How cognitive behaviour therapy (CBT) helped me

*This article is more than 5 years old* (Originally published in 2014)

John Farroway, member of the Queensland Speak Easy Association in Australia, explains how an online programme transformed his attitude to stammering.

Stammering has had a big impact on my life over the last 70 years. My stammer was picked up in my first year of school and I undertook speech therapy when I was nine. I had difficulty at high school and in my early twenties, so I again sought the assistance of a speech therapist (or pathologist, as they're known as here in Australia). After six months, the therapist said there was nothing more she could do for me and referred me to a psychiatrist. The psychiatrist detected spiking on the left-hand side of my brain and prescribed sedatives to help me deal with my stammer. He suggested that I change my job and leave home. Acting on this, I did just that and my new fellow employees were so friendly that I was no longer concerned with my stammer at work. After a few years I changed my job again and left my family home. Both these changes resulted in an improvement in my fluency so I abandoned my medication.

In my early fifties I became aware of something called the 'Smooth Speech' programme. Feeling the need for it, I found a therapist who taught it and I visited them over a six year period, undertaking an hour of practice each evening. At the end I was mainly stammer-free. However, my use of safety behaviours, such as avoidance and word-substitution, meant that I was very reluctant to speak to more than one person at a time.

I then became aware of an online Cognitive Behaviour Therapy (CBT) programme being run by the Australian Stuttering Research Centre when I was in my early seventies. I undertook this programme and as a result my life changed for the better.

Too many of us are losing the pleasant moments of life by going over thoughts about trivial things or incidents. One should identify one's unhelpful thoughts and learn to reframe and restructure them.

Social anxiety

Recent Australian research confirms previous studies, showing that an alarming number of people who stammer deal with social anxiety¹. In these cases people worry so much about displaying their stammering that it interferes with their quality of life. They limit or choose to avoid social settings and may deliberately avoid difficult words at restaurants and bars, making choices not on what they would like, but on what they can say. Stammering can cause people to change words mid-sentence or hide any overt dysfluency. The avoidance behaviour and covert stammering can come at a high emotional cost. The associated social anxiety can result in dramatic social, academic and career impairment. In comparing the stammering and non-stammering population, the same research found a 16- to 34-fold increased chance of a person who stammers having a social anxiety disorder than someone who doesn't.

What is Cognitive Behaviour Therapy?

Cognitive Behaviour Therapy (CBT) is a form of psychotherapy that can help manage social anxiety problems in a more positive way by changing the way we think and behave. It encourages you to examine how your actions can affect how you think and feel. How one thinks about one's stammering affects how badly one feels about it. The more one pays attention to one's stammering, the worse one feels. CBT offers coping techniques to deal with negative feelings.

The therapeutic approach of CBT is based on the belief that our behaviour (what we do or how we respond to situations), our emotions and what we feel about things, are all intrinsically interlinked. In other words, how we feel and what we are thinking will both affect how we behave. CBT states that our responses to situations and events, our behaviours, are the results of our perceptions about the situation or event. We may assume that if we are feeling anxious about a forthcoming event, it is the event that is causing the anxiety. CBT practitioners teach that this is not the case; it is in fact what we think or believe about the event which causes the anxiety. The alternative is also true – if we are happily anticipating an event we will be excited rather than anxious.

The CBT process identifies thoughts and beliefs about a particular subject or situation and asks if these are 'thinking errors', or Negative Automatic Thoughts (NATS). Ruminating on these can lead to a vicious cycle that lowers mood or maintains low mood. NATS include, among others, 'catastrophising' (expecting the worst to happen); 'mind reading' (thinking we know what others are thinking); 'predicting' what is going to happen and 'black and white thinking' (seeing the situation in one way, with no middle ground). The validity of these thoughts and beliefs are then challenged.

Standard CBT questions used to challenge thinking errors:

1. What evidence do you have for the thought?
2. What evidence do you have against the thought?
3. What would you tell a friend (to help them) if they had the thought?
4. Think of your most rational and supportive friend or family member. How would they react to the causal thought (one that causes an emotion)? What would they say?
5. Are you worrying about an outcome that you can't control? Is there any point to this type of worry?
6. What does the thought do for you? How does it make you feel? Is it helpful in any way, or is it just distressing?
7. How would your life be different if you didn't believe the thought?
8. If the causal thought was true, what is the worst outcome? Is it as bad as you think?

The CBT process suggests that one keeps a diary record of thoughts, feelings and responses. It is an active, not a passive, approach. One has to change negative unhelpful thoughts into helpful, affirmative or more balanced ones. CBT also addresses one's perception of how things should be and teaches that one's thoughts or predictions are not facts.

Other aspects of CBT

Attention Training Technique (ATT) is a process sometimes used within CBT. ATT increases one's level of mental flexibility and through listening to and focusing on a variety of everyday sounds around us, lets one's mind move away from dwelling on thoughts, feelings and negative ideas.

'Rescriptin'' is another aspect and can be used to gain control over a critical past event that has been the cause of great concern or anxiety. In quiet surroundings, one closes one's eyes and brings to mind the memory of the critical past event. One sees the image, absorbs oneself in it and 'rescripts' the event providing a more pleasant result to the encounter, so that the old outcome from the event is replaced.

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The 'dropping of safety behaviours' is also part of a CBT programme. Safety behaviours are often used to stop one's feared situations occurring. However, although making use of a safety behaviour may reduce anxiety at that time, frequent use does not give one the outcome one desires and reinforces fears.

With CBT, one should not listen to worrying moments and should not give up any more of one's life to anxiety and negative thinking. Too many of us are losing the pleasant moments of life by going over thoughts about trivial things or incidents. One should identify one's unhelpful thoughts and learn to reframe and restructure them.

How I benefitted from CBT

The online CBT trial programme I participated in was titled 'Web-based anxiety treatment for adults who stammer.' It was set up by the Australian Stuttering Research Centre, based at the University of Sydney. (*2021 Update: this programme is now called 'the iGlebe online social anxiety treatment for adults who stutter' and it is available free. Go to the iGlebe website*) 

It is government- and privately- funded (Australian government) and it is the world leader in stammering research. A five month period was allocated to complete the programme. It was suggested that it be accessed twice a week.

The programme I undertook was fully automated, with 70 to 100 audio recordings being made by two psychologists. I filled out questionnaires at the start and was then guided through a number of lessons and exercises on challenging my negative thinking. At the end I completed the same questionnaires I filled out at the start and was presented with graphs comparing my anxiety symptoms before and afterwards.

The programme had nine stages:

1. Pre-questionnaires
2. Thinking exercises
3. Challenging your thinking
4. Creating your model (from answers you give in the questionnaires)
5. Behavioural experiments
6. Challenging your thinking further
7. Self-processing, including Attention Training Technique and Rescripting
8. Relapse prevention
9. Post-questionnaires.

The programme was one of the great events of my life. It acknowledged that people who stammer often have undesirable thoughts and beliefs and I was shown how to change these. The results were immediate. The major item I picked up from the programme was the dropping of safety behaviours. I was able to go out and stop doing the things I had used for many years. Rescripting helped too; I recalled my most negative memory of when I was back at high school and the Deputy Headmaster, when I had problems saying my name, told the class I didn't even know my own name. Using the technique, I worked at rescripting the memory and consequently it doesn't hold the same impact anymore.

Shortly after the course finished I attended a dinner with 25 people. Normally this would involve the minimum of social conversation from me. On this occasion I made use of the techniques I had picked up and talked just about non-stop and on several occasions I was told to stop talking and eat as everyone was waiting for me to finish my meal so they could have the next course served. 

Each conversation that I approach I now face with determination and courage. No longer do I stand back and rehearse what I am going to say before saying it. I have become very outspoken and have no problem at all in speaking up at meetings to add to the discussion. People I have met since completing the CBT programme have no idea that I stammer and when I tell them they are amazed by my story of how CBT changed my life.

For more information on iGlebe, the free Australian Stuttering Research Centre's online social anxiety treatment for adults who stutter, visit the iGlebe website. Read the thesis 'A fully automated online Cognitive Behaviour Therapy for social anxiety for those who stammer', by Dr. Fjóla Dögg Helgadóttir (who set it up with Dr. Ross Menzies).

Reference

¹Iverach, L., O'Brian, S., Jones, M., Block, S., Lincoln, M., Harrison, E., Hewat, S., Menzies, R., Packman, M., & Onslow, M. (2009) Prevalence of anxiety disorders among adults seeking speech therapy for stuttering. Journal of Anxiety Disorders, 23(7), 928-934.

This article was first published in our old magazine Speaking Out, Summer/Autumn 2014.