El paramilitarismo en el departamento de Córdoba

“Motivation plays a huge role in terms of clients’ participation levels in therapy.”

Zandi is a novice SLT, and a bilingual isiZulu–English-speaking black African female. She served her community service at a rural public health facility. At the time of this research, she was working in an urban private practice.

I completed my undergraduate studies about three years ago. Since then I have worked in this public hospital, which also used to be my clinical block16 _{when I was at university.} One would think that I had an advantage of familiarity of my work environment as well as that I am isiZulu-speaking. However, your experiences as a student and then as qualified therapist are completely different. As a student, I had the support and encouragement of my clinical supervisors. I had been on my own since I qualified, which has been a difficult transition.

I worked with a 12-year girl once and I affectionately call her Sma. Sadly, she had a subdural empyema,17 _{which left her with hemiparesis,}18 _{She was typically very quiet;} however, in the session she was talking a bit, in IsiZulu. She mostly just smiled in response to me, but I know she had sentences in there. She had functional speech, which helped her communicate her basic needs. I had been working with her on and off for over a year now. She was warming up to me possibly because I see her quite often. I watched the physios19 _{work with her the other day. Or should I say, they worked ‘on’ her. They spoke} to her in English and she didn’t reply or speak much to them for that matter. She probably did not understand them. I think she did speak a bit of English before the neurological impairment; after all, she was in Grade 6 in an English-medium school. But I think she must have lost some of that language ability after she fell ill. As her speech therapist, I was able to tell if she did not understand me. I would notice the creasing of her forehead or the lack of head nodding. Sometimes she even cried. I watched her facial expressions. I simplified my language. I asked her if she understood. I have learnt how to read my client. They won’t always let you know outright that they don’t understand you. In each of the clinics during my undergraduate training, the tutors would point out to us if our clients were getting distracted and they gave us tips on how to watch if our clients did not understand

16 _{A defined period of students’ exposure to a clinical context or disorder, typically linked to a clinical} module (P.S. Flack, personal communication, September 14, 2017).

17 _{Subdural empyema is a collection of pus between the dura mater and the underlying arachnoid} mater (French, Schaefer, Keijzers, Barison, & Olson, 2014).

18 _{Hemiparesis is unilateral paresis, i.e. weakness of the entire left or right side of the body (Allison,} Reidy, Boyle, Naber, Carney, & Pidcock, 2017).

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us. This was not directly taught to us, but if and when it occurred in the clinical session and if the tutor were present, they would help us identify and problem solve this. I often find people, even the other healthcare professionals are not able to identify or understand when a client does not understand something. The client cannot respond to their questions because they don’t understand the question. However, this is overlooked by them. I remembered a time when her 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 went back into her shell. I could notice these subtle features of communication with Sma because I am a speech therapist. I was able to know when she was uncomfortable, in pain or frustrated or if she was happy, and even proud of what she was doing? I have found that motivation plays a huge role in terms of clients’ participation levels in therapy. The low levels of motivation make it quite challenging to work with the clients.

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;20 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. I wondered how it looked to other people who are watching me in the ward, like the doctors and nurses. They probably saw me greeting the client and then showing them pictures. It probably looked like nothing was really happening because of non-responses from the client. I just felt demotivated until such point that the client started to respond to me and my therapy. This sometimes happened.

The clients have been away from home for so long that they lose contact with the family. The lack of family presence and support does have an impact on their overall improvement. 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. Whatever

20 _{Passive movements: a physiotherapist moves the joint through the range of motion with no effort} from the patient (Stockley, Hughes, Morrison, & Rooney, 2010).

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their reasons were, you had a child and you needed to make the child know that you cared about them and to care about them was to be present.

I have seen mothers who have given birth and the very next day they leave the child in hospital to go home. They say that they have other children to take care of. But then what happens to this child who is a premmie.21 _{A premmie baby is delicate and needs to be} taken care of, but they go. This was not something that I was prepared for when I was at university.

Some clients had been here for a very long time, years even. Most of the clients were old. The clients’ impairments are quite severe and this pertains to their communication impairments as well. When I greeted most of the clients they turned and looked at me, even if they didn’t say hello back to me, they showed that they’re interested. Some of the clients were not motivated enough. There are adult clients who I noticed would listen to the other health professionals but not to me. Some clients saw the need to exercise their arm shown to them by the physio, but when I showed them exercises for their tongue, they would not be that keen. It seemed that they thought it a bit odd to have exercises for the tongue. They did not see it as a muscle that also needed strengthening. This has been quite demotivating for me. This made me feel that the clients did not see the value in therapy. Surely, if they saw value, then they would have complied. I motivate myself by focussing on anything positive that happened in the session. I sometimes go back the following day and sometimes the client would be doing better because they were less tired or upset. It worried me, their lack of adherence. Why was this not the first thing that came to their mind when they woke up, that they needed to do whatever it is that the speech therapist said? I didn’t know, maybe it was also a fault on my side. Maybe I did not emphasise the importance enough. What was the point? I felt like, well nobody ever listens to a speech therapist anyway, so why would the clients listen to me? I tried to emphasise that they needed to try and do it in their spare time. And I do it with them in the ward, and then I say ‘if you have time also please do it, at least twice a day’.

I tried to see it from their perspective. They probably thought, “Why should I work so hard to be sent home when these people don’t care about me because they don’t visit? If they don’t care about me, why should I go back to them? I might as well just stay at the hospital. If somebody stays away from you, they probably don’t care about you”.

My undergraduate education did have a role in preparing them for the working world, especially clinical practice. While at varsity22 _{we worked with real clients and were even} scored on the communication strategies used with clients. I was motivated to go an extra mile to keep my communication simple with a client who had a communication problem,

21 _{‘Premmie’ is colloquial term for premature babies.} 22 _{‘Varsity’ is a colloquial term for university.}

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because I was going to get marked on that as well. In working with real clients during my undergraduate training it prepared me for what I am dealing with now.

We had the community based rehabilitation clinical module.23 _{So we would go out to visit} clients’ homes. I remember working in groups where I had to deal with other members of the team which helped me learn about how to communicate with them as well, and not just the clients. As a speech therapist I had to be a sort of a role model when it came to communication. The client had to understand you, the others in the team relied on this. I was motivated to use communication strategies that would make me look like a superhero. I knew how simplify my language so that the client understands better. So there I felt like it was motivating us to work in a team. You had to show them what skills you possess.

If I could offer any suggestions to my alma mater, the Discipline of Speech-Language Therapy it would be expose the students to real clients … the clients that they’re going to be seeing in the real world and make explicit to them that you will be marked on your communication with the client so that they feel like they always have to apply communication strategies that could be applicable for each and every client that they see. They need to know that they cannot just use the same communication strategies with every client because they are going to be different.

The training often focusses on separate communication disorders. They are taught in silos, in boxes. They are taught that there is a speech sound disorders client;24 _{then there is a} separate language disorders client;25 _{a different voice disorders client.}26 _{They are not} exposed to training where the client that has speech, language and voice problems at the same time and needs to be treated for all at the same time. So I feel that teaching them like this is not really real-world exposure. The speech therapist is going to see a client with

23 _{The community-based rehabilitation clinical module is a fourth-level clinical module in which}

students work in disadvantaged communities conducting health promotion workshops and conducting community-based rehabilitation (CBR) for widespread gain in the community. CBR was initiated by the World Health Organization (WHO) following the Declaration of Alma-Ata in 1978 (see Thammaiah, Manchaiah, Easwar, Krishna, & McPherson, 2017). in an effort to enhance the quality of life for people with disabilities and their families, meet their basic needs, and ensure their inclusion and participation in society.

24 _{Speech sound disorders client – a client with a disorder in the areas of articulation and the} phonological representation of certain sounds in words or in isolation (Bowen, 2009).

25 _{Language disorders client – a client with impairment in the areas of comprehension, spoken} language, reading and/or writing (Minifie, 1994).

26 _{Voice disorders client – a client with a disorder of the voice due to misuse and/or abuse of the} voice, e.g. vocal nodules, polyps (Minifie, 1994).

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an aphasia,27 _dysarthria28 _{and dysphagia}29 … everything all together. The training should emulate more of what is happening during the electives.30 _{At least they are having this} exposure during their two-week elective block but maybe it’s just not enough. The electives are not evaluated by a tutor from the university where the mark contributes to the students’ year marks. From my experience, the permanent therapist at the elective block is just happy to have a helping hand over the university holiday time.

I have since left the hospital and I have set up my private practice. I think that I want to continue practising as a speech therapist but I would just like to control my environment and create a space that would work for me. So far, so good.

27 _{Benson (1979, p. 5, cited in McNeil & Pratt, 2001 p. 905) defined aphasia as “the loss or} impairment of language caused by brain damage”.

28 Dysarthria is defined as “difficult, poorly articulated speech resulting from interference in the control and execution over the muscles of speech usually caused by damage to a central or peripheral motor nerve” (Kramer, Schneck, & Biller, 2012, p. 187).

29 _{Dysphagia is a disorder of feeding and/or swallowing (Daniels, Schroeder, McClain, & Corey,} 2006).

30 _{Electives involves clinical exposure at hospitals of students’ choices during the vacation periods} under the supervision of the resident speech-language therapist (P.S. Flack, personal communication, September 14, 2017).

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