This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00]  Intro Kate Grandbois:  Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  Amy Wonkka:  Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  Kate Grandbois:  episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . Amy Wonkka:  Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  Kate Grandbois:  specified. We hope you enjoy  Announcer:  the course. Are you an SLP related [00:01:00] professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes EpisodeSponsor 1 Kate Grandbois:  Hello, everyone. Welcome to SLP Nerdcast. We are really excited to welcome two repeat guests today back onto our show for sort of a part two. We are really excited to welcome Heather Kaska and Kareena Khadi. [00:02:00] Welcome. Hi. Hi.  Amy Wonkka:  Heather and Karina, you're back here on the Nerdcast to discuss how to apply clinical skills in dyslexia and any of our listeners who might not have heard your previous recording with us. Can you please tell us a little bit about  Heather Caska:  yourselves?  Karina Kadhi:  Sure. I'll kind of, I'll start that. So my name is Karina. I am an SLPA. I've been practicing for about nine years now. And I've only worked, um, in pediatric, so, um, I love working with littles, I have a passion for early language, um, development, and, um, that type of intervention with littles, and Heather was my first, um, supervisor. For my first job and that's how we met and we quickly became a great team and a great pair. Yes, that's a  Heather Caska:  little bit about myself and I'm Heather. I have been a speech language pathologist for almost 10 years now. I started off my [00:03:00] career in skilled nursing working with adults for about a year and a half, but quickly learned and knew that my heart was with pediatrics and so working in pediatric clinics. I found a love for literacy and reading and started doing a lot of extra, um, education, uh, continuing education on dyslexia specifically. Um, I'm also the current president for the Arizona branch of the International Dyslexia Association. Um, I live in the Phoenix area and I own a small private practice in addition to our dyslexia education. Um, platform with Karina, um, and I have two small kids. They have a first grader and a three year old, so we're excited to be here again. Well, we're so excited to have  Kate Grandbois:  you. The first episode that you all did with us was really focused around the role of the SLP in the realm of dyslexia in general. But today you're going to be talking a little bit more about clinical application, which I am very excited to learn about because I know very little. Um, [00:04:00] so before we get into the good conversation, I do need to read our learning. objectives and disclosures. So let's get through that and then we'll get on to the good stuff. Learning objective number one, list the three principles and six key elements of structured literacy intervention. Learning objective number two, describe three evidence based intervention techniques and approaches to managing dyslexia and learning objective number three, describe three ways to incorporate structured literacy interventions into your current treatment plans. Disclosures. Heather's financial disclosures. Heather received an honorarium for participating in this course. Heather is the owner of a private practice called HBC language and literacy. Heather is also the co owner of sore with words, LLC, and co manages the sore with words educational platform on teachable Heather's non financial disclosures. Heather is the current president of the Arizona branch of the international dyslexia association. Heather also co manages the social media accounts for sore with words. Karina's financial disclosures. [00:05:00] Karina received an honorarium for participating in this course. Karina is also the co owner of soar with words, LLC, and co manages the soar with words, educational platform on teachable Karina's non financial disclosures, Karina co manages the social media accounts for sore with words. Kate, that's me. I am the owner and founder of Grand Bois Therapy and Consulting, LLC, and co founder of SLP Nerdcast. My non financial disclosures, I'm a member of ASHA SIG 12 and serve on the AAC Advisory Group for Massachusetts Advocates for Children. I'm also a member of the Berkshire Association for Behavior Analysis and Therapy. Amy,  Amy Wonkka:  that's me. My financial disclosures are that I'm an employee of a public school system and co founder of SLP Nerdcast, and my non financial disclosures are that I'm a member of ASHA Special Interest Group 12, AAC, um, and I participate in the AAC Advisory Group for Massachusetts Advocates for Children. All right! Heather and Karina, I know you're here to talk to us today about intervention, but before we start, [00:06:00] can you start us off by telling us just a little bit about dyslexia, maybe just a brief  Heather Caska:  overview about dyslexia? Yeah, absolutely. So I think one of the most difficult things about dyslexia is there are a lot of common misconceptions about what it is, but one of the biggest issues with dyslexia is just identifying it. And I think a lot of that comes down to the fact that there's really no one, um, agreed upon definition. So, um, the International Dyslexia Association has a definition, um, Most people go by. However, there's still a lot of disagreement across professionals as far as what really is. include should like criteria should be included in that definition. So we really like to go by the definition. So Dr. Tiffany Hogan and Dr. Hugh Katz put out a paper in 2021 called dyslexia and ounce of prevention better than a pound of diagnosing and treatment. And so the definition that they kind of proposed is [00:07:00] dyslexia is a severe and persistent difficulty learning to read and spell words, despite adequate opportunity and instruction. And the reason we really like this definition is because it's not specifying like any distinct causal basis. But it's looking at it like multiple factors. So you're looking at a lot of different, looking at that whole child and what could be some early indicators for dyslexia. So it's really going to fit more in that preventative model, which is what Karina and I are really passionate about that early identification and our role as SLPs and SLPAs on how we can help with that early identification and earlier mediation. So it's going to allow us to really identify those risk factors early on. Um, and then also, um, It's a big part of it is that definition is it's going to be more easily operationalized in like those educational settings, because we find that most of our educational systems are still set up for that. Let's wait and see model [00:08:00] that wait to fail model for these students, which is really putting them at a disservice. Um, we talk a lot about the dyslexia paradox, which was, um, kind of a term coined by Dr. Gavin, her colleagues. And what the dyslexia paradox is, is that it's acknowledging that dyslexia is not typically diagnosed until second grade or later, which is past that prime time for intervention. So we know that research is showing us that, um, reading interventions are significantly more effective in kindergarten and first grade. So most of our. Students, though, we're waiting, you know, let's wait and see, you know, they just need to keep practicing. And so they're not being identified until second or third grade. So we've already missed that prime window to make them to have the most effective intervention in place for them. Um, so some early like factors or factors that we need to consider when we're Trying to identify these students as family history. So if you know there's an older sibling that you know may have an [00:09:00] IEP or has struggled, that's going to be a big indicator that this is a student is not going to be one that will just catch up, necessarily, we I learned really quick early on when doing. Evaluations, not to ask specifically about dyslexia, because I would say eight times out of 10, I would get, no, you know, no one, no one has dyslexia in our family, but then as you would ask more questions, you would find out, well, dad got help for reading, you know, in school or so and so didn't, you know, or I didn't like, I really struggled, you know, I didn't like school, you know, as a, as a parent. And so that right there, I mean, most people didn't get that diagnosis. And so. It's a clear indicator that that there is a family history of learning difficulties, um, and then also just that poor response to adequate instruction. So if they, you know, they've been in preschool and they've been in kindergarten and their attendance is good, you know, but they're still just don't seem to be picking it up. That's another indicator.  Karina Kadhi:  One gets tricky with what [00:10:00] has gotten tricky recently, huh? With COVID.  Heather Caska:  Absolutely. And that's, that's a, that's such a great point. And so we, we've heard that a lot too, especially, you know, with our second and third graders now, because so that. They haven't been identified, which is not necessarily atypical, but a lot of it goes back to, well, they were, they were kindergarten, they were in kindergarten during COVID. And absolutely. I mean, I think everyone is struggling now because of what happened in COVID, but we're, we really need to remember to look at all these other factors too, and not just like It's can't just be an automatic. Well, it was cause of COVID because of COVID, like everyone's behind you. Right. Everyone. Yeah. Yep. There was there, everyone is behind, but we have to make sure we're really doing our due diligence, like looking at the whole child and other early indicators. So, and that could be that family history. Um, delayed speech and language skills, uh, and maybe if, you know, they have some, they're really struggling more with that phonological processing, working memory, [00:11:00] phonological awareness skills, um, some other factors to consider, any visual processing or executive function difficulties, um, and then even trauma, you know, trauma based, um, interventions are going to Um, and I think it would be really helpful for these students to as well as just looking at, um, socioeconomic status as well. So I think when we're trying to identify these kids early on need to really look at all these other factors that are going on as well. And chances  Karina Kadhi:  are, um, especially like in these early ages, we find that where I were identifying kids that are already on our caseload, um, for speech and language services. Um, and so then in the intervention and in the time we're already spending with them. Um, we're kind of picking up and noticing some of these other, um, factors and things and that, um, kind of a point we always like to make is that, um, most of these students are already on our caseload for speech and language at that age. But not yet identified for, [00:12:00] um, those reading difficulties.  Heather Caska:  Well, that's  Amy Wonkka:  such a good point. I, I wonder if you can talk to us a little bit about, I know literacy and reading is within our scope of practice, but when you're in a school in particular, like that's probably not your chief role in that position. But can you help us understand a little bit about Just the science of reading, structured literacy. Like what are some important things there for a speech language pathologist to be aware of, even if it's not like the hat that we're wearing in our,  Heather Caska:  in our role in that job.  Karina Kadhi:  Absolutely. Like we, that's, um, one of the biggest, that is the biggest piece that we like to, um, bring to awareness is, you know, we're lifelong learners and even you said it perfectly in a school setting. That's not our main role. Um, we are not the reading interventionalist. We are not the one doing, um. really addressing that. But if we can be aware of how many of those elements of structured literacy fall in [00:13:00] our wheelhouse, we can give like heck of support, right? So when, when we're talking about structured literacy and the science of reading, science of reading refers to just that body of research. That comes from many different professions, and that kind of helps us, um, understand how our brains learn to read, right? Because if we can understand how we learn to read, then we can intervene, um, better, and we can help students learn better. Um, and so that's what we're referring to for the science of reading, where structured literacy, um, is just, uh, evidence. evidence best practice, evidence based practice approach, um, to teaching, um, those reading skills based off of the science of reading. Um, so when we're talking about structured literacy, there's, um, six elements of it. So syllables, semantics, phonology, morphology, sound symbols, and syntax, um, are those six areas. And so, um, the, there's two of those that aren't [00:14:00] necessarily Um, closely related to our field or our skill set and that's being syllables and sound symbols. Um, but we also want to talk to you about how you can support those in intervention as well. But the other four big ones, syntax, semantics, phonology, and morphology, those are language, right? We're already addressing that in the therapy that we're doing in our speech room. And so if we could be more intentional about, um, maybe things we, the supports we embed, the way we scaffold, um, then we're supporting literacy skills in the therapy we're doing. Um, and so to kind of go along with the, um, Elements of Structured Literacy also has three, um, component or how, how would I describe that, Heather, like three principles. Thank you. Um, so that it's explicit, meaning that there's like direct teaching or not assuming that a kiddo knows something before that we're teaching everything explicitly, um, diagnostic. And so it's, um, individualized, has individualized instruction. Um, That's [00:15:00] monitored by ongoing assessments and stuff. And then, um, the last principle that it's cumulative and systematic. So it follows a logical order, um, and that each new step builds on concepts that we've already, that we have already explicitly taught that child. Um, So in a nutshell, that's structured literacy, those six elements and three principles there. And can see we we have a lot of knowledge in most of those elements and not that we have to be the ones doing that direct intervention. Um, but man, we can really support those underlying skills. Amy Wonkka:  Well, and I would think that there, sorry, Kate, I would think that there are just so many opportunities, as you mentioned, many of these students are already on our caseload. We're already providing speech and language services. Many of these six areas are things that we're maybe already working on as part of our speech and language goals and objectives. And then maybe it's also just a [00:16:00] matter of being very thoughtful about the material and activities that we're selecting, because there are a lot of ways to work on different goals and objectives. Right. Exactly. I mean, I think. The longer you've been in the field, the more you're like, ah, I could, I could work on it with this activity, this activity, this activity, they're all different ways to target these skills. Um, I didn't know if you wanted to, if you guys wanted to give us some examples of how, how a speech and language session might look a little different when you, when you're being thoughtful about trying to address the literacy component within your activity compared  Karina Kadhi:  to when you're not. Sure. Um, one of, we can, one of the, I think the easiest ones to, um, support is phonology. Um, especially obviously when we're working on those speech sound, um, goals, whether it's more articulation based or whether it's, um, more of like a phonological process. Um, some of the things that we do to support phonology or that range of phonological awareness rather for [00:17:00] these kids is, um, visual supports and, um, We mentioned last time, um, so different ones like the, um, Bjorm or, um, Lips. There's, there's different like dedicated programs out there, but really blocks. We love blocks. We love wadded up pieces of Play Doh and, uh, Toilet paper, tissue, whatever we can get our hands on that can serve as a manipulative, um, and to just bring awareness to the individual sound that they're working on, because without awareness, there is no generalizing that skill. And so we can work with a kid on how to make their F sound so they're blue in the face, but if they don't know when to apply it or when to use it, then we're not going to see that generalized as quickly. So really using manipulatives and visuals to, um. To support their phonological awareness so that they can then apply these, what we're working so hard on with them. Um, we like to, um, I'm just looking at my pictures here for that. [00:18:00] Some other things that we do in the speech room for that kind of piggyback off of phonology are also, um, support the sound symbol aspect of, um, Structured literacy and those, those same visuals, those sound cue cards, um, can easily be adapted by just writing the grapheme or that orthographic representation on the letter for them by tying that sound to the visual letter, um, is going to support them huge and just writing it out on that is another. Um, way to support to incorporate that sound symbol aspect of structured literacy without having to teach them the alphabet, right? Like, it's just exposure, just modeling that, um, what are some other ways? I was going to ask  Kate Grandbois:  you, you've mentioned the, the name of this episode that you've proposed is outside of the box. Is that sort of what you're getting at here? Can you tell us a little bit about how this might [00:19:00] differ from what we would typically think of as literacy  Heather Caska:  instruction? Yeah, I, that's a, um, it's a great question. So I think a lot, a lot of times as SLPs, we, when we get, when someone brings up, you know, dyslexia intervention or reading intervention, our automatic go to is, well, I, I'm not trained. I'm not trained in like a specific program. I'm not trained in Orton Gillingham. I'm not trained in, um, Linda Mood Bell or the Barton program. You know, there's a lot of really great Commercial programs available that are or in Gillingham based or structured literacy based, um, that are really can you can that are helpful to support these students. Um, but our whole thing is. Especially in the schools when that's not our primary role, we don't necessarily have to be trained or certified in these specific programs. Like, so thinking outside the box, um, is more of like using our clinical skills. You know, we already know, like Karina mentioned, four out of those six elements [00:20:00] fall, those are in our wheelhouse and these other two, you know, they're fairly closely related, but easy to support once you have some general knowledge about it. And so you don't necessarily have to be. trained in this program or, you know, certified in a certain type of intervention to support the students on your caseload. Um, as I think, especially in the schools as a school based SLP, it's important to be aware of what curriculum or intervention programs are being used, you know, in the classroom or even in like an ESS classroom. Um, to just to have a better idea of, you know, what the student is being exposed to, but to necessarily be trained in it, I don't think is necessary to support your students.  Kate Grandbois:  I really appreciate that perspective. What I've learned from you all and from a few other individuals over the years is that literacy can feel very siloed because of the different roles we play, particularly in an education setting where you have a [00:21:00] quote, reading teacher, and that's the person who does the reading intervention. Right, only them. Right, right. And so I think because we have this I don't know if you, if the word culture is the right word, but because you might have this professional workplace culture or set of standards or norms where reading might be a little siloed, I really, I really appreciate the perspective of sorting of trying to branch out outside of that and generalize some of these or create normalcy around, um, um, um, Intervening, addressing, addressing them. Exactly. Exactly.  Karina Kadhi:  Yeah. And we, we, we do get a lot of like pushback in, I wouldn't say pushback, but feedback in that. Um, well, that's not my role in a school. I can't look for all these other students. How do I, I can't go add on these additional students and screen more students. And that's why we always like to emphasize like, Yeah. Chances are they're already in your classroom, right? Like, if we can just focus on that [00:22:00] population, we're making a difference, right? Because, because we might have a little kindergarten or first grader working on these things who's not going to be screened or identified for any, um, literacy related difficulties at that age, you know? So if we can Um, kind of embrace like be open minded about that and, um, embrace that lifelong learner kind of mentality and bring more, um, awareness to, Hey, what are some other factors that I could, these kids already sitting in my room to help, um, identify that  Heather Caska:  I think. To they so a lot of states now do have legislation in place where you know, you're you have to be screened as universal screeners that are administered to all kindergartners first, it's usually like kinder through third grade. And so finding out like if you have students on your caseload or if you are, if your school is it has that RTI. where you're doing, you know, RTI with some of these younger students, find out about those [00:23:00] universal screeners, how are they performing? Are they below benchmark? Um, because those are kids too, you know, that might just need extra support. Here in Arizona, if they are, you know, kind of flagged on these universal screeners, then they are automatically put into a tier two intervention. Um, at one of the charter schools I worked at, you know, I did part of the tier two intervention. We did that. And so we started an RTI group for some of those kids that were, you know, that had more difficulty with the phonological awareness. And so that's what we were doing, um, as part of that tier two. And I know that's not, you know, realistic For all SLPs, like we have a lot on our plate already, especially in those school settings, but I think just being aware and asking those questions, you know, I have so and so on my caseload, how'd they do, how'd they do on their screener, you know, and then just finding what additional supports you can give them, you know, during your speech and language therapy. I wonder if  Amy Wonkka:  it makes sense to talk a little bit more in depth about [00:24:00] each of those different structured literacy elements. Um, I don't know which one you guys would like to start with, but I think just giving people an overview of the element and then just talking kind of specifically about it. So, like, I thought, Karina, you gave a great example of just if you're, if you're working on sounds, you could integrate that sound simple correspondence component, you know, so maybe just talking about some of those tips would be really helpful. Karina Kadhi:  Okay, I want to give some more examples for when, how we can incorporate some things we can do in our speech therapy to support that sound symbol element that not. Uh, element that we're maybe that falls under that language domain, um, like a few of the other ones. And so, um, we already mentioned the sound cue cards and, and then just, um, using the visual incorporating that visual grapheme when you're working on your sound. So just make that associate help them build that association. Um, another thing I like to do is, um, I [00:25:00] like to make sound. cards, I guess you can call them. And so say we have a kiddo working on S. So we might have on, on our little index cards, all the ways that he might come across the sound when he's reading. So S will be on there. SS is also on there. Cause at the end of words, It comes across that way, C E C I C Y is on that card also, that way he knows visually. These are, when I'm reading, these are all the ones where I'm going to have to use my snake sound or whatever sound I'm working on. But also, I'm just exposing them, um, and, um, and Modeling and just giving, bringing awareness that, hey, this can be represented different ways. These are all the, it's, I'm not his English teacher. I'm not going to quiz him on it. I'm not going to, it's just one thing that I'm embedding into my therapy to support that sound symbol component of not going to test them or quiz them. Right. But just something I can embed there. And I really like that. And the kiddos really like it too, because then we can go and do reading tasks and they can search for those and highlight them and then [00:26:00] practice reading at a sentence level, maybe, um, just to con. Oh,  Amy Wonkka:  Nope. I was just gonna say, just to contrast with that, like I can think of an example from when I was working outpatient and I would be working on articulation and I would go through my like super duper articulation cards with the pictures on them. And I would never draw that connection. I would just never make that explicit connection between the orthography, like the  Karina Kadhi:  written symbols. Yeah. The written representation. And again, that's not,  Amy Wonkka:  we're essentially both doing the same thing and working on that target sound production. But what you've done in your approach is you're just making that that much more visible, giving that student exactly visible. And I just, I love it. And I think it's, it feels like such a small thing. It seems  Karina Kadhi:  like it's easy, easy. Yes. Yeah. It's an easy thing. And again, we're not fancy when I say no card, usually it's like a ripped piece of printer paper that I'm like, Oh, here's a little square for you. Here's your card. Or, or have them make it right. They can pick whatever medium they wanna write it on, [00:27:00] and then it's more exciting for them. And so it doesn't, it, you're right, it, it can be very easy, um, and very low prep, uh, to be able to do that. Um, sound wall are another, I personally have never had, um, a sound wall in my speech room. I wish I would have, but, um, I wanna make one and I, and then it's a great, it would be a great resource to even have, um. Just like in the, maybe collab with teachers and have in the classroom setting, you know, um, those sound walls are, are a great way to help, um, tie in that sound, um, symbol when you're working on your speech sounds. Um, we also, let's see, we won't go into syllables yet, because that one can get, well, nevermind. Yeah, we will, because this one can be easy. So syllables is probably the one of the, um, the elements that we know the least about as speech therapists. Um, there are different syllable types and also different syllable division [00:28:00] rules. But the most important thing to know about syllables is why it's important, why it's part of structured literacy. Um, it's because when, uh, when students can predict what sound a vowel is going to make by knowing the type of syllable, it's going to make reading and spelling easier. So knowing how to break that word into syllables essentially makes them easier to read and spell. So if we could explicitly teach them that, we're giving them a tool, um, to support their decoding and spelling. Um, and so the different syllable, um, division rules, um, they can get kind of It's tricky. But again, that's not our role isn't to learn this and teach them this, but just, we take that approach of that. We're lifelong learners. And if we can have this in our toolbox and we can support kids just one different way. So we have some pretty good resources that explain this in a little more depth on our Instagram site. Um, and so we have some, um, I think they're called reels pinned,  Heather Caska:  saved on [00:29:00] there, highlighting.  Karina Kadhi:  They're on our highlights. Um, and so you guys can check those out and they'll go into a little bit more depth in, in this syllable component, but, um, We, ways that we have used this in our therapy is like, um, reading comprehension. Sometimes our kiddos get stuck on decoding bigger words. And so we whip out our syllable division, um, tools and kind of teach them how to segment and break apart those words to make it more manageable for them to read. And then they've decoded an unfamiliar word and now they know context. And so really just functionally using it, right. Um, And so if we can make our bring this syllable type and syllable division knowledge, just our attention. It's just another way to support them.  Heather Caska:  One thing that I've noticed, um, or that I've a pattern I've kind of seen in the schools too, is oftentimes we are asked like SLPs and SLPs are asked to like, can you give so and so their spelling test this week? Or like we help [00:30:00] support, you know, administering spelling tests. And so if you do that, this is also another way. Just having this knowledge, that's going to be helpful. So kind of backing up a little too, like the sound symbol. Um, one thing that we found, especially with our older students that, you know, like gaps that we find is just even that basic awareness or knowledge of what a consonant versus a vowel is. And then even. like long versus short vowel sound. So that's going to also be really important for that syllable division piece because it like certain syllable types, um, like if it's a closed syllable, it's a short vowel. But if your second grader has no knowledge of what a short vowel is, that's not going to be helpful for them either. So I think that's a big piece that we often miss and overlook that we can be really supporting too, is just that basic knowledge of like a consonant versus a vowel, like, you know, visually looking and can you show me which ones are your bowels, but then even, um, Like orally giving [00:31:00] them a sound like ah, is that a long vowel or a short vowel and really supporting that because one thing I've seen before too is they would give these visual supports for this student who was doing for like spelling tests. That's that was part of in his IEP where they would just underline for however many sounds there were in the word. There was that many lines. So it was helping him as far as that phonological phonemic awareness, but then they would also put little dots underneath the line that were supposed to be vowel sounds. And he was still writing, you know, consonants where those dots were, and it was like, well, that's a vowel come to find out the student had no idea what a vowel was like, he could not understand so that those supports weren't even supporting him because he didn't have that. And so I think just even that, you know, that knowledge, um, is, is something that we often overlook, especially in our older kids, um, where I found that that's one of the biggest [00:32:00] pieces that. You know, hindering, I don't, I don't know if that's the right word, like, um, the barrier. You're right. Yeah. Thank you. That's all right. A barrier to, to them with more of these, like the syllable type this, um, so  Kate Grandbois:  everything that you're both saying is making me think so much about the opportunities for collaboration. So if that student is already on your caseload. Making time for that five minute conversation with the classroom teacher. Where does this student where, where do you suspect they struggle? What are some of the literacy related goals? Or maybe it's not the special education teacher. Maybe it's the gen ed teacher. Maybe it's the quote reading specialist or the resource room person. I mean, every district has different labels for this, which is one of the reasons why I find this to be such a murky area, depending on where you are. But. Any collaboration with a literacy oriented [00:33:00] specialist can create so many additional opportunities for generalization. I have to  Karina Kadhi:  assume.  Heather Caska:  You're absolutely right. And that was a big piece we talked about in, um, like the, the last episode is one of our roles, like under one of our domains is collaboration. And so, especially with these students and you'll get, I mean. I've been fortunate in the schools I've worked in. Um, you know, I come in obviously with a lot of background and knowledge and literacy in this area and was little nervous at first coming into the schools thinking, you know, that they're going to be like, Whoa, like this speech therapist needs to stay in their lane. Like they're not a reading specialist, but I've been really fortunate in that everyone's been open to, you know, collaborating and discussing and. And suggestions and ideas, but then also me learning from them too. I'm not a teacher, you know, I don't, that's, that's different, you know, that's a whole different wheelhouse. And so just that collaboration and not only with the teachers, and [00:34:00] I think it's all of the above a reading interventionist, special education teacher, general education teacher, you know, um, but also with the school psychologist. Um, and even the occupational therapist, I mean, really, it's, it's truly a team support and the parents. I mean, it's, but you know, in the schools, I find it harder when I'm versus my prep, my private clients versus the students I work with in the school, I'm obviously in communication a lot more with my private clients. I see the parents where at school, you don't, you're not, you know, but I think keeping that, um, in mind too, that collaboration with the families as well. It's so important  Karina Kadhi:  because we do wear so many hats right in a, um, in a, in a school setting or even in a private setting. So um, sometimes that, or a lot of times that even just opens up the door for like divvying up goals. We've seen a lot to where our speech and language goals look really similar to like the, goals that they might have under their [00:35:00] ELA section of their IEP. And so divvying up things that way we're getting, um, max repetition, max exposure, um, yeah, it's always a great, it's always a great plan for these students and it kind of helps us too. Right. Where we're not trying to have to do all of these things we've made a plan with. The rest of the team and they're going to cover this and they'll help this and, um, so good things come from that  Heather Caska:  for sure. I think, um, to sometimes, you know, looking at those goals and like Karina said, a lot of times they're very similar or they at least support each other. But then I often see, especially in our older students where they're reading and writing goals like they have a goal for reading comprehension and reading fluency. But they're still completely missing those basic reading skills as far as just decoding and phonological awareness, but there's no goals for that. And so that's where we can really come in, especially when it comes to like the phonological awareness and support that too, or at least advocate for some of those goals. Because I can't tell [00:36:00] you how many times I've had a student come, you know, where I've looked at their IEP. Or even in the schools, you know, when they go to write the goals for a second or third grader, the goals are just reading comprehension. We'll answer, you know, WH questions after reading a grade level passage or read so many minutes or so many words per minute. And I was like, okay, yeah, but that's our end goal. But how are we addressing their decoding skills? Because they're not going to be able to answer those questions if they're focusing so much on what they're decoding, you know, but there's no goals to address that. And so I think that's. That's another piece where we can at least advocate for that or somehow try, try to support those, those goals as well. So the we've talked about three elements of structured literacy so far. Um, phonology, which is well within our wheelhouse. I think we're most familiar and even known for that. So teachers are going to come to us and ask for help with phonological awareness and phonology. And then we talked. About, um, sound symbol relationships [00:37:00] and syllables. So the next area that we are pretty familiar with as SLPs and SLPAs is morphology. And so I think one of the biggest takeaways for morphology is we need to remember that we have to think about their phonological skills too. We had one client specifically that stands out in my mind every time we talk about morphology, that this really, um, was an eye opener for us where we had goals for him. He had, he came into our clinic. He had goals already. He had had an evaluation. So we were working with him and one of his goals was like regular past tense verbs. Um, you know, wasn't marking those. And so we were, you know, addressing the past tense. And all of a sudden he just was not getting it. And I don't remember exactly what happened, but I was, we had another SLPA who was working with him. And I remember I was super supervising her session. And all of a [00:38:00] sudden I was like, Oh my gosh, this student has no phonological awareness. And so I was like, okay, hold on, let's take a step back. And so we gave, um, the student a phonological awareness screener and he performed very poorly on it. And I said, here's the thing, like we're trying to teach him what we're teaching him is to like these grammatical markers, you're adding a sound to the end of a word. But if he has zero awareness, that words are made up of all these different sounds anyway, of course, he's not understanding. Of course, he's not getting it. So we had to back up and take more of a phonological awareness approach with. And versus just like that syntax or morphological approach with him. And so that was just kind of like a big eye opener, um, For us as therapists and then just kind of keeping that in mind. So, um, I think for us, you know, that's, we're very aware of that, you know, it's part of our, our education, the different types of morph, um, Morpheme, so we have our inflectional or derivational [00:39:00] morphemes, um, and how we can go about building vocabulary and then even just building that syntax with that as well. But when it comes to more of the structured literacy, the piece we don't have as much knowledge about is when it comes to like those spelling patterns. And so, um, you know, there are rules for when you're adding a suffix. And typically, like if you're adding a suffix like ed or ing that starts with a vowel, there are certain spelling rules and spelling patterns, like if your base word ends with a Y, you know, do you change the Y to an I or do you just keep it and add the suffix to it? Um, and there's also rules like if, um, if you have, if your word ends in a CVC, do you double that? So think of the word stopped. S T O P P E D. Why are you doubling that P? Versus a word like jumped. You're not doubling the P in jumped, you're just adding E D. So there's, I know, these are things I have [00:40:00] never  Kate Grandbois:  considered. Exactly. I was 10 years old when I realized how completely ridiculous some of this  Heather Caska:  is. I know. And it is. It really is. And some students really benefit from being explicitly taught those rules. But then other students, it's just even, it's just too complex, overwhelming. It's more, it's very overwhelming. So we do have some resources again, like on our Instagram, like in our bio that just kind of like a cheat sheet of the most common, like spelling rules and spelling patterns as far as, um, like morphology and then just other spelling, spelling patterns too, that are commonly taught in these structured literacy programs, um, just for, just for you to have. Um, but I mean, again, when I got my training, I did my training through the Academy of Orrin Gillingham, practitioners and educators. It was a 90. Program. Like it was a nine day training. And so, I mean, obviously it's way beyond what we would have time for here. Um, but we do have like a cheat sheet as far as that. And then we have like a phonics practice sheet. And I, I don't [00:41:00] know if it's linked in our bio, but we can, you can always reach out to us too, and we can send that where you have the opportunity to go through and practice a lot of these skills as far as like identifying syllable types, syllable division that we've kind of talked about, and then even using and practicing some of these spelling patterns. So we have some opportunities. Opportunities for you to practice again, like Karina keeps reiterating. This is not for you necessarily to now turn around and teach, you know, especially if you're in the school school setting, but more so just that knowledge so you can better support the students and then just have more knowledge as far as like the interventions that they're getting, um, in the class too. But then you do. I mean, for us, private. practice. Like that's what we focus on. We are the reading intervention, reading intervention, you know, when they come to see us. So maybe you want to take that route and you just want to learn more too. But as far as just getting a little bit of knowledge. So, um, I mean, and again, a lot of times we're already addressing a lot of these issues. Morphology goals, you know, we have those syntax goals. We're [00:42:00] working on verb tense. We're working on plurals, um, and adding those, but I think again, adding that orthographic piece and really highlighting that is going to be helpful. Just that awareness. Um, and then also just again being aware of their phonological skills and making sure that's not something we've skipped over.  Karina Kadhi:   Some things that we've done, um, to work on morphology in our speech and language sessions, um, is, uh, it's always a big hit. We call it past tense basketball. Um, and we usually have three baskets set up. And this is when we're working on like, uh, our past tense. So it has three, it can sound three different ways, right? To the id, our past tense marker, as in, um, I can never think of examples, y'all. I'm gonna need some help. Um, like painted, walked. And jump. No, that was the same. Hugged. Okay, hugged. There you go. Um, and so, whether, and then depending on what we want to focus on, do we want [00:43:00] to work on that auditory awareness piece? So then maybe we'll verbally give our kiddos a sound and they have to isolate. So working on phonologic, um, phonemic awareness, again, they have to isolate that marker and think about what they heard. Um, And they have to shoot their basketball into the right basket and they get points if they get it right. Um, or we might, we might be working on decoding, right? So they might have strips of paper with the different, they're all spelled E D E, right? But they just make different sounds depending on other parts of the word. And so then they have to practice reading it correctly. Um, and then shoot it in the basket that it goes in. So it's, it's great repetition, great drill. You can target different aspects of that. Um, and we're supporting and addressing that morphology in there and speaking in some great, uh, phonemic and morphological awareness as well. That's always a big hit. Um, and then the other one I'm looking at here, I think you made this one, like that, that book. The, the suffix book, like fully [00:44:00]  Heather Caska:  lastly. Yeah. So when we're working on some of those morphemes to working on those suffixes and prefixes, some things that we've done with. Our students is we've created like little vocabulary notebooks where we add in like we have the suffix or the prefix, the definition of what it is, but then we always draw a picture to kind of help with. So like one I have is Lee L Y. Um, and our word that we use was slowly. That was our keyword. And so we drew a picture of a turtle and so kind of just, but again, making it very specific, the child, like letting the student come up with it because individualizing it and making sure it's meaningful to them is. Um, and that goes back to, to those speech sound cues that we talk about, um, you know, with some of our students that we've, we've worked with, um, we love the beyond speech sound cues. We use those a lot. And we also, um, do use like the lips pictures, but some, sometimes those don't click for our student. And so we let them come up with our own. And I don't remember if we mentioned this in our last, [00:45:00] um, episode we did, but Karina had a little girl and we were working on her. F and the, um, the mad cat wasn't working. We tried fish just coming up with the keyword instead of the environmental sound, nothing was working. And so her mom helped us, um, come up with, uh, part. And that was her keyword for, and it stuck, I mean, but we just, she could not. And so it was, it's hilarious, whatever it gets from there, right, exactly, you think you should see the picture, it's, it's so great, but it's just a great example of how individualizing and letting the student, you know, like a lot of times we, um, We draw, let them draw the picture and we've, some of them have come out really, um, hilarious, you know, like they draw the picture and you're like, what is that supposed to be? And, um, they're, Oh, it's a monkey itching its butt. And you're like, Oh, okay. Okay. [00:46:00] Um, for that, I itchy. And so, yeah, so I think it's important. And then just going, you know, going back to morphology, same for that, you know, when you're working any vocabulary, really, what is like, what do they picture in their mind for that? And that's, what's going to, that's, what's going to help because I mean, we can tell them things, but if it's not clicking for them, and that's another piece with those programs too, is they're very scripted, you know, and, and tutors and people that are trained in it are trained, you know, you do not go off the script. And I understand that as far as like. for it. But what if it's not, what if it's not working? Like, what if those keywords that are in that program are not clicking with that student because they don't have the background knowledge for that, or, you know, whatever, it's not meaningful to them. Um, they need to be able to use what is going to be meaningful. And I think us coming in as clinicians, we have that knowledge and Understand how important that is. So same goes back for that when you're just working on morphology too, and helping build that vocabulary. I just want to say that all  Kate Grandbois:  of the examples you're giving [00:47:00] make it feel so easy to address. Literacy in what we're already doing. I'm just imagining a situation where you might have a student on your caseload that you maybe you're working on speech sounds and that's what your goals are related to. But then if you take that extra step to collaborate and find out if you know if they do have some sort of. Services for literacy or need additional support for literacy, just tacking in those letters or putting in that extra step into your therapy program to tie it back to literacy. I, I. The way you're describing it makes it feel so accessible. Like it's not this whole extra thing you're doing. You're already doing it. You just need to  Heather Caska:  tweak it a little bit. Yeah. I'm  Karina Kadhi:  glad you say that because that's our goal.  Heather Caska:  That is, um, and even if the, even if your student doesn't have goals for literacy, like it's gonna benefit everyone, you know, you're benefiting. Everyone's going to benefit from that. And that's the [00:48:00] thing is not only students, not only students with dyslexia are going to benefit from structured literacy. All students benefit from structured literacy. So  Karina Kadhi:  I feel like that's going to funnel that can funnel us into executive function. Can we like jump to that? Yeah. He's really quick because what, what that no students going to We had a disadvantage from being exposed to this in their intervention, right? Because what we're doing is making it multimodal. What we're doing is making it accessible to everyone and just incorporating another neural pathway that's going to make an association, you know? So no one's going to be at a disadvantage from us embedding phonological or phonemic awareness into our speech therapy. No student is going to be harmed in this therapy. Right, but yeah, yeah, it's it can be something simple that we embed and hit on that. And so I talked a little [00:49:00] bit about, um, executive function. I know it's not a one of the formal six elements of structured literacy, but it's involved in everything. It's involved in, um, learn our students learning. So in a nutshell, uh, executive function skills are like, um, perception, awareness, attention, working memory, inhibition, initiation, self monitoring, retrieval, right? What Heather was talking about when, when that sound cue isn't working, it's not sticking. What's not sticking for me is I'm not able to like retrieve that information that I've learned and then apply it. And that, that's an executive function skill, um, or several together. Um, and so we love to embed, um. supports for executive functioning into our speech and language therapy as well. And so, um, a few different ways we could do that is. Making things multimodal, giving them visuals of things, um, making things tactile, just making, individualizing it, and finding what works for them. Um, and then probably the most valuable [00:50:00] tool that we can, oh, I say valuable in that we can do the easiest and reach the most students, um, without really having to, because EEF is a whole, can be a whole, Presentation on its own. Right. And so without having to dive too much into that, something that we really think that we could do to support this is called reflexive questioning. And Tara Sumter is a SLP who specializes in executive functioning and she has a book and she's extremely knowledgeable in this and so we got this, this strategy, if you will, from her and so it's the idea that it. Thank you. Our words matter and the way that we word things can support our students so a reflexive questioning really remote promote self reflection and self awareness, which ultimately leads to that generalization right which is what we want, and it doesn't give or tell our student what to do, but rather guides and models [00:51:00] self talk and teaches problem solving for them so in our speech room, what that might look like when we're working on our coughing camel sound or. And so maybe we are producing it and they make the instead of just nope try again that wasn't it. Some way we could use our words differently to put them into a reflexive question is where, where did you feel that working? Where should you feel it working? Because now we're forcing them to think and to kind of get some of those self talk patterns and self checking, self monitoring patterns in there. Another way that that one other thing that could look like in our speech room is we have that kiddo that really can't sit still and it's doing all this and instead of sit still sit down, sit down, that we're just telling them what to do right there's no thinking involved for them. Where should your body be right now, what's your job right now, what should you be doing right now, because then what's that's going to force them to come back and be like, Oh, wait, what should I be. And maybe they don't know, but then [00:52:00] that's an opportunity to, oh, so here's where we can, here you can ask. And, and so it's just great modeling, problem solving, making, um, our, our kiddos more independent and less reliant on those external cues. And more aware of their internal.  Heather Caska:  Yeah, I think and on top of that too. And I remember Tara talking a lot about this as well as it's also just like they're confident. So if you say like, um, you know, where did you feel that your tongue working? Um, I felt it in the front. You're right. Yeah. So you're not. Like you're not, it's not like a, nope, you do it wrong. Do it again. Wrong. Do it again. You know, where did you feel your tongue working in the front? You're right. Or should you feel it working in the back? You're right again. Can you show me that? Show me it working in the back so they can get the, and so I really like the independence and also just. That confidence to have like affirming. Yes, they're doing, you know, they're doing the right thing instead of constantly. Nope. Do it again. Wrong. Do it again. Um, because then that can just be super discouraging as well. Amy Wonkka:  I think that those are such nice. And I think that's one of the big points to raise to [00:53:00] not only about shifting the student into a more reflective state, but also providing a more positive environment for them to be in when they're practicing like those strategies seem, I can't remember exactly what you said, Karina, but the best bang for your buck in terms of, you know, it's not a big change to your, to, to what you're actually doing, but I think it benefits the student and your relationship in multiple ways. Totally. And similar to some of that. integrating the literacy concepts. I don't, I don't know that that would  Karina Kadhi:  be a bad approach for anybody. Yeah. Yeah. Yeah. Um, we can go, you want to go into semantics? Yeah.  Heather Caska:  So, um, the fifth element that we'll talk about as far as structured literacy, again, is very much in our wheelhouse. So we won't spend too much time talking about it, but semantics or vocabulary. Um, again, I think the biggest takeaway for this, it goes back again to that orthographic piece and writing it out. Um, there's, uh, a podcast episode with Dr. Mary [00:54:00] Eltz, um, and Dr. Shelley Gray and Dr. Tiffany Hogan, um, on the See, Hear, Speak podcast. And it just talks about working memory, um, and word learning, um, and it's. I've listened to the episode probably like five or six times because it's just, it's so good. But, um, Dr. Alt has this really great quote in there. Um, it says we don't always do a good job of identifying when students have both like oral and written language difficulties because what their research is showing is that kids that struggle both with oral and written language that there's, they, um, They do have a lot more difficulty learning words. And so when it, and so they just say by writing, even kids with dyslexia, by giving that orthographic representation of a word. So even think about that with sounds. We keep talking about that when you're working on articulation. Match it with those orthographic cues too, that they're, they're, they're significantly better at learning those words when you have the [00:55:00] orthographic piece too. So don't, don't forget about that. You know, when you're working on vocabulary development, write it out for all students, cause it's just going to really benefit them. Um, we have a really great resource, um, that we like front it's called from talking to writing. Um, it's a, it's a book that we really love. And it, um, addresses a lot of vocabulary and syntax, um, and even written expression. So, um, it starts just, you know, vocabulary goes into basic sentences and then even into, like, um, multi paragraph essays, um, scaffolds it to wonderful curriculum. We use it and adapt it a ton with the students that we work with in our, in the school and privately. Um, so just a, a really, um, useful resource. And then again, that just goes into syntax, something that we're probably already doing in our, in our speech and language rooms as well. Um, again, we love the book from talking to writing to support this, but just writing it out. So we do a lot of, um, [00:56:00] we start a lot kind of like bigger working on phrase. There's like who phrase, what phrase, where phrase, when, and kind of building that way. And we literally cut out colored pieces of paper, who, what, where, when, um, we have a lot of examples of these on our Instagram. I know of videos of how we've used it and really just helping showing how we can build sentences. And then we kind of break it down even smaller than into nouns and adjectives, like those parts of speech, but we start bigger, you know, with the, who phrase, who did it? The cat, what did the cat do? Ran? Where did the cat run? In the yard? The cat ran in the yard and just, and then, you know, then you can kind of go back and break it down into, okay, so what's your noun, what's your adjective, what's your verb. Another way we've kind of helped support even spelling like that is we will have like, um, on the whiteboard and we make three columns, maybe like noun, adjective, verb, and then we give them a word, maybe like a, a specific target spelling, like phonogram that they're using. Um, and then we use it in a sentence and then they just, they spell the word like in that column, as far as like, what's that a [00:57:00] noun, what's that a verb, what's an adjective. So just another way to just really support those syntax skills, but then also supporting. Um, their spelling as well, and just that sound symbol piece. So those are the six elements. So again, phonology, sound symbol, syllable, syntax, semantics, and morphology. Um, and four of those six well within our wheelhouse. And then the other two, um, you know, sound symbols, I think we have a little bit more knowledge syllables and syllable division. Syllable types might be be a little bit more new. But again, we have a lot of resources to kind of help you understand that. And then the last piece we always are, um, encouraging or that we, what we do address or encourage you to support is reading comprehension and written expression. So we've talked a lot about the reading comprehension already. Um, this really ties heavily into your executive function as well, as far as self monitoring really using, um, active reading strategies. building background knowledge, um, is going to be really [00:58:00] important for these students. Sometimes, you know, with some of our students, we've created these like active reading checklists, um, you know, for that visual support to kind of help them, you know, check in, um, you know, Review questions first. So we talk about background knowledge. We kind of do a scan of what we're about to read, looking at pictures, headings, read pre read and in comprehension questions that we have. And then as we go through and we read whatever we're reading, we have check in points where we kind of stop and do some self reflection. Okay. What did I picture for that? What am I reading? You know, and just using, and then kind of going. And then again for written expression, we use lots of visuals to kind of help as far as like the writing process and organizing your thoughts, a big thing we really encourage our students don't stop writing, you know, they'll start writing and they get stuck on spelling a word, and then the rest of their sentence is gone, you know, they completely lose their train of thought. We have one little girl, one girl that we worked with for a while. And she was, I think it's seventh, eighth grade at [00:59:00] this time. And Karina was doing like a writing, um, task with her in, in their session. And she was, I don't remember what it was, but she wrote the cooks going to write instead of kitchen. And Karina was like the cook's room and she's all, well, the kitchen, but I didn't know how, how to spell it. And so completely avoiding, you know, and changing their sentences. And it didn't sound as good,  Karina Kadhi:  right? That didn't, that wasn't as nice of a, of a sentence, um, for her.  Heather Caska:  Yeah. So really we're working on. Just add like teaching them, you know, it's okay, like just get it down and then we will come back and we'll edit later, you know, but it's hard because a lot of times kids with dyslexia, they're, they also tend to be perfectionist too. So it's hard for them, you know, if they don't, if they're not getting it, you know, right. Or it's not exactly the way it should be. And, um, we had another, um, boy tell us one day, he's like, I have my thoughts here, like they're here, but then it's like, as it goes down and gets to my hand, it gets lost. And then he just like, can't get his [01:00:00] thoughts on paper. And so like, just to have him be able to verbally express that was like really helpful for us, you know, like, what could we do to, to better support him then? Cause it's not like he doesn't have the ideas he has them, you know, but it's when he'd go to get it on paper, he loses it. And you hear that all the time with your students with dyslexia. So, um, really supporting that written expression. Scribing for them so you can get it, you know, you can get it down. That's often a big support or an accommodation on their IEP as well. Um, but just really encouraging them not to not to worry about spelling. So, um, and I think that's it. We talked about executive function. So, um, again, you're you're We're not saying that you now have to start adding all of these new students onto your caseload because I, we get that a lot to like new goals. Yeah, but just being aware of the students you have on your caseload, and how you can really support them with these structured literacy elements with the therapy that you're already [01:01:00] doing by just adding in some different elements or kind of tweaking your, your activities that you're doing with them. Kate Grandbois:  You all have shared so much with us today. I can't tell you how much more accessible this all feels now. And we're really, really grateful for you sharing it all. Do you have any additional last rec last set of recommendations or words of wisdom that you want to leave our listeners with?  Karina Kadhi:  Um, I, you know, I, I think it's just that I've really, and for myself personally too, is just that we're lifelong learners and sometimes it can feel like, oh, you're asking me to do what? Because I remember learning these spelling words, rules at one point and I felt the same way. But, um, but, but to know that we have a bigger, look at the bigger picture and that we can, we can play a bigger role in the, um, with, with these students, um, in the, in our existing role. Um, and hopefully we spark some interest for some, um, speech therapists that really have a passion for [01:02:00] literacy. Heather Caska:  Yeah, and I think especially in your kindergartners, because again, they're the ones we are most often the first professional that comes into contact with these students that are going to have, you know, learning difficulties, specifically in reading and writing. And so really just being more aware in our younger students because we're the ones that can really make that impact. Early on, um, because most likely they're not going to get tested or formally evaluated until later on. So especially in those younger students, just kind of come up with a good action plan of how you can better support them and be aware of them on your caseload. Thank you so much for  Kate Grandbois:  all of this. We're so grateful for your time. For anyone listening, all of the references mentioned will be listed in the show notes. Thank you again so much for being here and we hope to welcome you back here again  Karina Kadhi:  sometime soon. Thank you.  Kate Grandbois:  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA [01:03:00] CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon.

This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . [00:00:00]  Intro Kate Grandbois: Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  Amy Wonkka: Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  Kate Grandbois: episode of this podcast is a course offered for ashes EU. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . Amy Wonkka: Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise  Kate Grandbois: specified. We hope you enjoy  Announcer: the course. Are you an SLP related [00:01:00] professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ashes, EU, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited EU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes Episode Sponsor 1 Kate Grandbois: Welcome to SLP nerd cast. We are so excited to welcome today's guest. Welcome Megan Holmes.  Meghan Holmes: Hi, guys. Thanks so much for having me. I'm so excited.  Amy Wonkka: We're excited, too. Uh, you're here to discuss the SLPs role in palliative care. But before we get started, could you please tell us a little [00:02:00] bit about yourself  Meghan Holmes: or I graduated from Northeastern University in 2016. I did the accelerated bachelor's masters there. Um, and since then, I've worked exclusively with adults and geriatrics kind of across the continuum of care. I've done skilled nursing facilities, home health, uh, a long term acute care hospital. And I'm now working in an acute care hospital in central Massachusetts. Kate Grandbois: We're really excited about this. We had a lot of really, um, interesting conversations before we hit the record button about how. This topic of palliative care might not be obviously related to what we do as speech language pathologists, but as you're going to tell us soon, this is much more related to the role of the speech pathologist than you might think. So there's a cliffhanger there, and I'm looking forward for you. I'm looking forward to you filling in more information. But before we get there, I do need to read our learning objectives and our disclosures. I will get through those quickly, and then we'll get on to the good stuff. Learning objective number one, [00:03:00] define palliative care. Learning objective number two, describe knowledge and skills specific to the SLP role that can benefit patients, caregivers, and clinicians navigating serious illness. And learning objective number three, identify at least one communication tool that uses patient tested, person centered language as a framework for discussion around serious illness. Disclosures. Meg's financial disclosures. Meg received an honorarium for participating in this course. Meg receives a salary from UMass Memorial Health and Worcester State University. Meg's non financial disclosures. Meg has personal experience with palliative and hospice care. Meg is also a member of ASHA SIG 13 and a member of the Dysphagia Research Society. Kate, that's me. My financial disclosures. I am the owner and founder of Grand Bois Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosures. I'm a member of ASHA SIG 12 and I serve on the AAC advisory group for Massachusetts Advocates for [00:04:00] Children. I'm also a member of the Berkshire Association for Behavior Analysis and Therapy. Amy Wonkka: Amy, that's me. Financial disclosures. I am an employee of a public school and co founder of SLP Nerdcast, and my non financial disclosures are that I am a member of ASHA. I'm in Special Interest Group 12, which is AAC, and I participate in the AAC Advisory Group for Massachusetts. Advocates for children. All right, Megan, as Kate mentioned, before we hit record, we talked a little bit about the audience for this specific episode. And like, in my mind, when I think about palliative care, I'm thinking about geriatric clients, but it turns out I'm not super correct in that thought. Um, so could you start us off just by telling us a little bit about how, if you're an SLP and you're listening and you think this topic doesn't apply to you, In fact, it probably does. Meghan Holmes: Yeah, I think, you know, palliative care is just an extra layer of [00:05:00] support that can be, you know, given to a patient at any stage of a serious illness. But realistically, it's just those are your big picture doctors. And so they provide what the healthcare system and what, uh, the overall school system, I think, claims to provide, which is person centered or client centered or student centered care. And so if you are an SLP and you work with people and patients and clients, like those tools that we're going to talk about, I think are going to be helpful for you.  Kate Grandbois: And to sort of start us off with defining palliative care, you've just given us a generally a loose description of what it is. It is different than hospice care, or it is not different than hospice care. I feel like I've experienced some confusion around that delineation just in my personal life. Can you explain a little bit about the difference between those two  Meghan Holmes: things? Yeah, so palliative care is not necessarily end of life care in the way that hospice is [00:06:00] hospice in order to qualify for hospice. You know, you need to have a terminal illness with less than six months of life expectancy. Whereas palliative care is focusing on symptom management and quality of life. And so that can be initiated at diagnosis. Um, and so I think that the current model And, you know, the United States healthcare system is exactly the way that you currently understand it where palliative is like this bridge to hospice, but that's not necessarily true. Amy Wonkka: So, does the role of SLP. The role of SLP who are working to support palliative care is that does that look different depending on the setting that you're in like we I know we've talked about nursing homes we've talked about schools. Um, I know your experience is primarily with geriatric clients, but, uh, do you, can you give us sort of a view of how that might look depending upon the setting that you're in? Yeah,  Meghan Holmes: I think that, um, [00:07:00] specifically with adults, you are going to be working with patients who are at very different stages of their illness. Um, like my job is working in the acute care hospital. And so oftentimes that I see them when they've had an exacerbation of their serious illness, they've had some sort of setback. And so that's kind of. a prime opportunity for them to step back and be like, Oh man, like this is going to keep happening. What do I want next time to look like? Um, if you're working in a skilled nursing facility or home health, I think that you are seeing more of the day to day, like more stable and controlled symptoms of like, Hey, are you happy with how this is going? Um, I know. You know, 60 percent of adults have some sort of chronic illness and what blew my mind when I learned that fact was, you know, when I am reading a history of a patient, I'm like blowing past all of these [00:08:00] illnesses that are listed on my go. congestive heart failure, diabetes, hypertension, hyperlipidemia, not super related to dysphagia all the time. And so I'm like skimming it. I'm like, Oh my gosh, this person has four chronic illnesses that they have to manage every single day. And, you know, I think that remembering that we are treating an entire person and not just, Hey, I actually only care about the part of you that is relevant to me is really important. And just  Kate Grandbois: going back to what we said at the beginning, having now a better understanding of what palliative care is, this could absolutely be part of what an SLP in a school needs to be aware of, or in a pediatric setting outside of what you've listed, you know, still nursing facilities, acute care, all of those kinds of things. Because if you're really trying to support a family or a child or a person with a chronic illness, People live with chronic illnesses and in many places in many, [00:09:00] they experience treatment in many settings. Is that a fair assumption? Oh,  Meghan Holmes: absolutely. Yeah, I think, you know, remembering that everybody that you're interacting with is dealing with more than you can wrap your head around makes you a better clinician. And so, you know, having the ability and the tools to remind them that they do have more control than they think and kind of empower them to say hey what's been given to you so far is a recommendation based on this goal. Is this your goal also? And making sure that you're You know, advocating that their care gets adjusted appropriately in that way. So you've  Kate Grandbois: mentioned, you've already started mentioning, or you've touched on some of the things that an SLP might need to do in terms of skillset to support someone with a chronic illness. I'm assuming that counseling is also a piece of this. Can you tell us a little bit more about the knowledge and skills needed for an SLP [00:10:00] or even an SLP who might be listening and thinking, I work in an elementary school, but I'm already thinking of my My little client who's in kindergarten and kindergarten, who's living with a chronic illness. What kinds of knowledge and skills do we need when we're, when we can identify that we're working with someone with a chronic  Meghan Holmes: illness? Um, I think the quickest and easiest answers are of course, you know, compassion and patience and knowing that. Anger is never anger, right? Anger is often like fear or sadness or a lot of things and being able to take a step back and remember that, like, in this conversation, I am the face of a problem. I am not the problem, but I am like the person that this family or client or child is interacting with who, like, if they're mad at this situation, like. I'm here for that. And trying not to take that [00:11:00] personally, remembering to breathe, and I think using some sort of structured interview strategies has really helped me pull myself out of it, because I think You know, while empathy is important, leading a difficult professional conversation with empathy is too emotionally draining to be sustainable. And so the kind of framework that I fall back on a lot is the, from the Ariadne labs, the serious illness conversation guide. Um, and I can email that to you guys so that your listeners are able to have, um, a copy of it, but it's available online. Um, And it basically is intended to be not a script, but just a framework like training wheels of, Oh my gosh, we have this super tough thing to talk about. Where do I even begin, and how can I possibly as an SLP as you know, not the doctor as not the [00:12:00] whoever, what am I supposed to do about this, but you know, we still have a lot of value as clinicians. Because. We especially in the adult setting are working with communication and thinking and eating. And those are really, really important in terms of quality of life. Um, and so I do think that it's important that we insert ourselves into those conversations because Probably nobody else is going to  Kate Grandbois: You mentioned an interview or using a structured interview. Is there a format for a structured interview? That's specific to supporting someone. In palliative care, or are you referencing just using structured interviews in general to make sure you're providing person centered care? What does that interview process look like?  Meghan Holmes: Um, I think. What I'm referencing is using, um, that particular framework that breaks a [00:13:00] conversation kind of into steps. Um, and, you know, the first step is just to kind of announce like, Hey, I want to talk about this today. Is that okay? Like, um, And, you know, for somebody who, let's say they have Parkinson's disease and their Parkinson's has really started to advance to the point that they're having trouble swallowing. I'm like, Hey, you know, I want to talk about how your disease has impacted your swallowing. Are you up for it? Is that okay? You know, you can pick language that feels natural to you. Again, this format is not intended to be a script, but you know, and then you check in with the family or the patient or the client and you're saying like, tell me what you understand about where we're at with your swallowing and why we're talking about your swallowing and what we're worried about so that you can kind of hear what they have retained, what over the course of what you have hopefully already educated them about at least a few times, [00:14:00] so that, you know, if you are just monologuing at them and telling them something that they already know, they don't have any buy in into that conversation and they think that you're not going to listen to them. And so opening the conversation by saying, tell me what you know, tell me what you think, that can be really important and really helpful and really valuable and people are going to really appreciate it. Um, and so I think I'm just trying to open the guide right now so that I can make sure I'm not skipping any steps or anything. Um, but I think that, you know, people freeze in these tough people being SLPs and clinicians freeze in these really tough conversations because they feel like they don't know what to say. Um, and they don't want to say the wrong thing. You know, it's coming from a. Kind place and so, you know, if you have tools to be able to navigate it, then that helps a great deal.[00:15:00]  Kate Grandbois: In thinking about working with someone and supporting someone who has chronic illness and understanding that there might be caregivers involved, or as you mentioned, grief or anger, um, moving through those conversations with sensitivity is so important. And. I love the idea of a framework. We love a good framework here on the nerdcast. We talk about them all the time. Um, but knowing that there are frameworks or structured components out there to help with that is incredibly helpful. So we will make sure to link that reference in the show notes for anyone who is listening.  Meghan Holmes: Perfect. Yeah, I totally agree. And I think it, I have gotten better at it, but I still stumble, right? Like these are really, really hard topics. Um, and you know, you mentioned grief and one of the topics that comes up a lot in the acute care setting is anticipatory grief, which is either, you know, the [00:16:00] loved ones grieving before somebody is gone, or even just like, if you have a progressive illness, you're kind of. Preemptively grieving the loss of functions that you know is coming. Um, and, you know, trying to navigate grief in an SLP role and not like a social worker role or, you know, we have some amount of counseling training like that's heavy and I do think it's important that we, you know, have. Tools to help us. We have frameworks to guide us and we know when to back off and when it's not our place anymore. You know when it's going to potentially cause more harm, either to us or to the family because we're out of our depth. So, I do definitely want to make sure people are. careful and checking in with themselves, make sure that they're not going to overstep and cause themselves any harm. [00:17:00] Um, cause burnout is very real and compassion fatigue is very real. And, um, if it can be avoided, it should be.  Amy Wonkka: I, I a thousand percent agree. And I think, you know, we've had some other folks on the podcast in the past talking just about. How really, really important that is that self care and that self awareness and those strategies for ourselves to be able to check in with ourselves and monitor ourselves, and make sure we're taking care of ourselves so that we can effectively do our job for our clients. So that's, that's a very important point that I think we can't emphasize enough. I guess I also had a question. Connected to what you were saying in terms of like, we're not social workers, and we're not, you know, these other types of providers, how do you collaborate in your role, at least with other health care professionals, like physicians or nurses or social workers or counselors? Do you collaborate? Is there room for that kind of in providing wraparound [00:18:00] service? And what What might that look  Meghan Holmes: like? So I am definitely very spoiled to be in the acute care setting because palliative there's a palliative team, right? Like there are dedicated providers and social workers who like this is their whole jam. And so, um, they are a consult service that the primary medical team can engage. And so, like in some of these, yeah. You know, big family meeting type situations, they are guiding it and so I get to sit there and like, wait to be called on to say my piece instead of leading, you know, hospice is covered by most insurances and palliative care is not. And so I do think that, you know. SLPs who are not in the acute care setting or not working in an outpatient clinic that has access to a palliative team are a lot more on their own with this kind of thing. And so they need to be [00:19:00] collaborating with the primary medical team and the social workers to be like, hey, this patient told me this. And this is how our conversation went. Do you want to come with me next time this comes up? Or, um, do you feel comfortable calling this patient's family about this thing? Like, should I do it? And kind of figuring out who's taking lead on this, um, because I think what I realized, you know, the acute care setting that I work in is also a teaching hospital. So I'm working with a lot of interns and residents who are like, yeah, yeah, you do it. Like, I don't know. And, and I appreciate that because I, you know, they want to learn and they want to be able to offer this service and. They feel out of their depth. And so they're turning to me. And so I would encourage your listeners to also when they feel out of their depth, think about who on that interdisciplinary team they can turn to, to take lead and what they could offer. Kate Grandbois: And that also sort of makes me think about the role of the [00:20:00] SLP, because I have to presume if you're Lucky enough to be able to work as part of a team and have other disciplines at your disposal, you're bringing a wealth of knowledge related to, as you mentioned, communication, swallowing that the other professionals may not have. How do you tailor some of these skills to? Individuals with different skill level. I'm just sort of bringing this back to this concept of person centered care and interviews. So for example, if you're working with someone who's in cognitive decline, but has palliative, but is in palliative care, how do you approach and adapt your person centered care interviews or your communication style? How does that change how you approach a case?  Meghan Holmes: I think you're bringing in. More stakeholders, I think, to somebody who has experienced [00:21:00] cognitive decline, um, you know, one line that I think it's very important for SLPs to draw is, you know, I have often been asked, Hey, can you do a cognitive evaluation on this person to figure out if they have capacity to make medical decisions? No, I absolutely can tell you information about this person's attention, memory, all of these types of SLP related things. But capacity, the ability to, you know, Make a decision like that has to be determined by a physician. And so I think that if everybody on this interdisciplinary team is like, Hey, you know, Mr Smith here might not be able to make his own decision. You know, you're having these conversations, maybe still including Mr Smith. but probably focusing more on the health care proxy and the health care agent, the person who is going to ultimately make that call. Um, I'm thinking of specifically [00:22:00] patients with dementia. Um, you know, the overall goal of palliative care is to improve the quality of life and I think that there are definitely stages of dementia where being a part of those conversations is more distressing than it is helpful because they are confused and so they're hearing for the first time it feels like I'm dying. What? And so that is not going to be, first of all, productive or kind like you are causing undue stress. to your patient, your client, the person that you are allegedly caring for by involving them in something that they don't have the capacity to do. So you're shifting this kind of framework to be targeted more at family members and or you hope family members, but healthcare proxies in general. Um, And I think that, you know, that adds almost a new [00:23:00] layer because every family has very different dynamics, and it's, you have to come into those conversations without judgment. Especially me in the acute care setting, I'm often meeting somebody for the first time and interacting primarily with like their spouse or their child or somebody who has known them for longer than I could ever imagine. And so I say, listen, like my expertise is in swallowing, but your expertise is in your mom. And so we have to kind of work together so that we can make a plan. Um, and you know, Reminding them that we're on the same side here and we absolutely have the same goal, making sure that they feel heard.  Kate Grandbois: That brings me to a question about how you communicate and support the family. So if you are dealing primarily with, uh, a spouse, a partner, a caregiver, a care partner, I recently [00:24:00] learned that that's a preferred term care partner or their, or their children, their adult children, how are you? Counseling them in terms of how to support them in palliative care, because I have to assume in your setting or in any setting, you know, we're allotted one visit a day. I don't know what your service delivery models look like in acute care because I've never worked in acute care, but thinking of any speech pathologist, we're not with these families all day. How are you providing education to the care partners in these, in these instances?  Meghan Holmes: It's certainly easiest when they are visiting the patient and they are in house and I can just be like, hey, I'm the SLP. However, that's certainly not always the case. And so I spend a good amount of time on the phone in these types of conversations specifically, especially when The medical team has asked me to because in the acute care setting, you [00:25:00] know, the point family or the primary care partner is usually updated at least once a day. And so, you know, whether that be a nurse or a doctor like. That person is expecting a phone call from the hospital. And so if I'm like, Hey, when you talk to this care partner, do you want to bring this up? Or do you want me to make a separate call? And then, um, that's kind of what the plan ends up being. I think that the bigger meetings where like a palliative provider is present or, and a social worker and a case manager and the primary team and me and anybody else, those are usually. Scheduled separately. And so, you know, that is all right. I know that on Friday at 10. I'm going to be in this meeting. Um, and Having that conversation Amy Wonkka: about assessment, can you help us at least within the like acute care environment? [00:26:00] Like how, how does your assessment change with the incorporation of a palliative care component or how might it change over time with the same client? Um, what might that look like?  Meghan Holmes: Sure. So my, you know, primary focus in the acute setting is swallowing. It's dysphagia. And so, you know, I think that because I'm so passionate about palliative care, I've started to incorporate this in pretty much every assessment. So they don't look super different, but they do look different than past Megan's assessments. So I can talk to that. So I think that There is a lot heavier focus on education where you're saying, Hey, like, you know, we're worried about swallowing because we're worried about potentially pneumonia when you're in the hospital already. Or if your immune system is battling other things, you might not be very good at fighting off a pneumonia. Um, and I have found that it's [00:27:00] important to say the word fatal and like. You have to make clear, like, hey, when you are making decisions for yourself and your own body and your own life, like, I do need you to understand that potentially you are making a life limiting decision. Um, so I do think that saying like, hey, I have concerns about the safety of your swallowing. I have concerns about your ability to meet your nutritional needs. Um, and so. I had heard I'm not going to be able to remember who I heard this from, but I heard a quote that was basically if you don't provide choices, then you can't get consent. It's just coercion. And so I loved that, especially in the dysphagia world. And so I'm like, Hey, I Based on this goal of making you live as long as possible, recommend that you don't eat or drink anything and get a feeding tube. However, your other option would be [00:28:00] to eat and drink, even though we're acknowledging that you're probably going to aspirate sometimes, even though we're acknowledging that that aspiration could lead to pneumonia, which could ultimately lead to your death. And like, being delicate, but clear about the way you're presenting that. I love that  Amy Wonkka: quote, by the way. I'm sorry. I just jumped in front of Kate. I see you unmuting, but that, that is such a great point, right? We're not, we're not providing options if we're not providing all the options. And I think also. I, I'm going to ask you to circle back on the, on the, on the difficult conversation matrix and tell it or framework and tell us a little bit more about that. But I think something like that must be very helpful in having those types of conversations where you do use words like fatal and we don't kind of dance around the topic. And I'm thinking, you know, I'm, I'm not in a position where I'm having those conversations. I don't work in dysphagia. Um, [00:29:00] However, I think a lot of these ideas are broadly applicable to all of this. We talk in euphemisms all the time, you know, I mean, even in special education, you know, we being able to come out and be transparent and provide actual options, like actual choices and be clear about what we're really talking about. Has got to be only beneficial, but also stressful to begin having those conversations in that transparent manner. Kate Grandbois: I want to piggyback on that. I want to piggyback on that quickly because I, you've just made me think of something else in, in terms of that transparency. I think one thing I have experienced a lot in my career and that I have seen a lot is. Our hesitancy to provide clear prognosis. And I think, you know, because it's because it's bad news, you know, no one what, in your example, we don't want to hear that, [00:30:00] you know, you can aspirate and die in pediatrics, outside of something medically. You know, medically threatening or life threatening, we might say, you know, you're the likelihood of you developing oral speech is low based on X, Y, and Z. I feel that as clinicians. And maybe this is my professional culture. You guys could correct, you could, you could disagree with me completely, but just the, the willingness to be clear and provide information about a less than favorable prognosis, something that I am realizing right now that I have avoided my entire career. I mean, it's, and I have watched other people avoid it  Meghan Holmes: too. Yeah, I think that the best again I will come back to the framework I promise, but the best tool, or the best little clip it that I got from there is the phrase, I wish I worry, or I hope I worry. And so it's like, I hope. that you [00:31:00] do develop oral language someday. However, I'm worried that you won't because of XYZ. And so you are joining them in some of the grief of like, this is a bummer. Like, I know that this is what you wanted and I wish that I could tell you that it was possible, but I think we need to manage expectations so that we can set goals together. And so, you know, from a serious illness perspective, you're like, I hope that when this infection clears, then your swallowing improves. But I'm worried that because the swallowing difficulty is because of a progressive disease, that this might be as good as your swallowing ever is. And so, you know, using that, I hope, I wish it's like, yes, I, I hear you. That you want that, and I want that for you too. And I'm so sorry. But making sure that they understand kind of what the situation is so that they also know where you're coming from when you're potentially bringing up, like do you wanna consider. Non curative types of [00:32:00] treatment now. Um, like that's really hard to hear if you're not in a spot where you are ready to be like, Yeah, this progression that I have been afraid of is here. And now I have to like make some choices. I think that the SLP is who are focusing on dysphagia with a lot of these. you know, chronic, progressive, especially neurodegenerative diseases, swallowing is kind of like the crossroads where if that starts to become a problem, oftentimes that is the stage of disease that patients are ready to be thinking about hospice, where they're like, Oh, hold on, this is close to the end. But I think it's extra hard when, if that's one of the first functions to be impacted. And it's like, hold on, like, if you didn't, um, like I think they, they're less prepared for that type of conversation when diagnosis is really new or something like [00:33:00] that. I think that the clients and families that have An easier time with these types of conversations and are more ready to hear it. Or it's like, yep, like they were diagnosed with dementia 20 years ago and we've been told to expect this day and I hate that it's here. And it doesn't make it better or less hurtful that they were ready, but does start the conversation more easily. All right, so I can talk a little bit, uh, have it up now, the Ariadne framework now, if you want me to go right into that. Yeah, I would love you to. Okay.  Amy Wonkka: Just because I feel like it's, it's going to be very broadly applicable. This is my, like, projected,  Meghan Holmes: projected view, but we'll see. Okay, perfect. So again, this is from the Ariadne labs. They focused on, you know, they tested all of this language with patients to make sure that it was clear and like agreeable to patients. They were coming at this specifically from serious [00:34:00] illnesses, but Amy, spoiler, you're right. It's applicable to a lot of people. So the first step is set up the conversation. That was kind of what I had started talking about, where you're introducing the purpose and asking permission. It's like, hey, I'd like to talk about what is ahead with your illness, do some thinking in advance about what's important to you so that I can make sure we provide you with the care you want. Is this okay? And they have the is this okay, bolded because everything leading up to that point is not supernatural. Like I am consider myself to be fairly well versed in these types of conversations, and I would never talk like that. And so, you know, you do want to take the step and take the principle and put it in your own words. Because you're a human having a conversation with another human and you want to make sure that other human knows that that is happening. And so once you have set up the conversation, you know, everybody who's present is aware of what is about to be discussed. That's when you're [00:35:00] assessing understanding and preferences. You know, what is your understanding of where you are with your illness? Tell me what you know about why we're here today. Tell me what you know about, you know, the concerns that we have so far. Um. And then the other factor that they recommend is how much information do you want to be given today? Like, you're kind of checking in and saying, what, what kind of headspace are you in? Are we having like big talks or do you want to just kind of gloss over this? And both are okay. I think when I've. I learned a lot about this particular topic, palliative care in general through, uh, actually a nursing education program through my hospital that's interdisciplinary. And so the palliative doctor who was giving this presentation, she was like, just because the conversation didn't go the way that you wanted doesn't mean it wasn't productive. This is supposed to happen over the course of many, many [00:36:00] conversations, you will have this exact framework, many times, you know. Especially in the hospital. Maybe this is the first exacerbation of their illness and you're like, wait, hold on. Like, I'm not ready at all to be talking about the end when we just got here. And like, that's okay. But maybe next time they're hospitalized hopefully years from now they're like, Oh, I remember like we did start to talk about this and over time, you know, they have it kind of. That seed planted in their brain of like you get to pick like you don't have any control really over your illness in the course that this takes but you do have control over where your life goes in this point and so reminding them continuously like this is about you we're here for you you get to choose um is very very important very powerful um and the third step is sharing prognosis and so when you're in The hospital.[00:37:00]  Again, I'm a spoiled brat because I get to sit back and say, I'm going to defer to the medical team to let you know about the overall medical picture, because I do also firmly believe that that is not my role. I am not a neurologist, I am not, you know, a pulmonologist, I don't know enough about the disease to be able to give a life expectancy. And so like, you know, I don't think that SLPs should feel pressured to make that kind of claim because that's not within our scope at all. And so what we can do is share prognosis about something that we can diagnose. And so we can diagnose dysphagia. And so I'm like, you know, I can say, I wish I worry. I hope that I'm worried. And You know, one family meeting that I had somewhat recently was, um, I had a patient who had Parkinson's that was [00:38:00] fairly advanced, and he fell and he hit his head and so the like acute issue was that he had. A subdural hematoma because he fell and hit his head. And so the ICU team was very much like, well, like once this gets better, then he'll be back to his baseline, but that's not really how chronic illnesses work. And I suspect that they know that also, but it's like, you don't go back to your, the baseline you were at where I have a new baseline. And so in talking to this patient's family, I learned, oh yeah, he's been, you know, He's been hacking his brains out for meals for like weeks and weeks and I was like, it's interesting. Okay. And then they're like, yeah, he, I think he's had pneumonia. What is it? Is it six times in the past couple of years? And I'm like, okay. Okay. So like maybe this isn't a subdural hematoma issue. Maybe this is a Parkinson's issue. And so the, I hope I worry that I got to use was like, I hope that as he gets some strength back after this injury, you know, [00:39:00] He does feel strong enough to eat again, but I'm worried that these exact examples that you told me, you know, the coughing during intake, he's already had pneumonia a bunch. We know that Parkinson's impacts is swallowing. I'm worried that all of the things. That preempted this fall are working against him. Um, and it did kind of shift the conversation a little bit to be like, Oh, okay. So like, yes, this is one isolated incident. Anybody can fall and hit their head. But the person who fell and hit their head is somebody with an advanced chronic disease. And so that's kind of what we need to be talking about. Um, so I do think that a sharing prognosis ends up being Yeah. The scariest part. Um, and my advice for the students that I take in the hospital is silence is your friend. Like you need to let the people that you're talking to process what you've just said. Um, I [00:40:00] still actually from this palliative care course. The nursing education course at the hospital, I stole an activity and used it when I was teaching this Asia, where it's like partner up, and one partner has to say, talk about something that's important to them for five minutes, and the other partner can't say anything. And it's a really cool exercise because you realize how often you want to jump in and be like, I. Oh, I agree with that, or, oh, I have a thought, or, oh, I, because you're like seeking connection, and especially as SLPs, I feel like we're a chatty bunch, and so to realize how much more information comes out if you're silent was really powerful. You're like, oh, the people who are sharing were like, I probably said more than I would have to this classmate if I, you know, had the opportunity to stop talking or re evaluate, and, you know, it, As I'm saying this out loud, I'm like, sounds a little manipulative, but I promise it's for the greater good. And so, [00:41:00] um, I think the fear of not knowing what to say can be squashed. If you are okay with silence or you're like, give yourself a minute too. Right. You know, you don't have to have the perfect thing to say, because oftentimes it's better not to say anything at all. And I  Amy Wonkka: think it's a way that so many of us kind of deal with our. anxiety and uncomfortable feelings around having difficult conversations with clients. Um, I think back to particularly when I was earlier on in my career. Um, I sort of just tried to fill the space because I was feeling uncomfortable and I could see that my client or their primary care person partner was feeling uncomfortable. And so rather than. be present with that uncomfortableness together. I was like, ah,  Meghan Holmes: I'm just going to get through this.  Amy Wonkka: Um, I wonder if, if you, I mean, you just gave us a really great [00:42:00] example, but I wonder if you had any additional reflections just on how your practice has changed and how your interactions with your clients have changed in terms of your dysphagia service provision from when you first started out to now that you're sort of incorporating this palliative care approach for all of your clients? Meghan Holmes: Yeah, I think, um, it definitely has reframed how I think about alternative nutrition. Um, you know, I wholeheartedly stand by the no advanced dementia, the ethic statement that came out can put it better than I ever did. And I think that that is so important, but to kind of look at each patient case individually and be like, will their life be improved by this feeding [00:43:00] tube? In a lot of cases, yes, like, yeah, we do anticipate that your swallowing is going to take a long time or the improvement of your swallowing is going to take a long time. And so we want you to be out of the hospital and getting the calories that you need so that you can rehab so that you can eat safely, or, you know, you need to have this kind of backup plan because eating is so difficult for you and you might not be able to sustain yourself. Um, but. I think having this I approach every single recommendation I make as choices makes me think, Okay, what, where do I see this patient in six months, and, you know, I think every person has a different reaction to the overall medical world, and you know there are some [00:44:00] people who are going to take your opinion as fact. So I think you need to know what your opinion is when you're walking in and making that recommendation so that you can make sure that you do not share it. I think that the The question that I get all the time in these family meetings is like, if this was your mom, what would you do? Like, if this was your spouse, what would you do? And my response without fail is the only reason I know that answer is because I know what my mom would want. You know, we're asking you because you know what your mom would want. And so just kind of like, I hear you, flip it back. And so, I don't know, it's people are tough and I think, you know, you want. to be somebody who can support them. And I think that being the person who delivers tough news doesn't feel very supportive. Um, but you SLPs do have [00:45:00] knowledge that medical professionals that they have interacted with so far don't have. Um, and I think that we, in some cases, Also have more time than some other medical professionals to that we can spend with these patients and their families to have, you know, lengthy conversations. Um, the area me labs who've made this framework. Um, they also really specify that This type of conversation is its own billing code for physicians, and so it's like, nope, this is still worth your time physicians, because, you know, you can bill for these hours, having this specific type of conversation, because I think it's a tougher sell for somebody who feels very. you know, stressed and like they're in a time crunch to really sit down and have this conversation. So they have a big reminder, like physicians, you can, you [00:46:00] should. And, um, I thought that was very cool and very helpful. Um,  Kate Grandbois: Ashley, if you're listening, if you could please do some advocacy work to get us some reimbursable indirect service codes, that would be great. Thanks so much. Anyway, as you were  Meghan Holmes: saying, Meg. Oh, I wholeheartedly agree. Uh, I know. I. I'm very conscious as I'm speaking that I am spoiled in the acute care world. Like I am not as bound by insurance limitations as some other settings absolutely are. Um, and I think, you know, a quick tangent that's important about that is if you're in home health and if you're in skilled nursing facilities, if you're, you know, you are so conscious of my goals have to be achievable, they can't be for maintenance. And so you. have to kind of get creative with your goal setting when your patient has goals that are not necessarily curative or rehabilitative [00:47:00] or life prolonging because We are still providing skilled services that are defensible, but you have to make sure that you are protecting yourself. Um, one of the best ways that I would recommend doing that is to use patient reported outcome measures. You know, there are some for dysphagia, there's some for aphasia. Um, the ones that I turn to. Most often in the hospital setting is going to be the eat 10 and the MD Anderson dysphagia inventory. And so if you have a goal documented that you want the patient reported outcome scores to improve, then That helps you provide the quantifiable data that the insurance would need in order to justify the education and the strategy training and, you know, the time spent checking in with your patient, um, and using those to bill. [00:48:00] Um, I know that it shouldn't be like that, but it is. And so, you know, you have to get creative sometimes to provide the person centered care that we are. Billing for  so the fourth section of the framework is explore key topics. Um, and so that's kind of their overall goals, their fears and worries, their sources of strength. Um, and I think that I have seen this done more often by the palliative team, but I think that, you know, some ways that we can incorporate this into a more natural conversation is you're like, what are your biggest worries about what the future holds? And, you know, if your situation were to worsen, what is, what do we need to focus on the most? Um, I think incorporating how much does your family know how much do you want your family to know, um, who can we talk to about this if you're not up for it kind of making sure [00:49:00] that you are checking in and getting permission and remembering who you're focused on. The heartstrings to hear is like if you become sicker, how much are you willing to go through for the possibility of gaining more time. And so you're asking the person to examine, these are the treatments that are being offered to you. These are the benefits, but it's going to come with a burden as well. And like, where are you kind of in that benefit versus burden spectrum? And I think that that particular question is also where I, as the SLP, maybe just Megan as the human, tend to insert my own opinion the most often and so that's where I have to be the most careful about judgment. Because, you know, I can think of patients who are so confused, they are not their own [00:50:00] decision maker. And you know they're in the hospital and you can hear them down the hallway screaming, screaming, let me die, let me die, let me die, and then the You know, healthcare proxy is doing and full court press on whatever illness they're battling. And that feels gross as a human, but I think that what's important to remember is that this healthcare proxy was tasked with making the decisions that. This person who's yelling would have made in their right mind. So maybe she would have gone through absolutely anything for more time with this family member. And like, maybe, um, what I see is just the surface level of the worst day of both of their lives. And I need to pull my own judgment back and just be like, I have to present options. I have to provide support. I do not have to make decisions. And that is so freeing. And so if you can take the step [00:51:00] back to just be like, that's what's happening. And because this decision maker has told me what the goal is, that's what my goal is to, um, you know, It is, it can feel gross. And I think that the moral distress that can come from that where you feel like you're being asked to provide a service that you don't agree with can be very difficult, but reframing it in your mind to be this is still person centered care. This is what the voice of the person that I'm caring for has said that they want. Um, of course there are ethical dilemmas at play that we do not necessarily have to get involved with. Um, and those, thankfully, are rare. So I think that remove yourself from a position of decision making as often as you can and just [00:52:00] The, you know, right alongside them. Um, the very last of section is just to close the conversation. So summarizing it, making a recommendation, um, you know, affirming that you're there for them. So saying like, oh, I've heard you say that X, Y, Z is very important to you. So keeping that in mind, the plan that I think we've agreed on is this. Is that correct? Um, you know, how does this plan seem to you? And then, you know, promising what you can promise, which is I will do everything I can to help you through this. Um, I think the behind the scenes self care is like everything you can stops earlier than you think it does. And so it is very tempting to overextend because of shortcomings In institutions and you know systems that we are chosen to work in, [00:53:00] but you can't continue to be a provider if you overextend all the time. If you burn out you're good for nobody. Right. So, you know, I will do everything I can to help you through this is I will do everything within my power. That I can safely do to help you through this.  Kate Grandbois: That brings me to a question. I wanted to ask you about our third learning objective and, uh, the different tools that you use in your setting. But since you've brought up our own, the intersection of our own compassion and empathy and, you know, acknowledging that we're not a limitless amount of emotion, that burnout is real. How do you take care of your own emotional wellbeing in this role?  Meghan Holmes: I like therapy for everybody. I don't know if I can say that, but everybody should go to course. Yes, it's definitely important. Um, and I do think that. Having these kind [00:54:00] of training wheels of like a framework like this of a conversation like this, um, has made a world of a difference for me in a prior job, I was working, and I didn't have a lot of physician or administrative support. And the compassion fatigue became very overwhelming to the point that I. Had to leave that job with no backup plan and was like briefly unemployed because I was just like, I am X number of years into my career and it hasn't been that long I told you all I graduated in 2016. So I'm like, I can't believe that I already feel like this, how can I, you know, continue to work. And so finding a new setting, you know, asking in interviews. You know what types of supports are available to employees and like, what kind of experience do you guys have with these types of tough conversations and who takes lead on this type of thing. I think, can give you a lot [00:55:00] of information about whether or not that spot is going to be a good place for you. And I. I hope that there are SLPs out there who are ready and prepared to be the ones to take lead on this right out the gate, but I certainly wasn't. And so this is something that has come over time. So I think, unfortunately, being kind to yourself and giving yourself the grace to bumble through a lot of these really tough conversations is also what can help. Um, and. Yeah, I think it's mostly been a lot of boundary setting and like one other piece of advice that I got from the palliative team at our hospital. They actually they published an article about this and I think the Journal of Social Work for palliative care. They had a buddy system [00:56:00] throughout the pandemic, where they would, you know, have kind of check ins with. Hey, how are you doing? How are you, how are you taking care of yourself? And so just that kind of accountability buddy of, uh, I'm going to have to have something to say in this stupid weekly meeting, like of how I'm taking care of myself. Um, and they also, they opened every one of those meetings, um, with a moment of silence for the people who have lost that they lost. And so I think that that really helped me too. And that's something that I have done myself where you're like, Death is inevitable, but it's awful still. And so, you know, to understand that, you know, like, I hate that we're here, and I hate that I was, um, you know, that I do have to feel this, but like what a treat it was to like feel like I was able to. make the end of this person's life as comfortable [00:57:00] and pleasant as possible. Um, I think this job stops being fun if you to become jaded or, you know, disillusioned by how serious this is. And so, you know, you need to make sure that you're able to show up as your best self every day. So, I don't know if that was anything concrete, but that's what I do. I think  Amy Wonkka: it's very helpful. I mean, I think all of those. All of those tips and like strategies are important, um, therapy for everyone. Totally. But yeah, I mean, I, I think it's, it even just hearing you talk about it, it's, it's such a heavy. It's so heavy. It can be so heavy that I think having an active plan and being thoughtful about taking care of yourself sounds like it's almost required. Um, and I also think you [00:58:00] made a great point about work environment. I, I get on my soapbox of like part of the only way we're going to make our work environments better is by pushing for them to be better. And that includes choosing. To work in places that are more supportive, right? Work in the more supportive place. Be kind to yourself and like vote with your job, right? Um, in, I know we don't have a ton of time left, but I know we talked a lot about the framework tool in terms of, you know, a tool that you're using a lot in your work. I just wondered, are there any other formal or informal tools that you're using that you want to kind of give a shout out  Meghan Holmes: to? Or, yeah, I think, um, I used some of the, um, honeycomb therapy, motivational interview cheat sheet, I thought was really helpful, um, just to, again, help you realize that this conversation [00:59:00] that is probably going to take a long time, right? And this is at least, we'll say 10 to 30 minutes. And you're like, Okay. I have no idea what I'm even going to say. Okay, let me break this into how can I establish what this conversation is about. Um, how can I, um, make sure that this patient feels heard? I think one of the, one of the most helpful pieces of advice that I got from that Those principles was to reassure whoever you're talking to that, you know, they're doing their best. And it's like, it's clear that you've been working really hard to follow our recommendations. Um, I've said it to family members and like, it is clear that you have been taking excellent care of him. Because I think that a lot of the hesitation for, you know, palliative treatments, treatments focused on quality of life requires people to feel like [01:00:00] They are giving up on their loved one, or we, you know, we still have more to try. And you're like, yes, you absolutely have more to try and we still can. And also add this thing that focuses on their quality of life. This is not an either or this is an addition. Um, and so yeah, the honeycomb speech therapy, motivational interviewing. Um, I listened to, I don't. I have some counseling, um, CEUs, um, that are on another platform. I don't know if I can say that name or not, but yeah, okay. The of course you can, I'm like MedBridge has a bunch of, um, counseling courses that are very helpful. I think, um, it's funny, not with those specifically, but I think that in a lot of counseling CEUs, you start to. Or at least I kind of started to tune out too quickly because you're like, yeah, yeah, yeah, I know. And then you get into this [01:01:00] conversation. You're like, I did not know. And so you're like, listen to the whole thing. Make sure that you are practicing kind of in your head sometimes, um, that Ariadne labs framework. I also use with. You know, interdisciplinary team members and providers because I think that there is a lot of hesitancy to incorporate palliative care when the goal is life sustaining and curative treatments because, you know, the medical teams don't want to feel like, um, or the medical teams don't want to anything to interfere with the ultimate goal of that patient getting healthier. You know, kind of regardless of the cost and the lack of acknowledgement of the limitations of medicine or that there are some horrifying side effects to some of these medications that might not be worthwhile. So saying the I wish I were a [01:02:00] statement, even to Doctors has been really helpful for me where I'm like, Oh, yeah, you know, I hope they leave this hospital and we never see them again, but I'm worried that they're not going to follow this recommendation when they leave because it's so unpleasant and kind of helping to have the doctors join you in that conversation. The I wish I worry is my ultimate tool. I think that that's the most important thing that I hope your listeners take away from this is you have the power to be clear and direct and kind also, and that is the best way to do it.  Kate Grandbois: Didn't know how to do that. I am personally very much looking forward to incorporating that into my practice. Thank you so much for that list of references. We will make sure that there is a link to all of these in the show notes for all of our listeners. You've spent already a whole hour with us today. Thank you so much for being here. Are there any words of wisdom that you would like to leave our audience with before we say  Meghan Holmes: goodbye?[01:03:00]  Um, I think just be kind to yourself and whatever stage you're at with these types of tough conversations, you know, they will feel easier. They won't get easier, but they'll feel easier. I promise. Thank you  Kate Grandbois: so much for all of your time. This was really  Meghan Holmes: wonderful. Thank you. I had so much fun. Outro Sponsor 2 Kate Grandbois:  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon.[01:04:00]

This is a transcript from our podcast episode published December 11th, 2022. The podcast episode is offered for .1 ASHA CEU (introductory level, related area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. [00:00:00] Kate Grandbois:  Welcome to SLP nerd cast the number one professional resource for evidence based practice in speech, language pathology. I'm Kate Grandbois  [00:00:09] Amy Wonkka:  and I'm Amy Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast.  [00:00:16] Kate Grandbois:  Each episode of this podcast is a course offered for ASHA CEUs. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course, plus the corresponding short post test, is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP ncast.com . [00:00:41] Amy Wonkka:  Before we get started, one quick disclaimer, our courses are not meant to replace clinical advice. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise specified.   [00:00:53] Kate Grandbois:  We hope you enjoy the course. [00:00:55] Announcer:  Are you an SLP related [00:01:00] professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ASHA CEUs, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited CEUs all year at any time. SLP nerd cast courses are unique, evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes. [00:01:43] Kate Grandbois:  Welcome everyone to today's episode. We're so glad to have everybody here. We're um, really excited to welcome a guest Jill Woods onto the show. Usually I am here with my counterpart. Amy. Amy is out today, so I am here by myself, but I am not alone and I am [00:02:00] not lonely. Welcome, Jill. Thank you so much for being here. [00:02:03] Jill Woods:  Oh, thanks Kate. It's great to be here. I'm super excited.  [00:02:07] Kate Grandbois:  I'm really excited. Um, this is a topic that I am really interested in learning more about not only for my own practice, uh, but I know before we hit the record button, we had a really nice conversation about how important it is for private practice owners to feel comfortable and confident in marketing services and how that can create a lot of feelings of discomfort. And as clinicians, we don't get any business training. So being able to discuss all of this openly with you is gonna be really, really exciting. And I'm wondering if, um, before we dive into the content, if you wanna tell us a little bit about you and how you came to be doing what  you're doing. [00:02:44] Jill Woods:  Sure. So I am a podiatrist qualified in the UK as a podiatrist in 1995, which feels like a very, very long time ago now. Um, but before that I worked in marketing and PR, so I learned old school [00:03:00] marketing and old school PR. So the real kind of in the trenches, theoretical principles and practices. Um, so when I graduated as a podiatrist and started my own private practice, I was looking around at my competitors going, oh, why aren't they doing that? And why are they doing that like that? And suddenly the light bulb came on and I realized, ah, that's because I've worked in marketing before and they haven't, and we don't get any of this training when we're trained to be, you know, whatever clinical profession we're training in. We get no training. So I ran my own private practice. I also taught, um, on a podiatry program for a few years. Uh, and then I ended up my life, literally flipped on its head and I married, uh, a soldier in the British army. And we suddenly started moving around all the time. And so clinically I couldn't practice anymore. And so I had to find something else that I could do. And eventually through lots of trial and error, I won't tell you the long boring story, but through trial and error, we, uh, [00:04:00] I ended up in a position where I had a light bulb moment and thought, hang on, I could teach the marketing stuff I know and understand and have since honed through a couple of digital businesses and a and hospitality business that I ran, I can now teach all of those skills to my fellow health practitioners. And so 10 in 2010, I started practice momentum and started sharing what I know about marketing with fellow healthcare practitioners.  [00:04:24] Kate Grandbois:  This is gonna be so great. So your practice is called. Practice momentum. And this is really your primary focus. You're no longer a practicing podiatrist.  [00:04:32] Jill Woods:  No, I haven't practiced in, I haven't, I haven't. I always say I haven't lifted a scalpel in anger in a very long time.  [00:04:39] Kate Grandbois:  my goodness. That's a very different from our clinical, our clinical perspective is speech pathologist. That's a very interesting phrase.  [00:04:47] Jill Woods:  so I, the last patient I treated I think was in 2005, so it was a very long time ago. [00:04:51] Kate Grandbois:  Okay. Okay. Well, I'm really excited to talk about this. Um, I, even, as I mentioned before, we hit the record button, we had [00:05:00] such a great conversation, and I'm even thinking now of all of the little, all of little comments and questions that I wanna ask you. But before we get started, I do need to read our learning objectives and financial disclosures.  Learning objective number one, describe the seven point marketing cycle and how to apply it in your practice to help create effective long term marketing strategies. Learning objective number two, identify the three primary marketing principles that underpin an effective practice marketing strategy to help identify gaps in your current marketing, and learning objective number three, identify three exercises to use in your practice to ensure you are attracting, connecting with, and delivering a service to the right patients.  Disclosures. Jill woods' financial relationships. Jill is the owner of practice momentum, which provides marketing services for healthcare professionals. Jill Woods's non-financial disclosures. Jill is a licensed podiatrist. Kate, that's me. My financial disclosure is I am the owner and founder of Grandbois therapy and consulting, LLC. And co-founder of SLP nerd cast. [00:06:00] My non-financial disclosures. I'm a member of ASHA, SIG 12 and serve on the AAC advisory group for Massachusetts advocates for children. I'm also a member of the Berkshire association for behavior analysis and therapy and the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis, special interest group. Okay. Long, long blurb over. I can't wait to hear everything that you have to teach us. Why don't you start by telling us a little bit about this seven point marketing cycle or, or what's the precursor? What is the background information we need to have about this marketing cycle?  [00:06:35] Jill Woods:  Awesome. Okay. So the thing that I see all the time when I start working with healthcare practices is that they are doing what I call marketing spaghetti. They're literally like throwing random marketing things out there just to see if something might work. It's. [00:06:51] Kate Grandbois:  For everyone who can't see my face, I'm laughing because if anybody follows us on Instagram, it's basically spaghetti. That's exactly what it is. I [00:07:00] just, and then marketing is not my strength at all. So carry on. I just had a little light bulb moment of like, oh, that's exactly what I'm doing anyway. I'm already learning new things.  [00:07:10] Jill Woods:  So I mean, the thing that I want to say right at the beginning is you have trained as a clinician, right? You are an expert in your field. You have not trained as a marketer. Like you can do master's degrees in marketing. It's an enormous subject. So don't beat yourself up that you're not good at this thing. Okay. That's point number one. But you also now have to take ownership of it and go, right. So now what I, if I am doing marketing spaghetti, what else can I do? How can I do this differently? Um, and so what I want to do just initially is paint the picture of, um, your, of marketing and what it is so that we understand, cuz a lot of people think that marketing is just promotional. So your social media feeds your website, all that kind of stuff. And it's not, it's a huge subject. So marketing is made up of what we call seven PS. All right. We've got promotion, [00:08:00] product people, pricing, processes, place, and proof. Those are the seven PS that sit within marketing's lot time in it's a lot. It's a huge subject. So anytime you're in your practice and you're working on your pricing structure, or you're working at developing your, the product that you actually deliver, the services that you deliver, that's marketing, it's not just advertising, it's not just the promotional stuff. Okay. So as we go through what we're gonna be talking about now, I want you to understand that we are not just talking about promotional marketing. We're talking about all those different seven elements that make up the whole of marketing. Does that make sense?  [00:08:35] Kate Grandbois:  It does. It also really paints the picture. I mean, I've already let the cat outta the bag that I think marketing is my Instagram feed or that's what I did think it was. Okay. So that really does give the scope of how, how wide, how big of a topic this really is. And I'm surprised to hear that product is in there too.  [00:08:56] Jill Woods: Yeah Your product. So product development. So developing that [00:09:00] service, that patient experience that you are selling, that's part of your marketing activity.  [00:09:06] Kate Grandbois:  Okay. Interesting. Okay. Okay. Okay. Okay. Yep. I'm I'm with you. I'm here. Yes. Okay. Let's do this.  [00:09:12] Jill Woods: So for all of your marketing, you've got one single objective and that one single objective is to be famous locally for the thing you do. That's it. Okay. To be famous locally for the thing you do and everything that follows that we're gonna talk about now, hopefully will all lead back to that single thing. All right. Okay. Good. So you're with me so far.  [00:09:35] Kate Grandbois:  I'm here. I'm here. Yes. I'm I'm hook, line and sinker [00:09:38] Jill Woods:  Awesome. Okay. So we've got our seven PS of marketing, so we get how big it is. And the next thing I want to really talk to you about is this seven point marketing cycle, another seven. It's not a coincidence. I don't think it's a coincidence anyway. Um, but basically all of our potential patients who are out there in some kind of pain, whether that's physical pain, emotional pain, [00:10:00] it doesn't matter. People are out there in pain and you have the solution. So you owe it to all of those people in your local area who are struggling to get better at marketing so that they can understand that you are the person they should see for the solution to their problem. Right?  [00:10:18] Kate Grandbois:  Yes. And I am, you can see that there are words in my mouth because it's making me think of what we just talked about before we hit the record button, which is how important. How important market viability is with a science. So in speech pathology, we are providing rehabilitation or rehabilitative services to people with communication disorders. They may or may not be experiencing pain, but they do have a communication disorder of some variety. And, um, we could have the best services in the world. We could have the best, we could have a life saving intervention, but if we can't sell it to them, if we can't. Tell people how to [00:11:00] access those services. We're not helping to close that gap. Um, and I know before we started talking, I, in my nerdy ways referenced an article, there is starting to be research about this through the field of implementation science. And I'm just gonna quickly plug this article for people who are interested. There is an article called market viability, a neglected concept in implementation science, and it was published in implement in, um, implement, in the journal of implementation science in 2021. And it's by Proctor et al. I'll have the reference in the show notes, but I, I, what I what's important for me, it, for our listeners to take home aside from every, all the knowledge that you're about to share with us is that, What I learned from this article is that marketing is not icky. It does not have to give you those uncomfortable feelings. It really is providing a health related service that can improve your community. And without marketing and business savvy, you're not able to do that as effectively. And that's, that's my only soapbox. [00:12:00] This entire episode is literally all I have to offer is this one research article. So I will make sure it's listed  [00:12:05] Jill Woods:  perfect, but it, but to me in your practice, marketing is one of the most ethical things you can do because it's connecting you and your services to people in pain and, and, you know, with the speech and language patients and clients, they're not necessarily in physical pain, but they're struggling with an emotional pain of some sort because of this communication difficulty or swallowing problems. So, you know, it, it, it is important, but it to understand that it's ethical, what I'm about to tell you is not snake oil. It's not glass smoke mirrors. It's, it's how marketing can help you help more people.  Kate Grandbois: I love that.  Jill Woods: Okay. So the first thing we're gonna talk about is this seven point marketing cycle. So we've got seven points. I'm gonna go through them really quickly. And then I'm gonna go back and talk to each one of them. So you kind of understand what it is. So the seven point cycle is made up of know, like, trust, try, buy, repeat, [00:13:00] refer. Okay. Those are the seven points that sit on this cycle and every single potential patient, as they convert from being a potential patient into a paying patient, they work their way around this cycle. All right. Some of them hop maybe one step, but very few hop, big chunks. Most people go at some way around this cycle. Know, number one, know, people have to know you exist. So this means are you showing up on Google maps? Are you showing up in a Google search? Are, have you got something outside your business, your practice, your physical space that says we are in here. This is the practice and we are in this space. Okay. So people get to know that you exist. That's number one, number two. Like. They need to like you as a person. And we're gonna dwell on this a little bit further down the line, but people buy from people, especially in healthcare. Alright. And so [00:14:00] you have to, through the means of your seven piece of marketing, you have to let people get to know you as a person. All right. I'm entrusting you with my health for lots of healthcare practitioners. That means you are physically gonna be in my personal space. Like I have to like you as a person to, to entrust my health to you. All right. So that's step number two.  [00:14:23] Kate Grandbois:  There's a lot of, of intimacy when you're a clinician. Yeah. In terms of, you know, letting someone feel vulnerable, we do a lot of counseling work in speech pathology, even though we don't necessarily get training in it. So I, I think that likability carries a really, a really heavy weight anyway, continue. [00:14:36] Jill Woods:  It's it's really important. It's really important. And we're gonna talk a lot about that bit further down the line. The third one is trust, and this is, can they trust you as a clinician? So the likability is you as the person. The trust is you as a clinician. All right. So we're gonna look at things we can do in our marketing that will help us. Build that trust. So have we got videos on YouTube that show [00:15:00] before and after, you know, have we got reviews and, um, patient testimonials testimonials on our website reviews on our Google business page. Have we got that stuff there that will show that we are a trustworthy clinician? Are we talking about our CPD and our continual professional development that we're doing? So people know we're keeping with the times we're up to date, we're current, there's lots and lots of things you can do with your marketing that will help build that trust. Okay. Then the fourth thing is try, and this is missing from virtually every single practice I start working with in their marketing and try is can a potential patient try your expertise before they buy from you? Okay. So this looks like things like, have you got videos on YouTube demonstrating exercises people can do at home to alleviate symptoms. Okay. Have you got downloads on your website, information leaflets that they can download that teaches them how to prevent injury or prevent a problem? [00:16:00] Okay. So have you got a blog on your website where we can, you know, month from month, you're sharing new snippets of your knowledge, your knowhow, that's gonna help people from a distance. Podcasts. Have you been on a podcast? Okay. And done an interview to help people at a distance. And that's what the try is about. No money is exchanging hands, but you are enabling them to take a little bit of your information and try it for themselves. Nine times out of 10, they won't do it. And nine and a half times out of 10, it won't have any impact. But the fact that you are freely giving builds reciprocity. So there is this sense that I've, I've, I've got something for free from this expert. So now I'm gonna invest a bit more in learning to get to know them a bit more. Okay. Does that make sense? [00:16:49] Kate Grandbois:  I love that. It makes perfect sense. And I, I have to admit that I never would've thought of that. And even though I'm sitting here on a podcast, That makes a lot of sense.  [00:16:59] Jill Woods:  so [00:17:00] let's try then number five is by, and this is the obvious bit. This is your sales process. This is the actual delivery of the service. So the arrival, if they're coming to a clinic or the zoom call, if you're doing a virtual appointment, but the buy section is making sure that your sales and your payment operations are really slick and easy to follow and that your actual delivery of the service is up to par. So you're delivering what you say you are going to deliver in your, in your promotional marketing. Okay. Then number six is repeat. Now this is obviously there's an ethical issue around this. And I always tell the story that when I very first qualified the first practice I went to work in, we routinely rebooked our patients every six weeks. And I was like, oh, I don't need to see this patient in six weeks time. No, that's what we do here. So. Oh, interesting. I like that practice  [00:17:51] Kate Grandbois:  yeah. Yeah, because services need to be provided. I mean, that's a huge comp component of our ethical code too. Yeah. Making sure that our, our services are [00:18:00] matched to the need of the patient. [00:18:01] Jill Woods:  Yeah. So the repeat element is only where ethically necessary of course. But if people are willing to repeat, that's a really good indicator that they've liked what you've done, that you've really helped them, that you've had an impact, you know, the whole experience for them has been a positive one. All right. So we need to look at repeat, and have we got any marketing activities at all, where we are enabling that to be an easy process, can, can existing patients come onto our website and book their next appointment online really simply, you know, are there things that we can do to facilitate that repeating as long as it's ethical? [00:18:37] Kate Grandbois:  Okay. Interesting. Interesting.  [00:18:40] Jill Woods:  And then the final one is refer, and this is why it's a cycle. It comes all the way around. Cuz remember the very first thing we talked about is know people have to know we exist. And the last one before we get back to know is to refer. So we're going to see if there are ways we can encourage our existing patients to refer their friends, their family, to us, for the [00:19:00] problems that they know we can fix. [00:19:02] Kate Grandbois:  I love this, this whole cycle. And I'm sorry to interrupt you, but I'm having so many thoughts about this. A lot of what we talk about on this podcast is clinical skill. And I have to, I keep having these thoughts about how this marketing cycle, if you are in private practice and looking for ways, presumably you're listening to look for ways to improve your marketing in your private practice, but thinking about the connection between that and your clinical skills. So if you don't have patients who are repeating service or who are staying in your service past when ethically and clinically appropriate, mm-hmm, you know, That's a really good indicator that maybe you do need to look at your clinical skills or you, you know, or the component of trying, creating videos, creating materials to help people from afar. What are your clinical skills? What knowledge do you have that you can share with others? I, I think that there's a really interesting connection there. And probably once this set, once [00:20:00] this cycle is implemented, can give you some really nice feedback in terms of how you are doing as a clinician in your professional development. Just like a random little side note.  [00:20:10] Jill Woods:  Yeah, I know it it's perfectly true because as much as, you know, our clinical skills are part of our service delivery, our clinical skills and the clinical outcomes that we achieve for our patients are absolutely part of that patient experience that, that service, that product, whatever, however you wanna call it, but they're, they are part of it. But hopefully you'll start to see as we go through more of this, that they're not the only thing. Too many practitioners cling to their qualifications and their CPD and their piece of wizardry bit of kit, the fancy bit of kit that we've got. Yeah. But in fact, the patient experience is way more than that. Okay. And so this repeat concept is not, is not purely about clinical skills, but it is about your clinical skills. You've gotta be good. You don't have to be brilliant, but you've got to be good in order to facilitate this process and have good  [00:20:59] Kate Grandbois:  and have good [00:21:00] rapport that like know and trust so that someone feels comfortable, repeatedly being vulnerable. With you. I mean, even, you know, a lot of what we do requires a lot of vulnerability, but I'm thinking even as my experience, as a person, having gone to PT for my knee, you know, I'm laying on the table, my I'm in these weird gym shorts, you know, it's, it's not, I'm a patient in a clinical setting. Yeah. So I think all of us as humans have had that experience where we're feeling a little bit more vulnerable and wanting to make sure we're cultivating environments where the patient does feel  [00:21:29] Jill Woods:  comfortable. Yeah, absolutely. And this whole cycle, if you kind of. Stop and go back and re just quickly whiz back around this cycle, getting to know you exist to like you as a person, to trust you, to try your expertise, to buy from you, to repeat and to refer people to you. It's all about relationships. Your whole business is founded on that relationship that you can nurture from the minute they spot you on Google or the minute they walk past your premises and see an, a board outside or the minute they see you doing a [00:22:00] presentation at a local health group or something from that moment, you are curating a relationship with those people. And this process facilitates that building and nurturing from no somebody who doesn't even know you exist all the way through to being an absolute advocate and referring patients to you.  [00:22:17] Kate Grandbois:  Interesting. Well, I didn't know. I had heard the like no and trust. Okay. But the rest of that cycle was totally new to me. I mean, I'm not saying that I have implemented any of those things. Or I'm good at any of them necessarily, but, but that seems that the whole seven point cycle seems so comprehensive. Yeah.  [00:22:36] Jill Woods:  And the thing to, to understand is that to move somebody from 0.1 to 0.2, two to three, three to four, and so on, you've got to have marketing activity of some kind so that you've got, there could be gaps. We're gonna talk about that later, but you need to make sure that you've got a system and a process so that you are facilitating that progress around the cycle.  [00:22:59] Kate Grandbois:  Yes. I [00:23:00] can see unpacking each one of those points and needing to make multiple procedures or processes to support each one of them separately. [00:23:07] Jill Woods:  Yeah. And it, and, and you know, you, we are gonna talk about the safety, but don't overthink it. Like there, there, there's, there's simple ways to do this. You don't have to be flogging yourself, mercilessly with marketing to make this effective. Okay.  [00:23:20] Kate Grandbois:  Okay. I can do better. I'm here. Okay. Let's keep going. I'm learning  [00:23:24] Jill Woods:  so much. It's great. Yeah. Okay. So the next thing I really want to impress on people is the three kind of marketing success principles. These are the things that people, again, people come to me and say, Jill, can you teach me how to use Twitter? Can you teach me what to do on Instagram? What do I need to put on my website? They, they they're jumping. They're so far up the curve of marketing activity. They've missed some of the fundamental basics that you need in place before that stuff will succeed. Okay. Okay. So these three success principles are really part that they're part of that foundation to make sure people have got it [00:24:00] before they start wasting time, money and energy on marketing that is not gonna achieve their aim. All right. So your three marketing success principles are number one, clarity, number two, the human and number three consistency. Okay. Okay. So I'm gonna go back through and then unpick each one of those. So number one, clarity. So there are three things that you have got to be really clear about before you start paying money for Facebook ads. And before you start rebuilding your website. A- what do you want to create? Like, what is the practice you want to build?  [00:24:44] Kate Grandbois:  That's such a good question. It's like a vision board kind of question.  Jill Woods: That's it. Kate Grandbois: Right? I mean like, what is your big picture?  Jill Woods: Correct Kate Grandbois:  goal. Yeah. And I assume that has many, many facets. I mean, everything from the customer patient [00:25:00] experience to professional workplace culture, to  [00:25:04] Jill Woods:  how much money you want to make, how much time uou want to work each week?  [00:25:09] Kate Grandbois:  Yes. Oh my gosh. There's so many questions there. [00:25:11] Jill Woods:  Yeah. What kind of building do you want to work in? What kind of colleagues do you want to work with? Do you want to be in a multidisciplinary practice? Do you want a single disciplinary practice? You know you, but if you, as you go through building a business, you make decisions every single day and you should be running every single one of those decisions through a couple of filters. And this is filter. Number one, is it moving me towards what I want to create? Or is it moving me away from what I want to create? But in order to ask that question, you have to know what it is you want to create.  [00:25:44] Kate Grandbois:  I feel like I need to have someone embroider that quote on my office wall in my office because as a business owner, the, the phrase that we use internally here is it's so easy to get distracted by the shiny penny or a great [00:26:00] idea, or, you know, something that is exciting to you, but not moving you towards your goal and keeping you focused. And if you are listening out there and you are a private practice owner and you've experienced this, you are not alone. I am the shiny penny. I'm constantly chasing the shiny pennies and needing to be reminded to stay focused. I love the way you framed that about putting those thoughts and decisions through a filter related to moving towards your goals. I think that's such a great perspective.  [00:26:29] Jill Woods:  Yeah. So, so that's really where you need to start. If you are currently throwing spaghetti at the walls, Stop breathe. Number one, what's your vision? Where are we going? What are we trying to create? That's the first bit of clarity that you need. The second bit of clarity and this freaks quite a lot of cl clinicians out is who is your dream patient? Kate Grandbois: Interesting.  And I'm saying this in a singular, not patient patient, who is your dream [00:27:00] patient. Okay? Because if you are going to build a practice that serves you as much as it serves your patients and as clinicians, we're hell bent on helping other people and not helping ourselves. So this is the point in the conversation where we start talking about what do we want? So if the, the patients that are coming into our practice are going to be our dream patient, a life is gonna be much nicer. Much happier, much easier, much, much more flow to it, much more relaxed, much more may be potentially much more, um, uh, effective because they, these might be patients who are coming with very specific pathologies that we're excluding everybody else, because we really want to see these patients with a very specific pathology. Now in the UK, I work with a speech language therapist and she, we was like, she threw her hands up when I asked you this question, I,  [00:27:54] Kate Grandbois:  I was gonna say, I was gonna say this. I can see how this gives people very uncomfortable feelings. Yeah.  [00:27:59] Jill Woods:  So, but we, Kate Grandbois:  are you [00:28:00] gonna talk me off the ledge? Sorry.  Are you gonna talk me off the ledge? Jill Woods: Yeah. totally so we, so we talked through this process and we went back really deep. Like what, which, if I said to you, here's a, here's a, is a roster of all of your patients and you just quickly scanned the names. Which name would you stop at when you thought? Oh, they're brilliant. I love them. I love when I get to go and see them. And when I work with them, Because that's gonna start giving you clues as to who your dream patient is. Okay. But by the time I'd finished working with Ruth, she'd gone from, she wasn't. She had said she was gonna be an adult speech and language therapist, but by the time we finished and her, I want to tell you, her practice is really thriving. By the time we finished, we'd narrowed that down to stroke, adult stroke survivors, with speech problems, she wasn't interested in swallowing. She just wanted to do speech problems. So she now specializes it and they [00:29:00] were at least 18 months post-stroke. So all the ones that a lot of therapists had given up on, she was that the clinician for those people. [00:29:10] Kate Grandbois:  Okay. I, I hope do I hope we have time to sit and unpack this for a second because I have a lot of, I'm having a lot of thoughts and feelings on I'd like, I, I wanna share them with you. So. I'm thinking first and foremost, about the first of all in our profession, we're often expected to be generalists. So we are expected in a school setting often or in an outpatient hospital setting to treat what walks through the door, treat who's on your caseload. We're expected to be expert. Our scope of practice is incredibly wide. And we talk about that on this podcast a lot. When you're in private practice, you have a little bit more control over your caseload, but I have to assume that these uncomfortable feelings are either rooted in the expectation that we are generalists or [00:30:00] in feeling that it is unethical to turn someone away who needs our help. Jill Woods: Mm-hmm .  Kate Grandbois: So how do you navigate that discomfort with ethics? I know when I first started my practice, I remember getting worried that if I turned someone away, they would sue me for some sort of discrimination against, you know, not providing a service that I was qualified, quote, qualified to provide. I mean, now as a more seasoned clinician, I understand that scope of competence is really important and I cannot just treat everything regardless of whether or not it falls under my license. But what is the advice you have for anybody listening, who is having that moment of discomfort, because they want, they feel that they're ethically obligated to treat everybody who gets referred to them.  [00:30:42] Jill Woods: Yeah. So there's, I think there's two things here. There's the personal feeling of, I just wanna help everybody and there's the, the, the ethical piece. So I want to just backtrack a little bit. So the way that you choose your dream [00:31:00] patient, it doesn't have to be through a clinical pathology like Ruth did. It can be by its person type. So again, let's, let's, let's helicopter above your practice and let's look at your marketing assets. You've got a website, you've got a social media profile. You've probably got a, a premises of some sort. Maybe you are going out and doing talks and all the rest of it. Maybe you've got a blog on your website. You've got all this stuff going on. I am a patient and I come to your website and I've got about 10 seconds before I decide I'm in the wrong or the right place. Now, if you are trying to make the homepage of your website attract everyone, it's gonna fail miserably. Okay. You can. This is a fantastic Seth Godin is a marketing God. And he has a quote that says if you're marketing to everybody, you're marketing to no one. [00:32:00]  Kate Grandbois: Interesting.  Jill Woods: Okay. So that's, that's kind of point number one is that you don't have to go by, by pathology. You can go by person type. So what I mean by that is, for example, you might say, actually, I want to target young moms who are inexperienced, maybe it's first child, they're nervous about development, developmental issues. That's gonna be my target audience. Okay. And if you do that, then I can make the homepage of my website really resonate with that woman. I can make my social media profile resonate with that woman. I can make my physical surroundings resonate with that woman when she walks in the door. It doesn't have to be pathology specific. It can be person type. Does that make sense and answer that question [00:32:48] Kate Grandbois:  does it does. I'm not sure I'm feeling any less uncomfortable  [00:32:52] Jill Woods:  anxious. Okay. Two, the two other things,  [00:32:54] Kate Grandbois:  keep going, keep going. I know you're gonna get  me there. [00:32:55] Jill Woods:  So ethically let's talk about ethically and ethics. [00:33:00] So in medicine, who are the people in the senior positions in your industry? Usually they're the people that specialize. Okay. They're the people that specialize, and those are the ones who are respected in their industry. They might be hospital consultants. They might be private consultants. They might be surgeons. They might be whoever they might be. But usually those people have specialized in some area of clinical practice to, to become super good at that very small thing. Mm-hmm okay. Those are the people that we really entrust with our health because they've become specialist mm-hmm , they are day by day, turning away patients that are not their niche market. If you wanna put it into marketing terms  [00:33:50] Kate Grandbois:  you're right. I’m just realizing that. And that's not, I think the only thing that makes it feel uncomfortable is because it's through the marketing lens, but that's absolutely true [00:34:00] of all aspects of medicine. I do not go to a knee doctor for my elbow pain. Jill Woods: no, the weird analogy, but you know, no, no, but it's you get the idea? Yes. Yes.  Kate Grandbois: You're absolutely right. Okay. I keep going, keep going.  [00:34:13] So I've just had some, some dental work done. I had an abscess behind a tooth, so I went to my dentist and my dentist said, Nope, not my bag. You need to go and see an endodontist. I went to the endodontist and they said, Nope, not my bag. You need to go see a Perry penny, anywhere that one of them, the other dentist. And eventually I got to the right person who specializes in opening a gum up and taking all the gunge out and all of that stuff. Like I would not entrust that procedure to my dentist. Yeah,  [00:34:43] Kate Grandbois:  yes. Okay. I see it now. And I think that this is very, this perspective is very complimentary to what we talk about clinically all the time about your scope of competence, that if you are interested in developing a specialty and in speech pathology, we have many, because our [00:35:00] spoke scope of practice is so wide. And I often talk about how I'm an AAC specialist, and I always put it in air quotes, cuz it's just a, an area of clinical specialty, not necessarily a certification. Um, but I'm no longer qualified to treat someone with a stutter. I haven't treated someone with a, someone with a stutter since I didn't even do it in graduate school, through my clinical placement. So there is a component of ethical behavior. When you are, in other words, when you first started this conversation, it felt, it felt uncomfortable, but it's actually more it's as you spin it through a clinical competency lens. It's more ethical to turn people away who don't fall within your targeted scope of competence than it is to market and take everybody and put everyone on your caseload. Jill Woods: Correct.  Kate Grandbois: So that makes a lot of sense.  [00:35:50] Jill Woods:  Okay. So you're feeling like you were step back to the ledge now?  [00:35:54] Kate Grandbois:  Yes, I'm, I'm I'm way back from the ledge. Okay. And I see a beautiful view. It's a beautiful vista way back from the [00:36:00] ledge.  [00:36:00] Jill Woods:  So the final element of this is if we go back to the marketing, so we've kind of got over the, the clinical thing. We go back to the marketing. If you imagine three concentric circles, um, there's a red circle and then outside that there's a white circle and outside that there's a blue circle. Okay. In the, in the UK, that's our rural air force signature, um, insignia. But they're in the red circle. These are your dream patients. They're in the middle. Okay. Now, if you start building a clinical experience, you hone your clinical skills to serve these patients, patients better. You make your website attractive to them. You think about them on your social media and your Google profile. You're gonna start to attract more of those, those patients. Okay. But what happens? We move out to the white circle. You're going to attract patients who are a lot like those patients too. And the people in the blue circle are people who are quite like those patients. So you're gonna attract them too. So you are not, it's focusing on [00:37:00] one person is not at the exclusion of absolutely everybody else. But what you are doing is kind of pinning your colors to the mast and saying, these are the patients. I get good results for. These are the patients I enjoy seeing these are the patients who, you know, get a good for me, good for my business. And what I can do is good for them.  [00:37:22] Kate Grandbois:  That's what I was gonna say. Those are the people that you serve best. Those are the people that are, that's the word I was looking for are best matched to your clinical yes. Products. I mean, I, to just, what's so interesting about this is it's so much of what we already know and do it's just reframed with different vocabulary. Yeah. Yeah. So instead of targeting a customer, we would say, you know, tar a target patient, we would say. Someone who within with a clinical presentation within your scope. Yeah. Or within your area of clinical expertise. Yeah. But it's the same, it's just a different spin.  [00:37:53] Jill Woods:  Yeah. And so, and so ethically you are the best, you, you are the best person to treat this patient, but you are [00:38:00] not the best person to treat that patient. Therefore you should be referring that patient on. You shouldn't be seeing some of those patients in your practice. And you probably do that already. You know, you might, if you get a stutter patient, you might say, no, that's not my bag that, but, but I know somebody who can help you. Yeah. Here's a quality referral. I'm not just shutting the door in your face. Here's a quality referral. Go and see. So and so, and they, they will be able to help you. So it's I, oh,  [00:38:24] Kate Grandbois:  I feel so much better. I feel so much better. yeah. Cool. Good job. high five. [00:38:29] Jill Woods:  OK. So, so you, you need to identify that one person. And I always say to my patient, my, my clients give them a name. So every single time you are doing something with your marketing, you're saying, would Jennifer like this, would this work for Jennifer? Would this help Jennifer? And you're thinking about doing more CPD. Yeah. And that's exactly it. I get some of my, some of my clients are mad on Pinterest and I get them to set up a Pinterest board for their per, for their dream patients. And you can put their car and their house and their holidays and their [00:39:00] kids and their husbands and oh, and you can build a real picture of who this person is because the more, you know, and understand them the better here's your second filter, the better your dream patient filter becomes. Okay.  [00:39:14] Kate Grandbois:  Okay. So what's the second, the, the first filter just to recap is the first filter is, is this decision moving me towards my goal? And what's the second filter? [00:39:23] Jill Woods:  Would this help or serve Jennifer? Would she like it? Would she appreciate it? Would she prepare to pay for it? Does the dream patient filter.  [00:39:33] Kate Grandbois:  Okay. Your, so does what I'm is what I'm doing, going to help my avatar, my dream patient,  [00:39:37] Jill Woods:  correct. Or serve them better. It doesn't have to be help in a clinical term. It could be, am I moving to new premises that's got better parking, you know, that would serve them better. Do you know? It's a wider picture than, than just the clinical stuff?  [00:39:50] Kate Grandbois:  Yeah. Gotcha. Yep. I see it. Okay. I see, I see the whole vista. Yes, I think. [00:39:54] Jill Woods:  Okay. So, and then we've kind of overlapped with the third bit of clarity, but the third bit of [00:40:00] clarity is how do I help them? So clarity, number one, what do I want to do? What's my big vision, clarity, number two, who is my dream patient and clarity, number three, how do I help them? And this is where you start looking at that wider patient experience and saying, am I running my appointments at an appropriate timeframe? Are my clinical facilities appropriate for them? Can they easily get their buggies or the strollers in or whatever it might be. You, you, you are looking to serve that per that patient better. Okay. Okay. And so that is your third bit of clarity. How do we best serve these people?  [00:40:35] Kate Grandbois:  And when you are, out, out of those three is one more important than the other, or do they always go in that sequence? [00:40:42] Jill Woods:  Um, I would, I would personally always put 'em in that sequence because until you are clear about your big vision. What you want to achieve with the practice who your dream patient is, is not gonna be obvious. And then once you, if you don't know who your dream patient is, you can't say how you're gonna serve them. So they need to come in that [00:41:00] order. Okay. You can't say how you're gonna serve somebody. If you don't know who they are, what they likes and dislikes and yep. You know, and it's down to things like what magazine before COVID what magazines have you got in your waiting area, you know? Right. You would choose those based on who your dream client is. [00:41:17] Kate Grandbois:  Interesting. This is a really important filter. Yes. Okay. You know what, the next I go. The next time I go to the PT office. The next time I go to the endodontist or wherever I'm going, I'm gonna be looking around and wondering if I'm Jennifer.  [00:41:33] Jill Woods: Exactly, exactly, Exactly. All right. So, so hopefully that's clarity makes sense. Yes.  [00:41:40] Kate Grandbois:  Yes, it does. I'm here.  [00:41:41] Jill Woods:  Yep. Clear. Okay. Um, so once you've got that clarity, then you can move onto the next bit. And the next bit with the next kind of marketing success bit is to be human. All right. And this is super simple. People buy from people, especially in healthcare, we're invading people's space. We're asking them to be intimate and, [00:42:00] and, and, and, and, um, vulnerable with us. So this is really important. And I see too many healthcare practices who their, their profile picture on Instagram is their logo guilty. Yeah. I wanna see your face. Like, who am I gonna see when I come to the practice? All  [00:42:17] Kate Grandbois:  right. What would you say for practices though? Who have multiple clinicians working for them? [00:42:20] Jill Woods:  That's amazing. You can do some really fun stuff. I've got a, I've got a, as an example, I've got a fantastic photograph, which was taken at a, in a surgical unit and they've basically got a surgical light above them and they've all stood around in a circle and it's a circle photograph of all their heads in a circle with the light in the middle. It's stunning. It's really, really,  [00:42:40] Kate Grandbois:  oh, that's beautiful. So including your staff, including. Multiple human aspects of your business. [00:42:46] Jill Woods:  Yes. Oh, you can do fun stuff. The other one that I've seen that's really good fun is they've got, they've taken a picture on a timer thing and they've got, they've got all their staff out at sunset and they're all just stood in a line and it's just their silhouettes, but they're [00:43:00] real,  [00:43:00] Kate Grandbois: so nice. But they're people they're not a logo [00:43:02] Jill Woods:  is the real people. Yes. Okay. Starting to remember, it's all about relationships. We need human connection to build relationships.  [00:43:09] Kate Grandbois:  Yep. Oh man. I'm failing in this bad. It's okay. It's a learning moment. We're here. Yeah.  [00:43:13] Jill Woods:  This is why we're here. Okay, good. So don't hide behind your logos and also be, be prepared to share a little bit of you. Remember people got to like you as a person. Okay, so share a little bit about what makes you tick? Are you a dog owner? You know, do you like yoga? Do you, what do you do? Like crafting for a hobby? Do you love gardening? Do you go hiking? Do you, are you ski? Are you adrenaline junkie? Are you, are you, are you, are you a, and any of those things that you feel you have in common with Jennifer, those are the things that you should be talking about because that's gonna pull more of those Jennifers towards you. It  [00:43:52] Kate Grandbois:  also goes, this is so funny. It's like world's colliding because we've talked about this recently on an episode, [00:44:00] funny enough about stuttering and how important it is to let down some of those boundaries and be a human in therapy to create safe spaces for people to have more improved therapeutic interactions. And so again, here we are, it's the same, but through a marketing lens and how important that is for your entire practice. I I'm, my I'm having little brain explosion emojis happen as you're, as you're talking about all of these things.  [00:44:30] Jill Woods:  Awesome. That's exactly why we're here. Why are we doing this? So, so it's it's so it's super important to be prepared. You are asking your patients to be vulnerable with you. It's very important that you, to an extent can be a little bit vulnerable with them. All right. At the outset, even before you've met them. So some of the stuff you put on social media, here's me on a dog walk, first thing in the morning, look at this gorgeous sunrise, you know, all of that kind of stuff, or, oh my God. I just dropped the box of eggs all over the floor. Who else has done that when you've the fridge? You know, [00:45:00] just some of those little honest snippets that give people insight into who you are as a P excuse me as a person. Okay. Right? Yes. But this comes with a warning.    Kate Grandbois:  Oh, oh God. Okay. Okay.  Jill Woods: You ready?    Kate Grandbois:  I'm ready. Jill Woods: The home page of your website is all about the patient. Not about you,   Kate Grandbois:   right. That make sense.  Jill Woods: Okay. Because I, Jennifer, I come to your website and on your website, if you're talking about me, be, if you're talking about your moms, toddler tantrums, pathologies that you I'm as a new mom worrying about, right. I am in, I've come home. I'm in the right place. If I land on your website and all you are telling me is about, I've been qualified for 27 years. And I did my first degree at such and such a university I'm out of here. I'm going somewhere else.  [00:45:53] Kate Grandbois:  Yeah, man. I really got, I have a lot of work to do  [00:45:55] Jill Woods:  okay. Thoughts? Thoughts.  [00:45:58] Kate Grandbois: This is great. No, it's so important. [00:46:00] I think. And, and again, going back to where, who, how we were trained as clinicians. So thinking about to my graduate school experience, not only was I told explicitly to keep boundaries with patients and tell them nothing about myself. Yeah. I was also told that I was the expert and that I, you know, I, I was the one who knew everything. And now as an experienced clinician that nobody wants to hear about those things that just says nothing but ego. It has nothing, but there's no human softer element to that at all. And so when you, again, just looking at this theme, the same things that we always say clinically, but through a marketing lens, How important it is to connect with your patient and say things that are clinically relevant, but not, I know everything look at all my degrees, look at all the training I've had. That's not, you're right. That's not helpful. Cause it's, it's not, it's not humble. At all.  [00:46:57] Jill Woods:  There's a place for [00:47:00] that, but it's not the homepage of your website. Interesting. Okay. Okay. You know, absolutely. If you are, I mean, it's hard work getting a clinical qualification, like you've got your certificate in a big frame on the wall, take a photograph of that and share that on your social media, but don't put it on the homepage of your website and don't ram it down people's throats, you know? Right. It's yes. Painting. It's those gentle strokes that paint a picture.  [00:47:23] Kate Grandbois:  Another quote, to be embroidered on my wall. I'm gonna have to start writing these down [00:47:29] Jill Woods:  alright so, so, so you, so we're getting a bit sidetracked, but your about your home page is not about you. It's about the patient. Okay. Your about page is where you tell people about you. Okay. Okay. So the, the key with your about page is this, this a few things, first of all, each of those paragraphs that are about you, about the person you work with about your receptionist, about, about, about, they should be written by that person in the first [00:48:00] person. So I, me, my not Kate, this Kate, that Kate, the other. Okay. Okay. And the skill in doing this is to write, get them to write it and then read it aloud. And when they read it aloud, does it sound like them speaking. Or are they using long flowery words that they would never use in conversation. Okay. Okay. Try and make it as personal as possible on that page. So about sections written in the first person by the person, some really great photographs. That's not just you in your polo show or your uniform or whatever it is you wear in clinic, but it's you walking the dog or it's you like being mom taxi to, you know, four teenage kids. You don't have to put your kids in the photographs, but just that whole right. Paint that picture. What have you got in common with Jennifer? Paint that in some pictures that are on your, about page, on your website. Okay. Okay. Um, and keep the qualifications to the end. [00:49:00] Absolutely put them in that section, but people don't really care so they can just go at the end people. What here's a, a rabbit hole. We just go down another rabbit hill very quickly. What people care about is I have a problem. I want that transformation. They don't give a what comes in the middle. Okay. If I can see that you understand my pain and I can see that you've done this for other people, and you've created this transformation for other people in my similar situation, then I'm gonna invest a more time in getting to know you better. Okay. So the qualifications and stuff are, are nice to have, but in that initial engagement, they're not essential. Okay. So they can be on the about section, but they can be at the bottom of your blurb, like, oh, by the way, you know, I've been qualified 27 years or whatever it might be. Okay.  [00:49:52] Kate Grandbois:  Right. Exactly. Jill Woods:  Does that make sense?  Kate Grandbois:  You're qualified for 27 years. Doesn't mean you're a nice person or you're in somebody or you're in a good clinic. You're comfortable, right? [00:50:00] Exactly.  [00:50:02] Jill Woods:  You know,so does that make sense? Kate Grandbois:   It does. It makes perfect sense.  Jill Woods:  Okay, awesome. So then just another couple of things about that, this being personal videos, if you, if you're brave enough to do videos, videos are a great way of connecting with people. I can look you in the eye. I can get a sense from your body language, your vibe, your energy, all of that stuff comes through on video. So video's a great marketing tool to use. If you are comfortable in front of the camera, if you're just gonna stand there and read really rigidly from a note like this, it's not gonna serve you at all. All right. You've got to be somebody who's comfortable in front of the camera and you can learn that that's not, that's not inherent that you can learn that stuff. So that's fine. Okay. Um, and just, just remembering all of this, people have got to get, decide if they like and trust you. So you need both elements, clinical and personal. Make that combination work. Okay. Yep. Right. So that's number two. And then number three, the marketing thing that you must must, must get right. Is [00:51:00] consistency. And this means two  [00:51:03] Kate Grandbois:  things, no spaghetti.  [00:51:04] Jill Woods:  It means no spaghetti. It means no spaghetti um, but it means two things. You need to be consistent with your branding. We've not talked about branding at all, but you need to be consistent with your branding. Now, remember back at the beginning, I said, your objective is to be famous locally for the thing that you do. So your branding has two elements to it. It's got visual branding, which are your colors, your logo, your fonts, all of that stuff that you use consistently, hopefully. Um, and then you've also got your brand messaging and these are your strap line that you use everywhere. You create a value statement that you use as your bio on every single social media profile. Every time you write something you include that strap line or a bit from your bio repetition, repetition, repetition. Think about the big brands and they are constantly running ads that just share one thing over and over and over and over. [00:52:00] I'm thinking of  [00:52:00] Kate Grandbois:  Nike. Just do it.  [00:52:02] Jill Woods:  Correct. That was exact, it's a perfect example. Perfect example. Interesting. Okay, so you've got to show up consistently with a consistent message. Okay. In order to be famous locally for the thing you do.  [00:52:15] Kate Grandbois:  Yeah, we can do that. I'm thinking about all the listeners who are listening and I'm here by myself. I'm thinking it. I mean, there's just, there's, you're just, you've got so much wisdom and I'm, this is like, I, I need to be furiously taking notes about all of these things, but I love that. I think that the consistency piece is so simple, but maybe so hard to do so.  [00:52:33] Jill Woods:  And, and it is hard, but I've got, I've got a little get out of jail free card. So, so consistency, first of all, get consistent with your branding. Before you start running Facebook ads, before you start building a new website and before you do money, time and energy into all the other marketing stuff, get consistent with your branding so that all the stuff you do going out is gonna be accurate. It's gonna work is gonna talk to Jennifer. It's gonna do the job you need it to do. [00:53:00] Okay. Okay.  [00:53:01] Kate Grandbois:  Okay. I can do that. I'm feeling very motivated.  [00:53:03] Jill Woods:  And the second, second, the second bit of consistency is actually showing up. Right [00:53:08] Kate Grandbois: . You mean like showing up to work [00:53:09] Jill Woods:  with this is with your promotional marketing and with your PR your, um, uh, project development and all of that other stuff. Okay. So, but as an example, with regard to your promotional marketing, there's timelines to marketing. So if I say to you, are you showing up on social media every day? Okay in your practice, are you sharing something on social media every day, quick sideline, if you know Jennifer, you know which social media platform she's on. Just use that one platform scrap the rest. Okay. Interesting. Don't waste your time, money and energy going down all the Facebook or wherever all those other rabbit holes. You only need the platform where the eyeballs of your dream patients. Okay. Okay. So are you showing up social media daily? Are you showing up [00:54:00] on your Google business profile weekly and sharing new content on there on a weekly basis? Are you sending out email communication to your patient cohort and your potential patients on a monthly basis? Are you creating some kind of new content on your website or on your YouTube channel on a monthly basis? And are you going to live events quarterly? And are you maybe running some bigger marketing campaigns once every six months, those kind of timelines, you need to start showing up consistently with a consistent message. [00:54:32] Kate Grandbois: That makes a lot of sense. Yeah. Yes. I mean, it's, I, I can, okay. I can feel a lot of the, the energy and time requirements, but I can also see how necessary and how beneficial that could be. [00:54:45] Jill Woods:  Yeah. So the, and again, this isn't, there's an order to this. So start with your branding, get your brand messaging and your visual branding done, sorted, done, and then move on and start showing up and, and commit to showing up and [00:55:00] start at the bottom of that list. So start, but I commit to posting something daily on social media. Okay. Or I, if you, if you are already doing that, go up a level. Okay. I commit to posting weekly on my Google business profile. Okay. If you're already committing to that, what's the next one. I commit to monthly getting in touch and communicating with my patients via email. Okay. And you just work your way up that, that, that sort of ladder, if you like. Okay. Mm-hmm now the thing here is you do not have to do this all you can outsource. You can delegate. This is not all on you. Right. As long as I can still see your face and I can potentially hear your voice in your marketing, it doesn't have to be you doing the doing  [00:55:44] Kate Grandbois:  right. We like to delegate. We need to embrace delegating de delegation, our in a small private  [00:55:51] Jill Woods:  practice owners and outsourcing and outsourcing. Yes. Because outsourcing is gonna get you, um, people who know what they're doing, they're [00:56:00] skilled at that thing, whether it's Instagram or whether it's video editing or whatever it is, mm-hmm And you can find people who will do that for a fraction of the price. So outsourcing is perfectly doable within the budget that you've already got. Like, you can start somewhere with some of this stuff.  That tho those that's my seven, um, my cycle of seven elements of marketing and the three founding principles of marketing that are gonna make sure that your marketing is effective.  [00:56:29] Kate Grandbois:  That all sounds, it makes perfect sense. And I'm, I'm looking at our learning objectives and wondering how this ties into the exercises or, and I assume those are like action steps. [00:56:39] Jill Woods:  Yes, absolutely. Yes.  Kate Grandbois:  Okay, good.  Jill Woods: Yes. Okay. So number one. So I've got three, three kind of actions or exercises or action steps for you that you can have a go at doing. So, number one, not surprisingly, probably is gonna be to create your patient avatar. Okay. To literally get a cup of [00:57:00] tea, cuz I'm British. We drink tea, but doesn't matter. Get a cup of something coffee. If you're American, get a cup of tea, get a blank piece of paper. And just sit quietly with no distractions and start to think about who is this person who is the person that I can serve best? Who is the person that I can enjoy spending time with? Who is the person I'm gonna get good clinical outcomes from? Who is the person I can connect with on a personal basis? Who is that person? And just with a blank sheet of paper, just start writing, write random stuff that comes into your head. Who is she? Who is he? What do they do for a living? Do they have a family? Are they married? Are they not married? Do they? Where do they live? What kind of house do they live in? What hobbies do they have? What blogs do they read? What podcast do they listen to? You know, just, just brain dump, all of this kind of stuff onto, onto a page. So you're starting to really scratch the surface on this person so you can understand them.  [00:57:58] Kate Grandbois:  Okay. [00:58:00] And that, I mean, I, I would imagine that this exercise is critically important for your second filter. Right? I mean, all of those steps that you've taught us through, because you can't ask whether or not something you're doing helps, Jennifer, if you don't who Jennifer is.  [00:58:14] Jill Woods:  Correct. So that's, that is the first thing I would encourage. If you've never done this before, there'll be some resistance. Often clients are like, oh, can I not have five? No, you get one, you can have one dream patient and you need to get, literally get inside their head and learn who they are. And you can lit, you can do it with a piece of paper and a pencil. And just some time to figure out who this person is. And once you know her or him or them, it doesn't matter. You can then use that information to make sure that your, your, your, your promotional marketing, your product development, everything can be run through that filter so that you are going to become famous locally for the thing that you do, because you are serving that person with real intent.[00:59:00]  [00:59:00] Kate Grandbois:  Okay. I, I love how all of these things come full circle. Yeah. It's like magic. It's all connected.  [00:59:07] Jill Woods:  Any you just thought I might have planned this? Maybe.  [00:59:12] Kate Grandbois:  It's not like you do this for a living or anything. of course.  [00:59:15] Jill Woods:  Okay. So that's, that's, that's kind of like that's number one. That's the, the activity number one that you can go away and have a go is really spend some time getting clear on who that person is, because that is really gonna serve you well, going forward. All right. Okay. And I say, you can, you can be specific about the person and or pathology. It's entirely up to you. You get to choose.  Okay.  [00:59:35] Kate Grandbois:  Okay. Okay. Action step number one. I can do that.  [00:59:38] Jill Woods:  Yes. Okay. Number two, we're gonna run an audit for personality and human touch [00:59:47] Kate Grandbois:  love it. Like looking at your own goodies. Jill Woods: Yeah. Kate Grandbois: Oh boy.  [00:59:51] Jill Woods: So we're gonna look at your website. We're gonna look at your social media. We're gonna look at your very first [01:00:00] patient email. What's the very, like, what's your welcome email that you're sending out to your patients. Are they, do they get a sense of you or is it really formal?  [01:00:08] Kate Grandbois:  Well, well, as of this moment, they don't get one at all. So maybe that's something I have to do too. I hope everyone listening is having many of these light bulb moments so that I don't feel so alone and vulnerable as I sit here and learn with you. Anyway, move on. [01:00:20] Jill Woods: . You are, you are not having done this for over 10 years. I can guarantee you are not alone. Not alone. [01:00:27] Kate Grandbois:  It's like email. Whoops. Okay. Just  totally forgot. [01:00:28] Jill Woods:  So, or this, so this is gonna blow your mind then. So your new patient information pack. Yep. Okay. That is, does that feel personal? Can I see a photograph of you in that information pack, whether that's digital or a paper thing that you're sending out in the post and new patients, you know, so you need to audit all of those kind of touches that you are doing in your marketing and see, is there, is there an element of personality. Okay, because don't be afraid to, to share some of your personality. If you [01:01:00] are a bit hyper like me, all right. If you, if it's not there at the moment, but if you'd have gone to my website, literally a few weeks ago, the, the picture on the front page is me hula hooping in a field like, you know, that's me, that's, that's kind of like who I am and I'm not hiding behind a stiff shirt and a, and high heels and being very corporate marketing. Like you get who I am in my business. Right, right. That's so important. So run an audit of what you are currently doing. And the two kind of elements you're looking for are personality. And human touch. So human touch is, can I see you? Can I hear you, but also personality. Am I getting a feel that you are fun, that you are relaxed, that you are outgoing or that you are a details person or that you are into your research, and that's a big thing for you doing research based medicine. What, it doesn't matter what it is, but you need to be starting to portray that in your marketing.  [01:01:55] Kate Grandbois:  Yep. Yeah. I can see how all of that is connected to all of the things, [01:02:00] all of the filters, all of the mm-hmm the, the foundational perspectives. Yeah. Makes a lot of sense. Okay. All right. Well, you've given us two action steps. I haven't done either of them. And I have, I have with the third one I'm dying to know.  [01:02:13] Jill Woods:  And the third one we've already touched on the third one, but the third one is to look at, um, your, the list of consistency, consistent marketing and commit. I would love if everybody listening to this podcast in the comments. Could leave a comment that basically said today, I commit to and commit to one of those levels of marketing. Okay. Because it's that commitment to consistency. So is, is it gonna be every day, every week, every month, every quarter, every six months. What, on that scale, can you, are you going to commit to put it in the comments? Kate. I'm sure we'll watch. I might look I'm  [01:02:58] Kate Grandbois:  and I thought you were gonna say, [01:03:00] I'm gonna have to comment.  [01:03:03] Jill Woods: I'm gonna come I'll I'll come back. And now what people doing, but, but, but it, you've got to start being consistent. And the only way you're gonna start being consistent is to make a commitment. Now, whether you make that commitment to Kate and I, or whether you make that commitment to somebody else in your practice or somebody in your family or your best friend, it doesn't matter, but you need some accountability so that you are then gonna do it. Otherwise you'll procrastinate. You won't do it. It'll get lost. It'll get lost in the Melay of everything else that's going on in the practice. And it won't happen. But this well, and marketing is consistency.  [01:03:36] Kate Grandbois:  And I I'm sorry that I interrupted you, but I have to assume that those who are listening may have the same experiences that I've had in that it, the marketing piece genuinely feels a little uncomfortable or feels a little unnatural. So I just don't do it. I, or, or I avoid it or it gets pushed down on my to-do list or it's not as important as my billing or [01:04:00] the patients that I have scheduled, or my employee who needs my support or, you know, add it to the list when you're an entre. When, when you're a small business owner, you wear a million hats. I see. So, but, and I know, go  ahead. [01:04:10] Jill Woods:  That's why the vision, the starting point is so important. Mm-hmm because if I am hell bent on achieving that. Then that becomes my filter. And that means that I understand that I am gonna have to create some new digital content once a month, because I need something to talk about on my social media. I need something to talk about on my Google business profile. I need something to email my clients about. So if I know that, because I've got this big vision, this is where we are going, guys. This is what our practice is gonna be. And it can be practiced stroke life. The two are very closely intermeshed. Um, but I've got a, you probably can't see I've got a vision board on my wall.  [01:04:56] Kate Grandbois:  No you don't. It's beautiful for everybody listening, who can't see, there's this [01:05:00] beautiful thing hanging in her office. That's got a frame and all of these photos and some beautiful quotes that I can't quite read, but I'm sure are very inspiring  [01:05:09] Jill Woods:  in the, in the middle. It just says, it always seems impossible until it's done.  [01:05:14] Kate Grandbois:  Yes, it does. It always seems impossible until it’s done.  [01:05:17] Jill Woods:  It's the point? The point I want to make is that vision board is a mix of my business and my personal and home life. So it's a whole mele of, because the two are so closely connected. [01:05:29] Kate Grandbois:  You're so closely connected when you own a business and your business. The way I explain it to people is that the business sometimes feels like my third child, you know, it's, it's something that I I'm up at night worrying about and I am constantly trying to make sure it's okay. Um, and I think I have taken away so much from everything you have shared, and I also need to find someone to embroider some things from my office and now I need to also get a vision board. So to keep me focused, cuz as I have already admitted, the shiny [01:06:00] penny gets me every time and staying focused can be really, really challenging. I, I have,  [01:06:06] Jill Woods:  if you've got that clarity, like of what you're trying to achieve and you anchor everything to that, it takes away some of that chasing rabbits and squirrels. Yeah, because is this, but you've gotta have an awareness like watching this YouTube video of America's got talent. Is that moving me towards my vision or away from my vision? it's not certainly not moving me towards it. Right.  [01:06:28] Kate Grandbois:  Not told exactly, exactly. But I think you, even your recommendation of taking a minute to write down the vision or really consider the vision. I mean, I think a lot of us get into private practice because we wanna help because we want the flexibility because we wanna be our own boss because we wanna, we we're interested in business because we have a clinical expertise that we think is, is a value to our communities. But the actual exercise of sitting down and writing down what we want, I mean, I've never done it. I'm sure there's someone listening who has done it, but I'm also willing to bet there are a lot [01:07:00] of business owners out there who haven't done it. No. Um, I think even starting there is such wonderful advice. [01:07:05] Jill Woods:  Yeah. That's, that's my experiences. Often, if you ask people, what do you want? They can't tell you. They don't know.  Kate Grandbois Don't ask me  Jill Woods: but every day, but, but every day they're getting up and they're dedicating hours of their life that they'll never get back money. That they've, you know, hard earned money to build something that they don't actually know what they're building, right. And what they're working towards, but yet unwittingly, every single day, they invest time, money, and energy in the thing.without actually thinking through what is it? [01:07:38] Kate Grandbois:   It needs a name and it, it needs a, it needs some legs. It needs some structure. It needs, it needs a vision board. Now I, I'm never going to snarkily laugh at about a vision board ever again, the rest of my life. I so appreciate all of this. Before we wrap up. Do you have any final words or words of advice, parting words of wisdom [01:08:00] for people in the audience?  [01:08:02] Jill Woods:  I would just say, I know we've covered a lot of ground today, so I'm very aware that probably people's heads might be exploding just a little bit. Um, but I would say, no, nobody is born knowing this stuff, you have trained to be a clinician. You have not trained to be a marketer. I was very fortunate that I trained in marketing before I trained to be a podiatrist, but you haven't got those skills, but you can choose to start somewhere. And if you choose today to be that day, then I am gonna champion you. I will be here cheering you on all the way, because I know what an impact good marketing can have in your practice and in your personal life. Like if your practice is flourishing, you are less stressed, you've got more available cash. Like you can take more time off. Like if you've got a flourishing practice that comes from good solid marketing, your life is transformed.  [01:08:55] Kate Grandbois:  That's again, such wonderfully Sage advice and [01:09:00] I'm so, so grateful. Thank you so much for being here and teaching, teaching me so much, teaching our audience so much. Um, everybody who is listening Jill is obviously a wealth of knowledge. You are available to our audience for questions. This is your business. This is what you do. All of your contact information and practice information will be listed in the show notes. Um, you also have a YouTube channel that I, I will admit I was creeping on it before I had a chance to, to meet you and ask you questions. Um, your YouTube channel has so much more information on it, um, in case anybody does want to learn more. Thank you wo, so, so much for joining us today, this was a real treat.  [01:09:40] Jill Woods:  It's my absolute pleasure. I, I love what I do, and I feel very blessed to be able to do this as a job. Um, and so, yeah, just thanks so much, Kate for inviting me. I'm very, very grateful. [01:09:49] Kate Grandbois:  Well, it was wonderful to have you. Thanks again.  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. [01:10:00] You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com Thank you so much for joining us and we hope to welcome you back here again soon.

This is a transcript from our podcast episode published November 28th, 2022. The podcast episode is offered for .1 ASHA CEU (intermediate level, related area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. [00:00:00] Kate Grandbois:  Welcome to SLP nerd cast the number one professional resource for evidence based practice in speech, language pathology. I'm Kate Grandbois  [00:00:09] Amy Wonkka:  and I'm Amy Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast.  [00:00:16] Kate Grandbois:  Each episode of this podcast is a course offered for ASHA CEUs. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance to earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP nerdcast.com . [00:00:41] Amy Wonkka:  Before we get started one quick, disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise specified.  [00:00:53] Kate Grandbois:  We hope you enjoy the course.  [00:00:55] Announcer:  Are you an SLP related [00:01:00] professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ASHA CEUs and certificates of attendance. With SLP nerd cast membership, you can earn unlimited CEUs all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes. [00:01:43] Kate Grandbois:  Hello, everyone. Welcome to today's episode. We are so excited to welcome back. Some of our favorite guests. Welcome back. Ingrid Owens-Gonzalez, Liza Selvarajah and Desi Pena. Welcome back. [00:02:00]  [00:02:00] Liza Selvarajah:  Thank you. We're so happy.  [00:02:04] Amy Wonkka:  We're so happy to see you here. Ingrid, Liza and Desi. You are here to discuss issues related to culture bilingualism and speech language pathology. But before we get started, please tell us in our listeners a little bit yourselves.  [00:02:20] Liza Selvarajah:  Oh my goodness. I didn't know we were doing that again. Okay. um, I am a bilingual S L P French and English. Based in Montreal. Uh, let's say I have a private practice called Montreal speech therapy, and I just love, love, love, mentorship, and supporting just a multicultural way of thinking and working and learning. [00:02:48] Desi Pena:  I'll jump in. Um, so I'm Desi. And actually now that you mentioned your own private practice, I realize I never mentioned my own last time. Um, so I'm again, like I said, I'm Desi, uh, [00:03:00] Spanish, English, bilingual, SLP. Um, I also own a private practice here in Maine called Panorama speech therapy, LLC. Um, I'm still mostly contracting, um, with schools and agencies in the state of Maine. Um, and I guess another fun fact about me is that I've lived all over the east coast. Um, but most recently landed in Maine. So I’ll hand it over to Ingrid.  [00:03:27] Ingrid Owens-Gonzalez:  Hi guys. Um, my name is Ingrid. I am a school based SLP, Spanish bilingual, I'm based out of Northern New Mexico. I'm first gen Mexican American. And, um, I just love working with kids. I love working with multilingual multicultural kids, and I have a lot of things going on, um, that Kate will share with you on the disclosure section. But right now, uh, mentorship is really at the forefront of what I'm doing online. And I [00:04:00] just launched my speech place, LLC this summer. So [00:04:04] Kate Grandbois:  we're so glad to have you all back with us, and we're really excited to continue the conversation that we started with you during your last episode. Here with us. Um, and I wanted to take a minute before we start our conversation to read our learning objectives and our financial and non-financial disclosures. So everyone bear with me. We will try to get through this part as quickly as possible. We've got five people here today, so it's a, it's a lot of disclosing, uh, but we're gonna get through it. Okay. Learning objective number one, describe the potential harms of over-relying on external evidence for multicultural and multilingual learners  Learning objective number two, list at least two strategies to prevent harm in evaluations during the diagnostic process and learning objective number three, describe the importance of balancing the three pronged evidence based practice model when determining treatment. [00:05:00]  Disclosures. Ingrid's financial disclosures. Ingrid is the owner of my speech place, LLC. And is the employee of a public school. Ingrid also received an honorarium for participating in this course. Ingrid's non-financial disclosures. Ingrid is the co-founder of the bold SLP collective and the co-host of the bold SLP podcast. Ingrid is also the co-founder and lead mentor of the bilingual empowerment through allied mentorship program and an Asha step mentor. Ingrid is also the mother of two bilingual and bicultural children. Liza's financial disclosures. Liza owns a private practice called Montreal speech therapy. Liza received an honorarium for participating in this course. Liza's non-financial disclosures. Liza is the co-founder of the bold SLP collective and the co-host of the bold SLP podcast, and is a mentor of the bilingual empowerment through allied mentorship program. She is the mother of a bilingual and bicultural child. Desi's financial disclosures. Desi is the owner of Panorama speech therapy and [00:06:00] is faculty of the main New Hampshire leadership education and neurodevelopmental disabilities program. Desi also received an honorarium for participating in this course. Desi's non-financial disclosures. Desi is the co-founder of the bold SLP collective and the co-host of the bold SLP podcast. She has a mentor of the bilingual empowerment through allied mentorship, and she is a child of Cuban exiles and is also raising a bilingual bicultural child.  Kate Grandbois that's me, my financial disclosures. I am the owner and founder of Grandbois therapy and consulting LLC, and the co-founder of SLP nerd. My non-financial disclosures. I'm a member of ASHA SIG 12, and serve on the AAC advisory group for Massachusetts advocates for children. I'm also a member of the Berkshire association for behavior analysis and therapy, the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis, special interest group. I am a person of monolingual experience and a person of cultural privilege as a CIS white woman [00:07:00] in the United States of America.  [00:07:02] Amy Wonkka:  Amy that's me. My financial disclosures are that I am an employee of a public school system and co-founder of SLP nerd cast. And my non-financial disclosures are that I'm a member of ASHA. I'm part of special interest group 12, and I serve on the AAC advisory group for Massachusetts advocates for children. I also come to this discussion as a person who's experienced cultural privilege, uh, being a white cisgender woman in the United States of America. All right. We've made it through everybody's disclosures, learning objectives. Um, Ingrid Liza and Desi. Why don't you start us off with the first learning objective and talk to us about the potential harms of over-relying on external evidence for multilingual and multicultural clients. And maybe before we start just a little recap on external evidence, what is that [00:07:50] Ingrid Owens-Gonzalez:  you want me to jump in or Desi.  [00:07:53] Desi Pena:  You go first Ingrid you're up. okay.  [00:07:58] Ingrid Owens-Gonzalez:  So objective one [00:08:00] potential harms. I mean, they're really, truly immeasurable because you're impacting people's lives. So it's not something to look over. It really like sit in that word causing harm. Um, but external evidence is pretty much everything that is standardized or data driven outside of who you're looking at. So all the things that have been done outside of the person that you're treating, uh, more formally, it would be like standardized assessment, criterion, uh, checklists, things like that. That really don't have anything to do with who you have in front of you. Um, so that, that's kind of what we're like talking about when we say external evidence. And then as we know, we are very, very comfortable with that triangle. Uh that's. It irks me to see it written in black and white letters. It says that that's the best available information [00:09:00] gathered. Um, it's right on the ASHA website. And I know they're talking out about what the best available scientific evidence that's available, but just by putting that word right there, that's the best available information, then it makes it kind of imbalanced. Right. And that's kind of like our whole goal with this conversation. Um, it is just available information. We don't have to call it the best. Um, but it's just data and, you know, there's other forms of data. Like the ones you collect from your client and from the family and their perspectives.  [00:09:35] Desi Pena:  Um, and I just. Wanted to jump in just quickly to say that, um, the reason that the data isn't necessarily the best for multilingual or multicultural learners is because a lot of the data is really centered or gathered from children of, uh, a white mainstream general American English background, um, children who are not exposed to more [00:10:00] than one culture. And so it's the harmful piece about relying on that evidence is that you may be over or under diagnosing children with communication needs. Um, and what was really interesting, we recently. Recorded an episode, um, with Dr. V. Um, she's a professor at Howard and she really highlighted the point that, um, you know, everybody's comes from an individual place, right? We, we say, you know, multilingual multicultural, it, it's not, there's no such thing as a monolith, right? Like each child has a certain dialect that they're exposed to, whether that's mainstream English, speakers, whether that's Spanish speakers, whether that's, you know, people who may speak, you know, one of the many languages and for example, India, right? Like everyone has a dialect within a language. So it's something that, again, the external evidence isn't really accounting for [00:11:00] external evidence really looks at not so, so much like the granular details, pieces, but it looks at populations as a whole, which can be really harmful because then we're not individualizing our evaluation and our treatment, which is the whole point. [00:11:16] Ingrid Owens-Gonzalez:  So, well then you're looking at, if you're not represented in that external evidence, then it doesn't apply to you. Right. And so then. You get to the point where you're like, do I need to do research on every single population? It's like, no, you need to make smarter research. Mm-hmm that applies to every single population  [00:11:36] Desi Pena:  or be a better clinician, getting your clinical eye in tune with the fact that, oh, someone from the north of Mexico doesn't speak the same way as somebody from the south of Mexico, I should be accounting for the fact that there are dialectical differences and this happens to bilingual SLP all the time, too. So, um, I think it's really important to sharpen your critical tool kit, you know, critical eye in your [00:12:00] critical thinking toolbox rather than assuming that the evidence is the best thing you can lean on.  [00:12:07] Liza Selvarajah:  Mm-hmm  [00:12:08] Ingrid Owens-Gonzalez:  mm-hmm and in terms of harm, um, I just wanted to highlight that I know that we're coming from a, um, pediatrics centered lens here, but when I was working with adults, Whenever you're using external evidence to make decisions about dysphagia and not making decisions based on the patient that's in front of you. You can cause a lot of harm, not just physically, but also culturally to that family, putting a lot of undue burden for not considering their cultural practices. Um, you can cause a lot of harm if you're serving a family, um, who has a family member, who's had a TBI, and if you don't consider their cultural, uh, practices, then you make recommendations based on external evidence instead of what this family really needs or what this patient [00:13:00] really values. Um, so it goes across, um, our scope, even though all three of us are now are more school based pediatric, but like relying on external evidence, like Desi said, um, can lead to over identification in the schools or under identification. And it's the same in outpatient. It's the same in acute care. It's the same, uh, in a SNF. [00:13:27] Liza Selvarajah:  I just think of who had access to education back in the day, who was all of this written for, who were the norms standardized on? What was one's best practice? What was one standard is no longer the standard. And if we could reflect on that and see that the standards themselves, the external evidence is no longer good. What do we do? And how do we create these new ways of thinking? I, I was thinking how I was a little bit caught off guard at the beginning when I was asked to introduce myself thinking, oh, this is a [00:14:00] part two. I don't need to introduce myself. And I did. And my introduction was so different from the last time I introduced myself just one week ago and I am the same person. And within a week I've evolved into something new and something different. And to compare me to like a little white kid is so different. So how can that be the standard? Um, I think of setting kids up for failure. This is what it feels like. You are setting them up for failure, testing them on things that they are not familiar with that are not part of their culture, not part of their background. If you set them up for failure, then they will fail. And that is the harmful effect of it. Uh, effect of it. They're failing at something because we set them up to fail.  [00:14:44] Kate Grandbois:  I wanna piggyback on something that you said. So, if you're listening to this episode and you haven't yet gone back and listened to the first episode that we published with you all in that previous episode, we talked a lot about cultural [00:15:00] competency. We talked a lot about, um, how you can do harm by not doing the work of cultural competency first, when working with children who are not monolingual, who are bilingual, who are multicultural. Um, so if you're listening, I just encourage you, today's episode. We are gonna be diving into the, the clinical application. So please go back and listen to that. If you haven't. The second piece is I, I, as you were talking, as all of you were talking, I was reflecting on our jobs, which as I know a very general perspective, but we are trained as I'm putting this in air quotes experts, right? We are the commun. We are trained in communication, diagnosis, and intervention. That is what we go to graduate school for. I don't believe in the term experts. So air quotes, but you get my flavor, right? And if we don't, what I'm hearing about this potential harm, I think it's, it's goes [00:16:00] without saying that many of us, most of us are taught in graduate school to rely on external evidence. We are taught when we go through the evaluation process and we practice, sorry, I'm imagining myself as a grad student, I've got my easel, I've got my booklet. You know, I'm, I'm doing an evaluation for the first time and I am taught that assessment. Is a norm reference test. I am pretty confident that that is a standard experience. And yet there are so many people, not at all represented in that test. That is in fact, not my understanding is that this not an accurate measurement. It has, maybe it has its place. But what I am appreciate so much about your perspective is not only is it not an accurate measurement, but it is harmful to rely on that as a measurement. Um, Desi, I think, or Ingrid, I think you were the one who just mentioned the potential harm, not just of the over diagnosing and underdiagnosing, but the cultural harm, the emotional [00:17:00] harm. Uh, and that's what made me think of going back and really looking at this through the cultural competency piece, um, because the potential for harm is, is multifold. [00:17:12] Desi Pena:  I wanted to add on to that, that when in reading about, um, approaching evidence based practice from a, a legit three pronged approach. Um, and I know this is jumping into a different objective, so I'm gonna say it very quickly. Um, there is a standardization approach and that's a term from this one, um, article, uh, in social work that is linked in the show notes, I think, um, and just seeing standardization approach. Oh, and this ties back to what I was thinking about. Um, seeing that, that written out, it kind of made me feel seen too in a way. Um, I think about this recent mentorship meeting, we were, um, meeting for the BSLP program. We met with students who are trying to enter the field of speech pathology [00:18:00] and they all had concerns about the GRE. The GRE was not designed for any one of us. Um, you know, I was labeled as an English language learner when I entered school. Funny enough, I kind of questioned that now, if I should have even been labeled and received those services, um, You know, and I think that because of the fact that I'm bilingual, I just didn't, I'm not accurately represented those scores don't represent my actual abilities. And so I remember feeling that anxiety of I'm not gonna, I know I'm not gonna look good on paper, um, or on these standardized test scores. And it's because I'm not the standard. And I know that when those students brought those questions up to us, um, we all felt the same way. We all felt seen. It, you know, these tests don't, don't act, don't accurately capture our abilities. And so it's really nerve wracking when it's part of an admissions process. Um, and I think that it's great that more [00:19:00] universities are moving away from those standardized tests, cuz they just don't really give you a sense at all of who that person is. Um, when I taught, um, Uh, I, I did a master's degree in, in Spanish. Um, before I became a speech pathologist, um, I had a student who, um, they had to show proof of placement, right. That they could be placed in this, in this certain level of a Spanish course. And I had a student who showed me, uh, a copy of her SAT two scores, I think it was. And so it gave me the whole report, you know, what she got on her SATs. I mean, I don't, I'm not sure that that person broke 1000, um, you know, on the SATs, which back in the day, I don't know what, you know, what the numbers are now, but, you know, it was not a great score. Um, you know, it, in terms of like getting admitted to a university. It just, it's something that really I held onto. She was my best student that semester. I mean, she just got like a 98 in the course [00:20:00] or something and she was super dedicated and it meant nothing to, you know, to see those numbers. Um, and it just made me so angry because of course she was a student of color. Um, and. Sh, you know, again, like put her, put her on paper, she doesn't look that great. You put her in front of me. She's a wonderful student. It just, you know, I'm, I'm glad that she made it to that level of achievement. And I wasn't a barrier. Like thankfully her university saw something in her. Um, but it makes me angry at the same time. So I think it's hard to remove that piece here. Right? Like it's not all it's, it's harm in the sense of emotional harm, um, cultural harm. But then we're also talking about harming people who may, you know, who, who are successful or who can be successful. And it really kills me, uh to bring this up. But I think it's also something that, um, is a necessary part of this conversation. It goes beyond whatever [00:21:00] pathology, right? Air quotes, um, or disability like this affects people from all backgrounds, um, who may or may not have a disability. Yeah.  [00:21:10] Ingrid Owens-Gonzalez:  And to wrap up, um, learning objective one. I wanted to walk you through a scenario, uh, that I see in the schools a lot whenever, um, a bilingual S L P or any really bilingual professional is not involved. Um, you see a student come in in kindergarten, who is coming from a bilingual home. They get screened right away. Uh, maybe they fail the kindergarten English screener. And so they get referred to the bilingual department or to the RTI department, whatever you call your RTI team at your school and your district. Uh, and then they get further into their career kindergarten, first grade, and they're struggling to communicate. They're struggling to read, [00:22:00] and then you either can go one direction with it and say, oh, let's just wait, because he's bilingual. Or you can go the other direction with it and say, oh, we gotta put him, gotta test him, gotta test him. They gotta be in, in special education. And so if you're over relying on these tests, how do you know which way is the right way? If you don't have the other two pieces of that triangle, if all you have is, oh, he didn't pass the kindergarten screener and oh, he's not doing well on insert, whatever standardized tests your school uses to measure reading. You know, we used to use DIBELS and now we use, um, something station, you know, insert, whatever test. Um, how do you know what recommendation to make if all you have are numbers? Um, and so that's kind of what I wanted [00:23:00] to pause it to you guys in terms of harm. Um, If the student truly has a, a communication disorder, you have now waited two years to support them. And if the student doesn't have a communication disorder and instead is, uh, emergent bilingual, you have now waited two years to support them in another capacity, right? Because we have systems in place to support English language learners, but you were just waiting, waiting for what, for him to fail another test, you know, when all that other piece of the triangle was there to begin with, you could have talked to the parent, looked at their language, history, uh, looked at their background. Have they been to daycare? Have they been to preschool? Are they the youngest sibling? Are they the oldest sibling? Uh, is there a history of communication disorders in the family is their parent concern and [00:24:00] you just sitting there waiting. To find out. Um, so that's kind of where I'm coming from in terms of that learning objective. And I hope that kind of wraps it up pretty well. And then we can go to learning objective number two.  [00:24:17] Kate Grandbois:  No, it does. And I just, for the sake of our listeners who we've been referencing, this triangle, we've called it a three pronged approach. Um, I was not aware that this was our, our, that our evidence based practice model was three pronged until pro, maybe it might have gotten shown to me in graduate school, but it wasn't the way I practiced. Um, and so for anyone listening, if this is a novel concept to you, you are not alone. Um, I didn't learn about it in, in terms of embracing it as part of my practice until I had probably been practicing for a handful of years and for the sake of leveling the playing field and making sure everybody who's listening knows what we're talking about. Our evidence based practice model and speech pathology [00:25:00] is three-pronged as a triangle. I bet you could have guessed that given that's what we, what we've been calling it so far. Um, and that triangle is made up of evidence, which is both internal and external evidence, cultural per, um, client perspectives and values and clinical judgment. So again, often in speech pathology, we tend to think of quote, evidence as hard numbers research this component of external evidence. But that is one third, maybe even less than one third, because evidence is broken less than one third internal and external, right? So, so the, um, we really need to make sure that we are moving through evidence based practice as a process. With equal reliance on at least three of those components and they influence one another. Um, for anybody who wants to learn more about that, we actually have an episode with, um, Dr. Mary Beth Schmidt who wrote the EBP, uh, briefs about this process. [00:26:00] Um, so if you wanna learn more about the evidence based practice process and speech pathology, I will, uh, link that episode in the show notes. Anyway, carry on. I love that.  [00:26:10] Ingrid Owens-Gonzalez:  You said that like you haven't, you weren't trained in EBP and yet, you know, you weren't practicing at the beginning. I feel like none of us, well, maybe Desi, but, um, I went to grad school 11 years ago. I definitely was not trained on EBP. Yeah, I was. I think we don't talk about that enough. Like you come out and you're still learning. [00:26:28] Desi Pena:  I think the, the problem. I went into the, my assessments in grad school, the same way. Carry in your kit, bring your protocol, come on down. You know, like I never felt like, I, I mean, I, I had a, I think a few nuanced evaluations, like they were very excited cuz they had a bilingual client for me to evaluate as my first client. And it, it was a scramble. I mean, I don't mean to put down anyone from my program. They did the best they could. Um, [00:27:00] but I. I felt like my evaluations were test after test after test. Um, and I, you know, I know that we're, we read the manuals, we look at what evidence is in them that they'll work, you know, reliability, validity, sensitivity, specificity, but a lot of our instruments are not that great or robust even with the populations that form the standard sample. So, you know, it's really disappointing, um, to over rely on them so much. And I feel like, you know, you're very kind and , I'm not saying that I got bad training, but I, I think that one of the things that happens when you're a bilingual speech pathologist is you quickly pivot away from that training you might have, or you might start questioning things. Um, why is it this way? Why. Why are we using this as the baseline? When our [00:28:00] clients aren't in here, right? They're not, they're not represented here heavily. It's not super well designed or, you know, part of my diagnostic class was looking at sensitivity and specificity and reporting it out. We all had to do, take a test and, and spell it out. Um, and I, it was shocking after weeks of talking about what is sensitivity, what is specificity? What is content validity? I feel like when we started looking at all of those different elements, we quickly realized, wait a minute, those aren't all spelled out in these manuals. we were just like, oh, Hmm. So I wish my direct, my, I wish my professors had been like, Hey, they're not great. And I wish that that had been a conversation from the beginning, but it felt like the unspoken piece of grad school.  [00:28:50] Liza Selvarajah:  That's that's it right there, the unspoken piece. So no one ever said rely the most on the evidence, but that's what we saw. So when I [00:29:00] think of the triangle and, and thinking back to grad school, to me, I was like, okay, again, we talked about me thinking in pictures. So I was like, okay, what does client values mean? What does clinical judgment mean? What does evidence based mean? Okay. To me client values, they filled out the intake. So I've got their values right there on this piece of paper. So check, I did that part of the triangle, which is of course ridiculous. Now that I think about it, cuz it's so much deeper and a vested relationship is necessary and all these things. Anyway, so I checked off intake, got the client value. Then I was like clinical judgment. I don't have any, I better go really hard on the external editing.  [00:29:35] Kate Grandbois:  I love that. I feels that way sometimes I'm laughing [00:29:37] Desi Pena: . No, but. And you, they make you feel like you don't have any either. Sometimes, like not to, again, I'm not trying to crap on, like,  [00:29:47] Ingrid Owens-Gonzalez:  you didn't just finish a whole bachelor's degree on something else and pass the GREs and no. [00:29:56] Liza Selvarajah:  But here's, here's the crazy part. So I would like you have my whole kit read the [00:30:00] manual, like I'm so stressed about, did I turn the page at the right time? And am I reducing the validity? Because I oh yeah. Oh yeah. Teared the child down. Did I look at the answer? And that's why they pointed. I don't. So the stress was high. [00:30:13] Kate Grandbois:  It's so stressful.  [00:30:15] Liza Selvarajah: And then this is, again, this is a grad school experience. Not today. Now I'm just like, yeah, flip it. It's all good. So, so then once I get all my data, my, uh, my excellent data from this child that it definitely was not normed on. Then I put in receptive skills, this based on the score, expressive skills, this, oh, there's my clinical judgment, severe diagnosis and check. So I've got my three prong triangle, not realizing it's basically like a isosceles, you know, just like super heavy on this, these couple tests.  [00:30:45] Desi Pena:  Look that you're bringing out the geometry. I can't.  [00:30:47] Liza Selvarajah:  I had to look, I looked it up while you were talking [00:30:48] Ingrid Owens-Gonzalez:  what's the tangent, Liza.  [00:30:55] Kate Grandbois:  This is the first time geometry has made an experience on this show.[00:31:00]  [00:31:00] Ingrid Owens-Gonzalez:  why aren't we naing  [00:31:01] Desi Pena:  on the I'm sweating bullets a second. You say I saw solo.  [00:31:04] Liza Selvarajah:  So I brought up the isosceles triangle because the point to me was that it was so heavily based on external evidence. And the other two were just little ch little ticks, little check boxes. They weren't actually equally being weighed. And when we talk about Bicultural bilingual kids, we actually have to weigh much, much more of it on the client values and our clinical judgment, because the external evidence doesn't match. So that's yeah. That's why I brought up the new triangle. you're welcome. [00:31:36] Ingrid Owens-Gonzalez:  Love it. I just wanted to add that through that, like even within evidence, we tend to value external evidence over internal, and I kind of feel like we group internal evidence with. Client values, cultural values, further, you know, diminishing the importance [00:32:00] there, like, oh, what we see about their, their culture or their language is more important than what they're sharing with us. So, yeah, it's the mess of a geometry. It's not a triangle. It should be, but it's not. [00:32:12] Desi Pena:  I was gonna say, and if we're trying to get to the second objective about naming solutions, um, I wanted to share one of the things that I use the most is, um, resources from the leaders project, which is through Columbia university. It's run by Dr. Kate Crowley. Um, so website, it has free, um, CEUs, um, or continuing education on performing, um, reliable and, you know, balanced as possible, um, bilingual or multilingual evaluations. And one of the tools that's on there, um, is, and it is one of these interview. So again, I, I wouldn't necessarily call it like, you know, you download [00:33:00] this interview questionnaire and you're done. Um, I would say that it's good to consult with. And one of my favorite questions on that form that is available through the leaders project is to ask parents to compare that child, to other children within their community, even amongst their own kids. And I recently mentioned this to, um, a special educator, you know, that I always ask to compare to other children. And she's like, oh, but we're always told never to compare. I'm like, no, like, it's so important because you know, if the parents have concerns, they're gonna tell you immediately, this is not like my other children. And that to me is a big red flag in terms of trying to balance this evidence based triangle, you know, evidence based decision making in an, an assessment. If a parent tells me no, they're so different from my other children, I wanna know why that's my starting point in an evaluation. So I think it's really important to [00:34:00] list this solution, cuz I think this is a good starting point for anyone who may be wondering, where do I start these evaluations? You know, if, if we're not gonna weigh heavily, if we're not gonna lean it toward an isosceles triangle, how do I pivot it back toward the middle? That might be a good starting point.  [00:34:18] Liza Selvarajah:  I just wanna jump on your, your word comparison, because I feel that we hide a lot of what we truly do with scientific jargon. So we tell teachers and parents don't compare, but when we put in a standardized score, what are we doing? We are comparing, we are comparing [00:34:38] Kate Grandbois:  that's exactly what I was just thinking.You 're absolutely correct. It is like the whole point is comparison except, and I know we're going sort of back to this harm, but you're comparing it. It's apples and oranges. You cannot compare with a norm reference. It's not an appropriate comparison. Um, I love the, the concept of the leaders project and we'll link that in the show notes for anybody who's [00:35:00] listening. Tell us more about what strategies we can use to not rely so heavily on the external, components of external evidence.  [00:35:10] Ingrid Owens-Gonzalez:  From the leaders project. I also use the non-word repetition tasks a lot. They have a lot of them free for you to look on there. Uh, they have 'em in English, in Spanish, in Mandarin, uh, and there's, um, several different versions of them, uh, depending on what your, uh, your age group is. Um, so look into those, the non word repetition tasks on the leaders project, uh, that really kind of gives you another piece of the picture. It's not a whole picture, but it gives you another piece to add to your, uh, data to your portfolio on that child. If you're questioning some things, um, I always tend to use it, um, towards the end, if I'm still not sure with my other measures. Um, but the, to get to the meat of [00:36:00] what we're here, um, the, my strategy is using dynamic assessment and I always like to joke and people are like, what is that? I'm like, it's not, not static and they just look at me like, okay, I need to, I need to know more. Um, but if I never learned about dynamic assessment in grad school, so I wanted to point that out because I hear a lot of SLPs kind of feel, not shame, but like a little bit embarrassed or I don't know if there's a better word cuz it's professional, but they feel a little bit less than if they've never heard it before. And I wanted y'all to know, like I just started using that term four years ago and I don't even know if I even used it in the right context. Um, I used it, I heard it from, from uh, Dr. Edith Strand on her, [00:37:00] uh, childhood apraxia of speech course and free videos. She talks about, um, dynamic motor speech evaluation. And I was like, oh, that's what I'm doing. Um, but I come from a psychology background and I learned about mediated learning in my undergrad and a little bit in grad school. So that's kind of my perspective of where I started. And of course it came from an area of, I needed to do something because all these tests were not, uh, working for my population, but that's where I come from. So if you are feeling a certain way, because you've never heard of these things before, like, forget about that, that's just like we know about it now and we'll move forward. Um, because that's kind of how it happens for all of us. But, um, it really is just looking at a skill, figuring out where the student is at and then doing a little bit of teaching or support and then figuring out where the student [00:38:00] is at after. So whether you look at it from a lens of mediated learning, like, uh, Vygotsky, Zone of proximal development, or whether you look at it from a lens of, uh, dynamic assessment and levels of prompting, uh, it's all just, Hey, what can this child actually dowhen I help 'em or when I remove an obstacle, um, and for me and bicultural, bilingual children, a lot of the times is what can this child do if I just explain this in their home language, or what can this child do if I take this really, uh, niche, vocabulary word, like s'mores, you know, that maybe not culturally appropriate to their life, what if I substitute s'mores for something that's culturally appropriate for them and see if they can make me that sentence? Um, so that's what dynamic assessment looks like. [00:39:00] And that's been my biggest tool for becoming, uh, more culturally competent in my evaluations. But I feel like a lot of people look it up and they see mediated learning and test retest through all of these big words. And they're like, I don't have time for that. Um, I would say to them just, um, I think we linked it to the BIS examples on what to do. You can do it so quickly, just on a couple of items on the owls, say that a student had a hard time on a couple of items on the owls and you're done. And you did your clinician thing, your ones and zeros, which my favorite thing that I learned from Dr. Strand on that video was free on YouTube. Uh, she says we are clinicians, not technicians. And I, I always, I love that because you need to look be beyond all those ones and. So I will go to those zeros and figure out like, okay, if I [00:40:00] let them hear it one more time, does that help? If I, you know, say it in Spanish, does it help? If I provide pictures, does it help? And yes, I'm taking a little bit more time to do these things, but it makes my report writing that much easier. It makes my goal writing that much easier. My present levels writing, uh, even just your justification on eligibility forms, you have more than numbers to give. Uh, and I think we had that conversation yesterday with Dr. V as well. You have an actual, really good picture of the student and parents really connect to that when they feel like you really got to know that child, when you give an example of a response they gave and they're like, oh yeah, that sounds like my child. You really dug in there. I feel like I find more buy in anyway. Cause they're like, oh, you really are giving me the best picture of my kid. Um, so that's kind [00:41:00] of where I wanted to start off the discussion.  [00:41:01] Amy Wonkka:  I have a comment and a question. [00:41:03] Ingrid Owens-Gonzalez:  Yeah.  [00:41:05] Amy Wonkka:  Comment is that it sounds like you are being so thoughtful and that the example you gave with owls was really helpful for me. And you're being so thoughtful in asking further questions about, okay. So before, when I was being a technician, maybe I'm like, plus minus saying, going through and saying, these are the minuses, and you're asking more questions about why are these minuses? Are there things that I could change that would make them no longer be minuses. And so my comment with that is that any of that information you find out as a school based person, I think is also awesome stuff to put in the accommodation section of the IEP, if your state has an accommodation section. Um, and I guess a question I had that that may not be super answerable in this modality, but if somebody's used to kind of relying on that more technician type approach and saying like, okay, here are [00:42:00] the pluses, the minuses I've identified the deficits. Um, are there, are there helpful tips about the types of questions we might wanna ask as clinicians to dig a little bit more deeply? And then also how, how we can think about interpreting the information that we get. So if I haven't done this before and I feel a little uncomfortable, but I, I know I wanna start doing incorporating dynamic assessment more into my work. Um, are there patterns I look for? And that might make me think, okay, this, this is sort of tipping the scale for me in terms of. I I'm more likely to make this client be eligible for services versus, oh, no, actually I don't really think this person, um, should be receiving services. I didn't know if you, if you could talk us through a little bit of that. [00:42:45] Ingrid Owens-Gonzalez:  I can, unless Liza, Desi  [00:42:48] Desi Pena:  I can jump in. I wanted to add before we get a little bit too far, so. Part of this, um, objective that we're reviewing today, we actually covered in the first episode as well, when we talked [00:43:00] about ethnographic interviewing. So hopefully in your ethnographic interview, you've gotten some information from the parent valuable information, unbiased information. The whole idea with dynamic assessment also is it's an unbiased approach. So you've hopefully already gotten from them a sense of whether they're concerned or not. So I would say start there if the parent is concerned and they're saying, yeah, you know what? This kid is just not like my other kids, you know, they're highly distractable or I don't understand them or yeah, whenever we go to Abuelita's house, like nobody really understands what message they're trying to share with anybody. Right? Like you already have that in the background. Right? So then you go into your test and let's say, um, let's say the parent isn't concerned. And then you go run into this question with the s'more. I love that example. Right? So you run into this question with the s'more and you're like, okay, well really we're talking about like in this subtest they didn't [00:44:00] understand this question and there's a s'more they didn't understand this question. And it's about going to the veterinarian. They didn't understand this question. And it's about, um, uh, swimming in a, in the ocean, right? Well, maybe they don't have a pet. I mean, I know that in my family, like having pets, my family thinks pets are gross. Like, it just, you know what I mean? Like, I, it might be something worth asking yourself like, Hey, do you guys have a pet? Do you know anybody who has a pet? Do you know what a veterinarian is? Like, that's a new term for my son, cuz we don't have a pet. Right. Um, thinking about, okay, maybe they don't swim. Maybe culturally there is a boundary, like some swimming isn't part of something that they do. Maybe they've never been to the beach. Right. We're looking at what experiences they may have had and may have not had. Right. So I'd say that that's really important, especially if the parent's not concerned. Um, And I don't know, you guys can back me up on this or shoot me down. Um, but I feel like that's when I would start saying what's the [00:45:00] cultural load in these questions that they missed. So looking specifically at the ones that they didn't get, what is the cultural load? What's the cultural exposure they would need to those concepts to get those questions right. Um, so I don't know. Do you guys have an opinion on anything I've said? I don't. I also don't wanna,  [00:45:19] Liza Selvarajah:  I support everything you're saying. Um, I'm thinking about food. Food is a big cultural thing.  [00:45:25] Desi Pena:  Food is big [00:45:27] Liza Selvarajah:  and in our initial interviews with the parents. I wanna know what kind of food your child eats that way. I'm not using a standardized test with cultural food from, you know, Canada, America, that this child is not exposed to. Cuz let's say the goal with this kiddo is intelligibility, but they're out here trying to say smore, but you're trying to find an SM blend in a word that they've never heard. Now I'm here trying to teach vocabulary that's irrelevant to their life. And then pronunciation, when I could be targeting words that are meaningful to them, that [00:46:00] they want to be requesting at home and that parents understand. So I'm thinking about, um, Amy your question about like a, a data driven kind of clinician, which is what we were taught to be. And if you get a list from home of what the child eats and you find pictures, like you're even developing that relationship with the family and the child, I care about you and what your life is like. I'm not trying to pull you into mind. I'm here to support you, not fix you. . So all of that in there just plays into the relationship, which builds stronger communication skills. Cuz how much stronger are we as communicators when we feel a connection with the person that we're talking to. So I know I'm jumping into a lot of different things here, but to go back to the original question, I would get a list from the parents of food that the child eats. And I would show them that food and have them label the food as I would on a standardized test, but now more cater to this child. Um, and then from there we could, we could write up some goals.  [00:46:56] Desi Pena:  And I was gonna say, this is a nice thing too, like for a [00:47:00] private practitioner or somebody works outpatient, you can have them do this at home. Like this is like the intake call when you're calling them to get a sense of what's going on. These are all things that the parents can just prepare and bring. And, you know, in the two weeks before they come to your evaluation and hopefully you've explained to them the value of doing it. And so they, therefore they bring it. It's not to say that they will cuz sometimes it doesn't happen. But, um, you know, I think that there's so much, uh, again, value in giving them, let, letting them know that collaborative, Hey, I need to know what you culturally value, bring it with you. Don't leave it out. Like I know that that's the, the, the general feeling, right? That that's, that's separate. It's not, it's essential.  [00:47:48] Liza Selvarajah:   I have a quick story to share and I, I may have shared it on the last episode. So you could take it out if I'm repeating myself, but during COVID when we started zooming in with the families and seeing kind of like the home [00:48:00] life, it really broke that barrier of like professional in school. And it wasn't just a progress report the parent was getting or, or an evaluation. They were really like there for the sessions. And one big thing when I, it was really eye opening for me, I was doing, um, a little standard test with a kiddo and the parent was like, oh, they don't know that. We don't eat that at home. Just putting it out there. And I, I can imagine myself in grad school being like, well, this is the test, please be quiet. you know, and like trying to really meet this like experimental type of, uh, controlled. I wanna, I would want it to control every variable so that I have like the most reliable data back in the day. Now I'm like, you're so right. I turned off, I like stopped sharing screen. And I was like, why don't you open your fridge and tell me what's in there.  And she really pulled up her kid and her kid started labeling different things. And then she said, oh, she never says milk because I don't know that word is hard for her. Like, it was [00:49:00] so much easier for me to draw these, like, um, I wanna say a treatment plan, but draw goals and objectives. Very measurable ones right there in front of me all because we just broke that whole evidence based. I need all this external, I need to test it this way. And yeah.  [00:49:18] Kate Grandbois:  And just for the sake of coming full circle and moving into our third learning objective, I just wanna point out how in that story in, in most of what, what you all said is really focusing on client perspectives and values, client perspective, caregiver values, which is evidence based practice. So again, we think so often in our, in our professional culture, how we are, you know, the messages we receive and how we approach an evaluation or how we approach the story that you just told of, of assessing someone over zoom, um, and relying on this component of external evidence, but taking the child and lifting them into the, using the [00:50:00] vocabulary. That's evidence based practice because it is patient centered client centered care. Um, before we talk more about our final learning objective, I just wanted to go back quickly to the concept of dynamic assessment. And piggyback a little bit on something. You said Ingrid about how dynamic assessment can feel like a very intimidating term, because it's not necessarily something that we've taught. It feels very elusive, sort of like, oh, this mysterious assessment that I've never, cuz it's not a, it's not a test booklet necessarily. It's not something that you buy. There's no directions that you follow. It's not, it doesn't live in a box. Right. And in the assessment world, sometimes we feel more comfortable in a box with our directions. And what, and what have you. Um, I, we had, we've interviewed some researchers on dynamic assessment on the podcast before, so we can link some references in the show notes to talk a little bit more about what dynamic assessment is. It's a whole field of study. We're never gonna cover it in the context of this episode, but I wonder [00:51:00] if you could tell us for our listeners who might not be as familiar, what does dynamic assessment look like for you? If someone is listening and thinking, okay, now I know I need to do dynamic assessment or rely on that as a strategy. What's next? What does that mean? Like what does it, what does it look like?  [00:51:18] Ingrid Owens-Gonzalez:  I'll answer your question by answering Amy's because, oh, this is interesting. My grad, my graduate students and, um, that I've supervised and clinical fellows that I've supervised. Whenever I talk about dynamic assessment, they get that we have to do ethnographic interviews that we have to balance the triangle, um, that we still have to do some, um, standardized assessments because of the. You know, field that we're in because of, uh, the setting that we're in. Um, and then they stare at me and they're like, well, then now what? Um, so Amy, my answer to your question, and hopefully Kate's is, start with a test that you're comfortable with. [00:52:00] So we'll go with the owls example you gave the owls, you did perfect, totally controlled everything, you know, perfectly chef's kiss. Uh, the authors would be so proud and then you go back and you look just, they have it for you. They have the patterns for you in the back, what each one in zero meets. And I think a lot of people don't go back there to see what does this zero in question number 33 mean, oh, it's about syntax. What does the zero in question number 63 mean? Oh, it's about synonyms, uh, or 45 is about opposites. And you start there, you build that pattern. If you're not comfortable with gleaning information from a family interview, uh, gleaning information from their work samples or from their teacher, um, observations, start there, start with the test and then go see the [00:53:00] patterns. And from there you see what tasks is this student having a hard time with? And those are the tasks that you go back to, whatever framework you prefer. I like the test. You already did it right. Then go to their teach and then retest or teach retest. So test retest, I'm getting all confused. Test, test, teach, teach retest test. So you already tested and you already found some patterns and you wanna go back and see if with some support. Visual support, explaining it a different way. Uh, maybe in a different modality with some manipulatives, if they can get that concept, all dynamic assessment is, is taking away the bias of learning because you're not testing learning, we're not psychologists, we're testing language. So that's what I would say to my [00:54:00] students. Go to what you already have, what you're already comfortable with, what was drilled to you in grad school yeah. And then leave up behind and trust in your clinical experience because it's not ephemeral like clinical experience is just what it is. You've learned patterns from living through different sessions, different meetings, different clients, different CEU providers, speaking to other professionals. You're just picking up information, just like we pick up everything else. Um, you know, we all get better and better at driving somehow and we never take a driving class again. so that's kind of how I look at it. and I hope that I answered the question, Kate and Amy,  Kate Grandbois: you did.  [00:54:48] Desi Pena:  I was gonna say, I was gonna say the really cool thing too. I don't actually use the owls, but I use the CELF, um, unfortunately, um, but I use it, um, and I do the [00:55:00] same thing. I just literally see which ones they got wrong. So like on the CELF preschool, if anyone, you know, has access to the protocol or can think of the protocol, it has like a little box, a little grid at the bottom right hand. I just circle the ones they got wrong. And that's where I start looking for those patterns. Oh, it's always, when there's a descriptor, you know, on adjective use in the sentence. Oh, it's always when or when it's an ordinal concept, right? Like I start there and think. Oh, okay. Let me go back. And, and it's that, it's that teaching phase that is the most important part of a dynamic assessment. Okay. You got it wrong. Let me teach you how many times do I have to teach you? What visual, you know, am I using visual supports? What kind of queuing, how much queuing, how accurate are you after I remove all those cues and prompts? Um, and that's I, and I, I think what's also fascinating about this conversation is I think we should, we should already be doing this. Like, I, I think [00:56:00] that the thing that's shocking to people is the name dynamic assessment, but we should be doing this. Like I think about, um, testing articulation. Well, I wanna know how stimulable they are. Right. So I'm gonna go through my Goldman Fristo for anybody, everybody, right? Like, let's just say it's somebody who is a general American English speaker. Right. And there's no other culture. There's no other language. I'm gonna go through and say, wow, they got all those words with final consonants wrong. Okay. I'm gonna probe for, uh, final consonant deletion as a chronological process. So let me pull out these few words. Let me teach the child. Hey, you know what? This word has a tail or this word. Um, you know what I hear at the end, I hear this sound and see if they can do it alone, or if they need more support from me. So I feel like, you know, again, not to make anyone feel uncomfortable or like this is super basic and what are you doing? No, no, no, no, no. [00:57:00] Like let's undress the term because the more we undress it, the more we understand, oh, this is just probing. Like we're just taking a treatment target and trying it out. That's essentially what dynamic assessment is. And it's so important for multilingual, um, students, multicultural students, because they're at an unfair disadvantage when we lean so heavily on those standardized assessments that were not based on them. [00:57:30] Kate Grandbois:  That was so well said. I love the term undressing. Um, and, and just breaking it down, demystifying it so that it's not as intimidating so that clinicians can apply this, um, and be more effective in their, in, in their assessments. Um, in our last couple of minutes, I know we've, we've woven conversations about the three-pronged evidence based practice model throughout this conversation, but I just wanted to wrap up by, you know, really taking a minute to talk [00:58:00] about the importance of balancing those three components and what that feels like. I know in a lot of the stories that you've told you've illustrated, what balance feels like in terms of integrating, um, client perspectives and values with maybe, uh, with maybe the external evidence that you need to take. So, um, in some of our previous coursework on assessment, we acknowledge that in some instances, you, in some instances, instances, you have to conduct a norm referenced assessment because insurance will require it or your state requires it for eligibility. Um, so I, I love the term balancing in the subjective because it does encompass how you can move through this experience with prioritizing what you need to prioritize, to do an effective, uh, to conduct an effective comprehensive assessment. So what can you tell us about, um, the balancing act that clinicians may need to do when, when moving through this experience,  [00:58:58] Liza Selvarajah:  I think not being afraid [00:59:00] to firstly, the dynamic assessment just , it makes me laugh because every case becomes a complex case when they don't fit our usual way of testing. So if you run into a complex case, which is basically everyone, now you have to dynamically assess. So that's just, [ [00:59:17] Kate Grandbois:   I wanna some air quotes happening here for lots of air quotes. Sorry, lots of air quotes [00:59:22] Kate Grandbois:  No, no, no, it's fine. But you know, but you're right. Any quote complex, um, situation is, is, is not necessarily complex.  [00:59:32] Liza Selvarajah:  So now that, so now that we're dynamically assessing, there's a lot of teaching happening within the dynamic assessment and that's where I feel the client values and, um, our clinical judgment comes in and I feel that's where the balancing act is. If you do appropriate. Assessment. So within it, if you're teaching, if you're listening to parent feedback, you know, not being so, um, sciencey about it, I think we're really trying to [01:00:00] turn these kids into tiny little science experiments, where you got this score. Therefore you fall into this category, therefore this is your diagnosis, but it isn't like that. So if you really wanna balance that triangle, it all starts with like an appropriate assessment.  [01:00:16] Desi Pena:  And I was thinking, cuz I know you guys, you Kate and Amy do a lot of AAC evaluations, right? Those are complex. Let's put the air quotes in there. You know, you can't necessarily give a full standardized speaking language assessment to children who are non-speaking,  [01:00:39] Amy Wonkka: who are also not in the norms, usually correct. Captured in the normative sample. Right.  [01:00:44] Desi Pena:  So maybe if that maybe if we tie it back to that, um, you know, again, in, in, in the hopes of demystifying this whole process, right? Like. It's the same exact process, right? If you're confronted with a child who is exposed to [01:01:00] general American English, and they are, um, you know, monocultural, I'm trying to think of a they're, they're only exposed to one culture, right? Um, it's the same process, right? Just to, I, it, this is out of your comfort level, um, potentially because of what we discussed in the first episode of this series. Let's try to think of it this way. Maybe if it's harnessed this way, it will feel a little bit less complex to per se. But I think that, um, you know, really going back to the idea of, okay, this tool, isn't giving me the information I need. Uh, so what Liza was saying, right? This tool, isn't giving me the information I need. What is the information I need? And just asking yourself that question and then trying to balance it out. Okay. I've not had this situation before, but I am a clinician. I've not had this situation before, I have, but I have this parent, how can I level these two things? How can [01:02:00] I operationalize these two things so that I can move toward a better decision making process? Cuz that's what, you know, again, we, we talked about this very briefly, but evidence based practice is a process. So even if you have to like sketch this out, you know what I mean? Like I, I feel like again, If you can find, um, if you can find or advocate for yourself as a clinician for more time for these evaluations, I think that's another piece too, you know, as another solution or strategy, you know, say, Hey, this isn't straightforward. I need to do my ethical best by this child. If you expect me to take on a complex evaluation, uh, for example, for a non-speaking child and use X amount of time, this is this, this should be dedicated and we should really be spending a lot more time in making sure that we get this right for this family, for this culture, for this community. Um, so that's something else to consider adding to your [01:03:00] toolkit. Um, it's really the idea of how do I peel back the layers of my cultural discomfort and enter this space to do right by this child and this family.  [01:03:11] Amy Wonkka:  I just wanna say I 1000% agree. That's all. Thank you. [01:03:14] Liza Selvarajah:  Just listening, just really just listening to the kid, not through your lens, but through theirs, going back to the interview process, we talked about last time, last time on the CELF, there is a question with a banana and an apple and a glass of milk. And the child is meant to say apple and banana, uh, because that's the fruit and my kiddo said banana milk. And I said, why did you say that? And he said, every morning I have a glass of milk with a banana. That is correct to me, that is clinical judgment. That is a clear explanation to how those two went together. And if you're stuck in, but the norm and the standard says that only fruit should be placed together. That to me is a dynamic assessment, even though you're [01:04:00] using a standardized tool,  [01:04:03] Kate Grandbois:  that's such a great story and such a great point. Um, and I know as clinicians, you know, when we are experiencing, are going to write these up, right. And going to explain the findings of our assessment, and maybe we're in a situation where we had to use that assessment and we had to score it. But then just being able to explain that those scores don't represent the child's actual functional skill, because that is not the point of a norm reference assessment, norm reference assessment don't measure idiosyncratic skill changes. They don't, they don't account for, for personal experience or, or culture. That's not, that's not what they're there for. So even if you are and listening, and you're in a situation where in that exact story you felt even, you know, reflecting back on a choice you made you've, you did score that as quote, wrong. You can still use narrative and clinical judgment. Again, balancing this triangle to explain that score to [01:05:00] diminish that score, to put context around that score. Um, and of course, if you're in a position where you don't have to use that score, don't use it because it's not accurate, valid and reliable measurement. [01:05:11] Desi Pena:  Yes. That's it. I mean, yeah. Why use something that you don't need? Um, again, I feel like we're gonna we should like link this episode to the episode we just did with Dr. V's because she said the same thing use a checklist. Why are, why are you using like use an observational checklist go to that child's classroom? Ask the teacher, like, why are we relying on, you know, can they repeat this sentence about a nurse? Right? Like, this is one of the questions on the CELF,  [01:05:44] Ingrid Owens-Gonzalez:  my mom is a nurse at the community clinic.  [01:05:47] Desi Pena:  Oh, my word, right? Um, no, maybe my mom, I maybe, I don't know what a community clinic is. Um, but  [01:05:56] Ingrid Owens-Gonzalez:  I think it says my mom is the nurse at the community clinic. I'm like, [01:06:00] who talks like that?  [01:06:01] Desi Pena:  The nurse. Wow. Yes. Is it really the nurse? Okay, well, um, . Yeah, but I, you know, I think that we've come to this point where it's really crucial to set standards for ourselves, um, and to make sure that we are carrying out these evaluations also, just so we can make good treatment decisions too. Um, you know, obviously we wanna rule in and rule out, but no standardized tests and unfortunately I've seen this way too much, but no standardized tests should be dictating your goals. I've seen it way too often.  Kate Grandbois: Here here  [01:06:40] Ingrid Owens-Gonzalez:  standard. We get a little,  [01:06:43] Liza Selvarajah:  yeah.  [01:06:45] Desi Pena:  Yeah, pricing. One more goal about adjectives and a verbs. I'm gonna lose it.  [01:06:51] Kate Grandbois:  we, we, we, and there are lots of references for that. There that's been well documented in the literature that writing goals and objectives based on scores of a test [01:07:00] is inappropriate for a whole host of reasons that we obviously do not have time to get into, but we can link some of those previous episodes we've done. And some other additional literature in the show notes for anybody who does wanna learn more about that relationship. Um,  [01:07:14] Ingrid Owens-Gonzalez:  yeah, I just wanted to add to that last objective. I always go back to my question from last episode, who are you doing this for? Who are you doing all of these batteries for? Um, it's not gonna help the parents understand the teachers, understand it's not gonna help you understand. It's just gonna, what make it easy to fill in some boxes on your report template? I know it seems daunting, but really whenever you do dynamic assessment, the reports write themselves when you have all this information. And the thing that I like to tell my students, whenever they're like, oh, it's, it's more time. I'm like, not really. You're giving yourself credit for things that you already do. You're just putting them on your report so people can see [01:08:00] all the things that go into you making this recommendation. And even as an 11 year old veteran yesterday, I learned a new thing that I need to give myself credit for, that I never have before from Dr.V she talked about portfolio. Um, what was the word she used portfolio review assessment or review? Yeah, maybe portfolio review. I'm like I do that all the time. I don't receive a referral and that's credit to our, um, counselors and educational diagnosticians in my district is not coming from me, but my referral packets always include work samples and I always review them. And I always use them to inform what I'm doing, and I've never known how to give myself credit for that until Dr. V yesterday gave me the words for it. And so if you're looking at this, this is new, this is different. This is daunting. I really urge you and challenge you to twist that lens back and say, I already am great at this. I already did this master's degree. I already have all these years under my belt or [01:09:00] even months under my belt. And I already think about all of these things when I'm making these choices. And I want to give myself credit for them. [01:09:08] Desi Pena:  Yeah. Be a clinician, not a technician.  [01:09:14] Kate Grandbois:  it's a great quote. It's a really, really great quote.  [01:09:17] Ingrid Owens-Gonzalez: Yeah. That's  all Dr. Strand. Yeah. It's on the YouTube [01:09:19] Kate Grandbois:  and we we'll link we'll link all of the link, all of the references and resources. We've mentioned a lot  throughout the course of, of this episode. [01:09:26] Ingrid Owens-Gonzalez:  I need to give you more links. [01:09:29] Kate Grandbois:  Yes. Yes, we will. We will get them. Don't worry. In our, before we say goodbye, do you all have any advice for any of our listeners who maybe would like to learn more if this is their first, um, time coming in contact with these concepts of evidence based practice, balancing the three-pronged approach, dynamic assessment, potential harm of norm reference tests? What, what final parting words of wisdom can you, can you leave our audience with  [01:09:55] Desi Pena:  this isn't wisdom? But DM us, send us a message on Instagram. [01:10:00] Um, listened to our podcast, shameless plug, shameless plug. Um, I just think that the conversation shouldn't stop here. And if you're at the point where this is an uncomfortable topic and you're still like, wait a minute, what, please reach out. Um, we always try to respond to DMS. Um, and you know, the three of us are open to connecting. Um, So I think and finding a mentor. That's the other thing I don't know. I know that Ingrid and, uh, Liza mentioned mentorship, but it's so important, especially if you're navigating new waters. So I'll let you guys,Yeah. If you have anything else to add,  [01:10:44] Liza Selvarajah:  I get DMs on TikTok and Montreal speech therapy, and I just like tell a story so that everyone can hear it. So they get the question and the story so that I could support a lot of other SLPs out there.  Uh, but there's a quote I saw [01:11:00] on JRC, the SLPs, Instagram, uh, connection over data collection. So that's what I hold true  [01:11:07] Desi Pena:  here. I think Ingrid came up with that, right? Mm-hmm  [01:11:11] Liza Selvarajah:  stop.  [01:11:13] Ingrid Owens-Gonzalez:  I was so proud whenever she DMed me and she said, do you mind if I print this? But mine's a little different cuz I did connection. And then I did the greater than yeah. Back to my math nerdiness. I did connection greater than data collection and [01:11:31] Liza Selvarajah: oh my gosh, Ingrid, look at that. And I was like, there was a quote  that Ingrid came up with  [01:11:35] Kate Grandbois:  no cause connection is greater than I love it. Yes. Yes.  [01:11:39] Ingrid Owens-Gonzalez:  Oh, I love, I love Jordan. Uh, my last word as we do on our podcast, I think my last thing would be don't confuse internal evidence with client perspectives and culture. The triangle's already heavy on the evidence and then we're adding a whole nother wrench in the system. [01:12:00] Uh, I think that that happens a lot more than we think, like Liza was saying. Um, so that would be mine. And then give yourself credit. I think you're already doing a lot of these things. You just don't know how to write them down.  [01:12:14] Kate Grandbois:  That's awesome. Those were great. So good. As you say, the last words, those were great last words. Thank you all so much for joining us today, having you here is always such a treat we've learned so much from you. Um, as I mentioned, we will link all of the resources in the show notes. We will put a link to the bold SLP collective and podcast. Um, I can confirm everyone here on this panel is so friendly and so warm and so open to conversation. So if you are listening and you have additional questions or you wanna reach out, please don't hesitate. This is a, a very welcoming and curious and wonderful group of women. Um, Thank you again so much for being here. We're so grateful for [01:13:00] your time and I am a hundred percent sure we will find a way to collaborate with you again soon. So thanks so much for being here. [01:13:07] Desi Pena:  Thank you. [01:13:13] Kate Grandbois:  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com Thank you so much for joining us and we hope to welcome you back here again soon.

This is a transcript from our podcast episode published November 14th, 2022. The podcast episode is offered for .1 ASHA CEU (introductory level, related area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. S4 The Bold SLP Collective [00:00:00]  [00:00:00] Kate Grandbois:  Welcome to SLP nerd cast, the number one professional resource for evidence based practice in speech, language pathology. I'm Kate Grandbois  [00:00:09] Amy Wonkka:  and I'm Amy Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast.  [00:00:16] Kate Grandbois:  Each episode of this podcast is of course offered for ASHA CEUs. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course. Plus the corresponding short post test is equal to one certificate of attendance. To earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLP nerdcast.com . [00:00:41] Amy Wonkka:  Before we get started, one quick disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise specified. [00:00:53] Kate Grandbois:  We hope you enjoy the course. [00:00:55] Announcer:  Are you an SLP related [00:01:00] professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ASHA CEUs, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited CEUs all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes.  [00:01:43] Kate Grandbois:  Welcome everyone to today's episode. We are so excited to welcome the founding members of the bold SLP podcast and collective welcome Ingrid Owens -Gonzalez, Liza Selvarajah, and Desi Pena. [00:02:00]  [00:02:00] Liza Selvarajah:  Hello,  [00:02:03] Desi Peña:  Hey you guys.  [00:02:05] Amy Wonkka:  We're so happy to have you here with us today. Um, and you are here to discuss issues related to culture bilingualism and speech language pathology. But before we get started, uh, could you please tell us all a little bit about yourselves?  [00:02:21] Ingrid Owens-Gonzalez:  I can go first. My name is Ingrid Owens-Gonzalez. I've been in SLP for almost 11 years now. Uh, I am a graduate of the University of Texas at Dallas. Um, and then also New Mexico state university for my undergrad. I have two girls. And I've been married to my husband and we moved here to New Mexico, his hometown, uh, for over 10 years now. Um, and yeah, I'm on Instagram, my speech blend and the bold SLP collective, just trying to make connections, starting my private practice, just new [00:03:00] adventures all the time as I go along in this SLP journey. [00:03:04] Desi Peña:  All right, well, I'll step in next. Um, I'm Desi Pena. So I have been practicing as a speech pathologist for five years. Um, I'm a bilingual English, Spanish, um, speech pathologist, and I've lived all over the east coast. Um, I most recently landed in Maine a few years ago. Uh, thanks to my husband's work. Um, I work mostly with early childhood, so. Between the ages of like two and 10, approximately? Um, I, it was really great. A few hmm. I was gonna say maybe about almost two years ago, I met Ingrid on Instagram and that's how we started, um, getting together. And eventually Liza got wrapped up in it too, and we created the bold SLP podcast. Um, and so I think that's it for me. What about you, Liza?  [00:03:59] Liza Selvarajah:  Yeah, my name is [00:04:00] Liza Selvarajah. I'm a speech and language pathologist in Canada. Um, I own a company called Montreal speech therapy, and I've also been doing a lot of school based work. I'm a clinical educator with our local university here, and I'm super passionate about mentorship and collaborating with other SLPs. That's why I got wrapped up in the bold SLP collective. Um, I'm also very big with social media. I think that that's such a powerful tool and that's kind of what brought all of us together today too. I'm a mom. Um, I dance, I sing outside of speech therapy and uh, yeah, that's it for me.  [00:04:38] Kate Grandbois:  We're so excited to have this conversation with you all today. Before we jump into it, I have to read our learning objectives and our financial and non-financial disclosures. Learning objective number one, describe the role of culture and cultural erasure in the field of communication, sciences, and disorders. Learning objective number two, describe the difference between a traditional intake [00:05:00] interview and an ethnographic interview in the evaluation process, and learning objective number three, describe the difference between collaborative and authoritative approaches to applying an evidence based practice model when completing multicultural and or multilingual evaluations.  Disclosures Ingrid's financial disclosures. Ingrid is the owner of My Speech Place, LLC. And is the employee of a public school. Ingrid also received an honorarium for participating in this course. Ingrid's non-financial disclosures. Ingrid is the co-founder of the bold SLP collective and the co-host of the bold SLP podcast. Ingrid is also the co-founder Ingrid is also the co-founder and lead mentor of the bilingual empowerment through allied mentorship program and an Asha step mentor. Ingrid is also the mother of two bilingual and bicultural children. Liza's financial disclosures. Liza owns a private practice called Montreal speech therapy. Liza also received an honorarium for participating in this course Liza's non-financial disclosures. Liza is [00:06:00] the co-founder of the bold SLP collective and the co-host of the bold SLP podcast and is a mentor of the bilingual empowerment through allied mentorship. She is also the mother of the bilingual and bicultural. Desi's financial disclosures. Desi is the owner of Panorama speech therapy, LLC. And is faculty of the main New Hampshire leadership education in neurodevelopmental disabilities program. Desi also received an honorarium for participating in this course. Desi's non-financial disclosures: Desi is the co-founder of the bold SLP collective and the co-host of the Bold SLP podcast. Desi is a mentor of the bilingual empowerment through allied mentorship, and she is a child of Cuban American exiles, and is also raising a bilingual bicultural. Kate that's me. I am the owner, my financial disclosures. I am the owner and founder of Grandbois therapy and consulting LLC. And co-founder of SLP nerd cast. My non-financial disclosures. I'm a member of ASHA SIG 12 and serve on the AAC advisory group for Massachusetts advocates for children. [00:07:00] I'm also a member of the Berkshire association for behavior analysis and therapy and the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis, special interest group. I'm a person of monolingual experience and a person of cultural and a person of cultural privilege as a CIS white woman in the United States of America.  [00:07:19] Amy Wonkka:  Amy that's me. Uh, my financial disclosures are that I am an employee of a public school system and co-founder of SLP nerd cast. And my non-financial disclosures are that I'm a member of Asha and a member of Asha sig 12. I serve on the AAC advisory group for Massachusetts advocates for children, and I am also a monolingual person of cultural privilege as cisgender white woman in the United States of America.  [00:07:42] Kate Grandbois:  So before we get into all of the really wonderful conversation today, and before we start learning from the three of you, I wanted to just reflect on a conversation we had right before we hit the record button. So here at the nerd cast, whenever our guests join us, we go through a couple of housekeeping [00:08:00] things. We review our learning objective. We confirm the title of the episode and we review and confirm our financial and non-financial disclosures. And as we were going through those financial disclosures and non-financial disclosures and discussing what a non-financial disclosure was, what our lived experiences were that may cause us to present information in a certain way. Liza brought up a really good point and it generated a really great conversation. And I wanted to know if you could walk us quickly through the point that you.  [00:08:33] Liza Selvarajah:  Definitely. So this is new to, to us, I think just all the disclosure business. And so we had a lot of questions about what, what is meant to be disclosed and what, what exactly do you need to know? And what you so graciously explained was, are you bringing any bias into the conversation? If you are, then you need to disclose it. You didn't label any of the biases you just said, do you feel you're bringing any biases? And we somehow felt the need to talk about our biracial [00:09:00] bicultural kids and our backgrounds and, and something about that got me thinking, like, why are we othering ourselves? And like, what are we othered from? We're othering ourselves from a standard. And what is the standard? Cisgender white. And so neither of you, I think before this had ever disclosed that you were white or privileged or cisgendered and all of a sudden you're like, yeah, I, I didn't disclose it because it's the standard I'm putting giant quotes. You can't see me on the podcast.  [00:09:30] Kate Grandbois:  That's what I was doing. lots of air quotes happening over here, but it was such a  [00:09:34] Amy Wonkka:  good point. And it was, and it was such a good point that as members of a majority group, we actually one could argue have potentially the most bias coming into this conversation. I mean, particularly like reflecting on our learning objectives, um, you know, and, and it was, it was, you know, you'll notice our learning objectives or our disclosures look differently or sound differently on [00:10:00] this podcast than they ever have before. And it is an interesting, it was interesting for me to reflect on my personal bias and. All of the conversations we've had with so many different people on this podcast. And that, that question has never been something that I've raised myself. Um, so anybody who is listening, I think that that would be an interesting exercise to sort of ask yourself that question. What groups do you identify with? Um, and, and what potential bias does that give you? And have you ever asked yourself that question?  [00:10:36] Kate Grandbois:  It was such a good question. It was such a good question. And I think it's a nice, I know we're sort of starting off this episode with a very, uh, serious tone in terms of self-reflection and intersectionality, but it's a really, it's a, it's a, one of the most important threads of this topic that we are now going to hand over the mic to you all, um, to teach us. And I wonder if you could talk to us a [00:11:00] little bit about identity and bias and how that relates to culture in our first learning objective.  [00:11:07] Desi Peña:  Yeah, so I'll start us off. Um, I wanted to, I'm just such a nerd, so I'm on the right podcast. Um, I brought, um, this book, uh, with me, uh, it's called culturally responsive practices and speech language and hearing sciences. And it's by Dr. Hyter, uh, Dr. Hyter and Dr. Salas-Provance. Um, so this book is really wonderful and I was, um, introduced to Dr. Hyter through a continuing it that she offered back, uh, at the beginning of this year, 2022. Um, and she just rocked my world. I think that it was a conversation that I didn't really get to witness very often in speech therapy circles. So she really talked about the role of culture, the role of identity and the way that we, um, even discuss our own identities. Um, [00:12:00] So she, um, very much is a proponent of disclosing like positionality, like what sort of privileges you hold, what powers you hold and also, um, you know, what your racial or ethnic markers are, right? So she presents those up front. So it's something that we, as a, as, um, members of the bold SLP collective we've always discussed, um, and having this opportunity come on the podcast is really a great way for us to kinda structure that conversation. Um, as it's something that really runs its course when we record together. But, um, we've never presented it from this angle. So I'm happy to start with some definitions from Hyter’s book. And that way we can kind of just jump into the topic itself. Hyter for example, in her book defines culture at its core culture, as a set of factors from multiple dimensions that can describe how one person or a group of people experience life and engage in daily practices. [00:13:00] Culture is learned and transmitted socially through patterns of behavior driven by such factors as problem solving strategies, value systems, beliefs, symbols, attitudes, religions, artifacts, and communication. So all to say. Um, one of the reasons that I really thoroughly enjoy this book is because, um, as you're reading it, she actually gives you little vignettes stories of, um, where you can kind of place yourself in these new cultural context. So, um, kind of funnily enough, in the first chapter, she talks about going to a Matanza, which is, um, Something that I'm very familiar with. Um, as I mentioned in my disclosure, my family's Cuban American. We slaughter pigs and eat them. Um, so, you know, it's not uncommon for my family to go and watch the pig, get slaughtered, and then they bring it back. They put it on a spit and they just cook it up right in front of us over several hours. Right. We, we play music, we all get around the pig and we eat it's meat. Um, again, you know, so that was one of the [00:14:00] scenarios that she gave as an example, how comfortable would you feel? What are your biases going into that kind of situation? Um, So that's kind of the foundation for what we're hoping to talk about, right? Like what does culture mean? What are its core components and then how does that interplay with identity and then how does that relate to speech pathology? So in our view, um, and I hope I'm not talking over you guys very much, but I just wanted to say that, um, you know, for us it's essential and that's why the, this conversation is so important for us. We can't really disentangle language or communication from culture. Um, and sometimes, uh, we've observed that in our profession. There is this tendency to disaggregate those or to not consider culture as a backdrop, to everything that a person does. So it's really valuable for us to have this conversation, to highlight which ways we should be actually doing a deep dive into that [00:15:00] person's culture. And then what influence that culture might have on their communication behaviors, so that we are not imposing our own culture onto that child or that adult. [00:15:11] Kate Grandbois:  I think that makes a lot of sense, particularly when you think about what our profession is, I know it seems sort of obvious, but we study language. If language and culture are connected, and we have a hard time separating them as SLP. You would then assume that it's just as important for us to. At least consider culture. And yet I don't know about anyone else on this panel. I did not get any formal training in graduate school on how to consider and adjust my own perspectives or biases based on those considerations.  [00:15:48] Ingrid Owens-Gonzalez:  I didn't, I went to school a long time ago. Um, I hear from the new students that things are changing, which is very, very exciting. But [00:16:00] yeah, as you said, Kate, you know, when we go to school, um, a lot of us, me, myself, personally, I moved to the us when I was 16 from Mexico, I'm Mexican American, and I find myself learning a lot in grad school about standards and about how things work, you know, in X, Y, and Z setting with X, Y, and Z clients, uh, and never really going and learning about how to help my community. So I had to come out of grad school, learn that on my own and unlearn a lot of the things I had learned in grad school in order to serve my community in the way that was, you know, ethical and not harmful. So yeah, I, our program, my program didn't prepare me for that portion of my job as a bilingual speech therapist. [00:16:54] Liza Selvarajah:  I wanna jump on your, your pig story Desi. I love it so much. And it's so, so [00:17:00] beautifully visual because to one, something could seem scary or different. And then to another it's totally normal. And in our field, when something is different, it's a disorder. Or it's meant to be placed in a severity range. Um, I'd shared this story like already on, on the Instagram and TikTok, but there was a little four year old girl that I was screening a little Indian girl. And, you know, you have these common screening measures of like asking about food items or, uh, things in their pencil case, things like that. And she was like perfectly going through everything. But then when it came to food, she didn't wanna answer like, what is in your lunch box? She didn't wanna answer. And something about her told me that there is no language disorder here. She just she's trying to hide something. But I don't know why. And I, I couldn't tell if it was that she didn't have any food or if it's that the food that she had, she thought I wouldn't accept as a professional checking. [00:18:00] Cuz we know that like typically we're looking for things like sandwich, banana, apple, very like culturally white things that kids eat. So. She was silent for a while. And then I said, um, you know, in my lunchbox today, I have bryani and she was like, I have Chapi and I was like, and full points. Cause I'm not looking for what this test is. Like those specific words, right. They're not culturally appropriate for this child. I'm looking, can she communicate? Can she tell me what she eats? Yes, she can. So yeah, things like that to keep in mind.  [00:18:33] Kate Grandbois:  I think that is an awesome example of the intersections of the cultural quote, norm air quotes here, for those of you who can't see me and the, and the potential for a professional to jump right to disorder, to not pause, consider the role of culture in an individual's linguistic response or lack of response in your example, um, and [00:19:00] just jump right to, oh, fail, failed portion of the screening, this individual needs services. And we know that, and I, I don't have the literature right in front of me, but I think it's safe to say, maybe you all can share some of that literature. We know that over referral is a big problem. Um, and I think that was just a really great story to highlight how quickly, if you don't take that moment to pause and reflect on the importance of culture, how quickly that can turn into a referral for services that is totally not appropriate. [00:19:29] Liza Selvarajah:  I know we're going to jump in next time, um, to a like dynamic assessment, but just, just in terms of scoring, you know, that it, it just takes one point to move a child from like moderate, severe to severe, like it's, it's so arbitrary, it's so scientific. It takes the humanness and the connection out of it. And it treats our, our kiddos, like, I don't know, little standard robots with like same language, same culture. And that's, that's really what we're, we're trying to undo here.  [00:19:58] Amy Wonkka:  Well, and we've talked a lot on this show [00:20:00] too. Sorry, D I see that you're unmuted, but we've talked a lot on this show too. We've had some guests on, and I know today we're not talking in depth about dynamic assessment, but just talking about the inherent bias that is present in so many of our norm referenced standardized assessments, um, and which populations are even included in that normative sample. So there are a lot of, there are a lot of problems there inherent to, um, to assessment that we'll talk a lot more about in our next podcast with you guys.  [00:20:30] Desi Peña:  Yeah. And to feed off of that, I mean, we were, um, the, what Liza's talking about, like that practice, that ability to pivot, um, and say, okay, well let me figure out if I, um, maybe if I funnel it through the parent, maybe if I add a cultural element, maybe we can tweak a different response. Right. So that's that culturally responsive practice piece. Um, and so really we wanna take into consideration. Perspectives beliefs values. [00:21:00] And that can be tricky. Um, you know, especially if you've not really had exposure to other cultures or other ways of, um, experiencing what it is to live in a majority culture. Right. Cause that's kind of part of what we're talking about today in terms of bias, right. We all carry bias. Um, one of the points that we were hoping to talk about today is the role of implicit bias. Um, and what's been fascinating for the three of us Ingrid Liza and I to discuss is that we all carry bias that, um, from our own cultural perspectives, but also just like from white majority culture perspectives, because this is the way that we have been like professionally trained. You know, we all have administered standardized instruments that do not apply to children, um, of those backgrounds. And so how do we undo these practices? And one way is by recognizing that there are culturally responsive ways, um, there are ways to stop an [00:22:00] assessment and to say, wait a minute, before I deduct this point, what else can I do? So, um, again, yeah, not to jump the gun, but just to insert that this is what I, this is what stopping your bias looks like. It looks like pumping the brakes and maybe flagging that question coming back to it, referencing, um, someone else, someone who is part of that cultural group. Um, so anyway, that's just one idea and we'll, we'll keep adding more ideas, um, to your toolkit, um, in this conversation as to how to, how to just be a more responsive clinician. [00:22:36] Kate Grandbois:  And I, I wanna take a second and sort of loop this back to one of the first things we said in this episode of the, the power of pausing and reflecting on your own bias. So if you are listening to this episode and you are part of the, of the white majority, and you know, maybe you started this episode listening to Amy and I read our non financial disclosures and considering your own perspectives as [00:23:00] a, as an implicit. That is a great first step is just acknowledgement and reflection. Even if it is, feels uncomfortable or feels weird, or you just wanna have the conversation privately in your own head, and you're not ready to talk to somebody else about it. Just taking that minute to pause and consider that your own existence in the majority or your lived experience in the majority is an implicit bias that you can correct. Not necessarily correct, but you can account for, or mitigate through pausing. Um, and, and considering your, your, your own implicit bias.  [00:23:39] Desi Peña:  And I think this really brings us around to this idea of culturally erasure, um, which I wanted to hand off to Ingrid, cuz I, I feel like she really, um, embraced that concept. Uh, when we first started talking about this episode and I know it's something that has weighed on her as, um, an SLP and as a parent. So. [00:24:00] I hope I'm not putting you too much in the spotlight Ingrid, but I feel like you're definitely the, the bearer of that message.  [00:24:07] Ingrid Owens-Gonzalez:  I, well, for me personally, I think it started very early on in grad school. Um, assessment class is the worst grade I've ever gotten in my whole life, which is really ironic because I love assessment. I feel like I'm really good at it now. Uh, but back then, I was already asking questions that were not in the syllabus and that were not getting me the points I needed on the test. Um, but my first experience with erasure in this field, uh, was an assignment to go find a child to assess use the PLS or whatever was available. I think it was the tell actually, well, I went and found my neighbor and she's bilingual. Mexican American just like me [00:25:00] and I'm reading through the manual as I'm assigned, you know, and I'm like this little person that is volunteering to help me is not represented here. So I wrote that out on my report and that was my first inkling like this field is not designed for people like me, like, and I was, you know, 23 years old. So I'm already having that seed of like, oh, like this teacher is an expert in this. And her livelihood is, you know, here and her passion is publishing these things, but they're all based on white, upper middle class sometimes and neurotypical, monolingual kids and families. And they don't mean anything to me. And they won't mean anything to me in the reality of practice outside of this. And I was just starting my career. And like I said, it was the worst grade I've ever gotten. I thought I was gonna have to retake the [00:26:00] class if I didn't like bump up my C you know, cuz you need your B in your master's program because I just kept pushing. I was like not okay with the answers she was giving me about why, what did you with my assignment with the child that I found? Um, so that was my initial kind of like thread of how many other people are being erased and to start asking questions,  [00:26:24] Kate Grandbois:  I think that story highlights so many components of your you intersecting and brushing up against institutions. Mm-hmm . Um, but for our listeners who aren't familiar with the term cultural erasure, what is, what is that as a, as a construct, as a concept?  [00:26:44] Ingrid Owens-Gonzalez:  honestly, to me and you guys can look it up, like I'm not gonna read the definitions out there. To me, it just means, speaking for others, speaking for others who are of a different experience than you [00:27:00] and speaking for others under the assumption that you know better. And then in turn erasing the validity of their lived experiences of their culture, of their traditions. Um, so cultural erasure to me is just, we need to stop speaking to others if we wanna do some speaking for others, if we wanna do something about it. So, um, speaking for others is what it means to me. I don't know if Desi and Liza wanna jump in and help me out. I'm not the academic in the group. Um, when we were starting that conversation earlier, uh, I just wanted to highlight, because this is why I love these ladies so much. Like we were talking about disclosures. I had no idea what I should disclose, and I knew that something felt off about having to disclose that I'm in an interracial marriage that I have bicultural children. Like, why do I have to disclose that? So I started it off as a [00:28:00] joke. I think I said, um, do I have to disclose that I'm bad at volleyball? It's kind of like how I dealt with that feeling like I don't, it feels weird that my identity is being seen as something that can bring bias. And then Desi started asking questions and then Liza comes in with the, you know, the knockout punch and says, Hey, how come Kate and Amy don't have to disclose that they're white And so that to me is the absolute opposite of erasure. If that makes sense. Like, I felt validated just Liza saying that I'm like, oh, that's what I was feeling like. She gave me the words, like how come I have to disclose that I'm bilingual, you know? Um, so that to me is what erasure means.  [00:28:50] Liza Selvarajah:  I'm taking erasure as like very literally like erasing my culture all together. So right now, um, I [00:29:00] don't speak Tamil though my parents are from Sri Lanka and they spoke Tamil right through their lives until they came to Canada. And the way your tongue rolls and the way the language is spoken is very different from the way English is spoken, or maybe it's closer to Spanish with the Rs. And, um, so something like like, how are you? You know, is like I said that one day in, because I was talking about my uncle and the way he said something and my husband, who's black, like didn't was like, I haven't even heard those sounds come out of your mouth. Like it's so foreign to me. And that's when I realized how much of my culture had been erased. He hadn't even heard it. My daughter hadn't even heard these sounds, my daughter speaks French in English. Even though her grandparents fully speak, uh, Tamil and Sinhalese. So it kind of hit me in that moment. And I mean, we, and my husband was asking me like, what do you wanna do about that? Like how, how do we bring [00:30:00] it back? How do we not completely erase it? So thankfully our food, we still eat S Lanka and food. That's just a start just to like, keep that in there. Um, I just wanted to highlight that example, but something happened today that I messaged the group. I sent like a WhatsApp message to you. So I met, um, a Persian family this morning because their doctor had written all over the place that like, they think their child has a language disorder. Their child is not talking this and that. But I read on the parent intake form that they didn't see a problem. But since the doctor said to come, here they are. And it is expensive to have a language assessment. So I met with this family and the child is like fully chatting in Persian. They read a story together and I thought. Does your doctor know that you speak a different language at home? She was like, yeah, but like, I think she was just worried that like, not enough English is coming out and just utter nonsense. I was like, okay, well, these are the things I'm checking. And so say it in your language. I took a whole phonetic repertoire based on the words the child says in [00:31:00] Spanish, uh, Spanish. Sorry. Persian. I'm looking at you two. But yeah, I don't know. I thought the whole thing felt so icky. The fact that nobody asked like, well, is there another language spoken as opposed to just taking the silence as probably a language disorder, please go check. And this family. I didn't even charge them. I was like, this is ridiculous. Like we're not wasting each other's time. This was fun. Call me back when, when you need more help.  [00:31:27] Kate Grandbois:  well, and I, I, I, I so appreciate the stories that you're telling, because I think as, as human beings and for those of, for those of our listeners who are listening as human beings experiencing and listening to the experiences of others is a great way to highlight some things that are available for change. And in the story that you just told, where there's the physician making the referral without pausing and considering the role of culture and the risk of cultural erasure. I think about the [00:32:00] role of the speech pathologist and had that family landed in another. Speech pathologist clinic, who hadn't maybe done some work in cultural competency training, or hadn't considered the role of their own implicit bias. And again, that risk of referral for, and I'm using air quotes. For those of you who can't see me disordered language or language disorder, when there really is a larger component of, of being not in the being, not of the majority. Um, and in that lens, how much more important it is for us as the ones who are, and again, air quotes, diagnosing language disorders, people end up in our offices to investigate and provide the diagnosis, right? We are, that is so much more important for us as a profession. It's important for everyone, but we are often for a lot of families. One of the last points of contact before either for screening or for [00:33:00] evaluation before we get into this pipeline of services for not having a quote disorder.  [00:33:08] Amy Wonkka:  Well,and I, it makes me think of our second learning objective talking about the way that we are conducting our interviews is as, I mean, that's really where you start with a client that's where you start with a family. Um, so I didn't know if you, because I think that what I'm most accustomed to, my training was also a long time ago. I think that probably when you described traditional intake interviews and ethnographic interviews, I'm probably going to be doing a lot of things that fall under traditional intake interviews. So I was wondering if you could just talk us through what are those two different approaches to interviews, um, and, and what are some things that we can do to do better?  [00:33:52] Kate Grandbois:  I had never heard the term. Um, I will admit it. I mean, I think that this is something that's really important. And for anyone listening, who hasn't heard of this, that's okay. We're here [00:34:00] to learn. So please tell us about that and how they're different.  [00:34:05] Desi Peña:  So, uh, Carol Westby is, um, I think the most recognized name in terms of, uh, ethnographic interviewing, um, at least in the field of speech pathology. Um, so really the goal of it is just to have a more like conversation with families, um, using like open ended questions, um, I would say is the primary driver of what an ethnographic interview's goal is. Right. So, um, you would want to have them give examples, right? Walk, walk me through your day. What does this look like? What does that look like without inserting yourself and your own experiences. Right. So I think. We were talking about this a, a few weeks ago. And I said, right, like, I wouldn't ask you about breakfast per se, because maybe you don't eat breakfast. Um, and that may be tied to something [00:35:00] cultural and maybe just tied to your personal preference. But again, why would I wanna make that assumption that that's something that you partake in. When it's not something that makes a difference for you, if that makes sense. So, um, so I would say that that's mostly the basis of what, um, we are here to discuss. So I know it sounds very, very simple and very, very basic, but I think we can give a lot of examples through our own clinical practice of ways that we've incorporated this strategy. So, um, just to kind of tack on to what Liza said, um, in terms of her experience recently, um, I interviewed a family, um, who was. descent recently. Uh, the family at home speaks Mala, which is, um, a language, um, that is not very highly represented anywhere in the US, like very few speakers. [00:36:00] Um, And so one of the things that came up as a concern for this child was similar to what Liza had said about this Persian child. She had evaluated, um, there wasn't, he wasn't talking very much, but there was also a concern about feeding. So rather than just making assumptions that he's not eating or that the parents aren't trying certain things, I just said, tell me what his day looks like, what are his, you know, what, what does a meal look like for him? Um, and so I had them just list out times in the day when they try to feed him what they try to feed him. What's the vehicle? Is it a spoon? Is it a bottle? Whatever, um, means they try to feed him. And then I also wanted to make space for the fact that I, I recognize that in certain cultures, food is such a sensitive topic. So I asked them, you know, what is your biggest concern? You know, especially considering your culture that you come from. Uh, what are some things, what are, what are some [00:37:00] expectations in your culture around feeding your child? So again, not from my standpoint as well, he needs to eat and how are you getting him to eat food? Um, but more so, um, yeah, or even guiding the, the, you know, well, what does lunch look like? What does dinner look like? Right. We, I just literally wanted to take myself out of the equation by asking questions that were more open ended. Um, and that were more of like a grand tour is another way that they discuss this interview style.  [00:37:33] Kate Grandbois:  So I, I have so many things that I wanna say, because everything you said made me think of five other things. I'm gonna organize my thoughts here for a second. I, I think from what I've the way I've heard you explain it, the difference between a traditional interview and an ethnographic interview is very subtle, but critically important because of the word implicit in the term [00:38:00] implicit bias, and I'm gonna quote someone else. Um, I heard this quote from Jeanette Washington. I asked Jeanette where she heard it. She said she got it from somewhere else. And couldn't remember, so this is not me, but it made me think of this quote, which is ‘systems of oppression work within us and upon us’. And our language is so, is so our, our cultures are so deeply ingrained in us that they happen with a certain level of automaticity often. And you can insert yourself implicitly, quietly, accidentally in the words that you use and in interview is linguistically based. This is how you're collecting information and gathering data by asking questions. And it is so easy to insert yourself or your own implicit bias in questions. So I, I just, I had to say that because it was rattling around in my brain and all these connections were happening as you were talking about this very subtle, but critically [00:39:00] important, different. And it's because of that, I, I, I am assuming please feel free to correct me or reflect back something else. Uh, you know, in terms of this dialogue. Um, but it, it just, it struck me how critically important, but so subtle. So, so subtle [00:39:15] Desi Peña:  and I wanted to add in really quickly that, um, this is, this is how we try to undo that cultural erasure, right? By giving opportunities for those families to center their experiences. So it's not that the standardized assessment is crucial to my evaluation. No, it's that the family's experience has to be central to it because they experience their culture within this larger majority culture differently. Um, and I don't want to misidentify their child. [00:39:48] Kate Grandbois:  and it's also making me think of, and I know we're, this is sort of touching our third learning objective and we're not there yet, but centering someone's culture is evidence based practice. Our evidence based [00:40:00] practice model is three-pronged. We tend to, as our professional culture over rely on external evidence, this something, we talk about a lot on our podcast, but one third of our evidence based practice model is person-centered care and client perspectives and values and culture. It actually, as a matter of fact, as I'm saying this ASHA, if you're listening, please change it to be person centered perspectives, values, and culture, because that is a really important, important piece. And Liza, I can see that you have something to say, I'm sorry, I cut you off  [00:40:33] Liza Selvarajah:  just itching. So I think a huge difference here is that the goal of this interview is not to pathologize the child or family, but to support. and many of our pre-written intake forms or interview questions are really looking for that problem. Where is the problem? I check the reading, I check the food. I check the you're not looking for that. You're looking to know what this family goes through on a daily basis and what it is they need from us. And we're here to help. You had [00:41:00] mentioned Ingrid, like on our first podcast, um, in the bold SLP, something about like, we're not here for your average SLP. Like we're here for the ones who wanna think the ones who wanna change the one who, the ones who wanna create like a, a real impact. And this type of interviewing takes a lot of critical thinking skills. And on the spot analysis, it's not a check, like a check box of like, I check this, I check that it's really like a blank page almost. And you're really just listening and taking it in and accepting them wherever they are in whatever place they're. Linguistically culturally wherever. And so that's the thing, and I know a lot of new SLP just graduating. That's a very scary thing to go in with almost no information. You know, you want some kind of framework. But it's the framework that causes all the biases. So we're really trying to undo that. And I don't hope that I didn't make it more confusing for you, Kate.  [00:41:57] Kate Grandbois:  No, not at all. Um, it's actually making me [00:42:00] think of, um, a framework that we use in AAC, the SETT framework, where you're considering environmental variables, you're considering, uh, person-centered variables. You're considering communication partner variables, as opposed to, I think you think of an interview it's um, you go down your list of questions. It's exactly what you said. How about this? How about this? And you check them off as you go down, but using that, um, you know, using some sort of, not necessarily a framework, but I love that you said critical thinking skills, where the answer to a question may lead you to another question. It's sort of like a, choose your own adventure novel. Maybe I'm dating myself from the eighties, but you know, it's, it is the, it's an, it's an unwritten road that you travel down next to the family instead of in front of them, I guess, would be another sort of, I like visuals. It really helps me understand complex, uh, concepts. I wonder if you could tell us for anyone listening, who has never done an [00:43:00] ethnographic interview or is a new grad, or is intimidated by this concept or even intimidated by this topic? Uh, where, how can someone get experience with this? Do you, are there components of competency that you recommend, like mentorship or, um, a, a, a resource or a book that's that someone could read, uh, related to acquiring skills to be more competent in this area? [00:43:28] Ingrid Owens-Gonzalez:  I can jump in. Um, I actually was trained in this area, um, and this is something that has been around. Um, I think the article we, you will see in our show notes is from 2003. Um, and I was introduced to this concept in a neurology class. Um, because my program didn't have a bilingual track for me. So I took a neurology, a bilingual brain class. So it was a researcher who was, uh, working on what does a bilingual [00:44:00] brain do when, uh, dementia comes, that was kind of her area. And so I took this neurology class with her and she's the one who introduced me to this concept of, if you, to me, it was introduced, um, similar to what Desi said, kind of like a roadmap. Um, but she said, you're asking for the use of the tool. Like she viewed the brain as a tool and not just, uh, for the function, you know, you're not just like yes or no. Um, so that's how I was trained on it and how I'd heard the term and then knew to look it up and, and just experiencing a lot of the times the questionnaires that were given to me. From standardized assessments, just really not fitting, uh, the families that I was working with, you know, they didn't ask like, who does the child spend the most time with and what language do they speak? You know, that was critical for me. Uh, and it was nowhere to be found in these rubrics that had been designed before, without them in mind. So that's where, [00:45:00] where it comes from for me. But, um, I'm referencing an article that we put on, on our show notes and it's asking the right questions in the right ways. I mean, summary of what ethnographic interview is, it's that the title of this article and it was on the ASHA leader and it's anybody can go see it. And it's by Carol Westby. Um, does he link that to us, but like I said, I've heard this term before, and it's just honestly, a lot of going back to era or a lot of the things that we know. And, um, a lot of other monolingual SLPs don't know, we know by necessity. Because we are out there practicing with tools that are not designed for the people we serve. And so we have to figure it out. I read journal articles from Puerto Rico. I read journal articles from Mexico and fields of study in linguistics and, and social work. Like I, things that I can't find in ASHA, I go and find on my own [00:46:00] time because we're not there yet.  [00:46:03] Kate Grandbois:  That was very well said. Um, go ahead.  [00:46:07] Desi Peña:  I, I just wanted to jump back in before we move on. Um, I really love what Liza said about that blank page. I know that that's super uncomfortable, especially for anyone who is new to that concept. But I would really encourage people to do that. Even if it's somebody who's, you know, you think may belong to your own, like let's say you're a white SLP. Who's like, you know, grown up in the Northeast, like try that with somebody that is also white is also, you know, generations deep from the Northeast. See what that feels like. Um, but the, the other thing I was gonna say is, um, we always talk about, uh, standardized assessment, standardized assessment, but even non-standardized assessment, let's say you download a screener from teachers pay teachers, right? And it's for preschoolers. Let's say that in that screener, it [00:47:00] says, tell me about your last birthday party. Now, what would happen if you asked that to a child who is a Jehovah's witness, they don't celebrate birthdays. What if you said, tell me about the process for making a peanut butter and jelly sandwich. Well, if you had asked me as a child, I had never made a peanut butter and jelly sandwich until maybe I was like 10. And I had like brought that from school to home. Right. Like it wasn't something that I had exposure to and it would've over-identified me in those areas. Um, so I just wanted to say, put that plug in there, put that critical thinking piece. It is that we have to question standardized assessment, but we also have to question things that are not standardized things that are viewed from this lens of cultural erasure, right? Like making assumptions that all these children have exposure to birthday parties and dinosaurs and PB and J like they can, while they look, seem so harmless, it's really not in this assessment [00:48:00] context.  [00:48:02] Kate Grandbois:  I, I think those are great examples. Um, those are very American, very upper middle class, white American things, the apple and the peanut butter and jelly sandwich. I think that those were such great examples. And I'm, I, I wanna ask a question that might seem obvious. Um, but I, I, I think it's important to really take a minute to connect all the dots here of why this is important. Why is acquiring this skill as a speech pathologist important thinking about our field and the scope of practice that we have that is so wide or the SLPs working in schools who are expected to be generalists and have never, maybe had a bilingual child on their caseload. And all of a sudden there is one. So what are, what are the components of ethnographic interviews that are critically important? Why is this such an important thing for an SLP to acquire, even if they don't have a ton of [00:49:00] experience in this area?  [00:49:03] Ingrid Owens-Gonzalez:  I can jump in. Um, I know we're coming at it from our pediatric experience, but this is really helpful in med SLP world. Uh, especially when people are going through a stroke recovery or post TBI, uh, having that open mind that open framework really leads to better diagnosis. And I'm not a med SLP anymore. I started off as one and I tried to keep up with my med SLP things. But, uh, whenever you are say, even just recommending a diet, you can cause a lot of harm to a patient and a lot of stress to their family. If you don't do this kind of procedure, just take the little extra step to be open and listen to what their priorities are in [00:50:00] terms of food. Um, and I can think of one little story super quick that I'd never even connected to SLP until two summers ago. My grandmother had a stroke when I was six and I was living in Mexico, but we came to the us to be with her. And I remember her getting her list of. That would be good for her because she had diabetes. That's why she had her stroke. And there was pita bread on the list. You wanna talk about erasure? We didn't know what pita bread was. There was no Google, this is the nineties. And so we go to the store looking for pita bread. And now that I think about it, I'm like, what are the nutritional textural benefits to pet bread over gorditas or tortillas? Yes, or flour and corn things that we know that we make from scratch. But we had to get her pita bread. All of us were sitting around having tacos. And my [00:51:00] poor grandmother was eating pita bread because the doctor put pita bread on her list. And we had no idea what it was. And so now that I'm older and think about those things and I don't even think it was a doctor, it was a nutritionist, you know, cuz they were trying to keep her blood sugar under control. And now I look like the, if you look at the carbs in the pita and a corn tortilla, corn has more fiber, like it's even better than a wheat pita, but it was erased. Like our preferences were not taken into account. Our culture was not taken into account. So it's not just pediatrics. It's not just families. It's our entire scope where we need to like, be more critical and more open. I think  [00:51:50] Liza Selvarajah:  I had to, I have to jump in on that story in grid because, you know, I only teach through storytelling. I know it's the same there. Um, I was at like an ASHA [00:52:00] conference. I think it was like a south Asian caucus. Didn't even know that existed. That was very excited and that so many, um, south Asian SLPs, but they were talking about an Indian man at the hospital and he kept spitting out the applesauce. Cause it was like, what is this? Like, we don't mash apples. We don't eat that. And he just wouldn't and he kept not being able to move past that diet because he wouldn't swallow the apple sauce. And then this Indian SLP came in and was like, dahl, same viscosity, same texture just crushed up lentils. And he was able to go through it. But just that simple little critical thinking piece. Is it really the apple sauce that we want or is it the nutrients and the texture that we're referring to? Just like your, your tortilla story. People are, or SLPs in general. They, we kind of wanna make it easy on ourselves and just go with, whatever's always been done. And now we see that what's always been done only serviced a very small minority. They are the minority right now. So [00:53:00] it's just, who are we really supporting? So, yeah, it's scary to start with a blank page, but we talk about evidence based practice and following the child's lead that goes with following the family's lead, following the cultural needs, the bilingual needs, all of that is still part of following, following the lead. [00:53:18] Kate Grandbois:  And I think to go back to, to sort of reflect on my, my most recent question, why is this so important? Ingrid? I think you nailed it because you can do harm because there is potential harm. On the other side of the therapy table. On the other side of the hospital room, you can be doing harm in your treatment spaces and. When we, to me, when we are one of the things we've learned on this podcast, by interviewing so many people, is that regardless of your clinical specialty, regardless of your areas of competency, to be an effective clinician, you need to create safe spaces where your clients, patients, and families can feel vulnerable, can feel safe and [00:54:00] grieve work with you through counsel, whatever components of counseling are appropriate to their care. Um, and, and do the, do the therapeutic work in a safe environment. And you absolutely cannot do that without considering some of these cultural aspects. Because if someone is concerned about a risk for harm, they are not going to feel safe. They are not going to trust you as a clinician. And this is how, why it's so important to look at things through this lens because of those risks to me, as a, as a person reflecting all of this back to, to what you've been saying,  [00:54:39] Ingrid Owens-Gonzalez:  Now I really love that you picked up on that because I was actually thinking of something Desi shared with us. And it's, if you don't open up that safe space, then the families may not be willing to give you all the information that you need. And then you risk misdiagnosis, even if you're trying your best. And I remember Desi [00:55:00] that research that you participated in when they made you feel a certain way, when they just upright asked you, how much do you talk to your son in the car? Like, it seems so harmless, right? But Desi's like, I have a toddler. I just want quiet time in the car. Like the question already had a judgment. Yes.  [00:55:22] Kate Grandbois:  Already have I feel you, the judgment totally. A reasonable thing to say [00:55:25] Ingrid Owens-Gonzalez:  lean in there. And you know, Desi maybe is more likely to say, oh, I talked to him a whole bunch, you know, because it's already the, answer's already in the question for you. Yeah. What I want you  [00:55:37] Desi Peña:  to traditional interview style. [00:55:39] Ingrid Owens-Gonzalez:  Yes. And so how can we change that? How much do you talk in the car into a ethnographic interview? Kind of question is just, Hey, what does a typical car ride look like for your family? Maybe they play DVDs the whole time. Yeah. Maybe mom just needs quiet time and plays a podcast. Yeah. Maybe  [00:55:59] Kate Grandbois:  [00:56:00] here, here, you deserve it. You take that quiet time, [00:56:02] Desi Peña:  right. Or maybe your toddler gets car sick. Like I know families that the kid can't even get in the car seat without vomiting. Like maybe you just say, Hey, we're gonna go for a walk I'm gonna go run all the errands by myself. Um,  [00:56:16] Ingrid Owens-Gonzalez:  or you don’t have a car or they don't have a car run into other problems there and you have to just be willing, you know? So maybe before you ask that you ask, like, what is your household typical day for your household look like? And if they don't mention driving anywhere. Right. And they showed up on the bus to your, your clinic.  [00:56:35] Desi Peña:  strip back all the layers of privilege, right? We're assuming cars, we're assuming activities. We're assuming things that the child may or may not have access to. Let's just strip all of that and say, tell me about your day. Yes. Start from scratch. I have my blank sheet. Um, and I think the, tying it back to the, the question that you had originally asked Kate, I was thinking about, um, I was [00:57:00] thinking about the fact that, um, In this discussion that we've had, which has been so awesome about, uh, selecting treatment, right. We sometimes don't even think about the power dynamic. So where it seems that like, you're not thinking about, oh, this isn't harmful because you know, this is just like a list. Like everyone receives the same list. The power dynamics embedded in that culturally are so strong. Um, you know, so much to the point that yeah, families go out of their way to like try new foods when this is really not, it, it doesn't, it's not needed per se. Um, you know, we, we can adapt. Right. Um, and I wanted to bring it up because I know it ties into like our last objective, um, in terms of being a collaborator with families. Right. And I think that that's another place where we really ha have to access that vulnerability and recognize [00:58:00] power differentials. So if you're not capable of, of doing that cultural, um, responsive practice, you may not be aware that there's a power dynamic. There's a majority culture, there's a minority culture. There's a majority language, there's a minority language in each of these situations. How are you gonna level the playing fields culturally? Um, or how will, how will you, um, help reduce your bias as well as make that fit parent feel as if. They're a collaborator. Like that's a really big stretch for a lot of these families. They enter spaces where they are not considered collaborators. I mean, I, I think of this on my own as being a parent, like I have been in conversations with people where, um, or professionals and they just kind of tell me what it is and I'm like, well, but that's your perspective. Right. So, you know, not to say that I could push back at all my doctor's appointments. Um, although I have some really fascinating ones from it. [00:58:59] Ingrid Owens-Gonzalez:  That's [00:59:00] too real. We all know you do Desi  [00:59:02] Desi Peña:  no, I have some really, um, you know, I, I tend to be like a hesitant person, like I process later and then I'm like, oh shoot, I should have said this. Um, but I, I think that, um, you know, without really assessing ourselves without that self-reflection piece, um, think, you know, again, Be the, be the blank paper, right? Like try to be as blank as you can, because that is really how we can meet these families where they are. Like, I'm not, I, I try not to be super intimidating and bring in all this stuff with me. Like I, you know, I, I, I know that parents have to be kind of vulnerable with me. Um, I recently evaluated a child who only is exposed to Brazilian Portuguese. I had to just let the parents do the whole thing. I don't speak Portuguese . Um, and so, you know, little did they, you know, they, they, I had warned them like, this is what I'm gonna do. I'm gonna try to use other tools to help him communicate with you. However, um, [01:00:00] It's you like you're on mom and dad, you know, like I'm I, and, but I have to build trust before I can even get to that point where I'm asking them to perform certain tasks with him. Right. So, anyway, I feel like I went off on a big tangent, but maybe this is a good point to just bring in that last learning objective. [01:00:18] Kate Grandbois:  It is. And I have a, I have a comment that's gonna help us segue there. If you don't mind. I just think that another layer of power hierarchy for us to consider is being in the position of the quote expert to begin with. So there are components and this is an issue of infrastructure in medicine. Um, it's an issue of infrastructure in terms of our field there's issues of disciplinary centrism, where we think we're right, and the other professional is wrong. There are layer upon layer upon layer of power differentials that are inherent in, in the spaces that we inhabit, unless we can change them actively and try and control for [01:01:00] those things. So it's a really important piece. Um, Regardless of someone's lived experience. There may be feelings of vulner, extra feelings of vulnerability because of the, the power differential that's already at play. And I think moving, considering that it, it was just making, reading our third learning objectives about the authoritative approach to evidence based practice and needing to dismantle some of that authority. Um, I, I is a really important component regardless because it's of the infrastructures that we have,  [01:01:33] Ingrid Owens-Gonzalez:   [01:01:34] Amy Wonkka:   thisis a little tangential, but I think for, I know that a lot of our listeners are school based SLPs. And even just thinking about the team meeting, what is the team meeting? It is maybe one, maybe two caregivers and then a whole bunch of like fancy people that, that must be such an intimidating, uh, experience to walk into. So there, there are so many layers to this like infrastructure. [01:02:00]  [01:02:00] Ingrid Owens-Gonzalez:  Set up and now imagine you walk into that room and you're the only brown person who doesn't speak English  [01:02:10] Liza Selvarajah:  so much, Ingrid so much the power dynamics are so real and we don't know how much we're bringing. We, I know deep inside, a lot of us have like imposter syndrome and we're nervous and we don't wanna show how insecure we really are. So we double down on our power. We are the expert we are, but we really are not the expert on that child. So I'm so happy you brought the term expert in, because that is one of the first things. And I know you're gonna ask Kate, what are we gonna tell our SLPs to do from now on when I have these interviews, I tell the parent right away, you are the expert on your child. I wanna know everything and I wanna know how I can support you. So right away, I just shift the power right back to them because it's their, it's, it's theirs. And we're just collaborating with them. I remember starting out as an SLP, wanting to show that I know what I studied and I know what I do. And I [01:03:00] have all these check marks and, and I was so proud of myself with these big, giant words I used to use. I mean, who was I really helping? Just my ego. Apparently. [01:03:08] Kate Grandbois:  You're you're not alone. It was me too.  [01:03:10] Ingrid Owens-Gonzalez:  Yeah, I think I was gonna say, sorry, go ahead. I was just gonna say, who are you doing it for?  [01:03:21] Amy Wonkka:  Uh, It's scary though. Like I think I was it for me. Yeah. Like going into, I don't know, my first evaluation I ever did. I was so incredibly nervous and I think some of us myself anyway, that's how I deal with those nervous feelings I think is to sort of shroud it in all the expert words. And that is not a helpful strategy. That is  [01:03:39] Liza Selvarajah:  yeah. To go back to the blank page. I know that was part of objective two. Um, we wanna limit parents going off on tangents. We're nervous that what if they take us to a place and we don't have the answer. So we really try to control that, but let it, let them take the wheel. Let them say what they need to [01:04:00] say. More trust will be built. They talk about establishing rapport, right? In evidence based practice. They don't dive into it or how to do it, but they say that we need to, so that is a good way to do it. And then we could shift the power dynamics to show some sort of equality and collaboration. [01:04:15] Kate Grandbois:  I wanna use, I wanna elaborate on what you just said about the word rapport. I think a lot of us, particularly those of us in pediatrics and that's just my clinical experience. So that's what I'm gonna use. We think of rapport as fun. We think of rapport as I'm gonna get you to like me, I'm gonna get you to like being in my therapy room. Right. But rapport is true. Rapport is so much more than that. And I, I wanna tie this back again to our evidence based practice model. It's about vulnerability. It's about humility, which is something, again, that's the opposite of shrouding us in our expert words, right? The ego, the protection. humility is the counterbalance to that. And there's more strength in humility and supporting the person on the [01:05:00] other side of the table. And I love that you use the word rapport because that is so often used in our field to build these components of trust. And it is not what we think it is. And it's only when we get on the other side of maybe some experience or some uncomfortable feelings that we realize the power of humility and vulnerability. And again, This is evidence based practice, everyone. This is not, you know, us just needing to feel good about ourselves. Evidence is so much more than a research article. Um, it's so much more than a test score evidence, one third of our evidence based practice model is using these patient centered care approaches. Um, and I, I wonder if you could talk to us a little bit more about this, author, this, this, the words that you've used in your learning objective, the authoritative approach versus the collaborative approach. I know we've sort of described both of those a little bit. Um, but what can you tell us [01:06:00] about how you move through those two different categories? When specifically talking about evidence based practice?  [01:06:08] Ingrid Owens-Gonzalez:   [01:06:09] Liza Selvarajah: Well, I wanna go to Amy's example, plus, um, Ingrid having like that mother of color, let's say, come in into this big room full of professionals where you just feel so small. No one has said you are small. We don't respect or care about you, but that's just a feeling that you get when you walk in. So to me, the first thing we can do is believe the parent's story, whatever they say about the child. If they say my child is walking and talking and everything's fine at home, I can see all a bunch of teachers and psychologists like, Nope, that's not what happens at school. They're not listening. They're refusing to… that's the authoritative model where you're shutting down the parent and saying, that's not what we're seeing. And I always believe the parent right away. And I just very honestly say, I believe you. It's not what I'm seeing at school, but I believe that that's how they are at home. And I would love to bring that personality into the school. What can [01:07:00] we do to make this child feel safe here? To see the child that you see. So that's one kind of tip there.  [01:07:09] Desi Peña:  What I found super fascinating when we were, um, figuring out, you know, how to have this discussion, um, about collaborative approaches is how empty are, um, the, uh, the evidences, um, or, you know, just unstudied. I, I thought in speech pathology, this concept is like everything I kept finding were resources in early childhood, social work. I mean, just any other field other than ours. Um, and I know that we talk a lot about like family centered practices, but I feel like this is different. Um, the collaborative approach is what Liza said, like. Okay. What's what do you see? Okay. How do we get this child to do what you're seeing? Um, again, from the perspective of do no harm, I don't wanna do harm. I'm [01:08:00] assuming what you're telling me is what really happens. Um, so I just, um, I think that there's so much value in like, again, like a cultural, culturally responsive practice in terms of I reaching out. Um, I know that a lot of times it's hard because I know if you're practicing school SLP, like you're always limited on time, but I do think that if anything, maybe consider that you might be able to afford some more time to doing this work, to avoid. Engaging in a standardized assessment, that's really not gonna give you the information you need. Right. Um, so seeing if you might be able to shift your time or advocate for additional time for these populations, because this is the risk, the risk is harm. The risk is over identification. And in a lot of cases, we also have under identification, which is a lot trickier. Um, and maybe, uh, something to bring up on, on, on our next episode with you [01:09:00] guys. But, um, I do think that, uh, we just have a tendency of suppressing that third prong of evidence based practice, where we take into consideration these client perspectives. How about we just try to tilt it a little bit more and like push our administrators to also take that into consideration. I think that that's where we can leverage some of that power.  [01:09:26] Kate Grandbois:  I think you, I love, I love that suggestion. I think. Anyone who is listening, who has had any light bulb moment or any ha that's a good point, moment. A great place to start could be having the difficult conversation with your administrator or having a bro finding a way to broach the topic with a coworker or a colleague to shift your workplace culture. Because there are cultures within culture. This whole conversation is about different cultures, but we have professional cultures. Also, we have our professional culture as a field. You have your [01:10:00] workplace culture, your office culture, you know, what are the expectations? And. Starting to have these conversations on a small level, um, advo, or if you've already had those conversations on a smaller level with your counterparts and your colleagues, having that conversation with your administration, bringing additional resources into your administration for trainings, you know, starting to do some of this work. Um, having conversations about the bias in research. I know in our professional culture, this is something we talk about a lot on the podcast. We tend to think of quote, evidence as a research article. That's what we're taught in graduate school. There's a huge over-emphasis on external evidence. Um, and there is a ton of bias in research, a list of reference in the show notes of a, um, book called insurgent research, which is all about how research is really, uh, driven to support funding from other, in, in institutions of oppression. So even within the, the [01:11:00] category of external evidence, there are a lot of barriers. Um, and so even just, I know I just sort of went off on a tangent there, but point being it's layers upon layers upon layers of issues and starting to have the conversations on a small scale, um, is something that can actively be done to move the needle on a smaller level. [01:11:20] Desi Peña:  And I was gonna say the last thing that we talked about, um, as a group was cultural brokering, which I think Ingrid was gonna really talk about. But, um, you know, what does it look like if you could, beyond your administration, like who are members of your community that you've established trust with? Is there somebody who can be that cultural broker? Um, and with that, I'm just gonna pass it off to Ingrid. Cause I know she, she was the one that was gonna talk about that in detail.  [01:11:48] Ingrid Owens-Gonzalez:  Well, I just wanted to add to kind of close it all together. Um, and Kate, you said a lot of your listeners are school based. Uh, the people that I connect with in my practice at [01:12:00] my work is the teachers and like to put it all together in like that collaboration and, you know, being, not an authoritative figure, but a collaborative figure. There is more components than just the patient or the families. There's more people in this, um, client's bubble in life. Uh, and so in my particular practice, it's the teachers who I have to really collaborate with, listen to. And I always go back to that question I asked before and Yes, but who am I doing this for? If I'm not listening to what the parent says, if I'm not listening to what the teachers are saying, who am I doing all this testing for? Um, so that's kind of what, where I go back to, and then in terms of cultural brokering, I think we were just gonna discuss how taxing that is on us as bilingual bicultural, SLPs. Uh, and going back to my, again, [01:13:00] comment of, imagine you're in that room, that team meeting, and then you're, um, a Mexican mom and you walk in and you're the only one who doesn't speak English. Well, then I walk in. And immediately, I see that mom relax when I say Hola, [speaking spanish]. And so like, I'm there and I'm not entirely the interpreter, cuz that's a whole nother story cuz interpreting is not my job, but I'm there. And I said, oh that this, where are you from? And you know, I tell her I'm Chihuahua and immediately the tone, the vibe, the mood, the heaviness lifts. Um, so, but after those days I come home and I'm like, I had a bilingual meeting today and my husband knows like my brain is fried because not only did I spend all that time thinking and two languages, I spent time feeling [01:14:00] things that maybe the other professionals didn't feel. When I hear the demographics, the background history, I see myself in this child. I see myself in this mom. I see my mom and this mom. and it's just a lot of work that is not seen. So that was kind of what I wanted to bring up with, uh, cultural brokering. Um, I know we're running out of time, so maybe for another time, but, um, that was what was I say it a lot that's was, was in my heart when I put it in our learning of objectives and I, I put it in parentheses. Like, do you think we'll have time to talk about cultural brokering, but  [01:14:36] Kate Grandbois:  We started this episode talking about our own implicit lived experiences, Amy and I disclosed that were of the white cisgendered, uh, privileged  um, and I wonder if anybody who is listening, maybe hasn't considered the role of their. Bilingual colleagues. So I'm reflecting on what I said less than five minutes [01:15:00] ago. Move the needle in your office, talk to your colleagues. What would you recommend or what would you say to someone listening who is maybe realizing for the first time that if they do have a bilingual colleague that bilingual colleague may have a different professional experience and how to have that conversation and support that colleague? [01:15:20] Ingrid Owens-Gonzalez:  We actually, in a way we worked on that last summer. I don't know if Liza was a part of it, but I know Desi was, uh, we have an entire, uh, carousel post on, uh, bilingual SLP, uh, in bicultural SLPs. So bilingual bicultural, and we actually have a whole list of how can you be an ally to bilingual bicultural SLPs? And I think the first thing on the list, if I remember correctly is just have a conversation with us because a lot of people don't even know that we exist. Um, and then I think the second one was refer to [01:16:00] us because if you don't refer out to us and you make due with what you have, you make due with what, you know, you make due with your interpreter, instead of letting your administration know, Hey, there's a Spanish, bilingual, SLP. Like we should refer in this case, or there's a Portuguese, bilingual, SLP. We should refer in this case. How are our administrators supposed to know that these things are out there? These people are out there and that this is really the gold standard, you know, refer to a bilingual SLP. And then if you don't have that available to you, then use an interpreter ethically and there's ways to do that. And then if you don't have that, then you can consult. So even there's another step that a lot of people forget, like reach out to us, consult with us. And, um, I know that we added on there, like pay us for our time, you know, like invite us to go teach you about what we know, because a lot of it, we learned on our own on [01:17:00] our own time, on our own money. Um, so that would be what I would say. I don't know if that's exactly answering your question, but, um, I can also link that post cuz it was several of us who worked on it. I wanna say over 25 of us Desi who worked on that post that summer, uh, and all of us, um, I, and we wrote it out really pretty. It was like racially, ethnically linguistically and culturally diverse bilingual SLPs. Cuz we had SLPs who were bilingual from all over in that discussion and helping us draft that post  [01:17:37] Kate Grandbois:  we'll definitely link it. Um, in the show notes for people who want more resources on, on. do you guys have any, or do you all have any, um, parting words of wisdom or recommendations for LPs listening who either wanna learn more or wanna engage in more of this [01:18:00] conversation or any advice? [01:18:03] Liza Selvarajah:  Um, I think this is gonna be a little hardcore, but believing that there is a set standard contributes to erasure. So saying like, I don't see color, or I wanna treat them all the same. They are not the same become with very different cultures, very different backgrounds, different languages behind them. So lean into that and ask the right questions. [01:18:25] Ingrid Owens-Gonzalez:  Desi. Do you wanna go we do this on our podcast processing the last word [01:18:30] Desi Peña:  yeah, I was still processing, um, We've just covered so much. I think that, um, the things that have stood out to me, um, in having this discussion, um, I feel like Ingrid Liza and I, uh, you know, we always try to bring our own experiences to these conversations. Um, and especially with what Ingrid said, like sometimes I just don't process like how much work it is [01:19:00] for me, or like how much work it is for me personally, to always have to embed myself or always have to, um, recognize that I have an additional burden, I guess, like, I, I don't view it as a burden, but I, but I do recognize that like, , I do find myself being tired at the end of the day. So I just wanted to say if, you know, if whoever is listening to this can consider the fact that there are so many people involved. Um, and there are so many people that, um, you can rely on and. You know that, um, we really need to consider others, I guess, in this whole process. Right. Um, kind of like what Liza was saying, but the opposite in the sense that like, not from an assessment perspective, but just from like a total human perspective, we all have something that we're carrying. Um, and maybe folks who are not part of that central narrative carry a bit more. Um, so [01:20:00] just something to consider when speaking with these families and speaking with your colleagues who may be of a marginalized background,  [01:20:10] Ingrid Owens-Gonzalez:  I think my, uh, final message would be like, if anything that we talked about today made you uncomfortable, I would say discuss it. Within your peer group first, before reaching out to a person of color to question, you know, what we've taught here or what we talked about here, like, just discuss it within your peer group, if you are monolingual or if you are white or even white passing. I know, um, white presenting Desi, and I have had these conversations a lot, um, because my last name is Owens and Gonzalez and my first name is Ingrid. I get a lot of like, oh, I thought you were white. Um, and so I get a lot of insights sometimes, but that would be my thing if, cuz I know that it can be [01:21:00] hard to run away from the discomfort and just say, I can't do anything. Right. Um, but let's push past that and just sit in the discomfort and of yeah, I hold privilege and uh, others don't and what can I do to share it? Instead of hoarding it. So I think that would be my thing. [01:21:23] Kate Grandbois:  Thank you so much for joining us today. Yeah. This was a really wonderful conversation and I'm so glad that you're gonna come back.  Ingrid Owens-Gonzalez: Me too.  Kate Grandbois: We didn't really talk about that much, but if you're listening and you're still with us, we are going to be publishing part two, where we go through more specific components related to assessment, uh, dynamic assessment, um, evaluation action steps, those kinds of things. So stay tuned. We will be publishing that at some point in the near future. Um, thank you all so much again for joining us. We'll be listing all of the references and resources in the show notes. Please go [01:22:00] check out the Bold SLP collective and the Bold SLP podcast. Um, as, as has already been mentioned, there's a lot of really great information available through social media on these platforms. Um, and we're just so grateful for your time. Thank you so much for being here. Thank you.  [01:22:18] Desi Peña:  Thank you guys. Thank you so much.   [01:22:21] Kate Grandbois:  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon.[01:23:00]

This is a transcript from our podcast episode published September 5th, 2021. The podcast episode is offered for .1 ASHA CEU (introductory level, related area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. Kate Grandbois:  We have the great pleasure of welcoming Nina Reeves back to the show today. And we spent 20 minutes in laughter hanging out with the great Nina [00:02:00] prior to this recording. So Nina, thank you so much for joining us again. We so love having you here. You're so much fun. Welcome. [00:02:05] Nina Reeves:  Well, thanks for having me back. I'm really happy to be here again, and I know that there are smiles. People can hear our smiles. So we're going to have a little fun talking about stuttering, certainly.  [00:02:21] Amy Wonkka:  And Nina, you are here to discuss communicating with parents and teachers about stuttering before we get started. Can you tell us a little bit about yourself? [00:02:30] Nina Reeves:  Why yes I can Amy. I think that I think the major thing to know about me is that I'm a stutter nerd and everything in the area of stuttering or cluttering or any other type of fluency variation. I probably have read about it, talked about it, trained about it, and I just lovetalking to people about stuttering and working with children and adolescents who stutter in my private practice. And [00:03:00] I've been a school-based SLP all of my career because I really believe that that's a lot of where the rubber meets the road and that's where most kids are going to receive their therapy. And so I love being in the public schools and I hope I can continue until they kick me out.  [00:03:20] Kate Grandbois:  I seriously doubt that will happen. Um so you mentioned a private practice. You are, I wondered if you could tell us a little bit about stuttering therapy resources, because you're for anybody who has not listened to one of our previous episodes with Nina um this is your third installment with us here in, in the, in the den of nerds, in the den of speech nerds, I guess letting you go, you're not trapped. It's fine. We're going to move on. Otherwise, we're just going to keep laughing. So I wonder if for those of um so people look for people listening, who maybe aren't familiar with you and your work. If [00:04:00] you could tell us a little bit about stuttering therapy, resources and your website, because it is so full of information and so dense with resources. And I wonder if you could tell our listeners a little bit about what they can find there.  [00:04:14] Nina Reeves:  Well, thanks for that. It's great to, to talk about that because um it's, it's our publishing company. So Scott Yarus and I have been co-authors and partners on so many things across, over the years. And we had written some books together and found out that um publishers, big publishers aren't as keen on stuttering as we are. And so finally we decided to create our own publishing company so that we could keep our costs low and our value high. And so stuttering therapy resources was born at my kitchen table um 10 years ago in June of 2011. So, um happy anniversary to us pretty soon. And we, we loved just [00:05:00] creating our mission statement is to help SLPs help people who stutter. And so our mission is to create resources and provide as much information as possible to SLPs who work with people who stutter. And then also we have resources for parents of children who stutter and for teachers, because we know as we're going to talk about today, we know the stakeholders around that child need as much information and support that they don't often get because they're not in therapy, right. They're not there every week to have the speech language pathologist with them. And so we like to make sure that they feel covered in that way.  [00:05:47] Kate Grandbois: So, and, and just for the sake of saying it, you know, one of the things that we're passionate about here at SLP nerd cast is connecting people with resources. And I want to make it clear that you have a ton of free resources on your website. So if you are a speech language pathologist, [00:06:00] and you are interested in learning more about um working with people who stutter, please visit her website or their website um because there really is a lot of great resources out there to help improve your practice. And you have been tremendously generous. Um and you've created a discount code. So anybody who wants to learn more can get 10% off on your website through the end of this year. So that's through December 31st, 2021 using the code SLP nerd, because that's, what other code would you use really? And um and the website is www.stutteringtherapyresources.com . So now that we've got that behind us um we're really, really excited to learn from you again. I think, you know, Amy and I arequote, AAC specialists. So stuttering is not within our scope, but every time we talk to you, we learn something that is applicable to our practice. So I'm really excited to talk to you again today. I think I'm going to start by reading our disclosures and learning objectives. [00:07:00] So Nina Reeves financial disclosures. Nina is the author and co-owner of stuttering therapy, resources, Inc. She has royalty and ownership interest in intellectual propertyn those resources, Nina Reeves, nonfinancial disclosures. Nina is a past volunteer for both the national stuttering association and the stuttering foundation of America. Kate, that's me financial disclosures. I'm the owner and founder of Grandbois Therapy and Consulting LLC. And co-founder of SLP NERDcast. My nonfinancial disclosures. I'm a member of ASHA, sig12 and serve on the AAC advisory group for Massachusetts said, because for children, I'm also a member of the Berkshire association for behavior analysis and therapy, Mass ABA, and the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis, special interest group. [00:07:39] Nina Reeves:   [00:07:41] Amy Wonkka:  Amy,that's me. I'm an employee of a public school system and co-founder of SLP Nerdcast and my non-financial disclosures are that I'm a member of ASHA, SIG 12, and I also serve on the AAC advisory group for Massachusetts advocates for children [00:07:56] Kate Grandbois:  Learning objectives for the day learning objective number one, list three [00:08:00] aspects of creating a long-term support system for children who stutter. Llearning Objective number two, identify at least four major concepts for educating stakeholders about the disorder of stuttering. And learning objective number three, describe two counseling concepts for learning to listen to and support stakeholders of children who stutter.  [00:08:18] Amy Wonkka:  All right, Nina. We had such a great time talking to you last time and the time before last time you, you know, you know how it goes, tell us all the things, you know, drop some science, no pressure. Yeah, let's go. Let's go. [00:08:26] Nina Reeves:  Cause it's going to be, you know, it could be a short one. It could be a long one. It depends on what you want to know about, but we're going to really, I think, try to focus our energies today um on the overarching purpose of any stakeholder contact. Okay. Because I, when I say stakeholder, think parent, think teacher think grandma, grandpa um daycare provider think um [00:09:00] educator, all of the people, peers, siblings, these are all people who have a stake in the environment of being with a person who stutters because stuttering doesn't happen in a vacuum. It happens in a dynamic family and communication environment. So when we have any kind of stakeholder, stakeholder contact our our greatest mission, in my opinion, is to look at whatever that contact is and say, am I in this moment, doing my best to create a long-term support system for this child, because the people surrounding this child, you're not going to be with them forever. There's going to be SLPs who come and go in their lives. There are going to be times they're not in therapy at all. And the people around them. If we can help the [00:10:00] stakeholders, understand the disorder of stuttering and understand the lived experience of the person who stutters. I think that can reframe so much for our students and provide them with a long lasting support system that is going to go in, in the positive directions and not take a, let's say a child who stutters down the, you must be fluent or you're not doing the right thing road. And so if you want to create a long-term support system, one of the first things to do is to meet the stakeholders where they are. Now, this is a tough one for, for us as professionals, because we tend to focus a lot of our energy on our students, which is great on our students and clients. It's supposed to be student centered. Right. But it's family based. It's community-based, it's [00:11:00] environmentally based because that's where communication takes place. So if we want to help that child who stutters throughout their lives, we've got to find out what do these stakeholders know about stuttering? What do they understand about stuttering? And I'm going to talk about why those are two different things in a minute. We have to do a lot of listeningsts. A lot of gathering information from parents and teachers and others to find out their stories of what, what they think about stuttering, what their perspectives are, and then not only collect that information, but validate their feelings cause their concerns and their journeys are so relevant um to the journey of the child who stutters.That's [00:12:00] number one.  That's [00:12:00] number one.  [00:12:01] Kate Grandbois:  I, I just, okay. We're like less than 10 minutes into this and I am already having brain explosions. And I just want to recap two things you said that I ,CA I think we could repeat on repeat for this entire hour, because they're so important. Number one, the importance of having considering that stakeholders are with that student or client or child for the long term and you are transient and accepting that I feel like is critical, but number two, learning, meeting people where they are in terms of their own learning. So we do this with our students, but for some reason, when we go to train communication partners  or stakeholders, if they're adults or our peers in some capacity, we just expect them to understand it instead of really taking a minute to reflect on our own bias, really take, you know, ask them some of those, use that counseling approach to listen and ask open-ended questions and then validate. I mean, that is just so amazing. So yes. Thank you [00:13:00] so much for saying that. I have nothing else to contribute.  [00:13:02] Nina Reeves:  Well, thank you for that. And, and, you know, to that end, you know, when we talk about listening to their stories and validating their own journeys, because they're on their own separate journeys of learning, how to deal with stuttering in their families, in their classrooms um to that end, if you're going to validate their thoughts, their concerns, you've got to know what they are. So the second part of trying to create a long-term support system is to um recognize and support those social, emotional aspects of the, of the people surrounding the child, because the pain of a parent is really. It's, they, when they lack confidence in understanding and knowing what to do when the child is stuttering, that's real, but it's also normal. It's not abnormal for a parent not [00:14:00] to know what to do with stuttering. And we have to take that into our own consideration so that we understand when someone reacts, what we think is incorrectly,.i It's not incorrectly for them because their, their knowledge of this disorder and how to handle it is lower than ours. So we're there to support that. We have to find out what, where they are and support their journey with that. And anything that they do to react or respond to the stuttering um or to expect something from us in therapy. To the idea that our, the goal for them may be different than the goals we understand we can do. That's also real and normal. And so even if we have to step in and try to give the bigger picture, that's part of our role, we can, and we must [00:15:00] respect that heart space of the people surrounding this kiddo, because they're not coming at this from a head space, they're coming at this from fear, worry concern. Um and that is, um, where they're at. And if we can't help them manage that and work through it, you know, who is it? Is it, did David Luetterman say you can't solve a problem at the level that it's created or is that Wayne Dyer? I think that's a Wayne Dyer thing. So when if, if a parent is in fear and stays in constant fear about how their child is going to do, and what's going to happen to their child, then problem solving is out the window because our cognition doesn't play well in fight or flight. Right?. And I think that's an important concept when we want to [00:16:00] recognize and support the social emotional aspects.  [00:16:04] Amy Wonkka:  And maybe you can talk a little bit about, I think so often in our culture, we're not comfortable as clinicians with those feelings because we're not comfortable with those feelings. So I think part of it, part of what can be challenging for me, not, not in the context of um working with people who stutter, but as a clinician is, you know, kind of reminding yourself that it's okay. It's okay for people to feel these feelings.  [00:16:39] Amy Wonkka:  And it's not that we're all working toward this narrow continuum of like, it's okay to feel happy and to be actively working toward this one thing. And those are the only emotions that are kind of acceptable. I didn't know if you had some tips for clinicians to step out kind of like navigateppy, like the, you can tell that the family is feeling these feelings. Like if you're uncomfortable about that, [00:17:00] how do you help them? [00:16:59] Nina Reeves:  Like if you're uncomfortable about that, [00:17:00] how do you help them? Well, um, it's, it's so interesting for clinicians to move into a space of dealing with feelings. If they haven't dealt with some of their own feelings. And if they don't have a lot of that type of experience, then this may be challenging. So one of the things that can help is that um speech language pathologists can learn more about counseling. Okay. We're not, we're not trying to be counselors. Let's, let's get that fact right out there. I'm not saying I need you to go get a counseling degree, everything I've learned about counseling. In communication disorders is it's counseling based. It's from the psychological literature, but it's brought into communication disorders because that's our scope of practice. [00:18:00] But if we don't know that we have to deal with feelings, then we're probably not going to sit at an IEP meeting and feel very comfortable because when we diagnose um a challenge for a child, there are going to be emotions. And so I think helping people navigate those feelings and not try to run from them. Pretend they're not there. No, you can't feel that way. So that validation is um is part of it can be learned. That's the good news is that these types of things can be learned. And if you don't know a lot about it, there are places, you know, we were talking before the show about acceptance and commitment therapy, you can learn about soaboutso many things, but if I can give you a resource that I've probably given before, how to talk, so kids will listen and listen . Sso kids will talk by Faber and Mazlishslin. [00:19:00] I mean, talk about learning how to speak with people so that they feel comfortable sharing with you and then learning how to not, you don't have to get on the rollercoaster with people, right.to help them. But you can acknowledge and validate because as you were saying, Amy feelings are feelings. There are no good feelings and bad feelings, positive feelings and negative feelings, they're all feelings and they're all okay. And they're all normal. And I think that's what we have to remind ourselves of as clinicians. [00:19:42] Kate Grandbois:  Okay. I just, everything, everything you say is brilliant, but that aside u m just for the sake of saying it, I think my personal takeaway from that is not isn't the instinct of pushing your feelings away or it's more about accepting them and changing your relationship with them. [00:20:00] So, as an example, if you have anxiety using some of these strategies to, instead of say, don't have anxiety, you say, well, anxiety, you're here. I'm going to change my relationship with you and start to accept it. So if you um we have two podcast episodes published on acceptance commitment therapy um with a whole bunch of show notes that with lots of literature and books and references. So if you are interested in learning more about acceptance commitment therapy called ACT actum you can cruise over to those show notes and there's a lot of books and references. I just wanted to mention that quickly.  [00:20:31] Nina Reeves:  Yeah. And it's okay if you're feeling nervous about that, if you're thinking, you know, I'm not a counselor except that you are, because guess what? Ccounseling is a lot of? Ccommunication. Counseling is communication. It's listening. It's um reflecting. It's a lot of how you say what you say, and if we aren’t at semantic people, I don't know what we are. And so I think that [00:21:00] understanding that counseling is a part of our scope of practice. And instead of running from it, moving towards it and saying, I don't have to have a counseling degree to be better at this. And then that then serves my students and their families. And by the way, makes my therapy outcomes much more long lasting. [00:21:29] Amy Wonkka:  I think those are such great points. I also just want to put in a plug for, we interviewed Dr. Luterman, who's another wonderful um podcast to listen to. I felt like that was another mind blowing episode for me. And I really enjoyed that. We talked a lot about this. Yeah.  [00:21:47] Kate Grandbois:  And, and I, I just think it's, it's another component of our skillset as speech and language pathologist that is relevant, no matter who you are working with, it doesn't matter because communication impairments [00:22:00]  are, create emotion either for the individual who has the communication impairment or the stakeholders or the family, or the friends or the siblings or the neighbors, or et cetera, et cetera, et cetera. So, um and it's not only those skills, not only give you better outcomes, they also teach you self care because as you said, if you are, you know, not able to deal with those emotions personally, then you really need to do some of that work to bring more to the table. As the, as the saying goes, you can't pour from an empty cup.  [00:22:00] Nina Reeves:  are. Create emotion either for  [00:22:04] Kate Grandbois:  the individual who has the communication impairment or the stakeholders or the family, or the friends or the siblings or the neighbors, or et cetera, et cetera, et cetera. So, um and it's not only those skills, not only give you better outcomes, they also teach you self care because as you said, if you are, you know, not able to deal with those emotions personally, then you really need to do some of that work to bring more to the table. As the, as the saying goes, you can't pour from an empty cup.  [00:22:22] Nina Reeves:   [00:22:25] Kate Grandbois:   [00:22:28] Nina Reeves:  [00:22:30] Kate Grandbois:   [00:22:36] Nina Reeves:   [00:22:39] Amy Wonkka:  I have a question. Nina, you mentioned the difference you, how you're gathering information about what the stakeholders know. And what the stakeholders understand, or stand, how do you figure that out?  [00:22:45] Nina Reeves:  Well, um, well, it's a Luterman thing. I mean, let's talk about it, you know, we're geeks of um Dr. Luterman. So I am [00:23:00] going to say that one of the things I've learned from him um is the idea that um and I, and I'll say this again in, in, in this episode, but knowledge is not counseling. Okay. Knowledge is at the level of cognition. Okay. So I can spout information. So information is great and it's important. So what stuttering is what stuttering is and who caused it, nobody caused it. What? Okay, so we get all of that and I'll be talking about that in a minute, but that's not counseling. Right. That's informing. And so information is fine and that's how we know. No something, but understanding, and my, my experience is taking it from your head and getting it to your heart. And that's the understanding of what stuttering is. It's [00:24:00] experiential. Even if I don't stutter, I can listen to the lived experience of people who stutter. And I cannot maybe relate to being out of control of my speech mechanism, but I can relate to feeling out of control of other things and feeling like I can't get my point across sometimes, you know, cause everybody doesn't stutter. That's a myth, but we all have things that we can find common ground in. And that's, I think where the understanding part comes in. [00:24:41] Kate Grandbois:  I think that makes a lot of sense. I wonder if um you could talk to us a little bit about just the, the, not only the reasons why it's important to educate and counsel stakeholders, but maybe when are their conceptual [00:25:00] frameworks that you use, what are the cornerstones that guide your education when you're really working with, with families? [00:25:06] Nina Reeves:  I absolutely would love to talk about that. And it's, it's going to surprise you that the cornerstone that I use is in our ASHAAshleigh scope of practice, but I'm going to get to that in just a second. If I can um go back to the idea of the long-term support system, Um I want to give two more, very self-explanatory, . I don't need to narrate through it, but a couple more points on that. I believe that we have to see caregivers as an extension of our students' needs. Okay. So whatever our student needs, those caregivers are a part of our therapy. They're not ancillary. They're not something here's your hand out now go forth and prosper. You know, it's like, you've got to know that [00:26:00] working with and through the caregivers is going to serve that student's needs and make your outcomes more effective. The other thing is we have to think about getting people connected. On this journey. So there are so many ways to connect parents with other parents to connect all of those caregivers with other people who are traveling this road with someone who stutters in their classroom, their family um in their, in their space. And um there are organizations and we'll put those in show notes. These organizations live and breathe to help people who stutter feel supported and connected with each other because there's a fellowship among people who stutter, just like anything else. When you find like individuals, there can be a power um [00:27:00] that your speech therapist has been telling you this stufftime. aAd nauseum, but all of a sudden, another parent of a kid who stutter says it, and then it's like, wow, I didn't know that it finally comes.  [00:27:13] Kate Grandbois:  You're making me think of something that David Luterman said to us, which is the power of support groups and how it is completely within our scope as speech pathologists to create and facilitate support groups. And what that, what you're saying just makese, it just seems to hammer that home so much.  [00:27:34] Nina Reeves:  Yes. Because there are national ones, there are regional support groups. There are local support groups. And if there's nothing around you, you can do something in your district, within your own practice to try to find that connection, because it doesn't always have to be people sitting in a room, especially what did this year teach us? . Hello. [00:28:00] Now, if you go to a national stuttering association support group, I can tap into the one in New York. If I want to. If I just look on the website, find out when they're meeting and I can, I used to not be able to do that. Now I can, I don't know how long that lasts, maybe forever, but it doesn't always even mean that, you can do newsletters. You can look at um internet searches as long as you're vetting them first, please, please. And um you know, you can find ways to connect for kids or parents who may not want to like go to a group or tap into an internet group, but may read an article or a newsletter or watch a YouTube.  [00:28:50] Kate Grandbois:  Those are really great resources. [00:28:51] Nina Reeves:  Yes. And so that's the connection part. So that's for that long-term support system. And I'm going to, if it's okay. I can go [00:29:00] on to the idea of what are we going to inform? How are we going to inform. that sounds great. Okay. So before I go that way, let me do a little Luterman and I'm sorry if people are so probably sick of us talking about this, but um we've bonded over this and we found Dr. LutermanLindemann in different ways, but he, he resonates. And so we know that he is out there as a resource, and I, I love your, your episode with him. It was amazing. And so his most recent article, which we will put in the show notes um it helped me reconceptualize something I knew I was already doing, but didn't do to the extent that he's talking about and didn't have words for, I was just doing it. So I love a good, somebody who helps me understand what I'm doing. And so, um that, [00:30:00] that listening and support of the stakeholders and how much, and when we give information is very important. Cause I'm going to talk about the information in a moment. But before we do that, let's think about, he called it in the um, in the article, which when he calls it the client centered model, switching out of that medical model of dispensing information and switching into um listening without an agenda, which is something we were not trained to do. We always had ado. A clipboard and a checklist. Um and then including the stakeholders in the assessment and diagnostic process, it's like, I always knew I was including them in the goal writing and planning. And of course in collecting the [00:31:00] case history data and all of that, but maybe not as much in the actual, here is the transcription.  Here's the video I took of your child. And these are the moments in the transcription that I think are salient for you to see. And this is what ended up showing up on the paper, instead of just talking about what's on the paper, this is why this is on the paper, and this is how we framed whatframedwhat I learned about your child's stuttering and his experience with the stuttering. So I just think that's amazing. And then I love how he talks about the judicious provision of information. That's a greatIn other words,. Oh my gosh. I just love that because it helps me not do the big dump. Here comes everything you need to know about stuttering and stuttering therapy., um mom and dad, um caregiver teacher [00:32:00] in this one IEP meeting, here's all of it. And so they're not going to remember it. They're not going to understand it and it's going to be overwhelming because they just got a diagnosis or a confirmation of a diagnosis. So it's about asking, what do you need right now? Doesn't mean, you're not going to give more information later, but what do you need from me right now? What do you need to know now? And then parsing out judiciously information um Mo uh, but acknowledging that info is going to bring up as we were just talking about painful um feelings, feelings were, and, and trying to help people move toward their feelings rather than away from them, which is something that humans aren’te fabulous at all the time. And so I think the um, [00:33:00] acknowledging the fact that before we even give one piece of information, we have to, I call it swivel your chair around. Okay. So put yourself on the other side of that table and realize you're about to talk about not just data and info and research, but you're going to, you're going to be sharing in this family's lived experience. And at that point they don't need a lab coat. They don't need a clipboard. They need a listening air and a validating spirit, and they need you to watch what they're ready for and ask what they're ready for. and validate spirit. [00:33:48] Kate Grandbois:  I'm sorry, I just cut you off, but I just love that so much. That's it? That encompasses so much. It's so simple. Sorry, go ahead, Amy. I was, I was overcome with emotion. [00:33:58] Nina Reeves:   Amy Wonkka: You're [00:34:00] feeling it, having feelings you were! [00:34:00] Kate Grandbois: ,  [00:34:03] Nina Reeves:   [00:34:06] Amy Wonkka:  I mean, I feel like this is something that I'm still working on. Having been a clinician for quite a while, it's not something that is necessarily easy. If it's easy for you, that's amazing, Um but I feel like, you know, it, it is almost something if it doesn't just come naturally to you having that, self-monitoring to kind of check in with yourself as a strategy to say, okay, am I doing an information dump, possibly because I'm not comfortable with either being there for someone else's feelings or helping navigate that. And um my, I try to compensate with, with just more information and expertise than my lab coat of my clipboard and my numbers. And, you know, I think that even, even just little things like that, like you were saying, you know, it can be, it can be learned. And, and just like we might ask our students to self-monitor for these different things. I feel like that's a strategy that people can [00:35:00] think about using too is just, you know, do a check-in with yourself. Are you doing, are you employing the strategies that you. Wwould like to employ because you know that they are beneficial to your treatment of  the whole client, including all of those stakeholders. [00:35:12] Nina Reeves:   [00:35:13] Amy Wonkka: [00:35:18] Nina Reeves:  That is brilliant because I'm going to say checking in with yourself,. Llet's get honest about the fact that even research tells us, clinical anecdotal evidence and research tell us that stuttering and other fluency conditions are low men on the totem pole of comfortableness and confidence for speech language pathologists. So you're already coming to the table with feelings, feelings of uncomfortableness, feelings of inadequacy, feelings of, oh my gosh, I want to help this person, but I don't really know how, feelings of [00:36:00] fear. And so when you, uh, if you're not checking in with yourself, you are going to do the information dump in the clipboard, because guess what, that's comfortable. I can get this off the internet. Like I can read Scott Nina's book and I know, you know, the ICF model and blah, blah, blah, blah, blah. And then it just becomes rote info instead of a connection with where are these people at and what can they, what, what are they ready to handle? All right. And I want to, and I don't want to run out of time. So if it's okay, I'm going to lean towards the enhancing the understanding of stuttering part of this, because I don't know how to not give info. I just know better now when to give info. So, when um and, and how much at a time, um, depending upon the person that I'm working with, but [00:37:00] the good news is, is that understanding um some information about stuttering can be easily frameworked within the ICF model, . oOkay. Which is the world health organization, ICF model diagram, that's in the ASHA scope of practice. So ASHA.org . Scope of practice. There's the ICF model and um Scott Yaris and um Bob weasel had adapted it for stuttering and now um Scott and um Dr. Seth tensioner, he's a PhD. Whew. um I have readapted it. Um and it's so helpful. Um you can find a lot of that information on the app. Um oh, practice portal, ASHA practice portal. And so [00:38:00] please, there's a lot of evidence maps and things there that you're going to want. If you ain’t been there, you ain't been nowhere right now. So that's a good stepping off point. It doesn't give you everything you need to know, obviously, but there's a good place to start. And so this, this model in this diagram, helps us go back to what we talked about before bringing the big picture to the table because stakeholders and people who stutter can be um laser focused on what's happening in the mouth. Just because that's what they see on the, it's the surface stuttering behavior. And people don't understand that there's a whole lived experience underneath that. There's a whole person and a whole picture. So, quick rebrief. Reba rebreathe of the ICF model function, reaction environment, and impact. So is there an impairment [00:39:00] in the body function or structure? Okay. And for stuttering um it's the moment of stutter. It's the out of control moment where the, the speech won't come out in some way, there's extra tension in the speech muscles. And so there's a moment of stuttering, reactions is how I think, and I feel, and what I do in reaction, not just in the moment of stutter, but in reaction to the other aspects of the ICF model, which are environment, talk about stakeholders, environment and impact am I M umam I reacting to . tThe fact that I think you're going to think something, or that you might look at me funny, or that I don't want to raise my hand in class. So that's the, the, the environment and the impact coming in to this thought and [00:40:00] feeling, and moment where I decide what I'm going to do. Am I going to talk or not? Am I going to say the word I want to say or change it? So function, reaction environment, impact. They all feed on each other and I could do three hours on this. So I'm just going to say if you want more information, there's plenty of places to get, to get further into this, but bringing that big picture helps everyone immensely because when you're doing goal planning and therapy and there's no longer ever a goal about percents of fluentid speechd, right because you understand that's, that's,  a drug that's trying to address a surface stuttering behavior and missing a lot of the other parts of the ICF model and the lived experience of stuttering. And so when that [00:41:00] starts to happen, you're going to need to explain it to the parentsmerits. Well, here's the ICF model that helps them take it from just looking at the stutter and looking at the experience of stuttering and seeing that therapy is a lot bigger than that moment of stuttering. It's not all about strategies or fluency. It's about how do I learn to come to terms with, to handle my stuttering, to feel comfortable and confident communicating whether there's a stutter or not. Am I saying what I want to say when I want to say it to who I want to say it too. And that effective communication overarching goal shines through in, in the ICF model, because what we're trying to do, our role is not to get a kid fluent.[00:42:00]  Our role is effective, confident, spontaneous communication whether it's stuttered or not. And so that comes through when you're helping caregivers and stakeholders understand that bigger picture.  [00:42:25] Kate Grandbois:   [00:42:25] Nina Reeves:   [00:42:26] Kate Grandbois: Here here. I just, the focus on communication and independence and competence and the whole person is it's just a wonderful lens to look at this through. I don't want to derail you cause I know we have about 15 minutes left and you have a lot more brilliance to tell us, but when you were talking, it didn't make me think of a question: in looking through this lens in treating um you know, in working with stuttering and people who stutter. There is a lot to work on outside of the mouthask. [00:42:45] Kate Grandbois:   [00:42:42] Nina Reeves: Right. There's this, you know, this component of um you know, the emotional piece, the social piece, the stakeholders, when [00:43:00] you're a school SLP and you have three times 30 or whatever's on your grid, or I'm not sure what the standard would be, depending on where you are. Do you have recommendations for how to use your time effectively when you don't have regular access to the family, or when you, you know, you have legitimate workplace barriers that might make it feel like addressing some of these things is impossible. [00:43:24] Nina Reeves:  That is a fabulous question. I do have some recommendations for that because as a school-based speech language pathologist, I am a firm believer in the idea that quality therapy can be done anywhere you are. So let's just say, for instance, I, you know, when I'm in my school setting, I don't have as much access to the parents or the families, but guess who I have access to?. TheLet teachers and the peers and pretty [00:44:00] much probably the siblings. So there is unbelievable amounts of trade-off here that can help us understand. There's not, it's not just one place gets you the best because in my private practice, I have access to the families. But I have limited access to the peers and, or the teachers.   Kate Grandbois: Interesting.  Nina Reeves: And yeah, the teachers let's forget that they spend more time with the kids sometimes in that hundred and 80 days than the parents do. Hmm.  [00:44:34] Kate Grandbois:  Hmm. Which is totally okay.[00:44:37] Nina Reeves:  That's not a moment. That's not a moment of   judgment, but  [00:44:38] Kate Grandbois:  I mean, that's the, that's the life, that's the life schedule of our students. I mean, school is a huge, we say this in AAC all the time. You know, if you don't consider the school placement, you're missing how many hours in a week of an environment. So the, the thought of, you know, as that school, SLP, who's listening and saying, okay, I don't know how I'm going to tackle all of these things in my [00:45:00] speech room. You know, with the time that I've been allotted to me, I love the idea of embracing your school environment more as, as your stakeholder. That's brilliant.  [00:45:12] Nina Reeves:  And, you know, the, the idea is we all have, you know, and I'm going to be one of those people that just says, I know there are roadblocks, and I know there are stepping stones around those roadblocks, over them, through them, around them. There are ways to get this done. And there is no such thing as the ideal setting. So every, every school SLP is to think of. Well, you know, private practice is much more ideal for doing stuttering therapy. That's not really true because think about how many times they're coming to therapy with some of their peers from their class. And when you treat stuttering, as you know, everybody has their thing that they're working on and stuttering is normalized in your [00:46:00] therapy room, then it can become normalized in the hallway, normalized in the classrooms, the cafeteria and the bus. Yes. It all goes to the role of the SLP is to make certain that they're setting, no matter what setting they're in that they're setting an environment of acceptance of stuttering and normalizing and de awfulizing it and making it just the other, not de validating that it's a thing that, you know, this child may be struggling with, but not treating it as, oh my gosh. You know, this kid has language and this kid has artic, but oh my gosh, this kid has fluency issues. And it's, you know, it's another communication condition that we work with.  [00:46:51] Kate Grandbois:  Thank you for answering my question. Carry on, carry on. I felt like I interrupted your flow and like the last bit, but I had to ask. So thank you, for answering. So  [00:46:59] Nina Reeves:  thank you, for answeringFrancis. [00:47:00] No um I'm glad you asked because the other thing I want to say is. Because we're talking stakeholders today. One of the ideas that I would throw out there is the speech note, a book, and we write consistently in our, in our clinical guides for school, age, and early childhood, you're gonna um you're going to see these kinds of activities all through the books that we are putting it down in a notebook or, I don't know an iPad. Now you can do it on your whatever platform you're using and making sure that what we're working on in therapy is being recorded in ways that then becomes the encyclopedia of stuttering. And then they're sharing it with stakeholders, parents, teachers, theirre, their assignments are in there, and yes, there are assignments and stuttering therapy um because [00:48:00] it'll be what happens between the therapy sessions that makes the progress, not always what happens in the therapy sessions. And so, um bringing that big picture into that notebook so that the parents aren't always seeing this is the strategy we worked on today. Some days you're not going to work on strategies. I know that sounds like heresy. . I know people are like driving off the road right now. What, what do you mean we're not working on strategies? Um, no, I just don't drive off the road, parkparked the car, have your moment and then get back on, carry on. But I, I, I think it's important to know. We have a free resource about how to start the stutter notebook and there's, there's lots of information out there for school-based SLPs and wherever you work to create that space of continuing the conversation. So parents and caregivers and teachers can feel connected to the [00:49:00] therapy. This isn’t cCurb therapy. We're not going to drop them off with the therapist and go cure the kid, bring him back. This, this is not how it works. So, you know, family, it's family based child centered. And so we want to make sure that everyone understands not just from the IEP meeting or from when you sent home the progress reports. But more, more times during those um those therapy sessions where the child can really teach the teacher what they're learning or teach their parents or siblings, what they're learning in therapy. So it's an important part. Aanyway, because so many good ideas, so many good ideas. Oh my gosh. I, you know, that's why I do what I do. I might be passionate about this, but I don't know. All right. So there's another thought that I just want to make sure that we [00:50:00] get to, is the idea that, okay, from the ICF model, we are giving information, not just about the origin, but about the big picture um and that we don't want to stay too far in our heads, but make sure that we ask and check in. So how does that feel to you when you learn about this? Because in your gathering of information, you may have found out that the parents think that stuttering is caused by anxiety, and you're going to have to debunk that myth. And you're going to have to talk about neurology and possibly genetics. And if you're going to talk about either one of those things, you better be ready to talk about the feelings that are going to emote from that. Right? So checking in with them and asking them how they're feeling and knowing you don't have to fix the feeling. You don't have to fix it. [00:51:00] You can just listen to it, validate it, understand it, and you don't have to try to help them make that go away. Oh, don't be afraid your kid's going to be fine. Oh my gosh.  Please stop talking. Okay. You don't have that crystal ball that Dr. Lutermanindemann talks about nor that magic wand. So let's just let that flow, and just realizing that timing is everything, reiterating that you're going to give information over and over in small pieces when people are ready for it. And sometimes when they're not, but you've said it and then when they're ready for it, this is the fourth time they've heard it. And they've heard it from you and the stuttering foundation and the national stuttering association and blah, blah, blah, right. Or one of our YouTube that we did for parents um over the, the shutdown. We have those [00:52:00] for free on our, on our YouTube channel. You can get them from our website. You know, there's, there's a lot of info, good, solid information out there, a lot of not good solid information.  So please make sure that you're looking at it before you refer it.  [00:52:18] Kate Grandbois:  And being at being an informed consumer of information is critical no matter where you are in life. But I think it's even more so when you're considering, you know, working, working with some, you know, soft skills, collecting information and,  [00:52:33] Nina Reeves:  um [00:52:33] Kate Grandbois:  you know, using it to improve someone else's quality of life, that's really important to make sure you're consuming  the right information. [00:52:38] Nina Reeves:  the right information. And, and that's that you just did my wrap up, but that's cool. What I want. No, it's fine because it, it kind say it  [00:52:48] Kate Grandbois:  You kind of say it better than me though. You're going to do it. So just do it. Okay.  [00:52:53] Nina Reeves:  Fine. Well, it can't be stressed enough thatum [00:53:00] not only do people need to understand stuttering, but they need to understand stuttering therapy, right? So that ICF model feeds both of those parts, understanding stuttering, understanding the fact that stuttering therapy isn't going to be just on one of those things. It's going to be on the big picture and that it's going to be longer term. We are not going to have a discussion about when is he going to stop stuttering, right. Or that, oh my gosh, he's still stuttering because that's what stuttering is. And those are very tough things for stakeholders to hear for kids to understand for, for speech, language pathologists, to say. But the truth be the truth. And we want to make sure that we're coming from an evidence base and evidence shows that we don't cure stuttering. So, um that'll help the savvy consumer part of the parents' [00:54:00] world so that they can become savvy consumers of what they see online so that they're not chasing the next big thing in, in the stuttering community, we call it chasing the fluency God, and you know, like, what's the next best thing that's going to, you know, Ms. Nina can't promise fluency, but you know, this guy on online says he can do it over the phone in six weeks. Let's go, well, you know what? I'm not going to I'm, we're going to have a discussion about being a savvy consumer and where is the evidence and who gathered it? And where's the training we're going to do that. But if that's the journey, the parent needs to go on, that's the journey. Tthe parent needs to go on. And so I don't, I try not to drive agendas. I try to help support knowledge and understanding so that people can make informed decisions on their own.  [00:54:55] Kate Grandbois:  And this loops back to what you were saying at the beginning about making sure we're not only considering the, you [00:55:00] know, not only considering the stakeholders, but meeting them where they are and doing some of that active listening and validating. I wrote it down when you said it, listening ears and a validating spirit, because I was just so good. And I, I, it's just, you just keep talking, just, just wrap it up. Nina. It's just so good. Wrap it up. [00:55:14] Nina Reeves:  Okay. Well, you know, um I think I just spoke to the fact that understanding um therapy, um is different than just understanding stuttering. And we want to make sure we're feeding both of those um levels of understanding over time. One of the things that as we come to a close, I want to remind us all about is that the stakeholder roles are varied. Okay. The teacher is different than the parent. You know, everyone needs a certain sort of synergy of information and understanding, but there are pressures [00:56:00] on parents, . cCcaregiversaregivers, um that are different than the pressures on the teachers. And I think what we want to find out is what are those pressures that they feel? For instance, a parent just reminded me, like I knew this, but thank you for the re- remind is that there are a lot of parents and caregivers who are being pressured by the people surrounding them in the family, the extended family. And so they feel pressure to try to teach all of them, but they're still learning themselves. And they're feeling pressure to tell the grandma, Joan, not to do stop, start over, take a deep breath, think about what you're going to say and just relax. And because they know that that's no longer part of what they're going to do when their child is stuttering. The other people in the environment are still maybe on a different page. And so that [00:57:00] caregiver then feels that pressure. And so just realizing that it's not just the person who sits in front of you at an IEP meeting or brings the kid to therapy, it's the people surrounding them. All of my kids are starting to go visit family again.  And we're starting to have a lot of conversations about what doeis your extended family know about your stuttering and who told him, and who's, who's in charge and, you know, making sure that not just the parent feels that pressure, but maybe the child can be part of helping people in their environment, understand what's going on and setting their own boundaries and advocating for themselves. There's a power in that as well.  [00:57:45] Kate Grandbois:  Here here. I mean, it's, it's very hard to follow up with something when you speak Nina, because it's chopped full of lots of really good nuggets. I, I you've said everything. [00:58:00] I really can't contribute much else, but in our, in our last minute, do you have any parting words of wisdom that you would like to leave our audience with? [00:57:53] Nina Reeves:   [00:57:53] Kate Grandbois:   [00:58:10] Nina Reeves:  Oh, you know, I think most of it, it, since we're on the, the idea of stakeholders, mostly what I would say is that, you know, as a speech language pathologist, your role may feel overwhelming. When we talk about all of these aspects of stuttering therapy that maybe you weren't trained on and nobody talked to you about, but there are resources out there. There are people who want to help this next generation and all the generations of speech, language pathologists. My, my world is about helping SLPs feel comfortable and confident in what they're doing in stuttering therapy. And then that feeds the caregivers, the students, the [00:59:00] teachers. So when we get better at what we're doing um and I think we talked about this in one of our sessions. It's okay if you didn't get trained in this, but if you're 30 years into thisold, and you're still not sure what's going on. Then it's time to move towards that icky feeling of being okay to be vulnerable and get in there and get our hands on the experience of working with um people who stutter and making sure that we're mindful that it's not all technical right. There’s aA lot of clinical expertise that we can bring to the table. And you've got a lot of it already. You just forget that it's there because the word stuttering appears and stuttering, emotes fear. And I'm going to tell you, bring everything that you know about communication and pragmatics [01:00:00] and language load, and all of those things that you already know and bring them to the table in stuttering therapy. And it's going to serve you well.  [01:00:09] Kate Grandbois:  That's awesome. Thank you again so much Nina for being your brilliant self. Uum if anyone would like to use this episode for ASHA CEUs, they will be available on our website, just cruise over to our website, find this episode page, and you can follow the prompts. All of the resources that we listed today will be in the show notes. So if you're out and about in your car, you know, I was about to say on your bicycle, I don't bicycle. Maybe someone's on their bicycle, walking around doing, Amy bicycles or cycles. I don't know, but if you're out and about, and you are looking for a list of the resources that you've heard today, they are all listed in your phone, in your show notes. I'm very proud of us. We didn't laugh or break into a fit of laughter. Not one time. This was ,I'm very proud. We didn't cut our pickles out hard, to pat ourselves on the back here. You know, you're always welcome here and we love having you thank you again for your [01:01:00] time. And we hope everybody learned something here today.

This is a transcript from our podcast episode published October 17th, 2022. The podcast episode is offered for .1 ASHA CEU (intermediate level, professional area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. Episode Summary: Do you have a desire to walk alongside non-binary individuals on their personal journeys? Whether you are a seasoned, voice professional or new to the domain, this episode will inspire and inform as you consider your potential role in this partnership. Voice experts Barb Worth and AC Goldberg return to the airwaves, sharing their strategies to help you maintain culturally responsive practices as you collaborate with non-binary clients seeking voice alignment support. Tune in to clear up confusion on terminology and to gain practical strategies rooted in cooperative goal-setting, creative application of shared narratives, and a professional relationship built on trust and understanding. [00:00:00] Kate Grandbois:  Welcome to SLP nerd cast the number one professional resource for evidence based practice in speech, language pathology. I'm Kate Grandbois  [00:00:09] Amy Wonkka:  and I'm Amy Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast.  [00:00:16] Kate Grandbois:  Each episode of this podcast is a course offered for ASHA CEUs. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course plus the corresponding short post test is equal to one certificate of attendance. To earn CEUs today and take the post test. After this session, follow the link provided in the show notes or head to SLPnerdcast.com . [00:00:41] Amy Wonkka:  Before we get started, one quick disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise specified. [00:00:53] Kate Grandbois:  We hope you enjoy the course [00:00:55] Announcer: . Are you an SLP related [00:01:00] professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ASHA CEUs, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited CEU all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerdcaster10. A link for membership is in the show notes. [00:01:43] Kate Grandbois:  Welcome to SLP Nerd cast everyone. We're so excited for today's episode. We have two amazing individuals who have joined us before. Welcome Barb and AC.  [00:01:57] AC Goldberg:  Hi, thanks for having us. [00:02:00]  [00:02:00] Amy Wonkka:  We're so excited. So AC and Barb, you are here today to discuss gender expansive voice care with non-binary people. And like Kate said, you've both been on before. It's so nice to see you again, um, for our listeners who, who maybe haven't listened to any of your podcasts, uh, before we get started, can you tell us a little bit about yourselves?  [00:02:20] Barb Worth:  So, yeah, so I am been in the profession for almost 30 years and, um, mostly with working with adults, um, medical settings, uh, am a, uh, voice clinician. And then in the last 10 years have really dedicated my time and energy and focus, um, to, uh, working with transgender individuals, a non-binary individuals with regards to voice care, voice modification. And, um, I feel really passionate about training others. So I actually switched to an academic setting. I work at Emerson college and I am a clinical instructor and also an academic instructor in the area of voice. And I love training the [00:03:00] next generation, um, on this type of work.  [00:03:05] Kate Grandbois:  We're so glad to have you back, Barb. Thanks. All right. AC you go tell us all about you [00:03:08] AC Goldberg: . Oh my gosh. Um, my name is AC Goldberg. My pronouns are he him and his, um, I am a founder of, um, a cultural, uh, culturally responsive training. Platform, um, called the credits Institute where you can get, um, CEUs in intersectional, cultural responsiveness. I am also the founder of transplaining, which is my consulting agency, where you can bring me to talk to your agency about, um, culturally responsive care with transgender nonconforming individuals and two spirit LGBTQIA plus issues in the workplace in schools, hospital, clinical settings. Um, and that's where my passion lies is educating others to decrease disparities and, and institutional mistreatment among minoritized populations. I am currently transitioning from a school SLP role, um, to working for [00:04:00] myself consulting full time and also providing gender affirming and gender expansive voice care services to transgender nonconforming and non-binary individuals. So I'm excited.  [00:04:12] Kate Grandbois:  I am so excited. We're all so excited. And to anyone listening who is not familiar with your platform, please definitely go check out transplaining. You have so many wonderful resources on your website, so many great courses, um, and we're really excited and privileged to have you come and share some of your knowledge with us today. Both of you before we get into the really fun stuff, the powers that be require that I read our learning objectives and disclosures. So I'm gonna go ahead and get through that as quickly as possible so that we can get straight to learning from the both of you. =Learning objective number one, identify at least two steps you can take towards cultural and clinical competency when working with non-binary people.   Learning objective number two, describe at least two components of gender expansive voice and communication without using gendered language. [00:05:00] And learning objective number three, describe at least three potential considerations when working with a non-binary client receiving gender expansive voice and communication services. Disclosures. AC Goldberg's financial disclosure is AC is the founder of transplaining and the credit Institute and received an honorarium for participating in this course, AC Goldberg's non-financial disclosures AC is a founding member of the trans voice initiative and is a topic expert in gender for the informed SLP. He is a 2022 ASHA convention planning committee member in health literacy, access, communication, and outcomes. He is also on the community advisory board, overseeing research out of Boston university about the effects of exogenous testosterone therapy on communication and assigned female at birth speakers. AC is on the editorial board of the journal of communication disorders. Barb Worth's financial disclosures. Barb is a clinical and academic instructor in communication, sciences, and disorders at Emerson college, she instructs students in the delivery of voice [00:06:00] services to all populations. Barb received an honorarium for participating in this course. Barb's uh, Barb's non-financial disclosures. Barb has a decade of experience working with the transgender and nonconforming populations. Kate's financial disclosures. That's me. I'm the owner and founder of Grandbois therapy and consulting LLC. And co-founder of SLP nerd cast. My non-financial disclosures. I'm a member of ASHA, SIG 12, and serve on the AAC advisory group for Massachusetts advocates for children. I'm also a member of the Berkshire association for behavior analysis and therapy and the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis, special interest group. [00:06:38] Amy Wonkka:  Amy that's me. My financial disclosures are that I'm an employee of a public school system and co-founder of SLP nerd cast. And my non-financial disclosures are that I'm a member of ASHA special interest group 12, and I serve on the AAC advisory group for Massachusetts advocates for children. All right. We've made it through all of the disclosures, [00:07:00] um, AC and Barb. How about you start us off by telling us a bit about that first learning objective.  [00:07:08] Barb Worth:  I gotta look at it. Okay.  [00:07:12] AC Goldberg:  cultural responsiveness was our first learning  [00:07:15] Barb Worth:  and cultural responsiveness competency. Well, yeah. Okay. So first of all, you know, we did actually a whole podcast, um, for you all. So we highly recommend that you listen to that. Um, you know, It's so just, you know, important to do your homework, know your terminology, um, you know, use your resources like transplaining, yay, AC um, you know, Facebook pages, sources, books, organizations, do your homework if you wanna do this type of work. Um, but we are gonna talk about, um, some terminology and I think AC’s gonna take over now, um, because as we move forward with this particular, um, podcast, [00:08:00] I, I think, uh, we need to make sure that we're all on the same page with regards to understanding, um, terminology and also acronyms. So take it away AC.  [00:08:08] AC Goldberg:  Speaking of acronyms, um, and you know, yeah, cultural responsiveness. Obviously we want you to go back and listen to our first podcast, but it doesn't end there. Um, no, you know, cultural, um, you know, I just wanna make sure that we are, um, thorough in our explanation, you know, cultural responsiveness is a, is a commitment and dedication to ongoing learning about the populations that you serve. Um, so today we're really specifically gonna be delving into things that are related to non-binary identities. Um, and these are things that, um, the terminology changes, um, you know, each client of yours might have their own terminology to describe their gender. Um, and all of that is really important. Um, it's really important that you keep up with terminology because that changes rapidly daily. Um, it does daily. Yeah, it really does. It changes rapidly and you know, what [00:09:00] was, what was something that. Things like, you know, person first language versus identity, first language. Right? All of that, you know, even though it's individual to the person who is in front of you, um, the, I don't wanna say norm because I don't like that term. Um, but the, um, the most popular, um, of terms rotate change and new terms come up all the time. Right. And, you know, we wanna make sure that we're telling you all, like, you know, we'll tell you things today. We'll tell you to listen to our previous podcast. I bet things in that previous podcast are already, that have changed. Right. You know, mm-hmm so, um, this is a real, like do your homework and cultural responsiveness, right? Because you wanna make sure that you're, you're doing the best for the population that you serve. And it's just on, you know, engaging in ongoing learning, reading the articles that come out, listening to podcasts every so often, so that you do have up to date information because, um, you know, far too often in our field, people read something 20 years ago and take that as, you know, the information and they aren't as [00:10:00] engaged as, you know, Keeping up. So that's just something I wanted to say before I delve into termin.  [00:10:06] Barb Worth:  Absolutely. And you know, and I think you already alluded to this and we're gonna talk more about it, but also, you know, talking with your client, um, because what may be the latest and greatest terminology that you're reading about isn't necessarily their terminology. So sort of getting on the same.  [00:10:23] AC Goldberg:  Um, so yeah, exactly. So I'm gonna go and try my best to define these terms, um, which, um, the first of which is gender. Um, so gender is a set of expectations that are placed upon a person based on their sex assigned at birth. So when someone is born, a doctor looks at their external body and says, you know, it's a boy. And then this whole set of expectations based on one small body part gets placed upon them, you know, and through no fault of the people around them, those are societal expectations. Um, you know, they're steered in certain directions, certain interests, um, certain types of [00:11:00] things that they might wanna wear. Um, you know, gen roles that they might wanna play, even behavior and communication are impacted by our expectations around gender, um, gender isn't, something that is inherent, um, Or I'm sorry, isn't something that is inherently linked to, um, our sex assigned at birth. Um, everyone can have and feel an inherent gender within themselves. Um, but you know, society really conflates, um, sex and gender. So those are two completely separate things. And I wanna make sure that we all, you know, like we mentioned that kind of going forward because when we talk about people with non-binary genders, um, which I think I'll define first, um, you know, and then move into transgender, but a non-binary gender is someone who feels that their gender doesn't squarely align with male or female, but a non-binary person can look like anyone, use any [00:12:00] pronouns, um, you know, somebody who's non-binary, um, could look like any one of us in this room. Um, you know, you can't look at someone and say like, well, that person looks really non-binary. You don't know, um, what someone's internal sense of gender is by looking at them or even by knowing their pronouns. Um, and you know, non-binary identities can be. they're really, you know, it's really very, a beautiful, beautiful and liberatory concept to not be constrained to one set of expectations. Um, but non-binary identities can look like any other identity. Um, so, you know, when you, when you see people and you're like, you know, Hmm. A lot of people try and box people in, like, is that a, a man, or is that a woman? Um, Some non-binary people will easily be lumped, um, possibly incorrectly by people, um, by people obviously always incorrectly by people walking down the street. Um, but people are kind of always trying to fit us into a construct, um, of, you know, [00:13:00] what is this person, you know, they wanna greet you with a, with a, with a sir or a ma'am or something like that. People are always trying to box people in. It's almost the first thing that people try and do when they see you is fit you into a category. Um, and non-binary people, you know, they transcend those categories, which is a really beautiful, um, and liberatory way to live, um, your life, um, sort of free of those expectations. Um, Not all non-binary people consider themselves transgender. So let me define the term transgender and then kind of go back to, um, what I was talking about there, a transgender person is someone who doesn't feel like that their gender aligns with the expectations that were placed upon them, um, when they were assigned a sex at birth and all of the expectations that go with the gender that is associated with that sex. For instance, I was assigned female at birth or AFAB. Um, and I obviously don't look like someone who you would call female. I never felt like someone who, you know, embodied [00:14:00] that identity and therefore I consider myself transgender. Non-binary people may or may not consider themselves transgender. Non-binary people might not feel like there was ever a, you know, a change that there was ever a, you know, transition. Um, you know, they might come out as non-binary and not change a single thing about themselves, even their pronouns. Um, you know, so non-binary identities can really look and be like anything. Some non-binary people say that they are transgender. Some non-binary people don't consider themselves transgender and that's something that's individual to each person, and it's also not clinically relevant. So these are, that's a thing that, you know, when you are, when you're talking to a non-binary client, um, you know, whether or not they consider themselves transgender, doesn't really matter. It only thing that's important is what they want their voice to sound like. Um, so I'm gonna get into gender nonconforming, which is when we get into these. The acronyms on the next slide. Um, TG and C [00:15:00] is trans and gender nonconforming gender non-conformity, um, means that someone doesn't fit within like one specific gender box in either, you know, persona, look or the way that they just see themself in the world. Um, non-binary people are somewhat by definition, gender nonconforming, um, but. On the outside, because you can never tell, somebody could appear completely gender conforming, um, and still embody a non-binary identity. Um, so you know, and not all gender non-conforming people consider themselves non-binary or transgender. Um, you know, you might see people within the broader LGBTQ, um, population who are gender nonconforming. You might also see cisgender people who, you know, you look at and think, well, you know, that person does not stereotypically seem like X. Um, and that is a gender nonconforming person. It comes up for [00:16:00] the me. Go ahead, Kate.  [00:16:01] Kate Grandbois:  I have a question. I wanna say this back to you to make sure I've understood. So in terms of this terminology and, and the fluidity of this, someone who identifies as non-binary is in some ways, gender nonconforming, but not everyone who is gender nonconforming is non-binary. Is that correct? I just wanted to make sure I had that. Please continue.  [00:16:22] AC Goldberg:  No, that is correct. Exactly. Thank you for, for making that more clear for the audience too. Um, you know, not even everyone who's gender nonconforming considers themselves gender nonconforming, but society might, um, you know, it's um, and then we get into agender, um, people who are agender don't feel comfortable having a gender assigned to them. Agender just means a, a lack of, you know, a lack of gender, you know, the absence of gender. Um, so they don't feel comfortable with the construct being applied to them. Even sometimes a non-binary construct being applied to them. Doesn't, like the gender just doesn't fit with [00:17:00] them. Um, you know, it, isn't something that they feel can be applied in any way. Um, and that's someone who could come to you for, you know, for voice care and you have to understand, okay, this person has the absence of gender. Um, and whether or not they want their voice to have the absence of gender will be highly individual, but that someone who could come to you for this type of voice care, the gender spectrum is, um, this, you know, beautiful array of all different ways that, um, you know, that gender can be and present. Um, so, you know, if you have a gender, if you're not a gender, you are on the gender spectrum. It's not a continuum. It's not a straight line from like very manly man to like very feminine women. It's, you know, And non-binary is not like someone in the middle. Um, you know, that's not, that's not a thing. Um, it's, you know, if you picture, um, I wish I had a picture. Um, if you could just picture like a, you know, a beautiful, broad rainbow array of sort of all of the different ways that gender can be expressed and, um, and communicated, um, you [00:18:00] find, you know, where someone falls on the gender spectrum. Gender expression is how someone expresses their gender through, um, you know, through their look, their communication style, um, you know, possibly their pronouns and name depending. Um, you know, they're all different ways that people express their gender. Um, you know, they can express their gender through clothing, they can express their gender through makeup or the lack thereof. Um, they can express their gender through their voice, their, um, their non-verbal communication. Um, how, how else can people express their gender? Barb, am I skipping things? [00:18:36] Barb Worth:  I'm trying to think. I think you've covered it. I, I awesome. I can't think of any [00:18:40] AC Goldberg:  You know, gender is just such an interesting thing to realize that you are expressing and to take ownership over, you know, how your gender is expressed into, like, I, I love to do this activity when I'm running workshops is ask people, what are ways in which you express your gender? Um, you know, because it's [00:19:00] hard for most cisgender people to answer that um, because people, a lot of people haven't taken a deep dive into what gender actually is. So if you're listening and you're a cisgender person, who's never thought about that. Take a minute to reflect. The next two terms on this slide are gender fluid and gender queer, um, gender fluid, um, You know, that's the actual stuff that comes out of your eyes. That's your gender fluid. I'm joking. um, those are tears. I'm I'm just kidding. no. Um, your tears are not your gender fluid. Um, gender fluid is not an actual thing. It is an identity that many people have. Um, and actually I hope that, that I wasn't attempting to poke fun at it I was trying to, trying to make you laugh. But gender fluid people are people who don't embody one singular gender all the time. Um, gender fluid people, their gender expression and their gender, um, their gender expression and even their gender identity. May change and evolve. Um, you know, from hour to hour, from day to day from, you [00:20:00] know, from week to week, they might go through periods of ti of years where they feel more, um, like they want to express themselves more in one way than in the other way. Um, that's one of those identities that, um, it can be very stable within a person. The person says, you know, well, I'm gender fluid, but the public may not experience that as a stable thing because the public sees the person presenting in different ways at different times. And, um, gender fluid people have different voice needs, and we're gonna get into that. Um, I'm gonna get into that in a little bit, um, more time. Um, but a gender fluid person is just someone who's gender isn't stagnant, um, and you know, most people's genders are pretty stagnant. Um, and when you think about that gender fluidity is just such a beautiful thing. Um, and a gender queer person, um, is somewhat like a gender nonconforming person. It's just a little bit of a different label. Um, a gender queer person usually embodies one specific gender that is [00:21:00] neither, you know, neither male nor female may not consider themselves non-binary. Um, but also may have, um, voice peer needs that are aligned with that of the community. Um, and the next slide that we have that we're gonna go into are some acronyms. And I wanna just make sure that, um, everyone knows what the acronyms stand for. Um, so TG&C you'll see that a lot, especially if you're involved in any, um, education with me. Um, it stands for trans and gender nonconforming. Um, those that's just an umbrella. Um, non-binary people fall into that, even though they're not mentioned in, you know, specifically in there, because a lot of non-binary people either consider themselves trans or gender nonconforming. It's not meant to be an exclusionary acronym. Um, but, um, it would be very hard to get all of the, we have so many letters, um, to get all of those in there and have it still make sense. Um, M to F or [00:22:00] MTF is male to female. You might see that in a chart or somebody might say I'm in, I'm in F to M or I I'm an M to F transgender person. That just means sort of, I was assigned and assumed one thing. I am now presenting and embodying a different thing. Um, but those are, you know, mostly for those are mostly binary identities, um, not all the time, but those are mostly binary identities. There is some confusion sometimes I know with SLPs, especially, um, using, um, the term FTM, which can oftentimes stand for first time mom. Um, I have seen SLPs confused by this. Um, you know, when, when they get someone on their caseload, um, sometimes people will come to me for consulting and say, you know, I work in an outpatient center. Um, I, you know, was meeting with someone today and their intake form was about being an F to M and I assumed they meant first time mom, and then I was face to face with a man. And that was very [00:23:00] confusing. And I, I just, I, I need to have like a debrief about that and I'm happy to talk to anyone that happens to. But, um, you know, that is, um, That's an acronym that can be, you know, that can mean female to male or first time mom. And, you know, it's important that people understand that if you see it written somewhere or if someone describes themselves that way, not to automatically assume first time mom, and maybe to assume female to male, depending on the context. Um, that's a hard one. Um, Barb  [00:23:26] Barb Worth:  and I see, yeah, I, I'm wondering about, um, um, M to F and F to M um, my understanding too, is that they're, those terms are cut, becoming a little bit more out of favor. They are. Um, and I think that we're using, we're gonna talk about two other terms. Mm-hmm, AMAB and AFAB. So. Go go. [00:23:45] AC Goldberg:  There even. So even as they're falling outta favor, yeah. People might still use that language to describe themselves. Absolutely. Thank you for bringing that up because you should not use those term. Right. When we talk about cultural responsiveness, we talk about mirroring the language that your client uses. If [00:24:00] someone uses that terminology for themselves, it's fine. You aren't gonna wanna with assign anyone any of these acronyms unless they assign them to themselves. Beautiful. Yeah. Um, those are, you know, but what's coming into favor now and replacing those terms are AMAB and AFAB, which are, you know, pronounced AMAB and AFAB, and AMAB means assigned male at birth. And AFAB means  assigned female at birth. Those are pretty, you know, cut and dry, straightforward terms that we understand what that means. Um, and that way it becomes a little less confusing, especially if, um, you are seeing that on a form, um, it makes a, you know, you understand what it means instead of FTM, which could mean in a couple of different things. Um, and then there's NB a lot of people, um, do sometimes use this when they are abbreviating, um, for non-binary um, you actually shouldn't use NB. Um, it stands for non-black um, uh, the, the sort of, um, going way that non-binary people shorten non-binary is E [00:25:00] N B Y. Um, and they'll say enby, um, and I know that looked, that could look like an N and a B, but it's spelled E N B Y. Um, if you write an N and a B, it means non-black, um, and we wanna make sure that we're not accidentally, um, you know, stepping on any toes racially there. Um, but that does sometimes happen when people are, are abbreviating. Um, and I think that that's all the terms that we have, um, that are acronyms. Um, but I'm sure that as we continue talking, we will say more acronyms and we'll have to come back. And Barb, you have the next slide, I believe  [00:25:37] Barb Worth:  I do. So we're continuing on this road of being clinically competent, culturally responsive. Um, but I did wanna talk a little bit about clinical competency and I, you know, um, I came into this area of the field having a very strong voice background. I know that not everybody who does this type of work has the [00:26:00] type of experience that I have. However, I do really recommend that if you are interested in this type of work, that you go back to your voice class or take a voice class or do some research, um, it's really important to understand anatomy and physiology of the voice and the vocal mechanism when you do this type of work, because, you know, we, we could hurt people just like when you're doing dysphagia therapy. You could hurt somebody. And when you do this type of work, you could hurt somebody. And so it is so important to know about normal anatomy and physiology, and also to really understand how to screen for a voice disorder. Some people, um, you know, there's an incidence of voice disorders across, you know, all of the type of people that we see in our profession. Right. Um, but some people who do some self, um, voice modification. [00:27:00] So i.e. they're looking at YouTube videos, um, they're getting help from friends to modify their voices. Sometimes some of that work that they're doing is actually, um, not the best with regards to vocal health. So we actually have people who come to us who end up with muscle tension dysphonia um, particularly there, there are some practices where people are sort of raising their larynx, particularly people who wanna feminize their voice. Um, and some of the ways in which they're doing that can actually cause, um, some voice problems. So very important to understand, um, and know how to screen for, uh, voice disorders and to. always err, on the side of, if you're not sure, refer that person to an otolaryngologist, um, for a comprehensive, um, examination. Um, so I really recommend that, um, Second of all. I think, you know, [00:28:00] AC already talked about this, but you know, do your homework with regards to, um, cultural competency and also clinical competency in that you take some courses. So I'm so happy that you're listening to us, but let's not stop there. Um, there are some wonderful people doing wonderful things in our profession. Um, uh, you know, uh, Sandy Hirsch and, and, and her colleagues give a, uh, yearly conference on this. Um, there are other people doing wonderful work, um, seek them out. There's also, um, a gender spectrum voice and communication, Facebook page. Uh, I know lots of people, uh, uh, get ideas there. Um, post some, uh, some questions to the community, um, help I have this client, I don't know what to do. Can you help me? Um, I also, I really recommend forming a study group. So when I first started doing this, this work, there weren't that many of us in the Boston area. And [00:29:00] so we actually formed our own study group. We met on a monthly basis, actually at a hotel in, in Walham, Massachusetts , um, we found sort of this area, it was, and we shared, um, information. We discussed journal articles. Um, it was a fantastic. Now with zoom, you can do this with people across the, the country. So find some people who are interested in this, um, and, um, and, and learn, learn from each other.  [00:29:30] Kate Grandbois:  And I also just wanna remind our listeners that you all had come done, done a previous episode. With a specific focus on the clinical components of yes. Voice and resonance. And I remember cuz you asked me a bunch of questions and I knew the answers to zero of your questions because I know nothing about this. Um, but in that episode you did include a very. Comprehensive resource list with books and articles. We will link that in the show notes as well. So anybody who's listening who wants to [00:30:00] improve cultural competency specific to some of those found foundation specific to foundational knowledge related to voice, we can link some of those resources here as well. [00:30:07] Barb Worth:  Beautiful. And, you know, and I wanted to say too, that this is not an intro class, what, what AC and I are doing. So as we move forward, um, you know, we're not gonna explain the basis, uh, basics of how to do this type of work. Um, you know, for listeners, we're sort of assuming that, you know, the elements of how to do this work. Um, we're gonna talk about things like resonance and pitch and intonation. We're, we're not gonna just define those concepts because we're sort of assuming that, you know, those things, um, and we're assuming that you have some tools already in your toolbox. Um, so this specific, um, podcast is about working with a very specific, um, A part of this population. Um, so we're gonna continue on, um, talking about using non-gendered language.  [00:30:57] AC Goldberg:  A lot of clients are really triggered by gendered [00:31:00] language. Um, you know, obviously you wanna make sure that you're mirroring the language that your client is using. Um, but when you're thinking about working with someone who's non-binary, even if their goals sort of squarely line up with what you consider voice feminization or voice masculinization that might be, you know, a MIS categorization and a microaggression against the person who isn't trying to be more feminine, they're just trying to be more themself. Um, you know, and even though there are goals line up with things like a more high front resonance, you know, maybe a change in pitch, um, change in body language that you would associate with femininity to them, it's just associated with their vibe and their gender. Um, so we want to kind of attempt to, from this point in our, um, in our recording forward, uh, Talk about the voice, as we're talking about these things without using gendered language. And what we're gonna do is as we proceed [00:32:00] through, um, we are going to, um, you know, call each other in and say, you know, okay, Ooh, that was gendered. Like let's, let's reframe it. And let's see what we could say. Because as a clinician, I find myself doing this all the time, you know, with your clients, you're gonna establish your own set of vocabulary about what, the type of voices that they want to have. So. When you are working with a client to establish that vocabulary, you know, obviously you're gonna be asking them, well, whose voice do you like listening to? You know, what does that sound like? What does that feel like to you? You know, can we try it on together? Um, and then you're gonna come up with words that, you know, make sense for that, you know? Okay. Um, we can call that, you know, the twinkle effect. Um, we can call that your smooth sound. We can call that your boom, um, you know, we can call, we can call those things, any words that, that we want to use in here, and those don't have a gendered, those don't have a gendered [00:33:00] expectation associated with them. Um, yes, Kate,  [00:33:03] Kate Grandbois:  I just wanna make a point quickly how, if anyone's listening and, and, and feeling like that might be really challenging. I just wanna emphasize that it, it can feel challenging and that's okay. I even find myself having spent a lot of time with both of you, um, Even now, even still I find myself saying, all right, guys, you know, gendered language is so fluent for us as people. Um, and I think it's, it's okay to take that moment, feel uncomfortable, you know, lean into it, forgive yourself, move forward again. We're not gonna get into that soapbox. There's a lot more information in a previous course that you did with us. Um, but also to accept that it's, it can be fluent. It can feel uncomfortable and how important it is to establish, um, a safe space and, um, components of trust so that you can do this with a client in the clinical setting. I just wanted to say that quickly, because I know how easy it is, [00:34:00] um, to AC, you know, to, to fall into these gendered vocabulary traps, I guess we could call them cuz it, it is really a, a part of our, our fluent language. Um, as people.  [00:34:11] Barb Worth:  You know, I think that you, you actually, this is a great segue because talking about sort of trust and talking about creating a safe space, there are ways that we can do that. There are ways that we really, there are things that we really need to be very conscious about, very mindful about. And so Ace's gonna talk to us about sort of the things that we can do in our intakes and our interviews. And so from the very, very start from the moment that we meet our clients, how we can create a safe space. [00:34:47] AC Goldberg:  So, you know, That all starts with your institution, obviously with your intake forms, you have to make sure that they don't make someone check off an M, an F box. And you know, if that they do ask for people's pronouns [00:35:00] right up front, they do ask what name we should call you. And that's all, again, things that we've gone through in previous episodes, but when you're discussing goals with your client, because let's assume that all that has happened and they've had a great experience coming into your office, um, you wanna make sure that you're mirroring the language, um, that someone uses and ask them clarifying questions if they use gender terminology. Um, not because, you know, not because you can't mirror their own gender terminology, but because sometimes people's gendered terminology is because they don't have the terms to describe the vocal qualities that they're looking for. You know, someone might come in and say, I wanna sound, you know, I'm a non-binary person. I wanna sound more girly. Um, You have to ask them well, what do you mean by that? You know, who sounds girly? Like who sounds girly to you? Can we, can we get an example? Like I, you know, maybe we can, maybe we can make sure that we have the same understanding of that because what it all comes down to there is [00:36:00] that somebody might use the word girly and have a completely different understanding of what that means than their clinician and, you know, making sure that you come together and understand that vocabulary and then deconstructed and take the gender out. If your client, you know, uh, permits. You know, say they might say like, oh, I wanna go into my girly set, but you know, that's a set that involves, you know, four different things. Um, you know, if they like that term, go ahead and, you know, go for it. But making sure that you understand what someone means by those words, because we are so conditioned. To think of things in these binary, in these binary terms, you know, if somebody says like, you know, I wanna sound, I wanna have a more, you know, I, a more masculine sound, well, maybe they're talking about, they just want to have chest resonance. Um, and you know, they may not wanna sound more masculine. They may just wanna sound more like themselves, but they don't have the terms for things like chest resonance. So coming up with those, you know, with those terms together, understanding what your client needs, coming up with things together that really builds the, the, the [00:37:00] therapeutic rapport. Um, you know, the part of therapeutic rapport building with your client is really getting a chance to understand and see them as their gender. Um, you know, which is something that I think, you know, not all non-binary people are the same and, you know, that's one thing that I think, I mean, not all, not nobody is the same as anyone else, but I think a lot of times I get questions like, well, how do you do non-binary voice? And, you know, that's a… That question is obviously, you know, coming from a really good place. And I understand why people feel like they don't know, but it's the same as any other type of gender expansive voice work in that all you're doing is figuring out how the client wants to express their gender through their voice, coming up with a common, you know, terminology for it, and then goal setting alongside your client. Um, you know, there are other things that to consider, like a lot of people will sometimes assume that non-binary means [00:38:00] androgynous, although that might be the goal. And that might be the presentation of one person. That you're seeing it isn't the goal or presentation of all non-binary people non-binary is definitely many, many, many, many non-binary genders there isn't just one non-binary gender. Um, so making sure that you understand, um, you know, what the person is going for is very important and not sort of just assuming that they want something more neutral or androgynous, unless they ask for that. And another really important sort of safety consideration when you're establishing rapport with a client is talking to them about, um, like. Safety around their body, especially when you're doing things like breath work. Um, anyone could be wearing a compression garment, like a, like a chest binder. Um, and we never wanna assume that because of someone's gender expression, um, gender identity, or the words that they're using for themselves, that they're not wearing something like that. Um, you know, you just can't tell what someone's, what's under [00:39:00] someone's clothes. That is, you know, um, one of the things that is, you know, important to transgender and non-binary people and gender nonconforming people is that people are not trying to judge those things. So you just, you know, you don't know. Um, and it's very important to sort of ask those things in a comfortable way and, you know, make sure that you say like, okay, I wanna do some breathwork because we're gonna be working on loud voice. Um, but I'm a little concerned because I don't know whether, you know, whether you're wearing any sort of compression garments, if you are like, you don't have to have the person disclose to you what they're wearing. Like, if you are, why don't I demonstrate and you can do this at home. And if you're, if you're in a clinic and if you're over zoom, um, you could say like, you know, um, if you're comfortable doing this, you know, by yourself, here's. Here's how I would do it. If you wanna do it with me, um, you know, you can turn off your camera. Um, because a lot of the time people aren't comfortable, um, showing themselves when they're not wearing these garments, even if you're only seeing them from here to here, um, people feel very uncomfortable about their bodies. That's part of [00:40:00] the experience of, you know, your gender, not aligning with, you know, certain elements of the way that society sees your body. Um, you wanna, you know, prompt them, you know, to only engage in things like breath work, if they're not wearing something tight and we all understand that's because injuries to the chest wall are really common. You're expanding your, you know, if you're expanding your rib cage, if you're trying to get, you know, like really, um, loud quality to your voice, you can't do that safely if you're wearing something very tight. Um, so that's something that's very important and it's very important that, you know, your client understand that you, you understand, and you know that, and that you're trying to keep them safe. And, you know, that's the point of sort of that line of questioning because the whole, um, There are a lot of insensitive lines of questioning that come to transgender and non-binary people in clinical settings and the person understanding the point of the line of questioning or the sort of like, I'm gonna demonstrate some breathwork. If you're wearing a compression garment, I don't want you to do this right now. I want you to do it, you know, by yourself, in your house without me present and just kind of giving [00:41:00] someone an out to not discuss it is great. Um, and saying, you know, it's only because of your safety and because you could injure yourself, um, and that will help someone understand that they can trust you. They don't have to disclose what they're wearing or what they're not wearing. And then, you know, you've sort of given them an, an out to not have to engage right away in something that like, uh, oh, I'm in a clinic, I'm wearing something. I don't, you know, I don't think I can do this right now. So making sure that you understand, but without asking specifically, um, is important. Um, and I don't know, did I miss anything there, Barb about that sort of.  [00:41:35] Barb Worth:  I don't. I don't think so. I mean, I, I, I don't think so as far as intake and, and I mean, and just thinking about therapy in general, I think, you know, AC and I were talking yesterday about what information we wanted to, to, to present. And we were talking about sort of the differences between working with someone who is non-binary and someone who is, uh, a trans woman or a trans man. Right? So [00:42:00] one of the things that, that, I mean, with all of our clients, it's so important to listen, right? It's so important to have an understanding of their goals. Right. But I do think that working with people who are non-binary, um, sometimes their goals are having a voice that is very fluid, having a voice that can be different in different settings. Right. And that's when, when wer’re talking about terminology, it's so important to have shared vocabulary shared terms of what that means. Yes. Kate  [00:42:41] Kate Grandbois:  I was thinking about this earlier because AC you mentioned, uh, coming up with novel non-gendered language, like we're gonna call this your, your, the sparkle sound and yes. Or the boom. I, you had you it much better than me. Yes. But as you're going through that component of therapy, do you find it [00:43:00] helpful to play sound recordings or, or  Barb Worth: for some people Kate Grandbois:  to use other examples? Only here I am a speech pathologist. Yes. And I'm thinking I would have a hard time describing what I want my voice to sound like. So  [00:43:12] Barb Worth:  it's interesting Kate for some people. Yes. So I think for some people we spend time listening either we ask them to bring in voice samples or I have a, you know, basically a, a, a file filled with them. And sometimes it's not like it's not, I want this voice. It's let's let's create some terminology about what you hear in this voice. Right? So we play sound recordings and they'll say, oh, when that, that person does this, that sounds like, boom, to me, like we use the word boom. Or when that person does that, I hear a twangy quality. So now we have shared vocabulary and then we start to say, well, what did you think about that twangy quality? Is that something that you would ever wanna adapt into your [00:44:00] voice? And they say, yes, that's exactly what I was looking for or no, I would never wanna have that. Right. So, so then you're just sort of this, start this conversation. And I think that makes a lot of sense.  [00:44:10] Kate Grandbois:  Yeah. That makes a lot of sense.  [00:44:12] Barb Worth:  And then, you know, it's go ahead AC [00:44:13] AC Goldberg: . Yeah. I was gonna say the best part about that is when you're listening to voice samples together, um, not only do you get to kind of come up with that common shared language and, um, you get a lot of maybes, you know? Yes. Maybe, maybe, and then you get to start exploring. And that, that is so ,uch fun. Right. Um, that's so much fun to, to say, okay, well, let's try that on and let's see how it feels. Right. And, you know, go down a list of like, well, that didn't feel good. That did feel good. Sorry. You,  [00:44:41] Kate Grandbois:  I also have to assume that that can create moments of empowerment for someone where they are all of a sudden presented with choices. Oh, I didn't, I didn't know that twang was a thing. I didn't know I could sparkle. I don't know. Boom, whatever. I mean, absolutely. Just having a moment of excitement and, you know, creating a [00:45:00] shared space of creativity and empowerment.  [00:45:03] Barb Worth:  Well, and I think that, that they, they have to go hand in hand. So you have to create a, a shared space so that they are willing to put that on. Right. So they, they, they, they are, they're one can't happen without the other. So the clients really have to feel safe with you. In order to try something onto, in order to explore, we use that term explore. That is, that is what I teach my, my graduate students use the word explore because otherwise for a client, it can feel very right or wrong. I either do it or I, or I didn't do it and we don't want it to be about that. We wanted to, to be about. And that's the other thing that is also, you know, you talked about listening to other voices. We also don't want people, somebody to mimic another person. And did I do that right? That other person's voice correctly, it's not about that. It's about finding something new that you can do with your voice and deciding if you wanna make that your own. We also talk about sort of [00:46:00] a recipe and, you know, we talk about, you know, we are creating a cake or we're creating a recipe and do we want a sprinkle of this, of a sprinkle of twang and a cup of boom and a, uh, I don't know, you know, and, and, and a and a half a cup of sparkle, you know, and, and, you know, we kind of get silly with that. But I think that it, it helps people to sort of see it as an exploration, not as a writer or wrong. And, and, and I think Amy, you were gonna say something [00:46:30] Amy Wonkka:   I was just feeling like, and I don't know if it's because I don't do voice therapy, but I have no idea without this shared co-creation and co definition of terminology to describe voices. I don't know how you would figure out how to help the clients. Outside of that process. Like, I, I guess I'm just like, it feels like wine to me, right? Like we all use these different, the descriptors to talk about wine, strawberry notes of notes of cherry. What is that? Well, it's like, well, it's like wine. I mean, it [00:47:00] really is. [00:46:53] Barb Worth:  And I think that, you know, your strawberry is my blueberry. You know, it doesn't matter. As long as I understand what you as a clinician, I understand what your strawberry is. And we have a shared definition. Or that the client understands what their strawberry is, that's what's important and that they can re recreate it. And we do a lot of, okay, you got there now, do it five more times. Now do it 10 more times. You know, you're happy with what that, with that strawberry. Now I wanna hear it again. I wanna hear it again. I wanna hear it again so that there's sort of, you know, laying down that motor system so that they can continue to do it again and again, and again, do it at the word level, the phrase level, the sentence level, the conversation level and, and building that. [00:47:41] AC Goldberg:  And then you get to that higher up and then you get to build in strawberry boom and strawberry sparkle, and then we get all these seltzers in there.  Kate Grandbois: Um, I love this. It sounds so much like, so much fun.  AC Goldberg: It really is fun. It really is a fun, it's a fun clinical set to have. Yes. Um, because you know, [00:48:00] it's empowering, it's fun. It can be silly. Um, and it's, it is very exploratory. Um, So it's important when you're working with non-binary people to, to make sure that you understand what their goals are. You know, not everyone wants an androgynous voice. Some people might want androgynous voice. You also wanna know, you know, are we creating a new voice that you want to use habitually? Or are we creating one new vocal set that you're gonna use in certain specific situations? Or are we creating a couple of different vocal sets? Yes. Because you are gender fluid and yes, you want to present differently at different times. Um,  [00:48:40] Barb Worth:  so we have people who come and say, I need, I want strawberry voice in, in with my partner. Strawberry voice is, is, is what I want, but I need blueberry voice in a work setting. And I need to know, I need to, to be able to code switch between. And again, this is another difference with [00:49:00] sometimes with working with non-binary folks is that they need this ability to sort of move back and forth maybe between different voices in different situations, in different settings, depending upon how, how they're, they're feeling in the moment, what they're, you know,  [00:49:15] AC Goldberg:  or how they wanna be read, like how, oh, they, how they want for  [00:49:17] Barb Worth:  safety situations. [00:49:18] AC Goldberg:  Safety, right. Safety is really important. I, you know, that's one of the first things that I work on with people is, you know, yes. Um, let's work. That it's funny that that's, um, you know, first I sort of try and establish this shared vocabulary and understand their goals. And then I'm like, okay, let's get to safety first. Right? When are you least safe? And what vocal set do you want? And when we were talking yesterday, Barb, we talked about how Uber comes up a lot.  Barb Worth:  Oh, Uber comes up a lot.  AC Goldberg: This is no shade to Uber, but people feel very unsafe in their Ubers because yes, you know, they've got whatever username they've got and then sometimes you get a call and then you're in a car with a stranger. And it's scary because they don't know, you know, you don't know them, they don't know you. Um, oh my gosh. I could [00:50:00] tell a story that would take up the rest of our session about me having to fight, to get into an Uber that I ordered because they called me and clocked me as, as female, which happens to me often on the phone. Um, and  [00:50:13] Barb Worth:  this is yeah, the phone and the phone, you know, and one of the thing, you know, AC and I were talking about is that it's, it's these certain situations that, that maybe safety, or maybe, you know, it's sort of like aunt Mary aunt Mary is not accepting of my, of my gender. So I need to sort of. put on strawberry voice for, for aunt Mary to the extreme, right? So on the phone to be extreme to the, to the lift, to be extreme for aunt Mary or whatever situations that might be hostile or unfriendly or not open. Um, so we teach people to do that. So, you know, it's not role, role playing. We role  [00:50:53] AC Goldberg:  play situations, role playing is all, is all the time. And it's really fun to role play. Um, you know, that's, it's my favorite type [00:51:00] of, um, therapeutic activity, regardless of the type of therapy I love role playing, um, because it's silly and it's funny. Um, and it gets people sort of out of their comfort zone, but it also really helps people. You know, relax and expand Uhhuh, you know, and it, it does also help that therapeutic rapport, because as, as someone who's role playing with someone else, you're also taking risks. You're also making mistakes. You're also doing things silly. Um, you're also saying that didn't come out right. Did that sound strawberry to you? You know, I was trying to do strawberry there. Let me try again. And by modeling, like I didn't do that. I, I, I don't think I heard that. Let me try again. For your client, it shows that, you know, we can't be an expert in every single person's voice. Present vocal presentation, but we can show them that, you know, we can learn different vocal presentations too, alongside them and, you know, um, and that they will be able to do it. Um, but yeah, that sort of that code switching, um, comes up and is really important for [00:52:00] a lot of members of this community, um, because of safety. Um, and because of people, either the varying levels of acceptance that people experience as they, you know, walk through their lives,  [00:52:11] Barb Worth:  I know the really helpful tool are functional phrases. So, you know, having clients sort of come up with a list of phrases of like, let's take the Uber driver. What do you say to the Uber driver? What do you say on the phone to the Uber driver? What do you say in person to the Uber driver so that they practice that strawberry voice with the, you know, beforehand and in the, the confines of their bedroom or a safe space so that when they, that when they need to get into set that vocal set, they get into the lift, they get, they, they have those sort of very automatized phrases that they use with the Uber driver and using the, the, their, their desired voice. Um, yes, Kate,  [00:52:51] Kate Grandbois:  you may have gone over this in a previous episode, but in these situations, do you ever recommend or prescribe a certain amount of list, [00:53:00] someone listening to their own voice? A little bit of biofeedback. I know  [00:53:03] Barb Worth:  I may or may not. It's very loading. So they, again, it's having that conversation with your client. If that is something that they wanna engage in, I never, never require it. It is always optional. It can, it can be triggering for just for you. And, and also, as we know with audio, it is not a full representation of our, of our voice, right. There's limitations to it. Um, so we, we need to really counsel our clients around audio recording. [00:53:32] AC Goldberg:  Yeah. And it can just be, so it can be so triggering that, you know, yeah. Sometimes someone who's like, oh, I've, you know, I've gotten so much positive feedback on my voice. I'm ready to listen to it. Sometimes they listen to it and it devastates them. Yes. And that's, you know, a place where, you know, you go with your client, that's devastating to you also because you know that their voice is getting them, you know, read correctly. Um, gender wise all the time, they're feeling comfortable, they're feeling confident and [00:54:00] they hear it and they don't like it. Um, and that, you know, It's so loaded and some people wanna hear the recordings all the time because they want to, they wanna know, did I do it right? How did that sound, what did that sound like? That's a very individual thing. Um, I always do take recording samples. Um, you know, part of my, um,  [00:54:19] Barb Worth:  oh yes.    Kate Grandbois:  Data collection strategy. Yes.  [00:54:23] AC Goldberg:  It's the,  [00:54:23] Kate Grandbois:  that you don't routinely share unless you've had that conversation. Exactly.  [00:54:27] AC Goldberg:  Exactly. That's like my second question to someone, you know, you feel comfortable having your voice recorded. I have to record it for my own purposes, but you never have to hear it. Um, would you ever want it to be played back to you? Um, and if you do like here's, you know, what we can do, or we can take recordings every so often, um, or we can only take them, you know, beginning and end or what, you know, whatever you want. But I just having that baseline recording is, is an important thing to have because you're probably analyzing that for a lot of different things. Um, and. You don't want to force someone to listen to something that's gonna bring them [00:55:00] into that dysphoric place, because that can lead to shutting down and in, you know, you've gotta have really good counseling skills. Um, and it takes a lot to walk someone back from that feeling and get them to reengage with you in a session. Um, you know, it's necessary because that's gonna happen, um, in voice therapy, but recording is like one of the primary ways to, you know, set that off for a lot of people. So we just have to be very careful. [00:55:26] Kate Grandbois:  I'm so glad I asked now we know. Yes,  [00:55:28] Barb Worth:  yes. So in continuing to talk about exploration, I, I really wanna emphasize. The word, no. Or pass, that we always need to give our clients the option to say pass. I don't, I don't, I'm not, I'm not comfortable doing that. That is not what I wanna do. Um, I create a lot, I give people a lot of options. Would you like to try this or would you like to try this? Um, we do a lot of group work, particularly as our clients are sort of, you know, moving in their journey, moving in [00:56:00] the hierarchy. Um, they maybe they've had some individual work they're feeling now. I, I really want some more opportunities to, to work on my voice in it with, um, in a social settings.  [00:56:10] AC Goldberg:  I wanna circle into circle into, um, instances of misgendering, because we do a lot with binary trans, um, folks, and, you know, kind of when we're role playing, giving them the tools to respond and scripts, to respond to instances of misgendering, which is another one of those counseling tools to pull, pull out of your toolbox, you know? Yes, because it does feel really, really, really bad to get misgendered. Non-binary people are misgendered all the time because everyone's trying to gender them in one, you know, in one way or another, and they're not necessarily trying to do the, any harm. Um, but you know, it's really important that you discuss with your non binary clients, you know, Do you want to assert yourself as non-binary in those moments, if you're safe, um, you know, and if you're not safe, you know, with like, do you have a direction you would prefer to go in? Because some people will say, you know, I don't mind if I'm [00:57:00] called miss, but if I'm called, sir, I will lose my mind. And you know, they need to have a set in those situations where they, you know, can be extra. Just like when we talk about phone voice, we talk a lot about phone, voice, and, um, you. Phone voice is double, triple, extra your, your voice. I mean, it is, you know, it is the, if I did my phone voice, you would be like, you know, who is this wound? Because apparently my phone voice still sounds, um, it has remnants of, you know, a, a former gen gender presentation. Um, but phone voice, you have to, if you are, you know, like aiming for a high front resonance, you have to go past what you think even sounds, you know, even sounds like a typical person just to get someone to gender you correctly over the phone. Um, you know, and when you're non-binary, you know, It's important to kind of choose how you want your presentation to be in those instances, you know, is it going to be more triggering if you are read [00:58:00] in one direction or another, how will you respond? You know, um, if you're safe, are you gonna say, you know, um, oh, you know what? You don't have to call me, sir, or ma'am, um, in fact, you can just call me Max, um, and my pronouns are they in that and then move on with your day? Or are you gonna wanna just kind of switch into a set that is either going to get you read as male or female, um, so that you can just get the interaction over with and move on. This happens a lot. There's masks involved. Um, you know, we talked about situations like getting into, you know, getting into a cab, that type of thing. Um, there are you. Lots of places where people can play with their gender, the, their gender presentation in these vocal sets, especially online, like with gaming, yes. People can practice these sets and see how they're gendered when they're using, you know, um, extra strawberry sparkle or when they're using strawberry. Boom, you know, how does that get you gendered when you're playing this game? And people have a lot of [00:59:00] freedom exploration and, you know, just a lot of ability to be very expansive in those online role playing games. Yes. Um, that they don't have in other situations. So that's a great tool to have in your toolbox, um, for your clients to use.  [00:59:16] Kate Grandbois:  You are both such a wealth of knowledge, I'm feeling so inspired by all of this. I think it sounds like fun therapy. I think  Barb Worth:  it sure is  Kate Grandbois: you, you came into this with such an important point in terms of looking at all of this and approaching all of this through the culturally responsive lens, making sure as clinicians, we do that work first before moving into, um, the clinical voice components. And as we wrap up, I'm just wondering if you have any part for anybody listening, who wants to learn more, who is curious, um, what are your words of advice or parting words of wisdom [00:59:56] Barb Worth:  AC? Kate Grandbois:  Um, loaded question. I know  Barb Worth: there's [01:00:00] so many, it's hard. It's hard to know. [01:00:01] AC Goldberg:  to know. Yeah. I, you know, mine is about expectations. Um, you know, managing people's expectations around, um, around their voice, especially if they're gonna be, um, having more than one vocal set, you know, if you're not moving toward a new habitual voice, if you're moving toward a couple of different vocal sets, it will be a little bit harder. For someone to, you know, very easily gain access to that set, to switch back and forth easily and fluidly between two or three different vocal sets. So managing someone's clinical expectations around, you know, how long it will take to feel comfortable using this voice, um, you know, managing your own expectations. How long is this person gonna be on my caseload? You know, how long will it take to teach three different vocal sets? You know, some people, some people take a long time, some people it won't, but, you know, understanding or having one primary set and then two safety subsets. These are all things that come up when you're working with non-binary gender nonconforming, [01:01:00] gender fluid, and gender queer individuals, and even agender people. Um, and also understanding how to manage societal expectations. You know, your client, um, might, you know, wonder when can I expect other people to see me as this, when I'm using this voice and that's all difficult to navigate and, you know, falls into that counseling subset, that is so important. And I think that my parting word of wisdom here is you really need a strong background in counseling to engage in this work in general,  [01:01:31] Barb Worth:  AC you just took the words right outta my mouth. I mean, I, you know, it really is. And I think that, um, I think being an active listener, knowing what questions to ask, but also really hearing the terminology that they're using and really understanding the expectations, um, being fully present, creating that safe space, really [01:02:00] knowing that you are walking in a journey with someone and really honoring that. And not letting your biases get in the way of what you think is yeah, and right. And I think we talked about cultural responsiveness being ongoing. So making sure that you are doing the work yourself and listening to podcasts like this, going to conferences, doing all this important work, to make sure that you're keeping your biases in check, um, and that you will really understand this incredible area of our field. When you said it sounds like fun. It is so much fun. And it's an honor to walk people with people in this journey. [01:02:53] Kate Grandbois:   I love how you phrased that you are both such a wealth of knowledge. Thank you so much for being here with us today. Um, [01:03:00] for anyone listening, who wants to learn more everything we mentioned, um, all of the resources, all of the links will be listed in the show notes. We will be putting links over to previous episodes over to AC’s transplaining platform, as well as the credit platform, where there are courses available for graduate level credit, um, that do much deeper dives into other areas of cultural responsiveness. Thank you both again so much for being here and we hope to have you back again soon. [01:03:26] Barb Worth:  Thank you always. Thanks for having always a pleasure. Wonderful. . [01:03:30] Kate Grandbois:  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study. Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as [01:04:00] always, if you have any questions, please email us at info@slpnerdcast.com thank you so much for joining us and we hope to welcome you back here again soon.

This is a transcript from our podcast episode published May 30th, 2022. The podcast episode is offered for .1 ASHA CEU (introductory level, professional area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. Kate Grandbois:  Welcome everybody today. We are so excited for our guests. We've had multiple conversations leading up to today's episode and she's been incredibly flexible and she has so much to share. Welcome Kelly Vess. Welcome Kelly.  Kelly Vess:  Hi, I'm so excited to be here. This will be an amazing talk. Thanks for having.  Amy Wonkka:  [00:02:00] We're so happy to have you. And you're here today to discuss selecting treatment target, to achieve optimal gain in treating phonological disorders. But before we get started, can you please tell us a little bit about yourself? Kelly Vess:  Okay. Yes. I have close to 20 years of experience as a preschool speech language pathologist, and all along the way, I've been a researcher as well. So I researched every detail of my practice to be as efficient as possible. So you can always find me at ASHA every year, showing the latest research and what really makes a difference in your practice if you really want to get optimal outcomes. So that's something I'm extremely passionate about, which is why I'm so excited to be here today. Because what we're going to talk about today is what I found to make, to have the greatest impact on outcomes in treating speech sound disorders. So I'm so excited to share this. It's going to be [00:03:00] such a game changer for your listeners. Kate Grandbois:  That sounds like a, like something I can't wait to get into and a little over my head already, which is great because it means I'm going to learn something. Um, tell us a little bit about your background and, and what you do.  Kelly Vess:  Um, aside from being a speech pathologist, I'm also an author. I've written a book on, uh, speech sound disorders and how to treat the whole child with speech sound disorders, because we know that if a child has a speech sound disorder, the child is at greater risk for literacy impairment at greater risk for behavioral issues at greater risk for language issues and at greater risk for academic failure. So the book and treating speech sound disorders is not about treating a speech sound disorder. I'm passionate about treating the whole child and creating lifelong change. So that is my passion. I'm also a clinical supervisor. So year round, I do research with graduate students [00:04:00] and I teach graduate students how to treat speech sound disorders with preschoolers. Kate Grandbois:  That sounds so interesting. I love working with graduate students. It's such a fulfilling experience. I'm sure you feel the same way.  Kelly Vess:  What I love about it is we always ask, how can we do this better? So we're always saying, okay, this is good. This is great practice. This is best practice event. Can we make it better? And I think that that's, what's so neat about when you get a mastermind together, you get graduate students, you get yourself together and then you come together and you create this third mind. That's bigger than either of you combined. You create another mind, that's even greater. So I love working with graduate school students. We're always innovating and we're always creating better. And that's why I'm so excited to be here because your listeners bring this unique skillset, this unique talent, this new unique secret sauce to the table. And when they have new techniques that they add to that, they're going to innovate [00:05:00] whatever I share with you today and make it even better. Kate Grandbois:  You've already complimented so many people and you've only been here for just a few minutes. So this is already, I'm feeling very positive and excited and energized. So that's awesome. Well, before we get into all the good stuff, the powers that be,i.e. ASHA makes me read all of our learning objectives and financial and nonfinancial disclosure. So I'm going to go ahead and read through those and get them out of the way so that we can get onto the good stuff. So first and foremost learning objectives, learning objective number one, participants will be able to select cluster treatment targets based on multiple phonological processes present to improve efficiency of treatment  Learning objective number two, participants will be able to assess how stimulus treatment targets are to accurate production provided multimodal cueing and learning objective number three, participants will be able to make informed clinical judgments in selecting treatment targets based on phonological processes, variability of production, stimulability for [00:06:00] accuracy and developmental complexity, disclosures Kelly Vess financial disclosures. Kelly is the author of speech sound disorders, comprehensive evaluation and treatment for which she receives royalties. Kelly Vess, nonfinancial disclosure as Kelly is a member of ASHA, special interest group 1 language learning and education. Kate Grandbois financial disclosures. That's me. I am the owner and founder of GrandBois therapy and consulting LLC. And co-founder of SLP nerd cast. My nonfinancial disclosure is I'm a member of ASHA, SIG 12, and serve on the AAC advisory group from Massachusetts advocates for children. I'm also a member of the Berkshire association for behavior analysis and therapy mass ABA, the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis, special interest groups. Amy Wonkka:  Amy that's me. I have financial disclosures are that I am an employee of a public school system and a receive compensation as co-founder of SLP nerd cast. And my non-financial disclosures are that I am a member of ASHA's special interest group 12, and I serve on the AAC advisory group from Massachusetts advocates for [00:07:00] children. All right, we've done it. We've gotten through the boring bits and now onto the good stuff. Kelly, why don't you start off by giving us and our listeners just a little refresher. Can you tell us a little bit about phonological disorders specifically?  Kelly Vess:  Okay. Excellent. The final logical disorders are when we're looking at immature speaking patterns that are persisting beyond developmental age. So for instance, maybe the child is still deleting the final consonant of sounds. So that's fine. When the child is two years old and the child points to a dog and says, duh, but when the child is three years old and the child continues to delete the final consonant still has that immature speaking pattern. Then it becomes a phonological processing disorder. It's persisting beyond the age as expected. So the child is still saying duh for dog. And when we see that we know that this child is not, that there's [00:08:00] something about the linguistic system that's not well-developed, they don't seem to understand that a word has a beginning, middle and end, another example of a final logical processing that, that disorder example that you're going to see very commonly is a child fronting a sound. So if the child looks at the cat, instead of saying cat, the child's going to say Tat because pulling the tongue back and retracting the tongue is difficult for the child. So now the child's four years old and at four years old, that's persisting beyond age expectation. So for that reason, we're going to say this child has, is likely has a phonological processing disorder, these simplified speaking patterns, which were okay to do when you're younger are not being suppressed and they're not developing into more mature speech. So that's what we're looking at when we're looking at in preschool is phonological processing disorder. They're doing [00:09:00] things beyond age expectation that they should have suppressed and they should have developed a more mature speaking form.  Kate Grandbois:  So, thank you so much for that refresher, because as our listeners know, I don't know very much about these kinds of things. I've been working in the world of AAC for entirely too long. And as a matter of fact, this is Amy's area. She, you know, so much more about this than me, Amy, but with, with so many other things too, but I really appreciate sort of setting the groundwork and setting the stage for what we're going to talk about today and, and giving us that refresher. And I have to assume then that everything we're going to be talking about today from a treatment perspective is very much related to these linguistic foundations and as, and differs from a different kind of speech intervention approach. For example, for something that's motor related, is that an accurate assumption?  Kelly Vess:  Well, we're going to focus on today is classes of sounds, for instance, and phonological processing [00:10:00] disorder for child is stopping fricatives. The child is producing the P for F P and B for F and V, the child's boozing T and D for S and Z. The child is preserved producing probably T and D for “sh” and “juh”. So we have a lot, or for th the child is producing, uh, I'm sorry, P or B perhaps. So we have a whole class of sounds that are impacted. And what we're going to want to do is we're going to. Focused on the rule. We're not going to want to focus on six different sounds and take a chisel to that rock. What we're going to learn today is we're going to learn how to treat that phonoprocessing disorder. Treat that rule and take fireworks to that rock and explode that rock. And that's how Len Williams, the president of ASHA describes it. When we use the complexity approach, which we're talking about today, we're not taking a chisel to that rock to those six sounds. We're going to take a fireworks in that rock, [00:11:00] explode that rock and change the child's linguistic system by using the most complex sounds and sound combinations. That's what's so exciting about it. This is not. I think of Charlie and the chocolate factory oompah oompah oompadeedo approach in which you're doing one sound at a time, one by one, slow, so slow and said, it's an explosion that will literally change a child's linguistic system very, very quickly and impact all sounds simultaneously. Kate Grandbois:  Can I ask a question? Just so to say it back to you or make sure I've understood it. So the complexity approach is a specific approach that where you're treating a rule or a cluster or a group of phonological presentations, instead of treating one thing at a time, is that an [00:12:00] accurate description of the complexity, the approach, because I've never heard of it before. Just straight up. Kelly Vess:  Yeah. The complexity approach. Exactly. The complexity approach says, okay, the speech speech develops like a waterfall. And if we go in and if we go into those clusters, which are the last things to develop in our language and SKR, it develops at seven years of age. That's the very last cluster in our language. Let's go to the top of our mountain, the most complex sound and work at that level. And then we're going to improve that level and there's going to be a waterfall effect in which all of the sounds below it are going to spontaneously improve. That's what's neat about it. That's how speech develops. It doesn't work like a Geyser if I work on the earliest developing sounds. So I work on the, the simplest sounds, the P the B the M I only help P B and M. [00:13:00] If I don't improve the later developing sounds, its speech doesn't work like a Geyser in which it shoots up. It works like a waterfall in which it cascades down. So I care less about PBMTD and the earliest developing sounds because they're not going to impact the later ones. I care about the later developing sounds because if I work on these sounds, the earlier developing sounds are going to spontaneously develop. And that's what Lynn Williams was talking about. When she said you're bringing, putting a firecracker to the rock, you're blowing the rock up and improving all of these sounds underneath by working on the most difficult sounds. So that's what we're going to talk about today. For instance, if I work on the SKR blend, I'm going to work on stopping the fricatives. I'm going to work on fronting of velar sounds K and G to T and D. I'm going to work on [00:14:00] gliding of L and R. So I'm going to get three phonological processes that are very common to preschoolers all at the same time, three for the price of one. And what matters, why that matters so much is because we only have 30 to 60 minutes a week to make a difference. So we have to challenge creates change. Status quo does not. So I look at the brain like the body. If you only have 30 to 60 minutes a week to work out, you can make a difference. But you're going to have to be challenged in order to make a difference. You're not going to do it. Taking a walk 30 to 60 minutes a week. You're going to do it by doing something challenging. Let's say burpees, a full body anaerobic activity that tests your strength and all your muscles as. Well, you get three for the price of one you'll wear might make you cry afterwards. Kate Grandbois:  Everybody hates burpees. Yeah.  Kelly Vess:  Yeah, [00:15:00] exactly. But what are you doing? You're working multiple sounds at once. You're working multiple muscle groups at once. You're using your time efficiently and you're challenging. Cause challenge creates change. Status quo. Doesn't the children I work with when they come to me, they're at the one percentile they're at the standard score. 50, they have severe speech impairment due to find a logical processes by the end of the school year on average, during the normal range, they're in the 50 percentile, they have a hundred standard score and that's because I'm challenged creates change. I'm at the top of the mountain. I'm working on SKR with these kiddos and that's what we're going to talk about today in the waterfall. All that other stuff is spontaneously developing the ends of the words that they're dropping. I don't focus my time on that. That's going to spontaneously develop. So that, that's what we're going to talk about today and why it's so [00:16:00] exciting is that you're going to create your, these children are going to take a 180 because we're going to work smarter and not harder. And it's in the treatment target. The treatment target matters a lot.  Kate Grandbois:  Oh, I was. So I was just going to say, tell us more, tell us what to do. How do you do this?  Kelly Vess:  Okay. This is great. So the first thing we're going to do, step one, we're going to do the speech sound disorder test, the single word test. And we know there isn't a lot of reliability that, but we need to find out what are we going to work on? So what are we going to focus on those phonological processes? We don't care about the sounds. We care about the rules. What is this child doing? Okay. This child is stopping. They're stopping all fricatives. Okay. We need to pick what sound are we going to pick an S blend, what? because S is complex. So we and S is also highly frequent. So let's work on something high and complex S oh, they're also fronting. Okay. They're fronting the sounds. Are we going to [00:17:00] work on K G and Ang? No, let's go on for K. So we'll go. S K. Oh, they're gliding L and R. Okay. Let's go R in there. S K R will be the blend that we work on three for the price of one. Am I going to work on syllable deletion? No. Am I going to work on final consonant deletion? No, because that is going to naturally develop. I'm going to work on the top of the mountain, not in the bottom of the mountain. That's how it's going to roll, but let's so that's the starting point. The starting point is go to the top of the mountain. And you're probably wondering what if the child can’t do SKR blends. What if the child says, you know, you say, okay, so scrape and the child says tape, then what do you do? What we're going to do is we are going to empty out our tool box. We're going to give them every cue at once because we don't care what the child can do. That's status [00:18:00] quo. We care about what the child could do. That's dynamic assessment. So we're going to, what kind of cues are we going to give them everything, everything under the sun fits in your toolbox, give them everything and see what they're capable of. So for instance, when it comes to the queuing, here are the cues. I'm going to give them to check and see what are you capable of? Cause that's what I care about. I don't care what you can do on your own we're agents of change. Okay. We were not testers. We're changers. We're changing these children. So I'm going to say, all right, what would happen if I give you, you slow unison speech and I give you, what's called a temporal cue, which means I show it to you spatially. So if I'm making a snake sound, I'm going to make a snake with my finger and I'm going to do it really, really slowly and hold it out so you can hear it and you can join me. And why don't I, maybe you have to even meet a, you're going to hold this a touch cue [00:19:00] your face, your mouth back, recheck, retract your lips. Maybe you have the whole, just your lips in a smile form to make that, that as sound. And maybe I have to say a little visual imagery. Okay. Let's make the snake sound. I'm going to give you every cue in my toolbox and see if you can do it. And suppose friends, since the child says with everything, you'd give them with angry dog sound. You say, okay, let's make the anger dog sound. They say scrape. Now you're asking a good question. What are you going to do? Then we don't want to reinforce w for R we don't want to cement that because practice makes perfect, but practice also makes imperfect. So what are we going to do? We're going to still go for three clusters. We're going to say let's do S Q U blends. How about I squash it to you instead, we'll talk about that later, because three clusters where you put three sounds together is more [00:20:00] powerful than two. You're going to get bigger gains with three. That's what our research has found. So we'll talk a little bit about that later. So the second thing we're going to do is we're going to first, we're going to pick the top of the mountain sound that the child can produce if we give them every cue imaginable, and that's our starting point. So then what do we do after that? Right. So the child is like, can't produce the R. So you say, they say rake, they say, wake, you give them angry dog sound. And they still say, wait, what can we do then we're going to say location, location, location, just like real estate. We need better neighbors. So we're going to find neighboring sounds that can help them produce the R. So what sounds can we put before the letter R that gets some retracting that li those lips. [00:21:00] So if we would want a sound where they're going to retract the lips So they're going, it's going to make R easier Kate Grandbois:  I feel like I should know the answer. I don't know the answer and you need, you know, the answer, Kelly Vess:  I think of a consonant that will retract the lips.  Kate Grandbois:  Amy, what's your answer? Would I think anything thinking about like ger? Oh, there you go.  Kelly Vess:  Yeah, that makes sense. Yeah. So, what are we going to do? This really, really works is we're going to say I okay. You can't, you're doing w for R let's give you the G or the K blend. So let's say the word instead of we're going to say like meds, for instance, let's grind to me, please. If you're going to see that in Gerber, or maybe we're going to say a con let's, can you clean it? I mean, we're doing crank it to me please. So when you do the K and the G [00:22:00] are location, location, location, Kate Grandbois:  I love that acronym. That's very easy to remember. Yeah.  Amy Wonkka:  I want to say all of this back to you to make sure that I understand what you're saying. And I think that what you're saying, it's okay to say I'm wrong. I think that what you're saying is that the first thing a clinician wants to do when they're thinking about the target, because the target is so important, the first thing the clinician needs to do is get a feel for what the child is already producing. So identify those processes that might be in place, whether they're stopping final consonant, deletion, whatever, and then you're really doing, like you just described in so many really nice ways. You're doing this dynamic assessment. And so you're giving all of your clinician cues and seeing what is the child stimulable for. If I use dynamic assessment and try all of these different types of cues, what cues work and are there things that still the, the child isn't stimulable for? Even if I give all of my clinician [00:23:00] cues, so then if those cues don't work, then we need to, as clinicians put on our speech pathology hats, and think about what we know about place manner and voicing, and think about what are some other like sound friends that we can put next to the target to help facilitate that production. Is that, is that a fair restatement? Kelly Vess:  Awesome. Awesome. I love it. I love it. Exactly. I love it is the first, what are the rules? Let's crash those rules, second you said, okay, I'm going to empty my toolbox on you. And then third, if that's not working okay, I need some help. I need some neighbors. What would be good neighbors to help me to get that sound? I love it. So for R, because ours is so difficult, some other sounds that are really good are tr or dr blends because tr blend is actually the affricate ch. So once again, you can't round your lips when you do cha [00:24:00] you protrude them. Sure. drain. So, and then you have the word drop. So those are great blends to break the w for R I like to work on the w for our early, because that's a sound that persist into adulthood. Many of us know adults where it's habituated and the, and by kindergarten, I must find it to be too late where it's habituated often too much. And it's very difficult to change because they've said w for R a million times before. But yes. Thank you. That is awesome. Amy. I love  Kate Grandbois: good job, Amy. Amy Wonkka:  Good examples. No, that was great. All right, thumbs up. I got it right.  Kelly Vess:  It's great. Because what happens during these evaluations is the parent not only does, does the child believe in you. Like, whoa, I can do these things. It's very empowering when you, when you're, when you bring out and show them what they're capable of the parent bias, then as well, this is what makes [00:25:00] us different than Joe Schmo off the street. When they say tat and the person says, say cat, and they say tat, okay, game over. That's not like us. We're like game on. So yeah. Thank you so much for that wonderful summarization of 1, 2, 3. This is as simple as that.  Kate Grandbois:  I have a question that's related to something you said a few minutes ago, so you'll have to forgive me if this is slightly tangential, but you said something about what the research says. And I wondered if for those, um, SLPs who are listening, who maybe aren't as familiar with this approach or interested in applying this approach, does the research say anything about what profile of client this is best matched for? In other words, who is represented, what students or clients are represented in this research? Kelly Vess:  Well, the research shows that the children that with severe severe impairment really benefit from this approach. So children that have like don't have hardly any sounds developed [00:26:00] because by working on these more complex sounds, you're going to develop a lot of sounds. And I think it's a really important question that you ask, because when you're using this approach, when these kids come to me in the one percentile, they make huge gains initially, because they're getting puh P B T D N K. They're getting those F B those really simple sounds. And then it's like mountain biking. And you get to the top when you get to the R and the L and the blends you get off the bike, and those are more complex sounds. They're more difficult, whatever approach you're using. And you're walking really, really slowly. I do use this approach personally, with all of the preschoolers on my caseload and even the children that just have problems with R distortions, because I found in my work that you have to work over what your goal is when you're in speech therapy, you have to [00:27:00] overtrain, you have to work at a higher level for it to generalize outside of that room. So I've done research on R, I work on the word scrape SKR. And then they make benefit on are that way and the singleton position. Cause I work on at a harder level. And it's funny because all of these elementary speech pathologists are like, they email me, I've been working on R for like three years with the child. And then I started working on an SKR with them and they're getting it in like two months. And that's because you're working at a higher level and that's the way it works. It cascades down what you do in speech doesn't Geyser up and what you do in speech I find doesn't even move to the side. You've got to work at a higher level than the real world that you expect to happen. Kate Grandbois:  This makes a lot of sense. I mean, even though it's slightly above my pay grade, but I, I really appreciate the visuals that you're using and the, the acronyms and things. I think that that makes, that makes it feel doable and applicable.  Kelly Vess:  And I'll [00:28:00] tell you what my, what my research has also found, which is like, if I want to improve two element blends, like S blends two element, the word, like slide, I need to work at a higher level in speech therapy. I need to work on a word like splash, a three element word, and speech therapy for the child to be able to do it on testing. And for the child to be able to do it in the real world. So that that's what I've found and that's the way it works. You've got to go over it, whatever your goals are for the child to accomplish with no cues, you need to work over it with cues and speech and then fade them out. Amy Wonkka:  So when we think about, sorry, jumping in, I'm just looking at our learning objectives in that second learning objective, and thinking about stimulability, we talked a little bit about stimulability and if you try, you know, using your intervention approaches in that and the child still isn't stimulable, just like you said, we don't want to keep having this repeated practice of an error pattern and that's not what we want. We don't want to be learning an [00:29:00] incorrect production. Um, so we've talked about stimulability in the context of clinician cues and also, you know, kind of setting up those, I don't know, I'm going to call them sound friends, but sort of facilitate context for your target production. Can you talk to us a little bit just about some more of that multimodal cueing that you're using and just, you already gave us some really nice examples of that, but maybe helping our listeners think a little bit more about what, how you might sort through that stimulability piece a little bit. If you have a student who's maybe not stimulable with your cues, maybe they're not stimulable with the facilitative cues and how you change your cueing a little bit, um, for those kiddos. Kelly Vess:  Awesome. Like there's some that, like, for instance, I work with three-year-olds, there's some, some three-year-olds that can't produce K and G they cannot do it. And the reason for that is protracting and retracting the tongue [00:30:00] is really, really hard and they simply don't have that neuromuscular developed yet. And I'm not going to, there was a child. I'm going to tell you a story just to cement what we're saying, which the only word she could say G in, she could not front-end is saying the word ugly. I tried every key word out there. And why is that? Because I had uh I had lee. So she would say, that's not ugly. I want it please in the month, that was bizarre. But the next week we were working on, can you scrape it to me please? Because I have a cool girl teeth, but you have to start somewhere. Okay. But what about the child that can't do K and G what do we do then? Because they just can't. We work on L and R and that's because L and R our neighbors right next store there, that palatal sound right there. And do you know what happens when I work on L and R? When the child turns four and a half, typically K and G will naturally develop. [00:31:00] That's what I'm finding. I have found one child in the last 10 years where it persisted. The K and G and it was a lot of elbow grease at four and a half years too, but only one out of probably a hundred, but that's a great question. Some children, it's just, it's not there yet and you're going to have to shelf it and you're going to, but what I did when we work on L and R that's more complex and it's nice when K and G naturally develops, cause K and J could bring children to tears, holding their tongue down the tongue depressor, putting a cherry on their teeth, all of this, lying on their back and writing on a table and looking in a mirror, just stop. It just stopped. They're not ready for it yet. So, but thank you. That's a really great question. And I think another thing is we're going to get into it in a moment, which is really important is, is all of the cues and how do you remove those cues? Because that's super, super important. You give them everything in the toolbox. Now, how do you [00:32:00] take tools away? So I think we can go to that and this is very important. What should we go to that? So we're going to go, we're giving, I'm going to give you an example, the word scrape, which is the hardest to use and the language and language in our language. And I'm going to, you're going to hear it auditorily, but I want to give you an example of what it sounds like you, unison speech, really slowly going every sound. And then I'm going to show you what I'm going to take away, and we're going to go through the steps. So I'm going to be using my body. And when I use my body and fingers, these are cues. Sure. I've been trained in prompt. I know Kaufman. I know easy does it for Praxia. I know all of these cues out there. I create my own and so do my graduate students, based on what makes sense to me. And it's been highly effective. So what, what I think my rattlesnake looks different than someone else's Cobra. Everyone has a different [00:33:00] cue that they use depending on what feels right to them. So I'm just going to show you the SKR. I'm just going to show you how I do that would be like this and I'll yell out. I'm sorry. Snake sound. Let me hear you snakes so loud. What a loud snake sound.  Kate Grandbois:  And for people who can't see Kelly is doing these beautiful hand motions with like a Viper fingers and like swirly snake movements. So this is definitely a, a very, uh, immersed experience. Kelly Vess:  Yes. Thank you. And I liked it. I learned this from Lynn Williams back in 2008, when she came to Misha, she was like, this is a snake and the snake was going all over her body. Now the child can perceive this snake sound. So I always tell my graduate students pretend you’re at a Taylor swift concert and you're in the back row balcony seat. So you needed to use those gestures. So big, bigger is better and so loud. So they [00:34:00] really break in through this, the static. Okay. So we're doing this next time and then I'm going to take my finger. I'm not putting it in my mouth. Kind of make it a compat about CA so they're going to do the two and then with the angry, angry dog noise errr, once again, I'm holding onto it until they can join me. I'm giving them time to perceive it and I'm not going to take woo. I'm like, oh no, that's weak no that's a fish waiting for it to come out. Right. Okay. So that's maximum prompt. It's unison dadada. First thing to take out is auditory remove the auditory as soon as possible. So you're saying, so I'm not going to start. I'm going to stop talking as soon as possible. Why is that? Because auditory prompts are the hardest to fade, children become dependent on auditory prompts. And there was, besides that I want the child to be the teacher. I want to develop an internal locus of control. So I'm going to [00:35:00] use the word scrape and no other word. I'm not going to say screws, screen scrapes, scratch. No screech. Cause if I'm doing that, then I'm in control. And not only am I in control, the child's focusing on what to say and not how to speak. So I'm only going to say the word scrape. That's the only word I'm going to say all year. And there's research behind that. That says one exemplar, just one is better than many. And this is the why is because the child can master it. And the child can say, I don't care about the word I care about how I talk. Am I making a snake sound? Is the tongue in the back of my mouth? Do I have angry dog teeth? That's what's going on in the child's head. So we're doing toolbox. The first tool I take away is speech and I'm only miming, I’m miming with the child with my mouth. Will I jump in with an [00:36:00] angry dog teeth if to help out with the hard sounds? Yeah. So maybe the word is great or because I know the child has a little bit of problems with the w for R, but the first step is get rid of the auditory cue and give everything else to the child. Kate Grandbois:  Since this is an auditory modality. Just again, for the sake of saying it for our listeners, you are gesturing so emphatically. So when you're saying angry dog teeth, your, your lips are retracted. Your teeth are bared. Your you've got your hands up. Like little paws. I mean, this is. This is a very immersed experience. So as you're describing, removing different environmental cues and removing the speech, there are still a lot else. There's a lot going on for the child sitting across from you because you are really immersed in this multimodal queuing system.  Kelly Vess:  And that's extremely important. Thank you for bringing it up because I tell the interns, you really have to be like a [00:37:00] cheerleader, cause you're like, give me an S, you know, and if you're just like, you know, that really helps. No, it's a big, it's just like you have, you're giving letters to a sound and you're doing a cheer except the child's right next to you. But it really works because all of the energy that you're expelling too is really motivating to the child. And you know, what is the most motivating of the child? You're the teacher now I'm the student. I didn't even say a word I that, and I think that is the ultimate goal of therapy is internal locus of control. The child is in charge of the learning. The child has taken ownership. And that to me is the golden apple. If we've taught children, children learned that my efforts matter. That what I can be successful if I work hard, that's the best thing we can teach children with communication impairments. And it's interesting because the research James Lawn did meta and analytical research. Uh, he is an amazing [00:38:00] researcher of these children, that communication impairments in kindergarten. And when they're 32 years old, they're more likely to have an external locus of control, meaning they don't think they have control over their lives. They don't think they have control over their professional lives. They're less likely to think they have control over their personal lives, their personal success. They think it's outside of their country. Well, we can change their lives early on by letting them know you're the teacher you're in control. I'm the student. Wow. So in that hard work matters.  Kate Grandbois:  So once you remove the auditory cue, what's next or you're, you're still your cheerleader. You're making big movements. You're really having a good time. It's party time central, but you're no longer providing an auditory cue.  Kelly Vess: Yes. I love, I love you're asking all the important questions. Don't drop the baby because the child needs to be [00:39:00] 80%. And if we pull away too many tools in my toolbox and the child goes below 80%, we have two things that are going to happen. One we're going to habituate errors or two, we're going to frustrate the child. We don't want that to happen. So we're always going to give enough tools and support. We might have to add more like, whoa, I pulled back too much, sorry. Or we might have to pull back. Okay. You're 90% accurate. This is too easy for you. I got to stay at 80% of all times. That's a magic number. So we're there at 80%. The next thing I might pull up is tactile. I don't touch the children. I have the children touch themselves because they’re the teacher. So for instance, if we're doing the B sound, they put their hands over their mouth. Like, because there's something like that, they will touch their own mouth and I'll touch my own mouth. So the next cue is to get away from them touching themselves. And I think that's important because of the COVID and because of [00:40:00] illness. So they might hold their cheeks for the ch ch sound. They might hold their cheeks down for the choo choo sound that we're going to get away with now. And we're going to make it visual on the air. So I may choo choo with my hands. So we're going to get away from the child, touching the child's own phase to help produce the child sounds. So we took away the auditory first auditory. We always want to get rid of that as soon as possible, then we're going to get away from the child, touching the child's own face and using instead that what I call temporal cuing, which is what you're showing with your body and space, how to produce the sound like the snake that it's continuous, the snake keeps going and going with the SM that's known as a temporal cue. I'm going to hold on to those. I'm going to hold on to my visual cue. So I might just make a snake. I'm not giving the temporal the show, how to do it. I'm just putting a cobra so that they remember their snake sound and where I [00:41:00] might give an imagery cue, which I'm like, Ooh, I hear the snake sound snake sound. I might yell out snake sound. So I'm going to first take out auditory, then take out touching, and then, um, but, and then we're going to keep the temporal showing with our body, how to cue. We're going to keep a visual and we're going to keep the imagery.  Kate Grandbois:  And just for the sake of again, describing what you're doing, you're making these hand motions that are animal like. So you're still providing, when you're talking about a temporal cure, you're talking about moving your body continually to show time when you're talking about a visual cue, you're still making bear paws, or you're still making a little viper signal, which is, I've never really thought of making a little Viper motion with my hand, your two little fingers up like fangs. I love the way that you're making this. So multi-dimensional, that's it. I, it makes a lot of sense to remove the cueing in that order.  Kelly Vess:  Yeah. And that's the thing like learning, we've learned best when [00:42:00] it's multimodal. When both, I believe when the children too, when I show you the cues, I'm doing the children's, child's doing the cues with me. The child's also making a snake with their body. The child's also, so this is very important. We learn best when we're using all of, when we're multi expression, when the children are expressing themselves through their body and through their entire bodies. And when we're teaching, using our entire bodies. Song as well. I didn't mention song, but, but we do the songs too. So afterwards after we're done, I heard the snake sound, the snake sound, the snake sound. I heard the snake sound. I heard a loud, you know, I'll tell  Kate Grandbois:  Therapy with you sounds fun. Yeah. A lot of exciting things happening in your treatment.  Kelly Vess:  Yeah, and fun is so important. I'm glad you brought that up. We don't talk enough about that. I think in therapy and speech pathology realm, there's tons of research for emergent learning. And that just shows that if children love learning, they're going to go on to learn [00:43:00] more and become better at it. It's just like emergent reading. So I always, when I evaluate an activity with a graduate student or I always ask when the number one question is, how fun is this Kate Grandbois:  Oh, right. And I also think there's something to be said for the intersection of communication and joy and, and making sure that not only is it fun, but the individual that we're working with is experiencing some sort of joy while they are learning to communicate, or they are experiencing joy through, you know, as a result of their communication and, and, and especially that's. So it's so important for even us as adults, but especially for, for young young children who are struggling with the communication impairment of some sort,  Kelly Vess:  oh yeah. How many children? And so sad, I've seen so many three-year-olds three-year-olds would be like, I bring out a children's book and they're like, I'm not a good reader. And it's like, whoa, but that's what, that's exactly what you're saying it already, [00:44:00] you know, or they close their mouth. Cause they know, I can't say that word. Like they already have like, almost shame associated with their speech or their literacy or their language skills at three years of age. So if we can change that, like you said, it makes speech something joyful now that's huge. Kate Grandbois:  Absolutely. Okay. So you've walked us through this complexity approach and, you know, getting our biggest bang for our buck by targeting more complex sounds at the top of the mountain, as you said, and you've walked us through multimodal queuing and how to provide multimodal queuing and then fade multimodal queuing. I wonder if you could tell us a little bit more about learning objective number three, um, specifically around selecting the treatment targets that you're working with based on the phonological patterns that you see Kelly Vess: . Yeah, I love that. So what you're talking about right now is really, really [00:45:00] important. Oh, before I go into that, I want to talk a little bit, I'm going to go right back to that. Cause that's really important. Yeah. Go for it about how progress is going to be made, because I think a lot of people are going to do the complexity approach and they're going to say I've been working at SKR blends. Okay. Kelly, I've been, we're going to ask, Hey Kelly I’ve working on skr blends and they're 0%. Okay. I been working all year. I've been working on the word scrape and there's 0%. This does not work. That's what I think they're going to say. And I, and I, and I'm going to get back to that. I want you to know that speech develops like teeth. Okay. So if we can't change how speech develops, we're not going to make the molars, the molars come at right. First of all, how, how do teeth develop first? You have the front teeth, and then you have the lateral incisors teeth. And then after that, then the canines, and then you're going to have the molars. And I don't care what your dentist does. That's what everyone's teeth are going to develop. Okay. All around the [00:46:00] world and all the languages around the world. Speech always develops the same way. So first you're going to have vowels. Then you're going to have stops. Then you're going to have fricatives. Then you're going to have affricates. Then you're going to have to them clusters three element clusters and liquids. Those really hard liquids like L and R, okay. Coming up there at the top. So when you're working on three element blends, which are the top of the mountain, they're going to develop last. Okay. So when you do testing, what's going to happen. I've been working on SKR blends. When I show a parent the test results, we're going to say, oh, okay, I'm working at SKR. And they've developed P B T D N F V K G SH J, that none of these sounds that even touched, I didn't touch these sounds in any of these words, but those are going to spontaneously develop because of the waterfall effect. What are they going to struggle with? They're going to do multi-syllabic words. [00:47:00] They're going to do final consonants. What's going to be left for us to work on. Do you want to guess what, what is going to be still hard for the child that I'm working on SKR with? And what's left now that the child is struggling with.  Kate Grandbois:  I have no idea, Amy, Amy's going to, Amy's going to, Amy's going to guess. I can't  Amy Wonkka:  guess it's going to be those later developing sounds and clusters Kelly Vess:  that I'm working on. So what is your child? Okay. Your child, where they were at the top of the mountain. We're walking right now. We're walking that bike in the mountain biking and the child is going to have problems with clusters. The child is going to have problems with L and R. These late developing sounds are going to be left, but that's what I've been working on all year. Well, yeah, but we don't change how speech develops the earlier sounds will always develop before the later sounds, but they're just going to develop faster. And I just explained to the parents, we're just [00:48:00] running up these stairs.  Kate Grandbois:  So my question is related to, you know, in terms of thinking or talking to that SLP, who's been working on these later developing sounds all year and hasn't seen any progress. How would you recommend measuring progress in that scenario? Are you continually monitoring the development or probing for earlier development sounds to make sure that there is some. Some progress monitoring happening instead of just saying, well, we worked on this one blend all year. It didn't happen. Oh, well, like how do you, how do you measure progress along the way?  Kelly Vess:  I love what you're asking because every eight weeks I, I give a speech test, single word, speech tasks, and I see progress that way. So, okay. The child starts with 80 errors on the test. Now this is not uncommon. And three months later, there's 40 errors. And then three months later, now we only have 20 errors, but [00:49:00] guess what those 20 errors are, that are the L cause we're at the top of the hill now. But I explained to the parent how this is going to work. We're going to run up these stairs. Look at all of these early developing sounds that naturally develop. Look your child's saying the ends of words now. your child's saying all the syllables now, you know, this is working, but I explained to them also, okay, this is where we're now elbow grease time at the end that things are going to slow down. But that's what I do is you write, if I said, well, let's assess skr. Oh, we're still 0%. We're still 0%. Now I will tell you a population that doesn’t, that does not test while I've found is children with ADHD, uh, children with attentional deficits when I put speech tests in front of them. But I want to tell you just rest assured with these children, because if you're doing in therapy, the 80% rule, they're [00:50:00] 80% accuracy in accurate therapy. The parents are 80% accurate at home. I find it takes them a year and then a year later it's like fireworks. They're going from one percentile to the 50 percentile, normal as well. It just takes them a whole year. For it to generalize, to testing. They do not. I find a lot of them don't test well.  Kate Grandbois: Um, but from an ethical standpoint, you're monitoring progress of your treatment throughout the course of your treatment through data collection and goal modification. If you're in a, you know, if you're not writing IEP goals, right. I mean, you're not just hanging your hat on the, well, we'll see what happens in a year peg because we can't do that as SLPs. I appreciate. And I think it's important to note the importance of, uh, important to know the importance of, I think it's, I think it's valuable to make note that it's critical for us to be probing for some of the, for the impacts of some of our treatment, even if it's not directly [00:51:00] obvious for us in our treatment space. Kelly Vess:  Yeah. And that's what, what I care about is the level of cueing. They're always going to be ADP. 80%, maximum level of prompt, 80% visual, only level of prompt, 80% imagery, only level 80%, no prompting. So I really I'm, my goal when I write goals. Cause then I'll be like, what is your goal? My goal will look like this. The child would produce S K R with given a maximum level of prompting at 80% accuracy. The next goal. The child will produce essay, K R blends with 80% accuracy, given a moderate level of prompting, the next goal, a minimum level of prompting, the next goal, no prompting. So, um, or maybe even just minimal would be where we left off. Kate Grandbois:  Do you ever write goals for earlier developing sounds even though you're treating a more complex target. So for example, you [00:52:00] are hoping to address improvements in an earlier developing phonological process like stopping, but you're working on these much higher developing blends. Do you ever write goals for something that you're not directly working on and then measure or probe for progress towards those earlier developing skills? Kelly Vess:  Oh, I like that. I don't. But I realize that  Kate Grandbois: says the woman who knows nothing about phonological disorders as a full disclosure Kelly Vess: , no, I love it because I hear it. My goals from earlier intervention and they write goals, like the child was suppressed, stopping the child was depressed, fronting. The child was depressed, cluster reduction and they write, those are milestone goals for me. So I'm able to say achieve achieved and usually cluster reduction they're gliding it. Typically hasn't been achieved as, at the end. Those are the molars that come in last, even though I've been working on that the whole time. But yeah, that's, I like those. [00:53:00] You can definitely write your goals that way. Write your goals. I like to do SKR because it's clear on what I'm doing every day in practice, but if I did stopping gliding and fronting, those are great. Those are great goals to write. That equally assess them and maybe assess more the class that we're working on, the rule we're working on. If someone else were to pick it up and say, Hey, I, what am I doing? SKR? What? Yeah. So I love that.  Kate Grandbois: Amy, did you have a question?  Amy Wonkka:  I was just thinking back about kind of this complexity approach and how it, you know, kind of dress these different types of funnel, logical processes that we might see. And I guess I was wondering, are there ever times when you wouldn't look at a cluster. At, at producing a consonant cluster kind of as your treatment activity, would that change if you had a student who presented with a [00:54:00] specific profile of phonological processes or, you know, kind of, what, what does that thought process look like back sort of thinking about those target selections? Kelly Vess:  Yeah, I think that's a great question. I'm going to be, this is what I do, and it really, really works for me. A lot of the children I work with are vowelizers. So they, ah, ah, and I show this to my book. Our step one is SW blends. And the reason for that is because S is long. So it gives them time to perceive it. An S is 150 milliseconds long. Where if you look at PB TD, those stop sounds are only 30 milliseconds. So I want a sound that's long enough for them to perceive and join in on, and then the w is easy to produce. So it'd be like, I can draw it out. So I like to say the word sweep. So I'll say, so it sounds like that's [00:55:00] so. I can hold, Ooh, forever. I can hold “s” forever. So that gives the child time to join in with me in unison speech. And then, like I said, what happens when I work on SW blend is all of those earlier developing sounds naturally develop. I'm not wasting time working on P B T D and those early sounds. And they always naturally develop. I've never gone below S w ever. Uh, and that's what you're going to see in the book. You're going to see a lot of children that can't talk. And if we show SW as a step one and that's because we can use our body and give them more to proceed and more to join in on.  Amy Wonkka:  And that's making me think just back to way, way back at the time machine, but back to my grad school days and, and all of the, when we [00:56:00] first learned transcription and thinking about placement or in voicing and how important that is, you know, and, and just sometimes we have been trained to do sort of that more systematic approach and say like, okay, I'm going to work on things within this one class of, you know, manner. Right. So thinking about stops as a class, or thinking about continuants as a class. And so this complexity approach, if I, if I'm getting it correctly and it might not be, but, um, would be kind of integrating what we already know as speech pathologists about place manner voicing. And just thinking about these more complex combinations of things that really aren't in the student system at the moment. And we're trying to work on that in hopes that it's going to result in. Learning of other things, rather than going sort of methodically through like, okay, I'm doing stops. Okay. I'm doing affricates. Okay. I'm doing transitions [00:57:00] between, you know, a stop it or something like that. Is that, I mean, that's, that's sort of the big contrast, right? Kelly Vess:  You brought up such an important topic to end on, which was maximally distinct sounds. How do we, yes. How do we do acrobats in the mouth? How do we do Cirque de Solei in the mouth? Okay. We know that complex is better and let’s talk coordination. Okay. I love it. All right. So part of the complexity approach, that's super important. I'm glad you're bringing this up, but this is ending on a bang is that we need, what's known as maximally distinct sounds. So we have consonants, two types of consonants that are language. We have obstonants which the air flow is obstructed and we have sonorants where the airflow is glided along the tongue, like [00:58:00] sonorous. Okay. What we want to do when we do clusters is we want to make an abstract with a sonorant and that is creating Cirque de Solei in the mouth. You're going from zero to a hundred and you're improving motor coordination. And in doing that, you're going to improve syllable production. You're going to improve final consonants. You're going to improve blends. All of those things are going to be improved. Those coordination improves assimilation errors are going to be improved. So what are we going to do? We're going to take a sound like an S land. Are we going to say the word spoon? No, because then we have a fricative and a stop, and that's an obstrant with an obstrant. They're two alike. That's not Cirque de Solei in the mouth. We want to take that s blend “s”. And we want to put it, like I said, with the w which is a [00:59:00] glide. So we're going abstract to a sonorant sound Cirque de Solei in the mouth, major coordination, difficulty maximally distinct, and like Lynn Williams would say that's when you take fireworks to the rack, you're challenging motor coordination. So why would we take S L why is S L such a great blwns slide? Because you're taking an obstruent, which is the S sound, and you're combining it with a lateral liquid in which the air flows sonorous so obstruent, but the sonorant sounds so what is better SW or S L S. 'cause SL is more complex. So the higher up the mountain you go, the more sounds you're going to improve. Yeah.  Amy Wonkka: But all of this you're overlaying on top of it, all the stuff you talked about at the beginning in terms of stimulus ability. Right? So if you have a [01:00:00] child who's not stimulus for the “l”, no matter what you do and how you structure your cues, you might go with SW. Kelly Vess:  Yes, exactly. That's exactly what I'd go for. Yeah, exactly. So if they can't do SL like do SW do I do S T no, cause that's a fricative stop. Do I do S P S K? No, no, no, no, no. So I'm glad you brought up this extremely important, uh, point, which is mix your obstruents with the glides and th the, the glide even better would be that liquids L and R. But if you can't do that L and R. Go right to the w and like you said, cause practice makes perfect practice also makes imperfect. We do not want to reward W's for LNR. I love it. I love it. That thank you for bringing up that really super important, uh, concept in the complexity [01:01:00] approach.  Amy Wonkka:  This is fun. Thank you. I'm like getting my like grad school forgot all about sonorants and obstruents. So this is lovely.  Kate Grandbois:  And so this is all slightly above my head, but I'm, I'm learning a lot and I'm enjoying and appreciating a lot of this. And I wonder if in our last couple of minutes, there's anything else you'd like to tell us about selecting those treatment targets based on phonological processes.  Kelly Vess:  Oh, well, first of all, I want to thank you so much for having me. This has been a blast. I have drool coming down my mouth. We're talking about such an important topic that changes children's brains. It is awesome. So what we're going to leave with is when it comes to selecting treatment targets, it's like playing poker at the end of the day. It's just like playing poker. And what is poker? Three of a kind beats two. So three element clusters such as SPL [01:02:00] is better than two element clusters, such as SL, higher cards, later developing sounds are better than earlier developing sounds. So the king beats the two, you don't want to work on the P you want to work on the R and said, because like I said, speech doesn't develop like a Geyser. It always develops like a waterfall. And when I'm doing my own research, I find it doesn't even develop like a hose. If I'm working on something in speech, it's not laterally producing it produces downward. So I always want to go higher than what my goal is in speech always go higher than your goal because they always have the waterfall effect. And then I think in the last area, I want to tell you about that we didn't really discuss, but T H sound, I found T H to be a dud, even though it's a late developing sound. T H R blends are really late. And T [01:03:00] H is really late because it's outside of the mouth. I find that it doesn't have the impact the S blends do. So I know we didn't discuss that today, but put that in your pocket. T H R blends are outsiders. So if we're in Las Vegas, I always think they're the street musician. They're very talented, but they just don't have influence on others. They're outsiders. They're not the Celine Dion's or the Britney Spears. Those are the s blends.  Kate Grandbois:  It's such a great analogy. I was like, where's she going Las Vegas, but then that makes so much sense.  Kelly Vess:  It's all poker. Okay. And you've got your Britney Spears and you have your street, musicians are equally talented. The thr is very complex, but it's an outsider. It has, I've done research on this. It doesn't have the impact on the other sounds that nice waterfall effect that s blends do.  Kate Grandbois:  [01:04:00]This was  really, really interesting. And I appreciate, we both appreciate. All of your time. Thank you so much for joining us today. Amy, do you have any other final questions?  Amy Wonkka:  No, I wanted to thank you so much. This was really, this was really fun and it, it just makes me think of needing to go up and just go back to my college texts and look up the place manner voicing chart and just refresh my memory about all the relationships with the sounds to one another. Kelly Vess:  Okay, well, thank you. Your podcast is awesome. Um, I just love it and I'm so happy to be here. Thank you.  Kate Grandbois:  Well, no, thank you. Thank you. That was a very nice compliment that you just paid us and we're happy to have you for anyone who's listening. Thank you so much for joining us today. We hope you learned something. All of the references and resources that we mentioned throughout the episode will be listed in the show notes, and they're also listed on our website. So if you're listening while you're running or jogging or folding your laundry, no need to worry about having not taken notes. We've got it, all that written [01:05:00] down for you, Kelly. Thank you again so much for joining us today. Thank you so much. Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count for professional development in your area of study, please check in with your governing bodies or you can go to our website, www.SLPNerdcast.com . All the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@SLPnerdcast.com . Thank you so much for joining us and we hope to welcome you back here again soon.

This is a transcript from our podcast episode published May 30th, 2022. The podcast episode is offered for .1 ASHA CEU (introductory level, professional area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. [00:01:38] Kate Grandbois:  We have such an interesting topic to talk about today. We are here to discuss dysphagia or dysphagia. The jury is still out for me on which pronunciation is accurate and tele-health, which just sounds so interesting. And as our listeners know Amy and I work clinically [00:02:00] in a, the field of AAC. So we brought in our, I'm going to call you our dysphagia correspondent today. We asked our coworker and fellow nerd cast member Tracy Callahan to join us. Welcome Tracy.  [00:02:12] Tracey Callahan:  Hi, thanks so much. I'm really excited to be here.  [00:02:15] Kate Grandbois:  So we're excited to have you so that you can elevate this conversation and I know it's going to be really, really great. We're also very excited to welcome Dr. Georgia Malandraki welcome, Georgia.  [00:02:26] Georgia Malandraki:  Hi, everyone. Thank you so much.  [00:02:30] Amy Wonkka:  Thank you so much for coming. You are here to discuss swallowing and tele-health before we get started, can you tell us just a little bit about yourself?  [00:02:37] Georgia Malandraki:  Well, I'm a speech language pathologist. Just like you guys as well. And, um, I'm a board certified specialist in swallowing disorders, but I'm also an associate professor in speech language and hearing sciences at Purdue university, where, um, I have developed a, the Purdue I eat lab. It is a lab that deals with, uh, the study of swallowing physiology and neurophysiology [00:03:00] across the lifespan and a secondary focus, which has become a rather primary focus in the last few years. And definitely since the pandemic started has been the area of telehealth as well. So I'm very excited to be here today and to be, uh, discussing this topic with all of you.  [00:03:16] Kate Grandbois:  I have so many questions. I know, I know we all do, but before we get into the good stuff, um, the powers that be require that I read aloud our learning objectives, as well as our financial and nonfinancial disclosures. So if you're listening, I'm sorry that this is this, this is a required piece. It makes me read it so stick with us and we will, we will get to the good stuff in a minute. Learning objective number one, describe basic regulatory guidelines for the safe use of tele management of dysphasia. Learning objective number two, identify basic practical and clinical guidelines for the safe use of tele-management of dysphasia. Learning objective number three, summarize the research evidence available for the use of telehealth for dysphasia management and learning objective number four, describe new developments in wearable technologies for the [00:04:00] tele-management of dysphagia. Disclosures Georgia's financial disclosures. Georgia is an employee of Purdue university and receives a salary and grants to support her work. Georgia also receives grants from the National Institute of health related to work in tele-health. Georgia is the co-founder of a Purdue initiated startup Georgia's nonfinancial disclosures. Georgia is a member of, and the president elect of the dysphagia research society. She is also the Indiana speech and hearing association co-chair of the tele-health task force. Kate that's me, I'm the owner and founder of Grandbois therapy and consulting LLC, and co-founder of SLP nerd cast my nonfinancial disclosures. I'm a member of ASHA, sig 12 and serve on the AAC advisory group for Massachusetts advocates for children. I'm also a member of the Berkshire association for behavior analysis and therapy mass ABA, the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis specialist. [00:04:53] Amy Wonkka:  Amy that's me, financial disclosures. I'm an employee of a public school system and co-founder of SLP nerd cast. And my non-financial [00:05:00] disclosures are that I'm a member of ASHA SIG 12. And I also serve on the AAC advisory group for Massachusetts advocates for children. [00:05:06] Tracey Callahan:  Hi, I'm Tracy. I am an employee of SLP nerd cast. I own a private practice and I'm the owner of an online learning platform called guess monster games. My non-financial disclosures. I'm a member of ASHA and the corresponding special interest group, SIG 13 for dysphasia. I'm also a certified lactation counselor through the academy of lactation policy and practice. [00:05:29] Amy Wonkka:  All right, we've made it thanks for sticking with us listeners  [00:05:35] Kate Grandbois:   It’s so long, we try to make it shorter every time, but we just felt weird. But here we are.  [00:05:40] Amy Wonkka:  Oh, the other end, Georgia, could you start us off by telling us a little bit about that first learning objective? What, what are the rules? How can people be safe around tele-management of dysphasia? [00:05:53] Georgia Malandraki:  Yeah. Then this, this is a good question. It's a good first question as well. Cause a lot of, you know, a lot of times clinicians [00:06:00] tend to want to know about how can I do it clinically without necessarily looking at kind of the prerequisites before you look at clinical effectiveness or clinical at the patients. And I consider some of the regulatory guidance a little bit as a prerequisite. So before you start thinking about clinical adaptations, I think it is important to think about laws and regulations that surround, for example, patient privacy and confidentiality, which is one of the biggest risks whenever you use the internet. So whenever you use telehealth, that's one of the added risks that we have to address. And when we talk about dysphasia management specifically, a lot of clinicians also have safety concerns about their patients. So by abiding by regulatory laws and guidelines, you're actually also protecting yourself or mitigating some of the safety concerns and risks as well. So things like, as I said, making sure that you abide by, uh, privacy and confidentiality laws for hospitals and clinical settings, the HIPAA [00:07:00] law, the FERPA law, when we're talking about schools, um, but also in addition to kind of this federal law, some states or even facilities may have their own regulations or status that you need to be aware of. Uh, so that's another thing that you need to explore. So depending on the state you work in or the, uh, the facility you work in, it is important to investigate, um, talk to your risk management team, maybe or legal counsel. If, if you cannot find the information by yourself, talk to your state association or licensure board about what are some of the guidelines that may be state specific or facility specific for you, and then making sure that we abide by them. I know that sounds very vague, but in reality, there are two ways to abide by those types of guidelines. One is by taking technical defenses, meaning making sure that you are using a secure platform, making sure you're using a secure storage space, a secure network, and, you know, uh, and these [00:08:00] are the things that hopefully an it person or it teams can help with. Um, and then the second pathway to secure that you are biding by these regulations is to ensure that you have a consenting process in place. So both ASHA and the American telemedicine association, as well as state associations, highly recommend that you have a consenting process in place. I personally prefer a written consenting process, but even in some facilities in the states, even a retail, even a verbal I'm sorry, consenting process is fine. So irrespective of what you will be using, I think it is important that you let the patients know about the risks, the benefits, your qualifications to use this, to this new service delivery model for many people, right? And also what the, what steps you have taken to mitigate any of these risks. And once the patient hears those, if they accept to continue, that's going to be up to them. So I think those, those are the primary very, very now in a very [00:09:00] summarized overview way. Right. Um, is there some of the basic, uh, regulatory things that we need to think about at first? So privacy and confidentiality laws, the consenting process, technical defenses. Licensure requirements as well. That's another third thing that we need to think about, depending on the state, we work in a lot of licensure laws have been relaxed during the pandemic, but that doesn't mean that all states allow interstate, you know, uh, practices. So you, you also, that's something that you also have to check with your state licensure board, and ASHA has some really great resources. I'm happy to provide some of these links. If you guys don't have them already, uh, for your audience. Uh, but th they have some really great, um, and, and, and constantly updated resources that they give for each state in terms of licensure. And then of course, the other regulatory thing you have to consider is reimbursement. Which is a [00:10:00] is not negligible, as you all know, I'm sure. Right. Um, that has probably been the biggest hurdle. And again, I, uh, uh, I don't want to sound like an ASHA fanatic, but I do want to say that because of ASHA's efforts this past year and some of the state associations efforts as well, we finally were able to overcome at least temporarily some reimbursement hurdles as well. So things are a little better. We're still fighting, uh, to, to make things better for the future as well. So I would say those, those three big things are, you know, privacy, confidentiality, uh, licensure and, uh, reimbursement. So those are kind of the regular regulatory things that you need to keep in mind and investigate. Before you jump into the actual service delivery and usage.  [00:10:49] Tracey Callahan:  And I think one thing that's really exciting is that we're able to continue to provide services to patients that really need it because just because there's a [00:11:00] pandemic doesn't mean that people don't need dysphasia therapy. So I think that it's been a really useful tool for those of us maybe who didn't use it before, but now I find that I really like it. It's a really, really great tool. [00:11:13] Georgia Malandraki:  That's, that's great to hear. I've heard mixed things from clinicians. You know, some people like you really love it and want to continue using it. I would say probably at least half of the clinicians I talk to are belong in this category, but there are still a few that either, either very negative or they don't really know I'm sure. You know, so I think it is, it is, um, I, this is a challenge for us to persuade more people towards the positive or the positive things that can happen with the use of telehealth. And you're right. A lot of people can be very much helped irrespective of where they live or their ability to move and their ability to come to you. [00:11:52] Tracey Callahan:  Exactly. A lot of the patients that I see either live in a more rural area and the transportation is very difficult for them to [00:12:00] coordinate or physically the commute itself into a clinic is so taxing that by the time they get there, that they can't really do their best work. So I think it's a great tool and I'm excited, um, to continue. [00:12:16] Kate Grandbois:  So I have an obvious question. So when you're talking about telehealth as an overarching modality or a service delivery model, and there's obviously, you know, the person on the other side of the zoom screen can present with any myriad of, you know, this, you know, articulation, um, thinking of like the classic speech therapy, um, scenarios where your client or patient is engaged and looking at the camera, and you're able to create some sort of therapeutic environment, two dimensionally. So, and, and again, I don't, this, this is not my area, but when I think of dysphagia. I think of how physically hands-on it is. And I think of [00:13:00] the risk of aspirating and how I'm not there to give the Heimlich, or I don't know, there just seems like this extra, super scary component. So you already have the service delivery model of tele-health, which is really different and challenging in a lot of ways, but then you add dysphasia onto that and I'm all, I'm very intimidated by this, even as an idea, and it's not something I do clinically, what can you tell us about that? [00:13:22] Georgia Malandraki:  Yeah. Well, I think thank you for asking that question. That's probably the most common question I get. Uh, so I will, I will answer it to the safety part first, because I feel like that's kind of the core of your question. Um, and then let me know if I left anything out and I'll try to address the first part as well. Um, so what I want to say about safety, I understand, uh, I partly understand there's concerns. Um, uh, but I do understand, especially when they come from somebody who, who hasn't been doing this on a regular basis. So, uh, I think for those of us who have been treating patients in a regular basis in in-person settings, I'm talking [00:14:00] about now, you know, we all know that during any session, okay. In even if it is delivered in a person versus telehealth, you know, whatever the service delivery model is at any in any session that involves oral trials of foods and liquids, there's always a chance that a patient with dysphasia may aspirate or in rare instances may even choke, but there is no evidence to suggest that that risk is in any form higher during a session with a dysphagia clinician, an expert versus during their everyday life, when they eat and drink, there's no research that shows us that. And in addition to that, there is no research that shows us that during a dysphasia tele session the risk is higher than during a dysphasia in person session. So, um, I think this fear is a little bit exaggerated. So if you ask a dysphagia clinician, how many times did you have to do the Hamlet in an in-person session? I [00:15:00] guarantee you it's probably unless, unless they're working with a very specific, very, you know, advanced, severe populate type of population, it wasn't very frequent. Right. Or it was extremely rare. The situation was, what about, I don't know, Tracy, if you have an answer? Once. Okay. So I would argue that just like an in-person sessions in telehealth sessions, we are the professionals who can actually mitigate those risks. So for example, we are the ones who can decide, is it safe for this person to have oral trials. How can we make things safer? Can we have them perform oral care right before we start the world trials? Can we choose what we are going to give them the amounts and the volumes? This is something it's up to us to decide. And then in addition to those things, having a facilitator present is a very important thing. When you are doing oral trials, especially with patients that you believe are at risk for aspiration. So th [00:16:00] so there are some safety things that you can do having a safety plan in place, which is actually usually a safety plan, uh, should be in place for all types of tele sessions, not just for dysphasia tele sessions. And, uh, it's a, it's a plan that basically just says, what will, what are we going to do in the case of an emergency? So if you're not there to perform the Heimlich. So what will happen? So you have to have a safety plan in place that both the patient and their caregiver or their aide, or whoever is there with them will have agreed to in the beginning of the session is this is typically part of the consenting process. So that has to be very clearly delineated. It's very similar to you and I being certified in CPR. That's a safety plan of the hospital or the clinic we work in, right. To be certified so that we can address an emergency situation when you're not there, you have to have another safety plan in place. So that is important to have. But at the same time, I want to make sure that people understand that I don't want people to be so fearful of aspiration. First of all, [00:17:00] aspiration will happen. It happens with all of us and it is what it is. Patients with dysphagia are at high risk for aspiration. Choking, of course, is, is, is something to try and prevent of course, as much as possible. And that's why I'm saying we are the collisions to decide what will happen in the session, how it will happen when. How to mitigate those risks as much as possible. Does that make sense? I think Tracy, you had a question.  [00:17:24] Tracey Callahan:  Yeah. And, and when thinking about what we do for our dysphagia therapy that we would do in person, it's very similar. So if I have a patient who is at a high risk for aspiration, I'm going to do oral care first, not just because it's on tele-health, you know, and I found as I was doing more tele-health that there were a lot more similarities than I initially thought, um, just this, we would, the same, we would pick oral trials, what order we would do them and the amounts that we would pick [00:18:00] the foods that we would pick, all of those things we would do in telehealth. We would also do if we were doing in-person therapy as well.  [00:18:08] Georgia Malandraki:  Yes, exactly. And, uh, yeah, and I think that kind of answers partly the, the first part of Kate's question about, you know, I'm not there to, you know, to touch the patient. I don't have, you know, that fear that, you know, you're not next to the patient or, you know, that's something that a lot of people are concerned about as well. But the reality is, as Tracy just mentioned that a lot of the procedures we do are actually very hands off. So for parts of what we do, we may need to touch the patient. You know, when you do tracheostomy care, um, TP, things like that, you need to touch the patient or you need, if you're going to do telehealth, you need to have somebody who is knowledgeable the other end and you are really counseling them on how to do specific things. Right? So those types of procedures definitely required facilitators that have extensive training. If not clinicians, actually not [00:19:00] just facilitators, right? But for most procedures of the clinical assessment or tele treatment, we don't need to touch the patient. You know, it used to be believed that you need to do laryngeal palpation. Well, there was work that came out of the university of Wisconsin a few years ago that said that laryngeal palpation is 50% accurate. You know what that means? That means that the fact that if I use laryngeal patients identify a swallow. It's by chance accurate. Sometimes I will identify it as sometimes not. And actually I would argue that, um, uh, with telehealth, because you know, there are things you can do, like putting a tape on the thyroid notch, moving the camera on an angle that you can see really well, moving the camera, really close to the head and neck, uh, in a diagonal way. I can actually visualize the swallow. Sometimes I feel better than I could in person sometimes not with all patients. Of course, there's, you know, there, there is variation, but, um, but definitely, uh, you know, I had stopped using laryngeal palpation in the last few years anyway, so I [00:20:00] don't use it now. I don't feel that I'm missing anything. There are things you can definitely, it's better to do them in person, or you can get more information in person than you could get, uh, via telehealth. So there's definitely some things that you can do as well. But I think the majority of, uh, um, the items that we examine in a clinical assessment. And the majority, not all, but the majority of things that we do in treatment can actually be done are very feasible. And we are finding through our research that are also reliable.  [00:20:31] Kate Grandbois:  That was going to be my next question about the research. So, I mean, I feel like, you know, our familiarity with tele-health has increased dramatically over the last year because we were so, you know, we were thrown into it. I have to assume that even just given advances in technology, the research on dysphagia and tele-health is somewhat recent. Well, so what can you tell us about the, the evidence that's out there?  [00:20:58] Georgia Malandraki:  Yeah, actually the reality [00:21:00] is that a lot of research that we did have a lot of research evidence, even before COVID-19 on the use of telehealth for dysphasia. A lot of that research was primarily, uh, focused on, uh, the reliability and validity of doing clinical tele assessments and how comparable they are with in-person clinical assessments and the findings were pretty good, very rather positive. And a lot of that research came out of Australia, which is a massive county country, very big country, and a lot of rural areas. So they, and they don't have the reimbursement that in order the licensure restrictions that we have. So they have been using tele-health for quite a while. Um, so most of it was international research. We, we had also offered some research locally here in the U S um, and some across international borders, uh, that showed that also that both clinical assessments and videofluoroscopy assessments are also feasible and reliable via telehealth when compared to in-person assessments.[00:22:00]  Yes. Kate Grandbois:  That’s so surprising Georgia Malandraki: Oh, yeah. So there are, there are research papers out there. Um, I have at least three or four publications on, on that topic. Uh, and telefluoroscopy publications, we have at least two or three on this topic. The issue has been, I think the, the reason why this research has never really been translated into clinical practice in the us and in most countries across the world, I believe has been. I mean, there are many reasons, but I think the main reasons relate to, you know, the very strict regulations that we've had in this country. The other reason that I think is, is something for us, researchers to think about more. I think we now have thought about it a lot during COVID and have started acting on it relates to the fact that most of the research is done under very well controlled research conditions. So it's not as easily clinically translatable, you know, like some of the studies that we were doing, we were using specialized cameras and specialized, very expensive equipment and pan and [00:23:00] tilt and zoom cameras and echo canceling microphones, and, uh, uh, you know, special headphones and, uh, echo canceling headphones. Um, and you know, in microphones, special microphones and, you know, a lot of specialized types of equipment. Uh, we had very expensive infrastructure. We spend a lot of time doing trainings of facilitators that all the trainings were in person. So a lot of things that clinicians do not have available in their clinics. So it's very difficult. Even if the regulations were out there, it would have been a very difficult, um, direct translation of the research. So that's, that's a thing, another hurdle that we have to overcome. And then I think the other, the third piece, which I now I'm understanding how important it is after having talked to probably hundreds of clinicians in the past year, I would say on this topic is, is that fear that you explained earlier that fear of aspiration of choking, of not being close to the patient, which I'm hoping we've, we've persuaded the audience that [00:24:00] it's, it's not, uh, um, I don't want to say it's not a logical fear. I understand it, but it's, it's, it's a little bit of an exaggerated fear, but I think with the, with training and knowledge, it's a fear that can be overcome, uh, and with adequate preparation. But what I think those, you know, those. Too, there were those other two problems. And that's why that research was not clinically translated yet. Now, uh, what I want to add here is that during the pandemic, I think we all realized, I mean, researchers that have done this work before as well, we all realize that we need to try and build the evidence under today's conditions and actually today's conditions that pandemic conditions are much more naturalistic. Meaning, you know, the first few months of the pandemic, we were confined in our homes, the clinicians, the patients were confined in their homes, right. Uh, we wanted to keep. Providing services. So the only way to do it was to do it with whatever technology was available, whatever internet connectivity was available, providing [00:25:00] all the training online, because that's all we had. Right. And see how it works. And we have some data that, uh, we, we got one, one of our papers that was published a few months ago was a collaborative study with Dr. Michelle Tosha from Columbia university in New York city. But one of her PhD students led and, uh, showed in a small scale of course, because it was a proof of concept study that even under very variable conditions, clinical tele assessments were still feasible and were still reliable even during today's conditions. So that that's, that's type of that type of research we need more of, and we are continuing it, and I'm hoping that other teams are following as well. Uh, because we need more, uh, evidence under naturalistic conditions so that people can translate it clinically in a more rapid way.  Kate Grandbois: This is fascinating.  [00:25:52] Amy Wonkka:  And we've talked a lot on here. We've had a lot of researchers on across the field and kind of talking about that need. So it's [00:26:00] really exciting to hear that that's something that's already happening with dysphasia. And I think that also that type of real world naturalistic research is going to help make maybe some of those hesitant clinicians feel a little bit better too, because it's not just, you know, with these optimal conditions, it's, it's a bit more akin to like what you're actually dealing with as a clinician who's just treating in, in natural, um, contexts. I wonder if, if another, this is a nice segue into talking about wearable technologies for tele management. I, I didn't know that this was a thing prior to working on these learning objectives. I'm super curious about this and, and maybe the number one, what are they, but number two, how might that help support a clinician who is providing teleservices in this domain. [00:26:51] Georgia Malandraki:  Yeah. No, thank you for the question. Uh, so I think the, so first of all, wearable technologies are, you know, any type of, you know, the clothes that you can wear, you [00:27:00] know, it could be your smart watch or, um, or some other specialized devices that are specifically designed for a medical reason that, um, can, um, monitor different types of data, biological data, biophysical data, and then transmit that data through a cloud server or by you sending the device back to the clinician to your clinician for further interpretation and further guidance. So we, we had seen even before the pandemic, the, uh, initial development of different apps, That people could use at their home setting, for example, to, um, to monitor adherence of different exercises so that that's not new, that was, that was happening even before the pandemic and those apps are available for people to, uh, to purchase most of them. Uh, I believe some of them may be free some of the simplest ones. So that, that was one possibility for, uh, for, uh, for patients that was even available even before the pandemic. And now also there have been several [00:28:00] devices that have been developed in the past few years. For example, I don't know if you guys are familiar with the Iowa oral performance instrument, which is a device that you can measure tongue strengths and you can do, uh, tongue exercises, uh, with, um, and, uh, it is, it is a rather pricey device, uh, but it is a device that has a patient and  [00:28:22] Tracey Callahan:  there's some like biofeedback information on that. [00:28:25] Georgia Malandraki:  Yes. And there are, what I was going to say is there are two devices. The one is for the clinician and one is for the patient that they can take home. Uh, um, it, it is still even the patient device is not, is not cheap. It's not economical. So that's one consideration that we have to think about, but those types of devices now connect to a cloud server so that the data that are collected at the home setting can be transmitted to the clinician via those cloud servers. And there are similar devices out there as well. So this is, this is an area that we have been very interested in since I started working here at Purdue. Um, we have [00:29:00] been able to develop with some collaborators, um, a couple of different wearable technologies. The first one that is closer to commercialization is a wearable surface electromyography device. It's kind of like a sticker device that goes on the neck and can monitor muscle activity when the patient is performing the exercises. Um, the device is connected through a wireless unit to an app or a software on your computer or your phone that, uh, gives you a biofeedback. And just like the IOP as we talked about earlier. And. So the patient can actually see in real time how they're doing their exercises. And then the data are also, uh, are also transmitted to, uh, the clinician through a cloud server for further review and interpretation. Now, a lot of these devices, like the ones that I've been talking about, we have been developing are under development, so they're not available yet, but definitely I believe the future is bright. There are other, uh, wearables out there with similar capabilities so that they give the [00:30:00] capability to collect some data at the home setting and transfer the data to the clinician for further, uh, review. And I think that, that is, the advancement and further development of these types of devices is not only good for telehealth. I think it is important for in-person care as well. A lot of the treatments we have been doing with patients do not involve the use of biofeedback necessarily, or do not involve the use of accurate and reliable biofeedback. You know, it's different when you use a mirror or a tongue depressor, you know, that it doesn't really provide an accurate read of the behavior and very different when you actually use some objective data and we need to be moving more as a profession to collecting more objective data during treatment and during the evaluations, of course, uh, in general. And I would say that that that's a very good advancement for both the in-person and the telemanagement of dyaphagia.  [00:30:58] Tracey Callahan:  And then just [00:31:00] to, to comment on that, um, what's, what's great about having that data is that it can be really helpful for not only patients and for the clinicians, but also like caregivers. It's good for everybody to see that there's progress being made, that you know, that it is increasing some of these you can chart and see progress with a graph, uh, which can be really rewarding. So sometimes when doing these different exercises, it can be a little bit boring, but having that type of feedback and taking that kind of data can be a really helpful tool to help encourage the patient or person to kind of press on with the exercises and activities. [00:31:47] Georgia Malandraki:  Yeah. Yeah, absolutely. It has actually been found that the use of exercises improves adherence, uh, for sure at the same time, if, as a field, we want to move forward to a more or less [00:32:00] symptomatic treatment approach and a more physiological treatment approach. We need to be using exercise physiology principles, and those principles are telling us that we need to be working towards targets. If we don't have targets, you will only be able to improve the patient to a specific level and then that will be yet, you will get a plateau very quickly. So I think that's, that's another very important reason to, uh, continue working in this domain of developing more and more, uh, accurate and also affordable devices, because I think that's the biggest problem. The biggest problem is because this is a very small market compared to, you know, markets of other things that, you know, um, make a lot of money for people. Unfortunately, these devices end up being very costly and right now, not many of them, if any, are reimbursable. So there's a, these are hurdles that we need to, we have been working on and we need to be working on more. [00:32:56] Tracey Callahan:  I know that Kate and Amy both really love data. [00:33:00] Data is probably one of their favorite things that are able to provide really specific and objective data, uh, I think are, are wonderful. But also when we think about when we're doing therapy to know the improvement is there, other than just, they were able to swallow X number of bites over three sessions, you know, it's good to have some measurable numbers. [00:33:26] Georgia Malandraki:  Absolutely. Yep.  [00:33:28] Kate Grandbois:  Can you tell us a little bit about any specific adaptations that, so just thinking about a clinician who might be listening to this, who has experienced doing this kind of treatment in person and is interested, maybe they live in a rural area or they're interested in exploring tele-health. What are some of the specific adaptations that a clinician, a practicing clinician might need to consider when setting up tele-health for maybe the first time or the fifth time or the 10th?  [00:33:57] Georgia Malandraki:  Yeah. Yeah. So first of all, I would [00:34:00] say just, um, uh, just to make sure I repeat it enough that all these, the prerequisites that we talked about about the regulatory guidelines, the infrastructure, and all of those things, those need to come first and all those considerations. And once those have been taken care of, I think, um, there are actually relatively simple, uh, but a little bit time consuming adaptations that people can do. Meaning I think the, the biggest thing that you need to understand and do is that you will need some time to prepare materials, you know, um, in tele health, unlike in in-person services. Most of the times you need to make sure that the patient has the list of items you need them to have in front of them before the session starts, you know, in, in the clinic, you can grab something. If you forget something, usually you have pockets, right? Um, full of stuff or drawers full of stuff. So you can easily, uh, you know, do something else or have a plan B of what you want to try or how you want to do [00:35:00] things. With the telehealth you have to be pretty well-prepared. Yeah. For both plan a and plan B. So that's the biggest thing. So I would say you need to spend some time in the beginning. If we're talking just about clinical adaptations, for example, to maybe prepare some online materials or purchase some online materials. There's so many things nowadays available, create online forms, uh, and use secure platforms to deliver those forms. Um, you know, case history forms on, you know, things like you may be using the eight, 10 as a or other quality of life instruments. You may be using the MOCA or other cognitive screens, whatever, you know, whatever you use, you will need to make sure that you're using the appropriate electronic form. If you are going to be transferring into an electronic or a remote environment only. So that those types of things need a little bit of preparation. So that's, I think that's something that clinicians need to think a little bit about more. Also, you know, in terms of the items that you will need in the clinical assessment. [00:36:00] Uh, so what we have done is we have prepared like very cheap tele-health kits. And, uh, we usually send a list of items to the patient and if they cannot collect all the items that we believe are necessary, then we will consider sending them that very small tele-health kit so that they can, uh, have the items we need them to have in front of them. In case they didn't have them at the home setting at the same time, you need to be a little flexible because they may have something similar to what you wanted to try, but not exactly what you wanted to try. So you can decide how flexible you want to be. And again, this takes a little bit of preparation and communication beforehand. So, so there is some, um, initial time that has to be spent. The good thing I think. And those of you who have done the health, you know, as well, is that once you prepare uh, well, once you usually have material for quite a few more patients, right? So of course you need to make adaptations and you need to change a few things and a few of your stimuli and things like that. But especially for dysphagia care, things are [00:37:00] relatively standard. Of course, the way you do things change, but typically the types of things you do are not that different. Um, so, and they're not exhausted, you know, there's not an exhaustive list that you can't really possibly, uh, uh, prepare materials for most of it. So I think preparation is a big thing. And then when, when it, when it comes to the actual clinical application, the important thing is to be able to have the materials you need and to be able to see and hear well what you need to see and here. So you have to check to make sure that the internet connectivity is adequate. And this is something that we extensively talk about in some of the webinars I gave for ASHA and also some of the, um, the papers that the guidance papers that we published this past year. So for those of you who are interested in learning more about it and testing, then, you know, as I said that the internet connectivity and the technologies, the patient has to make sure that you have the, uh, adequate audio and video [00:38:00] for what you need to see and hear when it comes to the actual, uh, uh, you know, down to the day where you actually have to do the assessment, simple things, for example, like moving, I think I mentioned earlier, like moving, moving the head diagonally and moving the camera close to the patient so that you can see the head and neck well. Putting a tape on the thyroid notch helps with visualization of the swallows. It's not perfect, but it can be helpful, making sure that you use clear cups. And I like to use measuring cups so that I can see how much volume is being consumed as well of the different materials, you know, simple things like that can actually enhance the process really well. The other thing I really like using, especially for swallows or any type of oral trials that the patient is doing, I like having a second camera and buy a second camera. I don't mean going out and purchasing a it's an expensive, uh, know second external camera, but actually what we have been using during the pandemic, which wouldn't believe it would [00:39:00] work, but it worked really well is just using a phone. So we would send the zoom healthcare link to other the facilitator, the caregiver, and they would also connect to the session as an extra participant through their phone. They will use the camera with our direction as, uh, a close up camera. So I could see the patient from their regular camera in the front view. And then I would have the caregivers or facilitators phone providing me the lateral views, the diagonal views, the views inside the mouth, you know, things like that. So, so a simple solution like that, that. Really came out of necessity. We didn't know what else they use during the pandemic to make things more visible for us and better to visualize things better. And we tried it and it actually works much better than some of the pan tilt zoom cameras I was using a few years ago when I was doing tele fluoroscopies. So it's, it's, you know, technology has advanced so much in the last few years and it's [00:40:00] really, it's becoming more of our friend now in the area of tele-health. Um, so you know, those, those simple things I would say, and I probably mentioned too many, but, um, just to get an idea,  [00:40:10] Kate Grandbois:  no more information is always better. There's no such thing as too many, too many things. I'm wondering about the requirement of a facilitator and you've mentioned caregivers a few times. Is this an adaptation or something that's different that you feel is a requirement first? Or does the evidence say that it's a requirement for successful dysphagia intervention over telehealth? [00:40:32] Georgia Malandraki:  We don't have definitive evidence that says that it is absolutely necessary or not. We do have evidence that says that, uh, facilitators can get drained and can be very helpful. Uh, what I would tell you based on my experiences is that for clinical assessments, I consider a facilitator,I make it a requirement that a facilitator is present because there are many parts in the clinical assessment. Uh, like for example, I [00:41:00] want to try and test, uh, sensory responses. I want to try as part of the cranial nerve examination, or I want to try and test, uh, strength responses to the best of our ability. Of course. So the use of a facilitator for these types of things is very important in addition to, of course, as I said earlier, it, it, you know, it can be part of the safety plan. Um, so it, it can give me peace of mind. So for clinical tele assessments, I do find them necessary. And I, I personally require them in our clinic. For tele treatment sessions. Uh, there could be situations that they're not absolutely necessary, but I think that will depend highly on the age of the patient, their cognitive status, their general health status. And very importantly on what has been decided as the safety plan and agreed upon as the safety plan, because if your safety plan says that there will be a facilitator there, and that is what the patient has agreed to, then you need to have a facilitator present, but that's [00:42:00] not necessarily required if that's not what the safety plan says. So I throw it a lot, depends on all these other factors, plus the safety plan as well. And one thing I want to mention, it's not related to facilitators, but because I feel like I'm talking about tele clinical assessment until the treatments, and I'm not talking about instrumental assessments at all. I don't want people to think that I believe that we don't need these instrumental assessments by any means. They're a very big part of what we do. Very, very important. Right now, there are ways to use telehealth for instrumental assessments, but those ways are either very expensive. And, you know, for example, for televideofluoroscopy, you need to get buy in from radiology as well to buy specialized equipment to do that. And in addition to that, they're are not assessments that you could do from the home setting. You know? So until we will develop that, x-ray,  [00:42:50] Amy Wonkka:  I was trying to picture what that would look like.  [00:42:53] Georgia Malandraki:  So we don't have that ability yet, but, you know, but if you wanted to do, for example, from a big cost to that, to a rural [00:43:00] hospital or something like that, that is possible. If the technology is there, it is expensive technology. So that's one barrier. Uh, but that is a possibility. The other possibility for tele instrumental assessments is to do, to use asynchronous telehealth, which means, you know, somebody can conduct their assessment in real time. And if they want a second opinion or another more experienced clinician to take a look and give them a further interpretation to store and forward it, or basically save it and transfer it in a, in a safe way to another clinician for later review. So that that's a possibility as well. There are billing issues there and complexities in that case, but there are ways that ways to do those types of things. So just wanted to make sure that I touched base on that because I realized I was talking only about two things and I didn't want people to think, oh, she doesn't do instrumentals that's that's not at all, uh, to,  [00:43:55] Amy Wonkka:  no, we appreciate that. I think, I think one question we had kind of to back [00:44:00] up even further from what we've been talking about, how do you figure out who is a can, Iis everybody a candidate as a patient for teleservices? If not kind of, how do you figure that out? Or what are some questions that clinicians should be asking themselves? If they're curious?  [00:44:16] Georgia Malandraki:  Yeah, no, I think that's also a very good question and it is also a very common question. And one thing that, uh, Uh, I tell clinicians is that, uh, because a lot of people say, you know, what types of patients are candidates? And there's not really a good response for that question, because it's not about the type of, or the diagnosis of the patient. It's really about, um, a process of thinking of who could actually do this and benefit from this. And we are developing an algorithm that will be published very soon in SIG 13 perspectives. So hopefully it will be available to many clinicians to see very soon. Uh, but in this algorithm we're using a four step approach. So here, so this [00:45:00] is what I'm thinking. So usually when I have a patient and I'm thinking, are they a candidate for tele-health irrespective of their diagnosis? Okay. Or severity, I will first think about some very initial tele specific factors. So for example, do they have adequate enough hearing and vision and alertness to be able to attend. 30 minutes, 45, an hour session, whatever, whatever I believe this patient needs, right. Are they able to be positioned in front of a camera for a specific amount of time so that I can see and hear what I need and out? Are they capable to consent or do they have a proxy who can consent for them, you know, and go through the consenting process. So those are kind of the more general  tele specific criteria that are true across different settings, not just for dysphagia, right? If the answer to all of this is yes, then I move to the next step and I say, okay, now let me see, do I have the infrastructure available? Do I have, especially at the patients and [00:46:00] adequate connectivity and technology available, if not, could I get services that will give them the technology? So for example, just like you guys have AAC lending libraries, we're starting to have tele-health lending libraries with iPads and things like that, that we give out to patients. If the answer is yes, then I moved to the third step of the process and questions, which is now I'm asking about the clinical factors. Do I have all the materials I need to do what I need with the patient? Or can I give them the material? Can I provide that to them? If the answer is yes, then I go to my last question, which is, is a facilitator available, able, and willing to help and to act in the case of an emergency. And again, this is not absolutely necessary at all times, but it, for dysphasia tele-management, I very highly recommend it. And if they, if a facilitator is not available, does that mean that the patient is not a candidate? Not necessarily, it will depend, as we said earlier on age [00:47:00] medical status, cognitive status. And what is the emergency plan situation is something else we could do if a facilitator's not there if an emergency were to occur. So it is, it is, it is a multi-step process that, uh, that you have to think about. Instead of thinking about this patient versus this patient versus this diagnosis versus this age group, it's really more of a process. Does that make sense?  [00:47:25] Amy Wonkka:  It makes a lot of sense. And I think, you know, you, you already made the point, but just to sort of restate it. I think that so many of the things that you're talking about are applicable broadly when we think about telepractice in general, like these are, you know, the infrastructure questions that you should be asking yourself, you should have these things in place. You should have a way of assessing, you know, the hardware capabilities of your client. Like just, just the very logistical pieces really do need to be ironed out before you even get to the clinical piece sort of at all. Um, sorry, go ahead. [00:47:58] Georgia Malandraki:  No, it was going to [00:48:00] say, and that relates to that preparation that I was talking about earlier. That's part of it, you know, you need to do possibly, you know, a five to 10 minute trial session. You need to, you need to spend that extra time. I understand it's not always reimbursable, you know, it's it's time and energy and all of those things. So I think another important consideration, and I think I talked about it, especially in the latest ASHA, um, uh, webinar. Uh, I think it is important for people who are really serious about it and want to make sure that they can use telehealth beyond the pandemic. They really need to think about how do I fit this in, into my work flow, because there will need to be some initial time and energy spent. But I think if you do that extra preparation in the beginning and incorporate the use of telehealth into your workflow already, then it will be much easier to sustain it long-term and beyond the pandemic, I believe that people that don't want to use it anymore are the people that didn't do [00:49:00] that. Didn't do the preparation. They jumped into it very quickly because they had to, and they realized it's a lot of extra steps. It's a lot of extra effort and they didn't want to be doing that every time because they didn't put the preparation time in and they didn’t incorporate it in their workflow in the beginning. So it's all, I think part of that preparation time.  [00:49:20] Amy Wonkka: Well, and I think too, you know, you've talked about your specific institution, but I think that, you know, that's something else to think about. It's just at the institutional level, if you're working somewhere, you know, can you recruit, because some of this stuff you could potentially allocate these jobs to other people and kind of divide the workload up a little bit. That makes it feel a little bit more manageable. Like one person can come up with, you know, a bunch of sample, um, bandwidth, you know, even, even just really logistical stuff, like is your bandwidth this go on here and check it. Um, and so doing that at an institutional level, I think it's probably,  [00:49:54] Georgia Malandraki:  yeah, we, we actually, for [00:50:00] the testing of the connection, we had the receptionist in the clinic do that. You know, I mean, we, we trained them. We spend a little bit of time with them and said, this is what you need to do. This is what, you know, you connect, you go to this website, you check, you know, you ask the patient to do the same, you'll share your screen. You know, we, we shared some steps with them and they started doing it from then on, uh, we had, uh, some graduate assistants, do some other parts. So depending on where you are, um, and what type of help you can have. Definitely, you can definitely, if you have help, that's great. And, uh, you can definitely allocate. Absolutely.  [00:50:33] Tracey Callahan:  And one thing that, you know, some people were concerned about was the extra time for the patient, but I've actually found that the patients that I've seen really appreciated that we took the time ahead of time to make sure that their connectivity was there, that they knew where they should be positioned, uh, what equipment they should bring and that they were given time to ask questions about how the whole process would work. [00:50:59] Georgia Malandraki:  [00:51:00] Yes, absolutely. I find the same overall. Um, as I said earlier, there are always some people that it doesn't work for them, you know, that, um, uh, and especially, I don't know, but where, in what states you guys are located, but here in Indiana, we had a little bit of trouble with some of the older folks. Um, we, not all of them, but, you know, with some of them. So that was that, that was actually a challenge that we had to address. So we had to create step by step instructions and, you know, and do more trial sessions with them and all of those things. Um, and then after that, it worked much better, but overall, uh, overall I feel like it's actually. In, in the context of all the time that is allocated to a session from the patient's perspective, it's a time saver because they don't have to drive to the clinic. They don't have, you know, um, some of our patients drive from far away. Um, so that's a big time saver and energy saver and money saver too. So I [00:52:00] think, I think they have appreciated some of those components as well.  [00:52:04] Kate Grandbois:  I wonder if you could walk us through maybe a potential session, just for someone who is listening, who wants to, you know, we've got the lay of the land, the larger landscape, the safety precautions, some tips and tricks, but if you could go through a pretend session with us, maybe in sequence, I think that would be really interesting. [00:52:26] Georgia Malandraki:  Okay. I'll try it. So is it a tele evaluation or a tele treatment session? [00:52:34] Kate Grandbois:   Oh gosh. It doesn't matter. You pick dealer's choice.  [00:52:34] Georgia Malandraki:  Okay. Well, the, the, the big difference is if it isn't an evaluation session and it is the first time or one of the first times I'm meeting the patient, I will have spend about 10 to 15 minutes before to, uh, to train both of the patient and the facilitator on the safety plan. And it literally doesn't take more than 10 to 15 minutes for most situations. But I go through that because that's also part of the consenting process. Um, [00:53:00] and that that's, that's something that, you know, uh, with training of probably a graduate assistant or another assistant could possibly do in another clinic. But in the beginning, I usually, uh, tried to do it myself and the patients feel better that way. Um, I'm also probably the fastest in doing so going through that plan, it's a two page document. We go through it and we just say, you know, this is, uh, I'm explaining the risks and the benefits, this, uh, this is a, I'm explaining that our qualifications to do this, I'm asking them if they're willing to do it after I explain everything. So the part of the consenting process, and then I'm telling them that just like any other medical procedure, there are some safety things that we need to talk about. So I talk to them about, um, any safety concerns they may have about these risks. I answer any questions they have and once they agree, after that we're ready to start with a clinical session that can happen right away, or it could be, it could be another day that is being planned. If it is another day, the only thing [00:54:00] is before you start the session, you want to remind them, do you remember the emergency plan? What is it? What did we decide? Who's going to call 9 1 1, you know, ask some of those safety questions, take two minutes. Literally. No more than that. I promise. And then after that, and that's something you actually, we asked in the beginning of every session about or treatment. Okay. And then after that is answered and we are set that everybody knows their roles in the case of an emergency, then we can start with actual session for the clinical evaluation. We start with an interview process, a case just like you would start in in-person in clinic. Right. Uh, usually they will have completed a form. So we use that form to go through the responses, make sure they're accurate, uh, ask any clarification questions. And then we start with the cranial nerve assessment. Also, if they, if they have done any other questionnaires, we will also go through those questions as well. We will do, uh, the, the cranial nerve assessment. Uh, and that that's the [00:55:00] part where the facilitator will also be very helpful. Then we will do the oral trials. Uh, and then at the end we will spend 10 to 15 minutes to kind of summarize what we saw. Uh, we usually, I usually record part of that session. I don't record all sessions. So you don't, you don't necessarily have to record session. Actually. It could be a breach of confidentiality if you record those sessions. So that's another thing that you need to check by state reimbursement agency and all of that and facility. Uh, but I, I do record some of the evaluation sessions because sometimes I will go back and rewatch just to make sure that I captured all elements of the evaluation. Um, but we spend the last 10 to 15 minutes to basically summarize what happened, what we saw. We usually tell them that we will tell them more things in the next session. Um, if it's just an evaluation session and ask if they have any more questions, how did they feel about this encounter? If there's anything we could change. Um, so some tele specific [00:56:00] questions and, and that's basically it, uh, I don't know if I forgot anything. I probably forgot some of the cognitive screens and things like that, that we do. Uh, uh, but th those are usually part of the interview process in the beginning as well. And the treatment session is similar, but, you know, instead of the clinical evaluation steps, you follow you, uh, you go through the different instructions for the clinical, uh, for the, for the treatment. Um, we do have a lot of materials that we have prepared that we screen-share with patients. So for example, for the cranial nerve assessment, we have almost step-by-step pictures of what we want them to do. Now. Of course we are modeling it for them as well, but just in case they can't understand, we have step by step instructions. We also have step-by-step instructions for the facilitator. So that's part of the preparation that has been done. Um, so yeah, so that's what that would look like  [00:56:57] Tracey Callahan:  One thing I think is really [00:57:00] unique, um, about, uh, doing the assessment through tele-health is you're able to visualize what the patient is actually likely to be sitting in, what their positioning is going to be. Um, so in different clinics that I've worked in, we've had, you know, very expensive therapeutic chairs with bands and pillows and, and that's not realistic for most, if not all of our patients at home. So it's good to have that as part of the process. Uh, so we can make sure that the patient is realistically going to be positioned appropriately. And if the positioning isn't working, it's really great to work with the caregiver in real time to troubleshoot that and figure out what we could do. Okay. Could we bring in a box or a stack of board games or books underneath the feet to make sure that the patient is well supported or can we get some pillows for lateral support? And, um, and I think that's just really unique to [00:58:00] telehealth. I mean, also to home, home care, but thinking, um, difference between a clinic it's been really helpful and families and caregivers have really appreciated that aspect.  [00:58:13] Georgia Malandraki:  Yeah. I think that's a great point, Tracy. Absolutely. The, the, you know, you are in the naturalistic environment and, uh, in addition to, uh, all those things that you mentioned that are very, very helpful, especially in pediatrics. I know we haven't talked much about pediatrics, but hopefully a lot of the things we've covered also, uh, will be relevant to your pediatric, uh, clinical audience, but also the fact that, for example, especially in pediatrics. So the other thing that I have found very useful is that a lot of the materials have to be prepared by the caregiver at home before, so they are the materials that they have available. They would use in, in everyday life. They're not the materials that you just have in the clinic. So that's another way to generalize things much [00:59:00] faster.  [00:59:01] Tracey Callahan:  I agree that also thinking about, um, different cultural foods that people might have at home, that we don't have. One of the big complaints that I used to get was that people wouldn't eat chicken and, uh, the hospital would serve white meat chicken, and a lot of countries in the world do not believe that that is delicious. And so at home they're having the darker meat, chicken, or they're having part of the leg, or, or the thigh and, um, you know, that's really different, whereas, you know, I can't go down to the kitchen and say, no white meat, please. I would only like dark meat chicken for my trials today. It's really great to be able to have that available. And also if we're working on eating crackers with a patient, but they're not eating crackers at home, then you know, it's not really a useful goal to work on.  [00:59:53] Georgia Malandraki:  Yeah, absolutely. And you know, when we ask them to prepare like a list of items, [01:00:00] a lot of times we will give them just examples of things that they have available. And, and it's, it's, I know that the bad thing is we can’t standardize across patients if they're each one is using their own thing. Right. But, um, but the clinical assessment is essentially, um, of course, ideally you want to have as much standardize information as possible, and you can supplement that with standardized tools, but, um, when it comes to oral trials, because food is such a personal experience and as a such a cultural experience, as you said, I think it, it actually, uh, is, uh, has been very helpful for, to see what the different patients can come up with and what they want to try and, uh, how they do. So, yeah, absolutely.  [01:00:41] Kate Grandbois:  In our last minute or two, do you have any words of wisdom, if you could, you know, in reaching through reaching through the headphones to a clinician who is maybe just starting this, this at clinical adventure, do you have any, any pieces, last pieces of advice?  [01:00:59] Georgia Malandraki:  That's a, that's a pretty [01:01:00] heavy question. No pressure, no pressure at all, right? Yeah, no, I mean, I would say that, um, uh, you know, as anything else that is new. Uh, and requires a new skill. It needs time to be learned, but it's definitely something you can learn. And it, it, it needs time and investment, just like anything other new skill that you would like to learn. So, um, I would just recommend making sure to spend the time nowadays, there are many resources available, many webinars available. I believe there's going to be more and more trainings available in the upcoming months and years on this finally, because of COVID that was probably the silver lining graduate programs and incorporating this in their, you know, in their curriculum. So I believe, um, you know, there will be more and more resources. So I think if somebody and there are resources out there, so I believe that if somebody is really interested, they just need to be patient and give themselves [01:02:00] time. Yeah. Uh, and the investment of time and energy and money will pay off if they're very serious about it at the same time. Uh, you know, I just want to reiterate that we do have research evidence. We're starting to have more research evidence under more natural listing conditions in cause you know, I do hear a lot. There's no evidence. This is unsafe. This is this. This is that. If you don't have the knowledge, this is what you think. Your fear of something that is unknown. So I want to reiterate that there is knowledge out there. There are guidance, there are guidelines and there is some research. So just do your homework and take the time. And, uh, and one day you, I think you will be very glad you did.  [01:02:46] Kate Grandbois:  Those were wonderful last words. That was, that was great. This whole conversation has been so wonderful. Thank you so much for joining us. This was, this was so awesome.  Amy Wonkka: Yes. Thank you. If anyone,  [01:02:59] Georgia Malandraki:  thank you for [01:03:00] having me. I, you know, it's, it's great. You guys asked great questions and it was a great discussion. I appreciate having all of you here. Thank you. Believe  me.  [01:03:07] Kate Grandbois: The pleasure is on this side of the microphone, for sure. This was really great. If anybody is listening and would like to earn this, use this episode to earn ASHA CEUs, you can do so on our website, www.slpnerdcast.com . All of the resources that were mentioned will be linked in the show notes. So if you've listened and you want to learn a little bit more, dig a little bit deeper, read a little bit more literature, all of those resources are available for you in your podcast player or your phone or wherever you're listening. And we're, we're so glad to have you today, Georgia and hope everyone learned something today. So thanks again.  [01:03:41] Georgia Malandraki:  Very glad to be here.  [01:03:44] Kate Grandbois:  Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count for professional development in your area [01:04:00] of study, please check in with your governing bodies or you can go to our website, www.SLPnerdcast.com . All the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email  at info@slpnerdcast.com . Thank you so much for joining us and we hope to welcome you back here again soon.

This is a transcript from our podcast episode published March 7th, 2022. The podcast episode is offered for .1 ASHA CEU (introductory level, professional area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. [00:01:38] Kate Grandbois:  This episode was brought to you in part by listeners like you. And one of our amazing corporate sponsors Vooks. Our corporate sponsors keep our CEU prices low and our program ad free. boxes and library of animated, storybooks, and read along texts designed to improve engagement and reading fluency. Kids can track with the highlighted text and you can pause to go over words and [00:02:00] phrases, join 1 million educators and specialists by trying Vooks for free for seven days at Vooks.com .  So today we are talking about something very exciting and that, that I didn't think I was going to be so excited about if I'm going to be totally honest until we had a lot of really interesting discussions. We are going to discuss the research to practice gap. And while that might sound sort of dry, we're going to talk about why we should care about it as clinicians, because as it turns out, there are some mind blowing pieces of information about the research to practice gap. And as clinicians, we, we know what the, we know that there is a gap. Um, but what is it? So what is the research to practice gap and, and why is it that we, how does it affect our practice on a regular basis? Um, Amy, as our listeners know, Amy and I are both, um, working clinicians, working on the quote unquote frontlines of, you know, in schools [00:03:00] and, and with clients and students and all those kinds of things. And as we prepared for this episode, um, with the two researcher, guests that we have on our show today, this really fantastic analogy came up. Amy, do you want to say what it is? Amy Wonkka:  No, I think that you should do it.    Kate Grandbois: So there was this analogy that came up about, about researchers being in the ivory tower, which of course made us think of. [00:03:26] Amy Wonkka:  I would sing it, but I don't know if we’re allowed to sing the song.  [00:03:29] Kate Grandbois:  Why? Because of like copyright, I don't know.  [00:03:31] Amy Wonkka:  Can you  [00:03:32] Kate Grandbois:  sit, can you sing the Never Ending Story so the ivory tower made us think of, of course the never-ending story. So the Ivory, Meaning it to make it parallel to what we're talking about. Not to go on a 1980s movie tangen,t researchers do sit in the ivory tower, doing their research in this beautiful, clean, pristine situation. And then the information from the research coming down from the ivory tower to us clinicians working on the front [00:04:00] lines. And how long does it take the research to come down the ivory tower? What are the barriers that come down? What does that gap actually look like? Um, and for us, Amy and I, as the clinicians, we know that there are a lot of barriers, right? Um, so what, what of our barriers contribute to the research to practice gap? Is it that we don't have time to read, to read the research? Um, is it that we have a hard time finding the research that we actually need for a particular student or client. Is it that the research is done in a lab under perfect conditions up in the ivory tower. Um, and we don't really know what's going on in there. It's a super cool club. We don't get invited up there very often, you know, which is, gives us maybe, maybe it gives some people grumpy feelings. I don't know. There's like a whole world around this, this research to practice gap. That's really, really important because it affects our clinical practice. Um, and I think something that we've talked about and Amy correct me if I'm wrong, we've talked about a lot. Is that [00:05:00] the, what happens in a research lab doesn't necessarily represent what's happening in your classroom?  [00:05:06] Amy Wonkka:  Yeah. I mean, I think that we've talked a lot about the evidence-based practice triangle and thinking about that external evidence. And a lot of times you read those articles and you feel like, well, geez, these guys have no idea what my life is down here and internal evidence land. Um, and you know, I really don't know what it's like up in that ivory tower. Um, and so I think that while we want to integrate this external evidence, it's hard sometimes as a clinician to know what to do with it. Even if you do read something and you're like, ah, Okay. It's hard to know how to turn that into something that makes sense for you as a clinician and for your clients. Um, and then, you know, sometimes it's hard to even read the articles if you don't, you know, if you don't subscribe to the journals, which are super duper expensive, like you can't even read that article to have the thoughts about what that might mean for your practice. So there are lots and lots of barriers, uh, [00:06:00] and we're here today to learn a bit more about how we can break those down and how we can, how we can kind of work together. To best serve our clients from people who were in all of these different places in the swamp or the ivory tower [00:06:15] Kate Grandbois:  In the swamp of sadness. This is the best analogy of all time. So if anybody's listening, who hasn't seen that movie, you need to go watch it immediately. Um, but I promise you'll be able to follow along, even if you haven't seen it. So, um, you know, Amy, to sort of piggyback on what you were saying, there are all these hurd, there are all these hurdles to the research practice gap, and we have some strategies for them. So, um, for those of you who don't know the informed SLP, um, the informed SLP is a platform that produces digestible pieces of, um, summaries of the research that's out there. So we have platforms like that. We have other continuing education platforms, um, but. The, it's really hard to understand what the research from, from the [00:07:00] lowly, from all the way down here at the bottom, in the trenches, underneath the shadow of the ivory tower, it's very hard to sort of see where, what the research to practice gap is and what variables contribute to it and only, Like Amy said, only after we see the barriers, can we really sort of start to do some of the problem solving? So we're not researchers, we can't really solve this problem ourselves. So to get to the bottom of this, we invited two researchers, two researchers onto the show to answer some of our questions. Um, these are two veteran SLP nerd cast guests, and we're very excited to have them back. We are, um, very excited to welcome Dr. Cathy Binger and Dr. Natalie Douglas, back to the show. Welcome, Cathy. Welcome back [00:07:45] Cathy Binger:  It's a pleasure to be here. Thanks for having us.  [00:07:48] Natalie Douglas:  Yes. Thank you.  [00:07:50] Amy Wonkka:  All right. Before we get started for listeners who haven't joined us on our wonderful adventures with Cathy, Natalie before, can you each tell us just a little bit about [00:08:00] yourselves? Um, so people can understand why you're here to come talk to us.  [00:08:03] Natalie Douglas:  Yes. So Natalie here, um, so I'm actually on the faculty at Central Michigan university right now. I've been here since about 2013. Um, but before that I had about a 10 year gap where I was providing clinical services, mostly an outpatient hospital and long-term care settings. Um, so working as an SLP for about 10 years, Um, and actually one of the things that most propelled me back into academia was I was hoping that I was going to be able to have some tools to help me solve some of the problems that I was seeing on a day-to-day basis. That I didn't think that I could solve with the tools that I had based on my clinical training. So, um, most of my work at this point works on implementing best practices for people with dementia in nursing homes. [00:09:00] So I'm really grateful to be here with all of you again today.  [00:09:04] Kate Grandbois:  How about you, Cathy?  [00:09:06] Cathy Binger:  Yeah, I'm Cathy Binger. I'm a professor at the University of New Mexico. And, um, like Natalie, I took the long and winding road back to getting my PhD. Um, I went straight through school to become an SLP, thanks to career counseling, found the discipline, but then once I got out and practiced, um, I initially had thought that I would always get my PhD if I stayed in the field. Um, and then I ended up practicing for about eight years in there. I did some research, um, but mostly I was clinical, working clinically during that time. And I worked in lots of different settings. I worked in headstarts. Um, I've worked in five different states. I've worked, um, doing elementary. I work for an elementary school, public schools, um, middle school for a little bit as well. Um, even, you know, older populations with developmental disabilities, so worked with different populations, mainly little [00:10:00] kids, um, mostly in, in public kind of settings. And, um, I got really frustrated and as I think I knew I would even way back when, um, I was in school initially. And, uh, one of the phrases that kept coming back to me was from a high school teacher who was fond of saying if you're not part of the solution, you're part of the problem. Uh, so I had one foot out the door from the profession for a long, for a lot of those years during that time and really thought I would leave and go do something else at some point. And then a series of things happened that took me back to school to go back and get my PhD and, um, with an eye toward really wanting to help solve real world real world clinical problems. So, um, and I've been, uh, here at UNM for 17 years.  [00:10:54] Kate Grandbois:  And I should say to give credit where it's due. This issue of the research to practice gap is sort of what [00:11:00] brought us together. So if we're all being honest, I, you know, with my tail between my legs got caught on a podcast, talking about how one research article in particular was quite boring. And I had to flip to the end and Amy, of course laughs, I love it. You know, our, we do our little shtick and lo and behold, it was your research. And on top of it, you had the incredible wherewithal to reach out to me and say, yes, research is boring. Isn't that a problem? And here we are with this beautiful, you know, this, this issue that sort of brought us together, so kudos to you for not taking offense to my ridiculousness and reaching out across the aisle to try and discuss it and make it better [00:11:45] Cathy Binger: , but it's not ridiculousness. Right? That's the whole point. And nor are you lowly, nor are you like, I'd like for you guys to throw out all of those attitudes because that's not, you know, we have, we need to be peers. We need to be colleagues. We need to work [00:12:00] together. If we're going to address the problems that we're going to talk about today. So, [00:12:04] Kate Grandbois:  I love that and I love it so much. That's making me think of like three or four more questions that I want to ask you, but I haven't run our learning objectives yet. So I have to stay focused. Otherwise it's going to be hot mess express from here on out, which is, but we're going to stay focused. We're going to stay focused. Okay. So before we get into this and I ask all the questions you just made me think of, we're going to read our learning objectives. So learning objective number one, identify at least two common approaches to research that contribute to the research to practice. Learning objective number two, identify at least two barriers to dissemination of clinically applicable research findings. Learning objective number three, identify at least two strategies within practice-based research that researchers and clinicians can use to close the research to practice gap. Disclosures, Dr. Natalie Douglas financial disclosure as Dr. Douglas receives a salary from central Michigan university and the informed SLP. She also receives book royalties from plural publishing and has research funding from the American speech language hearing [00:13:00] foundation. Dr. Douglas’s nonfinancial exclosures. Dr. Douglas is a member of AsHA SIG two and SIG 15, the gerontological society for America and the aphasia access group. Dr. Cathy Binger’s financial relationships. Dr. Binger is employed by the university of New Mexico. Dr. Bingers non-financial relationships. Dr. Binger is a member of ASHA special interest group. Kate that's me, financial disclosures. I am the owner and founder of Grandbois Therapy and consulting LLC. And co-founder of SLP Nerdcast my non-financial disclosures. I'm a member of ASHA SIG 12, and serve on the AAC advisory group for Massachusetts advocates for children. I'm also a member of the Berkshire association for behavior analysis and therapy, Mass ABA, the association for behavior analysis international on the corresponding speech pathology and applied behavior analysis special interest group, Amy, um, Amy Wonka’s financial disclosures. Amy is an employee of a public school system and cofounder of SLP Nerdcast. Amy's non-financial disclosures. Amy is a member of ASHA SIG 12, and serves on the AAC advisory group for [00:14:00] Massachusetts advocates for children. Okay. That was very, very long and boring. And I'm sorry, I had to read it ASHA makes me do it. So now getting onto the good stuff. Um, something that you said right before we got through that long and boring piece brought me to a question. And I wondered if, um, before I, I have some general questions about what it's like to do research. So what goes on in the ivory tower, but I wondered if, from your perspective as a, as researchers, because we have such different workplace settings, right? Like we have such different jobs. I mean, even though they influence one another, or they should influence one another more, do you feel that there is a great divide? Let's call it between the researching world and the clinical world.  [00:14:48] Natalie Douglas:  Yes, there is a big one. And I just want to reiterate what Cathy said. It was actually making my stomach hurt. When you guys were talking about the ivory tower [00:14:58] Kate Grandbois:  I saw you cringe. I was going to text you later and [00:15:00] apologize. I didn't. I wanted to make sure your feelings weren't hurt, but I think it's real. [00:15:04] Natalie Douglas:  It is so real, but it's so. It just, it, I find it so heartbreaking. I just, it makes me so sad that we as, um, you know, we have to be part of the solution here. And I just to think of my colleagues thinking of themselves in that way, it makes me just, we, it just points to such, um, systemic issues that we have to get out ahead of, you know, and I think, um, I don't know what happened, um, along the way, systemically that has made the research world and the clinical world, especially in a field like speech language pathology, where, you know, clinical research questions from a research and a clinician perspective, you know, those guide what we do. And so it's just, it's [00:16:00] incredible to me that with such a common foundational principle of improving life for people with communication disorders, how things have gotten so siloed.  [00:16:14] Kate Grandbois:  Um, I love the way you put that. I loved the way you put that.  [00:16:18] Cathy Binger:  I wonder how much of it, or at least there's a piece of it. That's shame related. You know, we talked about this a little bit. The last time we were on. And Amy, I think you mentioned something in an email about this recently about, um, just, you know, how, how researchers slash professors slash, and so, you know, can can say things to clinicians, um, about, well, you know, you really should be reading the research literature more or, you know, that sort of thing that there’s this, the shaming element to it. What do you guys think about that?  [00:16:51] Kate Grandbois:  I definitely think so. And that was a, it was a conversation that I had had with a PhD level speech pathologist that I was collaborating with. [00:17:00] Um, and she said, well, you know, SLPs just don't read the research. And I went, whoa, well, you know, there was a, that was a fast generalization, you know, there are a lot of barriers to being a working clinician. Um, and I also think there's a component of prestige. So it is more school. It's a lot more of a commitment, you know, it's a lot more money and time or time money as Amy always says one of the one in the same and you know, it's as a working clinician, you know, a lot of us, oh, what would it be like to have our name in print? You know, it would be so cool. There is, there is this level of prestige that it is a higher, more important job.  [00:17:42] Amy Wonkka:  I think too, for a lot of us, like our… Prior to this, my interactions with people who were researchers or faculty was in a power differential dynamics, such that I was there paying to learn from this [00:18:00] person who knew more and was essentially, you know, my superior in content. So I think that a lot of us who haven't gone forward, you know, into kind of the next step, like is kind of do view it as like a next step. If you're really serious, you go on and you do research or, you know, you get your doctorate. Um, you know, we still also carry that piece with us where like, that was the nature of our relationship. I mean, even now I have professors who have like, told me a million times, like you can just call me Michelle and I'm like, no, no, I can't actually, I just, that is just not how your brain is, how your name is coated, my brain, you know? So, um, I think that that's, that's probably a piece of it too. And as somebody who works in the school, you know, I think depending on your work environment, there's also even sort of cultural differences in judgments that other, you know, I'm, I think it's pretty common Kate and I met in outpatient. So I think we've both worked there so we can speak a little bit to like sometimes what happens [00:19:00] outpatient is you think that you're better than everybody who works in the schools, you know, so there's, there's a lot of differences that we can, depending on the culture of our work environment that we may internalize or externalize that may or may not be true at all. Um, you know, like I had through this, I've talked to a lot of people who are, who are in my mind, pretty fancy people and everybody's been lovely and generous and shared, you know, information. So I think some of this is also constructs that we build ourselves. And so that's something else for the clinician to be aware of. If there's a paper you want to read, email the author, they might just share it with you. Like,  [00:19:36] Kate Grandbois:  oh my God, every single author I have called through this project, I have cold contacted 10,000 million people. It's not even a number. It was a lot. Every single per every single researcher I've contacted is thrilled to hear from you. I can't believe you read my paper. I'm so happy to hear and they want to talk about it. So I think, I think Amy you're right. A lot of this divide or the, the height of the ivory tower to [00:20:00] continue with this analogy is fictitious it's, it's not really there, but it is part of a construct that we've either perceived or created. [00:20:09] Amy Wonkka:  And there are institutional barriers to which we're going to talk about more now, um, through the rest of this podcast. But I think at least a piece of it is, is what we carry in our own brains. And we maybe need to challenge that a little bit, all of us, regardless of your work environment.  [00:20:24] Kate Grandbois:  And I think that this is, you know, the whole point of this episode is really to untangle the complexity of the research to practice gap and identify these barriers and suggest some strategies. Um, and this is one of them, this perceived distance or prestige, or, you know, um, unreachable nests and, uh, exclusive club-ness of the research world. I think another piece of it is not really having a good understanding of what researchers do. So not all re you guys were both clinicians. So you have, you were working clinicians before you were researchers. So you have [00:21:00] visibility. I won't say the swamp of sadness. I will say the beautiful field in which we frolic with our clients and students that make you feel better Natalie?  [00:21:10] Natalie Douglas:  much better visual things. [00:21:12] Kate Grandbois:  There you go. So with Atreu, you riding the horse Atreyu through the beautiful field of flowers. So we don't really, as clinicians, we don't really know what goes on in the ivory tower. So can you tell us a little bit about. What shapes your job as a researcher. So when you're doing the research, are you thinking about the, the working clinicians or are you really tackling a million, other logistics, like grant writing and staffing? We don't really know what goes into you, into your work as a daily, your daily lives as a researcher.  [00:21:50] Cathy Binger:  Natalie you want to take that first or do you want me to take a shot at that  [00:21:54] Natalie Douglas:  I will take it indirectly because I think it really is a [00:22:00] fascinating question. And it gets back to what you were saying in terms of creating constructs in our minds that serve as barriers. So one example would be, I don't work at a research intensive institution. I still do research, but as you were asking that question, I was like, well I can't. I can't answer that. And you know, people at research one institutions, th they, they can answer that. And, you know, just so you know, I mean, even within academia and within institutions, you know, there are all kinds of situations. Just like what you mentioned, where it's like, well, here I am at Central Michigan University and I love my institution, but it's not a research one institution. And so  [00:22:54] Kate Grandbois:  I don't even know what a research one institution is.  [00:22:58] Cathy Binger:  Yeah. There's, it's called the [00:23:00] Carnegie rankings. Every university is ranked in terms of his level of research intensivity. That's not a word, but yeah. And even within that, even if you are like the University of New Mexico, is there a research it's an R one caused a research intensive university. Um, and it, it dictates things like what's your course load. Um, you know, what, what's your, what, how many courses do you teach each semester, each year? Um, so a university, like Natalie's in all likelihood, she's probably going to teach more classes a year than I am. Whereas my output in terms of a researcher, they're at a higher level expectations for the amount of output that I have as a researcher. So there's a whole construct within all of that. And even at the R1 level, like, yeah, well, you know, UNM is not thought of as a whatever, like, you know, I could list them, but I won't, you know, other universities that are seen as more prestigious than a university, like UNM. So even within the, like, we're [00:24:00] constantly, it's a thing that we do is as people is, we're just constantly figuring out where we are in the social hierarchy. We often do ourselves no favors with that.  I think [00:24:09] Kate Grandbois: So well put, so let's get into some of those details. So you're at a race, you're at an institution that designates X percent of your working life to research versus clinical versus instruction. How long does it take you? So here we are in the beautiful fields. The researchers at the beautiful fields, the bottom of the ivory tower, you guys are at you think up some clinical question or you're peering out at us through the windows of the terror. Oh, wait, that looks like a problem. I have a clinical question. How long does it take you to do the research? Like what is what isn't cause that's gotta be part of the research practice gap.  [00:24:49] Amy Wonkka:  Or even like, what is the action? Like what are your action steps? You see, you see Kate, so you see her problem. [00:24:54] Cathy Binger:  Yeah. So let's start. How about, um, the two [00:25:00] very different questions? Well, the two highly related questions, but Natalie, let's just start with the big figures. So you start with that and then we can get, talk about like answering some of these other questions. [00:25:09] Natalie Douglas:  Sure. So there was a kind of review of mental health and education literature that was published several years ago, but you'll see this statistic kind of being flouted about, I don't know, flouted is a word either [00:25:24] Kate Grandbois:  We’re making up words today go with it [00:25:28] Cathy Binger:  bandied bandied about,  [00:25:30] Natalie Douglas:  um, but essentially saying that it takes 14 years for 17% of research to reach routine clinical practice. [00:25:45] Cathy Binger:  Or was it 17 years and 14%, one or the other, fuck it up while we're chatting.  [00:25:54] Amy Wonkka:  It’s a team. It's the team. And that's a lot longer than one.  [00:25:59] Kate Grandbois:  That's [00:26:00] insane. I know, regardless of how those numbers, if those numbers. So basically that means that if you're a clinician working the research that's happening right now in the lab, down the street, isn't going to be implemented for between 14 and 17 years. [00:26:19] Natalie Douglas:  Right. Like less than a quarter of that research as well. Right. So like less than 25% of that research.  [00:26:28] Kate Grandbois:  That's insane.  [00:26:29] Amy Wonkka:  What about all the other percent? What happens to that research?  [00:26:34] Natalie Douglas:  It sits in journals that are expensive behind paywalls  [00:26:37] Cathy Binger:  that's right.  [00:26:38] Natalie Douglas:  But might've helped you get promoted.  [00:26:41] Kate Grandbois:  Oh, my God. Okay. This is like a, it says just problems on problems. Okay. So I'm in the, I'm in the grassy field with my clinical problems, right. You guys are up in the ivory tower. That's getting shorter as we talk about this, because there's really no tower. We've made it up. Okay.  [00:26:55] Cathy Binger:  And there's, God knows there's no ivory, which is a good thing. [00:26:58] Kate Grandbois:  Right? Exactly. It's [00:27:00] dingy. It's true. Whitewash. So, so you see the clinical problem. You try to solve it by, by asking the clinical question and you probably have grant funding and there's no guarantee that, that the, the answers that you get from your research are going to be actually disseminated and implemented by the clinicians. And even if it does, it's going to take 14, 17 years. [00:27:26] Cathy Binger:  Yeah. I think they figured it was 17. Not that that's accurate to begin with, but yeah,  [00:27:29] Kate Grandbois:  that's bonkers. So, so let's, so I have to assume that that 17 year gap. For you guys, you ha you see the clinical problem. You ask the clinical question, but like Amy said, what are your action steps? Like you have to procure it. Do you have to procure funding, writing grants, find a coauthor? Like, what are you doing? What's happening in there? [00:27:54] Cathy Binger:  What's wrong with us? [00:27:59] Kate Grandbois:   That’s not how I [00:28:00] meant it [00:28:00] Cathy Binger:  yeah. Um, yeah, so it, as Natalie started to sit was saying, it looks really, it looks somewhat different depending on the research institution that you're at, the, um, what kind of research you're doing. Um, when, well, let's just focus to make this simple. We're just going to focus on clinical practice research, which is its own thing. Um, and is a minority of the articles that get published are actual clinical practice research, right? There's a lot of theoretically driven research, which is not, you know, which is important as well, and can, can, and should change how we go about thinking about the, oh, go ahead, Kate [00:28:45] Kate Grandbois: . I don't even know what though. Can you explain the difference between theoretical research and what was it?Clinically  [00:28:51] Cathy Binger:  clinical clinical practice research  [00:28:54] Kate Grandbois:  clinical practice research [00:28:55] Cathy Binger:  the goal of clinical practice research ultimately from its [00:29:00] inception is to, um, learn things about and change clinical practice. It's really focused on clinical practice, but let's say for example, in my world, um, I have questions about how children go about learning language, right? Typically developing children or children who speak different languages. You know, maybe I'm a linguist and I want to know how does language work in this branch of languages versus that branch of languages. What are the common themes that run across language learning, regardless of what language a child is learning. There are pieces of things in there that can ultimately inform clinical practice, but it's a long way from studying, you know, languages, X, Y, and Z, and looking from a linguistics perspective to see what's similar and what's different to changing. How am I dealing with I'm teaching language to a child with autism who's sitting right here in front of me. Right? [00:30:00] So that's more theoretical research, but there may be pieces in there that eventually could inform clinical practice, Natalie? [00:30:07] Natalie Douglas:  Okay. Yeah. I just wanted to point out for a little bit more context. So Megan Roberts and colleagues, um, in 2020, they published an article where over an 11 year period. So from 2008 to 2018, they reviewed articles from all the ASHA journals. So that would be like ASLP, JSLAR the audiology journal and the language speech, and hearing services in the schools. And they had certain criteria, but they ended up with 2,483 articles and only 25% of them were clinical practice research. Meaning that the large majority of what's published in the ASHA journals does not meet that criteria that [00:31:00] Cathy was talking about in terms of being relevant to clinical practice  [00:31:05] Cathy Binger:  directly relevant to clinical practice. Kate, you're going to faint. I think I'm going to,  [00:31:10] Amy Wonkka:  she’s got a serious expression going on. [00:31:13] Kate Grandbois:  That's insane to me. So basically there are some, I'm making the assumption that there are some, you know, constructs in the research world through funding or different kinds of different kinds of, I don't know, incentive or interest where researchers are publishing research that just sits in the fancy expensive journals and maybe gets you promoted or whatever you said before. Is that, is that a fair assumption based on those numbers? Or have I misunderstood that completely.  [00:31:46] Cathy Binger:  Well, there are lots of people who are interested, I don't know about lots. That might be an overstatement, but, um, you know, people within a discipline and a subdiscipline are interested in learning about these things like are interested in knowing how [00:32:00] things work and the underlying mechanisms and, and all that kind of stuff. Like there are lots of threads and pieces that go into, uh, let, let me say, if I'm going to develop an intervention, um, I'm going to look not just at what is it that has been, um, already proven to work, but I'm going to look at what do we know about language development that might be useful for me to feed into this intervention? And so it's not, I don't want to leave the impression that that 75% of the work is garbage and we shouldn't be doing it anymore, but it's not directly. If it, it can and should in various ways inform what we do, but it's, it's a long and winding road and that's not enough. Like, I think Natalie and I are both, you know, happy to come forth, be forthright and say, and that's not where we live. That's not where she and I want to live as researchers. We want to live more in the world of, okay, let's get to the direct clinical practice. Let's get to the finding ways [00:33:00] to change, help change media practice. But, but that's the system in which we work and live is this 75, 25% split that that's happening. Um,  [00:33:12] Kate Grandbois: That is wild. I am shocked to hear this [00:33:15] Natalie Douglas:  Yeah, no, I agree. And I think to a certain degree, you know, um, we can both add this to a degree, right? So we need basic science. We need fundamentals, we need, um, mechanistic type work. Um, you know, we need that work. It needs to be done, you know, but I think what we want to hopefully call attention to as, just as Cathy said, is. This system has a lot of barriers, you know? And so from the clinician's perspective, you know, I don't know what we'll end up titling this episode, but another title [00:34:00] might be, you know, evidence-based practice gap. It's not your fault, you know? Right. You know, cleaning out, so many asks, you know, there's layer upon layer and we need that basic science, but we also need work that's going to systematically, you know, because the other problem is that, of that 25% of clinically practice, you know, clinically applicable research. And that's probably even a high estimate. We don't know that that's changing human behavior. Right. Even that 25% is getting into where it needs to be.  [00:34:48] Kate Grandbois:  I was just thinking about that. So I, you know, Amy and I are very familiar with the barriers on our end, at the, you know, in the field, but this is, and that's, that's astounding. I mean, I have a colleague who's [00:35:00] working in a school who has a caseload of 140. She's not reading research in her spare time. She's crying in a dark closet trying to figure out when she's going to do all her paperwork. Right.  [00:35:10] Amy Wonkka:  I also can't have Kate say this without saying advocate for reasonable working conditions, people, this is something that we need to do for our clients. [00:35:15] Kate Grandbois:  It’s nuts. So we have a massive amount of barriers, you know, aside from an I, I made a list here while we. While we were preparing for this. So we have time and workload and caseload issues. We, uh, maybe don't necessarily think it's that interesting. So this is what, this is what Cathy, you caught me doing flipping to the last page. Like, ah, I'm not really interested in the statistics. What can I take away from this and use it in my, you know, using my job. There's a lot of research is heavy with jargon and math that yes, I took research methods. I took it more than the average bear, because I had a second, you know, certificate educational training as a BCBA. So I've taken more of it than most people. And I still, I, I haven't used it in 10 years. It's not something that's [00:36:00] fluent to me. So I'm really overwhelmed by it. And I'm not going to spend the extra time trying to really digest it from a mathematical, you know, research perspective. Um, the article I was dying to find this one article recently in preparing for an episode behind a paywall, had to pay the journal 300 some dollars to get access to it, which is absurd. Um, I might be looking for an article for a student or client that's not even well-represented in the research that I'm reading. So then I'm trying to think about, you know, other ways to implement that the, the treatment that I want to do in a way that is congruent with the external evidence, but also with internal evidence in my own data collection, um, And, you know, we consume a lot of research as part of this podcast, and sometimes it can be really hard, even being more closer to it than the average bears. I guess women bears the, it can be hard to sort of quickly and easily translate that into clinical implementation. So here we are in the clinical field with all of these barriers. And now you're [00:37:00] telling me that in the ivory tower, where in there are all of these additional barriers, guys, this is nuts. This is a huge problem.  [00:37:10] Cathy Binger:  It is. And it's not an insurmountable problem. Um, so yeah, I mean, I don't want to belittle any of that. And as we talked about a bit last time we were on the podcast. It. Research articles, I'm talking about peer reviewed research articles that are in, you know, true, um, solid research journals. They're not written for clinicians. They're written to meet criteria of research rigor, right? They have to, they have to be conducted in a rigorous manner. Now what that rigor looks like is going to vary depending on the kind of study you're doing, right? What rigor looks like for a focus group study or a survey is very different. And those two things are very different from conducting an intervention study, right? All of those things, but you have [00:38:00] to, the rigor needs to be there so that you can have faith in the findings. Then what needs to happen is, which doesn't is not rewarded in our jobs in the way that, um, you know, in terms of getting promotion and tenure and that kind of thing is then finding ways to more effectively disseminate those findings in all the different ways that we could do that, whether it's, you know, social media outlets and other online outlets and clinical newsletters and all that stuff. So it depends on where your job is, how much those things are valued as a, as a researcher in what, how intensive of a research institution you're working at, how much credit you get for doing that kind of work. Um, so yeah, there's all of that. Um, but do you want to talk a little bit about, um, like what some of that day-to-day stuff is like, like how do we go about planning research projects and what kinds of things are involved?  [00:38:55] Amy Wonkka:  Yeah, because I think it would be helpful as a clinician. Like, I want to be able to [00:39:00] read your research and I have read your research and like take step away from it and like, trust it and say like, okay, they found that this worked. So there's at least a somewhat reasonable likelihood that this might work or, or elements of this might work for my client. I'm going to try it and feel more confident about doing that. Than like I saw this worksheet that my friend used, she liked it. I'm going to try that worksheet. Right. Like, so what do you, what are you thinking about and doing, that make me better able to trust what your information is telling me,  [00:39:35] Natalie Douglas:  you know, I think that is really, that's such an interesting question. And I think it really depends on what the question is. Right. And so. I can just kind of walk you through a little bit of what, you know, for as like a timeline of kind of how things have went. So part of why I went back to [00:40:00] school was because especially in the nursing home setting, I felt so extremely overwhelmed with not being able to provide people with what I thought were evidence-based practices, right? So that was like a major problem I had in my mind. And so my first study, my first kind of published study along that line, um, was my dissertation study where we looked at whether or not clinicians were able to implement external memory aids for people with dementia in nursing homes. So as the beginning step, the question that we asked was essentially, are you able to implement external memory aides for people with dementia. So this was a survey based study. This was in the state of Florida. And we basically found out that [00:41:00] no, no we can't. And so an additional part of that study was to look at barriers and facilitators as to why. So then we asked, well, why can't you, when people would say very similar to what you have said, time, they said there's not, productivity standards. Um, we might train the nursing assistant on how to use the external memory aid, and then they don't do it. Um, so then we publish that study and then my next study, after that was, well, we better talk to you certified nursing assistants and kind of see their perspectives on this. And they actually said the opposite. So nursing assistants actually said, you know, we would be happy to implement this therapy tool for people with dementia, but no one has ever trained us. Um, and so that was their perspective and perception. [00:42:00] So it's like the SLP was like, we train the CNA, they don't do it. The CNA was like, what? We would love to do it, but no one's training us. So there's kind of like, and so just between those two studies, I think was five years, which seems, I know that seems really wild, but like, are you asking the right questions? And you know, um, and then, you know, during that time I was working on designing kind of a collaborative coaching program between an SLP and a nursing assistant in a person with dementia. So we did like a pilot program to look at outcomes. Um, and then that was published, but that was like another three years. And then even like right now, the next step is to try to see if that, that little program, you know, it can be kind of scaled up in, we're looking at, um, six nursing homes now. [00:43:00] Um, so basically you have from, you know, 2009 to now, we're like halfway through 2021, and there's a chance that we might have found something that hopefully addresses the barriers identified at the level of the SLP and the nursing assistant, um, to improve communication for people with dementia, but that was, you know, like a 10 year gap and we're still kind of gathering data on that. And as we talked about earlier, you know, I don't have, I do have an element of research expectation, but I don't, um, you know, my next step would be to apply for federal funding. Um, all of my funding at this point has been foundation level funding. Um, but there are people who, you know, have to in academia that they have to have that level of federal funding or else they don't get to keep their position. Um, and [00:44:00] those are kind of more on a five-year cycle and that kind of thing. Um, Cathy's trajectory, I think a little bit more.  [00:44:06] Kate Grandbois:  Well, that whole process that you just described, first of all, that's a long time, right? That's definitely a contributing factor, but something that you said made me think of the, this part of the solution piece is I it's, I guess it's barrier and solution is this concept of dissemination. So, you know, as your planning, as the researcher moving forward with the, you know, the research rigor and making sure that it meets certain standards and moving the sort of moving the ball forward, to answer your clinical question, thinking about the last day, the last stop on the train is getting the information out there, right? It's disseminating all that information and. If either of you could talk quickly about what, you know, in terms of bridging this gap, it's not your fault or whatever the title of this is going to be. You know, [00:45:00] there are things that we I'm sure that we as clinicians can do when we can talk about that. But what are the things that researchers given all of those barriers, um, you know, can do? Or what are the, you know, I'm sure it's different in every work setting, depending on what kind of university you're in, but what is that last stop in the train, you know, train line, the dissemination station. What does that look like for you guys?  [00:45:28] Cathy Binger:  So there's an element of that. So, you know, again, depending on the university that you're at, um, what the expectations are. I feel looking at it more from a job driven kind of perspective, The peer review publication is usually the gold standard, right? Like that you've, you have conducted rigorous research and that you have completed your research project or components of it, and you are publishing the results of that in a respected peer reviewed journal or journals. Um, so that's really what counts in terms of [00:46:00] promotion and tenure, especially at the higher level research institutions right now, that's purely from a job perspective. Now, if you look at it from a, um, who we are, as people perspective, I think, you know, most folks who do what we do, um, certainly want to be informing clinical practice. Like we got into this because we want to be changing, helping to change and improve clinical practice. So then there are those other components to, uh, for example, you know, publishing things in places like this, uh, the sig newsletters. Um, which are often, you know, more accessible, maybe more widely read, certainly by frontline clinicians, um, other kinds of clinical newsletters. So that's a, still a reading sort of activity. Um, and then more and more, there's more and more focused on various social media, um, avenues. And that's the thing that I think we're going to be seeing a whole lot more of that there's also a whole science to dissemination that Natalie can [00:47:00] talk about and she knows more about that than I do. So Natalie, you want to add to that? [00:47:03] Natalie Douglas:  Well, it's interesting that you said that because as, as I sit here and reflect on this, I think for Cathy and I who have kind of been in this world, you know, trying to. Be part of the solution. We see a peer review publication as the starting line, right? Like, whereas like, I think in traditional academic settings, that's your finish line, right? Like, but you know, um, when we're thinking about dissemination, you know, and implementation, the peer, a peer reviewed publication is really only the beginning. Right? And so I think part of what we've hit on a lot of these issues in terms of dissemination, but, you know, we know that passive methods of dissemination do not [00:48:00] change behavior and we've seen that time and time again. So even if you're getting something into you know, perspectives or like a sig journal, um, a special interest group journal. There's, it's very unlikely that that's going to change your behavior. So what we need is to look at our audience a little bit more closely, and I think that's where there's multiple empirical questions that we could ask. So we could ask for one where our SLPs in these settings where we want the research to go, how do they want to get information, right? So what are their preferences and where are they already going? Um, if we look at some other fields, we might know that there are, that peers are really, um, popular place to get information. And that can be really good. That can be not so good. Um, we know social media [00:49:00] is another one, but I think as researchers, the more that we can. Get to know the audience, right. And figure out patterns in terms of not just at the individual clinician level, but what's a typical day, right? What are these, what's the, what is the organizational context where these services are being provided? Because unless you're in a private practice, your services are not being provided in a vacuum, but within another system. Right. And there's all the constraints at the level of the organization. So in terms of dissemination, I definitely think as we have talked about as much as we can have more open, open science, you know, and I think CSD disseminate is a, um, a volunteer organization that they're encouraging authors to provide preprints so that there's less of the paywall. So I think that a movement towards open science [00:50:00] is really part of it, but I think we need to take a more active approach. And even before we're studying, before we're answering our research questions, asking clinicians what they need, what are the problems? What do you see as solutions and really collaborating upfront. You know? So there's a, um, there's a term, it's a phrase, um, that the University of Wisconsin, Madison, they did a training on it, but it's designing for dissemination. And it was like D for D right, where it's like, if we want to have these, this, if we want the information to go where it needs to go, we gotta be engaging people actively from the beginning and encourage that participation. [00:50:53] Amy Wonkka:  When I think as someone who's read, you know, I mean, I work in a very like narrow kind of [00:51:00] lane of the field. So there are researchers whose research I tend to read. And so if I see that something has come out by an author, I will read it. Um, and I have noticed that same thing that you were kind of talking about earlier, Natalie, we're like, okay, so this is a study, but then the next paper they publish is kind of connected to that study, but a little bit different. Um, and you know, I wonder too, as a clinician, even if you guys feel like, like Natalie and your example, you're, you're trying to answer a bigger question. But for me, it's helpful. Maybe even to have some of that information before it's like, super-duper proven because you're still doing more controlling for those variables and you're in, you're still looking at it with a much finer lens than I'm able to do in my just like clinical practice level. Um, and I guess this isn't really, it's not even a question. It's just like a thought that like, it would be cool if there was a way for us to kind of promote a bit of dialogue around some of this in-process research. [00:52:00] Um, and maybe thinking about like, Cathy, you had said that, that like peer reviewed, you know, journal is sort of the starting point. I wonder if like maybe there could be like a parallel path that's sort of happening at the same time. Um, I dunno, it's, it's very interesting to think about how many parts go into what you guys are doing in terms of your research. But the time is long [00:52:27] Cathy Binger:  Oh, go ahead.  [00:52:28] Amy Wonkka:  No, I was going to come back to, like, in terms of our strategies, um, you know, we've, we've talked about reaching out to people we've talked about, not like living inside of your construct that you've built for yourself. What, what else, what else are we doing? You guys are making changes at the institutional level in terms of the types of research that you're conducting. [00:52:51] Cathy Binger:  Yeah. That's I mean, that's, uh, one of the initial questions that Kate, I think Kate had asked was at what point in the [00:53:00] process do you think about the end point? Who's the clinician and the answer is, well, it depends on the kind of research that you're doing, but for, for research, like the kind of research that Natalie and I do, it's, that's day one, you know, Uh, trying to think about what's going on at the clinical end point, at the very start of what we're doing, otherwise, what we get to at the end, isn't going to be clinically relevant and we're getting better at, and Natalie's making a career out of doing exactly that from the very beginning of being, you know, getting input from clinicians before we collect data. Um, before we, you know, again, not this old fashioned style of top down approach where, oh, I'm sitting in the ivory tower and I have a great idea and I I'm going to go get this sucker funded and go spend at least the next five years of my life working on this. And shouldn't you all be grateful but more, Hey, like we're all in this together. We want to make sure what we're doing [00:54:00] is ultimately having an impact on clinical practice. Let's talk with clinicians from the very beginning, um, of the conceptualization stages and bguild our research that way and build our research, hopefully collaboratively, um, et cetera. And, you know, we're, I'm newer, as much as that sort of approach has always been in my head. In reality, I'm newer to that approach. Natalie's really started off with that approach and it's really, um, I'm never going to do research the same way again, I shouldn't say never, like there are still components of projects that we have where it's still really valuable, um, to do certain things that are at that other not higher, just different level of research. That's more maybe somewhat more theoretical, like for, I'll give you a hard and fast examples as quickly as I can. We're working on some measurement work right now. We don't really have any AAC world when [00:55:00] children are using picture symbols to communicate. We do not have valid, reliable, developmentally sensitive and socially valid um, measures for tracking progress. Um, and so we're working on we're in the initial stages of, of working on developing all of that. Now, is that going to have an impact tomorrow on your clinical practice? No. Um, but it can have a long-term impact on how everybody is, you know, measuring things along the way. Maybe it's going to be more, primarily more researchers, but maybe there'll be clinically too, but that work still has to get done. Um, there needs to be some input from clinicians on all of that, but it's a little bit different from doing an intervention project, right? Like if I'm doing an intervention project and developing interventions, then that's the kind of project where from now on, I need to be tapped in from the get-go with, depending on who my audience is, parents [00:56:00] teachers, educational assistants. You know, what have you, um, along the way, so there's still room for both, but we really want to be focused with certainly with certain projects, with getting input from the very beginning, from clinicians, et cetera, clinicians, families, et cetera,  [00:56:20] Kate Grandbois:  while you were talking, it was making me think of, you know, thinking of myself as an, as a younger also, but greener clinician, um, and where I got my information. Um, and I think. One thing from a clinician's perspective, that is, if anybody, you know, assuming that there are clinicians listening is making sure that we're being wise consumers of information. Um, you know, there are a lot of barriers to reading research as we've, as we've discussed. And I think the social component, like you said, a lot of people get their information from peers. And I don't know if it's the, the invention of social media that is different from when I [00:57:00] was first practicing, but there is so much misinformation out there about, or, or twisted information or diluted information. There's just, I think we need to be, um, as clinicians and people who are working in the field of science need to be informed consumers of the information that we see and skeptical of the information that we see, um, and then combine that with other sources of easily consumable information. I mean, I think, you know, if you guys are branching out from, with implementation science and all of, you know, all of this things that you're doing in the ivory tower, that's not so big and it's not so white, your other room, your other parallel field, I'll call it that over a bridge. Maybe that's a little more like friendly. Um, you know, if you're building a bridge from one side, I feel like there are things that we can do from the other side as well. Amy, I don't know if you have any other brilliant. Lots of brilliance that you always do.  [00:57:57] Amy Wonkka:  No, I think you oversell me. You're [00:58:00] overselling me. No, I think that, um, you know, it's it, I think that it's helpful as a clinician to know that there are all of these different pieces that are involved in research. And to know, like there actually formerly are different types of research and we do still want you guys to be doing all of those types. I want to know about typical language development. I want to know all of that information because that should also inform my practice as well. Um, and you know, in, in speaking with both of you, I think that having that awareness and maybe feeling a bit more comfortable, being able to reach out and have those conversations is like an actionable step that everybody can sort of take right now. [00:58:46] Kate Grandbois:  I think, you know, we've, we've, we've covered a lot in this episode. Um, I think everything from examining our own internal biases and our thoughts and feelings that we might have about relationships [00:59:00] between about the research to practice gap, realizing that we're all part of organizations that, and and systems that have implicit biases and constructs that are barriers that we may or may not can't, we may or may not be able to control. Um, and I think honestly, knowing that there are researchers out there, like you guys who are doing this great work in trying to, first of all, who are willing to talk about these, have these difficult conversations about bias and do it with a little bit of laughter on top of it. And, and, and acknowledging that this is a problem because you can't fix it if you don't know that it's there. Right. And doing that kind of research that tries to build that bridge and extend it is, is such a, is such a critical piece. So, um, thank you so much for everything that you do, and we're very grateful that you are willing to come on here and, and talk about these kinds of things that you're doing, the kind of research that you're [01:00:00] doing. Um, and I hope that everybody listening has acquired some appreciation for what it is to be a researcher and all the barriers that you all face. And knowing that there are a lot of people who are working to close the research to practice gap, um, to the best of our abilities, given the different barriers that we face in our setting. So thank you again for coming on and sharing all of your, all of your wisdom with us. Um, Do you have anything to say?  [01:00:27] Amy Wonkka:  It's not an ivory tower. It turns out it's just been two fields all along. It's just two fields connected  [01:00:33] Cathy Binger:  by right across the bridge.  [01:00:34] Kate Grandbois:  That's great. We're going to have to like you so much get like a cartoon or something drawn of this at some point. Um, so if you're still with us and you would like to use this episode for ASHA CEUs, you can do so at our website, www.slpnerdcast.com . If you have something to add to the conversation, you can email us anytime at info@SLPnercast.com . If you feel so inclined, please feel free to leave us a review [01:01:00] on your podcast player. We love hearing from our listeners and that pretty much wraps us up for today. Thank you again for joining us. And we hope everybody learns something. Thank you so much.  Thank you so much for joining us in today's episode. As always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count for professional development in your area of study, please check in with your governing bodies or you can go to our website, www.SLPNerdcast.com . All of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com . Thank you so much for joining us, and we hope to welcome you back here again soon. Another big thank you to our corporate sponsors Vooks who helped to make this episode possible. 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This is a transcript from our podcast episode published March 14th, 2022. The podcast episode is offered for .1 ASHA CEU (introductory level, professional area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. [00:01:38] Kate Grandbois:   We're so excited for today. We get to welcome back a repeat guestthat we always have so much fun with. Welcome Natalie Douglas.  [00:02:13] Natalie Douglas:  Hello. I'm so excited to talk with you again.  [00:02:17] Kate Grandbois:  Um, the last time that you were here, I think we had a moment where one of us screamed scurvy, which was like the most fun I think we have had on this podcast. Maybe not the most up there. It was great. So I can't wait to hear what you're going to teach us to say aside from scurvy. [00:02:36] Amy Wonkka:  I think, I think outside of scurvy, it's sounds like you're going to talk to us a bit about communication and life participation. We're super looking forward to, um, before we get started and for our listeners, um, who haven't met you before, can you tell us a little bit about yourself?  [00:02:56] Natalie Douglas:  Sure. So I am Natalie Douglas. I'm on the faculty at [00:03:00] Central Michigan University. I'm also an editor at the Informed SLP. And my biggest interest is in trying to merge the gap between research and practice through implementation science. Um, clinically, most of my work now is in quality of life and communication interventions for people with dementia in long-term care environments. So sometimes that's assisted living, sometimes skilled nursing facility. Um, I do have a bit of a clinical background. I worked for about 10 years in between masters and PhD in hospital settings, outpatient, a little bit of home health. So. That's kind of me in a snapshot.  [00:03:46] Kate Grandbois:  I love that you have that, um, that chunk of clinical experience prior to your doctorate. I know in a previous episode you told us a lot of anecdotes about the real working conditions of a clinician, um, and how the [00:04:00] research to practice gap is so completely apparent when I believe your story was something. Why would you read an article when you can't even find a dry erase board, but marker for your patient. And you're running around focus on that for 15 minutes, you know, the, the life of the real working clinician and the barriers that we all face. So your perspective is always so unique and we're really excited for you to teach us about this. Um, and as our listeners know, we know very little about this  [00:04:27] Amy Wonkka:  and just a plug for our previous episodes on implementation science, uh, which is a fascinating area of the field that I knew nothing about, um, prior to having those conversations with you. And it's, it's really interesting. And the idea of bridging that research to practice gap, uh, I think is such a huge, important thing for us to know about as a field.  [00:04:51] Kate Grandbois:  You're here and we could get on a soapbox about that, but we won't, I'm going to redirect, redirect us over to our learning objectives. [00:05:00] Um, so before we get into all the fun stuff and before, um, Natalie teaches us everything, I do need to read our learning objectives and disclosures and ask for me to skip this part. I can't ASHA make me read it. So please hang in there. I will get through it. Please describe elements of implementation, practice, that support training formal and informal carers and techniques to support quality of life and to make you bring it back. Learning Objective Number two is that case studies highlighting evidence-based approaches to manage, communicate this patient for a person with dementia, Learning Objective number 3 summarize studies, summarize strategies to position LPs as key members of the healthcare team within the skilled nursing facility loaders. Dr. Natalie let's receive a salary from central Michigan university and informed SLP. She also receives book royalties from plural publishing and has research funding from the American speech and hearing association. Douglas has no non-financial relationships to disclose consultancy and co-founder of SLP, nerd caps, nonfinancial disclosure, and the number 12 and serve on the AEC advisory group from Massachusetts advocates for children. I'm also a member of the Berkshire association for behavior analysis and therapy, mass ABA association for behavior analysis, international intercourse on Expedia speech and [00:06:00] applied behavior analysis special interest group [00:06:01] Amy Wonkka:  Amy that's me. I am an employee about the system and my non-finance disclosures that a number of ASHA SIG 12, and I also serve on the AAC advisory and massachusets advocates for children Right. We've made it through the dragons. How about you start us off by telling us a little about the first learning objective. And can you say a bit about care partners? I have to say, I'm not sure about the difference in care partners formal versus  [00:06:23] Natalie Douglas:  informal, right? Right. So a couple of key points to that. Thinking about somebody living with dementia. Along the same lines as a caregiver, but the idea was that you were parked at somebody who might just still have some level of dignity and autonomy and choice, as opposed to only the one to eight relationship of giving care. And so you can think of informal,  and formal care partners as kind of like unpaid to a degree, right? So the majority of dementia care in the United States, which costs billions of dollars annually is actually unpaid care, um, provided by [00:07:00] family members at home. And then we have your partners who are either through home health agencies, certified nursing assistants, um, direct caregivers who provide, you know, toileting feeding that type of care that they're paid for, um, activities either in a home health environment or skilled nursing assisted living those types of environments. [00:07:18] Kate Grandbois:  I know the term care partner also leads to me, interpreting it. Think of the, I guess, informal care partners. It implies that the caregiver is also experiencing components of dementia. At least when I think of it that way, because this is this disease has a really big impact on families, on quality of life force and those kinds of things. It's not, uh, like you said, it's not a unilateral relationship where persons just giving care and the other, person's just receiving the care.  [00:07:47] Natalie Douglas:  Exactly, exactly it. Dementia, it affects everybody the entire, you could, you know, even at a systems level two, you've got one maybe adult son or daughter [00:08:00] and they're local, and then they make certain decisions. But then an out of town, um, son or daughter might come in for a visit and kind of switch up those decisions. And you know, this is, it's just, there's a lot of complexity in terms of how dementia really impacts the whole family, friends, everyone.  [00:08:21] Kate Grandbois:  Um, so now that you've sort of laid out this, this more preferred term is more dynamic term and explain difference between formal and informal care partners. How does this relate to implementation practice and science? [00:08:33] Natalie Douglas:  Right. So if you think of implementation science as the study of which strategies can support evidence-based practice uptake, right? So implementation science is really thinking about what do I need to do to really get a practice that I know works scientifically into the real world. And that has inquiry in [00:09:00] terms of scientific study. The implementation practice. I've actually only learned about in the past couple of years. And so listeners that are really interested in this, I would bet you, they call he's essentially it’s saying if we will be able to teach in a best practice, we do have fights, but we also have to have the press. That's what we do all the time as speech, language pathologists, right? We're constantly juggling that line between the science or the internal evidence and then the realities of clinical practice. And so one of the resources that they put out, these folks who are studying and really exploring implementation practice, they have six, um, principles that kind of underlie implementation practice. So I don't know, or six domains, if you will. I don't know if we want to go over all of them or not, but I can [00:10:00] just preview it.  [00:10:02] Kate Grandbois:  Yeah. Give us a snapshot because I'm not, I'm very unfamiliar with this term, so yeah. Very interested. Yeah.  [00:10:09] Natalie Douglas:  Okay. So the first domain is being the first principle is being empathetic. Hello. We already know about that. Being curious, being committed, advancing equity, using critical thinking and embracing cross-disciplinary approaches. And like, none of these things are new there.  Kate Grandbois: I love this.  Yeah. They're all things that we do as clinicians all the time. But I think to see it laid out with this implementation lens, you know, it is extremely helpful, but one of the main, um, aspects of this is you co-create and engage from the beginning [00:11:00] in order to sustain change. Okay. So this is less of a top down. I have this information and I need to, from on high, put it down onto you. Right, but it's more of a, we're all in this situation, learning together. And we're kind of co-designing yes. Informed by evidence and the science, but we're also tailoring this to the context, if that makes sense. And we're making those necessary modifications.  [00:11:37] Kate Grandbois:  And can I say this back to you in case just as like a, to help digest that, because I think what you said was so obvious and, and something that we all do, but also it sounds like it's a little bit more complicated than that. And, and it, it sounds a little bit like a framework for how to go about implementing. Science or [00:12:00] implementing your knowledge. And I know Amy and I, we both love a good framework, but it helps give a little bit of structure to what you might already be doing. And when something has structured, you have footholds to implement it better or implement additional components that you might have overlooked. Is that the right sort of landscape? [00:12:20] Natalie Douglas:  It really is. It really is. So how they have it listed it's they, uh, Mets and colleagues it's called the implementation support practitioner profile.  [00:12:31] Kate Grandbois:  And we'll link this in the show notes for anybody who's out there running, driving, or what have you all of this will be in there. [00:12:36] Natalie Douglas:  Awesome. And so if you're guided by these principles of empathy, curiosity, commitment, critical thinking equity and cross-disciplinary approaches, it suggests that we co-create and engage. That we participate in ongoing improvement. So it's not a situation where we're like, okay, here it is boom. We're done [00:13:00] sign off. Right. But we're continuously monitoring either the client or the practice or whatever it is. And we're continually making these, these tweaks, knowing that we work with human beings within human systems. And so that's constantly going to require adaptation and change, and then it gives some suggestions for sustaining change. Right? So it's like, now that we maybe have seen this change happen, how do we do it? And no shocker to the two of view. I'm sure the main way that you do that is through growing and sustaining relationships. Right? And so I think when it comes to dementia care, this I've found this. So. You know, illuminating because it's like nothing works in training, any care partner without the foundation of that relationship. Right. And so, [00:14:00] yeah,  [00:14:00] Kate Grandbois:  I also just want to highlight that the first thing, the first component here is empathy. I mean, that really just reframes your knowledge to be focused on person centered care, Crip, client centered care, considering client and family stakeholders and values and empathy and making that connection with them. And that's, that's the first thing on this list, which is really wonderful. And just as a reminder to everybody listening, you know, client perspectives and values are part of our evidence-based practice model. We often get really hung up on evidence being a research article or this component of extra and evidence. And yes, that's important, but considering clients and patients and values is also creating an, an evidence-based practice environment. So I love that. I love that that's listed first because I think we, as a field, tend to lose sight of that sometimes, and really get really hung up on our knowledge on our external knowledge. [00:14:59] Amy Wonkka:  [00:15:00]Yeah.  I agree with your take on that completely. Um, and I think it also highlights, first of all, I'm like ready to go out and read these things. Cause this sounds like something,  [00:15:11] Kate Grandbois:  um, that furiously taking notes over there [00:15:13] Amy Wonkka:  I know I'm like don't open the article in the middle of the report, but I do, you know, I think it is it's sometimes we get a little tricked and feeling that like we know the one best right answer for other people. And Natalie, I feel like you did a really nice job. Just talking about how that's, that's actually a conversation and the one best answer. Isn't something that you can just duplicate and apply. To all of your clients who present as XYZ because they're part of a human system and you call the human family system. Um, and we all are, and, you know, having the empathy, like you were saying, Kate being curious about your client and their care partners [00:16:00] and what their values are, uh, is going to help us provide more meaningful and probably more effective therapy.  [00:16:06] Natalie Douglas: Yeah, absolutely. You know, and I think that I learned that as a practicing clinician, just feeling very burnt out and sad and like, I wasn't really helping anyone. And part of the situation was I was working PRN and I think a lot of people work PRN in skilled nursing facilities because it works really well with the schedule. And, um, but I would come in, you know, I would pick my kids up from school. And then I would like get them situated and go in for a few hours and then be done. And being there for those like three or four hours, I wasn't able to build the relationships that I needed to anything that I wanted to implement. It [00:17:00] was just extremely challenging to build that without that those relationships. And it was hard for me to provide a communication strategy, if you will, or a memory support, if I didn't know, okay. What's this person like during the day, what is the nursing assistants take on this? What is the most burdensome communication breakdown for them? Um, and those things were kind of absent. And I think sometimes that can be a really big challenge when we're thinking about people with dementia. If we don't have a picture of what's going on all day. Um, and I imagine it's probably pretty similar with a school caseload too.  [00:17:47] Kate Grandbois:  Yeah. I mean, I think no matter where we, as SLPs work, that, you know, workplace barriers and time restrictions are always a thing in terms of, you know, how we communicate with our colleagues, but also having access to [00:18:00] families, having access to home life, having access to and time built into our schedules for consulting with the families. Um, for, I mean, I, I have to imagine that counseling is also a massive piece of, of, you know, working. I've never worked with an individual with dementia, but, um, You know, counseling families who are grieving, who are going through this incredibly complex, challenging time, arguing with their brother in Idaho, who made these decisions when they were here for Christmas or whatever. I mean, there's a lot to unpack in these very complex situations. Um, and you know, we've said it on this podcast a thousand times before we don't necessarily get training in counseling, we don't necessarily have funding for indirect service. Most work settings don't have indirect service as a norm or even built in as an option. So in everything that you're saying, in terms of the skilled nursing facilities and the PRN schedules, [00:19:00] those are massive barriers to be able to adequately support these families. If some of the first things we need to do are established relationships.  [00:19:09] Amy Wonkka:  So to piggyback on, on that point, how, how do you integrate those elements of implementation practice and how might that change the way your training of the care partner looks? So the difference kind of between training without integrating those components versus kind of a more informed approach to care partner training [00:19:34] Natalie Douglas: . Right. And so I can answer the latter part in thinking about what I had to do, which was a lot of handouts. A lot of do this. A lot of, we need to, you know, do this type of strategy, kind of catching the nursing assistant, you know, wherever they were and trying to, you know, when they're obviously still so busy and overworked and [00:20:00] we're actually recruiting for a study right now. Um, we're, we're trying to study if there's a way to do this. So we're, um, therapists who, speech paths who are working at Encore rehabs, or, um, have a partnership with them where we're looking at. Um, I have a kind of dementia care partner training, CNA certified nursing assistant program that we piloted, but it, but in this new iteration, we're trying to layer in some of these principles of implementation practice to see if that matters, if it makes a difference. Um, so, and to see probably more importantly, is this an acceptable and feasible thing to do on the clock? You know, when you're working.  [00:20:54] Amy Wonkka:  So, is that an example of implementation science right there.  [00:20:58] Natalie Douglas:  Yeah, [00:21:00] it is. I mean, it's not done, we're trying to do it, you know, but, but I think the engage, you know, the partnership, right? The is part of implementation science, the collecting the data in the real world and having the, so in some care partner training studies, what they'll do and you know, it's legitimate, um, is you have an interventionist come in, right? So you have like a special research employee of the grant, you know, that's funded by a grant and they deliver the intervention. So in this scenario, it's the person that's already working. That's having to balance all of these situations and it's a mixed method study. So. You know, if the SLP is like, I can't do this, you know, the study isn't over. It's okay. Got it. Why, why can't you do this? Tell me what's going on. [00:22:00] Let's try to problem solve this. And I'm hoping that we're going to learn, um, a lot.  [00:22:07] Kate Grandbois:  That sounds incredibly interesting and also like a lot of work. So hats off to you for taking on such a robust project. Um, I'm thinking about our second learning objective and the and evidence-based practice approaches to managing communication. But before we get there to sort of set the stage, I wonder if you could just talk to us generally a little bit about components of supporting quality of life and communication for persons with dementia. [00:22:37] Natalie Douglas:  Right? So I think a person living with dementia, like. Every human being. They want a reason to get up in the morning. They want to have purpose and engagement, you know? Um, they don't necessarily, I mean, do you want to go play bingo every day? Right?  [00:22:57] Kate Grandbois:  It's a rhetorical question and not very [00:23:00] helpful. I apologize. I see your point. I do not want to go play bingo every day [00:23:03] Natalie Douglas:  Right. But I mean like, yeah, if that's your own work to like listen to like a person with questionable talent sing in the hall, you know, um,  [00:23:17] Kate Grandbois:  you know what I'm thinking of? I'm thinking of my in elementary school, we had to go sing at the nursing home a couple of times a year that's it's and it was our talent. It was my questionable talent. Me you're talking about it. Isn't it. They don't want to come in here and me sing. Or my kids. But to your point, you're right. I mean, they're, they're still human beings and they have interests.  [00:23:37] Natalie Douglas:  Right? Exactly. So I think one of the ways that we can best support, and this is supported in the literature as well, is to really get to know the person and to figure out what makes them tick. And if it's not something that maybe is within their wheelhouse right now, what is it that they used to love to talk [00:24:00] about? What is it that they used to do and what can we do to modify that or to set up the environment in a way so that that can be supported. So one example I can give is, um, we had, I have a student and part of what they work on for their, these are undergraduates is they are communicating with someone with dementia, a couple of hours a week as part of a service learning course. And so the student came and she was like, you know, I can't get this person to talk. It was a person, you know, in their eighties in a nursing home with Alzheimer's dementia. And she's like, he just kind of sat there and, um, just kind of awkward and, you know, so I'm like, well, what, what, you know, is there anything, is there anything about him that, you know, you know, and so sometimes that can be hard as you talked about access to family and access to interests, you know, but she happened to [00:25:00] see, um, something that had the Detroit tigers on it. And so I'm like, what about making, you know, a memory book of just some famous Detroit tigers players and some photos. And I'm like, I have no idea who the Tigers players are, but, you know, so she went in, she just had some type of, um, external item that they could kind of go through and it's like, oh, look, it's the baseball, you know, it's, um, you know, having that communication support and you guys know all about this, this is your area, right. Um, we can do that in a very low tech way. Um, but it has to be something that the person cares about. It can't be a random conversation topic, you know? So I think by cultivating interests, based on the person that can really support [00:26:00] quality of life and communication. And then the other thing is giving someone a meaningful role. And so we even try to do this in skilled nursing environments. And a lot of this comes from the Montessori for aging and dementia approach. So you might've heard of Montessori for kids, but there's a whole, um, study of Montessori for people with dementia and aging, where it's, you know, maybe I used to love to maybe I was a home, you know, I worked at home. So now we're going to have that person fold the towels, you know, in the, in the long-term care community. And that's going to be her role. Maybe I love to talk to people, but I can't remember anything. Well, I'm going to go pass the mail out to people, right. And that's going to be my role. So we can find ways to support engagement, really authentic and not[00:27:00] kind of a contrived activity. If that makes sense.  [00:27:03] Kate Grandbois:  I love the word authentic. I love it. I think it nails exactly what it is you're trying to do because there are components of what we, I think sometimes feel we have to do in therapy that are so contrived and that we, we do our best to make them fun. Right. We do our best to do, to be engaging, but it's sort of, it's exactly what Amy said before. It's not for us to decide it's for the person to decide. Um, and I know that can be tricky when you're working with someone who has a communication disorder, but that's, your job is to find something that's authentically enjoyable. And I think that's the best, the best, the best adjective that you could use there. No question. [00:27:45] Natalie Douglas:  Yeah. Yeah, we got to keep it real. They know. I mean, you might lose your memory and you lose skills, but you know, when things feel yucky, right. And people [00:28:00] with dementia, they don't want to be quizzed or, you know, feel like they're taking a test, you know, or feel bad about themselves. And sometimes these more impairment based activities can do just that with good intentions. But there are better things that we can do. I think  Amy Wonkka: so for the,  [00:28:19] Kate Grandbois:  oh, go ahead.  [00:28:22] Amy Wonkka:  I was just going to say that from a, from a quality of life standpoint, nobody wants to feel like they're failing a quiz all the time. So it makes sense that if your therapy activities are too deficit focused and it seems like you're making your client feel badly, you should probably pause and rethink how to, how to do things a little differently. [00:28:42] Natalie Douglas:  Yeah.  [00:28:43] Kate Grandbois:  So as the implementation science expert, I'm going to, I'm going to give you the crown, you're the queen of implementation science here at nerd CastleVille nerdcast central for all of the PRN SLPs who are listening, [00:29:00] who have these realistic workplace barriers, who are there for only a small number of hours a week. What are some practical, what are some practical things that they may be able to do within their workplace restrictions to make these connections to, um, I don't know, implement some of these evidence-based ways and overcome the hurdles that they, that the job just inherently has. [00:29:26] Natalie Douglas:  Right. I love that question so much. And I think the first thing I would say, the first thing I would say is recognize that you are working in a broken system and you are doing the best that you can. And you're, this is not about a failure on your part. It's just not like the restrictions that you're experiencing in terms of time and productivity. It's not your fault, [00:30:00] you know, and I think, I mean, I, it's, it's an impossible system to work in, in a lot of ways, you know? Um, so practically speaking, I would consider it skilled therapy, time to interview that person and get to know them because not everybody can do that. Right. That takes the skills of a speech language pathologist to dive in deeper and do. And you can call it dynamic assessment. You can call it informal assessment. Um, but using your skills as an SLP, to really deep dive into who that person is. And I would also use your skilled billable time to make those memory aids and [00:31:00] supports in the presence of the person with the person.  Kate Grandbois:  Love that idea. Natalie Douglas: Yeah, that's not my I, so this is Becky Khayum’s idea. With memory core and cognitive concierge. And she's one of our, um, she's a colleague and a friend of mine. And, um, she's like, you know, cause the productivity is a major issue, especially in skilled nursing facilities. And so it's a skilled service, right? Because maybe you're, you're, you're getting personal information and you're using that to tweak your external memory aid or your communication to support. Right. And so you're, you're trying it out. You're and you know, one of the things that she recommends, if you don't have, um, a huge budget, which not many people in snfs do is to ask your rehab manager to get one of those portable laminators, um, they're only like 50 bucks. And then. You know, with [00:32:00] all the other equipment that PT and OT have, it's a pretty reasonable request. And then you can, um, print and make some memory aids and trial them out, you know, as part of your session. Um, so that might be some practical tips that I hope, you know, might facilitate that.  [00:32:19] Amy Wonkka:  So in talking about these memory aids, I feel like you're leading us right into our second learning objective, talking about some case studies that highlight evidence-based practice approaches to manage communication in life participation. So I don't know if there are there other, there are other evidence-based approaches that we should be aware of? [00:32:39] Natalie Douglas:  Right. So I think that, you know, external memory aids and supports, we have the most evidence for that, you know, in terms of dementia, I think another really high impact, high evidence practice is environmental modifications.[00:33:00]  So what can I do to make the environment more conducive to communication? So this might look like simplifying the environment in terms of not making it too cluttery. Um, if you have an external memory aid, a lot of what we do in some of the buildings where we're implementing Montessori is we'll put the external memory aid in a frame. So it'll say like, please enjoy, um, the music, right? And like, it'll be like a memory that says that right next to some type of music player. Right. So they might be, oh, oh, look at this. I can. And it might be new every time and we don't expect the person to remember that. Um, but if it's a designed memory aid that is clear, you know, they're going to get that cue, you know, getting rid of clutter, labeling things like labeling the toothpaste, [00:34:00] labeling the soap, um, not having a bunch of like, you know, different chotchkies in various places. Um, so that things are nice and, um, clean, you know, one of the things that, um, we did in a community that we were working in was, um, there was this beautiful bay window and one of the, um, people with dementia, she loved to look outside. There was like a bird house and it was so nice. And wouldn't, you know, if somebody went and brought in this like nasty, fake plant and it like took up the whole window. Right, right. I don't know, but I took it and I put it in my car. [00:34:55] Kate Grandbois:  The plant thief! It was the brother from Idaho wasn't it. That's who it was. It was [00:35:00] right. But it's like, sorry to all of you in the Idaho.  [00:35:03] Natalie Douglas:  Sorry, Idaho. Um, yeah, but it's like, when you think about setting the environment up for communication, her looking at the birds and looking at the flowers outside, that's an opportunity for communication. Right. And so having that blocked, you know, and then we would even put a cue there that says, please enjoy looking outside. Oh, that's right. I love to look outside. You know, I love to watch these birds. Um, so I think external memory aids, the environment, training, communication partners, and care partners, and also. Instructional techniques such as errorless learning and spaced retrieval training can really support outcomes related to safety related to even swallowing strategies that a person with dementia might have. Um, and [00:36:00] other kind of key pieces to support engagement.  [00:36:05] Kate Grandbois:  What's a spaced retrieval strategy? [00:36:08] Natalie Douglas:  Oh good. I was hoping you would ask that. So if you, um, if you Google health professions press spaced retrieval training, there's a little four-minute video that, um, Jennifer Brush and Jeanette Benigas and Gail Elliott made as a companion to the resource spaced retrieval training. Step-by-step it's essentially you capitalize on the preserved procedural memory of a person with dementia. And this means I might not be able to tell you with my words, how to make a cup of coffee, but if you put the coffee filters, the [00:37:00] coffee in the pot and coffee was something that I made every morning. There's a very good chance. I can just walk up to the coffee and start doing it right now. What spaced retrieval will do is it targets one specific area of interest. So I'll give the example of, if you wanted to train someone to use a call button before they got up out of their bed, if you wanted them to call the nurse with the button, instead of just getting up, because maybe they're at risk for falling. Okay. So if I were to do spaced retrieval, I'd say, Hey, Kate, what do you want to do? What do you do when you get out of bed? And I, and then I would say you hit the call button. Okay. And then I would maybe take your hand and I would show you the call button and you would hit the call button. Right. And then [00:38:00] like one second later, I would say, Hey Kate, what do you do when you want to get out of bed? You hit the call button. Right? And so then you would say, I hit the call button while you're hitting the call button. Okay. If you didn't, if you weren't able to answer me. Right away then after a few times, I might say, okay, Kate's not really a candidate for spaced retrieval training. It's almost like a built-in screen, but if you were successful and you repeated me and you were able to do the action right away, I would wait two seconds. And then I would ask you again, and then if you were successful, I would wait four seconds. And then I would ask you again, and you can kind of go all the way up to like 15, 18 minutes to where ideally I might say, I might go and see some other clients and then come [00:39:00] back a few hours later and say, Hey, Kate, what are you doing when you want to get out of bed? I hit the call button. Right? And so it's one of those things where it's the opposite of what we think. With our typical speech therapy services in that we shouldn't expect it to generalize to other topics. Okay. So it's very situation specific. So if you want to train something using space retrieval, you only do it one at a time until that information is learned. [00:39:38] Amy Wonkka:  And in this example that you gave us, it involves a motor movement. Does it always involve a motor movement or could it be something else?  [00:39:46] Natalie Douglas:  Yes. So there have been studies where it's used for other things like, you know, important names, um, you know, names of loved ones, things of that nature. In my experience, I [00:40:00] find that it's, it is much more effective when you have a motor movement. The other way that we use spaced retrieval is as an instructional technique to attend to an external memory aid. So a lot of times people will say, you know, I put up signs, I put up cues and they don't look at them. Well, that's part of our skill set as well. Right. We have to train them how to use it. So it's like, what do you do when you want to know the schedule for the day? I look at my calendar. What do you do when you want to know the schedule for the day? I look at my calendar, right? So you can use it. I think it's more effective, especially in people with dementia when you're pairing it with a motor movement or when you're referring to some other type of support, like a memory aid. [00:40:52] Kate Grandbois:  That makes a lot of sense. Just that interaction between the environment, the movement. Making it a multi-sensory multifaceted learning [00:41:00] experience. I mean, we know from so many components of literature that that's a critical component of learning is making it more dynamic, engaging all of those things. So that, that makes a lot of sense. Are there any other evidence-based practice approaches that you want to go over before we start talking about, um, SLPs as key members of teams?  [00:41:22] Natalie Douglas:  You know, I think if you think about, if you, if we come at this from a person centered lens, and then we're thinking about creating, you know, from our instructional perspective, like the instructional techniques that we use in people with dementia, they, it really should be errorless learning. And like, if we don't, if the person is making a mistake at all, even once we got a backup and do something else, like it has to be totally successful because people with dementia are going to continue to lose [00:42:00] cognitive function. And so it's not a situation where it's like, okay, my goal is to stop this person from using cues, right? Like you want them to use every possible cue. And so if a person is making mistakes or not getting it, then we need to switch what we're doing or add more supports or something like that. So I think thinking about person centered, this external supports, an environment that supports communication and meaningful engagement. I think those, you know, that will go a long way.  [00:42:37] Kate Grandbois:  And my mind, you just painted a Venn diagram with these three circles and sort of like living somewhere in the middle of those, depending on patient specific variables and idiosyncratic changes that need to happen and stuff that was very eloquent.  [00:42:53] Natalie Douglas:  Yay. You're, you're just very kind, you know, eloquent coming out. [00:43:00]  [00:43:01] Kate Grandbois:  Well, considering I started this episode talking about how I wasn't going to scream scurvy in your face. I'm glad I've upped my game since the last time you were here. Um, so let's think about, and want to sort of paint a broader, broader strokes picture really quickly. So we're thinking about SLPs, who might be listening, working as, uh, in a PRN capacity with numerous hurdles to implementing some of these things, needing to have a focus on person centered care, considering these components of implementation practice. I think that the workplace setting, as we have said multiple times is such a real barrier. And I think your third learning objective really starts to get at that in terms of workplace settings and the team that you work on and how the SLP can, knowing this information that we've gone over really advocate to become a key member of the healthcare team and how that might impact some of [00:44:00] this work you're talking about. I wonder if you could tell us a little bit more about that.  [00:44:03] Natalie Douglas:  Right. Right. I think that by finding out, you know, what are the pain points of other people who are working within the community? So for example, what is the physical therapist trying to get the person with dementia to do, right? And so maybe we can do a memory support for hip precautions or fall precautions. Maybe we can use spaced retrieval to train the person to lock their wheelchair breaks before they get up. If that's a goal that the physical therapist has, or, you know, what is occupational therapy doing? What activities are they wheeling them down to? You know, what are the, um, activities assistant, what are they taking them to and how engaged are they? [00:45:00] So is there something that we can do that's kind of within the routine or the program of events of that person that we can help support? Right. So it's, we're kind of showing our value by saying, okay, look, they were just coming to activities and they were just sleeping the whole time. But yet we could say that they were in the activities room when really. There's a way that we could support that. What is a pain point for the nursing assistant? Is it getting dressed every day? Is it eating? Is it something that happens at night? Right. So I think by inquiring about what's hard from other staff members can really show our value, um, because we can make it easier for [00:46:00] everybody, because I think with people with dementia, the fundamental problem is the lack of ability to communicate. Right. And so when we have these things that people call behaviors. Right. Um, they're really responses, right. They're attempts to communicate, right. So when Mrs. Smith starts screaming in the hallway and crying, um, how can we attend to the emotion that's underneath that and validate where she's at and support. Right? So I think that a lot of times we're tempted in that setting to kind of just go in and get our minutes and get out. I mean, that's what I did. And a lot of cases, there's absolutely no judgment there. Um, but I think if there's any way that we can get the [00:47:00] bigger picture and make our plan of care somehow related to other aspects of the person's care, It can really show the value, like when we can open up communication for someone who's really struggling,  [00:47:18] Kate Grandbois:  you know, what, something that you just said reminded me of, um, we had Dr. David Luterman on as a guest, uh, what a ways back and for anybody who's listening, who hasn't listened to that episode, um, it's on counseling and he talked about responding to the subtle, the subtle knocking, so what is the underlying emotion? What's the underlying feeling and responding to that instead of the screaming, instead of the crying and trying to lead with empathy and respond to that subtle knocking. And I think he credited that to maybe Carl Rogers. I can't remember off the top of my head, but references there. And I think it's such great, great advice. [00:48:00]  [00:48:00] Natalie Douglas:  Yeah, I was going to tell you that I had my, um, counseling students this summer. That's how we started. The first day of counseling class was listening to that podcast  [00:48:11] Kate Grandbois:  So good to hear! He's amazing.  [00:48:15] Natalie Douglas:  It was awesome.  [00:48:17] Kate Grandbois:  I, you guys there for that, I was there for that interview and I've listened to it like three or four times. I made my husband listen to it. Really. He was really he's just so influential.  [00:48:29] Natalie Douglas:  Gosh, he's so dang wise,  [00:48:32] Kate Grandbois:  anyway, this is the first time we've gushed about a previous episode on the current episode. So that's a first, it's always, always exciting with you, Natalie, but I mean, but responding to that, that pain  [00:48:44] Natalie Douglas:  what's underneath? Exactly.  [00:48:47] Kate Grandbois:  It's that subtle knocking. Um, and for anyone who doesn't feel like they have it in their skillset or wants to learn more about counseling, I definitely, we all encourage you to do it. It's a key component of what we do as SLPs and we just don't get enough [00:49:00] training on it, unfortunately.  [00:49:01] Amy Wonkka:  And I feel like just to cycle back to the first learning objective, that's also got to make a difference in our client's quality of life.  [00:49:10] Natalie Douglas:  Absolutely, absolutely. You know, and I think one of the things that implementation practice has really challenged me on is trying to engage with direct care providers, you know, so in this case it would be certified nursing assistants. How do I engage with them in a way that is authentic and meaningful and real? So we already have a huge pay gap between what an SLP is making and what a certified nursing assistant is making. They're there, you know, cleaning up puke and blood and wiping butts. Um, and we're seeing the person for maybe 30 minutes, right? There's already [00:50:00] some perceived imbalance there. And so how do we kind of enter into what the nursing assistant has to do and engage in a way that would be meaningful? To the nursing assistant and the person with dementia and to us, because then we can see that we're really making a measurable difference. [00:50:27] Kate Grandbois:  I also, I feel like this is related to another topic that's come up recently here related to something totally unrelated to snfs, but that's bringing humanity back into therapy. So, so being a person showing up at work as a person, trying to make those connections with your colleagues, trying to make those connections with your patients when you can. And I mean, to your point, we've all just shown up at work just to get the hell out of there. I mean, that's part of being a human and there's no judgment there at all. But I think when, when you're a clinician working [00:51:00] in environments that where there is grief and there is pain and there is vomit or blood or something that is, you know, evokes an emotional reaction, it's impossible to just clock in and clock out every day. There is some component of humanity. That we need to embrace in our clinical work to improve the lives of our coworkers, our patients, and establish, I love how you've wrapped this up in establishing us as team members of the team, because there are workplace politics involved in humanity too, which is crazy. We don't think of it that way, but it's true.  [00:51:35] Natalie Douglas:  It really is true. And I will never forget. One of the biggest learning experiences for me was I was working with a nursing assistant and it was hard to connect and sometimes it's hard. Sometimes it's hard to connect with other humans. And, you know, I was asking her, you know, if she could use this communication strategy and I think the person had [00:52:00] swallowing strategies and she was just kinda like, yeah, yeah. Um, and I don't know how the topic came up, but there was a lice outbreak. Okay. And like, My kid had lice. Her kid had lice. Somehow that came up and I'm telling you, the moment of connection was so real. And it just was able to dissolve all the barriers between us. And I know that all three of us, the person with dementia, her, me, we all had a better day. We had a better outcome over this horrific thing that I hope never comes in my house again, it was a human, it was that humanity moment that you speak of.  [00:52:54] Amy Wonkka:  But hopefully folks will find something a little less intense than lice [00:52:59] Natalie Douglas:  a little less [00:53:00] invasive you guys can't see my hair. Yeah. I have a lot of hair curly and it's just like a lice field day in there. Yeah.  [00:53:11] Kate Grandbois:  I mean, but, but really, I mean, we talk about this as part of, um, in your professional collaboration that ASHA has really embraced. So, you know, having a focus on interprofessional education and interprofessional partnerships, um, it's something that's defined by the world health organization. It's something that's very real. It's not just making buddy buddy with, with your, with your coworkers. I had a mentee say to me one time, but I don't want to be friends with them. And I want to be friends with this person. And I had to sort of back up the train and, and highlight that this isn't about friendship. This is about positive working relationships and being, you know, showing up with professional maturity, showing up with humility and being a person, being a person and not a jerk. And everybody's allowed to be a jerk sometimes I definitely am [00:54:00] sometimes. Um, you know, it's, it's, it's, it's a thing. Um, and I, I, again, just bring this back to your learning objective. And I love that you did this. I think this is so brilliant, is that when you do that, when you embrace these qualities, your work environment, it will improve. There will be a ripple effect there. It's not just to be, you know, hokey pokey with everybody and sit around and give each other hugs all day long. There are actual realistic and logistical positive outcomes that will come from embracing this, this kind of team environment and person centered and humanity centered care. [00:54:38] Natalie Douglas:  I think so. I really think so.  [00:54:43] Kate Grandbois:  I think so too. [00:54:48] Amy Wonkka:  Are there any other strategies beyond being a human, being a friendly person, trying to actually identify the barriers for your colleagues and coworkers and work to support your client through [00:55:00] navigating those barriers? I'm thinking, you know, as someone who does partner training type tasks, you know, is, is there also this piece of be cognizant of how much work you're asking other people to do or any other. [00:55:15] Natalie Douglas:  Gosh yes. So much, so much yes Amy. Yes. Like so one example, um, that we use a lot in training, our students and other, you know, clinical fellows is I, I personally, I have learned that I, I don't want to give a nursing assistant something else to do, unless I'm willing to take something off of their plate. So sometimes I will say, you know, sometimes, I mean, sometimes, I mean, I'm a big advocate for cross training of everybody in the building when we're talking about a skilled nursing facility so that everybody can take [00:56:00] people to the bathroom. Everybody can take, you know, the transfer with, you know, with supports and of course there's training that's required to do that. But if I can, maybe I can go take this trash out. Maybe I can help make the bed, even if I'm not trained so that you can do this. Right. So it is more reciprocal. So not putting on the burden of more work, unless we can take something back because it's just not, it's just not feasible to add more to someone's workload. [00:56:36] Amy Wonkka:  And I almost wonder if that helps with the relationship piece, because it breaks down some of those kinds of hierarchical pieces too, of like, well, I don't, I don't do, I don't do transfers that, uh, I don't know. [00:56:45] Natalie Douglas:  That’s right that’s right. Exactly. And I know some people are constrained because like they're not chained and they're truly not allowed to do transfers or, you know, bathroom, different pieces, [00:57:00] different rules. Yes.  Amy Wonkka: Safety first, for sure.  Natalie Douglas: But if you can, you know, even if it's not a transfer bathroom, if it's a little thing like passing a tray, you know, or something that doesn't require training to kind of show  Kate Grandbois: comradery.  Natalie Douglas: Yes, exactly. Yeah.  [00:57:18] Amy Wonkka:  You could ask about training perhaps, you know, it, depending upon the management, like, it's, it doesn't there that requires training doesn't mean you couldn't ask about the training because we're sort of asking everybody else [00:57:31] Natalie Douglas:  that's right. Amy Wonkka: To want our training  Natalie Douglas: that's right,  [00:57:38] Kate Grandbois:  exactly right. How completely condescending of us to expect other people to be, to get our training. If we're not going to help you make the. That's not very nice. So in our last, in our last minute, I'm just thinking of people who might be listening in these positions, who are, have like listened to [00:58:00] all of this information over the last hour. Do you have any advice, any parting words of wisdom or advice for clinicians who either want to learn more about implementation practice or want to acquire more knowledge in this area, um, or, or anything? [00:58:19] Natalie Douglas:  You know, I would, I would only, my biggest piece of advice is probably to continue to care for yourself if you can. Um, this is such a high need high, you know, it just, it takes so much, it, it requires so much. And if you can, um, care for your, for yourself. And, you know, it's just so critical and I am so happy to, you know, there's a community of people that are really passionate about improving dementia care in these settings. And if there's anything that any of [00:59:00] us can do, I mean, I hope that you really will reach out. Um, of course there's books and articles and blah, blah, blah. Um, but not that those are bad, but, um, if you want to brainstorm something, you know, we're here, this is, this is what, this is what we do. But, you know, recognizing the work that you're doing in caring for yourself,  [00:59:21] Kate Grandbois:  that was really good parting words. I don't think I can follow anything up. I don't think I can follow that, Am?  [00:59:27] Amy Wonkka:  no was good. If, if, if we don't take care of ourselves, we burn out and there's no one, there's no one to do any of that helping.  [00:59:36] Kate Grandbois:  Thank you so much for being here today. You're just so full of wisdom and we learned so much from you every time you're here. So thank you so much for, for being here and for your time and all that stuff.  [00:59:47] Natalie Douglas:  Well, I'm so grateful to be here with all of you. There's only two of you but,  [00:59:53] Kate Grandbois:  there's so many people listening though, right? I mean, yeah, we hope we hope for all of the [01:00:00] things that we talked about today, there will be links in the show notes. So if you're driving, running, um, everything will be written down. There are references resources and links. There's also a link in your podcast player to earn ASHA CEUs if you so choose. Thanks everybody for being here. And we hope everybody learned something.  [01:00:19] Natalie Douglas:  Thank you.  [01:00:20] Kate Grandbois:  Thank you so much for joining us in today's episode. As always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count for professional development in your area. Please check in with your governing bodies or you can go to our website, www.SLPnerdcast.com . All the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com . Thank you so much for joining us and we hope to welcome you back here again soon.  Another big thank you to our corporate sponsors med [01:01:00] travelers who helped make this episode possible. Our corporate sponsors keep our CEU prices low and our program ad-free med travelers is your industry leader for exclusive allied health care travel opportunities. Med travelers has benefits like higher earning potential W2 employee status, and a flexible schedule. Visit med travelers.com to learn more. Med travelers did not participate in creating the contents of this episode.

This is a transcript from our podcast episode published March 1st, 2022. The podcast episode is offered for .1 ASHA CEU (introductory level, professional area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. Kate Grandbois: We're so excited for today's episode. I know I say that every single episode, but today Amy and I are welcoming a dear friend who we've worked with for a long time. And before we introduce her, I want to tell a little story. You can see everybody's look, we're in a zoom room. Everybody's looking at me. Of course they are. But the little story is in, oh gosh, I think it was 2000. It was over 10 years ago. It was over 10 years ago. We were attending a talk, Amy, do you remember this? And then we remember this cause we just talked about it. We were attending a talk about executive functioning and this woman, Beverly Montgomery was doing the talk and I was completely floored by how much knowledge she had, just so intelligent, so eloquent, so respectful and answering people's questions. It was one of the best talks I've ever been to. And [00:03:00] I made her be my friend and Amy made her be her friend. And so we're so lucky to have her here today to talk to us about collaboration with mental health professionals. Welcome Beverly,  [00:03:11] Beverly Montgomery:  thank you so much. I'm so excited to be here. This is a big treat for me. So thank you.  Amy Wonkka:  This is a very nice way to end the week  [00:03:20] Kate Grandbois:  and for dealing with that very long intro, that was quite personal. Maybe what you weren't expecting. That's okay. We'll move on.  [00:03:30] Amy Wonkka:  Beverly you are here to discuss various aspects of interprofessional collaboration within our field. Specifically the SLPs role in the area of mental health. Before we get started. Can you just tell us a little bit more about yourself?  [00:03:44] Beverly Montgomery:  Yeah. So I am not actually super involved in mental health, per se. If you look at my kind of job description, it's not that I work in a specific clinic or hospital, it's just that to do my job, um, I have found that [00:04:00] this type of collaboration is essential. So, um, I started off with a team approach because I was in the public schools for about 10 years, um, in a district-wide program as the speech pathologist, and then, um, had two kids and began my own private practice and decided to focus just on what I'm most passionate about, which is social communication and cognition and executive functioning. And right now that private practice is Let’s Communicate in Lexington. And, um, I absolutely love what we do.  [00:04:31] Kate Grandbois:  You're so passionate about what you do. And I have reached out to you so many times as a colleague in the area, looking for guidance and advice, and you're always so generous with your time and knowledgeable and answering all of my potentially annoying questions. So I'm so excited to take your knowledge and share it with whoever is listening. And before we sort of jump into the, all the fun stuff, I have to read our learning objectives and disclosures. So I will try and do that as quickly as possible, a learning [00:05:00] objective number one, state the purpose and benefit of interprofessional collaboration. Learning objective number two, define interprofessional education and interprofessional practice. Learning objective number three, describe a decision-making process for when and how to make mental health referrals. And learning objective number four, identify a variety of collaborative partners, both within and outside their organization. Disclosures Beverly Montgomery's financial disclosures. That really is the owner and operator of Let;s Communicate. Beverly's nonfinancial disclosures, Beverly has family members with diagnoses discussed in this course and has a professional bias towards integrated collaborative social communication treatment. Kate Granbois financial disclosures. That's me. I'm the owner and founder of Grandbois therapy and consulting LLC. And co-founder of SLP nerd cast. My non-financial disclosures. I'm a member of ASHA SIG. I serve on the AAC advisory group for Massachusetts advocates for children. I'm also a member of the Berkshire association for behavior analysis and therapy, [00:06:00] mass ABA, the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis, special interest group. [00:06:07] Amy Wonkka:  Amy that's me financial disclosures. I am an employee of a public school system and co-founder of SLP nerd cast. And my non-financial disclosures are that I am a member of ASHA's SIG 12, and I serve on the AAC advisory group for Massachusetts advocates for children.  All right now, to the exciting stuff, Beverly, why don't you start us off by telling us just a little bit about this first learning objective? What are some of the benefits for an SLP who's collaborating with mental health professionals?  [00:06:37] Beverly Montgomery:  Well, first I think number one, you can feel good that you're just doing your due diligence and following the ethical mandates as set by ASHA and other organizations. Um, it's, it's a mandate that ensures that you're providing the best possible care. And I absolutely couldn't do my job without this kind of collaboration right now for my current [00:07:00] caseload. I probably am collaborating with 15 to 20 different professions. And a lot of those are in the realm of mental health. Um, I think that if you are treating anybody who is a child and you have family systems things going on, you have grief. You have, um, co-parenting conflict going on. The, if you have, or if you're treating voice, if you're treating, um, you know, anybody with fluency, if you're treating anybody in geriatrics, in a medical setting, cancer, I actually can't really think of a setting where you would be isolated from the need to, um, reach out to a mental health professional at some point, because we can't operate in a vacuum. Right? So communication is by nature, social enterprise, um, which means that it has to do with our relationship with ourselves, but also our relationship with other people. And as soon as you've got both of those [00:08:00] things at play, I think mental health is going to come into the picture at some point. We also know that people with emotional and behavioral difficulties are hugely underserved and underdiagnosed when it comes to speech and language difficulties. So, um, there's also a very good chance that someone who is being seen by a mental health professional as their primary provider in fact has a challenge that would fall under our scope of practice. There was a meta analysis that was done that suggested that 81% of individuals with emotional behavioral disorders have at least below average expressive language abilities, if not language disorders, we've also seen really disturbing studies come out of, um, juvenile detention centers and things like that. So we know that this is an area where a lot of times, because of behavior or things, um, language disorders are being [00:09:00] misdiagnosed and missed and when they come to us and they already have a mental health concern, we can't really treat without understanding where their treatment journey has started. So that's another reason to collaborate. [00:09:14] Kate Grandbois:  That makes so much sense. And it's reminding me a little bit of some of the things we've talked about in previous episodes related to counseling and how we don't necessarily get explicit counseling as speech pathologists, but, and I'm literally quoting David Luterman here. And what he said in a previous episode with us is so much of what we do is grief work. And without the direct training to provide better counseling service, I have to imagine that engaging in some of this transdisciplinary work, when you are collaborating with a mental health professional, to either help you with those skills, provide you with those skills, train you in those skills, give you a referral is a critical piece to bridge that gap between the work we [00:10:00] need to be doing and our own competence in this area. [00:10:03] Beverly Montgomery:  And I think that, you know, we'll talk about this a little bit later, but I think that that's a really key indicator for a referral is if you feel like a significant amount of the work that you're doing with your client or patient or family is mental health counseling, instead of, you know, within the scope of practice of speech pathology, that's a great time to get a second opinion. You know, there is so much gray area, no, especially when it comes to the type of work, um, that many of us do in terms of identity and in terms of social and pragmatics and, um, you know, fluency and how people see themselves. And then the coping mechanisms we develop and the anxiety and depression that often go with those that it's, it's really hard to know, you know, where those lines are. And in my experience, they're very very, you know, gray it's, it's not a [00:11:00] clear picture. And one of the ways that I have found to be most effective in making sure that I feel like I'm operating a hundred percent within my scope of practice and expertise is by having that discussion with a mental health provider who will then say, Nope, that's not what I do. Or, uh, yes, that sounds very much like what I do. And I can take on this part and then you can take on this part and we'll work together on where they overlap, which to me, as a clinician feels much better and less overwhelming than feeling like it's all on my shoulders. Another great David Luterman point is just that, you know, a clinician who needs to be needed is setting themselves up for trouble, right? And our goal as clinicians is always to not be needed. And if I'm feeling like as I'm working with someone they're needing me more and more and more and more, that's another good sign that it's time to bring in another provider. I think another reason to do this is because our jobs are really hard [00:12:00] and no matter what setting we're in, there's not enough time to do what we're expected to do. The, I think the biggest barrier to doing this is time and funding, right? You know, indirect service doesn't get funded, um, in the same way and tracking down people, making phone calls, setting up times to talk. Those are all things that we're not given time to do no matter what our setting is. What I will say is that the amount of time I spend in the effectiveness of my treatment is absolutely proof that it pays off and it's worth it because I save more time in the end with that collaboration, just because I'm so much more focused in my treatment because of it. And because I don't spend the hours and hours researching and doing things to make sure I'm doing things right. If I'm worried that there is this kind of counseling piece that I'm addressing  [00:12:53] Amy Wonkka:  well, and we've talked a lot on the podcast too, just about the idea of us having a scope of practice. And then within that scope of practice, [00:13:00] we have our own scopes of competency. And so I think you brought up a lot of really good points. Like sometimes it's very clearly just not even within our scope of practice. Right. And there may be times where some of the work you're doing could be in your scope of practice, but it's not in your scope of competence. Um, and so. We're big proponents of collaborating with other professionals so that our clients get the quality service that they need. Can you talk to us a little bit just about interprofessional education? An interprofessional, I think that that's going to help us talk a little bit more about kind of what this looks like and how you may collaborate differently with different mental health professionals. [00:13:39] Beverly Montgomery:  Yeah. A lot of the collaboration I do is not even kind of, um, direct consultation regarding an individual student. So what it might be is more what would be considered interprofessional education. So that's the IPE part, which the world health organization defines as activities [00:14:00] that are two or more professions or professionals from different fields coming together to learn about, um, learn from, and learn with each other so that there can be effective collaboration and, um, outcomes can be improved for the individuals and families that you serve. So I do a lot of that when it comes to the social work that I do in terms of not as a social worker, but social cognition and social communication work that I do because a lot of. People in the mental health field, don't understand why I'm seeing people to work on social and I'm seeing them individually. And so there's a lot of education that goes on about how, you know, it, it could be that if I'm working with someone, for instance, who's really struggling with impulsivity that having them with peers that may be reactive to that impulsivity may not serve them best in learning the skills they need to then be successful with peers or that, you know, if anxiety is a major issue, being in a group with other dysregulated [00:15:00] individuals that have similar challenges might not be setting that individual up for success. So on the surface, a group might be the recommendation, but you know, after a discussion that professional might say, you know what, actually individual would be great because that would be starting from success. They do really well with adults right now. So if we could build the skills they don't have starting from that point of success, then we could work them into a group. Oh, I see what you're saying. And then they can help me figure out. Okay. So what does set them up for success in terms of challenging them? You know, like what are the motivators for this individual or, you know, a lot of what we get into with individuals who've have a history of social challenges is there's a lot of shame. And, you know, a lot of times I don't recognize that that's, what's at play. I had a little guy in my office and, um, he had a super hard time with a game and it turned out it was because he had played that [00:16:00] game two years ago in school and kicked a peer. And there was a lot of problem solving around it and he was still feeling so much shame about it, that just seeing the game on the table really dysregulated him.  And my framework for behavior is much more in terms of looking at what the antecedent was like when he's like walking into the room. And I wouldn't have known the two year antecedent piece that would have helped inform how I responded to that behavior. So that education piece is really important. Um, another huge piece is psychiatrists and medication. So if you're in long-term care, this is a really, really big one. Um, understanding what medications your patients are taking and how that impacts them. And, you know, may even be at the level of like a chemical restraint at that point. But a lot of the school age, people I see are on medications that are off label for them that have side effects that impact [00:17:00] their functioning across the day. I absolutely am not up on medications that are coming to market and I'm definitely not up on off-label use for prescription medications. Um, so I really look for help. And get a lot of help from, um, psychiatrists in that area. So those are, that's kind of a little bit more around like the education piece. The, uh, IPP is the interprofessional practice. Um, which again, if we use the world health organization definition, that's where you're having people from different professional backgrounds, um, kind of as a treatment team. So, um, people are providing a comprehensive healthcare or educational service by working directly with individuals and their families. So that's more of what you might see in a school or hospital setting where you've got a multi-disciplinary team of providers that are all working with the individual. And so really your [00:18:00] collaboration is around that individual versus around, you know, Tell me about what Ritalin does when taken by somebody with really high anxiety. Right? In one case, I would be asking you about a specific individual and the other I'm seeking to understand a little bit more, what stimulants do to somebody who's stimulated by anxiety.  [00:18:22] Kate Grandbois:  I think that discussing medications and with our students and clients is so critical and something that I'm not sure is discussed often, at least not in the works places where I've been, unless there's, you know, a significant change in medical status where, oh, it's, this is new information, but some of our students and clients maybe, maybe have been on medications for a long time or the information isn't forthcoming from the caregiver or parent. And it can have such an impact on communication and alertness and fatigue. And. Everything. I had a student whose [00:19:00] medication was making them really thirsty and they started having some toileting accidents because they were so full of water all the time and using, needing to use the bathroom more frequently, but their communication system was not set up. So they weren't asking for the bathroom. And all of a sudden it became this huge problem, but really stemming for the medication. The educational team attempted to address this from an educational lens at first, before, and I think maybe like a whole week or two went by before it was like, oh, there was a note in the L in the home lab. Oh, by the way, we're going to see so and so for all the, all the urination and all the, the, the thirst they have pervasive there is. And it was because of this medication. And as soon as the medication got changed, it was no longer an issue. But just thinking about the educational resources, the clinical resources that went into this, and if we ha, you know, by some miracle had different workplace restrictions or a different workplace settings, and more open channels of communication [00:20:00] with mental health professionals, medical professionals, so much of what we do, it's sort of like we're in the dark with a flashlight, but we need a floodlight to sort of see some of these other variables. I wonder if you have any thoughts or suggestions around communicating with mental health professionals, particularly I think psychiatrist is where they, where my head is that because, or where my question is coming from, because they can be very difficult to get a hold of not only that, but as SLPs, depending on our workplace, we don't necessarily have, you know, just the 30 minutes to burn in the middle of the day where maybe we can make a phone call. I mean, do I need to make comments about how we're being told to cry in our car? Probably not, but I just did anyway. I mean, we just don't have the time. So when you start talking about these critical conversations with mental health, it seems like it's even more insurmountable. I wonder if you have any thoughts or suggestions on that?  [00:20:56] Beverly Montgomery:  Yeah. So as school based setting, it [00:21:00] can be really hard, the medication piece, because, you know, unless the medication is administered at school, we may not even know. And that's true obviously in private practice too, in the sense that it is, you know, up to the parents to disclose the medication piece. Although I think it's, there seems to be more of a barrier between, um, parents and school-based providers sometimes then, um, private practice just because they're not individually selecting those providers they're assigned to them. So in that case, the school nurse can be a really good advocate for you and help you with that. And what you can do is just jot down three or four words that you're noticing during your session that either seem off or different. I've seen kids with, you know, definitely hunger and thirst differences because of medications. Um, definitely behavioral changes, definitely things like ticks throat clearing, like a horse, a raspy quality to their voice fatigue. You know, there's lots of things. If it seems off for what you are used to for that given [00:22:00] individual, and you're seeing it across more than three or four sessions, then it, it bears, you know, investigating. And, um, if you can ask the nurse, if they're aware of any medications that the student is on, very often. what I find is that if I don't have more than five minutes, and if I have one question for a psychiatrist and it's about a medication that's specific to their client, not that I want to consult with you about X student, they usually find a way to make that five minutes for me. And neither of us has more than five minutes to talk. So, um, you know, I think if usually with few exceptions, They have actually been very appreciative because it's not necessarily something the parents have seen because they're not seeing them in that setting. They're not seeing them consistently at that time of day it's information they don't have. So, um, you know, if you can make it very focused to what they're providing for your students and keep it really short and sweet, I have [00:23:00] found more success, but if not, then having the school nurse reach out through the pediatrician can also be a really good way to go. Um, and then you kind of get the communication through trickle down, but the point is you're still getting the answer to your question.  [00:23:14] Kate Grandbois:  I love that suggestion of going through the school nurse.  [00:23:17] Amy Wonkka:  I also, you know, I think it's, I think it's always an interesting conversation that's worth having and the separation that we sort of do in our culture between like physical health and mental health. And I think the medication is a really interesting example of where something that we may be doing. Something we've sorted into the mental health box affects something in the physical health box, but ultimately the more information we have to, whatever degree is necessary for our client and like, based on their preferences and their family's preferences, if there are pediatrics, um, in terms of what they want to share. But that, I mean, that is going to help us, depending upon what our collaborative goals are, you know, what their goals are, what we're all working on together. [00:24:00] Um, and so just having an awareness of all of those things, just like we want to know, we want a recent audiogram or hearing screening, or we want to know, you know, what's going on with somebody's visual system. Those are all going to affect what we're doing and how we're presenting information in therapy. I dunno. I think it's, it's an interesting thing that we do here to, to separate those things out and make them very separate and different. [00:24:25] Beverly Montgomery:  Yeah. And I think it's a challenge, you know, that we're, that we all have to deal with. I think the other, the other piece is that if you are coming from a truly curious and student or patient centered place, and you are asking a specific question based on your observations, that does not communicate judgment about whether or not there's medication involved, that's going to lead to a much higher chance of success than if the parents feel like this is a litmus test as for whether or not they're doing the right thing for their kids by medicating or not medicating. I cannot [00:25:00] prescribe medication. Therefore I have no opinion on whether or not you should be giving your child medication. What I can tell you is what I have seen through my clinical practice and what research tells me about medication. So, you know, that is my answer to parents is that, you know, what I can tell them is what I have seen and what I've read and, and what we know from the science. And then, you know, ultimately my job is to support them as parents, but whatever choice they make, the reason I need to know is X. And when I, again, I'm very specific about the types of things. Parents aren't necessarily aware that something like hydration and a 30 minute session would matter. Right. Like, why would it matter if they're more thirsty? They have a cup on their chair, so why does it matter? Like it's not their job to know what I need in my session. And so again, the more I can keep it very specific and focused to why I need to know versus asking a broad question. Like, does the student take any [00:26:00] medication? The more likely I am to be successful and communicate to the parent that this is a treatment oriented question and not a, um, judgemental or, or booby trap kind of question. [00:26:13] Amy Wonkka:  I think that's such a good point. And we've had speakers on before who have made the point that like, we don't necessarily need all of this nitty gritty information about people when we're doing an assessment or something like that. We don't need to find out the intricate details of what a family does in terms of medication or different things like that, unless it's relevant to our treatment. And by having a conversation about why and how it's relevant, that's going to help us with the families. But it's also going to help kind of circling back to our first two learning objectives, like in maybe the interprofessional education that we're seeking out. If we have a lot of questions about medication and how that might be affecting our clients and all of these different ways like that could be, maybe we go to a talk on that. Maybe we listen to some [00:27:00] pharmacology podcasts and try and make our way through understanding. Yeah. But we're looking for that information. Outside of our field, but to inform our practice within our field, um, you know, it brings us back to the recommendations around evidence-based practice. Part of what we're doing when we're doing evidence-based practice is we're formulating that clinical question. And so we may be wondering, geez, I have a lot of people on my caseload who might be taking a medication. I want to know, maybe I want to know what types of medications are more likely to result in X type of effect on my client, because I've seen these different things. So that would help us pursue that IPE piece. And then the interprofessional practice is more what I think of when I think of interprofessional collaboration. I think about that like collaborative team and part of that's probably just places where I've worked in my professional experience. Um, but that might help ask, help us, like better collaborate with those members of the teams as well. I had questions [00:28:00] about, so if you have that team in place, then we know how to like form those thoughtful questions for those people. But what if you don't have that team in place, but you feel like maybe you should. [00:28:08] Beverly Montgomery:  Yeah. So I think, um, One of the, uh, this is going to obviously depend on who the person is. So I'm going to start first because I tend to see more pediatric clients than adults. I see both, but I have more pediatric clients. I'm gonna start there and then we'll, we'll switch to adults. But I think for pediatric clients, you start with the parents, right? And the, and the question there that we might have is, you know, you do need to know if there's other providers. And again, the more you can tell people why you need the answer to a question when you ask the question, the more freely they may be able to give you the answer. So for example, when I say, I want to make sure that, you know, my treatment approach is consistent with other providers. Are there other providers that the individual is seeing and then, you know, obviously they would need to [00:29:00] sign consent for you to communicate with those people. One of the reasons why I have a social worker on staff is because I feel like the vast majority of my caseload, which are usually people who have been unsuccessful other places and have been labeled as difficult or too complex or a mystery or whatever else. That's kind of how they usually end up on, on my doorstep. And at that point, you know, a huge amount of those individuals need two services. And so you, you build the team because you see a need for it. And that can happen either through, again, going back through the pediatrician. Their school systems often have, um, you know, uh, contracts with, um, mental health search providers so that they can call one number and then that individual helps them find somebody who takes their insurance. And, um, and then, because you've kind of been on the journey with them, they're much more likely to share that information when they find a [00:30:00] provider with you. I have a lot of mental health providers that refer to me because they get the individuals and they realize this actually isn't a mental health concern. It's a speech and language challenge. So it goes both ways. Another way that you build that is by being interested. So when you get a neuro-psych report, if there's a significant portion of that report, that's addressing a mental health concern. And the individual who did the testing is probably, you know, a neuropsychologist, follow up with them. I just read a report again, get your consent. I just read a report by that you did by so-and-so. Is it going to be easy to get ahold of them? No, but if you let them know the specific question that you want an answer to, when you leave the message on your, on their voicemail, I have never had someone not get back to me eventually. You know, like we're all super busy. None of us have the time, but again, I also don't have the time for a long conversation. So it's not that I'm looking to consult for a half an hour on a [00:31:00] on a student either. I read this report, all of the ratings on these behavioral or emotional ratings were clinically significant, but I didn't read anything in the presentation that suggested that what was the followup like with the parents? Because they weren't clear on it. I asked the parents first, if they're not sure I get permission to, so you start building kind of your own team, even if it's somebody you only talk to once. The fact that a speech pathologist reaches out to a neuropsychologist, sticks out to the neuropsychologist too. And so I've also had it be where people are much more likely to, um, assume there's going to be a communication with me if they hear that I'm one of the service providers, because they know that I'm annoying. And I'm going to follow up with a question that I had, um, but, but the point being that they also know what's going to be short and brief and that I don't have time for more, you know? Um, so I think the way that you build the team is curiosity and focus, staying [00:32:00] really focused on that clinical question and then being a little dogged about it. You know, you might have to leave two or three voicemails, but in my experience, the voicemails don't take very long. So that's, you know, and then once it's scheduled for the five minutes, you do your five minutes and you're done, then you have your answer.  [00:32:17] Kate Grandbois:  You've mentioned as we've been talking, you've mentioned a variety of different kinds of mental health professionals. So we've talked about psychiatry. You've mentioned social workers. I wonder if there are other flavors of mental health professionals that you've worked with that you want to tell us a little bit about aside from the obvious ones we've mentioned.  [00:32:37] Beverly Montgomery:  Sure. Um, so depending on what family you're working with, there may be addiction specialists involved. You may also have equine specialists who are in the mental health field for a lot of kids who are doing like hippotherapy and using horses. And, um, there's also a licensed marriage and family therapists that are doing similar work. Um, there's guidance counselors at [00:33:00] school are school psychologists, um, and, um, I think I also, I also kind of consider mental health to be wellness in the proactive sense. So, um, it may be, you know, a yoga instructor. It might be a, you know, a mindfulness coach that the family uses. It could be a, um, you know, I actually had a conversation recently with an aroma therapy specialist who works with one of my students, um, because I wanted to find out what that was about.  [00:33:33] Kate Grandbois:  And I think the, I think one of the points that you're making that I absolutely love is that it's not our place to decide what the other professional is, is providing. So when you say aroma therapy specialist, it's like, oh, well, that's significantly different than anything I know about. That's not in the realm of science that, that we are aware of in our profession, but if it's a stakeholder for the family, it matters. And that's, that's the [00:34:00] point is that when you're really engaging in person centered care and family centered care, if it's an individual that is providing service, no matter what, the services that the family has stake in, or that they have stake in, in the family's wellness or the student's wellness or the child's wellness, then it matters. And it's worth your efforts to collaborate. I also, I actually recently in a different podcast episode, it came up that sometimes, um, we do share this scope with, with mental health professionals, like sharing language with neuro psych or sharing executive functioning with the school psychologist and how sometimes that relationship can be more prickly than it needs to be. In terms of, you know, who is, who is out of the two of you is treating the issue. And I also love the perspective you bring up, you know, sharing an area. And I wonder if you have any, um, before we move on to our next learning objective, if you have any suggestions [00:35:00] for managing some of those relationships for a shared scope of practice? [00:35:04] Beverly Montgomery:  Yeah, I think it may sound a little bit simplistic, but again, nobody owns these scopes of practice, right? There's a reason why they overlap and that's because we have different perspectives on it. So if you can, um, approach it from a place of curiosity and not assume that, you know, your way of doing it is the more correct way. If you genuinely want to find out how the person is working on executive functioning, I have not had, I've had a person tell me they don't time to tell me, but I've never had a person who is prickly about my asking if that's genuinely why I want to know if the reason why I'm asking is cause it's like kind of a passive aggressive way to tell them, I don't think they're doing a good job, then that's going to meet with a prickly response. Right. So I think if you can approach the work with curiosity that has something to do with it, I think also you can agree to disagree. So you do have different professions and it's okay to be. Like [00:36:00] the way someone's addressing it in their work and to like the way that you're addressing it and your work, and to be like, wow, I wouldn't do it that way. I'm really glad he's getting both, you know, like it's not your job to make the school psychologist work on speech pathology stuff. They don't have the training and we don't have their training. So there's plenty of work to go around and there's plenty of kids who need help. So nobody needs to own the work. You know, I think, um, I think the other, the other part of that, that you mentioned earlier was just about, it's not our job to judge, you know, I absolutely give my science-based opinion whenever I'm asked for an opinion, but if someone's just sharing that this is a provider that they have, um, then they're not asking for that. And I think it's my ethical obligation. Obviously, if I think there's any potential harm to indicate that. But otherwise I think it's kind of due diligence to find out. Evidence-based is based on the progress of the individual. So if, even [00:37:00] if we don't have a scientific base saying that best works for people with this profile in general, but we have individual data that for this individual, it works, then, you know what that's evidence-based like for that individual, we have evidence that this is working and we need to learn about it. [00:37:19] Kate Grandbois:  We’re fist pumping. Nobody can see us. We're like, yes, internal data collection is still EBP. [00:37:25] Beverly Montgomery:  I love data. And that's a way that honestly, that I help a lot of mental health professionals. They have that, um, they have not had the training in their field around data collection and writing measurable objectives around, uh, you know, the work that they're doing. Um, and often there's overlap with the work that I'm doing and that's an area that I can help with where, you know, I, I can help them with the language that they're using and, and really being specific around what it is that they're measuring. How do you know? Um, because it is a different type of work.  [00:37:56] Amy Wonkka:  It really is. And that integration of the internal and external [00:38:00] evidence is ultimately, I mean, if there is external evidence and there are studies that show something's effective, we still want that internal evidence to make sure it's actually effective for our clients. Um, we've talked a lot on this podcast just about the fact that most of the research studies are not done through the lens of imitation science they're done in a research setting. And so it may have been effective for those people who were in that study and that doesn't necessarily translate to our clients. So these are, these are important things to do, whether or not you have that external evidence. [00:38:36] Beverly Montgomery:  Yeah. And the more complex your individuals are, the less like the study participants that are going to be, because we, you know, in a study, we want to be as careful as possible, not to have confounding variables. So many of our patients, students and clients are confounding variables. They have lots of complexities, which [00:39:00] make them not ideal for a study. Um, which makes it really hard if we need to find research based evidence, um, on them specifically.  [00:39:09] Amy Wonkka:  Yes. And when we're talking about lower incidence populations and everybody has their unique variables that may or may not make this approach in this study, be a perfect fit. That's, that's part of why we're there as the clinician and part of why data collection is so important. And I love data collection too. [00:39:28] Kate Grandbois:  I also wanted to bring in what, since we're talking about the EBP and our evidence-based practice triangle and speech language pathology is just to sort of remind our listeners what it looks like and the three components. So we do have this component of evidence, which is comprised of external evidence and internal evidence. So the research articles and the internal data that you collect, we have our clinical judgment. So based on our experience and the best available information, what our is, our clinical opinion. And then the third piece is client and family values. And this sort of speaks [00:40:00] to what you were saying earlier about not placing judgment, because if it is incorporating client and family values in, into our practice is still evidence-based practice. And I think sometimes we get hung up on the external rev- evidence, and we think of EBP as a research article. So like where's the research. I need to find an article that says X, Y, or Z, but that's not, it's an integration of all of these things. So I, I love your perspective. Just sort of anchoring this back to our learning objectives and topic, your perspective of collaborating with mental health professionals, across a variety of perspectives and across a variety of trainings and making sure that we’re understanding how our EBP triangle and client family values and internal evidence relates to that collaboration. And that's really important. [00:40:57] Beverly Montgomery:  And I think that's again where we're going to save time. [00:41:00] Right? So treatment planning is a significant amount of my time. And the more I have this information, the more informed my treatment planning can be versus spending lots of times kind of trolling through articles and things like that. Looking for what should I be doing with an individual with X, right. Instead saying, this is what's working. This is, what's not, what's my clinical question. How do I answer that? And then there's my treatment plan, right? I think it's a different approach than many of us were taught. So it can feel a little uncomfortable, but at the same time, from a time perspective, it can be much more kind of cost saving when you bill yourself for your own time. [00:41:43] Kate Grandbois:  1000%. I wonder if you can just, I'm just looking at our learning objectives. I'm wondering if we can start talking a little bit about decision-making in terms of working with families who are experiencing grief, [00:42:00] experiencing trauma, seeking additional help, or maybe you've identified that they might need additional support, but maybe don't know it. Or there is a lot of tenderness and there's a lot of, you know, they're in a, in a fragile place. What are some of the decision-making procedures that you go through to tackle or address these issues and potentially make a referral?  [00:42:24] Beverly Montgomery:  Well, I think I spoke earlier about, we're gonna speak about adults late here, and I'm not sure I circled back to it. So I'm going to tie that in here too. I, um, I think the way that you build a team for adults is, is different, right? Cause you're not going to go through a pediatrician or something like that. So with adults, what I do is, um, again, um, have that intake or that evaluation. So as part of that process, I'm going to find some information. And then the first few sessions, um, you know, aren't going to be diagnostic sessions too, to see if kind of my clinical hypothesis is correct based on the evaluation or in tech [00:43:00] intake. And that's where I will kind of hold up a mirror for the individual and say, you know, I hear you talking a lot about how hard it is to do the homework between sessions. And I'm wondering what you think gets in the way. And if they're talking about the fact that it's just really hard to do anything, but get themselves out of bed and to work. And then, you know, like they have to force themselves to eat dinner and then they just, it's just one more thing they have to do, boy, that, that sounds kind of like a depressive, you know, individual to me that, that sounds like something I might want to ask more about. If they're saying that the reason they can't get to whatever the tasks are in between sessions is because, you know, they're taking care of an aging parent themselves at home. And, you know, there's just not enough time in the day. That's a beautiful invitation for me to say, so who do you have for you? Because I'm X and then describe what your role [00:44:00] is, but who do you have for you? Because you're a caregiver and, and that, so that's kind of how you build that team is, is in partnership with the adult. Or you can even say, you know, have, has there been any. Of therapy that you've ever done, that you found either effective or ineffective and really listen to their responses. Um, A. it can give you really good information if you hear about lots of awful treatment providers they've had in the past, that's really good information to have. Um, if they tell you that they had this really fantastic person and then it never really worked with anybody else. Well, okay. That's good information too. Um, or if this is the first time as an adult, that they're getting any sort of support, that's super important information, too. So just being able to, being willing to ask that question, but ask it broadly enough so you're not just asking about speech therapy and again, indicating you know, why it's helpful for you to know that you could probably shorten the, um, you know, potentially shorten the [00:45:00] number of treatment sessions, if you know what's most effective for the individual.  Thinking about, um, parents, I think about it from two lenses, right? You might be making a mental health referral for the parents themselves or the family as a unit. I am a strong advocate for sibling groups. I think a lot of our really complex individuals have siblings that have really complex lives that need support. And there's a couple of good sibling groups out there for that type of support. So I share those resources with families. I also think that being a parent is really, really hard. I was a great mom until I became one and figured out that I wasn't,  [00:45:42] Kate Grandbois:  oh my God. Can we both say that at the same time? Because that is the truest statement of the year. Parenting is just hard. I think about some of the things I recommended before I became a parent to other parents and I just didn't know how hard it was. It's exactly what you just said. Sorry. It's just this [00:46:00] personal soap box. I couldn't help but stand on for a second.  [00:46:03] Beverly Montgomery:  So true. And then, you know, you're, co-parenting with, it doesn't even have to be, you know, a spouse or a partner. You, you could be co-parenting with a nanny or co-parenting with, you know, um, uh, extended family that all lives in your house. If not, everyone's on the same page, that's a whole nother, you know, there are so many dynamics and, and we don't learn anything about family systems in our, in our training, um, which is a whole nother reason kind of to refer, but also just grief. You know, everyone's grief process is different. And I talked to so many clinicians who are like, oh, the parents are just in such denial. And I, and I understand why that's frustrating as a clinician, but it's also information, um, for you and rather than being frustrated with the fact that they're in denial, maybe giving them some resources. You know, and, and so then the next question is, well, how do you do that [00:47:00] without saying, oh geez, you seem messed up. You, you know, you need some help. Strike that one. Um, but like, how do you say that without seeming like you're going outside of your scope of practice or, you know, I think it's coming from, again, an observation holding up a mirror, you know, what? You look so tired and, and like, you know, I know that X, Y, and Z are things that Jimmy or whatever the kid's name is requires, but that takes such a toll. It's easy for me because it's my job. And I don't have the emotional piece. What's it like for you? If they identify to you that they are significantly struggling, it's okay to meet them in that place and kind of bear witness to that pain and say, how about we see if we can get you some more. And just leave it there. You don't have to know who the right person is in that moment or whatever, but just, I think we, we, as clinicians want to solve things. [00:48:00] And so it's really hard to see somebody who is in a challenging place if we don't have the solution, or if we know that that's just comes with the package, right. Kids with really significant needs are going to be even more challenging to parent. Right. So some of that's to some extent expected that doesn't mean we can't do what we can. And honestly, I've never had anybody be insulted. That's everyone's fear is like, what if they're insulted? If it doesn't feel like a good fit for you, it probably isn't. So that probably isn't the way you would say it. The point is to take the cue from the parent, right? You're not coming and saying, you know, I think it must be tough having this child, so you should probably get some. You know, you are again, holding up a mirror or reflecting things that you have observed just like you do in your reports or in your soap notes or whatever. You're making a direct clinical observation and sharing it, and then creating an opportunity for [00:49:00] that parent to share if they don't, they don't, and you don't need to go beyond your kind of scope to make guesses about what's going on, but if they do share, it's also okay to be with them in that vulnerable moment. I think that's part of working with the family is the closer you can stay to your therapeutic agenda with the child. The more authentic this request or advice is going to become. So, you know, oh, it came up in the session that, you know, so-and-so is having a really, really rough time with their sibling and that, um, You know, they're feeling really badly because they've said they're going to kill their sibling so many times in the last, and we know sibling relationships are tough, but have you noticed that that's been tougher than, than usual? That pertains directly to my work and yet is also in invitation for more information, right? [00:50:00] Again, I'm not looking for more people to give therapy to or to, to, you know, refer, refer out. But when something lands in my lap, I feel the need to address it. Um, and I guess that's the way I feel about, um, about this is if you had a sense that your progress is limited because something is getting in the way of their ability to access the work that you're doing and that something is depression, anxiety, identity issues, family, you know, systems, sociological issues, you know, poverty, your home conditions, all of these things are things that we can get the child help with. And then you can get back to focusing on your therapeutic agenda. I think you also have to, when the only caveat to that is not getting too far ahead of the parent. So would I have any of these conversations the first time I meet with them? No. You know, I think you have to have a relationship with the parent first and maybe they're having an off day. Right? Like [00:51:00] I'm not going to tell every parent that walks in the door they look tired. Cause I look tired all day, every day of my life. Like, that's  [00:51:05] Kate Grandbois:  I was just going to say, can anybody see me right now? Or are you talking about me? That's also a human condition.  [00:51:11] Beverly Montgomery:  You know, I, I think, um, I, and then the other caution I would say is just to. Maintain as much as you're going to a somewhat personal place, maintain your professional role. So, um, as you're doing that, you're doing it as a professional who yes cares. Um, but it's not their buddy or their friend or, or, you know, um, you're not there to provide comfort in that moment. Um, as much as you are to be a resource in that moment, which may provide comfort, right. But then there's this kind of a subtle distance. It's not your job to kind of jump in and problem solve. And this is a really hard one for me, because like I said, I, I, I want to solve it. Right. I, but I think that's where we can sometimes get a little ahead of where the parent is. And then with adolescents, [00:52:00] I address it with them and with their parents. And, um, I talked to them about, you know, I hear a lot of, I had this conversation, I'll give an example of a conversation I had, um, this week with one of my teens and, you know, he was really conflicted about the fact that he knows what the quote unquote right thing, or, you know, expected thing to do would be, but it just feels wrong to him. And he said, you know, is this my autism? Is this, you know, is it my autism that makes us feel wrong? And he's like, or maybe it's my add. Or maybe it could be the anxiety too, you know? And, and I said, well, I'm not sure it's super productive for us to try to figure out why it feels wrong. I think it's pretty profound that, you know, it feels wrong. So do you know what feels more right? And he said, yeah, I think I need to tell this teacher that it's not professional to be giving students resources that were published [00:53:00] before they were born. Like that is just bad educational practice. And I said, okay. So if that feels right, what feels like the right way to do that? And he's like, well, if you're not being direct, you're not being honest. And I know we've talked about honesty and feelings and all that, but that's just how I feel. And I said, okay, so again, we had this sort of counseling session right about it. But what he's struggling with is, you know, this is what feels right to me. I'm old enough to know what the rules are and what I'm expected to say, but I have this internal conflict. Right. And so, and then at the end of the session, you know, he said, um, I think maybe if I tell the teacher that because of my autism, it's really hard for me to get over some things, she might take the news better when I tell her that her resources are crap. And I said, and, and I said, well, I'm not [00:54:00] sure you can absolutely put it that way if you want to. But I think the more important part was that you were being honest about how it felt to you and you had a suggestion and how that would help you learn. And I said, you kept it about you. You didn't make it about the teacher. And he said perspective taking, I know, I know. And this is the guy I've been working with for 12 or 13 years. So he's known me for a long time. So, and then, um, and he's like, this neuro-diversity stuff is really tough. And I said, um, and I said, it is. Um, he's like, cause everyone says you're supposed to be you, but then you're also supposed to be like, who the world wants you to be. And I said, you know what? That is really tough. And I said, and if you ever want somebody else to talk to about that, you know, I'm sure that there are people that are really good at that.  Kate Grandbois: What a profound statement.  Beverly Montgomery:  And I said, and he's like, really who? And I said, well, I don't know who the right match for you would be, but there's a lot of counselors and stuff who really help [00:55:00] teens with that. And he said, oh, I think I'm going to talk to my parents about that. You know, again, what teen says, I want a counselor, like, but it's something he's significantly struggling with. And he saw it as a tool or a potential resource and sure enough, his parents emailed me and said, you know, do you have any names? So, um, it doesn't have to be a, a very emotional experience. It can be very organic and come from the moment.  [00:55:26] Kate Grandbois:  I just want to reflect back, something that you said that I found to be really important, which is being there for the family and not just being there for our clients. Right. So, and, and, and I think that's important for so many reasons. Not only because we're treating the whole family ready, we're really being present for the whole unit, but also because our, the parents are stakeholders, we're transient, they're permanent, hopefully permanent, right. They're going to be with the child for first grade, [00:56:00] second grade, third grade, when you are gone and no longer at that practice or with the next therapist or with the OT, they are a permanent, hopefully permanent. There are a, there is continuity there that we can not provide. So if you have a parent that's struggling or a family dynamic that is struggling, being able to address that will open so many doors for additional work that we can do as the communication specialists. So showing up for making recommendations that are reasonable within the home, making homework suggestions or home programming suggestions, that don't feel overwhelming knowing what to target in your therapy room, that has a good chance of being carried over because you've taken the time to show up for that family and have a deeper understanding of what their family dynamic is like, what their home life is like. And I feel that this is particularly true on the younger, you know, the [00:57:00] younger you go because the older you get, you get more independence and they're out of the house more just like, you know, that the student that you were describing before, I think showing up for the family is not something that we do just to be nice. It is part of our clinical work. And it will move, help us move our clinical work forward. Unfortunately, I think based on our field and some of our workplace settings and infrastructure norms showing up for the family and showing up to the parents and integrating them as part of our therapy is really difficult. Again, plug for funding for indirect service, but also in the schools. I mean, how often do you see the family, right? What's your family communication? Like how often do you have time to sit there with a grieving parent or caregiver and let them have the space and the moment of safety to tell you about how difficult things are at home or a big win that they had and how happy they are. I mean, we, we don't really get an [00:58:00] opportunity. To have that level of clinical intimacy with our families, and I just wanted to reflect back to you how important I thought that was. And, and it's something that I think we should all consider trying to do more or I know we all have a million things on our plates and it's almost impossible to do more, but it's, I guess, a different lens to look through or a different perspective to consider. [00:58:20] Amy Wonkka:  I think just also to, to value the moments we do have as somebody who has worked in a lot of different environments, but many of them have been school-based, you know, even there, you may have a parent teacher conference or you might have something, you know, where you're getting these brief check-ins and just valuing that moment, even though it might not be all of the moments that you wish it were for what it is. And it's also an opportunity to make those connections.  [00:58:47] Beverly Montgomery:  Or, you know, yes. Using the moments that you have and then making new quick opportunities. So I think back to when I was in the schools and I had a lunch bunch with kids, cause that was like, you know, a thing. Um, [00:59:00] and I would stick a little note in the kids' lunch boxes because some caregiver is going to be emptying those lunch boxes and filling them in all likelihood. Um, about two things we chatted about. And then, um, you know, I just put an invitation at the bottom. Let me know what you'd like to chat about at home. And I'd say twice a quarter, uh, you know, most of the kids would bring something back. It didn't always come, you know, it wasn't weekly. It wasn't. Um, but that probably would have been more than I could handle anyway. But the point was, I had an insight in a communication with the parents that was much more about getting to know them as a family than it was about, you know, the IEP process. And that helped me with communication with them, but also with the, with the kiddo, like if the kiddo needs to be talking about vocabulary, that is not what I'm teaching and they have trouble saying those words then, you know, I don't know that because I'm not a part of that culture. So [01:00:00] it's really helpful that I have that information from the family. The other piece I want to talk about with adults is also, um, you know, talking about progress and if you feel like, you know, um, I've also had conversations with adults where I feel like, you know, I think we have a great professional therapeutic rapport, but I feel like our, you know, and I, I love data. So I usually have some sort of nice visual that I can show. I feel like our progress is kind of plateauing or stagnant. Like I feel like we're not moving forward the way that we were, and you know, that can happen sometimes in therapy. But if I think that it's not just a normal ebb and flow, then I would also share that with the adult and say, you know, I'm wondering if it's time for a different type of work. And I said, you know, you've gotten to this place and what I think might be getting most in the way of your connecting with other individuals right now is [01:01:00] X. And again, this is based on a clinical observation you have made, you're not pulling it out of thin air or making a judgment it's data-driven. And you're saying, you know, would it be helpful if we brainstormed, you know, what the best way to address that is because I may not be it. And that's okay. You know, I think what I have found is that sometimes if there has been progress made, it's hard for adults to pause or add service providers because they feel almost like they're, I don't want to say cheating on you, but it's like a, it's almost like they think you're going to take it as an insult. If you're adding to the team and sometimes they need your permission to know that it's helpful, that you can't do it all and you don't want to do it all. And that, you know, there's, there's work here to be done. And there's some great people to do it. Um, but I'm not it, you know, um, it doesn't have to [01:02:00] mean leaving you, it could mean adding, but sometimes it does mean leaving you. And sometimes people need permission to do that. If they've made progress with you, because I don't, you know, it's not their job to know our work. And if our work isn't moving forward, we're the ones that need to tell them that they need a different lens or a different approach.  [01:02:21] Kate Grandbois:  I love that. And I wonder if in our last couple of minutes you have any parting words of wisdom or pieces of advice for our clinicians who are listening and maybe considering some of these things for the first time, or maybe they're masters of their domains, but they've learned a little something from you. [01:02:38] Beverly Montgomery:  I would just say that, you know, you can do this and still be yourself. And, and what I mean by that is nobody is suggesting that you collaborate with mental health professionals, the way that Kate or Amy or Beverly would. Right. We're saying, think about this when you have questions. Because you may not have considered it as an [01:03:00] avenue for answers. And, um, I guarantee you there's somebody on your caseload right now that you could brainstorm a collaborative partner for, um, that is somewhere within this, this realm. So, you know, in the last couple of minutes, as you're doing whatever paperwork or turning things off, do that thinking and figuring out who that person is and who you might reach out to in a 30 second next step. [01:03:26] Kate Grandbois:  I love that. Thank you for sharing all of your wisdom with us today. Beverly,  [01:03:31] Beverly Montgomery:  thank you for having me,  [01:03:32] Kate Grandbois:  we really appreciate you being here. If anybody is listening, um, and is wanting to learn more, there will be more, there will be additional resources listed in the show notes. Thank you again for being here and we hope everybody learned something today. Thanks again. Thank you. Thank you so much for joining us in today's episode. As always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, [01:04:00] depending on the regulations of your governing body. To determine if this episode will count for professional development in your area of study, please check in with your governing bodies or you can go to our website, www.SLPNerdcast.com . All the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@SLPnerdcast.com . Thank you so much for joining us, and we hope to welcome you back here again soon. Thank you to our corporate sponsors Vooks who helped to make this episode possible. Our corporate sponsors keep our CEU prices low and our program ad free. Vooks is a library of animated storybooks with read along text, designed to improve engagement and reading fluency. Kids can track with the highlighted text and you can pause to go over words and phrases. Join 1 million educators and specialists, by trying Vooks for free for seven days Vooks.com .