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Introduction

At the RCSLT, we know our membership is passionate about their profession, and everyday we receive emails, tweets, letters and phone calls from you all to prove it! So, in the month of love, we have decided to feature them all in one place. Read love stories submitted to Bulletin throughout the years here. 

Remember one that we haven't showcased, or know one that we don't? Tweet us at @rcslt_bulletin with the hashtag #RCSLTLove for a chance to be featured, and receive a 75th anniversary badge. 

Your love stories

Check out our favourite #RCSLTLove tweets below, for a chance to be feature here, tweet us with the hashtag #RCSLTLove.

@NessNoo @laurabraithslt
@SpeechieJan

@tesspower2

Nine months to say 'I love you'

We were supporting a young father of three who had suffered a severe stroke affecting his speech and voice muscles. To help with breathing he had had a tube inserted into his throat which also prevented him from being able to speak to his family.

To start the path to recovery, our team used an individually tailored programme to help him move on from the breathing tube and gradually, over several weeks, to start using his voice again. We developed strategies to help him begin using vocal speech and to support his plan: we agreed a target of his wife’s birthday, as he wanted to be able to say 'happy birthday’ to her verbally.

One of the ways we worked towards this was by taking him to the hospital shop so that he could choose a birthday card to give to his wife. This was a big step as he hadn’t been off the ward for over six months or met any members of the public with his breathing tube in place. The shop trip went well, and with assistance he wrote the card as the stroke had left him with arm weakness.

On the day of the birthday, for the first time in nine months, he vocalised 'I love you' to his wife which was unprompted. This had quite an impact on the whole team but for him and his wife it proved to be a turning point in re-establishing their relationship by building confidence and success with speech.

Lora Franceschi, SLT

 

The first time Stefan tried out a Cannon Communicator

When I started work as a speech therapist in 1982, I used to visit a small hospital for the elderly, which was four wards set among trees and flower beds, where patients in straw hats were sat outside during the summer weather.

It was a friendly long-stay hospital. The staff all knew the patients well and supported each other as a team. As a newly qualified therapist I benefitted from the advice of a kindly porter, who suggested my patient might be able to read better if we washed her glasses!

I had always enjoyed the company of older people, especially my grandparents and my great aunts, but here I was privileged to meet people from the previous century. Many born in the 1890s and some in the 1880s.

Stefan was of the unlucky generation who had fought in both world wars, but I struggled to imagine him as a soldier as he was a diminutive little man with wisps of white hair and smiling eyes. His nurse told me Stefan was Polish. He had escaped across Europe during WWII, stowed away on a ship to Scotland and then gone back to fight again as part of the British army. She had this story from his family because Stefan could not talk.  

He was severely dysarthric and struggled to hold apen. I was able to get him to point to letters to spell out 'cup and bed', indicating he had some spelling ability, and his comprehension checked out ok, so I gave him an alphabet board. However it stayed in his bedside locker as Stefan had adequate attention to his needs from the nurses on his ward where he was something of a favourite.

My next plan was to go to the communication aids cupboard at speech therapy HQ in the City Hospital, where I borrowed a Cannon communicator for Stefan. This was a small keyboard for typing messages which were then produced on a long thin piece of paper.

I loaded up the Cannon with its tiny roll of ticker tape and took it along to Stefan’s ward. Quite a crowd had gathered, as word had got around about the communication aid and people were curious to know what Stefan would say after all this time.

I showed Stefan how the Cannon worked, and he smiled and nodded when I asked if he wanted a go. And this is what he wrote:

LUFMAMUZER

His nurse tore off the message and passed it among the staff at Stefan’s request. Puzzled looks all round, until I thought to add a Polish accent to some phonetic spelling and his message became clear:

I LOVE MY MOTHER!

Not exactly the functional communication I had been hoping for, his mother must have been dead for 40 years or so by then, but the assembled staff were delighted. The nurses kissed his head, the doctor clapped, and the porter patted his shoulder; not a dry eye on the ward.

Stefan beamed. Maybe it was functional communication after all.

Clare McLaughlin

A bedtime story

I worked with 'J' who wished to increase the volume and clarity of his speech. He had a neurological condition which reduced his ability to project his voice, maintain adequate vocal volume and caused him to slur his speech at times – a condition we call dysarthria.

We began by discussing how this impacted on his daily life and what changes he would like to see from therapy. J identified that as a result of his speech problems, he couldn’t read bedtime stories to his young grandchildren and that they missed out on quality time together.

Over eight eight weeks we worked together using ‘LOUD’ therapy, exercises to increase his volume and clarity of speech. This taught him strategies about how to self-monitor his speaking and gave him feedback. At the end of our therapy block J’s speech remained quieter than his ‘normal’ voice but he felt it had improved.

He was able to successfully use the strategies and breathing techniques we practised to be able to read his bedtime stories to his grandchildren. This improved his quality of life and had a positive impact on his relationship with his grandchildren and on their development and learning.

Claire Simpson, SLT

Father of the bride 

A gentleman was referred to me with a stammer he had had since childhood. He had received speech and language therapy on numerous occasions both in childhood and as an adult.

When I met with him, I was keen to know why he had contacted the service, and he explained that his daughter was getting married and that he wanted to make his speech despite his stammer. From previous therapy he was aware of many of the strategies that help with a stammer but they often didn’t seem to work.

I suggested we try out an app for his phone that used ‘delayed auditory feedback’ which helps with real time speech. As SLTs we have to keep up with new innovations and also be able to help patients learn to use new technology.

The app worked by using headphones and a microphone attached to his phone. Delayed auditory feedback works by extending the time between speech and auditory perception. The user speaks into the microphone and then hears his voice via the headphones a fraction of a second later.

We spent a few sessions adjusting the parameters of the app to suit the patient and then trialled it with reading aloud and then during spontaneous speech. In our final two sessions we practised the wedding speech he had written in front of the speech and language therapy team. He went on to perform his father of the bride speech in front of a crowd of more than 50 people. 

Annabelle Colquhoun

Supporting a mental capacity assessment in relation to a decision to marry: a case study

Background:

Working in a community neuro team, the Speech and Language Therapy (SLT) case load is varied and interesting. I encountered a new challenge when I received a referral from an old-age psychiatrist seeking SLT support with an assessment of decision-making capacity for a gentleman in his 60s, Paul 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 and lived together since Paul’s stroke, had been to the registry office two months previous to give notice of marriage. This had been declined due to concerns from the registrar that Paul was not able to consent to the marriage, as he was unable to answer their questions. Paul and Jane approached his GP who referred him to the old age psychiatrist for a mental capacity assessment.

What is the SLT role?

I wanted to ensure I was following the correct procedures with regard to supporting a mental capacity assessment. I spoke with my trust’s mental capacity advisor to confirm that I was fulfilling my role appropriately. I read about the Mental Capacity Act1 and how it relates to marriage. Along with its key principles, most relevantly for my role the MCA stated “that all practicable steps must be taken to help the person to make a decision” . Another statement of relevance was that “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 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 investigated SLT’s 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 Paul 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. HM Government’s guidelines suggest possible questions:

  • “What is a husband/wife?
  • What is a marriage?
  • What is different about being married or unmarried?”

On liaison with the 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 in order that he felt familiar with it. 

The questions in their multiple-choice format. 

Outcome

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 ten 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 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 who provide advice on disability discrimination, as the barrier to their giving notice of marriage is now around interpretation of legal matters.

Reflections

This was a really important referral to SLT, as Paul would have been at high risk of being deemed not to have capacity if not supported to communicate his decisions, as his expressive language was so limited.

I was frustrated at the outcome of the situation, as despite a number of healthcare professionals advising that Paul demonstrated capacity to decide to marry; this was not given credence by the registry office. 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 who may come across adults with communication difficulties to be more aware of communication impairment and their role of working within the Mental Capacity Act and Equality Act.

This was a challenging experience for me, despite having worked as an SLT for a few years. 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 am interested to hear about other SLTs experiences of supporting mental capacity assessments in complex cases.

Anna Robinson, @robbo_ak

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