Never Underestimate Your Non-verbal Clients!

It can be very challenging to work with clients who are non-verbal, behaviourally unstable, physically impaired and suffering from severe cognitive impairments. As clinicians we may struggle to gather a true sense of their understanding, and it is easy to feel as though their comprehension and thinking skills are as impaired as their ability to communicate. At times like these, speech therapists need to think outside-the-box when developing goals and therapy activities. Keeping things personally meaningful or functional for clients is so important.


I have been providing speech therapy to an individual – let’s call him Hector – for 2½ years. Hector continues to amaze me by his level of understanding, despite his severe brain injury. It is so easy to underestimate clients like Hector due to his physical, behavioural and communication skills. Months of treatment has focused on training Hector to communicate by raising his left arm for “yes” and lowering it for “no”. Even this basic form of communication is, at times a major feat for Hector.

His poor attention and varying motivation, and extreme behavioural problems are additional factors contributing to inconsistency in participation and responses to speech therapy efforts. In addition, Hector’s first language is not English. I have needed to learn phrases in Spanish, as well as utilize a translation app during speech therapy sessions. To add insult to injury, Hector needed a tracheostomy inserted and thus needed soft restraints to prevent him from accidentally taking out this important device that keeps his airway clear.


Recent efforts have been focused on teaching Hector to use an iPad with a stylus that wraps around his hand and creates a finger extension, so that he can access a yes/no array and picture choices. This process required collaboration with the Occupation Therapist to ensure the best fit for Hector. Communication using this new process has also been difficult for Hector and is still in the beginning stages.


One amazing moment I experienced with Hector, was on a day he had been communicating very poorly in response to all of my questions. He became very upset when his Spanish speaking rehab therapist became involved. I attempted to find out why he was upset, to no avail, with a continued lack of response to my questions. I then began to explain that the rehab therapist was just trying to help me because my Spanish is not very good. Almost instantly, Hector raised his arm as high as it could go (his “yes” response) in agreement. I was speechless! I had definitely underestimated his sense of humor!


On another occasion, Hector had responded on his iPad, using the yes/no choices, that he was tired and wanted to go to bed. This is very unusual for Hector, so I assumed he had made an error. I asked him if he wanted to go outside and Hector responded by using the stylus to flip the pages on the iPad until he got to the picture of a bed. Hector had been shown this feature and function of the iPad, but had not yet been trained to use it.

I could not believe what I had just seen and again questioned if it was coincidental. Again, I had underestimated Hector. To be sure, I went back to the yes/no choices and asked: “Do you want to stay here?” – Hector selected “no”. Followed by: “Do you want to go to bed?” – Hector selected “yes”.

It is amazing what even the clients with the most difficulty communicating can accomplish when motivated by what is important to him or her. This is why it is so important to find activities that are relevant to clients to keep them engaged in their therapy! As therapist, it is equally important to never underestimate our client’s abilities.


Amanda Brown is a Speech-Language Pathologist with nearly a decade of experience in providing assessment and treatment to clients in the clinic and community settings. Amanda enjoys working with clients of all ages and applies a strong client-centred approach to her therapy, balanced with family/team collaboration.