The understanding of communication disability has been relatively confined to the field of speech-language therapy, with input from clinical linguistics, social work, and psychology. Duchan’s (2011) review of the history of speech-language therapy demonstrates that the profession was grounded in the medicalised models of disability. Her review shows that the aim of the early work on communication impairments in the early part of the 20th Century was to determine what constituted “defective” speech and to devise techniques to normalise the individual. Towards the middle of the 20th Century, deeper knowledge of acquired language impairments developed alongside developments in linguistics and psychology, which led to the conceptualisation of language and speech as distinct although inter-related processes (Duchan, 2011).
The mid-century years were characterised by a focus on the incidence and nature of communication impairments in children and adults, with a specific focus on the structural components of speech and language. During this time, a plethora of diagnostic categories, groups and sub-groups was established (e.g. ‘specific language impairment’; ‘apraxia’; ‘developmental apraxia of speech’; and ‘childhood aphasia’), with researchers seeking new categories and characteristics of the structural components of the speech and/or language of categorised groupings. The focus was on the individual; the central signifier of disability was the body. As Watermeyer (2009b, p. 27) wrote, “Of course, it is unsurprising that
professionals trained in the biological functioning of the body, rather than in social critique, are drawn to prioritising somatic factors in making sense of disability.”
69 It was toward the last quarter of the last century that researchers began to look beyond the structural components of language towards the use of language, which led to the development of a new field of scientific and clinical work which became known as “pragmatics”. In the most basic terms, pragmatics means the functional use of language in context. This working towards the broader focus of a functional contextual model from the micro focus on linguistic form, structure and content was considered so remarkable that it was described as a
“revolution” (Lund & Duchan, 1983). During the next 25 years, the pragmatic revolution was characterised by a marked shift from the analysis of communication impairments with the focus on the individual and on linguistic structure towards more transactional and social approaches that gave attention to communication partners and to contextual variables (Holland, 2008). The focus of clinical pragmatics, however, was on the transmission and reception of a linguistic message (Worrall, 2000).
Emerging alongside the pragmatics paradigm, research from the clinical perspective described whether the individual’s communication was “functional” (Duchan, 2001a) such that the individual could communicate his or her basic needs. Consequently, the functional approach was a step forward from the impairment-based, individualised model toward the consideration of the individual as well as the conversational partners in context (Worrall, 2000). Functional communication was defined by different people in a variety of ways. For example, the American Speech Language and Hearing Association (ASHA) (1990, cited by Worrall, 2000, p. 4) defined it as “the ability to receive or convey a message, regardless of the mode, to communicate effectively and independently in a given environment”, while Holland (1982, cited by Worrall, 2000, p. 4) defined it as “getting the message across in a variety of ways ranging from fully formed grammatical sentences to appropriate gestures rather than being limited to the use of grammatically correct utterances”. Hence, the study of functional communication was situated in a linguistic framework. In a seminal article that proposed a model of “communicative competence” for people who use AAC, Light (1989) suggested that
functional skills involve the skills which are required to initiate and maintain daily interactions within the natural environment, be it asking for directions from a stranger, telling a joke to a friend, ordering a pizza for lunch, or explaining the new data base to a fellow employee.” (p. 138)
An example of a measure that was developed to measure functional communication was the Communicative Effectiveness Index (CETI) (Lomas et al., 1989), a popular measure used in
70 a wide variety of studies, that is still used today, and that has been adapted by researchers (e.g. Joubert, Bornman, & Alant, 2011). The developers were intent on devising a tool that would take into account personal values, verbal and non-verbal behaviours, and that would measure performance. In addition, the tool was devised to measure change over time. They asked people with aphasia to describe situations in which they were required to communicate, and then gave that list to a panel of experts to veto. The result was a 16-item tool which requires significant others in the person’s life to rate performance on a 10-point scale from not able to fully able. To illustrate, the CETI comprises items such as “Giving yes and no answers appropriately”; “Communicating his/her emotions”; and “Indicating that he/she understands what is being said to him/her”.
This test is an example that shows that despite the enormous contribution that the shift in emphasis made to the understanding of the social aspects of communication, there were a number of limitations to this approach. Firstly, many clinicians did not conceptualise functional communication as a part of the social process and continued to see functional limitations as what people with communication impairments could not do (Duchan, 2001a). The term was often considered only as the person’s ability to independently get a message across, with little, if any, consideration of the role of communication in establishing and maintaining social links (LPAA Project Group et al., 2001). Worrall (2000) identified a number of limitations of the functional approach, including the fact that the functional communication approach did not consider sufficiently the individuality of experience. Later, the pragmatic-functional movement expanded to take a very much broader, panoramic view of communicative competence (Holland, 2008). The communicative partner was seen as critical to communicative success (Pound, Duchan, Penman, Hewitt, & Parr, 2007). Working from this basis, Kagan and her colleagues (Kagan, 1998; Kagan, Black, Duchan, & Simmons- Mackie, 2001; Simmons-Mackie & Kagan, 1999) showed that people with aphasia
communicate better with some partners than with others. This led Kagan and colleagues to develop guidelines for use in talking to people with aphasia. In so doing, they demonstrated the power of the communicative partner in helping to promote the potential for the individual with aphasia to communicate more successfully. Their ‘Supported Conversation for Adults with Aphasia’ ™ (Kagan et al., 2001) is an exemplary intervention method that moved the research focus from the individual onto the individual in interaction with others.
71 The close of the last century saw many programmes that advocated working with
communication partners of people with a variety of communication impairments (e.g. Brinton, Fujiki, Spencer, & Robinson, 1997; Girolametto & Weitzman, 2006; McConkey, Morris, & Purcell, 2001) and the eyes of researchers were drawn to issues around quality of life (Worrall & Holland, 2003). Thus, with this broader view of communication in context, the advent of the social model of disability (Threats, 2008), and a growing recognition of the chronic nature of some conditions (Holland, 2008), the participation of communicatively disabled people in society became to be looked upon as a natural extension of the clinical pragmatics movement.