The practitioners’ involvement and engagement with the family was one of the most prominent forces that resonated in all narratives. The family structures of the paediatric clients ranged from single (often teenage) mothers to families, i.e. both parents as well as siblings. The adult and geriatric clients’ family structures often seemed disconnected with a spouse or child who was responsible for care. These family structures were seen to chart the communication environment either in a productive
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or destructive way. For example, in Sharon’s narrative, we saw that she seemed to connect with a mother of a young child with communication difficulties:
We tried to understand each other. Somewhere between her broken English and my broken isiZulu, we connected. I think it was after a few sessions that the little boy was able to come to me and ask me for a toy. We both, his mum and I enjoyed that excitement. I think that was the first time that I truly believed in speech therapy and I know so did his mum.
(Extract from Sharon’s narrative, section 4.3) For Sharon, this clinical engagement was about connecting with the client and his mother, and about the mother and Sharon working collaboratively to help the child communicate. The connection with the client and his mother was Sharon’s goal. We see here that effective communication can be perceived as sharing a common success.
On the other hand, Zandi’s narrative revealed a more destructive force because of a mother’s irregular engagement with the client. The client’s motivation to communicate was negatively affected by the erratic visits by her mother:
I remembered a time when her (the client) mother came to visit her. She was in a good mood for the whole day and the day following that, anticipating the next weekend when her mother would visit her again. But, she did not. Over some time, she figured out that she has gone away and she was likely not coming back for a while. This was when she [client] went back into her shell.
(Extract from Zandi’s narrative, section 4.7) Zandi acknowledged that contact with the client’s family had to be regular in order for their presence to assist in the therapy process. We notice that the infrequent visits of the mother created additional anxiety for the client and left her alone and withdrawn. Perhaps the client was searching for certainty of knowing whether her mother was indeed going to visit her. This lack of support from the client’s mother transferred back into the therapy space.
In Lynn’s encounter with the client’s mother, she realised how the negative description of the client by his mother influenced her (Lynn’s) initial perceptions of the client, which affected her communication:
126 When I had met her previously she had quite a negative description of her son. She said that he doesn’t listen and is badly behaved. However, my initial observations gave me a sense that he was much better than what his mother made him out to be.
(Extract from Lynn’s narrative, section 4.5) It was only through her engagement with the client that she realised how she needed to negotiate her communication:
I could see that he didn’t understand me when I asked him a few questions. He slowly regained his composure. I communicated with him in simple sentences; I had to repeat myself frequently. I contorted and twisted my face to see if he would react. Would a smile work? Something eventually caught his attention. It was one of the toys that I brought along. As the session progressed, I could tell that this little boy wanted to communicate with me. I felt that he appreciated me trying my best to communicate with him at his level. I think he was enjoying the attention that I gave him.
(Extract from Lynn’s narrative, section 4.5) In this case, the mother lacked the coping strategies to understand her child’s communication, and this was transferred into the therapy space.
In the private practice context, Stephanie encountered parents who did not comply with or adhere to recommendations to conduct parent-directed speech-language therapy homework as a means of supplementing SLT-directed therapy, even though this was stated in the therapy contract:
There was a therapy contract that Mrs Williams signed that clearly stated that homework is a big part of therapy. I did not understand how she expected to see progress when I see Seth for half-an-hour once a week. Perhaps she had been very busy and could not do the homework. Perhaps she needed more reminders.
(Extract from Stephanie’s narrative, section 4.6) Here we can see that, even though Stephanie was affirming her frustrations, she followed this up with self-doubt about whether she was justified to feel this way. The use of the words ‘perhaps’ in two consecutive sentences suggests this. Stephanie also mentioned her reluctance to confront the parent about this:
127 In private practice there has been this real emphasis on making the parents happy. I really could not say anything because I had to keep my client numbers consistent.
(Extract from Stephanie’s narrative, section 4.6) On the other hand, Halima, working in a school context, regularly encountered a small diligent group of parents who enquired about their children’s progress and who attend parent meetings once every school term. She has seen positive outcomes of this parental interest in the development of the children’s communication skills.
As the only speech-language therapist at the school I was quite well known with the small, diligent group of parents who would often follow up on their children’s progress after school.
(Extract from Halima’s narrative, section 5.5) Parental and/or family attitudes toward speech-language therapy showed that families often did not display positive attitudes toward therapy as seen in Zandi and Mbali’s narratives within the public healthcare context:
There were lots of families who did not come to visit the clients and this was heart- breaking. I was not prepared for this because I didn’t know that this was part of the job during my undergraduate training. When I used to come to the hospital as a student, it was just once a week. It was a skewed picture to what actually happened every day. When you come to the real world and you realise that people don’t care a thing about their children. This made me so sad. I had gotten used to it to some point because I see it every day, but as a person it was destroying me to see a child waiting for a parent who will most likely never visit. I’m not sure if they're not making an effort or maybe it’s their circumstances also.
(Extract from Zandi’s narrative, section 4.7)
Mrs Ngubane hardly has any visitors with whom she can communicate. This is a big challenge to get family support for her. She needed someone from home who knows her and understands her better. However, the family have said that there are work commitments and other excuses. As mentioned previously, this is a long- term care facility, so they did come at first and then it slowly stopped. This had been a huge barrier to progress in therapy and generalisation to the outside environment.
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In the private practice context, similar parental attitudes were noticed:
I have felt sometimes in private practice that parents don’t appreciate what you say to them because they have often ignored what I have said. The worlds of urban private practice and that of rural community service areas were really different just based on the attitudes of parents and clients toward therapy.
(Extract from Stephanie’s narrative, section 4.6) Stephanie also mentioned in her narrative that the financial implications of therapy within the private practice context affect the communication as parents or family request ‘quick fixes’:
Also Mrs Williams kept asking how long would therapy take. I knew that she knew that it was only a half-an-hour session but her tone gave me the impression that she meant the entire duration of therapy. I told her that I don’t want to put pressure on Seth in therapy and that we go according to his pace.
(Extract from Stephanie’s narrative, section 4.6) Stephanie felt that she had to commit to a time frame on which Mrs Williams was insisting. Stephanie felt that she would be held to this time frame as a mark of her professional aptitude and skill. She was not willing to commit to this possibly due to her inexperience as a novice therapist and because she did not have sufficient experience to draw comparisons. This might not be something that Stephanie would want to admit, as this would betray her own insecurities in her lack of experience. She therefore chose to transfer the uncertainty back onto the client and his ability.
Lynn – within the public healthcare context – highlighted the financial strain on families in order to attend therapy:
I was sure to hear during the course of the day, the clients’ and their families’ stories of how dependent on public transport they were, and also how many could not afford the rising costs of transport. I was also sure to hear their silent complaints about the systems here at the hospital: they dread the long queues simply to collect the hospital files. I was aware that coming for therapy either for themselves or for their loved ones meant getting time off work or arranging for care for the other children at home, which may have its own financial implications. It seemed like much sacrifice for a forty-five minute session once or twice a month.
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We see here that Lynn’s compassion for her clients and their families extended beyond the therapy room. She was cognisant of their sacrifices to come for therapy and she appeared grateful for their attempts. From the extract it seemed as though Lynn did not think that the trade-off for therapy and what the client and his or her family had to go through seemed fair. This was an interesting conception from a practitioner. The inability to deal with the ‘world’ of the client is what disillusions the practitioner since much of its parameters are outside the SLT’s control, such as the employment of the client or parent, transport costs and other lifestyle matters.
It appeared that the practitioner viewed the relief or the comfort that the client received from therapy not worth the effort made to one’s everyday life to attend therapy. What does this suggest about the practitioner’s inherent views of their own profession? 6.6.2 Practitioner engagement with the clients
The practitioner’s engagement with clients is influenced by a number of factors, such as the level of comfort felt between the practitioner and the client, the client’s behaviour and demeanour, the practitioner’s perception of the client’s willingness to participate in therapy, and the practitioner’s ability to identify and avoid risks of miscommunication.
Clients’ willingness to participate in therapy seems to influence communicative exchanges. Carl was not comfortable in his engagement with one of his male clients due to possible different cultural conceptions of therapy as the client’s conceptions about old age and impairment differ from the practitioner’s worldview of treatment of impairments. The client might have viewed participating in therapy as a sign that he was weak and needed the help of yet another health professional. The client might also have failed to see how treatment could happen with just ‘talk therapy’ as the SLT did not work with any other tools or paraphernalia:
I vividly recall my sessions with Mr Khumalo and the sense of discomfort that I felt. Firstly, he did not want to accept that he needed speech therapy. It felt like an emasculating experience for him. Perhaps it was a cultural thing. When I approached his bed in the ward he furiously shook his head. “Angifuni,” he muttered.
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Stephanie also had an unwilling client. However, she did not have the option to postpone therapy because of the nature of private practice and the parent’s urgency for a ‘quick fix’ of the speech problem. Her engagement was influenced by business- related factors:
Little Seth was quite cheeky in the session: what we now label as ‘strong-willed’. He did not want to listen to me in the previous session and I was still unsure of how to get him to engage in the session without making him upset… I had to keep my client numbers consistent or else the practice manager would have asked me to source more clients in order to keep an adequate caseload.
(Extract from Stephanie’s narrative, section 4.6) Due to the private practice context operating according to a business model, the ‘consumer’ (in this case the client’s parent), could view therapy as a commodity that had been bought; therefore, it must deliver the expected results. The trade-off between paying for therapy and receiving results in therapy consequently became the focus. Zandi explained that communication as her tool or method for intervention was a negative factor because communication relies on a sender and receiver. When the receiver (in this case the client) is unwilling, it negatively affects the therapy process:
As a speech therapist I found that there were many negatives using communication as the treatment method for the impairment of communication. What made it even more challenging is that it feels like it all depended on the client and you feel like you have no control of it. For example, the physio can do passive movements; at least they’ve done something to help their client. Sometimes when I went to the wards, the client just stared at me. They were not actively engaging with me or showing me that they understood. Admittedly, this was demotivating. I felt like I am not really doing anything to help the client.
(Extract from Zandi’s narrative, section 4.7) The client did not want to engage in therapy possibly due to her difficulty in coming to terms with her impairments. She could possibly not believe that speech-language therapy could help her because of mistrust in the overall health system that she has encountered.
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