February – Love
The language of love: Editor’s Letter
In the words of Lennon and McCartney, ‘All you need is love’, and in this second month of the RCSLT’s 75th anniversary year, to tie in with February’s creative theme, we’ve got lots of love lined up for you.
In her first column for Bulletin, RCSLT director of professional development Judith Broll writes on the subject of love, food and adult dysphagia. While Jois Stansfield, emeritus professor at Manchester Metropolitan University, takes a trip down memory lane to take a look at passion for the profession in the early days of speech and language therapy.
What do you love most about being an SLT? Tell us on Twitter using #RCSLT75 or send an email to the Bulletin inbox with your anniversary-themed news. Remember, there’s a limited edition pin badge in it for any 75th submissions that we publish in the magazine.
Explore our website for all things love, read our main love features below, and check out our RCSLT love stories here.
A notice of marriage
In December 2018, Bulletin published this feature by Anna Robinson on supporting a mental capacity assessment for a couple who wanted to marry
Working in a community neuro- rehabilitation team means the speech and language therapy case load is varied and interesting. Recently, I encountered a new challenge when I received a referral from a psychiatrist seeking SLT support with an assessment of decision-making capacity for Paul, a gentleman in his 60s, who had aphasia following a stroke in 2012. On exploring the case history, I discovered that Paul and his partner Jane—who had been together for 20 years—had been to the registry office two months previously to give notice of marriage. But, due to the registrar’s concerns that Paul was not able to consent to the marriage as he was unable to answer their questions, this had been declined. Paul and Jane had then approached his GP, who referred him to the psychiatrist for a mental capacity assessment.
What is the SLT role?
To ensure I was following the correct procedures for supporting a mental capacity assessment, I spoke with my trust’s mental capacity advisor in the first instance, then read about the Mental Capacity Act (MCA) and how it related to marriage. Most relevant for my role were the following two statements in the MCA:
- “That all practicable steps must be taken to help the person to make a decision”.
- “Nothing in this Act permits a decision on any of the following matters to be made on behalf of a person— (a) consenting to marriage or a civil partnership…”
On questioning whether a mental capacity assessment should therefore be embarked upon in this instance I read further, in the context of mental capacity and learning disability, that “although a person cannot make a decision about marriage on another’s behalf, the principles of the Act can be used to determine whether or not a person…has the capacity to give informed consent.”
Knowing that it would be appropriate to facilitate the mental capacity assessment, I discussed the case with my colleagues and prepared for facilitating Paul’s communication.
How to facilitate
Ferguson et al (2010) investigated SLTs’ opinions on how to assess prior to supporting a mental capacity assessment and found that, although formal assessments were used, this was perceived as less important than informal observation of function.
I saw Paul for four sessions, using formal (sub-sections from the Comprehensive Aphasia Test) and informal assessment to develop a communication profile.
Paul’s receptive language was significantly stronger than his expressive language, which was also affected by verbal dyspraxia. He had minimal verbal output, consisting of automatic phrases. Paul’s verbal yes/no consistency was poor, as he often spoke an automatic phrase instead of ‘yes’ or ‘no’.
He could follow three-step instructions and was able to consistently match single written words to pictures by pointing. Informal observations at Paul’s house revealed that he regularly practised pointing to specific written words in books when Jane read aloud. Paul was noted to communicate with greater ease at home, but was distressed by unfamiliar tasks.
What questions to ask?
To determine whether Paul could understand, retain, weigh-up and communicate his decision, the right questions would need to be asked in the right format. Government guidelines suggest possible questions, including:
- What is a husband/wife?
- What is a marriage?
- What is different about being married or unmarried?
In consultation with psychiatrists, a list of 10 relevant questions was drawn up, which aimed to determine whether Paul fully understood what marriage was. As the risks and benefits of marriage are different for each individual, the weighing up questions were challenging. However, having gathered background information on the case, we were able to include some questions such as, ‘how might your family feel if you get married?’ which could give an insight to whether Paul could weigh up the risks (i.e. that his family might be upset).
The 10 questions were presented as short, written, multiple-choice questions—the format deemed most appropriate following assessment. For the majority of the questions, the answer was known, e.g. we knew that Paul and Jane had been together for 20 years. A different version of the same format of questions was presented to Paul a week before the assessment so that he felt familiar with it.
Two psychiatrists led the assessment with me facilitating. Jane accompanied Paul but left the room during the assessment. Paul was asked each question in turn and instructed to point to his choice of answer out of the three options. Paul answered eight of the 10 questions ‘correctly’ (in the way in which we would have expected). Jane was subsequently invited in and the psychiatrists informally assessed their interactions. Following discussion, Paul was deemed to have demonstrated capacity to make the decision to get married.
Unfortunately, despite the outcome of the mental capacity assessment, which was provided to the registrar, when Paul and Jane returned to the registry office they were once again declined. The registrar stated that this was because Paul was still required to answer their questions verbally. Despite my lengthy discussions with the registrar regarding the nature of aphasia and the need for a public agency to make reasonable adjustments to their processes to allow for a communication disability (The Equality Act), the registry office felt the adjustments needed contradicted marriage law and therefore declined to make them. The couple are now in touch with The Equality and Human Rights Commission, which provides advice on disability discrimination, as the barrier to their giving notice of marriage is now around interpretation of legal matters.
This was a really important referral to speech and language therapy, as without the requisite support, Paul would have been at high risk of being deemed not to have capacity to communicate his decisions, given that his expressive language was so limited.
I was frustrated at the outcome of the situation, as despite a number of healthcare professionals agreeing that Paul demonstrated the mental capacity to decide to marry, the registry office chose not to accept that advice. This made me wonder about how often, when working outside of health and social care, the established decision-making assessments we use are not recognised. I feel that we need to support agencies which may interact with adults with communication difficulties to be more aware of their role within the context of the Mental Capacity and Equality Acts.
Despite having worked as an SLT for a few years, this case was a challenging experience for me. As stated by Ferguson et al., there is a “need for further research to develop guidelines for practice and to build educational experiences for students and novice clinicians to assist them when they engage with the complex case management issues in this area”.
I hope that SLTs continue to receive increasing numbers of referrals for supporting mental capacity assessments in all areas of life, in order that patients are supported as fully as possible to make their own decisions. I would be interested to hear about other SLTs’ experiences of supporting mental capacity assessments in complex cases and would welcome being contacted about this.
Anna Robinson, Bulletin December 2018
Gary and Claire
In February 2019, Bulletin published a letter from Enya Killien, and with it being the month of love, we thought it was a good time to remind you of it…
After reading Anna Robinson’s feature on mental capacity and marriage (December’s Bulletin), I felt compelled to share my manager Gerlind Tredinnick’s service user ‘good news’ story. Gerlind and I work as part of the adult learning disability service in North East Lincolnshire, where a large part of our work is reducing prejudices towards people with a learning disability and challenging the assumption that they lack capacity.
Much of this includes ensuring reasonable adjustments (NHS 2016) are undertaken to support our service users. I’ve noted similar trends between Anna’s story and Gerlind’s, of the registrar insisting upon questions being answered verbally, which of course is often a major diﬃculty and barrier for our clients. With that in mind, here is Clare and Gary’s story:
“We’re Clare and Gary (pictured) and have been together since 2008. We moved into our ﬁrst home together in 2009. We got married in October 2018. We both have a learning disability and Gerlind, our SLT, has worked with us on and oﬀ since 2009. We’ve always been able to say to Gerlind what we want to work on. Clare: “I ﬁnd it diﬃcult to speak, but know what I want. I communicate by signing, gesturing, facial expressions and Proloquo2go (a communication app on my smartphone/tablet).” Gary: “My speech is not always clear and sometimes people struggle to understand me.
We prepared for over a year for the wedding. When registering the marriage and giving notice at the registry oﬃce, we had some diﬃculties because some people thought we did not understand everything about getting married and the commitment we want to make to each other. Gerlind helped us ﬁght these barriers and we were able to have the wedding we wanted. Gerlind helped us feel more conﬁ dent about saying our vows on our wedding day and we practised lots. Clare was really worried about this but was sure she wanted to use speech to say her vows. On the actual wedding day we both spoke all our vows and so many people were surprised and proud of us.”
Gerlind and I are lucky to work in a small locality allowing us some inﬂuence over services through training and partnership working, however, it is clear that nationally, there is still work to be done on behalf of people with a communication diﬃculty, with or without capacity.
Enya Killen, SLT
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