El fenómeno paramilitar en Colombia

“How do I explain to her that speech and language problems are not fixable with a pill?” Stephanie is a novice SLT, and an English-speaking white female. She served her community service at a rural public health facility and subsequently moved to an urban private practice. At the time of this research, she was still enjoying her work there.

Setting up a private practice as a speech-language therapist is oftentimes considered a major career aspiration for many. I should consider myself lucky then that I am newly qualified therapist who started working in the private sector a few months ago. I am a white, English-speaking therapist and most of my client-base is all English-speaking so I had not encountered problems with language differences in this context. My typical day includes visits to some of Durban’s most elite schools to do therapy and then to the private hospital for the afternoon appointments. My caseload had comprised of children with speech, language and learning problems. My clients and their au pairs or parents usually wait for me in our plush waiting room. The fish tank a major attraction for the children.

I had found that some of the parents in private practice see me as a young person, much younger than them. I felt this when they looked at me, “Can this person really be doing therapy with my kid?” I’ve never heard them articulate this though, so it might be all in my head. However, during my community service last year in a rural community I never really got this feeling. Everyone out there on the South African border with Mozambique were so appreciative: they just took what you said and just held onto it. I was one of just a few non- black healthcare providers. I could not speak isiZulu, yet the parents seemed to be grateful for whatever I could offer. They would come back every month always with a big smile; moreover, they listened to me. 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.

I saw Mrs Williams in the waiting room and I said hello more out of surprise than an actual greeting. I hadn’t expected to see her or her son again for therapy because of our previous session when I had got the sense that she did not believe that her son had a speech problem. She brought him into therapy saying that the teachers said that he needs to be in therapy. The teachers report to the parents that their child has a particular difficulty and then they make the referrals to me. After many emails to be parents, they usually come through reluctantly just to keep the teachers quiet I would imagine. It seems like many just subscribe to therapy out of duress. I think that the problem might be the stigma of therapy. The stigma that there is something wrong with their child. Perhaps Mrs Williams also does not want other people finding out that Seth saw me for therapy. Little Seth was quite cheeky

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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 felt that there was a certain amount of pressure with the short amount of time that I had to work with him. 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. But maybe in private practice, you need to be rigid and time-bound. How do I explain to her that speech and language problems are not fixable with a pill? This did put a little bit of pressure on me but no matter how much I have been badgered for a time frame, I have never said to a parent, “I’ll fix your child in a month,” because I don’t think that is fair to the child or me. I wanted to say to Mrs Williams, “I am a professional; I know what I am doing. Just give me some time.”

I think that the client’s progress also came down to the homework component of therapy. Seth had forgotten his homework book again this week. This was the third week in a row. I think that they must have lost it. I phoned Mrs Williams and sent her messages to remind them but they still forgot it. I doubt that he had done the homework but they still came for therapy which bugged me a little bit. How was Mrs Williams willing to pay so much money for therapy, but she was not willing to follow up with my recommendations in the home environment? It seemed counterproductive to me. This was a big frustration of mine. However, there were those times when there are those kids and parents who do not do the homework or the parents had not discussed their child’s progress with me. I offered Mrs Williams to sit in the session because I wanted her to see how I work with Seth so that she may have been motivated to do the same with him at home. I think she got a little bit defensive and afforded an excuse. She didn’t want to come into the session. She suggested that we wait for a week or two then she will come and watch. She never did come to watch him. I have really battled to understand this. Perhaps she felt that since she is paying for therapy, that it was solely my responsibility to help the little boy. I thought that maybe I should be more forceful in getting parents to come in, but I don’t know yet where that line was. It was so difficult to see the child that is struggling and the parents didn’t see that or don’t want to see that, when you know that they could help them at home.

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 or else the practice manager14 _{would have asked me to source more clients in order to keep an} adequate caseload. 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

14 _{A private practice manager is someone who oversees the day-to-day operations of the private} practice (R. Sewgambar, personal communication, September 18, 2017).

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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.

These reminders had me thinking that it appeared that there was a lot more communication in private practice with the parents: emails, phone calls and letters about the child’s progress. By comparison when I was engaged in community service last year in a rural setting, there was not as much dialogue with the parents probably because parents there did not have access to cell phones and emails. I also saw the rural parents only once a month rather than once a week as I do in the private schools/practice. I think my community service year was a little more difficult also because of the language barrier because I was not always able to answer parents’ questions or reciprocate what was being said to me since I am not a fluent speaker of isiZulu. A breakdown in communication was always a risk. IsiZulu is not even my fifth language so the language barrier posed a very big communication problem there. I think that being able to speak the same language as your client makes communicative interaction a lot easier.

Seth engaged with me during the session and we completed most of our aims. “Use speech-specific reinforcement,” this is what was drummed into our heads by our lecturers when we were at varsity. This is what I did and he responded to me.

“Why do you do that Steph?” laughed the ladies at the reception on more than one occasion when they hear my grandiose affirmations of the clients’ targets. I tend to be rambunctious and the kids love it.

“You see, children respond well to praise and speech-specific reinforcement. It was encouraged at university,” I said.

This simply means that as the SLT, you must include the target sound/word/behaviour in a celebratory praise so as to reinforce or emphasise the target soon after the child’s attempt, especially if their production was incorrect.

At university our tutors would observe us in our clinical sessions. They would tell us a little bit about how we did; they tried to give us the positives and negatives of the session and often in that order. These feedback sessions provided me with constructive guidance. It was also more individually specific to our role as clinicians. I often thought that it would be great if the tutors recorded a session of their own so we could see how it’s done by an experienced professional. We often went into clinics blind and not knowing what we were really doing.

In the private practice context I have found that my communication is a little more structured and formal when compared to last year which was informal because I worked simply with worked with what I had. In private practice we have standardised tests and designed resources as in assessment tools. This has made it easier to structure and plan a session. These tools have assisted me to communicate with my kiddies. Obviously, you yourself have to have good communication with your client and their parent and also other

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people involved, whether it’s the OT15 _{or their teacher or anyone else that they might be} seeing. I know with some of my kiddies, their tutors or au pairs bring them in. So my communication has to be really good, and I have to express myself well in order for them to then relay this information to the parents. Also when talking to the children and doing your therapy, you have to make sure that you tell them what to do and how to do it. You even have to tell them if they are doing something wrong. It all comes back to communication and making sure that you are guiding them properly and expressing yourself well. This was something that I would have to work on for some time to come. Perhaps it is a matter of emotional growth and professional maturity. Perhaps, in time, this will come.

15 _{OT is an occupational therapist who works with a client to help him or her achieve a fulfilled and} satisfied state in life through the use of purposeful activity or interventions designed to achieve functional outcomes which promote health, prevent injury or disability and which develop, improve, sustain or restore the highest possible level of independence (American Occupational Therapy Association [AOTA], 2018).

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