A standalone Internet cognitive behavior therapy treatment for social anxiety in adults who stutter: CBTpsych

Highlights

• There are few clinical psychology CBT experts who are specialised in stuttering.

• Scalable fully automated computerized cognitive behaviour therapy has been developed called the CBTpsych.

• Preliminary data suggest CBTpsych engages clients to participate in the tasks instructed by the program.

• Five of seven participants with social anxiety disorder diagnosis lost their diagnosis with CBTpsych after a 5-month period.

• Symptoms of social anxiety reduced and participant quality of life improved.

Abstract

Purpose

Social anxiety is common for those who stutter and efficacious cognitive behavior therapy (CBT) for them appears viable. However, there are difficulties with provision of CBT services for anxiety among those who stutter. Standalone Internet CBT treatment is a potential solution to those problems. CBTpsych is a fully automated, online social anxiety intervention for those who stutter. This report is a Phase I trial of CBTpsych.

Method

Fourteen participants were allowed 5 months to complete seven sections of CBTpsych. Pre-treatment and post-treatment assessments tested for social anxiety, common unhelpful thoughts related to stuttering, quality of life and stuttering frequency.

Results

Significant post-treatment improvements in social anxiety, unhelpful thoughts, and quality of life were reported. Five of seven participants diagnosed with social anxiety lost those diagnoses at post-treatment. The two participants who did not lose social anxiety diagnoses did not complete all the CBTpsych modules. CBTpsych did not improve stuttering frequency. Eleven of the fourteen participants who began treatment completed Section 4 or more of the CBTpsych intervention.

Conclusions

CBTpsych provides a potential means to provide CBT treatment for social anxiety associated with stuttering, to any client without cost, regardless of location. Further clinical trials are warranted.
Educational objectives: At the end of this activity the reader will be able to: (a) describe that social anxiety is common in those who stutter; (b) discuss the origin of social anxiety and the associated link with bullying; (c) summarize the problems in provision of effective evidence based cognitive behavior therapy for adults who stutter; (d) describe a scalable computerized treatment designed to tackle the service provision gap; (e) describe the unhelpful thoughts associated with stuttering that this fully automated computer program was able to tackle; (f) list the positive outcomes for individuals who stuttered that participated in this trial such as the reduction of social anxiety symptoms and improvement in the quality of life for individuals who stuttered and participated in this trial.

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.