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Walking with Dobermanns (part 1)

In this first of two articles inspired by the late Dr Mark Ylvisaker, Sam Simpson, Emma Gale and Ashleigh Denman reflect on the impact his ideas have had on their practice with people with brain injury, and the promise they hold for other difficult-to-serve client groups. With the help of her client PJ, Sam Simpson then goes on to demonstrate why Ylvisakers concept of identity mapping is central to true rehabilitation.
en years ago, speech and language therapists working with adults with acquired brain injury faced a dilemma. Intervention for this client group had a poor evidence base, with evidence on efficacy limited to speech and language diagnoses found more commonly in stroke (aphasia, dysarthria, right hemisphere language disorder, dysphagia) or learning disability (social skills), and there were few assessments tailored to the needs of people with brain injury. There was a paucity of evidence or discussion of the real issues clinicians in brain injury rehabilitation faced. As a result, many of us struggled with the legitimacy of our treatment approaches, in addition to difficulty engaging clients with a brain injury in a rehabilitation process designed for people who had had a stroke. The key clinical issues for us included communication difficulties falling under the umbrella of cognitive communication disorder, as well as more general social interaction impairments like reduced awareness of listener needs, reduced turn taking and poor inference and social inferencing skills. We also encountered impairments of insight and self-regulation, which often manifest as challenging behaviour and are more commonly seen as the province of clinical psychology. The models used by our multidisciplinary team colleagues - such as errorless learning theories, awareness and insight - also challenged us to find a firm theoretical basis for speech and language therapy intervention. It was in this context that we first came across the work of Mark Ylvisaker and his clinical psychologist colleague, Timothy Feeney, in a special brain injury edition of Aphasiology (Ylvisaker & Feeney, 2000a). For the three of us, these articles were a revelation. They told a story of dobermanns and poodles to differentiate between the two kinds of clients who typically access brain injury rehabilitation services. Poodles described clients who turn up on time, carry
READ THIS IF YOU WORK WITH CLIENTS WHO STRUGGLE WITH BEHAVIOURAL REGULATION IDENTITY RECONSTRUCTION IDENTIFYING MOTIVATING PERSONAL GOALS

Ashleigh, Sam and Emma

In memory of Mark Ylvisaker Dr. Mark Ylvisaker was Professor of Communication Sciences and Disorders, College of Saint Rose, Albany, New York, USA from 1990 until his death in May 2009. He worked with children and adults with cognitive, communication and behavioural disability for over 30 years in rehabilitation, special education, and community settings. He originally studied and taught philosophy before becoming a speech-language pathologist. He published extensively and served as consultant to a number of state, federal and international projects dealing with brain injury in children and adults. He also helped develop materials for educators, clinicians and parents, and was the primary contributor to the LEARNet web site www.bianys.org/learnet. Mark was delighted to hear about our forthcoming articles and had hoped to add his comments, but sadly this was not to be. out self-directed work and show gratitude for our hard work. In contrast, dobermanns are oppositional, unreliable, insightless and antiauthority, often exhibiting behaviour that is difficult to manage in rehabilitation settings and even less acceptable in the community. In short, the article described many of our clients, who often have a post-injury history of alcohol or drug misuse, with oppositional or anti-social behaviour, and who struggle to access traditional brain injury services. Ylvisaker and Feeney turned our traditional model of speech and language therapy intervention on its head. They highlighted the importance of engaging this difficult-to-serve group of clients, involving them in the goal setting process and finding out what motivates them. In addition to describing their programme, they were able to demonstrate how the outcomes improved the quality of life of their clients and reduced the cost to the state of their support longer-term. They proposed models

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of working which have helped to develop a practical, holistic, integrative approach to brain injury rehabilitation, based on sound theoretical models. They have since applied these to other adult and paediatric client groups who demonstrate self-regulatory impairments, such as those with attention deficit/hyperactivity disorder or autism, with significant success. In the intervening years, the work of Mark Ylvisaker and Tim Feeney has been adopted widely by speech and language therapists and clinical psychologists working in the field of brain injury. All three of us have attended conferences and study days Ylvisaker has run here in the UK on his many trips since he was first invited over by the Speech and Language Therapy Head Injury Specific Interest Group in 2003. Ylvisakers work highlights two competing models for rehabilitation (Ylvisaker et al.,1999). The traditional model is hierarchical, with a clear progression from work at the level of impairment, through activity, to a later focus on participation. The alternative model proposed by Ylvisaker reverses this traditional hierarchy (figure 1). Using this alternative model Ylvisaker has developed a range of interventions focusing on goal setting, group and individual project work, use of metaphor and identity mapping. Our second article in the Winter 09 issue will focus on project work, with Emma Gale detailing how she has applied this to groups in a rehabilitation setting and Ashleigh Denman describing some of the projects her individual clients have worked towards in the community. In the rest of this first article, Sam Simpson describes how she has put Ylvisakers ideas about identity reconstruction into practice with a recent client. been identified as a critical theme in outcome studies of severe brain injury and an obstacle to active engagement in rehabilitation. Ylvisaker thus positions identity reconstruction as central to rehabilitation. He argues that, unless there is a strong correlation between an individuals rehabilitation goals and sense of personal identity, rehabilitation efforts are at best likely to be ineffective and at worst counter-productive in that negative attitudes to disability and rehabilitation can be escalated. (Ylvisaker et al., 2008). With this in mind, Ylvisaker proposes a process of identity-oriented goal negotiation, which he terms identity mapping, as a means of coaching the development of a new life narrative. Identity mapping aims explicitly to assist individuals after a brain injury to construct an organised and compelling sense of personal identity through the use of metaphor. In brief the approach involves the use of a visual map (figure 2) and a central metaphorical figure or concept to elicit what is important to an individual. This acts as a platform to identify rehabilitation goals. Figure 2 Visual map The original literature gives a full account of the theoretical underpinnings of this approach (Yvisaker & Feeney, 2000b; Ylvisaker et al., 2008). For the purposes of this article, I aim to illustrate how I have recently applied the use of identity mapping and metaphor practically in my work with PJ, a 23 year-old man with a traumatic brain injury. In truth, my initial application of this approach was a somewhat chance event. I chose to experiment with identity mapping in direct response to metaphors PJ brought to therapy two weeks after my having attended an Ylvisaker study day. Little did I know the impact that identity mapping was to have on both my client and my subsequent clinical practice. PJ had his brain injury at the age of 18 when he was on the cusp of becoming a professional sportsman. Whilst in many respects his rehabilitation had been successful PJ was living back at home with his family, had a manual job and socialised regularly with old friends five years on, he was now grappling with questions about his future. He and his family had initiated access to independent speech and language therapy / counselling as PJ was reporting reduced confidence in group and novel social situations, which was impacting on his community access and social life. PJ reported significant feelings of despondency at this time, having no purpose and direction in life, feeling frequently bored and drinking heavily. The conversation that triggered the use of identity mapping related to PJs having re-watched the film Forrest Gump and having identified strongly with the character of Lieutenant Dan (see www.imdb.com/character/ ch0002105/bio for more information). The film had made such an impression on him that he was keen to explore why and so we constructed the identity map in figure 3 in response to this curiosity.

Identity reconstruction

Difficulty re-establishing an organised and compelling sense of personal identity has Figure 1 Models of rehabilitation Traditional model of rehabilitation Identify underlying impairments and disabilities, with less focus on participation. Focus on eliminating or reducing underlying impairments with restorative or training exercises. Compensatory strategies used if impairment persists. Later shift in focus to context and environmental compensations if activity and participation reduction persists. Ylvisaker model of rehabilitation Identify what is working/not working for the individual in everyday routines (that is, at a participation level). Identify potential to change negative routines into positive routines and build repertoires of successful behaviour, through changing activities, the environment, the support of others or the individuals own behaviour. Identify motivational sources for the individual. Facilitate intensive practice of positive routines in real-world contexts, to promote successful participation in meaningful activities, habituation of positive behaviours and the internalisation of strategic behaviours. Systematically withdraw supports. Ongoing review to consider re-introduction of supports according to fluctuation in life stressors.

Figure 3 PJs identity map

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The development of this identity map enabled PJ to talk openly for the first time about his struggle to re-construct a new robust personal identity since his injury. In addition it enabled him to reflect on and make sense of his drinking and increased anger dyscontrol at home. In relation to this, we constructed a second identity map capturing his fears about following the same path as an older relative this map has not been included here at PJs request. Whilst Ylvisaker tends to focus on positive identity maps, the process of isolating and elaborating particular features of this feared self enabled PJ to explore his fears openly. PJ subsequently chose to show these two maps to his family, thereby opening up discussions about the inner turmoil he was experiencing and the behaviours that he was very aware were impacting heavily on his family. PJ was enthusiastic about the process of identity mapping and reported specifically finding it helpful to organise muddled thoughts and get what was going on in my head down on paper in a clear way, as he felt that none of it had previously made any sense. He was also expressing his readiness for change (Prochaska & DiClemente, 1986), so we negotiated trialing identity mapping to elaborate specifically on his hoped-for self (figure 4). Whilst PJ was unable to identify an overarching metaphor (such as the original Lieutenant Dan one) that encapsulated all of the qualities and activities of his hoped-for self as recommended by Ylvisaker et al. (2008), he was nevertheless able to work with the concept of me as I would like to be as an integrated representation of the changes he would like to make. The very process of constructing this identity map served to give form, meaning, organisation and direction to his hopes and aspirations. The different dimensions were reported to be particularly helpful in breaking down the whole into more tangible and manageable parts - I could think about how I want to be, what I want to do and where I could find these things then I could pick what bit I wanted to look at and change. Writing the map down and having a permanent record also proved critical to the process everything became a reality once Id written it down something to aim for getting them written down made a valid point of me doing it. increased physical exercise, a healthy eating programme and exploration of further study options with the support of his family. PJs engagement in the rehabilitation process has increased considerably with him now taking a lead in directing the focus of therapy and accessing the support he wants as and when he determines it to be relevant and timely. PJ prioritised the overarching goal of returning to study. He consequently identified and signed up for a two year part-time National Diploma in Sport which commenced in September 2008. At the time of writing, he has just completed the second term of his first year. We recently reviewed the identity map in figure 4 as a means of tracking change. PJ reported finding it particularly helpful to have a clear, personally meaningful and selfdetermined mechanism to evaluate the many changes that have taken place over the past 12 months. It also enabled him to see the interconnections between the changes that he has made. For example, by starting college he now has a more natural structure to his week, has met many new people and made new friendships. This initial encounter with identity mapping has been highly formative for me. Having initially worked with PJ on developing his selfawareness, interaction skills and confidence in both one-to-one and group settings, identity mapping has enhanced goal negotiation and engagement to promote the generalisation of knowledge and skills into real-life meaningful contexts. Ylvisaker et al. (2008) propose a range of applications, as detailed in figure 5 below. I now regularly use identity maps as a means of better establishing rapport, getting a more integrated picture of my clients and negotiating personally meaningful goals. I also use more metaphors to assist clients to self-cue (for example, how would I approach this as Lieutenant Dan? As me as I would like to be?). Finally, as a trainee counsellor, I increasingly use it as a scaffold and springboard to exploring underlying feelings and emotional responses. We strongly believe identity mapping is an approach relevant to therapists working in many fields with clients of all ages. At the very least we hope this article inspires you to read

Intrinsically motivational

Thus the map became intrinsically motivational. This was evidenced by the many selfinitiated changes in behaviour that accompanied and followed the actual construction of the map, including a reduction in drinking,

Above: Figure 4 PJs hoped-for-self Right: Figure 5 Identity mapping and metaphors: a continuum (Ylvisaker et al., 2008)

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more about Ylvisakers work and at most that it promotes the cross-fertilisation of his ideas into other areas of clinical specialism through prompting you to consider how they might be applied to your work. Sam Simpson is a specialist speech and language therapist and trainee counsellor at intandem (www.intandem.co.uk), e-mail sam@intandem. co.uk. Ashleigh Denman is principal lead speech and language therapist with the Gloucestershire Brain Injury Team, e-mail Ashleigh.denman@glos. nhs.uk, while Emma Gale is clinical lead speech and language therapist at the Royal Hospital for Neurodisability in London, e-mail egale@rhn.org.uk. Part 2 of this article will be in the Winter 09 issue. Acknowledgement Our thanks to PJ for the courage he has shown and the teaching he has provided. SLTP References Prochaska, J.O. & DiClemente, C.C. (1986) Towards a comprehensive model of change, in Miller, W. & Heather N. Treating Addictive Behaviours. New York: Plenum Press, pp.3-27. Ylvisaker, M., Feeney, J. & Feeney, T. (1999) An everyday approach to long-term rehabilitation after traumatic brain injury, in Cornett, B. (ed.) Clinical practice management in speechlanguage pathology: Principles and practicalities. Gaithersburg, MD: Aspen Publishing Co., pp.117-162. Ylvisaker, M. & Feeney, T. (2000a) Reflections on Dobermanns, poodles and social rehabilitation for difficult-to-serve individuals with traumatic brain injury, Aphasiology 14(4), pp.407-431. Ylvisaker, M. & Feeney, T. (2000b) Construction of identity after traumatic brain injury, Brain Impairment, 1, pp.12-28. Ylvisaker, M., Mcpherson K., Kayes, N. & Pellet, E. (2008) Metaphoric identity mapping: Facilitating goal setting and engagement in rehabilitation after traumatic brain injury, Neuropsychological Rehabilitation, 18(5), pp.713-741.

Resources

Access Scottish Theatre lists forthcoming accessible performances in Scotland. An update service by e-bulletin is available. www.scottishtheatres.com/accessguide.php. The government has published revised guidance for practitioners and managers on sharing information legally and professionally with professionals working in different sectors such as education and health. www.everychildmatters.gov.uk/ informationsharing In What Makes My Family Stronger Contact a Family reports on the experiences of families in 2009 with disabled children. Over 60 per cent said they didnt feel listened to by professionals, and wanted their expertise to be acknowledged. www.cafamily.org.uk/pdfs/wmmfs.pdf Quality standards in vision care for deaf children and young people: Guidelines for professionals from Sense and the National Deaf Childrens Society seek to ensure that deaf children receive good vision care. Forty per cent of children who are born deaf also have eye problems. www.sense.org.uk The website of a multidisciplinary team of therapists in San Francisco includes photographs from a 10 day volunteer venture in the Dominican Republic. www.therapista.net/dominican/ Projects Abroad organises overseas volunteer work placements for gap years and career breaks in areas including healthcare and education. A recent scheme has focused on providing opportunities to out of work graduates. www.projects-abroad.co.uk/ A lecturer blogs about a 6 week project at an orphanage in Bethlehem teaching staff to use music with Palestinian children who suffer from extreme anxiety and abandonment issues. http://creativetherapiesnewport.blogspot.com/ Christian Heilmann has developed ways to make popular social networking tools You Tube, Flickr and SlideShare easier for children and people with learning disabilities to access. (Source: AbilityNet, www.abilitynet.org.uk.) http://icant.co.uk/easy-youtube/docs/index.html http://icant.co.uk/easy-flickr/ www.wait-till-i.com/2008/06/22/easy-slideshare/ Vocal Processs e-zine 37 includes front foot, back foot advice from Jeremy Fisher for changing the energy and emotional flow. Intended for performers, it may also be of interest to some speech and language therapy clients. www.vocalprocess.co.uk/resources_1.htm

CHANGE has developed accessible resources for parents who have difficulty reading and understanding information. www.changepeople.co.uk/catalogue. php?type=3 The latest research document in the I CAN Talk series is on Speech, Language and Communication Needs and the Early Years. The link also includes free resources to raise awareness of communication development and how to promote it. www.ican.org.uk/sitecore/content/Home/ Resources.aspx Scopes Campaigns Officer Jamie Robertson is the central figure in a Five News video investigating access to shops and transport in London for people who use a wheelchair. www.fivetvonline.tv/news. php?news=1840&dm_i=6J4,1HGJ,Q08EJ,4H8B,1 YoungMinds Very Important Kids (VIK) is a national panel of young people with mental health problems. Their manifesto with accompanying film and petition encourages change to improve young peoples mental health. www.youngminds.org.uk Crick Software has created free Clicker activities to support and reinforce messages about online safety for children with special needs as part of the Know IT All for Primary Schools project. www.LearningGrids.com; www.childnet-int. org/KIA/primary/ Connectors, a new reading scheme for 7-11 year olds from Scholastic, aims to develop comprehension strategies through speaking and listening. http://shop.scholastic.co.uk/series/599 The Social Market Foundation report From feast to famine: reforming the NHS for an age of austerity includes discussion around managing demand. www.smf.co.uk/assets/files/Health%20Report% 20From%20Feast%20to%20Famine.pdf New Local Government is a not-for-profit independent think tank which seeks to transform public services. Recent activities include lobbying the government to ensure people in their 20s and 30s think about saving now to cover their future health and social care needs. www.nlgn.org.uk A specialist dyslexia teacher and a teacher and mother of a boy with dyslexia have joined forces to produce a system of teaching and learning materials for adults to use with children who find reading, spelling and handwriting difficult. www.dyslexikit.co.uk (Source: www.wordswell.co.uk newsletter)

REFLECTIONS AM I READY TO TURN TRADITIONAL APPROACHES ON THEIR HEAD IF AN ALTERNATIVE BUT THEORETICALLY GROUNDED PRACTICE EMERGES? DO I CONSIDER THE ROLE OF PERSONAL IDENTITY IN GOAL SETTING AND OUTCOME? DO I SEEK WAYS TO GIVE FORM, MEANING, ORGANISATION AND DIRECTION TO THE HOPES AND ASPIRATIONS OF MY CLIENTS?
Do you wish to comment on the impact this article has had on you? Please see the information about Speech & Language Therapy in Practices Critical Friends at www.speechmag.com/About/Friends.

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