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

pensivewoman

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.

Tips to Wrangle Your Most Unruly Speechies

clock here
At the beginning of each school year, I have great expectations that this year is the year that all my little speechies are going to manage their behavior well in my treatment room with minimal incentives on my end. So much for great expectations. Because, of course, every year, I’m presented with new challenging behaviors to tackle because we educators know that “all kids are unique and different.”

Just when I think I have mastered all that I need to know about behavior management, one my little sweet speechies decides to bring a new unpleasant behavior into my speech room.

The good news is, I have learned much about managing these behaviors, both in the school setting and at home—from raising two little ones! These are my tips for keeping your therapy room calm and productive:

  • Say what you mean and mean what you say. Set the behavior expectations for your speech room at the beginning of the year and explain the consequences for not following your expectations. Each session, review these with students who need frequent reminders about their behavior. Visually post your rules and consequences, so they can see and hear them. Don’t be afraid to snap the whip and follow through with your consequences because it sends the message to the whole group that you mean business.
  • Bring on the visuals. Use visuals to remind students who struggle with transitions about the start and end of activities. I use a Time Timer and two to three warnings to let my students know when the activity will end. I am also creating a visual necklace that displays prompts to help show students what I want them to do. Visuals such as “all done,” “sit,” “clean up,” and “calm down” are on my list. I also use visual scheduling in treatment. For example, I might draw a chair with the child sitting down, then playdoh, cards for artic, and then clean up or a good-bye visual. As we complete each task, the child marks an X on it.
  • Empower students. We all want to be in control of our lives even when we can’t control our circumstances. This is the same for children. And although they cannot dictate the session, we can still give them choices, such as “You can sit in your chair or you can stand behind your chair,” or, “You can work for Legos or stickers,” or “You can finish your worksheet and earn your speech bucks, or sit in your chair and lose your speech bucks for the day.”
  • Encourage sensory integration. Some of your kids may struggle with focusing, staying still and controlling impulsiveness because their sensory regulation is off. Having fidget tools such as squishy balls available upon request may help your student. I explain that the squishy ball is a “tool” and if used as a toy, it will be taken away. Also, incorporating movement breaks or activities that infuse movement help keep our little speechies focused and in control of their body.
  • Abandon ship when necessary. We all plan wonderful, amazing treatment sessions filled with activities that we “think” all kids will love. Sometimes your most ideal therapy activities may not work for certain children. Don’t hesitate to abandon a toy or activity when a child does not appear interested in your fabulous board game! You will get more meaningful interactions with toys and activities that your students prefer, rather than trying to force them to like what you want to do. I always try to reintroduce an activity a couple weeks later to see if they may want to try it out again.

All in all, behavior management is an ongoing process that takes time, trial and error, and a willing SLP to dive in and try new techniques!

Felice Clark, CCC-SLP, is a school-based speech-language pathologist in Sacramento, Calif., and author of the blog, The Dabbling Speechie.