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When Patients Won’t Practice

by Kristie Knickerbocker
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You give 100 percent in each session, but end up repeating last week’s activities because your patient didn’t practice. Who’s at fault?

We all tend to get complacent with the materials and techniques we use. Thankfully, we also take CEU courses to keep ideas and implementations fresh. But what if you try everything in your bag of tricks and your patient still doesn’t improve?

I discussed this exact issue with two of my patients recently. Each one had a different situation, but both were making limited progress. “John,” for example, sought treatment with the hope that others would stop complaining about his voice quality. He says he stopped doing the diaphragmatic breathing exercises I assigned, because his voice wasn’t any better. I replied that it takes more than a week of doing only breathing exercises to make improvement. Breathing is just the first component of coordinating a new voice.

He and I talked about the real reason he was here. I discovered that although he felt his voice sounded disordered, it was really only affecting those around him. It really didn’t bother him that others thought his voice was annoying, so he decided not to continue sessions. Fair enough.

“Sara’s” case was different. She and I worked together for several weeks and ended up going through almost the same session each time. She reported practicing, but I didn’t see evidence of that in her productions. Frustrations arose and she felt like she was getting nowhere.

In our most recent session, we talked at length about life and the projected outcomes of her condition. Her voice issues affect her life, which upsets her. This emotional roadblock gets in the way of her dedicating time to practice outside the treatment room. She also feels guilt and blames herself for the issue, even though it’s not at all her fault. She realizes that these feelings are holding her back, so she’s taking time off from sessions and coming back when she’s ready to commit.

We should try to build up patients when they come to us feeling down on themselves. That might be tricky, however, because we also point out their mistakes in order to correct them. Sometimes sharing personal experiences as encouragement helps. It’s never a bad idea to refer clients to a therapist or counselor as supplemental treatment—it’s even in our code of ethics and scope of practice.

I do this occasionally when sessions frequently turn into “therapy.” If I think a patient would benefit from talking through issues with a trained professional, I always refer out. That way when the patient comes to our sessions, we focus on the voice disorder and I know the other issues are being addressed.

If your patient isn’t practicing, it’s time to find out why. Is it motivation? Is it you? Do your best to figure out what else the patient needs from you to be successful, and offer many options. Sometimes all you have to do is ask.


Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She provides voice, swallowing and speech-language treatment in her private practice, a tempo Voice Center, LLC, and lectures on the singing voice to area choirs and students. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders. Knickerbocker blogs on her website at www.atempovoicecenter.com. Follow her on Twitter @atempovoice or like her on Facebook at www.facebook.com/atempovoicecenter.


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Teresa Britt-Hutsell May 5, 2015 - 11:04 am

Terrific blog. All of us that are truly devoted have seen this, been a part of this, been frustrated by this. Often, in pediatrics, it’s the parents that require the so-called scolding as well. That’s extremely temperamental. Living through a physical loss of my own, I can seriously relate to their feelings and emotions resulting from their disability (be it that). However, intrinsically, I’m a fighter by nature. I don’t give up easily in my own life or for anything I’m passionate about. I did receive some counseling to help myself learn a valuable lesson…learn to seperate it out, control what you can to what extent you can, let go of what you can’t. But, never stop trying. As therapists, and according to our code of ethics, if we have exhausted every trick in our bag, Ian’s we have made little to no success over a reasonable amount of time, I feel it is our job to discharge secondary to non-Compliance. They have to do their part too be it adult or child. We are only “allowed” a certain level of control. We have to teach them how to help themselves, refer to others as needed, do our very best and look
Ourselves in the mirror with confidence knowing that, then we do have to know when to call it a factor we cannot control. We cannot keep draining insurance companies or personal pockets if there is little to no positive outcome. This relies again, solely to some degree at least on the responsible party themselves. We have a job to do. We do it with everything we have to do it with to the very best of our ability. Then, we must let go when it’s time to let go. Encouragement is a critical part of our job, teaching, referring, giving our clients patience factors knowing we have little control there as well, being sure we know what we are doing and doing our best at it. Those are our limitations. God bless you and your clients with this understanding. It’s very hard to accept. It’s clear you are a great therapist with a true passion for excellence both within yourself and your clients outcomes. But, there still may come that day. Blessings. Teresa

Kristie Knickerbocker May 5, 2015 - 5:22 pm

Thanks Teresa. You’re right when you say, “We have to teach them how to help themselves.” I find that I often am beginning a session with, “What else can I do to help you do this without me.” Thanks for reading.

worldvoiceday May 6, 2015 - 9:48 am

Great read Kristie I love your blog … As someone who has lived with a disordered voice for almost 9 years I can attest to the importance and value of patience, compassion and empathy from a SLP. The feeling of making little progress is hard enough to swallow …without the added fear of being judged or told that you’re not trying hard enough… particularly when you know you are following instruction religiously.

Dysphonia is a really tough gig, and a little bit of empathy can go a long way.

I have worked with 2 fantastic SLPs in my time… and another one who has all the technical quals but atrocious people skills, and who almost ‘broke’ my spirit entirely. Unlike you, she could not resist the temptation to dabble out of her depth ….wandering into uncharted psychology territory and giving my a man-sized serve of ‘tough love’. Poorly informed and brutally executed. All I can say is thank goodness it was ME that was the target of her poor judgement. I can recall driving home that night and thinking that if I was a less resilient type I may well have chosen to drive into a tree …. wracked with feelings of failure and hopelessness.

Instead I chose to rise above her insensitivity and get on with my life…without her. But not before providing her with feedback about the potentially damaging impact she had had, …and urging her to be more cautious when dealing with others. I genuinely believe that she was not comfortable with seeing that she didn’t have the answers … therefore my condition was my ‘fault’.

My reason for sharing this ??? well it’s almost 5 years on and that session is indelibly imprinted on my mind, serving as a powerful reminder of the impact that we can have on another human being ….Particularly in a therapeutic relationship.

So to all you speechies reading this …be firm but kind… don’t presume to know what your clients are experiencing in their daily struggles to get it right…. refer to a professional counsellor where needed….and most of all never ever ‘give up’ on anyone.

Kristie Knickerbocker May 6, 2015 - 12:26 pm

Thanks so much for sharing your story. It is hard to teach bedside manner, and it’s something you try your best to “pick up” when you observe other SLP’s giving sessions. We impact others each day and don’t even realize it.

Full Spectrum Mama May 6, 2015 - 10:16 am

Coming to this post as a parent, I have to share how challenging it is to get my child to practice ANYTHING on top of homework etc. Tips on that would be a fabulously useful post!

Kristie Knickerbocker May 6, 2015 - 12:32 pm

The best advice I have for this is try working it into daily routines. It is a lofty task to attempt to set aside time to “practice” speech goals at home as a parent. You are busy with meal prep, making sure your house is somewhat picked up, and trying to keep the tantrums at bay. I’ll keep it in mind for a future post, but tasks are most likely to stick with the child when they are worked into bathtime or mealtime.

Keri Vandongen May 6, 2015 - 5:32 pm

Thank you Kristie and Ashasphere for this fabulous blog that I shall share with my readers and followers. I agree as do many of my clients that speech practice and carryover are not easy to do.
Thus, I specialize in fun ways for kids to practice speech, while also supporting parents & others with learning how to help and motivate children to practice & carryover speech success.
~Keri with Speech Party

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