Going Home

The young man in my office struggled to explain, "I wait, wait, wait. Then Papa. And like this." He clasped his hands together, a look of great joy on his face, to show me how happy he had been to see his father. He continued, "We come here. And me this". He gestured to the healing sutures covered with soft downy hair over his ear. "Now, God. Me. Better," he explained, gesturing towards his crucifix.

It was a story worthy of a miracle. The young man was in his mid twenties. He had developed a sudden aphasia accompanied by an intense headache, and eventually loss of consciousness. He was discovered to have an arterial venous malformation, a tangle of blood vessels in the brain. He probably had been born with it and had never known. It was bleeding into his brain, causing the aphasia. An emergency surgery had saved his life. But there was a problem. There was another malformation. The surgeons wanted to remove that one also, before it ruptured. The young man politely refused. When he was discharged from the hospital he was referred to out-patient rehabilitation, including speech therapy.

He had a significant expressive aphasia with severe anomia, the ability to retrieve words. There had been improvement. It was early days, so prognosis was positive.
Our first session, he told me he was going to go home to find his brother, so would not be attending therapy long. I was dismayed. He wasn't recovered from surgery. He needed another surgery. Could he not delay his trip?

He shook his head and told me his story. He was from a troubled Central American country. As rebels were rounding up older boys and men to serve as soldiers in the bloody civil war, his father and he set out on foot to escape. His mother and brother stayed behind. Somehow he and his father became separated in Mexico City. What followed was a testament to perseverance and faith. Every day he scoured the poorest parts of the city trying to find his father. He waited outside various factories at shift changes, watching workers' faces, searching. It was not clear to me how long this went on or how he survived. He was only a teenager then. He told me he had been sick during his search, pointing to his head, indicating pain. He told me he almost gave up. One thing he was sure about, God saved him. And then when he was ready to give up, God helped him find his father.
So now he was sure God would provide again. He told me his mother had died. His younger brother was with his aunt. He needed to get him and bring him to Canada. He had no doubts.

This is definitely the hardest part of the evidence-based therapy model to both understand and accept. We know, in theory, that the client's perspective accounts for an equal slice of the pie to our clinical judgment and the available evidence. But in practice, it is much harder to see the client's perspective as an equal partner. Is it not our job, our responsibility, to educate and convince? When clinicians are trying out their fledgling wings of clinical experience, thus relying heavily on available evidence, this seems especially true. It is hard to remember and appreciate the client's vital role in the success of treatment. I think as experienced clinicians we are often very good at "hearing" our clients, and supporting their participation in their own treatment. But how good are we at communicating those skills to our younger colleagues?

My sister is a gifted educator. She recently reminded me that long-established models of change and motivational interviewing strategies must be taught. How vital this information and opportunity to practice it is for students and young clinicians. In speech-language pathology we need to do a better job at ensuring this knowledge, these skills, are handed down to the next generation. When a client is not ready to consider, or begin to plan for change, it is not our job to press on presenting evidence and offering our clinical expertise. It is our job to let the client know that if and when they might be ready, we will be able to offer support. And we must do that without judgment.

For my client, I was probably one of the few people, given his current communication skills, who could listen to his story. I am not sure how well I understood. Our communication was largely single words, short phrases and gestures. I was not sure how good his English was. But I was sure of his decision to refuse treatment, and his great faith. I wanted to argue, to insist, to make him accept treatment. I wanted to say we knew what was best. But what he needed was to tell his story, know he could come back when he was ready, and then leave.

I watched him walk away. It was hard.