Image from the Bla, Bla, Bla app – a voice activated app which can often interest dis-engaged clients
This post tackles engagement in Speech Therapy for people who have cognitive communication difficulties as part of their communication diagnosis as a result of acute brain injury (re stroke, head injury). I am not talking about clients in low awareness states (in a coma or emerging from a coma), or degenerative cognitive communication difficulties .
No case is ever straightforward, but the cases where a client might have a combination of aphasia/apraxia/dysarthria with cognitive communication difficulties on top is always tricky.
It can often make a client withdrawn or exhibit difficult to manage behaviours. However, we are the communication experts – if we do not get ‘in there’ with a client and break through these barriers, what hope has anybody else got of being able to do so? We are trained to rehab cognitive communication difficulties, and we should start unpicking the cognitive barriers bit by bit . Just like the other communication disorders, cognitive communication difficulties can get better at a neuronal level.
If a client is not interested in working with the materials/method you have planned for that session – that is not their fault. If they are wiped out and heavily fatigued -again, that is not their fault. The onus should be on us, as skilled clinicians, to break into a world they’ve entered without wanting to and don’t know how to escape from. There are, of course, times when we might walk away from a session because a client is is so deeply asleep an earthquake would not wake them! Or they are battling an infection. However, as speech therapy is a precious commodity, I try everything I can first!
What to do when clients are withdrawn/fatigued/turn away:
Positioning: Try to get clients into an upright sitting position if they are medically/physically able to tolerate this. We feel better when we sit upright and take in the world around us, so will our clients!
Environment: Playing about with the environment as much as you are able to can help. Over the years I’ve tried everything – turning lights on is a basic but helpful thing, providing coffee and a nice cake if they can eat/drink ok, putting on some of their music, taking them out for some fresh air/to a different room, showing an interest in their possessions/photos….
Our behaviour: I always use an upbeat voice – I don’t care if they think of me an the annoying woman with the over loud voice! One thing I’ve learnt in neuro rehab is that clients will copy your behaviour – if you want to elicit positive reactions, you need positive behaviour. I try not to patronise! I will explain who I am and what my expectations are, and how long I intend to be there. If possible, I will stand a few metres away as that will often entice someone to lift their head. I smile, and I also explain how much I want to work with them and get to know them.
Tools: I often that pulling out my iPad and playing about with a few apps might get someone’s attention. There are apps that react to noise (the bla bla bla app, or Talking Tom), apps like magic piano where you can touch keys to play tunes…. I might pick up photos or magazines close by and talk in an interested way about them.
Give therapy a go: I always start with simple, repetitive therapy tasks, even when a client’s eye remain closed. I count and ask them to count with me, or recite the days of the week. Or I make open vowel sounds with exaggerated lip movements (ahh/oo/ee). I always explain that I want to hear their voice, so please to join in with me. At this stage, you might not know what their speech/language/voice is like, hence starting with automatic speech work. Encourage any sound or attempt at sound they make – they are engaging! A loud rhythmic voice helps too -I think this must help tap into our early language acquisition – chanting along with our parents/at school. I help them view it as a warm up for the main session. I usually find that once I have a client engaged at this level, I can then start to throw in other activities – some language assessment for example, or if I know their difficulties, more targeted therapy. Once a client has made a big collective ‘push’ to communicate (and we know this means the coming together of so many systems), sessions are often plain sailing from there.
Be consistent: You may need to repeat all of the above session after session until you find you have a breakthrough – one day you might arrive and the client will be sat up and ready to go with their vocal warm up and very happy to see you!
Give something of yourself: I’m one of those people who makes up for other people’s quietness by burbling about all sorts. I’ve had to learn to manage this to be a more effective clinician! However, I do find that if you share interesting information with people who are withdrawing, you build a relationship and they look forward to seeing you. Their natural innate desire to communicate with others has been massively affected by their brain injury, but it does not mean that communication should be withdrawn from them, no matter how one-sided. I always talk about the weather (very British but always something to comment on!) something that has happened on the news, something funny that happened to me that day etc. I try to be a bringer of sunshine for that session, even if I least feel like it!!
These are just a few of my thoughts – we all know a one size fits all approach does not work for everybody, but I hope this gives some ideas to try.
Part 2 will address how to help when somebody’s attention/memory/behavioural problems are a barrier to sessions….