JCPSLP November 2017

Supporting social, emotional and mental health and well-being: Roles of speech-language pathologists

What’s the evidence? Speech-language pathology intervention to improve the social communication skills of individuals with schizophrenia Mary Woodward and Kirsten McCosker

Clinical scenario Ellie has been working as a speech-language pathologist (SLP) for three years, and has just taken her first position in an adult psychiatric hospital. She has received a referral to assist with communication with a patient, Mark, a 29-year- old man with schizophrenia. Mark has had multiple hospital admissions and has been in his current hospital for seven months. Ellie has met Mark and observed that when trying to have a conversation he stands very close to the other person, makes minimal eye contact and facial expression, and talks at length about topics which are difficult to follow. He is easily distracted and often does not answer questions accurately but he seems to focus better when looking at pictures. He often mumbles or shouts even when there is no-one in the room with him, and laughs at unknown stimuli. Nursing staff are finding it extremely difficult to communicate effectively with him. Response Ellie takes Mark’s case to supervision with Lucy, who has been working as a SLP in mental health for over 10 years. Ellie wonders what impact speech-language pathology might have for Mark and his treating team, and what aspect of his communication she might prioritise for intervention. Ellie and Lucy discuss the three components of evidence- based practice (research evidence, clinical experience/data, and informed client choice/preferences). Ellie poses the following clinical questions: • can speech-language pathology intervention improve the social communication skills of people with schizophrenia? • if so, what are the recommended methods of intervention? Lucy discusses her own experiences and outcomes with patients with similar presentations. She tells Ellie about the successful outcomes she has seen in social communication groups she has run previously in several of the mental health wards, with individualised treatment targets for each patient, as well as the 1:1 therapy she has offered to those who were unable to benefit fully from group intervention. She explains that in her clinical experience, she has seen a positive impact for many of her patients, and for their families/carers, but that progress is more modest when a patient has had limited insight into their difficulties and/or motivation to modify their communication. Lucy suggests that Ellie attempt to obtain Mark’s views about his own communication and possible treatment goals using the

Talking Mats® approach which provides a non-verbal means of expressing opinion and choice and has been used with a wide range of individuals including those with intellectual disability (Cameron & Murphy, 2002), mental health difficulties (Macer & Fox, 2010), dementia (Murphy, Gray, van Achterberg, Wyke, & Cox, 2010) or those in custody (Boardman, Crichton & Butterworth, 2016). Talking Mats® has also been widely used to enable individuals with communication difficulties to engage in goal-setting (Bornman & Murphy, 2006; Murphy & Boa, 2012). Lucy and Ellie discuss what is known about the communication skills and deficits of those with schizophrenia, including considering published research papers they have already read. They know that it is well- established in mental health literature that communication impairment is a core diagnostic feature of schizophrenia and other psychotic disorders (Boudewyn et al., 2017; Colle, Angeleri, Vallana, Sacco, Bara, & Bosco, 2013; Marini et al., 2008). Much of the literature related to this topic aims to identify the neurological mechanisms underlying what is often described as the semantically and syntactically “disorganised” verbal output of people with schizophrenia. This communication disturbance suggests a verbal manifestation of formal thought disorder (Ayer et al., 2016); however, it is unclear whether this is caused by higher level semantic processing deficits (Dwyer, 2014), linguistic sequencing deficits (Docherty, 2005) or is related to social cognitive impairment (Docherty, McCleery, Divilbliss,Schumann, Moe & Shakeel, 2013). Lucy and Ellie discuss the fact that, in addition to language difficulties, people with schizophrenia, as in Mark’s case, overwhelmingly present with significant pragmatic deficits i.e., difficulties with the social and contextual use of interpersonal communication. This may include difficulties with conversational turn- taking, understanding or using appropriate non-verbal communication, relevant and appropriate topic choice and maintenance, use of appropriate social register, extent of verbal elaboration in conversation and difficulty considering and estimating a listener’s level of prior knowledge. Mazza, Di Michele, Pollice, Roncone, and Casacchia (2008) and Langdon, Coltheart, Ward, and Catts (2002) refer to deficits in theory of mind (ToM) as the ultimate cause of pragmatic language deficits in people with schizophrenia. Whatever the cause, communication difficulties undoubtedly impact significantly on the functionality and quality of life of people with schizophrenia (Bambini et al., 2016; Tan, Thomas, & Rossell, 2014).

Mary Woodward (top) and Kirsten McCosker

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JCPSLP Volume 19, Number 3 2017

www.speechpathologyaustralia.org.au

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