In grad school way back when, SLP majors were partnered with a classmate and sent out to observe SLPs in a variety of workplace settings. We observed in a nursing home, a rehab center, a public elementary school, a hospital, a residential facility for clients with multiple disabilities, and a state school for the deaf. Of course, the goal was to gain insight into each of these settings, into the types of clients who were served, how treatment was delivered, and personal reflections of each of the practitioners. Following each visit, we were to write up our impressions. This exercise was one of the most valuable experiences of my education, as it helped me to determine my future goals — the type of setting in which I did or did not want to work and how I envisioned my future self delivering services. Much of this experience has faded from memory, having taken place over 25 years ago, but one observation has never left me: the “therapy voice.”
It was in a hospital that my partner and I first heard the “therapy voice.” The SLP met us in her office and we had a lovely conversation about the profession and her experiences with inpatient and outpatient therapy. Then we followed her to bedsides and into the clinic. While her therapy activities seemed appropriate to our novice eyes, what really struck us was the way her voice changed whenever she addressed her clients. Louder, slower, and higher pitched, her voice took on a whole different persona — one that signaled, to us at least, the message that “you are so impaired, you don’t know what I’m saying so I will shout it at you.” My partner and I looked at each in disbelief, that her friendly, conversational voice could immediately become so seemingly condescending. Now, mind you, I fully understand that she had years of communicating with people who presented with strokes, brain tumors, neurological disorders, hearing loss, and dementia, and I fully understand that one’s communication style has to accommodate those conditions. But we observed this same “therapy voice” when she was treating outpatient children and adults in the clinic for articulation, language, and fluency. It was amazing to us, the way she could switch back and forth when treating clients with the “therapy voice,” then turning to us with comments in a conversational manner. This wasn’t the last time I heard the “therapy voice” but it certainly was the first, most dramatic, and most memorable. My partner and I vowed, as we walked out of the hospital, to never, EVER, use the “therapy voice” in our practice.
The bulk of my 25-year career as a public school SLP has been spent with students who have moderate to profound disabilities. Obviously, I have had to adjust my language level with these students — shorter sentences, simplified vocabulary — but I have held to my promise and ALWAYS speak in a conversational tone of voice, one that presumes that “I know you understand what I am saying,” even when there is little or no outward sign of this. In other words, presume competence!
Two books I read recently bear out my intuitive use of conversational tone: “My Stroke of Insight” by Jill Bolte Taylor, and “Ghost Boy” by Martin Pistorius (reviewed on this blog HERE). Both authors were suddenly stricken with profound injury to the brain, one by stroke, one by an unidentified virus, and were essentially trapped inside bodies that would not, could not respond or be controlled. Both eventually recovered to a remarkable degree, thanks in no small part to their own strong will and the support of therapists, caregivers, and family. Both relate horror stories of how they were sometimes spoken to by people (family and medical staff) who didn’t think they could hear or understand. Jill Bolte Taylor includes a list of “do’s and don’ts” in her book, including the importance of communicating presumed competence and respect through words, but also through tone of voice and body language. I highly recommend these two books to all SLPs in any treatment setting, as they provide a rare, detailed, and highly personal account from people who experienced traumatic loss of communication.
Beyond reading these books, I really haven’t given much thought to the “therapy voice” in years, but this spring, I saw how damaging it can be. On May 10, my dear father suffered the first of several strokes. He was flown by helicopter to a nationally ranked medical center and was given the “clot-buster” drug within the “golden hour.” The stroke was on the left side of his brain, which initially caused right side paralysis and the inability to speak. Twenty-four hours, he had regained movement on his right side and could speak, although aphasia was obvious in the “word salad” and word-finding problems he exhibited. Within a few days, the aphasia lessened, and he was able to speak in longer, more accurate sentences. We were so encouraged by this and assured him that progress would continue. Unfortunately, less than a week after the first stroke, he had a second that required emergency surgery to clear a blocked carotid artery and to remove some of the new clots in his brain. Clots from the first stroke were left in place, due to the risk of bleeding. Dad again regained movement on his right side, albeit with weakness, and again could talk, but the second stroke wiped out the progress he had made and he was back to being more significantly aphasic. One only had to look in his eyes to know that he was fully aware of what had happened and was very afraid.
Once medically stable, Dad was released to the local hospital in a small town near his home for two weeks of rehab — OT, PT, Speech. Dad was evaluated by the SLP and therapy began immediately. Due to work obligations and distance (85 miles from my home), I could not be with my dad during these first few days, but I did get out there on day 4 so I could meet with the SLP and observe therapy. This observation was welcomed by the SLP and the rehab director, and I had a good conversation with the SLP about Dad’s status and goals. Then, when we walked into his room, I heard it — the “therapy voice.” “HELLO, RICHARD! DO YOU REMEMBER ME? I AM HERE TO HELP YOUR SPEECH.” This was said just inches from his face. Dad immediately recoiled and looked stricken — facial expression, eyes, and body language all expressed this. After a few minutes of this, I gently told the SLP that Dad’s hearing was fine and that his intellect had not been affected, only his ability to produce spoken language, and said that she could speak to him conversationally. I also said he was having trouble with yes/no questions, but I was sure that he understood. Dad shot me a grateful glance, but it didn’t change her approach. She opened up a book of aphasia therapy exercises and asked him “WHAT GOES WITH —” questions. When he couldn’t answer, she said, “YOU CAN’T DO THIS SO WE’LL DO SOMETHING ELSE.” She moved on a series of yes/no questions. When he answered “yes” to “ARE YOU A WOMAN?,” she answered, “NO, YOU ARE NOT. YOU ARE A MAN” and closed the book. Dad looked even more stricken. The next activity was naming photographs. He failed on the first three, so that activity ended, again with “YOU CAN’T DO THIS NOW SO WE WILL TRY AGAIN ANOTHER DAY.” By this point, it was all I could do to keep from taking the cards from her and modeling, “Look at this picture, Dad. What is this? I’ll help you, it’s a ball. What do you do with a ball? Can you show me? Yes, you can throw a ball like this; now you do it. You throw a ball. You can kick a ball, too, like this. Now you show me, kick a ball. Look at the picture again — see it is a ball, a red ball. Can you say that with me? Ball.” But I didn’t. After a few more failed activities, Dad watching all the time as data was collected, the session ended with Dad looking devastated and Mom in tears. I left the room with the SLP and repeated, very calmly, that Dad’s hearing was fine and suggested that he’d respond better to a conversational tone of voice and instruction, rather than just data collecting (the eval had already been done, remember) to show what he couldn’t do, and perhaps she could be more instructive when he couldn’t name pictures. Dad was a very intelligent and proud man, and failure at questions a toddler could answer cut him to the core. When speaking with the SLP, I was very aware that I am NOT a hospital/rehab SLP and did not want to say or do anything that would make Dad’s next two weeks more difficult. But I know how I would teach my students with disabilities — key word is “teach,” not just collect data. It’s very easy when people have impairment to only focus on what they can’t do. My approach is always to focus on abilities, no matter how limited, and build from there.
Well, according to my mom, nothing changed in those two weeks. Dad responded very well to the OT and PT, gaining skills and trying again with positive effort when he didn’t perform to his highest level, but became increasingly despondent as speech therapy time approached. After two weeks, he was sent home with in-home therapy. Because I was up to my eyeballs in the crazy end of the school year, I was not able to get out to their home during the week when the new SLP was there, but after a few frustrating sessions, Mom told her I was an SLP and she immediately asked for my phone number. We had a very good discussion in which she revealed that Dad would become emotional and even hostile when she was taking data on the same kind of tasks that he had been exposed to in the hospital. Mom had already told me this, saying that the OT and PT did not take data in front of him and worked on skills that were functional in his home and related to his personal interests and goals, whereas speech therapy was limited to drilling him with questions. I suggested that she put away the aphasia therapy book and cards for a while, and instead engage him in conversation about his family, his career, his hobbies, his dog, etc. I told her that Mom had many photo albums of family members, present and past, and brochures from many places that they had traveled; these would be great conversation starters for him. Dad was an accomplished woodworker, so I suggested that she take him to his workshop and talk about the tools and the things he had built. Dad lost the ability to read due to the strokes, but he was still able to put together jigsaw puzzles, an activity that he and Mom did every winter to pass the time; that would be another way to work on language skills in a relaxed context. And I stressed that, although Dad was 85 years old, he was 100% independent in all areas of life prior to the strokes — drove a car, cut his own grass, handled affairs without any difficulty. When I visited Dad weekly throughout this time, we had many great conversations about people and events in the past, conversations that he initiated and participated in fully, even if a word or two was wrong here and there. He talked about his concerns for my mom and the future. He could tell time and knew when his favorite shows were on. I’ve never seen so many episodes of “American Pickers” as I did this past spring and summer, and Dad was always able to make insightful and relevant comments about this and other shows we watched together each evening. I did not evaluate my dad and did not want to be his therapist, but it was very evident to me that his intellect was not affected. When we went out for a drive in their rural area, Dad was able to give me directions all over the countryside to point out places of interest, to get to a farm stand he particularly liked, and always found our way home — an errorless and most enjoyable change of scenery for him that gave him a sense of control. All of this, I shared with the SLP, giving lots of therapy suggestions that Dad would respond favorably to. I said I totally understood about the need for data (the bane of my school-based therapy existence), but suggested it could be done more discreetly. The conversation ended very well, with the SLP expressing her gratitude for my suggestions, as it was clear that she wanted to do her best with Dad and that she was as frustrated as he was.
Well, I’d like to say it ended well, but it didn’t. The picture cards came out again; Dad blew up and refused any more therapy from anyone — no OT, PT, or speech. We hoped after this meltdown that he would relent, and we encouraged him as much as we could to try again, but it was clear to him, and to Mom and I, that he was actually going to make more progress on his own, engaging in daily functional activities, having conversations about things that interested him, commenting during his TV shows, giving us directions when driving or about how to change the water filter, than he would be getting from an aphasia therapy book. And so, I started giving my mom strategies to help Dad that didn’t feel like therapy. That Dad was so soured on speech therapy, right from the beginning, just killed me, as you can imagine, and I have to think that a more conversational approach that presumed competence would have yielded a more positive outcome. I completely understood and explained to both of my parents that Dad’s anger and frustration was a very common bi-product of stroke and that it would ease with time and healing. However, Dad was too demoralized by his experience with speech therapy, and then extended that to all therapies and medical interventions. He didn’t feel any of it was helping him, and he was done with it all. Once he made this decision, his anxiety level dropped noticeably and he had a good month of small steps forward. I could see a positive change in his abilities and attitude every week and we were all greatly encouraged. Unfortunately, Dad suffered additional TIAs and complications from which he could not recover. On August 14, this proud, wonderful, admirable, and loving husband and father passed away.
Please understand that I write this not as an indictment of the SLPs who treated Dad. SLPs are the most caring, compassionate people I know. These SLPs were no exception. Both seemed to be genuinely nice and caring people, and I’m sure they have helped many patients in their careers. I especially appreciated the home-based SLP who reached out for ideas when she saw Dad shutting down. As stated earlier, I’m not a rehab therapist, so my practice is not shaped by years of dealing with adults with strokes, dementia, etc. Maybe rehab SLPs are more strictly bound to certain therapy materials and lessons; as a school-based SLP, I have free reign to do whatever I think will be helpful to my students, be it traditional therapy or materials/strategies that are highly personalized and even unconventional. That didn’t seem to be the case with the SLPs who treated Dad. I acknowledge that data must be collected to satisfy insurance requirements; it drives the IEP in schools, and I work hard to keep a balance between measuring progress and actually teaching. I certainly acknowledge that Dad’s strong personality and damage caused by the strokes also contributed to his very negative reactions. All that said, I guess I felt the need to write this for a few reasons. I am still very much hurting over the loss of my dad. I’m very saddened to know that he wasn’t helped by speech therapy and, in fact, was turned off to all therapies and medical treatment as a result.
This is the first time I’ve been a close observer of therapy with a loved one — very different from being the SLP treating other people’s loved ones. It was an eye-opening experience; I viewed the therapy professionally and my dad’s reactions to it personally, and found that very hard to reconcile. While a person’s prosody may seem inconsequential, Jill Bolte Taylor and Martin Pistorius would disagree, and so would Dad and I. Even if he hadn’t been able to understand the words that were spoken to him, he immediately sensed that the “therapy voice” was an affront to his status as a successful, intelligent, dignified man, and that was his introduction to speech therapy. I witnessed how Dad perceived each session as a series of tests on which he was found deficient, and saw how badly this wounded his pride and confidence. And I have to agree with him — the activities were rote and without instruction, strategies, or prompts to help him succeed. No amount of encouragement from me could convince him that he would improve if he would just cooperate and try. This was heartbreaking for my parents and for me; more than anything, I wanted to do whatever it took to help my dad recover his independence and dignity, and obviously, my mom desperately wanted that, too. Mom and I saw how Dad watched data being collected after every question, visibly wincing and withdrawing more and more with each tally mark, and that has made me much more aware of the way I keep data with my students. I feel guilty that I didn’t speak up more strongly with the rehab SLP when I saw how offended and saddened my dad was by her approach and tone of voice. I am not good at confrontation, I never pass judgment on a colleague, and I was in a very fragile place myself. As a result, I feel that I was overly cautious in expressing my concerns. I also knew that the SLP was not trying to do any harm; she was just unaware of the effect her manner was having on Dad. If I had been more clear about my observations, would therapy activities and the relationship have improved? Would Dad have been more accepting and willing to go along with therapy? That’s all water under the bridge now for Dad, but maybe by voicing my concerns now in this post, an SLP somewhere might rethink his/her approach and somebody else’s loved one will benefit. Indeed, shouldn’t we always engage in self-reflection about our practice and do our best to adapt our manner and therapy to each individual? That’s the first lesson in speech 101: “Establish rapport.” Right? If nothing else, maybe the reason I felt compelled to write this post is to finally release some of the feelings that have been bottled up all summer. It’s been a tough one.