#097: How We Approach Client Perspectives

Marisha: Hello there and welcome to the SLP Now podcast, where we share practical therapy, tips and ideas for busy speech-language pathologists. Grab your favorite beverage and sit back as we dive into this week's episode.

Marisha: Hello there and welcome to the SLP Now podcast. I'm your host Marisha. And this month we have Monica Lynn joining us to talk about all things evidence-based practice. So in episode 95, we did a review of the EBP triangle, just some of our initial thoughts. And then for the rest of the month, we are going to be diving into the different parts of the triangle. So without further ado, let's dive into this week's episode.

Marisha: Now, let's tackle all things client perspectives, at least as much as we can. Where should we start when we're thinking about client perspectives?

Monica Lynn: You know what I think the ASHA Evidence Maps is probably the best place to start just because I've got a whole tab for it. A lot of times there might only be one or two, but it doesn't have to just be from the client perspective tab, I feel like sometimes just in the regular tab. For example, if you go to the cultural and linguistic diversity one for external evidence and clinical judgment, that's it, just thinking about the cultural linguistic diversity is taking the client's background into account. So you're already kind of doing it. So the one that I looked at is the use of dynamic assessment. So even doing that, doing a dynamic assessment, you're taking into account that your student is bilingual in being able to do that.

Monica Lynn: So then there was a meta analysis right there. It says that is a great way for diagnostic accuracy for that. That's a great way to be able to take that into account, that client perspective ones. There was one on telepractice and outcomes for speech-sound disorders. We definitely had our fair share of telepractice this year, but this one study listed under client perspectives said that all studies included high levels of participant satisfaction with tele-health delivered speech and language interventions. This is for the study, I am sure that those of us that weren't able to do telepractice in the way that it was meant to be might have some differing opinions, but at least you would have kind of some place to go from in general that it is possible for this type of service delivery model to be successful. And then there was one on fluency and stuttering and the lived experience of stuttering.

Monica Lynn: And this one was like implications for rehab. So this was for adults, I believe, but just like how we're listening to autistic adults to learn from adults who stutter like SLP [inaudible 00:03:08]. But this study included five themes of lived experience of adults who stutter. So like avoidance is used to manage stuttering that stuttering unfavorably impacts employment experiences. It shapes your self identity. What kind of negative reactions there are. So some of these things that might even be like social, emotional things that we need to keep in mind even for when we have them when they're children, because that can shape the therapy that they have and their perspective about it can shape their thoughts about themselves, their self identity, their self-esteem, and then that can bleed into so many areas of their life that if we didn't consider those things, when we're doing therapy as children, that it might affect the way that they are as adults.

Monica Lynn: And those are kind of like important things to think about and part of the EBP triangle where it really might be just taking like an inventory of their thoughts and feelings about something. Like I know in my sessions we're always talking about how we feel about things and doing a lot of self regulation type stuff. And I think the lesson probably is, don't be scared to do it during your session. Therapy does not have to just be like, "Here's our material, here's our plan," black and white. We can include a lot of this stuff to be a whole picture of the student, just to make sure that we're having the best outcome that we could.

Marisha: Yeah, absolutely. It's interesting too, because last month when we were talking about narratives, we were talking about linguistic diversity. So I feel like our whole last episode last month was talking about how this could be implemented with narratives.

Marisha: And I'm curious if you have any, just more general suggestions in terms of that domain.

Monica Lynn: So I think for cultural staff, during your interview with the family, asking who the caregivers are at home, who's helping with homework, do the tips and the recommendations that you're giving align with their family values or their culture. So like a lot of the common things like reading books at home that might not be a cultural practice that they do at home. So that might be really difficult for them to incorporate at home. Or for a lot of my families the grandparents or the caregivers while parents are working, so they were helping a lot with schooling and they weren't very comfortable in English. So it might've been the older brother and sister who also had to do school at the same time. So they might not be able to do any of these things at home because parents are at work.

Monica Lynn: I also had a parent who uses ASL. So it's like asking them, "You should provide whatever you want at home, what you're comfortable with in the language that you are comfortable in." So it's like, "If you want to practice this, practice it in ASL. Do it in a way that is feasible for you." And I think it's just like being flexible with that because I know a lot of the external evidence is going to say that the practice has to happen at home for generalization to happen, but real life, that may not happen. So then you might have to work with the teacher to make sure that happens in the classroom, just because of the way that your population is and just to be sensitive to that. I think another one could be, are your materials diverse?

Monica Lynn: Is your population represented in your materials? Like if your students need more support in language, are you giving your directions in a way that they can understand? All of these things together it is a lot, but I feel like after you do it a lot, it just kind of becomes routine and then you don't have to think about it so much. But in the end, this might be some of the most important stuff too, just because it makes the family feel included.

Marisha: Yeah. If we don't have the student buy-in, or the family buy-in, or teacher buy-in too, we're not going to make much progress. We could be the most experienced SLP, totally dialed in on all of the research and all of our data collection have the best system ever, if we're not taking this into consideration, we could still have students that make minimal progress.

Marisha: I'm curious too, obviously we want to get the buy-in from the student and the family and the teacher, last time we talked about the language use questionnaire to just kind of understand where they're coming from and I think that can sometimes bring things to light, but what other things could we be considering when we're having those conversations? Is there anything that we can listen for or something that we can ask?

Monica Lynn: I think generally when we're using like that questionnaire, I use a general questionnaire about what the family feels like are the student's strengths, what they're doing well with, what helps them succeed, what they think the challenges are for them. And what is one thing that you would love to see your child succeed with? And maybe like, what are things that help with that?

Monica Lynn: If they have found that repeating directions, or having a visual, or something especially if you have a new student that you're assessing, all of that could be really valuable information. And we touched on it a little bit too with the teacher that you could ask the same sort of things in the classroom. But I think that it doesn't just go for narrative, I think that it goes for everything that, do you notice that if you have it projected up on the TV... our classrooms have TVs, we're really lucky and the teachers can project it and show an example of how you're supposed to do it. Does that visual help a lot or do you have to come over to the student's desk and repeat the verbal instructions when you're closer and you know that they have their attention?

Monica Lynn: So some of those things and kind of narrowing down what type of support that that student might need and really considering that student's individual support needs, I think can help. Also, the student's social, emotional situation. So if you're doing like a multi-disciplinary team approach, did anything else come up with the other people who are doing the assessment? IF you're picking a goal for stuttering is that going to be something that you're taking the student's social, emotional situation into account? For autism, are you incorporating methods that aren't going to make the student uncomfortable? Like making sure you're not using eye contact goals or preventing them from moving their body in a way that they need to? So those might be embedded support. So in my thing, I have embedded supports for... they can sit or stand if they need to, or if they need a movement break.

Monica Lynn: So those are all some things that you can look at for supports that you need to have a successful session that aren't necessarily based in, you're not going to read like a whole article on it, or you might not have internal data for it, but it's just kind of something that you're considering about the client as you get to know them to think about the best way to support them.

Marisha: Absolutely. And I think now would be a good time to tie all the pieces together. One example that stands out to me, and this was from Dr. Strand's seminar too, I think it's important just to listen and have an open perspective as to what is important too, because that's what this boils down to. What's important to our students and parents and teachers? She's got all of her clinical experience or expertise, and she definitely knows all of the research and she knows what progression of words is the most evidence-based.

Marisha: But this student really, really wanted to learn to say his name, it was not in the protocol, it didn't make sense in terms of where the student was, but that is what he really wanted to do. So they took some time every session to work on learning his name. So she incorporated all of those different parts of the triangle, that motivation I think really contributed and the student felt seen and heard, and it all went together. So I'm curious if you have one other example to wrap this up.

Monica Lynn: I do have a specific example, but that also made me think about using a student's special interest in the session. And it's like, sometimes if they are not in the mood, they're not super regulated, we will throw everything out the window and talk about trains for half an hour. But you know what? We still get the work done and they're still making progress.

Monica Lynn: So I think that's just something to keep in mind. But for pulling it all together, I think we could talk about... like a student you have with a phonological disorder, they're not making much progress, you learned about minimal pairs that seem like the easiest. There's a little bit of rhyming in there for phonological awareness, you feel like you're doing okay, but then you look at your internal evidence and you're like, "You know what? I feel like maybe we would've made a little bit more progress now." So then you look into other treatment methods. So you were looking into external evidence. So you see that from your assessment that student had phoneme collapsed. So then you could look into multiple oppositions and from also different external evidence research articles that you want to add some more phonological awareness activities as well.

Monica Lynn: So then you're going to use your clinical judgment to then put that together and try this new method, which Rebecca from [inaudible 00:13:08] and speech pathology has amazing stuff for that. And put that together, [inaudible 00:13:12], the phonological awareness, switch it up with the student, that the student has low frustration during sessions. So they're going to be able to try that when they're making new sounds. So you've thought about that student's social, emotional reaction that they might have to try a different method that might be a little bit more difficult. So that client perspective comes in there. The family at home has been asking for homework and they said they will practice because the student is really unintelligible. So now you've got that client and family perspective. So now you know that they are going to do some practice at home.

Monica Lynn: With really unintelligible students, I also do what you were talking about. I'll ask families to send me like 5 or 10 words that are really important for them that they struggle with and are frustrated at home with so that we can practice, or I might even teach the classroom aid after we've gotten it pretty good. We'll have like maybe a classroom aid if there is one. Just practice that list with them a couple of times every day. So I have that [inaudible 00:14:22], and then you wrap that all together and now you've got an EBP treatment plan.

Marisha: Oh, I love it. It's like a nice little bow.

Monica Lynn: Right?

Marisha: Wrapping it all together. That is the perfect way to wrap up the series all on EBP. Thank you for sharing all of your experience and research with us, Monica. It was super helpful.

Monica Lynn: Yeah. This has been fun.

Marisha: And yeah, we'll see you all next month.

Marisha: Thanks for listening to the SLP Now podcast. This podcast is part of a course offered for continuing education through SpeechTherapyPD. So yes, you can earn ASHA CEUs for listening to this podcast. If you enjoyed this episode, please share with your SLP friends and don't forget to subscribe to the podcast to get the latest episodes sent directly to you. See you next time.