2000 Conference Proceedings

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Speech-to-Speech: Telephone Access for People with Speech Disabilities

Bob Segalman, Ph.D., Research Analyst
Program Evaluation and Statistics Section
California Department of Rehabilitation
2000 Evergreen Street; Sacramento, CA 95815
Phone 1-800-854-7784 or 916-263-8689


People with moderate to severe speech disabilities in nine states can use a special telephone service 24 hours a day. This service, called Speech-to-Speech (STS), grew out of my own attempts to be understood over the telephone despite my cerebral palsied (CP) speech. STS provides communications assistants (CAs) for both voice synthesizer users and people with moderate to severe speech disabilities who have difficulty being understood by telephone. The Federal Communications Commission may require STS to be provided nationally in several years.

STS is now offered in nine states 24 hours a day: Wisconsin, Minnesota, Washington, South Carolina, California, Maryland, Georgia, Nevada and Arizona. Sweden and Australia have conducted national trials.

People with speech disabilities call a toll free number to use STS. STS extends telephone use to many people with speech disabilities who cannot use regular telephone service or the TTY Relay Service. Users now access STS through a toll-free STS number at the relay service. Previously, relay services were only accessible for calls between TTY and voice users. While CAs previously only translated TTY output to voice and vice-versa, now specially trained STS Cas repeat the words of the person with the speech disability to the listener.

While STS uses technology analogous to 3-way calling technology, it provides a human interface that 3-way calling does not. Three-way calling requires users to provide their own Cas and STS does not. Providing 3-way calling alone is not sufficient as only very rich people can afford to have CAs available around the clock in the way that STS CAs are available.


All STS users have speech which the general public has difficulty understanding. These users may also have dyslexia or limited hand use (from CP, head injury, degenerative conditions or strokes) which precludes keyboarding adequate to use a TTY relay service. Most STS users are probably adolescents and adults with CP or similar developmental disabilities.

Most STS users can be understood by patient listeners with acute hearing and excellent speech language skills. New CAs only need a few hours of experience listening to people with such speech disabilities. Yet, STS cannot assist people with speech so idiosyncratic that they are only understood by those who know them well.

Some people communicate on STS with a speech synthesizer or an artificial larynx. They require voicing services to facilitate communication similar to other users. Speech synthesizer and artificial larynx users also require CAs to be patient, experienced listeners who keep the able-bodied user's attention and facilitate turn taking in communi-cations. Many such users find that STS compensates for the general public's unpreparedness for the unusual sound of their devices or the turn-taking required for communication.

Providing telephone access to all such people broadens the historic contribution of relay service. Direct, speedy telephone access helps mainstream these people into jobs and many other activities. Such service expansion reflects the spirit of the Americans with Disabilities Act (ADA). The ADA advocates expanded applications of new technology to benefit all people with disabilities.

There is no central source for locating STS users. They must be identified one-by-one and their fears must be resolved before they were willing to use STS. For a state to successfully build a STS user constituency, an intense outreach effort is necessary. In California two of us, both professional counselors, spent 18 months canvassing the state to find new users.

We called and wrote agencies and mailed thousands of flyers. We focused on secondary providers who served this population to identify potential users. Many users were recruited through their Department of Rehabilitation counselor. Other recruitment sources were: 1) Speech pathologist members of the California chapter of the American Speech and Hearing Association and the United States Society for Augmentative and Alternative Communication, 2) Regional Centers in California serving clients with speech disabilities, 3) Distributors of speech synthesizers sold in California, 4) local Alliance for Technology agencies in California, 5) United Cerebral Palsy of California and 6) Independent Living Centers.

Our screening process identified potential STS users with the appropriate degree of speech disability. To be selected eighty percent of what they said had to be understood by the patient screener with acute hearing. They had to speak in complete sentences and have the social skills to hold a meaningful conversation.

STS is only useful to people with speech that CAs can understand most of the time. Therefore, we did not recruit people who are not understood most of the time. Screening also insures that users have sufficient telephone knowledge and experience to use STS. Potential users also have to demonstrate enough responsibility in other aspects of life so that we could expect them to find STS useful.



We conducted a one month system trial in California. Costs included: training CA, CA's salaries, setting up work stations, use of an 800 number, and administrative costs.

The CAs voiced what the user with a speech disability said after every three to four word phrase. That is also the procedure that works best in face-to-face voicing.

We wanted the trial to utilize Cross-Hearing. That is, to maximize communication, the CA, the user with a speech disability, and the speech-able user must all be able to hear each other throughout the call. Unfortun-ately, cross-hearing was not available for the 1995 trial.

The caller understandability criteria limited the number of times that a user with a speech disability could repeat a word or phrase without CA comprehension. After two repetitions the CA would ask the caller to "say that another way" or "say something else".

The former TTY CAs only needed a few hours of additional training prior to working as STS CAs in the trial. For the permanent program, audio tapes from the trial can be used to train additional CAs. These audio-tapes can give prospective CAs a "feel" for this type of relay work.

Twenty-five trial participants initiated or received 2,000 outbound telephone calls over 4-weeks. Some calls were made to trial participants by able-bodied users.

This first trial determined that STS is readily usable on an ongoing basis by this population. It can be effectively and efficiently run as part of a TTY relay system.

The trial showed that in a permanent STS service the CA and both callers must be able to hear each other throughout the call. We also learned that CAs had to be taught how to respect callers with speech disabilities. CAs were wisely selected for the trial based on good hearing and patience. Training by someone with a speech disability was necessary.

The trainer had to be available several hours a day during the trial.

The 25 speech disabled users initiated over 2,000 outbound calls. They could make calls between 1 pm and 5 pm, Monday through Friday. Now calling hours are 24 hours a day, seven days a week.

Calls were tape-recorded. Listening to those tapes helped verify the service's potential to provide successful telecommunications services for STS users.

The STS CA's role is similar to the TTY CA's role, but in STS user's speak rather than type. The CA facilitates communications between the user with a speech disability and a speech-able user or another user with a speech disability.

The STS CA : 1) Expects to hear distorted speech and is therefore not shocked or confused by them, 2) Uses earphones to eliminate all background noise, 3) Has acute hearing, 4) Can concentrate on understanding the words as the CA has no interest in content or no emotional involvement with the speaker to distract her/him, 5) Can solicit the speech-able user's patience. The speech of the trial participants was usually understandable under these favorable conditions.

The trial showed that: 1) The telecommunications message can be conveyed with a tolerable level of frustration for the users and CAs, 2) Speed of communications is increased compared with that experienced relay calls initiated by very slow typists.


A second trial (June 1996 to December 1997) resulted in a provisional service. During most of that trial two outreach workers with counseling degrees worked full-time. We developed a outreach model which helped identify the best ways to find STS users.

We telephoned a large proportion of California neurologists, physical medicine physicians and otolaryn-gologists (ENT). About one in five neurologists has at least one patient with a speech disability. Physicians were reluctant to make referrals until we identified our medical-counseling credentials. We received the most positive response from physical medicine physicians and those speech therapists who work in hospitals.

The psychological resistance of potential users often required us to telephone them up to ten times before they initiated a STS call themselves. Family members and caretakers can require counseling if they feel a loss of role and power when people with speech disabilities start to use the telephone independently.

Outreach was crucial to increase the user base so that the California Public Utilities Commission (CPUC) could justify removing STS from provisional status. There are now an 125 estimated users.

The service is a success! Consumers like the service which they demonstrate both by the high call volume and by their comments. As of September 1999, an estimated 150 users made more than 4,000 calls a month. This is double the number of call being made in June 1996 when the current trial began. Most consumers say that the CAs understand their speech most of the time and that their calls are successful. California consumers now want a permanent STS service to be established as soon as possible.

STS allows many customers to use the telephone independently for the first time! When one customer was asked if she would attempt the same calls on her own without STS, she replied: "Never in a million years!" Several employers of users say that using STS has improved on the job communication. One user plans to apply to law school if a permanent STS system becomes available so she can telephone clients.

Dr. Judy Montgomery, Past National President of the American Speech-Language-Hearing Association said that STS relieves the able-bodied caller of responsi-bility for deciphering garbled speech and allows her to concentrate on the content of the call. An aide to the Governor noted that STS's potential to increase employment of Californians with speech disabilities.


The plan is for STS to become permanent in California soon. We also hope that the Federal Communication Commission will require STS to be available everywhere in the US in several years.


  1. Next to getting married and earning a Ph.D., helping to start STS is the most exciting thing I ever did. I had the joy of helping others overcome what has been my worst frustration. In psychological terms, working to provide telephone service to others with speech disabilities has been for me a task at the very top of Maslow's scale of human activity.
  2. Some of this material was published previously elsewhere.

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