The Mental and Emotional Preparation of the Pupil Prior to Surgery

T h e r e c a n b e no se t ru les e s t ab l i shed in th is pre -opera t ive p r e p a r a t i o n s ince each person ' s r e a c t i o n to a n y crisis o r s t r a in is de ter mined or m e a s u r e d by one ' s o w n personal i ty s t r u c t u r e , and one ' s o w n w a y in previous ly dea l ing w i t h cr ises . M a n y t imes t h e su rgeon wil l p rov ide t h e n e c e s s a r y psychological he lp . Again, a we l l t r a ined speech t h e r a p i s t can be of g r e a t v a l u e to t h e prospec t ive p a t i e n t . In a n y case , t h e p repa ra t ion shou ld b e based u p o n a cr i t ical eva luat ion of t h e p e r s o n a l i t y of the p a t i e n t t h r o u g h a pe r sona l in t e rv iew. It is adv i sab le a t th i s t ime to inc lude a m e m b e r of t h e family. Dur ing t h e in t e rv iew the pup i l should be e n c o u r a g e d to d i scuss t h e m a n y p r o b l e m s he wil l h a v e to face. Na tu ra l ly , t h e loss of his vo ice and t h e resu l t ing socia l and economic p r o b l e m s a r e t h e m o s t ser ious . If possible , it is a d v a n t a g e o u s a t th is po in t t o have t h e pupi l m e e t s o m e o n e a b o u t his o w n age and social s t a t u s w h o h a s deve loped a good voice and r e t u r n e d to work . T h e n e w pa t i en t m u s t c o n s t a n t l y b e r ea s su red t h a t loss of speech is on ly t e m p o r a r y . 2. Patient's Approach to his


Speech and the Laryngectomized
By MARY A. DOEHLER Director of Esophogeal Speech, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts Since speech is the most characteristic human act and the first means by which social relationships are established and kept intact, its loss seriously threatens the laryngectomized patient's feeling of security and balance, both in the family and in the community.
To complete a satisfactory rehabilitation or adjustment involves several steps, none of which should be neglected.
I shall discuss these factors as I see them, in order of their importance to the patient, as I attempt to evaluate the teaching program.

The Mental and Emotional Preparation of the Pupil Prior to Surgery
There can be no set rules established in this pre-operative preparation since each person's reaction to any crisis or strain is determined or measured by one's own personality structure, and one's own way in previously dealing with crises.Many times the surgeon will provide the necessary psychological help.Again, a well-trained speech therapist can be of great value to the prospective patient.In any case, the preparation should be based upon a critical evaluation of the personality of the patient through a personal interview.It is advisable at this time to include a member of the family.During the interview the pupil should be encouraged to discuss the many problems he will have to face.Naturally, the loss of his voice and the resulting social and economic problems are the most serious.If possible, it is advantageous at this point to have the pupil meet someone about his own age and social status who has developed a good voice and returned to work.The new patient must constantly be reassured that loss of speech is only temporary.

Convalescence
How much the patient appreciates his post-operative condition depends upon his age, education, experience, and general personality make-up.

Speech Re-education
I am not in sympathy with beginning instruction prior to surgery, but I do recommend that the pupil be given the basic facts of how esophageal speech will be produced.This should be confined to a consideration of the general characteristics of esophageal speech -quality of tone and control of airwithout, at this time, burdening the pupil with the mechanics and problems associated with its production.He must be advised that, for a time, he should communicate by writing and in no case resort to whispering.Also, it should be stressed that much of his success in acquiring his new voice depends almost entirely on his determination to practise regularly.
I have found that the earlier instruction is begun following surgery the more satisfactory the results.I have followed four rather simple steps in developing this voice and always refrain from discussing surgery with the patient.These four steps are: 1) Open mouth 2) Close mouth 3) Swallow air (same as one swallows food or drink) .
4) Open mouth at once and with lips try to say "ba." You will note that, in the very first approach to this program, 1 call attention to the use of

JOURNAL OF THE SOUTH AFRICAN LOGOPEDIC SOCIETY August, 1963
the lips in forming sound.Over the years I have used phonetic sounds.This I believe has several advantages -the pupil is not confronted with trying to say words when at that time, his mental reaction is that he cannot speak, and speech is made of words either singly or in sequence.Many of these phonetic sounds are words in themselves, such as be, bi, me, mi, ti, to mention a few.My entire approach is geared to what the patient himself can accomplish and do well.Single syllables having been articulated and enunciated well, 1 then proceed to doubling, tripling, and the use of more advanced rhythms, thus enabling the pupil not only to learn to control this air, but at the same time giving him much variety in pitch..These rhythms are more fully explained in my manual "Esophageal Speech" and the recording which I have made for home practice.

Solving the Practical Problems of Living Without a Larynx
To many pupils the days immediately following surgery are the most frustrating.Many questions arise in his mind such as the control of mucous, ability to breathe, problems of eating, dressing and matters of personal hygiene.Some of these could have been explained prior to surgery, but they become more realistic once surgery has been performed.Those closely associated with the pupil should approach these problems with a very positive attitute, not one of sympathy but rather, one of complete understanding.The pupil should be assured that he will be able to eat and dress as he did prior to surgery, that he can shower, making sure that the stoma is covered at all times.Here the importance of team work with the doctor, nurse, family, social workers, and speech therapist is of utmost assistance to the pupil.
Many years ago the patient could anticipate only lyears of silence, but today, with new surgijcal techniques and the advancement in better teaching methods of esophageal speech, there is much encouragement for the patient to look forward to a normal and very satisfactory life in the future.

SUMMARY
The sudden loss of speech in the laryn-gectomee is a traumatic and frightening experience.He must be prepared before the operation for what is to follow and be reassured that the loss of speech is only temporary.
Prior to surgery the patient should be given the basic facts of how esophogeal speech will be produced.He must be advised that immediately after the operation he should communicate in writing, but on no account resort to whispered speech.
Therapy follows four rather simple steps: (i) open mouth; (ii) close mouth; (iii) swallow air (same as one swallows food or drink); (iv)open mouth at once and with lips try to say "ba".Phonetic sounds are used in preference to words, which may, in the early stages, have acquired negative aspects for the patient.As therapy progresses, more advanced syllables and rhythms are used.
Personal problems with regard to adjustment should be dealt with as they arise.