Lying in Wait

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.

Everybody Thinks They Can Do Speech Therapy

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.