Out of the Beehive

Salon H at the Downtown Philadelphia Marriott, and it's five minutes and counting until the educational portion of the 2016 ASHA Convention is on the air! Hovering over attendees is a large circular chandelier, glowing with the anticipation felt by all in the room, ready to lift off .

A confession to readers: I do not attend the convention's opening session.   The 2014 opening session at Orlando, my only attempt at team spirit since the format change,  was a massive beehive with few opportunities to soak up why we were there - other than the transcendent keynote address by the late Maya Angelou. We've lost 90 minutes on the first day, that had once been open for education. Yes, I said it.

 Finally: to start the day, LaGorio, Crary and Carnaby provided case presentations based upon the McNeill Dysphagia Treatment (MDTP). We were reassured continually through the seminar, that this presentation was NOT to be a "how-to" treatment of MDTP. That was quite OK with participants, as the data shows that outcomes following MDTP were superior to training the person served in compensations, or through compensations plus neuromuscular electrical stimulation.

Encouraging to see that in this treatment approach, the treatment for impaired swallowing is a high frequency of swallowing. When LaGorio reported that she has not used most of her traditional dysphagia treatment 'bag of tricks' in the last 10 years, the sighs of relief could have pulled paint off the wall. Carnaby echoed this statement at the final 15 minutes, remarking that the intensity and frequency of the programawww is critical for changing the physiology of the swallow, not solely the compensations that momentarily protect against aspiration. MDTP may be seen then as an activity - based treatment of swallowing, for which you as the clinician may obtain greater buy-in. We like that!

Though this is not a certain CNN travel show, a meal interlude is in order. ASHA Convention organizers are forever in my debt, for offering each year a catered lunch option to pre-order then pick up at the exhibit hall with a ticket. The quinoa salad on Thursday,  and then kale salad on Friday, were accompanied by a gluten free, vegan dessert that filled you up without bringing on the pm calorie crash. No fighting for time and space in area restaurants, and no paying convention center prices!

Maldonado, post-lunch, was not as fortunate with interest in his subject (males in the profession), as was the MDTP group: 2 attendees! I was the male. His study, borne of grounded theory, showed that the pay levels, the rigidity of gender roles holding back many men from becoming a speech-language pathologist, and the perceived truncating of career advance opportunities - all continue, as they have since the 1980's, to keep the prevalence of men in the professions at or near 4% of the total ASHA membership. The answer, my colleague, is blowing through the corridors.

Archer reported on the contributions of cognitive ethnography to treating cognitive - communicative disorders. Relevant to qualitative study of training improved interaction, were  the insights that cognitive reserve is distributed among agents in the community of persons served; and that an ethnography constructed of conversation analyses of the person helps map the road to cognitive- communicative 'recovery'. Blog readers will easily figure out - We like this too!

Palmer and colleagues ended the lecture sessions for the first day, with a review of irritable larynx syndrome with chronic cough. The constellation of behavioral treatments in the SLP's armamentaria  can be built upon  with technology eg endoscopy, but it is still the skill and humanity of the individual clinician, in this instance, that most often brings real relief to these persons served. Suppress the cough, gain increased laryngeal control,  and learn to think critically about coughing itself.

Thursday night was a treat, thanks to the sponsorship of a trolley tour of downtown Philly by Lingraphica, a leading vendor of AAC systems. Don't worry; the trolley cars were enclosed and comfy. We got gratis cheesesteaks, soda, beer and wine. We saw the performing arts district, the financial district, Old City (including a Liberty Bell peekaboo), Penn ' s Landing, and the Museum of Art with their famous "Rocky Steps". Wow - I made it!

Staying at a motel in North Wales PA, 25 miles NNW of the Convention Center, allowed some quiet after a day of high focus, seeing the local culture - and a fun side trip to Valley Forge prior to convention's start. Bedtime was welcome Thursday night. But Friday would come early.

Why Ethnography?

(Those blog readers needing additional grounding in the methods described and how they impact clinical speech-language pathology, can read Damico and Simmons - Mackie 's tutorial on qualitative research in a 2003 issue of the AMERICAN JOURNAL OF SPEECH -LANGUAGE PATHOLOGY.)

They called her "the Doctor", and there is a difference of opinion about why that was so. "She looks like a doctor", was the rationale often heard among persons she met at work.  She was NOT a Doctor! Her hair was greying over her ears, and she carried herself with a quiet, distinguished air. She also wore a lab coat, though she did not need the mark of the ancient guild - she had said she needed the "Captain Kangaroo" pockets in the coat to carry her stuff! She may need washable markers, and a penlight, and tongue depressors, and an applesauce container, And she had made a point, when her job started at the building, to meet and greet everyone who lived within and NOT just people on the clinical caseload. She had a method to her madness; really!

For example, when there was a new referral for service she might interact with the newest person served in a group setting (eating a meal, or participating in a leisure activity). Persons directly AND INDIRECTLY connected to the person served, often would volunteer their observations during or after the visit. Those observers may also, at times, help interpret the experience for the person served. Some of these observers are followers in the culture, but others are leaders - leaders on the playground, in the gardening session, or at weekly worship services. The Doctor learned the processes and agents that made the culture work: who had nominal power that made the culture run, and who in fact wielded actual power and influence. Some of the movers and shakers (who controlled the conversation at the big table at lunch; who could get you an extra dessert; who had been in therapy previously and could help the newest person served, adjust) - they might have insights into what the person needs, and might be open to an occasional interview.

The Doctor made certain that, from the beginning of her tenure at the facility, that most people knew who she was and what she did. It made clinical encounters in a group less anxious for the members (Who's that woman? What is she doing here? Is she going to talk to ME? You talking to me??), and made the culture - the community - more a circle of friends and supporters for the new person served. As the Doctor used to say, "One day you'll be rid of me; that is when you must rely on the support of all you spend time with here each day". It was the Doctor's intent to sketch in as clear detail as possible, that skilled intervention to help persons increase their function for cognition, communication and swallowing - it is finite, and the degree of change that comes about through clinical intervention can be sustained to some degree, by the processes of the culture.

The Doctor composed her ethnography of her work site, during the first month of her tenure at that facility. At the end of the process, there were explicit and implicit rules known. Hierarchies of control for persons, and for resources were more easily understood. How would a successful therapy outcome dovetail with the goals of the culture? She could predict that outcome much more easily now. Over the years, she knows that the study of her work 'culture' will have to be re examined, revised and rejudged for its validity. That is pittance little work on top of her clinical responsibilities, for it - the ethnography - can be a major road map to superior clinical outcomes.

is "is", 'IS'??

There is about you a constant level of background chatter as the day starts. When you wake and look about, everyone that is talking seems hard to understand; when you attempt to speak to those gathered about your bed - "Ah, good morning!" - they look curious, then quizzical then - forceful, accusatory then - condescending. "She just doesn't understand". "We'll keep her safe but  - let's move on".

You might think she had suffered  a stroke or some other disruption of consciousness; but, no - it was the aftermath of a political campaign. She saw the world as "A", while her interrogators were "B" folk.

And, like most people who base their quality of life and - their livelihood, on fluid and robust communication, misunderstandings and BREAKDOWNS in communication, like the political morass of the age, impassion her - and me - to give the best advice and guidance for conversational REPAIR. Communication is pretty wonderful, because we realize - in the nick of time - its habitual breakdown poses significant DANGER to the health of our social structures. What to do, as you maneuver the body social and politic in these times?

Speech-language pathologists often help the people we serve measure their meandering for conversation, then develop and implement successful strategies that approach straight lines of sharing information. Some of the clinical strategies can be applied to conversations the general public is having at this historical crossroads. In general, the strategies can include:

* Don't make noise and don't encourage any noise. Though you and your conversation partner may continue to harbor strong emotions about your side, communicate with just enough emotion through the clarity of your arguments, and not via the pH level of your insults.

*Approach the conversation by conveying in words and actions, - I am here to share. I am here to understand. I am not here to fight . Your sharing that message may encourage the partner to adopt the same position. If either you or the partner approaches  the invitation with a high level of emotion, you will have to repeat your conditions (Earthling, I come in peace);

*You and your partner may have to repeat, as often as necessary, those initial setting of conditions before the sharing of ideas can begin. If either of you does not agree to conditions, cut the connection until the ground rules can be set. I don't think we are ready for this discussion, you might say. But once you and the partner are ready to address an issue -

* Trust, but clarify. Stop and think often as positions are shared. Confirm your understanding of what has been said.  Periodically agree that the  initial conditions are in force, then recalibrate them as needed. Do occasional summaries of the discussion and confirm understanding between both parties. The goal therefore, is not to win but to understand. Understanding trumps warfare. Communication feeds more interaction. Interaction growing leads to - what's next.

My ethnography

 This is NOT the culture and heritage for most of us. But with the current political campaign we have endured over the past year in the United States (people around the globe are looking at this blog - AMAZING), we're often forced or cajoled or intimidated to choose sides on the important policy and social issues facing the US, after the election on November 8. Bold lines of distinction can be hastily drawn.

 I feel justified when I say that we tend to duck down when there is cultural confrontation. We want to avoid drawing a lot of attention to ourselves, though we want to see it all. We are fascinated by the car wreck occurring, - can't look away - but we know that if we get sucked into the confrontation, we will perhaps, - change??

That's how it is with living in a culture - loosely defined as the beliefs of a particular group. Whether you are a leader of a culture, or one of the more prevalent followers of the cultural standards, it is good to know what is what; whose palms need be greased, and where do you enter to start your acculturation. "My hair!"

Speech-language pathologists, no matter what their work setting, are often in a culture but not of the culture. You often benefit from knowing the culture's most subtle workings, so you can serve persons who come to you. To better serve those persons, it often helps to begin your work by knowing how the person's cultures help or hurt the outcome they desire from treatment.  In a new job setting or a new job circumstance, to answer those questions about the person's cultures -   write an ethnography.

An ethnography is a documentation of the culture: how it is constructed, how it works and the implications of its existence.  Ethnography is a skill set out of anthropology, requiring the SLP to apply all the powers of observation she/he has. Given the penchant of SLP's to evaluate the effects of interventions, writing an ethnography might portray the culture at its natural, or resting or baseline state. 

The writings may include as evidence, data from the culture's members, in the form of interviews, surveys,  photos, video and other illustrative data (news articles , manufactured products, social media posts) that tell the culture's story. With the intervention in play, the SLP can then re-examine the variables checked at as few he. Why, though, - why pile on the SLP so much extra work to - not only help the person served improve function, but also paint the big picture of what and where and how the culture influences the outcome?

For my ancestors

(Blogger's note: this material was previously been submitted in different form, to the STEP program of the American Speech-Language-Hearing Association).

We have celebrated the end of the earth's "productive" season for agriculture, and now memories of those persons dear to us who have died come to bloom again. I find peace in my life now more than ever from ritual and discipline, though aberrations and outliers from the routine I embrace and term them instruments of "Alzheimer's prevention". I think the cycles of gardening that have helped me attune my own psychic rhythms to the seasons, also help me appreciate the time of year and the need for respect shown our departed elders. Not only are the departed from my family, but also from my work and community life.

According to his Facebook account, his 79th birthday would have been yesterday. He was not, to my mind, a person who beckoned attention his way but who on receipt, ate it up like it was fresh hot fried chicken. He embodied for and expressed from his students rigor, professionalism, good cheer and clear thinking. When he undertook advising first the pre-medical students, then all those entering health careers at our University, we all knew that the pre-med kids were getting a very big bargain with him.

He was first my clinic supervisor when I entered the world of CSD as a client - my long time  stuttering problem had waxed and waned over the years of adolescence, but suddenly became a moose sitting in my traffic lane - as my vehicle was pointed towards a future as a teacher. At the end of my summer session after my junior year of university, the growth in my speech fluency allowed me to refocus my career plans to include - speech-language pathology!!

He was rightly skeptical that a liberal arts student who had been focusing on analysis of novels and plays, would easily flip to swim well in the world of whole-language reading and phonological processes. He accompanied me to the 1974 ASHA Convention in Las Vegas as coach and interpreter, to guide me to sessions that may help answer my question: What is therapy all about? He gave no more than a chuckle to my comment that, at 3 a.m. prior to the last day of meetings, I had respectfully declined an offer to "party" from the back of a mustard yellow Mustang on the Strip. "I have to get up at 6 - Convention!", I said. He put the topper on my pre-service training, even before my first undergraduate classes in CSD had begun (I had my fourth year to complete enough classes for a minor, and enter the master's program the following Fall). He taught me, at age 21, to tie a Windsor knot to prepare for Convention meetings.

He cultivated discipline and clarity in our clinical work. As our clinical supervisor he was a model of joy, method, and requiring big time investment of the client and supports in the treatment plan. He taught you  that you could accomplish big things. All this from a deceptively quiet guy.

Thank you, Dr. Hugh Bateman.