Here’s a thing I maybe shouldn’t admit to: I hate doing Pragmatic Language Therapy.
For those of you don’t know, “Pragmatic Language” refers to the use of verbal and nonverbal language in social situations. PLT, which closely overlaps with the terms “Social Communication” and “Social Skills,” is one of many areas that Speech-Language Pathologists (SLPs) can target. It includes a wide range of skills, such as:
- The use of pitch and tone (example: “She has a cat.” vs. “She has a cat?”)
- Perspective-taking (“How does that person feel and why?”)
- Using language for a variety of purposes (commenting, requesting, rejecting, etc)
- Clarifying miscommunication (saying something in a different way, saying “I don’t understand”)
- Following conversational rules (taking turns speaking, staying on topic) and rituals (greetings, farewells, etc)
- Starting and ending conversations or topics
Part of my dislike of PLT is the fear that I’ll have to teach a skill I barely know how to use in my own life. I have never been particularly socially adept, and there will always be aspects of the Neurotypical (NT) social sphere that elude me. So who am I to evaluate and teach these skills in other people?
That said, many of my feelings on the subject stem from my oft-repeated opinion that Speech-Language Pathology is an unapologetically ableist field. With PLT in particular, many of us are encouraging ableism in the people we serve and the other people around them.
It is possible to conduct PLT in a way that is inclusive and empowering instead of ableist. Some folks do benefit from direct instruction in Pragmatic Language, as long as therapists and educators are careful to avoid the pitfalls of ableism and other forms of bigotry.
Here are a few reasons why I dislike PLT, followed by a some questions for educators and clinicians to ask themselves when teaching social communication in any of its forms.
Reason #1: “Pragmatic Language” is an arbitrary category.
Someone on a forum for SLPs asked about the difference between “Social Communication” and “Pragmatic Language.” Almost every single person (myself included) replied with different ideas. This field is so subjective and ill-defined that we don’t even have agreed-upon definitions for the most general terms!
Beyond that, folks in and around SLP culture tend to use these terms to refer to behaviors that have little if anything to do with communication or language. A certain big name manufacturer of speech therapy materials seems to define “social skills” as everything from manners to eye-contact to school rules. I’m not sure in which universe “walk quietly in a single-file line” counts as communication, but it’s not the one I live in.
This blurring of the boundary between “pragmatic language” and “school behavior” means I get a lot of requests for Pragmatic Language evaluations of students who have emotional, mental health, or conduct/defiance disorders. Yes, it’s important to find out whether these students have communication difficulties underlying or exacerbating their struggles, but it’s neither fair nor productive to assume they do by default. If you tell a student “sit in the blue chair,” and they look you in the eye and deliberately sit in a red chair, that isn’t necessarily a communication breakdown. There is a strong possibility that that student is communicating something to you exactly as they intended. You don’t get to assume they have an impairment simply because they are communicating something you don’t want to hear in a way you don’t want them to communicate it.
Including challenging behaviors under “pragmatic language” comes from and contributes to an presumption that behavior and social skills are inextricably linked. This is sometimes true. The assumption that it is always true is, among other things, ableist. Which brings me to my next point:
Reason #2: Many judgements about social skills stem from ignorance and/or indifference to diverse perspectives.
Oh look, I’m complaining about ignorance and bigotry in my profession! It must be a weekday. Or a weekend. One of the two. Anyway…
In the United States, SLPs are required to show Cultural Competence in all aspects of our profession. As noted by the American Speech and Hearing Association, this can include: “age, disability, ethnicity, gender identity (encompasses gender expression), national origin (encompasses related aspects e.g., ancestry, culture, language, dialect, citizenship, and immigration status), race, religion, sex, sexual orientation, and veteran status.” Cultural Competence requires us to consider a person’s unique set of identities when we evaluate, write goals, and conduct therapy.
One of the reasons PLT stresses me out is that the “rules” of verbal and nonverbal social language differ drastically between all of the aforementioned groups, but NT people – especially white western folks – tend to view their way as The One Correct Way. Any deviation is flagged as something wrong that should be fixed. Cultural Competence requires a deliberate effort to consider individual differences. It means identifying our biases and deliberately working to overcome them.
Cultural differences affect language and communication in a variety of ways, but Pragmatic Language is possibly the most obvious one. Examples include physical proximity and boundaries, conversational turn-taking, direct vs indirect communication, conflict resolution, and social rituals. Body language that may come across as friendly to one person may feel aggressive to another; the opposite behavior may feel rude to the former person but welcoming to the latter. Cultural competence means acknowledging that neither perspective is is The Correct One.
To be fair, many Pragmatic Language assessments do specify that clinicians need to consider a person’s culture when evaluating them. The issue of Cultural Competence is more widely acknowledged than some of the other problems with PLT. That said, the overwhelming majority of SLPs in America are white, a demographic which is only recently starting to move away from seeing ourselves as the “default.”
Over and over I have witnessed SLPs making racist remarks – in seminars, at work, or on social media – about a person’s appearance, behavior, dialect, vernacular, or accent. Some SLPs have argued vehemently, even violently, about gender-neutral pronouns, queerness, or gender roles. These biases influence evaluation and treatment of language, and many of them impact PLT in particular. How can we truly be Culturally Competent when so many biases keep getting in our way?
In one of the more widely-known Pragmatic Language rating scales for kids and teenagers (the Pragmatics Profile of the CELF-5), one item asks how a student responds to “teasing, anger, failure, or disappointment.” Students receive the highest possible rating when they always (or almost always) respond using “culturally appropriate” language. There is no mechanic to consider students who mask their emotions due to anxiety, depression, or something else. In a different assessment (the SLDT), students receive the highest possible score for some items if they state that they would lie to peers in certain situations. These lies are rated higher than truthful responses showing empathy or sympathy. In a Social Skills checklist for Preschool-age children, students who spend almost all of their time playing with peers are given higher scores than children who play on their own at least some of the time. Students receive higher scores simply for being extraverted. In these cases, it is up to the clinician to consider individual differences.
Unsurprisingly, neurotype is not one of the factors listed under Cultural Competence, even though even some SLPs are starting to acknowledge that autism is an identity worth respecting. Excluding neurodiversity is especially problematic because a huge portion of the people who receive speech therapy, especially PLT, are autistic. Yet instead of recognizing autism as a different way of perceiving and interacting with the world, many practitioners of PLT train autistic folks to act neurotypical (also known as “masking” or “camouflaging”), even when their reasoning directly contradicts research.
Take, for example, the study that used MRI scans to demonstrate the negative effects of eye-contact on autistic people, or the study showing that interaction between autistic people is just as effective and meaningful as interaction between non-autistic people. Consider the research that shows masking/camouflaging to be one of the highest risk factors of suicide in autistic people. The fact that these articles haven’t made waves in the field of PLT indicates how little respect our field has for neurodiverse (ND) identities. Instead, clinicians and educators trick, bribe, prompt, or force autistic people to make eye-contact against their will. They continue to push the narrative that autistic people are inherently poor communicators who require extensive therapy in order to have successful relationships. By ignoring the perspectives, strengths, norms, or needs of autistic people, this narrative would blatantly violate the rule of Cultural Competence, except that ASHA has yet to include ND folks in its definition. As a profession, we do not seem to care.
Reason #3: PLT can be abusive and damaging.
Recently, The Guardian published an article about a school that forced a 10-year-old special education student to draw a picture of himself surrounded by a list of his personal faults. This “project” was their response to the student’s complaint that other students were bullying him. How did he come up with all his flaws, you ask? Simple: he was forced to sit down and listen as his peers, under the direction of the educators, told him all the reasons they didn’t like him.
There are so many problems with this: victim-blaming, humiliation, ableism, and abuse, for starters. Unfortunately, this incident is the product of a system that consistently others and humiliates people who are different, placing them at fault for any bullying that they face. For example, this research review on autism and bullying lists a series of social deficits that make autistic people prime targets for bullying, without placing any responsibility on the people who bully them. A more recent example is the range of reactions to the aforementioned incident from SLPs and other clinicians and educators on social media. Some people expressed discomfort or distress, but more people described similar practices that they use during PLT.
Although usually more underhanded and implicit, PLT has the potential to hurt students in the same way that this school did. Without careful consideration, it’s easy to accidentally teach a student self-hatred, internalized ableism, and victim-blaming. PLT can train people to think “I’m bad and it’s my fault that people bully me” or “I need to change who I am if I want to have friends,” even if we’re not making them write or say these things directly.
As mentioned before, PLT with autistic people teaches masking, which means adopting behaviors that mimic NT people. Far too few NT clinicians understand (or care?) how much emotional labor this takes (here is a long but amazing article on emotional labor and autism) or how false and draining it feels.
I’m going to give a personal example. My social experience as a preteen and early teenager was not, shall we say, great. (I’m going to skip the details, but you can probably infer them based on what frequently happens to ND students at school.) I lacked awareness of social nuances. I rarely if ever thought through what I was saying, how I was saying it, or how I might make people feel. This is not to say that I didn’t care how other people felt, just that some things that are obvious to NT people simply didn’t occur to me. To make matters worse, I was not diagnosed with Autism or ADHD until adulthood, so people were responding to me as if I was a NT child whose difficulties were due to personal faults.
And then I learned how to mask.
Like a lot of autistic people, I needed to be confronted with social expectations in blunt, concrete ways. Like a lot of autistic people (especially girls, though boys do this too) I learned the rules through imitation. I mimicked my peers, even when I didn’t like or understand their behavior, in a desperate attempt to be liked. It worked, in a sense. After years of trial-and-error, I created a mask that allowed me to blend in, which noticeably improved my social experiences. When I successfully pretended to be a NT person, I fit in…right up until I burned out.
Masking is exhausting. As an introvert, I already find social interaction draining, but doing it while pretending to be someone I’m not is even worse. Because that’s what masking feels like: pretending. When I mask, I’m playacting. I’m deceiving people. I’m adopting mannerisms – good and bad – that I see NT people use, because after a couple decades of practice, I’ve learned that This Thing works in This Context. Constantly maintaining that facade is exhausting.
What’s worse, because of the way my social experience improved as I got better at masking, I learned that I was only allowed to have friendships if I successfully fooled people into thinking I was someone I’m not. Even before I learned I was multiply-neurodivergent, I was hyper-aware that I was fundamentally different from everyone around me, and not in a good way. Years of teaching myself to mask may have improved my life on the surface, but with those improvements came an Anxiety Disorder (even now there are social nuances I don’t understand, which creates a deep-seated fear that I will mess up and ruin everything without knowing why), suicide attempt (just like the research indicates!), and the belief that my value as a person is entirely dependent on my ability to act like someone else.
This is just my experience as a white ND person. For ND people of color, the experience is even harder. With the extra scrutiny and discrimination against people of color by police, CVE programs, and white civilians, masking for autistic people of color is an actual matter of life and death.
If the link between suicide and masking was surprising before, hopefully it makes sense now.
When we conduct Pragmatic Language Therapy with autistic people, we are teaching them to mask. I cannot stress this enough. We are literally teaching autistic folks to act like someone they’re not, with the promise that their quality of life will improve as a direct result. The sad part is: it’s true. For many autistic folks, positive relationships with NT people, such as friendship, romance, employment, tolerance, and (for some) not being killed, directly correlate with their ability to successfully mask their autism.
This is due to a wider systemic and social problem that individual therapists can’t fix. But PLT, unless it’s conducted in a deliberate and mindful way, reinforces the idea that value and worth is inextricably linked to the ability to pass as NT.
Reason #4: Often, we aren’t teaching what we think we’re teaching.
Too often, social skills or other lessons with Special Education students teach universal compliance rather than skills promoting independence and dignity. We are constantly telling the people we work with that they don’t have the right to say “no.” In addition to the overuse of physical prompting, I’ve witnessed educators and clinicians saying things like: “You do not say no to other kids,” or “Never say no to an adult.” For people who think literally, imagine the sorts of problems this message can cause in the future. If you work with autistic or intellectually disabled people, step back and consider the scope and variety of abuse that you are potentially enabling when you teach a person to “never say no.”
This is an extreme example. There are also less extreme ones.
For one, there’s a certain fictional student designed to teach children how to listen with their “whole body.” Listening, he asserts, is not just about hearing what a person says; it’s also about looking at that person’s eyes and keeping your body completely still. This character teaches students how to show adults that they are listening, but does not acknowledge that for some people, Whole Body Listening is counterproductive.
With my double diagnosis of Autism and ADHD, I can tell you with great certainty that when I focus on looking at a person’s eyes and suppressing my tendency to fidget or stim, it is very difficult for me to process what they’re saying. Many, many, many,* many, MANY other ND folks report the same thing.
*For discussion of listening and looking, skip to ahead to 2:13. Honestly though, the entire video is worth a watch.
For ND people, I compare Whole Body Listening to rubbing your stomach while patting your head, or doing a crossword puzzle with the TV on. With time and practice, some of us can learn to those things simultaneously, but it will always take extra effort. For others, it simply cannot be done. Yet PLT tells ND people that our style of listening is “wrong,” that the “right” way to listen is to make things difficult, even impossible, for ourselves in order to help the speaker feel comfortable.
Another example of counterproductive PLT is “Size of the Problem.”If you follow me on Twitter, you may have seen my rant on this topic about six months ago. Here’s a condensed version:
My watch broke one morning at work, on a day when my schedule was particularly full. As a result, I shut down. You know what absolutely did not help me? Thinking about the “Size of the Problem.” I knew perfectly well that not having a watch didn’t make my day impossible. There are clocks on the walls of literally every classroom, including my own. That knowledge didn’t stop me from feeling, in the moment, like my day was imploding around me. I’ve had students and clients experience grand mal seizures during therapy sessions, and I responded to them exactly as I was trained. But when my watch broke, so did I.
Size of the Problem doesn’t work if it refuses to acknowledge when a person is genuinely upset. SotP doesn’t work if it treats people like they can’t recognize the difference between an emergency and an inconvenience, simply because their reactions are not what NTs expect. Very few people, NT or ND, feel comforted when someone tells them, “It’s not a big deal” or “You have nothing to be upset about.” SoTP is pretty much that, only as a structured lesson plan.
Implemented carelessly, SotP teaches a person to hide what they’re feeling because their emotions are wrong and should not be acknowledged. It teaches people that their internal reactions cannot be trusted. It teaches people to say “it’s not a big deal; I have nothing to be upset about” to themselves.
All this to say, if PLT doesn’t take each person’s perspective into account (which, funny enough, is one of the things PLT teaches people to do) it can teach something very different from its intention. It teaches people to comply with everything regardless of personal discomfort; it teaches people to make situations more difficult for themselves because their communication partners’ comfort is more important than their own.
So how do we conduct PLT without damaging the people we’re trying to help? Here are some questions to ask yourself when you are planning or implementing PLT.
Question #1: Am I making space for people who perceive the world differently than I do?
A lot of these questions focus on making therapy person-centered. This is a concept that many of us have probably discussed in Grad School and/or Continuing Education. Person-Centered (which is different from Person First, a concept that can be insulting to disabled people) therapy asks us to consider a person’s unique set of traits and perspectives. Their individual wants and needs should inform every step of evaluation and therapy. When you design and conduct PLT, are you considering the viewpoint of a person whose perspective is different from yours?
Let’s start with Size of the Problem. For all its faults, SoTP can equip a person to step back and think through problems. SoTP can help people who have trouble recognizing the difference between an emergency and a fixable inconvenience, as long as the criteria for this difference does not include: “How you should react.” For therapists, this means acknowledging that a person’s emotional size of the problem may differ from 1) the therapists’ emotional size of the problem and 2) the practical size of the problem. It means recognizing that these differences exist and should be acknowledged, not punished.
Instead of asking “How should I feel about this?” SoTP should ask questions like: “Do I need to find help?” “Should someone call 911?” or “When I feel calm, can I solve this on my own?” SoTP can acknowledge the difference between “big problems” and “small problems” by focusing on practical effects and steps to finding solutions, including strategies and materials, how quickly a problem should be addressed, or the level of help that is needed.
Although the next step crosses the (albeit arbitrary) line from social communication into emotional regulation (which PLT often does even though it seems out of our wheelhouse), SoTP can equip a person to acknowledge feelings of frustration and anger without feeling penalized or shamed. It can teach people to ask: “What do I need to do when I’m upset?” It can teach people to use strategies to calm down and deal with the situation.
This question also ties in to the rule of Cultural Competence. To be culturally competent, the SLP needs to acknowledge their own cultural background and how it influences their perception of other people. We need to recognize that our own identities are complex and dynamic while learning as much as we can about the people we work with. We need to understand differences in values, ideals, and habits without passing judgment. This means admitting that value judgment is an instinctive, implicit process influenced by unconscious personal biases, and that counteracting it involves self-examination and honesty, even when the results are uncomfortable to acknowledge.
With autistic people specifically, clinicians need to consider The Double Empathy problem, which posits that social breakdowns between autistics and non-autistics “are not due to autistic cognition alone, but a breakdown in reciprocity and mutual understanding that can happen between people with very differing ways of experiencing the world.” I already linked to the recent study corroborating this theory, but I’m including again because it’s just that important.
To be truly Culturally Competent, non-autistic clinicians who work with autistic people need to start acknowledging autism as a difference in perceiving the world, rather than a disorder that needs to be fixed. We need to understand that PLT from a NT perspective is teaching autistic people how to mask.
Unfortunately there are situations where masking autism is important or even necessary (see Question #2), and PLT can effectively teach some of these skills. The important thing here is to explicitly acknowledge that you are teaching an autistic person how to mask because the NT world is not always ready to accept them as they are. This places control in the hands of the person you are working with, while helping them separate their intrinsic personal value from their ability to “fit in.” Even in these cases, there are autistic people who will reject masking or PLT in any form. Cultural competence means accepting that this decision is valid even when you believe it will create long-term disadvantages.
Question #2: Are Pragmatic Language difficulties causing distress for the person I’m working with?
This is a subjective guideline, to be sure, but it’s an important one. As I mentioned above, many of the skills we target in PLT focus on making a person appear “normal” or making communication partners feel comfortable. However, there are some social skills that impact a person’s well-being in a much more practical way. Examples include:
- Wanting to interact with peers but not knowing how
- Frequent and frustrating breakdowns in communication
- Difficulty clarifying miscommunication or misunderstanding
- Limited functions of communication (example: the person can use language to share information but not request something they want or need)
- Difficulty with non-literal language
There are other examples, I’m sure. The trick is to carefully and critically examine the direct, concrete impact that Pragmatic Language difficulty has on a person’s life. Does a student play alone because they prefer it, or do they show signs of wanting to play with peers but being unable or unsure? Do both of these interpretations apply at different times? Does a patient struggle to express themselves clearly even though their language skills are intact? Does a client only make requests because they don’t know how to use language socially, or do they simply prefer interaction to be non-verbal? Can the person I’m evaluating advocate for themselves?
All of these issues need to be examined with regards to Cultural Competence. Does the person you’re working with have similar difficulties when interacting with their family? Religious community? Friends from the same cultural background? Do your research; does a pattern you’ve observed match a social norm from one or more of the person’s identities? If so, this is a difference to be acknowledged, not an impairment to be treated. Educating communication partners may be in order, but teaching the person to pretend to be from a different culture is not.
Also, we need to be very, very, very careful to avoid answering this question with something like, “This person is being bullied” or “This person doesn’t have friends.” In these cases, the person we’re working with is not the root cause of difficulties with social communication; the people around them are. It is not that person’s fault that other people are choosing to bully or exclude them. If you believe that bullying is the person’s fault or responsibility, take a step back. That is victim-blaming, and it is toxic and damaging. This assumption can and will find its way into your therapy, even if you don’t explicitly put it there.
Question #3: Is the communication breakdown affecting the well-being of the communication partners?
This is another tricky one. I’ve mentioned above that a lot of practices under PLT target skills to make communication partners feel comfortable, by teaching people to adopt behaviors and habits that are uncomfortable or counterproductive. It is very easy to answer this question by doing that, such as saying “Yes, this person’s lack of eye-contact makes people assume they aren’t paying attention.” I cannot stress enough that this is not culturally competent or respectful of individual differences. This teaches people how to prioritize other people’s needs over their own, and it’s exactly why I dislike PLT so much.
To teach PLT in an inclusive way, it’s important to look the specific ways that a person’s communication style affects the people around them. Is there discomfort due to differences in culture or identity, or is genuine, unintentional harm taking place? Do a person’s words, tone, body language, etc. make communication partners feel insulted or threatened? Are communication partners unable to express their wants or needs? How do established power dynamics (e.g. gender, body type, race) influence the answers to these questions?
These questions in particular are complicated because we may find ourselves in the position of weighing one person’s perspective against another’s. It is not fair to ask someone to consistently prioritize other people. At the same time, choosing not to qualify a person for PLT could prioritize their perspective over everyone they come into contact with, by saying “this is how this person acts and everyone else needs to deal with it.” How do we respect the person we’re evaluating without doing that?
In some cases, the answer to this question might be to educate communication partners. This includes making people aware of cultural differences, or spreading information about neurodiversity in away that promotes acceptance and understanding. In the case of genuine pathology, such as difficulty with social cognition due to brain injury or dementia, therapists may give communication partners recommendations for how to interact with the person.
In other cases, direct PLT may be needed to help a person understand the unintentional effect they have on the people around them. Perspective-taking is a particularly good example of this, because it teaches a person how to consider the thoughts and feelings of other people without making value judgments. Again, this puts the power in the hands of the person you are working with. Saying “speaking loudly can make people think I’m angry,” or “people feel frustrated if I don’t give them a turn to speak,” can give a person tools for improved interaction without making them feel like they need to behave in a particular way.
Teaching Active Listening can accomplish something similar, as long as you’re careful to avoid strategies that are counterproductive for the listener. For verbal autistic folks or people with ADHD, Active Listening might include repeating a person’s message or saying “it sounds like you feel __” rather than focusing on body posture or gaze. Again, it’s important to teach these skills as strategies to use in certain situations, rather than behaviors that influence a person’s value or worth.
Question #4: Is personal empowerment built into the therapy program?
Self-advocacy, on the opposite end of the Pragmatic Language continuum, is an important and powerful skill that every person deserves to have in their repertoire. For some people, this means learning to communicate with a variety of purposes such as requesting, rejecting, protesting, expressing preferences and non-preferences, and informing people that something is wrong. For others, this means understanding that their self-worth is not connected to their ability to successfully complete a social skills program. Far too few PLT programs think to include these skills, and the effect on the people we serve can be deeply damaging.
Here are some things that many people who have social and/or cognitive difficulties don’t hear often enough:
- You are a good person.
- You have value.
- The things you are good at matter.
- Respect, consent, and boundaries work both ways.
- You have the right to make choices.
- You have the right to say no to things you don’t like.
- Your body is your own.
For some people, teaching empowerment means saying these things over and over. A program called the Whole Child approach incorporates these concepts into everything they teach. You are a valuable person, and you can learn and grow and you will still be a valuable person. You can struggle with some things your entire life, and you will still be a valuable person.
For others, it means acknowledging that difference is not wrong. For example, some children are introverted, and that’s fine. Some children want to play with peers but don’t know how. Others alternate between group and solo play depending on mood, energy level, time, or environment. You can teach a child how to play with peers while reminding them that “sometimes kids want to play by themselves, and that’s okay too.”
For other folks, empowerment means making a distinction between social interaction and inherent worth. Take, for example, people who can talk for a long time about specific topics. Although fellow ND people understand and appreciate this skill, NT people often find it bothersome. Teaching empowerment means that while you encourage a ND person to let other people choose the topic sometimes, you also acknowledge that their own passions matter. ND people have important and interesting things to say and they deserve to talk about their interests as much as NT people deserve to talk about theirs.
Unfortunately, the larger world doesn’t often see it that way. Awareness and respect for differences due to race, ethnicity, neurotype, and other cultural identities simply do not exist in a lot of spaces. It’s even worse for people of color, who face additional risks in a world that is constantly viewing them through suspicion, fear, and outright hate. For people with multiple marginalizing identities, empowerment can be dangerous. This is an awful truth that is beyond our scope. All we can do is educate people in the spaces we inhabit and acknowledge that the world is still a very bigoted place.
In the meantime, what do we do? What is our role for marginalized people with pragmatic language difficulties? How do we teach empowerment when self-advocacy for some can result in incarceration, deportation, or death?
I don’t have the answers to these questions. I wish I did, but I don’t. That doesn’t mean they aren’t worth asking; just the opposite in fact. Being inclusive, person-centered, and culturally competent requires us to ask these questions constantly. We can listen, we can learn, we can educate ourselves and the people around us, and we can examine our own biases at every opportunity, in order to help the people we serve in an effective, inclusive, and meaningful way.