HOW I

How I help people move on (2):

Talking flats
M
oira had lived with a long history of neglect and physical abuse from her family. She was eventually given temporary supportive accommodation in the community as she was deemed to be capable of living independently of her mother with a support package in place. This move was supported by the Community Learning Disability Team and the staff team within her local resource centre, as both had been dealing with the consequences of her home situation for years. After living in temporary accommodation with other residents for some months, Moira was allocated her own home and was in the process of choosing the furnishings. She was looking forward to having her own tenancy. However, her brother was adamant that she should not live there but should be living with their mother. He wanted Moira to be registered under the Adults with Incapacity (Scotland) Act 2000, so that the family had guardianship over her and could decide where she should live. To achieve this, the family had hired a solicitor to take the case to court to prove that Moira could not make a decision for herself in terms of her own tenancy. The solicitor had contracted a private psychiatrist to meet with Moira and, after a short session, he had deemed her incapable of making decisions. This was in direct contrast to the professional opinion of both the Community Learning Disability Team psychiatrist and psychologist. Aware of my previous involvement with Moira, the teams clinical psychologist referred her to speech and language therapy. Her professional opinion was that Moira had the capacity and skills necessary to make appropriate choices for herself. However, she was aware that Moiras low level of confidence undermined these skills, and that she presented as a lady with very limited comprehension and expression. She was keen for this to be explored in more detail via speech and language therapy. Given the complex nature of the case, it was also necessary to evidence Moiras capacity clearly. This is one example of a gradual shift in the type of referral made by other team members

When the family of a lady with learning disabilities challenged her capacity to make decisions about where she should live, Maria Venditozzi found the Talking Mats framework ideal for gathering evidence of Moiras competence and ultimately for ensuring her wish to move into her own flat was respected.
to speech and language therapy over the 8 years I have worked within community teams. This change is mirrored in the referrals coming in from the community. In both cases, there is an appreciation of the role we offer in complex cases which involve the more subtle areas of language. This includes recognition of our input into high level social language dysfunction, such as in Aspergers syndrome, semantic/pragmatic language disorders and clients who can mask their language difficulties under a cloak of competence. In other cases, a clients reluctance to communicate verbally or within social norms such as with eye contact, has had a seriously detrimental effect in the way in which they have been managed generally and with regard to their communication. Speech and language therapy and training along with general improvements in social awareness have redressed this to some extent. As all these difficulties have far-reaching consequences, it is has been gratifying to note recognition and appreciation of this within the districts for whom I provide a service. My assessment found that there had been no change or deterioration in Moiras skills since the last speech and language therapy assessment some years previously. This confirmed that Moira was functioning at an approximately three word level, both in comprehension and in expression. Although she had these verbal communication skills, she was an extremely anxious lady and would only speak reluctantly and in a very quiet voice. Her eye contact was poor at times and she had closed body language. Overall, she presented as fearful and intimidated.

READ THIS IF YOU ARE INTERESTED IN OPPORTUNITIES FOR CHOICE ESTABLISHING CAPACITY THE LEGAL PROCESS

Time and space

To explore Moiras decision-making ability, I introduced Talking Mats at the next session. Talking Mats is a low tech communication framework involving a textured doormat and sets of symbols. It is designed to help people with communication difficulties reflect on their experiences and express their views. It was originally developed by the AAC Research Unit at the University of Stirling, and has since

been the subject of ongoing research with many different client groups (Nicoll, 2008). It was ideal for use with Moira as, Talking Mats can help people arrive at a decision by providing a structure where information is presented in small chunks supported by symbols. It gives people time and space to think about information, work out what it means and say what they feel in a visual way that can be easily recorded (AAC Research Unit, 2009). The session with Moira was video taped, audio taped and a photograph of each completed mat was taken. I felt such comprehensive recording was necessary due to the legal implications of the investigation. This session was carried out with the help of speech and language therapy students who were on placement at the time. Moira was co-operative and attentive throughout the session. She can get side tracked on a particular train of thought, so occasionally I had to re-focus her using the photographs or pictures as a prompt. This worked well and she would then continue with no difficulty. A trial of the Talking Mats was carried out with Moira using the topic food and Moira was able to quickly classify foods she liked (under happy face) or did not like (under sad face). She presented with very fearful behaviour as before and was reluctant to place the pictures

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onto the mat; she preferred me to place them on it where she indicated. We then discussed the subject of where she wanted to live. The key worker supported the session by providing photos of her mothers home, her new flat and the temporary residence where Moira was staying. Using a straightforward Talking Mat - Where I want to live - Moira confirmed that, from the three options, she wished to live in her own flat. We then explored the reasons for her choice in more detail through a number of sub mats. When asked about her current temporary residence, Moira was clear that she liked living there but complained that at times some of the other residents annoyed her. This was confirmed as true by her key worker, who explained that some new residents had challenging behaviours and could be difficult around Moira on occasion. We then addressed the subject of living in her new flat. Moira was very clear that she wanted to live there and why she wanted to live there. We explored this on a sub mat about feelings. This is pictured in figure 1, with the photograph of her flat removed. She considered that she would not (sad face / no) feel bad, cross or hurt, and she would not shout. She wondered if she might (maybe) cry and feel frightened. She thought that she would (happy face / yes) feel relaxed, safe, nervous, worried, angry and happy. She would have fun, be listened to, she would laugh and it would be quiet. Prior to the session I had had a long discussion with Moiras support worker in the Resource Centre. She reported that Moira was scared of her brother - and considered that there were ulterior motives for him wanting Moira back with their mother, who had now become infirm. Moira did have a few months of living with her brother prior to her temporary community accommodation, which was unsuccessful and, according to her key worker, caused Moira great distress. As it was important to get Moiras views directly on why she did not want to live with her mother, we completed a sub mat with the subject How I feel at mums house. Moira made a comprehensive picture list. Again using a happy face for yes and a sad face for no, she categorised how she felt (frightened, nervous, angry, in danger, tearful, shouting, a bad girl, worried, cross, happy, cheerful, hurt, sad) and how she didnt feel (safe, quiet, or that she laughed) at her mothers house. Shots of the two sections from this mat are in figure 2, with the photograph of her mothers house removed. When I asked Moira again if she wanted to live with mum she was adamant that she did not. She verbally stated that her mother and her brother hit her, and that her brother frightened her. She was able to indicate where on her body she had been hit. This video discussion was submitted along with the speech and language therapy report and photographs of the mats to the Chief Medical Officer. Figure 1 Moiras feelings about her new flat

Figure 2 a) Section of How I feel at mums house

Figure 2 b) How I dont feel at mums house

Complexity of emotion

Moiras responses to the mat How I feel at mums house were interesting and highlighted the complexity of emotion which Moira felt. Although the responses were negative overall and caused significant concerns for the teams involved in her wellbeing, she also acknowledged that at times she was happy and cheerful at home. This was an honest account of life there; Moira was not demonising her family but recognising that there were some good times shared. However, for many reasons, both simple and complex, she was making an active choice not to return there and to move into her own home and onto the next chapter in her life. The responses to how she would feel in her own flat were also realistic and there was evidence of sensible expectations of her future life there. She acknowledged that there would be times when she would be worried or angry. However, what was important was that she considered that she would feel safe and

relaxed there. She also realised that she would be able to seek support should she need it and that her concerns would be listened to. What was very poignant was the fact that she would not feel like a bad person or feel hurt any more. Moiras brother was advised by his solicitor to delay proceedings until the Chief Medical Officer had scrutinised the assessments from the Community Learning Disability Team. When it became evident that Moira was making allegations of harm and that she was very anxious about living in her mothers house, the Chief Medical Officer was understandably extremely concerned. The consequences of the assessment procedure - and particularly the video tape to evidence Moiras statement - resulted in the case being dropped by Moiras brother. Moira has since moved into her own accommodation where she has little contact with her family. The advantage of using Talking Mats as a therapeutic tool was twofold. Firstly, Moira was very timid and under-confident when

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HOW I / Let's talk shop

speaking and often used nonverbal means of communication, such as nodding/shaking her head for yes/no, despite her verbal skill levels. Using the mat gave her the opportunity to answer direct, personal questions with no pressure on her to respond verbally. We were able to visually tackle the issues which caused her distress, such as living with her mother. As we were addressing these, she became more confident and felt able to offer some verbal responses to supplement the pictures. Secondly, we also gained visual evidence of Moiras opinions regarding her future home. She was able to evidence clearly her decisionmaking skills and her capacity to make informed choices for her future wellbeing. This satisfied the decision-making panel of professionals who were working to ensure that Moiras needs were appropriately met. It was very satisfying to be involved in supporting someone to assert their opinion in the face of adversity. Moira deserved to have her views listened to and respected. Thankfully, the community team and speech and language therapy with the use of Talking Mats were able to facilitate this process to a happy conclusion. Maria Venditozzi is Principal Speech and Language Therapist with the Joint Learning Disability Service, NHS Greater Glasgow and Clyde, e-mail mvenditozzi@hotmail.com.

Acknowledgement

Thank you to Moira for allowing me to share her case. Identifying detail has been minimised to respect the privacy of her family. SLTP REFLECTIONS DO I ALLOW CLIENTS SPACE, TIME AND SUPPORT TO EXPLORE COMPLEX FEELINGS? DO I KEEP SUFFICIENTLY COMPREHENSIVE RECORDS OF CLIENTS VIEWS? DO I GAIN RESPECT OVER TIME FOR WHAT I BRING TO MULTIDISCIPLINARY TEAMS?

References

AAC Research Unit (2009) Talking Mats: A communication tool designed to help people who suffer from communication disabilities or difficulties. Available at: http://www.talkingmats. com (Accessed: 12 July 2009). Do you wish to comment on the impact Adults with Incapacity (Scotland) Act 2000 asp this article has had on you? Please see 4. Available at: http://www.opsi.gov.uk/legislaguidance for Speech & Language Thertion/scotland/acts2000/asp_20000004_en_1 apy in Practices Critical Friends at www. (Accessed: 12 July 2009). speechmag.com/About/Friends. Nicoll, A. (2008) The third person in the room, Speech & Language Therapy in Practice Winter E1-E4. Available at: http://www.speechmag.com/Members/ (Accessed: 12 July 2009).

Lets talk shop

The second Talk Shop (National Speech and Language Therapy Fair) in June 2009 showcased resources for the speech and language therapy profession. Delegates were asked to say what their favourite resource was and why. Information about the 2010 Talk Shop is at www.talk-shop.org.
My favourite resource today is Language Garden (www. languagegarden.org/). I particularly loved the way you could use it to generate long, complicated sentences with visual demonstration of different grammatical functions. I feel it fills a gap in my resource bank. Geraldine Hindley Our Sound Pictures CD is flexible, practical and - best of all - cheap at 20. The CD is packed full of pictures of all speech sounds in all word positions. I use it daily to provide resources for targets set in school. I use the pictures in clinic for eliciting words, picture sorting and lotto boards. The pictures come in full colour and also black and white so the children can personalise them. Abigail Padgett (Sandwell Childrens Therapies, tel. 021 530 8035) Alex Kellys Talkabout for Teenagers (www.alexkelly.biz/) because I work with adults with learning disabilities and, looking through this resource, could see lots of instances when it would be easy and effective to use with these clients as well as teenagers. I have found that working on social skills with adults with learning disabilities is a growing field, and we dont always know where to go for ideas. Previously a lot of my therapy has focused on functional communication and now, as clients build their skills, social aspects are becoming more of a priority for them. Izzy Leighton

My favourite was the CLUE Magnifying Glass. I really like how such a simple tool, made to look like a magnifying glass, provides a new, imaginative approach to working on semantics and word finding. As I work with teenagers, I particularly like how it can be used across most age ranges. Young children will enjoy turning the wheel, and older children will appreciate its user friendly appearance, with some higher level language to develop their vocabulary. It provides many useful questions and prompts to develop language. Katy Harrison (Katy wins a years subscription to Speech & Language Therapy in Practice) For more information on the CLUE (Category, Location, Use, Extra special features) Magnifying Glass, e-mail Sue Dobson, susan.dobson@dudley.nhs.uk Speech and language therapists are now fully involved in an educational context, working with students with social language and self-esteem issues. Alex Kellys Talkabout DVD (www.alexkelly. biz/) is a resource I had not seen before. It combines video clip examples of appropriate and less good social language and interaction, featuring children, teenagers and adults. It will be very useful in training and working with groups, and will complement her new Talkabout for Teenagers which arrives later this year. Having used the original Talkabout books for years now, this DVD (30) will be an invaluable addition. Jane Oates

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