A Christmas Party

Excerpted from the novel On the Trail of Evil with Dick Daring, Speech Therapist (out of print)

The upshot of this whole affair was contained in a statement I had heard a colleague make in a case conference some years ago. His patient was in the acute rehabilitation unit, in treatment after a traumatic brain injury. The guy was giving his rationale for the patient to feel optimistic about her recovery. He said this to her – “You are your neurons; but you are not just your neurons!” My colleague had started his training with a liberal arts undergraduate degree, so I usually gave him some slack for the unorthodox things he said and did in his practice. But – he was right, and his soft and sweet aphorism helped me get my own patient through her first Christmas after her own concussion. 

You always have to take what the patient is willing to give you was what kept running through my mind as I initially met with her. Married, mid-50’s, and found dangling from atop the compartment of her flipped sedan, saved from a worse fate by a stubborn seat/shoulder belt. Now in my office that mid-November, she could give a history of her immediate past through conversation pocked by pauses and nonverbal musings. The Boston Naming Test demonstrated mild-moderate anomia (problems finding words). On the Ross Information Processing Assessment, she had signs of mild global cognitive impairment, with short-term memory and problem-solving being the most affected of all her skills.  Screening for anosmia, or impaired smell, showed that she could not identify peanut butter when blindfolded. She did pick up the smell of instant coffee. We had a brief rest-break segue’ from the testing to interview. My patient told me then of her need to get back to homemaking. Her hubby just expected it, and – and she – well, gosh, she said, I feel like I can do it!

I knew better, but I also surmised from our initial conversation that it would be my head banging the wall if I attempted to talk her out of her homemaking routine.  Our twice-weekly sessions were made up of training, on the component skills that were weak in testing (memory, problem solving). A few minutes of review and warm-up preceded the skill training, and then a little cool-down, teaching and counseling ended each hour. My patient faced the training very well, and seemed to make steady progress with accessing words in conversation – and solving simple problems. She regularly, though, needed a few extra minutes to talk about how hard it had become at home to get her daily homemaking done. 

I knew she needed to develop insight about who she is now. When she was able to reveal how well she lived her life with her cognitive challenges, then we could together find ways to get the best outcome she could imagine. What could she imagine? Her husband had reminded her one day that the family Christmas party was coming up soon. She had already told me that, when making a casserole and a “Jell-O salad” one evening, she had the casserole ready to plate but couldn’t find the salad. Lifting the casserole dish cover, she reported feeling mortified that the Jell-O box was looking back at her, baked into the casserole!

Therapy then grew from just the component skill training, which we also call treatment of the impairment, to work on the skills she needed to hone to pull off this party. That was treatment at the activity level. Our activities included assembling and arranging all the ingredients to make the dishes my patient was serving (there were 5!); re-creating and stepping through each recipe; and completing individual recipes in the accustomed time span. The last activity took 2 weeks to reach criterion, where she could make a dip, bake some cookies or – make a Jell-O salad as efficiently as possible in the available time. 

You take what your patient gives you, I reminded myself as I got an apron almost saturated every session with flour and water. Finally, my patient was ready for the big test. We simulated the party in the outpatient rehab lounge. In the professional lingo, this is training at the participation (real life) level. Our practice sessions allowed her to gradually recognize the real-life context cues for starting baking for the cookies, and for making the salad! As we did after each activity training session, we spent all the time my patient needed to review the successes and her own need to ‘tighten up’ her control over the session. Though she admitted she was tired and a little mindblown from the work, she expressed confidence she could pull off the real party. And , a week later, at our next-to-last scheduled session, she reported that – exhaustion and an extra day required to reassemble the house afterwards – she did just that!

She was her neurons, but not just her neurons  - yep. Her love for her family, and her strong desire to get back into life after her injury – that made her decision to train her impaired central nervous system easier. As the training reached its zenith with the simulated party in our shop, my patient had learned much more about herself: how to get more rest; how to assert herself with hubby, so that he did volunteer more assistance at the party than he initially might have; how to plan her routines to get more done with the energy and focus she felt each day – rather than to say Oh, I’ve done that for years, no problem, she learned to say today, I’ll do that as well as I can with the skills I have. 

I think she had a better-than-average Christmas that year.

McGyvering Therapy

You sometimes get a chance, in your work as a CSD professional, to make a singular difference for someone you serve. It's the responsibility of the mindful clinician, fully focused in the moment of the clinical encounter,  to marshall all possible resources, techniques and training and enhance this person's outcome  with perhaps one simple decision. It is a testament to the primacy of communication in everyday life, that the mindful clinician can find a key to a successful outcome in everyday life.

Do you remember the ABC television series, “McGyver”? The hero stands atop a very tall dais in the pantheon of series TV, for his ability to solve fantastic and seemingly overwhelming problems with simple solutions. Is it possible that the speech-language pathologist has at her/his disposal such simple solutions to clinical problems? In this EBP day and age, “McGyver” solutions to clinical questions are not the solutions often sought. Yet, even though the solution chosen may not be strictly based upon experimentally-tested methods, the persons served often learn from these procedures and make positive change towards their desired outcomes. What are examples of “McGyvering” in speech-language therapy?

1. Take a “Life Savers” sugarless candy. Tie a strand of waxed dental floss to the candy, then instruct the person served to take it on the middle third of her/his tongue. The person sucking the candy receives discrete sensory feedback for isometric exercise. Concerns about salivary production and salivary control are easily addressed. The person wishing to practice the Mendelsohn maneuver (assigned to persons to improve laryngeal elevation and upper esophageal sphincter function) has a hard target for pressing the tongue dorsum into the soft palate.
2. Inspired by Netsell’s work with the U-tube manometer, the clinician may give a person served a glass that contains approximately 2 inches of water and a drinking straw. The person is asked to blow a continuous stream of bubbles for at least 5 seconds. Expiratory strength training such as that achieved by this activity, benefits persons with all variety of needs: voice, swallowing, speech and cognition.
3. Horticulture to go? In a long-term care setting, there are often persons served who do not want to leave their rooms – therefore wishing to decline your scheduled treatment – due to pain, depression, fatigue, cognitive impairment, etc. The speech-language pathologist may then take to the patient’s room, on a cart, a variety of horticultural materials for the patient to cultivate while sitting, or even while lying in bed. The mindful clinician can map onto the horticultural activity, a large number of cognitive, linguistic and communicative goals.

If there are general rules for “McGyvering” a treatment activity, they might include -using materials most people will have; replicating an activity most people perform in everyday life; giving the persons served copies of the treatment materials to use in their natural environments as soon as possible; and the person served can describe what is happening when they do the activity. I hope readers of this piece discover for themselves how to “McGyver” treatment.

Originally published 9/11/2012 in different form in ASHAsphere, the blog of the American Speech-Language-Hearing Association. 

Primary Prevention Products

Recently I walked through a speech clinic of the near future. You might expect that the examination rooms of this clinic would be stocked with high-powered flexible endoscopes, to see with stunning detail oral, laryngeal and pharyngeal structures. You might also look around for powerful tablets/smart phones and high-fidelity digital audio speakers, to provide crystal clear reproductions of a person’s speech output. Today’s communication sciences and disorders (CSD) professional is rapidly reformatting current practice models, with wholesale changes for third party reimbursement occurring as this blog is written. But instead of the high technology fittings of a large scale speech clinic, this speech clinic of the near future barely has changed, but for shelves that contain a number of prevention products. The CSD professional encounters something new but also something old, when introducing prevention activities into a clinical practice. But – what is prevention to a CSD professional? How futuristic is the push to include prevention as a CSD product line? Can most CSD practices absorb prevention into their business models?

When the American Speech-Language-Hearing Association (ASHA) advocated for prevention of disorders of communication, cognition and swallowing in its 1987 position paper, a slow-rolling but persistently accelerating snowball had been born. Prevention of communication* disorders, on the one hand, seems a radically divergent activity from traditional clinical practice for many speech-language pathologists and audiologists. “You mean I have to not only work with my patients to help them improve, but I also have to help change the world so I have fewer patients?” Exactly. That’s it. On the other hand, prevention is set firmly within the foundation of ASHA practice patterns. Prevention may in the short term help some in your community forestall the need for treatment. It will also in the long term bring more persons in need to the CSD professional’s door. 

With primary prevention, the CSD professional attempts to reduce or eliminate conditions that may bring about a communication disorder. You do this through either altering a person’s susceptibility to a condition (if I am exposed, what are the odds I will stay healthy?), or reducing the degree of exposure (should I simply avoid the risk in order to stay healthy?) that makes you susceptible. An example of altering your susceptibility might be improving your speech breathing, to speak over noise you encounter while working at a busy restaurant. The same restaurant worker may, in turn, reduce exposure by changing her/his work schedule to rest the voice. 

Primary prevention appears the most alien of the prevention concepts to CSD professionals. After all, most of us stop considering a new product line when there is no reimbursement for it! And – it’s not testing or treatment, but – but – it’s selling or teaching stuff, to people who may not have impairments. Can I teach healthy people things that may head off their becoming disabled? Can I sell things, and keep track of sales taxes? Yes, we can. If we are willing to lurch out of our comfort zones as clinicians, there may be tremendous return on investment with the increased community visibility we gain as health promotion professionals. So, - how do we do primary prevention in CSD? What is the stuff of it? What are the outcomes we want? 

On the primary prevention shelves of this near future clinic, I saw tools that included: 

I.                    Oral-motor/motor speech:

A.      Kazoobie kazoo @ $2

B.      Hohner beginner harmonica @ $8.50

II.                  Fluency

A.      Mouth Sounds, by Fred Newman @ $10

B.      The Speech Choir: With American Ballads and English Poetry for Choral Reading by Marjorie Gullan @ $1 (used)  

III.                Voice:

A.      C.D. Bigelow Elixir White/Green hair and body wash @ $10

B.      1 gallon of distilled water @ $1

IV.                Swallowing:

A.      1-qt Ziploc bag, containing a roll of Life Savers and a dispenser of mint waxed dental floss @ $5

B.      1 –qt. Ziploc bag, containing a bound supply of 1 doz. sterile tongue depressors @ $5

V.                  Cognition:

A.      Radius model ergonomic garden trowel @ $10

B.      GAMES magazine: single issue @ $5

VI.                Speech and language:

A.      The New Moosewood Cookbook, by Mollie Katzen @ $10

B.      Walk Off Weight with Your Pedometer:  A Simple 28-Day Pedometer Walking Program, by Jan Small @ $10

Readers should note that the selection of brand name products is purely coincidental by the blogger. Products have neither been trialed prior to this writing, nor are there financial or non-financial relationships between the blogger and any product company. Primary prevention products are chosen for stocking in this clinic of the near future for their relatively low price; their ready availability in the community, and their applicability to the needs of the prevention consumer. Price points are strictly ad hoc at this writing; experienced CSD practitioners will adjust the price point and product selection to a level that their customers will bear. 

The sales area for primary prevention has its own entrance from street level, thereby controlling the mixing of regular clinic patients (tertiary prevention consumers) with those shopping for their CSD wellness needs. Adjacent to the sales area is a video viewing room, with four computing devices available to consumers to view demonstrations of each primary prevention product. Reading racks mounted at eye level near the viewing stations, contain fliers and magazines from community services that support and announce wellness activities on community calendars. 

But – let’s make sure the original questions posed are answered. To wit:

How do we do primary prevention in CSD?

What is the stuff of it?

What are the outcomes we want? 

Ideally, primary prevention products and activities bring your customer into your marketplace. You help them stay healthy to function in their communities, so that the probability of their entering the healthcare system to identify and treat impairments is lowered. You do primary prevention through teaching, training, referring, marketing, selling, cooperating and participating in a large network of community and supports and services for your customer. Your collaborators in primary prevention may include office managers; health educators; fitness center trainers; bodyworkers; priests, rabbis, imams and healers; drama and singing and cooking teachers; and all those who work in wellness and health promotion. Outcome measurement may be as simple a function as that of measuring the customer’s changes in both health literacy and patient “activation”, as in the Patient Activation Measure of Hibbard and colleagues. The long-term outcome desired is that community healthcare costs are ratcheted downward. The story of primary prevention in CSD is, again, being written as we walk through this near future clinic. What do you see in the clinic of the future? Time to move into the secondary prevention wing now….*communication, cognition and swallowing

I am a speech-language pathologist!

….because at first, I needed a speech-language pathologist to speak better. I hope I am always communicating clearly and effectively with those I serve. 

….because I have a set of skills and tools, that can help some people in need do some amazing things. Let me try everyday to keep my skills finely honed, and responsive to the needs of all my customers and stakeholders. 

….because of the research and clinical advancements of my forebears and peers, I find even more lightning bolts at my fingertips for those I serve. Give me the energy and vision to leave some nugget of clinical riches for the next generation of professionals. 

 ….because my customers make me proud often, at how much better they assert themselves for a better life. Can I keep showing them that ‘moxie’ is not just a cola brand in the Northeast US?

….because there are family, friends, and neighbors who can become heroes for my customers when there is a need. I pray that if or when these advocates ask for help to give my customers, I have it. 

….because our society has room for everyone to live, work, recreate and participate in its functions. Can you name some of the ways your community can be made more accommodating to persons with communication, cognition and swallowing problems?

….because communication* is a complicated process that allows legions of science enthusiasts like me to get our geek on, when doing research and helping our customers. Let me keep on exploring, innovating, hypothesizing and discovering new ways to help. 

….because communication is essential across all domains of humanity, the clinical professional needs to get along with and learn from all kinds of people. Help me at a small scale, affect humanity BIG. 

....because as it is for traumatic brain injury, it is for everything else we deal with: "the only cure is prevention". Let's develop activities, products and societies that prevent communication disorders.

….because when we communicate we will “only connect”. Wanna connect? 

* in the interest of clarity and space, “communication” is used to stand for ‘communication, cognition and swallowing’.

What I Want to Do

“Experimental Psycholinguistics” was the course, during my life as an SLP doctoral student, that separated girl from woman – man from boy. Three hours of grind on a Monday afternoon almost always began with the professor standing pensively at his podium, saying “What I want to do….”. There were no rows of laptops  or tablets, all radiating readiness at that cue. The coffee was cheap and not the robust blends from far-flung corners of the world, but spat out instead by the one vending machine for one square block. Though we digested tons of theory and argued reams of hypotheses, it was that professor’s invocation to the class I remember most vividly. 

Flashback to the middle of that decade: I had begun graduate school on what was a non-traditional track. I didn’t feel I knew what therapy was all about. I had done well in methods courses. I had assisted other clinicians with their cases. My core communication sciences and disorders (CSD) courses were stimulating and making me want more. Sprinting around a child-sized table to refocus a child who suddenly bolted from the table, panting and flush with mortification – no, that was not great assisting! Stimuli presentation?  I could do that. Data collection? I did that after some practice. Maintaining focus and flow of the session?  Most of the time I crashed and burned badly while trying that.  I wished I had had, amongst the clinic supervisors and faculty, somewhere in my group of peers – someone to be Linus to my Charlie Brown and say,” I can tell you what therapy is all about. “

A few years had elapsed when, one day at my first job after the master’s degree, a copy of Elizabeth Bates’ Language and Context: the Acquisition of Pragmatics arrived in the mail. It took a few days to skim the book’s chapters, but then – I heard the voice exiting the stage… “That’s what therapy is all about, Charlie Brown”. Pragmatics, a hybrid born of philosophy, sociology and linguistics, led me to discover that for me, the object of therapy was establishing then following the rules of your context. You do good therapy by constructing and nurturing the environment that best grows your client’s skills. The focus of my treatment plans became – “in here, you do this”. How do I apply these concepts to daily operations of a clinical CSD program?  

 

In the present-day clinical environment, when I have to confront an inattentive or resistant client I say in essence: “This is not your house. You are here to (play/work on your goals/learn to speak [swallow] better.)”  You reinforce clients who show they agree with you. When you begin training generalization of target behaviors: “You are here for only 1-2% of the entire time you are awake. How can you build a strong new habit by just using 2% of your week?” If a client expresses reluctance to generalize a skill e.g. drinking thickened liquids at home, my answer might be: “When you leave here, I won’t know what you do. All this work is not for me but for you. You’ve seen this has worked. We’ll do our best to get you back to regular liquids”. I learned how to say “What I Want to Do….” I learned how to help my patient focus in the moment, to respect the therapeutic environment and use it as intended, and to bring the most energy possible to each time we meet. That’s what it’s all about.

(originally submitted in different form to ASHAsphere, the blog of the American Speech-Language-Hearing Association)