Organic SLP: An attitude or a science?

When you think of how SLP's work; where we do our work; and about the processes and the goals for our work - is organic SLP, science? Can the results of clinical practice that stresses communication for relationship-building, over drill work to increase component communication; the use of environmental structures and cues to make it easier for a person to function well;  the primacy of applying component skills for cognition, communication and swallowing, in the settings where they will be used; where rapid acquisition of goal targets is stressed; where customer satisfaction is accentuated through teaching and obtaining frequent feedback - be replicated across ages, disorder types and treatment settings?? Is organic SLP, science??

I would say, yes - that organic slp IS built upon a scientific framework, and that its principles can be upheld alongside the practice of what I have called "mechanistic SLP".The clinician who uses organic SLP principles has her/his roots in mechanistic SLP; namely, the tools for impairment-based evaluation and treatment can and should be used. There are scores, hundreds of incidences where a person with a cognition or communication problem would only begin to change when slow, methodical and segmental training of processes occurred. Impairment-based training is the core of our field, and the skill sets inherent in our clinical training will always be in that bag of tricks we scour before each encounter.

There does remain a need in SLP clinical practice, for a skill set that brings the person served from an entry point of dependence to that of relative independence as quickly as possible; that allows the SLP in an interdisciplinary practice setting (e.g. with physical and occupational therapy, or with education and psychology) to assert her/his expertise as vital to the successful outcome of the person served; that models for all the professionals involved with a person, superior customer service; that constructs a strategy system allowing the person to say: I can do this in real life when I - , and that treats communication processes largely where the processes will be used day-to-day. How can these additional be measured and evaluated, as having met the tests of scientific method?

The SLP clinician has the skill set to operationally define organic SLP processes, and to write targeted goals for treatment after baseline status is clearly described. For example, the person served may gain attention of a caregiver from across the room, using speech and gestures in a noisy setting, 25% of the time. Barriers to the person performing this function include the noise level ( TV on, dishes clattering, chatter within the room, PA system occasionally carrying announcements, person's weak voice and impaired hearing). Treatment includes identifying the components controlled, then controlling them as possible. It also includes compensating for the variables that cannot easily be controlled. How would you help the person increase her/his skill?

Gotta laugh

In the recent post "Organic SLP", I hinted that this style of practicing speech-language pathology (SLP) was very different from a style that I called "mechanistic SLP". Where mechanistic SLP meets persons served  where their bodily functions breakdown, organic SLP deals with the needs of persons in real life situations. When it comes to dealing with stressful real life situations, such as a person served who is feeling anxious or depressed, it is the SLP who may often lead the way for the person's improvement. Sometimes, a good belly laugh may start the healing.

I once worked with a man who had had a stroke, done his rehab and gone home. He then had come back to our rehab center, after the trial at home had been disastrous. He had lost his skill with walking, and lost much weight in the bargain....and with his clinical signs of depression seemingly sinking him at the beginning, there was a need for immediate change in his focus.

Why did I feel I was the ideal person to get him refocused? I had made a reputation in previous jobs, as the staff who would take on the most challenging "patients" around. I had been kicked, bitten, wrestled, punched, slapped, cursed and threatened on the quest for better communication. I had dressed in drag with previous patients, when their level of consciousness was minimal. Singing and dancing at a level beyond all levels of propriety in patients' rooms, especially for people who have difficulty speaking, you can bring out the darndest speech!

I knew that, above all, helping activate the person's limbic system within the brain by communicating highly loaded emotional content - it would have good odds of prompting more communication. As I did when I wore dresses (and a prominent blonde/white mustache); when I made confetti from Post-It Notes and threw it over my OWN head when someone did well; when I organized a patient kazoo band to promote expiratory airflow;  - minimal advance notice and stealth were the key. Kickstarting the brain into communication, however reflexive. requires often a strong, unexpected stimulus.

The man in question had gone down for a deep sleep, following his morning treatment session. Deep sleep! No response to shaking the mattress slightly - so FWISHHHHHHHHHHHHHHHHH with some stretching and then blowing, four party balloons were inflated with the help of my well-trained lungs. Two were inserted in his canvas slip-ons, that rested in the seat of his wheelchair. The remaining two balloons were placed on his tray table. When I appeared during the later lunch hour, blowing up balloons for others within plan sight of his table,  - his laugh and smile were priceless!

Organic SLP:

Speech-language pathology (SLP) has become a well known commodity in the US human service economy. In most urban areas and many rural ones, there are speech-language pathologists serving the population from cradle to grave. Many SLP's are focused upon the needs of children, while scores more are specialists in the needs of adults. The need to communicate stays constant throughout the life span, though the aims of good communication differ with the different demands of human development - cradle to grave. The majority of SLP's are found within educational settings, though a growing number of professionals work within healthcare settings.With wholesale changes being brought to the field- through increasing demands by payors for accountability, and by the tightening of efficiency standards by employers looking to get the best return on investment, there are SLP's who have their clinical practices streamlined to keep the productivity high.  When more people are served, that furthers the profession and all those who benefit from our services. More SLP's work as well.

 But when quantity of service may jeopardize quality - and anecdotal reports from the field hint at such a degradation of service quality in some work settings - it is worthwhile to consider a service model that holds communication between person served and clinician uppermost; where the person served directs the care but is accountable for the outcomes achieved; where meeting the person's needs includes treating problems at the level of participation (involvement in life situations), instead of predominantly at the level of impairment (breakdown of bodily functions);and where the SLP uses all the tools available to her/him in the worksite. This participation-based approach to practicing clinical SLP we will call "organic SLP", to contrast it with impairment-based approaches to SLP that might be called "mechanistic SLP". Why is there a need for this approach to clinical treatment of communication problems?

* Mechanistic SLP makes us the 'question lady'. SLP is often known simply as answering questions from drill books, where human communication is a dynamic and versatile skill set that one does in all conditions. There is a need for skill development where persons served will use them, as early as possible. The person served should be a partner in all interventions whenever she/he has the capacity to do so, giving feedback often on the effectiveness of intervention. Communication thus becomes the game, the transaction that is demanded by real life - not the rigid stimulus-response routine of drill settings.

* Mechanistic SLP makes us too much like physical and occupational therapy. In a multidisciplinary treatment setting, most persons served identify mobility and self-care needs as the reason they are in "therapy". SLP may follow treatment sessions of the other professionals, at which time the person served may say "I'm tired from therapy!" or "I talk just fine" or "Are you going to ask me questions?".  Organic SLP approaches establish a positive, affirming relationship with the person served, so that treatment time is not solely a number of repetitions completed, or a % age of trials attempted. It is building a therapeutic relationship based on cooperation, built throughout the person's day and for which the SLP will provide high levels of customer service.

* Mechanistic SLP forces us to train persons to change behaviors at the component skill level - it is not real life. Clinicians who follow the evaluation with a roster of component skill exercises (e.g. sentence completions to improve formulation of thoughts; contrastive word pronunciations to improve speech clarity) - and that is all there is - face a person served who does not know how to turn success at drill, to success in real life where that skill is desired. There need be, from the time of evaluation, time given in each session to map the person's success at use of a component behavior - onto the real life setting where the behavior will be ultimately used.

*Mechanistic SLP does rely upon the latest advances in applied behavioral science, to help persons with communication (and swallowing) disorders keep the highest quality of life. Regardless of the high degree of reliability and validity for many of these treatments. SLP clinicians must finally keep it simple when it comes to training the person served towards independence. The component skills should be stepping stones over which the person served will move, to get to a level of competence with real life. The person served should hear from the SLP, something to the effect: "You're trying to get rid of me, so you can do this on your own. We will both know when that day has come. Until that day comes come, we will review often what we are doing and why. I will need your input about what we are doing, so that we can both be confident we have achieved YOUR goal". That is the mission of a practitioner of organic SLP.

What else can we ask of clinical SLP's, such as those who work with adults, that allow the persons served to touch real life in their training?The next post will provide some answers.

Information Has to Get In to Be Used

The referral message came one day, as a hurried hand-off discussion in our office with my therapy coordinator: "She's pretty demented". When I later asked the person in question to consider an evaluation with speech-language pathology (me), she asked more than once - "what does this have to do with my walking?" I told the woman, who reclined in her wheelchair but occasionally vented energy by chewing at her nails, that there was no connection between her recent fall and problems communicating. She then asked me to repeat what I had just said. There; I had my diagnostic hunch confirmed. You can't use information if it does not get in first.

As many as half the population of seniors in America may be afflicted by hearing loss, though prevalence figures vary widely among age ranges and cultures. When an older adult who has hearing loss attempts to engage her/his community - to meet needs; to share information; to follow the rules of etiquette for the community; and - to maintain social closeness - there are often breakdowns in the efficiency of sharing information. When communication routinely breaks down, the person with hearing loss often may cut off, decline or withdraw from interaction entirely. The person's impaired sensory status can pose a significant safety risk. Speech-language pathology is one profession called upon to increase the hearing-impaired person's function.

Communication breakdown can be a factor of the type of hearing loss a person has: is more loudness needed to make the speech clear, or is more clarity? It can be due to the noise in the background: TV, other speakers, clattering dishes, or hard and smooth surfaces that reflect sound well. It can be affected by the cognitive status of the person, so that a person with impaired cognition who also does not hear well may not use strategies to listen intently. SO, what can be done to help the person with hearing loss communicate better??

Speechreading cues are often key tools in the tool box of a communication partner. Those cues include: giving the hearing-impaired listener a constant view of your face; keeping your face lighted; controlling your speaking pitch, its loudness and the speed of your conversation; stressing key words with either pitch, loudness or timing changes; and overarticulating (using exact pronunciation) each conversational turn you take. Each hearing-impaired person who benefits from speechreading has learned to apply the cues in both familiar and unfamiliar environments.

Background noise is often the lingering pest that nags at a hearing-impaired person's daily activities. Arrange for it to be turned down or off, or get away from it. The current generation of hearing aids, expensive though they may be, are much more successful at filtering out that noise. Hearing aid users should get help in adjusting to the aid though guided listening exercises.

Cognitive strategies for improved communication may be initiated by the hearing-impaired person, or by her/his communication partner and the community. Examples of strategies not previously discussed include keeping sentence structures and vocabulary concrete and simple; pairing conversational turns with gestures that clarify the message; conveying the emotions of the message with facial expressions; guessing of the intent of the message when not all words are understood; and writing key words for your message, if the listener does not initially understand what you said. Hearing-impaired persons who may benefit from strategies should have practice in their use.

The brief listing of helping strategies for hearing loss above is not comprehensive. For example, not all the current assistive technologies for hearing are hearing aids. Contact your friendly neighborhood speech-language pathologist, for more information on helping hearing-impaired persons better communicate. 

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