How to do Speech and Language Therapy: What’s the problem?

What is the problem?

It might seem obvious, but when a referral comes in, or at the first meeting, the speech and language therapist needs to find out what the problem is. By problem we mean how any speech or language difficulty is affecting an individual’s life negatively, or, how it might predictably affect the individual’s life.

Too often a cursory exploration of concerns is made, which is then followed by a few of the therapist’s favourite assessments, after which the therapist chooses something to work on – most probably an area or two which those assessments just happened to assess. These work areas may be written down as targets.

This is all wrong. The affect of the communication difficulty should be central, assessments should be relevant to those negative affects, there should be clear justification of those work areas and how they are going to make life better for the individual.

So, how do we do it?

In this first post, we are going to look at exploring the concerns to get to the root of a problem.

Explore the concerns

What is your client concerned/anxious about?

This is fundamental to any speech and language therapist’s work. If you neglect this, you might as well not bother. You will never know if you are working on something useful or not.

This is a conversation. You might have it with the individual seeking help, or with a carer, a teacher, a parent, or all of these. You need to find out what difficulty – in life – there is as a result of the communication, or could be avoided with changes in communication. Is it a concern for the individual? Or, is it just a concern of others around them? – in which case, is it valid for the individual? You are not making things up, it’s concerns for this particular individual – are *they* themselves at risk?

Here are some examples:

Correct (concerns which are concerns).
  • Failing to get needs met
  • Distressed when an activity changes
  • Feeling left out
  • Feeling isolated – not understanding what people are saying
  • Frustration
  • No longer able to enjoy a night out with friends

Note, there is no menu of worries to choose from, the worry will vary from individual to individual. You *cannot* find a risk by doing an off-the-shelf assessment!

If the concerns you came up with look anything like these, then you need to dig deeper:

Incorrect - things that aren't of themselves concerns (they don't describe the affect of the problems).
  • Unintelligible speech
  • Difficulty using adjectives
  • Problems with prepositions on, in, under
  • Difficulties with inferencing
  • Difficulties understanding complex sentences
  • Unable to use a subordinate clause

These are all about the mechanics of communication, but say nothing about the actual consequences of these skills (if any) on an individual. Jump into one of these without getting a proper handle on any concerns at your peril!

Suggestions for getting to the concern/worry

Have a discussion.
  • Start with how they are being affected – the person you are talking to or the person with the communication difficulty.
  • How might life look if the communication difficulty was less/went away? How would it be better?
  • What is the communication difficulty stopping you or them from doing?
  • Do not suggest solutions at this time. Suggesting a solution (perhaps because you think you have seen something similar before) will derail the conversation, and will make it more difficult to get to the concern.

Going further

Read more about why getting at the route of someone’s concerns is so important, and how not doing so constitutes a significant risk to services and the recipients of those services.


In my next post, I will talk about assessment of skills, and how you will use that to drive your therapy.