By any other name would smell as sweet
(Romeo and Juliet, II. ii)
It is an unfortunate irony that the subject which professes to deal with the difficulties and disorders of language should itself be in difficulties over its name. But such is the case, even though there is little real dispute as to what this subject of study actually consists of. The kinds of things that go on in speech clinics in Canada and the United States of America, under the supervision of people called ‘speech and language pathologists’, are very much the same as those that go on in the United Kingdom under the supervision of people called ‘speech and language therapists’, or in Australia under the supervision of people called ‘speech pathologists’. Likewise, in continental Europe, labels vary, but the job remains largely the same: in France one is an ‘orthophonist’; in Belgium and Germany, a ‘logopaedist’; in the Czech Republic, a ‘phonia-trist’ … What, then, is the job that all these people do?
All these people are professionals, trained to investigate and treat abnormal manifestations of communication, from whatever cause, in children and adults. The skills involved are many, and take three or four years of training to acquire. A rather fuller description is provided by the American Speech-Language-Hearing Association (the body that, in the USA, issues certificates of clinical competence to those who graduate from training programmes). They state that clinicians:
work to prevent speech, voice, language, communication, swallowing and related disabilities. They screen, identify, assess, diagnose, refer, and provide treatment and intervention … to persons of all ages with, or at risk for speech, voice, language, communication, swallowing and related disabilities. They counsel individuals with these disorders, as well as their families, caregivers, and other service providers. (1996 formulation)
In a similar vein, Communicating Quality (1996), a document produced by the Royal College of Speech and Language Therapists in Britain, identifies key areas of the clinician’s responsibility. These include specific statements of the speech and language therapist’s role in the prevention of speech and language difficulties and in the assessment and treatment of communication disorders when they occur.
There is, it would seem, considerable agreement about what these professionals are doing – enough, at least, to suggest that a single name for the subject would not be a problem. Why is this not so?
There are (in 1998) 17 universities across Britain and Ireland, offering a total of 21 undergraduate and master’s-level training courses in speech and language therapy. These 21 courses offer a bewildering array of course titles and, even ignoring minor differences between titles, there are 11 different titles on offer. This is particularly remarkable when one considers that most academic disciplines show agreement on their name: one goes to a university to read psychology; French; linguistics; philosophy – so why the extraordinary proliferation of discipline labels within speech and language therapy? The situation would be remarkable indeed if there was no overlap between the 11 variants of course title. Fortunately the situation is not quite so confusing. Of the 21 courses, 13 include ‘speech’ within the title, eight include ‘language’ and four include ‘communication’. A further variation on course name concerns how speech/language/communication are suffixed: ‘therapy’ appears in seven course labels, ‘pathology’ in a further 10, and ‘clinical sciences’ or ‘studies’ in eight. The first task in understanding the debate regarding the name of the subject is, accordingly, to differentiate between the terms ‘speech’, ‘language’ and ‘communication’.
There is, to some degree, a hierarchical relation between the three terms: speech is a manifestation of language, and, in turn, language is a component – and a very important component – of human communication. ‘Communication disorder’ is often used as a superordinate term, encompassing both speech and language disabilities, and other disabilities too. There are difficulties, however, in the use of superordinate terms in that their meanings are inevitably rather broad. Those courses whose titles include ‘communication’ prefix the term with ‘human’ or ‘clinical’. This is because ‘communication’ has a breadth of meaning that allows it to apply to non-human systems of communication, including animal signalling systems, but also to human artefacts such as computer and telephone systems.
The term ‘speech’ is one that is included within the job title of the North American, Australian and British professions. Speech is an acoustic or sound signal, produced by the combined action of various components of the vocal apparatus: the lungs, the larynx (or voice box), and various structures within the mouth (such as the tongue and lips). The movements of these structures result in vibration of air, and so an acoustic signal. However, speech is more than just a vibration in the air. After all, the lungs, larynx and oral structures perform other movements which result in an acoustic output – for example, yawning, sneezing or coughing – but these would not be regarded as speech. Speech has the characteristic that it encodes a linguistic message. It has a complex structure: the sounds of speech combine to form words, words combine to form sentences, and both words and sentences carry meaning.
We are already into the territory of the next term – ‘language’. Speech is the realization of language via an acoustic modality or channel, but other modalities are available through which we can send or receive linguistic messages. Instead of sending a message via speech, we can choose to write something down. The choice of whether to use speech or writing in sending messages depends on which is likely to be the more appropriate in a particular situation. Where the recipient of the message is remote in space or time, writing may be the more effective. When we need a permanent record of the message, it is again best to ‘have it in writing’. Where constraints of this kind do not operate, we will use speech. In addition to sending messages, we receive messages. Acoustic-speech messages are heard and then understood (auditory or speech comprehension). Written messages are read and then understood (reading comprehension).
We have now identified four modalities through which linguistic messages can be sent or received and these are summarized in Table 1.1. The speech/auditory channel is often referred to as the ‘primary’ channel. This is because it is the language channel we acquire first, and often with no explicit instruction. In contrast, reading and writing are learned later and through formal instruction at school. The ‘secondary’ status of the reading/writing channel is also indicated by the observation that, while all human cultures have spoken languages, many languages have never been written down, and even within supposedly literate cultures there are many adults who are unable to read. Recent estimates within the UK, for example, suggest that levels of illiteracy are increasing, with 5 to 10% of school-leavers failing to attain functional or useful levels of reading ability.
In addition to the ‘usual’ auditory/vocal and visual channels for sending and receiving linguistic messages, other compensatory channels are available in the event of damage to the above modes. Braille reading, for example, allows the blind to ‘read via a tactile route instead of the usual visual route. Sign language permits the deaf to send and receive messages via a visual/gestural route, so by-passing problematic auditory/vocal processing.
Messages carried by all these modalities, whether primary or secondary or special modalities, have certain common characteristics. In particular, they have a complex hierarchical structure: units combine to form a unit at a higher level (e.g. sounds/letters form words, words form phrases and sentences). Also, the units and their combinations carry meaning. Language in all its modalities is a symbolic system: words represent or ‘stand for’ other entities. These can be concrete entities such as ‘dogs’, ‘daffodils’ or ‘dictionaries’, or abstract constructs such as ‘honesty’ or ‘intelligence’.
The final term we need to define is ‘communication’. This is a superordinate term which can encompass both speech and language. Communication is the sending and receiving of messages. It refers to any message, not just the highly structured symbolic messages of language. A sneeze might tell you that I had a cold or maybe suffered from hayfever, but it is not a hierarchically structured or symbolic linguistic message. The study of patterned human communication, in all its modes, is known as semiotics. The ways in which humans communicate outside language are many and various. Patterns of eye contact, the posture adopted, and the amount of space or touching which takes place between individuals will send different messages. The facial expression and eye contact accompanying a linguistic message may entirely alter the message that is conveyed. The term ‘non-verbal communication’ (NVC) subsumes all these visual and tactile features of interaction.
We often see popular expressions such as ‘the language of gesture’, the ‘language of the face’, or ‘body language’ However, in the light of the distinctions we have made between the terms ‘language’ and ‘communication’, these must be seen as metaphorical extensions of the term ‘language’. They are not literally ‘language’, it is argued, because there are crucial qualitative differences between what goes on in speech/writing and what goes on in facial expressions/gestures, etc.1 Two criteria have been proposed as critical. The first is to point to the major difference in productivity between spoken language and gestural communication. Productivity refers to the creative capacity of language users to produce and understand an indefinitely large number of words and sentences. Words in spoken language are continually being invented and dying out. Fresh combinations of words are continually being produced and understood. It is probable that most, perhaps all, of the sentences in this book are new sentences to you, i.e. sentences that you have not read or heard before; and yet, because you have learnt the rules of the English ‘language’, you are able to decode these fresh combinations and arrive at their meaning. By contrast, gestural communication lacks productivity. Gestures are not continually being invented and dying out. Fresh combinations of gestures are not continually being produced. There is in fact a very limited range of gestures you can make using your hands, posture, face and so on; and similarly, a very limited set of meanings that can be communicated in this way. Webster’s Third New International Dictionary contains over half a million words. A ‘dictionary’ of body language would find it difficult to accumulate more than several hundred contrasts.
The second main difference between spoken language and gestural communication is in their internal organizations, or structures. The former displays what has been called duality of structure; the latter does not. Duality of structure refers to the way language is organized in terms of two abstract levels. At one level, as has already been suggested, language can be seen as a sequence of units, or segments, which lack meaning. Segments such as p, t, e, etc. do not have any meaning in themselves. However, when they are put together into certain sequences, and we look at the larger units so formed, then suddenly meaning is found: pet. At this second, higher level of analysis, language has meaning. It is this capacity, to produce meaningful units out of meaningless segments, which identifies a behaviour as being a language. By contrast, normal gestural communication lacks duality of structure. In addition, the minimal units of body ‘language’ are meaningful: the closing of one eye, the raising of one eyebrow, the clenching of a fist.2 Moreover, if a sequence of gestures is used – say, a wink followed by a shrug of the shoulders – there is a clear and direct relationship between the units in sequence and the units in isolation: the ‘meaning’ of the wink, and of the shrug, is preserved, which again suggests the lack of any real duality of structure.
Distinctions between speech, language and communication, as we shall see later, are useful in differentiating between different types of communicative handicap. We have already said that ‘communication’ can be used as a superordinate term, which can encompass both speech and language disabilities, and we shall be using the term in this way later in this chapter. Patients with a hoarse and croaky voice will have particular difficulties making themselves audible in a noisy environment, and so their difficulty in speaking will result in reduced communicative efficiency. In the same way, individuals who have a language disability – for instance, difficulty in finding an appropriate word and placing that word within a sentence – will be less effective communicators, as they are likely to experience considerable difficulty in conveying their thoughts, ideas and feelings. ‘Communication disorder’ then can subsume speech and language handicap, but it can also include a disability that is distinct from speech or language. A young adult with Down’s syndrome, who exuberantly greets total strangers with a hug, might be viewed as exhibiting inappropriate non-verbal behaviour. In this instance, we have a communicative/interactional problem that is independent of speech or language.
Now that we have made these distinctions between the terms ‘speech’, ‘language’ and ‘communication’, we can examine the debate that has taken place in the British profession regarding its name. The debate, which began in 1973, was finally resolved in 1991 when the profession changed its name from ‘speech therapy’ to ‘speech and language therapy’. Therapists in some districts have carried the change further and labelled themselves ‘communication therapists’. A wholesale change of name of a profession inevitably causes a degree of confusion, but when, in addition to change at a national level, there are regional variants of name, the potential for confusing the patients who receive the therapy service and the professionals who work alongside the speech and language/communication therapist is immense.
Prior to 1991, the British profession was named simply ‘speech therapy’. What are the implications of this term, and the associated term ‘speech therapist’, which have caused so much controversy over the last 30 years? There were two main objections to these labels. First, the profession does a great deal more than deal solely with speech. When there is a breakdown in a person’s communicative abilities, it is often the case that much more than speech is affected. Other modes of communication can be involved, such as listening, reading, writing or signing. And even within speech, as we have seen, there is far more involved than the surface sounds. Beneath the surface lies a world of grammar and meaning, and this may also contribute to someone’s problems in communication. Accordingly, therapists who were working with children with poor understanding of language, or who were introducing a gestural communication system to patients who had difficulties in controlling the movements of their tongue, or who were working with patients who had suffered a stroke to regain their writing abilities, found it incongruous to be called ‘speech’ therapists. ‘Speech’ was viewed as too restricting. Such people preferred instead to talk about ‘speech and language’ therapy or ‘communication’ therapy.
But if ‘speech’ caused problems, the term ‘therapy’ caused even more difficulty. This term is used in relation to a broad spectrum of activities, such as in ‘beauty therapy’ and ‘aromatherapy’, which are unrelated to its original sense of medical treatment. Many of these skills do not involve professional training of any kind, and those that do are often not comparable to the specialized academic training which speech and language therapists receive. As a consequence, many speech and language therapists feared that, if they continued to be referred to as ‘therapists’, their status would be misunderstood, or would be diminished in the eyes of the other professionals with whom they work. A particularly misleading implication, in their view, was that the term suggested that their only function was treatment, neglecting their role in assessment and prevention of disabilities. These fears were not entirely well-founded, as the medical notion of therapeutics is an extremely broad one, subsuming all aspects of patient management (including surgical, pharmacological and psychotherapeutic). If this notion was felt to summarize well what physicians did, the analogous use of the term in the context of language disability might not be as misleading as was feared.
As an alternative to ‘therapist’, consideration was given to the term ‘pathologist’, which is used throughout North America and Australia. ‘Pathology’ is a medical term, falling within a tradition where it is rigorously defined. One medical dictionary (Blakiston’s) defines it as ‘a branch of biological science which deals with the nature of disease, through study of its causes, its process, and its effects, together with the associated alterations of structure and function’. There are two central features of this definition for our purposes: it refers to ‘disease’, and this in turn refers to a disturbance of normal structure and function. In view of the fact that many of the conditions which speech-language clinicians treat are medical in origin, the result of disease, this alignment of their profession with the clinical word seems eminently sensible. On the other hand, by no means all of the conditions which are treated in a speech and language clinic are medical in origin, in any clear sense. Patients may have an apparently normal physical structure and function. Voice disorders may occur despite normal vocal apparatus (see further p. 199). The ENT (ear, nose and throat) department of the hospital to which a patient is referred may not be able to find anything physically wrong – no detectable pathology, in other words. Does it then make sense for this patient to be sent to the speech and language clinic and immediately have the disability placed under the heading of speech or language ‘pathology? Thanks to an extension of the meaning of the term ‘pathology’ in the past 100 years, this should no longer be a problem. The word has been extended to the study not only of disease but also of abnormal mental and moral conditions, according to the Oxford English Dictionary, since at least the 1840s. More recently, its sense of ‘deviation from any assumed normal state’ has become increasingly current, and the term ‘speech-language pathology’ falls within this development. Certainly in the USA, where there are more practitioners of this subject than in any other country, the designation ‘speech-language pathologist’ is the accepted norm.
With objections from within the profession to both components of the label ‘speech therapist’, in 1973 the British College of Speech Therapists held a poll of its membership to determine whether an alternative name might be found. The membership was asked to choose between 21 alternative names that had been proposed, the majority of which (13) were variants on the terms speech/language/communication and therapist/pathologist/specialist/practitioner. Not surprisingly, faced with so many alternatives, the results were inconclusive. No one label received an overwhelming majority. In fact, none of the alternatives received as many votes as ‘speech therapist’! Accordingly, a further vote took place (in 1974), the seven names receiving the largest number of votes in the earlier ballot being short-listed. But again, no decision was reached – indeed, only a small proportion of the membership voted the second time. The College concluded at the time that the name should be unchanged. But the matter was not dropped. Five years later, the question was raised again, further votes were taken, and the issue was finally reduced to a single choice: ‘speech pathologist’ versus ‘speech therapist’. The vote produced a two-to-one majority in favour of ‘speech therapist’. But the issue still did not rest. In 1983, a further ballot was held and the profession continued to vote to retain the name ‘speech therapist’. Finally, in 1990, the fifth ballot on the issue, two-thirds of the profession voted to change the name of the profession to ‘speech and language therapy’. Whether the issue is finally resolved is open to question in the face of regional variants of name such as ‘communication therapy’.
Lest this should be thought to be a peculiarly British obsession, it should be pointed out that a similar concern has often been expressed in other countries where this profession is practised. At present there is also a need to consider the merits of consistency throughout Europe -particularly in these days of the European Union – and throughout the English-speaking world. Nor is the terminological question trivial. The issues involved are those of professional identity and status, academic orientation, and intellectual, clinical and financial rewards.
The terminological issues which have caused such difficulties for clinicians in selecting a label that adequately names their profession also dogged the choice of the title for this book. It is called ‘Introduction to Language Pathology’ for a number of reasons. ‘Language’ is included within the title as it is a major facet of human communication and also because the concept of ‘speech’ is encompassed within it. The broader term ‘communication’ does not appear within the title because with its breadth comes ambiguity – there is confusion with non-human communicative systems. An attempt by one of the authors to telephone the ‘communication department’ of a hospital in which ‘communication therapists’ worked, resulted in the call being put through to a group of telephone engineers. In addition, there are many reasons why communication may fail between two human beings, which are outside the concerns of this book. Two individuals with opposing views which cannot be reconciled may experience a breakdown in communication, and we often hear the phrase ‘communication broke down between A and B’ with reference to talks between trade unions and employers, or warring factions within and between nations. We also hear of ‘communication problems’ in marriages and between generations of a family. We have selected ‘pathology’ as the second element of our title, as opposed to ‘therapy’, because the greater part of this book describes a model of the normal communicative process and the possible deviations from it. We make no claim to provide systematic guidelines for therapy.
When would you say that someone was communicatively ‘disabled? Sometimes the disability is fairly obvious; but by no means is it always so. Let us begin with the most obvious case. Everyone would agree that there will be problems if a person lacks ability in one or more of the main modes of language use (speaking, listening, reading, writing) and in the various components of non-verbal communication; and such disabilities are common. There are many who totally lack the ability to communicate in speech, or who have severe hearing impairments, or who cannot read and write. But these disabilities, it should be noted, are not equal in importance. We have already noted that the speech-hearing route is the primary modality in language. Disabilities in speech–hearing have more fundamental effects than problems with reading and writing. Within the primary modality, it is speech that generally attracts the most attention, because it is so much more obvious a facility to develop and use than is hearing and understanding. Consider the relative ease with which you are able to disguise lack of understanding of another’s talk, for instance, in a lecture, with the embarrassing experience of having to speak upon a subject or answer a question on which you know very little.
Could there be anything more serious than the complete absence of ability to speak and to understand speech? That there are indeed such possibilities becomes clear when we put the study of language into the broader context of communication as a whole. At least if you are hearing-impaired and without speech, and so denied easy use of the auditory-vocal channel of communication, you can communicate via visual channels through reading and writing or by gesture and signing. Given this perspective, the possibility of more serious breakdowns in communication than in speech–hearing alone is perhaps now obvious. A combination of vocal–auditory and visual disability, for example, will pose special problems. Such problems would identify the population of ‘deaf-blind’ children and adults. It is a disability that was first widely publicized when the story of Helen Keller was told. In such cases, tactile bases of communication have to be developed.
But language pathology is concerned with disorders beyond failures of sensory systems (hearing and vision) and movement systems (speaking and writing). Sensory systems are routes along which information travels to the brain; they allow the brain to monitor both the internal bodily environment and the external world for salient information. Movement systems permit action, or the modification of our environment in ways consistent with our needs; our visual receptors may inform us that a good friend is approaching, so we act by turning and producing a greeting. The brain lies at the centre of this information-processing system, and damage to the brain results in communicative disorders that cannot be resolved simply by changing the route of information input (for example, from hearing to vision or to tactile information) or the kind of output (for example, from speech to writing or to signing). Individuals with damaged brains present language pathologists with some of their most challenging problems.
Inability to communicate at a fundamental level presents a vivid picture whenever it is encountered. But it has always been disability in speech – the primary index of language ability – that has attracted most attention since the earliest times. One of the earliest references is in an Egyptian papyrus of around 3000 BC, which refers to the speechlessness that can come following head injuries. Many Greek and Roman scholars referred to speech problems. Aristotle, for example, in the Problemata, reflects: ‘Why is it that of all animals, man alone is apt to become hesitating in speech?’ Complete loss of speech and stuttering are the two types of disability which are repeatedly referred to by writers of the classical and medieval world. The themes emerge strongly after the Renaissance. Sir Francis Bacon, for example, wrote about stuttering (referred to as ‘stut’) in his Natural History (Sylva Sylvarum, 1627, Cent. IV, Sec. 386) (the spelling has been modernized):
The cause may be, in most, the refrigeration of the tongue, whereby it is less apt to move. And therefore we see that naturals [i.e. idiots] do generally stut less because it heateth; and so we see that they that stut, do stut more in the first offer to speak than in continuance; because the tongue is by motion somewhat heated. In some also it may be (though rarely) the dryness of the tongue, which likewise makes it less apt to move, as well as cold; for it is an affect that it comes to some wise and great men, as it did unto Moses …
An interesting early account of the results of a stroke (see further, p. 114) was that of Dr Samuel Johnson. He suffered a stroke in June 1783, when he was 73, which robbed him of his speech, but left him able to write. From many letters describing his feelings, here is an extract of one written three days after the stroke.3
On Monday the 16th I sat for my picture, and walked a considerable way with little inconvenience. In the afternoon and evening I felt myself light and easy, and began to plan schemes of life. Thus I went to bed, and in a short time waked and sat up as has long been my custom, when I felt a confusion and indistinctness in my head which lasted, I supposed about a half a minute: I was alarmed and prayed God, that however he might afflict my body he would spare my understanding. This prayer, that I might try the integrity of my faculties I made in Latin verse. The lines were not very good, but I know them not to be very good. I made them easily, and concluded myself to be unimpaired in my faculties.
Soon after I perceived that I had suffered a paralytic stroke, and that my Speech was taken from me. I had no pain and so little dejection in that dreadful state that I wondered at my own apathy, and considered that perhaps death itself when it should come, would excite less horror than seems now to attend it.
In order to rouse the vocal organs I took two drams. Wine has been celebrated for the production of eloquence; I put myself into violent motion, and, I think, repeated it. But all was vain; I then went to bed, and strange as it may seem, I think, slept. When I saw light, it was time to contrive what I should do. Though God stopped my speech he left my hand, I enjoyed a mercy which was not granted to my Dear Friend Laurence, who now perhaps overlooks me as I am writing and rejoices that I have what he wanted. My first note was necessarily to my servant, who came in talking, and could not immediately comprehend why he should read what I put into his hands.
Such an account may be compared with the more recent stories about the effects of strokes, illustrated below (p. 15).
Problems such as speechlessness and stuttering are obvious enough, but they by no means exhaust the range of topics which would have to be included under the heading of ‘language pathology’. These will be discussed in Chapter 5, where each specific disability will be described in a separate section. Is it possible, in the meantime, to characterize language pathology in very general terms? Two criteria have been suggested. First, communication becomes a matter for concern when it impedes rather than facilitates interaction. When it draws too much attention to itself, then the listener or reader is distracted from the meaning that the speaker or writer is attempting to convey. Such a situation arises when speech becomes very weak or inaudible, or handwriting becomes too faint to read. It happens when speech, even though audible, is unintelligible, or when writing, even though visible, is illegible. It happens again when the speech or writing, although intelligible, is unpleasant – an abnormally harsh tone of voice, for instance, or an erratic layout or line direction. If speech is non-fluent – full of hesitations and laboured pronunciation – there is cause for concern; or when it makes use of sounds, grammar or vocabulary which are outside the normal range of the language that the speaker uses. The opposite of this is also a cause for concern: when speakers fail, to some degree, to make use of the sounds, grammar or vocabulary of the language used around them, or use these features in ways considered by the community to be inappropriate to their age, sex, occupation, or the like. Similarly, just as difficulties in sending messages, through either speech or writing, will impair communication, so also difficulties in receiving messages will impair the communicative process. Failures to understand speech, inability to read, and incorrect interpretation of non-verbal signals will result in communicative failure, and so will be classed as language or communicative pathology.
There is, however, one problem against which the student of language pathology must always guard. This is the danger of confusing a genuine difficulty of communication, for any of the above reasons, with an apparent difficulty, due to the prejudice or intolerance of the listener and the society of which the listener is a member. It is often the case with regional accents, for example, that strong feelings are evoked: some accents are said to be ‘nice’ or ‘musical’, whereas others are said to be ‘ugly’ or ‘harsh’. Most people have feelings of this kind, and their study is interesting in its own right.4 The trouble comes when people attempt to impose their own standards of speech upon others, insisting, for instance, that a certain pronunciation is ‘wrong’ or ‘slovenly’, when in reality it may be the normal way of speaking for some social group. Such criticisms may take the form of a defence of imagined standards of excellence in a language – as one newspaper put it, ‘let us preserve the tongue that Shakespeare spoke!’ At other times these criticisms constitute a linguistic mask which hides an underlying distrust of the social values of the group involved. Either way, from the viewpoint of the language pathologist, such criticisms are beside the point. To attempt to change someone’s accent or dialect when there is strictly no need to do so – or, putting this another way, when the only motivation to do so comes from an attitude of superiority – involves considerations of a quite different order from anything discussed in this book. In some ways, the different attitudes involved can be summarized by drawing a contrast between speech and language therapy and elocution. Elocution is the art of clear speaking in public, as judged by the cultural standards of the time; it aims to develop the speaking voice to its aesthetic and rhetorical peak, well beyond that which is necessary for the continuance of everyday communication. Unfortunately, as a profession, elocution has often been associated with the instilling of attitudes of inferiority about one’s natural accent or voice (as satirized, for example, in the figure of Henry Higgins and his attitude to Eliza Doolittle, in Pygmalion/My Fair Lady). It should be plain, however, that the concern of the elocutionist is very different from that of speech pathology. A speech–language clinician is concerned to develop or restore language to an everyday norm, and would resist pressure to make this language conform to any real or imagined higher standards of aesthetic, rhetorical or social excellence.
So far the discussion of communicative disability has dealt with individuals who differ in their communicative abilities in significant ways from other members of their community. But there is a second criterion in the identification of communicative abnormality which, although less obvious than the first, is just as important. This refers to cases where people are concerned about their speech without there being any real cause for them to be so. From the point of view of the listener, the speakers are communicating adequately – in terms of all the criteria mentioned above (audibility, intelligibility etc.) – but they none the less think that all is not well. They may feel that their voice is too high or too harsh, or they may feel that their speech is unduly hesitant. This sometimes happens after people have undergone surgery which has altered the structure or function of their vocal tract: the new voice may be much more efficient than the old, to anyone who listens, but because individuals were used to their ‘old voice’, the new voice may sound quite wrong in their ears. Alternatively, parents might believe that their child has difficulty in talking, when in fact objective assessment reveals no such difficulties. Such unrealistic perceptions might have a negative effect on the subsequent communicative development of the child. And in other areas too, such as during the recovery of communication following a stroke, or in stuttering therapy, such pessimistic attitudes are not uncommon. These attitudes are often the target of treatment from the speech and language therapist, as without confidence in communicative ability the individual might withdraw from interactions.
What is linguistic disability like? How does the patient feel? Such questions occur to anyone encountering this subject for the first time, and it makes sense to get as much insight as possible into the nature of these difficulties at the very outset of our study. But where can we get the information? Unlike other forms of disability, patients cannot tell us much, by definition! If they could, they would not be linguistically disabled. But, in fact, it is possible to break out of this circle to some degree, as the quotation from Dr Johnson will have shown. And there are now many books and articles written by the parents, relatives, friends and professional advisers of the linguistically disabled, as well as by the patients themselves, attempting to convey some insight into the nature of the various handicaps, and the acute effect they can have on family and social life. Take, for example, the opening lines of The Siege, by Clara Claiborne Park, which is subtitled ‘The battle for communication with an autistic child’ (Penguin, 1972); here, the linguistic problem is only a part of a more pervasive social and emotional impairment, but its importance to the author is evident throughout the book:
We start with an image – a tiny, golden child on hands and knees, circling round and round a spot on the floor in mysterious self-absorbed delight. She does not look up, though she is smiling and laughing; she does not call our attention to the mysterious object of her pleasure. She does not see us at all. She and the spot are all there is, and though she is eighteen months old, an age for touching, tasting, pointing, pushing, exploring, she is doing none of these. She does not walk, or crawl upstairs, or pull herself to her feet to reach for objects. She doesn’t want any objects. Instead, she circles her spot. Or she sits, a long chain in her hand, snaking it up and down, up and down, watching it coil and uncoil, for twenty minutes, half an hour – until someone comes, moves her or feeds her or gives her another toy, or perhaps a book.
We are a bookish family. She too likes books. Rapidly, expertly, decisively, she flips the pages, one by one by one. Bright pictures or text are the same to her; one could not say she doesn’t see them, or that she does. Rapidly, with uninterrupted rhythm, the pages turn.
One speaks to her, loudly or softly. There is no response. She is deaf, perhaps. That would explain a lot of things – her total inattention to simple commands and requests, which we thought stubbornness; the fact that as month follows month she speaks no more than a word or two, and these only once or twice a week; even, perhaps, her self-absorption. But we do not really think she is deaf. She turns, when you least expect it, at a sudden noise. The soft whirr as the water enters the washing machine, makes her wheel round. And there are the words. If she were deaf there would be no words. But out of nowhere they appear. And into nowhere they disappear; each new word displaces its predecessor. At any given time she has a word, not a vocabulary, (pp. 9–10)
Here is another example, well into the story this time. It is an extract from Elizabeth Browning’s story of her severely handicapped child, partially deaf and with a severe language disorder: I can’t see what you’re saying (London, Elek, 1972):
One day at tea-time Freddy was in his high chair when he suddenly saw something which reminded him of something else. The crying out began, and he had taken to making ‘asking’ noises. Jean said she had seen him with a match-box in the bathroom and rushed upstairs and returned with it, triumphant. She was met by a face with eyebrows raised in hope and a smile hovering. The ensuing disappointment resulted in a howl of rage and frustration and a hand and arm hit the matchbox away. Heather remembered something in the garden and rushed out for that but with the same result. We then all left the table and searched the house until, at last added to the pile of objects like so much Kim’s Game, the cherished thing was found. By this time Freddy was banging his head on the high chair tray in agonies of frustration and crying and throwing himself about, and the rest of us were soon reduced to pieces of chewed string with our nerve-ends jangling and our patience extended to breaking-point. When the treasured object was finally found, the ensuing peace and calm was very alarming and much too unnerving to be enjoyed. We all knew it would only last until the next time he lost something, (p. 18)
Stroke: A Dairy of Recovery was written by Douglas Ritchie in 1960 (London, Faber & Faber). One year after the stroke, he felt like this:
My speech? I might have had two or three stray words but I could not tell. In the Centre I rarely spoke to anyone. I had nothing to say and I was embarrassed because I could not say anything. I read all the spare time I had. In the ambulance, where I used to spend upwards of two hours daily with four and five people week after week and where I was less embarrassed, I used sometimes to try different words. One week I was optimistic and the next there was nothing. But I had no doubts about speaking as normally as I did before I had the stroke: it was a question of time and of finding the man or woman who could find me the switch.
My writing was more depressing. I had only written ‘Good luck, Clif’ or a message like ‘cigarretes’ (spelt wrong – this might have roused my suspicions, but it did not), and for the rest made the excuse that I did not write with my left hand. But it was my mother’s birthday in May and I felt that I should write her a letter. I no sooner had the paper in front of me when every single word galloped out of sight. I was left staring at the blank sheet. Nearly half an hour passed, panic grew; this was nothing to do with my left hand. At length my wife came in and she dictated slowly, letter by letter, ‘many happy returns…’. I managed to forget my panic for a time. (pp. 96–7)
These, and other accounts of different types of disability,5 testify to the all-encompassing, profound effect of language disability on all who become personally involved with it. Students commencing their studies of this field cannot fail to be affected by it. And yet, as with all the caring professions, they must learn to distance themselves from it, otherwise their professional judgement and objectivity will be impaired. This is perhaps the central difficulty, as well as the attraction, of working in this field – whether as researcher or as professional: one needs to develop and combine the human qualities of mature and sympathetic caring with the academic skills of methodical analysis and interpretation. Both are needed for real insights into the nature of language disability. It is for this reason that this opening chapter has focused on both modes of knowing, juxtaposing ideas about terminology and theoretical frameworks, on the one hand, with personal anecdote and history on the other. It is a pattern that will recur throughout this book.
It is very easy in a book concerned with any disability to become enmeshed in the disorders, finding theories that provide satisfactory accounts of disorders both in the surface or behavioural signs and in the underlying mechanisms that produce the abnormal behaviours. It is possible to marshal our facts, provide a convincing account, and in the midst of all this academic rigour lose sight of the fact that communication disorders are part of a person, and that such disabilities have very serious implications for an individual’s ability to function successfully within human society.
To understand an ability such as language and communication, and the consequences of its disruption, it is often productive to ask ‘Why is this behaviour here?’, ‘What advantages accrue to the possessor of this faculty?’ This in turn involves considering the speculative accounts of how and why language evolved in the human species. Humans are unique in their possession of sophisticated communicative systems. Other species have been shown to have rudimentary communicative systems; for example, bees and vervet monkeys.6 Non-human primates – chimpanzees and gorillas in particular – have been taught to use sign or visual symbols. But such communicative systems are primitive in comparison to the flexibility and creativity of human language. The origins of language are unknown, but one influential hypothesis suggests that the evolution of language was linked to early man beginning to live in larger and increasingly complex social groups. Language allows group members to sustain social bonds and deal with disputes. In other primate species, the grooming of other group members’ fur is an important mechanism in maintaining group cohesion. But increasing group size means that physical grooming is no longer possible in sustaining bonds between group members. Talking allows an individual to address a number of listeners at the same time and also frees the hands to continue with other activities, such as foraging for food.7
The origins of language may be social, but once it has been mastered it endows its possessor with a powerful resource. Language permits the exchange of information – for example, not only about the location of food sources but also about how a new task could be performed, such as hunting and capturing an animal larger and more powerful than the hunter. Language allows the expert to instruct the novice and the transfer of knowledge across generations. Cultural innovations and knowledge, such as the manufacture and use of certain tools, can be accumulated.
Human communication and, in particular, facility with language, brings social and informational advantages, and this is true of contemporary human culture just as much as its evolutionary history. Human beings who lack this facility may face very severe disadvantage in these areas. Social relationships may be difficult to form and sustain; learning may be difficult, particularly where learning is from oral or written instruction such as in a classroom. Because language is the medium of so much of human learning (imagine a classroom or lecture theatre where there was no spoken or written language!) there will be intellectual consequences of a language disorder simply because the knowledge that impaired individuals have about their culture is reduced. The consequences of a language impairment suffered later in life – for example, following a stroke – may be less severe, but there are still likely to be difficulties in embarking on new learning. How do you learn to use a new kitchen gadget? Either through reading the instruction book or through somebody explaining its operation to you. Inability to read or to understand another’s speech will make acquisition of a new skill difficult.
Beyond building up their store of knowledge, language endows its possessors with a powerful intellectual resource. Language permits planning and talking through solutions to problems in ways other than ‘trial-and-error’ problem-solving, or learning from mistakes not to attempt the failed solution again. Trial-and-error learning has a place in skill and knowledge acquisition, but it suffers from the limitation that there are some errors which may not allow the problem-solver a further attempt at the problem – for example, learning to land an aircraft. Language is important for intellectual activities in other ways. When you are puzzling over a difficult problem and trying out solutions ‘in your head’, you will be aware that you are talking silently to yourself. This internal dialogue with yourself is called ‘inner speech’. You become aware of it in problem-solving situations where a solution to a problem is not immediately obvious. It appears in memory tasks, such as when you have been given complex verbal instructions to remember. Language therefore acts as scaffolding to other intellectual activities, such as memory and the reasoning out of solutions to problems; and individuals with language impairments may have to find other ways to support their thinking at times of high intellectual demand.
In any concern to analyse the intricacies of a behaviour, it is therefore important not to lose sight of the broader perspective. This is necessary not only to understand the patient’s predicament, but also to understand the nature of the disorder. A fundamental principle within all the caring professions, which include speech and language therapy, is a concern for the whole person and hence an emphasis on holism or the holistic approach. Holism demands that the patient is not viewed as just an instance of a particular communicative problem – for example, a difficulty in producing fluent speech; rather, the frame is set much wider. First, the focus is not solely on the patient’s most obvious communicative difficulty; therapists view patients in relation to the whole of their communicative abilities and evaluate their effectiveness both as senders and receivers of messages of all types (spoken, written, signed, nonverbal). Second, holism involves addressing the consequences of an impairment particularly on social and intellectual domains. We shall now look briefly at each of these issues.
Holism in communication
Patients are referred to a speech and language therapist often with some preliminary diagnosis of the communication difficulty – for example, delayed language development, stuttering, or abnormal tone of the voice. The clinician must consider the whole of the individual’s communicative system – that is, linguistic functioning together with non-verbal behaviour. The client must be assessed as both a sender and receiver of messages, and areas of strength and deficit identified. An anecdote may make the point most effectively here. One of the authors was working in a large general hospital. A patient, who was one of the porters from the hospital, was referred with the symptom of an abnormally high-pitched voice for an adult male. The patient was anxious about his voice, and reported that he was often mistaken for a woman on the telephone. He was particularly concerned at his inability to find a girlfriend, which he attributed to his high-pitched voice. Therapy began and was successful in lowering the pitch of the voice to some degree; however, the anxieties about the voice and the difficulty in recruiting girlfriends remained. Then, one day, the clinician, while out of the therapy treatment rooms, met the porter in the hospital corridor. Previously all conversations had been held in a treatment room, where the patient entered the room and sat down. The conversation in the hospital corridor revealed that the patient was an ‘invader of personal space’. One area of non-verbal communication deals with the physical distance between participants in conversation (proxemics). The amount of space between individuals varies between cultures, and is dependent on factors such as the intimacy of relationship of the participants. Within British culture and for a non-intimate relationship, the usual distance between participants is approximately an arm-length. The patient in this case habitually strayed within this area, making the other participant feel threatened and anxious. Treatment at this point moved to work on non-verbal communicative behaviours – in particular, work on maintaining a comfortable interpersonal distance. In this case, a narrow focus solely on speech missed crucial factors which affected the patient’s efficiency as a communicator.
In addition to integrating observations regarding language with non-linguistic components of communication, it is necessary for the language pathologist to view the language system in its entirety. Language is made up of sounds, vocabulary and grammar. In assessing the effectiveness of the individual’s language system, we need to consider this total system, rather than isolated components of it.
Communication and cognition
We have already suggested that language has an important role in supporting other areas of human intellectual activity, such as learning and memory. But the nature of the relationship is not unilateral: as well as language providing the scaffolding for other intellectual activities, other intellectual or cognitive functions support communicative abilities. Cognition is a very broad term, encompassing processes such as memory, attention, perception, learning and reasoning. Language is classified as a cognitive function, and it is closely integrated with many of the above processes – for example, incoming acoustic information has to be attended to and perceived, and in order to be understood has to be related to some stored memory trace. Patients who have very poor memory abilities – for example, people suffering from dementia – are likely to have communicative problems: they may have difficulties retrieving the words they need; they might forget what has just been said to them; they might forget what they are in the process of saying. To examine the communicative deficits without taking into account the broader cognitive picture will result in an incomplete description of problems, which is then only of partial value, particularly in the planning of intervention.
The third aspect of holism is to remember the whole person – the person’s reactions to the disability, the response of the family and friends, the environment in which the individual lives and works, and the social and economic consequences of any handicap. The extract below was written by a young man who had suffered a stroke. Before his illness he had worked as a journalist; however, the stroke had profound effects on his ability to speak and to read and write, in addition to causing a paralysis on the right side of his body:
I had a stroke. And it’s painful (psychological, mental). My leg, arm, fingers, brain, it’s gone. I can’t read. I can’t write. What’s wrong. It’s very confusing. God, don’t take my freedom, please. I can’t take anymore.
It takes little imagination to understand the emotional, economic and social consequences of this man’s handicap. Helping patients come to terms with their difficulties is a major challenge for the speech and language therapist. With adults it may involve counselling patients and their spouses, and such work is also important with the parents of handicapped children. Working with those around the patient, and assisting them in dealing with the difficulties associated with the disability, can result in creating a more supportive environment in which the disabled person will live.
Consideration of the environment within which the communicatively disabled person operates is also a factor of concern. Opportunities have to be created within that environment to facilitate communication. For example, background noise needs to be controlled in the hearing-impaired person’s environment, and opportunities to develop lipreading should be encouraged, by speakers allowing their lips to be seen as they talk. This approach – considering the carers’ behaviour and the physical environment of the communicatively-impaired individual – is an important factor in the treatment of communicative disability and will be discussed further in Chapter 6.
We have set a broad frame in which to study language disability: the wider aspects of communicative disability; communication in relation to cognition; and the social and emotional consequences of disability. The focus in this introductory book is inevitably on the first component – the nature of communicative disability. At all points, however, we hope that the reader will place these disabilities into the broader frame, and there will be illustrations throughout the following chapters which we hope will assist the reader to achieve this end.
1. Write down definitions of the terms ‘speech’, ‘language’ and ‘communication’.
2. Produce a diagram which captures the relationship between the three terms.
3. Outline the elements of a holistic approach.