Speaking with those who cannot speak - communication
Loss of speech (aphasia) it the most
severe form of disturbance in communication that anyone can suffer.
Loss of speech as aphasia is considered worse than dumbness. The term aphasia
includes many abilities which are involved in speech. In the case of aphasia,
one or more of the following abilities can be disturbed: speech, understanding
speech, reading, writing, spelling, counting and/or calculation. It is
precisely because the aphasic is unable to articulate his aphasia, and
extraordinary care has to be invested in order to understand him, that
he is constantly in danger, not only of being unable to escape his "cage
of speechlessness", but also of being
abandoned in it. An example of this is seen daily in clinical practice
in the handling of stroke patients with aphasia. Classification of aphasic
disturbances is shown in the table.
|Man is the being that speaks. He
ability to speak;
|this encapsulates what he is able
|To be dumb is to have an infirmity.
|is one who can speak and use language.
|speak is to be a person. The personality
|person is revealed by his speech,
As the number of trained
speech-therapists is still insufficient to cope with all of the aphasic
patients, every doctor who has anything to do with them must master the
basic mechanisms for communication with these patients. In the long term,
involvement of the relatives and others who are close is very important.
To them, Martha L. Taylor's book "Understanding Aphasia" can be helpful
(see References) .
The world of the
Usually speech is lost suddenly.
Feelings of helplessness, despair and dependence arise in the aphasic,
along with anxiety. Initially the patient can hardly comprehend why he
can no longer speak, understand or write, and why he is not understood.
These patients can easily get the impression that they have suddenly become
mad. Aphasia is never an isolated or simple disorder, but is a complex
handicap which leads to personality and behavioral changes. The patients
usually tire rapidly, suffer from concentration and perception disturbances,
are labile in mood, easily irritated and occasionally aggressive. Often
this aggression is a reaction to the behaviour of those in the environment
who do not understand. The ability to cope intellectually and physically
varies a great deal from day to day.
The most important initial
step is to explain to the aphasic in simple language that he is suffering
from a speech disorder, what is its cause and that this will most probably
improve with time or completely disappear. It is often necessary to explain
this problem many times. It is also just as important to make it clear
to the patient that he is not mad or mentally disturbed. It should be explained
next that certain speech exercises have been planned for him and they will
begin soon, and will make it easier for him to make himself understood
again as soon as possible. These steps reduce anxiety and aggression and
Automatic terms of
frequently-used speech (such as "hello", "how are you?") can be achieved
by many aphasics. Many are also able to count, recite the alphabet or sing
songs. However this spontaneous ability is not necessarily of prognostic
importance. Speech cannot be improved by means of singing. Of course an
aphasic who previously enjoyed singing, and is attempting to sing, should
limitations of speech therapy
Spontaneous improvement can
be obtained within 6 to 12 months after the acute phase of the illness.
The reason for speech therapy is partly to accelerate this spontaneous
improvement, and to achieve restoration of as much as possible of the body
of speech. Speech therapy does not only have the objective of improving
speech, but also provides a personal approach to the patient restoring
him with support and motivation.
Speech therapy should not
exhaust the patient. Short, frequent exercises are better than those which
are longer, and tire him. It is useful if the patient is motivated and
enthusiastic about speech therapy, but if this is given under pressure,
it can endanger rehabilitation.
The use of substitute
languages has not been shown to be effective in adults. It seems to
be even more difficult for the aphasic patient to learn a new form of communication
than to build up a limited number of common words. The mother tongue is
relearn most rapidly by those who have mastered several languages.
Success of speech therapy
depends on the severity of the speech disorder, the underlying disease,
the remaining intellectual ability, age and the motivation which can be
aroused for speech training. There are patients who remain completely aphasic
in spite of excellent speech therapy, and others who learn to speak almost
normally once again (President Eisenhower, Sir Winston Churchill).
The objective of practicing
speech is to help the aphasic patient learn a limited number of words,
which are targeted to his particular situation. For the patient confined
to a hospital bed, words such as "plate", "bed", "bed-pan" are more important
than "wood", "train" or "dog". It is also important to practice terms with
and actual significance rather than abstract terminology. The
aphasic learns the name of things he can see, hear or feel more easily
than general or compound terms. It is easier for him to relearn words such
as "bread", "leg" or "shirt" in the earlier phases, than "food", "travel"
or "clothing". Where words have similar meanings, the more usual term should
be employed ("phone" rather than "telephone", "paper" rather than "illustrated
At first, a small number
of words should be learnt; those which are important for daily living,
such as "bed", "chair", "toilet", "money", "watch", "bread", "butter",
"tea", "phone", "doctor", "shoe", "mouth", "key", "soap", "hand", "leg",
"table", "house". Words can be introduced later which have a particular
relevance for the aphasic patient, for example "flowers", "seed", "betroth"
for a gardener.
Furthermore it is important
that the aphasic is taught words in a useful order, which is substantives,
verbs and adjectives. Next would come adverbs, articles, prepositions and
conjunctions. Many aphasic patients have greater difficulties learning
the "small words" (prepositions, conjunctions and articles) than mastering
substantives. This applies especially to patients with motor aphasia, but
the reverse is true for those with amnesic aphasia.
Aphasic patients must be
continually encouraged to speak. This is best achieved when speaking
becomes a pleasant experience for the patient for which he is rewarded
by praise or attention. In general, the aphasic patient should be offered
plenty of opportunities to hear speech, although he should not be overwhelmed
(listening to conversations, radio, television). As has been said, more
frequent, short exercises are both more effective and more interesting
than extensive speech practice for longer time spans. The aim of therapy
should be realistic and dependent on possibilities which can be achieved
in the short term. The aphasic should be treated empathetically, so that
he recognizes that those around him understand how badly he is affected
by his handicap.
exercises can encourage both reading and speech. As the right side is usually
affected in aphasic hemiplegic patients, the patient often has to use his
left hand for writing. Writing exercises should be in script rather than
capitals, as most people can manage script rather than printing letters.
This would also result in the patient having to learn how to go on from
printing to script later.
Reading practice is
best carried out using printed or typed material as this is what most people
read anyway. Aphasic patients are better at reading larger type than a
normal size, possibly because the excessively large letters are more stimulating.
Initially patients are not able to read for any length of time due to limited
concentration. Many aphasic patients still spend time looking at their
daily paper, even though they cannot read or comprehend it. Maintaining
this habit can encourage the patient.
Mistakes in dealing
with aphasic patients
Forced speech or speech
therapy is usually not effective. The effect of speech therapy depends
to a large extent on how much the patient allows himself to be treated.
It is also not helpful to invite visitors in the hope that this will encourage
him to speak more (unless the patient himself would like it, and will not
be exhausted by a prolonged visit).
It is also not useful
to speak on behalf on the aphasic patient as this tends to extinguish
self-trust, and increases his feeling of dependence.
It is always inappropriate
to interrupt a person. This applies particularly to aphasic patients. He
must be given enough time to seek his own words, without an impatient reaction
of those around.
Initially it is of no great
importance that the aphasic patient can pronounce each word perfectly,
but he should be able to make himself understood. Every form of isolation
leads to a reduction in the amount of speech he can manage, and every over-exertion
to a disturbance of his confidence. It is most important that every attempt
to converse with the aphasic motivates him to activity, and never blocks
Ideally "speaking with those
who cannot speak" would not only result in comprehension and partial relearning
of speech, but would also lead to working through and conquering the disease
which led to the aphasia.
|Guide-lines for dealing
with aphasic patients
the aphasia and show understanding.
improvement, instilling it into the patient's mind
aphasia does not mean that the patient is mad or losing his mind.
simple sentences and speak slowly.
|Do not insist
on speech exercises.
objectives for the therapy.
appropriate for the personal situation of the patient.
importance of types of words (initially substantives, verbs and adjectives,
then adverbs, articles, prepositions and conjunctions).
in script (left hand?), reading exercises with large type.
and encourage speech (radio, television).
Geisler: Doctor and patient - a partnership through dialogue
Pharma Verlag Frankfurt/Germany, 1991
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