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Talking Matters
Yvonne Macleman is one of a small but growing number of speech and language therapists who have made the transition from traditional to emerging areas of practice. As a practical example of how our profession can play an integral part in Child & Adolescent Mental Health Services (CAMHS), she describes how she used Talking Mats with a young man with Aspergers Syndrome to facilitate an accurate mental state assessment.
READ THIS IF YOU ARE INTERESTED IN WORKING BEYOND TRADITIONAL BOUNDARIES FACILITATING EFFECTIVE COMMUNICATION CHANGING YOUR SPECIALISM

hild & Adolescent Mental Health Services (CAMHS) are an integral part of children and young peoples services. Speech and language therapists in CAMHS are however few and far between; in Scotland there are currently only 5.5 whole time equivalents, of which I am one. This is despite it being well recognised that communication difficulties and emotional/behavioural difficulties often co-exist. Cohen et al. (1998), for example, found that 38 per cent of children referred to child psychiatric services met one or more criteria for previously identified language impairment while 41 per cent met the criterion for unsuspected language impairment. In total 63.6 per cent of the children referred had language impairment. The link between communication impairments and emotional or behavioural disturbance cannot be thought about solely in simple terms such as primary or secondary conditions. The relationship is complex, as both areas are closely interrelated, and it requires genuinely integrated approaches to minimise the impact of these difficulties. Speech and language therapists with skills in communication impairment and in the field of mental health can provide this (Sellars, 2009). My post working with young people in CAMHS was created in 2003, and is currently split between the West of Scotland Adolescent In-Patient Unit at Skye House and one of the CAMHS out-patient teams. Speech and language therapists working within CAMHS settings use a transdisciplinary working model, taking on the specialist speech and language therapy role and at the same time working beyond traditional boundaries to function as integral members of the mental health team. This means that I may identify a language or communication impairment, but will not usually provide direct therapy. Although I will often liaise with and refer on to my colleagues in child health speech and language therapy, my role is indirect, namely facilitation of effective communication within mental health assessment and psychological therapies. I link closely with a young persons family, school, home or residential placement, and support effective communication between the young person and their commu-

nication partner, within the context of their mental health problem. This model is identified as a key element by the Royal College of Speech and Language Therapists (Gascoigne 2006) and our own service (Sellars, 2009).

Exciting challenge

Moving from adult learning disability services to mental health was a new and exciting challenge for me, with both similarities and differences in clinical knowledge and culture. I spent significant amounts of time reading around areas like attachment theory, eating disorders and psychosis, and have benefited from this new knowledge. I continue to work through Greater Glasgow & Clyde NHS New-to-CAMHS package, which I have found very useful. It has taken me a while to adjust to the move from a social model of disability in adult learning disability to a predominantly medical model of impairment in CAMHS. However I have also been able to bring my previous experience with me, and have recently started training my nursing colleagues in Skye House in inclusive communication strategies to help their engagement and communicative success with the young people in the wards. I have new experiences of working with other professionals like family therapists, psychotherapists, liaison teachers and forensic psychologists. I work as part of CAMHS, and as such, a referral cannot be made to me as a speech and language therapist in isolation. In terms of training and continuing professional development, I attend courses around areas like depression, autism spectrum disorder and cognitive behaviour therapy. I am also a committee member of the Scottish Speech and Language Therapy Specific Interest Group in Mental Health. My move into mental health highlighted for me the co-morbid nature of mental health problems across all client groups with speech, language and communication needs. The knowledge I have now about CAMHS would have been useful in my previous posts. CAMHS referrals come through GPs, and I would have felt more confident about making an onward referral to a GP about a child or young person

referred to the speech and language therapy department who may be presenting with a possible co-morbid depression, anxiety disorder, eating disorder or psychosis. Young people are referred to CAMHS for a range of mental health problems. They will usually complete a mental state assessment as part of a transdisciplinary assessment from which a psychiatric diagnosis can be made. The key to this assessment is communication, relying on effective sending and receiving of messages between the mental health professional and the client. The young persons responses are essential for completion of the assessment and formulation of a treatment plan, and this is where the speech and language therapy contribution to the team can really pay off, as this case example illustrates.

Greg

Greg, a 17 year old boy with a diagnosis of Aspergers Syndrome, was referred to a local CAMHS service for an urgent assessment due to his presentation of low mood, loss of interest and pleasure in daily life, and suicidal ideation. The referring agent noted that he was unable to describe his thoughts in any detail and that, in his previous assessment for Aspergers Syndrome, the assessment team had been keen to exclude a co-morbid depression but were unable to do so due to his lack of motivation to communicate. Howlin (1997), cited in RCSLT (2009), says, The inability of people with autism to communicate feelings of disturbance, anxiety or distress can also mean that it is often very difficult to diagnose depressive or anxiety states, particularly for clinicians who have little knowledge or understanding of developmental disorders. After discussion with the transdisciplinary team, I developed a Talking Mat mental state assessment with the consultant psychiatrist in preparation for Gregs appointment. Talking Mats is a low technology communication framework involving sets of symbols, which was originally developed for use with adults with learning disabilities, and is now being used more widely with a range of client groups. It is designed to help people with

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communication difficulties to think about issues discussed with them, and provide them with a way to express their opinions effectively. As the Talking Mats website explains, it 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 (www.talkingmats.com). The first appointment was attended by Greg, his mother, the consultant psychiatrist and me. The consultant psychiatrist says, The aim of the session was to attempt to undertake a more satisfactory mental state assessment of Greg, who had found it extremely difficult and stressful to communicate verbally in his first meeting with psychology colleagues. We explained the use of Talking Mats, demonstrated the materials and sought Gregs consent. I gave Greg the corresponding symbol for each question the psychiatrist asked. He was able to create a complete Talking Mat, which gave us a good insight into his internal thoughts and feelings, as well as any biological changes which are associated with depressive states like eating and sleeping patterns. From the Talking Mat, we were able to establish that Greg: feels worse in the morning, and feels tired all the time has suicidal thoughts quite often, but has made no plans to end his life does not feel hopeful about the future very often is not often able to do anything to make himself feel better is usually sleeping well, but does not know if he is eating well. Greg was given a diagnosis of a moderate depressive illness, and a follow-up phone call confirmed he wished to start taking antidepressant medication. He was clear that, although using the Talking Mats made speaking about his feelings easier, he did not want to engage in any form of talking therapy such as cognitive behaviour therapy. Gregs mother spontaneously commented on two separate occasions that she felt the Talking Mat was an easier way for her son to express his thoughts and feelings around a difficult area.

Use of Talking Mats with Greg Review appointments at two and four months after starting medication showed an improvement in Gregs mood and overall functioning. It is not possible to compare the use of Talking Mats directly, as symbols were added and omitted as dictated by the conversation during review appointments. However, some themes emerged: hopeful about the future moved from not very often to maybe tired moved from yes to quite often enjoying home moved from quite often to yes enjoying friends moved from quite often to yes taking anti-depressants consistent yes response. From the Talking Mat it was also possible to see Gregs increase in anxiety around going to college. We were able to offer support around this normal response, as well as highlighting this to his mother as a possible area for further discussion at home. Greg has now started attending college and his anti-depressant medication continues to be monitored by his GP. Consultation with academic colleagues allowed me to reflect on the implications of replicating this approach with other young people. This raised a number of questions: a. Do Talking Mats help with / enhance psychiatric diagnoses? b. Could the themes explored by Talking Mats be analysed qualitatively? c. Could Talking Mats help to determine if a mental health treatment has been effective? d. How reliable are Talking Mat responses? Do responses vary in a young person dependent, for example, on the time of day of the assessment? e. Could a Talking Mat mental state assessment be correlated with a published mental state assessment, like the KiddieSADS-PL (semi-structured diagnostic interview designed to assess current and past episodes of psychopathology in children and adolescents from 6-18 years), or the Beck Depression Inventory (selfreport questionnaire designed to assess the intensity of depression in young people and adults from 13-80 years)? I also wonder about the emotional impact of a mental state Talking Mat from a parents perspective, and how it might feel seeing your son or daughters difficult thoughts and feelings displayed in black and white. My family therapy colleague however commented that he thought the Talking Mat could actually be emotionally containing for both the young person and their family. From a communication point of view, I would avoid using double negatives in future Talking Mats. I had originally designed these to build in some level of reliability of response from Greg, who was able to cope with this level of language structure, but for many clients it would simply add to the language demands of a process which is meant to take the pressure off. Gregs case illustrates the value of Talking Mats within the CAMHS setting for the professionals, the family and most importantly the client. I now need to consider how to develop the evidence to prove the effectiveness of using Talking Mats to facilitate mental state assessment, as I am keen to demonstrate the many practical ways in which speech and language therapists are a valuable and integral part of transdisciplinary CAMHS teams. SLTP Yvonne Macleman is a speech and language therapist with Child & Adolescent Mental Health Service (CAMHS), NHS Greater Glasgow & Clyde, e-mail yvonne.macleman@ggc.scot.nhs.uk.

Quality and quantity

The psychiatrist and I agreed that the Talking Mat had increased both the quality and quantity of information gained from Greg, thereby allowing a diagnosis to be made and treatment plan formulated. As Coakes (2006, p.10) says, For children with emotional behavioural difficulties, attention deficit / hyperactivity disorder or autism spectrum disorder and associated moderate /severe language difficulties, Talking Mats has been proven to increase their ability to express their views in comparison to a verbal discussion. This is achieved by Talking Mats facilitating both engagement and linguistic ability.

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Acknowledgments References

Thanks go to Greg, CAMHS colleagues, Leila Mackie and Professor James Law. Coakes, L.A. (2006) Evaluating the ability of children with social emotional behavioural and communication difficulties (SEBCD) to express their views using Talking Mats. Unpublished report. Cohen, N.J., Barwick, M.A., Horodezky, N.B., Vallance, D.D. & Im, N. (1998) Language, Achievement, and Cognitive Processing in Psychiatrically Disturbed Children with Previously Identified and Unsuspected Language Impairments, Journal of Child Psychology and Psychiatry 39(6), pp.865-877. Gascoigne, M. (2006) Supporting children with speech, language and communication needs within integrated children's services. London: Royal College of Speech & Language Therapists. Available at: http://www.rcslt.org/docs/ free-pub/Supporting_children-website.pdf (Accessed 14 January 2010). RCSLT (2009) MH20 Inquiry into Child and Adolescent Mental Health Services. London: Royal College of Speech & Language Therapists. Available at: http://www.scottish.parliament. uk/s3/committees/hs/inquiries/mentalhealthservices/MH20.pdf (Accessed 29 January 2010). Sellars, V. (2009) Speech and Language Therapy within Child & Adolescent Mental Health Teams. NHS Greater Glasgow & Clyde unpublished departmental position paper.

Good journey?
Photo of Clifford courtesy of Geoff Wilson/RCSLT

Resources

Beck Depression Inventory, see www.psychcorp.co.uk/product.aspx?n=1316&s=1322& cat=1426&skey=2646. Kiddie-SADS-PL: latest version / usage rights at www.wpic.pitt.edu/ksads/default.htm Video clips of a variety of clients using Talking Mats are available at www.talkingmats.com

Clifford Hughes had a laryngectomy in 2001. His personal story of the everyday psychological, physiological and social challenges he faces and how he has rediscovered his voice serves to remind us why we chose the speech and language therapy profession.
Every now and then someone comes fleetingly into your life and makes a profound impression. Clifford Hughes is one of those people. I was asked by a friend to give a talk to a local group of which Clifford was a member. The group was random and eclectic and I later discovered that they had no idea what I was going to talk about. That always helps I find, because then I can talk about anything I like; an open opportunity to do my own thing. After my allotted time, and some lively feedback, the tea was wheeled in and I had the chance to speak to a few interested souls. Clifford came to speak to me. He describes very well in his article what it is like for him to speak and the enormous debt that he owes to the speech and language therapists who helped him along the way. But here we have a human being who would seem to have lost everything that made him him. In a way, he was his voice. That was how he communicated and connected with the world. It would be like a sculptor losing her hands or an athlete losing his limbs. No so with Clifford. He set about finding another way. He knew the talent was still there even though the method of communication was gone. But not only did he find a new way, he found other avenues to share his passion and joie de vivre. He shares his deep knowing that HE was not his voice but much much more. He is an example of the famous Churchillian words, Never never never never ever give up. I dont know how often you as speech and language therapists get to hear what a fabulous job you do. I hope this article will remind you that your work of enabling people to communicate more effectively is a pearl beyond price, and that there is no price to put on the courage of the human heart. Jo Middlemiss is a qualified Life Coach, who offers readers a complimentary half hour coaching session (for the cost only of your call). Please note that Jo moved in May 2009 and her new telephone number is 07803589959.

REFLECTIONS DO I GIVE SUFFICIENT PRIORITY TO THE COMMUNICATION IMPLICATIONS OF A CO-MORBID MENTAL HEALTH PROBLEM? DO I HELP OTHER PROFESSIONALS WITH THE COMMUNICATION ASPECTS OF ASSESSMENT TO ENSURE A CLIENT IS OFFERED APPROPRIATE TREATMENT? DO I PARTICIPATE IN A RANGE OF CONTINUING PROFESSIONAL DEVELOPMENT OPPORTUNITIES?
Do you wish to comment on the impact this article has had on you? Please see the information about Speech & Language Therapy in Practices Critical Friends at www.speechmag.com/About/Friends.

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SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2010