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A positive approach for committed professionals .

ISSN (online) 2045-6174

The big
on a small
he new DynaMyte is a lightweight,
capabilities which introduces a new dimension to
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freedom to the ambulant user.
advanced communication capabilities, and uses the same software. A built-in
remote control unit allows the user to
access computers and other household appliances, and it
portable device with powerful communication
DynaMyte is just half the size of DynaVox 2 and yet it retains all its
The DynaVox 2
features a system of alarms capable of performing a variety
communication aid of preset tasks. A clear, easy to operate touch display
has introduced a
provides access to the full range of DynaMyte's
new era of freedom to
communication power. Its long life battery and durable,
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DynaMyte is a natural product extension from the
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For full information and demonstration, contact
A ~
TELEPHONE : 01202 481818
~ ~
FAX: 01 202 476688
ISSN (online) 2045-6174
(publication date 23rd February)
ISSN 1368-2105
Published by:
Avril Nico ll
Lynwood Cottage
High Street
Tel/fax 01569 740348
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East Sussex BN23 6PT.
Avril Nicoll RegMRCSLT
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Avril Nicoll 1997
Contents of Speech & Language
Therapy in Practice the views
of the individual authors and not
necessarily the views of the publish
er. Publication of advertisements is
not an endorsement of the adver
tiser or product or service offered.
Cover picture:
qnical Teaching with video

News/ Reviews 17
Comment 2
Counselling, dyslexia, pragmatics,
autism, conversation analysis,
voice, language disorder, child
language, general treatment.
What do
carers think? 4
Reader Offer 20
Penny Hodgkinson
carries out Review one, get one free,
exploratory courtesy of Winslow
research into carer
attitudes towards
the communication
of adults with
learning disabilities.
Clinical Teaching 21
Julie Marshall and
Catherine Aldred's
observations on a
supplementary learning
paCkage using video.
Personal Construct
How I ...
Sasha Bemrose and Malcolm Cross
manage my 24
outline techniques of PCP using case
examples from their innovative work
with parents of deaf children .
Teams from adult
neurology, community paediatric
and learning disability fields
Group' @ sharetheirexperiences.
for - r
a positive -G - My Top
outcome 8 Resources
Group therapy has u-"
become a popular choice Heather Taylor
as an adjunct to individual , lists the ten items
work with people with ! she could not do
aphasia. Caroline without in her
Davidson and Carol work
Nelson ask if it can be '" ,> people With
effective in its own right. <l ; dysphonia.
ISSN (online) 2045-6174
Developing new skills
Group therapy has become a popular caseload
management tool for speech and language therapists with
many client groups. Ann Adams and her team hold
centralised groups, many on an ad hoc basis according to
need. These have the added advantage of encouraging
therapists to work together, and the way their Parent and
Toddler group in particular is run shows much imagination.
Caroline Davidson and Carol Nelson recognise a hazard of
group therapy in that individuals can end up being dealt
with sequentially - essentially receiving "inefficient individual
therapy within a group setting" They have discovered the
unique benefits of gathering people together and preparing
tasks which give the opportunity for debate and discussion
around the specific linguistic needs of the members. Group
therapy can be very rewarding for therapists as well as
participants but we need to prepare thoroughly and use it
Working to change the communication behaviour of
parents and carers is also often touted as an efficient way
of working, yet therapists frequently complain that advice
is not followed. Perhaps in general we lack the particular
skills needed to work in this way. Sasha Bemrose and
Malcolm Cross believe Personal Construct Psychology has
allowed them "to discover how parents see things, if and
why there is a need for change and within what parameters
this change can come about. Without this understanding,
any intervention focusing on change is likely to fail. "
Perhaps, then, we also make too many assumptions about
what others think. Penny Hodgkinson has explored
attitudes of carers and in the process discovered how to
change her practice to enable carers to make the
changes she wants to see; she now offers more detailed
assessment, demonstration of techniques in everyday
settings and training relating to an individual client.
We are encouraged to offer training in a bid to spread
expertise and make therapy more efficient but we need
particular skills to provide it to the required standard.
Therapists need more information about adult learning
theory and how to exploit new technology for training
purposes. Julie Marshall and Catherine Aldred have done just
that with their supplementary video teaching package
which could also be of use to practising therapists looking
to update their knowledge of a particular field.
Part of a therapist's skill comes with experience. This
month's My Top Resources shows how this constantly refines
what we offer clients. Some readers, when asked to con
tribute to the How I ... section in particular, feel reluctant
precisely because what they do evolves
and, as Ann Adams tells me, because
they already know what they do and
want to know what other people do
when faced with the same problem.
However, I need to hear about running
groups, managing caseloads, working
with parents / carers, teaching or any
other area of our work so we all have
the opportunity to develop the skills
which will benefit our clients.
Avril Nicoll
Lynwood Cottage, High Street, Drumlithie
Stonehaven AB39 3YZ
tel/ansa/ fax 01569 740348
ADA bid
Action for Dysphasic
Adults has secured _____ Association
Lott ery funding to
coT/tinue its regional Stroke unit call
The Stroke Association is lobbying
Parllilmenl to demand lhac all
develapm em work.
The charity also
people wh o have hlld a s trake are
features as The
treated in a stroke unit, no mal
Week's Good Cause
ter where tiley live.
011 Radio 4 on 22nd
This follows previous research
showing that, for every 22
Recent work of the
patients treated, one extra patient
charity includes is likely to suruive if trellted in a
encouraging strohe unit ralher than in a
coulISellors to leant conventional selling and, for
more about warhing
every 16 patients trea ted, one
extra patient would regain
with people with
independence. in II 1995 swdy
funded by the Stroke Associ(1lion,
ADA will send out
less than half of the consultants
leaflets and posters
surveyed had access to a
to anyane holding II
speciillised strO/le rehabilitation unit.
fund-raising event.
The Association continues to
ADA: tel. 0171 261 fund research, including a recent
award to City University, London
to test ways of helping people
with Jargon dysphasuz
develop functional
funding writing skills.
The latest In the Slgnalong at Work The Stroke
series, General Retail. rna be the last if Association: tel.
further fundi ng cannot be found. 0171 490 7999.
A lonery grant 10 uppo rt the signing
vocabulary developments i al an end and
the chari ~ ' i asJ,.;ng us r I consider
contri buting on pound a month. plea
Meanwhile, phases 1 - 3 of the Bas ic
ocabula ry are available in symbol
Cancer Relief is
form from Widgit Software LId on
looking for
their Rebus 4.
individuals and
Details: 01926 885303.
groups to take
part in its
Macmillan Miles
Volunteers needed event.
Sponsors pledge
Volunteer field workers are
one pound to
requi red to work on a range of
participants for
projects for Trek-Aid.
covering a mile.
The small charity helps Tibellln
often in imaginative
refugees in India and Nepal.
ways, all money
Specialist skills such as medicine,
raised going
dentistry, nursing, midwifery and
towards helping
opthalmology are especially lIalu
someone who has
able, but enthusiasm and com mit
cancer. The charity
ment are often needed as much as
funds specialist
transferable skills. The volunteer
Macmillan nurses
ing is on a small scale where peo
and doctors,
ple can learn from and interact
buildings for cancer
with Tibetans.
treatment and care
Speech and la nguage therapist
and grants for
Judith Mitchell is going to Nepal
patients in financial
wi th '[j-elz-Aid for three months
from March 1998. She wlll be
The event runs
working on several projects
from 9th to 17th
including assisting in the estab
May 1998. To take
lishment of a dental clinic, a
part. call 01372
vocational training scheme and a
health education programme.
Details: send a lmse SAE to
TREK-AID, 2 Somerset Cottages,
L-___________ cancer relief
Stol1e Village, Plymouth PL3 4A2.
ISSN (online) 2045-6174
Prevent the waste
The British Dyslexia Association claims there is widespread and
unacceptable tolerance of underachievement.
A national survey of LEA SEN policies suggests children often
don't start to get the right son of help until they are falling at
least four years behind. The BDA believes the Code of Practice for identifying
and assessing special educational needs should be implemented systematically across
the counuy and that specialist support should be available before a child falls so far behind.
A recent campaign therefore focused on the positive steps that can be taken for early identifica
tion and support. Activities of 'Stop the con.flict, prevent the waste' included booklets in Boots
stores and the launch of a BBC Education / BDA Teaching Today Pack for primalY school teach
ers. In addition, a new Early [ntelVention Project run jointly with AFASIC has staned. Designed
with the help of the Department of Human Communication Science at UCL and sponsored by
GI<LXO Wellcome pic. it aims to raise the awareness, understanding and skills of professionals
such as speech and language therapists, health visitors, playgroup leaders and nurselY workers in
the pi lot area of Bromley. Sir Monck, Chairman of the BDA, ays "We uo not want par
ents to be steered towards conflict. The answer lies in prevention, anel we hope this pilot scheme
wiJi be a model for an early intelVention training programme on a national s al e."
lYleanwhile the BDA has appointed a new Chief Executive. Joanne Rule comes from a background
in communications and the charity sector, most recently with the Royal College of I ursi ng.
BOA: tel. 0118 966 2677.
mental health
Research indicates mental
health problems cost the
English economy more than
32 billion a year, over fOllr
billion funded by the NHS.
The Health Education
Authority believes improved
me/lUll health results in better
physical health, greater
emotional resilience to survive
problelnS and enjoy life,
increased productivity and
improved citizenship. It is
ashing health TrILSts and
professionals to help promote
mental health by consulting
with. ILSers, gilrillg carers a
voice, forging closer links with
voluntary agencies and
providing a1l environment in
which people can feel confident
about discussing mental health
problems mid seeking treatmrot.
lt is also recommending schools
learn to recognise early symp
toms ana develop anti bullying
poliCies alld that local authori
ties consider the mental health
impact when planning and
delivering local services.
HEA: tel. 0171 3833833
Contribution recognised
,.-1The Royal College of Speech and Language
- j)""Therapists has awarded BT in recognition of its con
I #,.11 tribu tion to the work of the profession.
{'The company has financed research and study. It has also
backed the public awareness programmes, Speak Week and
Mary Smith, RCSLT Chair, said "BTs understanding of the dis
abling effect of a speech and language disorder and the desperate
ly isolating nature of the problem has led to massive input into
raising the public profile of this unseen disability."
The BT Centre for Human Communication has worked with the char
ity I CAN to provide Teach Speech, the first videoconferencing fadJi
ties for specialist speech and language therapy suppon (see picture).
Information on BT Education SelVices, part of its Community
Pannership Programme, which has award schemes for schools, fur
ther education and universities is available from Roger Sands or
Maria Carr, tel. 0171 636 6255.
First for Scope
A range of public policy issues
was debated at the first confer
ence of Scope, the UK's largest
disability charity.
These included the
Government's Green Paper on
special needs education, the
attitude of the media,
community care and the
health service.
By 2005, Scope aims to ensure
that all people with cerebral
palsy and related disabilities
will have the rights and
resources to control their own
Scope: tel. 0171 6365020.

papers devoted to the
impl ications of global ageing
have been published in an
awareness raising bid.
The papers cover the basic
science of ageing, disease and
older people, how they are
cared for within health care
systems, discrimination against
'the elderly' and the economic
and social aspects of the ageing
of populations worldwide.
Derails: BM} Publishing Group,
BMA House, Tavistoci? Square,
LOlldon WC1 H 9JP
vers and their
has been
launched by the AA.
This offers a replacement
vehicle to make sure the driver
and up to 16 passengers arrive
at their final destination
together. Details: 0345 125594.
welcome the GOl'ernmem takillg seriously an disrupted and their parents ("
Green paper
area which is too oftell lIeglected." He is COII The c1Ulrit)1 AFASIC is collcerlled tit tlte sug
(,riled howel'l?r that setrillg could mean ill gestion tilat the number of childrell with stare
effect mirliaUlre special schools within //Iain ments sllOuld be reduced alld will support this
1he Association of Teach(,l) and LeclUr('rs 11iI, stream and continues "There are pupils whose 0111)' if it feels confidem tile legislation stlfe
given a call1ious welcome to the GOllerlllllelll emotional problems malle it impossible for them guards II child's right to appropriate prollisioll.
Greell Papel; Excellence for all chi/dml - to cope with" school community I1lese chil It IIlso queries the colltimling emphasis 011
Meetillg Special Educational Needs. dren will JIoat illto the lowe:;! slremn ... worldng indusille educatioll, poillting out the Plln;cu!.lr
Gelleral Secrew1}1 Peta Smith sa),s "We wel alongside $Iow learners. \o\-'I1i/e the rigllLS of SIlC/1 needs of children with a lallguage disorder alld
come tile un;IIersal rot;tlemem for all pupils. dlil(/ren are being met, 11111111 happells to the the pital role pla)'ed b)1special scllools lI lid I.IIT
We welcome the streamlinillg of procedures. We rights of the chi/drro whose edueali(m ma)' be guage IInits.
ISSN (online) 2045-6174
in ALD -What do
carers thinl<?
Penny Hodgkinson carries out exploratory research
to discover the implications for her practice of
carer attitudes towards the communication needs
of adul with lear Ing disabili es.
There has been
little investiga
tion into what
carers think
about the
tion of the
elien ts they
support and
the role of the
speech and
language ther
COMMUNITY HEALTH apist, although
N H S r R U r the carer is
seen as a vital
element in therapy for adults with learning
disabilities (Figure 1). We work alongside
paid carers and family to develop and pro
mote opportunities for communication.
We recognise carers' communication skills
may need developing and enhancing. and
adapt the environment they provide - its
physical layout. routine and the opportu
nities and choices it offers.
There are well established training pack
ages and resources used to raise staff
awa reness of the particular communica
tion needs of adults with learning disabili
ties, such as Talkabout. Intecom and
ENABLE. Money (1997) outlines research
into the effectiveness of staff training,
quoting useful caveats from the work of
van der Gaag and Dormandy (1994).
Attitudes and perceptions will. however, be
crucial in taking up training and making
practical use of it and, whilst attitudes are
notoriously difficult to change, awareness
of them can influence seJ"vice delivery. If
carers are identified as vital in bringing
about change in communication patterns,
do they share this view of their role?
Training initiatives are often directed at
changing staff behaviours (simplifying lan
guage, using signs, symbols or objects of
references, introducing opportunities for
choices) but how do staff respond to the
demand for change in their behaviour?
And how does this link into their own per
ceptions of the communication of adults
with learning disabilities, and therefore the
role of the speedl and language therapist?
Do carers believe and therefore act upon
what they are told, rather than perhaps
being shown by a hands-on clinician?
Exploratory research
A small research project was set up in West
Suffolk to investigate. The semi-structured
interview approach used comes from a
qualitative methodology. The research was
designed to be exploratory rather than
experimental, and to elicit data which
could then be analysed. Other examples of
qualitative approaches in health research
include Whyte's work (1992) looking at
family and professional interaction caring
for children with Cystic Fibrosis. Grounded
th eory (Glaser & Strauss, 1967), in which
theories and themes are derived from data,
was considered the most appropriate way
to investigate this topic. Strauss (1987)
identified the qualitative approach may be
useful in developing policy and guiding
clinical practices. The link between the
research and policy development has also
been explored by Pahl (1992) who formu
lated the hypothesis that the closer the
link, the more influential the research will
be. Hence the speech and language thera
pist for this client group carried out the
Once the methodology had been estab
lished, the project went to the local Ethics
Committee for approval. Consent was
obtained from all participants prior to the
tape recording of the interviews. Pilot
int erviews were carried out with residential
care staff and these refined the questions
and reduced the involvement of the
researcher in the interview itself.
The twelve subjects were a typical staff
sample referring to and using a speech and
language therapy service. All were paid
staff working in a variety of settings
health, private residential. social services
and some were professionally qualified as
a nurse or s cial worker. They were work
ing wi thi n a geographical area which had
hitherto not fec illed speech and language
therapv for this dient group and all had
s me experience from previous work set
tings o f speech and language therapy for
adults with learning disabilities.
The interviews lasted between thirty min
utE'S and one and a half hours, focusing on
the questions:
1. Vlfhat are tile cummunication problems for
peoplewich lea rn ing disabilities?
2. What comrilunicllliolJ i$sues would mafie YOLL
seeh speech and language lhemp)' input?
3. How can we be t leanl ahemc , In individual's
commLLniwtion problems?
4. Whac strategies CIII1 we use co support /
develop / improve communication?
Each transcribed script was reviewed for
emergent Iheme and topics. A colour cod
ing system was used to identify ideas and
match these from subject to subject. A
number of themes emerging from the data
were clustered under the topic headings:
I. Individual skill levels I individual
difficulties (Theme I)
2. Environmental factors (Theme 2)
3. Assessment techniques - getting to
know you (Theme 3)
4. Intervention (Theme 4)
5. StaffTraining (Theme 5)
The perceptions revealed by these inter
views do not purport to be th ose of staff
nationwide, and the implications for the
author's individual working practice are
perhaps of the greatest significance.
Time spent in individual assessment is cru
cial in establishing specific skills and
deficits and providing practical informa
tion to staff. There are few tools specifical
ly designed for working with adu lts with
learning disabilities, either for assessment
or therapy In this author's experience,
ISSN (online) 2045-6174
Rgure I - Principles of Service
Delivery (Communicating
Quality 2)
"The active role of
carers is seen as essential,
with therapists positively
supporting their
"Building an environment
that is conducive to good
communication is
particularly significant to
this client group. It is
recognised that developing
improved physical
surroundings, personal
circumstances and
appropriate communication
used by carers will
significantly benefit the
success. These should
always be regarded as a
primary focus for
Indeed, if carers are not
able "to adopt and effect
the necessary change for
goals to be achieved", then
this may act as a trigger for
resea rch from applied linguistics has pro
vided useful models (Nunan, 1992).
Assessment should be comprehensive a nd
include both naturalistic and more formal
contrived communication and language
tasks foc using on specific skills. It shou ld
also link into the specific nature of the
client's learning di sa bility a nd take
account of thi s. The time implication may
be considerabl e. Jvly own working practice
has adapted and the assessment phase may
run into several sessio ns for o ne client in
vari ous settings.
The speech and language therapist acts
also as a source of information for carers
regarding medical aspects, individual syn
dromes and their associated disorders, sen
:..................................... ...... , .. ,., ....... ............................. .......................................................... .
Theme I - Individual skill / individual difficulties
tMost people communicate somehow in their way'
The speech and language therapist was expected to
start from the client and their specific skill set in any
review of communication skills.
was recognition amongst staff that lack of speech
did not preclude communication skHls. Speech, whilst
powerful, is not the only communication method and
stdff were tuned into this. Intelligibility in articulation was
not highly rated as a communication skill, but staff did
identify it should be considered in comprehensive
and clear reasons be given for not working
on It.
Staff felt professionals like speech and language therapists
should be in a position to provide detailed infolmation
about factors associated with specific syndromes. such as
physical and sensory deficits. They also perceived we are
able to access other services such as screening for
hearing and vision more readily, perhaps because we are
also employed by health. Staff generally felt hungry for
information and knowledge about what can be expected
in terms of individual skills / deficits with different
disabilities. There can be startlingly low levels of
knowledge about relatively common disabilities such as
Down's syndrome. This was found even in professional
staff who have many years of experience working with
people with learning disabilities.
A .of social identified as the most disabling
defiCit In commumcauon and marking people out as
learning disabled in the wider community. Other factors
considered important were individual client language
skills (particularly specific areas of vocabulary such the
language of emotion). There was recognition that
individual inabilities can lead to frustration and so-called
challenging behaviour. Challenging behaviour was
generally viewed as communication in another form.
sory impairments and the impact Ihese
Combine the best
have on com munication.
The views of carers and in particular their
The role of the therapist as a consultant
attributions as to the causes of specific
rather Ihat hands-on clinician with Ihis
communicati oI1 breakdown, and therefore
client group is not as c1ear-cllt as some ser
th e potent ial for change, need to be
vice del ivery models suggest. as there is a
exp lored before any therapeutic process is
need for me to demonstrate by my own
underta ken. Wh ilst training achieves
communication behaviour with clients
much in raising awareness of communica
how staff sho uld communi cate. There is
tion d ifficulties in general. it may not go
still a need to focus o n indi vi dual skill s
fa r enough in changing speci fic behaviours
and needs within the context of the overall
with individual clients. For Ihi s to come
learn ing disability, and to relay that assess
about, we need 10 combine the best from the
ment information to staff. There is also the
consultative model a nd Ihe less fashi onable
need to focus on the partnership element
but neverIheless sti ll va lid Iherapist role.
in commun ica tion and the research by
Penny l-fodg/limon is Specialist Speedl and
Dell a Money, the Over and Out package,
Therapist - AIiu/t Learning Oisabililie> Sen>ice uoirh
represents a step forward in this area. Mid-Arzgljo Commllnit)' (NHS) Hetlltii TTI/Sl.
ISSN (online) 2045-6174
Theme 2 - Environmental fadors
We have no idea how to tapin'
The staff interviewed were conscious of their role in
promoting communication and of the inflexibility of
some of their organisations and settings. Some felt
thei r days were so busy (organising Individual
Program Plans or other planning meetings, arranging
transport, fi lling days with meaningful activities,
covering staff shortages), it was sometimes hard to
be sensitive to communication methods which are
different N ew staff coming in need to be made
aware of specific individual communication needs,
not always easy to accomplish. Staff felt they
sometimes lack the "breathing space" to create
opportunities within the routines / constraints of
their organisation.They often relied heavily on
assumptions about communication abilities, both
over and under estimating skills and situations. It was
recognised however this was within their sphere of
influence - it is "our shortfall and our responsibility".
Staff accepted their role in adapting environments to
promote communication but also commented the
generally limited life experiences of clients may
contribute to limited opportunities overall for
The impression was one of de-skilling, a kind of
powerlessness in their ability to bring about change
in their own workplace and a sense of failure.
Speech and language therapists were felt to have a
role to play in empowering and acting as a
role-model for staff. Showing staff how to "tap in",
and demonstrating regularly and in context the
communication skills which were important was
highly rated rather than telling staff how to
Glaser, B. and Strauss, A. (1967) The
Discovery of Grounded Theory. Chicago:
Aldi ne.
Hurst-Brown, L. and Keens, A. (1990)
ENABLE: Enabling a Natural and Better
kifestyl e. London: Forum Consul ta ncy.
Jones, S. (1990) INTECOM; A package
designed to integrate carers into assess ing
and developing the com munication skills
of people with learning difficulties .
Windsor: NFER-Nelson.
Money, D. (1997) A compari son of three
approaches to de.livering a speech and lan
guage therapy service to people wi th learn
ing disabi I iti es. European Journal of
Disorders of Communication 32 (4).
Nunan, D. (1992) Research Methods in
Language Learning. Cambridge:
Cambridge Uni versity Press.
Pahl, J. (1992) Force fo r Change o r
Opti o nal Extra? The impact of research on
poli cy in social work and social welfare. In
Caner et al - Changing Social Work and
Welfare. OU Press.
RCSLT (1996) Communicating Qua li ty 2.
London: Roya l College of Speech and
Language Therapists.
Stevens, L. (19 93) Reflexivity: recognising
subj ectivity in research. In Health Research
in Practice (eds Colquhoun, D. and
Kellehear, A.) London: Chapman and Hall.
Strauss, A. L. (1987) Qualitative Analysis
for Social Scientists. Cambr idge:
Cambridge Uni versity Press.
Thu rman, S. and Money, D. (1996)
Theme 3 -Assessment
The common theme was
time; staff felt taking time to
get to know the client and
their different communicative
contexts was crucial.
Assessment should take place
in every context - home, day
service, residential care. Staff
felt speech and
therapists needed to De with
indiviauals and groups not
just to observebut to
participate. They found
checkJlsts and interview
schedules difficult to fill in,
aJthough they didn't object to
speed\ and language
staff filling them in with them.
There was some
disagreement as to whether
the therapist should rely on
carer reports or should
assess dlrectJy. Many staff
wanted the speech and
language therapist to be
actively and directJy involved
and not to rely on carer
reports / observations.
Others recognised the
impact on resources this
could cause.
Talkabout. Nottingham Community
(NHS) Trust.
van der Gaag, A. (1989) The view from
Wa lter's window; social environment and
the communicative competence of adults
with a mental handicap. JOllrnal of Mental
Deficiency Research 33, 221-7.
van der Gaag, A. and Dormandy, K.
(19 94) Commu nication and Adults with
Learning Disabilities. London: Whurr.
Whyte, D. (1992) A family nursi ng Approach
to the care of a Child with a chronic illness.
JOllrnal of Advanced Nursing 17.
The Summer '98 issue will feature an
approach to changing the communica
tion behaviour of carers for adults with
learning di sabilities.
ISSN (online) 2045-6174
Theme 5 - Stafftraining
This was perhaps the most
contentious area of staff
perceptions. Many had
Theme 4 - IntefYention attended workshops on
Staff felt strongly that intervention for improving issues around communication
communication should take place via care staff. It but felt unable to translate
should be consistent across all contexts as far as this into practice; in general
possible and time frames should be built in. staff training was viewed as
Therapists should supervise in a hands-on capacity unlikely to achieve change in
with care staff in situ to model and demonstrate the behaviour:
strategies to be used. Alternative and augmentative Training should be tailored to
communication (AAC) should be taught to all care individual cases, in-house and
staff before it is introduced to the client and signing more ongoing than one and
training sessions w hich are not based around two day more theoreticaJ
individual client needs are unl ikely to work. Staff workshops.To bring about
want to be told w hat to say and do by the therapist change, staff wanted specific
in the communicative situations as t hey arise, one examples of what to do and
saying " Put the words into our mouths". Again this what not to do.
has implications for the " hands-on" versus consultative
role of the speech and language therapist
Communication is such a context bound behaviour
that sometimes being on the spot can provide
opportunities for commenti ng on staff behaviour.
1FIiT"'____-... ..... ....... ... ......... .. ........... .. ........ ........... .. . ................
should use the best elements of the consultative and hands-on roles
iIC7.......... .................. ....... .. ............. . ..... ... .. .... . ... ........................ .. ....... . .. .... ...... ... . .. .. ................................................................. . ........................... . . . .
,............................................................................ .. ... ..... ........................ ... ........................ .......... ................................................. ......... ... ....... .
and language therapists are expected to provide detailed information
Individual 's aisability as well as communication strengths and needs.
4. Poor social skills and specific areas of vocabulary mark people out as different
and should therefore be considered for therapy; clear reasons should be given if
articulation skill s are not targeted.
sts should participate in daily activities so they can empower staff by
them appropriate communication methods regularly and in context.
6. Training should be in house, ongoing and tailored to individual cases,
providing speci fic examples of what to do and what not to do. Care staff should
be taugnt AAC before It is introduced to the client.
udes anq of carers have tc? be taken into account w hen .
change In their communication behaViour and Improving service deliver y.
L'- .....
ISSN (online) 2045-6174

challenging hlindness
at risk
The Royal National
Institute for the Blind is
slamming community
care for people with a
visual impairment.
It contends all newly
referred people with a
permanent and substan
tial sight loss arc at
immediate risk and
should be considered as
'disabled'. This should
trigger a full community
care assessment to take
into account other rele
vant social, medical and
environmental factors
which, combined with
visual impairment, can
increase the likelihood of
risk leading to accident.
A Questioll of Risll (free),
RNIH Crl.'tomer Serrtices,
tel. 034.5 023 153.
Realising possibilities
A research speech and language therapist has co-authored a book
highlighting communication problems.
Sarah Barnett collaborated with Professor Sheila Hollins, Professor
of Psychiatry of Learning Disabilities, to produce Michelle Finds a
Voice, the story of a young girl who tries to describe the theft of her
handbag to her family and the police using a very limited and out
dated language / sign chart.
The book is the fourteenth in a series designed to help healthcare
professionals and families realise the possibilities of communica
tion. Professor Hollins says "even professionals such as doctors,
therapists, psychologists and carers fail the 'MichellI'S' of this world
by denying them access to alternative and augmentative communi
cation systems,"
From: Royal College of Psychiatrists, tel. 0171 2352351 exU 46, price flO.
Teletubbies in good voice
Coaching was provided to the actors on the BBC's Teletubbies
to help the mature actors adopt the range of a child's voice.
Roz Comins of the Voice Care
Network carried out routine
voice work with the characters
including exercises for warm
up and to explore and find
appropriate voice quality.
A range of groups now recog
nise the value of voice coach
ing, including magistrates and
keep fit instructors, and the
particular needs of physical
education and swimming
teachers were explored at the
Network's third Annual Study Meeting. Also included was dis
cussion about classroom amplification.
The Voice Care Network runs practical interactive study days,
The next Annual Study Day will be in Birmingham from 6 - 7
September. For details, contact Roz Comins, tel. 01926864000,
South African
A specialist medical
reCTllitment colllpan)' in the
UK has opel1ed a South
African office.
Healthcall Euromed aims to
mahe the inteTllational move
of professionals, including
speech and language therapis15,
easier. The company reCTlli15
and places staff 011 a locum
and permanent basis.
Details: Leslie Giltz, tel. 0171
Schools Liaison
Schools Liaison
Officer to help
the 100 000
school aged children
ill tire UK who stammer.
Chen,), Hughes, who stmnmers
Irenel! has coll5iderable
experience in education . She
will be il1itiating a pilot scheme
of in-service teacher trainillg
wiLlI tire assistance of local
speech and language therapists.
Other duties will include
helping pupils with oral worh
and dealing with issues of
bullying and careers guidance.
Details: BSA, tel. 0181 983 1003.
The BSA now has a website:
Rhyme resources
A nursery rhyme activities book
has been added to Scholastic's
starting with rhyme series.
Counting rhyme and Action
rhyme activities are also
available for use with children
aged three to six and are
From: Scholastic, tel. 01926
Textphone help
Royal Mail has installed
specially designed text
phones at
_ .,. customer help
llllIIiiili:frji.""iillII centres for deaf
and hard of
hearing customers. Staff
have been trained by the Royal
National Institute for the Deaf.
Royal Mail Textphone calls:
Customer SelVice 0845 600 0606
Sales 0845 600 6066
Address Management
0845 606 0604.
PGSS onfilm
A new video, Paget Gorman Signed
Speech: The Filmed Vocabulary,
contains over 4000 signs jrom the
7th edition oj the manual.
Eight cassettes each run jor
approximately two hours:
Vol. 1Standard Hand Postures
Basic Signs with all their related signs
Vols 2 -4 Basic Signs as above, FOOD
Vol. 3 includes Prepositions.
Vol. 5 Nouns in categories (eg. Clothes,
Household, Family)
Vol. 6 Miscellaneous Nouns, Pronouns,
Adverbs, Conjunctions, Questions, BODY &
SENSATION hand signs.
Vol. 7 Verbs
Vol. 8 Adjectives, Determiners, Number,
Mathematics, Measurement, Calendar Time.
Cost: 90.00 per set oj eight tapes piUS p&p oj
Orders with payment to: The Paget Gorman
Society, 3 Gipsy Lane, Headington, Oxjord OX3
7PT Tel. 07865767908. The Society now has a
comprehensive site on the Internet:
for spouses
A new leaflet
gives partners
and spouses of
people who
about how to help.
The British Stammering
Association leaflet
explains how someone who stam
mers who undertakes therapy may discover
a new assertiveness, reveal vulnerabilities
for the first time, or begin to express feel
ings such as anger that they have tended to
bottle up. It encourages couples to talk to
each other about stammering.
Author Sarah-Jane Wren is assessing the
level of interest there would be in a course
for spouses and partners of stammerers at
the City Lit. (tel. 0171 242 0224) .
Cost: sOp per copy or 4 for ten (inc. pap)
from BSA, 15 Old Ford Road, London E2 gpJ.
ISSN (online) 2045-6174
orl<ing wrth

pers ectlves
from ersonal
Sasha Bemrose and
Malcolm Cross
outline techniques
of Personal
Psychology using
case examples from
their innovative
work with parents
of deaf children.
n our work with parents of young deaf children, therapy
often focuses on the interaction between the parent and
the child to develop a language rich environment. Before
this can take place, it is important to discover how par
ents see things, if and why there is a need for change and
within what parameters this change can come about.
Without this understanding, any intervention focusing
on change is likely to fail.
Personal Construct Psychology (PCP) values the parents' ways of
thinking and, s n approach, can challenge and libel'ate them. It
provi des tools for explorati on and can offer expl anations for the
ways we behave which al'e personal or unique 0 t he individual.
The therapist can help the parent discover and test the validity of
t hew personal construct system and, where nece sary, work
t oward change (Bannister & Fransella, 1986) .
A unique view
pCP IS based on George Kelly's notion of Const ructive
Aiternativism. Essentially his philosophical positJon remInds us the
pe specti ve we take of events i JUst one of an infinite range of
interpretations available t us. Therefore, ever yone IS responsible
for constructing a unique view of the wOI'ld. Construction and
Reconstruction are hemes cenlral Lo PCP The human capacity
to revise heir view of their ci rcumstances IS based on the under,
standing that events do not possess inherent or unvarYing mean
Ings. Instead, we make meanings or place intel'pretations upon
events (Kelly, 199 I ). I the language of PCP these interpretations
are called constructs and have a range of qual ities.
Our constructs are vali d ted by observing at' experiencing their
repl ications: we collect eVidence ba ed on OlW antiCipation o '
events. If a constnlct ha helped us under and a situatJon III the
past, t hen we will see this as a lid Interpreta Ion anci It '111 help
us predict rutul'e events. I . tor examp!e. we have ac ieved success
ISSN (online) 2045-6174
Carol has a one
an.d a half year
old daughter
This method was used
with Sarah who has a three year
old son with a profound hearing loss. She
had vague concerns about herself as a parent
and triadic elicitation helped explore the dimensions
she used to make sense of parenting. This was achieved
by asking Sarah to think of a number of parents she knew.
These parent figures included herself as she is now, as she was
before she became a parent, as she w ould like to be as a parent,
her parents, parents she admires and does not admire and so forth.
The therapist asked Sarah to choose three names at random and say
how two of them were similar (circled below) and different from the third.
Elements/People ~ Me ~ My Mum
. ,
'need to be
In control'
vs 'relaxed'
who has a mod
erate hearing
loss. Carol said
she felt her
daughter did not
talk and there
fore she was not
able to interact
with her. In this
nstance 'does not
One of the dimensions Sarah identified which she used to make sense of par
enting was 'in control' versus 'relaxed'. She felt she needed to be in control
but would like to be more easy going. The articulation of this construct
helped Sarah discover she did not have to be only 'in control' or 'relaxed'
but rather that different poles of the construct could apply at different
times. It enabled her to see ways of being more like the kind of parent
she wished to be. She identtfied aspects of parenting where she could
be more easy going (during play sessions with her son) and some
times where It was helpful for her to continue to be in control
(when disciplining h e l ~ son). After a few weeks Sarah reported
she felt more confident as a parent and was enjoying the time
she spent with hpr:... cl}n, attributi ng this to her new insights.
talk' was the emer
gent pole. She felt the
opposite of not talking
was 'saying words'. From
this elicitation the therapist
and Carol discussed non
verbal aspects of her
daughters communication,
ego pointing, vocalising, eye
contact. Following this dis
cussion she became more
aware of her daughter's
attempts at communicating
and began to accept these
as 'talking'. From this
reconstruction she was
then able to begin the
process of more effectively
Interacting with her child.
in the past by being pushy. then we are likel y to use this strategy again
in t he future. Constructs are unique and therefore we expect peo
ple to make sense of the same events differently Personal ConslnJct
Theory suggests we use particular constructs to make sense of a
finite range of events. Most importantly, personal construas are hiel-
archical, that is, some are More important than others.
When uSing PCP with parent s of deaf children, the personal con
structs chosen for exploration are t hose defined by the parent as
problematic or collaboratlvely identi fi ed by all part ies as Inhibiting
change in the desired directi on. Constructs may be eli crted in a vari
ety of ways including informal and tri adic. Further techniques of lad
dering cl.nd pyramiding can be used t o probe personal perspecti ves.
I )Informol Eliciting (Dolton & Dunnett, 1992) (Case I)
By listeni ng to the way the parent tal ks about particular issues, the
therapist can build up a picture of how they view their situat ion.
For example, the pal-ent may say "rt's hard work looking after a
deaf dllld" . We can infer the parent has a construct about looking
after their- child; 'hard work' versus something el se. In this instance
'hard work' is tne emergent pole. The therapist can t hen ask what
It would be li ke looking after t he chi ld if It was not 'hard work' . We
mar Lhen find the construct is 'hard work' vel-sus 'enioyable'.
2) Iriodic Elicitation (Dolton &Dunnett, 1992) (Case 2)
ThiS is a more formal method of el iciti ng constructs. It explores a
person's di mensions 01- constl-ucts rn some detail and is particu
larly useful when a person fi nds it difficult to identi fy or express
their constructs.
ISSN (online) 2045-6174
Case three
a) Laddering
Frances has a two year old son who has a mild hearing 10ss.The therapist had observed
Frances tended to control any interactions with her son.This was not helpful in facilitat
ing his communication development as it did not allow any chance for him to initiate or
respond.This in tum minimised opportunities and incentives for him to learn for himself.
Many sessions had been spent discussing this wit h Frances but a change in her interac
t ion style had not been evident. She reported it was important for her to do everything
for her son. Using laddering we wet-e able to ident ify why t his was so. The tick repre
sents the pole of the new superordinate construct which Frances prefers .
.I 'good parent' vs 'bad parent'
.I 'feel competent' vs feol I.l_ less'
.I 'it's myI role' vs ''la.'e n roe
.I 'do evel-ythi ng for vs '!etting my d do
my child' things for h
Frances identified the opposite of doing for her son was 'letting my child do
things for himsel f .The preferTed pole is 'do everything for my child' and thi S as Impor
tant for her because it gave het- a role. She preferred to have 'a role' because she need
ed to 'feel competent' as this made her a 'good parent' (superordinate construct). If she.........
let her son do things on his own, she would no longer have a role and feel useless and,
by implication, a bad pat-ent.
It was therefot-e vital to understand why this construct was important for Frances as,
when therapy focused on encouraging Frances to let her child become more indepen
dent she was resistant to change because this meant, for her, being a 'bad parent'.
b) Pyramiding
Frances was asked to think of different ways she could be a good parent.
..------- 'good parent' ---------..
'meet child's needs' 'teach * ew skills' 'provide opportunities to learn'
Frances identified she could be a good parent in a number of ways; by helping her son
develop and leam, by teaching him new skill s and by looking after his needs. From this,
we discussed how being a good parent could mean letting her son be more indepen
dent as it enabled him to grow and learn new skills. O nce Frances recognised she was
still a good pat-ent if she let her son experiment with new skills, she was able to change
in a way which increased het- child's learning opportunities whil e still enabling her to act
as she felt a 'good pat-ent' should.
3. Loddering (Cose 30)
Laddenng can be used to explore w hy people make certain choic
es, why they I-esi st change or are greatly upset by what appear. from
o r'perspective. t o be 'minor event s' The technique is based on t he
Idea that some personal constructs are more Important (superor
dinate) t han other constructs (subordinate). Thi s procedure begins
by identifying a construct of interest and it s opposite pole ( I st level).
The parent identifies which of the two poles they prefer and why
this is important for t hem (2nd level). The opposite of t his second
pole is Identified and the preferred pole chosen. ThiS process is
repeated until the parent can no longer t hink of a new constnuct.
4. Pyramiding (Cose 3b)
This is t he reverse of laddering. Once superordinate const ructs
have been discovered we can use pyramidi ng to make the impl i
cations of a part icular construct concrete. Pyramiding is facil itated
by asking "how)" questions.
Facilitatin2 change
The techniques <iliove are formal and informal ways of eliciting
and explOring personal constructsThrough their use,the therapi st
may assist the parent t o examine 'their constructs, determine
whether these are helpful or unhelpful and look t owards person
ally acceptabl e ways t o change. Therapy may be achieved t hrough
simply helping the parent see new paths. They can be helped to
visual ise what the change is t o be, enact the goal (behave 'as I t
were) and subsequently experience and make sense of this ne '
real it y. When Frances (case 3) thought about letting her son be
more independent. she behaved in a way which allowed hIm 1
ISSN (online) 2045-6174
leam for himself and in doing so he became mOI-e Independent
The out come of her child being more independent was examined
in terms of our predicti ons (the child is more communicative). In
this example our pred ict ions were correct, which reinforces the
change the parent has brought about.
PCP can be used by therapists to work effectively with parents of
deaf children and also a variety of other client groups. We feel it is
essential to have an understanding of the philosophy and theory
behind PCP and have only provided a rudimentary introduction. If
the speech and language therapist, like George Kelly, is not inter
ested in the truth or falsehood of a person's view but simply in the
ways in which they view themselves and their relationship with
others, then they may be freer In their interpretations.
Sosha 8emrose is 0 Specialist Speech & Language Therapist ,',11 m
Camden & islington Community Health Services NHS Trust. Malcolm
C Cross is bosed In the Department of Psychology, School of Sociol
Sciences, City University.

Any correspondence should be addressed to Sasha o[ 464 A Homsey
Rood. London N 19 'lEE (tel. 0 171 281 2562 evenings).
Bannistec D. & Fransella, F. (1986) Enquiring Man (3rd Edil lon).
London: Croom Helm.
Dalton, P & Dunnett, G. (1992) A psychology for living: Personal
construct theory for professionals and cli ents. Chichester: John
Wiley & Sons.
Kelly, GA (1955/1 99 I) The psychology of personal construct.
Volumes One & Two: Norton. Reprinted in London by Routledge
in 1991.
For the purposes of r.his ortlcle the parents' nomes hove been changed,
PCP Training Courses
Counsel ling Psychology Research & Training Centre
12 Onsl ow Gardens, South Croyden, Surrey CR2 9AB
Tel 0181 239 6947
This article is the second in a short series looking at how speech and language therapists have used training in other
fields to assist their work. Neuro Linguistic Programming - A speech & language therapist's guide was in Winter 97.
A personal view of counselling by Christina Shewell and FamilyTherapy will feature in future issues.
What is the basis of PCP holds that each individual has a unique view of
Personal Construct he world, under constant revision in response to
Psychology? received and their interpretation of it.
Why might intervention Because change is dependent on the unique view of
M.lMtII he individual concerned, barriers to change may be
of a parent / child
interaction model fail? missed if a therapist makes assumptions about how
parent sees the situation.
How can a speech and .. rough PCP a parent can see one view does not nec
preclude another, and that a range of options language therapist use
PCP? is open to them.
AAC development
A new speech output device is available from Liberator,
combining pawerful language with dynamic screen tech
Vanguard gives simultaneous access ta everyday words as
Helping teachers
A speech and language therapy service to mainstream schools has
published two practical guides to running language groups in schools.
The West Sussex team responded to requests for more practical
advice to help teachers meet the needs of the increasing numbers of
weI! as those needed in speCific situations. Using icons and J........
Single-meaning pictures, most words can be selected with
two activations. Pre-loaded words, songs, books and
activities reduce the need for programming, but this can
children in mainstream schools with a
speech and language impairment. The
guides are intended to provide teachers
. be accomplished quickly.
The synthesised and digitised speech can be accessed by
tOUCh, headpointing or switch-activated scanning. Built-in
infrared capabilities provide cantrol Of appliances such as
a television or video recorder.
The Prentke Romich Company device uses Unity and
Language Learning and Living vocabulary programs.
Details: Liberator, tel. 08004582288.
,_ and teaching assistants with a frame
work to run language groups.
(Note: The guides will be reviewed in a
later issue of the magazine.)
Practical Guide to Running Language
Groups in Schools - Key Stage 1 a 2
and Key Stage 2 a 3 are available
from The Speech a Language
Therapy Service, Worthing Priority
Care NHS Trust, The Satellite Centre,
Shoreham First School, Victoria
Road, Shoreham, West Sussex
BN43 5WR. 15.00 piUS 1 pap
ISSN (online) 2045-6174
Group . ~ r a p y
In recent years, larger
caseloads and time
limitations have
made group therapy
a popular choice in
aphasia treatment
However to some
therapists it is still
controversial, with
many using it only
as an adjunct to
individual treatment
Caroline Davidson
and Carol Nelson ask
if a group approach
can be effective in its
own right
s members of a busy department in an acute
general hospitaL we felt a group treatment
approach for people with aphasia had a lot to
offer and was not being used to its full poten
tial. Although clients seemed to have benefit
ed from previous groups, we had never for
mally evaluated outcomes. We therefore con
ducted a small study using clients attending individual therapy
who had plateaued. We asked if they would be interested in attend
ing a group to see if any further gains could be made. The five,
whose ages ranged from 54 to 60, had suffered a cerebrovascular
accident between four months and one year previously. All had
non-fluent type difficulties, from problems at a single word level to
word-finding difficulties within phrases.
In our earlier groups, some of the tasks were at times unstructured,
and emphasis was often placed on social skills. For this project, we
aimed to develop more structured activities in keeping with the
cJients' specific linguistic difficulties. To identify these, a broad
selection of PALPA assessments (Kay et aL 1996)(TabJe 1) was
administered to each client before and after the group therapy pro
gramme by a therapist who had not previously worked with the
client, but who was involved in the therapy group.
Whilst we felt it important to measure individual linguistic gains,
we were also aware of the need to assess interactive aspects of com
munication. We videotaped conversations between client and
speech and language therapy assistant before and after group ther
apy. A functional communication profile (Table 2) adapted from
the 'Adult Communication Analysis', published by the Centre for
Independent Living in Ohio (Florance, 1981) was used to grade
clients on a five point scale, where 1 indicates a very poor and 5 a
very good score in four different areas.
An analysis of verbal picture description ('Cookie Theft' picture,
Goodglass and Kaplan, 1983) was also used, following research by
Mackenzie et al (1997) into right hemisphere deficiL The system,
based on original research by Yorkston and Beukelman (1980) and
Myers (1979), examines the interpretative and literal units in clienLS'
descriptions. Figure 1 is an example of the analysis technique
ISSN (online) 2045-6174
TABLE 1: Pre-Treatment Programme Assessment scores and percentage of change after.
PALPA no. R.G. P.M. R.K. E.C. J.I.
initial %change initial i'.change initial i'.change initial i'.change initial %change
score after score after score after score after score after
2:Same-Dlfferent 55172
69172 +3i'. 63172 +9% 72172
72172 -11.
4:Minimal Pair 29/40 +4% 39/40
81140 +101. 39/40 +2i'. 39/40 +1%
- -
47:Spoken word 24/40 +10% 39/40 +2% 39/40
38/40 +51.
Picture Matching
48:Written Word 25/40 -5% 40/40
38/40 +3% 39/40 -3%
Picture Matching
53:Spoken 18/40 +7% 29/40 +15i'. 24/40 +10% 26/40 +27% 13/40 +331.
Picture naming
53:Repeating 36/40 -3% 39/40 +21. 28/40 +30% 36/40
31140 +1Oi'.
Picture Names
53:Wrltten 0/40
22/40 +7'" 0/40
1/40 +38% 0/40
Picture Naming
55:Sentence-Pic. 28/60 +1% 54/60 -51. 84/60 +61. 46/60 +6% 39/60 +20%
Matching (aud.)
56:5entence-Pic. 27/60 -8% 45/60 +1Oi'. 24/60 +20% 29/60 +9% 43/60 +111.
unication Profile
IABLE 2 functional Com
\ \
communicative Success:
, message acroSs
Ability to get one s
orcl correctly
Ability to say eac W
ancl contextually
Accura es
appropriate respons
The group ra n weekly for two hour sessions over twelve
weeks with two therapists. The clients did not receive
any addit ional individual peech and language therapy.
On assessment, all cl ients had problems both at a cen
tral semantic level and at the Ie eI of the phonol ogica l
output lex icon. Tasks were designed to target these
areas and three examples are detailed in Figure 2.
These therapeutic activities were designed to work
primarily on input and only at the end stages of the
12 week block did we try any verbal output tasks.
We were aware that. although there is a great deal of
information wri tten on the benefits of group trea t
ment, there is minimal discussion of therapy proce
dures. Thus many group tasks are employed from
individual thera py and there is a risk that each
client is treated sequentially within the group, with
little interaction between group members and the
therapist. What occurs then is not good group
hich are neither therapy but inefficient individual therapy within a
Responses W strictecl in length group setting. The tasks we used were taken from
abnormally con ________ therapy tas ks

_____--l and at times it was

E - very difficult to
of literal and interpret t" adapt them for
a Ive UnIts group therapy.
P' Holland (1975)
Icture description' reports we must be
Right. aware of the
The Wee bO\J is ct"'nd' _ Literal strengths and weak
" ':..J.. .. <A Inn " I nesses of individual
and Its "f."'II' nterpretatl've
<A mg Over group members and
"takin' Cookies structure acti vities so
g " all group members
onna hurt himself can participate. Thi s
did make preparation
ISSN (online) 2045-6174
of new tasks chall engi ng but by arranging them in hierarchies of
di fficu lty it all owed cl ients o f varying severi ty to part icipate in the
same task with in the gro up . Thi s also facilit ated in terpersonal
communica ti o n betwee n clien ts as they attempted to aid a nd help
each other.
Although therapy tasks we re designed to work specifi call y o n the
cli ents' areas of difficulty, we we re aware o f the need to encourage
more communicative skill s. There was a time fo r group discussion
and the cl ients were left a to ne at tea breaks to encourage them to
ini tiate and maintain a conversa tion.
PALPA outcomes
An improvement of at least 10 per cent was seen in two or more of
the nine PALPA assess ments with every cl ie nt (Table 1). Fou r of the
fi ve cl ients made- considerable progress in the spoken picture nam
ing assess ment ( ranging from 10 per cent to 33 per cent ), and three
showed an improvement of 10 pe r cent or more in the wri tten sen
tence-picture matching.
Individual clien ts a lso improved signifi cantly on a number o f
assess ments, ego EC scored 33 per ce nt more on written pi cture
na ming, IT improved by 20 pe r ce nt on sentence to pict ure match
ing (audi tory) and RK by 30 per cent on repea ting pict ure names .
These areas a ll showed progress even though t hey were not specifi
ca ll y targeted during therapy.
'v\le felt the mos t encouraging change was o n the spoken picture
nami ng task, especiall y as the majority o f therapy acti vi ties d id not
work on ve rbal output. The one client who di d not improve by 10
per ce nt or more still improved on his pre-assessment score by 7
per cent; it was later d iscovered he was suffering from lung ca nce r
whi ch may have affected his overall performance.
Altl10ugh PALPA assessments have not been formally sta ndardised,
all ite ms used d id have descripti ve stati stics for testing o n cont rol
subjects. We are awa re that imp rove ments made in many of the
assess ments would have to be repli ca ted o n re-assess ment to be sta
tisti call y viab le, but fee l the results to be encouraging considering
many o f the cl ients had ceased to make gain s in individ ual thera
py. We we re also aware of the di ffi culties encoun tered in us ing the
sa me therapi sts to test, re-test and treat these client s.
Functional outcomes
Even tho ugh funct io nal communi ca ti o n was not specifi cally tar
geted in therapy, small gains were made by all ( table 3) . All clients'
scores improved for communicative success (ability to get thei r
message across) and three out of fi ve improved on effi ciency ( mak
ing res ponses o f an appropri ate length) . Wh il e analysing the video
tapes, it became appare nt that cl ients' communicative confi dence
had a lso increased, but this was not formall y measured.
Initi all y cl ients had grea t di fficulty i ni tia ting a nd mai nt ai ning con
versatio n among the group without therapist input. After the twel ve
week block, cl ients were more relaxed and beginni ng to m at among
themselves in the wa iting room a nd at tea break. They also helped
eam other more readil y when communi cat ion broke down or when
one of the group members had parti cul ar d ifficulty with a task.
Picture descriDtion
The result s of the Cookie Thett picture analys is showed measurabl e
improve ment in all the client s' int erpretati ve uni ts - with scores
increaSing by between two and six point s - and in fo ur of the five
with thei r lit era l units (Tab le 4). Interestingly, in resea rch o n no n
brain-injured ad ult s ( Mackenzie et at, 1997), the int erpreta ti ve
units were found to be a more stabl e measurement tha n the lite r
al units.
Even though this was a new assessment to us, we felt it to be par
ticularl y useful in uying to measure discourse forma ll y.
Encouraging results
Ke-a rns (1986) has although mos t gro ups target one or
more pa ra meters, they are a ll intri cately relat ed and improvement
Figure 2 - Examples of therapy tasks
a) Phonology
Graphemes were written onto small pieces of
acetate and used with an overhead projector
(OHP). A CVC word was arranged on the OHP
and clients had to look at this while listening
to the same or another one spoken by the
therapist. They had to deci de if the two
words were the same or different.
Thi s t ask was then expanded by asking the
client s t o identify where the change had
occurred within the word. At this stage they
were given a choice of three graphemes and
had to decide what the original grapheme had
changed to. Initially the choice of three
graphemes differed in all parameters (voice.
manner and place) and as the task pro
gressed this was reduced until there was a
difference in only one parameter.
b) Semantics
(i) Odd one out task where four pictures were
put onto acetate. These were closely seman
tically related. Clients were asked to select
the odd one out and to justify their choice.
This initiated a great deal of group discussion
and debate. Examples are cokeltea/lemonadel
milk and bus/planeltrain/car.
(ii) The aim of the task was to strengthen
semantic links using semantic circles. The
clients had to identify which pictures could be
linked to the item in the centre of the page.
1 I

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/ 1\1cu-sE

(:..,pp '__ i::::


ISSN (online) 2045-6174
TABLE 3: Difference between Pre and Post Treatment Functional Communication Scores.
R.G. P.M R.K. E.C.
Communicative +1 +0.5 +1.5 +1.5
- -
Intelligibility +1 = +0.6
TABLE 4: Changes in 'Cookie Theft description scores after treatment programme.
R.G. P.M R.K. E.C. J.T.
Literal Unite +:3 +14 +4 +2 -2
Interpretative Units +:3 +2 +6 +4 +4
in one may affect the other. This study aimed to work on specific
linguistic areas and although improvements were seen in these,
there was also significant progress in social and communication
We plan to continue developing a group approach as we are very
encouraged by these results and feel the gains are well worth the
effort involved.
Florance, C. (1981) Methods of Commun icat ion Analysis used in
Family Interaction Therapy. In Brookshire, R.H. (ed.), Clinical
Aphasi%gy Conference Proceedings. Minneapolis, Minn. BRK
Goodglass, H. and Kaplan, E. (1983) Boston Diagnostic AphaSia
Examination. Lea & Febiger.
Holl and, A.L (1975) The Effectiveness of Treatment in Aphas ia.
In Brookshire, R.H. (ed.), Clinical Aphasiology Conferen ce
Proceedings. Minneapolis, Minn. BRI<.
Kay, ]., Lesser, R. and Coltheart, M. (1992) Psycholinguistic
Assessments of Language Processing in Aphasia (PALPA) .
Lawrence Erlbaum Associates Ltd.
Kearns, KP (1986) Croup Therapy for Aphasia: Theoretical and
Practical Considerati ons. In Chapel', R. (ed.), Language [nteT1lencion
Strategies in Atli lit plld_, ill (2ml f!el .) Williams and Wilkins.
Mackenzie, ' ., Begg, '., Lees, KR., and Brady, M. (1997) Right
Hemisphere Stroke: In cidence, severity and recovery of language
disorders. Suoke Association Final Report.
Myers, P.S. (1979) Profiles of Communication Deficits in Patients
wit h Right Cerebral Hemisphere Damage: Implicat ions for
Diagnosis and Treatment. In Brookshire, R.H. (ed.) Clinical
Aphasiology Conference Proceedings. Min neapolis, Minn. BRK.
Yorkston, KM. and Beukelman, D.R. (1980) An analysis of con
nected speech samples of aphasic and normal speakers. Journal of
Speech and Hearing Disorders 45, 27-36.
Are there pitfalls in
group' tnerapy for
people with apnasia?
What skills can group
therapy target'?
How can conversational
skills be measured?
~ A n s w e r s
Group members may be treated sequentially, with
tasks borrowed from one to one therapy, rather than
therapists taking the opportunity to adapt activities
to foster interaction and discussion.
It is possible to show measurable gains in specific
lingUistic areas, functional communication and
conversational skills through a therapy group.
Analysing picture description by literal and
interpretative units enaDles discourse to be
checked formally.
ISSN (online) 2045-6174
Word finding test essential
The Renfrew Language Scales
repackaged I revised
Catherme R nfrew
AelJon Picture Test [16.50 +VAT
Word Finding Vocobul ry Test [1 9.75 + VAT
Bus S o y Tes I 3.50 + VAT
Fa - this four th edltJon. the Renfrew Language
Scales have been repackaged and each test is
now stored in a clearly marked box. Each test
has a score sheet photocoplable onto A'i size
Action Picture Test
The stimulus pi ctuJ'es. administration and stan
dar'dlSatr on are t he same as t he thi rd edrtton.
W hile the manual is more cleari y laid out,
overall the con l ent is ver y srmilar
Word Finding Vocabulary Tpsl
The stimulus pictur-es have been updated and
represent a more contemporar y vocabular y
The draWings ar'e much cl earer The standardi
sat.on has been re-done on a larger sampl e
Bus Story Te t
There have been slight cnanges to the picture
deSign and colour. The st ory is now presented
in a Rip- book' style with the spine at the t op.
although p rs nally I preferred t he reading
uook style of p -eVIOUS ditions with the spine
at t he side - It was easi er t o um the pages, it
set t he scene for 'sharing' a st ory book and
Iso r inforced the not ion of left-to-right ori
The manual is r ore cl early I id out although
the content IS very similar to t hat of the third
editron The Ion has not changed.
The phot ocopiable score sheet provides a
us ful guide for' sconng " informali on".
In general:
" The new packaging made the tests easi er to
store than previous editions. However. as a
penp,-.tet lC her apist. I also found the new test s
bulky t o carr y.
, I found the pietur-e aterial more durable
than previous edttr ns.
The standa 'disation sanlples excl ude chil
dren Ith significant language diffi culties (eg
childre in language units for toe Ac ion
Picture Test, chil dren wll o are or are likely to
be stat ement ed for t he Word Findrng Test)
The mr: ao could therefore be artificially high,
so chil dren wilh r:111 d diffi culti es may appear to
have mOr-e significant problems.
The Renfrew Language Scales COl tinue to be a
val abl e assessment tool fOI' paediatric speech
and language therapists and students. If pur
chasing new test material I wo Id consider the
our' th edition oftheWor FiodingTest essential.
Howeve'" I would want to co SIder seli ously
e Ileed 0 I' place the hil-d editions of the
A Ion Picture Test and Bus St o y Test.
Jill Pormo Jse is () speech and anguage therapist
WIth the Un,ted BnSlO1 Heollhcwe NH5 Trust.
Sht is /Ilvolved m a project il nplementJng speech
nd language therapy in mainSlfeam schools ana
also wUlk.$ WIth chrldren WIt! aubs n.
Infinitely readable
Language Disorders in Children
and Adults
ed. S urla Chial James Low & Jane
l\II orsh /I
WhUl f
ISBN I 861560 14 1 0 4.50
In the words of Jane Marshall. thiS
book is writte,) at an "Interesti ng
wat ershed in Brrtish speech and lan
guage t herapy" . a t ime in \ hi ch psy
chol 1l1guisl ics are being appl ied In
both developmental and acqUired
pathology. Acmss the board we are
looking at language processes rather
t han descr ibing symptoms. Thi s book
looks at the l heory of psycholinguis
tiCS and the practical applicati on of
t heory to assessment, therapy and
appraisal of effi cacy.
The malll content of the book is
divided into four sections: phonologi
cal processing, leXical processing, sen
tence p r-ocessing d pragmatiCS. The
theory of processing is pr"esented in
each secti on and IS foll owed by com,
prehensive case histories of both child
and adult cli en . Each case histor y
incl udes extensive informat ion regard
ing assessment and t herapy tasks, ai ms
of t herapy and eval uati on oh he effec
of therapy. In each section a
shor t 'aft erv'Iord' dr aws paral lels
be ween chil d and adult cl ients.
In summary Ma!"ia BI ck states the
barners between chil d and adult
assessment have been shown to be
mor e histOrical than theore leal. She
points to the extensive common
gmund whi ch becomes inueaslngly
appal'ent t o the I'eader as she pm
gresses through thi s book.
The book res Its from a conference
where individual speech arl O language
t herapist researchers pl'E'sent ed wor k
wit h common gmund. It is therefo(e.
at times. difficul t o be cer-tain that
chil d nd adult assessment and hera
py are t apping Identi cal an:; a5 These
weaknesses are discussed openly as
are surprises i) therapy outcomes
whi ch we II experi ence worki ng with
real people 1Il dynamiC situati ons
This book combines the t heol'etical
IS ues surrounding language process
ing al ongSIde practi cal appli cations
wth bo h hdd and adul I is a must
for therapists workln With larguage
disordered chil dre and a uits. It is
intinit ely readable as whole or each
sectr on or case history can stand
Teresa Ead BSc (hons) ;\tISc RCSLT is
a Senior Speech & Langu<1ge Theraprst
witn Mid Essex Communtty & ental
Health Trust

A valiant attempt
NLP Counselling
Roy Bailey
ISBN 0 87388- 157-2 0 395
Neurolingulsti c Programming emel-ged in America
f!"Om observati on of the work of three t herapists
who were also superb con)municators: Satl r: Perls
and Er'i ckson. Gnnder, ? Professor of lingUisti cs, and
Bandler: who studied psychotherapy and comput ,
er s, analysed and descri bed t he ingredients of effec
tive communicat ion demonstrated by the t hree
therapists. ;)s it is now known, has since
become widely recognised as a I resource of
psychotherape bc t ool s for change by counsell ors,
d ents and speech nd language erapists ali ke.
Roy Bcu ley's introductory book is a useful addition
t o the book shel f for those familiar wit h NLP and
t hose new to the subject.
The book covers all aspects of communication; it
traces the orIgins of LP. gives a .I ossar y and
description of t he t erms used and ouLii nes tech
niques empl oyed for en co raging pOSiti ve hera
peutic outcomes. Speech nd language therapists
dealing with all dient groups will be pal-ti culariy
i 'erest ed In patterns of language used by clrents
which indicate the preferred sense 'lith which they
construct an I dividual realrty. be it vIsual. audrtory,
gustator y. olfactory or tacti le. Body language, eye
movements and their pi ce In communICation.
breatn and tone of voice and the ntpli cati ons of
these for conveying meaning are described in detail.
as 15 the nature of r apport - an essential first step in
buil ding rust and a secure wor king relationship.
Cl ear VI ual ch rts illu tr t e step by step the tech
niques covered. from re ramrng t o the constructi on
of therape tic met aphors. Tlle over-all impression is
of a vali ant attempt to cover a vast amount of
matenal in an organi sed. clear and approachable
way Roy Bai ley empl oys appmpi-iate case histor- y
dial ogue to good effect t o highlight the processes
he descri bes.
This t ext offers bot h a start mo poim for those newly
Interest ed In the subject and a I-eference h- ndbook
for those who have attended experiential work,
shops ,.nd who air-cady h ve a worki ng knowledge
of NLP Because the model used by LP practitJon
ers involves clos observation of communication
stril tegles dnd pmvi des opportunities for change
towar-ds rnor' e positive and effective intel- ctl on,
NLP is particuldrly useful for speech dnd langua e
t herClpists in e areas of voi ce and Duency therapy
and where there are learning difficulties. LP also
offel-s echniques for enhancmg and maintaining r-ap
pon . for probl em solvi g, for increaSi ng confidence
and accessing resource I slates of mind. all of which
skills are needed by both cirent and therapist to n
nbute t o i! sci ccessful outcome. This is a valuable
book for therapists who ill'e Interested in using '.his
type of approach in their practl e.
Jennrfer Bell, a member 0 rhe ASsoCllitron or Speech :?
Language Therapists in Irdependent Prf)ctICf: i.>
speech and languoge lheroplsr in Devon
(NLP - A Speech & Language Therapist's Guide by
C;Jrollne Skelton feiltured In the Inter 97 ISSile - .
Speech & Language Therapy in Practice
ISSN (online) 2045-6174
Many ideas will be used
Autism - P.D.D. More Creative Ideas From
Age Eight to Early Adulthood
janice I. Adams
Available (rom Winslow
Orderre{: 163-3635 97 06.95
This is a very practical book ror parents. carers
and professlonills. I contains theory bout
autIsm and POD and assumes readers are famil
Iar wIth the ImpaIrments present In these co d"
tions. There IS some 0 erlap with the uthor's
prev ous book. Autism - PDD. Creaave Ideas dUring
rhe School Years. Th,s book how vel" contaIns
mOl'e suggestions relatIng t o teenage years an
adulthood an area less well rep esented In the ht
erat re on utism.
The author IdentIfies he develop ent of a pro
p,iilte SOCi al and communICation skills 1S a strand
that should run t hrough pr grammes for every
alea of defiot. She suggests that we hdve to gaIn
InSights into the orid o f an utistic person to be
able t o help them. and modIfy the curncl/lum
The book IS dIVIded int four secons - 'SoClabfil:y
and Commun'catton: 'Benavlour, Feelings a- d
Emotions'. Relationships. Sex rty and the FaMily'
and 'Bri dging the Gap' (inclusIon of the autiStIc
person in society) .
Eilch sectJon begins WIth quotatJons from pe pi e
With autism including Donna WIlliams and Temp e
Grandin and ends wit h anecdotal examples and
case studies, These al-e very pow rful and emo
jive. The suggesti on ru-e a co plla 1011 of ideas
from profes lonals. families and caregivers and are
very practIcal. The sectio about sexuahty or
example 0 Llines ways of he p' ng the parents and
Siblings cop With the changes occumng in
puberty and gives practical suggesl10ns for copin
with senSItIve Issues such as masturbation nd
-n ns rua lon,
Throughout the b ok here 15 an emph sis on the
development of fundi nal con municatlon. The
Jse of ymbol 5 stems is seen as a way of givlllg
the autistic person access to communic ti on in a
Wider community There are many useful Ideas
about developin symbo use. br ex mple to
support behaviour programmes and to help
pup"s to become aware of heir own emotio s.
There are very clear illustrall ns of symbol sys
tems and suggestlon- fOI ' making these flexible
nd portable.
The au hor stresses hat many young people With
autism have lives contro led by others and sug
gests ways in w hich they can be helped to make
choices and decisions about their own hves. She
also describes ways of developino self monnonng.
th, Stext descnbes an American system of educa
tion and care in which there is greate emphasis
on Ineiuslon than t here is currentl y in this (Quntr y.
The layout is inconSIstent: although some check
li sts are very other sections are confusing. It
can be dIfficult to find specific informati on as
there is no index. W hen an activ' y is outli ned the
lack of detail is someti mes frustrating: however,
there cl re many references t o books and journals.
I found many Ideas I will use with our pupils. We
WIll certainly include thiS book in our staff library
and would recommend it to parents and carers.
especially t hose with children who are approach
ing adolescence.
Sue Allison, Speech and longuage Therapist. IS
Deputy Head at Ins ope House, Cheadle, Cheshire,
a school (or chIldren With autism.
Skilful weaving of theory and
Working with Pragmatics
lUCie A dersen-Wood & B nita Roe
IS8 0 86388 /68 8 2 7_50
WorkIng With Pragmati cs is not a
tome. It IS however an excellent,
well-researched and logically w ntten
book. As practical. down t o earth
therapist I like books at answer
simp e like w at? hy?
'lOd. most Importanty. howl This
book does exactly that.
The fi rst two chapt ers ex pi In an
define pragm ICS. There IS also an
outline of heorelical approaches to
pragmatics. ThIS means the I-eade!"
can ge a qUIck. comprehensive con
cept 01 the commonest theories.TI1e
res of the book I devoted 10 prag
matIc developmen assessmen and
therapy Students will love this book
- as a student. I well ,-emember ask
Ing the perennIal question. HOW?
The chapters on assessment e cour
age clinrcians 0 be thorough in both
Ion al and informal analysis of prag
ma ic disability. Thel'e IS a useful
overvIew of formal assessments
avadabl and some helpful 5U es
lions, The pragmatic rating scale
could be used t o priol'itlse cases Th,s
means one can be confident In plan
ning th ne essar y Intel' enli on.
making h,- book acceSSible 0 1- chni
Clans and students ahke. H Ing read
about theory and assessmen we
al-e dil-eaed to hlnk about pr ven
tlon of problems and trainmg of
other professionals. famtl y nd care
givers. Th,s book reminds us we
should be shari ng stra egies with
caregl 'er5 and enabling them to
effect change in their pproacn to
cli ents With pra matlc dlsabil y, i
school and at homeThrough ut this
book he au hors skIlfully weave the
theory and pl-ac Ice t ogether; c arify
Ing and formaiislng orking with
prrtgmatlCs. As a therapist worklng
primari: y In the classroom, I am sure
th,S book WIll incl-ease my abilIty to
wOI-k With cileills, parents and other
profess:onal colleagues more effec
tI vely
WorkIng with Pragmatics ay be
more appropriate for the paediatric
clinl ian but I feel It woul d Inform he
practice of both teachers and st .
dents. It co tams facts relevant fOI- all
profeSSionals workIng " i h Individu
al s who have dIffi culty Interacting
with others. Fi nally. for those who
become "hooked on pragmiltlcs".
there IS an annotated bibli ography
al lowing the reader t o select areas of
research they migh like to Investi
gate further
Carole E.. HIgginbottom IS a speec
and language therapist at Stam]
House School.
Interesting, but no surprises
Degree Students with Dyslexia
Growing up with a Specific Learning
Barbara Rldc.h Manon Farmer &
01ristophf" St erling
ISBN 1-86156041 9 {/9.50
Part of a wldel ' research st dy. this book
has been published to draw attention t o
th need to identify and support st dents
with dyslexi a who are in highel' education,
The main bulk of the book IS gIven over to
in-depth interviews with nIne dyslexi stu
de'1ts whose ag s ranged from 18 - 42
ye I-S. They came from a wide r"nge of
socia-economic backgrounds and were
studymg for a var iety of degrees. The stu
dents volunteered to t ke part and may
ot therefol-e be r'epresentat,ve sample.
Full data was collected on I 6 dysl exic and
16 control students. Only the dyslexic stu
dents w I inl rviewed. the ,ntervlews
being carried out by a research assist nt.
himself dyslexic
The A ult Dyslexic Checkhsl (Vlnegl-ad) was
used to olscnminate from non
dyslexic students I had t o track thi dow
on he Intemet as only three of the twenty
questions wCl 'e quoted. The highest ranking
question indicating dl'slex;a was" he1
wntlng cheques co you frequentl y find
youl'Self makIng mistakes?"The least Impor
tant was "When you have to say a long
word do you 0 e ,mes fi d It dimeul to
get ali the sounds In the right order?" Hmm!
The nter'"iews make Intel-estlng readino
w hile not producing any surpnses. 0 Iy
one student had been diagnosed befc re his
teens and several were no as essed until
their mid-twenties There IS grea vanation
in the type and seventy of difficulties both
practical and emotional as
described by J1e students.. Almost all the
students ,-velcomed h" ng a label 0 attach
to heir problems.
Sev ral of the students felt they had
e celled at talking and preferred oral pre
sentation while others lacked confi dence
and found It hard 0 order their thought
and xpress t hemselves. I searched the
book for any reference to speech and lan
guage disorders nd found one paragraph
near the end o f the book: S ckhouse &
Wells (1991) were quoted - dysleXIa has
been called "a hidden speech and lilnguage
disorder" and Snowling I-eports that dyslex
IC chil dren often have a history of Idte or
troublesome speech and language develop
me t. ot one of the dents was asked
about any early d,fficulties in the interViews,
If thIS book goes some w y t o improVing
support services for such students th t (an
only be a good thing. The author felt
dyslexIC children. their famIl ies and pnmary
and secondary teachers would find this
book useful. H ving read the inter views. I
would have I ci uded university lecturers on
that list. I wou d recommend this book t o
the above and for rncl usion in coll ege
li braries.
Sheila Gunn Is speech and language therapIst
at Derwen College. Osw try. Shropshire.
ISSN (online) 2045-6174
Interpretation needs skill
Ann Whitworth. Lise Perkms, Ruth Lesser
55 00 each
In recent years, I'esearch concemlng Conversati on
Analysis (CA) and its clinical applicati on has beCll
accruing at a rapidly Increasmg I-at e. The CAPPA
(Conversati on Anal ysi s Profil e For Peopl e With
Aphasia) and CAPPCI (Conversa Ion AnalysIs Profrl e
For People W it h Cog'1ltlve Impairments) have been
developed as resources for speech and language t her
apists t o help Incorpor-ate pnncipl es of CA into assess
ment for people with general ised cognitive Impair
ment - as in dement"l or fol lowing head inlur y - and
people wi th aphaSia. Tl,ese dSsessmenls JI-e t o be
used in close collaborati on with the cl ient's conversa
ti onal partners and as an adjunct t o li nguisti c measures
of language disabili ty.
Both assessments ale well presented and clearly IclJd
out In a formal t h;:!.t is eaSily accessible. They are pre,
sented using a slm.lar deSi gn and compnse:
., a structured mt el-Vlew to be conducted with the key
conversati onal partrer (and also for the person wrth
ilphasia in the C APPA)
, an analysis procedure fo r use with a ,en minute sam
pl e of conversation between the client and his I her
conversational partner
'" a summary profile that contains InfOI-matl on gath
ered from the Ilterview and conversat ion sample
allOWing companson of the two sources of informa
ti on and establishing a baseli ne for analysis.
Both the CAPPA and CAPPCI take a long t ime to
administer and scoring requil-es much intel-pretation,
agalO extremel y time consumi ng.
The structured interviews pr-ovlde a useful format for
eliciting Information on the clr ent's cur l'ent conver sa
ti onal ilbil ities, interacti on style and any changes that
have occun-ed. The questions included in the inter
views cover il wide range of areas and allow for dis
cussion on any cUI Tenl strat egies in use, the cli ent's
response to such st rategies and the seventy of the
I feel such a detailed intel"view for-mat IS not approprr
Jt e for use with some clients and carers. In par-tlCular;
I found the int erview wiLh the person wi t h aphasia In
the CAPPA onl y surtable f,) r a restricted number of
clients With relatively well preserved functi onal lan
guage comprehenSion Jnd expl"essi on.
PrOVided a suitabl e conversati on sample can be
obtained, thiS analYSIS can p"'ovide usefUl informatIon
t o help clini CI ans deVise highly Individualised therapy
pmgrammes, and carer training programmes. The
analysis procedure rollows a detailed and at ti mes
system. which demands an In"
depth knowledge of 1he assessments. Tllis procedul'e
IS again extremely time consuming.
Both the CAPPA and the CAPPCI successfully aSSimi
late and consolidate the many stl-ands or Informati on
and pnnCl ples of CA into Lwo useful assessments.
Ill fol"lllatlon gamed fr'Om uSing these assessments IS
undoubtedl y extremely valuabl e, although Inter-preta
tloii r-el:es heaVi ly on the skill of the cl ini Cian: there 15 a
deal'th of gUidelines prOVided vvithi n the assessment
on appropriat e therapy goal s.
The detail included within these assessment s is funda
mental 10 the prr ncipl es of CA. however, gi ven [he
gr-e<lt deal of ti me needed to compl ete the assessment
pr'Ocedure, the CAPPA and CA PPCI may not be the
most pl"actrcal resources for use within a busy com
munity dinlC.
( 1010 Robertson IS 0 speech and language therupis t in
Aberdeen Vllth Gmmpian Healthco re
Plenty to draw from
Creative Relaxation in Groupwork
irene Tubbs
ISBN 0-86388-143-2 E23 95
Irene Tubbs is a physical education spe
ciaJlst with expenence of working With
cl ients of aJl ages and abilities. As well as a
leachrng degree, she has dipl omas in
counselling, Illulti-modal psychotherapy,
stress counselling and management.
The book IS diVi ded into four sections,
col our coded for ease of reference. The
first sections, roughl y one third of
the book's content conSider the benefits
of relaxatlor] , how to chieve it and how
to organise and present workshops, Her
methodology Includes familiar themes
such as posture. oody IclJIguage, breathing
and oice. and also explores dance, usi c.
exencise, art and alternative ecaples,
Reaoers already persuaded 0 the bene
fits of alternatwe therapies will find little
t o cntlcise: others will be sceptical of the
unsupported cl ai ms couched in non-sci
entific language. The style IS r eadable and
informati ve and is focused t o proVIde a
t heoret ical basis for most of the "'1ork
shop ideas which foll ow. I found It easy 1.0
identi fy With many of the concl usi ons she
draws from hel- own experrence in obser
vati on and counselling. However; in such a
subj ecti ve cont ext. more academicall y
presented I-eferences descnbing expen
mental methods and resul ts would gi ve
hel' work greatel- cri tical credibility.
The 'PI"acti cal Workshop Ideas' are well
defined and easy t o follow.They compnse
wal-m-ups, main themes and I"elax down
sessi ons. ac1Jvity is defined by its ai m.
appropri ate age level , time and equip
ment requirements. The themes of relax
ation, t ension release, bneathing, voice and
use or wOI-ds are pal"tlcularly relevant to
my own area of work. and I found pl enty
here to draw from . some or the
thirteen stress-management exencises
demand consi derabl e confidence and
experr ence of handling emotions in a
group context. Ms Tubbs recommends
trainmg In Rational Emotive Therapy and
Cognitive Behavioural Therapy for two of
her exerci ses, and gives a general diS
claimer thift "we should never' use a spe
cialist skill tha we have not been lr 'alned
for ' However I felt there had been insuf
ficient di scussi on of the danger-s of self
discl osure and the need for IndIVI dual
support which may well ari se, both for
the gmup members and for the therapi st
or practrLJ oner
The book prOVides an Intm duction to
relaxat ion theor-y and practi ce which
would be a useful gUide t o a thelaplst set
ti ng up groups for adults or adolescents in
speCial needs, mental heal h. VOice, nuen
cy or neurology. It is presented in an AS
I-ing-bound format which makes the exel-
CiSes easil y accessible. T nel-e IS a bibliogra
phy and a bl'i ef desCll ptJon of some alter
native t herapies wrth contact addresses.
)0 Ponon BSc RegNI RCSLT is 0 Voice
Specralist With South Bucks {\IHS Trust
Too wide ranging
Treatment Resource Manual for
Speech-Language Pathology
Fromo P Roth & Colleen K. Worthington
ISBN 1-56593 636- / 0 000
Ah, is thi S lust what I wdnt) One book
for all treatment. This all Singing, all
danCi ng publi cation comes fium the
USA, so thel'e are sectiOns on US law
I-equirements and ethics. ThiS may
make Interesting leadi ng. My first
impreSSion ,",vas that thiS is a smail
book pnnt ed on big papec 1he prrnt
being large and spread out. An ad'/an
t age of thiS is that thel'e al'e many large
t abl es, such as developmen tal cha(ts
and glossil r ies.
The blurb on the I-ear makes J
of claims Including both comprehen
sive and basic information FOI" t reat
ment. I does Indeed cover many
aspects of our wo'"k. from '!:ssentlal
Ingredients for good t herapy' (for
example, adapti ng communication to
cl ients). through speCific therapy Ideas,
to ;In example of writing a nereml let
ter to other profeSSionals.
It IS my ImpreSSion that the alillS of thi s
book are too Wide ranging. Many
chapters end In a dlscialmer descnbing
the chapter as basic Information at an
intr'Oduaory level and fur her reading
is recommended As a I-esull of the
vaned tOpICS, many items are given a
mention onl y, for example collabora
tive wOI-king with teachers. Much of
what is in the book will be found on
speech and language t herapy quallfiea"
tion courses
At tempts are made to apply theol' y Lo
pract,ce. Often, different approaches
are introduced and each disorder is
defined and descnbed III stralghtfol-
wil.-d erms. The chap tel's vary in how
comprehenSively they cover a topiC.
For exarnpl e, the chaptel- on dysnuen
cy hardl y ment ol's Involvlllg cal-e
givers, w hi lst the one on child language
covers many aspects rrom tw o Lo eigh
teen years In sections. There are also
specifi c activiti es IIlcludlng ideas to elic
It drfferent pragmatic functions. Other
areas necessaril y have limited activities,
for exampl e word finding. There IS a
good balance of activities and hll1ts
acmss the book, such as al,leulatlon
therapy ror- difficult to elicit phones
One big hole is the absence of infor
malion proceSSing based therapy,
especially noticeable In the section on
adult aphasld.
Overall the book docs have uses, espe
cially for newly qualified c!rnrcians. I did
dip Into t and take Ideas and principles.
There are many practical Ideas but
are spread quite thinly acros'S dlsor
The book may Jlso prompt look
Ing at our job With a Wide perspective .
I did not get my all all danong
therapy book, but I p(obably wrll.
James Storey is u speech and language wtUl Sandwe/l NHS TrUSL
ISSN (online) 2045-6174
each, al
in . d DO"
in a The "Say anavailable
'best worksheets . t k.
to reoders are. p, '
z,ch, l.
and sticker charts.
Books t om a valiety of publishers and
co en g he 'ange of speech and
language erapy work are
'de Evaluation of
Be Sl
Introducing Strategies fo r
Parents and
Janice I. Adams
This author 110s also
written Autism-P.D.D.
Creative Ideas DUring
The Mighty M
Anita Robbins & Game
jackson arah
For two to six Players Order
rom three to seven reference
years, this board ' ' 4-3443_98
game is a {u 29.99 +
Work on VAT
Skills. The instructor'S
Includes game ideas manual
reprod 'bl ' a
UC/ e parent t
descriPtions ,etter,
the motor PIctures o{ al/
h rC/ses alld a
Iw ys a aila blefo r re ie ; the
reviewergets to keep the
Dok. As a special 0 er, on a
Order Edward Hardy
reference The BED. ThI alms
1sn89,91 to be a com pre-
the School Years and
More Creative Ideas From
Age Eight to Early Adu lthood. Bath
otocOpiable paperba
PUPPet pattern H d 'g
are also mirrors
the exercises. or teaching
)6.9S + hensive but easy
VAT bedside dysPhagia
fi rst come, first servedoasis,
readers offeringto do a review
\ ill also be given the choice of
one of the products bel ow.
Phone Avri Nicoll on 0I569
740348 or write to her at:
Speech &Language TherapyIn
Practice, FREEPOSTSC02255,
or e-mail to find
ou what books ' re avai lable fOl'
review and to take advantage of this
offer: Guidelines for writing a review
II> ill be pro ded,
The products below, new to the 1998
Winslowcata ogue, are being made
available free by thecompany to readers
o Speech and a guage Therapy in
Practice. Winslow doesnot publish
these prod cts b distnbutes them
In he UK
In 1998, inslow is publishing JUst one
ma in ca a ogue Ith fou rteen extra
pages, a new look andfour key areas -
Educatio ,Heal h, Elderly and Soc'al
Cal'e. For a freecopy,contact L n
Smith on 01869 244644or write to
Winslow Press Limited, Freepost 327,

use I
nt I'or adults. t
I' I
includes a screen, :eo;rol
motor evaluation, .
Pharyngeal Dysphagia h
s Assessment were
liquid is intrOduced
Pee,. 'nte,. ,
Order and S actIons
39.95 ' arquis &
ThiS m Y- TrOut
...J anual
ueve/oPed " Was
Protessianal fc help
cOm :s aCihtat
mUnJcation e SOCIal
Interaction and Peer
With among ad, I I
learnlnu ...J.
co .. <lISabi'" .
mmunicatio . Illes and
Act " n 1m" .
IVllies are "alf'Tnents"
to One
"Say and. WorkSheets
. la
SharOn Web f photOCopiable
hese books 0 t phonemes
ts targ
workshee lIabl
, wo
, isolation, sy s and for
In ente
groups, large to
Or one
phrases, s tho
indu e
carryover. Me hidden piCtures.
dot to dot. ssWord
mazes, cro d colouring
L1 puzzles an
are available from Winslow ond
the latter is reviewed m this issue
of the magazine, This book aims
to help parents and professiono/s
recognise the needs of the child in
the areas of communication,
behaviour, living skills and
seven, these
tocopiable actiVity I'.
resented lor
sheets . g, num.
. d pastln
cutting an , d
. patterning an
bering, h 2 3 and 4
matching teac ,
ste p sequenCing.
Wo,.kbook fo,. par
Teache,.s and
, s - 2nd edition
Harvey Parker
Written by a
this book
materials, tips {or a
gUidelines {or
m{ormation on
and b h ' medlCotion
e aV/our modificotj
Communication in
Infants and Young
500 ways to
Jennifer QUick
& Alexandra
Written by a teacher
and a speech and language
therapist, this is a re ference
manual suitable for parents
and caregivers such as
nursery and playgroup staff.
nd a summary report t o
a 'the client's record.
place In
- ctiVit' IOn
1m .'es fo,.
1 3 4 Sequences
Sharon Webber
Suitable for
ages th ree to
, al
pLP-ID: pra ralt\a
Lessons {or DrillS
. Illu
WIth ell Lark
Brenda 0
Developed these
I apraXIC a d
, s indu e
exerCiSe . suatlons SO
cartOon diu 'table for
I be SUI
may a SO t honemes
'ldren.Targe P " I vC
C , d ,n \..Y,
are wordS and
single wo
'd sentence
phrases an exerCises.
Reading Workbook for
Fred Vallier
Photocopiable worksheets
include graded activities for
perceptual training.
word recognition,
word reading,
sentence reading.
reading comprehension
and functional reading.
The exercises can also be
adapted for work on
auditory comprehension.
ISSN (online) 2045-6174
number of recent changes
and developments in high
er education, clinical edu
cation and adult learning
theories prompted tutors
on the BSc Speech
Pathology and Therapy
coul-se at the Unive(sity of Manchester to
consider ways of developing the clinical
education offered to their students, The
most infiuential of these factors are:
Developments In univer sity teaching and
adult learning in general, highlighting the
value of
a) experiential learning, as opposed to
Julie Marshall and
Catherine Aldred
observe that a
learn ing package
using video can
be a valuable
way of
in spite of the
initial time and
costs involved,
didactic classroom based teaching
b) Problem Based Learning, aimed at
developing analytic and broad based prob
lem-solving skil ls
c) self directed learning, in which students
take greater responsibility for their own
learning needs and processes,
Increased availability 0 t eaching temnol
ogy, such as video, computer-s and multi
Pressures on university teaching time
and dr nlca! pl acements, These pressl1res
Include inadequat e time for Ol1e-to-one
cli nical educ t ion within the university set
ti g, i sufficient eli ical placements, partle-
ISSN (online) 2045-6174
Figure I: Example of written tutorial
questions and sample answers:
Voice assessment video
I, What are the main factors
causing vocal abuse (for this
Shouting at children,
occasional throat cleal'ing
and high volume,
2. Why does the therapist
physically examine her neck
and shoulders?
To look for ' signs of tension,
asymmetry and to assess
discomfort and tenderness,
J How will the therapist's
explanations help the patient?
Decrease anxi ety about
cause of problem, 91ve
patient positive things that
she can do to impro e
her voice, understandi ng of
how natural acti ons
and her own anxiety have
caused her symptoms.
4, Are there any additions you
would make to the end of the
Ask patient if she has
questions, has she
understood, how does she
feel about what the
therapist has said, has she
thought of any other
facto rs while the assessment
has gone on?
ularly with certain cl ient groups, an inabili
t y t o provide every student with opportu
nities to work with every cl ient group and
speech and language therapy managers'
concerns about the limitati ons on clinical
experience for students' cl inical develop
ment and future employability
An increasing awareness that there are a
number of core clinical compet encies
applying across as well as Wi thin cli nical
fields, and that students' increased aware
ness of the transferability of these skills
may improve their clinical confidence and
A number of projects to support cl inical
education and learning were consi dered
and implemented in light of these factors.
One such project consisted of creating a
set of vi deos t o support the cl inical edu
cation of final year students. It was antici
pated it would
a) be relatively easy to implement
b) provide a permanent resource and
c) be virtuall y free of both material costs
and time commitments in the long-term,
although time consuming and expensi ve
for both NHS clinicians and university staff
in the short-term.
Enterpri se in Higher Education (EHE) was
a partl y government funded initiative to
encourage innovative developments to
Improve the employabi lity of university
graduates. This project appeared to meet
EHE funding criteria and a proposal sub
mitted in Apri l 1994 was subsequently
We planned to produce ten videos, each
of 20-40 minutes with the focus on a
client with a specific type of communica
t ion The disorders selected
reftected areas in which it had recently
been difficult to obtain sufficient clinical
experience for all students. These included
cl ients with voice disorders, acquired
dysarthria, acquired expressi ve and recep
tive dysphasia, Pervasive Communi cation
Disorder, hearing impairment and users of
Augmentati ve or Alternative
Communication. The number of Ideas
was restricted to elghl by the funding
available. W ritten tutorials would accom
pany each vi deo.
Foll owing the successflll bid. an expen
enced thel'apist was appointed to co-ordi
nat e the project for 40 days between
October 1994 and June 1995. Speech
and language therapy managers were
sked for suggesti ons of appropriate staff,
cl ients and locati ons. Indivi dual therapists
were then contacted and, if suit able clients
were available and agreed to be involved.
filming t ook place within their usual clinical
setting. The videos were made and edited
by the project co-ordinator and a video
technician. Speech and language therapists
gave their time and energy will ingly,
despite heavy workloads and were gener
all y very supportive of the project.
FollOWing filming. the videos were edited
to focus on specific aspects of the clinical
sessions. Written tutorial quest ions were
added to the videos and sample answers
provided by teaching staff Figure I pro
vides an examp le from the voice assess
ment video. Questi ons rel ated t o specific
aspects of the cli nical session and were
modelled on typic I observation, practi cal
and theoretical tasks given t o students
during live cliniC observation sessions.
Seven videos were ready for use by
October 1995 and the final one was ready
by October 1996.
Student s are expected to watch all eight
videos at ti mes of their choice dUring the
fi nal academiC year, but only have to com
plete the tutorials on a minimum of four
of the videos, selecting t hose relating to
the cl ient groups with which they have
least clinical experience. Completed tuto
nals are not assessed. but the students
evaluate their own performance against
the sample answers. if necessary watching
the vi deo again. Viewing facilities are avail
able within the department and they are
not permitted to take videos home, to
preserve client confident iality
The video learning package has so far
been used by two groups of year
speech and language therapy students.
Thei feedback. both verbal and written,
has been 0 erwhelmingly positive.
The most reqt;ently watched videos were
dysarthrta and dysphonia. both used by
I 8 per cent of -r e students. foll owed by
MC and e aphasia. studied by
I 4 per cent arc -:: per cent respectively
The least -rec;uefi - otched VIdeo was
on hear 0 :Jill e 11. Evaluation was
carned : :;clore the end of the acade
mic vear, :o rr ore may have watched them
at c laier oate.
S ..cents' ere asked to rate the videos on
a scale of one t o five for their usefulness
fIVe bei ng "most useful" and one being
"least useful"). Twenty nine per cent of the
videos were rated as five, 64 per cent as
four and seven per cenl as one. Examples
of the comments made by the students
The tutonals focused my thoughts and
view ing
Helped impmve my observation skills
Inspired discussi on between friends If
wat ched in a group
Some of t he treatment procedures
helped me both t o supplement and reject
some of my own approaches
Gives a credible source of therapy Ideas.
Most students wanted more videos on a
wider range of client groups. Negative
comment s were !I1d.i nly rel ated to the
need to improve the written tutOl' ials and
the viewing arrangements.
Clinicians have not been asked formall y to
ISSN (online) 2045-6174
evaluate the project, but al l t hose who are
aware of it. erther through direct involve
ment or through t heir students, have com
mented favourably on rt.
Uni versity staff involved have found it use
ful to have vi deo m terial using therapi sts
other t han themselv s and to have a prac
ti al supplement to lectures. It has been a
very positive development to work close
ly with colleagues in the NHS and has fos
tered the view that clinical education is a
JOint endeavour shared between those
who are predominantly cli niCians and
t hose who work predomlnan Iy in educa
tional institutions. Although the project
was t ime-consuming and expensive to
develop, now that it is complete the time
investment is minimal. Staff have devel
oped skills in implementing such a project
and have been encouraged to use more
frequent videolng of their own clinical
work, thus making it available t o larger
groups of students.

The client groups shown in the videos
were selected for two reason s: those
where it has been difficult to obtain suffi
cient experience for all students, and
those with particularly complex difficulties.
It was interesting t hat for one of t he orig
inal groups chosen - cl ients w rth cquil"ed
receptl e aphasi a - no video was made as
no surtable client s were available. The rea
sons given by therapists were that they are
no longer being referred such di ents but
are much more likely to be seeing clients
with global aphasia or those wit h dyspha
gia. It IS not clear whether this IS a com
mon situation but it may refiect increased
cont racts for acute hospital based as
opposed to community services. This issue
I'aises questions about the client groups of
which student s are expected to gain
experience, and the need to monitor the
changing treat ment priorities in the NHS
and adapt ed cational courses accordingly.
The success of the project and feedback
from students has generated ideas for fur
ther developments Including
I. Development of videos involving a
wi der range of client roups. These could
be used both to supplement current cl ini
cal experience and to precede it.
2. Use of some of the material s by groups
of students, such as those studying com
munication, linguistiCS and communicat ion
disorders and also by applicants to speech
and language therapy courses (only with
permission of clients and therapists, as
their original permission did not extend to
this usage).
3. Development of a larger bank of video
materials, some of which could be edited
from the original videos, to demonstrate a
wide range of core clinical skills.
Unfortunately these plans cannot go
ahead until further funding is available.
This project has provided the university
with a means of supplementing students'
clinical experience without putting
increased pressure on already overbur
dened cl inicians and educators. The use of
structured video teaching materials can
never replace hands-on clinical experience
but appears to be a useful supplement.
pal"tlcularl y at times when students would
normall y be carrying out substant ial
amounts of observation.
Julie Marshall is a Lecturer
in Speech Pathology at the
Centre for Audiology,
Education of the Deaf and
Speech Pathology,
The University of
Oxford Road,
M 13 9PL.
+44 (0) 161 275 3373
+44 (0)16/275
Catherine Aldred is a
Lecturer in Speech
Pathology at The University
of Manchester and a
Specialist Speech and
Language Therapist with
Stockport Healthcare Trust.
Why are new waY5
rMMI Development5 in adult learning theory,
of learni ng beinq technology, core competencie5 and pre55ure5
on teaching time and placement5 need to
be accommodated.
What do 5tudent5
IIIfII!nI di5cu55ion and therapy idea5.
1iMt.. The video5 can facilitate ob5ervation 5ki1l5,
like a bout the video
Have there been The U5e of video ha5 been extended a5 a
benefit5 for 5taff? practical tool and the joint nature of clinical
education empha5i5ed through the work
with NHS clinlcian5.
ISSN (online) 2045-6174
How l
language therapy team leaders for Fosse Health
Trust in Leicestershire. Both specialise In workfng
with adults with learning dlsabfittles.
The adult neuro team with South Downs Health NHS
Trust is Helen Garratt, Val Fam, Sharon Qarlc, MaryrCJS(t
McKay, Joe Osmond and Usa Cox.
Ann Adams is the Oinic (o-ordinator of a team of
speech and language therapists based at East Surrey
Hospital, Redhlll.
(aseload .
management IS a
skill of any
soeech and language
therapist, whatever
the numbers or dient
grQup involved.
Balancing available
resources with .
developments In the
profesSion and the
wishes of clients
brings man
ressures. ree
demonstrate the
reaJi!y of good
management :

solution to
be found but an
ongoing, e\(oMng
team exerase.
24 SPEI'C I1 & lANC: UAGU 11-l [ RAJlY I I'RAC' f1CE SPRING 1998
ISSN (online) 2045-6174
HOWl. ..
, AduH Leamin Disabi
,. South Down Health
U l llUII
Iy and demand
Teresa catdleside andJ fdcIestone
explain hcMttheir tmm is worldng
toMm1s ptrJVicb;Jamorejlexliesmtb?
The invitation to write this arrived at an
interesting time. Like other departments,
we have found ourselves subject to many
changes over the past few years. We have
been reviewing our service as a whole,
looking at our ways of working and identi
fying how we could improve and make
limited resources more effedive. Caseload
management is a major consideration.
The team
We form part of the speech and language
therapy learning disabilities team compris
ing a full-time manager, three team lead
ers, a specialist in profound and multiple
handicap (PMLD), a specialist and a chief
post in working with individuals who chal
lenge services, seven generalist therapists
whose caseloads include adults with learn
ing disabilities (based in Day Centres) and
three whole time equivalent assistants.
We are divided into three teams, North,
South and City, based on geographical and
social services / hea.lth care divisions cover
ing a population of 2785 individuals with
identifled learning disabilities
(Leicestershire Register of individuals with
Learning Disabilities). Although not all
known to our service, most will be seen for
assessment and / or therapy at some time.
Problems facing us include:
1. Numbers Although a comparatively
large department. the sheer number
already on our caseloads makes it very dif
ficult to manage the caseload successfully
and maintain a consistently high standard
of therapy. [n some ways we are victims of
our own success as development work with
other professionals has raised awareness of
our role. From these successes, particul arly
in working with PM LD clients, those who
challenge, and those with eating and
drinking difficulties, we are receiving
increasing referrals with an expectation we
will respond almost immediately and pro
vide input and liai son at an intensive level.
2. Contract Currency Perhaps the most
significant factor is that the speech and
language therapy contract with the pur
chasing authorities (most importantly
with the local Health Authority) is based
on the numbers of clients we see on a face-
to face basis. There is therefore always the
pressure to see large numbers, with the
ensuing difficulties in terms of quality for
the cI ient and stress for the therapist. There
are strong arguments against this basis for
contracting; see Communicating Quality 2
p.134, no. 9, also Money, 1997.
3. Consultative proiects We are increas
ingly involved with communication based
projects, such as making information more
accessible to clients with learning disabili
ties, ego health leaflets and videos. These
are very exciting and our expertise is often
essential for success. Problems arise in
that. again, time spent on this develop
ment work is not available for direct work
and, indeed, under the present system is
not acknowledged.
4. Audit, developing policies and proce
dures, research and development, out
come measures All are essential duties for
our team, but of course require adequate
time for meetings and planning. We also
feel strongly there should be development
of formal systems for support and mentor
ing of therapists new to or inexperienced
in learning disability work. Presently, to
cope with the numbers, all therapists need
to work alone, carrying their own caseload.
We see this as a major negative effect of
unmanageable caseloads.
5. Open ended versus episodes of therapy
Our way of working can be described as
'open ended' in that we see a client for ther
apy for a particular communicative need,
ego developing more appropriate ways of
greeting others, then, when that aim is
realised, another communicati on goal is
identified, ego working with signs/symbols
to make simple choices. This encourages
the therapist to keep the client's case 'open'
thereby continuing very high numbers and
causing ever-increasing problems main
taining casenote / caseload standards, man
aging revi evv procedures etc.
So, there seemed to be nothing for it but to
clear three days from our diaries and get
together as a team to thrash things out.
Planning renegotiation
We agreed the only way fOlward is to rene
gotiate the contract currency allowing us
flexibility for consultative and develop
ment work.
Over the next year we are going to work as a
team to develop a projed focusing our input
away from direct work towards changing
and adapting a client's communicative envi
ronment. We will then have 'permission' to
take time to work alongside a colleague and
be able to pool skills. There will be the
opportunity to develop effective and sensi
tive outcome measures, essential in any
negotiations to change the contract currency.
We have agreed a system of prioritisation
for new referrals, based on guidelines in
Communicating Quality 2.
We will carry out case studies from referral
to discharge to distinguish more effective
ways of working episodically. Through
these, we will identify the time needed for
assessment, goal planning, liaison, therapy
planning, face to face therapy, recording,
report writing, follow up work and review.
Differing methods of intervention and
management can then be compared and
changes in working practices made.
We need this period of informati on gather
ing so we have sufficient data to present to
managers and purchasers specifICally
regarding what constitutes an ideal model
of intervention in terms of length of input
/ episode, and the content or focus of our
intervention - from the individual to envi
ronmental. At the same time, our solutions
need to embrace quality measures and
continuing professional development.
Active team
These major service issues cannot be
add ressed overnight. It would also be
impossible to address them as an individ
ual therapist. We feel very fortunate to be
part of an active, forward looking team,
itself part of a large department (38.1
whole time equivalent). Working cohesive
ly gives us a voice and therefore the oppor
tunity to be proactive in initiating changes
to help us move from a quantitative
towards qualitative and, we are sure, very
effective model of input.
RCSLT (1996) Communicating Quality 2.
London: Roya I College of Speech and
Language Therapists.
tvloney, D. (1997) A comparison of three
approaches to delivering a speech and lan
guage therapy service to people with learn
ing disabilities. Euro.pean jOllrnai of
Diso.rders o.f Communicatio.n 32 (4).
The South Downs Adult Neuro
outstrips our ability to supply it. Issues relat the caseload to achieve an equita b le e rvicp
team values working with carers
ed to demand are response time to referral, across different sites and to adlieve fl exi
and voluntary organisations to how to <lddress the needs of carers and what bility of service so we can respo nd lO ari
help supply meet demands, is available to support people after their dis ations in demand. This is in :lddi tio n to
As many speech and language therapists charge from speech and language therapy. the aim of providing a qua lity, approp riate,
find, the demand for the service generally Challenges for our team include managing accessible service.
ISSN (online) 2045-6174
The service
South Downs Health Trust is a community
trust providing se rvi ces to 300 000 people.
It is a mLxed urban / rural area with a large
proportion of people over 65 years. The
5.5 whole time equivalent speech and lan
guage therapy Adult Neurology team is
based in Brighton. It provides a service to
inpatients in two acu te hospita ls, outpa
tients in a variety of sellings across the
trust, two rehabilitati on units, an elderly
physical and mental healt h day resource
centre and a limited domiciliary service,
Management strategies
The strategies we have implemented to
improve caseload management include:
1. Administration
A central wa iting li st is held, Thi s ensures
no referrals go "missing" and that it is pos
sible to get an overall picture of the service,
Each week an adult neurology team meet
ing is held, one of the functi ons being to
discuss the waiting li st and to prioritise
and allocate patients to therapists, There is
secretarial support to regi ster the new refer
rals on to the computer system, create
records and deal with acknowledgement
2, Location
Outpatients are seen at five sites across the
Trust area , Sessions are allocated to the dif
ferent sites but a certain amount of fl exi
bility is possible. The advantages of work
ing from different sites are that the patients
do no t have to travel too far and it facili
tat es eas ier liaison with ot her professionals
based in that locality.
3. Liaison with other organisations
We have links with a number of loca l
organisations for people who have had a
stroke, The Stroke Association's Dysphasic
Support Service runs two groups and does
"one to one" visits; we meet regul arly wi th
the local organiser to di scuss the people
involved in the scheme, The department
was instrumental in selling up the loca l
ADA (Action for Dysphasic Adu lts) self
help group which we still have some
Voluntary sector contacts
Action for Dysphasic Adults
1 Royal Street,
London SEl 7LL
tel. 0171 261 9572
The Stroke Association
Stroke House,
Whitecross Street
London Eel Y 8JJ
tel. 0171 490 7999
Parkinson's Disease Society
22 Upper Woburn Place
London wel H ORA
tel. 0171 383 3513
Alzheimer's Disease Society
Gordon House,
10 Greencoat Place
London SWl P 1PH
tel . 0171 306 0606
Motor Neurone Disease
PO Box 246
Northampton NNl 2PR
tel. 01604 250505.
involvement in . A Different Strokes gr up
for younger stroke survivors is being estab
lished and one of the speech and
therapists has been invo lved in tarring it.
Our Trust has a co mmunity uoke Rehab
Nursing Service \ hich ees both people
who have not been admined to hospital
and peopl e immediatel y after discharge.
They are an important link for us and we
recei e 3 number of referral s from them for
communi ty patients immediately post
stro ke.
The different organisati ons mean o ur
patients and carers can receive ongoing
suppo rt that co ntinues after they have
been discharged from speech and language
therapy. We also try to link up with oth er
o rgan isa ti ons s uch as the Alzhei mer's
Disease Society, the Parkinson's Disease
Sociery and the local specialist nurse, and
the l'vlotor Neurone Disease Assoc iat ion
and thei r Regio nal Ca re Advisor with
whom we have regular multidisciplinary
4. Informati o n and support
We make wide use of information leaf1ets
from different organ isations to supple
ment the informati on we give patients per
sonally. We are develop ing an advice
leaf1et for relatives / friends of people who
have just had a st roke, We run a carers
group for people caring for / livi ng with
peopl e with dysphasia, memory problems
and Parkinson's disease. This is a forum
where we ca n share info rmati on and dis
cuss issues important to them and they can
gain suppo rt from one another, Those who
take part find the experi ence helpful, par
ticularly the opportunity of sharing practi
cal \ Jys of dealing wi th problems.
The future
Our service is uf (I urse li mited by the over
all number of speech and language therapy
sessions ava ilable and, whi le it would be
great to have more lime. the task i to make
the be t u e of our limited r ources. Areas
we wan! t look at are:
(i) carer / relati ve groups for support and
promoti ng communication ski ll s and
knowledge to enhance the communi cation
between the dysphasic / dysarthric person
and their relati ve
(ii) ways of addressing the demand for
early response to acute communi ty stroke
(iii) linked to this, we wal1lto look at the
provision of speech and language therapy
for acute stroke patients, how we can give
the best intervention to them and their
fami lies, particularly with il view to target
ing therapy resources at the time when
they are most likely to be effective,
The challenge for our service as for many
of us is to show that what we do is clini
call y effective. We need to keep on looking
at o ur caseload management to ensu re it is
helping facilitate effecti ve practice,
Hearing impairment
Developments in assessment and technology are reported by an independent hearing
aid audiologist.
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determine specific communication difficulties in the hearing impaired and therefore the
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provide better sound quality and can be computer programmed to suit the individual
lifestyle, for example by reducing background noise.
A range of products is also available to make home life eaSier, including a Silent Alert
Radio Paging System, the Infraport television listening device and the Echo Induction
Loop. The Uniphone 1150 is a telephone compatible with 97 per cent of the world' s text
telephones which can be used by the deaf, hard of hearing and speech impaired.
For Cubex details or to arrange a demonstration / trial: Adam Shulberg, tel. 0171 9355511.
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A new book explores why human
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SdentIJk evidence Is combined with
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About Face by Jonathan Cole is
published by The MIT Press.
B ~ 2 465 at 14.95,
ISSN (online) 2045-6174
Commune Paediatric
A magi fonnula?
::t: It -< Ann Adams, with some
T SI R he/pfromherCDmmunity
paediafrictenm, describes
NH TRUST how theyare responding
tD changing c:irnJmstonCe5.
Ou r caseload management
scenario con tinues to evolve in
response to increased referral s,
changing education policy and
staffing challenges. From dis
cussion with colleagues, there
does not seem to be a precise,
tried and tested method that works fo r
Balance of staff (Figure 1)
Over the last seven years the balance of
staff has cha nged. Many clinics were run
by experienced part-time staff, now retired.
Recruiting has changed and new staff are
more likely to be full-time new gradu ates
who require conscientious support. The
district operates a Buddy system whereby a
more experienced therapist meets with the
new therapist on a regular basis.
Our central clinic covers the Redhill a nd
Reigate popul ation . Chil dre n are see n for
assessment a nd a package of care pre
scribed: review, group therapy or a block of
individual therapy whi ch might require a
wait. There is a priority system; MO star rating
is high priority and one is priority (fig. 2).
Motivation factors
Assessment of motivation of child and par
ent come in to play. If va luable resources are
given to those who do not put into practice
advice or therapy, there see ms little point in
providing more. Failure to attend continues
to be a problem, a lthough the procedure
has been tight ened up considerably. Clients
are sent a lett er asking if they wish to con
tinue having fail ed an appointment and are
asked to return the slip within a month,
otherwise they will be discharged. There
wi ll always be children who are re-referred
because of concern of other agencies.
Growth in referrals
As referral numbers have grown, different
methods of managing have been tried
including a move towards centralised
groups (figure 3). This helps the therapist by
removing the child from her caseload for
the time being or by working with another
therapist. The child ren improve in social
ski lls and learn from others. Parents meet
others in a similar situation and learn what
helps their child within the group. In gener
al, there are not enough children with simi
lar difficulties to warrant running groups at
outlying clinics. The running of groups
needs continual updating and improving,
according to the needs of the ch ildren con
cerned; thi s is done by the whole team.
Earlier referral
Whereas children were referred at about
three years, now they may be t\,o or be
transferred from Special Needs earlier than
that. This is panly a knock on effea of
Surrey Education Authority's change of age
of transfer four years ago. Junior school
transfer is now at seven rather than eight,
infa nt entry under fi ve yea rs and pre-school
pl aygroups have lowered the age to two and
a half wi th toilet training not esse ntial. This
has created extra pressure on our service in
that parents are hoping for a "cure" earlier.
To cope, the Parent and Toddler Group was
set up. One or MO therapists and an assis
tant use adjacent rooms, the parents and a
therapist in one and the chi ldren and other
staff next door. The door remains open so
chi ldren are free to move between rooms.
While the parents are sharing experi ences,
the therapist gauges the ir chil dre n's needs
and gives advice. The children are engaged
in play and their stage of play, type of inter
action and level of comprehension and
expression noted. Fo.llowing tl1e group, the
chil.d returns to the referr ing therapist.
Meanwhile, interest has been turning to
even younger children. Therapists are
bei ng timetabled in to the Health Visitors'
post-natal groups to give encouragement
o n the benefits of early language stimul a
tion . WILSTAAR is being considered to pre
vent a certai n amount of future referrals.
Figure I . scaff
Paediatric Head
Clinic Co-ordinator
Team of clinic therapists
Single-handed in own clinic plus
working with others at central cli nic
Specialist staff
expert advice from Infant and
Junior Language Unit Therapists
based in a local primary school
Part-time assistant
receipt and acknowledgement of
referrals piUS entry on to the waiting list
the operating of the group folder,
receiving referrals from clinic therapists
taking part in running groups with
a variety of therapists
word processing facilities also available
In central clinic to staff happy to make
use of them
used to keep service moving when a
vacancy occurs, although there is
still a knock-on effect for the new
L-_____thera ist
Rgure 2 Possible reasons fOr
priority rating
where optimum timing of
treatment is critical, ego post
condition will deteriorate if not
assessed and treated, ego
dysfluency and voice
other agencies waiting for a report
before further action
anxiety about social and emotional
problems of the patient
degree of anxiety of the parents
severity of problem described In
referral and in relation to age
a referral marked urgent
(If appropriate)

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Pavilion Publishing has also produced The Virtual Tenancy
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bilities as tenants and three new titles focusing on the ben
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Pavilion Publishing, tel. 07273 623222, Telesaje 2 price 88.73 +
Speech and language therapist
Rosie Wood has contributed to the
Dyslexia Handbook 1998.
The handbook aims to provide 'a
helpline in a book' for dyslexic
people, their families, and education
and healthcare professionals,
Substantially updated and
revised each year, it has sections
on useful national and local
organisations, dyslexia and
management of dyslexia. From:
BOA, tel. 07789662677, 5.
ISSN (online) 2045-6174
H OWl...
Liaison with education
Unlike the junior age group, there is not a
school based seIVice for the infant age group,
so they are seen by dinic therapists who
keep in dose touch with schools. Liaison has
increased because of the demands of the
Nationa l Curriculum with more children
having their language difficulties recognised.
Since the OFSTED inspections, nurseries are
wishing to improve their awareness and
knowledge of how to help.
Other changes from outside are a) the Code
of Practice whereby reports are requested
wi thin legal time limits and b) Local
Management of schools resulting in schools
buying in extra speed) and language thera
py from different sources. This can create
confusion and needs sensitive handling.
Coping with paperwork
The amount of paper work has increased,
with copies to many other agencies also. If
the report wri ting pile is rising to unac
ceptable limits, time needs to be put aside
from usual patient co ntact time. To con
centrate, it is often necessalY to find a quiet
room away from the office.
Working as a team
Regular clinic therapist meetings occur fol
lowi ng the six weekl y staff meeti ngs. This is
an opportunity to discover how clinics are
running, in terms of wa iting list, reviews,
etc. and anything that might h ave occurred
recentl y, like an influx of referra ls from a
new source. It is also a time when thera
pists might contribute their most recent
information on a new area of therapy. A
medley of tips from the team are in figure 4.
[ was asked to write this arti cl e while dis
cussing how best to manage a caseload,
particul arl y in respect to employing a new
graduat e to a single handed clinic. My
interest is of course in how other people
manage their caseload so, if any of you
have fo und the magic fo rmula, J sha ll look
fO lward to reading about it
Wiig, Secord & Semel (adapted 1994)
Clinical Eva lu ati o n of Language
Fund amen tals - Revised Ed ition UK
Adaptation (CELF-R""). The Psycho logical
Details of WJLSTMR training from Dr
Sally Ward, tel. 0171 383 3834. Manuals
and forms are ava il able fo ll owing training
and accreditation with WJLSTAAR.
fi&ure 3 Groups
Pre-school (In general one hour weekly for six weeks)
o Parent and Toddler
o listening and Attention
olWo language groups - low and higher level
Oral skills
olWo phonology groups - velar and fricative
School age
These are organised according to need and run intensively in the summer
holidays, daily for 1 - 2 hours for a week, ego
o Infant age language skills
o Pragmatics
o Junior language (run by Junior School service)
o Oral skills
o Velar
Therapists are both clinic and special school therapists, giving the chance of
skill sharing.
One group is run for parents of newly referred children two or three evenings per
year. Groups of stammerers from roughly nine years are run periodically as the
need arises.
spedal Needs
The general paediatric service has the option of referring children to a Special
Needs pre-school language group or a Communication Disorder group should
this be appropriate.
FigW'e 4 A Medley ofTlps from Colleagues
o Work in blocks of half terms for therapy and use holidays for reViews
and new referrals if you normally spend some time in schools.
o Try not to 'overload' with regulars but keep a few spaces for new
referrals and reviews. It is a question of balance as by seeing too many
new clients a bottleneck is formed and their treatment needs cannot
be met. However, this is rather easier to say than do.
o Be flexible and improve juggling skills.
o Put the onus on parents, ego their responSibility to help the child to
The department has a drawer full of different advice sheets to hand to
parents/ teachers or to send out with reports.
o Giving an appointment written on a compliments Slip provides the
parent with the correct address and telephone number.
o When sending sheets for practice, address it to the child as this gives
more incentive to practise.
o When a child has been assessed on the (ELF or pre-school version, a
copy of the explanatory notes about the subtests enclosed with the
report reduces the need for greatly detailed reports.
o It is Important to remember that a clinic waiting list is not owned by
the therapist but by the service .I trust or employing authority.
o It Is always easier to have a department policy with which to back up
individual practice.
o Write notes up immediately as a blank sheet is usually echoed by a
blank memory!
Practical Points - Caseload Management
1. Caseload !11anagement is a team not an individual exercise and therapists must have the
opportumty to pool resources.
2. Contracts must be flexible enough to reflect changing work practices.
3. A departmental prioritisation system is necessary.
4. Staff need time together to plan and discuss case load management so problems can be
picked up early aneJ addressed as a team.
5. Voluntary agencies can a ~ d r e s s gaps in provision, especially if supported by speech and
language therapy expertise.
6. Adequate administrative and technological support is essential.
ISSN (online) 2045-6174
18 - 19 June 1998
The Management of Dysphagia
in Tracheostomised and
Ventilator Dependent Patients
Tutors: Karen Dikeman & Marta
Kazandjian Cost: flSS
Host Scottish Speech a Language
Therapists' Specific Interest Group in
WilLie Clyde Hall, University of
Strathclyde, Glasgow
Linda Greig, Dept of Speech
a Language Therapy, St John's
for People
Who Stutter
T11t'nw Let's Keep Talking
Host Speakeasy Stuttering
Association of South Afr ica
Vellut . Johannesburg College of
Education, St Andrews Road,
Parktown, South Africa
DI:I.IIls PO Box 3390, Parklands,
2121 , South Africa . ' .. ...
26, 27 8- 28 August 1998
8th International Aphasia
Rehabilitation Conference
TOPIU" medical and neurological ;
aosscuitural and bilingualism; outcomes,
quality of life, functional communi
cation and the family; computers;
reading and neuropsychology;
traumati c brain injury; motor speech;
ageing, dementia and geriatrics.
Host The Department of Speech
Pathology and Audiology,
University of the Witwatersrand
Venue Mt Amanzi, Hartebeesport,
South Africa
Df'lilis PO Box 3390, Park lands,
2121 South Africa.
'i'S':" W'Octotier' i 998
Communicating the Evidence
Royal Coll ege of Speech a
Language Therapists
Vt-'II It> Adelphi Hotel, Liverpool
JGaA Conferences a Events.
tel. 01905 724734,
29 bdcifier- i November, 1998
The Third European Parkinson's
Disease Association Conference
Accommodation without surrender
Venue. The Barcelona Hilton,
Barcelona. Spain
I img1J3gc Joint English and
Martlet, Conference
Secretarial, tel. 01723 686889.
Various dales ' 1998
AFASIC In-Service Training
Includes Social Communication
Skills, Functional Language in the
Oassroom, An Introduction to WILSTAAR,
Followup day for WILSrAAR therapists,
Severe Receptive Language
Difficulties in the Classroom,
Understanding the Emotional and
Behavioural Problems of Language
Impaired Children, Collaborative
Working Styles Between Teachers
and Therapists, Professional
Partnerships and The Identification
and Assessment of Children with
Speech and Language Impairment.
\ enut> London Voluntary Service
Resource Centre
OMilII5. Carol Lingwood, tel. 01273
. 2f - 1999
Thjrd International Symposi!-,m:
Speech and ImpaIrments
Frorn Theory toPractice
Venue York
"1' "(tr , .., . to consider the interface
between speech and language disorder,
dyslexia and autism, and to link
theory to practice
Speakers include: Dorothy Bishop, Gina
ConURamsden, Margaret Snowling, Joy
Stackhouse and Susan Ellis Weismer.
Details: AFASIC Symposium
Secretariat, 29 Hove Park Villas,
Hove, East Sussex BN3 6HH,
ISSN (online) 2045-6174
9] D iscussion local
colleagues. an
SIG for for me. I
These are ot wn therefore I
work mainly on my made
like the and other meet
and fostered at ether with frequent
These, tog d y knowledge.
courses. expa.n 1 I:eres
(List of Spec;aCollege of Speech &
from the Roya . tel 0 171 613
Language TherapISts, .
2] My tape recorder
This is essential for obtaining an
objective record of a patient's voice
on the first assessment, and for later
comparison after therapy. Mi ne is
also in constant use, as every patient
takes home a tape of the exercises
we have done together for home
practice. This reduces pOSSible con
fusion when faced with a sheet of
exercises alone.
Heather Taylor is an Independent
Speech & Language Therapist who
specialises in the treatment of
patients with voice disorder.
I work at various private hospitals in the
North West, treating patients with voice
problems referred by their ENT Consllitants.
Three qllarters of my caseload consists of
people with dysphonia. I am responsible fM
their assessment, treatment and discharge.
The ten top items I have selected will not be
new to an experienced voice therapist, but
perhaps those starting to work with this
client grollp may gain a few tips. heets " by
erc\se S '-J ice Thera!',
\let of e)( "oice and 0 book on th\s
-------and\ng ,,!a a ted Irom lhe ere is a good 19
, whic.h
11 t'\y e)(f ''(aWl'-sigh tad MethOd l herapy are
-n.ese i"du ee l97 I), ",cc
t MethOd a MoSt 01 my d "d nhOtO"'
,.. R SOon , ",eee
h . ques. ... ' re a... s
\<..otby, lhde"oieecrait te
ali as req':nd short
by M tape) an more are dialogue a fore'6" '
co",es with co",puter SO ha'le passa\es. hing EngliSh as So",et\'lin&
.01 practice,eg.
cop' \ practice. I I lor readl"g Id
tof '1o
",aterial use u b Ed'l'iard ",rn
Language I<.! " WIlson, pu .
to Say by e
ISSN (online) 2045-6174