I’m not sure about the popularity of social media there, Kate. We have had clients who are on FaceBook, Twitter, and the like, but that’s a small sample size. In any case, there could be some interesting possibilities there—people grouped together could keep in touch between sessions, support group pages, etc. Thanks for the suggestion.

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