Sunday, 29 September 2013

The Consultative Model: Advancing the Stereotype and Undermining Our Therapeutic Skills. Geraldine Wotton BscHons, DipPsychCouns.MRCSLT. ASLTIP

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.
In the last four years I have held and expressed (Wotton99: 01) a growing concern about the mass application of the more “at a distance therapeutic approaches” (Wotton99) typified by the Consultative Model. Particularly when there have been no trials assessing the efficacy of these approaches or a debate as to the impact of these approaches replacing on going one to one work conducted by a qualified speech and language therapist. I would like to take this opportunity therefore to open up the debate.

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’ĂȘtre (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.

 M. Billig (1987) Arguing and Thinking: A Rhetorical Approach to Social Psychology. Cambridge University Press

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

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