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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. In this session… . Setting the scene: the MPC approach and the therapeutic relationship

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Using CBT with Teenagers

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  1. 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

  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” The Michael Palin Centre

  3. MPC approach (Cook & Botterill, 2005) Communication skills Speech Thinking & management feeling

  4. 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.

  5. CBT • Psychotherapy developed in the 1960’s by Aaron Beck • Widely used to treat emotional problems • Advantages: evidence based, short-term The Michael Palin Centre

  6. Principles • Time-limited • Focused • Structured • Educational • Collaborative • Theoretically driven The Michael Palin Centre

  7. 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. The Michael Palin Centre

  8. 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 The Michael Palin Centre

  9. Generic cognitive model Thoughts Behaviour Feelings Physiological responses The Michael Palin Centre

  10. Levels of cognitions • Negative automatic thoughts (verbal or images, activated memories) • Unhelpful assumptions • Negative core beliefs The Michael Palin Centre

  11. 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 The Michael Palin Centre

  12. Keytherapeutic 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 The Michael Palin Centre

  13. Social anxiety theory The Michael Palin Centre

  14. 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 The Michael Palin Centre

  15. 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. The Michael Palin Centre

  16. Fear of: • Behaving inappropriately or ineptly & other people noticing Perceived threat: • Negative reaction by others • Negative evaluation by others The Michael Palin Centre

  17. 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 The Michael Palin Centre

  18. 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

  19. 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. The Michael Palin Centre

  20. 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 The Michael Palin Centre

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  22. 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. The Michael Palin Centre

  23. 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 The Michael Palin Centre

  24. In threat situations: • Are self-focused but alsohyper-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 The Michael Palin Centre

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  26. 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 The Michael Palin Centre

  27. 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 The Michael Palin Centre

  28. Application to stuttering What is the evidence that this is relevant? The Michael Palin Centre

  29. 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 1990s Menzies, Onslow & Packman (1999) The Michael Palin Centre

  30. Young people 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) The Michael Palin Centre

  31. 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) The Michael Palin Centre

  32. 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) Kraaimaatet al. (2002) The Michael Palin Centre

  33. 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 controls Bricker-Katz, Lincoln & McCabe (2009) The Michael Palin Centre

  34. 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 years Ezrati-Vinacour, Platzky & Yairi (2001). The Michael Palin Centre

  35. Negative listener responses 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)

  36. 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)

  37. Cont. • Negative public attitudes to stuttering Huilit and Wurtz (1994) • Negative employer attitudes Hurst & Cooper (1983a) The Michael Palin Centre

  38. Cont. • Negative impact of stuttering on employment opportunities and job performance • “stuttering is handicapping in the work place.” Klein & Hood (2004) The Michael Palin Centre

  39. Cont. • Pervasive negative stereotyping of PWS as shy, self-conscious, anxious and lacking confidence Craig, Tran and Craig (2003) The Michael Palin Centre

  40. 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) The Michael Palin Centre

  41. 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) The Michael Palin Centre

  42. SAD: does the theory fit? Where anxiety is involved the main concern is about: • Performance and standards • Listener reactions • Listener judgement The Michael Palin Centre

  43. 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 The Michael Palin Centre

  44. 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… The Michael Palin Centre

  45. 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… The Michael Palin Centre

  46. 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 The Michael Palin Centre

  47. 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” The Michael Palin Centre

  48. 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... The Michael Palin Centre

  49. 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. The Michael Palin Centre

  50. 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) The Michael Palin Centre

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