Safety Behaviours and Speech Treatment for AWS
Could you please comment on recent research (Helgadottir et al. JSLHR 2014) that confirms that many SLPs working with those who stutter may be using safety behaviors as a means of managing social anxiety, and this could be having the effect of sustaining social anxiety. Many of the safety behaviors identified by clinicians were widely recommended by SLPs working with those who stutter as a means to manage anxiety. Examples included “encourage the listener to speak more by asking questions”, “let partner do the talking”, “try not to draw attention to yourself”. All of these strategies are of course ultimately unhelpful as they encourage the maintenance of threat belief.
Given it is the social anxiety that most compromises quality of life, would any of the experts NOT support calls for both a greater awareness of the possibility of Social Anxiety Disorder existing with stuttering and the use by SLPs of a screen (eg LSAS or SPIN) for Social Anxiety Disorder in their stuttering clients.
Regards to all,
Mark Irwin
Dear Mark,
I would apply caution in the interpretation of these findings. First, data was gathered from 160 SLP’s in Australia and is thus not a representative sample. This is basically a pilot study. Second, when you look at their data the majority of these 160 SLPs never or almost never recommend “safety behaviors”. They do highlight that at least 1 SLP does for each instance; however, without a larger controlled study that is not consequential (alarming that even one would, yes absolutely). In response to your second question, we still do not have a very clear understanding regarding whether stuttering is associated with a general social anxiety disorder (again, it is true for some, but that can not or should not be generalized to all PWS without conclusive evidence), or restricted to speech anxiety (learned). I do believe many SLPs already account for the anxiety within their therapy methods. Not many might conduct comprehensive tests or screenings of Social Anxiety Disorder (which would also be outside an SLPs scope of practice) but many of the more traditional stuttering modification methods do account for anxiety and apply principles from CBT as well as ACT (more recently).
Dear Farzan,
Thanks for your reply.
I do take your point regarding exercising caution. However the results do show of the 160 SLPs that “81% had recommended the use of safe speaking partners in socially threatening situations” and that , “51% of SLPs surveyed had even recommended avoiding unnecessary talking as a means of controlling anxiety”. I feel these results are significant enough to at least warrant a further investigation into this potential problem. Do you agree?
To be clear, I’m not suggesting SLPs recommend safety behaviours intentionally, only that some of their treatments may inadvertently be taken on as safety behaviours during the therapy process, and that – in alleviating speech-related anxiety – these treatments circumvent the root of the anxiety and only give the patient a security blanket to which they must constantly hang on.
You say that not many SLPs conduct screening of Social Anxiety Disorder because this would be outside their scope of practice. Presumably then it is outside their scope of practice to treat it? I personally would love to see additional training be offered to SLPs so that it would be formally within their scope. Do you agree that the promotion of a SAD screen would bring greater awareness of the safety behaviour issue, and allow SLPs to determine whether psychological referral is appropriate? (all of course to the potential benefit of AWS)
Regards, Mark
Mark,
Great points and thank you for the question and dialogue. I guess what I mean by exercising caution is not related only to the number of SLPs in the survey and their geographic restriction, but also caution to be applied in the interpretation of their responses on a survey, especially since the SLPs do not have an opportunity to explain their responses. For e.g. were these behaviors recommended as part of a situational hierarchy? If yes, it makes sense – if that was a general recommendation before dismissal from therapy then it is very concerning. So, I completely agree with you, more research using a variety of methods is warranted. This also in a sense demonstrates the need for more directly targeting feared speaking situations as is done with stuttering modification and CBT approaches, rather than focusing only on fluency (shaping) during therapy; which **might** lead a client to believe that fluency is important irrespective of how it is achieved. Lastly, I would personally tread general social anxiety with caution, since that is not my training. As part of stuttering therapy we are trained to work on speech situation hierarchies and desensitization to stuttering and listener reactions – that is where I would draw the “professional line” and refer a person out if they have a general social anxiety. Answer to your last question is also yes. Much more research is needed in what we do in therapy as well as how we train the next generation of SLPs. Excellent questions and thoughts, Mark, very thought provoking.
Regards,
Farzan
Farzan, I agree with the need to determine the explanation for the responses as you mentioned. And I also agree with your statement on fluency shaping therapy potentially achieving its result (fluency) at the expense of maintenance of anxiety. Obviously the professional approach would be to do as you suggest and refer out when Social Anxiety Disorder was present. (As you would be aware many AWS are blocked beyond speech having significant fears in such activities as use of public restrooms, and eating in public. Blumgart 2010) My question would be how could you determine this if you did not use a screen? In other words, and further to your kind remarks on my thought provoking questions, would you now support a call for the use of a SAD screen? And may I add, if not why not?
Regards, Mark
Hi Mark, I can only speak for myself honestly. My clinical work is limited to working with clients who attend the intensive program I offer at my University. In therapy, we first talk to the client and get to know them really well, so usually additional (non-speech/stuttering related fears) are revealed then. If not during the initial interview and discussion our therapy involved a healthy mix of speech restructuring with stuttering modification and CBT or ACT (depending on the individual) which involves a lot of activities outside the therapy room. We do rely on our own observations as well as our discussions with our clients. Now off course not every clinician in every setting might have that luxury and a tool such as the SAD would be a very good option for them (and for me when supervising clients who do not attend the intensive but just come in for a single diagnostic session). The point you raise is definitely concerning and of great interest to me, even in light of consistent findings of elevated state and trait anxiety levels in PWS compared to matched controls.
Regards,
Farzan