Psychotherapy With and Without Speech.

Hello, Jane. My name is Tom. Can you hear me? Blink once if yes, or blink twice if no.

One blink.

Is your name Jane?

One blink.

Is my name Tom?

One blink.

Is my name George?

Two blinks.

Is your name George?

Two blinks.

In psychotherapy I attend to the specific content of what a client is saying, as well as what may

be left out or avoided, what might be hinted at or signaled indirectly. I listen to the tone and pace

of a client’s speech, and to gestures and body postures that also communicate meanings. I follow

the attention of the client; how one establishes or breaks contact, and if the client is speaking

directly to the therapist as they search for new understanding or might be repeating comments

they have made to others, or even if they might be speaking to an internal audience more than to

the therapist. I pay attention to what the client inwardly attends to and ask questions or make

comments to guide their attention to what they might overlook or minimize or avoid.

While practicing psychotherapy in nursing homes, I might work with a client with intact

cognitive and language skills, or sometimes with someone with a brain injury or a neurological

condition, and the individual might even be a non-verbal communicator.

Some of my clients use non-verbal methods of communicating such as gestures, or a letter board,

or an electronic device for spelling or voicing their typed comments. I may need to extend my

patience and concentration when working with a non-verbal client. If an individual can only

offer yes/no responses, it is important to clarify and confirm the accuracy of their responses, and

consultations with a speech therapist is needed for that. When documenting the conversations, I

might state that I said or asked this, and the client indicated or selected that, to limit assumptions

or misunderstandings about the precise communication with the client.

When working with a non-verbal client it is, ironically, the non-verbal communication that is

lessened, as the client and therapist are focused more on the concrete words or meanings being

generated by the client than on the manner of communicating.

Jane is fully paralyzed, and she can only communicate by use of eye blinks – one for yes, and

two for no. Her yes/no responses had been tested by the speech therapist and were reliable, and

by responding to a series of my comments and questions, she could indicate her answers, and

gradually build up a conversation about her thoughts and feelings and concerns.

Consequent to a brain stem stroke, Rachel is paralyzed from the neck down. Her brain functions

are intact, and she makes facial expressions, but she cannot speak or move her body or limbs.

Rachel communicates by use of a clear plastic board with black alphabet letters, and 1 to 10

digits. I hold it up and watch her eyes through the board, and then say aloud each letter she

selects by looking at it, as she builds words and sentences. Rachel can have thoughtful and

meaningful conversations in psychotherapy, or with others – if someone is willing to make the

effort to use her method of communication. In our first conversation Rachel said, “We should do

staff in-service training, Tom, because they don’t always use my letterboard.”

Roger sustained a severe brain injury, and he was only able to move his right thumb, yet he

would lift his thumb once for yes, and twice for no, and with that method, Roger could generate

basic communications.

Doris was deaf for most of her life and was a skilled signer and reader of lips. She came to the

nursing facility after a stroke. I don’t know how to sign so I would write my questions and

comments, and Doris would read them and give verbal responses.

Mark had been in a persistent vegetative state after a brain injury. He eventually made a

surprising recovery, and regained his speech, and he moved about in a wheelchair. During the

period when he was unresponsive, Mark explained to me that he had been aware of others

speaking around him, yet he could not let them know. During his period of unresponsiveness,

Mark experienced an exact recurring sequence of twelve dreams, which he was glad to now be

able to share with me.

Social communications are an essential human need. Reduced ability to communicate or the loss

of speech can be a profound loss, and coming on top of an acquired disability condition can be

exceedingly difficult to cope with. When a person most needs to talk about their situation, they

might be unable to speak, or quite limited in their ability to communicate – if others do not

effectively assist their abilities with some augmentative type of communication method. A

person might lose the ability to verbalize speech, yet they do not thereby lose their need to

communicate. Psychotherapy with a non-verbal client is possible yet may require adaptation of

methods and therapeutic approach, and attitude.

I have been especially moved by the challenges faced by persons with one or another barrier to

ordinary human communications. I feel proud of the courage individuals’ display as they grapple

with enormous communication problems – problems that others might overlook.

Some clinicians and health care providers might think it is not effective to attempt psychotherapy

with significantly disabled persons or clients with an absence or impairment of speech. But

clients have many times expressed their appreciation for being helped to develop and refine

methods of communication – through speech therapy and psychotherapy.

It has been important to help my clients think about and prepare for ways they might more

successfully communicate with others, and not only with their therapist. For example, Rachel

could have a card posted in her room or attached to her wheelchair that explained her need for

help to communicate, and brief instructions for how to help. Or I might coach a client to practice

sharpening the point of their messages so they more quickly convey their needs or requests

before a listener might lose patience and end an interaction.

It has been important to help my clients think about and prepare for ways they might more

successfully communicate with others, and not only with their therapist. For example, Rachel

could have a card posted in her room or attached to her wheelchair that explained her need for

help to communicate, and brief instructions for how to help. Or I might coach a client to practice

sharpening the point of their messages so they more quickly convey their needs or requests

before a listener might lose patience and end an interaction.