Short communicationA standalone Internet cognitive behavior therapy treatment for social anxiety in adults who stutter: CBTpsych
Introduction
Current research literature makes clear that many who stutter—certainly those who present to speech clinics—struggle with social anxiety and its debilitating consequences (for a review, see Iverach, Menzies, O’Brian, et al., 2011). Reports associating Social Anxiety Disorder with stuttering are common, with the condition reported for 40% (Blumgart, Tran, & Craig, 2010), 44% (Stein, Baird, & Walker, 1996) and 60% (Menzies et al., 2008) of clinical cohorts. The condition is characterized by intense fear of negative evaluation and exaggerated threat of being judged by others (Beck et al., 1985, Clark, 2001, Rapee and Heimberg, 1997, Wells, 1997). This may involve fearing, avoiding or enduring with significant stress many of the following social encounters: meeting new people, expressing a controversial opinion or disagreement, being assertive, speaking in front of a group, being the center of attention, or making mistakes in front of others (Antony & Rowa, 2008).
Many reports have shown the promise of anxiety treatments during stuttering management (for example, Boudreau and Jeffrey, 1973, McIntyre et al., 1974). The long recognized need to manage anxiety concurrently with stuttering has been acknowledged in current literature (Blomgren et al., 2005, Davidson Thompson et al., 2009, Guitar, 2006, Lincoln et al., 1996, Plexico et al., 2005, Quesal, 1989). However, Menzies, Onslow, Packman, and O’Brian (2009) detail how few attempts have been made to utilize cognitive behavior therapy (CBT) strategies to control the anxiety of those who stutter (Atkins et al., 2003, Ezrati-Vinacour et al., 2007, Menzies et al., 2008, St Clare et al., 2009).
In short, it is possible that, with further clinical trialing, CBT will become included in the evidence-based treatments for those who stutter and who require social anxiety management. However, Menzies et al. (2008) cautioned that speech-language pathologists (SLPs) who use CBT with stuttering clients require adequate professional development to do so. Obviously, this imposes restricted access to suitable CBT treatment by the majority of those who stutter and who might need it. Revision of professional preparation programs worldwide to train SLPs to acceptable standards of CBT practice is clearly not a viable goal. Nor is it viable for every generalist SLP who might encounter adult stuttering clients to receive post-graduate CBT qualifications. Additionally, for logistic reasons it is not realistic to anticipate that management of every adult who stutters with social anxiety could occur with coordinated speech-language pathology and clinical psychology arms. Such an approach would not be an efficient use of clinical resources. A potential solution to solving this problem is using standalone computerized cognitive behavior therapy.
Many such standalone treatment packages have been developed to treat a wide range of mental health problems (Barak & Grohol, 2011). However, Kiluk et al. (2011) analyzed 75 randomized controlled trials published to date and concluded that in general standalone computerized CBT trials had weak control conditions, poor internal validity, and inaccurate use of intention to treat paradigm due to attrition. Given the above, it is important to test the viability of computer packages before conducting a randomized controlled trial.
In an attempt to repair the shortcomings of existing standalone Internet CBT treatments identified by Helgadottir, Menzies, Onslow, Packman, and O’Brian (2009a) the present team adapted the Menzies et al. (2008) CBT treatment for standalone Internet application, adding components from the evidence based Clark and Wells (1995) model in the package. A report of this program (Helgadottir et al., 2009a, Helgadottir et al., 2009b), with two adults diagnosed with stuttering and with Social Anxiety Disorder, suggested clinical improvements similar to those attained with the clinic version. The present study is a larger, Phase I trial to assess whether a computer program has potential to remove diagnosis of Social Anxiety Disorder, reduce social anxiety symptoms, unhelpful thoughts and beliefs about stuttering, and improve the quality of life for those who stutter. Phase I treatment trials are nonrandomized and are without control or comparison treatments. Their purpose is to establish the viability of further trialing with Phase II and III designs.
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Participants
Participants were adults who stuttered between 18 and 80 years of age. Exclusion criteria were (1) CBT treatment during the previous 6 months, (2) no regular access to Internet and email, (3) not having functional written and spoken English, and (4) endorsement of the suicide-planning item of the Beck Depression Inventory (Beck, Steer, & Brown, 1996; see below).
Nineteen participants were recruited from the treatment waiting list of the Australian Stuttering Research Centre (ASRC), and through
The intervention: CBTpsych
CBTpsych is an online computer program that is designed to treat the social anxiety of adults who stutter. The program involves no clinician, but presents customized feedback to participants based on established CBT procedures for social anxiety. It is based on the cognitive model of social anxiety developed by Clark and Wells (1995). Treatment based on this model has shown impressive effect sizes for nonstuttering clinically anxious groups (Clark et al., 2003, Clark et al., 2006, Mortberg et
Adherence
Table 1 shows the user patterns of the 14 participants that started the program.
On average users had 15.3 log-ins with CBTpsych, and mean login time was 7 h. The overall time spent working with the CBT intervention is likely to be much higher as important components of CBT occur in between sessions, in participants’ everyday life. The average period between logins to the program was 7 days.
Eight of the 14 participants who started the treatment completed all seven CBTpsych components during their
Discussion
The present study was a Phase I trial to assess whether a computer program has potential to remove diagnosis of Social Anxiety Disorder, reduce social anxiety symptoms, unhelpful thoughts and beliefs about stuttering, and improve the quality of life for those who stutter. SLPs who use CBT with stuttering clients require adequate professional development to do so, and this restricts access to CBT treatment by the majority of those who stutter. The results of this trial position CBTpsych as a
Financial Disclosures
Dr. Onslow as author of the paper “A standalone internet cognitive behavior therapy treatment for social anxiety in adults who stutter: CBTpsych” acknowledges funding from a Program Grant #633007 from the National Health and Medical Research Council of Australia. None of the other authors, Fjola Helgadottir, PhD; Ross Menzies, PhD; Ann Packman, PhD; Sue O’Brian, PhD, reported any relevant financial relationships to be disclosed.
Non-Financial Disclosures
None of the authors for this paper “A standalone internet cognitive behavior therapy treatment for social anxiety in adults who stutter: CBTpsych” by Fjola Helgadottir, PhD; Ross Menzies, PhD; Mark Onslow, PhD; Ann Packman, PhD; Sue O’Brian, PhD reported any relevant non-financial relationships to be disclosed.
Acknowledgements
This research was supported in part by a PhD stipend from Australian Stuttering Research Centre and Program Grant 633007 from the National Health and Medical Research Council of Australia.
Fjóla Dögg Helgadóttir is a senior research clinician and a specialist research clinical psychologist at the Department of Psychiatry at Oxford University, UK. Fjola has completed four degrees in psychology, Ph.D., MClinPsych, PostDipPsych, Bpsych (Hons) and received the Tracey Goodall Early Career Award for Research Achievement, and has run a private clinical psychology practice.
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Fjóla Dögg Helgadóttir is a senior research clinician and a specialist research clinical psychologist at the Department of Psychiatry at Oxford University, UK. Fjola has completed four degrees in psychology, Ph.D., MClinPsych, PostDipPsych, Bpsych (Hons) and received the Tracey Goodall Early Career Award for Research Achievement, and has run a private clinical psychology practice.
Ross G. Menzies is a clinical psychologist with an interest in the Origins and Management of Anxiety. He has developed cognitive behaviour therapy packages for the treatment of obsessive compulsive disorders and published theories of the origins of phobias. He is currently the director of the Anxiety Clinic at The University of Sydney
Mark Onslow is the Foundation Director of the Australian Stuttering Research Centre, Faculty of Health Sciences, The University of Sydney. His background is speech pathology. His research interests are the epidemiology of early stuttering in preschoolers, mental health of those who stutter, measurement of stuttering, and the nature and treatment of stuttering.
Ann Packman is a senior research officer at the Australian Stuttering Research Centre. She has worked for more than 30 years in the area of stuttering as a clinician, teacher and researcher. One of her current interests is theories of the cause of stuttering.
Sue O’Brian is a senior researcher at the Australian Stuttering Research Centre. She has extensive experience in the field of stuttering treatment and research. Her current interests include the effectiveness of early stuttering intervention in community settings, development of treatments for adults who stutter and stuttering measurement.
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Current address: Department of Psychiatry, University of Oxford, United Kingdom.