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New ways of delivering therapy

Prof. Mark Onslow | 01.12.2009

A new anxiety treatment website should go live in summer 2010, said Professor Onslow at the BSA National Conference. He suggested a 'stepped care' approach to therapy, including telehealth, and talked about research on anxiety.

Mark Onslow"Houston, we have a problem..." declared Mark Onslow of the Australian Stuttering Research Centre (ASRC), speaking at BSA's National Conference in September. Looking at the figures, said Mark, there are far too few specialist speech and language therapists to cope with demand from children and adults who stammer. How to address this? He proposed a stepped care approach, where you first use the simplest, cheapest intervention - and if that doesn't work you progressively escalate.

The first step he sees as standalone internet treatment, where you never see a therapist. The ASRC have already built and are trialling a website for anxiety treatment for people who stammer. This uses a cognitive behaviour therapy package designed specifically for those who stammer, to address unhelpful thoughts and beliefs. The site should be available to all free of charge from the middle of 2010. In a small-scale trial, he said, 3 out of 3 people "got spectacularly better" from their anxiety without having seen a clinician. The website, says Mark, uses innovative architecture, videos, and the voices of real psychologists, with thousands of pre-defined clinical scenarios.

The ASRC team is also developing a website for people to do the Camperdown Program, a speech restructuring approach for adolescents and adults. Indeed, he said, they are converting all their treatments to internet standalone versions with a view to introducing a wave of stepped care intervention internationally.

If your stammering needs (or those of your pre-schooler) are not 'mopped up' by website provision, he suggested, you could have clinical contact with a therapist maybe once a month or a fortnight over the internet using webcam technology like Skype. Brenda Carey in Australia is already treating people in Melbourne and beyond using this technology without ever meeting them (she found no rapport problems), and Mark himself treated people from his study. In a random trial of the Camperdown Program, a telehealth group - not even using Skype but just the telephone - matched the fluency outcomes of a face-to-face therapy group after 9 months, and the telehealth group took less contact time on average.

a telehealth group matched the fluency outcomes of a face-to-face therapy group after 9 months, and took less contact time.

If that was not sufficient, maybe you would need (for pre-schoolers) the Lidcombe Program every week over Skype. If you are an adult or adolescent, maybe you would need a weekly session with a therapist. Or maybe you are someone who requires the intensive residential format in which case (the ideal is!) you would get it. Responding to questions after the talk, Mark saw Skype as suitable for use in group treatment, although at present there are some technical limitations.

This might seem a 'wild' vision, said Mark, but ASRC had at least started on implementing this, with their proposed websites and telehealth therapy.

Role of anxiety

As well as fluency itself, anxiety is a problem faced by people who stammer. In an anxious state, you expect something harmful to happen to you. If you stammer you are likely to expect negative evaluation in a social context. These thoughts may dominate a person's life. In a worst case scenario, someone could become isolated, could focus on a non-verbal career, and perhaps not seek adequate professional development because of dominating negative thoughts such as "I could never succeed in the job anyway."

Anxiety can go so far as to lead to a diagnosis of social phobia or social anxiety. Mark described 'social anxiety disorder' under the official DSM-IV definition as characterised by a constant and unrealistic expectation of humilation and embarassment throughout your life. An example of an unrealistic expectation might be if you believe, as many who stammer do, that the 20 people in a room will notice you stammer every time you do so. To meet the definition, the person's life also needs to be characterised by avoidance and social isolation, because they do not enter situations where they expect these things to occur.

A recent study had found that two thirds of the ASRC clinical caseload warranted a diagnosis of social phobia. Also, the ASRC team had found and reported that, at least among those who seek treatment, people who stammer had 16- to 34-fold increased odds of having social phobia compared with matched controls, as well as increased odds of various other anxiety-related disorders (doi:10.1016/j.janxdis.2009.06.003).

Research indicates that negative social conditioning during school years is where it starts, said Mark. Children who stammer are perceived negatively by peers, and those peer relationship problems will remain into adulthood. It was virtually 100% certain that you will be bullied in your school years if you stammer, and there was good research evidence to suggest that this will cause social anxiety.

The ASRC team were also just completing an exploration of educational completion levels of people who stammer. Findings to date - very worringly - suggest that the greater the stammering severity, the less likely a person was to stay in education to a particular level: to the end of high school, into university, or to masters degree level.

It seems like we are starting to get an explanation why some can get their stammer under control and others just struggle endlessly and relapse.

Does anxiety affect fluency?

A key problem is that after therapy people who stammer often relapse. Mark talked about a study of speech restructuring treatment published in 2009 (doi:10.1016/j.jfludis.2009.02.002), where ASRC had found that it was those who had one or more anxiety-related disorders who tend to relapse. It seems, said Mark, like we are starting to get an explanation why some can get their stammer under control and others just struggle endlessly and relapse. It looks very like those with social anxiety - fear of negative evaluation - as a part of their lives are the ones who are going to find it a challenge to control the stammer.

In a 2008 paper (doi:10.1044/1092-4388(2008/07-0070)), the ASRC team had explored whether using cognitive behaviour therapy (CBT) to treat anxiety gave a boost to speech restructuring treatment for fluency. Surprisingly, no it did not help, in terms of percentage of syllables stuttered. But the CBT certainly did improve psychological function. Those who were not given CBT retained their social phobia diagnosis. Every single one of those who were given CBT no longer received a diagnosis of social phobia, and got high scores for how well they engaged with life. The people who had CBT were able to walk into nearly 100% of their 'scary situations'.

Many thanks to Mark for his interesting and stimulating talk which, from feedback to BSA, was very much appreciated by conference participants.

ASRC website:

Extended version of article in the Winter 2009 edition of Speaking Out, page 6.