SOCIAL BEHAVIOR AND PERSONALITY, 2010, 38(3), 301-310

© Society for Personality Research (Inc.)

DOI 10.2224/sbp.2010.38.3.301

The effect of cognitive-behavioral therapy on

stuttering

Mustafa Koç
Sakarya University, Sakarya, Turkey

The effects of the cognitive-behavioral approach to therapy on stuttering were examined. An

experimental method was used as the research method and was carried out in 2 stages. In the
first stage, the researcher investigated thinking, emotion, and the behavior of an individual
towards stuttering. In the second stage, a description of stuttering and its frequency was
formulated. The description was then applied as an educational program to treat stuttering.
At the end of the cognitive-behavioral therapy, there was a significant reduction in stuttering
behavior. Results showed that the cognitive-behavioral approach is effective for treating
stuttering.

Keywords: cognitive-behavioral therapy, stuttering.

Communication was defined as follows by Sillars (1995); to deliver, receive,

or alter the information, opinion, or thought through written, audio, or visual
instruments, or by using these all together so that the material that is desired
to be put across is fully conceived by everyone concerned. Human relationships
constitute the primary element of communal living. Human relationships are
based on communication. Communication gives voice to the exchange of
thoughts and feelings taking place between individuals (Cüceloğlu, 1984). A
considerable proportion of our everyday life depends on communication − for
example, an average of 75% of the time a person is awake is spent on verbal
communication (Healey, 2004).

Mustafa Koç, Faculty of Education, Sakarya University, Sakarya, Turkey.

Appreciation is due to anonymous reviewers.
Please address correspondence and reprint requests to: Mustafa Koç, Faculty of Education, Sakarya
University, Sakarya 54300, Turkey. Phone: +90 533 4294515; Fax: +90 0264 6141034; Email:
[email protected]

301
302 cognitive-behavioral therapy AND stuttering

Babies are born with the ability to understand sounds including spoken words.
Children can recognize and respond to voices from a young age. Within a few
weeks they start distinguishing phonemes in the voices of their parents and
others. Around the age of one year they begin to be able to understand adults and
produce sounds that they recognize (Özbay, 1999). Sense organs cannot function
without connection to others. Talking to another individual serves as a connection
between two people (Adams, 1991).
Communication is an emotional behavior rather than being solely a language
activity. This entails effective use of language, a fundamental instrument
providing interaction between people. Speech and language disorders are two
main problems which are experienced by individuals who cannot express
themselves. Language disorders can be defined as systematic and sequential
processing disorders regarding the grammatical and intentional linguistic
behavior of the child (Lucas, 1980). Three types of language disorders have been
identified: (1) receptive language disorder, also known as reflective disorder, (2)
expressive language disorder, which occurs during the production of language,
and (3) aphasia, which is generally experienced while writing, speaking, and
communicating.
A speech disorder is any speaking behavior which noticeably hinders
communication, negatively affects the speaker and the audience, and exhibits
substantial abnormality from standard and acceptable speech patterns (Ham,
1990). Speech disorders are generally observed in social environments. The
most noticeable of this type of disorder is stuttering (Bloodstein, 1993; Rieber
& Wollock, 1977; Silverman, 2004) and the most significant feeling caused by
stuttering is social anxiety. Some people cannot speak with continuous rhythm
and fluency; while speaking they recoil, falter, repeat some sounds, and block
others. This condition, in which normal, fluent speech is disrupted by repetitions,
pauses, and exclamations (Belgin, 1990; Bobrick, 1995) has become one of the
most frequently studied speech disorders (Murphy, 2002). Although familial
disposition and inflammatory diseases have been found to cause stuttering, the
disorder generally appears for psychological reasons (Bloodstein).
Konrot (1999) differentiates the types of language and speech disorders as
follows: language and speech disorders related to anatomical problems, language
and speech disorders related to physiological causes, language and speech
disorders related to neurological reasons, language and speech disorders related
to biochemical reasons, language and speech disorders related to psychological
reasons, language and speech disorders related to disruptions during adolescence,
language and speech disorders related to negative environmental factors,
language and speech disorders which are not related to any reason, and those
related to complicated reasons (Adams, 1991; Campbell, 2003; Gottwald & Hall,
2002; Gregory & Hill, 1980).
 cognitive-behavioral therapy AND stuttering 303
The researchers aimed to identify the effect of cognitive restructuring on
treatment of disorders, specifically stuttering, as related to psychological
problems. In the cognitive restructuring process the objective is to alter the
individual’s negative cognitions. During this process, negative cognitions
relating to stuttering not resulting from physiological, anatomic, neurologic,
biochemical, or any of the other reasons enumerated above, but appearing to be
psychological in origin, are identified. A behavioral therapy which is applied with
the aim of altering the individual’s cognitive structure of speech is likely to be
briefer and more therapeutic, because language is a complex learned behavior.
Language disorders may have several underlying factors, one of which is that
a child who is exposed to inappropriate language at home learns inappropriate
language techniques (Woolfolk, 1998).
Behavior therapy is aimed at eliminating abnormal learned behaviors and
replacing them with normal behaviors. As the aim of behavior therapy is to
teach new behavior patterns, these therapy methods are closely related to
behavioral learning theory. In behavior therapy, techniques of behavioral learning
theory such as conditioning, reinforcement, extinction, generalization, transfer,
backward conditioning, negative reinforcement, and role modeling are used
(Campbell, 2003).
As long as the underlying factors of a given behavior can be identified, applying
behavior correcting therapies may be able to help to eliminate the behavior.
During this process it is essential that the individual has self-awareness and this
is generally facilitated by meeting with a psychological advisor (Guitar, 1999).
Primal fears, anxieties, and obsessions can be expressed in a number of different
ways. A new approach aimed at, firstly, detecting the underlying thoughts and
related feelings that are causing stuttering, accepting and dealing with these, and
then reorganizing the cognitive structure, and secondly, treating the stuttering
with behavior therapy has been developed for use in this research, in which the
researcher studied the effect of cognitive restructuring, based on cognitive and
behavioral approaches for treatment of stuttering. Based on this, answers to the
following questions were sought:
1. In relation to the structure of irrational thoughts that cause stuttering,
does the individual: a) Use excessive generalizations?; b) Possess self-
destructive thoughts?; c) Use arbitrary inferences?; d) Act according to
all-or-nothing principles?
2. What is the effect of behavior therapy on treatment of stuttering after the
process of cognitive restructuring?

Method

The research was carried out in two stages using an experimental method. The
first stage consisted of identifying the individual’s thoughts and feelings related
304 cognitive-behavioral therapy AND stuttering

to stuttering and dealing with them. The second stage included the behavioral
dimension, in which stuttering has become a problem and its frequency was
detected. The desired behavior to replace stuttering was then identified.

Research Pattern and Process

Participants were three stutterers who applied to the Psychological Counseling
Center at Niğde University Faculty of Education. Participants’ demographic
statistics are shown in Table 1.

Table 1
Participants’ Demographic Statistics

Age Sex Number of years Frequency of Previous stuttering

of stuttering stuttering (daily) treatments

19 Female 13 820 None

21 Male 19 930 None
27 Male 17 1080 None

Before their applications were approved, the participants were examined in

a medical center to make sure their stuttering was not a result of physiological,
neurological, or anatomical factors. Their applications were confirmed after the
medical data confirmed that their stuttering was not due to any of these reasons.
The therapy process was administered in two stages. In the cognitive stage,
the individual believed that the stuttering was not physiological. Researchers
were interested in finding the reason that the stuttering began. Environments in
which the condition was experienced the most frequently were determined. The
researcher then investigated the thoughts the patient could not block in these
environments. The thoughts that caused the person to make excessive gener-
alizations, personalize most situations, and give way to feelings of worthlessness
were thereby determined. Alternative thoughts which could replace these were
proposed and the cognitive structure was tentatively restructured. The first stage
was completed when the individual decided that he/she had reached the cognitive
behavioral level of therapy.
At the behavioral level, determining the goal and subgoals with the clients
using a 10-phase therapy process was planned. In the second stage, before
starting the therapy, frequency of stuttering was recorded. During the process the
dependent variable (therapy method) was applied to the participants. Responding
variable data were recorded throughout this process. When the therapy was
completed the stuttering frequencies of the participants were measured again. In
the research stuttering was addressed as the dependent variable, and the treatment
process that was applied was the independent variable. The design of the research
was an uncontrolled pre- and posttest model.
 cognitive-behavioral therapy AND stuttering 305
Data Analysis
Data related to the cognitive restructuring and behavioral approach, derived
from pretest and posttest results, were examined in a graph using SPSS
software. Analysis related to behavioral approach was made diagrammatically.
In the diagrammatical analysis the x-axis shows the therapy phases, while the
y-axis shows the frequency of stuttering. The effect of the therapy method
was determined according to the curved lines which took shape on the chart.
Commencing and posttherapy levels of stuttering by the participants were
entered in the chart. The more the vertical distance between the commencing
level line and the posttherapy level line, the more effective the therapy method
is. Conversely, the less the distance between the two lines, the less effective the
therapy method is.

Results

In this section findings related to the cognitive restructuring oriented behavior

therapy, based on cognitive behavioral therapies, are dealt with.

Findings Related to Pretherapeutic and Posttherapeutic Stuttering

Frequencies of all Participants

Table 2
Pretherapeutic and Posttherapeutic Stuttering Frequencies

Process Ms. Ö. Mr. K. Mr. G.

Pretherapy 820 1080 930

1st phase 820 1080 935
2nd phase 825 1080 923
3rd phase 835 1100 945
4th phase 600 850 730
5th phase 280 395 335
6th phase 144 205 180
7th phase 58 102 90
8th phase 16 20 20
9th phase 4 10 17
10th phase 4 8 9

As can be seen in Figure 1, the pretherapeutic stuttering frequency of Ms. Ö.

is an average of 820. In the second and third phases of therapy an increase in
average frequency was observed. This increase may have resulted from the fact
that the adviser and the client were focused on stuttering in these phases. Ms.
Ö’s stuttering frequency shows a rapid decline from the fourth phase onwards. At
the tenth phase an average of four instances of stuttering a day was observed. It
306 cognitive-behavioral therapy AND stuttering

can therefore be inferred that the therapy method used on Ms. Ö. was effective.
Posttherapeutic observations are still in progress.

Ms. Ö’s Stuttering Frequencies

900
800
700
600
500
400
300
200
100
0
py se se se se se se se se se se
hera 1st pha 2nd pha 3rd pha 4th pha 5th pha 6th pha 7th pha 8th pha 9th pha 0th pha
Pret 1

Figure 1. Pretherapeutic and posttherapeutic stuttering frequencies of Ms. Ö.

Mr. G’s Stuttering Frequencies

900
800
700
600
500
400
300
200
100
0
py se se se se se se se se se se
hera 1st pha 2nd pha 3rd pha 4th pha 5th pha 6th pha 7th pha 8th pha 9th pha 0th pha
Pret 1

Figure 2. Pretherapeutic and posttherapeutic stuttering frequencies of Mr. G.

As can be seen in Figure 2, the pretherapeutic stuttering frequency average

of Mr. G. was 930. A slight increase in stuttering average in the first phase was
observed. The second phase shows a decrease as compared to the pretherapeutic
phase, but there is an increase in the third phase. A possible reason for this
increase is the fact that the client and the adviser focused on speech and examined
stuttering in detail in the third phase. Mr. G’s stuttering frequency shows a
rapid decrease from the fourth phase onward. In the tenth phase the instances
of stuttering were reduced to nine per day. It can therefore be concluded that
 cognitive-behavioral therapy AND stuttering 307
the cognitive-behavioral approach was effective for treating Mr. G’s stuttering.
Posttherapeutic observations are in still progress.

Mr. K’s Stuttering Frequencies

1200

1000

800

600

400

200

0
py se se se se se se se se se se
hera 1st pha 2nd pha 3rd pha 4th pha 5th pha 6th pha 7th pha 8th pha 9th pha 0th pha
Pret 1

Figure 3. Pretherapeutic and posttherapeutic stuttering frequencies of Mr. K.

As can be seen in Figure 3, Mr K’s average pretherapeutic stuttering frequency

was 1080. In the third phase of therapy an increase in stuttering average was
observed. A possible reason for this increase is the fact that the client and the
adviser focused on speech and examined stuttering in detail in the third phase. Mr.
K’s stuttering frequency shows a rapid decrease from the fourth phase onward.
It can therefore be said that the cognitive-behavioral approach was effective in
treating Mr. K’s stuttering. Posttherapeutic observations are still in progress.

Discussion

This research was carried out in two stages in order to determine whether or
not the cognitive restructuring process based on cognitive-behavioral approaches
is effective for the treatment of stuttering. The first stage consisted of identifying
the client’s thoughts, feelings, and behaviors related to stuttering and dealing with
these. The most efficient way to alter the undesired behavior is by determining
a desired action and teaching this to the client (Fraser & Perkins, 1987). At the
behavioral level that was the basis of the second stage, stuttering was defined,
its frequency was determined, and a treatment process was planned in order to
replace stuttering with the desired behavior. At the end of the treatment, changes
in the individual’s stuttering behavior were shown diagrammatically.
Primal thoughts and related feelings triggering undesired behavior should be
dealt with therapeutically. Individuals experiencing social anxiety are concerned
308 cognitive-behavioral therapy AND stuttering

about what other people think about them and they generally fear negative
assessments (Burger, 1993). Exercises aimed at adjusting observable behavior
are not effective for the elimination of primal anxieties or fears. This study is
unique in the sense that it deals with stuttering caused by a given experience, first
cognitively and then behaviorally. Stuttering for psychological reasons might be
defined as an expression of a conflict at a cognitive level. This approach – which
has been developed to cure stuttering through detecting, accepting, and dealing
with thoughts and related feelings that cause stuttering – and a reorganization
of cognitive structure followed by behavioral therapy was found to be effective.
With early diagnosis and treatment the method can be more effective and long-
lasting. Unfortunately, in Turkey, deviation from the normal phase of linguistic
development is generally not detected unless there is a dramatic deficiency.
However, when they go to school children with these speech deficiencies fail
to respond to the academic requirements as a result of their poor linguistic
development (Ege, 1994). Peters and Guitar (1991) state that it is desirable to
ensure speech deficiencies are treated, and there are several ways to do this.

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