Cognitive-Behavioral Therapy - a Remedy for Chronic Stuttering - Coursework Example

Reflective Social Work Practice Introduction Social anxiety is a major problem among nonclinical and clinical groups; still it has not been given adequate consideration in the literature (Bothe 2004). Cognitive-behavioral therapy, as found out by a number of studies, is a helpful treatment of social anxiety for adolescents and adults, demonstrating encouraging outcomes on self-report assessment of generalized and specific psychological disorder and on behavioral assessment of performance (McKay & Storch 2009). Cognitive-behavioral scholars assume that the solution to easing social phobias is a reform in the thought patterns of patients, shown in the content and manner of their speech (Yaruss, Quesal, & Murphy 2002). Ahmed, a 13-year old student and the focus of my case, suffers from chronic stuttering due to untreated social fear. He shows difficulty in speaking whenever he is in front of other people; particularly those whom he knows have authority over him. Hence, the objective of this reflective paper is to narrate and discuss the essential practice issues and challenges that are involved in my social work experience with Ahmed. First, the essay will explain my rationale for choosing cognitive-behavioral theory as a model for the treatment of chronic stuttering. Second, I will narrate the challenges of social work in Saudi Arabia, particularly with regard to working with women and families. And lastly, I will reflect on my own strengths and weaknesses as a social worker based on my experience with Ahmed. Cognitive-Behavioral Therapy: A Remedy for Chronic Stuttering In principles, in cognitive-behavioral therapies, the manner and content of patients’ speech should manifest reforms in their cognitive processing of their core problem (Bothe 2004). Stein, Baird, and Walker (1996) propose that individuals who have social anxiety and stutter would gain from cognitive-behavior therapy (CBT) sessions for social phobia. They described subjective substantiation of this in three subjects within their group who allegedly encountered declines in avoidance, social phobia, and general disability throughout a 3-month CBT program (Stein et al. 1996). Moreover, a statement of a speech restructuring treatment course subjectively revealed the favorable outcomes of employing CBT processes along with speech restructuring therapy. Blood (1995 as cited in Onslow, Packman, Block, Menzies, O’Brian, & St. Clare 2008) merged a computer-assisted biofeedback system for easing stuttering with a relapse management course founded on the self-efficacy model of Bandura, CBT, and the relapse prevention model of Donovan and Marlatt (1980 as cited in Onslow et al. 2008). The relapse package of Blood (1995 as cited in Onslow et al. 2008) is composed of the following parts: ‘(a) problem solving, (b) cognitive restructuring/reframing, and (c) nondirective supportive counseling’ (p. 3) Four male individuals participated in the experiment, with a ‘multiple-baseline, across subjects’ (Onslow et al. 2008: 3) framework. All four subjects exhibited substantial and steady drops in stuttering throughout the trial, and these improvements were sustained at one year follow-up. Inopportunely, the study’s design does not permit identification of the relative inputs of the psychological therapy and speech restructuring course. No participants were given either therapy module individually (Onslow et al. 2008). Comparable design concerns obscure Maxwell’s (1982 as cited in Onslow et al. 2008) findings. As in the investigation of Blood (1995 as cited in Onslow et al. 2008), Maxwell fused psychological therapy elements with speech therapy components involving ‘(a) targeting negative cognitive appraisals, (b) thought stopping, and (c) vicarious observation to encourage optimistic attitudes such as “Others have made significant gains in this program, and I can, too”’ (Onslow et al. 2008: 4). Further, Maxwell stated that a cluster of adults who stuttered exhibited substantial improvements on Riley’s Stuttering Severity Instrument. Inopportunely, as in the investigation of Blood, the design of Maxwell does not permit current researchers to determine the relative inputs of the CBT and speech elements (Onslow et al. 2008). Further endorsement of anxiolytic experiment in stuttering stems from earlier findings on the effectiveness of methodical desensitization in stuttering (McKay & Storch 2009). Presently regarded a rather extensive procedure with a pointless stress on relaxation program, methodical desensitization has been linked to clinician-observed and self-reported declines in stuttering as quickly as 10 hours (McKay & Storch 2009). The systematic desensitization programs employed in these investigations were pure phobia therapies in the sense that no effort was exerted to modify speech patterns at all (Bothe 2004). These findings indicate that targeting phobia itself may result in decreases in stuttering, not only declines in social anxieties. It is apparent that individuals who stutter and their clinicians identify a connection between anxiety and stuttering (Bothe 2004). A recent research work in Australia interviewed 300 stuttering adults and 300 speech-language pathologists (Lincoln, Onslow, Lewis & Wilson1996). The results showed that 97% of the speech-language pathologists and 87% of the stuttering participants thought that anxiety is a component of the disorder (Lincoln et al. 1996: 76). In spite of the lack of formal anxiety management education, 65% of the speech-language pathologists who remedied stuttering stated that they often employed some form of anxiety management techniques with individuals who stutter (p. 76-78). This seems to be the case all over the world, with Yaruss and colleagues (2002) report of treatment experiences stated by constituents of the United States National Stuttering Association. 56% of the participants described that their therapy involved “reducing the fear of stuttering or of speaking situations” (Yaruss et al. 2002: 120). Therapies that integrate alternatives of speech restructuring generally integrate processes for cognitive and behavioral management of phobia (Boberg & Kully 1994). Yet, until now, there is no evidence to confirm the effectiveness of such programs. Generally, there are three convincing explanations to rationalize an investigation of the effectiveness of current anxiolytic CBT procedures in treating individuals who stutter (Onslow et al. 2008): (1) the literature points to a relation between stuttering and anxiety; (2) social phobia is a common comorbidity with stuttering; and (3) anxiolytic methods are widely used to treat stuttering, but without any supporting data or formal treatment procedures derived from contemporary CBT treatment for social phobia (p. 5). The objectives of my social work with Ahmed, therefore, were to investigate the outcomes of cognitive-behavioral treatment on anxiety-related stuttering; and find out whether CBT therapy, independently or in combination with progressive immunization and desensitization lessens the severity of stuttering in people with social anxiety. The Challenges of Social Work in Saudi Arabia Social work researchers and related disciplines have discriminated among the skills and knowledge required to deal with the racial and ethnic diversity of population who may require social and mental health services. Yet, much remains unexplored, as multicultural social work is a diverse and complex experience. Furthermore, numerous ethnic populations, such as Arab groups, have not received equal interest from researchers and scholars (Tripodi 2006). Still, social workers in Saudi Arabia face considerable challenges, particularly in relation to working with women and families. Primarily, mental health and social services can be stigmatizing, especially for women. Arab clients find psychological and psychiatric treatments and family and marital interventions stigmatizing (Savaya 1995). The stigma of mental health and social services could hurt their marital opportunities, raise the possibility of separation, or, particularly among Muslims, be taken advantage by a husband as influence for acquiring another wife (Savaya 1995). Stigma may be prevented or lessened by incorporating mental health and social services into non-stigmatizing contexts or physical environment, such as general medical centers (Tripodi 2006). Cultural stereotypes concerning gender can make the helping relationship difficult. Arab men may find it difficult to accept or understand the directions of a female social worker (Al-Krenawi & Graham 2000). When this difficulty arises, it does not occur automatically from the male client only but could occur from a male relative or family member who has authority such as a father, older brother, or any senior male family member (Al-Krenawi & Graham 2000). Jalali (1982) stated that, of Iranian families, “the patriarchal organization of the family is to be acknowledged by addressing fathers first and as the head of the family. The social worker should not attempt to change cultural power hierarchies or role patterns since this will alienate the family” (p. 208). An opposite-sex helping relationship is difficult and may be unworkable. However, even if a favorable relationship is developed and the client recognizes the professional social work process, s/he may eventually feel attached and open up, which results in misunderstanding or conflict (Beckett & Maynard 2005). Every effort should be exerted to inform the client about the appropriateness or essence of the attachment, and guarantee should be given that the relationship is safeguarded by professional guidelines (Beckett & Maynard 2005). Similarly, a ‘female-male social worker-client’ (Al-Krenawi & Graham 2000: 4) relationship is effectively performed with culturally appropriate methods such as addressing the client ‘my sister,’ keeping prescribed physical distances between worker and client and minimal eye contact, and engaging the family in most, if not all, phases of therapy (Al-Krenawi & Graham 2000). Cultural differences between the Western society and ethnic Arab societies also are depicted in the character of interpersonal relations. It is quite difficult for the Arab client to recognize the prescribed distance between client and worker that is the standard in current helping cases, and perhaps the worker will have to deviate from the standards (Tripodi 2006). For the traditional Arab, it is more essential to develop a relationship than to resolve a dilemma. Relationships are developed through the Arab notion of confidence or trust (Tripodi 2006). A helping rapport can be built and sustained if clients trust the social workers (Durst 1994). In cases where the social worker and the client are of the same sex, the former should bear in mind the client’s need for show of familiarity and occasionally loosen the rigidity or formality that is the principle in Western social work (Beckett & Maynard 2005). In contrast, when the client and the social worker are of the opposite sex, the latter should keep even larger distance than usual, for risk of raising sexual indecency. Minimal eye contact may take place consequently and should not be seen as a resistance of the client to treatment (Beckett & Maynard 2005). In contrast to a Western therapeutic focus on the individual, every intervention with traditional Arab clients has to be anchored in the framework of the extended family, tribal background, or community (Al-Krenawi & Graham 2000). Contemporary talking therapy is a continuation of the growth of individualism, cultivated by democracy’s liberal political context. It represents the person as a self-sufficient body whose values, opinions, rights, and needs should be taken into consideration (Tripodi 2006). Apparently, the concept of ‘self-realization’ has been a major academic and therapeutic objective for many years (Fukuyama & Heath 1989 as cited in Al-Krenawi & Graham 2000). As a number of academics have emphasized, one of the most vital areas of intracultural diversity is whether a culture is collectivist or individualist (Al-Krenawi & Graham 2000). In Western individualist cultures, throughout the course of improvement people experience a major psychological separation from their significant others, such as their parents, and as a central component of this mechanism, they develop a distinctive and independent identity (McKay & Storch 2009). An identical course of individual development does not arise equally in collectivist culture in the Middle East. Nor does it among ethnic Arab populations, where the family or group identity remains the focal point and the person rooted in the collective identity (Savaya 1995). The engagement of the family in individual helping relationship is substantial, and frequently makes the task of the social worker more difficult. The family unit is highly respected among Arab individuals, who are raised to rely on their family as a constant source of assistance or support (Al-Krenawi & Graham 2000). Highly valued as well are extended family members. They are expected to participate and are conferred with in times of crisis. As stated by Meleis and La Fever (1984), even though Arabs “value privacy and guard it vehemently… their personal privacy within the family is virtually non-existent… Decisions regarding health care is made by the family group and are not the responsibility of the individual” (p. 76). In a number of instances the family will take part for the identified client or patient, even though they also lack in trust, while they anticipate much (Meleis & La Fever 1984). For instance, they may attempt to manipulate the interview by responding to the questions addressed to the patient while they refuse to give information that may be seen as humiliating. The involvement of family members simply can be encountered as pride or self-importance, bordering on rudeness, when they take action as authorities on issues that concern the social worker’s specialty (Beckett & Maynard 2005). These cultural conceptions of family can be favorably exploited by social worker’s eagerness to recognize the involvement so distinctive of Arab families, the informing themselves about Arab family ideals and ethics in order for them to considerately inform the family about the needed condition for an effective helping relationship. Professionals working with Arab people by obligation will interact with the family and have to reassess what may otherwise be perceived as overprotection, excessive involvement, or obvious codependency of the Arab family (Beckett & Maynard 2005). In fact, these attributes possibly will be very suitable in a culture where any less engagement would be regarded abandonment if not avoidance. If the cultural disparity is too immense, inviting a cultural specialist, a member of the culture who can act as a go-between between the social workers and the family, may be worthwhile. The selected specialist may be connected with the mental health department, another department, or may be a community member, but in all cases, s/he would have to be considered qualified by the family (Meleis & La Fever 1984). The specialist, in turn, “translates for the staff the symbolic meanings of behavior and action, and clarifies cultural properties, can be invaluable to treatment planning, and a key factor in staff acceptance of the patient” (Meleis & La Fever 1984: 85). To sum up, as a developing body of interdisciplinary research demonstrates, there are a number of vital features of mental health and social service practice with Arab people. These involve taking into consideration gender differences and relations, and the place of the individual in their communities and families. Such attributes provide the foundation for certain strategies in working with Arab clients or families: a focus on oriented, short-term therapy; communication or interaction patterns that are casual and passive (Tripodi 2006); and, where necessary, the combination of traditional and modern healing techniques. Self-Reflection We live in an age when social and mental health services have been ever more inadequate for numerous people. A lot of circumstances that are shown in our societies nowadays are increasingly persuading me, aiding me in my realization that mental health workers are important, are important healthcare practitioners, and will always be needed and in demand in the future. Social and mental health workers are in the appropriate position to develop in the understanding or recognition of social and mental health and to better understand the care practices and concepts that strengthen, cultivate, and safeguard the mental and social well-being of individuals and families. Social and mental health work can be a quite daunting task and as an experienced social worker, I have high regard for the abilities and dedication professional social workers give. There are numerous attributes that a professional social worker should possess. In my opinion, I think that I have already cultivated a number of these attributes given the time that I have spent working with various clients, such as Ahmed. To demonstrate my abilities, I will summarize in the following discussion the qualities that I have enhanced as well as how I have used them in my work with Ahmed. A professional social worker should espouse a quality of social and mental health practice. The social worker thoroughly improves the efficacy and quality of nursing practice. As a social worker myself, I have shown quality with my more with Ahmed by recording the use of mental health practice, such as the application of positive reinforcement in the therapy, in a responsible and ethical way. I also exercised creativity and originality in social work practice in order to enhance the effectiveness of CBT treatment for chronic stuttering. When I feel that the targeted results of quality are not attained, I begin to prepare that I should integrate new ideas or knowledge to set off the favorable changes that are required in the social and mental health services. Still, I have also reflected that the effectiveness of health care or of mental health care service for that matter also lies on other factors, such as cultural differences. I tried as much as possible to engage Ahmed’s family in the treatment process. In terms of education, I know that I still have a great deal to learn. This is one domain where I think I need further improvement. I still require more education to be capable of performing my function as a social worker. I, for my part, believe that even when I become a professional social worker, I still have to constantly study and learn. It is a prerequisite that a professional social worker should gain knowledge and proficiency that would demonstrate the most effective current social and mental health work practice. As a social worker, I have maintained a caring and empathic relationship with Ahmed, his family, friends, teachers, and community. Thereby, I am capable of improving my own professional social work practice and performance. In terms of the care Ahmed, I cooperated with him, his family, and others in the carrying out of the treatment and performance of my social work practice. Personally, I believe I have accomplished this during my apprenticeship. I stay in touch with Ahmed, his family, and other health care specialists concerning the treatment of Ahmed and my role in the delivery of that care. Hence I worked with Ahmed, his family, or other health care practitioners in developing a documented plan oriented on decisions and outcomes associated to care and provision of services needed by Ahmed. A professional social worker should also take into account factors in the use of resources that are connected to effectiveness, safety, cost and effect on the preparation and provision of social and mental health services. As a student worker, I was given the chance to assess aspects such as effectiveness, safety, efficiencies, costs and benefits, and effect on practice when I prefer practice alternatives that would lead to the targeted outcome. In addition, I was able to allocate and assign responsibilities which I anchor on the requirements and situation of Ahmed, risk of harm, stability of Ahmed’s condition, difficulty of the undertaking, and the certainty of the outcome. As a professional social worker, I was also able to help Ahmed and his family in becoming educated individuals about the alternatives, risks, costs and benefits of care and treatment in relation to illness, social and mental well-being. References Al-Krenawi, A. & Graham, J.R. (2000) Culturally sensitive social work practice with arab clients in mental health settings, National Association of Social Workers . Beckett, C. & Maynard, A. (2005) Values and Ethics in Social Work: An Introduction, London: Sage Publications Ltd. Boberg, E. & Kully, D. (1994) Long-term results of an intensive treatment program for adults and adolescents who stutter, Journal of Speech and Hearing Research , 1050-1059. Bothe, A. K. (Ed.) (2004) Evidence-Based Treatment of Stuttering: Empirical Bases and Clinical Applications, Mahwah, New Jersey: Psychology Press. Durst, D. (1994) Understanding the client-social worker relationship in a multicultural setting: Implications for practice, Journal of Multicultural Social Work , 29-42. Jalali, B. (1982) Irania families, In M. McGoldrick, J. Pearce & J. Giordano (eds) Ethnicity and family therapy (pp. 288-309), New York: Guilford Press. Lincoln, Onslow, Lewis, & Wilson (1996) A clinical trial of an operant treatment for school-age stuttering children, AJSLP , 73-85. McKay, D. & Storch, E.A. (eds) (2009) Cognitive Behavior Therapy for Children: Treating Complex and Refractory Cases, New York: Springer Publishing Company. Meleis, A. & La Fever, C. (1984) The Arab American and psychiatric care, Perspectives in Psychiatric Care , 72-86. Onslow, M., Packman, A., Block, S., Menzies, R.G., O'Brian, S. & St. Clare, T. (2008) An Experimental Clinical Trial of a Cognitive-Behavior Therapy Package for Chronic Stuttering, Journal of Speech, Language & Hearing Research . Savaya, R. (1995) Attitudes towards family and marital counselling among Israeli Arab women, Journal of Social Service Research , 35-51. Stein, M.B., Baird, A. & Walker, J.R. (1996) Social phobia in adults with stuttering, American Journal of Psychiatry , 278-280. Tripodi, T. (2006) International Social Work Research: Issues and Prospects, New York: Oxford University Press . Yaruss, J.S., Quesal, R.W., & Murphy, B. (2002) National Stuttering Association members' opinions about stuttering, Jounral of Fluency Disorders , 227-242. Read More