Cognitive Behavior Therapy

Speech therapy for stuttering takes many forms. I recently learned more about speech therapy as a process of discovery. This perspective is presented in the DVD Tools for Success: A Cognitive Behavior Therapy Taster by Frances Cook and Willie Botterill. (1)

Cognitive-behavior therapy (CBT) can be “readily adapted for working with the cognitive, affective, and behavioral aspects of stuttering” states handout accompanying the DVD. The premise of CBT is that thoughts, feelings, and behavior are inter-related and influence one another. An simple graphic illustrates thoughts, feelings, physiological responses and behavior in a circle. Initially, the relationship between these 4 aspects was explained as occurring in a clockwise direction: a person’s thoughts cause certain emotional reactions which in turn cause the body to respond which finally results in a specific behavior. Later, it was described as bi-directional. Towards the end of the DVD, a CBT approach is demonstrated during conversation with a group of children and a group of parents.

While I appreciated the therapeutic style and felt that the process could be a good fit for some of my students, I wondered about how CBT would affect real outcome. I recalled attending a workshop presented by the Albert Ellis Institute many years ago that espoused a similar approach to problems of depression, anxiety, relationships and addiction. The Albert Ellis Institute home page reads: “short term therapy, long term results” and I wonder aloud what evidence supports this claim. The Stuttering Hexagon (3) that John Harrison presents includes a diagram of the interaction between 6 different factors: behaviors, emotions, perceptions, beliefs, intentions and physiological responses. Does an appreciation for a multi-directional, multi-faceted mind-body relationship result in greater fluency?

Ms Cook and Ms Botterill, renowned therapists at the Michael Palin Center (4), report success using CBT with their clients who stutter. Slides 24 and 25 of their presentation define the commonly occurring reactions to stuttering as “Safety Behaviors.” These include specific speech behaviors such as “push harder” and “speak more quickly” as well as communicative choices such as “decide not to speak” and “pretend not to know the answer.” The premise is that when one changes a single factor of the Cognitive Model, then other factors also change because of their inherent interconnection. An SLP is to guide conversation with clients in such a way as to discover the specific thoughts, feelings, physiological responses and behaviors they experience. Then, reality checks, “cognitive reframing”, behavioral experiments, and problem-solving help to change unhelpful thought patterns and behaviors and therefore improve fluency.

In a way, proponents of a strictly behavioral approach to stuttering therapy made similar claims: improving speech fluency would positively influence cognitive and affective aspects of communication. I recall attending a Special Interest Division Conference in Boston, Massachusetts at which Bruce Ryan argued passionately that his systematic approach of increasingly difficult speech drills was successful. He even expressed regret that some of the younger SPLs may not have been exposed to his program, presumably because other training programs preempted his own. (5) Yet, the field of speech pathology has responded by drawing on principals of counseling therapy.

We now have a field divided. Research into genetics, assistive devices, temperament, self-monitoring skills and impulsivity, stages of change, quality of life, and evidence-based practice are overwhelming. Most SLPs choose not to keep up with the multitude of voices within the field of stuttering therapy. School districts propagate this state of affairs by refusing service to children who stutter in many cases. Insurance companies that deny coverage for stuttering therapy are accomplices.

Where are we now? Perhaps the recent National Public Radio interview with Kristin Chmela and Dan Slater (6) illustrates two answers to this question. Ms Chmela, an SLP, Specialist in Stuttering, and person who grew up stuttering, says that she has made a journey of recovery. (7) She seldom thinks, feels, or speaks like a stutterer. Mr. Slater talks about his continued internal anxiety and use of avoidance tricks. Ms Chmela eloquently describes stuttering and its management as something unique to every individual who stutters. This interview is a must-listen.

I will add principals of CBT to my speech therapy because it provides a framework for listening to the client. This is key to the therapeutic alliance, IMHO. The child, teen or adult who stutters is likely to have few, if any, sensitive listeners. Speech therapy may be the only place in which they talk. SLPs must allow plenty of time for careful listening and CBT allows for this.

(1) ©2009, www.stutteringhelp.org
(2) http://www.rebt.org/
(3) “How I Recovered from Stuttering” by John Harrison http://www.masteringstuttering.com/recovery-stuttering.htm
(4) I could find a webpage for this
(5) http://www.mnsu.edu/comdis/kuster/TherapyWWW/gilcu.html
(6) “The King’s Speech Passes Stutterers the Mic”, January 4, 2011, http://www.npr.org/2011/01/04/132653936/the-kings-speech-passes-stutterers-the-mic
(7) “Thoughts on Recovery” by Kristen Chmela, 1997, http://www.mnsu.edu/comdis/kuster/casestudy/path/chmela.html

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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.