Cognitive Behaviour Therapy

These studies then show the positive results of CBT on social anxiety. Unfortunately, several of them are lacking in a comparison group and are without long-term follow-up.

Advantages and disadvantages

Advantages

For PWS, it is clear that a compelling body of research exists in clinical psychology of potential benefits for PWS. Clinical trials to date are encouraging for the application of that body of information to PWS, although at present the evidence is limited. Subject numbers are small, long-term follow-up has not occurred and randomised evidence has been limited. However, as is the case for other applications, for PWS a short treatment of around 16 sessions seems sufficient to produce effects. There has been one attempt to design a CBT package specifically for the needs of PWS and are anxious.

Disadvantages

CBT depends critically on clients completing out-of-session tasks as directed by the clinician. If the client does not complete those tasks, then treatment success is not possible. Although this is a generally accepted limitation of CBT, with application to stuttering it is not an unusual limitation for speech and language therapy. There, the efficacy of any treatment depends on successful completion of prescribed activities by clients and their parents beyond the clinic.

CBT is an umbrella term including a number of therapies. Hence, there are a number of CBT packages each of which may have slightly different methods, such as duration of treatment, amount of out-of-session work and group or individual approach. This variety of different approaches within CBT makes it difficult to compare treatments, given that practitioners may be doing different things. However, a preliminary trial of a CBT package specifically for PWS may contribute to offsetting that problem for the future treatment of such clients.

Because CBT focuses on current negative appraisals and very specific cognitive-behavioural issues for the client, it does not always address the possible underlying causes of mental health conditions that might be driving such problems.

Conclusions and future directions

Preliminary research shows that CBT appears to be a promising method for reducing anxiety in clients who stutter. More and better research on its effectiveness in this group is needed. Unfortunately, it seems to have little direct affect on stuttering speech behaviour. Therefore, there is a need for research to establish which types of speech restructuring is the most effective match with CBT to reduce both social anxiety and stuttering speech behaviour.

CBT continues to develop in interesting ways. Currently, amongst the most prominent clinical models are those that focus particularly on the role of schemata in cognitive and behavioural difficulties. These have given rise to overtly schema-based approaches to cognitive therapy (Beck et al., 2004, Young, 1990). These include positive data logs (Padesky, 1994), which are systematically combined lists of positive experiences that are designed to build new, more constructive belief systems. Another development is continuum work or scaling (Pretzer, 1990), which is a strategy for helping people combat an unhelpful dichotomous thinking style.

Discussion

Joseph Attanasio
A basic question from our group. Despite many PWS meeting DSM-IV criteria for social phobia, is it really social phobia? Don’t PWS have good reason to be anxious?2 Are they really like others who are socially phobic but who don’t stutter?
Dave Rowley
I think in terms of the way they present clinically, the answer is yes they are.
Sheena Reilly
What is your view of when CBT should be introduced? Do you think it should occur in concert with speech restructuring? Do you think it should be done before or do you think it should be done separately from speech restructuring? What implications might your answer have for the skill mix of the therapist or therapists?
Dave Rowley
A key issue here is that you work out a treatment agenda with the client. What happens during treatment is jointly constructed. It might emerge, for example, that the client wants to tackle speech restructuring straight away before CBT. I am not really aware of any evidence about which we should do first. But obviously, if the client needs and wants to work on anxiety first then of course that is what should be done.
Sheena Reilly
And the implications of that for the skill mix of the therapist?
Dave Rowley
I would argue that a speech and language therapist who deals with stuttering has the right background and therapeutic skills to learn how to use CBT. Courses to learn CBT are available from a number of sources. I am not a big fan of having those who stutter treated concurrently by speech-language therapists and psychologists. I think CBT should be part of the skill mix of speech and language therapists who deal with adults who stutter.
Ann Packman
Our group was interested in how long the effect of CBT lasts? So what’s the evidence from the non-stuttering population and then what do you think about CBT with PWS?
Dave Rowley
The evidence in general is that its effects could be life long. But there is quite a lot of evidence of some relapsing cases that need further ‘doses’ of CBT. We don’t know yet about whether that will be the case for stuttering, but my guess is it will be much the same. I do not see any theoretical reason why it should be any different.
Joseph Attanasio
The data show obvious improvement in terms of anxiety and avoidance, but not much in stuttering behaviour. Does the decrease in anxiety as a result of CBT actually translate into more talking despite stuttering?
Dave Rowley
There are two issues; whether they speak more in terms of word output or whether they go into previously avoided situations with comfort. The latter is one of the goals of CBT. I don’t know of any evidence of whether that actually improves speech output in terms of an increase in words spoken.
Sheena Reilly
From what you said it seems a disadvantage of CBT for future clinical trials with stuttering, is that it cannot be a standardised package. What do you think are the implications of that for clinical trials?
Dave Rowley
I don’t want to give the impression that there are no CBT package protocols to follow, because there are. But the issue is that many therapists will use one component only of CBT, not the entire package. There is a tendency to refer to having done CBT when in fact that is not really what occurred, parts of the package have been carried out but not all of it. I feel this makes it difficult to evaluate a body of clinical trials evidence that comes under the umbrella of CBT. So a positive development in our field is recent efforts to develop clearly documented CBT packages targeted specifically at those who stutter.
Ann Packman
We wanted to know whether the terms desensitisation and exposure during CBT are the same things and if not how do they differ?
Dave Rowley
I see them as being interchangeable terms referring to similar things. The origins of CBT are in the amalgamation of systematic desensitisation and cognitive therapy.
Ann Packman
So the challenges to cognitions are not desensitisation but the cognitive part of CBT. For example, ‘Are people really laughing at you?’ Is that correct?
Dave Rowley
Yes it is. That component of CBT is to have clients specify the faulty cognitions they are having and to get rid of them. Earlier attempts at systematic desensitisation did involve much thinking about the thoughts driving the problem itself, and also changing behaviour that resulted from it. So today, cognitive challenge and restructuring and systematic desensitisation are active components of CBT.
Joseph Attanasio
Does CBT also deal with unrealistic and unhelpful cognitions such as ‘If I didn’t stutter I could be the greatest trial lawyer in the world’?
Dave Rowley
Indeed it does. Clinical psychologists come across a range of people with different kinds of anxiety disorders who make the assumption that if it were not for their disorder then they would, as you say, ‘be the greatest trial lawyer in the world’, or whatever else they may think. Part of CBT is to help people come to a realistic position about their potential.
Sheena Reilly
We were intrigued by the findings that the anxiety reduction does not translate to reduced stuttering frequency. We thought it has long been assumed that anxiety and stuttering mediate each other. What do you think about that and why did anxiety reduction not lead to stuttering reduction?
Dave Rowley
I don’t think I have a definitive answer to that, but I can tell you my thoughts about it. Anxiety is not a unitary phenomenon. Apart from the state-trait anxiety distinction that is well known, there are many components of anxiety that are not so commonly recognised. These include, for example, social avoidance and shyness. So in the first instance it may simply not be so straightforward to expect a relationship between general measures of ‘anxiety’ and stuttering rate. Perhaps part of the expectation that when anxiety reduces, stuttering will reduce is underpinned by an assumption that when anxiety increases stuttering will increase. That might be a reasonable, intuitive assumption, but as yet the research in support of it is scant (Ezrati-Vinacour and Levin, 2004; Gabel et al., 2002). But even if that is correct, it is not logical or scientific to expect the opposite effect. Considering the multi-faceted nature of stuttering as I just mentioned, when there is a positive correlation between stuttering and anxiety it is just not clear what variable or variables may have been responsible for that correlation. And even if it were clear, it would not be reasonable to expect them to have an effect in the opposite direction.
Sheena Reilly
Thank you, I think that is an important point.
Ann Packman
We were interested in the age range of people who may benefit from CBT. With those who stutter it seems clear that it can be done successfully with adults and young adults but do you think it could be used with children?
Dave Rowley
Indeed I know that one member of the group here has been using it with 9-year-old children. It seems to me that its not so much chronological age that is the crucial issue here, it is cognitive age and emotional age that is important. So I wouldn’t want to say that it should only be used for children 13 and above, for example. I think if children are able to express their own thoughts and ideas then CBT is potentially useful. Children become able to talk about their internal feelings, anxieties and worries often at 8 or 9 years. So there is no reason in such cases why CBT would not be appropriate.
Joseph Attanasio
Do some stuttering clients object to the notion of CBT? We wondered if this could be a clinical problem because our speech pathology clients typically come to us wanting to focus on stuttering. They may anticipate speech therapy and then they are confronted with psychology.
Dave Rowley
Yes, I know exactly what you mean. Of course many who present for speech therapy have a goal to reduce stuttering and unexpectedly they are involved in psychology. However you package it, CBT is psychotherapy. It is enjoying better press now at least in the United Kingdom. But I am sure many people are not entirely sure what it is and how it is distinct from psychiatry. But of course if this were a potential clinical issue, then any competent speech-language therapist would be aware of it and address it with the client as needed.

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1 Social anxiety disorder is another, more contemporary, term for social phobia.

2 The current version of the DSM-IV criteria (American Psychiatric Association, 1994) specifically excludes diagnosis of social phobia for those who stutter.

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