Don’t Beat Yourself Up—Your Client’s Behavior is Not Your Behavior

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My posts are meant primarily for new speech-language pathologists, and I know of a recent situation encountered by a clinical fellow—who we’ll call Karen—that I think warrants discussion. The fellow is just completing her second week at work; she has 16 children from age 3 to age 12 on her caseload for a total of 45 sessions. Some are preschool children with significant language impairment, and some are grade school children with autism spectrum disorder.

One in particular is an 8-year-old boy, Eli (not his real name), who has ASD and no real verbal language, and who displays serious negative behaviors—some of them hostile and aggressive, like biting—spurring intervention from the crisis-management team. His previous speech therapist had recorded some very positive sessions with him in her session notes. Eli’s IEP mandate is for three sessions a week, so Karen had only seen him only five times but had reported a few very positive sessions with him.

Yesterday, as Karen started her session with Eli, she felt confident that she could have him use his communication book to request items during a food activity.  That is, she felt confident until, out of the blue, with no provocation, Eli grabbed her arm and bit down hard. Karen pulled her arm away before Eli broke the skin, but not before he bruised and hurt her. And at the same time that he bit Karen, Eli bit his own lip and bled all over the materials Karen had spent a lot of time making for him. Well, there went her confidence. Needless to say, Karen was extremely upset, but she managed to hold it together long enough to get Eli and herself to the nurse, get him cleaned up, get an ice pack for her arm, get her materials wiped up and disposed of, and get herself to my office to decompress.

She came tentatively to my door and sheepishly peeked in to ask if I was busy. I noticed the ice pack on her arm and asked how she got hurt. It was then that she lost it and began to cry. She wasn’t really hurt very much, but she was very distraught. Ahh, what a wonderful teaching moment, I thought. OK, don’t be so shocked! I am not uncaring. It is just that it is not often I get such an immediate opportunity to discuss “not being emotionally involved” with a new speech-language pathologist.

We have all heard that we should not be emotionally involved with our clients. To me that was a very strange sentence when I was a new SLP. Of course I was emotionally involved! I was invested in the client’s success. I cared about the client. What were people talking about—about this not being emotionally involved? Well, over the years I have come to understand what this means, and I have tried to pass this information along to the clinical fellows and externs I supervise.

To me, it is about not having your ego caught up in the clients’ performance, but to have it grounded in your own performance. I have developed a few questions that a CF (or an extern, or any SLP) can ask herself or himself when feeling bad about a session. Let’s take a look at each one, as applied to Karen’s situation:

  • How do I really feel? I asked Karen if she was hurt. Was that why she was crying? Was she just upset about being bitten? As she examined her feelings, she determined that she felt she had done something wrong. Why did the child bite her? She said that she did not want to have the child taken off her caseload but that the bite made her feel that she wasn’t doing a good job. So she identified that she felt like a failure.
  • Why do I feel this way?  Well the other clinical fellow never reported being bitten by Eli, so Karen felt she must have done something wrong.
  • Could I have done something differently to change the outcome of the session? Aside from staying far enough away from the child that he couldn’t grab her (not always therapeutically appropriate), she concluded that she could not have done much differently.
  • What precipitated the client’s behavior? Karen could not really identify anything.
  • Did I do the best I know how to do? Karen she said she thought she had.

Regardless of your own answers to these questions, as applied to your own situations, every session can be a learning experience for the new clinician. Either you did all you could do, and you did it properly, or you did not. Either way, the client’s behavior is not your behavior. Your emotions should be based on your behavior. If you think you could have improved things, you did not fail. You learned. If you think you could not have done anything differently, you learned that you cannot always avoid a negative outcome, no matter what you do.

No matter what, you must not allow your emotions to get the better of you. You must be intellectually involved in your treatment and in your outcomes. Your sense of success and failure must come from knowing that you know what to do. Or it can come from knowing that you know how to improve, or that you know how to seek the help you need to improve. When you are present in your sessions and aware of your behavior and can assess your behavior after a negative outcome, you are remaining objective and not being “emotionally involved.”

Irene Gilbert Torres, MS, CCC-SLP, chair of ASHA’s Multicultural Issues Board, is a clinician in New York City. She concentrates primarily on infant and preschool evaluations and supervision of graduate students. She is an affiliate of ASHA Special Interest Groups 11, Administration and Supervision; 14, Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations; 16, School-Based Issues; and 17, Global Issues in Communication Sciences and Related Disorders. She can be reached at irenetorres@optonline.net.

Tricks to Take the Pain Out of Writing Treatment Goals

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Supervising has taught me a great deal about what trips up SLPs. And one of the most challenging things for new SLPs seems to writing treatment goals. One reason is, of course, that we know these goals will drive the treatment and that they are important; but it is more than that. We want goals to organize our treatment and make it more linear, more hierarchical. We want our goals to be read as a path to development, or recovery: first do this, then move to this and then go on to that. This is, after all, the essence of task analysis.

Speech and language development, or recovery, is not however, linear or even, in many instances, hierarchal. It is so much more, but that is for another post.  We also want our goals to address the clients’ most important needs and in some cases we are hard pressed to figure out just what is most important. We also need to have our goals fit in with the guidelines that our employer sets and that just keeps changing on us. So goals become a challenge.

When writing goals keep in mind that goals are supposed to be SMART: specific, measureable, attainable, relevant and timely. A pet peeve of mine are goals that say “the client will improve his receptive/expressive skills.” These are not SMART: First of all they are not specific, but more, importantly, there is no measurable component in them.  In a report you can head the respective goals with, “In order to improve his receptive/expressive skills the client will…..” But those sentences are not goals and are certainly not SMART goals.

There are numerous data banks of goals on the Web, but I have never found the goals in any database to be just quite right; they all need to be tweaked for the client. You can certainly look up goals in those databanks, but you have the skills to write goals on your own. They are not that difficult when you think them through. You can use a template such as ___ will ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­___ by ___ to ___ percent above baseline or ___ percent of the time as measured by ___ or some such formula but you still have to fill in everything from your own mental data bank. You can do this easily by using the answers to some simple questions you must ask yourself.

Let’s look more closely at SMART.

Specific
Part of the problem is thinking about goals as a separate entity. Goals are just a way to put what you want to do in therapy in writing. Most SLPs are not uncomfortable about doing therapy so why should goals be a problem? Ask the following questions for a start for your specific goals.

  • What are the client’s communicative strengths?
  • What are the client’s communicative weaknesses?
  • What are the skills contributing to the strengths?
  • What skills are deficient and therefore contributing to the weaknesses?
  • Which of client’s skills can be used to compensate for deficiencies?
  • Which skills that are lacking can I actually help the client attain?
  • What do I want to work on first? And now answer: Why do you want to work on that first?  That answer will help you determine if you have made a viable choice.
  • What are the tasks you will have the client complete or engage in to work on the skill?
  • What supports will you provide for the client?

When you have the answers to those questions you have the “specific” for the goals.

Measureable
Can you define the skill that will determine if the client is doing what you want him to do and can you measure progress in that skill?  How will you measure progress? When will you consider the goal accomplished? If you can answer all these questions move on; if not, go back and adjust the goal to something you know you can see or hear and therefore measure.

Attainable
Do you think the client can actually accomplish this in a year? If the answer is yes, move on. If the answer is no, go back and choose something you think the client can accomplish within a reasonable timeframe.

Relevant
Will the attainment of this goal serve a communicative function for the client or will it just be something you can do with the client?  Will it serve a purpose in the client’s life considering the limits and ramifications of the diagnosis and his cultural and social needs?  In the case of an IEP does this goal serve to move the child along to fulfill the common core standards?  If the answer is yes, move on if not… yes, you get the picture go back and start again.

Timely
Does the goal contain a time frame or a date for accomplishing the goal? And can the goal be attained in that time frame? If yes….

Short-term objectives need to follow the same criteria but they should not just be separate pieces of the overall task but rather steps to getting to the long-term goal. The timeframe for accomplishing each part of the short term objective is, obviously a portion of the long term goal and the objective should actually contain that time frame.

As I stated in my last post, what best facilitates treatment is knowing what you want the client to do and knowing that your treatment is actually addressing this. Well, such knowledge also facilitates goal-writing. Use it to write your goals. You have the skills. You need to convince yourself that you can use them. When you keep that in mind, goal writing can be simple.


Irene Gilbert Torres, MS, CCC-SLP
, chair of ASHA’s Multicultural Issues Board, is a clinician in New York City who contributes this ASHAsphere series for beginning SLPs and welcomes treatment questions to address in future posts. She concentrates primarily on infant and preschool evaluations and supervision of graduate students. She is an affiliate of ASHA Special Interest Groups 11, Administration and Supervision; 14, Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations; 16, School-Based Issues; and 17, Global Issues in Communication Sciences and Related Disorders.

What Every Beginning SLP Wants to Know

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Your course work is over.  Your campus supervision went well but now you are out in the “real world.”  You know about normal development.  You have read up on various language and speech disorders but now what?

During my more than four decades of work, I have found that the answers to the questions I get asked are not in textbooks. They are in the trenches of experience. Clinicians do not want to know when children eliminate fronting or when irregular past tense develops; they can look up things like that.  They want to know about the nitty-gritty of conducting a session.

Today an extern was asking a child to say, “I want the bus,” and he would not respond.  I stopped her and asked her what it was she wanted him to do.  She looked perplexed because this sounded like an odd question when it was so obvious that she wanted him to repeat the sentence.   Noticing her look, I then asked her what she was trying to “accomplish.”   She said she wanted the child to request.  Well,  if the child could repeat her sentence, he obviously had the structure, “I want the train,” and if he was whining, reaching for the train and saying “train,” then he had mastered requesting. So what was it that she really wanted him to do? What was it that she thought he couldn’t do?

When questioned about the child’s skills, the extern said that the child could say, “I want….” in various contexts and that he could label “train,” so she wanted him to use the structure of “I want the train” to get the train. What she was trying to accomplish, without knowing it, was having the child use the skills he already had. She was not teaching him to request. She wanted him to “use his words.”

Carryover is an integral part of therapy, but you cannot force a child to speak or to “use his words.”  This is a battle you will not win.  You can continue to ask him to repeat, withholding the toy until he says what you asked him to say.  But what purpose does that serve other than frustrating everyone?

To aid compliance, we set up a scenario in which there were two different toys in close proximity—so close that the child’s pointing did not make clear which toy he wanted.  Taking the toy he wanted was acceptable, but the extern continued to ask, “What do you want?” even when the child just took the toy.  As he took the toy, the extern would say, “Oh, you want the train.”  The extern then requested a toy she wanted by saying, “I want the ….” and taking it from her pile of toys.  She continued to arrange toys in such a way that pointing did not help the child get what he wanted, and when he whined, she ignored it. She just requested the toy she wanted and took it.

The extern set up play situations where she was able to ask, “What do you need now?” The child began to say the name of the toy he wanted.  With continued modeling, he said a reasonable approximation of, “I want the train” by the end of the session.  Exuberant praise and the acquisition of the toy were very reinforcing, and the child used the “I want” approximation a few more times during the session.  It did not become a “talk or else” situation. It was a situation where speaking made it easier for the child to get what he wanted.  The intervention was given context and the end product was the child’s obtaining what he wanted by requesting it.

The main point here is to know what you are doing, what you are trying to accomplish, and what is that you are doing that is at cross purposes to what you actually want.  And to not make speaking a challenge for the child or a condition for playing, but to demonstrate that speaking facilitates communication.

I was a beginning SLP once, know the frustrations, and want to help. If you have other not-in-the-textbook questions you’d like answered,  pose them below in the comment spaces so that I might address them in future blog posts.

Irene Gilbert Torres, MS, CCC-SLP, chair of ASHA’s Multicultural Issues Board, is a clinician in New York City. She concentrates primarily on infant and preschool evaluations and supervision of graduate students. She is an affiliate of ASHA Special Interest Groups 11, Administration and Supervision; 14, Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations; 16, School-Based Issues; and 17, Global Issues in Communication Sciences and Related Disorders.