Everyone should be able to use the telephone. "Just because people use a communication device to talk doesn't mean they can't participate in telephone communication," said Elizabeth Hanson, PhD, CCC-SLP, assistant professor at the University of South Dakota. "It's an important aspect of society. It should be part of our practice."

Speech-language pathologists should talk about and establish the need for telephone communication when clarifying standard issues, such as communication partners and access needs, during an evaluation for augmentative and alternative communication (AAC).

Dr. Hanson recently reviewed the communication needs of a woman with amyotrophic lateral sclerosis (ALS). The patient said she missed talking on the telephone, which she is unable to do in the traditional way because she has trouble using her hands and can no longer use her natural speech due to dysarthria.

"She's from a small, rural town, and the phone is how she keeps in touch with people," Dr. Hanson told ADVANCE. One of her therapy goals is to get back in touch with people by combining telecommunications equipment and AAC.

A study on the intelligibility of synthesized speech in telephone communication found that synthesized speech maintains high intelligibility in a quiet, controlled environment. Unfortunately, a quiet environment is not the norm.¹"When you're listening to your telephone, you're usually not in a quiet room-you're walking across a city street with your cell phone plastered to your ear," said Dr. Hanson. "As a caller or a clinician, we can't control the background noise and the quality of the phone on the receiving end; all we can control is how well we're sending the signal out."

Therefore, patients require phones of good quality. The phones also should be fully accessible. If patients plan to make calls independently, they need a phone that will allow them to do that.

Four types of competencies come into play for telephone use: linguistic, social, operational and strategic.²"They're not prerequisites," clarified Dr. Hanson, who said the idea of these competencies is helpful in organizing a treatment plan. "You don't have to be competent in them to talk on the phone. I use them to look at where the communicator has some good skills and strengths to build on and where they have fewer skills and need to build those areas. It helps me bring my treatment into better focus and cover all of the bases."

For example, a patient may be linguistically competent and have a strong command of language but have trouble working or understanding how to use a device. The clinician should focus on improving the person's operational competence.

AAC users face communication barriers in the areas of access and opportunity.³The first area refers to issues such as mobility, cognition and sensory-perceptual impairment. Speech-language pathologists can hone in on these issues, which are based on a person's abilities, during therapy.

"You're not going to give a type-and-talk board to a little kid or to somebody with a developmental disability who can't type," explained Dr. Hanson. "You want to have preprogrammed messages that are represented by appropriate symbols."

Opportunity barriers relate to outside sources, such as policies, practice, attitudes, knowledge and skill sets. Policies are not as problematic as the others, thanks to laws in place because of the American with Disabilities Act (ADA) and Assistive Technology Provision, both of which give people access to telecommunications equipment.

"You still run into problems with practice, attitudes, knowledge and skill because we don't have as much control over those," said Dr. Hanson. "We don't have the right supports in place in terms of people to help the person using AAC to actually access the phone or to create opportunities for a phone call in some cases."

Unsuccessful calls are the biggest problem when AAC is combined with telephones. Many people simply hang up on the individual because they have trouble understanding synthesized speech.

"That's what we're seeing in the research, and that supports the anecdotal evidence from clients and people who have talked about this," she said. "It's been very difficult to make it all work. The reasons seem to be based on the timing of the interaction and the type of message that is used to start the call."

This impacts AAC users.⁴Their confidence is likely to be shaken when they make 20 phone calls and succeed with only five callers because the other 15 were rude or hung up. "It's not something we've measured empirically, but it's a thread that underlies these studies. People can become quite discouraged when they can't make successful phone calls," said Dr. Hanson.

One possible solution is to use a floorholder, a means of establishing certain information at the beginning of a phone call to hold a person's interest. This includes who is talking or what the caller needs to have happen for the conversation to be successful. The term didn't originate in the context of telephone conversations, but it has direct application to them.⁵There are introductory, instructional and informational floorholders. Some AAC users feel that beginning with a personal greeting, such as introducing themselves, and asking to speak to someone tends to engage the people they are calling right away, according to Dr. Hanson. The people are less likely to hang up or think the call is a prank.

An instructional floorholder is used to tell receivers that they may need to wait for the caller to respond during the course of the conversation. "That's covered by the 'please wait' part of the message because it conveys to the partner that they may have to be patient and wait for the message to come across," she said. "The conversation is not going to occur as quickly as a typical conversation occurs."

Individuals also can offer information about themselves and their situation, such as "I'm using a computer to talk." Researchers don't know if one type of floorholder is better than another, but starting with one of them enhances the caller's chance of success, Dr. Hanson noted.

When teaching AAC users how to have successful telephone conversations, clinicians should start by laying out the big picture. Individuals who have had little opportunity to place phone calls may not know how the interaction works, how fast it moves, or the etiquette involved. As a result, she said, "It's important not to overlook that information for clients."

Most phone calls are fairly predictable. One person places a call, and another answers the phone. Callers say "hello," identify themselves, state their reason for calling, and ask a question. This predictability makes them perfect for scripting opportunities in therapy. Working out scripts removes the burden on callers of having to think about what they will say next.

AAC users come to understand how different it is to have a conversation with someone who isn't standing in front of them while simultaneously operating a speech-generating device and phone. "That's a tremendous cognitive load," said Dr. Hanson.

Initially, the conversation is scripted, very predictable and simple, she explained. "Then you systematically make it less predictable. You can start to mix up the script and make it less predictable once the person becomes a little more comfortable with the mechanics or operational competence."

Rehearse the script before making an actual call. The clinician can play the role of the person on the other end of the line or can invite someone else to play that part. Create a light atmosphere to help the caller relax.

"The receiver knows what is expected of him or her and is asking all the right questions and saying all the right things," said Dr. Hanson. "You methodically build up to actually placing a call to the person or to a place that's not expecting it."

Experiencing failure can be discouraging at this stage, so the clinician should make every effort to assure that the first call is successful. The speech-language pathologist can call a business, such as a pizzeria, and let the manager know the call is coming.

"Tell the manager what you are working on," said Dr. Hanson. "Say you have a person who is going to call and order a pizza. Ask if the manager could take the call the first time because you want it to be successful for the person. Do everything you can to help them be successful."

References

1. Drager, K.D.R., Hustad, K.C., Gable, K.L. (2004). Telephone communication: Synthetic and dysarthric speech intelligibility and listener preferences. Augmentative and Alternative Communication, 20 (2): 103-12.

2. Light, J. (1989b). Toward a definition of communicative competence for individuals using augmentative and alternative communication systems. Augmentative and Alternative Communication, 5 (2): 137-44.

3. Beukelman, D.R., Mirenda, P. (2005). Augmentative & Alternative Communication: Supporting Children and Adults with Complex Communication Needs (3rd ed.). Baltimore: Paul H. Brookes Publishing Co.

4. Nakamura, K., Vanderheiden, G.C., Smith, R.O. (1993). Attitudes and impressions toward receiving phone calls made with a voice output device in the United States and Japan. Technology and Disability, 2 (2): 71-80.

5. Bedrosian, J.L., Hoag, L.A., McCoy, K.F. (2003). Relevance and speed of message delivery trade-offs in augmentative and alternative communication. Journal of Speech, Language, and Hearing Research, 46: 800-17.

For More Information

• Elizabeth Hanson, PhD, ekhanson@usd.edu

Jason Mosheim is a Senior Associate Editor at ADVANCE. He can be contacted at jmosheim@advanceweb.com.