Journal of Surgical Oncology 1 1: 89-94 (1 979)
The Spouse as Facilitator for Esophageal Speech: A Research Perspective ......................................................................................... ......................................................................................... HARRIET WEIDMAN GIBBS, MS, and JEANNE ACHTERBERG-LAWLIS, PhD The role of the spouse in relation to the quality of esophageal speech of laryngectornized patients was investigated using psychodiagnostic instruments and speech ratings and through an assessment of the verbal interactions between the patient and spouse. Analysis of the results indicates that those speakers who were objectively judged to have higher quality speech and learned esophageal speech rapidly had spouses who were more likely t o disagree verbally with them, addressed them in a way that encouraged long answers, and evidenced reciprocal compatibility for meeting affectional needs.
......................................................................................... ......................................................................................... Key words: laryngectomee, speech, spouse
INTRODUCTION Cancer of the larynx is one of the most curable of all cancers, carrying with it a heightened probability of a full return to life, work, and recreation. Even with regional node involvement, approximately one-third of the patients can be expected to survive five years past the diagnosis [DiBartolo, 197 1 ] .It is precisely because the diagnosis is relatively good with this disease site that rehabilitation efforts for these individuals need t o be refined t o allow them to return t o the active involvement in life for which they are physically capable. There is a wide variance in quality of lifestyle attained post-surgery, with the ability to communicate intimately correlated with the reentry process [Keith, Ewert, and Flowers, 19741. Loss of speech is naturally the primary disability of the laryngectomee, and hence the pattern of his or her rehabilitation is centered on subsequent success in communication. It is widely accepted that good esophageal speech is the optimal method of communicating post-laryngectomy, but there is a percentage of the population who, for one reason or another, are unable to achieve esophageal speech [King, 1968;Putney, 19581. Putney, in analyzing440 patients, found that of the 38%who failed to develop a useful
From the Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center at Dallas. Address reprint requests to Jeanne Achterberg-Lawlis, Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center, 5323 Harry Hines Blvd, Dallas, TX 75235.
0022-4790/79/1102-0089%01.40 0 1979 Alan R. Liss. Inc.
90
Cibbs and Achterberg-Lawlis
voice, no consistent underlying physical factors could be found. Although anatomical limitations did not seem t o be a factor, the failure t o attain speech seemed to be related t o lack of energy, fortitude, or the industry necessary t o learn any new method. Some indication was found that disturbance of the musculature of the tongue and floor of the mouth might impede the development of speech, but that amount of tissue removed surrounding the larynx did not affect the development of a voice. In another study, King [ 19731 found that patients without neck dissection were much more likely to communicate by esophageal speech than those who had not had such surgery. Specific psychosocial and demographic factors have been studied in regard t o the determination of esophageal speech. For example, the age of patients seems to be important, with younger patients showing better results [King, 19681 ;sex of patients [Putney, 19581 seems t o be involved, with men more apt t o develop a useful speech; and socioeconomic status, indicating that private patients have a higher attainment of speech than do indigent groups studied [Smith, 1 9 6 6 ) . The most forceful position supporting the interference of psychological trauma on the learning of esophageal speech is that taken by Deidrich and Youngstrom [ 19661 . They conducted an exhaustive survey of the physiological movements involved in esophageal speech. After viewing their own data and those of other investigators, their striking conclusion was that “esophageal speech skill following a laryngectomy was not related t o morphological function of the reconstructed hypopharynx and pharyngoesophageal junction. These results support those who believe that psychological factors are probably more important to the development of good speech than anatomical factors” [ 1966, p. 611. Although the literature of the field documents the importance of psychological aspects of larynx cancer, it is not yet well documented which psychological factors are closely related to attainment. Those factors that have been associated with the failure to develop esophageal speech include depression, loss of self-esteem and feelings of inferiority, and secondary gains associated with the mute state [Bisi, Conley, 19721. Lack of motivation has been repeatedly indicated in the literature [Smith, 1966; Bisi, Conley, 1965; 1974; King, 1968; Nahum and Golden, 19631 as a factor of utmost importance in determining the postoperative course and rehabilitation of the patient in regard to the reestablishment of communication patterns. These factors and the concomitant passivity and dependency on others suggest the presence of the threat of isolation of these patients. In attempting to understand the motivation t o learn esophageal speech in laryngectomized patients involved with the Cancer Rehabilitation Program at The Unversity of Texas Health Science Center at Dallas, we became strongly aware of the relationship between isolation and poor interpersonal relationships and speech patterns in our patients. Clinically, there appeared t o be a distinct relationship between marital status and attainment of speech. For those in the married category, there appeared t o be a clear relationship between the spouse’s (spouse usually refers t o wife in these cases) willingness t o allow the patient t o speak, even if it involved some struggle; and the ultimate ability of those patients to attain satisfactory esophageal speech. In other words, the spouses who encouraged or facilitated speech (often by remaining silent) seemed t o be key determinants o f establishment of speech patterns. Previous reports [Nahum and Golden, 1963, etc.] indicate that communication or interaction patterns are most important in the attainment of voice, and, as is the case with this study, simply being with someone can be construed as a facilitator in regaining speech.
Spouse Influence on Esophageal Speech
91
The primary objective of the current study was to identify the degree and quality of interpersonal communication between a laryngectomized individual and the spouse and the effect that this has on the quality of speech that is achieved postoperatively.
METHODOLOGY Subjects Participants were ten members of the Lost Chord Club of Dallas, who use esophageal speech as their major mode of communication with varying levels of proficiency, and their spouses. All patients were middle class, white; two were females, eight males, with an age range from 45 t o 76 years. Procedure Arrangements were made for the participants and their spouses t o meet conjointly with investigators in the Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center at Dallas. The speech evaluation, which was audiotaped in its entirety, was given first and included the Grandfather Passage, a phonetically balanced word list, and a technical proficiency rating scale, which consists of phonation, duration, and number of syllables [adapted from Berlin, 19651. The Grandfather Passage and the word list readings were scored by three independent raters on a four-point scale: 1) 0-25% of the reading understood; 2) 25-50% understood; 3) 50-75% understood; 4) 75-100% understood. These ratings were combined with technical proficiency scores t o result in an overall four-point speech rating. Next, a 41-item medical and rehabilitation history questionnaire was administered t o the laryngectomees. Eight questions were asked of the patients regarding pre-surgical and post-surgical relationships with their spouses. Information was obtained concerning number of speech sessions; how soon after surgery speech lessons were begun; how long the patients had used esophageal speech; how well each felt he or she was understood by family, friends, and strangers; and work and social activity information. Spouses were administered a 14-item questionnaire designed to elicit perceptions of feelings and behaviors relevant to the laryngectomized spouse. Additionally, they were asked t o respond t o the eight questions regarding pre- and post-surgical relationships and marriage history. Both laryngectomee and spouse completed the FIRO-B [Schultz, 19761 following the administration of the questionnaire. The FIRO-B was selected as a measure of interpersonal relationships based on three dimensions identified, which include Control, Inclusion, and Affection. Since it was administered to both patients and spouses, differences and similarities constitute a major part of the analysis of the results of this test, whereby Reciprocal and Interchange Compatibility scores assume importance (ie, combined spouse/patient scores). A TAT card (No. 20) was preselected on the basis of pilot work which indicated that it was capable of eliciting a variety of responses, and was administered to both the patient and the spouse individually. Each was first asked t o discuss the card with the investigator individually and then they were brought together and asked to combine their responses into one story. The purpose of this exercise was t o identify proportionate amounts of time spent in communicating during the conjoint session. This segment of
92
Gibbs and Achterberg-Lawlis
TABLE 1. Significant Correlations Between Dissension Score and Qualities of Esophageal Speech
Less time t o learn esophageal speech Ability to speak in long sentences High rating of speech quality
I
t-Value
P
-0.7849 0.7222 0.6764
3.83 3.12
0.007 0.018 0.032
2.18
the evaluation was also audiotaped in its entirety, and the following data were included: Number of interruptions of patient by spouse; amount of disagreement between the two stories (based on a four-point objective scale assessing mood, character role, and theme of the story told), whether acquiescence occurred and who “gave in”; and whether or not the patient told the final version of the story. A rather large volume of data was gathered from each patient, tapping the nature of the marital relationship (pre- and post-surgery), need patterns, communication methods and patterns, and social activity. Demographic data included the amount of information the patient was given regarding his illness prior to surgery and drinking and smoking habits.
RESULTS AND DISCUSSION Data were analyzed by computing linear correlation coefficients (product moment) and subjecting them t o probability levels. In this way the degree of statistical relationship could be determined in a standardized range (0-1 .OO)as well as illustrating the direction of covariance (positive vs negative). The results were then computed with a t-statistic for a determination of probability levels for small samples. Only those variables that were significantly related to speech are considered here.* Analysis of the data revealed two major factors of influence: 1) the amount of dissension or disagreement between patient and spouse evident in the projective technique, and 2) certain interpersonal relationships revealed by the FIRO-B scales. The relationship among these factors is complex. If one first considers how long it takes the individual t o learn esophageal speech, the dissension score (increasing disagreement) is the strongest related factor (Table I). The less time it took the laryngectomee to learn esophageal speech, the higher the disagreement evident in the TAT card task. The amount of disagreement also correlated with the ability to speak in long sentences, and perhaps most important, it was correlated with the rating of speech quality based on the speech evaluation (Table I). Several suggestions are implicit here: Disagreement appears t o be a stimulus to speech development; and, of necessity, it requires two participants! Thus, the importance of the spouse’s role is underlined. A relationship where opposing views can be expressed openly is conducive t o learning speech quickly and effectively. Of the three dimensions of interpersonal relationships considered by the FIRO-B (Control, Inclusion, and Affection), Affection appears to have the strongest effect on speech. Scoring procedures with the FIRO-B subscales enables the researcher to identify total compatibility scores for two people, in addition t o compatibility in each of the *Significance was set at
The Spouse as Facilitator for Esophageal Speech: A Research Perspective ......................................................................................... ......................................................................................... HARRIET WEIDMAN GIBBS, MS, and JEANNE ACHTERBERG-LAWLIS, PhD The role of the spouse in relation to the quality of esophageal speech of laryngectornized patients was investigated using psychodiagnostic instruments and speech ratings and through an assessment of the verbal interactions between the patient and spouse. Analysis of the results indicates that those speakers who were objectively judged to have higher quality speech and learned esophageal speech rapidly had spouses who were more likely t o disagree verbally with them, addressed them in a way that encouraged long answers, and evidenced reciprocal compatibility for meeting affectional needs.
......................................................................................... ......................................................................................... Key words: laryngectomee, speech, spouse
INTRODUCTION Cancer of the larynx is one of the most curable of all cancers, carrying with it a heightened probability of a full return to life, work, and recreation. Even with regional node involvement, approximately one-third of the patients can be expected to survive five years past the diagnosis [DiBartolo, 197 1 ] .It is precisely because the diagnosis is relatively good with this disease site that rehabilitation efforts for these individuals need t o be refined t o allow them to return t o the active involvement in life for which they are physically capable. There is a wide variance in quality of lifestyle attained post-surgery, with the ability to communicate intimately correlated with the reentry process [Keith, Ewert, and Flowers, 19741. Loss of speech is naturally the primary disability of the laryngectomee, and hence the pattern of his or her rehabilitation is centered on subsequent success in communication. It is widely accepted that good esophageal speech is the optimal method of communicating post-laryngectomy, but there is a percentage of the population who, for one reason or another, are unable to achieve esophageal speech [King, 1968;Putney, 19581. Putney, in analyzing440 patients, found that of the 38%who failed to develop a useful
From the Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center at Dallas. Address reprint requests to Jeanne Achterberg-Lawlis, Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center, 5323 Harry Hines Blvd, Dallas, TX 75235.
0022-4790/79/1102-0089%01.40 0 1979 Alan R. Liss. Inc.
90
Cibbs and Achterberg-Lawlis
voice, no consistent underlying physical factors could be found. Although anatomical limitations did not seem t o be a factor, the failure t o attain speech seemed to be related t o lack of energy, fortitude, or the industry necessary t o learn any new method. Some indication was found that disturbance of the musculature of the tongue and floor of the mouth might impede the development of speech, but that amount of tissue removed surrounding the larynx did not affect the development of a voice. In another study, King [ 19731 found that patients without neck dissection were much more likely to communicate by esophageal speech than those who had not had such surgery. Specific psychosocial and demographic factors have been studied in regard t o the determination of esophageal speech. For example, the age of patients seems to be important, with younger patients showing better results [King, 19681 ;sex of patients [Putney, 19581 seems t o be involved, with men more apt t o develop a useful speech; and socioeconomic status, indicating that private patients have a higher attainment of speech than do indigent groups studied [Smith, 1 9 6 6 ) . The most forceful position supporting the interference of psychological trauma on the learning of esophageal speech is that taken by Deidrich and Youngstrom [ 19661 . They conducted an exhaustive survey of the physiological movements involved in esophageal speech. After viewing their own data and those of other investigators, their striking conclusion was that “esophageal speech skill following a laryngectomy was not related t o morphological function of the reconstructed hypopharynx and pharyngoesophageal junction. These results support those who believe that psychological factors are probably more important to the development of good speech than anatomical factors” [ 1966, p. 611. Although the literature of the field documents the importance of psychological aspects of larynx cancer, it is not yet well documented which psychological factors are closely related to attainment. Those factors that have been associated with the failure to develop esophageal speech include depression, loss of self-esteem and feelings of inferiority, and secondary gains associated with the mute state [Bisi, Conley, 19721. Lack of motivation has been repeatedly indicated in the literature [Smith, 1966; Bisi, Conley, 1965; 1974; King, 1968; Nahum and Golden, 19631 as a factor of utmost importance in determining the postoperative course and rehabilitation of the patient in regard to the reestablishment of communication patterns. These factors and the concomitant passivity and dependency on others suggest the presence of the threat of isolation of these patients. In attempting to understand the motivation t o learn esophageal speech in laryngectomized patients involved with the Cancer Rehabilitation Program at The Unversity of Texas Health Science Center at Dallas, we became strongly aware of the relationship between isolation and poor interpersonal relationships and speech patterns in our patients. Clinically, there appeared t o be a distinct relationship between marital status and attainment of speech. For those in the married category, there appeared t o be a clear relationship between the spouse’s (spouse usually refers t o wife in these cases) willingness t o allow the patient t o speak, even if it involved some struggle; and the ultimate ability of those patients to attain satisfactory esophageal speech. In other words, the spouses who encouraged or facilitated speech (often by remaining silent) seemed t o be key determinants o f establishment of speech patterns. Previous reports [Nahum and Golden, 1963, etc.] indicate that communication or interaction patterns are most important in the attainment of voice, and, as is the case with this study, simply being with someone can be construed as a facilitator in regaining speech.
Spouse Influence on Esophageal Speech
91
The primary objective of the current study was to identify the degree and quality of interpersonal communication between a laryngectomized individual and the spouse and the effect that this has on the quality of speech that is achieved postoperatively.
METHODOLOGY Subjects Participants were ten members of the Lost Chord Club of Dallas, who use esophageal speech as their major mode of communication with varying levels of proficiency, and their spouses. All patients were middle class, white; two were females, eight males, with an age range from 45 t o 76 years. Procedure Arrangements were made for the participants and their spouses t o meet conjointly with investigators in the Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center at Dallas. The speech evaluation, which was audiotaped in its entirety, was given first and included the Grandfather Passage, a phonetically balanced word list, and a technical proficiency rating scale, which consists of phonation, duration, and number of syllables [adapted from Berlin, 19651. The Grandfather Passage and the word list readings were scored by three independent raters on a four-point scale: 1) 0-25% of the reading understood; 2) 25-50% understood; 3) 50-75% understood; 4) 75-100% understood. These ratings were combined with technical proficiency scores t o result in an overall four-point speech rating. Next, a 41-item medical and rehabilitation history questionnaire was administered t o the laryngectomees. Eight questions were asked of the patients regarding pre-surgical and post-surgical relationships with their spouses. Information was obtained concerning number of speech sessions; how soon after surgery speech lessons were begun; how long the patients had used esophageal speech; how well each felt he or she was understood by family, friends, and strangers; and work and social activity information. Spouses were administered a 14-item questionnaire designed to elicit perceptions of feelings and behaviors relevant to the laryngectomized spouse. Additionally, they were asked t o respond t o the eight questions regarding pre- and post-surgical relationships and marriage history. Both laryngectomee and spouse completed the FIRO-B [Schultz, 19761 following the administration of the questionnaire. The FIRO-B was selected as a measure of interpersonal relationships based on three dimensions identified, which include Control, Inclusion, and Affection. Since it was administered to both patients and spouses, differences and similarities constitute a major part of the analysis of the results of this test, whereby Reciprocal and Interchange Compatibility scores assume importance (ie, combined spouse/patient scores). A TAT card (No. 20) was preselected on the basis of pilot work which indicated that it was capable of eliciting a variety of responses, and was administered to both the patient and the spouse individually. Each was first asked t o discuss the card with the investigator individually and then they were brought together and asked to combine their responses into one story. The purpose of this exercise was t o identify proportionate amounts of time spent in communicating during the conjoint session. This segment of
92
Gibbs and Achterberg-Lawlis
TABLE 1. Significant Correlations Between Dissension Score and Qualities of Esophageal Speech
Less time t o learn esophageal speech Ability to speak in long sentences High rating of speech quality
I
t-Value
P
-0.7849 0.7222 0.6764
3.83 3.12
0.007 0.018 0.032
2.18
the evaluation was also audiotaped in its entirety, and the following data were included: Number of interruptions of patient by spouse; amount of disagreement between the two stories (based on a four-point objective scale assessing mood, character role, and theme of the story told), whether acquiescence occurred and who “gave in”; and whether or not the patient told the final version of the story. A rather large volume of data was gathered from each patient, tapping the nature of the marital relationship (pre- and post-surgery), need patterns, communication methods and patterns, and social activity. Demographic data included the amount of information the patient was given regarding his illness prior to surgery and drinking and smoking habits.
RESULTS AND DISCUSSION Data were analyzed by computing linear correlation coefficients (product moment) and subjecting them t o probability levels. In this way the degree of statistical relationship could be determined in a standardized range (0-1 .OO)as well as illustrating the direction of covariance (positive vs negative). The results were then computed with a t-statistic for a determination of probability levels for small samples. Only those variables that were significantly related to speech are considered here.* Analysis of the data revealed two major factors of influence: 1) the amount of dissension or disagreement between patient and spouse evident in the projective technique, and 2) certain interpersonal relationships revealed by the FIRO-B scales. The relationship among these factors is complex. If one first considers how long it takes the individual t o learn esophageal speech, the dissension score (increasing disagreement) is the strongest related factor (Table I). The less time it took the laryngectomee to learn esophageal speech, the higher the disagreement evident in the TAT card task. The amount of disagreement also correlated with the ability to speak in long sentences, and perhaps most important, it was correlated with the rating of speech quality based on the speech evaluation (Table I). Several suggestions are implicit here: Disagreement appears t o be a stimulus to speech development; and, of necessity, it requires two participants! Thus, the importance of the spouse’s role is underlined. A relationship where opposing views can be expressed openly is conducive t o learning speech quickly and effectively. Of the three dimensions of interpersonal relationships considered by the FIRO-B (Control, Inclusion, and Affection), Affection appears to have the strongest effect on speech. Scoring procedures with the FIRO-B subscales enables the researcher to identify total compatibility scores for two people, in addition t o compatibility in each of the *Significance was set at
