Hungry Like The Wolf: How I help adult clients decide on speech therapy goals that matter (to them)

And now for something completely different.

Sometimes you read a research paper that blows your mind and changes your whole clinical approach to helping people with communication problems. In this article, I share my thoughts on one such paper that forced me to reconsider how best to support my adult clients set and achieve their goals.

Clients are people; people have lots of roles but one identity 

Most adults have many roles, including:

• their occupation (e.g. teacher, electrician, artist, lawyer, doctor, stay-at-home Dad);
• social relationships (e.g. husband, wife, partner, father, mother, daughter, son, sibling, friend);
• community membership (e.g. volunteers);
• hobbies (e.g. running, football, netball, music, collections); and
• memberships (e.g. churches, clubs).

But people are more than a collection of the roles they play. Each of us has an identity – a sense of self that provides a sense of continuity in life across different activities (Unrig et al., 2002). My identity allows me to experience the world and events through a relatively constant lens of “me”. My identity plays a big role in what motivates me to get up and work and to spend time with my family (Deci & Ryan, 2000). It helps me decide whether a given goal is something I want to pursue or not.

Serious brain injuries and illnesses can shatter your identity

For adults with a communication disability caused by an external event, e.g. a traumatic brain injury, stroke or Parkinson’s Disease, a loss of identity can be a serious obstacle to rehabilitation. An adult’s identity can be shaken by the effects of an injury or serious illness on an adult’s abilities and roles (Biderman et al., 2006), especially if the injury or illness affects those parts of the brain associated with identity. If a speech therapy plan clashes with a client’s sense of identity, or if the client’s sense of identity is disordered, speech therapy is likely to be ineffective (at best) or counterproductive (at worst).

Coping: negative and positive attitudes to bad events

To cope with the ups and downs of life, we all tell ourselves stories, often reinforcing our sense of identity. A positive self-concept is strongly correlated with quality of life for people who’ve had a serious injury (e.g. Vickery et al., 2005).

People who tend to cope better with serious negative events like brain injuries or strokes, tell themselves more positive stories (Nochi, 2000), e.g.:

These are all themes health workers like speech pathologists can help reinforce.

Some adults who have had a major setback like a brain injury become fixated on who they once were, what they could once do and what might have been. Traditional impairment-based therapy for people in this camp can backfire, constantly reminding the client of what has been lost. Understandably, impairment-based therapy for clients who see themselves as “damaged goods” can foster resentment, anger, resistance, negative attitudes to therapy, and even depression. Many adults in this position may need help first to reconstruct their identities post-injury (Klinger, 2005).

Positive goal setting for adults with acquired communication problems

Most human behaviour is goal-directed, and most of us strive towards multiple goals at once. Progress or failure in achieving a goal affects most of us emotionally, and can affect our motivation, and mental state. Our attitude is important to achieving goals, as is controlling our thoughts, emotions and behaviour as we pursue goals (Locke & Latham, 1990).

Helping individuals understand their strengths and weaknesses post-injury is a critical part of rehabilitation. Unawareness and denial (common for people who have had a serious brain injury) can be tackled by helping people build or rebuild their identities. One way of doing this is through a process called “metaphoric identity mapping”.

How metaphoric identity mapping works

In simple terms, speech pathologists and others work with the client to identity a personally meaningful “metaphoric centre” for their identity. This may be a personal hero (e.g. a sports star, musician, philosopher, or even a wild or mythical animal) that can then act as a symbol or image to unify a client’s personal goals and priorities. Meaningful tasks and activities using strategies consistent with the positive “hero” identity (e.g. Petrel et al., 2005).

Identity mapping can be used for different purposes in therapy:

• getting to know each other and building a good working relationship;
• to give the client a way of expressing values, goals, and preferred action strategies;
• to give the rehabilitation team (e.g. doctors, nurses, physiotherapists, occupational therapists and speech pathologists) a common language to use when coordinating goals with the client;
• to set goals that are both meaningful and realistic, and internally consistent and coherent;
• to help the client overcome his/her own resistance or other obstacles to action or therapy; and
• (with the involvement of psychologists) to assist with formal psychological interventions such as cognitive behaviour therapies.

Key steps in identity mapping:

• talk with the client about desirable activities and identify someone admired by the client, possibly associated with such activities (e.g. sports, movies, music, business, politics, religion, etc.);
• discuss important facts about the hero’s life and associate with the client’s life (e.g. struggle, set-backs, endurance through adversity);
• talk about associations with being the hero (e.g. how would you look, dress, behave, where would you go, etc.);
• talk with the client about goals associated with being like the person;
• talk with the client about how he/she would feel if able to achieve the goals; and
• talk with the client about actions and action strategies necessary or useful to pursue the goals.

What the research says

Key themes about identity mapping identified in the key study supporting it (citation below) are as follows:

• clients and clinicians find the process acceptable;
• mapping is useful for engaging clients in identifying goals that matter to them;
• clients and clinicians recognise the value of setting client-centred goals;
• serious brain injuries may make the process harder, e.g. thinking through characteristics of their hero in detail, or remembering their identity map; and
• identity mapping requires a significant “mind shift” for clinicians as well as clinical skills that not all clinicians have. It can push us out of our comfort zones!

In this non-experimental, qualitative study, all five clients successfully set goals, and four of the five clients achieved them.

Personal reflection on why I like identity mapping and my experiences with it to date

I’m a story-teller and the process of thinking through goal setting metaphorically comes fairly naturally to me as a clinician. My background in law and business has exposed me to similar concepts in other fields, e.g. developing so-called “avatars” of target clients as part of marketing and sales efforts.

To date, I’ve used elements of the process to develop detailed goals with clients with very different communication needs including:

• clients with Parkinson’s Disease looking to increase the volume of their speech through LSVT LOUD;
• a client undertaking therapy to control his rate of speech for business meetings;
• a young client who stutters, who had relapsed after several years of stuttering therapy;
• a client with Down Syndrome looking to improve his presentation skills for public advocacy work; and
• a client undertaking accent modification training to improve his intelligibility and ability to communicate professionally with native speakers of English.

Generally, clients have reported satisfaction with their goal selection. Consistent with the research, however, identity mapping has its challenges, including time and effort required to read up on client “heroes” I’d never heard of, and staying on track and task when a client’s choice of personal hero was someone controversial with several negative traits.

I would not necessarily use the technique for clients with pure motor speech disorders like apraxia of speech, dysarthria or voice disorders because the use of metaphor and visualisation don’t necessarily sit well with principles of motor learning; although, as noted above, I have used it as a planning tool to clarify goals for some clients with motor speech or voice issues.

Clinical bottom line

Although challenging at times, metaphoric identity mapping can help with setting client-centred goals for adults with communication problems. It focuses discussion on outcomes and activities that are personally meaningful for the client. It can also help speech pathologists and other health professionals co-ordinate their care for a client by giving us a consistent symbol and language to discuss and measure progress with.

Clients with very serious brain injuries may find the process challenging; and clinicians may find themselves working outside their comfort zones. But, for many clients, identity mapping can help re-establish a positive working relationship with their therapist and a sense of personal identity that can help engage and motivate clients to pursue their work and life goals.

Related articles:

• How to assess and treat people for communication problems caused by brain injuries

Principal source: Ylvisaker, M., McPherson, K., Kayes, N., & Pallet, E. (2008). Metaphoric identity mapping: facilitation goal setting and engagement in rehabilitation after traumatic brain injury. Neuropsychological Rehabilitation, 18, 713-741.

Image: http://tinyurl.com/j667o3z

Hi there, I’m David Kinnane.

Principal Speech Pathologist, Banter Speech & Language

Our talented team of certified practising speech pathologists provide unhurried, personalised and evidence-based speech pathology care to children and adults in the Inner West of Sydney and beyond, both in our clinic and via telehealth.

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