If you look around at what is going on in speech-language pathology lately, you will find therapies that are aimed at doing what might described as identity work. That is to say, therapies that take account of what clients think about themselves, their abilities and accomplishments, their disabilities, their future. What I'd like to do first in this talk is to describe a few examples of identity focused therapies examining the ways that those advocating the therapy talk about clients' identity. I will looking for what the discourse of professional descriptions reveals about how the professionals construct their client's identities.
I am also interested in the potentially disabling impact of discourse that takes place in and around ordinary clinical interactions-interactions that do not take into account of how the people being worked with perceive themselves, their future, and their communication difficulties. I will end my talk by calling for a shift from traditional therapies to more identity-based ones.
The therapies I will be considering at first are (1) ones that use a version of person-centered planning, (2) ones that incorporate personal narratives, and (3) ones that work to obtain social inclusion. Let me first show how each of these therapies are depicted by their proponents, and then what we can learn about identity from the discourse making up their descriptions.
A Cornell web-site describing a program for person centered planning , describes the practices thusly:
Person-centered planning is a new approach to empowering people with disability labels. It focuses on the people and their needs, not on the systems that may or may not be available to serve them. This ultimately leads to greater inclusion as valued members of both community and society.
The paragraph describes the focus of the planning as being on the needs of people with disability labels. The aim is to empower them, and to promote their inclusion as valued members of community and society. The terminology originates in a social model rather than a medical one. That is, the problem is seen as in the society that disempowers and excludes not in the possession of a disability. The idea of people of "having a disability" is further deconstructed in this paragraph by the terminology that describes them as having labels. This is, again, reflective of the social model in which diagnoses are view as labels that are assigned by professionals rather than as fixed medical conditions.
The Cornell web-site continues:
Person-centered planning involves the development of a "toolbox" of methods and resources that enable people with disability labels to choose their own paths to success; the planners simply help them to figure out where they want to go and how best to get there.
In this paragraph, the originator and primary agent designing the plan is the person with the disability label, not the professional. The person, sometimes referred to as focus person, chooses the path, the professional helps him or her get there. This sense that the primary agent in the process is the focus person is key to what qualifies this therapy as being identity focused. The focus person is empowered to create the plan, the professional serves as a consultant, support person, coach.
A second kind of identity therapy, the use of life narratives to provide people with a vehicle for expressing and constructing identities, has been part of the therapy programming of the staff at an aphasia center, Connect, in the UK . Those at Connect do not simply focus on client narratives, they also examine their own life narratives as professionals. They see personal narratives as a window on identity construction, the identity being that of the clinician as well as the person with aphasia. (Pound et al, 2000). They also see some narratives as conveying a healthier construal of identity than others. For example, they worry when they hear clinicians or clients using a restitution narrative, described by Arthur Frank (1995). One version of a restitution narrative casts the professional in the role of hero and all powerful and the client in the role of the one made well again through the powers of the hero. Pound and her colleagues at Connect put it this way:
The restitution narrative arises from the expectation that medicine (or other powers) can and will get you better. Within this structure, doctors and therapists are expert and often heroic fixers, and patients the tragic or long-suffering victims waiting to be rescued from their affliction (Pound et al. 2000, p. 182).
Pound et al provide an expression of a segment from this type of restitution narrative told by a client about her speech therapist:
I had so much trust and respect for her.if she'd told me jumping off a bridge into the water would help my speech.I'd have done it (Pound, 2000, p. 182).
The focus of these clinicians at Connect is not only to support their clients to express their life stories, they also work on expunging the restitution narrative from their own thinking and identities. They work on changing their construals of themselves as heroes to ones they and their clients become partners.
A first step must be with the delineation of what the therapist can and cannot offer. Sharing power and expertise and developing a true partnership between therapist and client may be a tortuous process, fraught with obstacles-disempowering external conditions, low morale, time pressures, fixed institutional attitudes and so on (Pound et al, 183).
The above passages reveal the authors' attention to the relationship between power and identity. Like in the discourse found of person centered planning, these authors and clinicians aim to foster positive identities of their patients by empowering them and by reconstructing their own professional identities as they act as partners rather than all-powerful heroes.
Another way that personal narratives have been used in therapies is to have clinicians listen deeply and empathically to their clients' life experiences. That is the clinician not only listens to the events in the clients life stories, but assumes the client's point of view in those events. This conceptual "deictic shift" on the part of the clinician from an outsider-observer to an empathic-participant allows the clinician to "identify with" the client, thereby calling the client's identity to the fore. While this seems difficult, it is an everyday activity. It is why clinicians cry when they watch moving tv dramas or why they lose all sense of time when reading engrossing novels. They are identifying with the characters in the stories and experiencing what those characters experience. (For more on this conceptual "identity" shift see Duchan, Bruder, & Hewitt, 1995).
This shift of emphasis from an objective to empathic stance toward the client has been studied Eliot Mishler who analyzed the discourse of doctor patient interviews. Mishler found two types of discourse in doctor-patient exchanges. One that takes place on an objective plane, is expressed in what Mishler calls the "voice of medicine." The second type of discourse, one in which the physician picks up on the experiential side of the patients' stories, Mishler dubs the "voice of the life world."
Here are two examples displaying the difference. Both are from intake interviews where the doctor is getting to know the patient. The first is an excerpt that occurs after the doctor has determined through question-answer exchanges that the patient has had a sore throat, a cold, and a cough for several days. The doctor is asking about the nature of the cold:
Doctor: What about the discharge? Any?
Patient: A little.
Doctor: What color is it?
Patient: I don't really know.I suppose a whitish-
Doctor: OK. Do you have any pressure around your eyes?
Doctor: OK. How do you feel? (Adapted from Mishler, p. 66).
In this segment of discourse the doctor is in control of the topic. He uses the discourse transition marker "OK" as a way to signal that the patient has said enough about the last question and that there is something new coming up. The sequence exemplifies an interview in which the voice of medicine dominates.
In this second interview presented by Mishler, the physician responds to what the patient has just said, inquiring about his experience of getting to the clinic.
Doctor: Where are you from?
Patient: Revere .
Doctor: Revere ?
Doctor: It's kinda hard for you to get in?
Patient: No, not too bad. ( adapted from Mishler, p. 156)
Later in the second interview the physician refers back to what the patient has said earlier, creating a discourse continuity:
Now what you mentioned to me, something about your leg ..do you have something now that is causing you some problems? (Mishler, p. 156)
Throughout, the second physician talks to the patient about what is going to happened, tying the tests to be done to her complaints and worries.
After a detailed analysis of the two interviews, Mishler describes some distinguishing features. In the first, the discourse is disjoint, resulting in a listing of symptoms related to the doctor's line of thinking, but not the patients experience. The physician is the one in control as can be seen by the pattern of question-answer exchanges and the use of discourse markers such as ok.
In the second interview, the discourse is more continuous, with the segments being related temporally or causally to one another. The patient has more control over what is talked about and the physician provides transitions relating the life world to the medical concerns. It works as does a narrative, tying to the plotted history of a persons ' life experiences.
Let's turn now to a consideration of a third type of identity therapy. It is contained in some of the approaches associated with the inclusion movement . Authors such as Steve Calculator and Cheryl Jorgensen have argued persuasively for expanding the construct of communication to include the idea of life participation. In his book on "Including Students with Severe Disabilities in Schools, Calculator says:
The purpose of all of our interventions, programs, indeed, schooling in general is to enable all students to actively participate in their communities so that others care enough about what happens to them to look for ways to include them as part of that community. (Calculator, p. 184).
In this type of therapy, the emphasis is on whether individuals are included in their social communities. The key words in this paragraph are "active participation", "others caring", and "inclusion in a community". All of these terms presuppose the centrality of positive active engagement to successful intervention.
Calculator does not talk in the above paragraph about their client's personal identity. I feel this is no accident, since their the authors are drawing from a social model. I place this therapy among the identity-based approaches, because I, too, take a social view of identity. It is under the conditions that are inclusionary and caring that positive identities are created.
The three therapies I have discussed--person centered planning, personal narrative, and inclusion-offer clients discourse contexts for exploring positive identities. The professional is low keyed, responsive, the client is active, and empowered. The discourse is coherent for the client, containing temporal and causal links, often based on talk about the life experiences, hopes, and fears of the client.
How do these three approaches that place clients and their identity in center stage compare with other, more traditional ways of going about therapy?
In traditional approaches, ones that following a traditional medical model, the discourse is asymmetric, with the therapist in control. What is talked about is what the professional sees as important. As a result, the therapies are likely to lack temporal and causal coherence for the client, and be dissociated from what would be called the person's identity.
As you might have guessed, I am very excited about the emergence of therapies nowadays that allow for the expression of a person's life experiences. Such therapies offer the clinician and client a positive alternative to traditional therapies that can have the unintended effect of silencing the client, blocking any expression of his or her personal concerns. This silencing of the client's voice, I feel, is a perverse form of identity theft. I propose that we follow the movement afoot for other forms of identity theft and that we work to identify the perpetrators and hold them accountable for their acts. .
Calculator, S. & Jorgensen, C. (1994). Including Students with Severe Disabilities in Schools. San Diego : Singular Publishing Group.
Cornell website on person centered planning. http://www.reachoflouisville.com/person-centered/whatisperson.htm.
Duchan, J., Bruder, G. & Hewitt, L. (Eds.) (1995), Deixis in Narrative: A Cognitive Science Perspective. Hillsdale, NJ : Erlbaum
Frank, Arthur W. (1995). The Wounded Storyteller: Body, Illness, and Ethics. Chicago, Il.: University of Chicago Press.
Mishler, E. (1984). The Discourse of Medicine: Dialectics of Medical Interviews. NJ: Ablex.
Pound, C., Parr, S., Lindsay, J. & Woolf, C. (2000). Beyond Aphasia: Therapies for Living with Communication Disability. Bicester, Oxon: Speechmark Publishing Ltd.