Sharing Therapy Moments

I had a couple of very lovely 'therapy moments' today. I am really enjoying my placement - working with adults with communication problems has been very rewarding. 

 

Lovely moment 1. I see a patient with Multiple Sclerosis every day to work on improving her voice quality and self-monitoring of her understanding. She's about 60 and had MS for 40 years of her life. She is such a pleasure to work with - always engaged and motivated during therapy. No matter how tired she is or if she had a bad day, she would always want to do work with me. A dream patient! Well, today she reported that she has been feeling a lot more confident as a communicator and finds that her speech is getting clearer. She said she had a wonderful conversation with the other patients in her room yesterday and not once did any one of them asked her to speak louder or to repeat because she wasn't intelligible, which were frequently what her listeners had to do before we started our therapy. She said she felt good to be part of the conversation and was pleased that she remembered the strategies we've been working on and how well they've worked. 

I am most certainly not saying that I'm a miracle worker here. This lady's progress is because she has been so 'switched on' throughout the therapy process, making the effort to work on her homework everyday. Such engagement and motivation are key factors for good prognosis during any therapy. 

Lovely moment 2. With a lady with Vascular Dementia. She's 80 years old. Bless her. She also has a gamut of many other medical difficulties. I am currently doing assessments on her to find out what her swallowing and speech difficulties are. Saw her once before and we didn't hit off on a particularly great start. She was a bit agitated and didn't really want to do much with me.

But you need to understand that her behavioural difficulties are partly due to her medical conditions, and not completely due to her trying to be a 'difficult patient'. This is something that not many people comprehend. People who have brain lesions, injury or trauma at the cerebral frontal lobes or at the right hemisphere are likely to exhibit behavioural and cognitive impairments. This second time, I prepared myself that I might need to negotiate with her because I aimed to complete all my assessments. She was great in terms of agreeing to do them with me. During the assessments, she kept saying 'I can't do it' and pushed the booklet away. We had a very good chat at various times and talked about how she feels about her communication. Apparently she feels she can't communicate as she used to and people often say they "don't understand what she is saying". Her awareness that her condition is deteriorating has been eating her self-esteem and it was now clear to me why she was previously unwilling to engage. While she does have significant cognitive problems, affecting her ability to follow and participate in conversations, but if people can slow down or use more simple language, she can and is able to converse.  All I did was to listen to her and told her to be patient and try to focus on the positives. I think when we get ill, it is only too easy to focus on the negatives. Sometimes, when people are feeling discouraged, what they really need is simply active listening. Well, I did just that and felt very nice that I managed to help make her day a little brighter today. 

 

Doing what I do, I've come to realise that one's identity, self-perception and self-esteem can be so tightly intertwined with one's ability to communicate. I quite like this quote from Schiffin, a social psychologist, "Conversation is a vehicle through which selves, relationships and situations are talked into being." 

Schizophrenia

Just felt like writing a bit on schizophrenia today. I've got a patient on my caseload who had a stroke a couple of months ago and has a history of schizophrenia. Before I studied about this psychiatric illness, I remembered that I used to think it was all about having multiple or split personalities. But it turned out that that was more a myth perpetrated by the media than the truth. Schizo is actually more accurately defined as the splitting of mental functions - a discrepancy between thinking and feeling. The jury is still out as to what causes it but there is probably a genetic link to it and relates to a chemical imbalance in the brain. Many suffer from debilitating hallucinations and delusions which could be firm convictions of what they are perceiving even when you show them evidence that indicate otherwise. 

Check out this video:

http://www.youtube.com/watch?v=H_jYqSA_fJk

There is nothing scary about mental illness. I believe there is a continuum running from 'normal people'  (what is 'normal anyway?) to people who have psychiatric disorders e.g. obsessive compulsive disorder, schizophrenia, personality disorders etc. Interestingly (for me), people with mental disorders do develop speech and language difficulties since their communication with people is often negatively affected. They might even be unable to speak or have severely disorganised speech ('word salads'). Next week, I'm going to try to find time to assess my patient to try to get a reliable yes/no response and to assess his level of understanding. Since his stroke two months ago (which appeared to be quite a serious one), he had no spoken output at all and his level of understanding has been a big question mark for the team. So no one really knows how much he really understands since he can't really gesture or talk. Hope I'll get somewhere with him next week!

Ah! Brits!

I have been reading an interesting book about British behaviour and conversation codes. It tickles me because for the past year and the half, I've experienced all their quirks but was not always quite quick enough to discern their meaning between the lines. Sometimes they annoy me because I don't 'get' precisely what they are saying; but at most times, they leave me with a one of those inexplicable silent smile or smirk. 

1. Brits love irony

Irony means saying the opposite of what you mean. The British may not always do that, but as a non-Brit, you really gotta be alert to the possibility that they will be! I've long learnt to never take what they say at face value. 

E.g. when you ask them a straightforward question such as "How are the children?" Be equally prepared for a straight answer "Fine thanks", and for an ironic one, "They are delightful - charming, helpful, studious, obedient through and through." To which the reply should be, "Oh dear... one of those days aey?"

2. The understatement rule

Apparently, most Brits frown upon earnestness, gushing, boasting, expressive zeal and emotion. (Just remember they are the opposite of Americans!) They would rather feign and go for deadpan indifference or calm understatements. I remembered that I was really grateful to my Phonetics tutor for being such a supportive tutor and was openly expressing my appreciation to her. She ended up looking stony as if I had hit her handbag on her head. There was a very awkward silence. Later my Brit friend said, "Ermm... you just did quite an un-British thing there, which probably embarrassed her [the tutor]... um Brits tend to say 'thank you' with a bit of wry humour and try to keep it understated." Alright then.  

So a debilitating, critical illness may be described as = "a bit of nuisance"

A truly horrific experience = "not exactly what I would have chosen"

A sight of striking beauty = "quite pretty"

An outstanding performance = "not bad"

An act of abominable cruelty = "not very friendly"

An unforgivable stupid misjudgement = "not very clever"

A disgustingly filthy restaurant with unbelievably rude service = "I wouldn't recommend it"

To be able to discern what is between the lines, you really have to watch their facial expressions (especially that raised eyebrow!) and tone of voice. These are the betrayers. Now I know what my classmates mean when they say "I've barely started my revision." Hmm. 

3.  The self-deprecation rule

This goes hand in hand with their tendency to understate. This is customary and is always done so subtly, you really have to catch it when it happens! How many times I must have taken what my friends said at face value and didn't realise that I had completely misinterpreted them! 

Here's a good example from the book: 

So you meet this man and find out he is a brain surgeon. When you ask him why he chose this profession, he might say, "Well, em, I read PPE (Philosophy, Political Science, Economics) at Oxford, but found it all rather beyond me. So er, I thought I'd better do something less difficult."

You laugh (of course), saying that brain surgery surely couldn't be easier. He then quickly enters into another self-deprecation, "Oh no, it's nowhere near as clever as it's cracked up to be. To be honest, it's like plumbing with a microscope - except that plumbing is probably more accurate."

Then when you later find out that he had a scholarship because of first class honours at Oxford, he says, "I was a dreadful little swot." 

The Brits are a quite funny sort, aren't they? 

Finding Hope and Focus

Day 5: Neurological Ward

I am at another placement now. This time - a hospital. I have been observing therapy sessions of my clinician with a lady  who recently suffered from a hemorrhage (vessel bleed) on the right side of her brain. She is a young mother with a 4 year old child. Her hemorrhage is related to other cardiovascular and neurological disorders that she had since young. Very sadly, the part of her brain that is most severely damaged is the hippocampus. (The hippocampus plays a critical role in the storage and encoding of memory.)

As such, she now has severe amnesia which affects the storage of new events in her long term memory. New events that we perceive or experience may be coded into our store of long term memory with the help of the hippocampus if our brains deemed that should be so. This lady would say something and forget that she said it within 5 minutes and repeat it again. She is often disorientated as she can't retain the memory of what she did that morning, what day it is, and what she did during therapy yesterday. This makes learning and recovery difficult. The prognosis for such memory disorders is often poor and it is possible that she may need 24 hours care for some time to come. It is obvious that she used to be a very articulate and intelligent lady before the incident. Like the tide, the memory loss ebbs and flows. The knowledge of this loss may be temporarily forgotten but when the memory of it returns, it hits her hard. And her cycle of grief begins again. How does one get over a grief that refuses to be remembered to be stowed away? 

Neurological (Brain) disorders express themselves in an incredible number of ways. Patients may be diagnosed with multiple sclerosis, traumatic brain injury (e.g. due to car accidents), brain tumors, stroke, meningitis, motor neuron disease, arterial venous malformation, etc. I meet pain and loss at this ward. I sense them sometimes when patients lower their heads down as they pass me, when their smiles betray a brave front, and when a young 30 year old man (with multiple sclerosis) asked me, "So what's it like out there?" The Buddha said suffering is a part of life. Suffering is a language every human being speaks. The Buddha also said cessation of suffering can come with mental discipline (the right mindfulness). But if a person's brain (of which the sense of mind and self originates) is damaged, how might this "right mindfulness" be cultivated in order for suffering to be ceased? 

But you should not think that all's gloom in the ward. I derive immense deep pleasure and learn a lot from supporting, interacting and working with them. Also present and revealed in gentle beautiful ways is beneficence. I meet her when I notice my bed-ridden patient (with a degenerative disease) holding hands with her blind and deaf husband, when I observe the dedication of the therapy team and nursing staff, and when I see the 71 year old mother of a patient sitting by her daughter every single day for hours.

"I find hope in the darkest of days and focus in the brightest. I do not judge the universe." Dalai Lama