|About the presenter: Barbara J. Amster, PhD, CCC/SLP is the founding Director of La Salle University's graduate and undergraduate programs in Speech-Language-Hearing Science. She has more than 30 years of clinical experience and holds Specialty Board Recognition in Fluency Disorders. Her master's degree is from the University of Pittsburgh and her doctorate from Temple University. She is an ASHA Fellow. She has published on the use of Cognitive Behavioral Therapy for people who stutter, as well as the speech-language development of young children in foster care.|
|About the presenter: Evelyn R. Klein, PhD, CCC/SLP is Associate Professor of Speech-Language-Hearing Science at La Salle University. In addition to being a speech-language pathologist for more than 25 years, she is also a licensed psychologist with post-doctoral training in clinical neuropsychology and cognitive behavioral therapy. She holds Board Specialty Recognition in Child Language. Dr. Klein teaches courses in counseling for communication disorders, research design, acquired language disorders, and language-learning disabilities. Among her varied research interests, she has published on the use of Cognitive Behavioral Therapy for people who stutter.|
"Good, better, best, never let it rest until your good is better and your better is best" is a saying that both of the authors remember hearing as children. You may have thought that striving toward perfection is a good thing but having the expectation that everything must be perfect, can lead to being dissatisfied with oneself and feelings of self-doubt. Realistically, nothing in the world is actually perfect and errors and mistakes are a natural part of the human condition. You probably know a number of people who have the tendency to be perfectionistic, who are often self-critical if their impossible standards are not met. Many people have this tendency and some of them are people who stutter (PWS) and some are not. Both of the authors are speech-language pathologists who have treated many people who stutter over the years and have known many of their clients quite well. Many of our adult clients who stutter were very self-critical, not only about their speech but also about their appearance, job performance, and relationships. Several of our pediatric clients who stutter often became very upset when their coloring went outside the lines or their stack of blocks wasn't perfectly aligned. Could these clients also be perfectionists? Could it be that a tendency towards perfectionism has some connection to stuttering?
Chronic or persistent stuttering is thought to be due to an interaction of environmental and constitutional factors. Just as heredity, speech-motor ability, and temperament may play a role so may the child's experiences and interactions with others. Many young children who stutter may stop stuttering during the preschool years (Yairi & Ambrose, 1992). But for others, stuttering persists and becomes chronic. Are there possible specific personality factors which may make stuttering more likely to persist? Perfectionism has occasionally been mentioned in the stuttering literature as a possible personality characteristic to explain how stuttering develops or is maintained (Riley & Riley, 2000). Perfectionistic individuals have unrealistic personal standards. Since these standards are difficult to meet, perfectionistic individuals often report feelings of incompetence and low self-esteem (Burns, 1980a, 1980b). Perfectionists tend to be less tolerant of mistakes and more self-critical (Burns, 1980a; Frost, Marten, Lahart, & Rosenblake, 1990). Amster and Klein (2005) conjectured that people who stutter (PWS) are often concerned about their speech errors and may view them as mistakes. If PWS are more perfectionistic, they might be more intolerant of their perceived speech errors, and more intense in their reactions to disfluency. In efforts to gain control of their speech, PWS may expend increased levels of energy, resulting in tension, effort, and struggle, the types of behaviors thought to make stuttering persist (Starkweather, 1987). A critical factor influencing each individuals' experience of stuttering involves thoughts and feelings about speech disruptions and their perceived reactions from others. When an individual is overly concerned and aware about their speech errors, the resulting distress may lead to fear and avoidance. Avoidance behaviors are often thought to be key features of chronic stuttering (Guitar, 2006; Van Riper, 1982). Could perfectionism be a personal characteristic related to stuttering?
There have been few experimental studies of perfectionism in PWS. Amster (1995) surveyed 47 PWS and 22 non stuttering adults with the Burns Perfectionism Scale (Burns, 1980a), a 10 item test that measures perfectionism, especially concern over making mistakes. She also adapted the scale so that participants answered the questions on the Burns Scale as they thought they would have responded as a child of about four or five years of age. She noted that the PWS in her study were more perfectionistic and considered themselves to have been more perfectionistic as young children than people who do not stutter.
It is important to consider that although perfectionistic tendencies can be destructive to self- esteem, (Flett, Hewitt, Blankstein, & Gray, 1998), they can be modified with appropriate treatment. Ferguson and Rodway (1994) used Cognitive Behavioral Therapy (CBT) with individuals who were perfectionistic and found that CBT may be effective in treating perfectionism and associated problems. In a series of experiments involving automatic perfectionistic thoughts, Flett et al. (1998) reported that perfectionistic thoughts increase distress and that cognitive-behavioral interventions may be particularly useful in reducing their frequency. With this in mind, the authors devised a treatment protocol using CBT with PWS. CBT is a treatment technique long used in psychotherapy based on the premise that our thoughts influence our feelings and how we behave. The goal is to systematically change the thoughts that make us feel bad, so that we can feel better about ourselves. So, how can someone change their thoughts?
Our study (Klein & Amster, 2004, Amster & Klein, 2007, Amster & Klein, 2008) involved eight adult PWS, five males and three females (age 27-56 years) who volunteered to participate in this eight week study. CBT was a new therapeutic approach for all of them, and all but one had received previous speech therapy. Each participant began with a baseline evaluation, three weeks of treatment solely with CBT, a mid-point evaluation, an additional three weeks of treatment which included CBT with the addition of selected stuttering modification techniques, an end of treatment evaluation, and another follow-up evaluation 15 weeks after treatment ended. Treatment included six weeks of weekly individual sessions and group sessions. On our first visit with our participants, all of them expressed feeling fearful and avoided some social situations. All of our participants performed in the perfectionistic range on the Burns Perfectionism Scale and on the adapted version of the scale. We also administered other measures of communication attitudes and stuttering severity (See Klein & Amster, 2004, Amster & Klein, 2007, Amster & Klein, 2008 for more information about the study).
The CBT therapy began with a discussion of personal goals and three goals for treatment were developed and selected by each participant. Goals generally related to speaking with less stuttering, especially in a group and on the phone, reducing worry about stuttering, reducing concerns about what others think of them, gaining more confidence when speaking, accepting stuttering, and speaking more spontaneously. A general desire was to care less about what others thought and to attempt to stop concealing stuttering. (See Klein & Amster, 2004). We discussed core beliefs which are the underlying thoughts that guide behavior on a daily basis. Our participants expressed core beliefs that shaped their thoughts such as, "If you cannot do it right, don't do it at all"; "Practice makes perfect"; and "Never be satisfied unless you have achieved near 100%". Core beliefs lead to automatic thoughts that everyone has throughout the day but sometimes these thoughts are self-defeating, not based in fact other than one's own viewpoint. The problem with these self-defeating thoughts, also known as cognitive distortions, is that they tend to make people feel bad about themselves. In order to change these self-defeating thoughts, we explored them by introducing eight common cognitive distortions that people often experience as errors in logic (Freeman, Pretzer, Fleming, & Simon, 1990). These included: (1) all or nothing thinking, (2) not seeing the whole picture, (3) focusing on the negative, (4) mind reading, (5) fortune telling, (6) catastrophizing, (7) should've-could've-would've thinking, and (8) taking it personally. For instance, the participants in our group noticed that they frequently had the cognitive distortion of "mind reading", expressing that other people thought poorly of them because they stuttered when there was really no evidence for this.
Participants were taught how to use an automatic thought record to write about a situation accompanying automatic thoughts, explore associated emotions, and provide an alternative response for a possible change in thinking. During group sessions, participants assisted each other by sharing their weekly experiences and helping each other interpret those events more positively. Teamwork and role-playing were helpful as the group worked through possible negative, positive, and neutral responses to various personal life situations. The participants reported that their typical responses often led to negative self-appraisals but that these could be changed.
Results of this preliminary study indicated that there was a reduction in perfectionistic thinking as well as stuttering over the course of the study and at 15 weeks follow-up (which was found to be statistically significant). The most significant decrease in perfectionism occurred during the first three weeks of the study and this improvement was maintained at follow-up. Perfectionistic tendencies continued to decline even after treatment ended. Participants noted that they avoided less, were less upset at making mistakes, and reacted less negatively to perceived failure. They reported at follow-up that they became more spontaneous in their speech production, monitoring their fluency less. They reduced their fear about stuttering and were no longer striving to speak perfectly. Statements from the participants at follow-up express these changes. "I notice that my speech has been not as much in my awareness.", "I have changed the way I think in that I do not care as much how I speak, whatever happens is OK." "When I have negative thoughts I am able to think positively. If I think more positively, I can think more fluently." "I notice my speech has been up and down as always, but I feel that I deal with it better." These statements indicate that in general, participants expressed more positive and self-accepting thoughts.
We are not saying that perfectionism causes stuttering, nor are we saying that CBT cures stuttering. Whether you stutter or not, a CBT approach may change self-defeating thoughts and may make you feel better about yourself. If this interests you or someone you care about, we suggest that you contact a professional who is trained in this treatment approach. There are also self-help books which may be useful. We suggest Dr. David Burns' classic text, The Feeling Good Handbook, originally published in 1980 which continues to have valuable and easy to understand information on how to use these techniques. Another book, The Spirituality of Imperfection by Ernest Kurtz and Katherine Ketcham (1993) gives pointers on self acceptance and accepting others based on several spiritual traditions as well as twelve-step programs. We have found that following a CBT approach makes us better able to cope with life's challenges and you may too.
We encourage future investigations in the area of perfectionism and stuttering to look at this trait in young children who stutter (CWS) to see if perfectionism plays a part in development of stuttering. All of the participants in our study considered themselves to have been perfectionistic as children. Perhaps having this trait may help to explain why some young children may be less able to tolerate disfluencies and are more likely to use tension, effort, and struggle to control their speech.
Amster, B. J. (1995). Perfectionism and stuttering. In C. Starkweather & H. Peters (Eds), Stuttering: Proceedings of First World Congress on Fluency Disorders, Vol. II (pp.540-543). Nijmegen, Netherlands: Nijmegen University Press.
Amster, B.J., & Klein, E.R. (2005, November). A preliminary study of perfectionism and stuttering: Follow-up to treatment. Paper presented at the meeting of the American Speech-Language-Hearing Association, San Diego, CA.
Amster, B. J. & Klein, E.R. (2007). The role of perfectionism in stuttering: a follow-up study. In J. Au-Yeung & M. M. Leahy (Eds.), Research, Treatment, and Self-Help In Fluency Disorders: New Horizon, Proceedings of the Fifth World Congress On Fluency Disorders (pp. 361-367). Dublin, Ireland, the International Fluency Association.
Amster, B.J., & Klein, E.R. (2008). Perfectionism in people who stutter: Preliminary findings using a modified cognitive-behavioral treatment approach. Behavioural and Cognitive Psychotherapy, 36, 35-40.
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Burns, D. (1980b). The Feeling Good Handbook. New York: William Morrow.
Ferguson, K. L., & Rodway, M. R. (1994). Cognitive behavioral treatment of perfectionism: Initial evaluation studies. Research for Social Work Practices, 4(3), 283-308.
Flett, G.L, Hewitt, P.L. Blankstein, K. R., & Gray, L. (1998). Psychological distress and the frequency of perfectionistic thinking. Journal of Personality and Social Psychology, 75(5),1363-1381.
Frost, R., O., Marten, P., Lahart, C., & Rosenblake, R. (1990). The dimensions of perfectionism. Cognitive Therapy and Research, 14(5), 449-468.
Guitar, B. (2006). Stuttering: An integrated approach to its nature and treatment (3rd ed.). Baltimore, MD: Lippincott Williams & Wilkins.
Klein, E.R., & Amster, B.J. (2004). The effects of cognitive behavioral therapy with people who stutter. In A. Packmann, A. Meltzer, & H. Peters (Eds.) Theory, research, and fluency disorders: Proceedings of the Fourth World Congress of Fluency Disorders. (pp. 154-160). Nijmegen, Netherlands: Nijmegen University Press.
Riley, G. & Riley, J (2000). A revised component model for diagnosing and treating children who stutter. Contemporary Issues in Communication Science and Disorders, 27, 188-199.
Van Riper, C. (1982). The nature of stuttering. Englewood Cliffs, NJ: Prentice-Hall.
Yairi, E., & Ambrose, N. (1992). A longitudinal study of stuttering in children: A preliminary report. Journal of Speech and Hearing Research, 35, 755-760.
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