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TOTAL COMMUNICATION

Photo opportunities
Speech and language therapy team leader Alison Matthews and communication development worker Terry Baynham celebrate the opportunities of skill mix for improving service quality, using the example of providing a photo rota for an adult with learning disabilities.

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IF YOU WANT TO KNOW MORE ABOUT SKILL MIX COMMUNICATION DICTIONARIES PHOTOGRAPHY FOR COMMUNICATION

Alison Matthews

Terry Baynham

here are currently only two speech and language therapists working for the adult learning disability service in Oldham (both posts four days per week). We were recently put in the very fortunate position of having a number of support workers seconded to us. These communication development workers are enabling us to provide a tailored service to more clients and to grow as a team. These staff have experience of working with adults with learning disabilities in day centres and supported living and we are developing their role (not to be confused with that of our total communication co-ordinators, on secondment to us one and a half days per month). While the role is similar to that of a speech and language therapy assistant, the communication development worker has more specialist knowledge and practical experience of adults with learning disabilities and undertakes additional training provided in-house, and externally where funds allow. There are now five communication development workers, so in the last 12 months our team has tripled in size. Each development worker has their own caseload supervised by the therapist and team manager and we are beginning to see potential for specialising within the team itself. To give you an idea of how the system works for clients, we will describe total communication work using photographs undertaken by one of the communication development workers (Terry) with Leslie, a fifty year old man with learning disabilities, and his carers. Leslie lived with his mother, who had been his sole carer for some considerable time until her sudden death. He had been accessing social service day provision at an outreach centre without any major problems. Upon the death of his mother the situation became critical and a place within social services supported accommodation was found for him as a matter of urgency. As can be imagined the sudden upheaval placed consider-

able strain on Leslie and also on the service providers. Staff from Supported Living made a referral to the Communication Therapy Team (speech and language therapy) requesting a Communication Dictionary.

Listen to me
Communication dictionaries have been developed in Oldham as a means of recording how an individuals communication is recognised and responded to. The dictionaries are based on the listen to me section in essential lifestyle planning (ELP) and a version developed by Anne ClarkeKehoe in the training pack Bringing People Back Home. The dictionary is divided into two parts; part one looks at the non verbal communication and any spoken language used by the service user and how it is interpreted by the carers and staff team. It also identifies how staff and carers should respond to the service user in order to develop communication in a consistent fashion. Part two of the communication dictionary process involves collating detailed information from teams and families about the persons skills in understanding spoken language. This aspect of the persons communication impairment can often be overlooked thus disabling the individual, usually by over-estimating their capacity to follow conversations and instructions. During part two of the communication dictionary process strategies are agreed and adopted to further develop the service users communication. Leslies team members agreed they needed a method for him to remember, or be reminded of, who was on duty in his new home whilst he wasnt there. This issue was causing him considerable stress, which in turn led to incidents of both aggressive and challenging behaviour. I asked Terry, one of the communication development workers seconded to the communication therapy team, to develop a strategy to assist Leslie.

Each development worker has their own caseload supervised by the therapist and team manager

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2006

TOTAL COMMUNICATION

Photographic rota
Figure 1 Using photographs issues to consider

Symbolic development
As we develop we go through stages of understanding how things can be represented. Some of the people we support will be at different stages on this path of development. The first stage is understanding the real object (knowing what it is for). We then understand photos of that object, later a drawing, a symbol and a finally written word that means that object.

Perspective
As with symbolic development, understanding perspective is a skill some of the people we support may not have. We know that people in the distance look smaller than people close up, but this may be confusing for some people. Try to get as near to the thing you are taking the picture of to make it fill the whole photo.

Focusing on part rather than the whole meaning


The photo may have something in it that the person focuses on rather than what was the intended meaning (for example, being interested in a packet of crisps on a table in a photograph which was meant to represent kitchen.)

Visual difficulties
Does the person need to wear glasses? Find out whether the person you are supporting has any age related eye problems such as cataracts. This will distort what the photo looks like. Some people dont have an actual problem with their eyes, but the messages going from the eyes to the brain get distorted or the brain cant deal with them properly. Some people find it hard to focus on photos because the muscles controlling their eyes arent working properly. You may see their eyes rapidly moving from side to side. This is called nystagmus. For further information, the Royal National Institute for the Blind has a useful Helpline, tel. 0845 766 9999.

Expressive, receptive or both?


Photos can be used to help someone understand (receptive language). They can be used for people to give us information (expressive language). For example we may start telling someone that we are going to the park by showing them a photo of the park (receptive). In the future they could point to the picture of the park to say they want to go there (expressive).

Where / How ?
Do the photos need to be accessible to people on the wall, or in a book or wallet? Could they be on colour coded card? Do the people who will be using the system need training? Discuss which photos are a priority and start with them. Think about the things the person would be motivated to talk about.

We agreed that a photographic rota might help. Leslie would be able to put a picture of the member of staff from the rota into his wallet to remind himself. He would also be able to convey that information to day service staff. Prior to the introduction of the photographic rota the incidents of challenging or aggressive behaviour had escalated to, on average, three per week, mostly due to Leslies inability to remember and impart the information to staff. This conduct had the knock-on effect of disrupting the lives and services of other service users and staff. Terry arranged several visits to see Leslie, both in a home situation and in the day centre. He issued both staff teams with a digital camera and asked them to supply photographs of each member of staff against a neutral background. The day service staff team also supplied photographs of activities undertaken by Leslie on a regular basis in order to assist him in planning these activities. In photography for total communication purposes, extra care needs to be taken with the quality. Staff were advised to ensure good lighting, with the subject in the centre and in focus, and no distractions in the foreground or background. The staff photographs were printed credit card size and placed in a wallet. They were accompanied by instructions on their use, which amounted to: Give Leslie a photograph of the staff member carrying out sleeping in duties on that day to place in his wallet. This should be done in the morning at a regular time to develop consistency. Tell Leslie that the photograph is there and who it is. Replace the previous days photograph in the wallet. Encourage Leslie to look in his wallet for the photograph rather than struggle to tell staff who is on duty. (Initially at least.) Day service staff or volunteers should be encouraged to ask Leslie to show them who is on duty if he cant remember, by using that days photograph. Initially Leslie thought that the photographs were his to keep in his wallet but was quite happy after a short period to exchange the previous days photograph for the current days. He has however become quite attached to one or two of the staff photographs and copies have had to be made as he would not return them. This has helped the process by identifying staff to whom Leslie is particularly attached. He is now much calmer and the stress caused by his inability to remember the staff member has now gone. He uses the photographs daily and is proud to show other people. He is also using photographs to tell staff where he would like to go and Terry is building up a library of these. There are still occasional lapses (approximately one per week) but these are easily dealt with by reminding Leslie of the photographs in his wallet. This process also helps the staff team by keeping the strategy fresh in their minds.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2006

TOTAL COMMUNICATION

In control
The major achievement of the process has been the reduction of incidences of challenging behaviour. There is now consistency of approach by staff, both at his home and his day service. Leslie is in control because he holds the relevant information and the service users around Leslie now have an improved quality of service too, as incidents of Leslies challenging behaviour have decreased dramatically. As with Leslie, the use of photographs to enable service users to understand who will be supporting them can be a good starting point for introducing photographs as a means of communicating. Our team has developed information for staff to consider against individual clients when they are introducing photos for communication purposes (figure 1) and a checklist for developing a photo rota (figure 2). The checklist includes practical questions that should ensure there is also planning for maintenance of the system. Although we are anxiously awaiting the results of a service review which may mean we are allocated additional resources for speech and language therapists, our experience of communication development workers confirms that, rather than being a compromise or a threat, skill mix is something to celebrate. Alison Matthews is speech and language therapy team leader and Terry Baynham is a former communication development worker with the Oldham Communication Therapy Team, The Hollies, Frederick Street, Oldham OL8 4BD, e-mail Alison.matthews@oldham.gov.uk. The Oldham team will shortly be opening a Communication Resource room, and are collecting photos of places and activities to create a web-based library.

Figure 2 Photo rota questions

1. Does the person you are developing the rota for recognise team members photographs? Take photos first to find out. Take well-lit photographs which are uncluttered. Go through them with the individual, and try asking questions to see if the service user knows who is who. 2. What size photos can you use? How big or small can they be? Digital cameras are really useful as you can produce different sizes of the same photograph. 3. Do you need to separate the day into morning, afternoon or evening? Perhaps morning, daytime and night-time might be more meaningful. Maybe you will need to separate out each section with a line or box. 4. Do you need a symbol or line drawing to help indicate morning, daytime or night? 5. Would different colours for each section help or confuse the person? 6. How many days at a time will you lay out? For example if you do the full weeks rota, are you sure the person can understand the idea of a full week? Would it be best to start with a day at a time? 7. Do you need to pair up the member of staff with an activity, or would this be too complicated? 8. Do the photographs need to be laminated? 9. How will you fix them onto the chart or rota board? Do you need to use Velcro? Can the service user be encouraged to take part in this? 10. Where will the rota be on display? Where will you store the photos that arent being used? 11. When you start off the rota, who will be responsible each day for ensuring it is used? 12. Are there other people who need to know about the idea of a photo rota, such as the persons family, friends, college, the day centre? 13. Do you need spare copies in case the originals are damaged? 14. If the idea to introduce a photo rota came from the repeated requests by the service user for information about who is on duty next? or whos on the sleep tonight? bear in mind that this may be a way of the person engaging you in conversation and, rather than reducing the requests for information, it may increase them, or they may find another repetitive question as a means of asking for interaction. Treat this as a request such as talk to me. It may also be a means of the person expressing anxiety about what is happening next.

References
Essential Lifestyle Planning see http://www.elpnet.net/index.html (accessed 11 January 2006). Szivos, S. & Clarke-Kehoe, A. (1990) Bringing People Back Home - developing communication skills. South East Thames Regional Health Authority with the Centre for Applied Psychology of Social Care, University of Kent.

REFLECTIONS
DO I ASSESS THE IMPACT OF RECOMMENDED COMMUNICATION STRATEGIES, FOR EXAMPLE ON INCIDENCE OF CHALLENGING BEHAVIOUR? DO I VALUE SUPPORT WORKERS / ASSISTANTS AND THE ROLE THEY PLAY IN SERVICE PROVISION? DO I ACCOMPANY ADVICE TO CARERS WITH SUFFICIENT DETAIL TO ALLOW THEM TO IMPLEMENT AND MAINTAIN IT?

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2006