SLT and mental health

Through adoption of specialist SLT in a mental health setting, significant improvements can be made to behaviours which challenge, and a new understanding of these can be gained by both the patient and clinical team.

Kim Ferrari, Lead Speech and Language Therapist at St Andrew’s Healthcare, discusses how the team’s innovative approach is delivering results

While Speech and Language Therapy (SLT) is widely used and recognised in brain injury rehabilitation, in the very specialist field of mental health work, its adoption remains more limited.

But with statistics showing that around 80 per cent of people in mental health services live with some form of language impairment – and around 30 per cent also have difficulties with their swallow – SLT has vast potential in helping to support this population.

Using SLT to engage with people with a mental health diagnosis in ways that are accessible and appropriate makes the multi- disciplinary approach much more effective in helping to recognise and understand behaviours that challenge and find a way forward.

At St Andrew’s, SLT is integral to its specialist MDT approach.

The mental health charity, based in Northampton, supports people with complex mental health difficulties to overcome their challenges and work towards living as independently as possible.

And through the introduction of an innovative new approach to SLT, St Andrew’s is supporting patients to make new levels of progress.

“As speech and language therapists, we’re uniquely trained to be able to identify communication needs and to be able to support people with communication difficulties to be actively involved in their care and treatment,” says Kim Ferrari, Lead SLT at St Andrew’s.

“At St Andrew’s, we see a lot of behaviours that challenge – but we view behaviour as a form of communication. So, if a person can’t communicate through language, they tend to try to convey their message through behaviours.

“By having SLT as part of the MDT here, we can help to unlock different ways for people to be able to communicate that isn’t going to cause harm to themselves or others – and we are seeing some positive progress in terms of achieving that.”

The importance of SLT in mental health settings

The use of SLT for people with a mental health diagnosis remains much less widely used than in a typical neuro setting, although its adoption is increasing.

But at St Andrew’s, its use is longstanding, and the vital role it can play in delivering new levels of support to patients is something its therapy team are well versed in.

“SLT in mental health is still quite a new concept, but there are clear links between speech, language and communication needs and mental health, which are complex and bi-directional,” says Kim.

“People who have communication needs are more likely to experience mental health difficulties; but equally, people with mental health conditions are more likely to present with communication needs.

“So we’ve got it working both ways, where our patients have either got a history of struggling to communicate, and maybe it has not been flagged at an earlier stage in life, leading to feelings of frustration if they can’t express their emotions to other people, which has then led to mental health difficulties as a result.

“Or we’ve got people with diagnoses like schizophrenia, depression, anxiety, and all of these come with their own communication challenges.”

Many mental health therapies are delivered via verbal means, commonly known as ‘talking therapies’ – but in the delivery of this, naturally those impacted by a difficulty to communicate will struggle to engage effectively or may even be excluded.

“If we look at the level of people in mental health services with some form of language impairment, it’s about 80 per cent, then it is going to affect their ability to engage in that therapy. This is then going to affect their ability to work along a rehab pathway,” says Kim.

“You have a higher risk of readmissions if individuals haven’t engaged in therapy effectively – so it’s really important that we look at ways of providing therapy for people with communication needs in a way that is accessible, to enable them to effectively access the support and services, which will support their recovery.”

Among the root causes for mental health issues is trauma, with people who have had a traumatic background from a young age often finding themselves in specialist settings in later life.

Kim believes these circumstances should also be considered in the delivery of SLT, through the use of a trauma-informed approach to therapy delivery.

“We know that experiencing trauma from a really young age can affect how the brain develops, specifically in regions that are responsible for executive functioning, emotional regulation, and the ability to process language,” says Kim.

“While these individuals are not classed as having a brain injury, they have seen alterations to their brain development based on their history.

“We do need more research in this area to advance our understanding, but trauma is another area in which we, as speech and language therapists, can support people to recognise their own communication profiles and provide them with new ways to communicate to the best of their ability, in an environment that creates safe opportunities to express themselves effectively.”

Swallowing problems can also be acute in mental health settings, and is an area where SLT is key in the MDT’s clinical approach.

“With around 30 per cent of the mental health population having difficulty swallowing as well, that is another role of SLT,” says Kim.

“A lot of the medication people take for mental health conditions can affect the swallow mechanisms, and we also see behaviours around mealtimes that can increase the risk of choking.

“So SLTs are needed in mental health settings to be able to intervene in this area as well.”

Adopting a life-changing new approach

As a specialist mental health setting which can trace its roots back to 1838, when St Andrew’s opened as a hospital to offer ‘humane’ care to the mentally ill, the charity is always keen to find new ways to support its patients, and often leads the very latest in research and innovative approaches to support that.

St Andrew’s is now helping to deliver new levels of specialist SLT support through doing things differently. The adoption of an arousal curve approach, which can help both patients and clinicians better understand how a patient’s level of mood and emotional arousal impacts on language, is having significant results.

Building on a model by Dave Hewett which has been more widely used as a teaching method, the introduction of the arousal curve as a therapeutic tool is helping to get to the root of patterns around behaviours that challenge and changes to an individual’s language ability, informing the wider MDT with new ways of supporting people and ensuring the patients themselves know why their communication skills can vary so dramatically.

“When we think of high arousal states, for example, if people are in a high stress situation, the brain floods with the stress hormone cortisol. This slows down neural connectivity, and therefore has an effect on how your brain is functioning. It can take 48 hours for the brain chemistry to return to normal,” says Kim.

“Everyone has an optimal communication window, where we can communicate as we typically would when feeling calm and safe.

“As arousal levels increase and more cortisol enters our system, we leave this optimal communication window and we find that language processing is negatively affected as a result.

“So by adopting a new therapeutic approach, we aim to highlight that when a person is still in their optimal communication window, staff can be using verbal de-escalation skills, but if this is not implemented early enough and we see someone getting to a crisis point, it’s important for people to recognise that the individual is no longer able to communicate in the same way – they’re not able to engage in those sorts of de-escalation conversations, they can’t process high level questions.

“Using the arousal curve is enabling SLT to take a more holistic look at the patient’s communication skills.

“We’re not just looking at them at a snapshot in time during one formal assessment – it enables us to look over a period of time and really try to build up a solid profile of the people we’re working with.

“We work on these arousal curves directly with patients, as well as staff.

“It gives the patient a chance to take a step back and think maybe about a particular incident that has happened, and to break down how they were feeling at each stage, how they were communicating and how this changed over time. It can be confusing, so breaking it down can help to make more sense of it all.

“We then encourage patients to think about how they want staff to communicate with them at various stages of an incident, particularly at times when their processing is affected.

“Some people say that when they are showing signs of hyper arousal, for example, they do not want staff to repeat what they are saying, as it leads to too much information to process.

“By engaging in this way, and implementing changes based on what the patient suggests, we can reduce the risk of people getting to a crisis point, because we can recognise the signs and symptoms earlier as their communication starts to change.

“Or it can be used on reflection, as staff can think back about what happened and what could have been implemented to give more effective support earlier.”

In the case of many patients at St Andrew’s, the arousal curve has enabled a better understanding of their communication profile.

Whilst people in the mental health divisions may score quite highly on standard language assessments, many said that the assessment results did not reflect their abilities during challenging situations.

Answering questions, remembering verbal information, expressing emotions and asking for help are some of the most frequently described skills that people can do well day to day but struggle with during a crisis.

“So by using the arousal curve, it has given many patients an explanation as to why these changes might be happening and why they struggle to communicate at certain times and not others. It’s often something that hasn’t been identified for them before despite happening since childhood.”

Incorporating the arousal curve into the therapeutic approach is a new initiative which is showing the opportunity for enhanced outcomes for patients and it is also proving valuable for staff in their ongoing learning.

“As well as the positive impact on patients, we are using it as a teaching tool for staff, to show how communications might change over time,” says Kim.

“Currently it is clinician-led, but longer-term, there is definitely scope to get partners in care involved. We try to make everything as person- centred as possible here, so we are looking at the potential for bringing in families and carers outside of St Andrew’s.

“Longer term, I think there could be really significant potential for this.”

Widening knowledge and best practice

With a longstanding specialism in mental health, the team at St Andrew’s are committed to sharing their knowledge and skills wherever possible – particularly in the field of SLT, where mental health is not always as widely known and understood.

“When I think back to being at university, we had very little teaching on mental health,” says Kim.

“A lot of teaching is much more geared towards working with children in schools or working in acute hospital settings. So newly-qualified speech and language therapists may well have very limited understanding or experience of specialist mental health work.

“That is something we want to change, and a big part of what we’re trying to do at St Andrew’s is to create student placement opportunities, so students can learn more about working in mental health. We’re trying to promote it as an area people can come straight out of university into.

“It can seem very scary for some people, because it’s different and unknown, but we want to share our knowledge and open it up so students can get the experience so it’s not so intimidating.

“It’s an area of SLT where they can make a big difference.”

Even if students do not move into a specialist mental health setting, a greater awareness of the speech, language and communication needs of those with mental health challenges can be invaluable in their career, says Kim.

“We hope that on our placement students can take their learning back to their universities and share more widely,” says Kim, who began her own career in SLT as a newly- qualified therapist at St Andrew’s.

“And ultimately in their career, they may work in a stroke unit, for example – but someone could be admitted who has a mental health history.

“The skills they learned on placement here mean they can tap into them further down the line and use that learning with patients elsewhere.

“I think having that knowledge is valuable, regardless of where they end up working.

“A trauma-informed approach is also something we hope our students will learn from us. If we can help embed that as part of everyday practice, then wherever they go afterwards, they can be utilising these skills so that the terms ‘patient-centred’ and ‘compassionate care’ aren’t just buzzwords – they’re actually used, and made more tangible in order to deliver the best possible care to the patient.”