Gardening aids in speech therapy: a primer

1. Look at your treatment plan, the blueprint for what needs changing with therapy.
2. Example: "the patient will name on demand, ten of ten objects common to her/his environment, with vocal/gestural/tactile/olfactory cues provided 100% of the time".
TELL ME THE NAME OF THIS!

3. That is treatment at the level of IMPAIRMENT of bodily function. When you see significant improvement of that behavior, you want to help the person take this skill set back to real life. Gardening allows the client to ease back into real life, or the PARTICIPATION level of function.
4. So, when it comes to identifying summer annuals that must be removed from garden beds, one needs to name these plants.
5. Your client will practice naming these summer plants:
A. Tomato

B. Zucchini
C. Cucumber
D. Eggplant
E. Marigold

F. Basil
G. Pole Bean
H. Cowpea

I. Bell Pepper
J. Corn
6. If the client does not spontaneously say the name of the plant when seeing it, a card can be produced which has a COLOR PHOTO of the plant, the PLANT's NAME written in BOLD PRINT adjacent, and some general information on the plant's LIFE CYCLE below.
7. The client can match the photo to the plant, or -
8. The client can imitate your naming of the plant. 
9. Successive experiences in the garden allow you opportunity to increase the client's skill level, to meet the goal set in the treatment plan.
10. Dig we must!

the only constant is change

There's a cold front coming tonight, we were reminded as the staff meeting for our university's speech clinic wrapping up. Make sure the kids are wearing their coats and hats and gloves when they leave!
I was later that morning to remind my team of speech-language pathologists that - with the freeze warning for tonight, our adult gardening group MUST soon get the summer annuals out of their garden beds. Why? There are fall and winter plantings to be done. Keeping in the remnants of summer annuals may be exhausting the soil. The garden environment, rather than reverting to "nature", benefits from thoughtful management that brings healthy growth of what is desired year round. Return on the investment made by our clinic administration, to get us started on this crazy adventure in the first place.

 And oh YEAH - have we had returns! Sidestepping the stragglers at our department meeting, we're off to mark the change of seasons! That is the beauty of having a teaching garden at the speech clinic. You never exhaust your imagination for activities. Children and adults are transformed by digging in the dirt. The increased visibility of speech therapists with the approach to gardening, makes the opportunities for recruiting energetic staff much easier!

There were tomato, basil and marigold plants to remove today. Many other annual flowers and vegetables had had their times, but most clients, students, the faculty and staff, our customers and families alike -they preferred their tomato fix. Our group arrived on time and was ready. Gloves, tools, an apron to protect the clothing, and therapy tools for each group member to help them complete their work. Every client was paired with a student to reinforce concepts and strategies trained in therapy rooms. They were to be communicating  about tomatoes! There were photos and concise written descriptions, for each sequence of the gardening process. For example:

PICKING A TOMATO:

1. Select a tomato that has the best shape and color.. They are firm and shiny.
2. Take the tomato in your fingers, and GENTLY pull away from the vine.
3. The tomato will POP off the stem, when it is ready to be picked.

The written guide is accompanied by a demonstration: I will do it, then watch you do it. Showing someone how to do something seems almost foolproof, but - one never stops learning!

It is so easy to keep data on how easily each client completes the tasks, and what level of cueing each person required to complete each task. What made the task remarkable today was - we got to eat our work in a salad!

why garden in therapy?

Gardening in therapy - how unusual! Why do it?

* CONS
** Gardening requires, above and beyond the training afforded CF candidates, additional exposure  and additional training (above/beyond SLP grad training), experience, and knowledge of gardening equipment, materials and supplies.
** Gardening also requires knowledge base and skill set for using hardscapes (base soil v raised bed v containers v hydroponics); those SLP's learning by doing may benefit from guidance by professionals in horticultural/design professional to have hardscapes that are desired for one physical setting, selected :
** requires additional knowledge base and skill set for growing plants; horticultural professional as consultants to SLP's
**  _ for pests and their appropriate management
** _  requires physical aptitude to complete typical gardening activities
** _ requires cognitive aptitude to plan and execute garden design
 ** __ dilutes the effectiveness of SLP in the clinical settings where hort is available
** _ challenges any SLP operational or capital budget, already stretched by consumable materials/supplies
**_ a challenge to daily SLP productivity

*PROS
**        it brings increased visibility to the field of SLP, in all the work settings where these professionals exist, in a manner not previously afforded. Increased public visibility may assist the gardening SLP in marketing, fundraising and program development in the larger community.
** gives SLP a laboratory for treatment at the level of participation, where component skills for communication, cognition and swallowing are synthesized into the 'stuff of everyday life'.
**_ A laboratory for swallowing disorders? Yes, since one pivotal variable in treating swallowing problems , is to provide food the person will eat. A functioning vegetable garden gives the SLP clinician options for growing, harvesting, cooking, preparing and presenting the food; a new SLP skill set!
** allows the SLP to tap into physical activities not always seen in the treatment room, but that co-occur with communication, cognition and swallowing to meet a social need
**allows the SLP to market her/his services more easily to patients, family, rehab team, physicians, facility staff and administration, payors, the general public. Are there great gardening therapy outcomes? Get them out there.
** provides the SLP opportunities to expand her/his skill set and knowledge base to interact with the clinical population, using gardening activities in ways not usually available through the clinical process;
** affords the SLP access to innovative and fun activites at relatively low cost; benefits of which can be shared w/ the person served
** empowers the SLP to stress that any real life environment in daily life is a potential therapeutic setting; the skills and imagination of the SLP and her/his colleagues, are the sole limits of such a program.

memories in a field pea

All of my obsessions with gardening; with Southern food and culture; with communication in everyday life and how the CSD professional engages it clinically; and the public stature of CSD clinicians, that benefits them both professionally and personally; - I give all credit, honor and power for my grown-up life to the humble field pea, Pisum sativum. Like the madelines Swann enjoyed as the evocation of his life, in the famous novels of Proust -the field peas brought together all the crossroads of my life, during a dinner my mother served when I was home one semester from college.

"Good morning, and welcome to speech therapy in the garden. Today we're going to talk about and plant some cowpeas, or what some call generally southern peas.  They are called "southern" because these varieties of legumes (beans, peas, peanuts) originated in the southern US. These peas are extremely heat-tolerant, and grow well in shade and the poorest of soils. Since the roots of these plants have the ability to draw up nitrogen, they are excellent green manure for your garden soil. They can also be used as forage for farm animals. Let's plant some today: before we start, let's look at the seed."

Mom at that meal, served plates of field peas (Pink Eye Purple Hull?), with scoops of white rice and wedges of hot cornbread. The bread was sweet and crispy on top, and moist and succulent on the bottom when slathered with butter. The rice: tender and slightly sticky to hold the pot liquor and the butter from other food - goes down so good as you combine the dishes. The field pea, - if the Delta had had any elevation, peas could roll off the plate and head downhill to New Orleans. But they couldn't and didn't roll away, - soon GULP! they were gone. And my life had a unifying force.

"This is a summer season plant. That means we need soil temperatures of 70 degrees or more, to germinate the seed. Here at this midwestern university clinic, that means the best times to grow this plant is during the summer session. Is there anyone who wishes to spend their summer session, caring for such an annual? I didn't think so. That's not a worry, however. We have affiliated with our clinic garden, staff and volunteers from the Cooperative Extension service, and from the high school FFA program, will tend the garden for us during the summer. We gain from their expertise in horticulture, and they learn how a garden can be a 'therapy room'."

And they were so GOOD: the time the peas spent simmering in a cast iron pot with the pork flavoring, making them creamy inside but still giving up all their fiber and sweetness; they combined with the rice in a bite having buttery energy and dark, rich protein; and ahhhh- there was within them such a complex history; the peas having been eaten as much as 100,000 years prior; that seeds from the numerous pea varieties traveled with African slaves to their new home; that the non-native plants were miraculous sustenance for southern poor through the years of both struggle and bounty; -that the peas were ideal for the tropical and bare conditions of many Southern farmland: not much moisture needed; and excessive heat and poor soil well tolerated. No amount of historical review can nevertheless compare with the best way to acquaint yourself with Pisum sativum; namely, by shelling a few dozen of her mature, dried pods on the back steps with family @ twilight.

"Field pea. Crowder pea. Blackeyed pea. Speckled butter beans. Mississippi Silver. Whatever cultivars (specific plant) you choose to plant and harvest, they are all fascinating plants. Now, I have photos of each seed -and five cards that have names of each cultivar. Please match the photo of each cultivar with its name."

There was among us in my family, on any of a hundred evenings just like this one, a number of regulars at shelling time: my two sisters, the domestic worker hired by my mother as cook, nanny and moral force; and the family do, at that time a big ol' boxer. Lots of practice , with chocolate brown warm fingers coaxing stubby, pink ones on how to pop a pod;  - wow, I had a bit part in tonight's dinner. This bit of kitchen work was a ritual beloved through much of my home region, for decades and across the centuries - from Mississippi back to the cultivars' origin in Asia.

"Good work. We've sprouted the pea seed; we've planted the seedlings, watered them and kept watch against pests. The sun and heat have been good to our plants, and we soon  will harvest the pea pods. You know I've worked with you to keep an accurate record of the garden season. We have had to keep accurate records of data for each day, including rain, weather conditions, plant conditions, and all actions taken each day. Let's review now, how successful we have been in growing our peas".

Teach, teach, teach!

Teaching the persons that you serve in CSD programs  - THAT would seem to be embarrassingly self-evident. Well, doesn't it?! Aren't you teaching these skills for communicating, thinking and swallowing to the people you serve? Don't you instruct their families, the caregivers, your colleagues, the referral sources and third party payers in the plan of care? When it becomes time for completion of the plan of care, doesn't the SLP lead the person served through the home exercise program? Well, yes, you might answer - but that is not all the teaching that might be done.

SLP's teach when they want the person served and her/his stakeholders, to understand what it all means. With the "Fantastic Four" movie coming later this summer,  I think of Sue Storm Richards, alias Invisible Woman (what a commentary). Sue would often ask her husband during a mission: "Reed, what does it all mean?". My middle school peers and I (late 60's) would often make Sue jokes when reading the latest comic - but Sue was onto something.

That is why: you tell a mother of a child on the autistic spectrum, how communication may begin with  the coding of behaviors that may occur regularly. For example, shaking both hands in the air may mean "I am afraid". If you are working with an intubated adult in the hospital's intensive care unit, that same gesture might mean "please come look at my bandage". A person with a severe stutter can show that same behavior, and it can be a learned behavior that at one time, helped extinguish the stuttering moment. For still another person, the evaluation findings of nonfluent aphasia may require you describe your decision making that came to the diagnosis. How does her performance on word repetition tasks,  impact the impressions of her disability?

This is teaching's goal: to help the persons served use data obtained in the clinical setting. They then may feel full partners in the plan of care. When the person served has information that totally keeps them in the loop, she/he has greater focus upon treatment activities, and is possibly more efficient for completing the treatment program. What else can happen as a result of continual teaching?

Teaching the patient and stakeholders bolsters their skills for advocacy. Self-advocacy - "please approve my request for this speech generating device, Mr. Insurance Company"; stakeholder advocacy - " my husband can still do his job, after his brain injury, with the accommodation of wearing tinted glasses in the workplace"; system advocacy - "if cigarette taxes are kept high in states with the highest rates of head/neck cancer, rates of cancers which may lead to communication and swallowing impairments could come down".

Teaching is also essential to all aspects of preventing communication and swallowing problems. Treatment of these problems (tertiary prevention) is done to prevent permanent disability. Secondary prevention, or surveillance, includes teaching the person served and any stakeholder the implications os screening clinic data - or giving answers to questions after a community lecture. The quantum leap beyond teaching persons of their risk for communication and swallowing disorders, is to help people minimize their risk of impairment - or directly control factors that may bring on disease. Primary prevention activities remain undiscovered country to professionals in CSD. They may still hold the strongest hope for answering the question posed by our consumers: what does it all mean?

On the trail of evil

Speech-language pathologists don't solve mysteries. They do not unearth lost treasures from obscure places around the world. When wrongs may be righted, there often is no great financial reward at the end of the quest. But we knew that, going into the professions. We knew that making a financial killing in CSD would require our working multiple jobs and sleeping seldom. And - we need our sleep! Instead of financial riches being our reward for a CSD career, many of us have seen the need to "fight evil".

Poor and ineffective communication* is often the source of poor and ineffective human relationships; by extension, the source of a deficit in the individuals'  quality of life. I will often remind students who choose to train with me, at the beginning of each work day: "fight evil!". When our professions keep quality of life - and its implementation through improved function of communication processes -at the forefront, we fulfill our mission to the persons we serve.

May 2015, known as "Better Hearing and Speech Month", is now over. Each May, what have we and our peers done that will keep us remembered? Since 1927, professionals in communication sciences and disorders have used May to promote what they do, and why treating communication disorders by skilled professionals is important. Here is why.

People communicate everywhere. Most caring and observant persons are able to stimulate human communication in others. Speech-language pathologists know which stimulation methods are most effective.  In a world that is more diverse and more dependent upon the sharing of information  than ever, effective communication skills through the lifespan level the playing field for all persons. In making CSD an integral component of the human service system, society helps prevent human illness by sustaining communication wellness. I cannot say enough to support my colleagues in the professions, as well as those persons who have entrusted their care to me, for all the opportunities given us to fight evil.

*please read: communication and swallowing

Did you write it?

Documentation has often been the near death of my speech therapy career, more times than I can count. I write a blog now so - I must admire something about writing. But until recently, clinical writing threatened to become the black hole where most of my love for the field might be SUCKED! When I was in training, and even following graduate training - good writing was expected but not well taught. You were shown reports in the university clinic, and expected to emulate the style(s) shown in these reports.  That's all!?! That's all good clinical writing is - ?!?!?!?!? Don't you believe it. But, until I had had enough experience in the trenches, writing  many reports and notes - I rarely had more than other notes from which to learn good clinical writing principles.

Good clinical writing is, above all, a record of what you actually do with your patients. The SLP who writes well can tell the patient's story, in ways that not only satisfy the people who pay  the bills. There is also a need to pass along the uniqueness of the person you serve. When you meet this benchmark of telling the person's story, you give your patient more effective treatment that fits these unique needs  The effective clinical record also meets the standards for behavioral applied science, - namely, what you did and what the patient did in response. And, when the effective written record is completed, other professionals who may also serve your patient will give their best informed service.

There are day to day realities to face about good clinical documentation:

1. "If it wasn't documented, the encounter did not happen". The essence of the SLP ''s work then is - the production of the written record. With point of service documentation (performed at the time of the encounter)  being the trend in clinical practice, the record is completed near the time of the encounter. The clinician who can meet these standards is more confident that the record accurately reflects the actions taken in the encounter.

2. "Data-driven" - your documentation provides value for your patient's care, when it contains the discrete measurements you specify to track changes in your patient's behavior. It could be number of correct initial "s" sounds from a word list, or the number of initiations of conversation, or the average duration of a swallow of ice cream. Your data trends drive your treatment. Let your documentation be easily read with data.

3. Writing clinical notes well tells your readers: you are a skilled observer, not only taking good data but telling a good story. It tells your reader how well behavior has been deconstructed to train the core skills, and anticipates how behavior will be reconstructed so your patient can reenter real life. It requires writing with economy to meet reporting pressures, and writing with clarity so that your patient receives appropriate care.