I first thought, when starting this post, that the subject was a "gift". Long-time readers of this blog will recall that I once blurted out - I didn't know what therapy was all about! Readers will also remember that the sign about therapy given unto me, as Linus gave one that Christmas to Charlie Brown, was built on the logic of the ICF (International Classification of Functioning, Disability and Health). That is, there are contexts for how a person served will function, across the domains of cognition, communication and swallowing. That is, though observer (therapist) A might see the person served at mealtime, showing behavior B (eating without coughing, choking), observer C (teacher, nurse, direct care staff) may report that the person, at mealtime, is doing behavior D (coughing up a lung). The therapist can also see the person served as an impairment of bodily function (loss of base of tongue retraction), vs impaired performance of an activity (chewing and swallowing a hot dog and bun), vs impaired participation in a social environment (eating dinner with friends in a restaurant).
As the designated expert in this clinical situation, you may have the answer sought to help a person served - often in a single observation, a cross-sectional observation that may capture sufficient data to pin down a diagnosis for therapy - or you may not. To get your job done as a diagnostician, answer these questions: are your tools sufficiently sensitive and specific to meet the clinical needs you have anticipated? Did you schedule the evaluation at the appropriate time? Did you access sufficient history beforehand, to plan an evaluation? If you enter the evaluation setting and you discover the person has entirely different needs than first reported, what are your backup plans?
Speech-language pathologists are able to study the culture of their work environment, to compose their personal ethnography of the worksite. This analysis of the physical setting, the persons served and the staff serving them gives you perspective for the needs of your person served, in the environment where their function is in question. Ethnographic study of an observation grows out of a longitudinal observation, borne out of multiple observation data collections; you note during the observations, trends in behaviors, the lines of formal power and actual power among staff and persons served, and the factors that may contribute to the presenting problem with the person served.
For example, the person served may be a grade school student who is nonspeaking; therefore, at the center of concern by numerous school staff, family and peers. Those numerous persons in the circles (or cloud) of support surrounding the student, affect her/his function passively and actively. How the cloud of support persons affects the student's behavior in question; that is, how they facilitate or impede her/his ability to communicate needs, share information, follow conversational competence rules, and maintain social closeness; this can influence the organization of your evaluation for this student.
Your detective work for the person served in her/his environment, where you are a passive observer gathering data, helps control for an observer effect that can affect the validity of your evaluation. The benefits of your ethnography of the worksite culture pop out, like snowdrop bulbs pop from snowbank before spring. What influences your person served in their natural settings, will be invaluable for you in evaluation and treatment planning.
I often tell the persons I serve, at the time of the initial evaluation, "your job is to get rid of me". Well designed and executed SLP treatment plans come about, partially as a result of a well - done evaluation. The evaluation, in turn, is most effective when the environments for a person served are best understood. Remarks overheard in a typical clinical environment: "Who is that guy, and what is he doing here?". He is lying in wait.
I occasionally tell my fellow healers with a half-smirk on my face, when trying to justify some bump in the road during a tough workday: "You know, speech therapy has an inferiority complex". It's an off - handed comment, very much like the very bad joke I use to decline a high-carb treat offered at work: "it makes my hair fall out". Some of my workdays are tough, though they're not any more frequent than those of any other speech-language pathologist. We're the communication specialists, aren't we? It's part of our mission to close the circle, to help
the joint establishment of meaning.
I share that comment about inferiority, because it sometimes feels as if everybody thinks they can do speech therapy. That's right! All the people with whom I work; all my family; neighbors; producers of TV shows and movies; the stakeholders of persons served, and their relatives and neighbors, etc. All these folks and more try to tell the story of CSD, without employing speech therapists to do the storytelling...I am Woody Allen on a "Dick Cavett Show" stage, kvetching about how unappreciated my colleagues and I can feel. Thirty-six years of work since receiving my "C's", have taught me that there is no shortage of others who know and can do an SLP's work, better than an SLP can.
My colleagues tell me that I shouldn't get my arytenoids in a bunch, about the free advice on clinical practice I'm given almost daily. Do I get this advice, because I slighted a person served? Does the advice betray some insecurity I have about my competence for the job? Should I just shut up and then say, "thank you" to my benefactors? I love my work, and know I do often make a difference. But, regardless of their motivation, it seems that there still occur in our practice settings, circumstances that bring about -
* no referral
* late referral
* vague referral
* colleagues making treatment decisions
* direct care staff making treatment decisions
We'll drill down - or, lift the shells - in a subsequent blog post.
May 5: It's time. It has to be time; time to get out into the garden and start supporting the growth of plants for our speech and language clinic. Not only will we grow spring plants that adorn windowsills and waiting areas of our clinic, but we will also mine a lot of clinical gold from the vegetables and flowers grown outdoors as a haven from the urban noise, and as a repository of good foods and visual delights.
Spring is the distant turn of sunlight, that gives us more and more motivation to brave still cold winds, scratch open the soil layers and insert a bit of germinal life into the desiccated, shivering world. It should be time. It has to be time, because we've waited so long. The FARMERS' ALMANAC says that the last spring frost date for this area is April 20, but there is so much to be done prior to that date. Please, let it be time.
There are, first, curriculum and therapy plans to be structured around garden activities. What are the plants; what are their characteristics; how will we plant, cultivate and harvest them; how will garden workers participate in the Spring - Fall growing season; what change will occur in the garden beds through the seasons; - and how will we communicate about and consume the fruits of the garden!?
June 1: Patience is a virtue. When the spring was approaching, I felt that it might take forever to get to this time of the year. There were the waves of thunderstorms; the alternating blasts of humid heat; the squirrels and other beasties, large and small; varying degrees of indecision by the clinical staff about what to plant, and how to train the persons served; - and, whew! How did we do it?
The curriculum fell into place easily, due to the fact that most plants have not evolved significantly since vegetable and flower gardens entered mass market visibility. You plant peas when the ground can be worked in spring, for example. When squirrels, rabbits and their kin are about, you plant enough for them, as well as for yourself. To remind those critters that they do not control this garden space, you plant enough for the critters and for you.
June 30: there's been a band of thunderstorm cells, passing by fast this afternoon. Thank goodness the 6 tomato vines, 4 pepper plants, pea vines, bok choi sprouts and romaine seedlings - all withstood the quick, hot storm. Too much accomplished, to lose plants to storm damage. It's time. Strength. Health. Vitality. It's time.
That's right. I said it. Practicing speech - language pathology requires an adventurous soul. As Merriam - Webster implies, speech - language pathologists are "disposed to seek adventure or to cope with the new and unknown".
You may have that day received numerous referrals for swallowing, many of them the aftermath of a single coughing episode for each person. Your treatment day may be marinated in boilerplate writing, to help keep the doors open. Meeting a milepost for your day, alongside that of a colleague, you may be asked "How many (patient appointments) do you have left?" Rapid rewrites of your daily schedule, require your turning on a dime to meet changing attentional demands by our customers. Get that documentation done before the end of business. Make the telephone calls. Attend the meetings, scheduled and impromptu. You have a productivity target to meet. Make sure you have all you need, to do the night work that lifts your work to the highest level of quality. Get it done. Do it!
You can hear in the background the pounding rhythm of "Working for a Living", by Huey Lewis and the News.The thumping; the pressure. There's always a need to strive, to push and to grasp the next rung on the ladder - surge ahead on the long staircase that is the rehab journey, to arrive at the next landing to gain perspective. What makes speech-language pathology work, adventurous? How does the CSD clinician prepare for the adventurous life? How does a professional plan for success, in such a workaday world?
I see an individual clinical encounter as dripping with adventure. Bold? Risky? Speech-language pathology? After all, you as the person's clinician guide persons served to tap energies they scarcely recognize within themselves. Changes in bodily function have apparently occurred out of the blue, and the person is often clueless how to remedy such a catastrophic event.
You are well prepared by training to take the arduous journey that evaluation and treatment represent. Your adventure begins with leading the person beyond her limits of perception, of motor power or of reasoning. Does she find the strength to recover from being lost in a dark wood, not able to affect change in her skills without your help?
With the evaluation done, there is the refocusing of the quest to achieve the person's goals. When the person served can contribute energy to identifying and clarifying the goals, the road to reaching them is clear. A clear path to the person's goals helps give agency to the person, and makes her the one wearing the armor.
An adventurous quest to achieve treatment goals may still bring many challenges; physical, psychological, financial, spiritual, and so forth. There are hills to climb, torrents to ford, monsters to confront and territory to claim. The person served learns to recognize decision points to be met during her treatment program. She gains confidence for acting as it is needed, and when it is needed.
The quest may, regardless, seem contrived, complex, cumbersome and "not real life". The person served may sometimes say, "I'm never going to use this". The adventure of a person's treatment program will stand the test of time when done right - when the goals sought after are firmly in hand, when the future is easily imagined, and quests are yielded to others more in need.
When my wife learned of her diagnosis this past summer, it was a challenge for me to 'stay clinical' about the situation. Meldrick Lewis, that wisecracking detective from my favorite cop show, had said once that homicide detectives working a case should keep everyone around them 'at a distance'. That has been one of my strengths as a CSD clinician over the years; one of my marketable skills as an SLP. No matter the noise about the person I had been helping; no matter the amount of stress in my day; - I could keep it clinical, blocking out the clouds of peripheral activity to the case and to myself, - I could say, it's just agitated behavior. It's just the patient urinating on the chair, or it's Capgras syndrome - she's still a human being and my patient. My responsibility to her is to focus on the reason for skilled SLP to be called in.
My wife is not my patient. It's the slicing open of my clinical mask by her recent medical status change, that has made me newly aware of the following: When you're on this side of the encounter - when you are personally involved in a treatment program - it's not so easy to stay indifferent to the emotions that rattle and slap against you. You can't easily push back the anxiety, the fear, the puzzlement, the latent skepticism, or the stark reality that you feel utterly powerless against these medical 'forces'. But, I initially told myself - you know the system. You even know a bit about this medical condition, and what can be done. That led to a relatively large conundrum for this healthcare worker, one that is related to the contemporary psychological dictum - it's not just about you.
I live in the caregiver's world now, albeit a fairly literate caregiver when it comes to health knowledge. I can deduce the effectiveness of medications, and follow directions for treatments. I can approach doctors, nurses, social workers and all their ilk assertively, to deduce their thinking about what needs to be done. But I ultimately have no power; at least no clinical power, to help steer my wife's outcome towards its conclusion. Caregiver power is regardless, substantial.
It's an entirely different skill set - one based on intimate knowledge; attentiveness; patience; the big picture; the little things; not sweating the small stuff; not dropping the ball; being there and celebrating every little success on the journey - celebrating every landing that is reached, on the long staircase my wife is climbing towards her recovery. It's a switch in my psyche that I toggle now; namely, to go between the clinical professional and the grateful caregiver. Grateful I get the chance to be there for her when she needs it. Grateful that I can empathize better, with the caregivers of my patients I meet almost daily.
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