Speech and language therapy

1. Introduction

Version followed: speech and language therapy as published by the Royal College of Speech and Language Therapists (RCSLT, UK professional body) and regulated by the Health and Care Professions Council (HCPC), with the American Speech-Language-Hearing Association (ASHA) Scope of Practice in Speech-Language Pathology (2016) for the US; RCSLT statements and guidance dated May 2020 to June 2026 as cited below.

Speech and language therapy is a registered health profession, not a single psychotherapy technique. In the UK a speech and language therapist (SLT) "assesses, treats and helps to prevent speech, language and swallowing difficulties" [source: UK Regulated Professions Register]. The titles "speech and language therapist" and "speech therapist" are protected; the regulator is the HCPC under the Health Professions Order 2001, registration is mandatory to practise, renewed every two years with continuing professional development (CPD) and random CPD audit; the RCSLT is the professional body that issues clinical guidance but is not the regulator [source: UK Regulated Professions Register; RCSLT, HCPC registration and professional standards]. In the US the equivalent is the speech-language pathologist (SLP), who practises "in the areas of communication and swallowing across the life span", typically holds ASHA's Certificate of Clinical Competence (CCC-SLP), and works under state licensure laws, which the ASHA scope says it "does not supersede" [source: ASHA Scope of Practice 2016]. Licensure requirements differ by state and are not verified state by state here [uncertain].

Core idea of how change happens, as the profession presents it: communication and swallowing are assessed and treated directly (impairment level), the communication environment and communication partners are changed so the person can take part (access level), and information, assessments and interventions run by other professionals, including psychological therapies, are adapted so the person can benefit from them [source: RCSLT, Talking about mental health, May 2020]. For the psychotherapist the key point is that talking therapies are language-heavy: unrecognised communication needs can make assessments inaccurate, consent and risk assessments unreliable, and clients look "not engaging" when the problem is language demand [source: RCSLT 2020]. Your role is to recognise these needs, refer, collaborate, adapt your own therapy, and integrate psychological work with SLT care. Swallowing (dysphagia) is a medical safety matter handled by the SLT and medical team; the psychotherapist recognises and routes concerns, never assesses or advises on swallowing.

Scope of this guide: mental health, neurodevelopmental and neurological settings; aphasia and acquired brain injury; eating, drinking and swallowing; stammering; selective mutism; children's consent and safeguarding. Melodic intonation therapy (an SLT method for non-fluent aphasia) is written up separately in Domain VIII, 056; see the pointer row in section 4.

2. Framework

Because speech and language therapy is a profession, the "framework" is the care pathway SLTs describe, plus how a psychotherapist's work dovetails with it.

SLT pathway (as published)

Referral and information gathering. Case history from the person and caregivers, review of medical records [source: RCSLT, Eating, drinking and swallowing, March 2025].
Assessment and diagnosis. SLTs "provide assessment, diagnosis, joint goal-setting and intervention" for communication and for eating, drinking and swallowing difficulties [source: RCSLT ABI and CCD guidance news, 2 June 2026]. Swallowing assessment may include instrumental tests (videofluoroscopy, endoscopic assessment, manometry) [source: RCSLT EDS 2025].
Joint goal-setting with the person, family and team [source: RCSLT ABI/CCD 2026; ASHA 2016 on interprofessional collaboration and shared decision-making].
Intervention, in four roles RCSLT names for mental health services: managing (direct assessment and treatment of speech, language, communication and swallowing), enabling (helping people access information, co-produce recovery, express themselves and benefit from interventions), adapting (modifying assessments, group work and other psychological interventions), and supporting (helping multidisciplinary team colleagues communicate with the person) [source: RCSLT 2020].
Review, ending and onward referral. RCSLT advises telling people how many sessions are available, preparing them for the last one, and considering an SLT review after a course of counselling-skills work; SLTs refer on (GP, CAMHS, psychology or psychiatry, voluntary counselling services) when needs exceed their competence [source: RCSLT, Counselling guidance].

Session count and format. Sources cited give no standard session number for SLT; frequency, setting (clinic, ward, school, home, telepractice) and duration depend on condition and service [uncertain]. One research protocol for adapted psychological care in aphasia used about seven weekly sessions of roughly an hour [source: Baker et al. 2024]; this is a feasibility protocol, not a standard.

Psychotherapist's parallel phases [synthesis]

Before or at intake: screen for communication and swallowing concerns; ask about existing SLT involvement; obtain consent to liaise.
Joint planning: agree with the SLT which communication supports to use in therapy, who leads on what, and how information will be shared.
During therapy: use agreed supports; monitor whether the client is understanding and expressing; pass on any swallowing, choking or new communication concerns.
Ending: plan the ending accessibly; coordinate with SLT discharge or review.

Criteria for moving between phases [synthesis]: move from screening to referral when communication or swallowing concerns are observed or reported; from referral to joint planning once SLT assessment findings are shared (with consent); into adapted therapy when you and the client can verify mutual understanding with the agreed supports; review the plan whenever comprehension checks fail repeatedly, the client's condition changes (e.g. new neurological event, medication change reported by the prescriber), or safety concerns appear.

3. Guiding principles

Communication access is part of clinical quality. Practical meaning: assume verbal-only assessment may give inaccurate results and adapt before concluding a client lacks insight or engagement [source: RCSLT 2020].
Acknowledge competence. Treat the person with aphasia as a competent adult who "knows more than they can say": adult tone, normal volume, name the communication difficulty openly, include them when you speak with a companion [source: Aphasia Institute, Supported Conversation module, 2012].
Reveal competence. Make your message clear, give the person a way to answer, and verify what they meant [source: Aphasia Institute 2012].
Accessible information for consent. Care must be explained "in an accessible format"; capacity is assessed for each decision, at each moment [source: RCSLT, Consent guidance, March 2026].
Stay in scope, both ways. SLTs "are not professional counsellors" and use counselling skills only for emotional issues related to the communication disorder [source: RCSLT Counselling guidance]; ASHA likewise says SLPs refer when counselling needs fall outside communication and swallowing [source: ASHA 2016]. Practical meaning: psychological treatment of anxiety, depression or trauma is your job; communication and swallowing assessment and treatment are theirs.
Swallowing safety is medical. Practical meaning: never suggest food textures, thickeners, positioning or swallowing strategies; report concerns to the GP, prescriber or SLT [source: RCSLT EDS 2025 on SLT and MDT role; synthesis on the psychotherapist's boundary].
Interprofessional collaboration. Collaboration "requires joint communication and shared decision making" [source: ASHA 2016]. Practical meaning: shared goals, agreed roles, consented information flow.
Stammering-affirming stance. Stammering is a form of speech variation; avoid deficit language (RCSLT advises against "dysfluency"); aim for communicating freely and with comfort, not only fluency [source: RCSLT Stammering position statement, October 2025].
No pressure to speak in selective mutism. It is an anxiety disorder; do not pressurise, bribe or publicly praise speaking [source: RCSLT, Selective mutism].
Person's choice and autonomy. Offer choices with decision support [source: Baker et al. 2024]; respect refusal of any part of assessment or intervention and record it [source: RCSLT Consent 2026].
Confidentiality across professions. Do not pass on information without the person's permission, except where law or safeguarding requires [source: RCSLT Counselling guidance; synthesis on legal exceptions].
Children have a voice. The child's right "to give an opinion and have their views considered" applies even when a parent consents [source: RCSLT Consent 2026, citing the UN Convention on the Rights of the Child].

4. Intervention inventory

Part A describes what SLTs deliver, at a descriptive level, so you can explain it to clients and coordinate. Part B is the psychotherapist's own work.

Part A. What the SLT delivers (descriptive)

A1. Communication assessment and support in mental health services

Purpose / when used: identifying speech, language, communication and swallowing needs in adult mental health and CAMHS, which RCSLT reports are common and often unidentified (e.g. a cited figure that 81% of children with social, emotional and mental health needs have significant unidentified language deficits; a small adult study reporting language impairment in 80% of 60 people) [source: RCSLT 2020; RCSLT notes the evidence base is limited].
What the SLT does: direct assessment and management; making information about the condition and services accessible; adapting assessments, groups and psychological interventions; training and supporting MDT staff, including on adjusting psychological interventions and information for families; contributing to more accurate capacity and risk assessment [source: RCSLT 2020]. In psychosis, RCSLT notes communication partners can "inadvertently contribute to communication breakdown" and that SLT input has been reported to increase a patient's verbal communication [source: RCSLT 2020]. RCSLT calls for SLTs to be part of the core mental health workforce; in practice they are not always embedded [source: RCSLT 2020; RCSLT news on NICE depression guideline, June 2022].
Psychotherapist's link: ask for an SLT communication assessment or advice when your formulation depends on verbal report and you doubt comprehension or expression; ask the SLT to advise on adapting your materials [synthesis].
Watch for: apparent non-engagement, inconsistent answers, "yes" to everything, difficulty with abstract or hypothetical questions, very literal interpretation [synthesis].
Example language (illustrative): "A speech and language therapist could look at how you best take in and get across information, so our sessions suit you better." [synthesis]

A2. Aphasia, acquired brain injury and cognitive-communication disorders (neurological settings)

Purpose / when used: after stroke, brain injury or progressive neurological disease. RCSLT published updated acquired brain injury (ABI) guidance and new cognitive-communication disorder (CCD) guidance on 2 June 2026, covering assessment, diagnosis, joint goal-setting and intervention for communication and swallowing, with public information on how others can support the person [source: RCSLT ABI/CCD news 2026]. Detailed content is member-only and not verified [uncertain].
What the SLT does: assessment of language (understanding, speaking, reading, writing) and cognitive-communication; impairment-focused therapy; training communication partners; supported conversation; aphasia-friendly information [source: RCSLT ABI/CCD 2026 for the general role; Aphasia Institute 2012 for supported conversation; specific aphasia therapy methods not verified, uncertain].
Pointer: Melodic intonation therapy is an SLT method for non-fluent aphasia; see Domain VIII, 056. It is delivered by trained SLTs; the psychotherapist's role is collaborative support of mood, motivation and adjustment around it.
Psychotherapist's link: mood, adjustment and identity after communication loss; joint work on access to psychological therapy (B2, B3).
Example language (illustrative): "Your speech therapist is working on the words; here we can work on how it feels to have lost them." [synthesis]
Watch for: low mood, withdrawal and frustration after communication loss; the client being left out of conversations about their own care. [synthesis]

A3. Neurodevelopmental settings (developmental language disorder, autism, learning disability)

Purpose / when used: children and adults with developmental language disorder (DLD), autism or learning disability. RCSLT cites evidence that SLT is effective for autism and learning disability, and reports that children with a mental health disorder report speech or language problems far more often than peers [source: RCSLT 2020]. RCSLT also flags young people in the justice system as at increased risk of communication needs [source: RCSLT 2020].
What the SLT does: assessment and diagnosis of language and social communication; advice to schools and families; augmentative and alternative communication (AAC) is within scope in the US as "the full range of AAC technologies" [source: ASHA 2016]. Specific programmes are not verified [uncertain].
Psychotherapist's link: check whether a child or adult referred for anxiety, low mood or behaviour has had a language assessment; use the SLT's recommendations (vocabulary level, visual supports, AAC) in sessions [synthesis].
Example language (illustrative): "Has anyone ever checked how you understand and use language? It might help me explain things in a way that works for you." [synthesis]
Watch for: anxiety or behaviour problems that may partly reflect unrecognised language difficulty. [synthesis]

A4. Eating, drinking and swallowing (dysphagia): a medical safety matter

Purpose / when used: EDS difficulties (also called dysphagia, or feeding difficulties in children) [source: RCSLT EDS 2025]. RCSLT reports raised prevalence in mental health populations (over 30% of adults with mental health disorders have some swallowing impairment in cited studies), that antipsychotics and anxiolytics can affect swallowing, that difficulty swallowing medication can lead to choking, and cited studies of markedly higher choking death rates in schizophrenia and among psychiatric inpatients [source: RCSLT 2020].
What the SLT does: case history and record review; detailed EDS assessment; instrumental assessment where needed (videofluoroscopy, endoscopic assessment, manometry); identifying and reducing risks such as choking and chest infection; advice on strategies, positioning, exercises and food presentation; texture modification guided by the International Dysphagia Diet Standardisation Initiative (IDDSI), weighed against malnutrition, dehydration and the person's views; education of the person and carers; work within an MDT with dietitians, OTs, physiotherapists, pharmacists, dentists [source: RCSLT EDS 2025]. RCSLT has separate guidance on eating and drinking with acknowledged risks (not verified) [uncertain].
Signs RCSLT lists: food or drink escaping from the mouth or nose, coughing or choking, food sticking, a wet or hoarse voice, long mealtimes, chewing difficulty, bringing food back, breathlessness when eating, chest infections, weight loss [source: RCSLT EDS 2025].
Psychological aspects: embarrassment, loss of enjoyment, fear of eating or drinking, avoiding eating with others, mealtime anxiety for the person and family; mental health conditions are listed among causes of EDS difficulty in adults [source: RCSLT EDS 2025].
Psychotherapist's link: recognise and route (B5); treat the psychological consequences only once medical and SLT assessment is in place.
Example language (illustrative): "Coughing when you eat or drink needs checking by a doctor and a swallowing specialist. Can I let your GP know?" [synthesis]
Watch for: coughing, choking or a wet voice when eating or drinking, weight loss, new fear of eating; route these to the medical team. [synthesis]

A5. Stammering

Purpose / when used: developmental stammering (usually starting in early childhood) and stammering acquired later, which often follows neurological, psychological or pharmacological change [source: RCSLT Stammering position statement 2025].
What the SLT does, as RCSLT states its aims: helping people communicate to their potential, talk freely and speak with ease and comfort; creating environments where stammering is accepted as "how some people speak"; reducing negative impact on the person, carers and environment; connecting people who stammer; supporting self-advocacy; early intervention in young children to support parent-child interaction and reduce parental anxiety; group therapy for self-acceptance and confidence [source: RCSLT 2025]. The position statement does not name specific techniques and calls for research on stammering-affirming approaches [source: RCSLT 2025].
Psychotherapist's link: anxiety, social anxiety, concealment and avoidance, effects of stigma and bullying are noted in the statement and are where psychological work fits (B6).
Example language (illustrative): "Take all the time you need. What matters to me is what you want to say." [synthesis]
Watch for: concealment and avoidance that shrink the client's life; new stammering in adulthood, which needs medical review. [synthesis]

A6. Selective mutism

Purpose / when used: an anxiety disorder in which a child speaks freely in some situations but not others for a month or more, not explained by another communication or language difficulty, and limiting academic or social functioning; low-profile and high-profile presentations; adult selective mutism is described as an emerging area [source: RCSLT, Selective mutism].
What the SLT does: assessment, identification and management, working with school or college staff and other professionals; RCSLT stresses early intervention [source: RCSLT Selective mutism]. Specific step-by-step techniques are not given in the source cited [uncertain].
Psychotherapist's link: joint anxiety-focused work with the SLT, family and school (B7).
Example language (illustrative): "You don't have to talk to me. You can point, nod or draw, and that counts." [synthesis]
Watch for: pressure to speak from adults at home or school; praise that draws attention to speaking. [synthesis]

A7. Counselling skills within SLT (boundary marker)

What it is: SLTs use counselling skills for emotional issues related to the communication disorder, as part of holistic care. Where counselling skills are the main approach, RCSLT expects agreement on focus at the outset, postgraduate counselling-skills training, enhanced supervision and manager awareness; SLTs know the limits of competence and refer on [source: RCSLT Counselling guidance]. RCSLT lists communication-access tools used in this area, including Talking Mats and the Connect Communication Disability Profile [source: RCSLT Counselling guidance].
Psychotherapist's link: you are a likely referral destination when emotional needs go beyond the communication disorder; SLTs may also support a client's communication so they can access your counselling [source: RCSLT Counselling guidance].
Example language (illustrative, to the SLT): "It sounds as if the worry has grown beyond the speech difficulty itself. I'm happy to take a referral for that." [synthesis]
Watch for: emotional needs beyond the communication disorder going unreferred. [synthesis]

Part B. The psychotherapist's interventions

B1. Screening for communication needs and referring to SLT

Purpose: catch unrecognised communication needs that distort assessment, consent and engagement [source: RCSLT 2020 for the rationale; steps are synthesis].
Steps: (1) At intake ask about history of speech, language, hearing, reading or writing difficulty, schooling support, stroke, head injury or neurological illness, and any past or current SLT. (2) Observe: delayed or off-target answers, word-finding pauses, reliance on "yes", difficulty with multi-part questions, difficulty retelling what you said. (3) Check understanding by asking the client to say back the key point in their own words. (4) If concerns persist, discuss referral with the client and route through the GP, the MDT or a local SLT service (NHS) or a registered independent SLT; in the UK check the HCPC register, in the US check state licensure and CCC-SLP [source: HCPC/RCSLT; ASHA 2016]. (5) With consent, send a short referral stating what you observed and what you need help with (e.g. adapting therapy materials).
Example language (illustrative): "Some people find that talking therapy asks a lot of words. I'd like to make sure the way I talk works for you. Would it help to have a speech and language therapist look at what makes conversations easier?"
Watch for: the client feeling labelled as "not clever enough"; RCSLT notes that suggesting referral can imply a problem is "too big" [source: RCSLT Counselling guidance]. Frame it as fitting therapy to the person. It is working when SLT advice changes how you run sessions and comprehension checks improve.

B2. Supported conversation in sessions

Purpose: let a person with aphasia or other language impairment take part as the competent adult they are [source: Aphasia Institute 2012].
Steps: (1) Acknowledge competence: adult tone, normal volume; say you know they understand more than they can say; if a companion is present, include the client and say openly why you are asking the companion. (2) Message in: short simple sentences, expressive voice, easily understood gestures, key words written large and bold, one picture at a time. (3) Message out: yes/no questions the client can answer, one question at a time, invite gesture, pointing or writing, give time. (4) Verify: summarise slowly what you think they mean, with key words or gestures, and check [source: Aphasia Institute 2012]. (5) Keep a pen, paper, and a simple 0–10 or picture rating line to hand for feelings and intensity [synthesis; pictorial rating approach see B3].
Example language (illustrative): "I know you know what you want to say. Take your time. [writes WORRY ... SAD ... ANGRY] Point to the one that fits best today." Then: "So: sad, mostly about work. Yes?"
Watch for: answering for the client, finishing sentences, speaking only to the companion, moving on without verifying. The Aphasia Institute rates acknowledging and revealing competence on a 0–4 scale for training; you can self-rate after sessions [source: Aphasia Institute 2012]. It is working when the client's answers become more specific and verified summaries are confirmed.

B3. Adapting psychological therapy for aphasia and communication needs

Purpose: make structured psychological care accessible. The elements below are drawn from the Aphasia PRISM feasibility protocol (behavioural activation, problem solving or relaxation for people with aphasia), which is a research protocol, not an established manual [source: Baker et al. 2024].
Steps: (1) Ask the SLT for the client's communication profile and recommended supports. (2) Use aphasia-friendly written material every session: few words, large clear print, bold key words, supporting pictures, one item at a time [source: Baker et al. 2024]. (3) Monitor mood with a pictorial scale rather than a verbal questionnaire; the protocol used the Depression Intensity Scale Circles (not reproduced here) [source: Baker et al. 2024]. (4) Offer a choice of therapy approach with decision-making support [source: Baker et al. 2024]. (5) Set concrete goals, plan actions and link them to daily routines with between-session practice; recorded audio-visual relaxation material can replace written scripts [source: Baker et al. 2024]. (6) Involve a family member if the client nominates one, for communication and practice support [source: Baker et al. 2024]. (7) Choose in-person or telehealth by communication access; the protocol notes telehealth may not suit moderate-severe aphasia [source: Baker et al. 2024]. (8) Use final sessions to revisit goals, barriers and resources [source: Baker et al. 2024]. (9) Slow your pace, cut abstract metaphors, use concrete examples, and allow longer or more frequent shorter sessions if fatigue is an issue [synthesis].
Example language (illustrative): "Here are three ways we could work. [cards: DO MORE / SOLVE A PROBLEM / RELAX] Which one first?"
Watch for: fatigue, frustration, written material that is still too dense, family members taking over. It is working when the client completes planned activities and mood ratings shift.

B4. Accessible consent and capacity support

Purpose: valid consent requires information the person can understand; capacity is decision-specific and time-specific [source: RCSLT Consent 2026].
Steps: (1) Present information about therapy, confidentiality and its limits in accessible form (short written points, pictures, Talking Mats or similar, aphasia-friendly materials) [source: RCSLT Consent 2026]. (2) Check understanding by asking for teach-back or pointing to options. (3) Do not conclude a person lacks capacity because their communication is impaired; ask the SLT to support any formal capacity assessment (RCSLT lists the Communication Aid to Capacity Assessment among resources) [source: RCSLT Consent 2026; RCSLT 2020 on accurate risk and capacity assessment]. (4) Where capacity is lacking for a decision, follow the applicable law (Mental Capacity Act 2005 in England and Wales; Adults with Incapacity (Scotland) Act 2000; Mental Capacity Act (Northern Ireland) 2016) and best-interests procedure, and record the assessment [source: RCSLT Consent 2026]. US: follow state law and your licensing board [uncertain, not verified]. (5) Revisit consent; it is ongoing and can be withdrawn [source: RCSLT Consent 2026]. (6) Get separate written consent for any audio or video recording, explaining purpose and future use [source: RCSLT Consent 2026].
Example language (illustrative): "This card says what we talk about stays private. This one says when I would have to tell someone: if you or someone else is in danger. Show me which one means 'private'."
Watch for: acquiescent "yes"; consent obtained from a relative without the client's involvement.

B5. Dysphagia and choking: recognise and route (medical matter)

Purpose: keep clients safe. Swallowing difficulty and choking risk are raised in mental health populations and with some medications [source: RCSLT 2020]; assessment and management belong to the SLT and medical team [source: RCSLT EDS 2025].
Steps: (1) Know the signs RCSLT lists (A4). (2) If a client reports or you see coughing or choking with food, drink or tablets, food sticking, wet or hoarse voice after drinking, recurrent chest infections, weight loss, or new fear of eating, tell the client this needs a medical and SLT check and, with consent, inform the GP, prescriber or MDT promptly [source for signs: RCSLT EDS 2025; routing is synthesis]. (3) Do not advise on textures, thickening, positioning, swallowing technique, or medication form; route all medication questions to the prescriber [synthesis]. (4) If someone is actively choking in session, follow emergency first-aid procedures and call emergency services [synthesis]. (5) Once medical and SLT assessment is in place, offer psychological support for fear of eating, mealtime anxiety, embarrassment and social withdrawal [source: RCSLT EDS 2025 for these impacts]. (6) Distinguish carefully: avoidance of food may reflect dysphagia, fear after a choking episode, or an eating disorder; do not treat as purely psychological until physical causes are excluded by the medical team [synthesis].
Example language (illustrative): "You've mentioned coughing when you drink. That can have a physical cause, and it's important a doctor and a swallowing specialist check it. Can I let your GP know?"
Watch for: recommending modified diets yourself; delaying referral while working on anxiety; dismissing reported swallowing problems as somatic or psychosomatic.

B6. Psychological work with people who stammer

Purpose: address anxiety, social anxiety, concealment, avoidance and effects of stigma or bullying, which RCSLT identifies as linked to stammering [source: RCSLT 2025]; coordinate with SLT on goals.
Steps: (1) Ask the client what they want: some want to speak more fluently, others to speak freely and with less fear; respect the stammering-affirming stance RCSLT takes [source: RCSLT 2025]. (2) Use the client's preferred term; RCSLT uses "stammering" (or "stuttering") and avoids "dysfluency" [source: RCSLT 2025]. (3) In sessions, wait; do not finish words, look away, or rush [synthesis]. (4) Work on avoidance and safety behaviours (word substitution, avoiding calls) with the client's consent, using your own modality's methods, aligned with any SLT goals [synthesis]. (5) Explore experiences of stigma and bullying, and support self-advocacy (e.g. asking for time in exams or meetings) [source: RCSLT 2025 for self-advocacy aim and exam-time example]. (6) Consider pointing to peer connection, which RCSLT names as an aim [source: RCSLT 2025]. (7) New stammering in adolescence or adulthood can follow neurological, psychological or pharmacological change: route to medical review and SLT rather than assuming a purely psychological cause [source: RCSLT 2025; routing is synthesis].
Example language (illustrative): "Take all the time you need. I'm interested in what you say, not how fast."
Watch for: framing fluency as the only success; your own discomfort with silence. It is working when avoidance falls and the client speaks in situations they had been avoiding.

B7. Selective mutism: joint anxiety-focused work

Purpose: support a child (or adult) whose speaking is blocked by anxiety, in partnership with SLT, family and school [source: RCSLT Selective mutism for the condition and SLT role; steps are synthesis unless tagged].
Steps: (1) Confirm an SLT has assessed speech and language, since the diagnosis requires that the pattern is not explained by another communication difficulty [source: RCSLT Selective mutism]. (2) Agree one shared plan across SLT, school staff, parents and you, so the child meets the same approach everywhere [synthesis]. (3) Remove pressure: no bribes, no demands to speak, no public praise for speaking; RCSLT gives these cautions [source: RCSLT Selective mutism]. (4) Accept non-verbal communication (pointing, nodding, writing, gesture) as full participation in your sessions [synthesis]. (5) Build gradual, child-paced steps toward speaking with more people and places, "small steps when they feel ready" in RCSLT's parent advice; adjust environments rather than avoiding social events [source: RCSLT Selective mutism; specific graded methods are not in the source cited, so plan them jointly with the SLT, synthesis]. (6) Address parental anxiety and family accommodation [synthesis]. (7) For adults, recognise this as an emerging area; find professionals willing to learn and signpost adult peer support [source: RCSLT Selective mutism].
Example language (illustrative): "You don't need to talk with me today. You can point or draw, and that counts."
Watch for: adults testing the child by asking direct questions in front of others; praise that draws attention. It is working when anxiety signs ease and the child communicates in more settings.

B8. Joint working and information sharing with the SLT

Purpose: interprofessional collaboration with shared decision-making [source: ASHA 2016].
Steps: (1) Get the client's consent for what will be shared with whom; RCSLT says counselling information should not be passed on without permission [source: RCSLT Counselling guidance]. (2) Agree roles in writing: SLT leads communication and swallowing; you lead psychological assessment, risk and therapy [synthesis consistent with RCSLT and ASHA scope statements]. (3) Agree shared goals and how you will review them [source: RCSLT ABI/CCD 2026 on joint goal-setting]. (4) Consider joint sessions where helpful (e.g. agreeing communication supports, or a joint session on fear of speaking) [synthesis]. (5) Ask SLT to adapt your group materials or psychoeducation [source: RCSLT 2020 on SLTs modifying group work and psychological interventions]. (6) Feed back to the SLT any mood, motivation or risk factors that may affect their therapy, within consent [synthesis].
Example language (illustrative), to a colleague: "My client finds long questions hard. Could you suggest how I should word the session plan and mood check?"
Watch for: duplicated or contradictory advice; the client being asked the same history repeatedly.

B9. Children: consent, assent and safeguarding

Purpose: lawful, ethical work with children who have communication needs.
Steps (UK, as RCSLT sets out): (1) For under-16s, consent is normally sought from a person with parental responsibility; one such person's consent is generally valid even if another withholds it (Children Act 1989). (2) A child under 16 may consent if they have sufficient maturity to understand the nature, purpose and likely outcome (Gillick competence); encourage involvement of parents unless clearly not in the child's interest. (3) Young people aged 16–17 are presumed competent, though parental or court decisions may override in their best interests. (4) A headteacher cannot consent for a child; foster carers do not automatically hold full parental responsibility. (5) Under-16s need parental consent for internet-delivered services [source: RCSLT Consent 2026]. Equivalent rules differ across UK nations and US states [uncertain, not verified].
Assent (the child's own agreement when they cannot legally consent): RCSLT's consent page does not use the term [source: RCSLT Consent 2026]; good practice is to seek the child's agreement in accessible form and give weight to their views, consistent with the child's right "to give an opinion and have their views considered" [source: RCSLT Consent 2026; the assent procedure is synthesis]. Use pictures, symbol choices, Talking Mats-style choices or the SLT's recommended system; accept non-verbal "no" (turning away, distress) as meaningful [synthesis].
Safeguarding [synthesis; the sources cited do not give a safeguarding protocol]: children with communication needs may be less able to disclose harm or understand what is happening, so (a) follow your local safeguarding procedures and statutory guidance; (b) when a child with communication needs may be disclosing, use their usual communication method, ask open, non-leading questions, record their words or signs exactly, and do not investigate yourself; (c) involve the SLT (with the safeguarding lead's agreement) to support the child's communication in any formal process; (d) never let a carer who may be implicated act as interpreter.
Example language (illustrative): "This is your picture board. You can show me yes, no or stop at any time."
Watch for: proceeding on a parent's consent while the child clearly objects; assuming silence means agreement.

B10. Psychological care for adjustment to communication disability

Purpose: treat low mood, anxiety, grief and identity change after communication loss or with lifelong communication difficulty, as the referral destination when SLT counselling skills reach their limit [source: RCSLT Counselling guidance on referring to GP, CAMHS, psychology or psychiatry, counselling services].
Steps: (1) Accept referrals from SLTs and clarify what the SLT is continuing to provide. (2) Assess mood using accessible measures and observation, with SLT input where verbal measures are unsuitable [source: Baker et al. 2024 for pictorial mood monitoring; synthesis for assessment]. (3) Deliver your usual evidence-based therapy with B2–B3 adaptations. (4) Include family or carers where the client wishes [source: Baker et al. 2024]. (5) Plan the ending accessibly, with notice of how many sessions remain [source: RCSLT Counselling guidance on endings; applied here as synthesis].
Example language (illustrative): "Losing words is a real loss. We can work on how you're feeling about it, alongside the speech work."
Watch for: suicidal thinking that the client cannot easily put into words; use accessible risk questions and involve the team (see section 5).

B11. Supporting engagement with SLT

Purpose: help clients use SLT well, without taking over SLT tasks [synthesis].
Steps: (1) Explore ambivalence about SLT home practice or about recommendations such as modified diets, without advising any change; pass concerns to the SLT [synthesis; principle from RCSLT EDS 2025 that changes are weighed against the person's views]. (2) Work on motivation, frustration tolerance and hope. (3) Help the client prepare questions for SLT and medical appointments.
Example language (illustrative): "It sounds like the thickened drinks are hard to live with. That's important for your speech therapist to hear. Shall we write down what you want to tell them?"
Watch for: colluding with non-adherence to swallowing advice; that decision is for the client with the SLT and medical team.

5. Handling problems

Most guidance here is [synthesis] built on the sources in sections 1–4; source-based points are tagged.

Client seems "not engaging" or "lacking insight". Consider language demand before attributing it to motivation; RCSLT warns people with communication needs may be perceived as not engaging [source: RCSLT 2020]. Response: simplify, verify understanding (B2), request SLT advice (B1).
Client says "yes" to everything. Replace yes/no questions on key points with choices between written options, and verify by teach-back [synthesis; Aphasia Institute 2012 on verification].
Overwhelm or fatigue in aphasia or brain injury. Shorten tasks, one idea per session segment, more written support, breaks; consider shorter, more frequent sessions [synthesis].
Frustration or shame when words fail. Name it, acknowledge competence, slow down, give time [source: Aphasia Institute 2012 on acknowledging frustration].
Risk assessment with limited language. Do not skip it. Use accessible formats (written key words, pictures, rating lines), ask directly and concretely, involve the SLT on how to ask and the MDT or crisis team as usual; make a safety plan in accessible form; treat non-verbal distress signals seriously [synthesis; RCSLT 2020 on risk assessments being unreliable without accessible information].
Swallowing concern raised mid-therapy, or client refuses SLT recommendations. Do not advise; tell the client it needs a medical and SLT review and, with consent, inform the GP, prescriber or MDT; in an emergency follow first-aid and emergency procedures. If they refuse advice, explore their reasons and pass them on; a capacitous person may refuse care once aware of risks [source: RCSLT Consent 2026 on refusal; RCSLT EDS 2025 on weighing the person's views; routing is synthesis].
Medication and swallowing or speech changes. Antipsychotics and anxiolytics can affect swallowing [source: RCSLT 2020]; new stammering can follow pharmacological change [source: RCSLT 2025]. Response: route to the prescriber; never suggest altering medication [synthesis].
Family member answers for the client. Thank them, then redirect to the client using supported conversation; agree roles for the companion [source: Aphasia Institute 2012 on including the client; synthesis].
Disagreement between professionals (e.g. psychological versus communication explanation of a child's silence). Arrange a joint meeting, share observations across settings, agree a single plan [synthesis].
Rupture after referral to SLT (client feels judged as deficient). Repair openly; frame SLT as making therapy fit the person [synthesis; RCSLT Counselling guidance notes referral can feel like the problem is "too big"].
Stammering client wants you to "fix" fluency. Explore their goals; refer to SLT for speech work; keep your focus on fear, avoidance and stigma [synthesis; RCSLT 2025 on goals].
Selective mutism: no progress, or pressure from school. Review whether pressure has crept back, check consistency across adults, return to smaller steps, meet the SLT and school [synthesis; RCSLT Selective mutism on avoiding pressure].
Child objects though parent consents. Pause, explore the child's view accessibly, adjust the plan; record the child's view; seek advice if the child continues to refuse [synthesis; RCSLT Consent 2026 on the child's views].
Safeguarding concern in a child with communication needs. Follow local procedures without delay; use the child's communication system; record exactly; involve the safeguarding lead and, through them, SLT support [synthesis].
No SLT available locally. Use the registers (HCPC in the UK; state licensure and ASHA certification in the US) to find a qualified practitioner; meanwhile use supported conversation and accessible materials; do not take on swallowing assessment or speech therapy yourself [source: HCPC/ASHA for registration; synthesis].
Telehealth barriers. Offer in-person sessions where communication access needs it [source: Baker et al. 2024].

Sources

Online sources:

Cross-reference: Domain VIII, 056 Melodic intonation therapy.

Not verified [uncertain]: RCSLT member-only ABI/CCD guidance and "eating and drinking with acknowledged risks" guidance; US state licensure statutes; specific aphasia, DLD and selective mutism treatment manuals.

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