As an Indian male, Carl was concerned that he was an agent of the imposition of Eurocentric ideas on his black African female paediatric client. Colours, numbers and the English alphabet comprise the usual repertoire for the stimulation and acculturation of the paediatric population in the English-speaking world. Carl, however, questioned whether this was appropriate for children from other linguistic and cultural groups. Are there universal guidelines for paediatric language stimulation? Concerns such as these form the cornerstone of contestation as a simple act such as the stimulation of colours, numbers and the English alphabet could be reinforcing Western conceptions of literacy and imposition of a medical hegemony within the profession without bringing in the biography of the client. In an instant, speech-language therapy diverted from being altruistic to being culturally imperialist. Brewer and Andrews (2016) stated that it is often difficult to see ethnicity-based discrimination as part of cultural imperialism in one’s own practice, even when one is aware of this discrimination in general. Related to Carl’s engagement with his black African elderly male client, we see there were mixed conceptions of speech-language therapy on the part of Carl and his client. This client had had a stroke and was referred to Carl for speech-language therapy by the doctor. The client was despondent and refused therapy. He could have also responded in this way because of his level of understanding that a stroke is perhaps the natural process of aging, in a fatalistic sense. The client was perhaps interpreting the interventions offered by Carl as inappropriate to circumvent the inevitable fatalistic end point of life: death. He had possibly abandoned hope as can be read from his reaction. It is important to note that this explanation is for the purpose of theorisation and conception of this argument pertinent to clinical engagement and is not true for all aged or senior members of society. Carl could have understood the benefit of therapy and his role with this client differently from the client. Carl could have interpreted this encounter as palliative care where an SLT has a significant role to play in the management of communication and swallowing impairments and disability in people (O’Reilly & Walshe, 2015). Roe and Leslie (2010) state that the aim of the SLT in palliative care is to affirm life and minimise the complications of life-limiting disease. The concern is that the role of the SLT has been perceived as frequently
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misunderstood or unrecognised among SLTs themselves internationally; hence, there is considerable uncertainty and absence of clarity regarding what is appropriate and ethical speech-language therapy involvement in this client group (O’Reilly & Walshe, 2015). If the role of the SLT is so uncertain among SLTs themselves, then it is no wonder that clients may be resistant to this idea as well. As can be seen in this case, the mixed understandings and conceptions of therapy have consequences beyond the clinical engagement. This interaction left Carl questioning his role as an SLT, the value of speech-language therapy, and his positionality as a novice male SLT. Notions of the overlap of speech-language therapy with palliative care (unfortunately) did not feature in his worldview.
Lynn’s clients travelled distances to attend therapy and had to incur substantial financial costs for transport and subsistence to access therapy. As revealed in the narrative, often the clients’ journeys to the hospital, the long queues to collect hospital files, the financial burden, and the logistical arrangements could be understood as all too much for the client and the family. Therefore, by the time they entered the SLT’s room, they might consider their commitment to the therapy process fulfilled. The SLT, though, expects the client and the family to be integral to the therapy process even during and after the clinical practice session. The mismatch of conceptions of commitment and continued expected engagement (from both the clients and the therapists) is what could bring about problematics about the purposes and outcome of the clinical engagement.
Similarly, in the private practice context, the mother of Stephanie’s client appeared to expect more of a return on payment for speech-language therapy. The nature of the therapy sessions was seen as a contractual financial arrangement between the practitioner and the client and/or family. The parent is paying for certainty that she assumes that the SLT should provide as though therapy is a transactional process. There is no recognition for the added factor of the complex communicative engagement between therapist and client. The mother’s actions indicated that she did not consider herself to be part of the therapy process other than providing payment for services rendered.
In a long-term rehabilitation public healthcare facility, Mbali experienced a lack of interest and co-operation from the clients’ families. Many clients in this setting were left in the care of the state, i.e. in the custody of the hospital or in the care of the
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healthcare professionals because their families had abandoned them. Some of these clients have plateaued in terms of their performance in therapy yet due to their ‘hospitalisation’ they were receiving and continued to receive services. What then are their conceptions and expectations of therapy? What should the SLT do with these clients from an ethical and moral perspective? Is speech-language therapy (from the perspective of both the client and the therapist) merely a ritualistic practice not really intended to achieve any outcome? Is too little and/or too much expected of the professional and the client? When Mbali contacted the client’s wife to discuss his condition and therapy with her, the wife was not interested and rushed Mbali off the phone. We see that Mbali attempted to make contact and involve the family in the way she knew how but this interest was not reciprocated. This highlights some of the problematics faced in the clinical context and reflected on in the narratives.
The cases above suggest that the novice SLT tended to circumscribe the scope and intersected-ness with the worldviews of the clients in a deep sense. The prime adherence seems to be guided by the participants’ conception of upholding a ‘normative’ (hegemonic) notion of idealised practice.