Using CBT for a justified fear?

Question

I am a speech language pathologist. I have a 19 year old patient who grew up with a number of different speech impediments (not a stutter). He was bullied a lot, and because of this he is very sensitive about how he speaks.

Recently, he has become so anxious about it he has developed a stutter. Note that stuttering was not one of the impediments he grew up with. He only developed it a couple of months ago because of his anxiety. He is not in a financial position to afford a psychologist, so I decided to help him with his anxiety. I know I'm not in a position to get rid of his anxiety; thats outside my scope of practice - I'm only trying to help with the manifestation of his anxiety in his speech, which is within my scope.

He blocks completely - in other words, when trying to pronounce certain words, he becomes completely silent for a couple of seconds as he tries to "push" the word out. Rather than the usual case of repeating the same sound over and over again, he simply becomes silent while he waits for the word to come out.

His main fear is not being able to get the word out and just being completely silent while the other person is waiting for him to complete his sentence. This fear is quite justified unfortunately - most of us would be confused if a person just stopped talking and would ask him to continue. I've used CBT for a stutter before, but that was to show the patient that some of their fears (i.e. being laughed at) were irrational.

How do I address the anxiety that stems from a fear that is relatively justified and logical?

Answer 1

The first option is to investigate exactly what his worries are and to put them in perspective. Often, people catastrophize their fears, imagining the worst possible scenario for a given situation. While that outcome may be a realistic possibility, often is not the only or even the most likely possibility.

For instance, is he afraid that people will think he lacks intelligence? Or that people will laugh and make fun of him? You might examine his thought this way:

1. What is the worst possible outcome if he stutters or freezes in front of another person?

2. What is the best possible outcome in the same situation?

3. What does he think is the most likely outcome? (Usually this is somewhere in between the two extremes).

Second, you can caution him against mind-reading (i.e., assuming he knows what others will say, do or think). If he is concerned that when he freezes, "people will think I'm stupid," encourage him to think of other possibilities. They might think that, or they might just be confused, or they might recognize he's socially uncomfortable and have compassion.

Third, while the thought or fear itself may be true (e.g. "She made fun of me") the meaning he attaches to it might not be completely valid.

What does it say about him? For instance, if he thinks "She's right, I'm stupid, I'm a loser" you can explore all of his strengths and things he does well. Often people maximize painful experiences or don't give themselves credit for other accomplishments. Other thoughts, such as "This is something I struggle with, but I'm good at other things," might be more adaptive.

What does it say about that other person? You could work with him to reframe his thoughts (e.g. "She just doesn't understand and isn't sure how to react," or "That person has to be mean to others to make himself feel good; what he says isn't really true.")

What does it mean if someone reacts poorly when he freezes? If his thought is akin to "They'll think I'm stupid" figure out what it would mean in his life if they thought that way. How would that impact him? Is it "If I freeze, they'll think I'm stupid, and then I won't....get the job, make a friend, etc."? If you can figure out what consequences he is concerned about, then you can go back to option 1 and think through how likely those scenarios are.

Often fears and anxieties have some kernel of realistic risk to them. Some spiders or snakes can be dangerous, some people can judge us and be cruel, etc. However, if the fear is paralyzing, there is often a distortion to the thoughts that can be discussed and possibly adapted to reduce anxiety.

This book may provide additional ideas:

Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond. Guilford Press. (pgs. 1801-84 discuss some of the points mentioned above).

Answer 2

CBT stands for Cognitive Behaviour Therapy (I mention this because in the thrill of learning it, the "B" part is often ignored or forgotten). CBT integrates aspect of both cognitive psychotherapy and behaviour psychotherapy.

Behaviour psychotherapy was formed earlier and its basic gist (very simply put) is that our behaviours and environment can influence our thoughts and feelings and so changing our behaviour / environment can change how we think and feel. (Knowing the basics of cognitive therapy, which supposes that your thoughts influence your emotions and behaviours, you can understand how it was logical to integrate both to treat someone - and thus we have CBT.)

So for the situation you described where the cognitive distortions have all been addressed, and part of the problem still exists or a new one is revealed, it may be helpful to try and address it through behavioural changes.

For example, exposure therapy is a technique in Behaviour therapy that is used to reduce certain kinds of anxiety, and could be helpful here.

As suggested by others in the comments too, for example, a behavioural change he could do is to reveal to people before hand that he has a speech impediment that sometimes causes him to stutter or pause as he searches for words. You can role play this with him. Then ask him to say it to a close friend or family member not aware of it. And then slowly escalate to saying it to a stranger.

Or ask him to deliberately pause when speaking with someone and see what their reaction is. (First role play it with him).

Sometimes facing your fears this way (in a more controlled manner) reveals new cognitive distortions (examples of which user30295 has described in his detailed answer) that one may not be aware of, and that would need to be addressed using cognitive therapy techniques.