Using CBT with Teenagers

Using CBT with Teenagers

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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The Michael Palin Centre 2

In this session…

• 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”

MPC approach (Cook & Botterill, 2005)

Communication skills

Speech Thinking & management feeling

Socratic questioning

• 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.


CBT

• Psychotherapy developed in the 1960’s by Aaron Beck

• Widely used to treat emotional problems

• Advantages: evidence based, short-term


Principles

• Time-limited • Focused• Structured• Educational• Collaborative• Theoretically driven


Information processing theory

• 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.


Information processing (cont.)

• 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


Thoughts

Physiological responses

Behaviour Feelings

Generic cognitive model


Levels of cognitions

• Negative automatic thoughts (verbal or images, activated memories)

• Unhelpful assumptions

• Negative core beliefs


Negative automatic thoughts (NATs)

• Fleeting, momentary• Habitual• Not always noticed but mood changes• Linked to core beliefs• Highly believable• Tend to be accepted as fact


Key therapeutic ideas so far…

• 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

Social anxiety theory



Appraisal and anxiety

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


Social Anxiety Disorder (SAD) DSM-IV

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.


Fear of:

• Behaving inappropriately or ineptly & other people noticing

Perceived threat:• Negative reaction by others• Negative evaluation by others


Theoretical models

• 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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Clark & Wells (1995)

• 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.

The Michael Palin Centre


Clark & Wells (cont.)

• Attention becomes self-focused. * Close monitoring of self* Reduced attention to external cues

• Self-focus reduces social performance and positive cues are missed.


Clark & Wells (cont.)

• 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



Key clinical ideas

• 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.


Rapee & Heimberg (1997)

• 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


In threat situations:

• 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



Key clinical ideas

• Clients may be attending to negative cues more than neutral or positive ones

• Clients may have unnecessarily high standards about social performance


Comparison

• Both models propose central role of self-focussed attention and construction of stereotypical self-image based on memories and current anxiety symptoms

• Differ in whether or not attentional bias to external threat is involved

Application to stuttering

What is the evidence that this is relevant?



Overview

• Historically an interest in relationship between anxiety and stuttering

• Development of specific models of anxiety helpful

• Interest in understanding & measuring social evaluative concerns since 1990sMenzies, Onslow & Packman (1999)


Young people

Adolescents who stutter found to score more highly than controls on measures of: • social anxiety

Mulcahy, Hennessey, Beilby & Byrnes (2008)

• communication apprehensionBlood, Blood, Tellis & Gabel (2001)

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Adults who stutter (AWS)

• AWS found to score more highly on measures of social

anxiety than non-socially anxious fluent individuals.

Mahr & Torosian (1999) Kraaimaat , Vanryckeghem & Van Dam-Baggen (2002)Messenger, Onslow, Packman & Menzies (2004)



AWS and Social Anxiety (cont.)

• 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)


AWS & social anxiety cont.

• 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 controlsBricker-Katz, Lincoln & McCabe (2009)


Negative listener responses

• 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 yearsEzrati-Vinacour, Platzky & Yairi (2001).

Negative listener responses

CWS are:• more often rejected than their fluent peers

Davis, Howell & Cook (2002)

• more likely to be bulliedBlood & Blood (2004, 2007) Blood, Boyle, Blood & Nalesnik (2010)Davis et al.,(2002)Hugh-Jones & Smith (1999)

Negative social attitudes & stereotyping

• Teachers describe CWS more negatively Crowe & Walton (1981)

Dorsey & Guenther (2000)Lass, Ruscello, Schmitt, Pannbacker, Orlando, Dean, et al.

(1992)Silverman & Marik (1993)


Cont.

• Negative public attitudes to stuttering Huilit and Wurtz (1994)

• Negative employer attitudes Hurst & Cooper (1983a)


Cont.

• Negative impact of stuttering on employment opportunities and job performance

• “stuttering is handicapping in the work place.” Klein & Hood (2004)


Cont.

• Pervasive negative stereotyping of PWS as shy, self-conscious, anxious and lacking confidence Craig, Tran and Craig (2003)


CWS attitudes to speech

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)


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)


SAD: does the theory fit?

Where anxiety is involved the main concern is about:• Performance and standards• Listener reactions• Listener judgement


NATs reported by people who stutter (PWS): performance

• I’ll stutter• I’ll get stuck• They’ll feel awkward• They’ll feel embarrassed• I won’t be able to cope


NATs reported by PWS:negative listener reactions

• People will laugh / snigger / smirk• People will stare• I’ll get picked on / teased• They will copy me• They will…• People will…• People will…


NATs reported by PWS: negative listener evaluation

• They will think there’s something wrong with me• They will think I’m weird• They will think…• They will think…• They will think…


NATs reported by PWS: post-event processing

• 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


Safety Behaviours

• 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”


In conclusion: some caveats and cautions

• 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...


Key features of SAD may help to explain the client’s experience

• 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.


Treatment implications: integrated approach

• 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)

Assessment & clinical decision-making

• 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?


CBT core interventions: Menzies et al (2009)

• 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)


1. Explain the model – does it fit?

• Cat / burglar• Catherine’s exercise• Work with recent or imminent experience• Explore emotions, thoughts, physiological

reactions, behavioural responses and any links• Reading /self-help

2. Identify NATs

• 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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Likely high intensity tasks

• Fluency practice when struggling (I can’t, that was rubbish, I should…)

• Mirror work

• Watching self on video

• Presentation practice, interview practice

• Outside assignments**


Questions therapists ask

• 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

Intensity and belief ratings

• 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?

Thought record

The Michael Palin Centre59

Situation Emotions(0-100%)

Negative automatic thoughts(0-100%)

About to watch myself in the mirror

Terror 90 %

I’ll see myself stutter (100%)

I’ll look like a freak(90%)

Tips

• 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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Questions therapists ask

• 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?


4. Behavioural experiments

• 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


Be specific and concrete

• 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?


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?


Problem solving

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?


Problem solving steps

• 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.


6. Attentional bias

• 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)

Reflections on CBT in group work

• 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

In groups:

• 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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Parents’ cognitive cycles (Biggart, Cook & Fry, 2006)

I’ll stutter. I can’t do

it.

Nervous, panic

Hot and shaky

Hang back,

look to parent

He’ll stutter

Anxious

Tense up

Speak for him

Conclusions: CBT aims to

• Increase psychological flexibility

• Increase resilience / positive coping

• Increase confidence

• Reduce Impact of stuttering

• Support positive core sense of self

THERAPEUTIC SKILLS INVOLVED

• Specific CT skills

• Core counselling skills

• Ability to work collaboratively • Self awareness as a therapist


References

• 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.


References

• 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.


References (cont.)

• Menzies, R.G., Onslow, M., & Packman, A. & O’Brien, S. (2009). Cognitive behaviour therapy for adults who stutter: a tutorial for speech-language 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.


References

• 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.


Further training resources

• 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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Using CBT with Teenagers

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