ACQ Vol 13 no 3 2011

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.

146

ACQ Volume 13, Number 3 2011

ACQ uiring Knowledge in Speech, Language and Hearing