Assessing the bigger picture

Yesterday I shared a link to my communication history questionnaire which is an essential part of my assessment process of a new client.

After formal assessment we need to get an idea of how a person’s communication difficulties are impacting on their life situation, and this involves stepping back and taking in the bigger picture.

  • Sometimes clients come up with only mild difficulties on assessment, but the impact on their life is huge.  Their communication might be ‘functional’ and they may be able to convey their needs/emotions but they may present with a reduced verbal fluency or high level language difficulties.  However, would we be happy with this situation in our lives? Good communication is essential in all jobs and aspects of life.  If someone is trying to pick up the threads of their life after the shock of a brain injury that has just left mild impairments, they are going to find life a lot harder if they are battling constant tip of the tongue phenomenon, a loss of fluency of language, mildly slurred speech or mild processing problems.
  • Conversely, some clients are so impacted we can feel overwhelmed in deciding what to work on first.

During the process of assessment, I always try and find out as much as possible about a client’s life pre brain injury and contrast it to what they are able to do now.  I ask if there is any video footage or voice recordings of the client pre-brain injury that I can have access to.  This can be really striking.  Two examples – one of my client’s complained of changes to his voice, although it sounded normal on assessment.  We rang his phone’s voice-mail together and listened to the message he had recorded pre-stroke.  The difference in both voices was very significant and gave me an understanding of why his ‘functional’ voice was a priority for therapy.  Another client I am seeing now has a fluent aphasia.  He is in a video on YouTube which shows him speaking knowledgeably about his very specialist job – it was strange to see on screen exactly the same person as in front of me- but with all their meaningful words now wiped out. It  brought it home how important our input is.

I’m finding more and more that my younger clients have public social media accounts that either they or their family give me permission to look at.  This gives me a really good insight into their writing style, what they love, what they are passionate about…  I know that if I lost the power of communication, a look at my personal instagram and twitter account would reveal a lot of information about what makes me ‘me’.

As part of my assessment, I also try and gain an understanding of the client’s family dynamics and how their life works, so I don’t just bulldoze in with insensitive goals or unrealistic expectations.   I ask questions and also observe.  Every situation is different, and also changes over time, so keep checking in!

I also will use a communication history questionnaire – I find the information it provides really useful in building up a picture of the person I am providing therapy too.  However, I do also try to take into account it’s limitations.  It is usually not filled out by the client themselves (if they are high level clients, I usually ask them the questions as part of my case history) but by their partners or a close relative/friend.  I dread to think how wrong my husband might get some of the questions!

I also think carefully about making therapy resources based around someone’s stand out interests on the form.  I do sometimes do this and if a client is really passionate about an interest, you usually find you can ‘tap’ into an area of language that has been built up over years and therefore they have a better understanding and expression in this area compared to general conversation.  However I know that we are complex people – my interest in things waxes and wanes depending on my mood.  I don’t really talk about speech therapy outside work.  I love talking about my interests with friends who also love the same thing – I would not usually talk to someone I don’t know about home interiors for example.  What I do love is having really interesting conversations on a range of public interest topics with a range of people – and I try to keep this is mind when incorporating information from the form into therapy sessions.

Once I have stepped back and have the bigger picture in place I can begin to think about goals and a therapy plan.

This is based usually on 4 things:

  1. Where does the client want to be in the the future/what is their potential (this is a whole series of blog posts in itself, but starting to take the ‘long view’ even if it is a few years away is important – are you looking at a return to work, or to parts of their old life pre-brain injury, or are you looking at helping them shape a life very different from before? see here for a blog post I wrote on aims for rehabilitation.)
  2. What is most important to sort right now and what is the client’s priority?
  3. What setting you are in
  4. What you can provide input wise

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