Cognitive Behavior Therapy and Mindfulness Training in the Treatment of Adults Who Stutter

Introduction: Stuttering is a developmental speech disorder with multiple etiological factors. Cognitive behavior therapy (CBT) has shown effectiveness in reducing anxiety symptoms and dysfluent speech in adults who stutter (AWS). So we planned to study the comparative efficacy of CBT and CBT combined with mindfulness training (MT) in AWS. Aim: The aim of this preliminary study was to examine and compare the efficacy of CBT and CBT combined with MT in reducing anxiety symptoms, and dysfluent speech and increasing communication attitude, quality of life, self-esteem and speech fluency in AWS. Method and Materials: A matched two group pretest and posttest interventional design was employed. The sample consisted of ten adults with the diagnosis of stuttering (ICD-10, 1992) who were randomly allotted to Group One (CBT; N=5) and Group Two (CBT+MT; N=5). The therapeutic program included 15-20 sessions of one hour each. Statistical Analysis: Obtained data were analyzed using the Wilcoxon Sign Rank Test for within the group, before and after intervention comparison and Mann Whitney U Test for between group comparisons. Results: Significant difference in both CBT group and CBT+MT group is observed in the area of communication attitude (U=1.00, p<0.05). Conclusion: The findings of the study show that CBT and CBT+MT are effective in the treatment of AWS, but CBT+MT is more effective than CBT alone.

repetition or prolongation of sounds or syllables or words, or by frequent hesitation or pauses that disrupt the rhythmic flow of speech (WHO, 1993). Therefore the core behaviors of stuttering are repetitions, prolongations and blocks (Guitar, 2006).
Cognitive Behavior Therapy (CBT) is one of the major orientations of psychotherapy (Roth & Fonagy, 2005). It is mainly concerned with understanding the role of cognitions, or the personal meaning that the individuals assign to events and on working within this domain in order to achieve cognitive as well as behavioral change. It is structured, focused on specific problems, time-limited and educative, encouraging individuals to understand their difficulties better (Beck, 1995). CBT is used with adults experiencing high levels of trait, state, and social anxiety related to stuttering and speaking (Hancock K & Craig, 1998;Ezrati-Vinacour & Levin, 2004). It has been reported that approximately 50% of adults who stutter (AWS) may have significantly high levels of social anxiety (Kraaimaat, Vanryckeghem, & Van Dam-Baggen, 2002;Menzies et al., 2008). The goal of CBT in AWS is to reduce social avoidance and anxiety (Craig & Tran, 2006;Menzies, Onslow, Packman, & O'Brian, 2009). For example, Reddy, Sharma, and Shivashankar (2010) observed reduction of stuttering, anxiety, dysfunctional cognitions and improvement in quality of life after implementing 16-18 sessions of CBT.
The term 'mindfulness' is an English translation of the Pali word Sati. Pali was the language of Buddhist psychology 2,500 years ago, and mindfulness is the core teaching of this tradition. The word Sati indicates awareness, attention, and remembering (Germer, 2005). Mindfulness has been defined as "the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgementally to the unfolding of experience moment by moment" (Kabat-Zinn, 2003). In psychotherapy, the concept of mindfulness is defined as "an awareness of present experience with acceptance" (Germer, 2005). Mindfulness-based interventions include Mindfulness-Based Stress Reduction (MBSR) (Kabat-Zinn, 1994), Mindfulness-Based Cognitive Therapy (MBCT) (Segal, Williams, & Teasdale, 2002), Acceptance and Commitment Therapy (Hayes, Luoma, Bond, Masuda, & Lillis, 2006) and Dialectical Behavior Therapy (Linehan, 1993). Mindfulness-based therapies have shown effectiveness in the reduction of depression and anxiety symptoms in clinical population and unpleasant affect and psychological stress in nonclinical population (Bohlmeijer, Prenger, Taal, & Cuijpers, 2010;Grossman, Niemann, Schmidt, & Walach, 2004).
Research studies show that speech therapy treatment for stuttering is available in early childhood (Jones et al., 2005) but stuttering in adults is much less responsive to speech therapy (Craig & Hancock, 1995). Behavioral speech programs involving speech restructuring are the strongest evidence-based stuttering treatments for AWS (Onslow, Jones, O'Brian, Menzies, & Packman, 2008). The aim of this study was to compare the efficacy of CBT alone and CBT combined with mindfulness training (MT) for increasing mindfulness, communication attitude, quality of life, self-esteem and speech fluency and reducing level of anxiety, frequency and severity of stuttering in AWS.

METHOD AND MATERIALS Participants
The sample consisted of ten adults with the diagnosis of stuttering (ICD-10 DCR, F98.5; WHO, 1993), recruited from Out Patient Clinic of Department of Clinical Psychology. Participants with the diagnosis of stuttering, aged between 18 to 35 years, educated at least till class X, and having obtained a minimum total score of 20 on Stuttering Severity Instrument (SSI) (Riley, 1994) were included. Participants with significant medical, psychiatric, neurological disorders as associated conditions, obtaining less than 20 total scores on SSI, and having previous exposure to the cognitive behavioral intervention were excluded. Participants were randomly allotted to the Group One (CBT; N=5) and Group Two (CBT+MT; N=5). All the participants were explained the purpose and procedure of the study, written informed consent was taken and confidentiality was assured as enshrined in the mandate on ethical guidelines followed at the institute (Venkatesan, 2009)

Research Design
A matched two group pretest and posttest interventional design was employed. Equal number of cases was randomly assigned to CBT and CBT+MT group. Two independent variables are CBT and CBT+MT and their effect were observed on dependent variables like mindfulness, communication attitude, quality of life, anxiety, self-esteem, perception of stuttering, and severity of stuttering.

Socio-Demographic and Clinical Data Sheet: A Socio-demographic and Clinical Data Sheet
was used to obtain the relevant information on the demographic and clinical history. Toronto Mindfulness Scale (TMS; Lau et Al., 2006): A 13-item state-mindfulness measure that uses a 5 point Likert-type scale from not at all (0) to very much (4). The scale has two sub-scales: Curiosity, 6 items, subscale score ranging from 0-24, and Decentering, 7 items, with a subscale score ranging from 0-28. Cronbach's alphas are reported to range from 0.86 to 0.91 for Curiosity and 0.85 to 0.87 for Decentering (Park, Reilly-Spong & Gross, 2013).

Modified Erickson Scale of Communication Attitudes (MESCA; Andrews & Cutler, 1974):
MESCA measures communication attitude. This 24-item scale distinguishes the extent to which a stuttering person's communication attitude deviates from normed attitudes. Statements require a true or false answer. The higher the score, the poorer the communication attitude. WHO Quality of Life-BREF Scale (WHOQoL-BREF; WHOQoL Group, 1998): It consists of 24 items and provides a profile of scores on four dimensions of quality of life: physical health, psychological, social relationships, and the environment. It is available in both selfadministered and interviewer administered forms. Higher scores reflect a better quality of life.
Beck Anxiety Inventory (BAI; Beck & Steer, 1993): BAI is a 21-item scale developed to assess the severity of anxiety symptoms. Respondents are asked to rate each item on a 4point scale ranging from 0 (not at all) to 3 (severely, can barely stand it). Ratings are for the past week. Items are summed to obtain total scores ranging from 0 to 63. Rosenberg's Self-Esteem Scale (RSES; Rosenberg, 1965): A 10-item scale that measures global self-worth by measuring both positive and negative feelings about the self. The scale is believed to be uni-dimensional. All items are answered using a 4-point Likert scale format ranging from strongly agree to strongly disagree. Items 2, 5, 6, 8, 9 are reverse scored. Items are scored as follows: "Strongly Disagree" 1 point, "Disagree" 2 points, "Agree" 3 points, and "Strongly Agree" 4 points. Scores for all ten items are summed up. Higher scores indicate higher self-esteem. and was based on a 20-minutes interview session. The interview was then used to assess the frequency and duration of stuttering and any associated physical concomitants, and these were converted to SSI-3 scores using the specified guidelines. The adult who stutter scored 20 or higher, this score placed between the 12 and 23rd percentile and rated as mild. Higher score reflects higher severity level of stuttering.

Therapeutic Program
Cognitive Behavior Therapy intervention program included orientation regarding the nature, causes and treatment of stuttering. The 'cognitive-behavioral model' and 'vicious cycle' of stuttering was drawn and discussed with the participants. The cognitive-behavioral model is based upon the assumption that our thoughts and beliefs influence our emotions, physiology, and behavior (Beck, 1995). Negative automatic thoughts were identified and challenged by checking the evidence. They were taught deep breathing and relaxation techniques to control speechrelated anxiety. Cognitive/speech restructuring was incorporated to modify speech-related dysfunctional beliefs. Problem solving technique was introduced to increase their sense of being able to cope up with speech-related difficulties when they arise. They were asked to self-monitor the speech-related anxiety symptoms during communication with strangers and authority persons like teachers and employer and also asked to self-monitor speech-related dysfunctional beliefs and speech-related difficulties if any, and maintain a diary for the same.
Mindfulness Training included sitting mindfulness meditation; awareness about their thoughts, feelings and body; awareness of the present moment; identifying past, present and future thinking; integrating mindfulness and acceptance into daily life (Semple, Lee, & Miller, 2006). Participants of both the groups were encouraged to generalize controlled fluency in all situations and with different listeners inside and outside the clinical setting and also were asked to maintain the improvement through everyday practice and interaction with others.

Procedure
Patients with stuttering were screened based on inclusion and exclusion criteria. After that they underwent pre assessment individually on various scales, namely, Toronto Mindfulness Scale, Modified Erickson Scale of Communication Attitudes, WHO Quality of Life-BREF Scale, Beck Anxiety Inventory, Rosenberg's Self-Esteem Scale, Perceptions of Stuttering Inventory, and Stuttering Severity Instrument. After pre assessment both group CBT and CBT+MT were subjected to an individual treatment program. The treatment program consisted of 15-20 sessions of CBT or CBT+MT that were held over a period of eight weeks. Two to three sessions were held every week and each session lasted for 60 minutes. After Intervention, they were again rated on same measures. Participants were assigned homework consisting of regular practice at home and maintenance of a diary for the same.

Statistical Analysis
The collected data as raw scores on respondent ratings were compiled and subjected to statistical analysis by using SPSS statistics for windows, version 17.0 (SPSS Inc, 2008). Obtained data was analyzed using non-parametric statistics, namely, Mann Whitney U Test (for between group comparison) and Wilcoxon Sign Rank Test (for within group comparison).

RESULTS
In present study, the CBT group consisted of five male patients with a mean age of 20.60

DISCUSSION
The present study was conducted to examine the comparative efficacy of CBT and CBT+MT in the treatment of AWS. The study shows that both CBT and CBT+MT group improved significantly on the measures of mindfulness, communication attitude, quality of life, anxiety and dysfluent speech. The study also reports that CBT+MT group is more effective in the improvement of communication attitude in AWS in comparison to CBT alone. The finding of this study is in line with the studies where a reduction of stuttering, anxiety symptoms and improvement in self-esteem, quality of life, and communication attitude were shown after implementing 16-18 sessions of CBT as well as MBCT (Reddy et al., 2010;Gupta, 2015). The result of the study is consistent with the finding of De Veer, Brouwers, Evers, and Tomic (2009), they examined the psychological impact of the MBSR program on persons who stutter and showed that immediately after the eight-week MBSR program as well as four weeks later, participating persons who stutter suffered less from stress and anxiety about speech situations. However, they were not significantly more confident in their ability to retain fluency in speech situations than those in the waiting list. On the other hand, CBT intervention was associated with significant and sustained improvements in psychological functioning but did not improve fluency .
In sum, the findings of the study support the use of the CBT+MT program over CBT alone spread over 15-20 sessions of around 60 minutes duration each for bringing positive changes in measures of anxiety, speech dysfluency, communication attitude, mindfulness, self-esteem, and quality of life in AWS. Thus, CBT+MT program can be used for the long-term treatment of AWS. This program is cost-effective in terms of time and can be conducted in a group setting. A small sample size is the major limitation of this study. Further empirical researches are needed with larger sample size using double blind procedure, control group and follow up to test the efficacy of CBT+MT for the treatment of AWS.