Mindfulness Training for Adults Who Stutter

Stuttering

INTRODUCTION

Stuttering can be described as a genetically based, neurophysiological disorder characterized by atypical disruptions in the fluency of speech. Stuttering occurs in approximately 1% of the general population and in 5% of primary school children (Gupta, Yashodharakumar, & Vasudha, 2016). Males are four times more likely to stutter compared to females (Perez & Stoeckle, 2016). The etiology of stuttering is unknown and there is no cure for stuttering. However, research supports a genetic basis of stuttering. Up to 90% of children who stutter can recover from stuttering with speech therapy interventions or through natural recovery (Perez & Stoeckle, 2016). However, many children enter adulthood with a stutter and a significant amount of these adults may have ongoing psychosocial and emotional issues related to stuttering. There are emerging data to suggest that age of onset of stuttering (>3yrs), family history of persistence, male gender, and lower language skills are predictors of persistent stuttering.

Speech-language pathologists are trained in providing interventions that target reduction of disfluencies in the speech of people who stutter, and more recently, have focused on interventions that simultaneously target emotional support for people who stutter. In fact, most people who stutter prefer an integrated treatment approach, with appropriate goals that address both feelings and attitudes about stuttering and speech fluency (Yaruss & Quesal, 2002). Attitudes and feelings about stuttering are important to consider because communication competence and confidence for people who stutter can be diminished through avoidance or through behavioral techniques present in traditional stuttering intervention methods that are difficult to generalize to everyday conversation. Managing reactions to disfluent speech can be an effective technique for regulating disfluent speech and reducing the psychosocial effects associated with stuttering.

Disfluent speech caused by stuttering can impact emotional well-being. Emotional reactions to stuttering instances include anxiety and frustration associated with anticipated embarrassment and humiliation when speaking (Craig & Tran, 2014). The potential negative psychosocial impact of stuttering may lead to lowered motivation and avoidance of situations when anticipation of stuttering instances might occur. Increased anxiety and avoidance of social situations can adversely affect the quality of life of individuals who stutter (Boyle, 2015). Therefore, speech therapy interventions targeting the reduction of anxiety and psychological stress symptoms associated with stuttering are necessary to benefit both communication effectiveness and the quality of life for people who stutter. Increasingly, mindfulness techniques have been used to decrease psychological symptoms, including those caused by stuttering. Mindfulness practices have been adopted by some speech-language pathologists as a therapeutic intervention used to enhance communication effectiveness and the quality of life for people who stutter. This paper will provide an overview of the different aspects of mindfulness based therapy techniques including: the definition of mindfulness, the history of mindfulness, assessment and treatment of stuttering, the benefits of mindfulness in stuttering management for adults, and considerations for future research.

MINDFULNESS

Mindfulness therapy techniques used for stuttering differ from traditional stuttering interventions, such as stuttering modification that focuses on reducing the stuttering moment as it is happening and fluency shaping that focuses on manipulating speech by beginning every first word of every utterance with an easy onset in an effort to speak with 100% fluency. In contrast, mindfulness encourages acceptance, rather than attempting to change or manipulate. Mindfulness can be defined as paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally (Boyle, 2011). Mindfulness philosophies are based off of the religious foundations of Buddhist meditation and can be traced back more than 2,500 years (Ditrich, 2016). The goal of Buddhist meditation, which includes mindfulness, is liberation from suffering and awakening from delusions, cravings and aversions (Ditrich, 2016).

In Buddhist tradition, mindfulness is always one component within the overall ethical framework of Buddhist discourse, but mindfulness alone does not lead to liberation from suffering (Ditrich, 2016). Although mindfulness continues to be a key component of Buddhist meditation, mindfulness techniques have been adopted by people from many different backgrounds as a way to bring awareness to the present moment for the apparent benefits.

Secularized mindfulness practices have been used to enhance psychological and physical well-being since the late twentieth century (Ditrich, 2016). Therapies in which mindfulness plays a central role have been shown to have positive outcomes for a broad range of clinical symptoms. Mental health professionals utilize mindfulness methods with clients in order to decrease anxiety and depression, decrease stress, reduce weight stigma, reduce unhealthy eating patterns, and increase overall emotional well-being (Palmeira, Pinto-Gouveia, & Cunha, 2017). Teachers utilize mindfulness techniques in order to improve school-aged children’s attention, test anxiety, social skills, and overall global executive control (Volanen et al., 2016). Mindfulness-based interventions include Mindfulness-Based Stress Reduction, Mindfulness Based Cognitive Therapy, and Acceptance and Commitment Therapy (Boyle, 2011). Speech-language pathologists have recently begun to explore mindfulness interventions for treatment of communication disorders, including for adults who stutter. By using mindfulness techniques in speech therapy, adults who stutter may see positive emotional well-being outcomes, increases in attention and awareness, and they may also experience a reduction in stuttering instances.

MINDFULNESS AND STUTTERING MANAGEMENT

Mindfulness based interventions use specific techniques that are unique to mindfulness. However, there are several similarities between mindfulness and other stuttering management interventions. Clinicians familiar with more traditional stuttering therapy techniques may target similar outcomes as those targeted through the use of mindfulness-based interventions. Clinicians who implement mindfulness interventions for adults who stutter might target: awareness and attention, emotional regulation and perception of thought, and acceptance.

Awareness and Attention

Focused attention is a skill that can be taught through mindfulness training. Mindfulness begins by bringing awareness to the present experience. Mindfulness training has been shown to increase attentional control (Chambers, Lo, & Allen, 2008) and increase sustained attention on tasks (Jha, Krompinger, & Blame, 2007). In addition, mindfulness training has been found to increase activation in areas of the brain involved in sustaining and monitoring the focus of attention (Tomasino & Fabbro, 2015). Regulating the focus of attention to the changing field of thoughts, feelings, and sensations from moment to moment can lead to a feeling of being alert to what is occurring in the present (Bishop et al., 2004).
Sustained attention can be applicable to many different facets of stuttering therapy. People who stutter sometimes experience difficulties controlling and focusing attention required to make changes in traditional stuttering therapy (Boyle, 2011). In addition, increased attention and awareness to thoughts, feelings, and behaviors associated with stuttering may have possible implications on the psychosocial and emotional consequences associated with stuttering. Mindfulness training could assist in recognizing when feelings of fear and avoidance arise during a stuttering moment or during a period of relapse. Recognizing these feelings can allow people who stutter to respond mindfully and non-judgmentally.

Emotional Regulation and Perception of Thought

Rumination on a thought that is not the present moment, such as negative past events or feared future events, can confuse the mind into thinking contrived thoughts are representative of the present situation. These thoughts can lead to negative emotional feelings of anxiety and depression and can prevent effective problem solving (Ramel, Goldin, Carmona, & McQuaid, 2004). During mindfulness practice, thoughts are viewed as passing mental events rather than accurate reflections of reality (Boyle, 2011). Emotional-regulation emphasizes acknowledging the minds tendency to fabricate experiences that are not true to reality and bringing attention back to the present. Rather than ruminating on a particular thought, or allowing yourself to follow an elaborative thought stream, mindfulness involves a direct experience in the mind and body (Bishop et al., 2004). Mindfulness has been shown to decrease the activation in areas of the brain that are part of the default mode network that has been related to monitoring the reliability of internal and external information, which are often a source of worry and anxiety (Tomasino & Fabbro, 2015). Mindfulness may help in navigating the differences between perceived thought and reality and lead to a decrease in negative emotional clinical symptoms.

People who stutter may experience negativity as their mind generates perceived thoughts about their stuttering. Clinicians involved in the treatment of stuttering have to take into account emotional regulation and perception of thought in both their assessment and treatment of stuttering (Craig & Tran, 2013). By recognizing that thought is just a figment of reality, people who stutter may improve their overall perception of their stutter and thus improve their overall emotional regulation. For this reason, mindfulness should be considered as treatment strategy for adults who stutter because of the emphasis on improved emotional regulation and perception of thought related to stuttering.

Acceptance

Acceptance is being open to the present experience, whether the experience is good, bad, or neutral. Acceptance is the opposite of avoidance, escape or suppression of symptoms. Instead of reprimand for letting the mind wander during mindfulness practice, a person is expected to accept the unwanted thought and bring the mind back to the present without any self-criticism. Avoidance, suppression, and escape can result in higher levels of anxiety and unpleasant experiences (Boyle, 2011). In contrast, positive psychological well-being is expected to result from being mindful and accepting of experiences.

Anxiety related to suppression and avoidance of stuttering are negative prognostic indicators for stuttering management and quality of life of people who stutter (Boyle, 2015). Increased anxiety in people who stutter can overload the capacity of the speech motor system and thus disrupt functioning (Craig & Tran, 2014). Those who internalize stigma and apply stigmatizing attitudes to themselves experience lower levels of psychological well-being. However, many people who stutter are resilient and can buffer self-esteem, self-efficacy, and life satisfaction even in the face of public stigma (Boyle, 2012). Professionals emphasize the importance of acceptance in stuttering management, as avoiding stuttering instances can exacerbate stuttering. Incorporating both intentional acceptance and self-regulation into mindfulness practice can lead to meaningful psychological and quality of life changes for people who stutter.

Source: Mindfulness Training for Adults Who Stutter An Overview for Speech-Language Pathologists