Monday, 15 April 2013


In the 23 years of my clinical practise I have never ceased to be amazed by the progress our clients can make despite their initial prognosis and I have become increasingly convinced that the therapeutic relationship is critical to this.

It is my ambition to develop a greater understanding of this and in turn to put the therapeutic relationship back on the map, as a professional necessity not nicety.

In a recently published book by Robert Fourie Therapeutic Processes for Communication Disorders 2011 he and his co authors, compel us to renew our understanding of the importance of the therapeutic relationship, as integral to our work.

The idea of recognising the necessity to nurture the therapeutic relationship is nothing new though. In the days of my training and early practise it was regarded as critical to the furtherance of our work.

Shula Chiat in 1997 stated

  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”

However such determined advancement of the therapeutic relationship as a vital part of our work, is in stark contrast to the current practise of many SLT’s, particularly those of us who work within the NHS, many of whom rarely see their clients.

This is, in my opinion, the negative heritage of the sole use of the scientific model as a methodology to provide us with professional credibility.

In the early 90s the scientific model took a foothold as the main and only means of legitimately researching our work. Unfortunately in attempt to become methodologically clean, the relationship has been airbrushed out.

It seems to me that the subsequent devaluing of the relationship with our clients in albeit in a legitimate attempt to tighten up our act, has however, left us professionally vulnerable and far less certain about our work.

The human face of our work has virtually disappeared and therein we have lost sight of the real power house of change.

Rupert Sheldrake in his inspiring book The Science Delusion published 2012 discusses the immense power of the placebo effect on healing

“Placebo responses show that health and sickness are not just a matter of physics and chemistry. They also depend on hopes meanings and beliefs. Placebo responses are an integral part of healing” Sheldrake 2012.

The placebo we bring to our clients is the knowledge and experience we have accumulated over the years, which reassures and brings hope and the sense that they, the client, are in our good hands.

The therapeutic relationship is though more than a cradle of human comfort. It is through this crucible of human connection that we deepen our understanding of our client’s needs and advance our therapeutic efficacy. Those of us who work closely with our clients know very well that the relationship is the birthplace of our intervention. The intimacy of our interaction with our clients enables us to accumulate more and more information, from which a picture emerges and it is upon this we develop our insights and our therapeutic intervention.

However those of us who work closely with our clients, also recognise that the insights that ignite life into our work, are arrived at not just through the outcomes of the manual labour of our tests and assessments, but also through the volume of information we ‘pick up’ unconsciously as we work alongside our clients.  It is this emergent intuitive aspect of the relationship that is recognised as the real source of change and insight.

The power of this innate human ability for what is now regarded as ‘unconscious rapid cognition’ or ‘thin slicing’ is beautifully described by Malcolm Gladwell in his book Blink 2006.

“The notion of an ‘adaptive subconscious’, is thought of as a giant computer that quickly and quietly processes a lot of data we need in order to function as human beings” Gladwell 2006

The resultant ‘gut feeling experience’ he argues can be, contrary to conventional thinking, more reliable than information we consciously filter and it is this skill that enables us to get nearer to that, which remains unknown to us.

It seems to me that being able to utilise these subconscious levels of understanding doesn’t just provide another way of exploring the clients internal processing, but facilitates an  opening up between therapist and client through which we experience intuitive leaps.

Intuitive leaps are without question the recognised touchstone of human creativity and discovery. It is through these leaps of intuition that we advance a deeper understanding of our work and as a result more meaningfully develop our therapeutic interventions.

Astonishingly though, the notion of intuition remains, within our profession at least, either ignored or perceived to be of interest only to the vague and woolly minded.  The unbelievable foolishness of hanging on to such ideological position can more be properly appreciated when you cast a look around at the great thinkers of our time, many of whom understood only too well, the immense value of our ability as humans to access our intuitive mind.

“The intuitive mind is a sacred gift and the rational mind is a faithful servant. We have created a society that honours the servant and has forgotten the gift”. Albert Einstein

In view of this I believe it is critical we recognise the gift and the power of the therapeutic relationship as the touchstone of our work.

And more to the point I believe if we continue to ignore its importance, we do so at our professional peril.

S.Chiat, J Law, & J Marshall (1997) Language Disorders in Children  and Adults. Whurr Publishers

The Consultative Model: Advancing the Stereotype and Undermining Our Therapeutic Skills  GeraldineWotton 2003

 The Science Delusion Rupert Sheldrake 2012
 Blink Malcom Gladwell 2006

 Presentation made at Association for SLT in Independent Practitioners Conference March 2013
Author Geraldine Wotton- People are free to use this material from this article as long as you credit the author

Wednesday, 3 April 2013

Why Speech&Language Therapy ?: Speech and Language Therapy: A great profession.. ...

Why Speech&Language Therapy ?: Speech and Language Therapy: A great profession.. ...:  I absolutely love my job. It is so satisfying to see the dramatic changes one can bring about even with the most disabled of our clien...

Speech and Language Therapy: A great profession.. In danger of extinction ?

 I absolutely love my job. It is so satisfying to see the dramatic changes one can bring about even with the most disabled of our client group. It is an honour to be part of a process that can significantly change the lives of the individuals I work with and have a huge impact on those around them. My passion for my work has not dimmed since my early days as a “rooky” therapist within the sobering environment of Horton Hospital and the  old, but no longer existing  ‘asylum’ in Surrey.  I know that many of my colleagues share my huge enthusiasm about the work we do, which is why so many of us continue to fight to stay within the Profession we love, despite the challenges we, like so many of our peers within the Health Services, currently face.

Speech and Language Therapists work with a huge variety of people with speech, language and communication impairments, from birth to senescence.  We are found within Health Centres, Hospitals, GP Surgeries, Schools and Nurseries. In addition to the work we undertake within the arena of speech language and communication, our in-depth knowledge of the neuro musculature of the head and neck has equipped us to play a key role in the assessment and treatment of swallowing and eating disorders.

The sheer number and variety of the disorders that fall within our remit give many of us the opportunity to develop expertise in our own area of special interest and despite the apparent unitary nature of these impairments e.g. Dysphasia or Down Syndrome, each individual person we work with presents a different and therefore unique challenge. There is, in short, no such thing as a text book case.

It goes without saying therefore that we are a bright lot who are put through our paces during the jam packed and gruelling 4 year degree course that equips us to take on the huge task we face in our clinics. We cover in considerable depth linguistics, psychology, statistics, audiology, neurology and anatomy, as well as the voluminous array of disorders we are likely to meet within our clinics. On top of this we are developing our practical skills as therapists within placements and assessed regularly as to our clinical as well as our academic competence.

The important message for me to get across is that speech and language therapy can and does produce significant and measurable change to the speech and language of those we work with. Given that we are still such a young profession, established only after the war in 1945, we have made incredible progress in understanding our discipline as well as in articulating and mapping interventions.

 Never has there been a more exciting time to work as a therapist, as more and more is being understood about the plasticity of the mind and the ground breaking opportunities this could provide to those of us at the clinical “coal face”.  Goodness knows what frontiers will be advanced as a result in the future which may enable us to work much faster and even more effectively with our client.

Critical to this development though is our continued therapeutic contact with our clients. However the increasing reality for many of my NHS colleagues, is that the opportunities for such direct work are becoming fewer and fewer. Many therapists have, because of this, opted for independent practice where they can continue practising and developing their therapeutic skills. This whittling away at our opportunities to work directly with our clients poses a major threat to our profession and many of us are extremely concerned that we may not survive as an independent discipline if this continues.

 The financial shortfall within the NHS is given as a legitimate reason for such reduction in our service provision. Yet in one fell swoop, such a proposition doesn’t just demonstrate a serious failure to recognise the vital value of our work, but shows a complete lack of understanding as to the devastating human and financial costs that will inevitably result because of the failure to provide our service.

In 2009 the Royal College of Speech and Language Therapists produced a paper ” Locked out and Locked up: Communication is the Key”. In this they highlight the incidence of speech and language disorders amongst the prison population, focusing on those within Young Offenders Institutes, of which 60% have some recognised communication and/or language disorder. In this they state:
“There is a strong correlation between poor education s, particularly those of literacy skills and subsequent criminal behaviour. Improving literacy and social skills is essential to reduce re-offending (Snow and Powell, 2004) ....A third of children with speech and language difficulties develop mental health problems, often resulting in criminal involvement”

In 2010 a paper published by the Prince’s Trust and RBS suggested that the result of an increasing prison population amongst juveniles was costing our nation £1.2 billion per annum.

It is clear to me, that the decision to cut our service has less to do with the lack of money within the Treasury Coffers and more to do with a lack of understanding as to the nature and wider importance of our work. This maybe a failure on our part and one that is perhaps due to the lack of professional maturity and confidence, which under the normal course of events would come with time and age,  as we evolve and develop our ideas and our practice.

Time is sadly not on our side at present. However I believe we can survive, but we have to show far more ferocity in our self belief and not shy away from presenting our case, because what we have to contribute is vital and so much is at stake if we do not.