Whose voice is it anyway? Hushing and hearing ‘voices’ in speech and language therapy interactions with people with chronic schizophrenia

Abstract

Some people with schizophrenia are considered to have communication difficulties because of concomitant language impairment and/or because of suppressed or 'unusual' communication skills due to the often-chronic nature and manifestation of the illness process. Conversations with a person with schizophrenia pose many pragmatic challenges as they may include delusional talk or hallucinatory references considered irrelevant or inappropriate to ongoing conversation. Yet delusional talk and references to hallucinations are often an intrinsic part of the overall presentation in people with schizophrenia. The speech and language therapist (SLT) must be aware of the influence and function of these pragmatic challenges in therapeutic interactions with this client group. One way of increasing this awareness in this context is through an exploration of co-constructed 'voices' in speech and language therapy (SLT) interactions. This paper aims to explore the 'voices' in speech and language therapy interactions with clients with schizophrenia. Identifying and revealing voices as constructed or negotiated by participants should help to illuminate the construction of meaning and the nature of the therapeutic interaction in this context. The analysis of conversations between people with schizophrenia, a speech and language therapist, and speech and language therapy students during clinical sessions reveals 'voices' being aired in the interactions. These voices, described primarily as 'the voice of speech and language therapy' and 'the voice of the lived experience of schizophrenia', are jointly constructed and 'heard' to greater or lesser extents depending on the context of the interaction. The analysis illustrates that whereas the speech and language therapist's primary agenda is actively to engage the client in conversational interaction for assessment and therapeutic purposes (i.e. the voice of speech and language therapy), this is sometimes (but not always) at the cost of hushing other talk. This is especially the case when the talk is delusional and seemingly inappropriate within the clinician-defined agenda. However, talk about the nature of the illness (and in particular hallucinations) and the potential impact on communication is compatible with the clinician's agenda and allowed to proceed. Therefore, the voice of the lived experience of schizophrenia is silenced within delusional talk, yet heard in talk about hallucinatory experiences and communication difficulties. It will be shown how these voices interact to illuminate the participants' agendas and define the therapeutic interaction in this context; that is to say, the therapist manipulates talk that fails to conform to specific speech and language therapy goals, preferring to promote and encourage agenda-relevant talk. The analysis shows that the voice of SLT and the voice of the lived experience of schizophrenia are heard to greater or lesser extents, as determined by the context and content of the talk-in-interaction. However, the voice of SLT must blend with, rather than hush, the plurality of voices that characterise therapeutic interactions. An increased awareness of competing voices, as they struggle to be heard in SLT interactions, may prompt therapists to consider and evaluate their often agenda-driven influence on the unfolding interactions we call 'therapy'.