Category Archives: Thoughts about Therapy

Check out a new resource for running language groups

The book, with the hat used in the game!

The book, with the hat used in the game!

I recently got my hands on Communication & Language Activities – Running Groups for School-Aged Children, edited by Sarah Nash. Disclosure: I was given a copy of this book by the publisher to review, I used to work in the Hackney Team and Sarah is a friend. That said, here’s what I think.

I loved the illustration on the cover, and was keen to see how the book had been structured. There’s a comprehensive and clearly written introduction, covering topics like planning the sessions, dealing with difficulties and supporting carry over to the classroom.

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To connect with our clients we must model vulnerability

Keep_Calm_and_Carry_On_Poster

I believe that wonderful things happen when we step outside our comfort zone and do things that scare us, when we’re brave and allow ourselves to be vulnerable.

There was recently a discussion on twitter about SLTs presenting a calm exterior even when we’re panicking or out of control on the inside. We all know this feeling! It got me thinking, we need to present ourselves in a way that inspires confidence in the people we work with. We also need to bring our vulnerability to work – and not worry about people seeing our uncertainty. It’s hard and something I continue to struggle with.

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Having a go when it might go wrong: what I learned from communicating on holiday

Tunis

I’m on holiday in Tunisia! Travelling is a wonderful adventure, the food, architecture and landscape are exotic and exciting. Communication can be a challenge; although I’m a Speech and Language Therapist I’m not a natural linguist. My high school French is rusty and my Arabic skills stretch to hello & thank you, here in Tunisia I’m trying a total communication approach!

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Using Evidence-Based Practice in Real-Life

I’ve been thinking about how evidence-based practice is relevant to daily life as a therapist. I enjoyed reading Arlene McCurtin and Hazel Roddam’s Review, Evidence-based practice: SLTs under siege or opportunity for growth? The use and nature of research evidence in the profession, in the International Journal of Language and Communication Disorders. Check it out!

Many clinicians and managers I’ve spoken to think that evidence-based practice (EBP) consists solely of evidence from systematic research. Which means the mantra – base service decisions on EBP, can seem punitive rather than supportive. Watch Kate Malcomess describe how clinicians can feel dismissed and devalued if they don’t have an evidence base, in her 5 minute lightning talk. McCurin and Roddam use a definition by Dollaghan (2007) that highlights there are three components of EBP: research evidence, the expertise of the clinician (internal to clinical practice), and patient values and preferences.

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Invest in Yourself: Learn Essential SLT Skills for the Next Decade

Open Road

When I remember the therapy package I offered “Freddy”, I wince. Over 18 months, I gave him four six-week blocks of therapy: 24 sessions in all. When I eventually discharged Freddy, he still couldn’t consistently produce velars—and worse, he still didn’t care. Even though his parents realised that I didn’t have a magic wand, they didn’t practise with him at home. So I didn’t achieve my objective and I wasted several precious days—days I could’ve used working with other clients. I had clients on a waiting list who were ready to engage with therapy and work towards realistic targets. What a waste.

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Attachment to our clients makes diagnosis more difficult

There’s nothing like getting a huge hug from a 3-year-old speech therapy client: what a way to tell me he enjoys therapy!

The affection goes both ways: we grow attached to our clients. We notice progress, point it out to families, and celebrate with them. When we work with families for long enough, we meet new siblings, hear about first days at school, and get invited home to birthday parties and for tea!

Clouding my judgement

But is it possible for therapists to get too attached? I’m trying to make a tricky differential diagnosis and reflecting on whether my affection for this little chap is muddling me up. Am I observing his skills through rose tinted glasses? Placing more of an emphasis on things he can do while skimming over things he can’t?

I’m trying to clarify my thinking by making objective observations: noting down what I see without interpretation. I’m comparing these observations to what I expect from a child his age, as well as his clinical presentation from a year ago. I’m reviewing how he responded to different types of therapy and attempting Dynamic Assessment. I’m also planning to observe him at nursery, to see how he responds to other adults. I’ll figure it out!

Do you form close bonds with particular clients? Do you think it supports therapy outcomes? Or do you have to focus on being impartial?

The challenge of discharging children with lisps

Resources are tight in the National Health Service: think one full time therapist with a caseload of around 125 children. So we have to pay close attention during our initial assessments to make sure children meet our criteria for therapy.

For speech sound therapy, children need to have at least 3 processes and reduced intelligibility, as well as age appropriate language and attention skills to qualify. So we give children with lisps, or difficulties with /th/, activities to practise at home, and discharge them. In some cases that’s easier said than done …

I can understand why parents are anxious about lisps; they worry about teasing and bullying. Sometimes I find it hard to reason with them; they’re trying to do the best for their child and I’m trying to manage the needs of a large caseload. We’re in conflict.

I almost want to play them video clips of my pre-verbal child with autism, my dyspraxic child, or my child with a severe stammer and explain that these children are my priority. Not great for confidentiality and probably not effective either!

Empowering parents to support their own child seems like the best strategy. If I can elicit an accurate /s/ in isolation during the session, I can usually convince the parents to agree to discharge. I explain the hierarchy for generalising the sound into conversation and give them written instructions for home practice.

If I can’t prompt the child to produce the correct sound in isolation (I find those lateral lisps tricky!) I tend to go down the ‘your child is not stimulable / ready’ route. I ask the parents to practise discrimination tasks with their child, talk about how the sound is produced and come back in 6 months to a year if the child hasn’t made progress and they’re still concerned.

How do you deal with parents who won’t accept that their child doesn’t meet the criteria for intervention?

Video Interaction Guidance

I recently connected with Liz Panton via twitter. Liz sent me this comment after reading Clare Chilvers’ idea about using video:

SLTs, clients, students, etc. can have an entirely positive video experience with no tears and nasty surprises using Video Interaction Guidance (VIG) – also knows as SPIN and VEROC (Video Enhanced Reflection on Communication).

There is evidence that the VIG approach, focussing on strengths in interaction, is a very effective way to use video to improve communication.

I have tried it with clients with severe communication problems, eg. no speech at all many years post-stroke, with other health professionals and SLT students. Even the most video-phobic have enjoyed the experience and have improved in confidence as well as communicative competence.

I would recommend the VIG approach to anyone interested in using video as a clinical or reflective practice tool.

Liz Panton MRCSLT
Gateshead PCT (South of Tyne and Wear)

Thanks Liz! That website looks like a really useful resource.

Care Aims in education vs. medical model

Clare Grace raised a great question in response to my post from 2009, Clinical Risk vs. Clinical Need: managing workload and throughput:

My biggest conundrum at the minute, is that the risk assessment tools are very medical model – and don’t seem to reflect anything within the tools/structures of education – and 80% of our caseload is working into an educational setting – any thoughts or ideas would be greatly appreciated.

Although I’m no longer working in the same service, I can remember discussions about how the approach fitted with our work in education.

I’m looking at Malcomess’ “risk” and “clinical risk” grids. The risk assessment requires judgements about functional impact on Activities for Daily Living (ADL) and environmental adaptation. We can consider ADL in the classroom. In terms of environmental adaptation I’ve found a note I wrote on one of the handouts saying: “score environment which is least adaptive (and central.)” So a child in an educational environment which is significantly contributing to risk would score highly on the context column.

In terms of clinical risk we discussed thinking about school staff as well as carers in the first column: motivation for change / carer responsibility. We need to consider who in the child’s life is primary, in relation to impact. A teacher who is unable or unwilling to collaborate in the treatment process would cause a child to score lower in this column (if the SLT service was entirely school based.)

What do you think about using the tools in education settings?

Counselling in speech and language therapy: denial, grief, and blob people

I’m interested in how Speech and Language Therapists (SLTs) use counselling in clinical work. I’m also drafting targets for my Personal Development Plan (PDP) and want to include one about counselling; perhaps writing this will clarify my thinking!

What is counselling?

The British Association for Counselling and Psychotherapy uses this definition:

Counselling takes place when a counsellor sees a client in a private and confidential setting to explore a difficulty the client is having, distress they may be experiencing or perhaps their dissatisfaction with life, or loss of a sense of direction and purpose. It is always at the request of the client as no one can properly be ‘sent’ for counselling.

By listening attentively and patiently the counsellor can begin to perceive the difficulties from the client’s point of view and can help them to see things more clearly, possibly from a different perspective. Counselling is a way of enabling choice or change or of reducing confusion.

Why do SLTs need to use counselling skills?

SLTs work with clients (and their parents or carers) who may be experiencing denial or grief. We might need to use counselling skills if our clients:

  • are unable to engage in therapy,
  • demonstrate strong emotions,
  • tell us they’re feeling low,
  • are tearful, or
  • struggle to adjust to their difficulties.

(List taken from Sparkes and Simpson, see below.) Sometimes we need to address these feelings explicitly before we are able to move forward with therapy.

One particular session with a parent left me feeling uncomfortable: her son had just been diagnosed with autism, and she spent the therapy session in tears. When I reflected on the session, it felt like I’d been unable to support her; so I decided to develop my counselling skills.

Resources and training

I searched Amazon for some books to get me started. I ordered Counselling Skills for Health Professionals by Philip Burnard and Person-Centred Counselling in Action by Dave Mearns and Brian Thorne. I found Counselling Skills for Health Professionals relevant and easy to read; it has practical ideas, short case studies, and an interesting chapter on culture and communication. In contrast, I found the language in Person-Centred Counselling in Action complicated and difficult to follow. Although it contains lots of interesting ideas—and it made me think—SLTs are not really the target audience.

I also attended a one day course called “Feeling out of your depth? Innovative approaches to using counselling skills within speech and language therapy” at University College London. The course was led by Cathy Sparkes and Sam Simpson. It was great! I took away lots of practical ideas for working with clients and families, and learnt more about my own skills and boundaries.

Using “blob people”

One of the ideas Cathy and Sam shared was using the blob people pictures. At work we use the “blob tree” as part of our initial assessment for people who stammer. I liked the list of possible questions that Cathy and Sam discussed: I can easily see how to use them in my clinical work.

The pictures show lots of blob people (who are neither male or female, young or old) in different situations; check out the blob bar! Possible questions to initiate discussion include:

  • Which one are you?
  • With friends, which one are you?
  • Which one would you like to be?

The pictures and questions are a great resource, check them out.

Personal development target

I was prompted to think again about using counselling skills during a recent initial assessment. During the session the parents seemed to move from denial that there was a problem to grief that their son’s language was severely delayed. There was another family waiting, so I couldn’t explore the parents’ distress. Looking at the definition above, I did try to help them see things more clearly, and to reduce their confusion, but maybe I could have done more.

Is there a personal development target here somewhere? How about:

To practise using counselling skills in assessment and therapy sessions, in order to help parents think clearly and be ready to engage with therapy.

What do you think?