Speech therapy in subnormality: are the ski l ls o f a speech therapist really needed in a hospital f o r the severely subnormal ? MARGARET GREENE, Consultant Speech Therapist, Department of Medical Electronics, St. Bartholomew‘s Hospital and South Ockendon Hospital Research Unit, South Ockendon, Essex.

Background In recent years the belief has taken root that not

only the educationally subnormal but also the severely subnormal child can benefit from speech therapy. Changes of attitude have come about with the increasing realisation of the importance of language in the develop- ment of learning and intelligence. I t seems logical to expect that, if non-communicating subnormal persons can be taught speech, then they will learn social skills and become more amenable.

Thus, a general demand for speech therapists to work in hospitals for the mentally handicapped has arisen from overworked staff overwhelmed by the problems involved in management of the most difficult, non- communicating patients. Most speech therapists shun this work and are far from forthcoming in applying for the posts advertised. This is very largely because their training leaves them totally unprepared for treating the severely handicapped. Their training is highly academic and clinical techniques for assessment and treatment are linguistically orientated. Speech therapists find it hard to conceive the low level at which the severely subnormal patient functions. They are bewildered and a t a loss when confronted by patients who have little comprehension of speech and no words, but often have aggressive, bizarre behaviour and shocking social habits.

Studies in neurology make it plain to them that these are severely brain damaged persons and, if neurologists are sceptical regarding the efficacy of speech therapy for intelligent stroke patients, then is it not unreasonable to question its efficacy with the severely subnormal, whose very plight is due to irreparable congenital brain damage which prevents learning, especially the learning of language. These arguments are reasonable enough and are reinforced in times of economic stringency, such as at present, when priority must be given to more hopeful cases who are known to benefit from speech therapy.

It is, therefore, easy to dismiss speech therapy for the severely subnormal as a luxury service and to explain to nursing staff and teachers that their patients are not speaking because they have not the cerebral equipment to do so; that speech therapists cannot, in fact, bring about miracles. However, in actual fact, it is not so easy to dismiss repeated cries for help from dedicated workers, especially when despite all reasoning nurses in charge of severely subnormal people, knowing their patients and their personalities better than the speech therapist, are convinced that speech therapy can help. The experiment

So, it was rather in the spirit of wanting to prove that speech therapy was a waste of time than to establish a service, that an experiment to this end was started at South Ockendon Hospital in 1973. St. Bartholomew’s Hospital had already established a Research Unit, based at South Ockendon, largely to provide an evoked audi- tory response service and to design equipment to assist in the physical management of handicapped patients. However, the chief demand was for a speech therapist

since advertising the post had failed to produce any applicants. The Area Health Authority services amounted to an occasional visit from a speech therapist to the Hospital School; this was not followed up by a regular and constructive programme. The staff

Eventually, a solution was devised whereby for an experimental period of six months, a ward sister of long experience in the hospital was released from her normal duties in order to develop a communication service for carefully selected patients. A speech therapist was appointed to act in an advisory capacity and to attend at regular 3 or 4 weekly intervals.

The selection of an experienced nurse had enormous advantages; she knew all the wards, hospital staff and most of the patients. She also knew how to control disturbed patients, which had been the most alarming aspect of working in this field for the speech therapist. The nurse selected had long shown a real and practical interest in communication with the severely subnormal and had attended courses at the local polytechnic in education of the severely handicapped and a course in speech correction given by a speech therapist. In this. be it noted, the articulation programme was far morc valuable than that of language stimulation. She was also to attend further courses at Wallingford and at Lea Hospital; such courses are an essential ingredient in the training of a “communications therapist”.

The speech therapist recruited, having worked for 10 years at St. Bartholomew’s Hospital, had no idea of how to work with the severely subnormal but was ready to learn. It was thought that knowledge in the use of medical electronic speech aids might a t least be useful.

It was soon agreed between the speech therapist and the nurse that they were not going to “do speech therapy” but “improve communication”, that is, establish social contact and friendly relations with disturbed and other patients by whatever means possible, by talking to them, making eye-contact and by gesture. Eliciting speech must come later but it was recognised that, in most cases, speech would not come at all, though signs and appropriately used names might.

The speech therapist found she could make sugges- tions concerning many aspects of communication, for example, listening techniques to promote compre- hension, tongue and lip exercises to help swallowing and articulation, posture, breathing and vocalising to promote voice and audibility of utterance. She was able to demonstrate to the communications nurse, other nursing staff and teachers what was possible, how to carry out exercises, and their purpose. The nurse was then able to carry on the programme during the speech therapist’s absence.

A major task was to involve everybody in contact with the patient in the treatment and to establish con- sistent treatment, whether this were in school, ward, physiotherapy, occupational or activity centre. Although there was a treatment room available in the Research Centre this was not much used, the nurse going to the

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wards and elsewhere and working “on the spot”, often helping with feeding, dressing, toileting and integrating communication in living activity. Student nurses were given instruction in how to carry out programmes as part of their practical training so that an interest in helping patients to communicate was fostered from the start resulting in increased satisfaction in their work besides improving the lot of the patients.

The patients I t must be stated that the patients referred for com-

munication therapy were mostly adults, often transferred from other hospitals, and debarred from school or having left school at 18 years without having made much progress. They were often aggressive to others or to themselves; might be unable to feed themselves, or make any social contact with staff or patients. The overall aim was to improve the quality of life, not only for the patient but also for the staff and the patient’s relatives if they still visited. Communication was carried into all activities, anywhere it might be convenient to see the patient, with nursing staff present. I t did not take place in a “speech therapy clinic”, divorced from the real life of the patient.

Patients were reterred by doctors, nurses and the psychologist and it must be stressed that, from the out- set, the psychologist’s contribution was essential to the success of the venture. Behaviour modification tech- niques had to be used with all patients, and it was the psychologist who started the patient off, selecting which aspect of behaviour to modify in a controlled situation. He instructed the nurse and reviewed and encouraged her efforts throughout treatment. He was, at the same time, responsible for promoting courses in behaviour modification for the nursing staff which established a suitable climate for the introduction and consistent application of communication therapy.

Patients who could not speak but wanted to com- municate were encouraged to gesture and, latterly, we have recognised the possibilities of introducing the use of the Mukutorz Sigri Luizguuge, not only with deaf patients, but also with other non-communicators who are not deaf and are sufficiently socialised and co- operative. A sign language based on that for the deaf and dumb offers possibilities of vocabulary extension - framing of simple statements, questions and work in groups. The signs can be used by nursing staff and when many of them cannot speak much English, this is a real advantage. Parents can learn the signs and, being a universal language, the patient can use it in other hospitals or in clubs. Teaching and use of the Mukutori Sign Language should not be considered the prerogative of the speech therapist but must be shared ‘by nurses, teachers, occupational and physiotherapists. The speech therapist, however, may be able to make a unique contribution in ideas on how to break down learning into simple stages and especially link signing with educational methods in the hapita1 school.

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The results The South Ockendon six-month experiment was felt

to be sufficiently promising for the trial period to be extended. Now, after 3 years, it seems to be fairly established.

We do not claim to have been successful with all the patients referred for courses in communication therapy. Sometimes we have been partially successful; there have becn rclapses; some failures; but enough success to justify the continuation of the programme. As time passes we extend help to more and different types of palients and hope to improve on selection and treatment.

This is not the place to give detailed case histories and treatment methods. It must suffice to mention some of the patients who have benefited and been brought nearer to leading a happy existence: a boy who had screaming fits, hit his face till it bled and was quite unapproachable, became quiet and friendly and was ablc to go on excursions and enjoy school; a chronic dribblcr learned to swallow better and feed herself, with an increasc in self-respect and self-help; a boy who hid away under a table in a corner and was incontinent became sociable and helpful; a chronic spitter benefited from a programme of restitution or over-correction therapy and, subsequently, was able to participate in hospital activities in a civilised way.

The answer to the question which was asked at the bcginning of this account, “Is speech therapy really nceded in hospitals for the severely subnormal?” is, we think, to be found in the above notes on patients. A speech therapist will recognise at once that this is not “speech therapy” at all, when related to the accepted concept of his/her professional role, since speech itself scarcely enters into the functioning of these patients. Ncverthcless, i t seems that a speech therapist can make a useful contribution to the development of comrnuni- critiori, working with hospital staff and a nurse cxperienced in care of the severely handicapped.

It seems to us that the full-time commitment of a speech therapist is not necessary and would be an unwarranted waste of valuable time since so much of the training can be done by the staff who are in constant contact with patients. There is obviously a need for in-training facilities to be provided for nurses undertaking the work of communication therapists; cqually obvious is the need for postgraduate and very practical courses in severe subnormality for speech therapists. Their three-year training is already over- loaded and not all speech therapists would wish to work in this specialised field. But, for those who do, such courses should include instruction on how to act in a consultant capacity which in itself is important for success.

In conclusion The solution to provision of a speech therapy service

at South Ockendon Hospital has been described in the hopc that it may encourage other centres to start up similar services. It should not be difficult to select the right nurse to be seconded to a full time appointment as communication therapist and the local health authority should be able to provide a speech therapist for a few sessions a month. This speech therapist must be adequately prepared for the work, must be reliable and regular in his/her visits and must not delegate such visits to colleagues. A service such as this is not cxpensive; neither nurse nor therapist need much in the way of premises since perhaps the most important ingredient to success is that therapy or treatment should be integrated into the daily life of the patients con- cerned.

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