Category Archives: Notes on clinical supervision

02.25.18 — My first first-person account of being a Clinical Practicum Instructor

Notes on clinical supervision

Almost a year ago exactly, circumstances aligned that I knew for sure that I could not stay in the work position I was in:  I couldn’t do good for it, and it wasn’t doing me any good.

But I had worked so hard to understand clinical practice as a speech-language pathologist in a supervisory capacity:  that role, that teaching, that responsibility.  A  lot of my time, energy, and resources had been dedicated to learning as much as I could.  My mind and sense of investment still haven’t quite adapted to letting that go.  I also had the time to think about it and try to come to a more coherent review of it all.

The result is what I characterize as a first-person account.  It includes how I thought/felt/approached things and specific resources.  I think it has helped me to process things, and I like to think that it may be helpful to someone else.

Conversations About Conversations:  Graduate Student Clinicians 1 includes a review of how I related to being a clinical supervisor generally, and primarily focuses on the practicalities of the situation.

Conversations About Conversations:  Graduate Student Clinicians 2 applies more specifically to my sense of how to teach being a speech-language pathologist to individuals with complex communication needs.

Conversations About Conversations:  References are the resources that I pulled from in a semi-APA style, I think.  I didn’t work to hard to get it formatted that way because this really is not a research thing.

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03.06.16 — Talking about dying.

Grief, Notes on clinical supervision

Since 2009, across a wide range of personal and professional circumstances, I have spent a significant amount of time thinking and feeling about dying.  It is important to clarify that I say this anchored in the personal belief that having these thoughts is entirely different than wanting or moving intentionally in the direction of death.   I would extend that even fantasizing about dying may be a lot more about fatigue and craving liberation from suffering.  Recognizing these distinctions and supporting a person and his/her loved ones to navigate these kinds of thoughts and feelings is ~not~ the domain of a speech-language pathologist.  I do believe that being able to ~communicate~ thoughts and feelings about dying, thereby reaching/accessing those with the expertise to process that information appropriately, is.

That can be tricky on it’s own.  Persons who need to hear this information include (but is not limited to):

– loved ones and caregivers,

– physicians and health care providers who need to enact medical directives for what constitutes a person’s wishes about what happens to her or his life,

– legal counsel to prepare appropriate documentation in support of decisions,

– persons with expertise navigating complex mental/emotional landscapes (such as social workers, psychologists, and end-of-life doulas).

– spiritual and/or faith-based counsel.

For persons who rely on means other than speech, all of this can be overwhelmingly challenging and emotional.   It may require going through someone that the person would otherwise not wish to be present for those conversations, or relying on someone else’s interpretation and commitment to follow through, or using a ‘voice’ which bears little resemblance to the personality and tone the person would consider their own.  It may be tedious and error-prone in spelling things out, literally, letter by letter.   For all of these reasons, a speech-language pathologist invested in palliative care and end-of-life conversations can have a critical role.

Self-care as that speech-language pathologist is equally vital.

This is a combination of resources that have informed my own world view about these matters, but I do not mean to imply that I have the best or only view; and I absolutely believe that choosing to engage in the life of a person who is actively dying should be done very mindfully.

  • There are many , many resources at Health Journeys that I have found meaningful, including Healthful Sleep, preparing for surgical procedures, easing the suffering the comes with experiences of loss, coming to terms with events outside of personal control, peaceful dying, and in support of caregivers.  I imagine there are other providers of these kinds of guided imagery, affirmations, and meditative music — I like this one, but I do not have a relationship with them or profit in any way from their use.
  • I experienced the movie Stranger Than Fiction as having profound messages about life and death, with both tender and entertaining points.  The scene between Will Ferrel and Dustin Hoffman talking about coming to terms with death is incredibly beautiful.
  • Maurice Sendak talked openly about his thought process leading into his death.  My favorite is the illustrated Fresh Air talk, and the last interview he ever gave touches on being present as well as reflective.
  • There have been a number of TED talks that review death and dying.
  • AudioDharma has a three-part series on Dying in the Dharma.
  • The Transformative  Power of Crisis by Dr. Robert Alter and Jane Alter discusses a variety of topics that impact a person’s life, including death.
  • The documentary Rivers and Tides, and learning about Andy Goldsworthy’s work generally, for-sure changed my life in all matters of how I regard time and experience.  This clip cuts off at an unfortunate point (right before he says something  deeply poetic), but still illustrates a connectivity that I believe in.

For now, I will close — I imagine this collection will continue to evolve and grow though.

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01.17.15 — Supervisory Notes: Thoughts on wait time and pacing

Notes on clinical supervision

I think it’s pretty well universally agreed that interactions with persons who have complex communication needs require wait time (MORE!), and pacing (SLOW DOWN!).  But it can be tricky — it’s harder than most people realize to wait because even 2 seconds will feel awkward, and as SLPs we often feel driven to use as much of the time as possible.  Effectiveness and quality of instruction may take a serious loss in the effort though.

Having a strategy (and, in some cases, a visual cue), may be critical.  No matter how slowly you may think you are talking/waiting, go ahead and give it an extra pause.  Nervousness carries a TON of energy, and people will talk much faster than they realize as a result.  Adults already talk faster than even many typically developing kids can process (http://speech-language-pathology-audiology.advanceweb.com/article/how-to-talk-to-children.aspx).  Thinking about Mr. Rogers was an incredibly compelling strategy for me — before a session, I’d think:  “How would Mr. Rogers say this…” and it would help me to focus my rate, warmth, etc.  If you are not familiar with Mr. Rogers, these are clips that I find very productive — and keep in mind that in these, he is talking to adults:
– Accepting Daytime Emmy Lifetime Achievement award:  https://www.youtube.com/watch?v=Upm9LnuCBUM
– Testimony to the US Senate re: funding for PBS:  https://www.youtube.com/watch?v=yXEuEUQIP3Q

For the expectant delay, practice some kind of method for getting through it — with partners who aren’t SLPs I say things like, count at least to 7 in your head, think your favorite song lyric/hymn/prayer/affirmation in your head, etc.  With an SLP it may be helpful to practice/think of what you are looking for:  “Listen and check:  eyes, facial expression, body tension, hand movement” so that you are ~doing~ something with that time and mindful of subtle signals that the individual is processing, attempting to respond, forgot the task, etc.

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11.20.2014 — Supervisory Notes, thoughts on upcoming holidays

Notes on clinical supervision,

“I recently came across an article that may be of interest to clinicians in  work with children who have autism spectrum disorders and/or are sensitive to lights/noises.  “Tis the Season for … Precipitating Factors” by Pam Sikorski (found at:  http://bit.ly/1qrBvwk ) talks about how overwhelming the holiday season can be — honestly, for everyone: adults, kids, kids with special needs alike — and recommendations for coping.

I think this time of year is often thought of as super exciting fun time, and maybe it is…but my experience has also included:
-> Not all kids celebrate Thanksgiving or Christmas, but we are all bombarded with the stuff that comes with it.
-> Not all kids have great holiday experiences.  Some do not have much (re: food, gifts, heated homes, etc.), some are thrown wildly out of comfort zones by long travel, unfamiliar places, and people (even family) that they do not know so well.
-> Not all kids thrive under an environment of “Santa is watching closely for every bad thing you do and will punish you harshly under the tree for imperfect behavior.”  I might argue that no kid does well with Santa as a hyper-surveillance bully, but parents and teachers do what they do.
-> Even for kids who LOVE all the holidays, grown-ups are very frequently not having a super fun exciting time.  Grown-ups are often stressed and grumpy by all of the various demands to make it a super exciting fun time, but that stress does impact everyone.
-> And when I say “grown-ups” I mean, quite possibly every adult the child comes into contact with.  Their parents, teachers, bus drivers, and even strangers in the store may all collectively shift from being sources of comfort and respite, to distanced/distracted/cranky/worried near-zombies.

To make all of this even more challenging:  the weather is often bitter, days are shorter, and everyone is prone to getting sick.

Certainly it’s always a matter of doing a mini-assessment of touching base with parents about what their holiday traditions do or do not include, and observing the child to gauge where s/he may be at in this whirlwind.  If everybody seems okay, it’s fine to incorporate activities and enthusiasm for the holidays.  If you’re getting the sense that these are not a part of the child’s home/cultural experience OR contribute to being overwhelmed, this is a good time to soften tone, rate, and expectations.  Two, keeping familiar structure and expectations help the child feel safe with you.  It ~might~ be fun to break routines and do crafts or make snacks or whatever…or it might send a learner further unanchored.

As always, being mindful goes a long way.

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10.22.2014: Supervisory Notes — Resources related to AAC & Aphasia

Notes on clinical supervision, ,

There is considerably more I would like to someday do to collect my thoughts around AAC and persons who have aphasia, but for now I just wanted to document the resources I have used to-date to inform my process with assessment and intervention.

One of my challenges here is that this clinic is typically the “last” stop/hope for folks — more often than not, they’ve  already been through acute care facilities, outpatient rehab, and whatever home care their insurance would pay for.  I am usually consulted (a) when other efforts have proved unproductive and/or (b) there’s no more money.  This frequently means that there may well be a lot of non-functional habits and frustration built up.  As a result, what we do here may be very different than I would do if I was at any of the prior stages (front line/acute care, outpatient, in-home).
That said, my bias is clear:  I am strongly in favor of multimodal intervention for pretty much any/everyone.  I signed and used visual schedules made from Boardmaker symbols with my own children as infants, I used hand signals and visual cues for kids with artic/language and fluency, I write things out and provide visual aids with graduate students seeking a Master’s degree, and I would never never never meet with someone I knew had experienced a brain event and just talk to them and plan for them to just talk to me.    In short, I feel like my own sense of myself as an SLP aligns pretty well by the Beukelman & Mirenda Participation Model which is described in their AAC text.

As it applies specifically to persons with aphasia, there is additional information about the Life Participation Approach to Aphasia:
– ASHA statement: http://www.asha.org/public/speech/disorders/LPAA/
– ASHA Leader article:  http://bit.ly/1wjDQr7
– Supporting Communication for Adults with Acute and Chronic Aphasia (Simmons-Mackie, King, & Beukelman, 2013)

I feel like the AAC Aphasia Screening materials from the University of Nebraska Lincoln, http://aac.unl.edu/screen/screen.html  may be helpful to “aid in determining whether the person with aphasia can benefit from partner dependent or independent alternative communication strategies” (quote from the Purpose description, p. 3).
I have also found the following courses throughwww.speechpathology.com to be enormously helpful:
* #5361 AAC and Aphasia by Sarah Wallace
* #4208 Use of AAC Devices and Strategies for People with Aphasia by Sarah Wallace
– #5157 Steps to Success with Technology for individuals with Aphasia by Denise McCall
– #5742 AAC Medicare/Medicaid Funding and Documentation by Patricia Ourand
* #5138 Selecting Apps for Therapy: A tutorial for SLPs on using an EBP model to assist with choosing intervention tools by Lara Wakefield & Theresa Schaber
* #5186 The PICO Template for Reviewing Speech-Language Therapy Apps: A decision-making tool for SLPs by Lara Wakefield & Theresa Schaber
– #5781 AAC Apps:  Finding the Right One For Your Client by Carole Zangari
* #5518 Denial of Deficits and Aphasia by George Wallace
* #5068 Coping with the impact of Aphasia:  What do Significant Others Need and How Can SLPs Help? by Barbara B. Shadden
* #6079 Helping Clients and Families Attain Their Goals:  A Basic Counseling Function by Audrey Holland — although this is described as being generally about counseling (and it is), the examples are more specific to persons with aphasia.
– #5447 Counseling Around the Edges by Audrey Holland
– #4995 Counseling and Communication Disorders:  Working with Feelings and Emotions by Michael FlahiveThese are roughly in the order that I might rank them in strength/value related to Aphasia, plus the asterisks represent the best within each category.  Many of these are available in a variety of formats although I tended to take the “Text” courses when possible.  There are other Aphasia, Aphasia & AAC, & apps decision-making resources at www.speechpathology.com I just haven’t gotten to them yet.
Finally, the AAC-RERC has a free webcast on AAC for Aphasia: A Review of Visual Scenes Display Project:  http://bit.ly/1nwWn3q and an example funding report:  http://bit.ly/1t5dawn

11.20.14 Update — Supervisory Notes, “Trust the Process” Reflection

Notes on clinical supervision, ,

A couple of thoughts were brewing in my head all at about the same time right before Thanksgiving in 2013.  This was also updated in November 2014.

Event 1:  Dr. McNaughton made a comment at an AAC Faculty meeting that in the SPED department, they use a “CONE” approach — trying to be mindful of the Content of the Next Environment — to review whether or not students are prepared to move forward.  “Prepared” is something of a trigger word for me.  Students have either told me directly or provided in written feedback that they very much appreciate our discussions, my guidance, resources I share, etc.; however, that they worry that they are not prepared for the Real World, for how things actually go in the schools.  I work very hard to align what I teach them through clinical practicum experiences to what they learn in their courses, I hope to model EBP with my supervision just as I hope they will apply it in their clinical careers (and, over time, as they have opportunities to mentor or provide supervision themselves).  So I have struggled with how to reconcile the idea that some students suggest they feel more ‘principled’ than ‘prepared’ when we’re done.  At present, I’ve come to the notion in my own mind that my role is not to prepare them how to DO the work — it’s a mistake to think that’s even possible — but how to THINK THROUGH the work.  Uncertainty is part of the gig:  there will always be an unfamiliar diagnosis, or an unusual presentation of skills/needs, an unexpected confluence of personal and work events.  My goal isn’t to share with them every possible scenario, it’s to hopefully put a foundation of problem solving skills and coping strategies that will support their efforts.

Event 2:  A surprising number of second year grad students have expressed the notion, “I just want to know what you know.”  I have had a surprisingly emotional reaction to that idea — that’s simply not fair.  I didn’t know what I know now when I was where where they are — I’ve worked hard to know what I know now.  I’ve earned it.  Further, I am certain I don’t know everything:  I’m very much committed to being a learner yet myself.

So given these thoughts, I wanted to present an activity to the students I am working with to engage them in an experience.  In a general sense, my goal was oriented around the notion of “Trust the Process.”  To not get to caught up or rushed in knowing it all, to not feel like that is the goal, to not consider uncertainty and the disquiet that comes with it as indicators of failure/weakness.  In addition, since it was in front of the Thanksgiving holiday and at a stressful point of the semester (the stampede to the end), I also wanted it to be very different than the assignments they get in their courses.  The following is the email I sent.

“We are at an interesting place in the semester, and I would expect everyone is feeling a degree of tension about getting from here to the next point.

For everyone I am working with through the clinic, I would like for you to please set aside 15 minutes to BRIEFLY review the following, choose one, and email me a 1-paragraph response.  There are no right/wrong answers.  I want to repeat that:  There is no specific answer I am looking for other than authentic consideration.  Due to me by November 30th.

(1).  In 2011, Alan Kamhi established a Clinical Forum on “Balancing Certainty and Uncertainty in Clinical Practice,” and posed the question, “How certain are you that your clinical decisions and practices are the most optimal ones for your patients?” Although I found the whole forum to be excellent and thought-provoking, attached is a three-page response (also in hard copy in your box):  Finn, P. (2011).  Critical Thinking:  Knowledge and Skills for Evidence Based Practice.  Language Speech, and Hearing Services in the Schools, 42: 69-72.

((2).  This 5:22 minute clip from Between the Folds on https://www.youtube.com/watch?v=OlbneFIcXyU.  I highly recommend the entire documentary if you have access, but for now I’m especially interested in this segment.

(3).  A diagram on OODA.  (Note:  The link here includes text and discussion but I just send the diagram itself as an attachment to the email.)

******

I chose these because they do speak to the value of critical review, of being systematic and engaged in learning/questioning/evaluating specifically as an SLP (the Finn article); because the origami sequence is amazing in Between the Folds and he specifically talks about the process and the tension that exists within it; and the diagram comes from a business website but actually illustrates a flowchart of how to engage EBP.  I chose these because they inspire me, and I was interested in reaching the students in different ways (clinical/research-based; artful; graphic).

The responses have been truly great — I have loved the reflections and conversations we’ve had, and this lent itself very well as a lead into a discussion on actively Engaging in Learning (Lesson Plan available in Resources).

So it’s been a wonderful and exciting learning experience for me, too.   I’ve so enjoyed their perspectives into all of this, and how different it is from the other things they do while in the graduate program or that we have done together with their clinical practicum.   Some of them haven’t gone exactly down the path of “Trust the Process” but that’s okay — there were no right or wrong answers.

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05.28.14 — Talking about assessment and intervention with persons who have ALS (original 11.13.13)

Notes on clinical supervision, , , ,

Since 2009, there have been a number of referrals for AAC assessments to our clinic for individuals diagnosed with Amyotrophic Lateral Sclerosis (ALS) or Lou Gehrig’s disease.  The following are resources, strategies, or supports that I have tried to organize here for easy reference.

As the instructor of clinical practicum experiences in these situations, when I first meet with graduate student clinicians about a client diagnosed with ALS, very early on in the process I stress the importance of their being mindful of their own emotional well-being during the experience.  Working with individuals who have complex communication needs and their families ~always~ has the potential for feelings to be intense and entangled.  With a diagnosis of ALS, everyone involved is confronted with the harshest realities of human frailty and mortality.  Everyone copes differently, but I want to make it clear from the outset that it is my belief that trying to ignore or deny that part of this experience, actually cuts them off from the individual they are trying to serve, and is potentially detrimental to themselves.  I have provided students with the contact information for the University counseling services, but overall I have been extremely impressed with how well these young adults rise to this experience.

In terms of learning about ALS (overviews about the nature and course of the disease), as well as specific information to guide assessment and being dynamically responsive to changes during intervention:

— The  chapter in Augmentative Communication Strategies for Adults with Acute or Chronic Medical Conditions (2007), with supplementary materials, specific to ALS.  These are the materials we primarily use for the assessment, along with our general structure (consistent with Beukelman & Mirenda’s 2012 Participation Model).

— A review article by Beukelman, D., Fager, S., & Nordness, A. (2011). Communication support for people with ALS. Neurology Research International, 2011, Article ID 714693, 6 pages. Full text available online at:  http://www.hindawi.com/journals/nri/2011/714693/

— This webcast is for individuals with minimal movement.  You can just focus on that segment specific to ALS if you prefer:  Beukelman, D. & Fager,
S. (2010). Supporting Communication for Persons with Minimal Movement (ALS, Brainstem Stroke).  Available on YouTube at http://www.youtube.com/watch?v=aaSJAkubDn8&lr=1&uid=90FYvbn0laJRwVsb-7GRMw

— First person biographies offer unique insight into the experience.  Morris Schwartz may have the most famous books about him written, Tuesdays with Morrie (which was also made into a movie).  However, Morrie:  In His Own Words: Life Wisdom from a Remarkable Man contains his perspective specifically.

— In July of 2005, the Augmentative Communication News (volume 17: 2) focused on ALS and includes an interview in the Social Networks with Linda, wife of Tom, about their experience through his ALS:  the strategies they used to help him remain socially engaged, and some of the emotional navigation that evolved through the progress of the disease.

— The University of Nebraska-Lincoln has a variety of resources related ALS including compiled references, and vocabulary resources.

— The website Amy and pALS by Amy Roman, MS/CCC-SLP has considerable information that may be productive.

In terms of means that may be relevant to consider (not necessarily in order of importance):

— No-Tech:  In terms of establishing behaviors for yes/no, eye gaze behaviors are typically most reliable.  Personally, I like looking up for “yes” and looking to a side for “no” because I feel like these approximate nodding, and shaking the head and that, if possible motorically, these are less open to misinterpretation than blink patterns.  I do counsel individuals against using smiles for yes.  It has been my experience that this runs a high risk of emotional disconnect — there are a great many questions for which the answer may be “yes” but which no one would ever smile about.

— No-Tech:  One gentleman and his wife had conveyed favorite musicians and musical groups.  I searched for song lyrics for love songs by these individuals.  I explained that I knew that there was much in his heart that he would want to say, but  physical and emotional fatigue had made it so difficult.  We reviewed the song lyrics, and he was able to convey by eye gaze two that carried sentiments he would’ve liked to say to his wife and I gave her those print-outs.

— No-Tech:  Partner coaching is critical so that there are agreed upon understanding of how to structure partner-assisted scanning, how to be attentive to subtle signals, confirming etiquette (is it okay to guess/interrupt?).    Dr. Cathy Binger and Dr. Jennifer Kent Walsh wrote about how to coach communication partners in their 2012 ASHA Leader article, “Communication Takes Two,” available through:  http://aac.psu.edu/?p=1378.  A review of partner vision and hearing is also important so that systems are developed which can be seen and heard appropriately.

— No-Tech and/or Low Tech:  Teaching the individual about self-monitoring their circumstances to strategically determine:  (a) if they wanted to communicate, and an introductory strategy, (b) what/how much they wanted to say, (c) what means would be most appropriate/effective for the situation, and (d) knowing when/how to get out of a situation and an exit strategy.  For example, at the grocery store a person might run into a casual acquaintance who does not know their diagnosis — deciding the depth and length of conversation is very different than a  check out clerk who may ask about an unusual vocal quality or use of an AAC support system.  With the former, a person might exchange pleasantries and make plans to re-connect at a later time, or might have a prepared card or voice output message to support intelligibility to convey some information.  The clerk’s curiosity does not ever trump the individual’s right to privacy, and a smile/wave off or completely ignoring questions may all be appropriate and right for conserving physical and emotional energy.   The PowerPoint “SelfMonitoring_SelfPartnerEnvironment” (in Resources with password “m4ter14ls”), was designed as instructional materials to structure talking about and practicing these considerations, but could also be used (shrunk to a smaller size) as a visual cue either for the individual or for assistants.

— Low Tech:  The Speakbook (www.Speakbook.org), is a low-tech and free eye-gaze based system which has the potential to be remarkably comprehensive.  This may be appropriate for a person who has complex motor challenges and requires an eye-gaze based means, and would be used with a partner either to directly select (e.g., look at corner square and then to shape to identify message), or to support assisted scanning (e.g., look at shape and partner reviews messages).   In my own experience, it can be a little involved to assemble from home (getting the pages organized), and in pricing it a local office supply/print shop, it was around $50 to get produced on cardstock, laminated, and bound.  That did not include cutting out the section for the eye gaze connection.  In populating it, I found I needed to have it opened out fully so that I could ensure that I was placing messages in coordinating locations for both persons to look at the same location.***

— Low Tech:  PODD  communication books may be appropriate for a person who has motor skills to turn pages and point, or with a partner to scaffold assisted scanning.   This would be constructed similar to a book with tabs for the pages — the ‘main’ page is more or less just like a table of contents, and the premise is that includes sentence starters with directions to the page which extends related/topic-specific information.***

*** A number of persons and families have expressed some frustrations/challenges with brainstorming what to put in as vocabulary and messages.  There are two examples under the Resources (one related to the Speakbook, one in PODD style), which was my attempt to give a basic starting point — a means of considering if a message is needed (and is phrased the way the person would want it to be), if a message is not needed and should be removed, or if a message is needed but not presently represented.   Search under “Sample Eye Gaze Based Low-Tech Communication Support for a Literate Adult” for one which is designed around the Speakbook — if printed double-sided, it does match up.  Search under “Sample Communication Book for Literate Adult” for one which is more in keeping with a PODD style.  The content in both is very similar and includes messages based on a review of the research by Fried-Oken et. al., (2006) and Beukelman & Gutmann (1999), as well as my own experiences since 2009.   Both include messages relative to urgent medical needs which require immediate attention, and one for less urgent medical concerns but that still should be shared with the team.  There are blanks, and a blank page for creating additional content.   Of course, all of this should be personalized/individualized for relevance, organization, and wording; however, there were a couple of instances that definitely stood out to me and these are highlighted in red:   if the person wanted to use their high-tech SGD, whatever that was;  the terms “spouse” or “SO” were used to reference the individual’s Significant Other.    For myself, I found that having rules to be systematic was helpful.  With the Speakbook, I used the heart  (top) lines in each quadrant to signify the most important/urgent messages, the circle (second) lines were generally for statements/directives by the speaker, the triangle (third) lines were for questions/requests to the partner, and the square (last) lines were for resolving breakdowns.  Similarly, in the PODD-style book, the bottom table on each page included partner-focused questions for column 1, rows 1-4; notification of urgency as column 1, row 5; and the same 5 messages for resolving breakdowns as column 2.  I theorized that over time/repeated use, a person could potentially also use hand signals for these numbers (as long as motor skills were retained), as a no-tech generalization for conversation management.

— Low Tech:  The MegaBee  (http://www.megabee.net/) is potentially interesting as a low-tech option, although I personally have never used it.

— Low Tech:  The plastic cover sheet used for poster frames could be used to create a simple eye gaze board with options and alphabet.  I do find it helpful to have key (e.g., Help, Something’s Wrong), frequent (I need my glasses, I’m glad you came by), or starter messages (Tell me about…, How is….), along with an alphabet.  Alphabet boards should be considered for what organization is most meaningful and effective:  for example, ABC order, QWERTY, Vowel aligned (each row starts at a vowel), or by frequency of spelling patterns in English.

— Low Tech:  With one gentleman, his family had shared a photo album that had been created for the 50th wedding anniversary with he and his wife.  Based on a review of these memories, the team generated a list of things that he ~might~ want to say, also using messages available via commercially available greeting cards or online e-cards associated with categories such as I love you, Just Because, Anniversary, etc.  He indicated by eye gaze messages that he considered most relevant in reflecting his feelings.  These were printed onto iron-on transfer material for making t-shirts, and then put onto a pillow case as a means of his expressing Pillow Talk messages of love to his wife.  After he passed away, she repeatedly expressed how much that Pillow meant to her — that she used it herself and it was a great comfort.

— High Tech:  There are clearly a range of communication apps with iOS or Android platforms which may be appropriate for some circumstances/stages of ALS.  There are also a variety of dedicated devices which provide comprehensive communication, environmental controls, and other quality of life features (in addition to warranties and tech support), and have a wide range of access methods.

For published references/resources related vocabulary generation,

— Westby, Burda & Mehta (2003) has a solid review of interviewing approaches.  This is available at ASHA: http://www.asha.org/Publications/leader/2003/030429/f030429b.htm

— See What We Say:  Situational Vocabulary for Adults who use Augmentative and Alternative Communication by Barbara Collier and Janice Light (2000).  This may also be helpful for practicing using eye gaze or other no-tech communication signals.

— Relative to communicating at the most intimate levels of social closeness, the quizzes at http://www.5lovelanguages.com may be a way to solicit what means and messages are most relevant to the individual and their closest partners and brainstorm what strategies/supports will contribute to the ability to express and receive the social intimacy that is needed now.– it’s possible to print out the surveys, and they can be reviewed from a variety of categories including for a person who is single, from the perspective of wife or husband, and child-parent.

— Relative to communicating end of life decisions about the course of medical care with persons who had ALS and had asked for support in communicating their wishes, I have used the reference Your Life, Your Choices as a systematic structure.  This is a .pdf publication which goes through the components of an Advanced Directive, and I developed Word document (and an alphabet board) to provide eye gaze responses — this is in the Resources (“m4ter14ls”), under EndOfLife_CommunicationSupports .  For one family, I provided them with these materials and it was my understanding that they conducted the process on their own.  With another couple, the person and his wife were comfortable with the student team being a part of the discussion, and the students conducted this review.  In a third, the person and his wife felt they did not want this particular conversation to be a part of a group dynamic, and I met with them privately (without the students).  I left this decision entirely up to the individual because while I know the graduate student clinicians benefit from the learning experience, this is also well past what I consider to be appropriate to capitalize on as a “teachable” moment.  When the student team was involved, we worked together closely to prepare — including having them go through the process together in role play so that they had the experience of saying/hearing these ideas and options out loud.  In both of the cases where I was involved, I was explicit that I am not a physician or lawyer and so could not discuss the medical or legal ramifications:  my sole function was to provide a means of voice/communication.  In both cases, I gave opportunities to ‘exit’ the conversation repeatedly, and the focus was entirely on unconditional positive regard:  it was not my function in any way to comment/judge on what was expressed, only to support means of expressing it.  In both cases the spouses were present and also received the information entirely positively — there were a lot of tears, but no one tried to talk the person out of their feelings or wishes.

Finally, as of April 1, 2014, funding of systems became more complicated for persons who use Medicare as their primary insurance provider.   Speech Generating Devices have been considered Durable Medical Equipment for some time now but the Centers for Medicare & Medicaid Services (CMS) added them to a list of other DME which is under a Capped Rental Policy — as with hospital beds, blood pressure cuffs, and wheelchairs.

Accordingly, an AAC technology system still has to be justified according to a comprehensive SLP assessment, and prescribed by a physician (including documentation of a face-to-face visit within 6 months of the prescription).

HOWEVER, the system does not belong to the client.  It remains ‘owned’ by the insurance company for a period of 13 months.  As such:
– Monthly calls will be made to ensure status of client and location.
–> There is a 20% monthly copay associated,
–> It must be reported if the client has to change living environments.  That is, if client has to be hospitalized for a significant duration, goes into a nursing facility, or is declared on hospice, the manufacturer may either suspend billing to Medicare (which also suspends the 13-month timeline at that point), bill families, or require the system to be returned.   The assumption is that the facility will have these equipment on hand  (like hospital beds, blood pressure cuffs, and other DME).  There is no recognition/acknowledgement that these systems are highly personalized & customized, so even if a hospital or nursing care facility does happen to have a system on hand it may well not meet the unique needs of the individual.

– The system must remain LOCKED for the 13 month duration.  Since it belongs to the insurance company, not the person, it is only a speech prosthetic.

–> Although we cannot say a requirement of a system is that it be unlocked, we need to be very vigilant in advocating for the medical necessity of internet access as a function of communication:  discussions/texting with physicians and medical providers (such as pharmacies) is increasingly common; research on medical condition; ability to access forms of persons with shared experience for medical advice and emotional support; and minimizing risk for social isolation and depression are all very real concerns for many of our clients.  In addition, many of the manufacturers rely on Internet-based software updates and trouble-shooting options to ensure that systems are functioning appropriately.

– The system sent to an individual may not be new and if repairs are needed within the 13-month period, the system that is returned may not be the same one.  Any content/customization could be lost.  Suppliers are required to keep systems maintained for 5-years, but how well maintained is not described, and we certainly know how much a difference it can make whether or not a system has been through a variety of users.  In addition, the repair scenario is an argument for having an operational goal for making a back-up or other log of critical settings.

Because this is Medicare’s policy, other private insurance companies are or may follow the same approach.

Here is ASHA’s report about these changes:  http://www.asha.org/News/2013/CMS-Determines-Rent-to-Own-as-Only-Option-for-SGDs/

There is a sample funding report provided by http://aac-rerc.psu.edu specific to a person with profound dysarthria secondary to ALS (although this reflects an example prior to the capped rental change):   http://aac-rerc.psu.edu/index.php/pages/show/id/21#example4

That’s all I can think of for now.

End blip.

 

11.1.13 — Supervisory Notes, Lesson Plans for Clinical Practicum Experiences

Notes on clinical supervision

I started preparing more formal lesson plans primarily for two reasons:  (1) If I said that it was important (indeed, required!),  for the graduate student clinicians to have thought through their instruction, I felt I had to seriously reflect on what messages I conveyed if I then didn’t; and (2) If I wanted to complete the grading rubric with integrity, I needed to know for certain that they had been taught the targeted skills at some point.  Otherwise, it just felt like I was judging/critiquing them on things unfairly.  So that lead to the third point:  (3) it was a chance to model what features of a lesson plan I would be looking for from them — an opportunity to discuss the process.

When we have the first conversation and review my initial lesson plan, I do talk about how being a clinical practicum instructor doesn’t precisely map onto the kinds of teaching involved with being a clinician, so it isn’t a 1:1 example.  I also disclose that I rarely did these kinds of plans when I worked in the schools — it was partially more intuitive at that point, but also a matter of basic survival given the time I had for planning.  I did do a fair amount of thinking about teaching-learning as part of developing or preparing my materials of instruction though.  Regardless, I say to the students that the argument that the lesson plans required by our clinic are not “real world” may be true but is, in any case, irrelevant to me insofar as it serves an entirely different purpose/function which is fundamentally critical to our experience here and now.  The lesson plan (and other required documentation procedures), are a platform for the dialogue we share about the client, about SLP generally, learning approaches, research foundations, etc.  It is my window into their thought process.

With more experienced clinicians, I typically fade out the requirement of written lesson plans being submitted to me over the course of the semester (unless I have concerns).   I feel like it’s in the same vein as Shapiro’s 1985 research around contracts between supervisors and supervisees — with findings of an inverse relationship between the level of experience and completing commitments when written documentation was involved.  Two, I want to be conscientious and responsive to their stress level at that point in their academic programs; if I already have a sense of their process, and they can verbally discuss their plan, I do not want lesson plans to be “busy work.”

To again reference McCrea & Brasseur, The Supervisory Process in Speech-Language Pathology and Audiology (2003), goes into specific details about the nature of planning in Chapter 5, and highlight:  “Professional growth for all participants comes as a result of careful, systematic, fourfold planning:  for the client, for the clinician, the supervise, and the supervisor.  In other words, it is not enough to plan the clinical process, the process through which the client learns; the supervisory process, through which the supervisee and supervisor learn, must also be planned if maximum growth is to be achieved.” (p. 106).

So far, I have specific lesson plans for the Clinical Practicum Instruction around the  following topics:

– getting started (first meeting, review of what a lesson plan looks like, expectations),

– documentation (word choice, structure),

– writing goals (word choice, structure, design of instruction, prognosis),

– session structure (transition, introduction, instruction, directions, guided practice, wrap-up), and

– engaging in learning (the rationale for why it is important  and how to invest in continued learning after the University setting with conferences, web resources, text-learning, etc).

These are all available under Resources (password = “m4ter14ls”), and should be easily accessed by searching under Lesson Plans.

End blip.

10.29.13 — Supervisory Notes: Providing written feedback

Notes on clinical supervision, ,

I know many, many SLPs who are ‘blank sheet of paper’ data collectors — they can walk in a session with just a notebook, and write down notes or tallies as they go.  I am not that sort of SLP.  Whether it’s just my strong preference for structure, or my fears of forgetting something important, I have always liked setting up data collection sheets which provide both some space for specific targets (outlined according to the goals), and some space for writing down subjective impressions or notes for consideration.  When I started working as an instructor for clinical practicum experiences (aka, “supervisor”), I found it was no different:  I greatly benefit from having key points or skills designated.

McCrea & Brasseur, discuss Observing in the Supervisory Process in Chapter 6 of The Supervisory Process in Speech-Language Pathology and Audiology (2003), and specifically lend insight into different methods of data collection (p. 166 – 171).   My own “take-away” thoughts from their discussion included, “The understanding and appropriate use of systematic observation and data collection methods by supervisors is important for establishing supervision as a thoughtful, scientific, and validated process.  Supervisors need to be skilled observers, but more than that, they must also develop efficient, practical procedures for recording their observations for later use.” (p. 166).

This also meant that I had set up the opportunity to model:

— the value of data collection — I’m not a fan of “do as I say, not as I do.”  If I tell the students that it is critically important for them to take notes and keep track of learning trends, I think it is just as important that I am also doing so as a means of informing my own teaching,

— at least one example of how data collection can be structured.  We talk about how this is a very personalized endeavor and what works for one person may not work for another; that whatever the method of data collection/coding/tallies is, it should have low cognitive demands (if I have to think to much about my system of note-taking, it means I am distracted from my teaching and at risk for inaccuracy).

— a shared sense of expectations.  When we review my note-taking tools, I talk about what I will be looking for in their conduct, and the rationale.  We discuss how some learners may be curious about the notes they take, and that it can be an opportunity to engage them in self-monitoring.  Others may be distracted by the side activity or wonder about how they are performing, and so these are important considerations to take into account.  If, for whatever reason, it was not appropriate to directly share my  data, I always used to say, “I take notes to help me remember everything I’m learning about you.”

The SOAP format always basically made sense to me, and I designed the sheet that I use to include that structure  as well as the key points required in the grading rubric we use for either intervention or assessment.  I print two copies of the form and use carbon paper — the graduate student clinician gets the top copy (immediately following the session), and I keep the carbon version.   I do have a rating scale at the bottom and I need to track down where specifically I found these categories — they are not mine, but I am using them for now as a means of gauging my presence in the clinical process, how much influence or instruction was imparted for those areas.  I’m not convinced this is meaningful for me, but I’m giving it a try for a bit longer.

Although their particular tool didn’t quite work for me (see also, “data collection is very personal…”), I hope that it reflects the findings discussed in Wilson, D. & Emm, M. (April 2013).  Opportunity for Effective Feedback:  A Supervision Tool.  Perspectives on Administration and Supervision:  28-34.

Specifically, in brief:

(1) “Tracy, Van Dusen, and Robinson (1987) state that effective feedback needs to provide the recipient with knowledge and rationales for improvement.” (p. 28)
(2) balance with positive reinforcement and corrective feedback; “Supervisors are encouraged to be respectful, goal-based, non-judgmental, specific, and focused on behaviors, and to give the right amount of feedback and suggestions for improvement.” (p. 28)
(3) Be mindful of types of feedback:  vague-positive, specific-positive, vague-corrective, specific-corrective.  This is also consistent with McCrea & Brasseur, who cautioned about overuse of “…evaluative statements reflecting their perceptions of the appropriateness of the behaviors in the treatment or assessment session as they view it; for example, “Your directions were too difficult for the client” (p. 167).  They caution that although these kinds of statements may be needed at times, they should be associated with immediate plans for learning more effective strategies and self-evaluation.  That “it is these active, direct behaviors of the supervisor that do not encourage, in fact probably discourage, self-analysis and creative thinking on the part of supervises.” (p. 168).

(4) Finally, for Wilson, D. & Emm, M. (April 2013):  “The observation record was a single sheet form containing identifying information, a list of possible focus areas, and narrative space for both positive and corrective feedback comments.” (p. 29)

Over time, I have modified the forms I use based on feedback from the students, my experience with using it, and trying to apply principles of andragogy (how adults learn), as described in  Gordon-Pershey, M. & Walden, P. (April 2013).  Supervisor and Supervisee Perceptions of an Adult Learning Model of Graduate Student Supervision.  Perspectives on Administration and Supervision:  12-27.  Specifically, that my feedback is hopefully consistent with:  “The hallmarks of reflective practice are conscious thought about clinical situations, critical evaluation of possible solutions in clinical situations, and self-reflective assessment of the outcomes of one’s clinical actions (Jarvis, 1987; Schon, 1990; Walden, 2011).” (p. 13)

These are all under Resources (“m4ter14ls”), and should be findable with the search term “SOAP” but the one for intervention is not coming up for me unless I use the search term “observing”.  I don’t know why that is.  There is a series of supervision SOAP notes for assessments which follow the different phases of the model we use for AAC assessments at PSU.

End blip.

10.17.13 — Supervisory Notes, Talking about 2nd phase of assessment w/examples

Notes on clinical supervision, , ,

In the clinical practicum instruction I provide for assessments of individuals with complex communication disorders, we apply a multiple-phase process: (1) information gathering through record review, interview, surveys/checklists, and observation with familiar partners in familiar surroundings (by video if distance prohibits on-site visits), (2) direct observation at the campus clinic via structured “naturalistic” opportunities to review current communication (receptive, expressive, and pragmatic language; means of communication; purposes of communication; sensory and/or motor, seating and positioning considerations; literacy; partner-interactions, etc.), (3) direct observation at the campus clinic via structured “naturalistic” opportunities for what strategies and supports may effect meaningful change in the individual’s communication opportunities and effectiveness, and according to what features (e.g., size, symbol representation, organization, etc.);  and (4) a review of findings.  There is considerable overlap among the phases and it requires multiple sessions to complete.   I find that students have a sense of the principles involved and frequently have practiced these ideologies through case study example projects for courses.  But having a real person to think about and face, a team to work within, a family or school to report to, and, most importantly, the genuine hope to truly help an individual, all add a profound stress on how to think all of this through.  After talking with students, the following is an email I send to review the principles we discussed.  This example is for a preteen young woman with complex sensory and motor needs in addition to no verbal communication and mixed reports about minimal language (e.g., both making choices to convey wants and answering yes/no questions are in question).

“We’ve talked about how the assessment plan for our first session here on campus needs to reflect what unanswered questions you feel you need to directly observe, and what strategies/supports you would like to consider for review (no tech, low tech, high tech).  Much like plans for intervention, this should include your objective (what you want to learn), rationale (why/how what you learn will inform next steps), the activity or structured event, whatever materials are needed to complete activity, means of communication, and data collection.  Different from intervention at the clinic, I also need to know who is doing what.

When we met at the very beginning, we said that we needed to start from what we know now and hypotheses based on our observations and what the literature/research base would inform as relevant for her age/experience.  We want to consider our objectives for how we are going to learn what we need to know, and then develop activities that will allow us opportunities to gather information.  When we talked earlier, I wanted to expand on that piece with some examples but I know it can be difficult to remember everything.  My apologies for the long email but I hope this can be a reference of my thought process and how it leads to specific questions/objectives.

For example:
Rationale:  Based on interview and parent completion of surveys/checklists, determine CLIENT’s receptive and expressive vocabulary.  Observations and parental report indicate that CLIENT has an extremely limited vocabulary.  No tech:  Siegel and Cress’ (2002) Communication Signal Inventory from Exemplary Practices for Beginning Communicators (p. 36-38) to determine what behaviors/patterns/signals familiar partners successfully cue into.  Multimodal (no tech, low tech, high tech): The PSU research on early intervention with beginning communicators (with young children) and early research with older individuals who are at beginning levels of communication suggest in-context support of vocabulary and benefits of social sequences (aka, joint action routines).  The UW AugComm Continuum of Communication Independence discusses a need for a clear and reliable signal for acceptance and rejection as foundational for building yes/no.

Accordingly, assessment questions/objectives may include (but are not limited to):
(1).  Provide structured opportunities for observation of CLIENT’s receptive vocabulary, expressive behaviors/signals/signs.
(2).  Provide structured opportunities for observation and assessment of supports/interventions to expand her vocabulary with symbolic means.
(a).  Given instruction and coaching on partner assisted scanning consistent with Linda Burkhardt’s research; please particularly note information re: Rett Syndrome since that has been suggested as the closest comparable profile):  what is parental reaction; based on observations, what is sense of vision/motor obstacles; observable behaviors of reaction from CLIENT?; observable indicators of potential?; if yes, journals/data collection to be sent home for specific targets?
(b).  Given instruction and coaching on principles of intervention outlined by Light & Drager research, adapted for older individuals who are beginning communicators:  what is parental reaction; observable behaviors of reaction from CLIENT?; observable indicators of potential?; if yes, journals/data collection to be sent home for specific targets?  Will require provision of some materials (e.g., printed symbols/photographs; recommendations for apps).

At present, CLIENT has extremely limited means of communication and it is not clear what types of references will be most beneficial/effective for her.
(3).  Provide structured opportunities for observation and assessment of symbolic representation:  signs/gestures, actual objects, photographs of discrete items, photographs of scenes/contexts; picture symbols; text; photographs, picture symbols, or text which have been modified for high contrast, etc.  What would we need to know about vocabulary/concepts that she currently understands in order to be able to set this up; or, in the absence of that information, what kinds of teaching/structure would we need to put in place for a valid assessment?  What are observable behaviors of reaction from CLIENT?  Are there distinctions in engagement (interacting at all, without specifying whether or not was ‘correct’), versus accuracy (seeking a specific answer)?  What are observable behaviors to indicate processing for # of options presented:  one at a time w/partner assisted scanning?  choice of 2?  more?  Presentation in vertical versus horizontal?  Size of symbol?

(4).  Provide structured opportunities for observation and assessment of organization (e.g., categorical, event, PODD):  given a review of options, what is parental reaction?  What are observable indicators of ease of use for partner to augment input and make means of expression available?  Accuracy?  What can we provide for home trial — for example, a simple book of references based around her reported key partners, interests, activities (categorical); a book based around concepts organized for her daily routine (event based); a book based around conversational sequences common for her life events and/or teens (PODD).

Those are just examples, but please refer to the materials I have provided for what Beukelman & Mirenda considers the key areas for assessment, the information and references compiled by the National Joint Committee for the Communication Needs of Persons with Severe Disabilities; and the published materials such as the Communication Matrix;  Functional Communication Profile, Revised; TECEL; Social Networks; and AAC Profile (among others) as means of structuring or focusing our efforts.  Again, always start with your objective (what do you wish to learn), and we can build activities around that.”

It’s a long process and has been argued that may not well match what can be accomplished outside of a University clinic environment.  I hear that argument, and know that there is valid concern on whether my approach authentically prepares clinicians for different environments.  That said, I feel that it is my mandate to align my practices as closely as possible with what is taught in the courses as best practice — that to do otherwise perpetuates poor practices elsewhere.  So I strive to be an example, sounding board, model, coach, etc. towards that goal and hope that students will adapt and advocate over time to the circumstances they face to raise the expectations and practices elsewhere.

End blip.