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Hildred Schuell learned how to help aphasic patients to gradually improve, by protecting the flow of communication during therapy sessions, by removing the element of panic and struggle.
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I want to tell you a story -- a true story.
We are in Santa Monica, California, on the beach. The wind is coming from the ocean and the air is clear. It must be a work day -- there are more birds than people.
I have come to Santa Monica, and to this beach, to think about Hildred Schuell, the woman who discovered that most cases of aphasia are curable. Hildred died years ago, but my friend Christine Harris-Sloan worked with her, and I have been studying Hildred's writings with Christine's guidance. She is very kind and very intelligent, but after reading everything she has and badgering her with questions for weeks I find that she cannot really answer my deepest question, and that maybe no one can. She and a few others know what to do to help an aphasic client heal, and they know that it works, but no one seems to really understand why it works. Or maybe what I want to know becomes obvious when one uses Hildred's therapy with aphasic patients, and the problem is my lack of experience.
Aphasia is defined as a loss of all or part of ones ability to use language, caused by damage to certain areas of the brain. It was aphasia that led to the discovery that the two sides of the human brain have different functions; the first forty or so cases reported all had left-side damage. The classical theories held that there were several kinds of aphasia, affecting speaking, understanding speech, writing, and reading. The accepted doctrine was that people with damage limited to a certain area might have trouble speaking but no trouble understanding, while patients with damage to another area might be very articulate but have trouble understanding spoken or written language.
The conventional wisdom was that speech and language therapy were basically useless with these patients -- typically there would be a period of spontaneous recovery, which would happen with or without therapy as some of the tissue healed, and after that no therapy of any sort would restore whatever functions had failed to recover spontaneously. The only realistic goals for therapy were to teach compensatory coping strategies and to provide emotional support.
My mentor at the University of Minnesota, Professor James J. Jenkins, had worked with Hildred Schuell for years and published several papers and a book with her. One day, as we were driving over to the V.A. Hospital where Jim was to introduce us, he said something I knew I would never forget: "All the hot-shot neurologists think Hildred's theories are crap -- but she's the only aphasiologist in the world that can cure a patient."
It took a while for that to really sink in; first to be sure he was serious -- he was. He had said precisely what he meant. Second, to understand that he was correct. To the best of my understanding, after all these years of passionate interest and study, he was -- she knew how to cure aphasic patients and how to teach other people how to cure them. She even knew how to tell which patients could not be cured. Sadly, however, she died a few weeks after we met, and I never got to work with her directly.
I did get to work with her student Christine Harris (now Christine Sloan) and of course with Jim Jenkins. What follows is a summary of what I learned from them, and from Hildred's writings.
Working with Jim Jenkins, Hildred found excellent evidence that most aphasics have about the same level of impairment in all four language modalities -- reading, writing, speaking, and understanding speech, unless the fundamental sensory or motor abilities were also impaired on tasks that have nothing to do with language.
For example, a patient's family might report that he could hear and understand speech perfectly well, but could hardly speak at all. The family physician had confirmed the diagnosis, as had a neurologist to whom the case was referred. What Hildred found, with her careful testing -- using recorded speech to ask questions that could only be answered if the person really could understand the speech, with no help from situational cues and nonverbal gestures -- was that the patient's ability to understand speech was just as badly impaired as their ability to speak. The exceptions were all patients with sensory or motor impairments, as revealed by tasks like identifying common sounds -- like water dripping -- by pointing to a picture of a faucet. On the other hand, somebody who cannot use their tongue to lick their lips may also have trouble using their tongue for speaking, but that is not a language impairment, it is a motor impairment affecting any task that requires coordinated gestures with the tongue.
Hildred also proved that nearly all aphasic patients, except those in one diagnostic category, can gradually improve if given the right kind of help. "The right kind of help" has two main characteristics:
First, the patient and the therapist or helper must agree on and practice one basic rule: The patient is not allowed to struggle. The entry fee for playing this particular therapy game is to relax. Whenever the patient begins to struggle, to panic, to try to force the words out -- stop. Let's both relax, and whenever we are both ready, we can start again if we want to. This relaxed play is the absolute inviolable condition of this healing process. Succeeding at the task is never to be allowed to become more important than succeeding at relaxing.
Second, in the space thus created, protected from any sort of coercion by either partner directed at either the other partner or them self, the game is played with no possibility of failure. One of Hildred's students recounts an incident that must have occurred hundreds of times over the years as new therapists were trained -- the student has reported that her patient can't do the currently assigned task. Hildred responds: "That's very interesting -- how did you discover that?" "We tried it at least thirty times and he just can't do it." "That's O.K. Try it a hundred and twenty times.
Failure is impossible, but not because the patient will eventually succeed at whatever task is assigned. Therapists certainly will sometimes choose a task that is too advanced, too far beyond the client's current level of skill. Failure is impossible by executive decree -- because Hildred said so. Eventually the trainees learn, from their own direct experience, that sooner or later the therapist will succeed in coming up with the right exercise, and then the client will eventually produce the right articulatory gestures.
That is really all there is to it, for most patients, except for a few details, details such as the fact that no insurance plan in existence will pay for years of daily therapy sessions at $50 to $100 each. (That is why the method had to be developed by somebody working in a V.A. hospital, one of the finest in the country.) For people who do not have access to such resources, an alternative plan had to be developed wherein the sessions that the patient can afford are done with a family member of friend or volunteer present, someone who can learn the technique and then continue to work with the patient with occasional guidance from the therapist, long after the money has been used up.
The patients who will never recover are those with the cluster of symptoms that Hildred called "global aphasia." She distinguished two types of speech, "reactive" and "intentional." Reactive language is produced in reaction to someone else's utterance, in words dictated by a habitual formula -- for example, "fine," in response to "How are you?" Intentional language is generated to accomplish some purpose of the speaker. Global aphasics have no intentional language. When such patients are given language therapy with the method described above, their reactive language may improve -- they might, for example, progress from "fine" to "Fine thank you, how are you?" However, they will never regain any intentional language at all. It may be that someday a mode of therapy that works for them will be developed, but Hildred's definitely does not.
All in all, we are left with two mysteries: First, why does Hildred's method of therapy work? Second, given that it does work, why does it fail to work with the global aphasics? That's where I was that day on the beach -- certain that those were the key questions and equally certain that I had no way to proceed further in the effort to answer them. I had already read everything there was to read about Hildred's work, and discussed it over and over again with Christine, and it wasn't enough. So I gave up -- gave up the mental effort and started enjoying the sand and the ocean.
The sand sloped up from the water, up to a low ridge, then down several feet and then up again, forming a shallow basin behind the front ridge. A storm had come in at high tide and left ponds of stagnant water stranded in the basin, all along the beach.
A work crew had brought in a small bulldozer and cut a trench through the ridge from the pond to the sea. They had then dug with a shovel a much narrower trench in the middle of the buldozer-wide trench. Only a narrow dam of sand was left blocking the narrow trench when they went to lunch.
Most children like to play with water and sand, and I am no exception -- I'm just older than a lot of the other children. With my finger I absent-mindedly traced a narrow track through the small sand dam blocking the shovel-wide trench. A tiny trickle started flowing toward the sea.
I must have been daydreaming about aphasia again, for when I next noticed the trenches I was shocked to see that the flow had become much stronger. The trickle had slowly washed away the sides of my finger-width grove, which had become nearly as wide as the shovel-wide trench, and was now about two inches deep. As I watched, entranced, the flow continued to widen and deepen, until it filled the bulldozer trench and was over a foot deep! The more it flowed, the wider and deeper it got. The stagnant water flowed swiftly into the ocean, free once more.
Then I nearly fainted. Hildred's therapy! Protect what ever flow of communication has survived, and it will gradually increase, just by being allowed to flow. And if none has survived, there is no flow to protect, no trickle of communication at all, and no possibility of recovery.
I remembered an old principle from systems theory that I had read in the Whole Earth Catalog: "Energy flowing through a system tends to organize that system."
That is why INREAL works for everyone in the room. Protect the basic human connection of kindness, respect and mutual interest in whatever is currently going on, protect the flow of genuine communication, and anyone can communicate successfully with anyone.
The hardest thing to remember, I think, is that genuine communication cannot be developed "on purpose." No one can strategize or coerce their way into genuine communication. Genuine communication is simply shared joy -- not for sale anywhere at any price. There is only one intentional act that can actually foster genuine communication, and that is to protect the shared joy from being undermined by preconceived notions about what "should" be happening.
Shared joy happens automatically when we give up aggression, seduction, and prejudice. Not all, at once, usually, but gradually. It can happen all at once, as in the Zen experience of satori -- sudden enlightenment. But even someone who has had numerous satori experiences may find that stabilizing the experience, learning to risk joy in all the different situations we encounter, may take a long time.
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Helping Others: A Personal View by Christine Sloan
I know of four excellent books by and about Hildred Schuell, her work, therapy, and insights. Unfortunately, all of them are out of print.
L.F. Sies, Ed. Aphasia Theory and Therapy: Selected Lectures and Papers of Hildred Schuell. Baltimore University Press, 1974.
H. Schuell, J. Jenkins, and E. Jiménes-Pabon. Aphasia in Adults: Diagnosis, Prognosis, and Therapy. New York: Hoeber, 1964.
J. Jenkins, E. Jiménes-Pabon, R. Shaw, and J. Sefer. Schuell's "Aphasia in Adults." New York: Harper and Row, 1975.
Hildred Schuell. A Study of Boys and Girls: Differences That Matter. Austin, Texas: Delta Kappa Gamma Society, 1947
One of her books is in print, but it doesn't discuss her ideas about therapy:
Hildred Schuell and Joyce W. Sefer. Differential Diagnosis of Aphasia With the Minnesota Test. University of Minnesota Press, 1973.
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Revised on August 20, 2000
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