Jane Fry, MSc (Psych Couns), RCSLT,
PG Dip. CT (Oxford Cognitive Therapy
Centre, U.K.)
The Michael Palin Centre, London, U.K.
www.stammeringcentre.org
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• Setting the scene: the MPC approach and the
therapeutic relationship
• Introduction to Cognitive Behaviour Therapy
(CBT)
• Application to stuttering
• Clinical implications for working with young
people
• A “taster”
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MPC approach (Cook & Botterill, 2005)
Communication
skills
Speech
management
Thinking &
feeling
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Not an inquisition, a debate or persuasion
Be genuinely curious
Be alert to thinking you know the answer
Best questions are direct, uncomplicated, open
Support with summaries and empathic responses.
• Psychotherapy developed in the 1960’s by
Aaron Beck
• Widely used to treat emotional problems
• Advantages: evidence based, short-term
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Time-limited
Focused
Structured
Educational
Collaborative
Theoretically driven
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• Individuals make sense of the world by
interpreting their experience.
• This process is shaped by the individual’s
underlying assumptions and beliefs, developed
in response to early experience.
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• The way an individual interprets events affects
his or her responses (emotionally,
physiologically, behaviourally)
• Interpretations can be biased or inaccurate
• Responses can be counterproductive and
maintain or exacerbate difficulties
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Thoughts
Behaviour
Feelings
Physiological responses
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• Negative automatic thoughts
(verbal or images, activated memories)
• Unhelpful assumptions
• Negative core beliefs
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Fleeting, momentary
Habitual
Not always noticed but mood changes
Linked to core beliefs
Highly believable
Tend to be accepted as fact
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Thoughts are just thoughts
There is always another way of looking at things
And it can be helpful to do so
Explore, and work with, rather than react to
negative thoughts
• Explore more effective ways of coping
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Social anxiety theory
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Anxiety occurs when we anticipate threat (physical
or social), and
• over-estimate the likelihood of a feared event
• over-estimate the danger, risk or impact
• under-estimate our ability to cope
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A marked and persistent fear of one or more social or
performance situations in which the person is exposed
to unfamiliar persons or possible scrutiny by others.
The individual fears that he or she will act in a way, or
show anxiety symptoms, that will be humiliating or
embarrassing.
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• Behaving inappropriately or ineptly & other
people noticing
• Negative reaction by others
• Negative evaluation by others
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• Clark & Wells (1995)
• Rapee & Heimberg (1997)
• Both emphasise central role of attentional processes
in maintaining social fear
• Propose different dynamics re attentional processes
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• Negative assumptions about social situations
• Negative bias in pre-event processing
* perceive threat
* own performance
* negative listener evaluation
• Somatic and cognitive anxiety responses are
triggered.
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• Attention becomes self-focused.
* Close monitoring of self
* Reduced attention to external cues
• Self-focus reduces social performance and positive
cues are missed.
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• Sense of self constructed based on individual’s own
impression of self (-ve)
• Safety behaviours adopted
* increase likelihood of feared event
* prevent disconfirmation
• Negative bias in post-event processing
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• Clients may be paying less attention to
environmental cues and missing helpful or
reassuring information.
• Dropping safety behaviours is important clinically
but clients first to explore and challenge their
fears.
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• People wish to be liked and held in esteem
• Assume others are naturally critical and that negative
evaluation is likely
• Make judgements about probability and consequences
of negative evaluation by others
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• Are self-focused but also hyper-vigilant to
external cues that fit with their fears
• Construct a sense of themselves based on how
they think others see them
• Make comparisons between this and what they
assume are required standards
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• Clients may be attending to negative cues more than
neutral or positive ones
• Clients may have unnecessarily high standards about
social performance
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• Both models propose central role of self-focussed
attention and construction of stereotypical selfimage based on memories and current anxiety
symptoms
• Differ in whether or not attentional bias to external
threat is involved
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Application to stuttering
What is the evidence that this is
relevant?
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• Historically an interest in relationship between
anxiety and stuttering
• Development of specific models of anxiety
helpful
• Interest in understanding & measuring social
evaluative concerns since 1990s
Menzies, Onslow & Packman (1999)
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Adolescents who stutter found to score more
highly than controls on measures of:
• social anxiety
Mulcahy, Hennessey, Beilby & Byrnes (2008)
• communication apprehension
Blood, Blood, Tellis & Gabel (2001)
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• AWS found to score more highly on measures of
social anxiety than non-socially anxious fluent
individuals.
Mahr & Torosian (1999)
Kraaimaat , Vanryckeghem & Van DamBaggen (2002)
Messenger, Onslow, Packman & Menzies
(2004)
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• Scores of AWS can be as high as those of
individuals with clinical diagnosis of SAD.
Stein, Baird & Walker (1996)
Schneier, Wexler & Liebowitz (1997)
Kraaimaat et al. (2002)
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• Vulnerability to social anxiety may persist across
the lifespan & does not necessarily ameliorate
• PWS aged 55 years + scored significantly higher
on Fear of Negative Evaluation Scale than fluent
controls
Bricker-Katz, Lincoln & McCabe (2009)
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• CWNS as young as 3 years discriminate
between fluent and stuttered speech and
show a preference for fluent.
Ezrati-Vinacour & Levin (2004)
Langevin, Packman & Onslow (2009)
• Increase in their negative evaluation of
stammering by 4 years
Ezrati-Vinacour, Platzky & Yairi (2001).
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CWS are:
• more often rejected than their fluent peers
Davis, Howell & Cook (2002)
• more likely to be bullied
Blood & Blood (2004, 2007)
Blood, Boyle, Blood & Nalesnik (2010)
Davis et al.,(2002)
Hugh-Jones & Smith (1999)
• Teachers describe CWS more negatively
Crowe & Walton (1981)
Dorsey & Guenther (2000)
Lass, Ruscello, Schmitt, Pannbacker, Orlando, Dean, et al. (1992)
Silverman & Marik (1993)
• Negative public attitudes to stuttering
Huilit and Wurtz (1994)
• Negative employer attitudes
Hurst & Cooper (1983a)
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Cont.
• Negative impact of stuttering on employment
opportunities and job performance
• “stuttering is handicapping in the work place.”
Klein & Hood (2004)
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• Pervasive negative stereotyping of PWS as shy, selfconscious, anxious and lacking confidence
Craig, Tran and Craig (2003)
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CWS as young as three or four years old demonstrate
significantly more negative attitudes towards their
own speech than their fluent peers
Vanryckeghem, Brutten & Hernandez (2005)
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Adolescents who stutter are more likely to
become more shy, socially avoidant and
fearful of communication than their fluent
peers, and to develop pervasive negative
attitudes and beliefs about themselves as
communicators.
Craig and Tran (2006)
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Where anxiety is involved the main concern is
about:
• Performance and standards
• Listener reactions
• Listener judgement
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I’ll stutter
I’ll get stuck
They’ll feel awkward
They’ll feel embarrassed
I won’t be able to cope
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People will laugh / snigger / smirk
People will stare
I’ll get picked on / teased
They will copy me
They will…
People will…
People will…
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They will think there’s something wrong with me
They will think I’m weird
They will think…
They will think…
They will think…
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It’s my fault
I can’t even speak
I’m stupid
I’m different
I should have been able to say that
That was useless
I’m rubbish
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Speak more quickly
Push harder
Mentally rehearse - go over the sentence.
Scan ahead and avoid problem words
Decide not to speak or say as little as possible
Be a good listener.
Pretend not to know the answer
“Blatantly avoid the situation”
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• Diagnosis of SAD or not?
• Does it fit for everyone?
• Anxiety is not the only emotion associated with
stuttering
• But where anxiety is a feature...
• and where that is the client’s area of concern...
• and taking developmental levels into account...
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• Negative attitudes about self as speaker
• Negative automatic thoughts related to listener
reactions and judgement (pre and post event)
• Focus of attention may shift when people
anticipate or are in the midst of a moment of
stammering
• Use of safety behaviours – i.e. deciding not to
speak or say a particular word.
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• Speech restructuring & CBT
Menzies, O’Brien, Packman, St Clare &
Block (2008)
• Speech restructuring & CBT & social skills
training
Fry, J., Botterill, W., & Pring, T (2009)
Craig, Blumgart & Tran (2011)
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• What emotions are associated with stammering?
How intense?
• Does the client worry about consequences of
stammering (what people will do, think of them). If
so, how central / well elaborated are these thoughts?
• What does the client do to cope? Anything
counterproductive? (eg avoidance).
• Is the idea of the vicious circle potentially useful
or not particularly?
• Is psychological work likely to help this client
reach his or her goals? Relevant or not
particularly?
• Identify NATs: stuttering and the perceived
consequences of stuttering
• Question NATs: probability, cost, helpfulness,
alternative views
• Behavioural experiments: test NATs & utility
of safety behaviours, problem solving
• Attentional training: switch focus of
attention.
Internal to external (Clark & Wells)
External (-ve) to external neutral or +ve
(Rapee & Heimberg)
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Cat / burglar
Catherine’s exercise
Work with recent or imminent experience
Explore emotions, thoughts, physiological
reactions, behavioural responses and any links
• Reading /self-help
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• Interview, questionnaires, embedded in
narrative
• Recent or future event
• Verbalise thoughts before, during and after
therapy tasks.
• Follow changes in affect: “what’s going
through your mind right now?”
• Thought records
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• Fluency practice when struggling (I can’t, that was
rubbish, I should…)
• Mirror work
• Watching self on video
• Presentation practice, interview practice
• Outside assignments**
• What thoughts went through / are going through
your mind?
• What did you imagine might happen?
• And then what?
• What was/is the worst thing that could happen?
• Suppose that were to happen, what would be the
worst thing about that for you?
• Did you have a mental picture at that moment
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• When that feeling was at its worst how strong
was it?
• How nervous / embarrassed did you feel at the
time?
• How much did you believe that at the time?
• How convincing was that thought at the time?
Situation Emotions
(0-100%)
About
to
watch
myself
in the
mirror
Negative automatic
thoughts
(0-100%)
Terror 90 % I’ll see myself
stutter (100%)
I’ll look like a freak
(90%)
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Feelings first
Check for images
Use clients’ actual words
Spell out telegraphic thoughts
(“Can you put that into words? “Oh god”
means…?”, “Arrgh” means…)
• Turn questions into statements
• Go beyond the first thought (downward arrow)
• Identify the hot thought
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• What is the evidence?
• Any evidence that does not fit?
• What is the effect of thinking that? Does
that help or make you feel worse?
• Is there something more helpful you
could say to yourself?
• Is there another way of looking at it?
• What are your options? How can you
deal with this?
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Foster a sense of empirical enquiry about NATs
Facilitated not set
Linked to specific NATs
Concrete
Meaningful
Set up to be “win-win”
No agendas. Genuine curiosity
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• What do you think might happen?
• What would tell you that a person thought
this?
• What would tell you that this wasn’t the
case?
• How could you check this out for sure?
• Feedback:
• What did you do? What happened?
• What did you find out?
• What do you make of that?
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Example
• NAT: People will walk away if I stammer
• Experiment:
* Observe therapist stammer to 10 people
* How many people walked away?
* Any other explanations for this?
* How many people did not walk away?
• Debrief. What did I find out? What does this
mean for me?
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Supposing the worst did happen…
• What could you do, or say to yourself, to help
you cope?
• How have you dealt with this in the past?
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• Identify the problem and the goal
• Brainstorm possible solutions
• Think about the pros / cons of each and either
keep or discard
• Prioritise
• Try out first solution. Reflect. Try
next choices if needed.
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• Work on observation & listening skills
(focus of attention)
• Use video feedback
• Pair and group work – peer’s point of view
• Explicit focus on positives
“What went well?”
• Signs of change (SFBT)
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• Part of multi-component approach
• Variable responses likely
• Not the same as individual work
• More broad based - thinking skills – less detailed
examination
• Less focus on core / schema level
• Minimise psycho-educational work
• Maximise in-vivo learning
• Use the group to generate other views,
counter biases and increase learning appeal.
What is the interpersonal
context?
Teachers? Parents?
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I’ll stutter. I
can’t do it.
Nervous,
panic
He’ll stutter
Hang back,
look to parent
Speak for
him
Hot and
shaky
Anxious
Tense up
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• Increase psychological flexibility
• Increase resilience / positive coping
• Increase confidence
• Reduce Impact of stuttering
• Support positive core sense of self
• Specific CT skills
• Core counselling skills
• Ability to work collaboratively
• Self awareness as a therapist
• Beck, J.S.(1995) Cognitive Therapy: Basics and
Beyond. NY: Guilford Press.
• Butler, G.(1999) Overcoming Social Anxiety and
Shyness: A Self-help Guide Using Cognitive
Behavioural Techniques. London: Robinson.
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• Clark, D.M. & Wells, A. (1995). A cognitive model of
social phobia. In R.G. Heimberg, M. Liebowitz, D.A.
Hope, & F.R. Schneier (Eds.), Social phobia:
Diagnosis, assessment and treatment (pp69-93).
New York: Guilford Press.
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• Menzies, R.G., Onslow, M., & Packman, A. &
O’Brien, S. (2009). Cognitive behaviour therapy
for adults who stutter: a tutorial for speechlanguage pathologists. Journal of fluency
disorders, 34 (3), 187-200.
• Rapee, R.M., & Heimberg, R.G. (1997). A
cognitive-behavioural model of anxiety in social
phobia. Behaviour Research and Therapy, 35,
741-756.
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• Stallard, P (2002) Think Good Feel Good: A
Cognitive Behavioural Therapy Workbook
for Children and Young People. John Wiley
& Sons: Chichester
• Stallard, P. (2005) A Clinician’s Guide to
Think Good-Feel Good: Using CBT with
children and young people. John Wiley &
Sons: Chichester.
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• Tools for Success: A CBT taster (Frances
Cook and
Willie Botterill, The Michael Palin Centre,
London, UK)
• Oxford Cognitive Therapy Centre
• BABCP – advertises CBT training around
the UK
• The Michael Palin Centre – 3 day intro to
CBT
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