BOUNDARY ISSUES (3)

A complementary view
You have fairly strong views on complementary therapy. Perhaps you have derived a lot of personal benefit and you are aware of the impact it could have on certain clients, although they havent raised the issue. Or perhaps you are very sceptical but are asked for advice from a client who is keen to try such an approach...
wonder how many readers have taken up some kind of complementary therapy. Have you tried acupuncture, visualisation, homeopathy, reflexology, osteopathy, meditation? Or perhaps someone from your family or one of your friends uses complementary approaches to health and wellbeing? What counts as complementary therapy for you? The definition from the Cochrane Collaboration (http://www.cochrane.org/policy-manual/251cochrane-complementary-medicine-fieldbursary-scheme) (accessed 23 July 2010) says that complementary medicine includes all practices and ideas that are outside the domain of conventional medicine in several countries and defined by its users as preventing or treating illness, or promoting health and wellbeing. Their definition includes a long list of treatments and practices. As an individual, where do you sit on the spectrum of belief in their effectiveness? Do you believe complementary practices to be effective, to have potential for some people and some conditions? Perhaps you view them as hocus pocus and akin to black magic? What is the basis of your belief? Have you read widely on the subject in peer reviewed journals, read books from popular psychology or is your belief based on receiving training in a particular method or on personal experience? The Cochrane Collaboration now has a field that focuses on the reviewing of complementary practices and they have reviewed the effectiveness of herbal medicine, acupuncture and aromatherapy (amongst others) in a number of contexts. As speech and language therapists under the regulation of the Health Professions Council (HPC) and our professional body, the Royal College of Speech & Language Therapists (RCSLT) our scope of practice covers those needs associated with speech, language, communication or swallowing difficulties. Other conditions, unless they impinge on these aspects of an individuals behaviour, are outside our frame of reference. So, even if we have found acupuncture effective for our own back problems and even if we are aware of peer reviewed evidence showing its effectiveness, it is outside our duty of care to an individual and therefore inappropriate for us to offer a professional opinion about it. If the conversation comes at the end of a session and is offered as a personal rather than a professional opinion, then one still has to be

Sue Roulstone considers the following scenario:

BOUNDARY ISSUES EXPLAINED The Health Professions Council Standards of Conduct, Performance and Ethics require us to behave with honesty and integrity at all times (p.14). We are reminded that poor conduct outside of your professional life may still affect someones confidence in you and your profession (p.9). Arguably, our clinical conversations and research literature do not focus sufficiently on moral principles, but they at least touch on the ethics around issues such as prioritisation and evidence-based practice. In this new series we think through the sort of everyday events which although they receive much less attention - also need to be on our ethical radar screen. aware of the fact that, as a professional, our voice carries weight and power to influence. The client or carer has come to us for our expertise in speech, language, communication or swallowing. But, because of our professional status in that relationship, they are likely to believe us about other things too. Together you have built up trust and a relationship that then has power to influence. One therefore has a responsibility to use that power with discretion. Even if we state clearly that this is a personal opinion and outside our realm of professional expertise, our existing relationship with them as a professional puts us in a powerful position. Some complementary approaches may be perceived to be applicable to aspects of speech, language, communication or swallowing and here I have to express my own lack of knowledge of the wider literature. Certainly in my own area of expertise - primary speech and language impairments - I am unaware of any evidence base relating to the use of what I had typically considered to be complementary methods, although I am aware of them in other fields such as stuttering and voice disorders. However, Cochrane defines complementary approaches as those that sit outside the domain of conventional practice. This leads me to think more broadly about what one might consider here. Cochranes inclusion of sound therapy as an example of a complementary approach might lead one to think more in terms of those controversial or nontraditional practices (Pannbacker & Hayes, 2007) which are popular but nonetheless cause heated debates within the field.

It seems there are three key questions that practitioners should be asking with respect to the use of complementary methods: I. Is this particular approach considered by RCSLT, HPC and my managers to be within my scope of practice? II. What is the evidence for this particular approach with the particular disorder or client I am dealing with? III. How competent am I to deliver this particular approach?

I. Scope of practice

The Health Professions Council has no specific guidance about the use of complementary methods and would refer registrants firstly to the Standards of conduct, performance and ethics (HPC, 2008) which require registrants to practise within the limits of their knowledge, skills and experience, and secondly to their own professional scope of practice documents. The Royal College of Speech & Language Therapists (2008) notes that complementary therapies are not part of a speech and language therapists core practice and that, in the future, some complementary practices may become the subject of regulation. In this case, therapists wishing to use such approaches would be required to register with the relevant body. RCSLT reminds us that we should always take the advice of and work closely with our managers and employers, since the use of methods which are outside our usual scope of practice may not be covered by the standard insurance policies. It further recommends that we discuss any extended scope of practice with RCSLT advisers, adhere to local governance and risk processes, and seek out relevant policy and position papers.

22

SPEECH & LANGUAGE THERAPY IN PRACTICe AUTUMN 2010

BOUNDARY ISSUES (3) / SOFTWARE SOLUTIONS

II. The evidence

If we have an agreement that a particular approach is within our scope of practice, or is agreed as an extended scope of practice with our managers, we also need to consider the evidence base for it. We have a duty laid on us by the Royal College of Speech & Language Therapists and the Health Professions Council to deliver practices that are, as far as possible, evidence based. As indicated above, the Cochrane Collaboration already has a number of systematic reviews of complementary approaches. Sound therapyhas been reviewed as part of a review of auditory integration approaches for autism spectrum disorders and as a masking technique in tinnitus. One might argue that not all traditional interventions used in routine practice have high levels of evidence associated with them; however, it is our responsibility to know what the level and nature of the evidence is and to be prepared to discuss that with regard to any interventions we offer. Writing about the use of controversial and non-traditional practices, Pannbacker & Hayes (2007) alert us to the dangers of reliance on personal testimonies, the risk of harm, and the limitations of a weak underlying theoretical rationale when evaluating the potential of interventions to be effective.

Software solutions
With technology becoming ever more sophisticated and accessible for therapy, our in-depth reviews help you decide whats hot and whats not. ANATOMY
diagrams. It would have been good to have similar sections on videofluroscopy and gastro-oesophageal reflux disease. The animation section includes 3D movements of the face, elevation / depression of the corners of the mouth, movement of larynx / pharynx and elevation / depression of the hyoid bone. This is an expensive resource and the price above only gives a single user licence. It is however a good clinical tool and resource for teaching. Ann Gosman is a specialist speech and language therapist with NHS Orkney.

3D Anatomy for Speech and Language Pathology (DVD-ROM) Ed. P.C. Belafsky, M. Coffey, D. Costello, M. Gilman, N. Lewis-McColloch, Y.A. Sumida, M.E. Atkinson, S. McHanwell & R. Tunstall Primal Pictures ISBN 978-1-907061-12-7 Single user licence 145+VAT (multi-user online licences, student and faculty pricing on request)

Deeper understanding

III. Our competence

Finally we must consider our own competence to undertake any new approach to intervention, whether traditional and accepted or complementary or controversial. The Royal College of Speech & Language Therapists provides the link to the British Complementary Medicine Association (www.bcma.co.uk) for further information on the relevant training and standards for use of complementary therapies. So, when we are next in a position where our opinion on a complementary therapy might be sought, how will we respond? Do we have our answer ready or do we have some work to do to sort out our position? Might it just be a quick response to a passing question or is there more to think about Sue Roulstone is Underwood Trust Professor of Language and Communication Impairment at the University of the West of England, based at the Speech & Language Therapy Research Unit, Frenchay Hospital, Bristol, email susan. roulstone@uwe.ac.uk.

Health Professions Council (2008) Standards of conduct, performance and ethics. Available at: http://www.hpcuk.org/assets/documents/10002367FINALcopyofSCPEJ uly2008.pdf (Accessed: 31 July 2010). Pannbacker, M. & Hayes, S. (2007) Controversial Treatment in speech-language pathology: what are the issues?, TEJAS Journal of Audiology and Speech-Language Pathology Available at: http://www.txsha.org/_pdf/ TEJAS/2007/06%20Controversial%20Treatments.pdf (Accessed 31 July 2010). Royal College of Speech & Language Therapists (2008) POLICY STATEMENT: Evolving Roles in Speech and Language Therapy. Available at: http://www.rcslt.org/members/ publications/RCSLT_Evolving_roles_Policy_Statement_ October_2008_a.pdf (Accessed: 31 July 2010).

References

This DVD-ROM is an excellent resource for students, clinical work, presentations / lectures and for training purposes. It is easy to navigate and shows hundreds of 3D anatomy views of the head and neck including facial muscles, tongue, oro nasal cavities, larynx, pharynx and ear. It is divided into six sections: anatomy, slides, movies, animations, clinical information and patient information. The anatomy plates can be built up and rotated to add or remove layers of anatomy to view and label any structure with ease. I found this enjoyable to use. It gives the experienced clinician a deeper understanding of anatomy and physiology. The illustrations can be found in any good text book but this gives a 3D effect of muscles, blood supply and innervations, with names appearing as you move the mouse. The slides are mostly related to voice disorders. The Clinical Section shows functions such as the normal swallow, voice production and articulation. This will be useful for voice clients or when training nurses in swallowing / swallow screening procedure. The clinical text is provided by a team of clinical authors based in the UK, with contributions from the USA. It is a good resource for UK audiences. Conditions in this section include acute laryngitis, vocal fold paralysis, swallowing problems after stroke and head and neck cancer. Patient Education complements the topics covered in the clinical section. The section on Fiberoptic Endoscopic Evaluation of Swallowing, for example, is explained in patient-friendly language. (What is FEES? Reasons for the procedure. Some of the risks and follow up information.) It has coloured illustrations and a short summary. Each sheet is printable and editable with images and

LANGUAGE

Language Garden www.languagegarden.org David Warr Single Licence 40.00 (inc. VAT)

Good value and fun

This is an online language programme designed primarily for young people with English as a second language. It incorporates the notion of different levels of language and shows progression from verbs, nouns to prepositions, adverbs, clauses and passives. The sentences are shown as a branch in the form of a mind map structure. One component leads from another. It also makes use of colour coding to help the learner with different components of language. We would recommend this activity as it is interactive, fun to use and has a multisensory approach, as it has listening, speaking, reading and writing activities. We found higher levels of the programme were visually very complex and wonder if this programme could be adapted into a linear model. This could then be used for language delayed / disordered clients. This is a good value resource obviously well designed by somebody who has practical experience of teaching English as a second language. Claire Watson, Karen Shuttleworth and Alison Taylor are speech and language therapists in Cumbria.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2010

23