Cognitive therapy is the NHS treatment of choice for a range of psychological and emotional issues. Jane Fry of the Michael Palin Centre looks at its use with stammering.
Many people who stammer may have heard about Cognitive Therapy, or Cognitive Behaviour Therapy (CBT) but may not be sure what it involves, or may simply be interested in knowing more. This article will talk about some of the basic principles of Cognitive Therapy and explain how it can be helpful in therapy for stammering.
What is cognitive therapy?
Cognitive Therapy is a form of psychotherapy which was originally developed by Aaron Beck in the 1960s to understand and treat depression. Today it is the treatment of choice in the NHS for a range of psychological or emotional difficulties, including depression, anxiety, health anxiety, panic, social anxiety, school anxiety and phobia. It is used with children as well as adults, and is also used in work with couples and families. The high profile that Cognitive Therapy enjoys is largely due to the extensive body of research which has shown that it is effective with a range of difficulties.
What are the main ideas behind it?
Beck, along with his contemporary George Kelly who developed Personal Construct Psychology, was interested in the way that people make sense of the world. They shared the view that there is no single, objective 'reality' as such, which means that there are always different ways of looking at things. They both suggested that we are all involved in a continual process of interpreting the world and our experiences, and we develop psychological systems and patterns along the way.
people do not become upset about things that happen so much as what they make of things that happen. (Beck, 1989)
This may be necessary and helpful because it makes the world more predictable. However, Beck argued that we all sometimes make errors, jump to conclusions and generally get things wrong. He was primarily interested in the way that some people develop patterns of 'unhelpful thinking', negative self-talk and negative beliefs about themselves, and also 'core beliefs' which make them particularly vulnerable to uncomfortable emotions and limit their ability to live as they wish to.Beck proposed that people do not become upset about things that happen so much as what they make of things that happen. The way that people feel emotionally and physically in a situation, and the way that they react, is linked to how they interpret that situation. Take anxiety as an example. According to cognitive theory, when people become anxious it is because they are interpreting an imminent situation as being 'threatening' in some way. It does not stop there. The anxiety will be higher:
- the more a person views the feared event as likely to happen,
- the more that is seen as being at stake should it happen, and
- the less a person sees themselves as being able to cope.
So the way that people see things or interpret things is crucial. When a threat is anticipated, be it physical or social, there is a 'wired in' response which triggers physical feelings, such as 'butterflies' or an increased heart rate, and also a natural and instinctive behavioural response to do something protective, such as avoiding the source of the threat in the first place.
One of the most important ideas in cognitive therapy is that in difficult situations people tend to respond in ways which inadvertently reinforce problems, creating a vicious circle. It is important to remember that this is something we can all relate to, whether we stammer or not. Continuing with the example of anxiety, avoiding a feared situation might get an individual 'off the hook' as it were, but ultimately it stops them from finding out that things might have actually been OK, or not as bad as they feared, or indeed that they might have coped. The person loses the opportunity to build confidence, and their fears associated with that situation are reinforced.
How does this relate to stammering?
There is not a great deal of research into cognitive therapy and stammering yet. However, the idea of the vicious circle seems to fit with many people who stammer, and certain themes seem to be common to many people's experience.
For example, people who stammer who have speech-related anxiety may notice sudden, automatic and highly convincing negative thoughts, or predictions, about what will happen in a challenging situation. These negative thoughts tend to be about stammering itself (eg: "I'll get stuck", "I'll mess up"), or how other people will react (eg: "they'll laugh at me", "they'll ignore me", "they'll talk about me behind my back", "they'll look at me in a funny way") and how they themselves will be viewed (eg: "they'll think less of me", "they'll look down on me", "they'll think I'm weird", "they'll think there's something wrong with me").
With these predictions setting the scene, people may find that they approach the situation with more emotional and physical tension than they would have otherwise done, and that as a result they are indeed more likely to stammer. Alternatively, people may cope by doing something protective, i.e. deciding not to speak, or choosing a word which feels like a safer bet. The power of the vicious circle of stammering is found in the way that these natural, instinctive, and often protective responses reinforce the original fears about the situation - by increasing the likelihood of stammering, and decreasing the opportunity that the individual has to find out that their fears may not have been realised, or that they may actually have been able to cope.
Cognitive therapy is also concerned with patterns of assumptions and beliefs which are deeper and more intricately associated with a person's sense of self. These develop over time in response to a variety of factors, including negative experiences, and can underpin an individual's vulnerability to patterns of negative thinking.
What happens in therapy?
Cognitive therapy helps people who stammer (for example) to understand the role of their negative automatic thoughts, assumptions and core beliefs in maintaining problems. In the first instance people are helped to identify their negative thoughts, by tuning into negative emotional reactions when they occur, and noticing what thoughts or mental pictures are going through their minds at that time. They are then encouraged to ask themselves questions which help them to explore other perspectives or ways of thinking.
To give a flavour of this, lets take a hypothetical situation and negative automatic thought and work through some typical CBT questions. These questions are designed to help you decide whether to pay more attention to a negative thought, or less; whether to buy into it, or not.
Example: Supposing at work you worry that you will stammer when you talk with your boss. When you tune into the negative automatic thoughts surrounding this you find that you are not only predicting that you will stammer, but also that your boss will respond in a particular way ("he won't listen"), and that he'll draw a conclusion about you ("he'll think I'm useless"). One of the main CBT skills to learn is to look for evidence that either supports or disconfirms your thought, so the first question is:
What is the evidence that supports my prediction? (facts that anyone would agree with rather than my interpretation) Is there any evidence that what I'm thinking is not accurate, or not entirely accurate?
With this question you look systematically at anything at all which shows that you are on the right track: that this is indeed what happens when you stammer with your boss, and it is what your boss thinks about you. Evidence has to be concrete. To help you collect your evidence you might decide to run an experiment, where you observe and record how many times in the day your boss cuts across you when you stammer, but also of course how many times he doesn't.
There is of course a problem with making absolute decisions about what other people think. This is something to consider in itself, but in terms of looking for evidence about what your boss thinks of you, you would make a list of anything which is concrete evidence that your boss does think you're "useless", as well as a list of things which shows something different, for example that he thinks you do your job well or values your contribution. Writing these things down, including everything, will help you to stand back and think things through in a way which is balanced rather than based on anxiety, old patterns and gut feelings.
Is there another way of looking at things? Would someone else see things differently, or would I see things differently if I were feeling better?
This question helps you to take a larger view. So perhaps your boss does cut across you when you stammer - is that necessarily because he doesn't rate you in the workplace or could it be about something else, such as not knowing what to do when someone stammers? Or is that simply his style with everyone and not specific to you?
What is the worst that I'm predicting? Am I over-estimating the chances of disaster? Am I underestimating my ability to handle it?
It is normal to focus on the worst case scenario when you feel vulnerable and worried, however the fact that you're thinking something does not mean that it is bound to happen. Remembering that the worst does not always happen, in fact it very rarely does, can help to reduce anxiety.
The last question here can be the most helpful because it steers you towards problem-solving, which is all about taking charge, getting back in control and moving forward in a positive way. Supposing when you look at it, there is evidence that your boss treats you differently because you stammer...what are your options? What can you do about it? What can you do to improve the situation? What do you choose to do that will work best for you?
Am I being a fair judge? Am I ignoring my strengths, or positives about the situation?
Sometimes we are our own worst enemy and our own harshest critic. These questions help you to notice when you are being unreasonably tough on yourself, and instead to pay attention to your strengths and positive qualities which you might otherwise ignore. Attention is powerful and it can also become biased. Paying attention to the positives in yourself, in a situation, and in life in general may not come naturally but you may find that it enhances your self-esteem, confidence and sense of well-being.
In this hypothetical situation, supposing you do stammer, but you continue, you make your point and make it well, you contribute, you say what you want to say...these are positives that might be easy to ignore if you focus on the moment of stammering that you are frustrated with or disappointed about. The question is: what do you want to take the most notice of? This does not mean ignoring things that you genuinely want to change, but rather making sure that you think things over in a fair and balanced way and that you recognize your achievements.
Cognitive therapy also helps people to understand any thinking 'traps' or biases which they may fall into. These include:
- 'Post-mortem' thinking: Going over things in your mind afterwards, dwelling on the negative.
- Mental filter: Focussing on and highlighting the negative, while ignoring positives and being unreasonably self-critical (eg: "That was rubbish, I should've managed that so much better" - while ignoring the value of having contributed, and got one's point across).
- Mind-reading: Making assumptions about what other people are thinking or are going to think (eg: "They'll think there's something wrong with me").
- Over-generalisation: Making sweeping generalisations based on one event that goes far beyond the current situation (eg: you say less than you would like in a meeting and conclude "I never get my point across to anyone").
- Catastrophising / fortune telling: Expecting the worst to happen even when there is no evidence to suggest that it might.
Anyone reading this list will recognise themselves in there somewhere - we all do a bit of all of these some of the time. These thinking traps can become a problem if they become an habitual pattern. When that is the case it can be helpful to notice the pattern, ask yourself whether it helps you or not, and challenge it.
The core skills of cognitive therapy can look deceptively straightforward when on the printed page. In reality it can take a while for any of us to change the way we think and to develop better, more helpful, thinking skills. The examples in this article may give you some tips, but if you feel you need more then look for one of the many self-help books on cognitive therapy, or find out about therapy.
Is it like positive thinking?
No, the reality is that people often have past or current experience when things have not gone well. Cognitive therapy does not suggest that worries or anxieties are 'all in the mind' and that all one has to do is to 'think positively'. As everyone knows there are times when fears are justified. For example, sometimes listeners do respond in a way which is unhelpful. One of the real strengths of cognitive therapy is that it focuses on building coping strengths and problem-solving skills, so that individuals can be more flexible in their thinking and emotionally resilient when adverse circumstances arise.
Where can I get cognitive therapy?
At the Michael Palin Centre (MPC) we have three members of staff who have trained at the Oxford Cognitive Therapy Centre, which is a centre of excellence in cognitive therapy. One further member of staff is currently training. Information about how to be referred to the MPC is on our website, www.stammeringcentre.org. At the MPC cognitive therapy may be integrated into work on fluency skills, desensitisation and general communication skills or it may be delivered on its own for young adults and adults who want to focus more on the psychological aspects of their experience. It is particularly important in our work with children, parents and young people where developing a robust and positive self-view is likely to protect against future difficulties.
Many other therapists in the UK have completed brief, introductory or more comprehensive training in cognitive therapy and incorporate its core ideas in their work. Clinical psychologists who are trained in cognitive therapy can be contacted through the British Association for Behavioural and Cognitive Psychotherapies (www.babcp.com), and there are also many excellent self-help books available, two of which are listed in the box.