Engagement in Clinical Practice

This issue of Seminars in Speech and Language focuses on the concept of engagement. As used in this issue, the term engagement is defined as the level of interpersonal involvement that people display in social situations. Engagement is signaled in a variety of ways. For example, gaze can signal engagement or disengagement in conversation. When a listener gazes and orients his or her body in the direction of a speaker, it tends to signal interest and involvement in the conversation. Conversely, gaze aversion and body orientation away from a speaker can signal lack of attention and “disengagement” from the conversation.

During the process of conducting therapy, speech-language pathologists (SLPs) attempt to “engage” their clients in the therapeutic activity to ensure that the therapy process is maximally effective. Although few people would dispute this fact, the speech-language pathology literature provides little insight into the concept of engagement or methods for how to maximize it in clinical discourse. This issue of Seminars in Speech and Language opens the way for such a discussion. Several articles employing various qualitative methods of analyzing discourse and clinical interactions provide insights into behaviors that promote substantive engagement of clients in therapeutic interactions.

In an introduction to engagement in clinical discourse, Simmons-Mackie and Kovarsky define engagement, suggest various levels of analysis for studying engagement, and propose reasons why engagement is an important concept for our field. Duchan explores a wide range of “engagement” literature and derives several principles that clinicians can use to maximize engagement of clients in language learning and clinical activities as well as the wider social community. Based on a comparative discourse analysis of two group therapy sessions for aphasia, Simmons-Mackie and Damico demonstrate strategies that are effective and behaviors that are ineffective for engaging clients in group conversation therapy. Their data suggest that “subtle” interactive behaviors of clinicians powerfully affect the level of engagement of clients. Two articles in this issue discuss “teasing” and “humor” as discourse strategies for gaining rapport and maximizing engagement. Walsh and Leahy, using discourse analysis as their analytic method, explore the use of “teasing” or “cajoling” in swallowing therapy for an individual with dysphagia and cognitive-communication symptoms associated with a right hemisphere brain lesion. The authors demonstrate how the SLP's “cajoling” remarks in response to the client's potentially “inappropriate” comments serve to maximize the client's engagement in swallowing therapy. On the surface, many would assume that the clinician's responses to the client's marginally appropriate remarks would reinforce these inappropriate behaviors. However, the authors' detailed analysis of the clinical discourse suggests that, in fact, the clinician skillfully uses the client's teasing remarks as a way to move the session forward and maximize his participation in an unpleasant task. Again, the take-home message is that subtle and skillful interactive behaviors of clinicians are critical in promoting clinical engagement of clients in the therapy process. Kovarsky et al also explore the concept of teasing and laughter as positive engagement strategies used by students interacting with adults with traumatic brain injury (TBI). The situation that the authors describe is not a therapy session in the traditional sense; rather, it is a setting designed to promote social interaction and conversation between adults with TBI and speech-language pathology students. Using discourse examples, the authors describe how teasing and humor heighten involvement of the participants in the conversation. The authors also contrast their findings with those from a study of traditional aphasia therapy to demonstrate how patterns of teasing, humor, and engagement distinguish traditional didactic therapy interactions from more natural conversational interaction. Finally, Mastergeorge proposes a tool composed of six domains for assessing levels of engagement in instructional activities. Although originally designed for measuring student engagement in classroom learning, this tool is readily adaptable to adult learning environments. For example, clinicians can judge client engagement in therapy interactions or engagement of families in learning methods of supporting communication. In addition, the tool should prove useful in maximizing involvement of participants (students, clients, families, and health care providers) in educational programs aimed at topics such as communicative access in health care, or in knowledge regarding communication disorders.

I hope that readers will find engagement a useful concept for helping explain aspects of motivation and cooperation of clients in therapy. The concept is also useful in explaining an important element influencing participation in social interactions for people with communication disorders. This issue introduces the concept of engagement in clinical discourse and lays the groundwork for future research into engagement. Also, these articles provide insights that will help clinicians manage therapeutic engagement to foster successful therapy interactions.