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ACQ
Volume 13, Number 3 2011
ACQ
uiring Knowledge in Speech, Language and Hearing
Financial and time constraints
There are known time and cost implications when working
with interpreters (Enderby et al., 2009). In Gloria’s case, two
sessions were required for initial assessment, and therapy
sessions often seemed to be more time intensive, with less
direct therapy completed compared to treatment of
English-speaking patients. The ongoing education and
training of the interpreter and Jane was also time intensive.
It was often difficult to extend the session as the
professional interpreter was booked for one hour at a cost
of $88 per hour. Such difficulties may suggest that patients
with LEP may require longer, more intensive home visits
than English-speaking patients, resulting in an increase in
time and cost.
The interpreter
An interpreter can provide more than language mediation –
they can also provide cultural and linguistic information,
help establish rapport with the patient, or clarify a
misunderstanding of the patient (Isaac, 2005). A Kissi
interpreter was required for all visits with Gloria and was an
integral member of the team. The same interpreter was
present for all sessions making treatment and education
consistent. She provided historical information about
Gloria’s refugee history, the Kissi culture, and previous
health care which enhanced the speech pathologist’s
understanding of Gloria’s situation. As this interpreter had
little experience with dysarthria treatment, some training
was needed. Education and informal explanations to the
interpreter appeared to aid rapport, enhance the
interpreter’s understanding of the program, as well as
improve the cueing of Gloria. The interpreter was able to
remember speech and swallowing strategies and would
spontaneously ask Gloria to slow down or to take a deep
breath. She also assisted in the creation of Kissi articulation
drills, multisyllabic words, and tongue twisters.
Speech pathologists must be mindful of confidentiality
and trust, especially when working with a small language
community (Tribe & Thompson, 2008). The interpreter in
this case was known to Gloria. Prior to the stroke, the
interpreter and her mother would visit Gloria and her family
socially. The interpreter reported that she had visited
Gloria while she was in hospital as members of the small
Kissi group would often do. Even though Gloria and her
family appeared agreeable and consented to have the
interpreter present, it was difficult to discuss any concerns
or alternatives as the interpreter was the only one available
and required at all times.
Outcomes
After RITH services, Gloria reported that the program was
“very helpful” and she showed improvement across a range
of articulation and phonation measures. Gloria, her family,
and the interpreter also reported improved speech
intelligibility in Kissi. Gloria’s swallowing also improved with
more prompt swallowing, no signs of aspiration, and a
return to a normal diet and fluids. As non-English-speaking
patients who have dysarthria may need help to access
services (Enderby et al., 2009), the speech pathologist, with
Gloria’s permission, contacted Gloria’s English teachers and
provided information about dysarthria and strategies to
assist Gloria in the classroom. Gloria has now finished
outpatient therapy and has returned to her English lessons
where she is reportedly making good progress.
service, Gloria reported that three weeks of home visiting
therapy was not long enough. After Gloria had attended
outpatient therapy, she again reported that she would have
preferred to have had ongoing therapy at home rather
than as an inpatient or as an outpatient. This may be
due to a more culturally appropriate context, with greater
communication opportunities between her family and the
speech pathologist or simply perhaps convenience.
Cultural differences with learning
Liberian refugees may need encouragement to become
active participants in formal education, such as checking on
homework, as this was not common in Liberian education
even before the civil wars (Schmidt, 2009). Gloria appeared
to dislike being asked how much home practice she had
done or what she had practised. This made it difficult for
the speech pathologist to check the frequency, accuracy of
home practice, and use of techniques. We can assume that
Gloria had limited exposure to schooling, as formal
education was not introduced until the late 1950s and was
very limited (Schmidt, 2009). Many adult Liberians learn
orally rather than through writing and are more accustomed
to memorisation rather than through asking questions
(Schmidt, 2009). Gloria could not read or write proficiently
in Kissi or English and had difficulties remembering
exercises and practising on her own. Home practice
therefore relied on diagrams and memorisation of exercises.
Some paper-based home exercises were written in English
and were interpreted by Gloria’s granddaughter.
Developing rapport
As the Kissi are very age-oriented and tribes are dominated
and led by the elderly (Sherman, 2011), in retrospect, it may
have been preferable for Gloria to have been treated by an
age-matched speech pathologist. Initially, Gloria did not
react to non-verbal attempts by the speech pathologist to
build rapport. Gloria used reduced eye contact and
mumbled responses with the speech pathologist which
seemed in contrast to the naturalness of communication
between Gloria and the interpreter. This could be partly
explained by the need to speak through an interpreter but
more probably due to a lack of familiarity and because of
cultural differences. Liberian refugees have often had a
prolonged refugee experience and have learned to be “on
guard”, thus requiring more time to develop trust (Schmidt,
2009). As rapport with both patient and interpreter has a
significant effect on assessment (Clark 1998), the speech
pathologist provided extra education and rationales for
exercises, quickly followed up on the provision of resources
as promised, frequently reviewed goals, and set up regular
appointment times. The speech pathologist also changed
her dress for the visits, adding a colourful scarf to mirror
Gloria’s brightly coloured traditional clothing and head
scarves. Kissi social greetings were learned by the speech
pathologist and gestures were used regularly to enhance
communication and rapport. Gradually, Gloria appeared
more comfortable with the speech pathologist and they
were able to laugh together in a similar manner to the
relationship Gloria had with the interpreter. Gloria’s
confidence in participating in therapy improved from 6/10
pre therapy to 8/10 post therapy when using a self-rated
scale. This may suggest that by developing rapport and
trust, the confidence in speech therapy of a patient with
LEP can improve over a short period of time.