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Speech and Language Therapy today

by Maria Farry(more info)

listed in sound and music, originally published in issue 31 - August 1998

What is Speech and Language Therapy?

Speech and Language Therapy is the process of enabling people to communicate to the best of their ability. A speech and language therapist will assess, diagnose and treat a variety of clinical and other communication difficulties. (See Table 1)

Table 1

Communication Problems may result from, inter alia:

Dysfluency    (stammering)
Voice Disorders    (weakness, hoarseness or total lack of a voice which may have an organic (physical) or psychogenic (emotional) aetiology)
Delayed or Disordered
Language Development
Dyslexia
Articulation Problems
   (difficulty pronouncing sounds and/or words)
Degenerative Disorders     (e.g. Motor Neurone Disease)
A Stroke
Physical Disability  
(e.g. deafness)

Although in law anyone may call themselves a speech and language therapist, only registered members of The Royal College of Speech and Language Therapists who have graduated and are licensed to practise by the College are entitled to show the initials Reg. MCSLT after their name and, in addition, the initials ASTIIP if they are also working independently and are a member of the Association. This shows that a therapist is a member of the Royal College, fully qualified, up to date, and following the Royal College's code of ethics.

Because the profession covers a wide spectrum of disorders, many speech and language therapists eventually specialise in one or two of the main clinical fields – e.g. dysfluency, voice, severe developmental language disorder, deafness etc. Within the profession there are clinical interest groups which form a significant part of a therapist's continuing professional development within her/his chosen speciality.

A patient may self refer directly or be referred by a GP, paediatrician, educational psychologist, psychiatrist, neurologist, ENT consultant, health visitor, special needs tutor, a school, or a hospital.

It could be said that the ability to communicate and to form relationships is man's greatest gift and is what makes life worthwhile – even, as can happen – in the absence of almost any other function.

The actor Christopher Reeve, when the full implications of his condition following a fall from a horse (he is paralysed from the neck downwards) were understood by him, has said that he seriously considered taking his own life. At that time, the only reason he did not was that his wife impressed upon him that, however appalling his injuries, he could still communicate and they still therefore had a relationship – "You are still you" she told him.

A patient suffering from a degenerative disease such as motor neurone disease would require continuous reassessment and re-educating in speaking techniques to cope with the continuous deterioration in his voice and articulation, and this might eventually include non-verbal language. In addition, advice and counselling regarding the stress of suffering such a disease, and the sense of loss regarding his ability to communicate, his role within the family, and his independence, and how to compensate for this, would be part of any speech and language therapy programme.

A communication disorder therefore, whether it has a primarily physical or a psychogenic basis, will inevitably mean an accompanying element of psychological and/or emotional distress. How can we be who we are if we cannot communicate effectively? The extent of the emotional distress suffered by a patient would depend upon various factors, including the severity of the presenting symptom, its prognosis, and whether or not the underlying aetiology of the problem is itself a psychological one.

Whatever the presenting symptom or the true cause of a communication problem, the speech and language therapist will consider it within the framework of the whole person. How we communicate is such a significant part of who we are (one might say it is who we are!) that effective therapy can only be achieved within an holistic framework. The dynamic and effective (and inspiring!) therapist will have an eclectic repertoire which may include several of the following, one or more of which may be used with an individual patient, depending upon that patient's specific needs and personality:

  • Psychotherapeutic Counselling (Personal Construct Psychotherapy, Gestalt Therapy, Jungian or Adlerian Psychotherapy, Cognitive Therapy, Brief Therapy, Family Therapy).
  • Hypnosis
  • Relaxation Techniques
  • Breathing Work
  • Drama Work
  •  Music Song and Poetry used e.g. to develop a very young child's ear for sound (with or without an actual speech "problem") for fluency, rhythm etc. all of which are important for speech.
  • Aromatherapy (this is proving very beneficial with, for example, the elderly demented patient).
  • Alexander Technique(a voice problem is a whole body problem – posture, breathing, resonance etc.).

From the first year of undergraduate training to the end of her/his career, the speech and language therapist will be employing counselling skills. Counselling skills could perhaps be said to be one of, if not the most important factor in determining the effectiveness of a therapist – over and above their qualifying skills.

As communication is so much part and parcel of who we are, it follows that a therapist must be assessing, diagnosing and treating the whole person and not merely the presenting symptom.

Traditionally, and progressively more so, there are too few speech and language therapists to serve the needs of the population who require their services. Within the NHS this means not only longer and longer waiting lists, but, inevitably, the curtailment of therapy programmes, in a vain attempt to balance the needs of the individual against the needs of the population as a whole.

The Independent Speech and Language Therapist

With, for example, a problem such as a child who has begun to stammer, it is of prime importance that parents obtain the advice of a speech and language therapist as soon as possible. Stammering invariably first manifests itself in the early years, during the time of a child's language development. How the dysfluency is managed at this absolutely crucial stage can to a very great extent determine whether or not the dysfluency persists into later childhood and even adulthood. (See Case Studies) Working independently enables a therapist to see patients at sometimes very short notice and at a time which is mutually convenient. My own schedule includes very early morning (adults or children), evenings (adults), Saturday mornings (children and parents) in addition to weekday appointments.

Therapists may also attend a school for one or two full days per week in order to be able to assess and treat children; observe them in the classroom; liaise with teaching staff (including special needs teachers) and be available to consult and advise parents at the end of the school day – perhaps about a child with severe problems in terms of social skills and the ability to mix and communicate with other children. Something ostensibly as simple as delayed articulation could mean that a child's speech is not as developed as that of his peers.

This can have implications for social development (he may be teased or ostracised by his classmates) which are potentially far more damaging than the articulation problem itself.

Working independently enables a therapist to pursue those fields which most successfully combine her/his prevailing interest and particular skills. They are free to evolve according to their own vision of the kind of therapist they wish to be. This may encompass, in addition to their qualifying skills, holistic and complementary therapies such as aromatherapy, hypnotherapy and, for example, developing a presentation skills course – something which is a natural extension of their clinical work, whilst continuing to operate within the framework of the profession's ethical standards.

What is ASTIIP?

The Association of Speech and Language Therapists in Independent Practice is the official representative and advisory body for speech and language therapists working independently. It is affiliated to the Royal College of Speech and Language Therapists and the College officially advocates that therapists who are practising independently should be members of the Association (ASTIIP).

Only therapists who are registered members of the Royal College and have practised full time for at least two years are eligible for membership to ASTIIP.

ASTIIP seeks to ensure the highest possible standards of clinical practice and professional conduct for therapists working privately. In addition to its other functions, ASTIIP deals with enquiries nationwide for those seeking referral to an independent therapist. They can be contacted on 01630 655858.

Case Studies

Karl

Karl, aged five, came to see me with his mother. His mother is German, his father is Swiss. Father's job has entailed the family moving house three times from one country to another, since Karl's birth. Three changes of home, three changes of culture and language, one change of school, loss of friends, little or no contact with his extended family. Karl is highly intelligent, tri-lingual – and has a severe stammer.

Management, for the most part, has consisted of counselling Karl's parents and working with them to try to reduce where possible the pressure Karl feels. This included their agreement to speak only English for the time being (both parents are fluent in English and have settled here) and to employ an English- speaking nanny rather than the Swedish au pair they were considering. Karl's father in particular found it extremely difficult to accept that Karl stammered and admitted that he often lost his temper with him when he did stammer. (Father himself stammered when he was very young but only on very rare occasions as an adult.) As Karl is an intelligent and mature five-year-old who is well aware that he has a problem, we were able to discuss it openly and practise speech and relaxation techniques which we managed to make into fun in addition to the serious and sometimes sad moments.

Georgina

Georgina, aged 30, came to see me with what initially presented as a very weak, sometimes hoarse or non-existent voice and extreme bodily tension. She had been referred to me by her ENT consultant, who could find no organic cause for her dysphonia, although she had consulted him on four or five occasions over the preceding twelve months, and was angry and defensive that she had been asked to see me. (The consultant had refused to see her again unless and until she had been assessed by a speech and language therapist.)

After what was, for Georgina (and to some extent also her therapist!) many very difficult sessions, we reached the point where she felt able to recognise and discuss the deep and unresolved well of anger (and therefore also guilt) and sadness she was carrying towards her parents. Her childhood had not been at all happy and she felt that her parents had always been harshly critical of her in almost every respect on the one hand (and also frequently absent) but who had also consistently professed (verbally) to love and adore her.

Therapy consisted of direct bodywork (relaxation and drama work) to free her voice at the physical level and working through her feelings about herself and her parents so as to "free her voice" at the more profound emotional level. This took almost a year and she is now due to return in three months time for a review appointment.



Speech/Language Problems

• Communication involves listening, processing what is heard, speaking, reading and writing. Problems may occur in one or more of these areas.
• 2.5 million people in the UK have a speech or language difficulty.
• 5% of children enter school with problems of speech and/or language.

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About Maria Farry

Maria Farry MCSLT LCSLT set up the Ravenscaur House Clinic (operating in London and Cumbria) in 1987, following a period of several years in the NHS. She is the founder and immediate past Chairman of ASTIIP and has been involved in many important innovations within the profession as a whole and the independent sector in particular. She lectures on the ethics of independent practice at University College London. Maria Farry can be contacted on 0171-585 0186.

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