Where are we now Current practices in SLP with adults with mental health disorders

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Where are we now? Current practices in SLP with
adults with mental health disorders?

• Jennifer Brophy
• Clinical Specialist SLP
• Dublin, Ireland

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Their Words

• I talk a lot. I dont like silence. If I stop
  talking my thoughts will get in too deep. I dont
  want to isolate myself. I talk all the time
  because its a distraction. Try to distract my
  thoughts
• (Mary 20 year old lady with schizophrenia)

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Current SLP service provision

• Adults with communication and/or swallowing
  difficulties
• Acute in onset
• Enduring or chronic in nature requiring residency
• Community based day centre/day hospital.

• Schizophrenia
• Bi Polar Disorder
• Depressive Illness
• Anxiety Disorders
• Obsessive Compulsive Disorder
• Personality Disorder.

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The Team
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Philosophy of Intervention

• Person centred
• Build on strengths to develop impaired or
  suppressed skills.
• Focus on areas of performance most likely to
  effect change and maximise communicative
  competence.

• Revealing Ability
• Vs.
• Treating Disability

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Recovery Model

• Gold standard (Schizophrenia Ireland, 2003)
• Focus on increasing the patients ability to
  successfully cope with lifes challenges, and to
  successfully manage their symptoms. (American
  Psychiatric Association, 2005)
• who and what existed before the illness and who
  and what endure during and after?
• (Barham Hayward, 19952)

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Model of Intervention
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Person
Environment
Personal Factors
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(No Transcript)
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Social Communication InterventionSkills Based

• Social Communication Skills Training (SLP)
• Traumatic Brain Injury
• Dahlberg et al (2007)
• Dysfluency
• Cook Fry (2006)
• Child and Adolescent Mental Health
• Sim et al (2006)
• Mental Health
• Walsh, I. (2006)

• Issues re.
• Efficacy vs. real world validity
• Acquisition
• Generalisation
• Cognitive impairment

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Evaluations

• ? self rating of conversation skills.
• ? formal language assessment not statistically
  significant.
• ? meta communication talking about talk
• Testimonials
• I am more confident talking to people outside of
  the group
• learned how to speak out and relax
• being part of a group was good, a bit of a
  laugh
• Im more observant now when I meet people
• I have a way to start a conversation now

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Social Communication Experiential

• Provides opportunity for successful interaction.
• Facilitation by skilled communication partners.
• In vivo supports necessary to make success of
  these opportunities
• I could see the way my partner handled himself
  in a crowd of people I could learn from the way
  he does it. He talks to people and hes friendly
  and it made me feel I could, you know, maybe I
  could to that too, if I put my mind to it
• (Davidson, 2001287)

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Kagan (1995) Long term psychosocial consequence
of communication impairment.
Reduced ability and opportunity to
Engage in conversation
Reveal competence

Reduced Communicative Access To Social
Community Life
Reduced Participation in Social Community Life
Reduced Mental Social Health
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CBT SLTA useful combination?
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Social Isolation Cycle (Hutchings et al, 1991)
Thinks No-one likes me, no one wants to Speak
to me Feels Rejected, unwanted,
unpopular Behaves Avoids starting conversations
and interacting, Does not use body language
effectively
Social isolation
Can result in
Avoiding Social situations resulting in Less
opportunities to practice and meet other people
resulting in Lack of confidence and a fear of
rejection, potential embarrassment.
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CBT and SLT

• Important to discuss communication difficulty
  while understanding world from persons point of
  view.
• Behavioural Work concomitant changes in self
  perception i.e. as a communicator.
• .

• Realisation of changes in communication from a
  cognitive perspective can access more
  accurately the personal meaning of change.
• No awareness No change.

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Environment

• ? interaction related stress
• ? challenging behavior
• Support clients to access mainstream community
  services local leisure facilities.

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Environment Education and Training

• Carers and other professionals
• Barriers to effective communication
• Basic communication skills
• Verbal and non-verbal communication
• Communication Facilitation Techniques
• Communication opportunities

• Brindle (2006) - Use of communication
  scaffolding techniques.
• Kagan (1998)Techniques to
• acknowledge
• reveal competence

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Wider Community

• Education and Training
• Health Promotion
• Involvement in carers groups

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Outcome Measures

• Uniqueness of each individual
• None standardized or tested in this population.
• Functional assessment tools lack
  reliability/validity.
• However..

• Other domains of practice provide useful tools
• Cognitive Communication disorders such as TBI,
  RHLD, Dementia.
• The Missing Voice (Kovarsky Curran, 2007)

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Case Vignette

• Client Mary (20 years)
• Diagnosis Schizophrenia
• Reason for Referral Difficulty with social
  boundaries, difficulty paying attention,
  interrupts with non-relevant conversation.

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Background Information

• First presentation 16 years
• Previous inpatient and day hospital attendance
• Positive Family History of schizophrenia.
• SLP as a child.
• Chaotic home environment.
• Completed high school. Supported employment.
• Intermittent high anxiety, poor coping
  strategies, needs reassurance

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Assessment?Intervention

• Formal
• Breakdown _at_ different levels of information
  processing chain
• paragraph comprehension,
• verbal abstract reasoning,
• controlled fluency
• naming tasks.

• Informal
• Able to express emotions and opinions
• Over elaboration of topic with progressive
  decrease in relevance.
• Inappropriate topic selection for context.
• Fast rate of speech
• Repetitive hand movements - touching hair and
  face frequently

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Intervention

• One to One Therapy
• Social Communication Group Therapy
• Experiential in vivo feedback
• MDT Input Nursing, Psychology, Work Placement

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Evaluation

• Feedback from CPs
• Therapy Blueprint
• What have I learned about my communication
  skills?
• What difference has that made in my social/work
  life etc?
• What will make it difficult for me to maintain
  these skills over the coming months?
• What can I do about this?

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Summary

• Unique needs
• Engagement Motivation
• Unchartered course through their illness.
• Importance of therapeutic relationship and trust.
• Recovery model (suppressed skills.)
• Rate of relapse frequently high.
• However .. given the nature of the language
  and communication difficulties inherent in mental
  illness, SLPs already have many of the requisite
  skills needed to effectively manage intervention
  in this domain of clinical practice.

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References

• American Psychiatric Association. Position
  Statement on the Use of the Concept of Recovery.
  Washington, DC American. Psychiatric
  Association 2005
• Barham, P. Hayward, R. (1995) Relocating
  madness from the mental patient to the person.
  Free association books London.
• Brindle, B. (2006) Facilitating communication in
  small activity groups a program to support
  adults with communication impairments.
  Activities, Adaptation Aging (30) 1-21.
• Cook, F Fry, J (2006). Connecting stuttering
  measurement and management III Accountable
  Therapy. International Journal of Language and
  Communication Disorders (42) 379-394
• Dahlberg, C., Cusick, C.P., Hawley, M., Newman,
  J.K., Morey, C., Harrison-Felix, C. Whiteneck,
  G.G. (2007) Treatment efficacy of social
  communication skills training after traumatic
  brain injury a randomized treatment and deferred
  treatment controlled trial. Archives of Physical
  and Medical Rehabilitation (88) 1561-1573.

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References

• Davidson et al (2001) It was just realizing that
  life isnt one big horror A Qualitative Study
  of Supported Socialization. Psychiatric
  Rehabilitation Journal, 24 (3) 275-292.
• Hutchings, S., Comins, J. Offlier, J. (1991)
  The Social Skills Handbook. Oxford. Winslow
  Press.
• Kagan, A. (1998) Supported conversation for
  adults with aphasiamethods and resources for
  training conversation partners. Aphasiology(12)
  816-930
• Kovarsky, D. (2007) A missing voice in the
  discourse of evidence-based practice. Topics in
  Language Disorders (27) 50-61
• Schizophrenia Ireland (2003) Recovery in
  practice submission to the expert group on
  mental health policy. Retrieved 29th March 2008
  from http//www.sirl.ie/other/repository_docs/12.p
  df
• Walsh, I., Regan, J., Sowman, R., Parsons, B.,
  McKay, P., (2007) A needs analysis for the
  provision of a speech and language therapy
  service to adults with mental health disorders.
  Irish Journal of Psychological Medicine, 24 (3)
  89-93

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References

• Walsh, I.P. (2006) Exploring the efficacy of
  social communication skills programmes for people
  with mental health disorders a pilot study.
  Paper presented at the Royal College of Speech
  Language Therapists conference Realizing the
  Vision. University of Ulster, Jordanstown,
  Northern Ireland.
• WHO. (2001) International classification of
  functioning, disability and health (TCF) Geneva,
  Switzerland World Health Organisation.
• Walsh, I. (2008) Language socialization among
  people with mental health disorders. In P.A. Duff
  N.H. Hornberger (eds) Encyclopaedia of Language
  Education. New York Springer.
• Sim, L., Whiteside, S., Dittner, C. Mellon, M.
  (2006) Effectiveness of a SST programme on school
  aged children transition to the clinical
  setting. Journal of Child Family Studies (15)
  409-418.