2003 IFA Congress: Montreal, Canada

Using Cognitive Therapy in Group-Work with Young Adults

Jane Fry, and Frances Cook
The Michael Palin Centre for Stammering Children, Finsbary Health Centre, Pine St., London EC1R OLP

SUMMARY

Cognitive Therapy principles and techniques are increasingly used in the treatment of young adults and adults who stutter. This paper is a summary of a workshop describing how Cognitive Therapy as developed by Beck (1976) and others, has been applied within a group treatment programme for young adults who stutter, between 15 and 18 years of age, at the Michael Palin Centre for Stammering Children. This two-week intensive therapy programme combines communication skills training, speech management strategies, and core Cognitive Therapy techniques which are seen as instrumental in promoting therapeutic change.

  1. Introduction
There is widespread agreement that therapy for chronic stuttering should address covert aspects of the disorder as well as overt stuttering behaviours. Covert features can be thought of as the individuals’ cognitive, affective and behavioural responses to anticipated or actual stutters (Murphy 1999, Prins 1993). Affective responses may include the experience of fear, anxiety, shame, embarrassment, guilt and self-consciousness (Sheehan, 1970; Van Riper,l982) while behavioural responses typically include word or situation avoidance, or the implementation of other coping strategies, some of which can be maladaptive.

Interest in the cognitive dimensions of stuttering has historically focussed on understanding the role of negative attitudes and beliefs that individuals may develop as stuttering becomes more advanced (Guitar,l998). However, more recently, the role of actual thought processes has emerged in both theoretical and clinical discussions. For example, Yaruss (1998) includes “thought processes associated with stuttering” in his proposed model of the disorder, and Murphy (1999) proposes that “negative thoughts and feelings...increase the disability attached to stuttering” as well as compromising long term progress. Wright et al’s (1998) self-report assessment includes a rating of negative thoughts before, during and after speaking and Neilson (1999) has reported on the use of “cognitive elements” in a behavioural fluency-shaping programme.

  1. Fundamentals of Cognitive Theory
The application of cognitive theory to stuttering is intuitively appealing even though research directly related to this field is in its infancy. The theory proposes that cognitions, in the form of negative automatic thoughts, appraisals, memories, images, assumptions and beliefs, have a critical influence on an individual’s emotional, somatic and behavioural responses to events (A.T. Beck, 1976; Meichenbaum, 1977). Anxiety results when individuals over-estimate the probability of a feared event occurring, over-estimate its potential emotional or personal cost, and under-estimate their ability to cope (Beck et al., 1985). Applied to social anxiety, the theory states that individuals expect that they will behave ineptly and that others will judge them negatively. In response to this fear Safety Behaviours are adopted which are designed to prevent a feared event occurring but reinforce fears by exacerbating the problem or preventing disconfirmation (Clark & Wells, 1995). Applied to stuttering, the concept of Safety Behaviours could include the range of escape or avoidance behaviours that typically are reported by adult clients. This highlights a second fundamental premise of cognitive theory, namely that individuals develop maladaptive coping strategies that reinforce rather than diminish problems.

Theories of chronic stuttering have consistently linked anticipation of fluency breaks to physiological and affective responses as Well as to behavioural avoidance (Bloodstein, 2001). Less attention has been paid to the impact on the person who stutters when a negative listener reaction is expected or perceived. The cognitive model of social anxiety described by Clark & Wells (1995) potentially offers a framework for understanding the thought processes involved in anticipation of stuttering and a theoretical rationale for using a cognitive approach in therapy.

  1. Characteristics of cognitive therapy
Cognitive Therapy is a short-term form of psychological treatment that emphasises “collaborative empiricism‚Äù. Therapist and client work together to develop a shared understanding of problems, gain information and develop solutions (J.S. Beck, 1995; Fennell, 1989). This collaborative style has particular relevance for therapists working with adolescents as it complements their developmental need for independent decision-making and individuation. Therapy is educational, with clients fully involved in understanding the framework and direction of therapy, and is orientated towards the development of self-help skills with a view to relapse management. Therapist skills include the ability to elicit underlying meanings through “guided discovery” and Socratic dialogue. The latter involves systematically using questions to help clients reach a personal understanding of their difficulties and make choices that will move them towards their goals.

Many clinicians currently incorporate cognitive principles, techniques and skills into individual or group treatment programmes for stuttering. It is important to note that some therapy programmes which describe “cognitive” and “behavioural” components may not necessarily adhere to the process and rationale of Cognitive Therapy as originally outlined or as described by contemporary leaders in the field.

It is the aim of this workshop to outline some central components of Cognitive Therapy as described by Beck (1976) and those who have developed his theory, and to describe how these have been integrated into a group therapy programme for teenagers at the Michael Palin Centre. The original format of this programme, which is based on communication skills training, was described by Rustin, Cook & Spence (1995). In its current format it combines communication skills training, speech management skills, with a developing emphasis on identification and desensitisation, and a clearly defined Cognitive Therapy component. The overall aim of the programme is to foster greater awareness and use of a range of communication skills, enable greater choice in how moments of stuttering are managed, and develop the ability to recognise and modify inaccurate and unhelpful internal dialogue or “self-talk”.

In essence, Cognitive Therapy is concerned with exploring and understanding a clients’ system of negative automatic thoughts, appraisals, rules and beliefs, and modifying these through a combination of cognitive and behavioural techniques (Wells, 1997). After first “buying into” the model, clients learn to differentiate emotions and identify negative automatic thoughts, to verbally challenge negative automatic thoughts, to develop hypotheses and conduct “behavioural experiments” and to apply problem-solving skills. Cognitive Therapy with adults may also address maladaptive beliefs or “schemas” which form the foundations of individual cognitive vulnerabilities, however work with children and teenagers is more likely to focus on the development of critical thinking skills rather than on schema work (Stallard, 2002). 

  1. Socialising clients into the cognitive model
The generic cognitive model is presented on day two of the programme. The aim at this point is to demonstrate the relationship between thoughts, feelings, somatic and behavioural responses, to educate clients about normal fight / flight / freeze responses to anxiety, to illustrate the dynamic of the self-fulfilling prophecy or “vicious circle” of stuttering, and to introduce the concept that different perspectives for the same “event” can exist. A broader aim is to promote a shared understanding of each individual’s experience and coping strategies, to normalise these, to establish commonality within the group, to contribute to the development of “expert” knowledge about stuttering, and to present the optimistic message that change is possible. J.S. Beck (1995) suggests that techniques typically used to present the model to adult clients can be used with older adolescents. The techniques used in this part of the programme include:
  •  a brief presentation of the model
  • an exploration of the affective, somatic and behavioural responses resulting from the interpretation of a sound heard in the night as firstly “an intruder” and secondly “the cat."
  • a demonstration of the effect of the self-instruction “I’m weak” on muscle strength as demonstrated using a volunteer Speech and Language Therapy student.
  • an observation of responses while standing in a circle with eyes closed when instructed that a balloon will be burst behind one of them.
  • presentation of a picture in which an image of either an old woman or a young woman can alternately be seen, in order to emphasise the way in which different perspectives are possible.
  • use of reading material which summarises key ideas.
  1. Identifying negative automatic thoughts
The ability to identify negative automatic thoughts and discriminate emotions is fundamental to Cognitive Therapy. Negative automatic thoughts are cognitions that occur spontaneously and are associated with a negative shift in mood. They are fleeting and habitual, and as a result they tend to go unnoticed although the client may be aware that their mood has changed (Fennell, 1989). Numerous techniques for helping clients to identify negative automatic thoughts have been described. These include: completion of self-report inventories, use of thought records or diaries, recall and visualisation of a recent event, role plays and verbalising cognitions before during or after tasks (J .S. Beck, 1995; Stallard 2002). Importantly, Cognitive Therapists also remain alert to negative shifts in affect within sessions and invite clients to verbalise their thoughts at that moment in time (Wells, 1997).

We begin by identifying negative automatic thoughts in a group exercise, as this further allows experience to be shared and encourages self-disclosure. It is unlikely that all members will have a recent distressing event in common, and working through examples client-by-client is potentially time-consuming and risks losing clients’ interest. Instead, the group is invited to visualise a scenario in the future, such as giving a presentation in class, that is likely to trigger a degree of apprehension for all. The therapist’s skill is found in helping clients to access deeper level personal meanings or predictions about the perceived consequences of stuttering.

This stage in cognitive therapy marries well with the process of desensitisation to stuttering that our clients embark. on and takes place during the second or third day. Tasks such as describing overt stuttering behaviours with the aid of a mirror, telephone assignments or making presentations will, for some clients, trigger the most pertinent or “hot” negative automatic thoughts in situ. For example, when invited to watch himself speak in a mirror for the first time, one clie11t’s facial expression suggested a shift in mood. When asked “What is going through your mind right now?” he identified “I don’t want to see myself‚Äù. Further questioning revealed a prediction that the worst thing about observing himself would be that he would “look like a freak‚Äù. Similarly, before completing his first telephone assignment he identified the prediction: “I’ll stutter” followed by “They won’t listen.”

Once the language of negative thoughts is established this dialogue becomes a routine part of the preparation for assignments including: video presentations and feedback, speaking to members of the public and telephone work. Therapists also check for negative automatic thoughts during speech management tasks for example when feared words are confronted or when clients express frustration with the tenuous nature of their developing control.

  1. Challenging negative automatic thoughts
Next, clients are introduced to strategies for critically examining and verbally challenging their negative thoughts. These are: reviewing evidence, considering alternative explanations, considering the helpfulness of cognitions, and recognising thinking biases.

The impact of this stage in therapy is that it opens up other possible perspectives and encourages a stance of curiosity and questioning which is in itself empowering. Initially clients work in pairs to discuss what could be considered as “hard evidence” for a specific negative thought. Typically as a result of this discussion, some potential observations are relegated to the category of “questionable evidence” and a review of possible alternative explanations for these is undertaken. In this way the clients practise drawing conclusions about the validity of negative automatic thoughts as a group. The group is then introduced to the concept of judging negative thoughts according to their utility or helpfulness, following which common thinking errors are reviewed. Thinking “traps” such as black and white thinking, jumping to conclusions, mind-reading, and generalisation are described and student Speech and language therapists in the group are asked to identify those which they recognise in their own thinking. This is done in order to emphasise the normality of thinking errors, while also emphasising their unhelpfulness.

Once the language and the process of questioning thoughts is established, therapists make use of opportunities within the group and on an individual level to consolidate this skill with actual thoughts that arise in sessions. Whether questioning the validity or helpfulness of thoughts, or enquiring about whether a bias in thinking is present, the aim for therapists is to use questions that encourage awareness and curiosity rather than engage in debate or persuasion.

  1. Behavioural experiments
Behavioural experiments allow clients to test specific thoughts and beliefs out in the real world in order to establish their reliability or “truth” (Beck et al, 1979). In the treatment of anxiety they are directed towards predictions associated with anticipatory anxiety and the effects of reducing safety behaviours, such as avoidance, which otherwise serve to maintain primary fears (Clark & Wells, 1995). Experiments may include gathering evidence for and against negative automatic thoughts or gaining information by making structured observations (Friedberg & McClure, 2002).

To be effective, they need to be designed collaboratively by therapist and client as the necessary element of exposure involved can be expected to trigger apprehension. Clients first identify a key prediction and define it in precise terms. Criteria are set for observing responses and deciding whether they count as evidence which supports the prediction or not, and strategies for dealing with feared outcomes are prepared. Clients then undertake the experiment and evaluate the results with the therapist (Bennett-Levy 2003).

While the overall format and rationale for experiments are discussed within the group, they are designed and conducted on an individual basis. Telephone tasks provide an excellent starting point for many clients for beginning this process, with a common prediction being that the other person will hang up or talk to them in a “patronising” manner. At a later stage clients work in pairs on assignments outside the centre and are encouraged to discuss the hypothesis that they are testing with each other, as well as to report back their findings to the group. Experiments may include finding out about how people react to stuttering, observing others communication skills, and observing reactions to being open about being a person who stutters. This is an important time to encourage disclosure about stuttering, and for clients with a range of avoidance strategies, to experiment with relinquishing these and stuttering openly. Clients who have minimal stuttering, either due to successful speech management or a high level of natural fluency at the time may experiment with voluntary stuttering at this time.

While verbal challenging of negative automatic thoughts may pave the way for change by loosening beliefs (Fennell 1989) and raising awareness of internal dialogue (Bennett-Levy, 2003), it has been argued that behavioural experiments offer the most powerful strategy for promoting cognitive change (Wells, 1997). However, Wells (1997) acknowledges that therapists may notice negative automatic thoughts of their own when designing behavioural experiments, with these typically focused on the fear of “making clients worse”, and that as a result they may shy away from undertaking this aspect of therapy. This raises a useful concern about the importance of therapists’ being aware of their own internal process when conducting treatment and the importance of challenging one’s fears.

  1. Problem solving
According to cognitive theory, anxiety is lessened when risk is reappraised but also when individuals’ perceived ability to cope is enhanced (Beck et al., 1985). The steps involved in problem- solving involve defining the problem and goal, brainstorming possible solutions, considering the consequences of each course of action and retaining or discarding each idea accordingly, prioritising remaining choices and then implementing the first idea and reviewing its effectiveness (Rustin et al, 1995). This is introduced using a genuine problem brought to the group by one of the student Speech and Language Therapists and then is used with problems generated by the group themselves. Within a cognitive therapy framework problem solving can also be applied to a specific prediction about a feared event (for example “They’ll laugh at me‚Äù) and thus provide a way to develop a contingency plan for dealing with the worst-case scenario should it arise.

  1. Preparation for the future
Cognitive Therapy emphasises the development of self-help skills with a view to managing relapse more successfully. To this end it is explicitly predicted that every individual will encounter periods when they feel that things are not going well. Each client is invited to complete an action plan which consists of a review of the key aspects of the course that have been particularly helpful, and strategies to use when difficulties are encountered. Questions include: “What did you work on that has been particularly helpful to you?” and “What is your advice to yourself when things are not going well?” As well as contributing to a sense of self-efficacy, this exercise underlines the personal responsibility involved for each client in managing stuttering in the future.

  1. Conclusion

While not exhaustive this paper has reviewed a sequence of fundamental steps intrinsic to Cognitive Therapy which are pertinent to the treatment of stuttering. There are several advantages to integrating these into group-work with young adults who stutter. Apart from providing an opportunity to share and normalise experience, individuals can draw on others in the group to generate alternative perspectives when they themselves are unable to. In addition, when conducting behavioural experiments, the momentum provided by more confident members supports those who have greater apprehension. For therapists, cognitive theory provides a means of understanding clients experience as well as a framework that guides therapy. While currently based on research into anxiety disorders, and while to date there is no data on the use of this procedure with people who stutter, it is hoped that the trend towards using cognitive therapy to stuttering will lead to the development of a more specifically tailored theoretical model which will guide research and clinical practice in the future.

References:
Beck, AT (1976) Cognitive Therapy and the emotional disorders. New York: International Universities Press.

Beck A.T., Emery, G., & Greenberg, R. (1985) Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books.

Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979) Cognitive Therapy of depression. New York: Guilford Press.

Beck, J .S. (1995) Cognitive Therapy: Basics andbBeyond. London: The Guilford Press.

Bennett-Levy, J. (2003) Mechanisms of change in cognitive therapy: The case of automatic thought records and behavioural experiments. Behavioural and Cognitive Psychotherapy, 31, 261- 277.

Bloodstein, O. (2001) Incipient and developed stuttering as two distinct disorders: resolving a dilemma. Journal of Fluency Disorders, 26, 67-73.

Clark, D.A. & Wells, A. (1995) A cognitive model of social anxiety. In R. Heimberg, M. Liebowitz.,D.A. Hope & F.R. Schneier (Eds.), Social phobia: Diagnosis, assessment and treatment. New York: Guildford Press.

Fennell, M.J.V. (1989) Depression. In: K. Hawton, P.M._ Salkovskis, J. Kirk, & D.M. Clark (Eds.), Cognitive BehaviourTherapy for psychiatric problems: A practical guide. Oxford: Oxford Medical Publications.

Guitar, B. (1998). Stuttering: An integrated approach to its nature and treatment. Baltimore, Williams & Wilkins.

Miechenbaum, D.H. (1977) Cognitive-Behaviour Modification: An integrative approach. New York, Plenum Press

Murphy, B. (1999) A preliminary look at shame, guilt and stuttering. In: N. Bernstein-Ratner & E. C. Healey (Eds.)Stuttering research and practice: Bridging the gap.London: Lawrence Erlbaum Associates.

Neilson, M. (1999) Cognitive - Behavioural treatment of adults who stutter: the process and the art. In: R.F. Curlee,(Ed.) Stuttering and related disorders of fluency, 2"" edition. (pp181-199). New York: Thieme Medical Publishers.

Prins, D.A. (1993) Management of stuttering: Treatment of adolescents and adults. In: R. Curlee (Ed.) Stuttering and related disorders of fluency. New York,:Thieme Medical Publishers.

Rustin, L., Cook, F., & Spence, R. (1996). Management of stammering in adolescence: A communication skills approach. London: Whurr.

Sheehan, J. G. (1970) Stuttering: Research and therapy. New York: Harper and Row.

Stallard, P. (2002) Think good - Feel good: A Cognitive Behaviour Therapy workbook for children and young people. Chichester: John Wiley & Sons Ltd.

Van Riper, C. (1982) The nature of stuttering. Englewood Cliffs, NJ: Prencice-Hall.

Wells, A. (1997) Cognitive Therapy of anxiety disorders: A practical manual and conceptual guide. Chichester: John Wiley & Sons Ltd.

Wright, L., Ayre, A., & Grogan, S. (1998) Outcome measurement in adult stuttering therapy: A self-rating profile._International Journal of Language and Communication Disorders, 33, Supplement, 378-383.

Yaruss, S. (1998). Describing the consequences of disorders: Stuttering and the international classification of impairments, disabilities, and handicaps. Journal of Speech, Language and Hearing Research,41: 249-257.

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