The cow is pushing the woman
(or my observations of a comprehension test)

I have now spent several days, spread over a few months, alongside the speech and language therapists at Addenbrooke's Hospital. I have observed the versatility of approach and adaptability of the therapists during their work with patients. Each patient is an individual, their circumstances personal and unique and their medical condition variable. This necessitates an open-minded approach to all sessions and an understanding and empathy with the human condition.

From my observations of speech therapy sessions, I realise that I frequently make assumptions during everyday conversation - assumptions that my words are not only heard but also understood. It is quickly apparent that, particularly in the surroundings of a hospital (and notwithstanding everyday situations) communication must generally be clear and corroborated.

One of the first appointments I attend, shadowing a therapist on the rehabilitation ward, is to witness a comprehension test. The patient is an elegant lady of mature years with an air of alertness and intelligence. The test involves looking at a set of pictures in a book - four to a page - whilst the therapist reads out a phrase.

The patient then has the task of indicating which of the four pictures accurately illustrates the spoken words. As the test progresses, each spoken phrase is constructed with subtle grammatical differences and the complexity of these phrases increases as the patient proceeds through the book. The test is simple and straightforward, the focus directed solely at language and the comprehension of the nuances of grammar. The language is isolated and pure, which, along with the increase in complexity of grammar provides total focus on the words.

The pictures are presented in an unsophisticated style - basic line drawings - and show four closely related pictures of similar actions. For example, the phrase 'the cat is asleep on the rug' is linked to four pictures of a sleeping cat in four different places in a room - one of these being the rug. The simplicity in the presentation of these images serves to reinforce the need to understand the language element of the test. Some of the drawings depicted however, do require an open mind to everyday experience. "The cow is pushing the woman" does, I note, bring a smile to the patient's lips.

As the test progresses and with the turning of each page, I realise I too am inwardly selecting the most appropriate picture to match the spoken words. At times, I find I am struggling to make an accurate choice. However, if the patient seems unsure of their response, I hear the therapist gently prompting. The therapist keeps a note of the patient's answers together with relevant observations during the session. It is clear, as I watch this patient capably turn the pages to progress through the book, that she has coped admirably with the short session. To my uneducated eye she has completed the tasks asked of her with energy and concentration.

This early experience is in stark contrast to a later shadowing session - in this case with a patient who, on first meeting, gives out clear physical signs and body language that they understand the therapist's requests. Smiling, nodding and gesturing affirmatively they give the outward appearance of being totally in tune with their environment and the events within it. Small clues however reveal that this appearance is misleading. The positive nodding that is a physical reply to the question 'Have you eaten lunch today? " belies the fact that this patient has not yet eaten lunch and is on her way to the dining room. Presence of social signals is, I learn, no guarantee of the comprehension of contextual information.

Assumption is easily done. In everyday life we respond to even the most minute clues in our fellow humans. We take cues from others' reactions and responses and act accordingly, tempering our own responses to an appropriate level or area. I am aware that all the therapists I have observed employ the full armoury of senses in their approaches to their patients; direct eye contact, clear speech, visual stimuli, sensory stimuli, simple vocabulary and directness. How responsible are we, those who take our skills for granted, for expecting, assuming and perhaps even judging others in their responses.