strategy development

Inclusive communication coming soon near you?

Della Money Sue Thurman

The white paper Valuing People committed speech and language therapy services to the promotion of choice, inclusion, independence and civil rights. With communication at the heart of this, Della Money and Sue Thurman describe how the Means, Reasons and Opportunities model is evolving to make explicit the responsibility we all share.

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if you offer training believe comprehension is inadequately understood are developing service policies

ver ten years ago, the Means, groups, and more specifically to incorporate the Reasons and Opportunities model of role of understanding (Sutton & Thurman, 1998; communication was developed and Thurman, 2001). used for teaching a group of staff working with people with learning Expanding on our Means, Reasons and disabilities in Leicestershire by the first author. Opportunities model, we identified five core roles Subsequently it was used in Nottinghamshire as for our service (Table 1) which, to maximise the an integral part of the Talkabout Teaching effectiveness of communication, may be for Package (Money & Thurman, 1994; 1996). The (i) the individual original model (figure 1) has since developed and (ii) those in their immediate environment expanded to be used by a variety of therapists, (Bradshaw, 1998) and/or teachers, nurses, lecturers and other profession(iii) their local communities (Bradshaw & als, across a variety of specialisms, and throughCarnaby, in press). out the UK. This has led down interesting and Valuing People, the first governdiverse paths, and we Table 1 Core roles ment white paper for people with ourselves have continued 1. Managing health needs, for learning disabilities in over thirty to develop the model to example, hearing impairment, men- years, requires that all organisareflect both current and tal health and secondary speech tions working with people with emerging influences on and language therapy referrals learning disabilities both develop practice. However, we 2. Making information accessible, communication policies and proare still asked about the including simplifying spoken and duce and disseminate information original version, and feel in accessible formats. As we write, it is time to share our written language, use of signs and the Royal College of Speech & own development of the symbols, information strategies Language Therapists is finalising Means, Reasons and 3. Shared means of communicaclinical guidelines to highlight Opportunities model. tion such as objects, symbols, good practice in the delivery of From initially being signs, speech speech and language therapy for developed purely as a 4. Promoting reasons for compeople with learning disabilities. teaching tool to repremunication like choices and deciThese state importantly that, in line sent visually the imporsions with the themes laid out in Valuing tance of the relationship 5. Creating opportunities for People, speech and language therbetween the how, why, communication, for example apy service delivery should be comwho, where and when through a range of people, places mitted to the promotion of choice, of communication, inclusion, independence and civil Means, Reasons and and activities. rights. This type of approach Opportunities has come requires speech and language therto form the basis of all apists to consider communication our service delivery. This needs in the context of a social model of disability, includes initial carer interviews, through to alongside the broader societal issues (van der Gaag, detailed video recordings used for research 1998). It is vital that the speech and language ther(Money, 1997), and observations for service evaluapist is not seen as the sole person accountable for ation (Thurman, 1998). It has been extended to communication, and that it is a shared responsibiliunderpin evaluating service delivery (Money, ty amongst all of those who live or work with peo1997b; Money, 2002). It has also been developed ple with learning disabilities. for use within a number of different service user

Core roles

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

strategy development

Means
(How we communicate) speech & writing
Non-verbal signs symbols gestures body language facial expression pointing objects & pictures behaviour Paralinguistic volume intonation rate tone fluency

Reasons
(Why we communicate)
attention greetings wants/needs request information give information ask questions protest/deny feelings choices preferences

Means
(How we communicate)

Reasons
(Why we communicate)

COMMUNITY ENVIRONMENT INDIVIDUAL

Means Reasons

Opportunities
(Where, when and with whom we communicate)

(How we communicate)

(Why we communicate)

Opportunities
(Where, when and with whom we communicate)

Opportunities
(Where, when and with whom we communicate)
partner time & place shared language shared communication system shared interests Figure 1 Means, Reasons and Opportunities: The original model

Real-world understanding
Verbal Situational Functional

Real-world understanding
Verbal Situational Functional

Figure 2 Means, Reasons and Opportunities: The developed model

Figure 3 Means, Reasons and Opportunities: The working model

Developing communication policies or strategies to address these issues is therefore essential if we are to deliver on the white paper. A communication strategy is a multi-agency plan to develop a consistent and coherent approach to meeting the communication needs of people with learning disabilities, within both their daily environments and wider contexts. This includes facilitating the use and understanding of a range of different means, reasons and opportunities for communication. A successful strategy has to involve the key elements of management support, training, and networks, and be underpinned by agreed and adequate resources. (Jones, 2001). Recently therefore, the Means, Reasons and Opportunities model has been adapted for use as a working model for a framework of inclusive communication as part of our communication strategy across Nottinghamshire. As already described, the relationship between the understanding and use of means, reasons and opportunities for communication was implicit in the original version. However, we have found that the link needs to be made explicit due to the growing culture of consent, user involvement, advocacy and person centred planning for people with learning disabilities. The increased significance of these issues has revealed frequent confusion in staffs own understanding. Jones (2000) describes an evaluation of the Somerset Total Communication approach which found that, despite considerable emphasis throughout training, staff still failed to recognise the importance of verbal comprehension.

It is the relationship between functional, verbal and situational understanding that determines the service users level of real-world understanding.

Real-world understanding
We therefore believed it was necessary to develop a model of Means, Reasons and Opportunities

that incorporated comprehension explicitly, and introduced the idea of real-world understanding (figure 2). Using real-world understanding, we distinguish the differences between verbal and situational understanding, and introduce the concept of functional understanding, describing the effect of these three elements on the service users understanding of means, reasons and opportunities, out in the real world. Through functional understanding we are attempting to explain the impact on a users situational and verbal understanding of their physical, emotional and sensory well being, self esteem, context, time of day and relationships. It is therefore the relationship between functional, verbal and situational understanding that determines the service users level of real-world understanding. However, as we prepared to launch the concept of a communication strategy across Nottinghamshire, we realised that introducing real-world understanding to our model of inclusive communication was still not sufficient. The model would additionally need to encompass some service delivery principles, building on the core roles and focused across three levels. For a successful communication strategy that promotes inclusive communication, the model needed to represent individual, environmental and community focuses to service delivery. We defined an individual focus as person centred, based on a clear communication need, and delivered through specialist clinical and therapeutic skills. It may also incorporate focused health promotion. An environmental focus is context centred. It encompasses all training and development initiatives, from ongoing teaching (for example, Talkabout, signs and symbols, and our local Enjoyable Eating course), tailored workshops (such as Challenging Communication (Thurman & Sutton, 2000), using symbol software), to targeted sessions aimed to meet identified individual or unit needs. It also includes the role of health facilitation, providing access and support/advice for other professionals.

Thirdly, we defined a community focus, which involves service development initiatives, such as policies and public involvement including wider training and advice to other services in the community.

Best practice
The use of Total Communication or Inclusive communication is increasingly recognised as best practice and effective use of speech and language therapy resources (Jones, 2000; Bradshaw, 2000). A commonly agreed definition of these terms remains elusive, although the Royal College of Speech & Language Therapists guidelines will propose they describe an approach that seeks to create a supportive and effective communication environment, using every available means of communication to understand and be understood. Speech and language therapists have typically delivered their services through training, consultancy and other inter-disciplinary work with health and social care professionals and carers, alongside their specific therapeutic approaches (Money, 1997b; Purcell et al, 1999; 2000). However there is still a need to develop a more extensive evidence base on which to base its practice through sharing of skills and experience, with a responsibility on all practitioners to network with their colleagues and contribute to the growing body of evidence. So far, what key elements have we got for a working model of inclusive communication? A decade on, we still feel that means, reasons and opportunities are at the core of communication. However, in addition we need to be explicit about real-world understanding, and also incorporate our foci for service delivery - the individual, environment and the community. We therefore propose the working model illustrated by figure 3. We would welcome any comments and feedback that could usefully lead us all towards a comprehensive model for promoting inclusive communication. Della Money and Sue Thurman are heads of speech and language therapy services for people with learning disabilities, Nottinghamshire Healthcare NHS Trust. "

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References
Bradshaw, J. (1998) Assessing and intervening in the communication environment. British Journal of Learning Disabilities 26, 62-66. Bradshaw, J. (2000) A total communication approach: towards meeting the communication needs of people with learning disabilities. Tizard Learning Disability review 5 (1) 27-30. Bradshaw, J. & Carnaby, S. (in press) Talking normalisation: The role of communication in integration. Department of Health (2001) Valuing people: A new strategy for learning disability for the 21st century. London: Department of Health. Jones, J. (2000) The total communication approach: towards meeting the communication needs of people with learning disabilities. Tizard Learning Disability review 5 (1) 20-26. Jones, J. (2001) The Communication gap - a paper exploring the fundamental nature of communication achieving the New Vision of the White Paper Valuing People, Policy Forum: Foundation for People with Learning Disabilities, August. Money, D. (1997a) A comparison of three approaches to delivering a speech and language therapy service to people with learning disabilities. Unpublished PhD Thesis, De Montfort University, Leicester. Money, D. (1997b) A comparison of three approaches to delivering a speech and language therapy service to people with learning disabilities. European Journal of Disorders of Communication 32; 449-466. Money, D. (2002) Speech and Language Therapy Management Models in Management of Communication Needs in People with Learning Disabilities. Whurr. Money, D. & Thurman, S. (1994) Talkabout Communication. Bulletin of the College of Speech and Language Therapists 504; 12-13. Money, D. & Thurman, S. (1996) An introduction to Talkabout, Nottingham Community Health Trust. Purcell, M., Morris, I. & McConkey, R. (1999) Staff perceptions of the communicative competence of adult persons with intellectual disabilities. British Journal of Developmental disabilities. Purcell, M., McConkey, R. & Morris, I. (2000) Staff communication with people with intellectual disabilities: the impact of a work based training programme. International Journal of language and Communication Disorders 35 (1) 147-158. Sutton, K. & Thurman, S. (1998) Challenging communication: People with learning disabilities who challenge services. International Journal of Language and Communication Disorders 33; 415-420. Thurman, S. (1997) Challenging behaviour through communication. British Journal of Learning Disabilities 25;111-116. Thurman, S. (2001) Challenging communication. Mental Health and Learning Disability Care Feb 4 (6) 203-206. Thurman, S. & Sutton, K. (2000) Challenging Communication: a resource pack for SLTs working with staff who work and care for individuals who challenge and are challenged by services. Nottinghamshire Healthcare. van der Gaag, A. (1998) Communication skills and adults with learning disabilities: eliminating professional myopia. British Journal of Learning Disabilities 26; 88 -93.

Reflections
Do I see the importance of networking and contributing to the professions evidence base? Do we have the necessary support, training and resources to deliver on government policy? Do we update protocols to reflect current and emerging influences on practice?

..resources...resources....resources...resources...
African-Caribbean leaflets
Leaflets on healthy eating, high blood pressure and reducing the risk of stroke have been produced specifically for African-Caribbeans who are estimated to be twice as likely to have a stroke as Europeans. Free from the Stroke Association, tel. 01604 623933.

Autism jobs
A new service intends to provide a comprehensive link between job seekers and recruiters who work with people with autism. Users can search for jobs by keyword, employer and region. www.autismjobs.org.

Whats that Scally doing?

Learn about verbs and their actions in a fun way with Scally, a friendly alien. Scally can act out more than 400 verbs and aims to get children thinking about verbs in different ways. A booklet offering 50 activity ideas has a section devoted to special educational needs. Scallys World of Verbs - Single user 39.25 + VAT. Special price for parents 19.99 inc.VAT. From Topologika, tel. 01326 377771, www.topologika.com.

Encephalitis: the facts

Factsheets on encephalitis which can be downloaded from the internet include speech and language difficulties in children, practical advice for social workers, health visitors and therapists, and practical advice for teachers. For adults, in addition to factsheets on different types of encephalitis, recovery and rehabilitation issues such as memory problems, returning to work and the role of the occupational therapist are covered. See www.esg.org.uk.

Get active
Action Lotto, a game designed particularly for children with speech and language difficulties, allows pupils to identify and match everyday actions based around the home, in kitchen, bedroom, lounge and garden scenes. For 1-4 players, aged 4+, 29.95 from LDA tel. 01223 357788.

Hearing aid development

Charity at Christmas
The Fragile X Society has three Christmas card designs. Happy Santa, Leaving Bethlehem and Smiling Santa are each in packs of 10 costing 3. Details: Marie Williams, tel. 0290 575515. Signalong has three exclusive designs of Christmas card in a pack of six costing 5.50. Details: Mike Kennard, tel. 01634 819915.

The makers of the Adapto hearing aid believe it addresses the three main reasons for poor user satisfaction as it prioritises speech over noise, reduces the side effects of occlusion and reflects individual processing ability and preferences. From Oticon ltd via hearing care professionals.

Coming from Signalong

Signalong is developing new resources on health matters (well woman and well man) and what shall I wear today? To be involved in this process, contact Sarah Bissett on 01634 832469.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002