(English) A post-rationalist vision of speech therapy

Karina Tiripicchio (Psychologist), Rocio González Hernández (Speech and Language Therapist), Patricia Almirón Cairoli (Psychologist), Glampiero Arciero (Psychiatrist)

Canary Association of Post-Rationalist Psychotherapy
Tenerife. Canary Islands. Spain

ABSTRACT

The aim of this work is to give a view of the speech disorders from the perspective of a post-rationalist model. We outline the necessity to elaborate a wider spectrum view linking the speech therapy with the person who is suffering from a speech problem. With this aim we will consider language, speech and voice problems in relation with the Personal Meaning Organization. The methodology of the post-rationalist approach will be illustrated with two clinical cases: a youth diagnosed stammering and a woman diagnosed dysphonia.

* In this study we make references to language, speech and voice disorders that do not imply any neurological or post-traumatic lesion

THEORETICAL FRAME

The moment the speech therapy assumes the psychopathological postulates and principles of cognitive post-rationalist therapy, the way of understanding and giving sense to the speech disorders radically changes. Therefore it is necessary to enrich the evaluation methodology and enlarge the intervention strategies.

The first noticeable effect when the speech therapy assumes the epistemological principles of the post-rationalist model is the necessity to review the concept of language and its functions.

The speech therapy based on scientific principles of cognitivism considers language as a constituent ability that enables the individual the symbolization through words of entities that exists regardless of his/her experience.

However, from our point of view, language begins with an action. Language is the result of an interaction with other human beings and it is a way of giving shape to a shared praxis and not as an independent reality (Maturana, H.; 1990). Also, if the language is articulated in the course of the interaction, through the progressive appropriation of a shared meaning, language cannot be seemed as a constitutive ability of the individual. Since the proposition that brings together the” subjective” side and the “the objective” meaning is the basic unit of the speech, the entrance in the language is characterised by the use of the proposition. Therefore, the language allows us to give a structure to the personal identity (Arciero, G.; 2000).

From this theoretical frame, the speech therapy abandons the idea that language is only an impersonal physical device and considers the necessity of reviewing the disorders of the language, speech and the voice. In this study we will consider the speech symptoms as the individual way a person has, to give sense to his or her experience. We do think that when a person asks for help, because he or she has a stammering problem or a sudden lost of voice (dysphonia), the first questions we should think about are: why has this person a stammering problem?, what is the meaning of the lost of voice within the personal history of this person?.

THERAPEUTICAL APPROACH

If we consider that the human system, it is a system with its own organization, we will not be able to realise that the speech and language disorders are connected with categories which refer to an external and objective reality. We explain the appearance of these clinical disorders as a difficulty the individual has, of assuming certain disturbing events in his or her life. (Guidano V.; 1991). From this approach, we consider the speech and language disorders as interferences in the continuity of the narrative plot in the patient’s life. This means that certain events in the patient’s life affect him or her in such a way that a discrepancy with his/her sense of personal continuity is produced .The impossibility to articulate in a flexible way the intensity and frequency of this emotive situations with his/her own internal coherence is going to cause a speech, language or voice disorder (Arciero G.; Guidano V.; 1999).

To give an example, we will talk about the case of a woman diagnosed a dysphonia (vocal nodules). This woman is a student of flute in the local Conservatoire .We have observed that some specific situations in her daily life disturb her in such a way that she ends up loosing her voice. This happens to her whenever she has oral exams, performances as a soloist or chamber concerts. These situations, besides being lived by her with a very high emotional intensity are very frequent in her everyday training routine to become a musician. However from her point of view her speech disorder has only to do with a disorder in her speech organs and she is unable to establish a connection between her problem and this stressful situations in her life. For her, her voice disorder is not related to her personal experience.

Consequently, the post-rationalist speech and language therapist’s task consists on redefining the problem, relating it to the patient’s character. This redefinition should at the same time, create a clinical and interpersonal context as well as making clear the symptoms are not due to an external cause. The therapist should help the patient to find out the global and emotional meaning of her symptoms with the aim of creating alternative points of view that allow the patient to shift the focus of attention to other aspects of herself. The basic procedure consists on pinpointing to the stressful situations lived by the patient which are the cause of disturbing feelings and emotions and proceed to its reconstruction using the self-organization method. The speech and language therapist must help the patient to analyse how her subjective experience is built and distinguish the different components in it: emotions, feelings and images, as well as the way she perceives herself as a person when these situations take place. The therapist must also train the patient to recognise when these feelings arise, that is to say, what kind events and contexts produce these feelings in her. In the example of the woman with a dysphonia, the basic reformulation consisted on redefining her voice disorder as resulting from her hypersensitivity (which was a feature of her character and personality) to other people`s opinions about her. She was too concern with what the people would think of her. In this case it was obvious that it was necessary to reconstruct those situations when there was a change in her emotions and feelings due to other people’s opinions about her. The situations when she lost her voice were all quite similar. She would go to the conservatoire, she would prepare her exams or performances for days but as the day of the exam or the concert came closer, her fear to face the people and a feeling of being unable to cope with it grew and grew and in the end she would loose her voice and could not do the exam or give the concert. We would like to conclude highlighting that to propose a post-rationalist approach to the speech and language disorders does not mean to abandon the habitual techniques used to heal the speech organs, but rather it is conceived as another element to take into account when dealing with these pathologies.

CLINICAL CASES

CASE A

The patient is a woman who is 20 years old. She is a student of flute in the local Conservatoire. This year she will start University, combining her studies at University (Industrial Relations) with her music training. Professionally she wants to become a music teacher. She has got a younger brother who is 11. She has sometimes to look after him and she quite implied in his education. Her father is 52 years old. He works in a Military Quarter as a mechanic. Her mother is an instrumentalist of Canarian folklore. She plays in a local folk group and is also a music teacher. She is 49 years old. They are a typical middle class family. The patient visits the therapist because she has a voice problem. She has a deep husky voice, it is hard for her to speak and while she is speaking she sometimes loses her voice.

WHEN DID THE SYMTOMS APPEAR? The first time the patient lost her voice was in October 1999 when her mother had to undergo an ear operation and she was starting the academic year. She had to undertake responsibilities at home and take care of her younger brother.

CLINICAL HISTORY: It began like a progressive loss of voice from which she has never recovered again. The symptoms worsen when she has to deal with stressful situations in her life: oral exams, performances as a soloist, chamber concerts. An improvement takes place when these stressful situations are over.

She is advised to visit a Phoniatric Service and they give the following DIAGNOSIS: vocal nodules in both vocal pleats.

DESCRIPTION OF THE VOICE: husky voice, muffled. High pitch. Deep tone. Impossibility to sing. Vocal and muscular effort used when speaking.

PERSONAL MEANING ORGANIZATION: Eating Disorder

OBJECTIVE OF THE INTERVENTION:

To prepare the clinical and interpersonal context
To build the therapeutic context
To reformulate the symptom looking at the vocal mechanism as a part of the physical and emotional body (as an internal problem)
To reconstruct the Personal Experience
To re-establish the pneumo-phonic balance
To recover the optimum fundamental frequency (the phonatory frequency more convenient for the speech organ)

METHODOLOGY OF THE INTERVENTION:

The methodology to follow is the result of the combination of the Self-observation Method of cognitive post-rationalist therapy and the acquisition of a Vocal Emission Technique.

Frequency: two weekly meetings of one hour in the first two months and one hour weekly meeting the rest of the therapy.

Each session will have two parts: a first part dedicated to the vocal production, and a second part dealing with the

Reconstruction of the Personal Experience.

CASE B

The patient is a 21 years old man. He is studying History and Geography in the University of La Laguna. His mother is a matron in a medical centre. His father died when he was 4. He has a younger brother who is 17 years old. It is a middle class family. They are from Fuerteventura Island. He moved to Tenerife three years ago to study at the University of La Laguna. He visits the speech and language therapist because he stammers. He is very concerned about this problem because it interferes with his social and affective relationships.

WHEN DID THE SYMPTOM APPEAR?: The symptom first appeared when, after the death of his father, he was living for a time with his grandparents.

HISTORY OF THE SYMPTOM: This problem of fluency has been permanent from his childhood up to the present time. He did a speech therapy when he was 12. There was an improvement in those months but when he stopped the therapy, his stammering problem actually got worse. At the moment, this fluency problem is a noticeable and constant feature in his speech. The problem gets worse when he has to speak to people he does not know, his teachers or with women he fancies. He neither stammers when singing nor when he is drunk. When reading there are less problems.

DESCRIPTION OF HIS SPEECH: fluency disorder. Deep tone and lack of coordination when breathing. To try to cope with his speech problem the patient uses short sentences, associated movements and he has nervous tics because of the effort he makes to communicate.

DIAGNOSIS: Stammer.

PERSONAL MEANING ORGANIZATION: Eating Disorder

OBJECTIVES OF THE INTERVENTION:

To prepare the clinical and interpersonal context
To build the therapeutic context
To reformulate the symptom looking at the speech mechanism as a part of the physical and emotional body (as an internal problem)
To reconstruct the Personal Experience
To acquire an alternative speech model
To re-establish the pneumo-phonic equilibrium

METHODOLOGY OF THE INTERVENTION:

The methodology to follow is the combination of three methods:

· The self-observation method of the post-rationalist therapy

· The acquisition of a speech pattern

· The acquisition of a vocal emission technique

Frequency: one hour weekly meeting

Each session will have two parts: The first part dedicated to the vocal production and the second part dedicated to the Reconstruction of the Personal Experience.

FINAL REFLECTION

With this work we only seek to open the way to look at the speech and language disorders as difficulties in the capacity to articulate events in life with a personal continuity .To find an explanatory approach of the emotions that arise in people that suffer pathologies of language voice and speech was the reason why we thought it was necessary to bring near the Speech and Language Therapy to a Cognitive Post-rationalist Model of psychotherapy. This approach was originally created because of the need to explain this disorders. The symptoms are now observed in a different way, full of emotional meaning. What it was in the beginning just an explanation of how external facts could be useful for the speech and language therapist’s task, became a job to articulate again the Methods of Evaluation, the objectives and phases of intervention and the model of Human being from which Language emerges.

BIBLIOGRAPHY

Arciero, G. Guidano,V. (1999) Experience, explanation and the search of coherence
Arciero, G. (2000) In press Guidano, V. (1991) The self in process. Barcelona, Paidós.
Maturana, H. (1990) Emotions and Language in education and politics. Santiago de Chile. Hachette