Category Archives: Students

Supervision keeps us awake!

I have been fortunate in my career to have some really excellent supervision, but all too often I hear from colleagues that the service they work in does not offer quality supervision. I regularly hear that for many it becomes a tick box managerial function, concentrating more on the doing of therapy rather than the being or becoming a therapist. Yes, we need to have time to check on whether we are using the right procedures, we need affirmation that we are abiding by the right policies, but this should not form the main focus of supervision sessions. I have found it helpful when supervising colleagues to devote some time in each session to the doing, i.e. the day-to-day activities of the job, but to ensure that there is enough time to talk about the being and becoming, i.e. to explore our emotional and psychological responses to our work and how the work is affecting us. Geller in Fourie (2011) rightly says that “attention to the affective and intersubjective aspects of clinical relationships has been neglected in speech-language pathology” (p. 197).

We encourage students at the Universities at Medway programme to use reflection from day 1 to explore their feelings about their experiences in becoming a therapist. We need time to explore our emotional responses and reflective writing offers a chance to do this. In professional contexts we could learn so much from colleagues in psychology about issues related to transference and countertransference. One particularly useful session I recall was where I was encouraged by an experienced supervisor to unpack the feelings that had been aroused by working with a family where there were bereavement issues, which in turn had awoken emotional responses in myself. This allowed me a safe space to reflect on my role with this family and to make me more aware of my own responses.

Nicky Weld’s book on transformative supervision for the helping professions has been very influential for me. She points to a fear of people having emotion-based conversations in supervision for fear of not being able to manage what comes forward. This lack of acknowledgement of our emotional responses can ultimately lead to a risk of burnout. In the context of ever-reducing funding, I would urge colleagues to ensure that quality supervision is provided and that time is made to attend to creating, through supervision, a safe, protected environment for learning, personal and professional development without which we will stop growing. Ryan (2004) says of supervision: “It wakes us up to what we are doing. When we are alive to what we are doing we wake up to what is, instead of falling asleep in the comfort stories of our clinical routines” (p.44). Let us stay awake and not fall asleep on the job by falling back into familiar routines. Supervision can help us unpack received wisdom.

photo-feb-2016

 

Jane Stokes
Senior Lecturer, Speech and Language Therapy
Faculty of Education and Health
University of Greenwich

 

 

 

 

See further reading:

Geller E. (2011) Using oneself as a vehicle for change in relational and reflective practice. in R. Fourie (ed) Therapeutic Process for Communication Disorders. Hove: Psychology Press, 9.195-212.

Ryan S. (2004) Vital Practice. Portland UK: Sea Change Publications

Weld N. (2012) A Practical Guide to Transformative Supervision for the Helping Professions; Amplifying Insight. London: Jessica Kingsley

Stammering activism and speech and language therapy: an inside view

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This month Sam is guest blogger for the Did I Stutter? Project – you may read her blog here

Power, professionals, privilege and person-centredness…

DSC01389_lightAs an allied health professional and educator in the health and social care sector, I interview a lot of would-be health and social care professionals. Almost without fail, these university applicants talk about caring and their desire to work with people, of communication skills and understanding. In due course the successful students study hard to achieve their professional registration. The academic Caroline Ellis-Hills and her team have written that rehabilitation is about helping people to live a life not dominated by their disability; a shift from the traditional medical ‘fix-it’ models. With professional registration comes the opportunity to use newly acquired knowledge to support people to live such lives. This privileged opportunity is one of both position and potential power.  In policy, education and as health and social care professionals, we talk about being ‘patient-centred’; in reality and borne out in the research literature, we may be falling short in this aspect of our practice. It is my observation that many therapists, including me, readily slip into a ‘gift’ model of rehabilitation; one where as a product of our knowledge, we tend to hold the power and suggest what is best in the light of available evidence. As a result we tend to dominate and drive rehabilitation and in turn lose sight of the person at the centre. Again the research literature reflects this. For some years now, William Levack and his colleagues have looked in detail at what happens in goal setting; a central tenet of rehabilitation practice. They have observed that while therapists talk about person-centredness and empowerment, when there is disagreement between patients and teams about which goals to set, patient preferences seem to get lost. Regrettably, I recognise my own practice in Levack’s observation of therapists steering a patient to set less ambitious, more realistic goals; a goal Levack and his colleagues call a ‘privileged goal’. In the past I have rationalised this as therapeutic, avoiding raising unrealistic expectations and supporting the development of insight, but I am increasingly ill-at-ease with this element of practice and it is fast joining my list of behaviours and practices to eliminate in rehabilitation along with the over used and thinly considered phrase: ‘no rehab’ potential’. Furthermore, I’m asking myself (and my students), what’s the more normal behaviour; setting a realistic goal or setting an unrealistic goal? Hands-up …. I set a lot of unrealistic goals … for myself, over and over again …. so, I don’t really demonstrate very good learning either. Is this a health condition?

It’s reassuring that the research literature is documenting these phenomena and encouraging practitioners to think about practices that have become so embedded that we have ceased to examine what is really happening in these powerful interactions. However, notwithstanding the contribution of evidence based practice in recent years, we need to be wary of being too dependent on the research literature. For me, the most powerful prompt to re-evaluate my practice came from two ad hoc personal interactions. The first with a social work colleague who many years ago told me: ‘when someone is told they have ‘no rehab’ potential’, they feel like they have scored ‘null points’ for life’. The second was hearing the experiences of my school friend’s husband, David. David had an aggressive brain tumour in 2005, (http://www.braintumourresearch.org/david-grant_725 ). When diagnosed he was told his life expectancy was about 15 months. A decade later, David is still here. He’s only recently retired from fulltime work and remains both independent and active, contributing to student education, cancer charity and policy work.

When I first heard David talking about his goals I remember worrying that he lacked insight about the gravity of his condition. David’s goals were big, ambitious and emotionally laden; things like, ‘I’m going to walk my daughter to school on her first day at school’. As a friend, I struggled with how to react. I felt empathy for any therapists who might have been trying to rein him in and recalibrate his expectations. Actually, it was me who had to recalibrate; David did not and does not lack insight. He is absolutely realistic about the gravity of his condition, but this does not mean he cannot also be active and hopeful. The importance of supporting and nurturing hope features little in health and social care education but is an area gathering attention. Returning to the research for a moment, there’s evidence that, just like David, patients can remain hopeful but equally grasp the seriousness of their condition. Bright and her colleagues reviewed the literature about hope in relation to stroke and suggest that while there’s some evidence that health and social care professionals can have a positive role in fostering hope, they are just as likely to dash hopes, to justify this as setting realistic expectations and what’s more, seldom see fostering hope as their role.

Clearly there is a balance to be struck, but I have always thought that there is huge merit in the phrase David recalls his oncologist using: ‘David, you have a very nasty brain tumour, but a small minority of people do very well; join them!’. After all, how do the health and social care professionals ‘know’ what a realistic expectation is?  For a couple of decades now we have been encouraged to look at the evidence, the statistics and empirical research; to embrace evidence based practice. There is of course value in such evidence, but it doesn’t tell us the whole story. David, for example, is excluded from brain tumour survivor research because …… well, he’s survived too long! The occupational therapist and writer in the field of rehabilitation, Karen Whalley Hammel, encourages us to tease apart the ties between knowledge and power. As far back as 1999, Coulter wrote in the British Medical Journal: ‘….while the professional is knowledgeable about the individual’s condition, only service users and carers know about their experiences, circumstances, habits, preferences and values; the partnership approach to care should be based on mutual respect.’ There are echoes here of George Kelly’s characterisation of two experts in the room. A decade and a half later we still talk about patient-centredness as if it is a new concept and campaigns such as Kate Granger’s (http://hellomynameis.org.uk/), suggest there is still a way to go and that there are small things that can make an enormous difference.

I’m encouraged that increasingly I see issues of hope and person-focus thoughtfully discussed by both therapists in training and those more established in practice and I find myself thinking: ‘Is an experienced practitioner the one with the most up-to-date disease-specific research knowledge or the wise one, open to possibility, practising their craft with care and respect and above all with a focus on the individual?’

Deborah Harding
Senior Lecturer, Rehabilitation
Faculty of Health and Social Care Sciences
St George’s, University of London
Email: d.harding@sgul.kingston.ac.uk
Twitter: @HardingDebs

Sadly – not all academic journals are open access yet, but for those who are interested here are the references for any literature I have cited:

Bright, F.A.S., Kayes, N.M., McCann, C.M. and McPherson, K.M. (2011) Understanding hope after stroke: A systematic review of the literature using concept analysis.  Topics in Stroke Rehabilitation. 18(5): 490-508

Coulter, A. (1999) Paternalism or partnership? Patients have grown up – and there’s no going back. British Medical Journal, 3 19: 719–20

Ellis-Hills, C., Payne, S. And Ward, C. (2008) Using stroke to explore the Life Thread Model: An alternative approach to understanding rehabilitation following an acquired disability. Disability and Rehabilitation, 30(2): 150-159

Kelly, G. (1963) A theory of personality: The psychology of personal constructs. New York : Norton

Levack, W., Dean, S.G., Siegert, R.J. & McPherson, K.M. (2011) ‘Navigating patient-centred goal setting in inpatient stroke rehabilitation: How clinicians control the process to meet perceived professional responsibilities’, Patient Education and Counseling. 85(2): 206-213

Whalley Hammel, K., (2006) Perspectives on Disability and Rehabilitation: contesting assumptions; challenging practice. London: Churchill Livingston

Insider accounts: Living with communication disability

As a student Speech and Language Therapist (SLT) nearing the end of your training, you begin to feel a bit like you might know a few things. After four years of placements and the range of experiences you have amassed through interaction with a variety of clients and their families, you start to think ‘Ok, I’m beginning to get the hang of this.’ Your tentative steps become surer as you get to grips with assessments and hypotheses and management plans and the wonderful array of devices in the SLT toolkit. But, as a fledgling clinician it is also important to sometimes silence the internal noise of ‘What does this test result mean?’, ‘Which therapy approach do I think is best?’, ‘How many intervention sessions should I give this client?’ And just listen.

In a lecture called ‘Insider accounts: Living with communication disability’, Cathy Sparkes and Sam Simpson provided us with this opportunity. They invited a group of their clients with a range of communication disabilities to come in and talk to all the final year student SLTs at UCL. With our assessor’s hats firmly off, we were able to sit back and listen to people’s lived experiences. All the speakers were very generous with their stories, sharing the painful, puzzling and even playful moments of coming to terms with their respective communication disabilities, both acquired and lifelong, and moving forward with their lives. Many accounts were the result of a number of years of experience and reflection, and it was partly this that made the session so unique for us.

As an SLT, you are generally involved for a very small snapshot of a client’s journey – a few months, maybe a year if you’re lucky. To borrow an analogy, you are ‘a stripe in the scarf of their story’ [1]. But this experience enabled us to more fully appreciate the stripes that come later on, when our input may have finished and our clients have had to renegotiate what it means to live in the world. Furthermore, the speakers were able to give us access to what some of our clients might be feeling now, as we’re meeting them in the early stages after a stroke or brain injury. For example, it may be easy for us to categorise our clients in the light of what they can outwardly communicate. However, the Comprehensive Aphasia Test does not allow us to measure the presence or otherwise of someone’s inner voice – you know, the one that narrates your thoughts and feelings – I had never before considered that loss of spoken language might also lead to inner silence, as so articulately described by one of our speakers.

It was a thought-provoking and at times, moving morning, and overwhelming feedback from the students was that we felt our practice would be changed as a result. The session reminded us to always dig deeper than what we might be presented with on the surface, step outside of our therapeutic comfort zones to provide flexible and individualised support to our clients, and of course, to listen.

Kat UCL Student - 1

 

Katherine Newton
Student Speech and Language Therapist, UCL

[1] McIntosh J., Charles N., Lyon B. & James K. (2011). The Strands of Speech and Language Therapy: Weaving a Therapy Plan for Neurorehabilitation. Milton Keynes: Speechmark

News Group: Behind the Scenes (2/2)

I wrote last month about how some of our neuro-rehabilitation service users benefit from the experience of attending the news group we run on the ward.

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As a service, we have found that we can use our group provision for a number of purposes:

 

We can use the group to provide different packages of care to different service users within the same session. We may invite people to attend news group as part of their goal-based therapy. For example, they may be working towards a more consistent use of intelligibility strategies, or demonstrating increased communicative confidence by facilitating discussion or presenting a news item as part of the session.

Some people know they are able to participate relatively independently in group conversation. However, they may continue to benefit from support, for example to counter the effects of fatigue or distractibility. Further speech and language therapy (SLT) input for these people beyond discharge from our ward may not be indicated, but there are benefits to them continuing to attend the group while they are with us. This monitoring and maintenance package allows room for fine-tuning and further confidence boosting prior to discharge. Such people are also often positive role models for other group members who may require higher levels of support to engage in group conversation.

Some group members still early on in their admission, or newly referred to SLT by others in the multidisciplinary team, may join us for a number of assessment sessions. This may be because the group setting reveals more interactive skills than they are able to show in the often more transactionally-based ward setting. Alternatively, for some there may be an indication of higher-level language processing or social communication difficulties, which do not impact particularly on the ward. Attending the group allows further assessment of the impact, which their impairments may have in more complex group conversation. It can also provide a concrete starting point from which to discuss these subtle difficulties with the service users who may not themselves necessarily consider any difficulties to be present

Group sessions provide rich observation opportunities for new staff and students. Over the past year, we have been joined by students from nursing, medicine, physiotherapy and occupational therapy. We invite new staff members to join us as part of their induction. The richness of the experience of coming to the group as an observer is that there is the opportunity to meet people with a number of different communication diagnoses, and to see in action the strengths and needs these diagnoses may create. A further positive is that none of our observers is passive; anyone coming to visit our group is invited to participate, thus enriching their own experience and learning, while providing further positive role modelling for our service users. Our own SLT students will often take on facilitation of the group for the duration of their placement, which works particularly well with peer placements.

The news group is a joint project between occupational therapy (OT) and SLT. We have found that we need to meet frequently to review and discuss the strengths, needs and progress of each participant to ensure we keep our input focused. Otherwise, there can be a risk of running a session which goes through the motions of looking at recent news stories, but which gives no specific input to any of the packages of care identified for each service user. I will admit that this has happened at times especially if staffing is low or the ward very busy. After a ‘going through the motions’ session, I feel I have facilitated an opportunity for social interaction and the chance for some people perhaps to take on a bit of information about current news events. However, I also feel that the same session could have been facilitated by an enthusiastic volunteer with no specific training in or knowledge of communication impairment.

News group review has now evolved into a joint SLT and OT review of the needs of whoever is on our ward at any given time, and whether there are other groups we could run. This can often change from month to month as we aim to create group opportunities for the people we have on our ward, rather than to try to shoe-horn people in to a fixed format. For example, in the last fortnight we find we have several people with specific comprehension needs and have this week started a ‘points of view’ group structured with a very low language load, but providing opportunities for interaction and expression of likes and dislikes through music appreciation (a clear split in today’s group between heavy metal and the Jackson 5!), chocolate tasting, TV reviewing and more as we plan it..!

Nic Martin

Living with a communication disability: insider accounts

image001 ‘Nothing ever becomes real till it is experienced’
John Keats
One of the greatest challenges in acquiring any new skill is taking the knowledge you have gained and applying it to the real world in a meaningful and positive way. Bridging the gap between theory and experience is something I, as a student speech and language therapist, have had to contend with. Speech and language therapists work with a wide range of clients at various stages of their lives and recovery, and whilst training there are limits on the range of clients you are able to work with due to various factors, such as timing and placement provision. The reality of being a newly qualified speech and language therapist is being faced with client groups that you have no previous experience of working with. Although you have the theoretical knowledge and transferable skills this prospect can feel daunting.

Sam Simpson and Cathy Sparkes have recognised the importance of learning through experience and how talking to people with a communication disability can enhance the developing skills of student speech and language therapists. ‘Living with a communication disability: insider accounts’ was one of a series of lectures Sam and Cathy gave to speech and language therapy students at University College London this year. It provided an open forum for students to meet clients with a range of communication disabilities, to hear their stories and ask them questions. This experience differed from meeting clients in a placement setting as our role was not to assess, provide therapy or to advise them, but to listen to their personal narrative and use their experience to reflect on our practice as speech and language therapists in training.

Clients sharing their stories in an open and honest way made me reflect on the extent to which communication disability impacts a person’s life. What stood out to me were how the clients’ communication difficulties impacted their identity and role within society. Examples included difficulties returning to their previous occupation and maintaining social networks and relationships. Viewing the client holistically has been embedded into our training, but I believe meeting clients and hearing their first-hand accounts has made me reflect on my perception of what speech and language therapy can offer. As a student I am guilty often of getting overwhelmed with theory and the process of therapy, which can narrow my view of the client. This experience has taught me to view every client I meet holistically and to consider the wide-ranging and varied impact a communication disability can have on an individual. I hope to carry this experience with me beyond my training into my clinical work as a constant reminder of the importance of the person at the centre of the communication disability.

Lindsey Beer

Therapy: admitting defeat or an accomplishment?

It took 18 years of living with my stammer before I finally decided to seek help in the form of stammering therapy with Sam at intandem. 

So, why did it take me so long? 

Well, the answer was because I did not want to admit I had a stammer. By pretending it wasn’t there meant that it somehow wasn’t a problem and that it would just disappear… Of course it did not. If I admitted defeat maybe it would rear its head even more? Was I embarrassed by the idea of having a stammer…? Sure! 

Throughout the years my fluency has gone through high and lows. Approximately a year ago I felt I was really struggling. I had become a lot more conscious of my stammer and was even more keen to hide it. The negative feelings surrounding my stammer had increased, which in turn made me stammer more. I felt like I was on a downward spiral and through all the battling I could see no way out.  april14   So, I ‘admitted defeat’ and sought help. 

A year on, my thoughts and attitudes towards my stammer have changed quite radically. One of the key turning points for me was ‘self advertising’, which involved telling friends, family and others that I stammered. Through Sam I had an opportunity to put this into practice by speaking of my experiences to groups of speech and language therapy students: the first time I would give a speech to an audience who all knew I stammered. The scenario was quite alien and I was not sure how I would respond. 

The experience proved more rewarding than I could have ever imagined! The audience’s knowledge of my speech actually reduced the pressure to try not to stammer. If I felt a stammer coming I was more willing to let it out. Quite quickly and without realising I became more relaxed, a lot more fluent and public speaking actually became enjoyable. 

Now a year into speech therapy I have developed a more realistic view of others’ perceptions of my stammer and also put my own stammer into perspective. Rather than battling to avoid stammering I am now more willing to stammer openly. The end result (one which I was always looking for) has been an improvement in my fluency, however it is the underlying feeling of speaking without fear and being freer to engage in the things that I want that has made the biggest difference. 

So, in hindsight, ‘admitting defeat’ feels more like an accomplishment, and much, much more! 

Kal

Living well with stuttering

To celebrate International Stuttering Awareness Day on Tuesday 22 October 2013, Selena Donaldson, speech and language therapist for The Fluency Network at The University of Auckland hosted an informative breakfast seminar. This seminar featured a pre-recorded question and answer session with Sam Simpson and Rachel Everard, two of the co-authors of ‘Stammering Therapy From the Inside’. This event marked the opening of The Fluency Network at The University of Auckland, New Zealand’s newest service for people who
stammer.

Sam and Rachel introduced the concept of ‘living well with stuttering’. They discussed the idea of therapy supporting living with stuttering in a more comfortable way and deconstructed the common misconception that stuttering is something that has to be ‘fixed’. Sam and Rachel acknowledged that there is a range of approaches to stuttering therapy, and that the therapy process parallels a journey, in which a person may try different things at different points in life. They emphasised the importance of being transparent with clients about the type of approach taken, and the theoretical base behind it. Rachel stated from her own personal experience of stammering that although there are useful fluency shaping techniques available, those techniques can be difficult to apply in practice, unless the person becomes more open and accepting of their stuttering.

During this seminar, Sam and Rachel also spoke of self-disclosure. They emphasised the importance of not viewing stuttering as something that needs to be hidden, and promoted the value of stuttering being acknowledged by family and friends. They also emphasised the speech and language therapists’ role in offering clients a flexible model of therapy to help clients on their journey towards self-acceptance. These were concepts I have recently explored with a client at the University of Auckland Fluency Network Clinic. My client was interested in fluency shaping and the freedom approach to stuttering as well. Self-disclosure proved to be a highly powerful tool for this client, who was initially apprehensive about self-advertising and voluntary stuttering due to his past negative experiences. Having independently decided to self-disclose in a group situation outside of the therapy environment, he reported the experience to have been positive, stating, “the stutter doesn’t define me”.

It was wonderful to hear from Sam and Rachel, across the world, on International Stuttering Awareness Day, and to open the University’s new service with their astute and holistic clinical reflections.

Irene Yap
Master of Speech Language Therapy (Practice), final year student
The University of Auckland

Kinship and worship

International Stammering Awareness Day, 22nd October 2013

Over the summer I went travelling throughout Vietnam – a wonderful country where I had the pleasure of meeting many warm, openhearted people, eager to share their fascinating history, rich cultural heritage and exquisite cuisine.

Throughout my travels, I was frequently moved by the important role ‘kinship’ plays in Vietnamese culture, evidenced in strong family values and a deep respect for the other. So very contrasting to the Western emphasis on individualism and personal gain.

I was also struck by how central the practice of ‘worship’ is to Vietnamese life regardless of religious denomination. I returned home inspired by these important principles of community and celebration; and deeply committed to integrating them more fully into my work.

Tuesday 22nd October 2013 is International Stammering Awareness Day: an ideal opportunity to unite the community of people who stammer in order to give voice to the lived experience of stammering and raise public awareness.

intandem will be marking the occasion in two ways this year:

  • The Fluency Network – I will be taking part in a question and answer session via teleconferencing to mark the official launch of The Fluency Network, a newly established adult stammering service attached to the University Of Auckland, New Zealand
  • Book launch at Waterstones Teddington – on Wednesday 23rd Oct we are co-ordinating a local book launch to mark the publication of ‘Stammering Therapy from the Inside – New Perspectives on Working with Young People and Adults’. Do come along and offer your support
    – Click here for details

Through these two events we hope to bring together people who stammer, their families and friends as well as therapists and other people with an interest in stammering in order to foster new connections, open up dialogues and establish greater collaboration at both local and international levels.

Through kinship and the gathering together of the stammering community, we hope to extend our thinking about stammering, to celebrate developments in stammering therapy and to signpost relevant services in the voluntary, educational and independent sectors.

‘Alone we can do so little; together we can do so much’
-Helen Keller

Sam