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REVIEW ARTICLE
Year : 2019  |  Volume : 28  |  Issue : 1  |  Page : 4-12  Table of Contents     

Management of stuttering using cognitive behavior therapy and mindfulness meditation


1 Scientist II, National Drug Dependence Treatment Centre Ghaziabad, Uttar Pradesh, All India Institute of Medical Sciences, New Delhi, India
2 Department of Psychiatry, Command Hospital Air Force, Bengaluru, Karnataka, India
3 Department of Education, Jawaharlal Nehru University, New Delhi, India
4 Consultant Psychiatrist, Queensland Health Services, Australia

Date of Submission02-Mar-2019
Date of Acceptance24-Aug-2019
Date of Web Publication11-Dec-2019

Correspondence Address:
Dr. Anindya Kumar Gupta
Department of Psychiatry, Command Hospital Air Force, Old Airport Road, Agram Post, Bengaluru - 560 007, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ipj.ipj_18_19

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   Abstract 


Stuttering is a speech fluency disorder with varied etiological explanations. It is important to identify symptoms early so that adequate and timely intervention can be delivered with focus on management and recovery. Stuttering, besides affecting speech fluency, might have a number of negative psychosocial consequences for the sufferer that may lead to immense anxiety, besides other symptoms. Therefore, it is thus imperative to include multiple dimensions in the holistic treatment of stuttering. Cognitive behavior therapy and mindfulness equip the client with the skills to manage the problems that occur as a result of stuttering. Since the rate of relapse in this condition is high, the chosen therapeutic paradigm must involve booster sessions over a long term. Periodic, detailed assessment would update the therapist about the barriers in treatment and would help in devising appropriate methods to get rid of these hindrances.

Keywords: Associated disorders, behavioral management, cognitive behavior therapy, mindfulness meditation, psychosocial interventions, relapse, stammering, stuttering


How to cite this article:
Mongia M, Gupta AK, Vijay A, Sadhu R. Management of stuttering using cognitive behavior therapy and mindfulness meditation. Ind Psychiatry J 2019;28:4-12

How to cite this URL:
Mongia M, Gupta AK, Vijay A, Sadhu R. Management of stuttering using cognitive behavior therapy and mindfulness meditation. Ind Psychiatry J [serial online] 2019 [cited 2020 Feb 24];28:4-12. Available from: http://www.industrialpsychiatry.org/text.asp?2019/28/1/4/272682



Stuttering is a speech fluency disorder involving repetitions, prolongations of sounds, syllables or words, or blocks, that may disturb the normal flow of speech. Children with stuttering issues may manifest problems in behavioral, emotional, and social functioning around 3 years of age. Older children who stutter may already report or manifest these problems. Irrespective of culture, children with stuttering issues are viewed in a negative light. Understandably, it may lead to disability (the functional communication difficulties experienced in the speaker's everyday life), impairment (the observable characteristics of the speech difficulty), and handicap (the impact of the stuttering disorder on the speaker's overall quality of life) and hence may be a cause for concern for several professionals, including family physicians, speech therapists, psychologists, and pediatricians.[1],[2],[3]

The World Health Organization defined “Stuttering” as a disability as under:-

“Disorders in the rhythm of speech, in which the individual knows precisely what he wishes to say, but at the time is unable to say it because of an involuntary, repetitive prolongation or cessation of a sound.”[4]

“Stuttering” and “stammering” are terms that are often confused as different; however, these are mostly used interchangeably. Stutterers, although capable of thinking coherently, cannot easily translate ideas and thoughts into clear, fluent speech. This in turn may lead to a set of negative feelings, such as, shame, fear, anger, frustration, avoidance, hostility, and negative attitudes, for example, thinking that one may not be able to converse normally in different social situations.[5],[6],[7],[8] Negative social consequences of communication may lead to a poorer quality of life.[8],[9]

Untreated stuttering in childhood may be a risk factor for developing anxiety disorder and depression in adulthood.[9] Therefore, the client's speech may already be disorganized and resultant anxiety, depression, and other associated psychiatric illnesses may lead to further, frequent disruptions and dysfluency. These speech disruptions or involuntary core behaviors are generally associated with secondary behaviors, such as frequent eye blinking or lip tremors and avoidance or escape behaviors.[3],[4]


   Brief Etiology of Stuttering Top


Stuttering has been understood as a multifaceted speech disorder.[10] Dynamic developmental factors as well as environmental factors must be taken into consideration together.[8] Thus, it can be both developmental and acquired in nature. Emotional reactivity is a crucial factor in stuttering and must be evaluated in depth to obtain a comprehensive account of the phenomenon.[7] According to some psychological theories, individuals with a low emotional threshold and limited neurological makeup are at risk for developing stuttering.[11] Stuttering has also been identified as a biopsychosocial crisis by cognitive behavioral model,[3],[12] which mandates thorough assessment. The actual cause of stuttering is not known. It is attributed to a combination of constitutional and environmental factors. Therapy helps in quick improvement of the problem. Negative, stressful emotions have been positively associated with stuttering.[2]

Considering the high relapse rates of this condition, early detection and referral to a psychologist is highly recommended to decrease the frequency of stuttering, associated secondary behaviors, and/or psychiatric disorders.


   Assessment Top


Family physicians play an important role in the assessment of patients who stutter because they are often the first to address the condition with parents or patients. Although many cases resolve spontaneously, referral to a speech therapist and a psychologist for therapeutic intervention usually is necessary if stuttering is severe or persists for more than 6–12 months, if the patient has a family history of dysfluency, or if the family or patient is overly concerned about stuttering behaviors.[13]

The initial assessment should establish the severity of speech dysfluency. Psychologists may educate parents and help them differentiate normal dysfluency from the initial stages of stuttering. Even with normal dysfluency or mild stuttering, patients and families may benefit from referral to a fluency subspecialist or speech-language pathologist for additional support and acknowledgment of individual concerns.[14]

Distinguishing between normal, mild, and severe stuttering can help determine the next step of the physician assessment and what type and degree of counseling should be provided. Furthermore, a clear differentiation between neurogenic and developmental stuttering is important. Integrated assessment of cognitive, social and emotional, linguistic, and motor skills is considered important due to the multifaceted etiology of stuttering.[15]

Regardless of the level of severity, the psychologist should assess whether stuttering is causing the patient or family anxiety or discomfort. Although hearing loss has not been linked to stuttering, a referral to an audiologist for a formal hearing assessment may help determine if other conditions, such as a loss or discrimination disorder, exist.[16]

The language exposure of the client needs to be taken into account to understand whether that which we are labeling as stuttering is actually an outcome of confusion between the various languages that the client has been exposed to, simultaneously. Aspects of linguistic skill assessment may include- level of stuttering, overall language skills, overall articulation and phonological ability and word finding and/or receptive/expressive vocabulary ability. Since a conglomeration of factors affects speech, the treatment is best done when assessment is multidisciplinary in nature.[17]

Assessing the motor speech activity via fluency counts and speech rate data, duration of stuttering, speech prolongations, frequency, type, severity, secondary coping behaviors, and overall speech control may also be helpful.[18]

Cognitive assessment may be done pre, post, and during the intervention. Awareness of the client regarding stuttering is also considered to be an important component and is understood through two perspectives. The positive aspect of awareness relates to the ability of the individual to identify moments of stuttering, associated stress/tensions, and its impact on him/her while stuttering. The other aspect is about increased awareness and sensitivity which might lead to a further increase in stuttering.[19]

Social and emotional issues associated with deficits in speech function such as poor self-esteem, confidence, interpersonal relationships, anxiety, and depression need to be assessed in detail. Persistent symptoms may lead to significant distress. This may involve evaluating frequency of avoidance of stressful events, frequency of stuttering in academic subjects and extracurricular activities, impact of the problem on peer relations, frequency of stuttering while communicating with different individuals, and frequency in events where the individual is expected to/has to speak.[20]

Psychologists can formally assess speech using subjective and objective testing. Standardized scales for each may help the clinician understand the client's level of subjective and objective stress, overall quality of life, and well-being.

Several assessment instruments may thus be administered to get a holistic picture of the client's problems. Scales such as Stuttering Severity Instrument (4),[21] Perception of Stuttering Inventory,[22] Beck's Anxiety Inventory,[23] Rosenberg's Self-Esteem Scale,[24] and World Health Organization-Quality of Life Scale[25] may help in gathering relevant information about the client. Cognitive behavior therapy (CBT)-minded therapists may additionally require a detailed assessment of the individual's cognitive distortions for which any standardized cognitive distortions scale may be used.[26]


   Management Top


An effective management plan for stuttering would involve affective (negative feelings and emotions [namely, anxiety, depression, or shame]), behavioral (i.e., avoidance), and cognitive (namely, poor self-esteem and negative self-evaluation) aspects as the condition has its toll on all these areas.[27],[28] Deficit speech behaviours may lead to negative perception of the situation or self or others. The individual may feel inferior and resultantly, may have low self-esteem. It is, therefore, important to break this vicious cycle of thoughts, beliefs, and feelings.

Besides speech issues, communication and participation in social activities must be focused upon for a comprehensive management of stuttering. CBT and mindfulness meditation (MM) may help not only in managing the primary symptoms by increasing awareness of the condition and its consequences but also may help equip the individual with adequate skills for present and future management of the problem and its behavioral, social, and related consequences.[28] These aspects may need differential management strategies across the lifespan.[11],[28]


   Behavioral Management Top


Behavioral management for children focuses on working on core speech disorder and multifactorial treatment involving the environmental influences on the individual. Treatment approaches for adults involve focusing on cognitive/anxiolytic issues (secondary behaviors) and improving speech fluency.[29] Monitoring the rate of speech, speaking short sentences slowly while observing their breathing and gradually moving to longer sentences, with adequate practice, may help in behaviorally managing speech disfluencies. Reinforcing appropriate deliveries, mobilizing social support, and valuing clients' strengths may promote recovery, as per this paradigm.[30]

Behavior therapy uses strategies such as verbal contingencies. such as praise for a stutter-free speech, request for self-evaluation through simple questions for stutter-free speech (not suggested to be practiced while stuttering), acknowledgment of stutter-free speech, and request for self-correction with much persistence. The therapy also involves parents to use the verbal contingencies during daily unstructured conversations till they become efficient in using them in structured conversations. Stage two begins after a week of severity scale ratings of one (no stuttering) or two (mild), by the parents. Stage 2 involves two goals: one is to pass on the responsibility of management of stuttering to the parents' in an organized and progressive manner and the other is the retention of the results attained during therapy. The possibility for relapse still remains, and clients and their relatives need to be educated accordingly.[27],[29],[31]


   Cognitive Behavior Therapy Top


The experiences of individuals with this disorder may include negative affect, behavioral, and cognitive reactions, both from the speaker with stuttering issues and the environment. It also involves significant limitations in the individual's ability to participate in daily activities and a negative effect on the person's overall quality of life. Individuals who stutter may strive for lower levels of achievement due to low self-esteem and the overwhelming fear of failure.[11]

A cognitive behavioral model of stuttering, therefore, targets the biopsychosocial crisis prominent in this condition and focuses on the primary behavioral, cognitive, and emotional symptoms.[32]

CBT strategies demonstrated to be effective by research in this population include psychoeducation, relaxation, deep breathing, humming, prolongation, cognitive restructuring, problem-solving strategies, and assertiveness, thereby addressing speech issues, low self-esteem, over generalization, catastrophic beliefs, social inhibition, and avoidance of social situations to an extent of social phobia.[33],[34]

Negative associations with stuttering often lead to social anxiety. Therefore, it is imperative to involve methods of treatment for negative attitudes and avoidance related to stuttering. Common components to manage anxiety in CBT involve cognitive restructuring (analyzing cognitive errors and taking appropriate action), attentional training (developing skills to be aware of and in control of where our attention gets placed), and behavioral experiments (include strategies to deal with social situations linked to negative associations with stuttering).[35]

After addressing the client's unhelpful thoughts and avoided behaviors, the psychologist educates the client and the family about stuttering. Then, behavioral experiments to face the avoided situations, such as speaking in public, are planned. The gradual modification in the client's self-focused behavior is facilitated. Cognitive errors and observers' perspectives are analyzed. Cognitive errors involve distorted perception of events that take place such as magnification (distortion of the importance of positive or negative events), personalization (when an individual puts blame of a negative event on oneself even though the individual is not responsible, did not know to respond differently, the extenuating nature of the circumstance, or the actions of other people), or jumping to conclusions (responding to a situation without having complete information of it).[36],[37]

The treatment progresses in this manner, and client's efforts are appreciated through reinforcements. Strategies such as modeling and role plays may be used during treatment. Modeling refers to the practice of slower rate of speech with pauses. Whereas, role playing refers to enacting events that create anxiety. The significance of generalizing the skills learned during the therapeutic setting should be promoted by involving family as cotherapists.

Over time, the clients may learn to challenge their own fear of negative evaluation. Once attained, these skills help the clients in dealing with such issues in future, and then, the main goal of treatment becomes relapse prevention for which booster sessions may be conducted periodically. CBT does not cure stuttering but provides the client with the skills to deal with stuttering-related problems in everyday situations which facilitate adequate management of the problem.[38]

There is an exhaustive amount of interventions in the CBT approach that this paper briefly covers. These include stuttering modification therapy, dysfunctional thought record scheme, and cognitive interventions among others. Stuttering modification therapy aims to cultivate acceptance toward the problem of stuttering and reduce anxieties and fears in events of stuttering. It motivates the client to become a confident communicator. Nonavoidance therapy is its most commonly used form.[37],[39]

Dysfunctional thought record scheme focuses on identifying and analyzing common dysfunctional thoughts created by the client through self-monitoring and then replacing those thoughts with more functional and realistic ones. It promotes the practicing of alternate patterns of behavior that challenge cognitive distortions.[40]

Cognitive interventions for stuttering may involve sessions for identifying and modifying cognitive distortions (unhelpful thoughts that distort reality), clarifying idiosyncratic meaning by questioning, examining facts (may be done by watching video recordings), reattribution (analyzing cognitive distortions by considering variable causes of an event), decatastrophizing (questions using what if-are asked in order to prepare client for feared consequences), listing alternatives, enlarging perspectives, and cognitive repetition (repetition of statements that challenge cognitive distortions).[39],[40]

Deep breathing is another relevant strategy where the individual takes deep breaths and is aware of the breathing pattern at the moment. Relaxation may be practiced through suggestions for relaxing speech musculature when the individual feels tensed such as pausing while stuttering or practicing stuttering voluntarily with varied levels of tension. Humming is also an effective strategy that helps relax the vocal chords. Humming is practiced by first humming quietly with the mouth closed and then with the lips open. Deep breathing and relaxation help an individual to release tension from the body and reduce anxiety, thereby reducing the frequency of stuttering episodes. Prolongation is a form of speech restructuring wherein changes in speech production help the individual to suppress stuttering to varying degrees.[35],[36] Voluntary stuttering involves social situations where the client produces stuttering voluntarily. Here, the social situations move from that where the individual is comfortable to those that are feared. Cognitive restructuring involves challenging unhelpful thoughts through evidence-based procedures such as Unhelpful Thoughts and Beliefs about Stuttering Checklist. Problem-solving strategies involve identifying the actual problem, evaluating possible solutions, and breaking the possible solutions into achievable tasks.[41]

Stuttering openly can be stressful. We become vulnerable. Being comfortable and assertive and letting your needs be known can relieve stress. Stuttering assertively may involve using “I” statements, practicing using “I” statements with someone one feels comfortable with; saying “I stutter, and I am OK with it and hope you are too” puts the stutterer comfortably in control of the communication encounter and gives the listener a cue as to how to react. All this needs to be done while maintaining good eye contact. The client may benefit by practicing maintaining eye contact while doing some voluntary stuttering. Maintaining eye contact is a sign of self-confidence.

Further, the client needs to learn to be brave enough to respond even when someone reacts negatively to your stuttering. If someone laughs or makes fun of their stuttering, they may react by saying, “hey, I stutter, and I really don't like it when someone laughs at me. It hurts my feelings.” He/she may consider practicing saying that with someone they trust.

In addition, they may need training in reframing negative thoughts into positive ones. Whenever their mind says they can't do something because they stutter, they need to learn to turn that around into an opportunity for a challenge.[39],[40],[41],[42]


   Mindfulness Meditation Top


Mindfulness-based approaches aim to increase the possibility of choice through responding mindfully rather than reacting automatically and cultivate kindness and compassion toward self. It also heightens the possibility of experiencing calm.[43]

Practicing mindfulness impacts the individual by helping to understand the paradox of change coming about through “letting be” rather than trying to fix. It encourages approaching and opening up to difficult experiences which can reduce the reactive pattern of tensing which triggers negative cycles of thoughts, feelings, and behaviors along with disengaging from rumination and habituated negative thinking patterns.[43],[44]

Along with the benefits stated above, mindfulness is relevant for stuttering as it involves means whereby people can develop greater opening up to difficulty which is important for desensitization. It emphasizes on an increased awareness of the body – getting out of the head and coming to the present moment. The ability to “respond” rather than “react” can facilitate use of speech therapy techniques along with stress management/relaxation.[45]

Here, it would be prudent to point out the following about mindfulness:-

Mindfulness is not a form of relaxation. When one moves toward becoming mindful of what's going on in one's lives, it can be anything besides unwinding. As one takes in more about oneselves, in any case, he/she turns out to be less astounded by the sentiments that emerge inside. There is a process of building up a less receptive relationship to internal experience.[46]

Mindfulness is not a religion. In spite of the fact that it has been practiced by Buddhist nuns and priests for >2500 years, any intentional action that builds consciousness of minute-to-minute experience is a mindfulness workout. The present day cognitive sciences view mindfulness as one of the core healing factors in psychotherapy.[47]

Mindfulness is not tied in with rising above normal life. It is reaching every snapshot of one's lives, regardless of how insignificant or mundane. It is likewise about encountering oneself all the more completely, not attempting to sidestep the unremarkable, worn out edges of one's lives.[48]

Mindfulness is not emptying the mind of thoughts. Mindfulness enables an individual to build up a more amicable association with his contemplations and sentiments through profound comprehension of how the mind functions. It might feel as though one has less thoughts, since he/she is not battling with them.[48],[49]

Mindfulness is not about being complacent. Acceptance does not mean agreement or complacency. It means acknowledging whatever's going on, which is a good idea because it is already happening.[50]


   Mindfulness-Based Interventions Top


The four major approaches in mindfulness used in the management of stuttering are mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), acceptance and commitment therapy (ACT), and dialectical behavior therapy (DBT).

MBSR is an 8-week training course with 2 ½ h sessions that emphasize on the decrease in the levels of stress and anxiety related to situations where they have to speak. The focus lies on the client's self-efficacy beliefs (here the focus is on the client's attitude toward the feared situation and the ability to use the coping strategies during the situation), coping behavior (problem-focused strategies emphasized such as seeking support, making task-list, planning and executing the plans), locus of control (feeling more in control during stressful situations, being able to accept situations that are beyond their control), and attitude toward speech situations. Practicing it involves sitting meditation where attention is drawn to physical sensations, breathing, thoughts, and emotions. Body scan involves concentrating on various parts of the body one by one and being aware of the sensations.[51] This practice reflects the link between the mind and the body. Yoga exercises are also a part of the program that facilitates the client's increasing awareness of the muscle movements in the body. Exercises such as these help the client to be aware of their thoughts, emotions, and physical reactions when they are stuttering. When they become aware of the sensations in their body and the thoughts and emotions in the mind, they are in a better position to respond to the situation as the identification of the problem has taken place.[52]

MBCT aims at developing skills for the increase and retention of attentional focus, distinguishing between perceived sensations and direct experiences and being able to view thoughts and feelings separately. Some of its strategies include being aware of everyday actions as it helps them to respond rather than to react. Paying attention to physical sensations during everyday activities such as eating, walking, singing, and speaking helps the client to be aware of physical sensations that take place during speech production. With a similar objective, the strategy of awareness of breath is practiced where the client focuses on physical sensations while inhaling and exhaling. Another strategy involves modifying the understanding of the association between thoughts and emotions. Here, the clients learn that thoughts are not absolute truths. Group of tasks in this strategy that help the client to understand thoughts in a different manner involve decreasing the overwhelming emotions by writing them down on paper, trying to understand the origin of these thoughts among others. Another strategy involves developing an action plan in case of relapse. Here, a list of actions, behaviors, and feelings are developed associated with the times when the client feels in control of speaking and during relapse.[53]

These lists create awareness among the clients in the early stages of relapse as they are able to identify the symptoms before they increase in complexity. After the identification of the problem, steps such as 3-min awareness of breath, using problem-focused coping strategies, and involving themselves in activities that make them feel empowered are suggested.[54]

ACT aims to find workable solutions for the problems due to stuttering, while showing acceptance toward it. Thus, the main aim is not to reduce the rate of stuttering but the negative associations attached to it. Acceptance of the situation, understanding, and awareness of emotional control along with the consequences of the efforts to control emotion is known to reduce the impact of negative emotions. Personal values become the main focus, on the basis of which values' identification, values' clarification, and behavioral decisions are made. The six core processes of this model are self-concept, defusion, acceptance, mindfulness, values, and committed action. Self-concept is the client's perceptions and definitions of themselves. They learn that stuttering is only a part of their self; it does not define their whole being. Defusion relates to behavioral flexibility displayed in social situations. Acceptance reflects the client's ability to acknowledge their thoughts and emotions without any attempt to change. The concepts of willingness and acceptance are introduced in place of avoidance of stressful situations regarding stuttering. The daily struggles with stuttering arise because of the value placed on fluent speech by the society. Mindfulness promotes a focus on the present, where values represent the domains of life that are the most meaningful to the client, and committed actions represent the steps that one takes to reach their goals.[55]

Another approach to mindfulness is the DBT model. This approach has a comprehensive nature wherein it involves aspects of cognitive-behavior approaches such as cognitive restructuring, behavioral exposure, and stimulus control. It emphasizes on four aspects, namely five functions of treatment, biosocial theory and focusing on emotions in treatment, dialectical philosophy and acceptance and mindfulness. The five functions of treatment involve enhancing capabilities (learning skills for emotional regulation, awareness of the physical sensations in speech production, skills for interpersonal effectiveness, etc.,), generalizing capabilities (incorporation of learned skills in daily life), improving motivation and reducing dysfunctional behaviors (involves tasks such as self-monitoring form to evaluate the consistency of achieving treatment targets which helps the therapist to prioritize treatment sessions), enhancing and maintaining therapist behaviors and motivation (which can be attributed to high rate of relapse in individuals with stuttering), and structuring the environment (by educating the family and creating support systems). Biosocial theory focuses on developing skills for emotional regulation such as understanding, recognizing, and labeling negative emotions in stressful situations. Dialectical philosophy focuses on the idea that acceptance and change-oriented treatment processes work hand-in-hand in an effective treatment. Here, the therapists emphasize a balance of both acceptance of the client's perspective (beliefs about self, fears related to speech related situations, spillover of the effects on other aspects of life) and change-oriented progress during therapy. Strategies are either acceptance based (acceptance of the present and not struggling to change it, acknowledging the truth in the experience, emotions and thoughts of the present situation, tolerating stress, being mindful of current emotional situation or other experiences) or change based (solving the problem, changing behaviors, changing environments, and reinforcements).[56] Acceptance-based strategies such as sitting meditation require the client to change their association with thoughts, for example, accepting a negative thought as one that has originated in the mind and not as an absolute truth that defines the person. Change-based strategies, however, involve aspects of cognitive-behavioral therapy, such as restructuring of cognitive errors.[57]


   Cognitive Behavior Therapy and Mindfulness Top


When coupled with CBT strategies, this awareness and understanding may help the clients reflect back on the factors that worsen the stuttering and increase the related psychological or behavioral problems. Thus, CBT along with MM may help an individual with stuttering problem to not just be aware of his speech and associated problems but also develop a positive attitude toward communication, in general. These therapeutic strategies would help clients improve their speech fluency, frequency and intensity of stuttering, self-esteem, and quality of life in addition to reducing the associated emotional or interpersonal issues due to anxiety and/or depression.[58],[59] These involve a combination of strategies such as self-monitoring of dysfunctional beliefs related to speech, sitting meditation, and body scan. This combination of approaches is cost-effective.[13]

Validating the efficacy of CBT and mindfulness remains an important issue for any progress in future. Efficacy of any therapy is its ability of achieving the intended result. The methodological issues of measuring efficacy can be fraught with pitfalls as the examination often does not cover all the key elements of the structure of stuttering. The reduction of the percentage of dysfluency is often perceived as the main indicator of efficacy at the expense of other variables, chiefly improvement in self-esteem and quality of life.[60] Measurement of physiological, psychological, and social factors to correlate with the existing severity of speech dysfluency may be omitted by the examiner while performing a meta-analysis of pooled data from various studies. It is also difficult to formulate a strict control group in a double-blind randomized control study design for measuring efficacy of such explicit interventions such as CBT and MBSR, MBCT, DBT and ACT and their combinations.[61],[62] However, encouraging results of the above approaches alone or in combination have been found in recent works of various countries. An overview of research over the efficiency of therapies of stuttering has validated the above approaches recently.[13],[63],[64] An elegant perspective about grounding clinical and cognitive scientists in an interdisciplinary discussion for conditions which straddles the domains of mind and body has been put forward in this regard.[65]


   Treatment Duration Top


In general, the CBT and mindfulness treatment program, depending on the severity of the client's symptoms, may range from 3 months to 3 years, with variable number of sessions.[11],[12] Booster sessions during follow-up may help in maintaining the positive outcomes over a longer term.


   Methodological Limitations Top


The literature suggests that factors such as small sample size, lack of blinding, absence of or shorter duration of booster sessions, and lack of adequately trained officials may lead to poor outcomes of various interventions for stuttering.

All types of interventions used in stuttering, i.e., namely feedback and technology interventions, cognitive interventions, behavioral modification interventions, speech motor interventions, speech motor combined with cognitive interventions, and multiple component interventions, and studies that compare interventions to each other may have positive outcomes for the clients with stuttering. However, it is unclear that which form of intervention is the most suited to which client. Need for a greater consensus on significant outcomes is realized as it would help to evaluate approaches in treatment for stuttering and how they influence change. Analysis to identify the relation between the case of clients and the most beneficial interventions is required.[62],[65],[66]

Also sensed is a need to emphasize variables such as participant and clinician characteristics, time since onset, and session time (number of sessions per week, minutes per se ssion) during research so that comparative investigation may be feasible. In addition, there may be a high risk of bias in such studies. It is also important to consider the possible adverse impact of interventions.[67],[68]

More, well-designed, structured, and large-scale studies are, thus, needed to establish the efficacy of these approaches in stuttering management. Particularly, double-blind, placebo-controlled randomized controlled trials are needed in keeping with the evidence-based practices.


   Conclusion Top


Stuttering is a speech fluency disorder that has a multifaceted etiology. Early identification and treatment play an important role in recovery. Stuttering, other than the impact on speech fluency, might have negative social consequences for an individual. This leads to anxiety. Therefore, the treatment for stuttering includes multiple dimensions. CBT and mindfulness equip the client with the skills to interact with the problems. The rate of relapse among clients seems to be high. This demands for the availability of booster sessions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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