Within the last two years
there has been an increasing debate within the profession typified by the
letters in Bulletin i.e. November /December 2001 and my article ‘The Therapy
Process: Disposable or Indispensable’ (Speech and Language Therapy in Practice
Summer 1999) as to the efficacy of
- Consultative models of delivery i.e. the Therapist becoming more of an assessor providing programmes to be carried out by non speech and language therapists with interim reassessment and programme updates also undertaken by the speech and language therapist.
- Learning Support Assistants LSAs /SLT Assistants becoming primary deliverers and instigators of therapy at the coal face so to speak
As opposed to
- Ongoing one to one therapy conducted primarily by the speech and language therapist. This approach would also include elements of the above.
I believe that it is the
close up experience when working one to one that ultimately forms the bedrock
of our own professional knowledge base. Increasing this knowledge base enriches
our understanding as to the nature of the disorders we are dealing with. It
essentially provides us with the raw material from which we can derive driving
principles and begin to methodically create and test our hypothesis. There is
nothing new in this approach to therapy. The principles highlighted above are
very much embodied within the psycholinguistic approaches as advocated by
Harris and Coltheart 1986: Stackhouse and Wells 1997: Chiat et al 1997.
Commenting as to the benefits
of such a methodical approach Chiat 1997 states
‘Intervention and the patient’s
responses to it may contribute fresh insights into the difficulties which may
in turn lead to a revision of the therapy hypothesis.”
However more relevant to
arguments posed by this paper she further adds.
“The emphasis… is on
interactions: between intact and impaired levels of processing; between
observations emerging from assessments and those emerging from therapy; between
the patient and therapist. Therapy so conceived is dynamic, moving from initial
hypotheses about the sort of intervention that will facilitates the patient’s
processing, according to the patients response to that intervention”
In other words the therapy outcome is not just dependent
upon the therapist’s ability to use their skilled eyes to filter and interpret
the client’s responses and thereby to “categorise” and more importantly to
“particularise” data Billig (1987) but it is crucially intimately linked to the
proximity of the therapist to their client. It is therefore the close up
methodical search for what is going on that is in my opinion the bedrock of how
we construct our therapy on a session by session basis and how we understand
the evolving nature of the disorders we deal with.
Interpreting the raw data via
the filter system of an untrained person can therefore only blunt acquisition
of our conceptual constructs (Mcghee 01) which in turn will only further blur
our deeper understanding of the disorders we deal with.
Implicit therefore within the
underlying philosophy and process of the consultative model is a belief that
our understanding of speech and language disorders is complete and that further
understanding of them has nothing to do with what happens at a clinical level.
But most importantly and even more concerning, the reliance on the consultative
process diminishes the complex and dynamic nature of many of the disorders we work
with.
My clinical experience to
date leads me to believe that in many circumstances rather than dealing with
unitary passive disorders we are often working with a constellation of
symptoms. These are overlaid by and interface with the individual’s personality,
own hard wiring and impact of environmental factors these all contribute to the
pattern of a presenting disorder. Such a conglomeration means we are often left
uncertain as to what it is we are looking at inevitably leading us to inter
professional debates as to the ‘real nature’ of specific disorders. This point
is particularly highlighted by Trevarthern et al (1998) where they speculate
about the relationship of autism with other disorders.
“There is an increasing
recognition of a need to broaden the concept of autism both in terms of the
expectation of a higher rate of associated conditions in the members of the
extended family…This means it will not always be possible to distinguish autism
sharply from either receptive or productive language disorders.”
Therefore the autistic child may after many sessions
reveal himself to being language disordered or vv. Similarly the phonologically
disordered child may prove to be ariculatory disordered or perhaps dyslexic and
with each variation in the arising presentation requires a different approach
and emphasis.
Without this understanding
and ability to see the changing nature of the disorder which only our skills
can offer us we could end up by only pulling one end of the string. Thereby
only tightening the knot leading us to a dead end and a child whom is perceived
as untreatable; the experience of many of the children on my caseload
previously ‘treated’ via the consultative approach. The untrained eye may only
see a child going nowhere whereas a trained eye will see and understand the
developmental pattern which if tackled/seen in a different way will lead to an
ultimate unravelling.
At the heart of this is an
understanding and appreciation of working the case on an individual level.
Individualising the case presents us though with considerable professional and
personal challenges as the closer we look; the stereotypical pattern
dissipates, leaving us confronted by irregularity and contradiction. Such that
the picture emerging only vaguely maps onto the confident patterns so boldly
outlined in our textbook cases and quantitatively researched caricatures.
In Carl Jung’s illuminating
book The Undiscovered Self-1958 he states that “ The distinctive thing about
real facts however, is their individuality. Not to put too fine a point on it
one could say that the real picture consists of nothing but exceptions to the
rule and that …absolute reality has predominately the character of
irregularity”
The inherent nature of the consultative model i.e. its
delivery at a distance means therefore the therapist can only construe the client’s
needs using amassed information via
- Often quantitatively researched data, inevitably offering a reductionist regularised picture which at best offers significant signposts but tell us very little about the individualised needs of the person they are meant to be treating and
- The filter system of an untrained eye
At
the Association of Speech and Language Therapist in Independent Practice
Conference (March 2003) the Chair Woman from RCSLT Caroline Fraser outlined the
goals College had delineated to protect professional standards and competency.
Two of which were to
1. Protect therapeutic skills base and
2. Ensure service delivery is client driven
However
given the above discussion I believe if the Profession persists in using the
consultative model as a standard for service delivery it is hard to see how
these two goals can be achieved. More worrying it will become increasingly
difficult for us to argue our professional raison d’être (Wotton99) and our
inevitably weakening legitimacy.
It
is our access to and involvement with our clients, the providers of our
knowledge base that empowers us to argue coherently as to the efficacy of our
input. In turn it is our input at this level that will ensure that the clients’
individual needs will always drive the process and thereby mean that we will
ultimately meet those needs far more effectively.
References
M. Billig (1987)
Arguing and Thinking: A Rhetorical Approach to Social Psychology. Cambridge
University Press
M.Harris & Max
Coltheart (1986) Language Processing in Children and Adults. Routledge &
Kegan Paul
Jung C. (1958) The
Undiscovered Self. Routledge
P. Mcghee (2001)
Thinking Psychologically. Palgrave
C. Trevarthen et al
(1998) Children with Autism: Diagnosis and Interventions to Meet Their Needs
Routledge & Kegan
Paul
J Stackhouse & B
Wells (1997) Children’s Speech and Literacy Difficulties: A psycholinguistic
framework. Whurr Publishers
Wotton. G. (1999) The
therapy process: disposable or indispensable Speech and Language Therapy in
Practice. Summer Edition
Wotton. G. (2001)
Letter to Bulletin. December Edition
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