Evaluation and learning

In line with the analysis presented in earlier chapters, it may be a pertinent to recalibrate the interaction at the heart of therapy as a learning environment. This would provide client and SLT with a different way to understand their social roles; not as ‘patient’ and ‘expert’, but as ‘learner’ and ‘guide’. This is no easy task as, historically, theories of learning have not been a central feature of SLT training, though orientation to learning at some level can be seen in a review of the

professional literature. The key Competency-Based Occupational Standards (SPA, 2011) document describing competencies for entry into a profession in Australia refers to lifelong learning as a ‘generic’ competency for graduates and includes a specific unit of competency on ‘lifelong learning and reflective practice’ (Unit 7: 36). In addition, it identifies that an aspect of ‘Implementing

Intervention’ (Unit 4: 25) involves attention to client learning styles and learning needs.

It is instructive to consider (see Text box on page 178) the specific set of performance criteria listed under Element 4.2, as there is general reference to client learning styles/needs, but also specific reference to providing clear explanations of tasks and feedback and reinforcement. Similarly, the UK’s professional association for SLTs, the Royal College of Speech-Language Therapists

mentions ‘theories of learning’, client ‘learning styles’ and ‘context-bound learning’ in its description of graduate competencies (RCSLT, n.d).

When working directly with a client, demonstrate the following:

obtaining, selecting and using materials that are appropriate to the client’s age, culture, abilities, learning style, interests and focus

clear explanations of tasks

use of feedback and reinforcement that are specific to the client/group and address the client’s learning needs

modification of the intervention according to the client’s success or failure recognised behaviour-change techniques, e.g. effective timing, reinforcement monitoring and measurement of outcomes

planning for future intervention (independently or as part of a team), e.g. prioritising, time planning

resolving interpersonal conflict.

Figure 8.1 CBOS Unit 4, element 4.2 (SPAA, 2011:25)

In my own experience of both teaching undergraduate speech-language therapy students, and accrediting speech-language therapy programs as part of the Speech Pathology Australia accreditation panel, I am not aware of any programs that support students to conceptualise the activity they are engaging in with their clients as a teaching activity; or the converse, that clients are involved in a learning activity. The persistence of the term therapy effectively obscures the learning that is required for the client to make some kind of change in their communication skills. The emphasis in therapy is predominantly on what the client is ‘doing’. Little attention is given to the impact of what the SLT says and does, as instructor-facilitator, in effectively supporting and

shaping the client’s learning, or re-learning, of basic linguistic skills. When we look more closely at what SLTs say and do, we can see the lingering impact of behaviourist theories of learning, with very little sense of learning as a process of active engagement, of meaning making, or as a social phenomenon.

There has been some consideration of the nature of learning in aphasia therapy (see Horton, 2008 for a useful summary) with calls for greater explication of the therories that underpin client learning in therapy (Ferguson, 1999), greater attention to the principles of adult learning (Hopper & Holland,

2005; Kimbarrow, 2007) and greater attention to the role that error-less or error-ful responses make in completion of tasks (Fillingham, Sage & Lambon, 2006; Beckley, Best, Johnson, Edwards, Maxim & Beeke, 2013). As Linebaugh (1999) rightly points out, it is likely that different theories of learning will be applicable to different kinds of therapy. The call for greater explication of the processes of therapy (Ferguson, 1999; Byng, 2000; Horton, 2008) in order that the processes

involved in therapy can be better understood, critiqued and potentially improved has been addressed by some recent research (Beckley et al, 2013; Wilkinson, 2013). What is still not routine is a clear discussion in published research of things like the therapist/researchers philosophy of intervention, theories of learning that apply to different kinds of client – depending on their age, cognitive abilities, motivation and on the nature of service delivery (individual, group, consultancy). The lack of overt discussion of what theories of learning are relevant to individual clients and their espoused goals is a reflection of the largely unconscious ways in which SLTs learn what Higgs, Tichen & Neville (2001:5) refer to as ‘craft knowledge’ as opposed to theoretical or propositional knowledge. Their description of craft knowledge, as comprising both general knowledge about working with clients gained from hands-on experience, and specific knowledge of the individual client, links to what Perakyla & Vehvilainen (2003) refer to as ‘stocks of interactional knowledge’. Both authors note that this kind of knowledge often remains tacit. Much of what novice

practitioners learn about structuring therapy tasks in ways that promote client learning occurs during clinical practicums and represents an important but under-examined aspect of professional practice. As Perakyla & Vehvilainen (2003) claim, beliefs, attitudes and practices are generally learnt unconsciously, and are thus resistant to overt reflection. I would argue that evaluation practices, and the ways in which they link to some overarching theory of learning of behaviour change, fall into the category of implicit patterns of professional behaviour. When asked, most SLTs are not able to identify the theory of learning that underpins their therapy work.

There are many different kinds of learning – and not all things to be learned are necessarily learned the same way. Gagné (1985) identified five different kinds of learning: information, intellectual, cognitive, motor, and attitudinal. More recently, Richard Millwood (2013) developed a visual representation of different learning theories and their implications for education (shown in Appendix B), as part of the uropean Union initiative ‘Holistic Approaches to Technology nhanced Learning’. As this resource shows, and as Millwood states on the accompanying blog, learning theories are highly contested, “with conflicting contributions from many scientific disciplines, practice and policy positions”, and the “complexity of education is matched by [the]

complexity of learning outcomes” (no page reference for online blog).

While some therapy tasks are more closely geared to ‘motor’ learning, or learning through ‘doing’ (through repetition, copying models and following instructions), there are aspects of engagement in therapy that require clients to ‘know’ about things like the rules for interaction (“now you know that pointing without any words is not acceptable here in this room”) and about their own progress in therapy (“well, you’re saying it”). It is easy to see the vestiges of behaviourism in both the professional literature around ‘feedback’ and the ubiquity of triadic exchanges involving SLT evaluations in the third-turn. It is also possible to see links to Vygotsky (1934/1987) in the ways SLTs use diverse and multiple strategies to scaffold client learning and that these support strategies are often only activated once clients show they are unable to complete the task to a sufficient standard on their own. This supports Horton (2008) findings that SLTs use ‘ad hoc’ approaches to supporting learning, which he indicated “appear to be underwritten by an adherence to the

principles of stimulation approaches or to those akin to the zone of proximal development” (2008: 1010).

There is little evidence in the data that SLTs overtly operate from a theory of learning that relates to the motor or cognitive or intellectual abilities the therapy tasks aim to develop, or that they employ different models of learning for children and adults. There is evidence only of incidental discussion with clients about specific evaluations and no evidence that SLTs support clients to reflect on their performance, something that Gardner (2006) notes is an important part of the overall learning process.

It is plausible that future research aimed at building an inventory of potential learning sites within SLT-client interaction might need to focus on the session more broadly than the close focus this research has taken to the action sequences around the completion of tasks. The learning principles that SLTs are utilizing may well be imbued with the process of therapy at a more gloable level than was the focus of the analysis in this research. Information on how therapy is programmed over the course of individual session, and longer periods of time, might provide more detail on how SLTs and clients understand learning in the context of therapy. As such, there is a need for more global analysis of patterns of discourse within and across sessions, combined with ethnographic

observations and reflections of both clients and SLTs to identify SLT intentions and client understandings.

One important by-product of conceptualizing therapy as a learning environment is that it would enable SLTs to more readily access research findings from other learning environments, particularly

language learning environments, which can usefully inform the way SLT professionals understand the interaction at the heart of ‘therapy’, particularly what the role of the learner might be. In particular, research from second-language learning contexts has potentially produced insights that bear consideration in relation to SLT practice. Damhuis (2000) suggested that learner initiation of interaction and learner control of topic result in better learning outcomes. McHoul (1985) noted that the turn-taking frameworks often found in learning interactions with second-language learners, similar to the triadic turn-taking structures found in SLT interactions, make it difficult for learners to initiate an interaction. Seedhouse (2004) argued that a focus on form and accuracy imbues second-language learning contexts with “extreme asymmetry” (2004:104), constraining learners in more ways than they might be in regular conversation. Gardner (2008) suggests that reearchers in second language acquisition, are beginning to “build an inventory of sites of potential lerning” (2008: 237) and that one particular focus of attention should be on “giving the recipient the opportunity to actively respond” (2008:238). These insights might be usefully applied to SLT practice, though further investigation is needed of the ways in which the 1:1 learning environment found in SLT-client interactions shapes the kind of roles that are available to learner (client) and learning facilitator (SLT).