This is a transcript from our podcast episode published March 27th, 2023. The podcast episode is offered for .1 ASHA CEUs. 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] 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 nerdcaster10. A link for membership is in the show notes.  Episode [00:01:43] Kate Grandbois:  Hello everyone. Welcome to today's episode. We have a really, really interesting topic today that I am really excited to learn about. As our expert guest, we have Ginny Weill joining us today. She is a speech [00:02:00] language pathologist who works in a nicu, um, which is a setting I have had the pleasure of never setting foot in because I have children, and my children were never in the nicu So welcome, Ginny.  [00:02:11] Virginia Weill:  Thank you. Thank you so much for inviting me. I'm excited.  [00:02:15] Kate Grandbois:  I'm so glad that you're here. This is gonna be great. Um, I wonder if you could tell us a little bit about yourself before we get started.  [00:02:23] Virginia Weill:  Sure. So I, um, grew up in Maine, so I'm a New Englander. Um, I went off, I did, you know, most of my schooling undergrad here in New England, and I thought for grad school, let's get outta New England, go south. So I went to Virginia. Um, and then I realized there that I missed the fall. I missed New England, I missed the snow. So, um, when we had an opportunity in grad school to start doing clinical placements, I found, you know, my two up in New England at hospitals. Um, and that's kind of how I found my journey back up into this area. Um, so I [00:03:00] actually worked in Connecticut at a standalone pediatric hospital there for about eight years. Um, I did my clinical fellowship year there. I did a clinical placement there and they were gracious enough to, uh, invite me to stay a little longer. So I started out in outpatient therapy actually. So, you know, doing your typical autism AAC voice, um, articulation. And then slowly as I became more competent, I got invited to start to do some more inpatient work. Um, so I started to see more of the medical side of things, more of the medical side of patients and how a speech pathologist can help these kiddos, um, in the hospital. Um, and then I started doing more swallow studies. So I did mbss, the modified barium swallow studies. I started to do fees. Those are the fiber optic endoscopic evaluation of swallowing along with the otolaryngologists or the ENTs. Um, I started, you know, throwing myself into clinics and being a standalone pediatric hospital, we had countless [00:04:00] clinics. So I did aero digestive clinic, um, cleft pallet clinic, voice clinic, fees clinic, and even feeding team. Um, and then in my last few years there I was, um, I started to get into the nicu and then, um, you know, about four years ago, this hospital that I'm currently in had a nicu speech pathology position, stars aligned and I actually was able to move back home to Maine. So I've been here at the hospital that I currently am at for a little over four years, where I'm focused more in the nicu. But of course I still do, you know, countless swallow studies. I do fees with our ENTs. I do a couple clinics here, the Aero Digestive and the Cleft Palate Clinic. Um, and then I starting to focus more on cardiac and aero digestive patients. Also on the pediatric floor. So like outside of that NICU group, but just on pediatrics. Um,  [00:04:56] Kate Grandbois:  so you really went from an [00:05:00] outpatient SLP in a hospital, really immersed yourself into the medical world. I mean, I am not that familiar with what happens in a nicu. I'm about to learn from you, but I imagine it is a much more intense medical environment when compared to, let's say, an outpatient AAC clinic, which is where I was. [00:05:16] Virginia Weill:  110%. And I think, you know, all of the experience that I had up until that point prepared me for the high intensity of the nicu. You know, if I had just gone from outpatient or the school systems, if I had a placement in, I don't think mentally I could have handled the nicu. I think I had, you know, having all those years of experience, um, kind of preparing me and getting me, getting my feet wet and how do I talk to a physician? How do I argue with a physician respectfully? Um, how do I talk?  [00:05:48] Kate Grandbois:  Oh, I wanna hear that story. Oh gosh, I think we all wanna hear that .  [00:05:54] Virginia Weill:  Um, but yeah, it really prepared me for the nicu, so I'm very thankful for all the experience I had at that hospital. It [00:06:00] really, um, prepared me for my love. And my love is the NICU and the families and the patients, and. [00:06:06] Kate Grandbois:  Well, I can't wait to hear more about it. Before we get into all of the good stuff, we do have to read our learning objectives and financial and non-financial disclosures, so I'm gonna read through those as quickly as I can to get them over with, and then you can shower us with all of your knowledge and teach me everything about the nicu. All right, learning objective number one. Identify three roles of the SLP in the NICU. Learning objective number two, identify two reasons why thickening with cereal is not recommended in the NICU, and learning objective number three, identify two possible etiologies of strider in an infant disclosures. Ginny Wild's financial disclosures.  [00:06:43] Kate Grandbois:  Ginny receives a salary working in a NICU as part of a level one trauma hospital. Ginny is a member of Asha Sig 13. Kate, that's me. My financial disclosures. I am the owner and founder of GrandboisTherapy and Consulting, LLC and co-founder of SLP Nerd Cast my non-financial disclosures. I am [00:07:00] 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 special interest group. Okay. All of that stuff is behind us. I'm here. I'm ready to learn from you. I'm very excited. Why don't you start off by telling us a little bit about. What it is, like the first learning objective is there are three roles of the SLP in the nicu, and I can only really guess what one of them is. So I'm really excited to hear more about what that is actually like for you on a day in and day out basis. [00:07:40] Virginia Weill:  Sure, of course. Um, so before I get into that, um, exactly what my role is in our nicu, I just wanted to talk a little bit about what the NICU levels are. So there's not just a nicu, there's actually four different levels. Um, and the one I work in is actually, well, we have kind of two, A level two and a level [00:08:00] three. Um, so a level two is just a special care nursery. We call ours a continuing care nursery or ccn. Um, this is intermediate level care for moderately preterm infants. Um, they maybe need a little bit of respiratory support, mostly working on feeding and growing. Um, and then our level three nicu, which is really our NICU here. Um, high level diagnostics, um, intensive care, um, a lot of surgical subspecialties for cardiology. Um, and the level four, which is not us, but like for example, Boston Children's is a level four and they can do things like ecmo, the um, mechanical oxygenation. So here in our NICU at our level two and three primary job, oral stimulation, um, a lot of times we'll do oral stem on our trached, invent kiddos that are not necessarily safe to orally feed yet. But we wanna keep positive learning experiences and positive oral experiences, um, frequent throughout the day. [00:09:00] Um, we do, this is a lot feeding and swallowing assessments at bed, at bedside. Um, we can dive into a lot more of that later. We do our modified barium swallow studies or video fluroscopic swallow studies. Um, we do fees with ENT. Um, we work a lot with communication and cognition. Um, specifically right now we have a lot of trached and vent kiddos are a little bit older, and so we're doing a lot of communication language, cognition and, you know, collaborating with OT and PT during those sessions. Um, and then this is day in and day out collaboration with families and the team. Um, they listen a lot to our recommendations in terms of whether we wanna get other people involved, like the pulmonologist, the ENT, the gastroenterologist. Um, and then another thing that we do is education. Education for the nurses. The physicians, a lot of the families. Um, and yeah.  [00:09:56] Kate Grandbois:  Okay, so you just blew my mind. I would've said, uh, [00:10:00] feeding and swallowing . That was the one thing I was pretty sure a speech pathologist did in the nicu. I have a lot of questions. I'm wondering what oral stimulation looks like. What does that, what do you do? What does that look like?  [00:10:11] Virginia Weill:  It's a fancy term for, for example, offering a pacifier, offering a pacifier dipped in the mother's milk or in formula. Um, we do a lot of like, uh, perioral stimulation, like massage to the cheeks, to the chin, to the lips with glove finger to the forehead. Miss that specifically is for the kiddos who have had tape on their face a lot, have had like the masks for breathing, and they just are so, um, hypersensitive, hyper aware of anyone that touches their face. They have this knee jerk reaction and so we kind of have to calm those senses, um, so that they can tolerate things around their mouth and their face again.  [00:10:54] Kate Grandbois:  I feel like before we get any further, I wanna address a, a thought that I keep having, [00:11:00] which is that these are tiny, tiny humans. I mean, it, it's something when you just said, I don't know if anybody's watching this on YouTube. They probably saw me frown when you said they've got tape all over their faces. Cuz I'm imagining this, you know, little preemie, these little babies with tubes and tape. I mean, that, that must be challenging.  [00:11:17] Virginia Weill:  Yeah, it's very hard. And you know, the nurses do such an amazing job with, you know, two person cares to really try to calm the one nurse will calm the baby and really contain them and then the other nurse, you know, does the feeding tube or the diaper change or you know, whatever medically they need to do. But it's so important and our NICU was so great at really making sure and trying to protect the baby from all this noxious stimuli.  [00:11:42] Kate Grandbois:  And I love the idea of considering, you know, on this show we talk about person-centered care all the time, um, and really bringing an individual's values or a family's values into our care. So when you're talking about trying to create positive [00:12:00] experiences and taking into consideration the level of sensitivity on the face where they, that might not be a critical piece of keeping them alive, per se, right? Or a critical piece related to preventing aspiration.  [00:12:16] Virginia Weill:  But it's a critical piece of their quality of life, their tiny little faces, because they're still creating, I mean, their brain is still growing so much and creating all these different pathways and every stick, every tape removal, every gag on the pacifier, every cough on a bottle, you know, that's gonna set them up for those positive or negative experiences down the road, or, you know, it's so every little thing counts. And so we have to do everything in our power to protect them.  [00:12:42] Kate Grandbois:  Okay. So going back to, um, the different roles of the SLP, so you also mentioned collaboration and education. I have to assume that this is a huge part of your job when someone so little is so medically fragile.  [00:12:59] Virginia Weill:  [00:13:00] Absolutely. So, um, we, as the therapist, we get invited a lot to the NICU skills fair. So from an education for the nurse standpoint, I mean, the nurses, even if they've been there decades, they still learn something new from us. You know, it's still beneficial for us to update them on the newest research out there in terms of nipple flow rates or, um, formulas that are no longer existing anymore. Or, you know, positioners, you know, for OT and PT. So it's, you know, every day we are talking to nurses and, you know, obviously the families can get into that later. Um, on the importance of reading the baby's feeding cues. If they're sleeping, you let them sleep. You don't need a stick of bottle in their mouth. Um, why it's important not to do, you know, popsicles or lollipops with trach kids. You know, why it's just as important and to do the pacifier dip of the mother's milk, you know, so it's, it's education every day to ensure the best care for these little ones.  [00:13:59] Kate Grandbois:  And collaboration too. I'm [00:14:00] sure there are a lot of critical decisions being made in a moment's notice, um, information from all your different colleagues, not just nursing, but you've, you've listed so many already, cardiology, pulmonology, I mean, I'm sure these little babies being in the NICU have many people on their medical team, and I'm sure you have to do, you have to be a really effective communicator and collaborator to facilitate those decisions. [00:14:26] Virginia Weill:  Absolutely. And, and now that babies are being born sooner and sooner, earlier and earlier, um, you know, pulmonary, a lot of them are on oxygen pulmonary involved a lot from the beginning. Um, and you know, the impact of breathing on feeding, it's huge. And so communicating with the pulmonologist on kiddos that we think are aspirating. When do we do swallow studies? When do we thicken? Um, and, you know, the cardiac babies, you know, if they go in for surgery and maybe they have a vocal cord paralyzed afterwards, depending on where the, the surgery was, you know, getting ENT involved to take a look. And so it's all [00:15:00] that. You know, communication back and forth. What's going on in your head? This is my plan. What are your thoughts on my plan? Um, so it's always, you need to always have good communication skills and, and be willing to listen and compromise too.  [00:15:14] Kate Grandbois:  Well now, you know, I'm gonna ask the question that I wanted to ask before. How do you disagree respectfully with the physician? [00:15:21] Virginia Weill:  Oh, um, actually one of the case studies that I wanna talk about, there was a little bit of a disagreement. Um, I, what I do is I verbalize my most up to date evidence based practice, what I feel is gold standard. Um, I usually explain why I am not recommending what they would like me to do, um, and then I leave it up to them to make the choice of what to do. Uh, it's, it's, it's challenging and, you know, sometimes it is, like, for example, right now we have a kiddo in the NICU and the doctor really wants to use cereal to [00:16:00] thicken. And I really don't want to use it be, but she's,  [00:16:03] Kate Grandbois:  oh, because of that second learning objective we haven't gotten to yet. Why not to use cereal? [00:16:08] Virginia Weill:  But she wants to use it because guess what? It's full of carbs and it's gonna make the baby gain weight. I get it. But at the same time, we have to protect her lungs. She's still on oxygen. She was on a lot of oxygen a week ago. So it's, what are we gonna do? So tomorrow we're gonna sit down together and we're gonna have a discussion with the, um, registered dietician, the physician and myself and, and problem solve and see how we can make sure this baby gains weight for brain development, but also protects their lungs. So,  [00:16:37] Kate Grandbois:  holy moly. So, I mean, these are really, really heavy decisions. Not only are you talking about potentially life altering clinical decisions, but this is also, again, just a tiny little person. I keep thinking about that. [00:16:48] Virginia Weill:  I know. Yeah. So it's, you know, it's all about communication and, um, communication and education. I feel like. [00:17:00] Because that's the only way you can communicate effectively is to educate them as to why you're recommending what you're recommending.  [00:17:07] Kate Grandbois:  Right. Okay. Well, out of all of the roles that you've mentioned, which was, which was many, I wonder if you could tell us a little bit more about the feeding and swallowing piece and lead us into that second learning objective and why you're gonna go into this meeting tomorrow about not thinking, not thickening with cereal. [00:17:25] Virginia Weill:  I would say currently right now, the, the earliest baby we have born, I think was maybe 23 weeks. Right. 23 weeks. Wow. To 40 weeks. Some of them are born at term, but they have, you know, certain diagnoses that place them at risk for, um, feeding issues or breathing issues. Um, so yeah, so I, you know, I start to see babies typically right now when they start to bottle feed our breastfeed. Usually the lactation consultants, um, see most of just the solo breast feeders [00:18:00] or chest feeders. Um, you know, if they have concerns about aspiration they'll bring in the speech pathologist, but most of our kiddos are bottle feeding that I specifically see. Um, and if they're born this early, they don't have that coordinated suck swallow breath that they need for air way protection. And so my role is to basically teach that. Teach that by choosing the right bottle, by choosing the right nipple flow rate, um, choosing the right position that they're fed in, you know, cradle versus side lying on the left versus on the right. Um, you know, pacing them, meaning, you know, emptying the nipple so that they cue the baby to stop and catch their breath. Um, so this is what I do day in and day out and it's a lot of education for the families. It's cause new, cause a lot of families have babies born full term first and then this now a pre, and they're like, I don't know how to feed a kid. My baby, you know, this is how I fed him before. What do you mean sidelying? [00:18:56] Kate Grandbois:  So I was just having these thoughts while you were talking [00:19:00] because I have two babies. I had two full term babies who never visited the NICU and feeding my babies, I breastfed my babies, but feeding them was one of the most stressful experiences of my early parenting life. Now they're older and they give me a whole other headache of stressful problems, but this is a tremendous stressor on these families. I have to imagine, I'm imagining myself in that position having just physically experienced birth, or maybe they've been there for a while and you're healed a little bit, but even so, you have got a sick, a sick baby in the nicu that the counseling piece for you must be critical. It must be a huge part of what you do. [00:19:50] Virginia Weill:  It is, and you know, it's the nurses, you know, when the babies transition from our NICU into our continuing care nursery, the nurses and the NICU almost [00:20:00] say like, it's to graduation. It's closer, one up closer to going home because we kind of label our continuing care nursery. That's the feeders and growers. Those are the kids that are learning how to feed and then they'll go home. And the nurses and even our, the, the feeding therapists, we say to the families when we meet them, not in like a pessimistic, you know, glass half empty way, but feeding is what's gonna keep you here. It is the hardest thing to learn because the baby is in control. The only way you can speed up your discharge date is by just reading your baby's cues. And even if that's letting the baby sleep through a care time or sleep through a feed. You are still helping them get to that end goal of going home. And I think that's the hardest and most frustrating thing, certainly for these families who have been there since 28 weeks and now their babies are 38 weeks and the moms and dads have been in there every single day. [00:20:54] Kate Grandbois:  Oh my gosh. The stress. I can't even, yeah, I mean, you're, you're, you're not sleeping. [00:21:00] You're not even in your own home. You may have had to take extended or unpaid paternity or maternity leave. There are so many stressors that go into those first few weeks of parenthood alone. Um, so I, I, I can't imagine as the professional, as the speech pathologist focused on feeding, knowing that that is the root of what they need to do in the nicu or to, or to, as you said, quote, graduate from the nicu. That's a tremendous, that's a tremendous responsibility. Yeah.  [00:21:32] Virginia Weill:  And I try to, you know, say to the families, I try to be gentle, you know, and just provide that education. Give them the handout, you know, once your baby starts to feed in the nicu. But if they don't and they start to push their children, or they, you know, aren’t respecting the baby's cues and, and forcing that bottle into their mouth, that's when I start to try to scare them almost because I want them to know that, like we've talked about before, every little thing you do now you're gonna set them up for either [00:22:00] success or failure with feeding down the road, being a picky eater,  Kate Grandbois:  no pressure.  Virginia Weill: Yeah. Right. I mean, but that's sometimes what parents need to hear because we, in the medical profession, I feel like sometimes we talk so softly, we talk very gently because we don't wanna scare people. We don't, cuz you're already in a stressful situation. But when these little ones lives and feeding, you know, trajectories are in the balance. You do want the best for them. And if the family isn't listening, then you have to say, Hey, do you want a clear communicator? Yeah. Do you want your kid to be a picky eater? Do you want your kid to go home with a feeding tube? You know, this is, we're trying to avoid this, so you need to listen and follow these recommendations. Um, we don't encounter that too often, but unfortunately, you know, it does exist.  [00:22:46] Kate Grandbois:  It does happen. Well, and, and as the clinician. Putting on your counseling hat on and knowing when to be direct. Knowing when to do active listening. Yeah. Knowing when to softly educate, knowing when to let them have a grieving, stressful moment [00:23:00] because they're new parents under a lot of duress. I feel like those are all the counseling skills that we need, um, that we don't necessarily get in graduate school. So I always love, I feel like counseling is such a huge part of our jobs across the continuum of scope of practice and speech pathology. So I always like to just pause and highlight that for a second. Um, I wonder if you could, just thinking again about our sec, our second learning objective and the thickening, the with cereal, how do you, how do you get there? I assume you mentioned bedside swallow, you mentioned mbs. I assume that there is an assessment or procedure that happens first.  [00:23:36] Virginia Weill:  Yes, of course. So, um, I actually have a little case study if you would be okay with me kind of going through that, like how we in this kiddo, we actually, um, thickened, um, after a little discussion with the medical team. Um, so, let me give you a little background here. So this patient, this baby, um, was born late preterm and at outside hospital. She was transferred to us on day of life [00:24:00] three for prematurity, but also desaturation specifically with feeding. Um, she also  [00:24:06] Kate Grandbois:  desaturation, what do you mean, desaturation?  [00:24:09] Virginia Weill:  So the oxygen levels go down.  [00:24:10] Kate Grandbois:  Oh, oh, uh, oxygen desaturation. Yes. Okay.  [00:24:14] Virginia Weill:  Um, so we call them dsat. So, but also saturations. Uh, she also had hypoglycemia at birth and needed some oral glucose gel. So for a feeding therapist, um, anytime a baby has difficulty managing sugars or the mother was a diabetic during pregnancy, um, sometimes that can impact, um, brain development and the impact on feeding may delay their feeding skills a little bit. So that's also a very important red flag for me to kind of think of in terms of chart reviewing before I go see this kid. Um, she started developing desaturations, requiring a little bit of oxygen at the outside hospital. And then once she was transferred to our nicu, we quickly weaned her down to room air, which is great. It's a good sign. Um, and then the nurse reached out to [00:25:00] me about the concerns with feeding. Um, luckily at our hospital and our nicu, um, we get automatic orders. So anytime a baby's admitted, uh, either in our hospital or from an outside hospital, we get automatic orders and it's our decision of whether we see them that day or the baby may be too young or too medically complex. So we kind of, we wait and defer until they're more appropriate. Um, and of note, this baby did not have a nasogastric tube in place, an NG tube, um, which typically a lot of our NICU kiddos get one placed just to start fluid and hydration. Um, so I get called up to go see this kiddo. Um, I feed her with, so our hospital, our NICU carries a Dr. Brown's bottle system, and we have all the nipple flow rates out there for Dr. Brown's. So I started her with the Dr. Brown's preemie. Um, because of her age, I felt she was appropriate and should probably be able to handle this flow rate. However, she immediately started coughing. Her face turned color [00:26:00] to blue gray.  [00:26:01] Kate Grandbois: Oh my gosh, I'm already having so much anxiety for you. This is what, just what you do on a regular basis. I'd be so nervous. [00:26:06] Virginia Weill:  I know. It's, it's, and the parents are standing there too, so it's, you know, you have a crowd. The nurse is standing there. Cuz you know, as a speech pathologist, we are the experts in feeding and swallowing. We are.  [00:26:19] Kate Grandbois:  We, I'm not, yeah. ,  [00:26:21] Virginia Weill:  they're watching, they're seeing what I'm doing, you know? Right. Um, and of course oxygen drops. She has desaturations, which would be associated with that color change. So I stop and I say, all right, let's try the ultra preemie. So Dr. Browns makes an ultra preemie, which is pretty slow. Um, but when I gave it to her, she was inefficient. She couldn't get anything out. So she was sucking like eight times before she could swallow, which. It's not, that's not efficient, it's not functional for a baby. So I went back to the preemie. I tried to do strategies like nipple half filled and pacing, didn't work, coughing, changing, clear signs of aspiration and distress. So I stopped the [00:27:00] feed and I said, I'll come back at the next one and I'm gonna see if I can find a different bottle system that hopefully the flow rate is between the ultra and the preemie. So we're hitting somewhere in the middle. So that was the plan. So I come back, so this time I'm, I try all the Avid bottle system. So they've come out with a new nipple flow rate and, um, we're still all the feeding therapists here, still trying to figure 'em all out. But I try the two slowest flow rates and she still gulped, face turned color desaturating. Um, so I stopped that, went back to the preemie again, tried to pace a little bit more, like literally every suck. I was giving her a break to catch her breath. Still coughing, oxygen dropping. So I actually turned to the family who witnessed all of this very stoically and I said, you know, I am gonna talk to the doctors, but I am gonna recommend consideration of a little feeding tube in the nose for just, you know, short term as she continues to grow and [00:28:00] her brain continues to develop. I said, she's still a little early, she may just need some more time. And they were totally on board.  [00:28:07] Kate Grandbois:  So as you're going through this process, at what point would you recommend an mbs?  [00:28:14] Virginia Weill:  So this kiddo, if I wanna say she was 36 and change, not even 37 weeks yet. So typically at our hospital, we don't recommend an MBS until about 38 weeks. Now, of course, Our kids, yes. Because we want them, we wanna maxi, I mean, it has radiation and we wanna maximize. Their neurodevelopment time so that when we finally do the modified, we're not setting them up for, you know, for failure in the sense of, uh, false positives for aspiration, or they still are so discoordinated because they're just still too early. Like we know that they're not gonna be coordinated and they're not gonna do well in terms of airway protection. So that's why I did not jump on the modified barium swallow study. So I [00:29:00] went out to the team and luckily they were rounding right then and there, and I told them everything. I saw what I talked to the family about, that I recommended the ng, and the doctor said no. And I said, oh, oh, okay. Well we can't continue to feed like this. It's not safe, you know, airways,  Kate Grandbois: why did they say no?  Virginia Weill:  Well, because they wanted to try thickened feeds. And I said,  Kate Grandbois: here we go.  Virginia Weill:  Uh, yes. And I said, thickened feeds for a kiddo under 38. Typically we don't recommend, just like we typically don't rec, recommend a swallow study for under 38 weeks. And they said, well, she's showing enough clinical symptoms at bedside that, uh, she's aspirating in, that she's in distress. So wouldn't she show those same signs with thickened if she were aspirating thickened? Because what I said is the, you shouldn't, if a, if a patient, whether it's an adult or a baby, is showing signs of aspiration, we don't, with thin liquids for example, we don't know if [00:30:00] we give 'em thickened. They may silently be aspirating thickened. So that's why we need to test using an instrumental swallow study to make sure that they're actually safe on the thickened. And certainly with these babies, a lot of times they don't have the mecca, the cough mechanism yet to tell us. That they’re aspirating, right? [00:30:17] Kate Grandbois: Tiny little ribs and they're tiny little muscles.  [00:30:20] Virginia Weill:  And the lor, was it the laryngeal? The cough reflux doesn't even develop until past 40 weeks. So if this baby is younger than 37 and coughing with feeds, she's probably aspirating a lot. But that's why I said I think we should hold off on thicken and just give her a few days with a feeding tube. And the team still wanted to do thickened. So this is a perfect example of, I said my, what I knew was evidence based, correct? Um, and I explained my rationale to why, but I also saw their side of, well, if she's showing such gross signs of, of aspiration with thin, wouldn't she show it with thickened? [00:31:00] Which I, I can't really argue with. I can say, actually, you're probably right. My gut is that she still would cough, um, or desaturate, or her face would change color. So I said, all right, at the next feed, I will try thickened feeds. And it was not cereal though. It was a, a formula that we use that's naturally thicker and she did great. I know. Kate Grandbois:  It has a happy ending.  Virginia Weill: She did a happy ending. I'm so glad to hear that. So that's, that's, I think the, the, the piece here is yes, you have disagreements with people and you may be wrong and they may be right, but at the same time you learn from each other, you know, and the patient really is, is the reason why you do all this and who you're protecting. And so as long as she looks safe and she doesn't drop her heart rate, or doesn't drop her oxygen, and she's taking her volumes and she's growing that I'm happy. And the medical team is happy. Right?  [00:31:55] Kate Grandbois:  It's a great example of leaving your ego at the door because you're not there to have an [00:32:00] argument or a pissing contest with another colleague, you're there in your case to save a little baby. Right. And you've mentioned a couple of reasons or a couple scenarios when you wouldn't offer thickened liquids. So if they're under 38 weeks, um, you mentioned that it can create distress with, with breathing or with the lungs. Um, and it's not indicated for other pulmonary reasons, but what's with the cereal? Why were we thickening with cereal?  [00:32:26] Virginia Weill:  Yeah. So back in the day we did rice and oatmeal all the time. And then, you know, arsenic became the big thing with rice and so everyone went to oatmeal. But, um, the big thing is a lot of babies in the nicu, um, their parents are able to either purchase donor breast milk or they're able to pump themselves and have breast milk or chest milk. So we can't thicken breast milk with cereal because of the amylase enzyme breaks down the cereal or the carb. In the mixture, [00:33:00] which then reduces the effectiveness of the thickened liquids. Does that make sense? And  [00:33:05] Kate Grandbois:  that's unique to breast milk and chest milk.  [00:33:07] Virginia Weill:  Just breast milk and chest milk. Yeah. Oh man. That's like a cereals of carb, and so that enzyme breaks it down. So literally we've seen it when I first started, you know, they would do it a little bit more often, and you would see the breast milk and the cereal, and then thick, and then all of a sudden in five minutes, thin all broken down. Interesting. It's very interesting. But that's the reason why we should not be using cereal with breast milk.  [00:33:30] Kate Grandbois:  What if it's, um, formula?  [00:33:34] Virginia Weill:  Formula is okay.  [00:33:36] Kate Grandbois:  To thicken with cereal. For those of you listening at home, she's grimacing while she's sitting. [00:33:43] Virginia Weill:   I, I know. Even with my mask on the doctors know. Cause I can tell by my eyes I'm grimacing Um, yes. So, you know, we weigh the pros and cons of using cereal. Um, it adds in a lot of unneeded carbs in terms of the [00:34:00] microbiome of the baby. So nutritionists, um, or the dieticians don't love it, um, because it may set these kiddos up if, you know, they're on the cereal for long term, for a high rate of diabetes, obesity, you know, down the road, which we try to avoid. Everything we do now is impacting these kids later in life. So that's why we really try not to use. That being said, with current, uh, manufacturing issues, a lot of the formulas that we use to thicken, well actually the formula we use like nil AR is not being produced right now. So families literally are going to 10 different Walmarts and 10 different targets to try to find this formula. And so this discussion tomorrow that I'm having with the physician and the, um, the dietician is, well, the family can't find it. We need to have another option. We need this baby to gain weight. So cereal is what we're gonna do. So that's, so yeah, cereal can be used, but it, pros and cons of it need to be discussed with the medical team and with the family so that they're aware. [00:34:59] Kate Grandbois:  What, is [00:35:00] there a reason why you are not thickening with other traditional thickening agents that you would use in the hospital for, for adults?  Virginia Weill: Like simply thick?  Kate Grandbois: Yeah. Is that a silly question? Virginia Weill:  No, not a silly,  Kate Grandbois: it's clearly me showing my, I don't work in a medical facility.  [00:35:18] Virginia Weill:  Great question. So we're actually working on a thickening guideline right now for our neonates and then also just our pediatric population. So yes, absolutely. There are tons of thickening agents out there that I love and I highly recommend, like Simply Thick, for example. It's a beautiful gel that just dissolves, um, super expensive though. Um, or another xantham gum based powder, uh, like Thicken Up. Clear. I love that. That's powder pretty cheap. Families can find it on Amazon. The problem is you can't recommend those younger than 12 months of age.  [00:35:52] Kate Grandbois:  Interesting. For dietary reasons? [00:35:54] Virginia Weill:  Dietary, but also gut. So they, um, there was a recall [00:36:00] Ooh, years ago, right? I think when I started working, um, on a certain product because they, they were, it was being used in neonates and it caused NEC or nec, necrotizing enter colitis, which is basically part of the, the gut dies and some babies actually passed away. So that's why thickening agents really got strict on what age, um, you can start to use it because of the impact on the gut.  [00:36:29] Kate Grandbois:  I'm glad I asked. I'm sure it wouldn't happen in any nicu, but that, that seems very, very serious. [00:36:36] Virginia Weill:  Yeah. And actually Gel Mix is another product that came out. I'm not endorsing any of them, I'm just saying what's out there. Um, but Gel Mix just came out and that's a Cara Bean based thickener. We can use that in breast milk actually. But, here's the but, you can't use it in kids younger than 42 weeks or um, 42 weeks and they have to be six pounds. Okay. [00:37:00] So a lot of these babies that we see usually are younger than 42. And so we have to try to find something like NL AR to use instead cuz we gotta wait until they hit that 42 week and six pound mark to try all the, the gel mix with moms. [00:37:13] Kate Grandbois:  So there's a pretty narrow window of application for that. Yeah, that makes a lot of sense.  [00:37:20] Virginia Weill:  But a lot of hospitals are using it appropriately, you know, for when those babies reach that age.  [00:37:25] Kate Grandbois:  Okay. Are there any other reasons to not use cereal for thickening?  [00:37:32] Virginia Weill: No, I would say it's not in breast milk. Cause it breaks down the carbs, it breaks down the cereal, so you have an inconsistent viscosity and then, um, it's just a lot of carbs and a lot of calories, empty calories that messes up their gut biome, I mean, and sets 'em up for potential issues down the road. [00:37:53] Kate Grandbois:  Okay, so earlier in this conversation we were talking about. Before we got into the thickening and other interventions, we were talking [00:38:00] about, um, the assessment piece. And this is when you shared the, the clinical story with us about this baby who I'm so glad, had the positive outcome and did well. If there are instances where you, or, or I guess are there instances where you do recommend an MBS and have other unwanted outcome? Like you go through an MBS and they need a persistent application of an NG tube?  [00:38:33] Virginia Weill:  Yes. So the hard parts of my job are when I have to say to the family, I'm not recommending that he consistently take the bottle or be allowed to have a full volume, or I am gonna recommend a G-tube or a longer, longer means of nutrition. Usually how I put it, um, I will say 99% of the time, I personally do not recommend strict NPO due to aspiration, [00:39:00] which I know is a very, um, controversial discussion topic between pulmonologists and the speech pathologist. And I'm sure it's different at each, um, hospital in between clinicians. Um, but I come from the background of, you know, if you, if I see aspiration on a mbs, on a baby, on a NICU baby, and I say you strict npo, how are we going to practice in this key timeframe that their brain is still developing this whole suck swallow breathe. How are they gonna practice if they can't eat anything? So what I've, you know, brought to our institution or supported it, is small volumes. So I actually have another case that I can talk about specifically about mbss, where, uh, I limited, I limited his volumes to 10 mls, 15 mls, 20 mls until he got better protected his airway better, um, and could prove that [00:40:00] his lung status wasn't being impacted by potential aspiration. [00:40:06] Kate Grandbois:  Okay, that makes a lot of sense. So, moving into our third learning objective, you've got this fancy word in here, strider. I know what it means. But I wonder if you can tell us a little bit about what it is. [00:40:16] Virginia Weill:  Yes. So this is one of my, um, uh, I don't say like pet peeves, but it's, it's something that always I wanna educate everybody on. And I actually am doing a talk for our hospital soon, and this is one of the things that I'm talking about.  [00:40:30] Kate Grandbois:  You brought a, so you have a soapbox. You brought the soapbox with you,  [00:40:32] Virginia Weill:   Yeah.  [00:40:33] Kate Grandbois:  So get on it. Get on up there.  [00:40:35] Virginia Weill:  Yeah. So, uh, let's see, Strider. So Strider is that squeaking sound that you hear, so I'm going to imitate it cuz people say, do a good job of it. It's that. So you can hear this when you're changing their diaper and they're crying. You can hear this just when they're sleeping, sometimes on their back, if their tongue is a little bit more floppy or their jaws recessed a little bit, you can hear like, you know, [00:41:00] like deeper sound. Um, or what I focus more on is the feeding piece of when you just hear strider with feeding, what does that mean? Why aren't you hearing it throughout the day or throughout the, the care time with the child? And you know, I, because I'm on Aerodigestive team, I see some of these outpatients referred from pediatricians for laryngeal malaysia because they have strider and the ENT scopes and there's no laryngealmalaysia,  [00:41:28] Kate Grandbois:  okay. To level the playing field. Give me a reminder of what Ingal Malaysia is.  [00:41:32] Virginia Weill:  Laryngomalaysia is basically a floppy upper airway. So you have Laryngeal Malaysia, tracheal Malaysia, and Barco Malaysia. Okay. And sometimes you can have all three. Okay. Um, and usually what I, um, deal with, if I can put it that way, more is the LaryngoMalaysia. Cuz people wanna know why are they squeaking so much? Um, is it airway protection? Is it a vocal cord out? [00:42:00] Um, you know, in the cardiac babies who have surgery, they hit the recurrent laryngeal nerve sometimes just to move it around to get to the heart and it tweaks a vocal cord so the vocal cord doesn't move all the way. It's kind of paralyzed in a specific position and that kiddo's gonna have strider as well. So anytime, I guess my big takeaway for this is anytime you have a patient, whether it's a neonate, outpatient, pediatric, and you hear strider, ask an ENT to take a look and see what is the reason for the strider, because it is not always laryngo malaysia. Okay. I had one kid, um, I saw a kiddo on pediatrics. She was older, like a few months old. Came in for actually failure to thrive, meaning just her weight isn't good. Um, and I was feeding and I heard this strider. I'm like, no one's mentioned this. And so I brought it to the residents and they said, oh yeah, let's get ENT to come take a look. She actually had a paralyzed vocal cord and they had no idea why. She had never [00:43:00] had cardiac surgery or no two cords. Both of her cords were paralyzed and like this kind of the between middle and uh, open and closed paramedial position. And, um, so thank goodness, you know, they did an MRI to make sure she didn't have any neurologic involvement, which thank goodness she didn't. But, you know, ENT then continued to follow her about every three months and rescope her just to see what was going on with her vocal cords. So like that's, again, you've gotta get ENT involved and have them take a look at these kiddos. [00:43:27] Kate Grandbois:  That's so interesting. So is it, just to say this back to you to make sure I've understood, it sounds like any time there is strider, it warrants a referral to ENTTo get scoped. Virginia Weill:  Yep. Same with, yeah. Yes.  Kate Grandbois: And you would say that for even, would you say that for babies outside the nicu  [00:43:49] Virginia Weill:  Yes. Everywhere. Any infant full term, just going to the pediatricians. Um, kiddo. Yeah. Any, even if you're visiting your friend who just had a baby and [00:44:00] they're feeding and all of a sudden you're like, wow, that kid sounds like a mouse over there. I don't know if your friend would be open to it, but you would say, Hey, has your pediatrician recommended an ENT consult because you don't know why the baby's squeaking and you'd wanna find out.  [00:44:15] Kate Grandbois:  Interesting. Okay. Okay. So you've gone over two possible etiologies of strider in infants. Um, you've mentioned to us all of the reasons why we should be concerned about a potential strider and when to refer. The answer is 100% of the time.  I, I know that you have some other case studies that you brought to us. Do you wanna walk us through those? Sure.  [00:44:39] Virginia Weill:  So one of them kind of goes back to, um, your MBS question in the NICU and when it, when you redo them. So I guess another one of my soapbox things besides strider is mbss. They are not a pass or fail, and I. Even some of my, uh, [00:45:00] colleagues will say they pass and I turn to them and I say, it is not a pass or fail. I don't know what you're, like. You are smart. Stop saying this. Um, and a lot of physicians will just say, both in the adult world and the pediatric world, well did they pass? And I said, there's no pass or fail. It is, you are assessing. Our job as a speech pathologist is to assess the biomechanics of the swallow. You know, you are providing the team basically a risk level of whether you think airway compromise is gonna happen and why. And I think you always have to ask yourself, why am I seeing what I'm seeing? Sure. You can list residue, you can list, you know, material in the nose, up in the nasal cavity. You can list aspiration, but that doesn't tell the treating therapist or the physicians why this is happening. They wanna know what can they do to help prevent this in the future. So I think that's where we really need to not, you know, minimize our role in a [00:46:00] patient's medical workup. We have a huge advantage here to really show the family, the patient, the medical team, what we do and how important it is in the health of the patient. Um, it's, you know, mbss are just a moment in time, so I'm just looking at my little dots here. My bullets, mbss are not, are just a moment in time. So if you see aspiration, great. If you don't see aspiration, it doesn't mean it's not gonna happen or it's not happening. Same with reflux cuz so many res, so  Kate Grandbois: great reminder. Mm-hmm. .  Virginia Weill: Yeah. Reflux. Well first of all, as swallow study is not a test for reflux, but if we see it, great. If we don't see it doesn't mean that your child doesn't have reflux. And I always have to say that to families. Just cause we didn't see it doesn't mean it's not happening. I believe you, your story, I believe you, you know,  [00:46:45] Kate Grandbois:  and how validating that must be. I think the, the, the quote that you just said, that it's a snapshot of a moment in time is such a good reminder of what that test actually is and does. [00:46:56] Virginia Weill:  Yeah. So, um, kind [00:47:00] of, so talking about, uh, mbss in the nicu, like I talked about before, we usually don't complete them younger than 38 weeks, but of course there are those outliers. Um, and of course we've completed them before 38 weeks, but that's kind of our, our our time. Okay. Um, we usually recommend a swallow study once we've trialed all the other strategies at bedside and we're still concerned about airway compromise. So in that first case study that I talked about, the thickening kiddo, if she had been older, if she had been 38 or 37 and change, I probably would've said, let's do a swallow study. Let's take her down and let's really see what's going on. Um, because she was showing so many overt signs of distress at bedside. Um, we try to complete the swallow studies at around a feed time. So in the nicu, babies are fed on a certain time schedule every three hours typically. And so we try to complete the study at that time so the babies are hungry and then they are awake and rooting and engaged in the feed. Um, we feed the [00:48:00] baby downstairs and fluro in the same position that they're gonna be fed upstairs and at home. So we're really, yeah, we're really mimicking. We're trying to the best we can, what a natural feed looks like. Um, and then I have the family or the nurses bring down all the bottles that the babies are using or could use or have brought, you know, have trialed at bedside. Just who knows, you know, maybe with an AVMP bottle they're aspirating, but with the Dr. Brown, they're not. So I have all those bottles down there to try. Um, and I think, you know, I know Boston Children's does this and so we've started to do it too where, um, certainly with Dr. Browns, we give them a new nipple for every swallow study so that we're standardizing that flow rate even more. So some kids babies will use the same ultra preemie nipple for two weeks, but if they come down for a swallow, guess what? Whoop, you're getting a brand new one so that we know the flow rate is perfect. [00:48:51] Kate Grandbois:  Okay, that makes a lot of sense [00:48:53] Virginia Weill: . Yeah. Um, and then in our NICU kids, sometimes we have a [00:49:00] very small window of a couple minutes that we have this baby with enough respiratory support to actually feed and go to get a good assessment. So I know, um, I think, you know, researchers are working on the baby imp, which is similar to the MBS imp, which,  [00:49:16] Kate Grandbois:  what's an imp What, what is the imp?  [00:49:18] Virginia Weill:  It's a profile Impairment Profile, , and it's a standardized assessment.  [00:49:24] Kate Grandbois:  I don't mean to put you on the spot, but it is an acronym. Yeah. That refers to an assessment measure. [00:49:29] Virginia Weill:  Yes. And, uh, okay, don't, okay. I'm not great with adults, but I believe the mbsm is a standardized way to complete swallow studies. Okay. And so now they're trying to create,  Kate Grandbois: you know more than me, keep going,  Virginia Weill:  now they're trying to create a baby imp. Okay, so, um, where was I getting? Oh, so I, so I know like you're supposed to, you know, start with a certain consistency and kind of go from there. But with NICU babies you have, like I said, maybe a couple minutes of time and [00:50:00] you gotta use it to the best to gain as much information as you can in that two minutes. So, for example, this kiddo that, um, we did this swallow study on he upstairs showing overt signs of aspiration, pulling off the nipple, coughing, random desaturations, random heart rate drops. [00:50:20] Kate Grandbois:  I would be terrified. I'm, I'm having secondary fear just listening to this story. Keep going.  [00:50:25] Virginia Weill:  Uh, so we,  [00:50:26] Kate Grandbois:  it is very, going back to what you said at the beginning, it's a very intense environment. It is giving credit where it's due.  [00:50:32] Virginia Weill:  Um, so we knew he was likely aspirating within liquids, but our question was, is he safe on thickened? So I started that specific swallow study with thickened liquids because I knew I had my two minute window to get the information I needed. And sure enough, we did it. He, we got a good assessment downstairs on the thickened. Um, unfortunately he was aspirating it. Um, and he, I then had time to still do thin liquids under fluoroscopy [00:51:00] and he was aspirating that. But this is a perfect example of, I cleared him for very minimal amounts of PO. Meaning by mouth. Um, and I got, I got pulmonary involved, got him on some oxygen to help with his worker breathing and his tachypnea and tachypnea just fast breathing.  [00:51:18] Kate Grandbois:  Um, thank you for defining that. You knew that was coming out of my mouth in two seconds. [00:51:21] Virginia Weill:  Yeah, you're, um, and then, I mean the, the end for this kiddo, he went home actually with an ng, so I did not recommend a G-tube for him. I thought he just needed a little bit more time, maybe a few weeks and then he could probably get his act together.  [00:51:39] Kate Grandbois:  So through, at, even after you recommended the NG tube, was he still cleared for small amounts just to sort of keep up that positive relationship with oral motor movement, sex, swallow, braid, all of that kind of stuff? [00:51:52] Virginia Weill:  Exactly, yes. And the other positive thing is, um, I forgot to mention before, um, a lot of the kids who [00:52:00] I, who are aspirating, but I let them have a small volume, it's because they're on breast milk. Okay, so the breast milk, not the pulmonologist like me to say this, but it's a bodily fluid that the babies already know. So if it's going into their lungs, their lungs already know what breast, what that breast milk is, and they don't react as much as to a formula with rice starch.  Kate Grandbois: Is that's true.  Virginia Weill: Yeah. So, um, like in the adult world, you know, think about the Frazier water protocol. I dunno what that is, right? Oh, okay. Um, I think it's, you know, like if you have, you have to fit all this criteria, but basically you're allowed water, free water knowing that you're gonna aspirate a little bit of it. Same thing with ladies. You don't have protocol, but the pulmonologist say, okay, Ginny, if he is on breast milk and you're limiting the volume, I'm, I'm okay with him having a little bit to keep up the.  [00:52:53] Kate Grandbois:  Okay. That's so interesting and makes a lot of sense.  [00:52:56] Virginia Weill:  Yeah, I mean, that's what we do here. So, I mean, I don't know what other hospitals, I [00:53:00] know other hospitals can be a little bit more strict in terms of no strict NPO we need to protect the lungs at, at any cost. But I think, you know, we compromise a lot here and hopefully to benefit the patient.  [00:53:11] Kate Grandbois:  Well, and I think the takeaway is if you're listening and you're an SLP either in a NICU or interested in getting into a nicu, at the end of the day, this is really about collaborative medical decision making, um, and working within the, the practice of, of your workplace setting. So don't worry, we, we know that the information you're giving us is not the end all and be all of what you should, what should've do. These are all case by case decisions, um, made with the rest of the medical team. You have covered so much ground with us today, and before we wrap up, I just have two questions. Okay. The first question is about something you mentioned at the beginning of this episode, um, related to the role of the slp, which was working on communication in a nicu, communication and language. And I'm a pediatric therapist. When [00:54:00] I, when my, my intervention is games and activities and, you know, I've got my, my bubbles and my star charts and, and whatever I've got pulled together. I'm having a really hard time imagining what communication and language intervention looks at, looks like in tiny, tiny babies, number one, but also in a really intense medical environment. So can you tell us a little bit about what that looks like?  [00:54:26] Virginia Weill:  Sure. That's a great question. Uh, so funny, I'll start it with a funny thing. Um, when I enter the room and meet the family for the first time, I say, hi, my name is Ginny. I'm one of the speech pathologists, and then I say, who focuses on feeding? Because I've had so many parents say, you're a speech therapist. Well, my kid's not talking. Like, you don't need to teach them anything. Yeah. [00:54:49] Kate Grandbois:  My, my tiny baby is, is 30 weeks old. Yeah. I'm not sure why you're here .  [00:54:52] Virginia Weill:  Literally, and I totally get it.  [00:54:56] Kate Grandbois:  I mean, it's related to my question, like, what does that even look like?  [00:54:59] Virginia Weill:  Yeah. So, and [00:55:00] I, so I, first I start out, if they do say that I, you know, gently start sarcastically, respond back with actually I'm helping you learn the communication that your body or that your baby is giving you, you know, by the hand going up, the baby, turning their head when you give them the nipple, that's communication between the baby and to you. Um, and then the other piece of it, uh, is just. Having the babies listen to the adults talk, just the exposure to language. I know a lot of bigger hospitals are starting reading programs where volunteers just go into their room and they read books just out loud so the babies can hear language and not hear the beeps and the alarms all go on off all the time. Um, and you know, for us, when babies reach a certain age, we kind of put them in baby rehab. We call it baby steps program, where we give the families boxes, little Tupperwares full of books, rattles, um, sensory those soft [00:56:00] books that, you know, scratching  Kate Grandbois: the crinkle ones.  Virginia Weill: Yeah, crinkle. Yeah, yeah, yeah. Um, and so I think it's at 42 weeks they start to do that. And the nurses, the families, the therapists, the volunteers hold the baby and they literally are reading the books to these kids.  Kate Grandbois: That sounds like so much fun.  Virginia Weill: It is so much fun. The families love it. They love seeing their baby Almost normalize cuz we have them on a mat doing be tummy time, you know? Um, and then even for the older kids, like sometimes, you know, tra to invent kiddos are with us for a longer period of time, we can start to actually work on signing, you know, working on imitation of blabs. I mean it's hard with the mask, but, um, parents. Um, working on gestures, you know, if the baby wants to get up, you know, lifting the arms up, you know, so then we kind of get more into the conventional communication, um, when the kiddos are older. But yeah, with, they're younger, it's just the exposure, exposure to language stimulation. [00:56:56] Kate Grandbois:  I, I really appreciated the description [00:57:00] of listening to human voices instead of beeps because it really sort of paints a picture in my mind of this sterile medical environment, you know, with the machines and the tubes and the plastic and the fluorescent lights and, and all of those kinds of things. And when you think about that in cont in contrast with how quickly these little brains are developing and how much they are absorbing something small, something as small as focusing on making sure that there is spoken language in the room could be, I have to assume a really big step. A really big deal.  [00:57:34] Virginia Weill:  I went to, um, one course years ago, and I can't remember what hospital it was, but they actually had a routine that when the nurses did handoff, they did it in the baby's room. So the babies, like, you're just adding to the amount of language and voice. Positive stimulation that these babies are listening to. And I just, I love that. Obviously it stick in my mind. It stuck in my mind. Um, but I, yeah, so I love it when hospitals do [00:58:00] things like that. [00:58:00] Kate Grandbois:  Yeah. That's awesome. Okay, so my second, my second question, which is my last question. Can you tell us a little bit about what an SLP can do if they are interested in working in a nicu? So, in all of, I'm somewhat familiar with the app, with the ASHA demographics data, just because I look at it all the time for other things and I, the NICU is not listed on there, there, I have to imagine that there are not a ton. Of LPs who are employed in a nicu. So if anybody is listening and wants to get into this workplace setting, what would you recommend? [00:58:36] Virginia Weill:  I would say, um, first just from my own experience, getting medical experience in general, getting into the hospital, whether it's adults or pediatrics, so you can learn, can I thrive in this environment because outpatient is so different from, so different. Um, so once you have experience in the medical setting, getting some pediatrics, so you're starting, you're starting this, you know, [00:59:00] broad and you're gonna start narrow, narrow narrowing your, um, experience. Um, and I found this, and I can post this later as a handout, but I found this on one of the journals. Um, they talked about a minimum of three years of experience practicing as a speech pathologist in the pediatric setting. It's highly recommended specialized mentoring in neonatal therapists, whether it's in, in neonatal therapy, whether it's in person or online. Um, initial and ongoing participation in peer reviewed education specific to neonatal therapy is necessary for safe and effective practice, um, and mentoring mentor practice hours and established competence in the nicu. Um, so I think it's,  Kate Grandbois: is that in an article,  Virginia Weill: uh, it's a journal, a perinatology,  [00:59:48] Kate Grandbois:  we, would you mind sending us that reference and we'll put it in the show notes for anybody who's interested in reading further? [00:59:53] Virginia Weill:  Absolutely. Um, and so, you know, I think I, I, and I admit it, I was very lucky the [01:00:00] stars align in how I got to where I am today. But I know that people have to work super hard to get into the nicu and it's exhausting. So if you, you know, have the pedia medical, you're in a hospital setting, you have that check that box, then you get into pediatrics, you check that box, you know, and being in a medical setting, a lot of what you do is feeding and swallowing. So you need to make sure you have good experience with that. Um, and yeah, you know, finding a good mentor too is really important.  [01:00:31] Kate Grandbois:  That's awesome. Thank you so much for sharing all of your knowledge with us today. We're so grateful for all of your time. This has been so, so wonderful to anybody who is listening. And if you're out on working out or folding your laundry or commuting, we will have all of the references and resources listed in the show notes. Um, they will also be listed on our website. Ginny, thank you again so much for being here.  [01:00:57] Virginia Weill:  You're very welcome. Thank you for inviting me.[01:01:00]  Closing [01:01:00] 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 March 13th, 2023. The podcast episode is offered for .05 ASHA CEUs. 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] 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 nerdcaster10. A link for membership is in the show notes.  Episode [00:01:41] Kate Grandbois:  Welcome everyone to today's episode. We are so excited to welcome back a guest who has been on our show before. Welcome Dr. Ali Arena. You are here today to talk to us about the use of improv and therapy, and I'm so excited. Welcome back to the show.  [00:01:58] Ali Arena:  Yeah. Thanks for having me. I love [00:02:00] being on with you guys  [00:02:02] Kate Grandbois:  Before we get started, and you, uh, put me through some very uncomfortable and awkward games and put me on the spot that you, that you gave me a warning about. This is gonna be an entertaining one, everybody. Yeah. Um, why don't you tell us a little bit about yourself and how you came to know improv.  [00:02:19] Ali Arena:  Yeah. Okay. So it's actually interesting. I wanted to take improv cuz I was reading a trauma book and it helps you feel more in your body. The thought of being put on the spot was terrifying, which kind of made me be like, wait a second. I do that to my clients all the time cuz I'm asking them open-ended questions cuz that used to be a goal I would always have for people. Right? And so I found improv through one my cousin, she does it for a living. And then my really good friend, Maya Watkins, who I will refer to a decent amount in this presentation, she teaches it specifically for Neurodiverse children. [00:03:00] So her and I had paired up because she was, oh, you work with Neurodiverse children, so do I. Let's run a group. And I really saw the power of not running a typical social skills group, right? I really saw the beauty in not having all the structure going with the flow. So things that we're actually trying to teach these kids, but we don't model all that often. Um, and I've just learned you know, improv is a pretty good rapport builder because, I'm gonna kind of put you on the spot, Kate. It's a little uncomfortable and it's good. It's kind of nice for, you know, your clients to see, oh, you can feel uncomfortable too, or We're learning together. So, I don't know. I just found it a great tool.  [00:03:43] Kate Grandbois:  I am a creature of comfort. I don't like change and I like to be in my routine. I'm already feeling a little nervous about what you're gonna, what you're gonna do, but I think you make an amazing point that this is what we are asking people to do when [00:04:00] they learn in our therapy rooms, is to be vulnerable and be put on the spot and have to engage in something new and different that makes 'em uncomfortable. So I'm here for it. You're gonna coach me through it and everything is gonna be fine. It's gonna be great. Um, before we, before we get started, I do need to read our learning objectives. So learning objective number one, identify the four competencies of the improv method that foster interpersonal relationships facilitate healing from trauma and that relate to neurodiverse minds. Learning objective number two, identify three games that correlate with your specific therapeutic interventions, and learning objective number three, identify the three core qualities of the improviser's mindset. Disclosures, Ali's, financial disclosures. Allie received an honorarium for participating in this course. Ali's non-financial disclosures. Ali has no non-financial relationships to disclose. Kate, that's me. I am the owner and founder [00:05:00] of GrandboisTherapy 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 with the corresponding speech pathology and applied behavior analysis special interest group. Okay, we've gotten through the boring stuff. I think we should start with you telling us a little bit. Improv. So when I think of improv, I think of Saturday Night Live, I think of Second City, I think it's called. Yeah. Cool. Um, the school that teaches the famous school that teaches improv, um, I think of standup comedy. I don't think of intervention. So tell us a little bit more about what improv is.  [00:05:48] Ali Arena:  Yeah. So it, it is exactly what you're saying, right? Improv is truly being in the moment and being flexible. So a big part of improv is a concept called, Yes, and [00:06:00] so , um, I wanna go out this weekend and I wanna have pizza. Yeah. And we should do this other thing. The other big part about improv is you can't be wrong. So it's not, um, yes. And I wanna go pee, get pizza, and then go to a circus and someone can't go, no, there's no circus this weekend. You can't do that. There's no, you don't call people out. You really have to go with what a person is saying. So really talented improvisers, um, Will Ferrell, Steve Corell, these people The Office. A lot of that's improvised. You have to realize they're really present and they're just listening to what the person is saying. Taking that and making another thought with it. Um, and you, when you look at that, that humor is so amazing cause it's so simple. They're not doing anything crazy. They're just being present, being flexible, and they have enough knowledge to keep going back and forth in a conversation. So if [00:07:00] you think about therapy, what we're really trying to do is help our students, clients, whatever words we wanna use to be more present, to have reciprocal conversation, to have more flexible thinking, to take perspective. And these are all things that an improviser is doing, but they learned them. Yes I think some people have a natural skill, unlike you and I who are , oh my God, don't put me on the spot.  Kate Grandbois: Please don't talk to me. Ali Arena: But they still, they have learned these skills over time. Um, another thing about improvising is, You have to be pretty good at reading people's body language. You have to be okay with the unexpected. That is what improv is. Um, Tina Faye in her book, Bossy Pants, I don't know if you read that, talks about, I've seen it, I haven't read it, talks about how improv is The secret weapon and how, um, she talks about how the, lipstick basically someone just made that up, that's a creation that [00:08:00] someone was, oh, I'll just put in this little tube, and then women could put it on their lips. She'd be, that's a form of improvising. It really is just taking a concept and continuing to go with it.  [00:08:10] Kate Grandbois: I love the component of not being able to be wrong. I think that alleviates so much of the pressure and insec, I, I'm speaking for myself here, the pressure and insecurity that you might feel when you're in a vulnerable position doing something new for the first time, and you don't wanna upset anyone. You don't wanna say something, quote stupid, you don't wanna be made fun of. You don't wanna, you know, there's all of this insecurity and worry about your actions. So if one of the rules is that you can't be wrong, How much more fun is that that really alleviates so much of that pressure to perform, I guess. [00:08:46] Ali Arena:  Yeah, and it's, you know, uh, schools are now using improv a lot as processing groups. With Covid, they would use it, um, they would just kind of have these classes where they play games and we're gonna play a game [00:09:00] together. And it's more, you'll be surprised what kids will talk about, I did this, two or three years ago, and a lot of kids would say Trump. They'd be, Trump, Trump, Trump. And they were using it to be funny. But over time they were also saying other words, uh, , nuclear war, financial distractions. Oh my goodness, oh, okay. So if this is what you're saying in improv, this is what's on your mind, right?  It, sometimes kids do it for reaction, but other times you're , that's the thought that came to you that quickly. You are really thinking about this. So improv can also be a really good way to see. What's on someone's mind, right. If you, if you and I played in [00:09:38] Kate Grandbois:  sort of like a free flow sort of stream of consciousness. Yes. Interesting. Yeah. Okay. So how is the improv method as an intervention technique different from improv in general or, you know, as a general concept?  [00:09:57] Ali Arena:  So I think with the [00:10:00] method, what, um, I did and, and Maya Walkins, she's a social and emotional, uh, counselor and teacher, and she created these games. So I just wanna give her credit as we started to play. But her and I really sat and we’re, okay, what are things that we're constantly working on with the kiddos that we see. And we realize, we talk about self-agency a lot. We talk about executive functioning, we talk about interpersonal skills, and we talk about boundaries. But if I were to sit with you and I was, okay, Kate, we're gonna talk about your boundaries. Are you following your time boundaries or do you have social boundaries? You would be like, no,  [00:10:33] Kate Grandbois:  I just fell asleep. I'm not here anymore. I don't wanna be here. [00:10:35] Ali Arena:  And also, you can't say the word boundaries to a five-year-old.  That doesn't do anything. Right? Right. So we realized, okay, if these are things that we're talking about all the time, let's just create games that correlate with them. That's really what the improv method is. and I love it for my Neurodiverse kids and anyone who's had a decent amount of trauma [00:11:00] and typically my trauma and Neurodiverse kids are, they're both a lot of times, right. But because if you think about someone with a neurodiverse brain, they often struggle with being in the moment and attending cuz they're so in their head. They struggle with black and white thinking. They struggle with perspective taking. So if you're creating games that directly relate to these, it's just a different way to have fun in therapy. Um, I don't know, do you know who Esther Parrell is? She's a famous psychologist. She is, um, I love her. She has one of those amazing therapies, soothing voices. She has a great podcast, but her whole thing, she does a lot of couples counseling, but she just created a game and she did all this research about, essentially play is what's healed a lot of couples, not intensive therapy going back and forth with checklist checklists. It was play. So that's where the improv method has come from.[00:12:00]  [00:12:01] Kate Grandbois:  Okay. That's awesome. That's really, really helpful. I'm wondering if you can tell us a little bit about, um, whether or not this intervention is used only in direct service from if in in, in other words, if we have people who are listening and thinking, okay, this might be a really nice tool for me to use in my sessions. Is this something you can do one-on-one? Does it require a group? I'm thinking about, you know, what I've seen in improv, I, I guess commercially, it's almost always a group of individuals, but is this something that you can easily incorporate into your sessions regardless of what kind of service delivery model you have? [00:12:39] Ali Arena:  Yeah, so I definitely, I love group, um, purely just cuz you're getting more answers, right? Or you're getting more responses. But I do try to do improv a decent amount in my individual sessions as a continual rapport. Loosen up sometimes with my ADHD kiddos when they've just [00:13:00] gone, you know, to another place. I try to bring 'em back with, um, an improv game. So I love this one game. I'll do one right now. Um, that's called. Zip zap zop. Right? And literally when I get to zop, you would turn and you and I would say a word, right? And let's say you said, Chocolate and I said Milk, then we're gonna turn back around and go zip Zap, zop and see if we can get a word that's almost the same. So most likely you and I would say chocolate milk, but sometimes someone might say Spider-Man. And I might say, I [00:13:34] Kate Grandbois:   was gonna say this sounds maybe harder than . [00:13:35] Ali Arena:  Yeah, no, for sure. But  Kate Grandbois: I think sounds harder than maybe. I think it is,  Ali Arena:  yeah. I mean, look, I think again, so you're not gonna be wrong, but you're also a clinician. So let's say you do three rounds of that. You're still saying , you're trying and the kid's maybe not picking up on it. You're like, you know what? We need a new game. Let's try something different. Right. Okay. Um, so it's, again, it's, it's showing [00:14:00] that flexibility. I love when I'm doing improv with a client and they're quicker than me and I'm like, oh my God, wait. You, this is a part of your brain I haven't seen. So that's another cool thing about when you're doing it individually, you might see strengths you didn't know they had. Um, there's a lot of research. I think it's even in our stuttering research, right? When kids are sort of acting or they're in a different form of themselves, you'll see a different version. They're able to turn off some of those other barriers and you can see them really blossom. So I think, I think therapists have played games similar to this. Let's tell a story together. So a princess went to the forest and then, and you can have a kid fill in, right? and then you keep going back and forth. So that's improv. It's, it's being flexible. The other thing, and I should have said this at the beginning, improv does not require supplies. So that's why it's so beautiful for group. It's great for [00:15:00] camp, it's great for parents in the car, right? There's no, you don't have to ha, there's no materials to do improv. It is all imaginary and it's all on the spot.  [00:15:10] Kate Grandbois:  That sounds awesome. Yeah. I'm looking at our first learning objective. Do you have in, in these four competencies? I, I feel like you've mentioned. You must have mentioned a handful of them already or some of them already. Do you have a list, like a concrete list of the competencies that go into successful, the successful application of the improv method? [00:15:33] Ali Arena:  Yeah, so again, it's hitting self-agency, executive functioning, interpersonal skills and boundaries, but so, What I do have is, I mean, we could go through, could I do a case study with you really quick to give you an example of, okay, so we're gonna talk about Paul. Paul is 32, he is autistic. He also has some childhood trauma. Um, he is, uh, [00:16:00] in a lot of ways he is done really great. He's a personal trainer, but he's ready for more of a corporate job and he realized he's actually really good at coding. Um, so now he has to start interviewing. So originally I did the old school, okay, let's practice an interview back and forth and I'm gonna ask you questions and you're gonna tell me answers. And it was the most painful thing ever. He actually deteriorated. I was, wait, no, we've had better conversations than this. What's happening? And I think it's, I put him on the spot, right? So when I started to say things, Okay, let's just do, yes, and let's get you outta your head. Let's get movement going. Um, I would have him play numerous games and then we would start to do interview. He was much better. So, It with Paul, the fact that we did improv before his confidence increased, so I, it's kind of, it's a little bit like an ABA principle of shaping too, right? Okay, let's do a lot of things that you're gonna feel good and [00:17:00] successful at and confident before going into. Maybe more of a strategic interview. The other thing about not being wrong is really helpful. If he says an answer that I'm, okay, there's more. I can literally say, okay, yes, and tell me more about this and tell me more about this. And by the end, we had a full answer. So I guess the competencies it's, or the, yeah, the competencies is really, That you are looking at what your client needs to do social and emotionally and seeing what games you can pair with it. And I can give you Kate after a handout of games that match.  Kate Grandbois: That would be awesome. That would be awesome.  Ali Arena: Like YouTube videos, I think it's helpful for people to have a little bit of a reference, um, cuz it's hard vocally hearing someone do this. Um, and then I know you had also asked about just kind of , so what is the improviser's mindset right? And I think it's important to remember that an improviser is going to be flexible, [00:18:00] right? So they're, they're open, they're observant. And this is something that I think is really important as, um, clinicians, we forget this. We can say , okay, new choice. , so if someone's doing something that's not working, we can show, you know what? Let's do a new choice. Let's, um, this happens a lot. I don't know if you've ever been in a conversation with a client where, They've gone down a zone. Actually, I was just talking to a client who, um, was, is very upset about our political cl uh, climate, which fair, but he was going for a while, and so a little bit through it, I was, okay, you know what? We're gonna be flexible right now. We're gonna do a new choice of topic. And it's just such an easier way of saying, let's change the topic as opposed to, You've been on this topic too long and it's not, it's too long and you've gone too far. And we need to,  [00:18:47] Kate Grandbois:  which is so much negative feedback. I mean, that doesn't feel good, right? I mean that's, you know, criticism. Yeah. Use plain language.  [00:18:56] Ali Arena:  It is. And, but we, you know, I think as clinic, I'm guilty of [00:19:00] this, so I'm not like acting like I've never done that. I think we're taught so often to, our job is to support and in some ways correct. Right. So we might go into that mode and there's just, I think improv has taught me to be kinder and flexible in what I'm doing. So that's part of the improviser's mindset. So just adding flexibility. Um, and also when you kind of have this mindset, you're able to simultaneously teach and learn. And what I mean about that is you're able to, when you are being flexible, I think you're able to take in what your client's saying a little bit more as opposed to being so in your head of, okay, we did this goal. We have to move to this goal. And I've been there, we've all had crazy caseloads, but it just teaches you to be a little bit more flexible. The other big part of an improviser's mindset is receptivity. So it's patience to allow individuals to [00:20:00] practice the task at hand. Um, you have to trust your partner in improv. You have to trust the clinician. You have to trust other people, um, and you have to trust that everyone's being present in a game. And it also really talks about receptivity, is listening, responding, and modeling. So let's say you and I are playing a game. And you, you kind of say something that I'm like, whoa, that was a little wacky. I can model how to bring it back as opposed to, um, I am putting Kate on the spot. We did not rehearse this at all. Kate, what's your favorite? Um,  Kate Grandbois: here it comes. I'm ready.  Ali Arena: You ready? What's your favorite movie? But I want you to say something , Inappropriate. A movie that I would be , oh, we shouldn't talk about that one. [00:20:44] Kate Grandbois:  Um, let's see. Indecent proposal. Yeah.  [00:20:47] Ali Arena:  Okay. Oh, indecent proposal.  [00:20:49] Kate Grandbois:  Um, it dates me too.  [00:20:52] Ali Arena:  It's fine. Moving on. I could be like indecent proposal. Proposal. Isn't that when people get married? Who hears a movie where people [00:21:00] get married? Right. So it's just , Moving it and I'm modeling a different way to talk about something. Okay. I'm also modeling an appropriate transition. Um, but I, the receptivity is there and me saying indecent proposal. Okay, proposal and moving on. So I'm not saying , , that movie is rated R, you shouldn't see that movie. Or , how did you see that movie? Or , you know? Right, right.  [00:21:23] Kate Grandbois:  Um, you're just kinda So it's a yes and instead of no, we don't talk about that here. That was an appropriate Correct. Yourself, it's sort of reflecting and modeling way to shift towards something that might be received differently.  [00:21:39] Ali Arena:  Yes. And you're modeling it for kids cuz there are plenty of things that are either said to kids or that's around them, that they don't know how to respond. You're modeling how to transition appropriately. Um, and you're also, you're facilitating trust. Trust that I can say whatever, and you'll move it along. So let's say [00:22:00] you, I literally had a kid do this one time where you're playing a categories game and he would just go, Trump or Butt. Those were the only things he would say to me, . And so I would be , we'd go around. And he would say, Trump. And I'd be like, yeah, Trump. Yes. And, and I would say orange hair, I'd be funny with it. And then a kid would go, oh, orange Pony. So again, I'm not, cuz when you pause, you make it weird for everyone. Right. You, if you go, oh, he's saying Trump. That gives him an opportunity to start saying whatever else. Um, so when you are more in the moment, you're able to move things along better. Um, and the last core quality of an improviser's mindset is adaptation. So it's being able to adapt, right? So it's building off the strengths of each individual. It's having confidence that you're prepared for any situation that might come up while you're using your imagination.  [00:22:55] Kate Grandbois:  That's huge. Yes. Yes. In life. I mean, I'm, I want, I, I feel like I [00:23:00] need to practice my own improv skills. I mean, these are really wonderful qualities to have in terms of quality of life and fulfillment as a person, not just because you have a communication disorder. [00:23:12] Ali Arena:  Absolutely. No, I com and that's why I think I love this so much and it's the last part of adaptation is just like. And learning what triggers may arise and adjusting your behaviors in a thoughtful way. So , you know, let's say I've had kids before. sexually has come up a lot. Um, I work with a lot of clients who are variant into anime, and I don't know if you know this, there's a huge debate over Subverse, not Subbed, right? And , if you like subtitles, then you're not a true anime user. Right. Interesting. Yeah. I've learned so much about just things I never knew about, but, so I've been in debates with these individuals and we've been able to have them move, have the confidence to have their opinion, but to move on. So let's say I was like, no, Kate, [00:24:00] um, If you don't listen to things without subtitles, you don't really enjoy Japanese culture, okay, let's say I go there and you kind of sit there frozen. I can intervene and say, yeah, you know what? I don't know that much about Japanese culture. Can people start to tell me parts of Japanese culture? Right? It's just a way of adapting what someone said, and if you do that enough, other people see it and they'll model that as well. That's what's really cool about these groups is I start to see. Do what I'm doing. They basically make me not important, which is amazing. They, they kind of try to get me out of the group. I think that's great.  [00:24:39] Kate Grandbois:  That's awesome. Well, I think it might be time to, for you to give me some games. What are some games that we can play? So what, and um, just for the sake of saying it, for everybody who's listening at home, we will thank you so much for offering the handout. Yeah. It will be linked in the show notes. Um, and we'll have it available for download for free on our [00:25:00] website for anyone who is listening and would like to get a copy.  [00:25:04] Ali Arena:  Perfect. I just need to canva it up a little bit. It just is links at the moment. Um, so, and I also, if people are interested, I can send you, I'll just confirm with Maya, she recorded some of these on YouTube and what's really cool is she made them adaptable to both verbal and non-verbal children. So again, this is, you can usually, that's awesome. And be a part of improv. So here is, actually, we didn't review this one, Kate, she's on the spot right now. Um, this is one that you could do that's totally non-verbal. So Kate, I'm gonna give you a ball and you can hold this ball. And based on how you're feeling, you can make the ball smaller, you can make it huge, you can make it medium, and you're gonna pass it back to me. So here's your ball.  [00:25:49] Kate Grandbois:  You're gonna have to narrate for our use for our listeners. Yeah. On the podcast what I'm doing. Okay.  [00:25:54] Ali Arena:  So, okay, so my hands are open. I hand Kate a ball. She now has the ball. Okay. Her ball's medium [00:26:00] sized. Um, can you give me back the ball? Thank you. Oh, my ball just got so much bigger. All right, Kate, here's my big ball. What are you gonna, oh, nice. Okay. You kept it big. We could do that back and forth for a while. And it's kind of interesting, a lot of kids will start with a super small ball and then it will get bigger and bigger. Sometimes I ask them if they're able to communicate, what color is your ball? Um, a question I ask a lot of kids when I start groups that I'm amazed by the answer, what color represents how you feel today? Um, because yes, as an adult, that's actually hard to answer. Some kids have the most, one kid told me that he was like the macaroni and cheese. Because, oh, that's amazing. He felt very neutral. He was just kind of muted today. That's literally what he said. And then I've had a kid say, I'm lime green because I have as much energy as when I'm playing soccer, and that's the color of my jersey. Yeah, that's [00:27:00] amazing. Yes, but it's so different than, How are you doing today, ? They're just gonna say good, right? [00:27:06] Kate Grandbois:  Oh, it's so much more creative. There's so much more emotion and person personality. And personal experience involved in a question like that. I absolutely loved that.  [00:27:19] Ali Arena:  And it just adds fun. Another one, I'm not gonna make you do this cause I feel like as an adult it's just uncomfortable, but it's called stone face. And so you have a kid go up and he's stone face, he's not gonna have any reaction. And then we all pick a word that we can say to try to make him laugh. So our word, it could be, let's have it be pizza. So the only thing we could do is say pizza, to try to make stone face laugh. But you can do whatever you want with your body, right? Or you can scream pizza, you can whisper pizza, you can say pizza far away. So again, I love these because it's you have to be in your body, you're thinking about your [00:28:00] nonverbals. Um, it's really great cuz kids laugh immediately. Stone face never lasts that long. Um, it's, and it's fun. It's fun. What's great about it too is if I'm like, okay, everyone, let's pick a word and let's say Mary says pizza. I'd be like, oh, love pizza. Let's do pizza. And I'm moving quickly, right? So it's not like I, I don't, I try not to even let a kid get to a point. They're like, no, wait, I wanted it to be Spider-Man. Right? Because again, you can't pick a wrong word. So if that were to happen, I'd say, great. Next word, spider-Man. Keep going and move it along. Um, so I'll play one more game with you. We did, we went over this, everybody. So we'll see. , .  Kate Grandbois: Okay, I'm ready.    Ali Arena: Okay, so this is called gift giving. So you could do this two ways. You could intentionally give a gi, give someone a gift they won't like. I would do this for someone who's very rigid, right? Who only sees a certain purpose in things. I would intentionally try to give them something they don't like. Someone who also maybe [00:29:00] has a hard time taking perspective. I would give them a gift that's super neutral, a lamp. And then for someone who I'm just trying to figure out what they do, like I try to give them gifts I think they like. So again, improv, you're not physically giving them anything. So for Kate, let's go with neutral. I'm gonna give Kate a lamp. All she has to do is say thank you. You have to say thank you every time cause it's a gift. And that's kind that Also teaches even if you get a gift at the holidays and it's not what you want and a lamp, you still say thank you. Right, right. So you say thank you and what you can do with it. So Kate, here is your lamp.  [00:29:35] Kate Grandbois: Thank you so much for this lamp. I am going to put it in my closet for when I read. In my closet because my closet is really dark and, and there's no, there's no lamp in my closet.  [00:29:51] Ali Arena: I love that you have a cozy place in your closet for reading. That's, [00:29:56] Kate Grandbois:   I tried to get a really creative answer cause love that I'm reading my closet, but I love [00:30:00] that there's sort of, the sky is the limit aspects of this in terms of what you come up with and there's no wrong answer. That's so great.  [00:30:07] Ali Arena:  So Kate, can you give me a gift that's , that you think would, I wouldn't want, so kind of a crappy gift. , kids have given me poop before. That's how,  [00:30:15] Kate Grandbois:  Okay. okay.. Allie, I just got you this gift at the pet store. It's some cat litter.  [00:30:25] Ali Arena:  Thank you. I am going to bring this to a shelter where they have cats because I don't have one. . Okay.  [00:30:32] Kate Grandbois:  Right. I'm so glad, I'm so glad that you that you liked the gift I gave you [00:30:35] Ali Arena:  Yes. So, see how it's, um, see how someone could, I could have been like, Kate, I don't have a cat. I have a dog. Right, right. , I could've given you attitude, but it's just the, it's the receptivity. It's the going back and forth. Um, the last thing I'll say, cause I know we have to kind of wrap up, is these games are meant to be short. I'm not talking, you're doing these for 10 minutes, you're doing this. [00:31:00] Two to possibly three minutes. These aren't meant to be really long. They're just meant to establish some rapport, have fun, and either move on to a different game or move on to an intention. I might do this right before, if I was gonna read a book or something, I would do a game before and after the book. [00:31:17] Kate Grandbois:  I love this. I have one final question for you. Um, well, two final questions I guess. But the first is, when you are planning for therapy and you are interested in using improv in your therapy, and you obviously have a maybe more of a bank of games that you, that you pull from, do you have any strategies for how you match the game to maybe the targets or goals that you've, or objectives that you've written for the clients in your therapy room? How do you go about that process in terms of planning to use improv in therapy?  [00:31:52] Ali Arena:  Yeah, you know, I think it's kind of similar to the trajectory that you take as a clinician, right? You're at a point where you're like, oh, this game works for this, a[00:32:00] board game, right. Um, I definitely have started to create my own little list. Um, the book, I'll have you reference the book Maya wrote with all of these games, she does a pretty good job of saying, I would use this for this goal. So you can start to pair it that way. Um, I also try to think about it too, what games work for my certain types of kiddos. So, um, that helps me too, if I really have a lot of perspective taking kiddos, I might use certain games. Um, that for that age group, that's a little tough at times. And then, but perspective taking for a younger kid, that doesn't work. So I try to think about it with age too.  [00:32:40] Kate Grandbois:  That makes a lot of sense. For anybody who is listening, who is wanting to learn more about improv or would like to begin integrating improv into their therapy, what additional resources, I know you mentioned a book that, um, your friend Maya wrote. Can you tell us a little bit about the [00:33:00] book or maybe point us in some directions for where our listeners can learn? [00:33:04] Ali Arena:  Absolutely. So, um, again, that book was, she researched a bunch of social skills and improv groups and kind of looked at what games work. So there's that. Her and I run classes together a lot. Anyone is more than welcome to come observe and see kind of how that works. Um, and, you know, improv really is everywhere.  You were saying. There's Second City, there's Groundlings in LA um, there's groups all over. I would almost just say, take an improv class for yourself. Um, there's a lot online now because of Covid and just see, you know, what that experience is like for you.  [00:33:44] Kate Grandbois:  That's such a great suggestion. Thank you so much for joining us. I feel like we covered so much information in a short period of time. Thank you. But I think for me, having no experience with improv, even just thinking about it as a therapy tool, [00:34:00] that focuses on, you know, these core components, but also that there is no wrong answer that you can use it to improve. To have more fun when you're addressing some of these skills is a really powerful message and we really appreciate your time. Thank you so much for joining us.  [00:34:18] Ali Arena:  Of course. Thank you. Outro [00:34:20] 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 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 February 27th, 2023. The podcast episode is offered for .05 ASHA CEUs. 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 . This is a transcript from our podcast episode published February 27th, 2023. The podcast episode is offered for .05 ASHA CEUs. 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] Kate Grandbois:  Welcome to SLP nerd cast the number one professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy  [00:00:09] Amy Wonkka:  Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each  [00:00:16] 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 . [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  [00:00:53] Kate Grandbois:  specified. We hope you enjoy  [00:00:55] 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. [00:01:43] Kate Grandbois:  Welcome everyone to today's episode today, we had one of the most amazing conversations with a panel of guests who joined us. There were six of us, seven of us.  [00:01:56] Amy Wonkka:  It was the most people we've ever had on the, it was  [00:01:58] Kate Grandbois:  the, at the same time, it was [00:02:00] the most people we've ever had here on the show at the same. Um, and this panel of guests was here to discuss the client's perspective, um, when receiving gender aligning voice modification services. And we're just so grateful. Um, we left this conversation feeling. So warm and full and it was just awesome. So we are really excited to share it with you. We wanna get to the good stuff as quickly as possible. So I am going to read through our learning objectives and disclosures, and then we will cut right over to all the joy. Yes. Okay. Learning objective, number one, describe at least two ways. Clients find gender aligning voice modification to be beneficial to their daily. Learning objective, number two, describe at least two suggestions a client could make regarding how clinicians may demonstrate their cultural responsivity and learning. Objective number three, describe at least one way a client may work to maintain their voice strategies after [00:03:00] discharge disclosures ACS financial disclosures, AC Goldberg is the founder of transplanting 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. He is also on the community advisory board, overseeing research out a Boston university around 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 birth'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 services to all populations. Barb received an honorarium for participating in this course, Barb Worth's non-financial disclosures.  Barb has a [00:04:00] decade of experience working with the transgender and nonconforming population. Kate's financial disclosures. That's me. I am the owner and founder of grand bought therapy and consulting LLC. And co-founder of SLP nerd cast. My non-financial disclosures. I'm a member of ashes, take 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 in the corresponding speech pathology and applied behavior analysis. Special interest. [00:04:27] 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 am a member of Asha I'm in special interest group 12, and I serve on the AAC advisory group for Massachusetts advocates for children. [00:04:45] Kate Grandbois:  Okay, now that that's behind us, we are so thrilled to welcome our panel of guests. We hope everyone enjoys. Welcome everybody. We are so excited to have this amazing panel of guests. Thank you so [00:05:00] much for joining us. We're so thrilled to listen to what you have to share and, and  [00:05:06] Barb Worth:  learn from you. [00:05:09] Kate Grandbois:  I'm Kate. Uh, it's lovely to meet you. My pronouns are she her? And I'm a speech language pathologist I've been practicing for over 10 years. Um, and I'm really, really excited to learn from you all today. [00:05:25] Barb Worth:  My name is Amy. I'm  [00:05:26] Guest 2:  also a speech language pathologist. My pronouns are she her? I've been a speech language pathologist for over 15 years, which sounds like a  [00:05:34] Barb Worth:  long time when I say it out loud. Uh, thank you  [00:05:37] Guest 2:  so much for joining us. And I'm so excited to having a conversation  [00:05:41] Barb Worth:  with you all today. My name. So now I'm gonna  [00:05:44] AC Goldberg:  make, I'm sorry, go ahead. Oh, no, this is great. No, I was gonna say, you know, um, we should go in order of speech seniority here. So, oh. Um, my name, um, is AC Goldberg, my pronouns, or he, him and his, I am a speech pathologist. Um, and I am also a transgender person. [00:06:00] Um, and I have been a speech language pathologist now for almost 20 years. [00:06:05] Barb Worth:  And I am Barb worth. I use she, her pronouns and this spring, it will be 30 years that I am a speech language pathologist. So why don't we start with April may.  [00:06:19] Guest 2:  Hi, uh, I'm April, may I use she, her pronouns? Um, I've been doing, um, uh, I guess gender framing, voice therapy for. Uh, I, since last spring, right? Yeah. So less than a year. Um, and yeah, I'm, I'm trans F um, that's my intro. Yay, Eddie. Nice to meet  [00:06:42] Guest 1:  you. Hey there. Uh, my name's Eddie, um, uh, my pronouns are he hang and, uh, I'm a trans guy and, uh, I'm a visual artist and a singer, uh, musician. So yeah, I'm, I'm excited to be here. Thanks for having me.  Fantastic.  [00:06:59] Barb Worth:  And Julia, [00:07:00]  [00:07:01] Guest 3:  hello everyone. I'm Julia. Um, I go by, she, her, um, I am a transgender woman. I went to Barb's program at Emerson, uh, in 20 18, 20 19, and really loved it. It was my happy space. Um, so, um, yeah, so I use those techniques. I learned there every day in my job as a software developer, happy to meet everybody.  [00:07:26] Barb Worth:  Beautiful. Well, let's start with what brought all of you to, um, receive gender affirming or gender aligning, voice modification. And whoever wants to go first,  [00:07:44] Guest 3:  um, I can start off. Yeah, so I, um, I started my gender affirmation, uh, like, uh, hormone. Uh, treatment for myself, uh, in June of 2019. And, uh, I, I had some family [00:08:00] stuff going on and I, it was a big interruption in my life, got back home and the COVID hit. So I was, uh, I basically, my voice started changing basically during, uh, like COVID lockdowns when I wasn't no longer. Talking to people regularly, just like, you know, not didn't have those everyday situations to go out and, and practice my new voice. So I, I looked up, but I, I thought, you know, I should, I should really be working on this. I can't just let it go. Um, you know, it's a little bit, when you go through such a personal change with something as personal as your voice, Like drastically changing, you know, it's, uh, it's emotional you when, when, when you lose your voice. So, um, I, I did some Googling and I found AC and I was super excited because it was like one of the first pages I found was, um, you know, it was a blog article that he wrote and I was as a trans, uh, person. I, [00:09:00] I didn't know if there'd be anything that would be inclusive. I thought it would maybe be very. I don't know, retrograde or something. I don't know. I was still a little pessimistic. So when I found C's article, I was, I was filled with hope and so I like contacted him right away. So, yeah. It's good.  [00:09:18] Guest 2:  Beautiful.  [00:09:20] AC Goldberg:  That me so happy DY. I'm just so happy to see you. And so happy that you're here working with you is so much fun.  [00:09:27] Guest 3:  awesome. Yeah, no, I, I really enjoyed our sessions together and, uh, it was just really helpful. Like at first I thought it was just gonna be. You know, I've come from a music background. So I thought a lot of it would be, you know, pitch and intonation and, and things like that. Like something from that, but just having that, your, your specialty and just, uh, you know, you really taught me a lot about, you know, like habituated voice. That was very important for me, cuz I had this general sense that, you know, a lot of psychology goes behind. Gender, you [00:10:00] know, gendered ways that we speak in our various cultures. Um, things like that, but I didn't really know. I didn't have, you know, the foundational knowledge. So it was really cool how you taught MEAC about that. And it helped, you know, even though I was, I, I still felt like I was really at the beginning of. Of my, my progress, cuz it, you know, it takes a while to process everything you learn, even in those individual sessions. And then, you know, I still society was still kind of shut down. So I mean, talking to my cat or talking to my partner. You know, I was, uh, mimicking David from shits Creek for a while. We had that, oh  [00:10:37] AC Goldberg:  my gosh, that was the best. Oh my gosh. That was the absolute best. you not wanting to lose? I remember you not wanting to lose your, your posity because, um, you wanted to have that expression in your voice, but you felt like in order to stay in the range that made you feel affirmed in your gender, that you had to not have those peaks. I remember that that was so much fun. [00:11:00] Um,  [00:11:00] Guest 3:  Yeah. Yeah, exactly. I mean, I, uh, I didn't realize how in my mind, like, um, a certain way of speaking, like to me, felt more masculine, but then it didn't sound expressive and I've done a lot of work since like it that's still sinking in for me. And I'm still, it's still something like the foundation you gave me. I was still something I work on every day. Now that I'm out working, I've got. You know, I've got other, um, friends who are identify as trans-masculine trans male and like seeing how they pitch their voice. It's just like that what you taught me, plus having now these experiences of like living day to day with this new voice, it's, it's still changing a bit, but. You know, having that knowledge has really increased my confidence a lot. And it's like, I, I, I, I went from feeling like, oh no, like, am I ever gonna be able to like, speak like, this is it's a little bit scary to like feeling empowered and you know, it's a really good thing. So. [00:12:00] Yeah, thanks again for I'm glad I found you. oh God. I'm so glad  [00:12:05] AC Goldberg:  that you're here. Um, I, we have so many more questions and maybe we'll circle, um, back to you, but, um, Barb, can I ask one of your clients to answer a question? Um, uh, just be in order of arrival, I'm gonna ask April may, um, what brought you to sort of seek out this type of service? Like, what was your. How did you initiate the process? Like what was it in you that wanted that?  [00:12:31] Guest 2:  Uh, yeah, I was actually, uh, off of a lot of things that Eddie said, cause I really did a lot to that. Um, there was originally, I started off by myself, like going online and like on YouTube. Um, and. It's rough, um, doing that alone. Um, because I think, I mean, inherently speaking is a very like two person thing. Uh, and it's to nowhere there to hear it, it, it can feel very hopeless. And, um, [00:13:00] so I, I ended up seeking out, um, Something more, uh, professional because, uh, I was originally a very extroverted person and I was finding that, um, I was becoming less, I was becoming like an introvert, um, just because I was afraid to speak, um, and, and be perceived in a way. That was not how I wanted to be perceived, especially because, um, I, I started college last year. Um, so it was like coming into a new environment and being like, seen as a person. Um, and it was, that was my, um, my decision was like, as I, I came to school was like, I'm just gonna be like the person I am for the first time socially transitioning and then medically transitioning. But. I, I was feeling really unmotivated. Um, cuz I think there's a lot of, a lot of things that can really, um, [00:14:00] bring you down when you. Don't feel like your voice aligns? Um, simply because I think, um, when you're dysphoric and you're transitioning and you're trying to be a different way, it's easy to forget how you look and, um, kind of block that out, but it's very, very hard to not hear how you sound when you speak. Um, so I ended up actually. Um, Googling like, um, voice, um, therapy, gender affirming care. And, um, one of the first things that came up was, uh, my college website, cuz I, I actually go to Emerson and I was very confused. Found out was a, um, whole. Um, program that was, uh, one block away from me. and, uh, yeah, that's how I ended up getting into it. And I'm really, really glad that I did  [00:14:55] Guest 1:  well. We're so happy to have  [00:14:56] Barb Worth:  you. Yeah. And April may, [00:15:00] um, received both individual and then also group work, right?  [00:15:04] Guest 2:  Yeah. I was originally just, um, solo, um, and that was all online. And then, um, this last, uh, summer session I was doing though in a.  [00:15:14] Barb Worth:  Great. Well, we, we love having you and Julia. So Julia also, um, was with our program for a while and received, um, individual and group therapy. And I don't remember how you initially found us and I don't remember, you know, what initially tell us, you know, kind of the same question. What, what were you thinking about your voice? Why did you want to modify it? [00:15:37] Guest 3:  Okay. So, um, so I was a pretty late transitioner and, uh, yeah, I've been speaking a certain way my whole life, you know, for decades. And, um, you know, when you're transitioning, it's a lot, um, you know, I couldn't look really BA you know, beyond two weeks, um, without just having so much anxiety. So I pushed really my. [00:16:00] I always knew. I wanted to try to, you know, um, have a different voice. Um, but I really, I couldn't deal with it at all. Um, you know, during the first part of my transition, so it all kind of came to a head as I, I went to New York city once by myself. Um, during that year I was transitioning and, um, I took the bus there. And came back the same bus the next day. And, you know, I was trying, so the, the bus, there was some confusion about the schedule. So the buses were not leaving from the station. They were leaving from like a block, you know, this other place that had to walk to myself. And I didn't know which bus was mine, and I was scared to speak to anybody. I just, you know, I just didn't want to be visible because of my voice. Um, it was a scary experience. Like I, you know, I didn't know who to trust and like who I could talk to and like, you know, out myself as trans and you know, it just, it was really scary. And eventually I, I [00:17:00] found my boss and I just got on the bus and I broke down crying and I'm like, I have to do something about this, you know? Um, so I did, I put it on my list and, um, actually. I didn't find out about, um, the Emerson program, my wife actually Googled around and found it and said, Hey, this looks like a good program. Um, I had just also like looked at YouTube videos and I also, I bought like a DVD of, you know, techniques and things like that, but it was really hard, like April may said to, to do those yourself, um, cuz you're like highly technical, you know, in the exercises. And you know, I was just trying to see if. A professional could really help me. And yeah, so that, um, so that's what led me to em,  [00:17:48] Barb Worth:  Beautiful. And I'm curious, and this is a question for you, Julian, for everybody. Um, you know, did you enter into it sort of with this very clear idea of what you were looking for or [00:18:00] was this something that evolved along the way? And that's really a question for anybody. Yeah. Julia.  [00:18:06] Guest 3:  Yeah. Yeah. So, no, I had, no, I didn't know what I was capable of. You know, like Uhhuh , I didn't know what voice I was capable of. And I remember, um, somebody asking me like, well, what, what's kind of your voice model? And I'm like, I don't know. Like, I, I don't know if I can sail like her or, you know, or her mm-hmm Um, I just wanna sound like me. Um, so it, it was very hard to know, you know, what I was capable of and yeah. So I, I didn't, you know, I didn't have anything specific in mind. I just wanted to, what I really wanted was to be gendered correctly without where a she, her button on my chest. So, yeah.  [00:18:46] Guest 1:  Yeah. Beautiful. [00:18:48] Guest 2:  Anybody else? Yeah. April a. Yeah. You might know Barb. Um, from watching my sessions, I, I have gone through a million variations of my voice. Um, [00:19:00] and honestly personally change it, um, almost daily mm-hmm um, I, I identify as gender fluid specifically. Um, so some days I am feeling a more, um, Usually like a more masculine, fem voice versus like a very fem found voice. But, um, yeah, like going in initially, um, just like Julia said, uh, you don't really know what's there, you know, like, like you don't know what you don't know. Right. And, um, it's like, it's honestly to like learning a whole. Skill whole new like language, essentially with like learning how to modulate and like seeing where that can take you. Um, and then like learning the different aspects. Um, modulation and playing with like, oh, I want to be like breathy. And like, my resonance is forward today. Or like, I want my resonance to be like back more, but like, I [00:20:00] want my pitch to still be high or it like all these different, like variations of, of the, those things can like make different voices. And, um, I don't know. I've I had a wonderful time explor.  [00:20:12] Barb Worth:  Well, and I also know April, may you also do some online work and you, and you do some D and D right? So, yeah. So it's important for you to have a lot of versatility in your voice,  [00:20:23] Guest 2:  correct? Yeah. I, um, I do like. A little bit of voice acting. Um, I play Dungeons and dragons, uh, and do like other role play games. And I usually, uh, run that. So I like to, um, well, I honestly just like to use my, my transness as like a boon in that situation because, um, I, I, a lot of, um, People, I mean, a lot of DMS, can't just be like, oh, hi, how are you doing? And then in the next like, voice go like, hello? Like, how are you? it's [00:21:00] I don't know. I think it's a, it's a skill and it, uh, can catch people off guard and, um, I like to utilize it and I feel comfortable doing so. So, um, it's, it's fun. I love, I love it.  [00:21:12] Barb Worth:  Exploration is what it's all about. We use that, that term constantly in our clinic. Don't we? April, may . Yeah, that's great. And you embrace that and I really  [00:21:20] Guest 3:  appreciate that. Yeah, it can  [00:21:22] Guest 2:  definitely be scary. I think until I got to this, um, like group work vocal group, um, the idea of going outside of. What was expected of me, cuz I even like when you're like in a, like a, a session trying to like change your voice, there's like this expectation specifically like myself as a trans feminist that like, I want to like move my voice in a feminine way. And, and to an extent I really do, but um, to another extent, like sometimes I'm not feeling that way and yeah. Um, I think it's a really, it's a really. Tool to be able to, [00:22:00] um, change so fluidly because, um, it really just allows like versatility and your presentation. Um, and makes me feel good. So,  [00:22:11] Barb Worth:  and you're good at it. so Eddie, I'm thinking you could probably relate to this  [00:22:17] Guest 3:  conversation. Yeah, for sure. Like, I think, uh, some of the expectations that changed for me was just, uh, AC went over, you know, just like analyzing different, um, voices in terms of gender. Like I'm, I'm good at analyzing singing voices. But, um, when it comes to speaking voices, it's just interesting to I'm after the sessions, I I'm paying attention more to people's everyday speaking voices, how I would gender them just based off of sound alone. It's, it's, it's difficult, right? When you always have a visual and to break things down. And I didn't really realize how narrow my own sort of, um, I guess [00:23:00] biases towards voices and gender, just like the actual technical, um, makeup of a voice and, um, with ity and, and pitch and Tomber and things, and, uh, sort of expectations I'd put on myself. And, uh, yeah, so I, and I feel like I was sort of in a place where I always just push my voice down, um, to speak and say things and. It was hard on my voice. And I was like, oh, low, you know, I wanna be masculine or whatever, but it's like, it was difficult cuz I was having a hard time expressing my personality fully. So I think that's the expectation I wasn't expecting to, um, Uproot a lot of internalized biases in terms of gender. I thought I was a little more open minded, so it's a really good learning experience. And it's actually taught me things now that I'm working on my singing voice more, the sessions with AC has helped me increase that. Sort of, uh, you know, [00:24:00] that analytical ability with singing voices as well, because, because it was such an internalized bias, um, you know, Yeah, I'm, I'm able to use it in other ways to explore and experiment with my singing voice as well. So that was, that was really unexpected. And that's just been in the past few weeks that I really have done some, some different things with a certain range, um, with my, like a higher, um, sort of breathy singing voice that I was like, oh, All these, there's all these male singers out there, or however they identify. Um, and I, I was thinking about their voice voices in a very specific way. And now that I've had this, uh, you know, these sessions, I'm able to sort of be more analytical in a way that's like really helpful. And it's, uh, I don't know. It's, it's made me more expansive. So I really appreciate that, uh, sort of, uh, personal insight and upgrading. Of my own knowledge with it. So yeah, hopefully that makes sense. that's  [00:24:59] AC Goldberg:  so cool. [00:25:00] Yeah, that's so cool. I just, the fact that you are a singer and a performer and that you're able to take this and, you know, carry it into that space is really awesome. And the fact that it makes you feel I. Empowered to explore like a head voice or whatever it is that you're talking about at the top of your range. Um, I've recently started doing that as well as someone who's a singer who has been actively kind of not singing, um, because of sort of discomfort around the fact that my voice changed and you know, how do I get my vibe in my singing? With my new voice. And I know that I'm not gonna center my own voice experiences in this podcast, but, um, I think it's really important for people to know that there's a component of, you know, Some people who are very attached to their singing voice, regardless of, you know, um, whether they're an actual performer, um, might experience a tremendous amount of grief when, um, you know, when trying to align their voice with their gender, that they can no longer [00:26:00] sing, um, in a certain way, or that they want to be able to sing and express themselves in a certain way. And, um, it's hard for them to figure out how to explore that and still feel aligned with their gender. And I'm so happy that you're doing that. And Julia, I saw your like brow raise a few times during, um, while Eddie was talking. Did you have thoughts that you wanted to add? Um, well, just  [00:26:23] Guest 3:  about the singing, I, I totally get that. Um, I used to, you know, like doing karaoke and stuff like that, but I've, I've avoided it, um, since transitioning my voice. Um, and, um, you know, I'm getting to the point now where I think, you know, I'm singing in the shower a lot. Um, and I haven't actually, I I've been meaning to record myself singing, to see, you know, really how it sounds. Um, but I think I'm getting close to, you know, that breakthrough. I mean, it takes a while, you know, you have to develop confidence in it. Um, but yeah, I, I, I took completely feel. Yeah, Julia, one of the things I [00:27:00] don't know if this is helpful at all, but recording yourself is a wonderful tool. That's I've done that throughout my whole life with singing, just recording and playing back. I do it ad nauseum. Like , I, I have hard drives full of just like singing practice because having that feedback of your own voice is just for me, it's been a technique that's I've been able. Fully like changed my voice in so many ways by doing that. Um, and I just really appreciated AC what you said about like grief and, and voice changes. Because I don't know, as a trans guy, when I had what would be considered a more feminine, uh, singing voice, like I was a high soprano, a very soaring notes and. To sort of deal with that. Psychologically, that person, that voice sort of had to become a character for me. And it represented sort of, I don't know, almost like a Sonic shield for like my emotions. Cause I was like, this person, this voice is not what I would've chosen, but this is the voice that I have to express myself. [00:28:00] And when you get to a certain place with singing, when you're able to sing from your heart and it's technically, you know, it sounds good and people you're able to connect. With people with your voice, losing that after so many years was definitely an emotional process, but also being, feeling more affirmed when I went through my vocal changes was great. And, um, You know, Julia speaking about like safety issues, like, you know, as a trans person being gendered properly is like everything being safe in, in public spaces, in relationships, things like that. And so to have that sort of, it's like, you know, to sort of profound things, intention, you're like, you're becoming, you're sounding more like yourself, but you're also losing something. And I feel like I'm sort of always working through. Um, but then what April said about also having fun with just like being able to experiment, cuz you've had so many voice [00:29:00] now I've had so many voices in my life, you know, you can have a lot of fun with it too. So it's uh, I'm really appreciating this discussion. It's like, yeah, it's really good. So,  [00:29:10] Barb Worth:  you know, we're, we're sort of talking about all the ways that you U you all use your voice, um, all the different settings context, and I'm wondering, you know, how do you work on your voice outside of formal training? You know, so all of you have received formal training from either AC or I, or, and, and maybe elsewhere as well, but, you know, do you have. Program a warmup. Are there things specifically that you do when you are, um, when you're not with us and you've talked a little bit about that, but I'd like to hear more.  [00:29:47] Guest 3:  Um, yeah, for me, I, I hope it's okay. That I'm speaking again. I don't wanna take up too much, but, um, yeah, I this keyboard I, uh, having a keyboard, even if it's not a full ranged [00:30:00] piano or whatever, for me, um, having a, um, an instrument where you can work on pitch and, uh, you know, yeah. I feel like without. There's no anchor of like notes and I mean, I'm a musician, so that's my background, uh, piano, especially, um, I find with a confidence thing with, um, like resonance and tone. If you're not having, like, for me, if I'm having a tired voice day, it can be a little bit, you know, it can affect confidence a little bit having that, like a keyboard or, or a instrument that you're sort of resonating with. It's um, You know, your vocal chords are vibrating as so as the instrument and having that sound buffer, you know, and sort of helping you, it's almost like a, a sound friend there, you know, all the notes mm-hmm and you can kind of match that. So it's, uh, you have something to sing with or, or to even just, you can use it with your, I can use it with my speaking [00:31:00] voices. Well, and check where my range is, so sure. That's that's, what's been helpful to me, so beautiful.  [00:31:07] Guest 2:  I I think for me, um, I, I just have this, I, and I'm so thankful for this incredible support system with my friends right now. Um, where essentially, um, like most of my friends have been the chance that start. Of my transition. Um, and so they understand that like, essentially I'm a work in progress , um, which is okay. It's like, it's okay to be, um, finding yourself and like, not, not know who, like you are quite yet, or to not to, to know who you are, but to not be there yet. Um, and I think, I think most of it for me is like, is just this mental barrier that comes with, um, Right. I guess, practicing, um, and over exploring your voice, um, in social settings. Right? [00:32:00] And so, cause, cause I think, um, you know, you can sit down for an hour a day and, and practice a voice, but you're not gonna get nearly as much as if you, you know, you go out to dinner with a friend and you just, um, You just, you just explore. Um, and sometimes I tell my friends like, oh, my voice is probably gonna change a lot. Um, like, and, and they know that as like, if, if in one like sentence, I sound one way I want sentence said another way. And it's because, you know, in my head I'm, I'm thinking about it and I'm trying new things. Or, or sometimes I. Um, these, um, I'm trying to think of the word for them. The, the, the words you say to get you back to your voice. Um, if that makes sense, I'm not sure if there's any anchor words. I like anchor words. Yeah. Yeah. And so just like telling your friends, like, yeah, sometimes I'm gonna go 1, 2, 3, 4, and like, just ignore it. cause it's, it's just gonna happen. But [00:33:00] yeah, uh, that and something I've been enjoying recently as like a, a warmup, um, for me to kind of find my, my like voice of the day, if you will, um, is I will say hi in like every different voice I have going up and down, um, at one is a warmup, um, to kind of get my voice like going. Um, and also I find that if you. Work out the, like your whole vocal range. It makes it easier to then like choose a specific one and like set to it. But, um, yeah, that's, that's kind of my, my process. Um,  [00:33:34] Barb Worth:  Beautiful. So, you know, so it sounds like we've talked a little bit about warmups. We've talked a little bit about the, the, the importance of having social support of having places to practice. You talked about anchor words, which are fantastic. So little, little things that we can interject to kind of reset the voice. Um, we talked about use of the piano. Um, Julia, I'm wondering, can you add to that list? Just ?  [00:33:57] Guest 3:  Sure. Um, so, so pre COVID I used [00:34:00] to commute to work and Uhhuh used to go to this thing called an. Um, um, yeah, so, um, I used to, uh, so I would take the bus to his place and I would have like a 15 minute walk from there. So I would walk down the street alone and I would be doing my pitch. Whoops. Um, ah, You know, I would try to make sure nobody was around me cause I I'm sure I sounded crazy doing on them, but like, you know, they were kind of like woo, like that, you know, and going up and down. Um, and then I would have my AirPods in and I would, I would bring up voice analysts on my phone and ah, I would just talk. I would talk about my day, what I was gonna do. And then I would listen, listen back to it. Um, and you know, that's how I would commute to work. So I'd get kind of like ready before I went into the office, um, to do that. Um, so then, you know, then we all, you know, came home to work and you know what, that, that did. I found a really good advantage of [00:35:00] that and that's that I could bring my iPad right here by my computer. And I could record myself during meetings, um, because we all know that like, so I, I still bring up, like to gets secure in the rainbow package. And, and I, I read those, but like, I'm performing kind of, but like when you're, when you're talking like in a meeting like this, it's totally different, like you're not. Thinking about every word you're giving, you're giving the, um, your speech, like only like 10 or 20% of your cognitive, you know, load. And, uh, as opposed to like, when you're practic, when you're doing, you know, reading it specifically, your all your mind is focused on that. Um, so, so, yeah, so that was really illuminating, like taking myself during meetings and I would then listen back to it and. The things I was very unhappy with. I would just say them again and again, and felt like I got it. Right. And, um, that was really helpful because it's, cuz those moments when you're not focused completely on your speech, when you know what I found that I [00:36:00] let myself down a lot during those moments. So, you know, really that, that drilling of those common things that you say really helped. Yeah, the,  [00:36:11] AC Goldberg:  the everyday the everyday words. Um, I have a question. I know we're, we're about to run out of time, but, um, I, I want, um, to ask you all sort of how this process and how, um, you know, the clinical relationship that you had, um, with, you know, myself with Barb, uh, with anyone that you may have worked with at Emerson, how that compares to. Other types of healthcare services that you've received, um, you know, relating to, or not relating to gender. Um, you know, what, what that sort of felt like to you? Um, similarities, differences, um, you know, um, I want our listeners to be able to, you know, understand a little bit of, um, a little bit of what that felt like to you. [00:36:58] Guest 2:  I [00:37:00] specifically with the Robin center, I've felt like they've been great. Um, I think when, when it comes to like transcare, or just like how, like going into a hospital in general as a trans person, um, I think like no event is good. If that makes any sense. I think there's a lot of. Um, specifically me in the past, going into a hospital and being like, oh, my name is this, but my legal name is this or them coming in and like asking questions about, you know, transness and it's like a. Maybe, um, I don't know, you're my doctor. Maybe you should have known that going in, but, um, I don't know. I've always felt like none of that is like up for questioning when I'm, um, specifically going into the, the Robin center. So like that that's honestly been a, a big deal for. For comfort. It's just like, [00:38:00] um, not even just feeling seen, but like feeling that like being accepted within the space was never in question. You know what I mean? Like, um, it's almost like, um, like when you, when you see people putting an effort to make you feel comfortable, that's great. But, um, just. Effortless comfort is I think the same, the amazing thing as a trans person to experience, cuz it's not something you get to experience a lot. So I, I think it's a really big deal  [00:38:34] Barb Worth:  that that makes me just feel so happy. I can't even tell you. I'm actually  [00:38:38] AC Goldberg:  tearing up. I'm here. I'm tearing up and I don't work there because it just, I know what it's like to experience that it's really genuine. [00:38:50] Guest 3:  I, I would just second that like, um, you know, I, I, all, all my experiences, like outside of Robin center, like you, you have to be on guard, you know, you have to like [00:39:00] really watch out for yourself and like, let everybody know who you are. Um, and. You know, still then things go wrong. Uh, and it hurts. It really hurts. So, um, I never felt that at the Robinson, I think that's one of the reasons why it was my happy place. Um, you know, cuz it was just, it was, I was having fun. I was in a group experience. Um, you know, it was students teaching me, you know, so it was like, you know, being around a lot of young, enthusiastic people and like other trans people. And I just, I, I, it was just a really positive experience among my other trans health that I, that I sought out. It was not the best.  [00:39:41] Barb Worth:  Thank you, Julia. I'm curious too. Um, and for this is for you, Eddie, um, what specifically do you think our listeners should be paying attention to? You know, let's sort of take it the next step of  [00:39:59] Guest 1:  what  [00:39:59] Barb Worth:  [00:40:00] advice, what would you say? Like when people are thinking about offering these, uh, sorts of services,  [00:40:07] Guest 1:  what do we, what do we need to do better? Eddie  [00:40:13] Guest 3:  I dunno, I had, I had had a really good experience with AC. I mean, I was yeah. Isolated at home and feeling alone, and then I've got AC and again, like, yeah. What, uh, Julia was saying about it, you know, kind of feeling like effortless, acceptance and feeling. You know, I belonged it was a zoom window, but you know, when you're, when you go out into the world as a trans person and yeah, you have to be in guard, you have to any room you're in any space, you know, you just have to, I don't know. That's how I feel. You're always in a defensive posture. So, um, I just think, you know, any healthcare practitioner, whether it's in your field or, you know, otherwise it's, uh, paying attention to content like AC puts out on transplanting, [00:41:00] things like that. Just really being open, continuing to in the conversation. And yeah, like, I, I feel like this, like, what you're doing is, is great. Just this session is exactly just more of this mm-hmm .  [00:41:17] Guest 1:  Yeah, beautiful.  [00:41:19] Guest 2:  April may. Yeah, I was just gonna add onto something. I think you actually said earlier about, um, implicit bias and, um, specifically like the idea of, um, like, I guess maybe even like internalized transphobia. Yeah. And like perceptions of gender that we have. Um, and I think my most important thing in the thing I tell people, um, when they're like coming into contact with trans people, working with trans people, and maybe there's just maybe their gender group as well. Um, I think either way, um, I think, uh, implicit bias and, um, checking those implicit biases has to be something that's active.[00:42:00]  Um, I don't think it's something, you know, you do, and then it's done, um, as, as amazing as that would be. I think, um, you have to continue to, um, the send to those people. Um, Who are experiencing, um, I guess like different levels of privilege than you. Um, and just like, keep, I guess, updating your internal map of, um, just, just the ways you, you treat others in regards to their identity, especially with something as like sensitive as, um, you know, voice care. Um, An active assessment of Biase is a, a huge deal. And it goes a long way.  [00:42:48] Guest 1:  Yes. Yes. Thank you for that.  [00:42:51] Barb Worth:  Great. And I think that it's a good message that we need to continue. That it isn't something you just check the box, right? It has to be something that we [00:43:00] do on a daily basis on an ongoing basis.  [00:43:03] Guest 2:  What is something you learn as like a trans person, cuz um, I, I think being trans and transitioning a big part of that is mental because, um, just like anyone else you're socialized. In a certain way towards gender, uh, and you're raised into a society that treats it a certain way. And, um, you, you can find this dissonance in your own sense of self because you were raised one way, but, um, you feel a different way in, in those clash. And so, yeah, it's, I think it's a big deal.  [00:43:34] Guest 1:  Yeah. Thank you  [00:43:36] Barb Worth:  for. [00:43:36] AC Goldberg:  thank you all so much for, for just being here and holding the space with us. I know that we're, you know, kind of coming to a close and, um, thank you so much for being willing to come on here. And like your ongoing, just vulnerability in this conversation is really appreciated because you know, the listener, the people who will listen to this podcast, you know, they're going to be faced with [00:44:00] potentially serving the trans population. Um, and. I think that, you know, it's at the utmost importance that they understand how vulnerable we are in clinical spaces. Um, and you know, how important it is to engage in culturally responsive practices. Um, because we do come with so much, we do bring so much baggage from other clinical interactions, um, into these spaces. And I just I've had such a wonderful. Time, listening to your voices and listening to your stories. And I know Barb is doing such amazing work, um, and Eddie, it is so wonderful to see you, Kate and Amy, thank you so much for holding this space for us here today. Thank you  [00:44:38] Kate Grandbois:  all so much for all of this. I have enjoyed this conversation so much, and I'm so grateful for your time and vulnerability and, and sharing your stories with our audience. Really. So.  [00:44:50] Guest 2:  Agreed. Thank you all so very much. And it was, it was lovely to virtually meet you all too. Thank you  [00:44:56] AC Goldberg:  so much trans joy. I just agree so much [00:45:00] trans joy right now. Like, like so much of it. It's just like overflow. Um, and if I didn't  [00:45:06] 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 February 13th, 2023. 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 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 ashes, EU, 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 really excited for today. We actually get to welcome one of the authors of Amy's favorite paper. So anybody who has been listening to the show for a while knows that Amy, out of the two of us is, is the [00:02:00] research maverick, um, in terms of reading every word in some of her favorite literature. And, um, today we get the pleasure of welcoming Dr. Mary Beth Schmitt, who is the author, um, who is the editor and co-author of Evidence, Evidence Based Practice of Retrospective Overview and Proposal for Future Directions. Welcome, Dr. Mary Beth Schmitt.  [00:02:22] Mary Beth Schmitt:  Hi, thanks for having me.  [00:02:24] Amy Wonkka:  So, as Kate mentioned, Dr. Schmitt, you're here to discuss evidence fits based practice. Very excited for this conversation. Uh, but before we get started, can you tell us a little bit about yourself? [00:02:34] Mary Beth Schmitt:  Sure. Um, how long do you have? No, ? Um, so I, I, first and foremost as am a speech language pathologist, I worked for 11 years in a variety of settings, but with kids who had, um, language disorders. And never in a thousand years ever anticipated going back to get my PhD. [00:03:00] Like you told me early on, I just would've laughed at you like that. It just wasn't on my radar. Um, but, um, you know, as life does got to a point where, um, I was struggling with this idea of evidence based practice and we were seeing effects with the kids I was working with and the families were wanting more of this particular program, and I just felt this ethical obligation, um, to go back and help our field contribute to the evidence. I was like, I don't know why. Stuff is working that's working and why things aren't working that aren't working. Um, I knew that I was feeling like I was relying a lot on my kind of professional expertise, and while that has value, I knew it wasn't the only thing of value, right? And so, um, after much like mashing of teeth is, um, really a lot of discernment. Went back and got my PhD in clinical science. So working to identify what works best for [00:04:00] kids in the public schools with the primary goal of giving, getting that evidence into the hands of speech language pathologists. And so now I get to do both, right? I get to work with SLPs and continue working with families and kids with LD, um, DLD, um, and then contribute to, um, the evidence in our field on what works best for working with. So when I'm not doing that, I'm mama to two girls and two fur babies and, um, trying to survive Texas heat right now.  [00:04:31] Kate Grandbois:  That's amazing. Well, we've just had a heat wave here in New England, so we feel you, we don't, we don't often get the extreme heat, but I enjoy a lot of heat. You mean not so much? I don't. Um, but we're really excited for this conversation because one of the things that we talk about a lot on this podcast is how not only what constitutes, quote, evidence in our field, but also how difficult it can be for us to apply that evidence based on all the barriers we have in our workplace settings [00:05:00] between, uh, caseloads and caseload versus workload. I bring this example up a lot. I have a colleague here in the area who worked in a school with a caseload of 144. Oh, and I can promise you she was not reading research articles in her spare time. So, no. Um, I know. So we have a lot of barriers, uh, in our, in the regular in and outs of our day to applying evidence based practices. And we're really excited to talk to you about what it is and how, what are some action steps that we can, uh, take to improve that. But before we get started, I do need to read our learning objectives and disclosures. So, learning objective number one, describe the importance of clinically relevant answerable questions when engaging in evidence-based practice. Learning objective number two, list three ways a busy SLP can stay on top of the external evidence outside of continually reading research articles.  Learning objective number three, discuss how to be a cautious consumer of information and ways in which external [00:06:00] evidence may be incorporated and applied in clinical practice disclosures. Mary Beth. Mary Beth Schmitt’s financial disclosures. Mary Beth receives salary support from NIH for a current study related to treatment intensity. She receives compensation for her role as EBP brief editor Mary Beth is employed and receives a salary from University of Texas, Austin. Mary Beth received an honorarium for participating in this course. Mary Beth Schmitt’s  non-financial disclosures. Mary Beth is an ASHA member. Kate, that's me, my financial disclosures.I am the owner and founder of Grandbois Therapy and Consulting, LLC and co 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. [00:06:57] Amy Wonkka:  Amy, that's me. My financial [00:07:00] disclosures are that I'm an employee of a public school and co-founder of SLP Nerd Cast, and my non-financial disclosures are that I'm a member of ASHA. I'm in special Interest Group 12, and I serve on the AAC Advisory Group for Massachusetts Advocates for Children. All right. We did it. We made it through the learning objectives and our disclosures. Dr. Schmitt, why don't you start us off by telling us a little bit about the importance of an answerable clinical question when engaging in evidence-based practice? And this is the piece that gets me very excited, because I think asking questions is such, such a key piece. So talk to us a little bit about that, please [00:07:37] Mary Beth Schmitt: . Yeah, thank you. You know, and this is one, Oh my gosh, I wish I had understood the value of this earlier on in my profession, honestly. Right? It's kind of that idea of focusing your intention. And we're in this profession where [00:08:00] thankfully, you know, the evidence guiding our profession and guiding our practice with our clients is growing, is growing exponentially. That can also be really hard, right? There's a lot of information out there. And so if, if you go in thinking, Oh, I need to, I need to do more research, or I need to go get more continuing ed, or whatever the case may be, you run the risk of kind of either ending up down a rabbit hole, right? Or not really even being sure why you're going to gather more information in the first place. Um, and so that just broadly speaking, it, it really helps narrow in and identify why are you even looking for more information? What is it that you're needing? Who on your caseload is needing support? Um, what's not working well? What, where are you stuck? Right. That can really kind of orient our thinking and orient our [00:09:00] focus so that when we do have a couple extra minutes to go find some extra information, it can be really targeted, um, and fruitful time. [00:09:09] Amy Wonkka:  And I feel like this, when I, when I read the article on EBP, that kind of sparked our, our desire to connect with you. Um, and we'll link it in the show notes. You know, It, it did for me. It's, it's, what is this saying? You're trying to take a drink from a fire hydrant or, you know, like, like there's so much, there's so much information out there, um, that the idea of having this pretty specific clinical question that you are using, to funnel your information just makes a lot of sense. We've talked a lot on this show about the importance of clinical questions when we're conducting assessments, right? What are we, what are we trying to find out through our assessment or yeah, what are we trying to find out through our data collection and progress monitoring? Um, so I feel like the idea of having an answerable question in [00:10:00] mind when we're pursuing professional development or we're reading, trying to find what articles we want to read makes, makes such a big difference. You know, I mean, Kate and I work in the field of AAC and there there are so many articles. Like if I was just saying I need to learn more about AAC, well geez, that is a fire hydrant worth of articles. Where do I start? [00:10:23] Mary Beth Schmitt:  That's right. You know, and the other piece of answering the asking a clinically relevant and answerable question is arguably there's a lot in your practice that's working well. Right, Like there may be a lot of components that you don't wanna change. And asking that question really kind of helps you as the clinician disentangle those of like, okay, if I'm looking at it from outcomes perspective, or maybe I'm looking at it from just kind of overall wellbeing and [00:11:00] functioning, you know, my client's functioning in their, um, kind of in their given environment, You know, whether that's school or work or, um, with their family units or whatever the case may be. And so knowing, okay, what's the metric that I'm looking at? What am I using to base my decision on? And then when I look at my clients like, Okay, what's working really well? Let that be. Not that we can't continue to finesse when we are presented with new information, but just if we're initiating this, what's working well? Okay, awesome. What's not, you know, who's maybe not making progress that I'm surprised by, or who's somebody new on my caseload that maybe is carrying a diagnosis that I really don't know enough about and I'm not sure how to adequately and competently address. Um, maybe who's doing okay in my clinic setting that is really struggling to generalize and I'm needing some support there. And so really [00:12:00] being able to kind of separate out what are you already doing well, and then where do we need to focus some time and some energy.  [00:12:10] Kate Grandbois:  That brings me to a question I, as you were speaking, Thinking about this component of the answerable question. So you know, there are a million questions we can ask about our clients, particularly if you're working in a setting as a quote generalist, right? And our scope of practice is so wide and you're expected to treat everything on your caseload or anything that walks through the clinic door or what have you. And you do come in contact with an individual who carries a diagnosis, as you said, that you're not familiar with, or even if it's a diagnosis you're familiar with, but something about the clinical presentation feels out of your scope of competence and you have so many questions. What, how do you identify what is an answerable question versus going to the literature and drink, trying to drink from a fire hydrant, it's such a [00:13:00] great analogy by the way. It just gives you this visual of like, it's just being so overwhelmed, fight by so much information. So what would you say is an, how can you reframe a question to be an answerable question? [00:13:12] Mary Beth Schmitt:  It's a great question. Um, it's a great question is my questionable question. So I guess common, and I didn't come up with this, this is in the literature of, um, you know, even back, uh, rooted in medicine and potentially even before that. But, um, is this idea of a pico question. So it's standing for P I C O, the, so identifying the patient population. And so that can be very, very specific. Um, or it can be. Um, kind of a larger population. So it might be, you know, for my, [00:14:00] for my six year old client who has, um, whatever apraxia and dysphagia and is an AAC user would, and then the I and the C are too contrasting or, um, competing interventions that you're curious about. Would I kind of, maybe some new approach that you've heard about or see something that's more like a control or more, more commonplace. So see, you might think about as kind of what you're already doing, you know, so what is it that you're already doing, Whether that's, um, a therapy approach you're using, whether that's, um, maybe the setting in which. You're, you're providing intervention. Um, maybe it's the dosage, maybe you know, something, it doesn't always have to be an actual intervention, but something about the decisions you're making on behalf of that patient.[00:15:00]  So the thing of that, as you see, then the eye is, well, what are some other options? Right? And so whether that came from, maybe you're, and we're gonna get to this a little bit later, hopefully, but, um, you know, maybe you're, you're listening at a conference and you hear a new approach that you've never heard of before, right? And so that becomes your “I”. And then, “O”, is what are, what outcome are you looking for? You know, is it, um, you know, improvements on particular goals, you know, over the course of six months? Is it dismissal? Is it generalization to a new context? You know, what, what outcome are you looking for? Maybe it's a reduction in negative behavior. Maybe it's an increase in communicative functions, right? So it kind of goes back to what even brought you to the question. What, what got you to the point of I'm stuck and I need to ask a question. What, what is it that's stuck? And that, [00:16:00] that's really your O  [00:16:03] Amy Wonkka:  when I see where that can be so much more helpful than just going into it saying, I need to learn more about apraxia and AAC. Right, Right. Because then, then you're, you'r , I don't know, you're putting a, a nozzle on your fire hydrants to extend our, our, not that great analogy further, um, . But I think, you know,  [00:16:23] Kate Grandbois:  it's a perfect analogy. It's the perfect analogy for this experience [00:16:28] Amy Wonkka: because the, the information that's out there, and we, and we've talked a lot about research because I think that that's, We typically think of, or it's what I typically think of anyway when I think about evidence. But you've also mentioned things like conferences, you know, we'll talk a little bit more about some other places that we can get information as SLPs. Um, and when you add all of those pieces in there, you add in social media, you add in conferences, you add in books you might read. Right. Uh, it's a lot of information. So by having these questions, and maybe we might have a few [00:17:00] questions related to this client. We have a client where,  [00:17:02] Mary Beth Schmitt:  you know, absolutely.  [00:17:03] Amy Wonkka:  We might say, Oh, the, I feel like we're not making effective pro, I'm a school based person. So I think in terms of like, FAPE and things like, so if we're not making effective progress, I might have a couple of different goals. I might have a couple of different questions. Um, so it's really helpful to have that, that framework, that PICO framework to sort of help create those questions.  [00:17:24] Mary Beth Schmitt:  You know, when you raise a really important point with that, Amy, of, you know, when we talk about evidence, you were talking about the different forms of, of evidence. You as the clinician bring evidence, right? And so maybe, maybe you are at a loss, you're like, it's not going well. But I don't even know where to begin on forming a question one one way. And this would just be one approach would maybe track some data for a little bit, right? Of, especially, especially if this particular client, if you have someone with seemingly similar [00:18:00] diagnoses, right? To where just the diagnosis itself, your intervention itself, like everything else is, seems to be similar. What, what is it about this one? And, and track the data. Um, it doesn't have to be for long, you know, depending on what your, what your experience is. Um, but yeah, and see if you can narrow down of like, well, interesting, you know, this, I'm seeing this client for a different amount of therapy than the other one. Or, I'm seeing this client with five kids and the other one I'm seeing individually and or, right, like it could be just the structure. I'm kind of leading to another, another way of thinking about it. Take data and look at, look at the client, but then look at kind of the other components of what does the structure of the therapy look like? What does the process of it look like? So what interventions are you trying? What materials are you using? Um, and see if the data doesn't kind of [00:19:00] pinpoint some directions to let you then start, start asking some questions.  [00:19:05] Amy Wonkka:  Well, and that's really connecting to that. When we think about ASHA's evidence based triangle, you're connecting that clinical expertise with the internal evidence, Right? Our observations about our individual client and another piece I loved that you brought up. I think sometimes we think a lot about the actual intervention or treatment package, right? Am I doing, am I gonna do, you know, a motor based approach? Am I gonna do a cycles approach? What type of approach am I going to use? But there are other variables that could be at play. Like, it literally could be as simple, and I say that with air quotes because scheduling is, is anything but simple. But you know, it could be something as simple as the size of your group or maybe what time of day you see the client. Or you know, there's a lot of different environmental and client variables that could be at [00:20:00] play too that you might wanna just take a second to reflect on. Like should that be a question too? And, And that question might not be so much answered in the research. Right. That's probably gonna be answered more through internal evidence.  [00:20:14] Mary Beth Schmitt:  That's right. Or at least initially, right. To be like, Oh, interesting my. We're just kind of stuck on the, Or I'm stuck on this one. You know, like it's something structural, like I'm noticing a difference between my large groups and small groups. Interesting. I wonder if there's something there or, or I'm noticing something different in my afternoon groups versus my morning, you know, is there something connected to time of day or is there something with basic needs of food and just fatigue? And you know, there's some studies coming out now about sleep and kids with, um, communication disorders, right? So it even that of just like pausing enough to take some data to be like, Oh, interesting. I'm seeing this pattern that can then lead you to some of the [00:21:00] external evidence. And as you say, not not end up so overwhelmed with like, I don't even, I don't even know where to start. And then the flip side, I don't know where to start. I don't know what to read and then I have no idea whether or not to implement any of it.  [00:21:13] Kate Grandbois:  And I just for the sake of emphasizing the importance of this triangle, as you said, and how they all influence one another. Um, I know I mentioned this, um, in our conversation before we hit the record button, but so often as a professional culture, we're in the culture of our profession, I guess I should say. We think of evidence as research articles. We think of evidence as, um, this, this component of external evidence, but there really are, there are. It's so important to consider your internal data collection and your client perspectives and values and your clinical judgment because all of these components work in tandem together and influence each other. And I love the idea of relying on those to help bring you to the clinical [00:22:00] question, to find the external pieces of evidence as opposed to just going straight to the external evidence. Because that's when you get the, and I'm just gonna keep saying it, fire hydrant drinking experience [00:22:11] Mary Beth Schmitt: . That's right.  [00:22:14] Amy Wonkka:  Which nobody really wants. [00:22:15] Kate Grandbois:  Nobody wants that. We want, That's what happens when you, like not a fire something or when you like, go to the as of wire and type in your research, your research terms, your question, terms like AAC, you're gonna get thousands and thousands of hits. That's not helpful. [00:22:29] Amy Wonkka:  Just this morning I was in a Google hole, It's, it's real.  Kate Grandbois: I believe you.  Amy Wonkka: It's real. It happens. It's real. Um, . I think one other piece, just reflecting back on the evidence based triangle that may help you form your question to begin with is that client, patient and caregiver perspective. So we've talked a lot about, right, We've talked about generating that question based on our own feeling that something maybe isn't working, but maybe it's, it's something that a caregiver brings to you. Maybe [00:23:00] they have a question and you're like, Hm, I'm not sure I can find out about it. [00:23:03] Mary Beth Schmitt:  Absolutely. Absolutely. And you know, this is something I've been kind of trying to disentangle with my students. Some of, sometimes I wonder if, if using this term, uh, with speech language pathologists as us being the experts, were the language experts, were the communication experts inadvertently puts us in this weird shame place where it's like, ah, I'm the expert. Like I, I have to know. Like, I can't ask a question. I sure. I can't let anybody else know I don't know. And, and that's just a bunch of lies, you know, But I, but I see it happening more and more of like, This huge weight of responsibility. And um, and it's interesting, there's been some pieces I've read on [00:24:00] what do you even mean by experts? And the people who study expertise talk about it as not knowledge but your process. They're like experts.  Kate Grandbois: That's interesting.  Mary Beth Schmitt: People who, right, who process information really, um, efficiently in their area to come to a decision. They're not the owners of all the knowledge. It's just based on their training and based on their years of experience, the way they process and implement data coming from research or, or, or information, um, is a more, much more efficient and effective process than that of a. [00:24:41] Kate Grandbois:  I love that. That makes so much sense. Yeah. I think  [00:24:45] Amy Wonkka:  and, and I think that, I mean, we talk all the, like our scope of practice is huge, so huge, physically impossible to know all of the things. And even when you sort of hyper specialize in one area, it's still impossible to know all the things. Yeah. [00:25:00] Nobody knows all the things. Um, and so I think with that, it's also really empowering to like cut yourself some slack and remember like you are not a human dictionary or encyclopedia, I suppose, but you're, you're just somebody who's there to help filter through that information as, as a more informed consumer, um, who can integrate that information. I think that's, that's such a good point.  [00:25:26] Kate Grandbois:  And sort of, and tying it back to what you said before about the process that we go through to come to a decision that is this, Would you say Pico, p i c o? Yeah. You know the framework to come to a clinical question. So if you are in a position or if you're listening and you have someone on your caseload or someone in your clinic that is very, feels very overwhelming to you. You have a lot of clinical questions. You're feeling like you're out work, operating outside your scope of competence or on the fringe of your competency. Taking a minute [00:26:00] to use a framework like this PICO framework to bring yourself to a clinical question, I would have to imagine alleviate some of those feelings of fear or overwhelm or, or being overwhelmed and based on your description of expertise, continues to put you in a place of comfort and competence in using the knowledge that you have. Um, I, I feel like it's very uncomfortable for me to say that anyone is an expert in anything because I, I've been practicing for 15 years. I feel like I know nothing. Right. You know? Cause like we are by our code of ethics beholden to life an exercise of lifelong learning. So it feels a little weird to say that we're experts in something. Um, but I think, you know, to your point, we do need to make sure we feel confident helping families and knowing that we do have master's degrees and we do have, you know, fighting off imposter syndrome by using frameworks like this to carve out the, the good clinical questions and seek the [00:27:00] information that we need to feel more competent. Sorry, that was a long soapbox, sort of tying it all up together.  [00:27:06] Mary Beth Schmitt:  Yeah, no, that's exactly right. And then that's where that third piece of the triangle of your client comes into play of, if we redefine expert as being an efficient kind of, um, synthesizer of information, then it allows our families to be experts in their, um, their family member, you know, whether it's their spouse or their, um, parent or their child or, you know, whoever it is. And then the clients themselves to be experts of themselves. Um, and I think just more and more, um, you know, especially when our. Our culture is different than that of our clients. Our linguistic background is different or just we're just different. And so allowing them to be experts in the position that they bring, in, the, the needs that [00:28:00] they have, their, um, their wishes and desires, then it allows them to be a part of that EBP triangle. And it increases the likelihood then that whatever decision we end up making, um, is something that's gonna be working for them, right? That it, it'll be effective for the clients we're serving.  [00:28:20] Amy Wonkka:  I thousand percent agree. And I think that it's all almost impossible to allow other people into the expert club if you're holding onto your, your expert label so tightly. And so, yeah, it really, to provide client centered care, you need to let that go. You need to let that, that expert hat hang up on the, on the hat rack.  [00:28:45] Amy Wonkka:  I'm going to ask a question that sort of brings us into our second learning objective, because we've talked a lot about forming that question. So let's say we have our question, It was informed by our clinical judgment, [00:29:00] internal evidence, caregiver perspectives and values. How, how can we, how can we seek out sources of information? That could be research articles, but could also be other places, Like how do we stay on top of these types of things? Um, as busy SLPs? [00:29:16] Mary Beth Schmitt:  I appreciate this question so much because honestly, it's a question I'm always asking myself too, like, even as a researcher, I mean, it's my job to stay in the literature and it's hard to keep up with all the things and research is, let's just be frank, like it's hard to read. If I've got some time and I'm like, I would like to do a little extra reading, research articles are not gonna be what I choose. Like it's a different genre if we weren't trained in how to read that genre, that's hard. Um, and then understanding whether or not it's good research, right? Whether or not we should even pay attention. Like that's hard. And [00:30:00] so that could be its own conversation that it is important to know the research. Like I, I think we can say that, right? Like to be at the top of our license to be experts in pr, in processing all this information, we do need to know, um, what the current research is, because I hope that our field looks different in another 10 to 20 years. But I hope the evidence we have to guide individual, um, practice and specific care for our caregivers and our patients looks different in 10 to 20 years. But if I'm not connected to that, Then I run the risk of being very irrelevant and potentially even doing damage and causing harm. And so, so then I think the question is like, okay, maybe you wanna look at the research. Awesome. And I've heard of SLPs that'll do like journal clubs with people in their community, whether, you know, if they're in the schools, it could be other teachers and maybe admins, [00:31:00] um, maybe it's other SLPs if they're in the hospital, you know, maybe it's their rehab unit. And they'll, they'll pick an article across these disciplines, right? So like, even for SLPs, like in the schools, maybe it's an educationally relevant article. Maybe it's something in special ed. Maybe it's something you know, more specific to occupational therapy, you know, where it's related, right? But not specific, but they pick an article, everybody reads it, and then they have conversations about like, what did you get out of it? How do you see this applying? And, and I love that model, right? For one, for busy SLPs, it becomes a little bit social, right? And so it's, it's section time, it's it's community building, and then you're with other people and other brains to really think about is this relevant? If so, what could this look like in our, in our field and in our specific setting? Um, how would do we wanna try it and with whom? So I [00:32:00] think that's one way to stay pretty close to the research and the research articles, but doing it in a way that might be a little bit less overwhelming and less lonely. Honestly, you rely on other smart brains too, to really  [00:32:13] Kate Grandbois: maybe pour yourself a glass of wine or, or have your journal club meetings and rest. I'm just thinking of myself and what I, what would make it more enjoyable. But the other thing I love about that suggestion is the ability to digest it with peers. Uh, the ability to brainstorm actual application from the research. So, you know, this research article, so much of the research that's out there is not, exa is not about our exact client. It's not about the exact presentation that we see in the school or in the clinic, right? It, it involves materials that happen in the lab or it, you know, it involves an intervention that's not replicable in your setting. So sitting with colleagues and trying to come up with ways to extend this research from the [00:33:00] lab into your setting in a way that is applicable and doable. Is, is a huge, um, one of the things I think we're, we are missing so much of in our field is that extension of the research. So I love the idea of doing this with colleagues to brainstorm. More brains are always better than one brain. We say that here all the time. But the same is true for your own, for your own setting. And anyone who is listening who is interested in this, I highly recommend having a conversation with your supervisor or your administration and advocating for something like this in your workplace setting so that it becomes a cultural norm of your job.  um, to any, you can, you can get cert, you can get CEUs for it if an administrator provides a certificate of attendance for you, so you can find a way to work it into your workplace setting. Um, you can also schedule it at a bar. I, I, I fully support that choice after work hours, if that works for you, . Um, [00:34:00] but just trying a, trying to find a way to make something like that a part of your schedule is, I guess my point can be a really nice way to, to integrate it into daily habits or your monthly habits or what have you. [00:34:11] Mary Beth Schmitt: Yeah. And thinking about, you know, you were saying, you know, lab focused in the research to, um, more like real world scenarios. But the other, the other thing to think about with the articles too is like, don't be afraid of the SLP to have an article that doesn't actually have kids. Or sorry, I default to kids. That's just my world, but doesn't have persons with a communication disorder as the focus, I cannot tell you how much I have learned and how much has informed a pico question by reading educationally relevant articles. Where they were do, they were looking at mechanisms happening in classrooms. Cuz guess what? That's where our kids are. And so by looking at that, that turns into a pico question. Like, oh, interesting. Peers matter for kids with typically developing language. Does that [00:35:00] matter for kids with who have a language disorder? Or, you know, maybe whatever that looks like in a hospital setting or in a nursing home or whatever. So don't, don't automatically dismiss research that doesn't have your specific population in it, that that becomes your pico question. Could this also relate or have an impact? Maybe yes, maybe no. And then you take your data to, to find out.  Amy Wonkka: It's such a good, Oh, sorry, go ahead. No, sorry, go ahead.  Mary Beth Schmitt: Nope, I was gonna move on to another idea. [00:35:33] Amy Wonkka:  Oh, I was just gonna say, I, I think that that's such a good point too, that everything that we learn, whether it comes from our field, an allied field, um, is going to help inform. Everything that we're doing moving forward. Even if you read something and you think, ah, that that seems weird and I don't understand it very much, you're still more informed. You know, it's something that somebody in a different discipline might be doing. It might raise some [00:36:00] questions for you. It gives you some background knowledge in the future if you encounter that approach again. Um, so there is this piece of, Yeah, we, it's, it's not just as, I mean I love me at ASHA Journal, but it's not just ASHA journals, um, that we can look at to gain information. And I think you were gonna tell us maybe about some other ways to get this information too.  [00:36:18] Mary Beth Schmitt:  Yeah. These are just other ideas. Um, you know, but maybe stepping outta your comfort zone a little bit or widening your. Call it kind of diversifying your feed. It doesn't have to be over social media, but like what conferences are you going to, you know, and maybe, maybe you need to, you know, the state associations or Asha, maybe that makes the most sense just because you can go and get all of your continuing it. Awesome. Then maybe carve out some sessions that are specific to research, right? And so you, you already have your pico questions in mind, or maybe not. Um, but in each kind of topic area, there's some that are more, [00:37:00] um, clinician focused. Like they're more practicality of like, here's what to do, you know, Monday morning with your clients and their new ideas. And those are, those have a lot of value. Maybe one way you can start to broaden and get in some of this research is to go to a couple research focus talks that align with either a pico question or they align with one of your, um, population groups. Or there's something, there's something relevant in the title and the abstract of the research to your practice. And it doesn't have to be your whole conference, right? But, I think going into these research presentations and even the posters like that could be an accessible way. You know, because there you can talk with the researcher, you can kind of engage in a more in depth way. And so that might be an easier entry point if you've never really considered going to a research talk before. Um, and then [00:38:00] don't expect the research to have all the answers, right? It we're still going back to that triangle, so you're going to get a just more information to maybe guide your answer of your people question to guide kind of how you look at the data that you're collecting. And so don't expect it to have all the answers, it's just, it's just one more piece. And so that would be something I would encourage you of just where are you when you're up for your continuing ad, What's your go to? And broaden that maybe to include some that are, are more research focused.  [00:38:37] Kate Grandbois: That's a great suggestion. Thanks . Go ahead.  [00:38:44] Amy Wonkka:  I feel like that's a great tip. Um, I also have done, because I work in a school, I've done some continuing education geared toward educators, and I personally have found that to be very helpful. Yeah. Because the school based SLPs, [00:39:00] we are there to help our students access the curriculum. And as an slp that, that can be really daunting. Um, an educator is usually responsible for curriculum within their grade band. Um, if they're a secondary teacher, you know, within their subject area, maybe a couple of grade bands, but an slp, you could be. Responsible for curriculum K to five or K to six. And so having some understanding of what that means, what are, what are your state standards, all of those pieces, again, are really going to help, I find, inform that, that pico question that I'm asking. Uh, because without some of that background knowledge and under understanding what the classroom teacher is thinking about, it's really hard to know how to support our students in there. [00:39:48] Kate Grandbois:  And just to, uh, piggyback on that comment, um, there is, uh, one of my favorite terms that I heard over the last couple of years was disciplinary centrism. [00:40:00] So this concept that we think our discipl. Knows we are the experts of communication, as you said, but no, and no one else knows as much as we do, right? That's absolutely not true, right? And so be the concept of looking, going out of our silos, going into occupational therapy, education, physical therapy, if it's relevant, psychology, um, you know, any additional other field to compliment what the knowledge that we have is incredibly helpful for deepening and understanding of a topic. Um, that's, that's one comment. And the second is that continuing education, because we are required to do it, is a wonderful vessel through which to acquire more knowledge. And if you are listening, and this is news to you, write it down, tattoo it somewhere on your body, the ASHA CEU is not required. For your continuing education units, you can use courses through edu from [00:41:00] education. You can use courses from occupational therapy, physical therapy, applied behavior analysis, psychology. As long as you are participating and getting that certificate of attendance and go to the ASHA website, it's real. People don't believe us sometimes when we, when we talk about this. So you can use coursework and webinars and articles and things from other disciplines for maintaining your CS and in some cases your state licensure check with your state licensure. Um, but just again, just like you said, branching out of your comfort zone and considering other disciplines as part of your continuing education and knowing with confidence that it will count towards your certification, um, and continuing education requirements. It's a tiny soapbox. I had to get on it. I saw it there. I just, I had to, I had to take it.  [00:41:46] Mary Beth Schmitt:  That’s not a soapbox, that's important information. I'm not sure I knew that. Even . That's good. It's, it's so important. It's huge. It's huge because we end up with this incredible bias, [00:42:00] right? When we're, and it's actually a thing called confirmation bias. When we go, we think we're doing pico, we think we're doing evidence based practice, but we go into our pico question with a huge assumption of what we know the answer to be. Or we go in looking for confirmation that we're right. And so by broadening, by listening to other disciplines considering the wholeness of our clients, right? And they're not just this unidimensional creature that only needing support with communication, Maybe yes, maybe no. But they have all these other influences in their lives, like I think that's just really important information all around. So thanks.  [00:42:41] Kate Grandbois:  You're welcome. I'm glad I was able to share something of value.  [00:42:44] Mary Beth Schmitt:  It is a lot of value. Yeah,  [00:42:46] Amy Wonkka:  we can, we can link some information in the show notes to the ASHA and CMH article maybe. [00:42:49] Kate Grandbois:  Yes. And they changed the name of it just to make it more confusing. It's now pdh. So professional development hours. You need 30 professional development hours. Not Asha CEUs. Asha [00:43:00] CEU is a brand that they sell. And that's all I'll say.  [00:43:03] Mary Beth Schmitt:  Okay, I love that. You know, And then for another idea, um, they're speaking of ASHA too, but not just ASHA. There are some resources where, some of the work has already been done. So like ASHA has a, a team and there were, and it's an ongoing process of creating evidence based practice maps, um, through their practice portal. Um, it is evolving, right? So there's not gonna be answers for all of your people questions, but there's a lot there and there's a lot of information, but it's kind of in one space where you can go through and you can, they link the articles if you wanna go look at the articles, but they also do a nice job of summarizing kind of the evidence across a particular topic and whether or not there's evidence to rely on from the research or whether it's still kind of uncertain. And what that lets you know is how much [00:44:00] more you need to rely on the other pieces of. Right. So if, if information is kind of new, um, there's not enough there to be definitive about, great. You take that as more information, but then you, you go and rely on that other internal data your client needs and those perspectives to really make the, the decision if the evidence gets weighty enough. Then you can use that with a little bit more certainty and then still consider the other pieces of the triangle. So those practice maps are real, um, huge asset I think, and something to just kind of keep an eye on and see if anything new is popping up. Um, but there's other, since we've been talking about this particular article, you know, EBP briefs, I'll put a plugin. Um, it's free, you, it's indexed through Eric. So what that means is if you put in a Google term, there's a chance that some of those topics would come up, or you can go straight to that website and kind of click around. But these are not research articles like your normal research article. These [00:45:00] are written as clinical questions. So the authors present a clinical scenario, they ask a pico question, they go through the process of kind of compiling different sources of external and internal evidence to come to a decision. And so your decision might be different, but it, the article itself models the process. Um, and then, is the name of the acronym. E V C A I. I had to write it down for myself cause I, I always get the acronym mixed up, but it's evidence based Communication Assessment and Intervention. They choose one research article and have, um, another author review it. Right? And so they do a summary of the article, but then it's very much we geared towards clinicians of what aspects of this research article are worth paying attention to. And here are some ways you might think about implementation and then maybe what are some of the limitations or cautions that you might [00:46:00] use moving forward. And so that is a little bit more narrow, right? Cuz it's just about one article. But they do a really nice job of choosing some, um, they choose high quality research articles to review. Um, and then just the clinical connection piece that it's, it's really geared for clinician consumers I think makes it a really helpful resource.  [00:46:23] Kate Grandbois:  That's wonderfully helpful to know. Uh, and I think out of all of the, all of the ways that you've described the, you know, extending our, cont our coursework into different fields or making sure that it's research focused, um, journal clubs, the power of being able to quickly look something up online in between sessions. I mean, for the backdrop of this is busy SLPs, right? Yeah. So if you have a minute, and you're, and this is also sort of leading us into our third learning objective in terms of where we find our information, right? If you do. Google something. I know we, it's funny to use Google as a [00:47:00] verb cuz it is a company. Um, but if you're looking something up on the ASHA wire or if you're looking up something up on the ASHA website, um, the evidence based practice maps are very quick and easy at your fingertips in, in comparison to some of these other suggestions. Um, and the EBP EBP briefs, it sounds like it's also a little bit easier to find in terms of quickly looking something up on your lunch break. Um, you know, in between sessions if you finish up your paperwork early, squeaking this in throughout your day as a means to get access to that information. I. Waiting six months until the ASHA Conference or waiting until, you know, you meet your friends at a bar. In my mind it's in a bar. Maybe that's just because, I don't know, it's just that time of day or something. I don't know. Um, but, you know, instead of waiting, being able to look something up from a source that you trust, um, either through the EBP maps or the EBP briefs.  [00:47:57] Mary Beth Schmitt:  Yep, absolutely. [00:48:00]  [00:48:00] Amy Wonkka:  And there are other, I mean, I think this brings us to not like a, not a huge discussion, but there are, we're in the age of social media. There are also private companies that do things like this, that sort of aggregate the research and try and give people the highlights and a digestible format. And I think, you know, one piece with having access to so much information is sort of the burden to use your expert filter processor role to help make good decisions about, you know, kind of the potential biases of the aggregator or wherever you are, you know, receiving your information. Um, and using that just as another filter when you're assessing the quality of the information that you're getting, getting get, I'm, I'm a little too old for social media, I feel like, so I'm, I'm not a huge fan, but I do think, you know, it's nice to have access to so many things online, um, and. Having this ready access to so much information.[00:49:00]  Just because something is on social media doesn't mean that it's bad information, but I think we do wanna be thoughtful about the type of information that we're getting. And if you see something on social media, maybe make sure that you confirm that information with some other sources. Um, just being a thoughtful consumer. [00:49:20] Kate Grandbois:  Yes. And here we are at our third learning objective with the, talking about the importance of being a cautious consumer of information. Uh, and you're right, there are private companies that are posting and using social media to disseminate evidence and research based information. And often they will cite a source. There will be a reference or a research article that is posted in conjunction, uh, We encourage you to go look that up if you, if you see that or do your own investigating. Um, but there are also others that post things without a source, and that doesn't necessarily mean that it's not EBP, but maybe in that instance you could [00:50:00] send them a dm, send them a Facebook message, Hey, I was wondering if you had a reference for X, Y, and z. And then there is other information that is, that is false, that was posted maybe with the, under the guise of it being EBP. Um, and I know the, the old adage, it's not that old, but everything you read on the internet isn't true. Well, the same thing applies here. Um, just because it is posted in, in, in on social media doesn't necessarily mean that it's gone through the scientific process of research and be, and, and the peer review process of ending up in a journal it may have. Um, but I think it's really important to make sure in between sessions while we're Googling something or looking something up, or let's face it, 10 o'clock at night, we're exhausted. We're scrolling our feeds before we go to sleep and we see a post that resonates with us because it is related to that pico question that we have. And we save it and we think, Ooh, I gotta look this up tomorrow. Making sure we consider what that source is. I don't [00:51:00] know if that, that's a mini soap box that I had to go and I speak just for myself, maybe for Amy A. Little bit too. You can correct me, but I dunno if you have anything  [00:51:08] Mary Beth Schmitt:  to add. No, it's very important to be discerning and I would just broaden it, right? Any information you get, right, Whether it's, you know, published, peer reviewed journal or at a conference or on social media. Like you, you don't wanna check your, um, your brain at the door and just be, you know, be ready for the, the taking. Like really be, um, Yeah, that conscientious consumer I think is important. But there was something you said cake that, uh, that I think is really important to distinguish when we're talking about EBP, like that, you're talking about Google becoming a verb, right? I think EBP is actually a verb that has become a noun, right? And it's noting yes, it's say more process evidence based, pro [00:52:00] evidence based practice is a process. I have a hard time saying that, right? It's that process of integrating information that triangle, right? That external information from ideally from a highly credible research, gold standard, whatever, you know, that aspect of it, but your data as your clinician, the information from your client, it's the evidence based practice is the process we use as, um, professionals in integrating information from all of those components to making a decision. For our clients. For our patients. It's not a product, so you cannot go by ebp. Right? When you're at the exhibit halls and somebody is saying like, Hey, we have an evidence based, um, tool to use Monday morning, no. Nope. Actually they don't. Right? That's a marketing tool. [00:53:00] No. There, there might be some value in that new material, right? There might be something about that particular product that you wanna consider for your clients, but you can't go buy that and then check the box of, Now I have done evidence based practice, right? There's not any one thing that is EBP. It's a process that you are constantly using as the expert with your clients and the, the decisions that are made change it. They change when any element of that triangle changes. So if the client you're thinking about changes, if you get new information that changes, your data changes, it changes, right? And so it's, I think that's such a critical point. Like if, if people hear nothing else, right? EBP is a verb. It is a process that we are supposed to constantly be [00:54:00] doing. You can't go by it.  [00:54:03] Amy Wonkka:  So would it be fair to say, just thinking about that third learning objective, that the way that we are incorporating that external evidence in our EBP is by engaging in that process, by engaging in that thought process. And I think you make such a great point about. You know, it's, it's not just social media. Social media is where we see a lot of things in quick, quick and easily digestible bites. Yeah. Yeah. But it is also conferences. It is also the books that we read or the articles that we read and engaging in that process. I, I love, I love the idea that EBP is not a noun it's a verb. Um, and I think that that gives clinicians also a little bit of flexibility to think about. Right. It's, it's not a place that we achieve. It's not a place that we get to. We don't reach the, the mountain of [00:55:00] EBP that're always working on engaging in EBP. [00:55:03] Mary Beth Schmitt:  Yeah. Yeah. It's constant. I mean, that's also a little exhausting, [00:55:14] Kate Grandbois:  Especially thinking about the backdrop of people with really high caseloads and. You know, no time to eat lunch and taking paperwork home and working on the weekends. If you're thinking, I mean that, I feel, I'm thinking about myself listening to this episode. I'm feeling very overwhelmed about not needing to know the research and needing to read the research. And it's a process that's never over. But I, I, I, I wanna emphasize that this is a doable thing in small increments when, and something that we can integrate into our daily routines without it feeling like a really overwhelming process. Um, either through some of these strategies that we've already talked about [00:56:00] or just continually reflecting on your clinical question and coming back to that, um, over and over again. [00:56:07] Mary Beth Schmitt:  Right. Right. Cause I think that's important, right? It's, if e EBP is constant, then it's just, it's a mindset we stay in of. It would be easy enough to show up, do our therapy, go home and just show up, do therapy, go home, you know, on repeat, but show up and then be interrogating, right? Of ourselves and of our practice. And so maybe you're not changing EBP also doesn't mean you're changing something every day, right? And it doesn't mean you're doing a total gut overhaul of how you're doing intervention. It's a process of you're constantly asking yourself questions. Is this working? How do I know? Where could I tweak? How can I like, kind of keep my toe right in the waters of new information coming out through the [00:57:00] research so that I do know when there's something interesting enough that I need to give it consideration. And so I think that's important for listeners seeker too, by saying that we're constantly doing EBP. That doesn't mean you're constantly changing. It's just you're constantly kind of staying in that curiosity mode.  What's working. [00:57:19] Kate Grandbois:  I love that curiosity mode. Yeah. That's such a, that feels doable. I can wear, I can wear a curiosity, but I'm gonna make a t-shirt that says curiosity mode That's gonna be our maybe in our, in our makes a merch or something. Um, I wonder if, I know we've already talked a little bit about this in terms of, uh, when we were talking about discussing articles with colleagues in clinical application, but in our last couple of minutes, I wondered if you could tell us a little bit about how we can take some of that external evidence if we don't have access to colleague discussions or if we don't have access to a journal club, what are other ways in which we can consider the external evidence and make it [00:58:00] clinically applicable. [00:58:01] Mary Beth Schmitt:  Yes. So it's, Can I just say first that it's hard and there's no one right way to do it, but it can be if we say in curiosity mode, right? It can be, I think, accessible. And so what I would recommend is don't trade out on everybody unless you want to, Right? But, you're maybe you go to a conference and you hear something new, or you read an article and you're like, Oh, that's interesting and it gives you some information on your pico. Maybe you start with one or two clients or one or two groups that, um, that inform the Pico question, right? The one or two who maybe aren't making yearly progress or you've been struggling to know exactly how. Start there, and then this is really important. Take your own data. If you can, I would even recommend, depending on what you, what it is you're wanting to change, take some weeks' worth of data before you change anything.[00:59:00]  Maybe you already did that to lead up into your pico question, then implement it again just with a couple of your clients and take more data and then see are you noticing a difference? Um, is it working really well? And then you're like, Oh, that actually wasn't too hard. I'm seeing this noticeable change. Maybe I wanna try it then with another client or with another group. Um, and that way too, it gives you the freedom to try new information or new evidence, even if your specific client wasn't represented well in the research. Right, because that for so many of us, that's true. Like we're working with very heterogeneous populations and if we're waiting for the research to give us exactly who we're working with, we're gonna be waiting a long time. And so that EBP really allows us to, Okay, here's this tidbit that sounds interesting, but now I'm gonna implement it using my professional knowledge. I'm gonna take data on it. So [01:00:00] now I'm using my internal evidence plus their needs and their buy-in and looking at it holistically over time.  [01:00:08] Kate Grandbois:  I love this. I love this, I love this. I think that's so often, at least I'm reflecting on myself as a new grad. Reading this research and thinking that if I didn't replicate it almost to a T. Or if I didn't take the whole intervention package, it, you know, breaking off a little bit, a little bit of it and applying it through with my clinical judgment and with measurement, internal measurement felt like cheating. It felt like I was being naughty, like I was, I was doing, I wasn't doing the, the serve, doing the, the research justice is what I'm trying to say. Yeah. So being given permission to do that and also feeling comfortable and confident that that is our evidence based practice process. This feels, it just feels real nice. So thank you for clearing that up.  [01:00:56] Amy Wonkka:  Well, and I love the data collection and internal [01:01:00] evidence piece as well, because it's just another way to think critically about that information. So we're thinking critically about the source. We're thinking critically about, you know, is this something that's been replicated a lot? And then we're also thinking critically about, But what does it mean for my client? And, and I think you can't have that last question answered if you're not collecting some internal evidence and the idea of having some data from before you start the intervention, I also was like air fiving you in my brain because I think, you know, you need to sort of know what was going on before to know if it was helpful or not. You know, when, when you, when you changed your intervention or you changed your approach or you changed some variable. So all of that makes so much sense. Um, and I think really allows clinicians to integrate all of those pieces of the evidence based practice triangle. So yes. Good stuff.  [01:01:54] Kate Grandbois:  In our last couple of minutes, do you have any parting words of [01:02:00] wisdom or if there are any SLPs or teachers or anyone listening who feels a little bit overwhelmed about embracing, truly being able to embrace EBP within their, within the restrictions of our very busy schedules? What, what, what pieces of advice do you have? [01:02:15] Mary Beth Schmitt:  You know, I do. Um, A couple of things. One, I think it really does start with, we talked about the, the curiosity, um, redefining expert kind of growth mindset like that, that is a huge piece of EBP, right? So like starting there, you don't even change anything. Maybe it's just a year to be really curious. and write those curiosity questions down. Maybe you spark conversation, right? There's no paper anywhere in, in sites. You're not reading anything. It's just like, Huh, this is something I'm noticing or this is, [01:03:00] this is has me thinking. Like, let's face it, we're all facing a lot of challenges right now. Um, there's a lot to be curious about that, that don't come with a lot of answers. And so that's where I just like, give you permission, right? Like, I dunno that it's mine to give, but if it helps,  Kate Grandbois: that's wonderful. I'll take it. Mary Beth Schmitt:  Okay. Well, and I just, I don't think we give ourselves enough credit for our, our mind and like our head space. And so staying curious, remember that this is growth mindset, so there is no idea of perfecting EBP It's just this showing up. Showing up for ourselves, showing up for our clients, staying curious. You don't own all the knowledge, you're not supposed to own all the knowledge. So expertise is just this constant refinement of asking questions, being curious about it, gathering information. Um, and then if it's helpful, it [01:04:00] has been helpful to me honestly. And so I'll share, um, I started on social media starting to follow researchers who try to get their work out there in a digestible form. My lab is trying to do that and we are so grateful for followers who are giving us feedback on like, what's helpful, what's not.  [01:04:21] Kate Grandbois:  Um, and how can our listeners find you? Tell us, give us all your in contact information that you're comfortable sharing. [01:04:26] Mary Beth Schmitt:  Well, we had to have an acronym, right? Because Hello SLP. . So we are, and I'll give this to you guys, but we're @UT cuz I'm at UT Austin. Um, we're @UTCL3Lab cuz we're the children's language literacy and learning lab. And a little alliteration there too, like Love it. All of it. . So @ut CL3lab. Um, and right now we're on Facebook and Instagram, but that is really part of our mission. Our mission is to [01:05:00] do research related to kids in the schools and parcel it down into digestible bits for SLP that they can take it and consider it. Like just consider it. Um, and that's another, another thing that we've been doing, both on the, So you can find us on our website and then you can find us on social media, on our website. We also have these one page PDFs, um, of research articles that SLP can. To start conversations with parents that can take an into IEP meetings, to their administrators, teachers, to the journal club that is like, here's some evidence that I want to think about. Can we use this? And so we're trying to put out that digestible information that, that SLPs can just take and use. Um, but why I started on all that, that is all true. We're also talking about like, okay, so here's some new research information, [01:06:00] right? And using this analogy of the swimming pool, because it's really hot right now in Texas. So, so this idea of you don't have to completely gut your practice and start fresh, that maybe you're just at a point of sitting on the side and dipping your toe in. And that looks like starting conversations, right? Just asking questions, staying curious, engaging in conversations. Maybe you're ready to float. Like, you don't wanna get your head wet yet. You're willing to get in the water. Um, and that's the gather data. Maybe you're already doing some of what research is suggesting works, you just haven't paid attention to that component of it because you're making a thousand decisions for your clients every day, right? And so just gather your data, ask some questions, really look a little bit deeper into the research, and maybe you're ready to dive down into the defense, right? And so then we will, we'll give some strategies of like, Okay, if you're ready, here's what the research suggests. Here's how to [01:07:00] kind of shift the structure. Here's how to shift your groups. Here's how to work within the constraints of your current situation. And so that's some of the work that we're doing behind the scenes to try to give that to SLPs. But I would just, I would also share that mindset with them, right? Of EBP. Again, it's that curiosity staying in that head space. And so you get to decide what's feasible for you in terms of actual implementation.  [01:07:32] Kate Grandbois:  That was so massively helpful and so clear, and thank you so much for being here and sharing all of your wisdom with us. Um, we're really, really grateful for your time and we'll have all of the resources that you mentioned listed in our show notes. We'll have your contact information and your website and all of the downloads, um, and resources listed there as well. So if anybody's listening in your commuting or jogging or folding laundry or whatever it is you're doing, all of those links will [01:08:00] be at your fingertips, available in your phone, your podcast player or what have you. Thank you again, so, so much Mary Beth, and  [01:08:09] Mary Beth Schmitt:  thank you for having me.  [01:08:12] Kate Grandbois:  Yeah, this has been a real pleasure. Thanks 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 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 . Martin Holland Part 1 [00:00:00]  Intro Kate Grandbois:  Welcome to SLP nerd cast 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. Are you interested in coming onto the podcast to discuss one of your favorite treatment techniques or a piece of research that you particularly love? We are currently planning season six that begins in September, 2024. And our call for papers is [00:02:00] open. Our call for our call for papers process is what you might find for any other conference or convention.  Yeti Stereo Microphone-6:  You'll need to submit a topic, a title a summary of what you're going to discuss as well as a few references to make sure it's evidence-based. We review all of our submissions. In-house in conjunction with our advisory board who bring outside expertise to the table. Our goal is to replicate the peer review process as closely as possible.  If you're interested in joining us on the show. Please consider submitting a call for papers proposal. The link for submission is in our bio. You can also find it on our website at www.slpnerdcast.com .  Yeti Stereo Microphone-7:  This year's call for papers will close on March 4th, 2024.  Yeti Stereo Microphone-6:  We can't wait to learn from so many of you in season six, and we really look forward to reviewing all of your submissions.  Kate Grandbois:  Hello everyone. Welcome to S L p Nerd Cast. I'm without my co-host Amy Wonka today, but I'm not alone today. I have the pleasure of welcoming Martin [00:03:00] Holland. Welcome Martin. Hi Kate. How are you? I am wonderful. I'm really excited for today's conversation. I have a little story to tell about how we met and how you came to be a guest on our podcast. But first I was wondering if you could tell our listeners a little bit about  Martin Holland:  yourself. Well, thank you for that opportunity. First of all, I'm thrilled to be here. I was telling you beforehand, I have a passion for numbers and a soft spot for speech language pathologist. My wife is a S L P and has a clinic. Uh, she now has 26 therapists. She's magnificent. So this is melding two of my favorite things. And I hope, uh, do a good job and, and useful to people. Um, about me. Just quickly, uh, I've been in business for 49 years. I started eight companies, two of them failed, sold four of them. Still work with two. I'm currently a business coach because after selling my last company, I thought, I don't want to do [00:04:00] this again. And this is really, really hard, right? And maybe I can be useful to other people through my experience in, in what I've learned over the years. Took a couple of years to learn how to be a coach. Uh, but it's worked out just the way I thought it. It is also melding a couple of my passions, which is helping other people. That's my entire purpose in life, particularly business people, because that's where I'm suited to help people. And also it's, I'm passionate about helping people, but I'm really thrilled when I get paid to do that. Right? And that happens too. So, um, That's kind of quickly my background. My eight companies are across a broad range of industries, from biotechnology to chemicals, to manufacturing, to contracting, to agriculture. And now, uh, with my wife's practice, I'm working, uh, with a speech language pathology practice.  Kate Grandbois:  And that's one of the things that I love so [00:05:00] much about your experience is the range of industries that you've worked in. Um, and before we get in today's, into today's material, I wanna tell this little story about how I came to know your work and how we came to be introduced to one another. Um, as our audience knows, I'm a small business owner. I run this podcast. I have a private practice here outside of Boston, and I have always struggled with several aspects of running my business. I've never really struggled with being a speech pathologist because that's what I was trained to do, but all of these other additional pieces that go into running a business, marketing, looking at my financial statements, trying to make a budget, trying to stick to the budget, financial forecasting, using my, using my business information to make good decisions, planning ahead, all those things, it's always been very overwhelming to me. And about a year ago, a little over a year ago, we're recording this in June of 2023, so this was probably [00:06:00] April, 2022. I was at a family dinner and I was having a conversation with my brother-in-law who was also self-employed in a totally different industry than me. And we were talking about work, and he said, oh my, you have to, you have to read this book. I just finished reading this book and it completely changed the way I look at my business. And my brother-in-law is brilliant and he reads, he's probably read like hundreds of business books. So when he tells me I have to read this book, I'm like, all right. So I haven't really read a lot of business books in the past. So he gives me a copy of his book and I read it. And the way I describe this book, which is your book is, it's like a beach read for numbers. This book, I understood it. I understood for the first time so many components of running my business, and I had my own little nerdy fan girl moment over this book. And so I bou, I looked you up and I I connected with, I did. I looked you up. I connected with you on LinkedIn as an as a human does, I suppose. And to my [00:07:00] surprise, you wrote me back within like a day you wrote me this nice little message that said, I thank you so much for the connection. I, are you a speech language pathologist? And I thought, oh, I felt so special. I thought, oh my goodness, this brilliant person who wrote this amazing book knows what speech pathology is. And then of course, you told me about your wife and you were so generous with your time and we had a few phone calls and I've just learned so much from you. Um, and you have a podcast too, don't you? Why don't you tell us a little bit about your  Martin Holland:  podcast? Yeah. A large part of, uh, my business is, uh, dealing with what I call industrial clients, manufacturers, contractors, home builders, things like that. So we have a podcast called the Cashflow Contractor. Um, we've been on, we've got 162 episodes up, and I was telling you this morning, Kate, that, uh, what did I call it? Listen, our, uh, technical person found this, but we're ranked, uh, in the top [00:08:00] 10% globally for podcasts. Listen to those.com , and I'm encouraging you to look it up because you're gonna be way up there too. I know you will be. So, um,  Kate Grandbois:  I hope so. Yeah, my fingers are crossed.  Martin Holland:  It's been a lot of fun. I mean, I learned more probably from our podcasts than I, anybody. I mean, we get to interview all kinds of people. We do some internally to explain concepts, but thanks for bringing it up to Cashflow Contractor  Kate Grandbois:  and, and, you know, podcasting is, its, is its own whole world that we could talk about for a million years. Um, and I'm really excited to dive into what you've put in your book and what, how it can be applied to the field of speech pathology. Um, so let me get into covering some of our boring housekeeping things. I need to read our learning objectives and then our financial and non-financial disclosures, and then we'll just dive right into it. All right. Learning objective number one. Describe why keeping accurate accounting books is important to building a private [00:09:00] practice learning objective. Number two, list at least two strategies to improve bookkeeping without a background in accounting and learning. Objective number three, define breakeven and how it is relevant to private practice financial disclosures. Martin Hollins Financial Disclosures. Martin is the author of a book titled The Profit Problem. They Say, I make money, so why don't I have any. Martin also runs a business coaching firm called Ail Business Coaching Martin's Non-Financial Disclosures. Martin has no non-financial relationships to disclose my financial disclosures. I am the owner and founder of Grand Wa Therapy and Consulting L L C and co-founder of S L P Nerd Cast My Non-financial disclosures. I'm a member of Ashes SIG 12 and serve on the E a C advisory group for Massachusetts Advocates for Children. I'm also a member of the Berkshire Association for Behavior Analysis and Therapy. All right. Boring stuff is over. Let's jump right in. Why don't you start off by telling us a little bit about what accounting [00:10:00] even is? Why should, and why should we care?  Martin Holland:  Well, let me answer, ask, answer why you should care first. Okay. Begin with the why. Makes it a lot easier. Jim. Jim Rowan says, if the prize is apparent, the price is easy, right? So if there's a reason, maybe it won't be so hard, but I suggest that anybody listening to this who's in in business already understands why they need good books. They may not recognize it as such, but those sleepless nights where you're wondering, I thought, can I hire somebody? I rented this building. What do I have to do to be able to pay for it? We've got a lot of sessions, but I don't have any money. Uh oh man. There's a payroll deposit due. I all these questions that people keep people awake. That's what, uh, business accounting and bookkeeping is intended to resolve. And I like to throw this in there because I like history, [00:11:00] but the problems that you confront concerning those types of issues are timeless. Bookkeeping was invented in the 12 hundreds. That means that in the Christmas story, Dr. Scrooge Crotchet was keeping books, right? That's later in the 12 hundreds. But in the 12 hundreds, the original bookkeepers were keeping books while their neighbors were dying from bubonic play. That is how old it is, and it's unchanged. The processes are unchanged. We now do it with a computer instead of big old books. But it is unchanged. And that's because, um, it resolves these questions. So what is it? It is the faithful, timely, and accurate recording of transactions. That's what it is. That is very essential. Now once you've done that, there are all kinds of things we can do with the information that make it useful. But that's really at its basis what, what bookkeeping and accounting are. And that's why it's [00:12:00] difficult because it's basically attention to detail, assiduous, detention to detail. And a lot of people, most people don't like to do that. So, but that's what accounting is. It's recording transactions faithfully and accurately. Kate Grandbois:  So you've already mentioned a few questions that I've wrestled with, what can I afford? I need to buy a new test. Is there enough money in it for my, in my budget? I need to hire someone. How do I, how do I do that? And what do I pay them and what can I afford to pay them? And all of those kinds of things. How does accounting help us to answer those questions? Okay,  Martin Holland:  let's jump back just a little bit. Um, Because the original questions that accounting answers, um, which take back to the 12 hundreds, is first, am I making money? Okay. That, that would be nice to know. I don't know where your listeners are, stand in that equation, but if they don't really know if [00:13:00] they're making money, they're not alone. I would say 80% of businesses that I, and I've dealt with over 500 directly in my coaching business, they don't know, had a guy in here the other day and I said, how you doing? He's a new client. He says, great. My sales rep 50%, 54% last year. And I said, do you make any money? He goes, got no idea. Right? So that's the  Kate Grandbois:  number one. I laughed cause I, I totally sympathize with that perspective.  Martin Holland:  Oh, people don't know. So I hope there's comfort in that because, uh, people trying to take a guess, they open up their cell phone and look at their bank account and they kind of realize maybe, uh, Medicare owes me this much and Cigna owes me this much. And maybe, and then kind of, maybe I'm gonna owe that much and. Anyway, they're trying to do it in their head, right? Middle gymnastics. But the first thing that they do is answer the question, am I making money? And that's not as simple as a question as a lot of times people think that's why it's hard to do. But that's number one that you have to know that, and you have to be making money. If you are not making [00:14:00] money, um, I'm not gonna say it. So you need to fix that because otherwise you're going away. Right? Second question, what do I own? Right? What assets do I own? It's not as big a deal in SLP as it is in contracting and things like that, but you need to know what you own. Part of what you own is accounts receivable. Okay? Accounts receivable, are all those, uh, payments you haven't received yet from the insurance companies, right? Okay. The third question is, what do I owe? So am I making money? What do I own? What do I owe? And that's what do I owe the government for payroll taxes? What do I owe my credit card? Maybe I got a loan to open my practice and buy computers and so on. Maybe I've got my vehicle chart. What do I owe? Then the, the next question it answers is, what, what is left over for me? This one isn't that big a deal, but it's if you take what you own and you subtract what you owe, theoretically that's what's left over for you. Okay? And then the last question that books answer is, where [00:15:00] did my cash go? The fact that you make money has almost nothing. They're related, but almost nothing to do with whether or not you have cash. Okay? I will just say if you bill a hundred thousand dollars worth of insurance, um, payable or receivables, which you haven't received any of it, your books might show, Hey, you made a hundred thousand dollars, which you did. But I don't have a hundred thousand. Why not? Because it's tied up in accounts receivable. And so the answer to that question, uh, we can dive into that. If, if it's of interest of where does your money go, but am I making money? What do I own? What do I owe? What's left over for me and where do I cash goes? Those are the foundational questions that are answered by books I'd like to point out. Those are all rearward looking questions. They're all looking to the past. That's important for taxes. That's important for you to understand how well you're [00:16:00] doing to learn from it, but it's past, to me, the most exciting and useful use of books is to answer the question, what should I do? Okay? If you don't have information to guide your decision, you're going to make your. Decisions based on your gut feel a lot of times, which might depend on, it's a nice day today, it's pretty out and I feel good. And the, the, you might make one set of decisions the next day. You think you have covid, it's cloudy and rainy, and you've just had an argument with your spouse and you're going, I'm never gonna do. So those are not decisions. I mean, they're, they are decisions, but they're not reason decisions. So my favorite, highest and best use, and I hope we get into a specific example of this with my wife's business, how we do it is to make decisions. And, uh, none of those require that you know how to [00:17:00] keep books. Matter of fact, by the end of this, I'm gonna make it clear, you should not keep books. Somebody needs to keep books. And you need listeners to understand how to use the information they provide. And, uh, Did that answer your question? It was what is accounting  Kate Grandbois:  answer? No, it did, it did answer my question and it reminded me. I I have two follow up questions actually. One is related to the title of this episode, and I think you just touched on it a little bit. So the title of this episode is You Can't Run Your Business from an iPhone app, and you just mentioned, you know, right. Something about how many of us who don't have a deep understanding of accounting or maybe don't have an accountant yet, or aren't keeping really clean books. You know, we go to answer these questions, I need to, I need to purchase a test, or do I have enough money to hire an assistant or a biller or whatever. And you open your, I assume this is related to opening like your bank app and being like, how much money do I have? Exactly. And looking at the bank balance, right? Is that what you're [00:18:00] referring  Martin Holland:  to? Absolutely. Uh, yeah. It's, it's a great title for the episode and I see it all the time. Uh, I have an example that I use when I give talks or keynotes and it's a picture of two iPhones company, a company, B company a's got $750,000 open to the bank app. Got $700,000 in the bank, company B's, got $75,000. And I ask people, which company would you rather b? And they're usually on to me, they don't always just pick the big one, but it's pretty natural to go, Hey, I'd rather have whatever I said, $700,000. I said, well, let's dig a little deeper. So we looked behind, not in their iPhone, but, and they have a half million dollar payroll coming up Friday and they got $150,000 of past due payroll taxes and they have 75,000 due on their American Express card. And they have, uh, maybe 15,000 due on their, to their bank on their, um, mortgage.  Kate Grandbois:  Right? My blood pressure's going up just listening to this  Martin Holland:  list. [00:19:00] Well, you go to company B'S only got $75,000 or whatever I said in the bank. He's got a $5,000 payroll, he's got a $1,200 credit card payment and everything else is paid up. Now, which company do you want to be? And the point is you cannot tell even remotely by looking at the bank apps. That is not the whole picture. To our listeners who might be solopreneurs, everything's cashed, they don't have a lot of things. They might have a good idea by looking at their bank balance, but you don't progress. Well, here's something I need to say. I said it all the time. Why do you need to keep books? In my experience, I have never seen a company thrive without good books ever. It does not happen. Now you can be a solopreneur and get by, and in which case, and I don't mean this insultingly, but what you have is a high risk job. And I say high risk because you gotta pay yourself. [00:20:00] If you're working for somebody else, that's their burden to pay you, right? But books. I've never seen a company grow and thrive without good books. They either start with them or they implement them when they come to the realization that I can't go further without 'em. And that's just a, a major, there's a great quote I read the other day. It said, if the books are a mess, so is everything else. That's a great quote. And that refers to kind of the discipline and the that, that go along with the books, but that's true also. Mm-hmm. So there's your reason. If nothing else, if you want to, if you want to thrive in business, you're gonna have to deal with it. Kate Grandbois:  Something else that you said earlier was related to the importance of cash and accounts receivable. And anybody who's listening who maybe doesn't have a a, a good accounting background, accounts receivable is the money that you're expecting but don't have yet. Right. Right. So, right. If you take insurance, the [00:21:00] claims that are being processed or the invoices that you've sent out to private pay clients who, and they just haven't paid you yet. Right. So the money that you're expecting, one of the things that you say pretty free, or one of my big takeaways from your book was Cash is king. Yeah. Can you tell us a little bit about why  Martin Holland:  cash is king? Well, because you cannot settle any transaction without cash ultimately. Mm-hmm. And I have, uh, in my book, and I don't want to belabor this too much, but the cycle of business and, um, To start a business, you need cash. There are two ways to get it. You borrow it or you invest it. Use the cash to buy assets, which are things you own, which would be your tests, your materials, your computers, the furniture in your offices, your setup. So you buy assets, use the assets to generate sales, which in S L P is generally insurance for private pay from which you hope you have a margin, which we're gonna talk about, which is enough to pay your overhead, which we'll talk about. And you generate a [00:22:00] profit. Woohoo. I generated a profit and you must do that. But so what? You can't pay your payroll taxes with profit. You have to convert that profit to cash. And the reason I bring that up, um, is in general, if you ask somebody, tell me about your business, they'll tell you about their sales. Oh, I did a million last year. I did 10 million last year. I grew from 5 million to 15 million in the last three years. Oh, okay. Did you make any money? I don't know. Well, I think so. Looks pretty good, but I don't know. How's the cash doing? Ooh, don't wanna talk about cash. Okay. So I will mention this in passing because it may be useful, but if you make a profit and you do not have cash, there are only four reasons for that. And the benefit of knowing what the reasons that you might make a profit and not have cash are is if you identify the [00:23:00] problem, you can take action to correct it. Right? So those four reasons are one we've already discussed. You haven't been paid yet. So I make a profit because I billed them a million dollars, but I have a million dollars in accounts receivable, so I don't have the money yet. I have a profit, but not the money. Second thing is you use the money to buy assets. Now, that's not as big a deal in S L P, however, we just bought a building and a bunch of stuff, but you use the money. So I made a profit, but I. Bought stuff with it. And non expenses, assets are not expenses. That's a subtlety. But I bought assets with it the third. So I haven't been paid yet. I already spent it on assets. The third thing is, um, I used it to pay down debt. So I made a hundred thousand dollars, but I owe my bank a million and I paid them a hundred. Right? So you made money but you don't have the cash. And the fourth reason is you took it in draws. When you take money out of [00:24:00] your business, not as a salary, salary, you get paid for working in your business. Draws and distributions are what you get paid for. Taking the risk of owning your business, the money that you take out as draws does not affect your profit cuz it's not an expense, but it does affect your cash. So if there are people out there who make a profit, strongly believe they make a profit, have books that tell them to make a profit, but they don't have any cash. It's gonna be one or a combination of those four reasons, and that's where you go to start improving things. Did that answer your question about cash? Kate Grandbois:  It did. And you know, it, it brings me back to the importance of understanding your books and first of all, having books to begin with. Right. Um, and I wanna address this before we get into, you've already brought up so many things that I wanna get to, like overhead margins break, even the example that you brought up with your wife of how you use the information you [00:25:00] have to make for, to look forward and, and plan some of those things out. But before we get to that, for people who are listening, who the, this is the first time they're understanding what accounts receivable is, or they're, they are solopreneurs and they're managing their business from their banking app, or you know, someone who is just starting out. If someone doesn't have the experience with QuickBooks or experience with accounting and maybe. Doesn't quite have a grasp around this, where would you suggest that they begin, even if they don't necessarily have the, the capital to hire an accountant? And again, this is one of the reasons why I loved your book because you have a chapter called Financial Statements Explained without Numbers or Math, right? So conceptually, what do you do when the, when you're at the beginning of this journey?  Martin Holland:  Well, there are certain sonic omes, you know, without which not. Mm-hmm. Um, and books is one of them. So if you can't afford books, [00:26:00] as we say in Oklahoma, save up a little bit before you start your business. And then I do make it clear or I try to make it clear you should not keep your books as we were talking before, bookkeeping. I hope I don't belittle, um, or this isn't negative towards SLPs cuz I huge respect for what you know and learn and experience. But I will say that bookkeeping and accounting. Is as complicated as speech language pathology. You can get PhDs in both subjects, right? So it me trying to, you most people trying to do their own books would be like, like me going in and say, well, I've watched Diane do this for, we've been married 45 years. For 45 years. I could, I ought to be able to work with that apraxia. Actually, I know that word. I'm not even sure what it is, uh, well, I can't do it. So where you start is you can find a bookkeeper. I mean all, all sorts of different [00:27:00] ways to do it and book, uh, QuickBooks, something like that might cost you 50, $75 a month. You can hook it up with your banks and it downloads a transaction, not you, them, and they just get started. Okay, $300 a month, maybe it's as important as rent. And especially if you start out. Doing. If you've been in business 10 years and you decide you wanna make your books right, uh, it can be expensive. So that's how I suggest they start, is that they realize, Nope, this is one of the prerequisites to being in business. I'm going to do it, gonna find a bookkeeper, and we're gonna start. And then you will at least have that information, which you can rearrange and things later, but you will have it recorded. Kate Grandbois:  And I wanna add one thing to that, just from my own mistakes. I'm having owned a business for about 15 years. Having a really good, under fundamental understanding of what your books can tell you, I think is another missing [00:28:00] piece because I kept books by myself for a few years. I've had an accountant for probably 10 outta the 15 years I've been in business, but it was only in the last year or so, maybe two years that I understood how to use them or understood what some of the fundamental components were. So I'm, my only addition to that for anyone listening who is sort of new to business or wanting to learn more about business is taking the time. You know, in speech pathology, we spend a lot of our professional development learning about clinical issues or different treatment techniques, but. Taking a minute to do continuing education like this podcast or like reading your book or some other professional development about some of the edges of business, just to understand a little bit of the, those foundational pieces can be an incredible, um, an incredibly helpful strategy in moving through the business process. Correct. Would you, would you agree?  Martin Holland:  Oh, a hundred hundred percent. [00:29:00] The one thing I would say is there will take some, just like when you were in your CF year, right? Or, or doing whatever you call that beforehand, where you go visit places, you know, you're at speech pathology or speech pathologist, but there's a whole lot you don't know. And there's a whole lot that you know, but you didn't realize you knew, right? Yep. Well, it's gonna be the same with books, but get started with the books. Let them be there. You don't have to, the day you start understand the subtleties that can come over time. If we were sitting here today, I, I do want to use some examples to show, to incentivize people, but if I were to get into some of the real subtleties today, I'd be giving you answers that you hadn't asked the question about yet. There will come a time in your practice if, in your bus, in the business side of your practice where you're going, I wonder if I could understand this or how I could know that or what informa, aha. [00:30:00] Now you've asked the question. Now let's go look for the answers. And you have a place to look because you've been recording data, right? It's rather than just sitting there going, man, I wish I could find that out. So that's why I say start, get a bookkeeper to start for you, even if you don't understand it. That will come over time.  Kate Grandbois:  I, I think that that's great advice. Um, let's talk a little bit about, now that we understand the incredible importance of what, why we should keep books, how we can begin to keep books where we can find additional information about, um, understanding the books that we keep. Let's talk a little bit about the forward thinking aspect. And I know that there is a lot that that goes into this and we've got a whole half hour left to talk about this cuz I know we can talk about it. You have a whole book about it. Um, do you think it's best for us to really start first talking about overhead and then [00:31:00] how that translates into looking at what a margin is because that's, that's our last learning objective. Martin Holland:  Yeah, I think so. Um, well, let's just talk about the, when you talk about overhead, uh, you're talking about expense and let's just look at the, uh, The financial statement that deals with income and expense. It's the profit and loss, p and l income statement, whatever you, it's the one where it shows how much money you brought in as income and how much money that went out as expenses. And the difference between the two, if it's a positive number, it's a profit. If the, if it's a negative number, meaning the expenses were more than the income, it's a loss. Okay. Pretty pedestrian stuff. And interesting and useful for paying taxes. Not really useful to run a business. And I, when I was thinking about doing this, I'm thinking, boy, we've got practitioners out there who do [00:32:00] business a lot of different ways. I'm gonna discuss it the way Diane does it. Um, and so income is money that comes in. It's not, um, money that you put in. It's not a bank loan. It's money that comes in from sales. Uh, from in s l P is from billing, right? It's money that comes in easy. We got a top line up there. The money that goes out in expense can be divided into two types. One is variable expense and the other is fixed expense. Okay, so what's that mean? Variable expenses are expenses that go up and down with sales. Now in Diane's practice, we pay therapists, well, we do both, but we pay most of the therapists, uh, per session. And I'm gonna get into the actual math of that and show how we used it. So if they do more sessions, we have more variable expense, cuz we pay the therapists more. We have fewer sessions, we pay them less. So that [00:33:00] that cost, that variable cost because it varies of paying. Our speech pass goes up and down according to sales. Okay? We also have fixed expenses, otherwise known as overhead. Everybody uses that number or that name. But overhead expenses are expenses that do not go up and down with sales, at least not in the near term. Obviously in five years you've quadrupled your practice, you got more overhead, but it's things like the, um, your software charges, which are significant. Holy cow. Uh, it's your liability insurance. It's your rent, uh, it's your staff, meaning the, uh, fixed staff, meaning the billing agents or clinic supervisor, you know, records people. It's those expenses that stay the same every month. So the way we look at, at things, and I hope to make this sound useful here in just a second, but the way we look at it is the money that comes in from billing [00:34:00] minus the money that we pay therapists. In our case, the variable cost leaves over what, what's called a margin, right? It's a gross profit margin. And the way I like to think about it is it's our share of the sales dollar in our business. I mean, I know this cuz I track it all the time. We give about 65% of all the money that we bring in goes directly to therapists, the SOPs, OTs, and, uh, physical therapists. Boom. So what's left over? If we sell a million dollars worth of stuff, what's leftover is 350,000 Lear. Mm-hmm. That's, that's our share of the money. If, if I say, well, let's go out and double it, I go out and sell 2 million. I don't get another million. Right. I get another 350,000. Yep. Okay. So then what I do with what we, I, Diane does with that money [00:35:00] is first you must pay your overhead. There's no choice. I must pay my overhead when I've earned enough margin. To pay my overhead. I've reached what we call breakeven overall breakeven. Okay. If I ask people generally, I don't wanna go too far into, we, I'll just throw it out there. If I ask people generally looking at their profit loss statement and I say, how much do you have to sell to breakeven? They usually tell me the total expense number. And that's not right. And I won't go in, the math is in the book, but,  Kate Grandbois:  but I wanna, I wanna, I wanna unpack this a little bit because the concept of break even was a mind blowing realization for me. Um, as a matter of fact, my brother-in-law when he handed me the book, said, get text me when you get to break even. And I just texted him the brain explosion emoji and he texted back the brain explosion emoji. All this is a  Martin Holland:  man, [00:36:00] I love you guys. I love your whole family. I loved it.  Kate Grandbois:  Hey, so we, we really, we really had an, we really nerded out over this, over this concept. It's a real, it's really, really important. Um, at least I gleaned from your book how important it is in terms of the health of a business and how you make plans and how you, how you manage things. So I wanna, I wanna go through it again, maybe with one more example, um, because it was something that, that, it was hard for me to wrap my head around as a person without a lot of accounting background.  Martin Holland:  Well, this is where it gets a little difficult. I don't know how some people love this stuff. Some people go, I don't get it. But I, this is an important part. We said, if at our practice, we sell a hundred thousand or a million, we pay 650,000 to the therapist. Which leads 350,000 for us. That 350,000 is 35% of a [00:37:00] million. So the, the advantage of doing that is saying for every dollar I sell, I get 35%, 35 cents. Okay. So break even. This is the math of it. The break even is if you, I'm just gonna use a hundred thousand Yeah. Good round  Kate Grandbois:  numbers.  Martin Holland:  Yeah. This is, this is what's really helpful. Well, it winds off, it winds up, I'm gonna say if my overhead, my office rent, my, my, my office staff, which are paid the same amount every month, my software costs and all that stuff, insurance is a hundred thousand. I divide that number by 35 cents by 0.35. Okay? Yep. Because I get 35 cents, I don't get a dollar, I get 35 cents after. Paid those therapists, they're paid. I get 35 cents, I divide a hundred thousand by 0.35 35 cents, and I get 285,000. That's how [00:38:00] much I have to sell to break even, and that's only one kind of break even that's to break even where I haven't made a profit and I haven't made a loss, profit loss statement, bottom line would be 0.0. Okay? That's just the beginning of how to use it, but that is the absolute minimum that you must do. If you don't know that. If you don't know that, it's likely that you're gonna take the foot off. Well, I'm gonna tell a story that I tell in the book. It's not really a story, it's a statement I make frequently. Most of us go to work on the first of the month and every day thereafter thinking, Hey, I'm making a little money. My employees are making a little money. My landlord's making a little money, my insurance making a little money. My supplier, everybody's making a little money today. No, no. Everybody might be making a little [00:39:00] revenue, but you are not making any money at all in this case, until you hit 285,000. Only then and only then does the next dollar of sales give you a 35 cent profit. I hope people see how I got that. There's 35 cents from each dollar. So when I've used enough of 'em to pay all the bills, the next dollar is 35 cents. Next dollar after that's another 35, right? So the danger in thinking everybody's making a little money today is that if you don't break even till the 28th of the month, you better not go fishing on the 29th cuz you've blown your last opportunity to make money before all those monthly bills reset. This is such  Kate Grandbois:  a critically important component of planning. At least for me. I used to think of my books as sort of the way you described it. Oh, well, money's coming in. We're we're making money because I have money in my bank account. Right. But thinking [00:40:00] of it more as a, well, that's the, that was the visual that came. So I had, I have a deficit until I get a certain number of visits.  Martin Holland:  The guy who originally taught me break Breakevens only been around since 1964. So, which is old, but not compared to 1200. Right. The guy who originally explained it to me was a consultant, uh, to my father in his business. And I was lucky to be sitting at the table with him, and he used a well as the advance, oh, look at that. Perfect. Yeah, you gotta fill that well up to get to, even now, it starts piling up on top. Then the whole thing drains out again. When you start a next month and you have another rent, another salary due, you know all that, and you gotta fill the, well again, Okay. Right. So that's one form of breaking, and I hope we have the idea of margin is my share of the dollar first have to pay overhead. Once I've done that, it begins accumulated profit. Now, let's say you want to move your facility to a new location that costs [00:41:00] $5,000 a month. More so $5,000 divided by 0.35. You've gotta sell 14,000. You got where I got that. Mm-hmm. Took 5,000 increase in overhead, divided it by 35 cents and said, oh, this, I gotta do $14,000 more in sales just to pay for that. Right? $5,000 increase. Now you have some information. Is that reasonable? I mean, literally, I'm gonna go through our decision to move to this building and so on, and that was one of the considerations. What can we really do in there? Can I, can I do 50,000 out of there? Okay. 50,000 times, 35% is like $170,000. Uh, yeah. I can pay five and bring in 170 or 75. Right? So I hope that's, that's just one of the many ways, um, that you can use break even to make decisions. Can I hire another administrative person? Here's something. I know [00:42:00] there are billing softwares out there that we don't use. Uh, we do it our billing, our, I mean, we use ER or EMR software, but we do our own billing, which is hideously. I don't have to tell anybody about that. I know  Kate Grandbois:  you just saw my eye roll. It's just, it's just, it's a whole beast in its own  Martin Holland:  tens of thousands of dollars that, uh, we gave up early on because Diane was working solo when she started the business and calling the insurance, didn't know how to do it, and they'd call back. She's in session. She'd call back, couldn't talk to anybody. Pretty soon we time out. Anyway, just hideously. Well, there's a software, there are software solutions for that. One of 'em wanted seven and 5%. Mm-hmm. And I go, wait a minute. Seven and 5% of a million dollars. Let's just say, about $75,000. Okay. Is that worth it? I don't know. I mean, maybe. I don't know. But let's say you go to 2 million, it's 150 grand. [00:43:00] Really? Maybe I could have done 75. I would've had to pay somebody to do my billing, but I couldn't do, I mean, but that person could do more than a million dollars worth of billing for that. Anyway, it gives you something to work at, and I'm gonna show you maybe, or tell you right now about our decisions and how that would've affected them.  Here's the way we use Braun, uh, to make decisions recently that cause us to spend many, many, many dollars buying a building and so on. First of all, we are blessed to have a large backlog. So sales isn't a big issue. It's whether or not we can serve them. We have, um, in, in our location in Norman, we have 16 therapist rooms, okay? And we, each therapist has their own room. Each one of those rooms cost us $34,600 a year to be there in overhead. Where he paid the therapist overhead is take our, that's about [00:44:00] $550,000 a year, divided by 16. So each room has to produce that much revenue, margin, margin, not revenue. Annually for us to break even. Okay? Now let me tell you how we, how we use that down here. With payroll tax and so on we get $25 per session. That's our revenue, that's our 35 cents. That $25 per session, 34,600 is what a room cost divided by $25 is 1,384 sessions a year.  Kate Grandbois:  Even watching you do math makes me feel nervous. For those of us without, without financial backgrounds, I think that this is, but this is such a critically important exercise cuz how can you have a healthy business without, without doing all of these little equations and  Martin Holland:  what, what we all, and if you can't do 'em, people don't like it. And I say, okay, don't like it, but get somebody to help you. [00:45:00] Diane doesn't like it, but boy, she's got about five or six numbers and when we talk about those, she's really into it. And then when I wax on poetic like I'm doing with you, she goes, I'm out. It makes me very nervous. I I gotta go water the geraniums, I'll be back in. Right, right, right.  But we have to do 18 sessions a week, , have to, to pay the bills. But that is the absolute minimum that our therapists have to do but that's how we use breakeven on almost everything. And we're looking at another location and it still boils down to can we get the therapists? Of course. What do we have to produce? I'm keenly aware that a large part of the population wants a work-life balance, right. Diane's vision for her company is to be the clinic of choice for moms and the clinic of choice for the finest SLPs. That's what she lives for.  So we're trying to balance that.[00:46:00] There is a level that you have to do for the company to survive.  Kate Grandbois:  And I wanna pause and, and talk a little bit about that. You probably saw me rustling around on my desk looking for an article. I couldn't find it, but I Googled it. Um, this concept of the idea that making money equals greed or the concept of. Needing to worry about the bottom line means that, you know, there are, there are components of being an evil corporation trying to shove all the dollars in your pockets, right? I think that's a, that's a very common theme in our American culture. Um, and I don't wanna get into that because that's a, that's like a whole other hour long conversation about, about, you know, corporate greed. Um, but there is an article, this is a part of my professional development that I've been, um, learning over the last year. I, I gleaned some of it from your book and I've gleaned some of it from, um, implementation Science, which is a, a new sort of [00:47:00] branch of study in our field. And there is one article in particular that I wanna highlight here that I highly recommend anybody in business read. And it's called Market Viability, A Neglected Concept in Implementation Science. And the study of implementation science is the study of how our research is implemented. So what research exists out there that we can actually implement in real world settings to make an ac make an imp to make an impact. So this, you know, research practice gap, how are we using the knowledge that we have to treat our patients? And I swear I'm gonna get to a point and sort of marry all these concepts together here. No, that's fascinating. The, the, the, this, this article for me, in combination with how you would address this in your book market viability, um, a neglected concept in, in, in implementation science really unpacks the idea that if you don't have a healthy business, If you don't have money to pay your employees, if you don't have a good calculated margin to [00:48:00] reinvest in the materials that you need in the building that you need, in the sensory equipment that your clients need. If you don't have a good understanding of the market that your product is going into, then you can't do good work. You can't contribute to your community. You can't help your patients. You can't apply the most updated treatments to an entire population or to an entire community, and I think it's really important to sort of zoom all the way out and acknowledge that. Worrying about your budget, worrying about, you know, calculating your margin, understanding that you have a well to fill, understanding that you need you, nobody volunteers, everybody needs to be able to take home a paycheck to their families or to, you know, have housing and to buy food. All of these things are real world problems, and it doesn't necessarily mean that you're being, as you mentioned earlier, there isn't, there aren't necessarily components of greed in this. These are necessary components of [00:49:00] science. These are necessary components of healthcare. These are necessary components of effective treatment. Um, and there is this really important marriage between business knowledge, market viability, and science. That has to happen. Oh, for good things to happen for other people. It's there, there are components of altruism in this. You can't in this conversation,  Martin Holland:  be philanthropic if you don't make a profit.  Kate Grandbois:  Yes. So profit is not evil. Is, is I think the point that I'm trying to make. No, I've got, I've got a  Martin Holland:  chapter in the book. It is your responsibility, okay? Look, if you say it's bad to make a profit, what you're saying is that every penny we bring in, we need to pay out to the software guys, the utility bill, the engine. If I, if I make any more than that, it's bad. It's not. But people who haven't been around business, people who've been around business a long time, often begin to wonder, how do I ever benefit from profit? Because [00:50:00] the profit's tied up in accounts receivable. It's tied up in our down payment on this building that we bought. It's tied up in, uh, all the, the things that I told that I told you about in growing. We give 65% of our revenue to our therapists. That's not to mention the staff people and so on. You know, 90%, 85% of what we bring in go out to support people. If I don't make a profit, I'm not there. Let those people go. Right. And here's one thing that I really enjoy, not enjoy, but I like to make this point. Everybody makes a profit. Everybody. If you are working for somebody and it costs you more to go to work, then you get paid. When you get there, you quit going. You have to make a profit in order to support yourself outside of work. Everybody does that. Everybody. I mean, it's part of our soul. I won't go there. It's not worth it. Right? [00:51:00] Everybody has to make a profit.  Right. So profit is they, things can't work. Everybody lives that way, but they don't transfer it to a bigger picture and say, Hey, really, you know, I won't go to work if I don't make a profit. Why would I expect a business to go to work and pay all these things out and not make a profit that funds its growth and funds? Its survived. So maybe I'll get down off my soap box now, but I hope I didn't offend anybody.  Kate Grandbois:  No, no, I, I, you know, I think in thinking about these larger concepts and how it applies to the decisions we make as small businesses, that's where. The rubber meets the road, so to speak. Right. So, you know, as those of us who are running small businesses, or as anybody who is listening out there is thinking about these concepts and how it applies to your individual small business, I think the takeaway for me is it is okay to [00:52:00] focus on making a profit without feeling like you are short-changing anyone, or there are negative aspects we think of. There's just so much connotation with profitability being negative. I. And the reality is, is that once you go through these exercises and you calculate your margins and you understand your fixed expenses versus your overhead, and you understand some of these fundamentals, this is sort of coming full circle with why is accounting even important? Understanding that profit is the goal and that cash is king, is a, can be a generous and critically important component for your community, not just because you wanna align your pockets with profit.   If you do it ethically, meaning no cheating, lying, stealing, misleading, right? No, no theft, no corruption, and you focus on profit. You will focus on serving your customers even if you don't want to. Martin Holland:  Cuz that is the [00:53:00] only way they are not forced to do business with you. And if you make 'em mad because of your hours or your attitude or whatever it is, it's gonna go away. But it sounds bad to focus on profit, but if you focus on profit, you will find that you must do things that serve people. It's the only way you can say, I'm gonna charge $900 an hour for a private the, and you might get somebody, but maybe that's Boston, but I'm gonna charge $900 an hour cause I'm gonna make a profit. Well guess what? Nine outta 10 of your therapists or your a clients being going, you know, it didn't work for me. I'm only gonna be open between one and three because that's when I work best and I wanna sleep in. Doesn't work right, because they want after school for the kiddos. And anyway, I can keep coming up with those kind of examples. A and I  Kate Grandbois:  think one of the key differences, again, just bringing all of these larger [00:54:00] fundamentals back to speech pathology, is that our clients, our indivi, our customers are individuals with communication disorders. That's why we exist. So by serving our customers and by, by focusing on profit and making sure that we are serving our customers, we are doing that good. Um, just in the nature of being in business.  Martin Holland:  Yes. Yeah, a hundred percent. And it, and it really is, uh, just a little bit philosophical here. Real advances came when people specialized and became more efficient. Okay, just brief overview that specialty. I don't make my own shoes because I wouldn't be very good at it, but I'm willing to pay a guy what might be an exorbitant profit. Who knows where to buy the leather. He makes good shoes, they last longer, and I don't have to do it. And he's so good. He can do it kind of cheap. That's that's not outrageous. I just bought my time back. I'm happy to do it. And that started with business and that's where it [00:55:00] resides. And anyway. We're getting well into  Kate Grandbois:  profit. No, I, I appreciate all of these and just, I am in looking at the time, I'm wondering if you have any final words of wisdom for our audience. So anybody who's listening, regardless of where they are in their, in their business journey, in their learning journey. I know you've worked with so many different kinds of businesses in your career. Are, are there any nuggets of wisdom that you think would be helpful that we haven't already covered? Martin Holland:  Well, two things. Um, I don't know if it qualifies as wisdom, but in my experience of my own businesses and my 500 clients, I found that all businesses are unique, but all businesses are the same. Right? The things we're talking about, especially in bookkeeping, but other things we could talk about in the operation of business, they're universal. There's no question that retailing is different than s l P, but that's only a fraction of your business, right? [00:56:00] Um, The second thing is, I, I mentioned the Sword of Damocles. I'm gonna presume people know what that is, but the Sword of Damocles was a no, I've never heard of it King. Okay. It, well, it's important cuz you're living it. Um, and I, we, we were tied on time, but uh, Damocles was a courtyard of King Philipp in Greece sometime before b you know, BC time. And he was saying, oh the king, you've got it so good you can have anything you want, anytime you want. And he said, well, you wanna try it for a day? He goes, sure, damn it, please. He said, sit at the head of the table. So he sat him at the head of the table and a golden throne brought food and all this. And then he looked up and there was a sword hanging over his head, dangling by a single horse hair, horsetail hair. He allowed pretty quickly that he didn't wanna, he'd had a knot. Business owners always have the sword of Damocles hanging over their head cause it's, it's up to you and I so. [00:57:00] Love and respect that. Okay. And I'll say one other thing. This would be my last thing. A, a podcaster one time asked me on kind of short notice what the qualities of a great business owner were. And I can think of lots of things, but I came up with this, uh, pretty quickly and I go, oh, I like it. You will thrive best in business if you view business as an adventure. Okay, I'm on a quest. It's up the hill and down the hill. I mean, yeah, you're an SLP and you're doing your stuff, but I'm on this adventure. My defeats did not wipe me out. My triumphs, you know, kipling me with triumph triumphant disaster and treat those two imposters just the same. Uh, it, it is an adventure and it's best looked at as that way. It's not your identity, it's not who you are. It's an adventure. Second thing was I. Business owners really, really do well [00:58:00] and make it look easy, tend to make, be decisive. In other words, they make decisions when they have adequate but not complete information. By the time you get complete information, the opportunity's gone because the event has happened. But they don't, they make a decision. They don't equivocate and languish and worry and bemoan, oh, I messed up. If they messed up, they make another decision. And the third thing is they tend to be focused. And that doesn't mean that you can only just do one thing, but if you're working on your practice and you're wanting to build an area, look at that area, work on that area, get that area established in, in, uh, systemized, let's say, and brought in established in your business and then moved to the next thing, one at a time, even while you keep maintain your practice. But one thing at a time is you get better and better. So that was a lot of one other things  Kate Grandbois:  that was so helpful. I have appreciated this conversation so much. Thank you so much for being here with us today. Loved it. Loved it. For anyone listening, if [00:59:00] we've mentioned any resources, they, everything will be listed in the show notes. All of our references will also be listed in the show notes. If you have any questions, send us an email anytime. Thank you so much again, Martin.  Martin Holland:  You're welcome. Thanks. Outro 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.   ​ [01:00:00]

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 Sponsor 1 Announcer:  This episode is brought to you in part by listeners like you and our corporate sponsor, Feeding Matters. Advance your pediatric feeding knowledge at the entirely virtual International Pediatric Feeding Disorder Conference, held live April 24th through the 26th, 2024, with all [00:02:00] sessions available on demand for 30 days. Earn over 20 CEUs on your schedule. Visit feedingmatters. org slash conference for more information.  Episode Kate Grandbois:  Hello, everyone. Welcome to SLP Nerdcast. We are really excited for today's episode. We are here with two expert guests to discuss social justice curriculum in schools. Please welcome Lauren Tavares and Sarah Hasse. Hi.  Sarah Hahesy:  Hi.  Amy Wonkka:  Lauren and Sarah, you are here to discuss social justice in speech language pathology, but before we get started, can you please tell us just a little bit about  Lauren Tavares:  yourselves? Sure. Thanks for having us. Hi, I'm Lauren. Um, I am a school based SLP. I work in a kindergarten through eighth grade public school. Um, I work in classrooms from Kindergarten through third grade and I get to teach in an autism program with kindergarten through eighth graders. [00:03:00] One of the best parts about my job is pushing in and doing lessons with excellent people  Sarah Hahesy:  like Sarah. Um, and I'm a third grade teacher and I'm going into my 17th year of teaching and social justice work is basically one of the biggest highlights of my job and I love that I get to collaborate with Lauren and create this. Wonderful curriculum for our students  Kate Grandbois:  here at the nerdcast. We love it when individuals in different disciplines get together and collaborate. So we're really happy to have both of your perspectives here to teach us more about social justice. Before we get into the good parts of the conversation, I do need to read our learning objectives and disclosures. I will get through that as quickly as I can. Learning objective number one defines social justice and how it relates to ethics in speech language pathology. Learning objective number two list two components of infrastructure that support social justice curriculums in schools and learning [00:04:00] objective number three describe how social justice is related to curriculum in an educational setting disclosures Sarah's financial disclosures Sarah works for a public school and is paid to facilitate a seed group. Sarah received an honorarium for participating in this course. Sarah's non financial disclosures. Sarah has no non financial relationships to disclose. Lauren's financial disclosures. Lauren is an employee of a public school and is paid to facilitate a seed group. Lauren received an honorarium for participating in this course. Lauren's non financial disclosures, Lauren is a member of the American Speech and Hearing Association. 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 am a member of ASHA SIG 12 and I 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.  Amy Wonkka:  Amy, that's me. My financial disclosures are that I'm an employee of a public school system and [00:05:00] co founder of SLP Nerdcast, and my non financial disclosures are that I'm a member of ASHA, Special Interest Group 12, and I participate in the AAC Advisory Group for Massachusetts Advocates for Children. All right, Sarah and Lauren, can you please tell us a little bit about your journeys and what led you to learn more and to want to learn more about social justice curriculums?  Lauren Tavares:  Sure. Um, so for me, um, and I think for a lot of people, this has kind of been a lifelong journey. Um, I grew up in a suburb of Boston and I was one of very, like one of very few people of color in my town. I was the only black person in my grade. Um, and it was the nineties and the predominant practice was to be colorblind. And I found that really harmful growing up. Um, it really ignored a lot of my livid experience and what I was going through when and what I brought to school with me as a learner. Um, and then I went on personal journey myself and when I came to work at my current [00:06:00] school as an adult. Um, I was really lucky because Sarah and a few other colleagues had already started meeting together and collaborating around social justice in the classroom. And it was so exciting. Um, it was really exciting to see people already doing this work and, and start to be part of creating a really kind of robust educational experience for our students. And especially where my own had really  Sarah Hahesy:  been lacking. Yeah. Um, when I started teaching, um, the principal at the time was very into having talks. Um, About anti racism and often our faculty meetings would be about that. So that's kind of when I mean, I think I had little bits of this throughout my own like childhood. But I grew up as a white woman and, you know, a lot of it. I also was indoctrinated with being colorblind and not talking about it and ignoring it. So when I got to my third year, I took a course that kind of just like [00:07:00] changed my whole life. And from there, it just led me to do more and more social justice courses. And, um, one of them was white people challenging racism, which is out. Outside of like the Cambridge, um, they have an out of school sort of thing for adults. And, um, I took that course and then I met with a bunch of people at my school, and we wanted to really just form an accountability group with each other. And, um, we found this great resource called. Raising race conscious children and, um, where they have like a list of strategies that you can try and it's, you know, it's geared towards parents and talking to their kids about race or about ableism or whatever. And, um, we just really loved it we had some training with them, and we decided as a group we wanted to read a picture book, and we [00:08:00] wanted to name race. And then we wanted to meet every month just to see how we were doing and then it's kind of grown from there where now we, um, We did take a little bit of a break during COVID, but then we came back and did it again. But we do find time during our collab time to meet at least once a month. And, um, it's not a lot of time, which we've always wanted more and more and more time. But, um, it's just been this amazing thing where we've built this community that is all driven to be, you know, race conscious or just like, Just conscious and able to talk about difficult things with our students and our staff. And because of that, our principal, um, What was it three years ago, Lauren, she asked us to do, um, you know, the seed leader training, which is seeking educational equity and diversity. And we both did it and we have trained now. I think about 30 people in our school, and it's the [00:09:00] only school in our district that has had this much input and I think it's because we've like built this small group that Ben has like really expanded out and it's. It's amazing. And it's so empowering and awesome to see that our school is so driven to do this. And I love this work because there's nothing better than, you know, reading a book with a student or students and having conversations with them and then just seeing them feel seen and being understood. And, um, it's just, it's the best. So that's how I came here.  Kate Grandbois:  So you've mentioned the, that you both are seed trainers, seed facilitators. I'm not quite sure what the terminology is. And you mentioned this training. I know you're going to mention it a few more times as this episode unfolds. Can you tell us a little bit about the structure of the training you went through? I presume it wasn't a one hour webinar that you took. I assume it was a little bit more intense than that. Can you tell us a little bit about it? [00:10:00]  Sarah Hahesy:  Do you want to start Lauren?  Lauren Tavares:  Sure. Um, so Sarah and I took this training through the National Seed Project a few summers ago, um, and they train educators in, um, how to work in, in areas of social justice in schools. Um, and our job, we got training to facilitate groups for, um, our colleagues to learn about, uh, social justice and really think about yourselves and, um, think about how you. How you grew up, like where your biases are, what you're bringing to the table in the classroom, those kinds of things. And, um, and that's how we do our groups. Our training was, um, was two weeks over a summer, um, where we, where we just went full in on learning and we had groups and we had, um, we had our own sort of seminars that we really engaged in with all different, all different groups from people all over the U S. Sarah Hahesy:  And the focus of it is to tell our stories, and to really [00:11:00] get to know each other through our stories. And that's kind of what they train us and there's 10 different modules that we go through every month with our group and it's really intensive, but it's always like whenever we have a meeting. We're like, Oh my God, it's three hours. But then at the end, everyone was like, that's awesome. This is amazing. And it really is. It's been, um, it's been so awesome to do it and to do it with Lauren, because she's just such a great collaborator. Thank you so much for  Kate Grandbois:  sharing more about the training. I think it was just important to share that this is available. This is a resource that's out there. Um, in case anyone, as we move through some of this content wants to learn more about it, and we'll link all of that in the show notes as well. I wonder if you could start us off with some of the fundamentals, for example, what is social justice? I think a lot of us have heard this term, particularly in the last few years, um, but tell us a little bit [00:12:00] in more depth what social justice  Sarah Hahesy:  is. Um, the definition that Lauren and I like to use as that social justice is about distributing resources fairly and treating all students equitably so that they feel safe and secure, um, physically and psychologically, and we got that definition from the National Educators Association. And what that looks like to us is that in schools. We just want everyone's learning to be equitable and their needs to be met and for them to feel whole in the classroom and the school.  Amy Wonkka:  And I think that connects us with the concept of oppression, which is an institutional barrier. I don't know if you guys want to talk a little bit about that too and how it connects with social justice. Lauren Tavares:  Sure. Um, I mean, oppression is a huge factor in thinking about social justice and how to teach. Um, and institutional oppression is really the systemic mistreating of a social [00:13:00] identity group. And a lot of times, especially right now in society, we're thinking a lot about race. Um, but it's really important to recognize that we are talking about many different social identity groups that includes race. That also includes gender and gender identity, class ability, um, ability level, sexual orientation, and many more groups. And then because we are whole people, oftentimes, uh, we ha we identify with more than one of those groups. And so it's also the intersection of where those groups, how those groups really, um, how we identify and how those groups impact  Kate Grandbois:  us. And I know one of the main things we want to talk about today is how all of this relates to education. I mean, I know we haven't truly gotten there yet, but you can already see a very obvious connection here. If your definition is related to equitable distribution of resources and making children or students feel safe and secure that is required in [00:14:00] schools for, for children to, or I keep saying children, but students to. Engage in engage with their curriculum. Um, and I know our primary audience is speech pathologists who are working with students who are presumably on IEPs or getting some additional support, which brings us to something else that you wanted to highlight, which is ableism. So what can you tell us a little bit about ableism and how this loops back to concepts of oppression and social justice? Lauren Tavares:  Sure. Um, well, well, I have my own lived experience as an SLP. The way I first came to this work is through working, um, in areas of ableism. Um, one, that's, that's, I mean, that's where we're trained. We're trained with, um, working with people with all different ability levels. Um, and I think, We all know it's really important to advocate for our students and our clients. And ableism really being the discrimination and prejudice against people with disabilities. [00:15:00] And that includes physical, cognitive, and mental health. Amy Wonkka:  When we think about the curriculum and the work that you're doing in your schools. What are some key questions or early talking points that you used in your conversations with your colleagues to sort of lay the groundwork for people understanding these key concepts? So some of the ideas just underlying social justice in general and oppression and ableism, um, and helping people engage in that conversation at the very beginning. Um,  Sarah Hahesy:  I think this is answering the question. Um, but we do a lot of like identity work first. You know, kind of getting to know who yourself you like who you are. And then we kind of connect at least what I do in the classroom is do a lot of like windows and mirrors work which is language from seed. A window is how you're looking into you know a part of someone's [00:16:00] world that is new to you. And whereas a mirror is something that you are, you see reflected in yourself. And so, first you need to know who you are, and then. You can start to like see how you are similar to someone or how you're different. And, um, it's, it's been, I mean, I don't know if we do that in our seed group. I don't know if like our school does it totally with our whole staff, but, um, we're working on making sure we do more of those things, um, with our staff, but I always start the school year with it. Um, just so my students get to know each other, um, and what I'm expecting from them and what they want out of the classroom.  Lauren Tavares:  And I think that's the beginning for us as SLPs too. That's where I really come in and support in the classroom as well. It's those perspective taking skills that we work on, conversational abilities, um, understanding of others, developing empathy, [00:17:00] basic routine following, and learning the classroom and developing as they develop that community is those really foundational skills are so important. Kate Grandbois:  And of course, all of this is very closely tied to ethics, right? I mean, I know as speech pathologists, we have an ethical code that we are required to abide by. And I'm sure in education, there are other components of ethics that guide your work as a teacher. Um, as a general educator, what can you tell us about the overarching connections between our work considering ableism, oppression, and social justice and  Lauren Tavares:  ethics? I mean, it really relates to knowing the whole child and knowing who you're working with. Um, we need to understand our students whole profiles, who they are, where they're coming from, what they're dealing with, and what they bring to school with them, and also advocate for their needs and through social justice, we Um, we [00:18:00] understand those identity groups that students are a part of, and it helps us understand them. Students, all students really deserve to have a learning space where they feel seen and represented and safe. And that is the work that we're trying to do when we create a community that really supports our students.  Sarah Hahesy:  And observationally, what I've seen more and do in my classroom is bring awareness to students who might not work with an SLP or, or a special educator, and just have them learn about neurodiversity, and you know what they can expect, or what they might see and, um, And how you can include those students and how you can interact with them. And, um, she's really done an amazing job developing this curriculum over the past few years. And we had like a very magical moment this year together, where we, she taught her neurodiversity, you know unit, and, um, You know, [00:19:00] along with like the community building we had done and all of that, we had students sharing their communication challenges with the class, which they had been very reluctant at the beginning of the year and then by the end, they're like, Oh, I want you all to know this about me and the class was like, Oh, cool, you know, it was like a really just like a conversation. It wasn't like a big deal. It's just, it was beautiful. And, um, You know, and it, you know, it influenced other people to share what they're, you know, working on and, and, you know, that's what we want for them, you know, to, like, see each other and be aware of each other so that we can make these spaces where everyone feels safe and whole and represented. I think kids are  Lauren Tavares:  really, really receptive to these discussions. Like they're, as soon as we open up the discussion, like they are, they're ready to dive in and say like, so how do we help in the classroom? They've come up with ideas for students that I've worked with for a long time in areas that I've worked with for a long time that I've never thought of. They're like, oh, we should have that here or we should do [00:20:00] this for our friends. Um, and they're really, they're really ready. They want to be part of this community, um, that we're building. Sarah Hahesy:  And just like naming race, like naming, you know, neurodiversity, naming all those different parts of people. Um, it's really reassuring to students too, because they like to know things and they like to know people and, um, it makes them feel like, oh yeah, I've seen that or, oh, I've never seen that. And it's. It's really nice, especially because we have such a diverse school. So like it really helps them navigate their school.  Kate Grandbois:  Everything you're saying makes me reflect on the title of this episode, which is Community Connection and Social Justice. What can you tell us about how concepts of community and https: otter. ai Lauren Tavares:  I mean, the first thing is is that you need a lot of [00:21:00] support to really push forward in this area. Um, and it's hard. And I think that the first thing for me was finding my community within the school. I'm finding co workers that help keep me accountable to my work finding people that I can go and talk to who are on board and also working on this in their classrooms as well. Finding support within administration was huge for us. And then also just really thinking about the community we have in our school, thinking about what our students homes look like, what our students backgrounds look like, and what the families are, are doing  Sarah Hahesy:  at home. Yeah, and, um, we've been very fortunate that we've had so much funding as well to build this community and to get more training and to, um, be able to continue this work. Um, we, we were very lucky that our district paid for our seed training and all the courses I [00:22:00] took in the beginning of my, you know, teaching career was all covered by the district. So, we do work in a district that is very focused on equity, it's actually one of our core values. And so that's, that's something that's built in for us that some people may not actually have but it's been really important. I think and pushing us forward to have that, but I honestly couldn't continue this work if I didn't have people like Lauren and the people at our school who were doing like the small group stuff and working together. Amy Wonkka:  And I think if you're listening and you're in a less resource, a less well resourced district, um, there are, I don't know if either of you have thoughts about other ways that people can sort of pursue this education, you know, if you don't have that level of financial backing from your district, I think, you know, to, to Lauren's part, piece about, The importance of having coworkers who are forming that community with you. Um, you know, I think that that's [00:23:00] something you can potentially do. You still need administrative support to some degree for the time. Um, but I think, you know, it sounds like you guys went through a lot of training, professional development on this journey. Um, I don't know if you know of any resources for people who might not be able to get that piece of infrastructure support in place. Sarah Hahesy:  Yeah. Um, No, I mentioned this before, but raising race conscious children is a really great website, you can go to, um, learning for justice is another really great one, um, that we use a lot. There's just so many books on this. So, uh, something that was the most popular of all of our like meetings that we used to have and still have our whenever we had a book club. So we would choose like a fiction book or a nonfiction book and we would read it and talk about it together. We also used to like listen to podcasts and maybe share that out with each other. Um, but books are always, I [00:24:00] feel like in the classroom and out of the classroom a great way to start and grow your knowledge in this area. And I know you  Kate Grandbois:  all are going to come back and do a part to talking a little bit more specifically about components of the curriculum and maybe this question fits in with that. Um, but I wonder if you could tell us a little bit about. Any, any strategies you might recommend for someone who's listening, who maybe wants to bring this curriculum into their district, but is maybe the first person to consider something like this or anticipates a little bit of pushback from administrators. What are some of the benefits of bringing this into a new in bringing this into an infrastructure as a new concept? Or what are some selling points that someone might be able to bring to their administrations? Oh,  Sarah Hahesy:  go ahead, Lauren.  Lauren Tavares:  Well, something that worked for us, like Sarah [00:25:00] said, in our, in our district, equity is a core value. A lot of districts have language that say what their values and plans are. Some of these kind of definitions can lead to a lot of real performative work, especially if we're not pushing. And so, I think that being able to use those words and advocate for yourself, um, by saying like we, we talked about equity. This is, this is in our core values and really being clear about why you're doing what you're doing is really the first step, um, in really fighting for what you're doing.  Sarah Hahesy:  And I also think you can, if there's any pushback on that, you can always do it as part of your like building of your community. In your classroom, because you know if you do a lot of identity work. It's not necessarily like going to raise red flags, it's because students are sharing about themselves, and you're learning about each other. [00:26:00] And they get to know each other they get to know where their names came from they share all these things and like through that you're like learning other people's stories which then grows your empathy and compassion for people in the world. So, you can do a lot of that there's so many great books that you can read with your students. And, you know, you can, you know, buy yourself or choose to find people at your school who you could be like, okay, let's work on this strategy this year. And you don't have to overwhelm yourself but that's what we did we wanted to name race in picture books and do one a week like that was our goal. And we ended up doing more than that. But that's where we started. So you can start small and it could just also. I know a lot of people just want to work on their own and just like listen to podcasts. You know, do readings, find articles, read books, um, you know, fiction and nonfiction, um, just so that they can grow their awareness as well. Lauren Tavares:  I think the biggest part is [00:27:00] starting where you're comfortable too. Um, I, for me, I, there's, there can be this kind of misconception that as a person of color that I feel comfortable walking in and talking about race. That was not always the case. I did a lot of learning to get to where I do feel comfortable in that area. But as an SLP. I felt comfortable going in and talking to kids about the areas that I worked in because that's where our training is. Um, so the first thing that I ever did in the area of social justice was, um, I talked to our guidance counselor at our school and we were looking at the fact that our school has an autism program and we weren't talking about autism with the kids. Um, and we weren't talking about neurodiversity. And so that was the first thing we did. We sat down with a group of second graders and said, we're gonna talk about this today, and. It's really validating when you sit down with a group of children and they're like, yes, we are ready to talk about this. We've been waiting to talk about this. And, um, you've given like, you've given them permission [00:28:00] to like have these questions and ask, instead of making their own judgments and assumptions based on students challenges that they see in their peers, they're, you're doing some guided learning with them in this area. And that was where I felt comfortable really diving into this work and. It was really exciting to see, to hear what students had to say, they were all really positive about the topics and being able to engage in the discussion about, about neurodiversity when we started that. And then that helps me build confidence in really moving into other areas as well and having these open discussions. Sarah Hahesy:  Yeah. And you just made me think about another thing that kids really like is about fairness. And that's another way that you can jump into this is talking about, you know, I always start difficult conversations with, when I was a kid, we never talked about this. You were so fortunate that we can talk about race or that we can talk about ableism or whatever the [00:29:00] concept is. So I name it for them and then I tell them, you know, how far, you know, They are, whereas, whereas I was not as far at their age, and, um, they kind of love that. And they also are just, I mean, I work with third graders, so they're very into fairness and equity on their own. Anyways, they want everyone to be treated well. And, um, so just knowing where your kids are and thinking about stories that could really bring out like, you know, their character traits, like, you know, Kids want to see the right thing done. They want to learn about other people and just, you know, finding ways to just have those interactions happening in your classrooms or your spaces. It's Really, really powerful. I have a  Amy Wonkka:  question for both of you, maybe a little more for Sarah, because it's about, do you find the social justice work you're doing slides into other areas of your curriculum? Like, do you find that because of the work you guys are doing in this area, you're [00:30:00] having a deeper look at your science and social studies or your ELA? Um, and if so, what, what are some of those things that you've noticed?  Kate Grandbois:  Yeah.  Sarah Hahesy:  So I mean, I've talked a lot about the beginning of the year because that's kind of where I'm gearing up for. But, um, not only did I get like social justice training when I first started, but I also was trained in responsive classroom, which talks a lot about, um, you know, the guiding principle. The first guiding principle is that teaching social and emotional skills is as important as teaching academic content and, um, So that being said, you know, setting up your year where you teach everyone. I mean, this goes to like, um, equity and a big sense being like in my classroom. This is how we stack chairs in my classroom. This is how we walk in the hallways and showing them this and actually I don't know how it's going to work out. I'll, I'll let you know but we kind of did this whole school wide project with our seventh grade buddies, [00:31:00] and where we made videos. About like how to walk in the hallway and how to do all these things because it was like kind of a challenge and you know the kids felt so empowered to do it. Um, but also I hope that it's like a thing that everyone's like, Oh yeah I saw that in that video and we're supposed to do this and so just, you know, they know what it's supposed to look like sound like feel like. So that's one part of like responsive classroom. We also have morning meeting. Where we're greeting each other and we're sitting in a circle and I really like push it every day. I'm like, you have to sit in a circle. You have to talk to each other. You have to say good morning. You have to greet them, you know, like by looking at them, if that's comfortable for you, but like, you know, just really acknowledging the people in your classroom. And, you know, we do a whole bunch of like fun getting to know you activities. And there's so much that you can do with that. And then this social justice work you can really put it into everything so you can have it, and [00:32:00] you're reading you can choose your read alouds and what you want to convey like what messages do you want to put in there. And I said this before but talking about windows and mirrors and really having them think about. You know, Oh, am I like this character? Am I different from this character? And it's kind of nice with a book because it's not a real person. So it's like, it's doing the work and practicing it in a way that might not be as like nerve wracking for students. Um, and a book that I use now is, um, on the day you begin by Jacqueline Woodson. That's a great book to start the school year with. Um, it shows a lot of different perspectives and it starts so many of our conversations off, um, You know, on the way that I want them to go for the school year, I used to use first day jitters, which is also an awesome book, but, um, that didn't always set the tone in the way that I wanted it to go. So reading you can really push that and, um, from there [00:33:00] like our district is also looking into diversifying our books and having different characters and all like representations of all that sort. But if your district isn't doing that. There's so many people you can follow on Instagram. You can find all sorts of book lists. That you could focus this work on to, um, we also, um, this goes into our social studies units because we talk about the Wampanoag. We always start the year talking about Indigenous Peoples Day, and our district changed it from Columbus Day and so it's always a nice conversation to have about like why would we change that and know this is what you should know about Columbus, and, um, And then when we talk about the Wampanoag, um, I've really, um, worked on this for a few years, but just thinking about, you know, they're still here and telling the stories of resiliency and how they overcame that, like, massive oppression that they faced then [00:34:00] and now, and just, um, You know, talking about their relationship with the pilgrims and why they needed each other and how like that worked. Um, and I think if you focus on resiliency versus like, I mean, you have to talk about the sad and horrible things too, but you have to show how people overcame this and kind of focus on that. Um, and then the final place that we do a lot of this work is in writing. We have a persuasive writing unit, and, you know, I always. so much. Use mini lesson examples that are like things that I would want to see changed in the world, you know, like gender neutral toy aisles, um, making. I haven't used this yet, but I'm going to this year. But like, um, you know, storefronts in Massachusetts are impossible to get into. They're so inaccessible. And I broke my ankle a few years ago and I also had kids and I like pushing a stroller into [00:35:00] some of these places. It's impossible. And we really should make it accessible for everyone. And, you know, I, I just choose things that I've seen and that are really important to me, and then they do the same. And so, you know, just thinking about their advocacy skills and how to, um, bring about the world that they want to see and that they have the power to do that. And so you can kind of do it through everything. I guess I didn't bring up science, but. You know, Kate Grandbois:  and how does this, how do these components of curriculum end up shaping your work in speech pathology, Lauren?  Lauren Tavares:  Um, I spend, I spend a lot of time pushing into classrooms. So some of it is supporting this work as like we are working with students, either in the classroom or pulling them out and working on know those comprehension skills and reading and those writing and writing skills, things like that language organization, we can work in those areas that Sarah was talking and using those texts and, um, and [00:36:00] thinking really Yeah. Being really thoughtful about an intentional about our choices in what material to use what books to use what to base our work on. And also, Sarah mentioned responsive classroom, that is so much of the social skills that we are working on. We are working on building connection between peers and perspective, their perspective taking of each other. Those greetings in the morning are hard for a lot of my students. And so that's a way that I can come in and support this work and think about how they're going to navigate the social pragmatics of engaging with others, especially in these classrooms that are built around these principles. Kate Grandbois:  This has all been really, really helpful and informational, especially thinking about how this relates to the infrastructures that we work in, the communities that we're involved in, even just thinking about school as a community, instead of a place where you drop your kids off every day, [00:37:00] which, you know, is a really important distinction. This is a classroom that they're spending. So many hours in through the course of the year. Um, I wonder if I know that I know that you're coming back for a part two, where you're going to unpack in a little bit more detail, what this curriculum actually looks like in practice before we close, do you have any final words of advice or suggestions for our listeners? Lauren Tavares:  I mean, we definitely want to acknowledge that this is hard work. It's a, it's a lot of work as teachers to implement this, um, these skills, and it's a lot of learning to do, and it can be scary at first. Um, and Sarah and I, we had some stumbles, and then we, we've had a lot of successes, but it doesn't all happen at once. Um, and so it's really in finding your people, finding your support, building your confidence, and starting small. Start with where you feel comfortable, start with one strategy, [00:38:00] and find what, what's important to you to  Sarah Hahesy:  begin. and the final thing that, um, has really helped me in this work, I mean, everything that you said, Lauren, I a thousand times agree with, but, um, Just thinking about how, when you do this work, it benefits all of us. It benefits everyone. And that is why it is so important that you try to do this. Um, it makes a huge difference and, um, it's just, it's also really like, it just makes you feel great when, when you do it right. And when you don't, it's great to have those people to check in with and be like, Oh yeah, I should have said it this way. And to go with that. You can always go back like the conversation. If you have a conversation that you don't think went well, you can always go back to your class and be like, you know, I didn't really like how he said this. Can I try again. And, you know, just kind of bringing up that, like you can try to fix this and do [00:39:00] this work, because it really is essential. Thank  Kate Grandbois:  you so much to you both for sharing all of this with us today. We're really, really excited for a part two. Um, we already both have so many questions that we're really excited to ask you, but we will hold our tongues for the next time that you come onto the show. Thank you again so much for being  Sarah Hahesy:  here. Thank you for having us. This was great. Thank you so much. Sponsor 2 Announcer:  Thank you again to our corporate sponsor, Feeding Matters. The entirely virtual Pediatric Feeding Disorder Conference is a great place to advance your skills with speakers from around the world. Earn over 20 CEUs of research focused and evidence based education. Learn more at feedingmatters. org slash conference.  Outro 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 [00:40:00] 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 Sponsor 1 Announcer:  This episode is brought to you in part by listeners like you and by our corporate sponsor Practice Perfect EMR. Billing, scheduling, documentation, patient communication, business metrics, and more. Practice Perfect EMR specializes in speech [00:02:00] therapy practices like yours, connecting everything. Check them out at www. practiceperfectemr. com.  Kate Grandbois:  Hello, everyone. Welcome to SLP Nerdcast. Today, we are really excited to talk about burnout in schools, and we are here with our expert guest, Dr. Lisa Morante. Welcome, Lisa. Hi,  Leesa Marante:  thank you for having me.  Amy Wonkka:  Now, Lisa, you are here to discuss ways to tackle burnout as an SLP in the school setting. And before we get started, can you please tell us a little bit about  Leesa Marante:  yourself? Of course. Um, I'm a speech therapist. I'm a speech language pathologist, um, communication advocate. Sometimes I like to call myself, um, a consultant for school based SLPs. I have a, a business where I provide solutions for school SLPs who are stressed out and for school districts who want. retaining SLPs in their schools. Um, I've spent most of my career so far in the school setting. I'm on [00:03:00] year eight of my career. Um, but for most of my journey, I felt like I've worn two hats, a clinician hat and that my research academic hat. So I went back To school after my clinical fellowship ended where I was feeling extremely burnt out. Um, that was, I was in two schools my first year out. But then I went back and got my PhD with a focus on language and literacy at Florida State a couple years ago, I just finished it. Um, and for the most part of my research interests, then sent surrounded or centered around increasing the language outcomes of students with developmental language disorders. So that's where most of my program of study focused on. Um, but then the pandemic hit and I realized that. We may need a different avenue for targeting these outcomes, like what's impacting our SLPs from providing these evidence based practices that we, you know, know and love and have learned so much about, but it's still not [00:04:00] working. Something's still not working. So, an avenue for, for helping those language outcomes for me was figuring out how to help those SLPs in the schools. And if you spend any time in schools, you know, that there are plenty of kids who are not getting the services that they want or that they need, um, because we're understaffed or overloaded. So essentially my work from the last couple of years, last three years or so has been an attempt at increasing retention of school based SLPs, helping provide effective interventions and just figuring out. What's the cause of burnout? What, what can we do as clinicians in this field that's so overstretched? Kate Grandbois:  We've talked about burnout on this podcast before, but never specifically as it relates to individuals working in the schools. We actually were introduced to you through one of your colleagues, Dr. Kelly Farquharson, who we have interviewed before, and she referenced an article that you co authored together called Tackling [00:05:00] Burnout in the School Setting. Practical tips for school based speech language pathologists. And I know a lot of what we're going to talk about today is rooted or derived from that article. So we will link it in the show notes and we will likely be referencing it throughout the interview. Um, and before we get into all of that, I do need to read our learning objectives and our disclosures. So I will try to get through that as quickly as I can learning objective number one, define burnout as it relates to speech language pathology. Learning objective number two, list two reasons why the school based SLP is susceptible to burnout. And learning objective number three, list three strategies to mitigate burnout when working in a school setting. Lisa's financial disclosures. Lisa is the owner of a consulting service called school SLP solutions that provides consulting services to school based SLPs who experienced burnout and to school districts who want support in retaining their school SLPs. Lisa also received an honorarium for participating in this course. Lisa's [00:06:00] non financial disclosures. Lisa is a member of ASHA SIG 16, a member of FLASHA and TISHA. Kate, that's me. I am the owner and founder of Grand Bois Therapy 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 Wonkka:  Amy, 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 am a member of ASHA Special Interest Group 12, which is AAC, and I participate in the AAC Advisory Group for Massachusetts Advocates for Children. All right. Now on to the good stuff. Lisa, why don't you start us off by telling us a bit about that first learning objective? In your paper that you co authored with Dr. Farquharson, you guys talked a lot about just defining burnout and what that is and what that looks like in the school, and I think [00:07:00] it'd be a great place to start and just give people some background on,  Leesa Marante:  on that term. Yeah, of course. So I think the pandemic sort of highlighted the nuances of everyone's job, not just in our field, but you know, in every field at that time. So, you know, in turn, that made the term burnout sort of a buzzword kind of lost its definition, its meaning across, you know, in society, everyone's burnt out, which is true, it can be, it can be true, but burnout is something that we all heard about. And it Defined specifically on increased feelings of depersonalization. So the not feeling connected to what you're doing, um, increasing feelings of emotional exhaustion, feeling exhausted with, with your job. You feel like you're not able to give it your all because you're not, no longer connected. You know, no longer feeling personalized to, um, to what you are doing and then decreased feelings of personal accomplishment. So you have, [00:08:00] you don't feel like anything you're doing is working or you feel like you're working hard, but it's not effective and it's kind of this cycle. So With burnout, there can be physical symptoms, um, and they can also be psychological symptoms. So sometimes there's an increase in headaches, lethargy, so you are really tired all the time, nothing seems to be working, um, you're irritable, you're unable to solve problems, where you feel like everything is harder to do than, um, you're used to, and you know, the far end of the spectrum is exhaustion and dread. You dread to come into work, you dread and dread to accomplish. Tasks that you usually don't feel that dread, but burnout is often, you know, described as a form of emotional exhaustion. And, you know, as a result of like that fatigue that you get after extending yourself, overextending yourself at work, when you have these job stressors that are continuous and ongoing and really no end in sight, and you've [00:09:00] exhausted all of your support, all of your time, your effort, and those are called resources. Those are the resources that we use. In our day to day life, time, effort, money. Those are the main ones that we kind of as humans use. And when you're overextended those, get diminished. And that's what causes those symptoms of burnout. So the World Health Organization, it classifies burnout as an occupational and not an medical condition. It's not a medical condition. Considering but it does have medical outcomes where you are potentially if you let it on, let it go if you let the burnout symptoms go you will start feeling some medical impacts and that's that's important to catch before you get there. You don't want it to be. More severe, we get anxiety and depression and it's all related in the cyclical ongoing circle of dread. Amy Wonkka:  Well, I think there are many of us school based practitioners, particularly people who work through the pandemic, who can relate to all [00:10:00] or part of those symptoms that you just described. And I think You know, making the point that it's sort of a continuum and you can experience some of those feelings and I thought you guys did a really nice job with that in your paper to just talking about how, you know, you can have some of the pieces of burnout before it sort of becomes full on burnout. And then the idea that If you sit in that place of burnout for a really long time, it can have even farther reaching repercussions. I think it's important for all of us to identify, um, as SLPs who are potentially experiencing some of these some of these symptoms. Um, I. I was wondering in reading the article, one of the pieces that I liked a lot, and this might be an abrupt jump, so feel free to stick with burnout for a little bit if you want. Um, but I really liked the idea about these possible stressors that SLPs have the control to change. So the idea that when you're operating within a system, there [00:11:00] are some things, and I, and I, I have these conversations with my colleagues all the time, like there are some things we really can't change, but there are some things we can change. So I didn't know if you wanted to talk just a little bit about helping SLPs identify the difference between those two.  Leesa Marante:  Yeah. And a little bit more about burnout. Burnout isn't in a dichotomous variable. So the, you know, it's not a yes or no type of thing. You're not either burnt out or you're, you are burnt out. You're feeling a little bit more stressed this month in, in work because you have 20 IEPs due and you have to update, but maybe next month you're not feeling as burnt out because you have a bunch of fun things happening. You know, it's um, holiday season where you have a lot of parties and you get to have fun with your kids. So the burnout symptoms or the feelings of burnout definitely. I've been flow as your school year goes on to those three pillars that I mentioned earlier to depersonalization emotional exhaustion and personal [00:12:00] accomplishment, definitely very and they could have varying levels just depending on your experience depending on your, your situation, your school caseload. And there's just so many factors and that's why it's very hard to address because everyone's situation is completely different from. Even in, within the school setting within the school district, even on campus, you may have multiple SLPs on campus, and my caseload might be very different from the other speech therapists on campus and I might not be feeling any of those increasing personalization with my caseload, but she may hate it, she may have just a lot of Issues with her with her new kiddos that she does not familiar with and she might have those increased levels of depersonalization where she's like, I know, I know nothing about my kids. So, to address your second question. Yeah, there is a point where you have to kind of have a lot of self awareness [00:13:00] and say okay what is it that I have control over we don't have control over legislation, things that happen like paperwork stuff that are school district or state are requiring now because of A due process that we had no idea three districts over, um, that we have a new form we have to do because of that. Um, however, what we do have control is when we complete that form, what we do to incorporate more paperwork time in our schedule and who we need, who we can delegate these things to, um, there's, there's many things that we can control versus things that are, um, just out of our control. I mean, I kind of redundant there, but just. There's a, there's a lot, there's a lot of things that we cannot control in the school setting and then a lot of it is our, is, you know, money, our time, and all the things that we have to do on our roles and responsibilities, but we have to remember as a speech therapist, our main goals to increase our kids [00:14:00] Communication skills and have fun. I always tell my clients, like, have fun with what you do. You came into this field for a reason. And if you feel like not doing therapy today because you have just spent two hours doing paperwork before the session, then play a game. You're still targeting your goals some way or another. Um, so Yeah, the first thing is identifying what is it that you can't change and then it's like this locus of control. What is it that you can control and then you can tackle that first.  Kate Grandbois:  So  Leesa Marante:  the, the things that we can control, um, might look differently across your years. That you're still working on that thing. You're still working on, okay, this is my schedule. It causes me a lot of stress and anxiety, but This year, I'm going to take control over it and not let my paperwork time go by the wayside. I'm going to make sure that my paperwork time saves my paperwork time and be really stern about it with my co [00:15:00] workers, make sure that they can't spring meetings on, make sure that I do all, use all my strategies to make sure no one comes into my room while I'm writing my reports, um, is that I've also had to do that. My door is not open. I'm not going to get up to open it. I'm putting a do not disturb sign so that I can write. Kate Grandbois:  I love the idea of signage on your office door to sort of set that boundary. I have so many colleagues who often complain that they have so much paperwork to do, but can't do their paperwork at work because they have a shared office or because. It's they're always someone's always in the hallway asking them a question or they get up doing X, Y, or Z. Um, and I, I really appreciate the gentle reminder that we do have the control and capacity to set boundaries and we can do that kindly without. Creating a lot of discomfort. And I think a visual sign is a great way to, you know, some hanging a sign on the office door or [00:16:00] putting in your ear pods. Sometimes I would put in ear pods without even playing music just because it looks like I'm not available. Um, so thinking about how to establish some of those boundaries is a great idea. I'm wondering if you could tell us a little bit about why burnout in the schools is. It's own unique thing. You mentioned a lot of barriers or contributing factors to burnout that are out of our control, like legislation. Are there components of that that make burnout in the schools  Leesa Marante:  more unique when compared  Kate Grandbois:  to other settings? So  Leesa Marante:  burnout can happen with any job. It's an occupational hazard because occupational stress is a very, it's a caveat of our working, you know, something that's high, high. stakes, you know, we need our job, we need to keep our job, we need to do our job well so that we can meet our, make our payments, do our pay our bills, it's a livelihood type thing. Um, so [00:17:00] burnout can happen in any situation. It can also happen in other aspects of our life, like motherhood, it can happen in parenthood, when you do something that's high stressful, that's I stress for a prolonged period of time, um, in the schools and I, the literature shows, you know, any helping profession, any profession that you are with others, you have contact with people, you're doing things with, you're managing a lot of human capabilities, right? You're managing what you say to someone else. You are dealing with other people's expectations, emotions. So, the, the burnout literature in the education setting. It's similar to the education or similar to the literature in a medical field so nurses also burn out really easily because they're also in high stress situations where there's prolonged for a long period of work. The stress happens over a long period of time. Um, so in schools, we are, there's high stakes, we are [00:18:00] teaching young minds, and we are making sure that what we teach our young, young youth, when we teach our youth, um, and we're working with kids who have language disorders or communication disorders, there's a lot at stake.  There's a lot of factors that are at play and a lot of those factors impact how we do our job well. And we, I wish, I wish we didn't have those things, you know, I wish we didn't have, um, an issue with place. Like where do we get therapy? That's a, that's a big thing because our schools. Not even for speech therapy, but our schools are under are understaffed there or there's way more kids that need to be in the schools right now there's not enough schools to have small classroom sizes, so they need all the space they can get. So that's not something that is in our control like Amy was saying like it's not in our control. It needs to be of where we, it's not, it's not in our control of where we provide therapy. [00:19:00] If you have a huge classroom to write therapy that's a very good thing. That's a, that's a great thing. So that's probably not one of your stressors. That, where am I going to provide therapy today? It's not one of the things that happen that come across your mind. So that's not one of your stressors. That's not going to impact your burnout. But, you know, not getting paid enough. That's also not in our control. That's going to be a stressor. Because you're doing all this hard work and then you're not, at the end of the month, you're not getting enough money to make your, your bills, make ends meet. Because that's also happening right now, across Not just for school therapists, but for everybody in the education system, I know many teachers who have multiple jobs and kids that they have to hang out with after school to, you know, they spend their whole day hanging out with kids and then they have to go home and still stay on and, you know, do things at home with their family and then go to multiple jobs. So it's, it's an ongoing thing of just being on [00:20:00] constantly. That's why we see a lot of burnout in the schools. There's just so much time in the day. There's not enough time in the day to get all the things that we need to do done well. And one of my, I think it was Kelly actually, who, um, she said something really insightful for me while I was doing my PhD. You're, right now, you're juggling a lot of, a lot of balls. Right? You're juggling a lot. You have to decide which balls are rubber and which balls are glass. Some of them can be dropped. The rubber ones can be dropped because they can bounce right back up and you'll pick them up. The glass ones can't get dropped. So getting good grades in your PhD probably is one of those rubber balls that you don't need because you're at the end of your education. You're still needing to learn, right? Making sure you still want to do things well, but making sure that you are still writing, that your dissertation completed. Those are the glass balls that you can't drop. So you don't want to be in your PhD for seven years. You need to make sure that you figure that out. [00:21:00] Same with proof. The clients that I see that work with burnout, it's what are some things that can get dropped in your, in your situation right now? Yeah, you can, you don't have to do RTI right now for that, for those students. You can delegate that task. You don't have to see them yourself. You can teach your, collaborate with your teachers, provide the strategies, um, that you will be doing to your teachers who see them more often than you can. Maybe if RTI is one of those stressors for you, that can be a rubber ball. Right now, the glass ball for you might be paperwork. Paperwork shouldn't go by the wayside because that is the one that is going to get us, that's probably the The one that's going to be the most litigious if we drop it. Therapy might not need to be pretty. The therapy can be very spontaneous. It can be reading a book with your, with your students. You don't need to have the fanciest, prettiest laminated materials. had to [00:22:00] do good therapy. Um, so that might be one of those rubber balls that might get dropped for this month or however that season you're feeling the burnout. Um, so I'm not sure if I answered your question.  Kate Grandbois:  I love this analogy so much. I'm already doing mental inventory of my rubber balls and glass balls. It's not looking good over here. That's a, that's a separate conversation.  Leesa Marante:  I  Kate Grandbois:  was just going to say, I, I, the analogy is so, it's very true, but really helps us compartmentalize. And acknowledge that we can't do everything. We are not bottomless wells of emotional bandwidth. Um, it also makes me think about the pressure that maybe I put on myself to be the perfect therapist, or to make sure that my laminate, my laminated materials are cut beautifully and I'm prepared and polished.[00:23:00]  Um, all of that is fake. All of that is in my mind and it's making me just reflect on that personally. I'm thinking about my colleagues and other people I know out there who bring a lot of that internalized pressure to the table, um, and feel that, you know, we have, we, that all of the balls are glass, that we can't mess up in any capacity. I, I really  Leesa Marante:  appreciated all of that. Yeah. And you said something that, you know, resonated to you. We feel like we need to do everything, but we shouldn't need to do everything. You know, we are the expert in the building for speech and language and literacy, but we can delegate our tasks. We can collaborate. Collaboration is also one of those buzzwords, but if you do it well, and it does take some time, I think I was in my last school for four years, and the third and fourth year were the years that collaboration was perfect. It did take me a good chunk to get it going, um, but it saved me so much time those third and fourth years because the teachers [00:24:00] already knew, okay, yep, these are the things that I have to look out for. Oh, that's, she's not going to get qualified with one speech sound. Let's work on that in the classroom. I'm not even going to bother Mrs. Morante with, with a referral for that. Sounds that sounds not appropriate or the sound is appropriate. It's age related. So giving that information and collaborating and working with teachers takes time, but it's also one of those that can save you a lot of time. And we shouldn't have to do everything because we're not trained to do everything for trying to be the speech and language expert in the, in the building and therapy can look different for everybody. And I think that's part of what I mentioned in mentioned this in the, in the article, setting boundaries for others and ourselves is really important. And like you said earlier, it looks, it doesn't have to be mean. Boundaries are only mean when the person you're talking to, [00:25:00] where you're putting the boundary for, is surprised by that boundary, where they were using you for that information, right? So if you put a boundary, you say no to that person, and that person gets offended, that person was using that space before that boundary was put in place. Um, so it shouldn't bother anybody. If you put boundaries, you say, Hey, I can't can't do that this week. We're not going to do another evaluation. Let's give them two more weeks of intervention. See where we go from there to allow some more flexibility on my schedule. And some of these examples I'm using might not always Farewell and some school districts right some school districts are very particular about processes. So just take my examples as a, it's just what they are examples might not be really specific for your setting. But if you are in any way resonating with some of these examples, it can be done, putting boundaries saying no to the IP meeting that you can't make like [00:26:00] no I'm not going to do a four o'clock meeting that's after my. Contract hours. I am not available. If you say that and you continue to say that, they are not going to schedule you another time. You're going to find another time that works for everyone. Other people get accommodated. I'm not a speech therapist. We give an example in that paper where we spontaneous IEP meetings is also very happens often where like, oh, we had an IEP meeting, we forgot this person had speech. Sorry, legally, you had to give me seven days notice. And knowing, that's another thing, we didn't mention this in the article, knowing your legislation is really important and it will give you a lot of power to, like knowledge is power. If you know the rules, if you know legally what you are requesting, like you, you, I can't just show up and update your IP. I have, I need time to do that, to be effective and to be well, well done. I need time. So putting that boundary. And alleviate that stress of [00:27:00] all of a sudden, so many things, so many,  Kate Grandbois:  I'm sitting here watching Amy's wheels turn. I knew, I know that there's going to be something good coming. Amy,  Leesa Marante:  I want to know what your stressors are so I can,  Amy Wonkka:  I think that you, so there are so many things. I think that for myself, at least, and I'm sure that there are other SLPs out there part of. What we're doing in the field is we're trying to help people, but we're also sort of people pleasers. And so the idea of setting boundaries can be super challenging. And I think that's an important point of self reflection as the SLP to recognize if that's something that's hard for you. Um, but also recognize that that's a challenge you probably need to step up to the plate for if you're also experiencing feelings of burnout because without. Setting those boundaries in place. It's going to be awfully hard. I mean, we'll talk more about some of the strategies that you mentioned in the article, um, about [00:28:00] addressing burnout, but a lot of those involve like setting boundaries and spinning up for yourself. So we also may need to do some work ourselves to get more comfortable with setting those boundaries. Um, and there are, I think the idea of the sign on the door is such a nice, such a nice, like. Not scary or not as scary thing to do compared to, you know, some of the crucial conversations. I'll ask you about that later. You guys talk about that in the paper. Um, but at the end of the day, by setting these limits and setting these boundaries, we're also, we're not only advocating for what's best for us. We're advocating for what's best for our students because when we're burnt out and when we're experiencing. Um, all of those like cluster of symptoms that you described earlier, we're not able to do our best work for our clients either. So it's like a win, win, win. Um, I also was like dancing around when you were saying no, no, the laws and legislation because that's where  Kate Grandbois:  you were going. I'm waiting for it. I knew it, but  Amy Wonkka:  it's true. It might not be the [00:29:00] most exciting stuff to learn about, but when you do learn about it, it can also. It can also. Help you feel a little less nervous about putting those boundaries in place because it's not just you, Amy or Lisa or Kate, like being the person who's being the squeaky wheel, you're, you're just sharing the rules that were in place, hopefully.  Leesa Marante:  Part of that is, we're usually the only ones that know the law well enough special education usually is the one that knows the law well enough. I do spend, I, my last school district, I did spend a lot of time telling even admin, like, no, we legally can't do this, or we can't provide that service because of X, Y, and Z. We had to really explain a lot of our decision making. And that's what kind of also adds to our stressors, explaining our job, explaining that we do have knowledge. Explaining why we are not make why we're making this decision, you know, if you had to just imagine doing a therapy session. I'm in a private practice now, so I can't I have a lot of parents who [00:30:00] sit in in the session. And I find myself kind of explaining what I'm doing or why I'm doing it this way. So just imagine having someone, second guess, every decision you're making, like, not just your self doubt, right, but just someone, a real person, outside person, third person, talking to you saying, Oh, you, you made, you changed that, uh, That dosage of therapy, why, why'd you do that? And that's how IEP meetings feel to some, some people where like all my decisions are being questioned, not because they're doubting you, but they also don't have that knowledge that, oh, we don't need to be seen 30 minutes. And I'll talk about that too later, but for one of the strategies, like you don't have to be seen 30 minutes twice a week. That's just an arbitrary dose that we've kind of got used to writing, but it's, that's where it comes from. Like explaining yourself is tedious. But if you do that enough, and you work at the same place long enough, which is [00:31:00] also an issue, we don't have many people staying in place, staying put long enough, um, those stressors kind of go away as, as persistent as you get. So consistency is really, really important for a lot of the things we're mentioning today. It won't happen in just one year. Your first year is going to be the roughest. But second year when you already get used to all the changes you make, your work habits adjust and your work habits. Become more efficient. And  Kate Grandbois:  for anyone who does want to learn more about dosage and frequency, we do have an episode on that with Dr. Mary Beth Schmidt, who wrote one of the papers related to this. So, and our minds were completely blown. It's not 2 times 30 or 3 times 15 or whatever it is that you're, you know, your, your professional norm or what your professional culture, your workplace culture dictates. Um, so in addition to learning about the laws and regulations. Reeducating yourself on effective dose, dosage and frequency. What we learned was that it [00:32:00] can have a positive impact on things like caseload and workload. Um, and I will, we will link that episode in the show notes for anyone who wants to listen. I was wondering if you could. Maybe list a few resources for us. If someone is listening and they don't, if they are new in the field or if they don't have access to, um, knowledge related to rules, regulations, policies, where might someone go to learn that information I'm thinking of union reps or anyone in is, or is there typically a position or a resource that someone can go to, to get better versed in that kind of thing? Leesa Marante:  Absolutely. You can go online and look for information on IDEA. The education website provides a lot of resources for parents and that's actually very helpful to understand all the jargon of legislation, um, using those parent handouts and even for your state. So your state, website, state education website should have a clear [00:33:00] definitions of your, the disabilities that we diagnose, the disabilities that are provided for special education. Also ask your special education directors. They should have resources as well. Um, if you're new to, to the field, um, or you're in your clinical fellowship here, In the schools, it's very important to reach out to the special education director that if your district has a lead speech therapist, they should have all that information for you, because it also varies by state states. I worked, I worked in Georgia, Florida and Texas and yes the communication disorder stay the same but the regulations are very different, even the diagnostic. determination. In Florida, it's not as stringent as Texas. Texas, I have to have below seven percentile and they have different definitions. So always look to see what definitions they have for what considered, what is considered a disorder. It's  Amy Wonkka:  also interesting working [00:34:00] across other states just to recognize I was chatting with an SLP in New Jersey the other day and they have, I think it's 90 days to complete an evaluation, whereas in Massachusetts, I have 30. So just being aware of differences from state to state and how that might affect you if you're an SLP who's school based and might be. Moving from one state to another. Also kind of rereading all of that information for your new state, uh, just to be aware of what changes. Maybe in place in your new location. Um, I wonder if we could talk a little bit about the idea of a time audit. I read this in your article and I loved it because I thought it was super action oriented and just a way to like, okay, I'm feeling burnt out. Where do I start? Um, I think it's like a nice way to wrap your head around some places that you  Leesa Marante:  might start. Cool. Yeah. Have you ever felt. [00:35:00] At the end of the day, you're like, wow, where did my day go? And you had a list of things you wanted to do, but probably the day went by, but you got maybe two out of the 10 things that were on that list. Um, doing a time audit kind of centers you and kind of, you know, makes you Slow down and become very intentional with what you're doing. So if you just pick one day, pick one day that you feel like you have a lot of stuff to do, a lot of deadlines, a lot of clients to see, and you figure out, okay, I have this many breaks throughout the day. I'm going to put a timer to see how long it takes me to do whatever I sit down to do on my computer. So if you get to your school, some, some people get to say your start time is. I would get or 720 if you're in elementary school, depending on what setting you're in, you sit down, you open your computer and you start a timer. [00:36:00] Okay, for that 20 minutes I answered emails, and then my first session started. It also might be, you took 20 minutes to answer emails but in that 20 minutes you also check your phone you also got up to get coffee, you also went and got the materials out. So, so time audit. We'll kind of bring that to light if you're actually paying attention to what it is you're spending your time on, and this is not in any way like you're not supposed to have any fun, you're not supposed to pause and talk to anyone. What you do by time auditing, what you do is really focus. Okay, it only takes me 10 minutes to update three goals. If I have no interruptions. So in your mind, you should say, okay, this shouldn't be that time consuming. If I have, I can do it in 10 minutes. So the next time you have a 10 minute free block, I can update an IP really quick. Um, [00:37:00] so that's the, the gist of it, where, where is my time going? What am I really doing during that time that I've set aside for this? And how long does it really take me to do a task?  Amy Wonkka:  I love it because it's, it's such like I, I've done versions of this myself and I found that I have no idea that like I had my, my mental idea of how much I could get done in a, in a set period of time was, was way off base in a lot of cases. Yeah, and like a  Leesa Marante:  really good thing that I like to do is I write a list of the top three things I need to get done. I don't make a list of 10 things. I make a list of these are the top three things I need to get done by the end of today. And that helps me feel a little bit more empowered of what I, I got these three things accomplished. I'm happy. Uh, on, on Twitter, a lot of academics call it the bare minimums. And then they put What actual bear icons like these are the three bare minimums of the day to feel accomplished and feel good about myself. And that's, that's half the battle, feeling good about what you do. Because that also [00:38:00] helps with the personal accomplishment. We want to keep that high. So whatever you need to do to get your personal accomplishment. Pillar filled personal accomplishment cup filled. Um, but another thing that I like to do is if I'm doing tasks and I'm like, Oh, I got to do this one thing. And I go off and do another task. I write that task down on my list and cross it off. Like I, that wasn't on my list, but it's something I did today. And that's something you can put on your list so that you feel like, Oh, I did. I did things. Um, because that way you feel like you actually got your list done, may have added a few things here and there, but you still have this sense of accomplishment towards the end of the day. Amy Wonkka:  Yeah, I love it. And I love that when you're, when you're doing the timer setting and you're like encompassing all the things you do in the task. I also like that a lot because like you said, like we aren't robots, like we aren't like I, I can't be [00:39:00] 100 percent on task. for eight hours straight. Like I just physically can't do that. Um, so I think it's nice too, to incorporate those other things. Like sometimes you need to go pee. And sometimes you chat with your office mate for a few seconds, you know, like I think that incorporating that into the time that it takes to do a task is really helpful. And it makes me think about your. Your analogy about like the rubber balls and the glass balls, because if you're doing something like a time study and you get a better idea of how long it takes you to do those glass ball things, like one aspect of working in a school. And I've worked in a, in a bunch of different schools in Massachusetts and Ohio, and in, in all of those settings, like the way that you usually have your day structured is that you have your time with students. And then you have some amount of like discretionary time preparation time, whatever they call it, but that's. Really, the only time you have in your day to get all of those non student facing tasks done. Um, so if you can better fill that with your [00:40:00] like glass ball activities and you have a realistic idea about how long those glass ball activities take like that right there. Can be very de stressing just to have that organization in place. Don't you think  Kate Grandbois:  It really makes me also think about previous conversations we've had related to self advocacy and negotiating in your workplace, because if you have that data, you've done that timing analysis and you know, that an evaluation. Takes you X amount of time, but your administrators thinks it takes you 30 minutes because they don't understand your job or they don't really understand, you know, what it is you do in the building, which unfortunately is the case. You can take that data to advocate for different caseload allocations or more prep time or a lower evaluation rates or whatever it is you think will improve your, your workplace culture or your, your amount of bandwidth  Leesa Marante:  for, for work tasks. Yeah, and the [00:41:00] thing about providing data to your administration, so your admin, they have some control over what you do. It also depends. So I'm going to say this, but it really depends on the district that you're in. So some school districts have SLP's have autonomy, if you have multiple You're welcome. Sites, they don't necessarily pick on you that much, but if you're at your one school and your supervisor is your admin, your admin, um, it makes it really hard to, to say, this is why I have Fridays completely free. I need to do all of this paperwork, including write evaluations, including doing completing those evaluations. It's not that I'm not busy during that time. So writing that data also shows a reason for not doing extra duty. Not having to be in the hallways for for teacher duty when you're, you know, if you're in a middle school, you have to monitor the hall during switching times but or after school drop off those types of things where you [00:42:00] necessarily have that extra time, because you have all these other responsibilities that you want to get done within contract time. Showing that time audit is going to help your case for that. I haven't had to do duty because of that.  Amy Wonkka:  And I feel like you're, you're talking about another question that we had, which was getting burnout before it becomes burnout. So if I feel like. I'm feeling stressed. I'm feeling extra stressed. And it's, it's not just this month. It was last month and every month I think next month will be better. And it's not, what are some strategies we can try and utilize to, to mitigate burnout before it's becoming a big problem. And I feel like the time study is like a great. Starting point. You already mentioned advocating, you know, things like duties. I think that that's, that's another really big piece. Like if you're a building based person and you're doing bus duty or, you know, you're out at recess, [00:43:00] um, maybe having that conversation, are there other things that, that other suggestions that might help.  Leesa Marante:  Yeah. Figuring out what the stressors Versus if they're temporary or if they're permanent if is it a cyclical cyclical problem or is it a temporary problem like I said a little bit earlier than making sure that you're that thing that's causing you stress if it's something that always happens every month at the same time, like we are having the same issue even though we fix it, we try to fix it. What's going on. Um, you know, if you had keep having that IEP meeting spring up on you from the same case manager. Every, every time there's an IEP and it's causing you a lot of stress, this is where you can have those crucial, crucial conversations with, with this person saying, Hey, this is causing me a lot of stress. Please give me enough notice so I can make sure that. Or let me know a month in advance that this IEP is happening so that I have adequate time to [00:44:00] prepare for the IEP. And that's a very specific problem to have. But having these crucial conversations with the individuals that might be causing that cyclical problem is important. Um, if it's a temporary problem, you know, perhaps you have IEP meetings that are coming up that have lawyers in them or advocates that you are feeling this. initial stressor, like, Oh, I don't know what I'm going to say, what I'm going to do. What if they find out I'm a fraud, you know, that imposter syndrome that we feel all the time because we're in a helping profession. Um, we know it's temporary. And a lot of the strategies we can do for those temporary problems is seek social support. That's where my, a lot of my, my dissertation was on providing social support SLPs, because that is a really Key feature of our community.  So it's really important to provide social support as a resource for SLPs school based therapists are often, [00:45:00] you know, by themselves in their classroom doing things isolated. And as soon as we provide support, we can continue talking about it like this is right now we're offering support to SLPs, it might not be social, but because we're not talking to them right now, but we are definitely providing them support in any in a certain way and I just remembered what I was going to say. So if you were, if your issue, what's causing you stress is temporary and You have an IEP coming up that will have a few lawyers in it and you just feel this sense of dreading, you're dreading it, um, you don't feel confident, your imposter syndrome is coming up, seek other SLPs who have experienced what you're about to experience, this is your first IEP with a, with a lawyer, that's what's causing you, like, I don't know what I'm going to say, um, or I'm not, I don't know what to expect, seeking that information, seeking support, even if you need support to say, like, I know what I [00:46:00] need. Like I've, I've asked Kate and Amy for a lot of support throughout this presentation and throughout this conversation we're having, um, just to get like, Hey, you're doing great. That does wonders for for someone and then know that that stressor is temporary. So, a really big thing is to decide what are your stressors, what is temporary what is cyclical cyclical problems usually need the most work. And those are the ones you either want to target. Over time, you target it using those crucial conversations, perhaps you need to have those crucial conversations with your administrators, with your, um, other case managers, other speech therapists. Maybe it's your supervisor, if you need, if that cyclical problem is that you are getting two or three new referrals every week, and you don't have enough time to evaluate them, like you're really out of time. Maybe your supervisor can help, but you have to ask. You're not going to get, this is something I also [00:47:00] tell a lot of my clients, you can't get an answer that you want if you don't ask. You're going to get no either way if you don't ask. Right? Um, it's such  Amy Wonkka:  a good point because and I think I think in some ways it goes back to that like uncomfortable feeling about setting boundaries, right? Like if you're uncomfortable setting boundaries, you're probably also uncomfortable asking for things that you need, which is like setting boundaries is just a flavor within that continuum of getting what you need, right? Um, I wonder if you could talk to us a little bit more about the crucial conversations because in the paper, um, The examples, um, that were in there. I was like, Oh, these are just like the yucky, like uncomfortable, stressful conversations that get like your palms sweating before you even have the conversation, but they're crucial. You can tell us a little bit about why they're so important for us to like have  Leesa Marante:  them. Yeah. Any conversation that is high stakes. So [00:48:00] your high stakes situations is your wellbeing. Your high stakes is your job. Your job might be impacted. Um, You might not even like confrontation that might be considered a high stakes because it's something that you're out of your comfort zone. Um, so those conversations that have those senses that make those senses kind of heightened are going to be crucial. You wouldn't want to have the, or you wouldn't have the idea to have a conversation if it wasn't going to help you. Um, so what we, we really have to realize that, and you can, you don't have to put this if you want. I might be a little bit controversial, but we're in a shortage right now for speech therapy. Speech therapists are needed. Use that to your advantage. You are not going to get fired. You are needed. They need you to be covered. They need you to, um, they need you there. There's no way that what you as long as you are not [00:49:00] providing, um, you know, the worst on evidence based therapy, you are actually, you know, trying to attempt to see your kids, you're doing your best at providing therapy, you're doing your best to get all your paperwork done. You're doing your best. They're not going to fire you for having a conversation that you are trying to help get support for yourself. However, there are situations where your superior might not be. A person that you feel comfortable doing so find someone who you feel comfortable having this conversation with. It may not even be someone who, who has power to change, it might be your coworker. Like, hey, I need to talk to you about this I'm going to pretend you're my, my superior. Let me, let me have this conversation with you and see what. Give me some feedback. I know not everyone is blessed to have a superior who might be easygoing who might not have a lot of repercussions. So that fear of there might be repercussions [00:50:00] and there's there's systems in place. To allow for this kind of these kind of conversations to happen in the workplace. And if there isn't, you need to move districts, you need to get out of that situation because that is, it's not okay you should feel comfortable having conversations with people who are higher up than you on the, on the ladder, because those people are there to serve you. Does that make sense? Like they're higher up, but they are here to make sure that we are having a really good culture in our campus. That's a, that's an admin duty. They need to make sure that the culture of their campus is positive. They need to make sure that their culture or that their, their staff feel safe on campus. So if you're already feeling like you're not feeling safe on campus to talk to your administrators with complete ease and complete Conversationality then there might be there's an issue a bigger issue at play. So I like to tell my students. I know my clients. I'm sorry. [00:51:00] I know my whole purpose is to keep SLP's in the in the setting where they are in, but there's a lot of situations where that is not feasible and I'm not recommended. Kate Grandbois:  All of what you're saying is making me think about something you said earlier related to how this is more difficult for someone in their first year. I'm imagining trying to overcome all of these hurdles, my imposter syndrome, my, you know, being brand new in a job and wanting to keep my job. Everything for reasons related to health insurance and my salary, not wanting to. Create waves, not wanting to create quote enemies and all of the fear that might come along with self advocating and having some of these critical conversations. I'm also thinking about how this might be particularly difficult for an SLP who is the only SLP in a district and doesn't necessarily have colleagues to corroborate, you know, the time analysis of no, it actually does take us [00:52:00] more than a half an hour to write a report or, or whatever it is. Um, And how many other contextual variables might really make some of these strategies feel more difficult versus, let's say, a seasoned SLP who's in a district, who's in a department of 16 other SLPs, you know what I'm saying? Yeah,  Leesa Marante:  and the, you're absolutely right. I remember my clinical fellowship year, I was. Everything we were talking about was heightened. I didn't want to talk to my admin, even though I knew my admin was in the wrong like I was like no. Oh, that doesn't make me feel comfortable I'm staying in my room. I am not going to have that crucial conversation and that's that's okay. You know your first year. You're going to have a lot of those barriers, and I'm hoping that you know that person stays in that setting and then just adjust for the second year, because we have to know going in that that your first year in any job is going to be hard. It's a transition, because it's new. [00:53:00] A lot of the time, you know, graduate students, being in the school, you know, not just being in school but your clinical fellowship years the first time you probably have a full time 12 hour a day job, depending on the setting. And it's going to be a lot, no matter where you are. So just knowing that you have time to change, have time to adjust that first year is always, it's going to be like a year of adjustment, but absolutely. I wouldn't, I would not have said anything to any of my, I wouldn't have had crucial conversations that first year. And I probably didn't. And that's  Kate Grandbois:  probably why I left. Well, if anyone out there is listening and is feeling overly intimidated by these critical conversations, or if you are the only SLP in your district, or you are brand new to the field and feel some of these strategies are insurmountable, we happen to know someone who has a business who is just available to help you with just such a thing. And I can, I can vouch for the fact that you're very [00:54:00] approachable, very friendly, very helpful and very reachable. So, we will make sure to put. Your, um, business information in the show notes for anybody who is just looking to have a little bit of support or extra nudge in one direction or another. If, um, you know, any of these barriers ring true. Leesa Marante:  Thank you.  Amy Wonkka:  I wonder if we can talk just a little bit, I know we're getting short on time, but we've talked a little bit about things to do to mitigate burnout before it becomes a problem. I wonder if there's anything additional or different that you would do. If you haven't been able to mitigate, mitigate it. And you get to the point where you're like, Oh no, I'm super burned out. What do I do?  Leesa Marante:  And that happens. How many, I have had so many conversations with SLPs who've been in this field for 30 years and they're feeling it now, 30 years. I'm like, good job for making it so far without feeling these that way. Um, what I tell them is to start slow, [00:55:00] pick one thing and work at that because 30 years is a long time to make habits. And it's going to take some time to make those changes. For my dissertation, I did support groups with SLPs across the country. And I did have a lot of SLPs who were seasoned. And they, 20 plus years, and they worked through lunch. They worked through lunch most of their, most of their career. And I, the six week support group that we had, I said, Okay, by the end of the support group, I really want you to not work through lunch. When it took them a long time, a lot of effort to not turn on the computer, to not have to have 30 minutes of not working, eat your sandwich outside, eat your sandwich in the car, that's something I do. I go to my car and have my lunch in my car so that I have a break from talking to anybody. No one's going to talk to me in the lunchroom about anything work related, not going to answer my email I'm going to scroll social media, I'm going to watch a YouTube video while I'm eating something that is [00:56:00] not work related and have that that break. But it does take time. So the more time you've practiced wrong, not wrong, I shouldn't say wrong, inefficient habits that have caused more stress, reduced your resources as a speech therapist, you're going to continue doing that because it's a habit. It's something that we do consistently. And I think the, you know, the saying is it takes 22 days to break a habit. Um, so it really It's effortful. So definitely starting slow, picking one thing to change that's gonna, that you know will have positive impact on you. I know in the article we mentioned a lot of other things, but I think that's been the most effective way of mitigating that. It's like, pick one thing that's going to help you and adjust. Moving forward.  Amy Wonkka:  I love that lunch example for a lot. I'm also a car lunch person. I have received  Kate Grandbois:  many Amy Wonkka:  Yeah, it's just like it's nice because you're [00:57:00] in a literally different physical space too So if you're already somebody who has trouble Like closing your door or if you're in a shared office like just being in a different physical space kind of I think helps promote that disconnect a little bit. And I find it really helps me be more engaged when I go back in too. And I think that that is another piece that resonated for me in the conversation we've been having with you today in the paper that you wrote Dr. Farr Carson. I think, you know, these things that we're doing. are better for us as like human being people, but they're also making us better able to do the work we're there to do when we're at work. Um, also lunch is super important. I, I, I love that example. I also love that it is something that happens every day. So thinking about. So if you can think of something like it as cheap, like framing it, like you're changing sort of a bad habit. I'm using air quotes. I don't have a better way to describe that. But thinking about I'm trying to change my bad habits to [00:58:00] be, you know, mitigating my burnout. Doing something every single day is a nice way to practice changing that habit, too. So if you can think of something like lunch or maybe like reserving your planning time or prep time to get specific tasks done, and you're going to be able to practice that every day, I think is also really helpful. So thanks for that.  Leesa Marante:  Another really easy fun one, fun one I guess, yeah, um, is reducing your exposure to email throughout the day. Don't have your email open because the dings, it's evidence based, the dings will distract you from what the task that you're attending to. So have a specific time where you check email, make sure your phone email is turned off after the workday is over, those, those little things add up over time and you don't realize how much time you spent answering emails. Take back your time. I feel like I'm  Kate Grandbois:  leaving today with so many strategies and I'm so grateful. Do you have any final words of [00:59:00] wisdom or final recommendations for our listeners before we wrap up?  Leesa Marante:  I do. I wish there was a wand I can wave to fix it all. You know, an easy answer for everyone. Um, like there's not just one solution that fits all, but the reality is that our experience is very, and like, it's gonna, we're gonna fix our situation. It's gonna take time. Change is slow, but it's happening. Become a member of your state association. They're the ones that are going to help. Make those changes for your state, for your school level. Um, they all, they're the ones supporting your school legislature, but yeah, you're not alone ask for help. It's hard to ask for help and it's, it's okay to, to ask for help, take a step back and it's okay also to say, this isn't working for me and change your setting, change your job, And get ahead of the Dread remember why you do this. Thank you so much, Lisa. Thank you.  Sponsor 2 Announcer:  [01:00:00] Thank you again to our corporate sponsor, Practice Perfect EMR. Billing, scheduling, documentation, patient communication, business metrics, and more. Practice Perfect EMR specializes in speech therapy practices like yours, connecting everything. Check them out at www. practiceperfectemr. com. Outro 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 [01:01:00] joining us and we hope to welcome you back here again soon.

This is a transcript from our podcast episode published May 16th, 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's episode. We have the great pleasure of welcoming Dr. cott Yaris. Welcome Scott.  [00:01:47] Scott Yaris:  Thank you so much, Kate. It's great to be here.  [00:01:50] Amy Wonkka:  And Scott, we're so excited to have you, you are here today to discuss stuttering therapy before we get started. Can you tell us just a little bit about yourself?  [00:01:59] Scott Yaris:  [00:02:00] Sure thing. Thanks Amy. And again, thanks for the opportunity to talk with you and with your audience today. Uh, yes. Uh, about me, I'm a professor of communicative sciences and disorders at Michigan State University, been a practicing clinician for about 30 years now. And all of my clinical work has been in stuttering. It's all I've ever done. It's the reason I got into the field and, um, I've been very fortunate throughout my career to be able to specialize in this way. So I teach to do research, do clinical work call about stuttering.  [00:02:30] Kate Grandbois:  That's amazing. How long have you been in the field? Did you say that.  [00:02:35] Scott Yaris:  30 years. That's a, but  [00:02:39] Kate Grandbois:  that's really, really impressive. Well, we're so excited to learn from, learn from you. We've done. We've worked with your business counterpart and Nina Reeves, and we're excited to get into more of the technical things with you today related to research. And what's changed over the last couple of years in the world of stuttering, but before we get [00:03:00] into all that good stuff, we have to go over some logistics and housekeeping. Sometimes people write in and ask us to skip this part. I can't ASHA makes me read it. So we're going to get through the learning objectives and disclosures as quickly as possible.  Learning objective number one, describe what is meant by the statement, stuttering is more than just stuttering. Learning objective number two, list two ways that stuttering assessment and treatment have changed in recent years. Learning objective number three, describe what is meant by the statement it's okay to say. Disclosures Scott Yaris’s financial disclosures. Scott is a co-owner of Stuttering Therapy Resources, Inc and receives an income related to intellectual property. Scott Yaris’s nonfinancial disclosures. Scott does not have any non-financial relationships to disclose. Kate, that's me, I'm the owner and founder of Grandbois Therapy and Consulting and co-founder of SLP nerd cast, my nonfinancial disclosures I'm a member ofASHA, SIG 12, and serve on the AAC advisory group from Massachusetts advocates for children. I'm also a member of the Berkshire [00:04:00] 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 group. [00:04:09] Amy Wonkka:  Amy that's me. My financial disclosures are that I am an employee of a public school system and I received compensation as co-founder of SLP Nerdcast. And my non-financial disclosures are that I am a member of ASHA, SIG 12, and I serve on the AAC advisory group for Massachusetts advocates for children. All right, we did it. We made it through, the boring bits are done. Scott onto the good stuff, in an initial conversation that we had about this topic. You mentioned, you know, you, you hear often that people don't feel prepared to help children who stutter. Can you tell us a little about that and why, why that is the case. [00:04:47] Scott Yaris:  You bet, you bet. It's a challenge that we face in our field, that many speech language pathologists simply don't feel comfortable with their skills for helping those who stutter. And it's a problem because when [00:05:00] people don't feel as confident in their skills, when they don't feel as knowledgeable, it's harder for them to provide good clinical service. The clinicians that I've spoken with, they know that they want to help people who stutter and they, they know that they don't feel good about this area. So very often they're eager for more information, they're eager for some validation, for some guidance. As to why this is? There's a lot of potential answers for this. Some of it has to do with just a lack of training. We have documented over the years that there are many graduate programs in our field that don't provide a course on stuttering. They're not required to, according to ASHA. Oh yeah.  [00:05:43] Kate Grandbois:  Really what? Not to interrupt you. But that is a shocker.  [00:05:46] Scott Yaris:  Yeah. Yeah. Um, there is no requirement for specific courses for accreditation, for graduate programs. There is instead the requirement to document knowledge and skills, but of course [00:06:00] there's a wide range of ways to document knowledge and skills and what that knowledge might be and what those skills might be is often left to quite a bit of interpretation. And so many clinicians may not have a class, may not have many clinical hours, if any, at all, they may, for example, count hours related to neurogenic stuttering, as you know, fluency. Types of hours, but they may never have seen a child who stutters in a school setting. And if that's where their career is going to be, then they know they're not prepared. They're know, they know they're not ready to help them,  [00:06:40] Kate Grandbois:  So let me get this. I'm, I'm really digesting this in real life at this exact moment, because I'm really, we graduate as speech pathologists with the scope of practice that is so wide, massive, and I can't wrap my head around universe where [00:07:00] you are given the keys to the car, so to speak, but not taught how to drive it. You're not given explicit instruction or given the, a structured opportunity to gain the content knowledge to do your job. So if in instances where graduates, recent graduates, haven't had a class or clinicians haven't had a formal class, how are the knowledges, knowledge and skills demonstrated? How do they get away with that? I guess is my question.  [00:07:26] Scott Yaris:  That's a really good question. And I wish I could answer it without throwing a whole lot of people under that car that we're all now driving without keys. Uh, because the challenge is simply that our scope of practice is too broad in my opinion, right? There's no way that in our graduate programs, we can train everybody in every one of these areas in the time that. As our field has grown as our scope of practice has exploded. Uh, we don't still get more than five or six semesters in the graduate [00:08:00] programs to educate our students. And so something falls by the wayside.  Often stuttering is one of the areas that falls by the wayside. Voice is another one of those areas that falls by the wayside, organic conditions, cerebral palsy, for example, is one of those that falls by the wayside. And I don't know the issues outside of stuttering, right? I'm only a stuttering guy. That's all I can really speak to with any authority, but I've talked to friends in other areas that have faced the same issue, um, craniofacial falls by the wayside in many programs. And so clinicians, uh, student clinicians don't get that broad training that they need. And it's simply because the field is too broad. I don't think anybody is saying, oh, Hey, let's make sure that people don't know anything about stuttering. They're just saying, oh, Hey, we are out of minutes, and our, our, our, our masters students are just stressed beyond belief as it is. So  [00:08:54] Kate Grandbois:  I have to assume this may have something to do with the universities research grants and things. So [00:09:00] they designed coursework around faculty and staff that they have available. And so, for example, we're in Boston and, you know, there are as a large research lab at BU for this one specific thing. And so they're guaranteed to have courses on that one specific thing. Is there a component of that? And in other words, if you're looking at grad schools and you're, you're a grad student, think about where you're applying for your education, if you're interested in fluency. [00:09:27] Scott Yaris:  That's absolutely right. In part it's it's, if there's a faculty member in the department to advocate for it, for example, in the departments that I've been fortunate to work in, you bet we've had classes on stuttering because I advocate for them and others like me do the same. But if I work there to advocate, then it's possible that somebody else is going to advocate for their area. Right. And there will be more emphasis and more coursework on some other areas. And so it is an appropriate question for people to, to consider, as [00:10:00] they're looking at graduate schools, if they have an area of interest they want to see, are there courses, or has this topic area that I'm interested in, been combined with some other, you know, and then of course there's the clinical hours. Am I going to be able to get clinical experience in an area? And unless there is an effort to create a client population in certain disordered areas, stuttering, voice craniofacial. Then the students won't necessarily get thethe hours there. My colleagues and I have done a few research projects looking at the training that's provided in the graduate programs. Demonstrating that over time, there has been a reduction in the number of programs that require hours in stuttering, that there's been a reduction in the expertise of the faculty in stuttering. They, they don't take stuttering as their primary area of interest. Again, there are only so many areas. I'm sorry. There are only so many people, there are too many areas. There are only so many people. And so, yeah, it is a challenge and that's one of the [00:11:00] reasons that many clinicians simply don't feel confident when they've graduated. Another one of the reasons not to put this all on, on the graduate programs is a lot of times people will go many years without having a child who stutters on their caseload. And so they don't feel like they've been engaged in this on a regular basis, or there are other conditions that have been demanding their time more. They find that their caseload is filled with autistic children. And they've only got one child who stutters well, when they're trying to decide where they're going to put their CE time, they, they feel pressure, uh, understandably so, to make sure that they're prepared for the larger bulk of their caseload. And so the problems compound and they build, so that clinicians find themselves all of a sudden, there's three kids who stutter, you know, on their caseload this, this year, or there's, as I've heard from several people, you know, at the beginning of the school year, nine, somebody emailed me. I got nine kids who stutter this year, I haven't seen a kid who [00:12:00] stutters in in years, then they panic. And that's hopefully where we come in is to try to help with reducing that panic.  [00:12:07] Amy Wonkka:  And what would you tell that clinician, if you are that clinician who has one new student or nine new students, and you don't feel confident, whether it's because you didn't get a course in grad school or grad school was many, many years ago, some of the things you learned in your course, you know, what, what would be something that you could tell that clinician? [00:12:24] Scott Yaris:  You bet the most important thing that I start with when I'm talking to clinicians who aren't comfortable with stuttering is that in my opinion, every speech language pathologist can be a superb stuttering therapist. Even if you don't feel that confidence right now, you can learn what you need to learn to make a real difference in that child's life in that family's life. And so even if you don't feel confident coming in, don't worry. Don't worry because we all start there. No matter what the area is, we can move forward. [00:12:57] Kate Grandbois:  Everything you're saying is making me think of [00:13:00] something. A professor said to me in graduate school, which is speech and language pathology is a science and an art. And when I'm thinking about the scenario you described of a clinician, not having the competence or the confidence, because they have 10 autistic children on their caseload and one child who stutters then, you know, you may have the content knowledge, let's play, pretend that you did get a class, right? You did, you know, you know, the research, you know, the statistics, you know, the, you know, all the things in terms of content, but there is the art piece too, of sitting down with an individual and doing, giving your best therapy that is tailored to, and specific to that individual. And I wonder if this is related to what's in your first learning objective of stuttering is more than just stuttering because in thinking about what we've learned from Nina [00:14:00] in our other episodes, there is a lot to stuttering therapy that you don't necessarily learn in a book.  [00:14:07] Scott Yaris:  Exactly. The facts I always told my students at the beginning of a semester, facts are easy. Learn them.  Okay. This class is not about facts. It's about being able to be with another human being who's experiencing a difficulty in their lives and having the skills to be able to help them with that difficulty. The skills aren't really about facts. I personally would much rather have somebody who is a great clinician who can relate to another human being than somebody who knows everything there is to know about stuttering. They'll learn that stuff if they need to know it, but really what it's about is being a human, being able to be with another human being and bringing those unique clinical skills that we develop as part of our training, no matter what the condition is that we're working with, but bringing those to the [00:15:00] situation, those clinical skills, and one of the things in our, in our school-age stuttering therapy book in particular Nita, and I spent a few words talking about the skills that clinicians already bring to the table. Speech language pathologists, whether they know anything at all about stuttering, they know how to listen. They know how to reflect. They know how to model. They know how to validate. They know how to show empathy. Those are the things that really matter in helping a person cope with stuttering. We'll fill in the facts as we go. We'll fill in the specific techniques as we go. If you have technique without that clinical piece, you can't be a good clinician. If you've got the clinical piece, even if you don't know the technique yet we will add that part in stuttering therapy is not about strategies. It's not about techniques. It's about connections and speech language pathologists are great at connections.  [00:15:54] Kate Grandbois: I love that. That was, that was just so great I’m sitting here taking notes. I can't [00:16:00] emphasize it enough. I guess just to repeat it back to you, because it was so empowering how important it is to bring humanity into your clinical space and to be a person first and the clinician second, and create a safe space for human connection, which can be vulnerable and scary and, and, and, but that's how we grow. [00:16:21] Scott Yaris:  Absolutely. I want clinicians to know that they don't have to know it all before they sit with a client who stutters and it's in fact, it's okay for that student who stutters to know that you don't know everything about stuttering, because we're going to learn it from them. Their stuttering is. So I'm going to learn from them what their stuttering is like. Uh, I happen because of my specialty. I happened to know lots of individuals who stutter in. I know all of their individual stories, but still, I need to know this individual that I'm sitting with right now when I'm in a therapy session. Uh, and so that's fresh each time. And all of that history doesn't necessarily help me with this particular [00:17:00] person. I've got to learn about them. And any speech language pathologist can do that once they learn to listen, once they learn to recognize what stuttering really is and not just what people think it is. That's, that's one of the important lessons. Stuttering is not just a speech thing, right? Stuttering is a life thing. And when we realize that, then we get the opportunity to make a real difference for them.  [00:17:23] Kate Grandbois:  You're dropping so much wisdom. I'm having a hard time coming up with intelligent things to say, because I feel like every other sentence is this beautiful one-liner that I just need to sit and sit with for a while, but something you said just a moment ago, sparked a question in terms of how this relates to the misconceptions of stuttering. So the clinician who is interested in gaining the content knowledge, interested in refining skills related to counseling and human connection, are there misconceptions about stuttering either [00:18:00] by society at large, that influence how we as clinicians approach this treatment?  [00:18:09] Scott Yaris:  Absolutely. And it's a very difficult thing in my mind because these misperceptions are rampant, first of all, and they're perpetuated not just by society, but also by our own field, unfortunately. And it relates to that learning objective about stuttering being more than just stuttering. From a listener's perspective, from a perspective of, of a clinician, a family member, a teacher, or a person in society. We think of stuttering as a speech disruption as a moment in time, when the person is stuck saying what they want to say, okay, fine, fine. But that's only the listener's perspective. It doesn't account for the speaker's perspective of stuttering. And so many of these [00:19:00] misperceptions that we have come from that separation between what we hear and see and what the person is actually leading. The best way to overcome these misperceptions that we have come from making a transition away from thinking about what we hear and see to what the person who stutters is living. So for example, a common misperception about stuttering is that it's just a speech thing, but we know that, oh, well, you know what? Stuttering is a lot more than just repetitions and prolongations and blocks. It's about fear. It's about anxiety. It's about, uh, difficulty succeeding in class. It's about not being willing or able to raise your hand even when you know the answer or when you have a burning question, it's about not being sure if you'll be able to ask someone out or how you'll do it, the job interview, it's about being terrified of your telephone and about, uh, every time that phone rings, [00:20:00] all of these other aspects of life experience are part of what stuttering is. And that's so much more than, oh, that was a repetition. So while we're focused on the listener or observer perspective, we're thinking about fluency as being something valuable. But if you ask people who stutter, what really bothers them about their stuttering, they don't say it's my lack of fluency. They say, it's my difficulty in doing the things I want to do in my life, saying the things I want to say in the way that I want to say them about not knowing about whether my name will come out when I go to introduce myself and having the wonder and worry and cringe, when the person I'm talking to says, what did you forget your name? Right? And so it's all of that other stuff. And when we shift toward recognizing that stuttering is more than just stuttering, stuttering as a life experience is about more than just speech behavior. That's when [00:21:00] we become open to recognizing what our real goal ought to be as speech language pathologists, it's not just to make fluency happen, whatever that is. And that's a different topic, but it's about helping people live their lives to the fullest and helping them communicate in the way that they want to communicate. Unfortunately, our field doesn't all know that. And unfortunately not only does society perpetuate some of these myths, but our field tends to focus on observable, fluency and value, and honor, and praise people who speak fluently, uh, rather than keeping the focus on communication, which is the reason that we open our mouths in the first place. Right? When we talk, the three of us, we're not saying, okay, in this next sentence, I want to be fluent. We're saying no in this next sentence, I want to convey an idea. I want it. I want to say something meaningful. People who stutter are like that too, until they're taught that fluency is more valuable than their meaning then their content and their message. [00:22:00] If we could shift that, boy, could we make a difference in people's lives  [00:22:05] Amy Wonkka:  And it makes me, in listening to you speak? It also makes me think about something that Kate and I have talked about a lot on this podcast in, in a completely different area of the field, um, in augmentative and alternative communication. Just thinking about the importance of, of client centered intervention, right? And so all of those things that I've heard you talking about are also to me, I'm thinking yes, like shift away from this sort of deficits model of, you know, we need to come in and, and fix the problem. Folks can't see my air quotes, but fix the problem. And, and in doing that, you shift from exactly that like something's wrong, something's wrong with you, I'm here to fix that thing that's wrong. Um, to shared goals working with your client do identify those goals that are meaningful for them. And it, and it is. I mean, I think in some ways it's sort of a shift in thinking for a lot of us. Yeah. I [00:23:00] mean, I went to school and not, and I was perhaps, so if my professors would disagree, but you know, I mean, I went into a lot of my therapy sessions, really focused on like fixing the problem, identifying the problem and fix the problem. And so it, it's a bit of a paradigm shift, I think for some of us [00:23:15] Kate Grandbois:  Not only that, but just to piggyback on everything you said with, which I agree with, of course, is anybody who's listening, who is maybe thinking of this paradigm shift for the first time, just remember that our evidence-based practice triangle in speech and language pathology. One third of that is client and caregiver perspectives and values. So you're actually not really doing evidence-based practice unless you incorporate these components into your therapy. Another way to look at it. By taking the content knowledge and putting it on a shelf or putting a pause button on it or making it second, or even making it the caboose and [00:24:00] focusing on your client and their perspectives and values that is still evidence-based practice. We get so hung up on what articles do I need to read? What strategies do I have to have? What's the recent literature and publications and blah, blah, blah. And yes, that's a component of evidence-based practice, but it's not all of it. And so I like to, I like to remind people of that often, because I think it's part of our triangle, our evidence-based practice model that gets lost in the shuffle a lot because in graduate school, we're so continually bombarded with quote evidence or best available evidence or whatever you want to say. Um, and the person in front of you is the most important part.  [00:24:41] Amy Wonkka:  I think one of the things though, that can make it hard and hopefully, um, Scott, you can talk to us a little bit about this is the assessment process, right? Because our assessment process is really set up to focus on the speech of things, you know, focus on the speech, focus on the language, administer these assessments, identify the [00:25:00] problems. So if we're trying to focus on more than just the speech or just the language, how do we maybe rethink our assessment process?  [00:25:12] Scott Yaris:  That's one of my favorite questions in the whole world, because that's what my research has been on for, for a long time. Now, more than a couple of decades, when we approach stuttering, how do we measure what's meaningful to the person who stutters? And I came at that because when I was a beginning faculty member, uh, I wanted to study treatment outcomes in stuttering, treatment efficacy, you know, what works in stuttering therapy. But the very first question I had to ask then is what does works mean? And does what works means this person got more fluent? Well, we know that the evidence shows that fluency is a very slippery kind of thing, and people may be more fluent sometimes, but not more fluid other times. And how do we define what's [00:26:00] fluent anyway, it's a mess. There's a way out of it by shifting our focus away from that observable fluency, recognizing that stuttering is more than just stuttering and looking at the broader impact of stuttering on people's lives. And that's actually what led me to the development with my colleague, Bob Quesal and the later with Greg Coleman of the Oasis, uh, the overall assessment of the speaker's experience with stuttering or the Oasis is a tool designed to do exactly what you're saying. It's to look at the rest of the condition of stuttering, how does stuttering affect people? And we know for example, that some people may stutter quite a bit on the surface, right? Yet not have adverse impact in their lives and therefore not need therapy because they're living just fine. Whereas other people may not stutter all that much on the surface. That experience a tremendous negative impact. And they're the ones who may benefit from what [00:27:00] we have to offer as clinicians. And as we've used the Oasis in research over the years, and as we've used it to look at more different aspects of the experience of stuttering, we've discovered some pretty stunning things that I actually feel are, are, uh, an indictment of our field. Um, one of the most important findings from a paper, it relates to the point that you brought up Kate about the, the, the research, you know, what papers should I read? Well, my, my colleagues Tisha and I published a couple of years ago now, papers showing that adults who stutter, who take as their goal when speaking to be fluent. Okay. When they, when they speak, they try to be fluent. Those individuals actually experienced greater adverse impact in their lives than adults who stutter, who take as their goal when speaking saying what they want. Wow, wait a minute. That means that all that emphasis that we've had on being fluent, all this focus on [00:28:00] getting the speech just right, that we, as speech, language pathologists have played into, cause we thought we were supposed to, actually may be associated with greater adverse impact in people's lives. Now, our evidence then is saying that maybe we should turn that around and focus on helping people communicate and say what they want to say, because those are the people who actually have less problem in their lives associated with their stuttering. It’s not just about speech. And when we focus on speech too much, when we overwhelm people with technique, technique, technique, I think we may be steering them in very much the wrong direction. [00:28:39] Kate Grandbois:  And doing the exact opposite of what, as Amy said earlier, we sometimes intend to do, you know, I have all this knowledge, I'm going to fix it. I'm going to help you. I'm here to help you, but actually I'm making it worse by accident. I mean, not that anybody's purposely doing harm, but this paradigm shift that we need to do, [00:29:00] you know, we can, we have the, we have the risk of causing harm by over, over applying our content knowledge, I guess. [00:29:08] Scott Yaris:  Uh, but now that we know, Ooh, right, before, if we didn't know that, right fine, a speech therapist supposed to work on speech. Okay, great. I'm going to, and now we say, oh, wait a minute. Now we've got this evidence that says that it's not having the desired outcome. We better rethink what we're doing and refocus our efforts.  Again but that taps beautifully into what speech language pathologists are really, really good. Helping people communicate, validating people, helping them come to terms with the fact that they're different. Oh, we're great at that. So that's what I tell that, going back to the prior question, that clinician who's uncomfortable, don't worry about 8 million techniques. That's not going to help anybody anyway. There's a place for technique. Sure. But it's part of a bigger picture. And when we take that bigger picture, clinicians feel much, much more confident. Right. One of my [00:30:00] favorite things to do, I, I used to do a lot of live presentations all over the, you know, these days I do them all by Zoom, but I've done over 700 continuing ed talks, uh, around the world over the last many years. And one of my favorite things is when somebody comes up to me after one of those talks and say, you know, I, I, I kind of had figured this out a little bit, but I didn't know it was okay. I didn't know it was okay for me to stop telling people, to use their techniques and start telling them that they're okay. And what they say is valuable. But now having heard you say that, it just makes sense to me. And I love to be able to provide that validation. A lot of people have figured this out. People stutter, they know.  [00:30:44] Kate Grandbois:  It's making me think of what I learned in graduate school and how things have changed or have they changed? I guess that's my question. I mean, I'm thinking about everything you're saying and thinking about our second learning objective, the ways that assessment and treatment have changed over the years, I [00:31:00] have to, I guess I'm assuming that there has been a paradigm shift a little bit at the, maybe the academic level, um, the research level. And I know it takes a while for some of these things to trickle down and become everyday practice. But where are we as a field in terms of this shift and what other things have changed in this realm of paradigm shift? [00:31:24] Scott Yaris:  Yeah, absolutely. I think if you think it's fair to say that there are there have long been two threats, there have long been two camps, if you will. Although I don't really like love to put it that way, but there have long been those people who are focused primarily on the speech aspect of stuff. Okay. And those people who are focused on the broader consequences of stuttering and for a while, the battles were fierce between these two factions. You may have heard the, the old, it was supposed to be a pejorative [00:32:00] term to say, oh yeah, you're just creating a happy stutterer as if that's a bad thing, you know, for somebody to be happy. But that was what the fluency related people would say to those of us who looked at the whole person. Right. And you can hear my bias as I'm talking about it, because I can't talk about it in any other way, other than my bias, you know, approach of saying, yeah, we ought to be looking at the whole person because that's who comes to us. Right. I don't have a stutter walk into my clinical setting. I have a person walk into my clinical setting. So I have biases about that. But this battle has been going on for, for decades. I think it's fair to say that the shift is that there's greater consensus amongst most, but not all specialists and other clinicians on the importance of the human being in stuttering therapy. It's not a hundred percent by any means. There are still those out there who would say that the primary issue for people who stutter is their speech fluency, [00:33:00] even though evidence suggests otherwise there are still people out there who would say that the goal of the speech language pathologist should be to focus on fluency, even though the ASHA scope of practice says otherwise. But I think we're in the majority these days, I don't know you, you may have listeners who will disagree with me and they get to do that, but right now you're recording me. So I get to say my opinion, but yeah, I think that that's really what the shift is though, is that there is a broader recognition of the fact that we need to be broader in our therapy and look at the rest of the human being. It's still a battle. So it's, it's an ongoing disagreement that we have, but I do think that the change is accelerating lately because of a shift away from more medical terminology for describing conditions like stuttering, for example, you will notice that I don't use the word [00:34:00] disorder when I'm talking about stuttering. I'll use characteristic, I'll use condition. I'll use difference rather than disorder, because as we, um, embrace a neurodiverse view of conditions like stuttering, we have the opportunity to change how we talk about and how we think about people who stutter or as many people who start or prefer stutterers. And it's completely okay to say that even though for awhile, it wasn't right. We're we're going through this change. Um, autistic people led the way. Uh, on this and are still leading the way and are still fighting this battle on a, on a daily basis. In stuttering, we are facing this as well. Understanding that speech language pathologist, unintentionally engage in microaggressions every session when they're praising somebody’s fluency. That's a problem [00:35:00] because there are entire therapy approaches based on praising fluency, right? So we are right in the thick of this battle, this of this internal strife, right? Cause even, even though I'm trying to understand this myself, I'm still on the learning end, uh, as well. So, uh, but we have some great, great leaders in the fields who are talking about how to view stuttering as, uh, uh, not a dis a difference that needs to be viewed negatively. Um, people talk about the, the joy of being in a moment of stuttering and being able to feel that stutter and not feel disordered or different or bad, you know, bad, different because of it. We have a ways to go, but it's an exciting change, uh, right now that's going on. Uh, and so that's part of what that paradigm shift is, and it's current and it's going on right now. And, um, what, well, our field has changed so much. Everything I learned in graduate school is not what I teach. [00:36:00] In graduate school now, right. Everything. And that's great because that's science that's, what's supposed to happen. Right. If I was still teaching the same thing that I learned 30 years ago, then I would feel like we had a problem because that would mean that our science was, was, has had stagnated. Uh, no, I teach what I'm going to teach this year is different from what I taught last year. Uh, and I hope that that'll continue to be the case because it means we're changing and growing and learning and struggling, and it's hard. Uh, but it shows that.  [00:36:27] Kate Grandbois:  Can you tell us a little, maybe this is a bad question, in which case you can say so, but I'm wondering if the role of addressing your own implicit bias or self care or, um, you know, doing a lot of self-reflection work on the part of the clinician is a critical piece of this. Just knowing that there is a, this paradigm shift you're talking about going away from content knowledge and, and towards person centered care. You [00:37:00] know, there is a, there is a counseling component there, and there is, you know, in order to make space for someone else, you really need to be, I think, in a pretty good place yourself, is that an appropriate assumption? Yes, you can tell me I'm wrong. That's fine. I'm feeling a little vulnerable.  [00:37:18] Scott Yaris:  Yeah, no. And I appreciate your you're putting that out there and sharing it. I, I agree. You know, if we compare what we do to another field, like say counseling psychology, for example, uh, we use a lot of the same skills that counseling psychologists would use. We use them on different topic areas, certainly, but we use a lot of the same skills. And if you look at the graduate training for counseling psychologist, they do indeed go through that self reflection, self exploration process. And, and our students often don't get the opportunity to do that because we are as a field still [00:38:00] so focused on content. And as our scope of practice grows and expands even further, there's more pressure on us as faculty to shove more content into the program. And it is a ongoing every, every institution that I've been at, uh, and that I have friends that, it's an ongoing challenge talking about how can we fit more content in, we can't. And so we need to go through this shift of all right. Well, let's focus on creating the human being skills that we want our clinicians to have. Uh, and then we'll fill in the content, uh, as, as we can as needed. But a lot of it's going to ultimately fall to continuing education because we can't do it all in five or six semesters anyway. But I would rather, if I had the opportunity, find a way to give our students the opportunity to go through that growth and reflection, because that will help them develop the empathy and the ability to be [00:39:00] with people in times of difficulty. That is frankly hard. You know, it, it, it takes a vulnerability. You just use the word, you know, to be able to be a really good clinician. Graduate school is already a really vulnerable time. So it's very difficult, you know, to put this burden on our students as well.  [00:39:19] Kate Grandbois:  If anyone is listening and wanting to get more information about counseling skills, we interviewed Dr. David Luterman about a year ago, and I can link it. Um, he gave a list of resources and suggestions for improving your skills in counseling. I, that I can list in the show notes. And for the sake of saying it, you've referenced a bunch of great resources, the Oasis, um, uh, the, when you discuss the results of the paper that you published, we'll list all of those in the show notes as well. So that, um, anybody who's listening and driving and jogging or whatever, has a little, has a little body of their own, a little library of the resources that they need in their phones. I'm wondering as we sort of [00:40:00] continue to reflect on this paradigm shift, you've mentioned the Oasis, which is, I'm not sure when that was published, but I assume that was a shift in terms of looking at the whole person in assessment. Are there any other resources that you would recommend to our listeners that can help them continue this paradigm shift through evaluation and treatment?  [00:40:23] Scott Yaris:  Well, I'm so glad you asked about that because one of my personal goals, my personal mission is to try to help speech language pathologists, feel more confident in their skills for helping people who stutter, because ultimately I think that'll lead to better clinical services, right? For this population that I, that I care so deeply about. So my friend, my colleague, that you mentioned before, Nina Reeves, uh, and I started a company years ago called stuttering therapy resources. And what we do in stuttering therapy resources is we develop resources for stuttering therapy. Our tagline, our mission is [00:41:00] helping speech language pathologists, help people who stutter. And what we try to do through STR is identify those gaps. In, um, materials that are available because there are a lot of great materials out there. I don't mean to say that we're the only ones who do this, but try to identify, uh, ways of helping clinicians know what to do in stuttering therapy, but not just as a cookbook instead to know why they're doing what they're doing and of therapy. And the reason for that is simple. There is no study that's ever been done, and there is no book that's ever been written that can tell you what to do with the specific client who's sitting in front of you in a therapy setting, because every person is unique. So when we talk about evidence-based practice and going to the available literature, I can't find a study that says, well, this is what to do with Jay Scott Doris, when he's sitting at, [00:42:00] at this point in his life, when he's 53 years old and he's had these experiences in his experiences in his life, he needs this. Right. That just doesn't exist. So, what we try to do is help clinicians understand the rationale for what they're doing in therapy. Have the confidence to be able to flex it. As we like to say, to adapt the therapy to that particular client's needs at that particular time in their life with their unique background. And so we write books, uh, we have two primary therapy guides, one for young children who stutter one for older children who stutter. We write materials for teachers and parents. Uh, we have a focus on helping children who experienced bullying and, and the emphasis in all of our books and our materials is on the we like to call them, thinking,clinicians guides to stuttering therapy, uh, so that they understand what, what the principles are that they want to apply and adapt and adjust.[00:43:00]  Uh, so that's what we do through stuttering therapy, resources, in addition to blog posts and blogs and handouts and videos, uh, and all, uh, um, all sorts of materials, all designed to increase that sense of confidence. Again, I don't mean to suggest that we're the only ones out there doing that. There's some great stuff out there, but, uh, but we, we do like to try to put this angle on, um, helping clinicians develop that sense of confidence, that they can sit with a person who stutters and don't, and not feel like they need a script, but feel like they have that ability to be with them and follow their clinical and personal intuition. But know why.  [00:43:41] Kate Grandbois:  That's a great list or description of what you guys have. And I will say I've been on your website. It is full of information. You guys have so much stuff up there and I'll link everything so that our listeners can find things pretty easily. I wanted to, um, you mentioned the Oasis. Do you have a link to the Oasis on your [00:44:00] website? I believe you do.  [00:44:02] Scott Yaris:  Stuttering therapy, resources.com/Oasis   [00:44:05] Kate Grandbois:  there you go. I wonder if there is, if you could tell us a little bit about like it app applying assessment across the lifespan. So are there different lenses that you take from a preschool assessment versus a school-age assessment? How do you, what are some of the guideposts that you use? [00:44:27] Scott Yaris:  You bet. Absolutely. And indeed, there is a difference in my assessment goals at the preschool age compared to basically school, age and above. That's the main distinction that I make is preschool and young school, age ages say two to six versus school, age and above ages, six to infinity. Because the question that we face with the young ones is not so much whether they're stuttering, because if they're stuttering on the surface, you can see [00:45:00] that on the surface with little ones, the young ones haven't yet learned how to hide their stuff. Uh, adults who stutter teens, school-aged children, they can hide it from you. Right. And so for them asking, did I see a stuttering behavior that doesn't really tell you anything meaningful. Little preschoolers will try to do that too, but they're frankly not that good at it yet because their brains are just this big, you know, they're still, they're still developing and you can typically tell them that if they're demonstrating stuttering behavior, then they're stuttering. The question is not, are they stuttering? But rather are they likely to continue stuttering? So for those young ones, assessment is about, what's the risk that this child will continue to stutter without therapy. And if the risk is high well that I want to treat them right. And if the risk is lower, then I may not need to be quite as urgent about getting them into a formal therapy session, but I definitely want to help the parents. And the child, [00:46:00] not to worry along the way. So we know that most preschool children who stutter will indeed grow through their stuttering. It'll be a stage that they go through as part of their development, but it won't stick with them over the long-term. We want to make sure that if they are at greater risk for continuing to stutter, that we're providing more formal therapy, but even if they're not, we want to provide support.  After about age six or seven though? The chances of that recovery occurring, diminished tremendously. It's not to say it never happens, but most children who are still stuttering by about age six or seven or eight, are likely to continue doing that in some fashion throughout their lives. And it's at that point that we shift our focus from, are they stuttering? Are they going to continue stuttering too? Are they experiencing negative impact associated with their stuttering? Because if they've [00:47:00] experienced negative impact, well, then we want to reduce that negative impact. That's what we do in therapy. The hard news that is difficult for our field to accept, it's difficult for families to accept, but it can be accepted is that there's no cure for stuttering. Right. So if a person of age 12 or 15 is still stuttering, uh, they'll probably be dealing with stuttering in some fashion throughout their lives. Our goal is to make sure that they're not experiencing a burden associated with their stuttering, that it's not causing a problem in their lives. If they're experiencing a problem, we treat the problem in particular, the burden, the adverse impact, the difficulty with communication. If on the other hand, they stutter, but it's not holding them back. They're not feeling negatively about it. They're not restricted in their ability to do the things they want to do in their life. And they don't need us that they don't need therapy [00:48:00] just cause they stutter if they have no negative impact. So that's really where that key differences in the assessment with the little ones, it's a risk assessment to try to prevent the development of lifetime stuttering for the older ones where lifetime stuttering is highly likely. We want to prevent the adverse impact.  [00:48:21] Kate Grandbois:  And is the, is the lens similar for treatment? [00:48:26] Scott Yaris:  Yes, absolutely. Absolutely. The treatment goals then for the young ones, we're focused on increasing the likelihood that recovery will occur. In other words, giving the child the best chance of being one of those children who grows through their stuttering. For the older ones, it's to help to reduce the burden. So identify the ways in which stuttering is having a negative impact on their lives and focusing specifically on reducing that negative impact. That may [00:49:00] involve some fluency work, but more often than not, it involves all sorts of other things as well.  [00:49:08] Amy Wonkka:  Well, and as somebody who, you know, doesn't really work in this area of the field and I'm not super familiar with the Oasis, it does make me wonder, you know, if I'm using an assessment tool like that, what are some pieces of that assessment that are going to help guide me as a clinician to make sure that I'm not over focusing on those strategies or fluency and making sure that I'm aware of all of these other things that I need to be aware of? [00:49:36] Scott Yaris:   Absolutely. Great question. The Oasis. I just give a super quick background on it. It was developed based on the world health organization's framework, the international classification of functioning, disability and health or ICF for short. Okay. Many of your listeners may already be familiar with the ICF. I hope they are because if [00:50:00] they've read their ASHA scope of practice document, they'll find that it's right there in our scope of practice, the ICF was designed to describe not what can go wrong with you. It's not a diagnostic tool it's designed to describe what that means for your life. How does it affect your life that you stutter that you have whatever other difference or condition you might have? What does that mean for you? And so, because the Oasis is based on that directly, it's divided into different subtests that tell us about different aspects of the overall experience of stuttering. So for example, section two of the Oasis focuses on the kinds of reactions that people might have to the fact that they stutter reactions can occur in a variety of different ways. For example, we can talk about how a person feels about the fact that they stutter their emotional reactions, maybe embarrassed, maybe fearful about talking, maybe [00:51:00] ashamed, feeling like they've done something wrong. You can talk about physical reactions, like tension or struggle. That you might commonly see in people stutter or attempt to knots that are like avoidance or escape behavior. You can talk about thought reactions, like low self-esteem, low, self-confidence a poor sense of self efficacy or not thinking like you're a good speaker. Those feelings and actions and thoughts actually are what contribute to the adverse impact that a person experiences. But if I have a person who scores high on section two of the Oasis, higher scores mean more adverse impact in that area. Then I know that I need to focus some of my therapy on reducing those negative reactions. If on the other hand, I have a person who has relatively minimal, lower scores on section two, then I may not spend much of my time in [00:52:00] that aspect of therapy and I may focus my therapy on other areas. So the idea was to use it as a, not just a diagnostic tool, not just as an, uh, uh, treatment, um, um, not just as an assessment tool, but as a treatment planning tool to say, oh yeah, this person is having a lot of difficulty, the section three, communicating in the work setting, I'm going to focus my therapy on generalizing to the work setting. This person is experiencing difficulty in their ability to pursue their life goals or in their satisfaction with communication that's section four. Well then I'm going to be focusing on improving their overall sense of satisfaction with communication and their lives as a whole related to centering. So yes, it's designed to tie directly in section by section to different aspects of the therapy process.  [00:52:50] Kate Grandbois:  That's an incredibly comprehensive assessment. I mean, I'm as, says the naive person who has not at all familiar with it because I don't work. I work with I'm an AAC quote, [00:53:00] unquote specialist, but I love that there is an assessment tool out there to support this paradigm shift and to look at the whole person and not just percent fluency, which is what I recall from my graduate education 15, 15 years ago. And it is also making me think a little bit about this last learning objective and the sentence it's okay to stutter. I wonder if you want to tell us a little bit about that.  [00:53:29] Scott Yaris:  You bet the four most important words, that speech language pathologists, teachers, parents, and of course people themselves can learn as soon as we acknowledge the fact that there's no cure for stuttering. And that's a difficult fact for many to acknowledge. I get that. I totally do. But as soon as we acknowledge that, then we have no choice. But to accept that and say, well, then if I can't change [00:54:00] this about myself, if I can't eliminate this characteristic about myself, that I may not love, uh, that means I have to learn to live with it. And if it means I have to learn to live with it, I have to accept it. Now acceptance is a concept that has caused all sorts of difficulty in my field in particular. It probably has in other areas of the field, but I only know stuttering because people, some people tend to view acceptance as this all or none kind of thing. You accept something, you're, you're just letting yourself go. You're not going to work on it. You're just gonna, you know, that happy stutter complaint again, but that's not what acceptance means. Uh, Nina and I were fortunate at the last ASHA schools connect just this past summer, uh, to do a presentation on what acceptance means in stuttering therapy. Acceptance does not mean giving up. [00:55:00] It does not mean giving in. It does not mean just stuttering all over the place and not caring. Acceptance is an active process by which an individual comes to terms with the fact that they are different and that it's okay to be different. And that being different does not mean that you're bad or that you've done something wrong or that you need to be fixed. It means that you're different and that's it. And you can be striving to change that difference. You just don't have to hate yourself along the way. And that's true for many, many areas of our field. I can give you plenty of examples, for example, um, my father has Parkinson's he's in the relatively early stages. He does not love the fact that he has Parkinson's of course not. Right, but he doesn't have to be mad at himself for the changes that he's experiencing. It's not his fault that he's [00:56:00] experiencing these changes. Uh, what he can work on instead is learning to live with those changes in the most effective way possible. Well, it's not the fault of my clients who stutter that they stutter. They don't have to hate themselves for the fact that they stutter. They can accept the fact that their speech fluency is different from other people's speech fluency. And they can still be working to change that speech fluency if they want. Okay. But along the way, they can recognize that they're okay, that they can still live full, productive, happy, active lives, that they can still say what they want to say, do what they want to do. And indeed be who they want to be. Even though they're different. This is not an easy thing. In fact, coming to terms with our differences, coming to accept ourselves for who we are and how we are. That's the hardest thing about. Right. No matter what your differences, that's the hardest thing in the world [00:57:00] yet when you live with a stigmatized difference, like stuttering, it's that much harder because everywhere you look, the messages that you receive from society, from your parents, from your teachers, from your speech language pathologist, is focused on your deficit as they view it. And to be able to stand up in, in light of all of that and to say, I know I'm different and I'm okay. That takes all the strengths that takes all the strengths. And so I view our role as speech language pathologists as being one of helping people have the strength to stand up and make that statement to say that they're okay. And I got to tell you, we don't do that by praising their fluency. We don't do that by holding up examples of fluent people who stutter. And saying, oh, look, if you only try hard enough, you can be like that person. We don't [00:58:00] do that by, um, you know, some people who stutter actually, I'm a, uh, fluent person who stutters or, you know, I, oh, I haven't stuttered in what messages does that does that send? So our job as speech, language pathologists, I think is to help people be who they really are and that's hard and that's hard. So that's why I say the four most important words that any person who stutters any parent, any clinician, any teacher can ever learn is that it's okay to stop because it's not the person's fault that their neurological system is different. Once upon a time, it was considered a terrible thing to be left handed. Right? Well, guess what, today, our society does not hold that stigma as much anymore. Maybe we can get to a few. What our society does not hold that same stigma about having a difference in the smoothness of your speech production, [00:59:00] but we won't get there if we are continuing to value perceptibly, fluent speech, over speech that is different in terms of its rate or rhythm or effort or smoothness. Uh, but if we know that it's okay for speech to be stuttered, if it's okay for there to be a disruption in speech, but the person boy had amazing and wonderful things to say, that's where I'd love to see us get. And I think that we as speech language pathologists actually have a responsibility to try to push the field in that direction because sadly we've played a role in supporting the stigma, not intentionally, but because, you know, we thought we were supposed to we’re speech, speech therapists, speech teacher, you know, speech, speech, speech. I really would like our field better. If we were communication specialists.  [00:59:50] Kate Grandbois:  I have said that so many times. Oh yeah. Agreed, agreed. Anyway, continue your professing. Because what you're saying [01:00:00] is beautiful [01:00:01] Scott Yaris:  That's that's where I am though. That's my, my thing is, you know, and not just me, there's lots of folks who agree with me on this, but it is a bit of an uphill battle, especially around stuttering because stuttered speech can look different and it can sound different. And if people feel like, oh no, I'm supposed to do something about that. And I got to tell you, speech, speech, language pathologists, they're the worst at this because we feel this sense of responsibility. Like, oh, I was supposed to do something and I didn't know what to do. That's that brings us back to that first learning objective about clinicians’ own sense of a lack of self-confidence. They feel like they failed in some way when their kids continue to stutter. It is not the job of a speech language pathologist to fix a person. As a person who stutters is not broken, they're different. There are different can break them. I don't want to minimize the pain that people who stutter experience.[01:01:00]  Right. A couple of my colleagues and I right now are working on a paper of suicidal ideation amongst people who stutter. It can cause tremendous pain for people who stutter. So I'm not saying this to belittle or diminish that, but if we can change how we think about stuttering for change, how we talk about stuttering, if we can change how we view this with respect to societal stigma, self-stigma professional stigma within our field, perhaps we can diminish some of that burden  [01:01:30] Kate Grandbois:  In our last minutes do you have any rec any final recommendations or action steps that anyone who is listening, who feels inspired and wants to contribute to make these changes? Do you have any suggestions?  [01:01:45] Scott Yaris:  Oh, yes, absolutely books and books worth. But yeah, in a, in a, in a quick nutshell, one of the things that Nina and I are often commenting to each other about is this, remember clinicians, [01:02:00] you have what it takes. Every speech language pathologist can be a superb stuttering therapist. Don't forget all the things that you already know, just because you heard the word stutter, right. Because that's the, taps into our insecurities and it taps into our uncertainties to hear that, oh, I don't know anything about stuttering. No, but you know about people, you know, about listening, you know, about validating, you know, about all these great things. And if you can sit with a person who's in crisis, a person perhaps who stutters, or a person who has some other condition and share their ver their vulnerability, be in that moment with them convey positive regard to use some counseling catchphrase. To validate their fears and to let them know that you may not know all the answers, but you'll be there with them as you explore it together. Uh, very often that's what people who stutter [01:03:00] like so many other people need to hear is that we're, we're gonna work through this and to convey to people who stutter, just as I want to convey to people who clinic, uh, there is hope there is good reason for optimism when we're talking about stuttering. Yes. It can be a hellishly difficult condition for some people to live with. Absolutely. But there's also reasons for hope and optimism because people who stutter can do anything they want to do. And they don't have to be famous people who started to do it. They can be people like you and me doing the things they want to do being fulfilled. And the stuttering doesn't have to hold them back. And once we know that as speech, language pathologists, we have to know that in our soul, then we can convey that to our clients. That's the most important thing  [01:03:55] Kate Grandbois:  I don't, I can't follow up with anything that was just so good. I could [01:04:00] listen to you talk forever. This has been such an, uh, an amazing discussion and we're so grateful for all of your expertise. Everybody who's listening. All of the resources will be listed in the show notes. And thank you times a thousand. Thank you so much for being here with us.  [01:04:19] Scott Yaris:  I'm grateful to the two of you for inviting me. This was great fun. I hope we'll get to do it again. There's so much fun stuff yet to talk about. And I think we share some interests in science fiction and we share some interests in  [01:04:37] Kate Grandbois:  Scott we're friends. Thank you so much for joining us. [01:04:38] Scott Yaris:  Absolutely. Thank you again for the opportunity.  [01:04:43] 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 of study, please check [01:05:00] 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 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 the number one 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 Trigger Warning Kate Grandbois: The episode you are about to listen to includes topics that are of a sensitive nature, including death, loss of a child and early pregnancy loss. These topics may be triggering for some. We invite you to explore this episode at a time that is comfortable for you [00:02:00] and to open your heart to the stories that are shared. Episode Kate Grandbois: Welcome to SLP Nerdcast. We're so excited to welcome our two expert guests today. Welcome Bibi Morin and Julie Swanson.  Bebe Marin: Hello. Thanks for having us.  Amy Wonkka: Baby and Julie, you are here to discuss how to best address trauma and grief within our own professional practice in order to better support families and staff, as well as to shed some light based on your own personal experiences. Before we get started, could you please tell us a little bit more about  Bebe Marin: yourselves? Sure. Julie, do you want to start? Sure. Yeah.  Julie Swanson: Hi. Um, I am a mom of three. I have, um, lost, we lost our first IVF miracle baby, um, Gus Swanson to SIDS in 2016. We welcomed two beautiful boys afterwards also from IVF. Um, [00:03:00] one was born in 2017 and the other one was born in 2021. So I am an active forever grieving parent, um, who, Is just constantly trying to keep the memory of my my angel baby alive within our family and um, I have since become the executive director of a non profit called Emma's Footprints in which we help families who've experienced a pregnancy and infant loss and um, we pay for funerals, um, cremations, burials, uh, counseling sessions, um, support groups, we offer, um, a lot. Mom one on one mom care. And I mean, so much more I could keep going symposium. We've now created couples retreats. We really, really dive into supporting and walking beside the families as best as we can and providing them resources to continue their growth on the grief journey that they'll forever live. So  Bebe Marin: that's [00:04:00] about me. And then I have an early intervention speech therapy company. So we're home based three and younger. And my experience had been that throughout my professional career, I have lost little ones unexpectedly. So there was a trauma response. To planning on going, you know, to the zoo and then you get that phone call that your little one is passed away. Um, and this year I did attend the symposium put together by Emma's Footprints and the Highmark Caring Place, and one of the local hospitals and it was a beautifully. put together very comprehensive training on grief and loss. And it got me thinking as a clinician, I really didn't have counseling. So I would avoid roads because that's where my little one had passed, or I would avoid situations. And I wasn't really dealing with the loss of [00:05:00] that child. And then thinking about how does that affect me as a clinician? And then how do I go back the next week and see my other 20 families when you know you're suffering the loss of a little one that you really fall in love with. So at that training, I spoke with Julie and I said I would love to do something for our staff that have lost little ones, but I also felt like most of us have not learned how to go into those homes, and then support those grieving parents. The dads grieve differently than the moms. I did not know that prior to the symposium. So that's sort of how I became interested in this subject and spent this year interviewing, um, OTs, pt, speech therapists, trying to see what do we need to do as employers? But then also, how do we train staff so that they're confident going into a [00:06:00] home, so they don't say the wrong things and they do the right things. So that's sort of where we're coming from now as we speak with you too. Thank you  Kate Grandbois: so much for being here. This is a conversation that we're very excited to host and create space for, as I know you will teach us later in this episode. This is something that we are not discussing enough as a profession. So we're really excited to have you before we get into the conversation. I do need to read our learning objectives and disclosures. So everyone, thank you for your patience. Learning objective number one. List at least two considerations for supporting grieving parents and families in early intervention. Learning objective number two, list at least two considerations for supporting professionals and staff after the loss of a client. Disclosures, BB's financial disclosures, BB received an honorarium for participating in this course. BB's non financial disclosures, BB has no non [00:07:00] financial relationships to disclose. Julie's financial disclosures. Julie is the executive director of Emma's Footprints. Julie's non financial disclosures. Julie has no non financial relationships to disclose. Kate, that's me. I am the owner and founder of Grand Voie 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, that's me.  Amy Wonkka: Uh, 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, which is AAC, uh, and I participate in the AAC Advisory Group for Massachusetts Advocates for Children. All right, uh, Bibi and Julie, Why don't you start us off by telling us a little bit about why this topic is [00:08:00] so important? What what  Bebe Marin: interests  Amy Wonkka: you most in talking about this with our listeners  Bebe Marin: today? I can start. I felt that it would have been fantastic to have gone into homes with some background grief awareness, trauma awareness, and not from a pediatric perspective. We were all taking those wonderful trauma informed kind of classes. This would be more how do I go in as a clinician and into an early intervention home and Accurately support a family member so that I'm saying the right things, but more importantly, doing the right things by a grieving young parent.  I was interested in sharing. That perspective with clinicians so that they can go into a home and feel a little more comfortable, less awkward and talking [00:09:00] about the child that they've lost. And in Julie's case, I went in with a sibling. So I did not have the pleasure of meeting Gus. But it was helpful to know what's the right way to engage the parent and how do you make it less awkward or difficult during your interactions in that home visit.  Kate Grandbois: And I know something that we mentioned before we even hit the record button today is that many of us don't come to this profession with a lot of counseling experience. Many of us don't come into the profession with a lot of trauma informed experience or content knowledge. Some of us, if we're lucky, had a one class in graduate school that talked about counseling. Um, and I appreciate, highlight, you know, just. Holding space for a moment to acknowledge that this might be really new [00:10:00] and uncomfortable for many of us going into the home, particularly given that our culture doesn't necessarily openly talk about death and grief and loss, um, in general. Would you agree with that statement?  Julie Swanson: Absolutely. I would say that I, in my work line, it is literally our job to show up and try and make this a comfortable conversation. How can we provide tools? How can we make it okay? How can we guide and make the conversation flow easier? It doesn't have to be hard, but It's not something that we can avoid anymore. And I think that's why if we want to show up as a better human being in our own grief and in our own trauma, we have to keep working, right? Like, it's like that with anything in life, really. So I, I can't say that it's It's not something we don't talk about. It's something we're constantly talking about. It's almost annoying how much we talk [00:11:00] about grief. So, um, I'm excited to dive into this conversation and hope that, um, the listeners walk away feeling a little bit more confident in, in this  Bebe Marin: subject. So something that Julie helped me as a clinician learn, um, as I went in on a weekly basis, um, was Mention the child's name. Like I did not know Gus, but to be able to say, tell me about him, what was he like, like that was so important to her to have him be validated, but then it also got rid of some of the awkwardness. Um, so that was important for me. And then kind of asking her how she was feeling that specific day, because if it was, everyone was buying backpacks. It was not going to be a good day if they were posting pictures of birthday parties that he would have been at that was not going to be a good day. Can you elaborate a little bit Julie on what some of the triggers are for [00:12:00] you so that clinicians can be aware of some of what would make a session a little different that day. Yeah,  Julie Swanson: I think that it's important to know and understand that we don't know what our triggers are until they're in front of us. So we can't predict how grief is going to show up that day. It might not show up at all on a, on a death anniversary, but it might show up a week later or a week prior. Same with birthdays, anniversaries. So. I specifically remember, um, my little guy was receiving services and I was upset. Number one, that he had to receive services, which I think is probably a common thing as a parent. Um, but let's layer trauma on top of it. And I was more upset because I had lost a child who was so perfect in my eyes. Right. So I already. Overcame, you know, the infertility world and then I had a healthy baby and then I had the traumatic of [00:13:00] him passing away and burying him and dealing with all of that. And then I welcome another beautiful boy. Oh, wait, he can't talk. Okay, great. Let's let's do this. I don't want to do this. Right. So that alone was a trigger in itself. Um, agreeing to services and having you show up. Um, I don't, I honestly, I just feel like When you receive services to, it's like, I feel like I'm being robbed of things that should come so easily like talking should just come so easily. Right. And it doesn't. And so, um, that was a trigger in itself. And then also many things. Um, I don't know, like, Like you mentioned, um, pre kindergarten. I think preschool. I'm sorry. I take that back. Preschool. Gus was supposed to start preschool that year while you were doing services for my little guy, Walter. And so I am seeing all my friends who had healthy, thriving babies around me. Their [00:14:00] kids are going to preschool and mine is not. So I'm actually not even focused on Walter. And in his growth, I'm more focused on what I don't have anymore. And so I remember that specifically being like a time, something that I've learned through therapy and counseling that holds space for that holds space for the hard moments. Don't just try and keep going forward. So it was a phone call to BB saying, I can't show up today. For Walter and what he deserves. So I'm going to show up for myself and let's take a pause back and I'll just go play outside for the day instead of trying to do services. Um, I think that it's hard to as parents that are grieving, right? Loss happens at any point in time. It could be, it doesn't have to be a baby either. It could be any, any type of loss that happens to you.  Bebe Marin: You bring up that really good... Observation, which is so we come in and we're here to help you and I can fix him and I have strategies and [00:15:00] if the mom is grieving over backpacks or meet the teacher day to be able as clinicians to say, how do you feel today? Is everything okay? Is there anything you want me to be aware of? Um, because it's easy for us to say, I really want to work on our goal. So I need him to imitate gestures with songs or I need him to work on these signs. And that's not going to happen today. So to be able to say what can happen. And yeah, be able to take a look at like what are the dues when you're working with a family who's grieving. And like we said, it can be five, six years later chronologically. It's still an acute grieving moment if that's what the parent is feeling, but to be there to listen is one of the best things we can do for clinicians in general, but also [00:16:00] then like share the memories. That is something that I learned through Julie as well. Um, what, it means to be patient. So we're working on a quarterly goal and we're hoping in 12 weeks we can say this is the progress that we've achieved. When the family's grieving, that takes precedent over anything. And so even though we are routines based, we'll change the routine. So I remember one time, Julie, I was talking to her about intervention and we're having a really good session and her eyes kept deviating. And so we stopped this session and said, what's going on? And then she was able to say, I can't focus today. Can we just get outside? So we went outside and she has this beautiful garden for Gus with decorations and ornaments. So we spent our session helping her go through what she was feeling, letting her [00:17:00] guide. Us in terms of what are we talking about? What are we doing? And then we just blended intervention and very naturally as she and Walter showed me Gus's garden. Um, yeah, it's important I think for when we receive the evaluation report for the service coordination team to have embedded in there. And this section that talks about the family. If there is nothing that tells me that this mom lost a child to SIDS. I have no ability to come in and already think I'm going to need to support them and not treat them the way you would a family who has not lost a child who's not experiencing grief the way Julie's family did. So I think that it's important for us as clinicians [00:18:00] to get the right information before we even see a family. I think you guys have. made such  Amy Wonkka: wonderful points. And I think, you know, as the clinician going in, just that awareness that somebody's experience of that  Bebe Marin: trauma may vary from day  Amy Wonkka: to day and moment to moment, it might come after, you know, sort of the thing that we have on our heads, that might be a challenging time. Are there, I guess this is more of a question for you, Julie, but are there Other pieces there that you wish that SLPs and other providers better understood in their relationship with parents who are grieving?  Julie Swanson: I think that, um, Bibi kind of touched on it a second ago, but  Bebe Marin: I  Julie Swanson: Still to this day, it's always like awkward paperwork you have to fill out for things. And then it's like, well, how do I answer that question when I'm trying to actively include him in my life, our lives as a family, but you won't want me to put it [00:19:00] anywhere on a piece of paper. That's no, no finger to point to blame. It's just the way it has been. And I think it's time we, that changes. I think it should say, you know, have you experienced I mean, a pregnancy and infant loss, let's just say it. Like it's, it's a very common thing. And so check. Yes. Like I w I'm willing to say yes to the things that I've lost, because I think it opens me up as a, as a parent receiving services or not just the communication and the conversational piece of you walking into my home. I think that's key to, um, at least What, like connecting with the family in a different way than just services, because it's, it's hard for us to open our doors and our hearts emotionally, right? When we've experienced such trauma, we want to hide and maybe not say the things, but the second somebody asks, I guarantee you, um, probably 75 [00:20:00] percent of the moms that we say, tell us about your baby, tell us about your story. Instantly, the connection is there and they're willing to open up. So I think that's really  Bebe Marin: important. I think that comes into, like, the don'ts. When you are working with a family, as a clinician, you're used to saying, I know how to fix this, or I have some great strategies. When it comes to working with grieving families, um, we want to avoid certain things. And I listened to their Dads in Grief podcast and I thought, holy cow, like these dads. We're seeing some really, like, amazing, gut wrenching observations. The first one that they talked about that we want to avoid is the use of aphorisms. He's in a better place. No, he's not. His best place was in my arms. What are you talking about? Um, and there was some real anger when I heard these gentlemen [00:21:00] talking about that, or at least she isn't suffering now. Um, wow, she looks like she's sleeping. No, we don't want to say things like that. And then as clinicians later we don't want to say things like well, I can say a phrase that might make you feel better. We're better off not. Saying aphorisms because a they've heard them already be they trigger anger and rage and a lot of our parents, if not tears. Um, the other thing, too, is not anticipating that we can tell them how to grieve or when it's been long enough. Julie, can you elaborate a little bit on some of those don'ts? Um, yeah, I think  Julie Swanson: you kind of nailed them and really just saying those I, I, I can't tell you how to grieve. I can tell you that it's not going to, it's not going to, you know, you can't say things that you haven't experienced before. Right. So, um, this really does suck, [00:22:00] you know, like just period, you know, we don't need to beat around the bush and, um, you know, I'm sorry for your loss. Um, what can I do for you today? Those types of things really make a difference. Bebe Marin: And I think as clinicians to not trying to get the parents mind off of it. So using distraction, redirection, there are days when that's not the best practice. Um, so there are certain days when I remember with a family that had lost a child, um, getting costumes. For Halloween was a big trigger, um, and not trying to redirect her and see, well, what are we going to do for this little girl? And what costumes are you wanting her to wear it? If they're grieving over the one that they can't buy a costume for, stay there until they're done talking [00:23:00] about it. And not trying to take their mind off of it. Um, or the other thing that a lot of my clinicians that I interviewed talked about was working with a family who's had a child pass away as a toddler is not all that common. What is common is parents who either their IVF families, or they will lose. pregnancies, you're working with a toddler, and she'll cancel and say, I have to cancel today. And then you go in and she might say, I had a miscarriage. And then you can't just come back the next week and pretend it never happened or not talk about it. For some of the younger parents, it matters that clinicians talk about it, bring it up. Um, and the fact that a mom may have lost a child at eight weeks versus the week before it's the child [00:24:00] is due that matters. That baby was there. He was here. He was present. And to say, I canceled because I had a miscarriage and not validate what happened is truly not best practice. Um, so that's probably something I'd love. clinicians to be aware of. It is awkward. It can bring tears. And if you are a clinician who's had early pregnancy loss, um, I lost my son at 16 weeks and didn't go to counseling, didn't really talk about it until I met Julie. And I thought, holy cow, I never grieved my own son's loss. And now I know that we really need to help these moms and dads grieve losses of that are early pregnancy, that was still a child, it was still a baby, ask, you know, did they have a name. Was there a burial. [00:25:00] There's a lot of conversation that we can ask clinicians have in our sessions that will help bond with that family better but also may help. A family who may not have the support of an organization like Emma's Footprints, help them begin to have conversations that are a little difficult or painful. I'm going to add  Julie Swanson: one thing here before we move on. Um, we always say to, to just get curious. So the second you just get curious, the, the questions just come naturally. Like you said, like, what was his name? You know, what happened? Did you go to the hospital? You know, those type of things. Just get curious in the conversation and you know, takes over.  Kate Grandbois: I so appreciate all of these. Reflections, perspectives, and I'm reflecting on, on [00:26:00] my own experiences and my own as a clinician, as a, as a human, as a mother, and I just want to highlight or point out that to any clinician listening who is feeling uncomfortable or is feeling that this isn't their place, or they don't want to have these difficult, personally difficult conversations with other families, what you're describing is person centered care. What you're describing is part of our evidence based practice model. What you're describing is ethical. So even though this might not be fluent, even though it might be uncomfortable, making these choices, having these conversations, being curious, showing up for the family, centering the family's grief, supporting the whole family. These are Fundamental components of our licensure, I also wanted, wanted to ask whether or not you had any suggestions for how a clinician can take care of [00:27:00] themselves. I can only imagine that for a clinician. To be curious and to ask these difficult questions or to move through this discomfort the clinician needs to be somewhat well centered and also not having a bad day or experiencing grief or loss of their own. What can you tell us about, um, the clinician's role in this in terms of managing their own mental health?  Bebe Marin: So I have had different types of acute loss. Of toddlers. And it's always the traumatic ones that for me are particularly difficult because you are not anticipating, um, you know, death by car accident or by fire or drownings. So those are particularly traumatic. So I personally suffered, I feel, um, [00:28:00] in a way that I had never experienced before. So taking care of. My staff as well then, right? Because now I know what that feels like. Um, we have to give ourselves grace. To grieve and say so I know I have 22 clients this week. I am no good to any of you because I can't be cute and perky and present when I'm grieving over the loss of this little, you know, child that I really was in love with. So I think being able to come to your administrator and say, I really can't do my job for the next few days. So I'm going to cancel all my families and as administrators, I'll Maybe being the one to say, I understand you lost a child. What can I do for you? What do you need? Um, here's money so you can buy them, you know, food.[00:29:00]  Um, I have personally gone and helped them pick out a coffin. I have interpreted for them and had the service coordinator help me make a GoFundMe page. So there's things that we can do. as administrators to support staff. But in terms of the self care, I think the first thing we did was to say, when I interviewed clinicians, what would have been helpful to you? And the first most common thing they said was, I need to be able to grieve with the team that was involved. So that meant the PT, the nutritionist, the OT, the speech person, the special instruction person, Getting them to what we ended up with was the caring place because it is a nonprofit. We're all coming from multiple agencies so we have different logistics. But to come together as a group and have a debriefing by a trained professional who is a counselor [00:30:00] specializing in trauma and grief. And then being able to offer after they have a couple of these debriefings individual sessions if that specific clinician. Says I'm not done. I need more help. So that's what we're doing in the county is offering that for clinicians. Um, but I don't know that when you have lost a client, if you're able to really articulate what you do need. So I think that's where the team that employs those clinicians needs to have something in place, rather than playing catch up, which is what I Work with, with Julie and the caring place was to have something already that as soon as we lose a little one, there is a process. Um, and that it's not a fly by the seat of your pants kind of a thing when there's a loss. Let's, let's talk about it. No, there's a procedure. We've already interviewed [00:31:00] people. This is what they say they want. And then working with the trained professionals, um, to get them the counseling they need, the debriefing kind of coaching sessions that they need. Um, and then the other thing that I have found is who is your clinician that has just lost that client? Okay. Is it someone who is more resilient for multiple different reasons? Is it someone whose personality type is more vulnerable and struggling? So clinician one may need different things than clinician two. So I think as administrators having enough supports so that that individual clinician gets what she needs so that she can go back to work when she's ready and not need to take a different job because the one that we do is just taking pieces of her soul. You know, each time she loses one or each time something happens.[00:32:00]  And in early intervention if you've done this work. It isn't a job as much as a vocation. Which I know for SLPs in general, it is a vocation. But when you're in a home twice a week for a year and a half, you are sort of an extended family member. And then to traumatically lose a child, it's very different than, you know, a different type of loss or a different type of setting because you're intimately bonded with the dad, the mom, their pet, their grandparents. So, um, supporting those clinicians takes on, I think, a different perspective as administrators of home centered care. Kate Grandbois: I appreciate that so much. And I am really wondering if you have any recommendations for how a clinician or supervisor or an administration could [00:33:00] initiate some of these structured. Um, I have to assume that many work environments out there don't already have these in place for a variety of reasons. Do you have any resources for where people can go if they're listening to this episode and have either recently experienced a loss or would like to put something in place in. In the instance where there is a loss, um, what resources are available out there to sort of guide administrations and workplaces to better support their staff and clinicians?  Bebe Marin: Julie, do you have any? Um,  Julie Swanson: for pregnancy and infant loss. We, um, do serve everywhere and anywhere. Um, we send care packages everywhere. So if you are serving a family that has experienced a pregnancy or infant loss, please reach out to Emma's footprints. You can go find us on Facebook, Instagram, or our website is Emma's footprints. com. Um, our contact is on there. You can text [00:34:00] us, email us. There's many ways to get ahold of us. Um, we can connect you with resources that we know in your area. If we, if They exist and we are aware of them. We have our database on the back end and then also, um, you know, a care package to a family that has experienced a pregnancy and infant loss can change their day. And so that, that's just a simple, uh, you know, submission that we, that you would send in and we'll get that  Bebe Marin: to them. And then as an administrator, after I had experienced that incredible symposium training, we created an in our county, um, a team of administrators to then interview staff, look at our own resources in our county and the caring place, the Highmark Caring Place, um, was very helpful to us in terms of walking us through If what they could do for, um, our [00:35:00] clinicians. Um, and then just if you come up with a group of people who find this topic relevant and important, once you start talking about it, you'll do what's right for your community. So when I first Asha. And I said, I can't find literature on this. I can find literature on NICU nurses in England, but I want to know what about clinicians in the United States, and I really couldn't find a lot of articles at all. And in speaking with a director there, clinical director at ASHA, she said, would you write an article? Can you share? Your information because this is something we really don't have a lot on. Um, as an organization, you know, Asha doesn't have a lot of information, but county wise find people like you that find this topic important and then decide what are the resources in your own community and have something in [00:36:00] place as early intervention providers or whatever type of. you know, an organization you're with, have something in place so that step one, clinician calls supervisor. Step two, supervisor reaches out to, you know, the person from the caring place. And then, you know, like there's procedures that we've come up with that make sense to us for our little city. But I think someone needs to put something in place. We averaged about one loss a year over the last five years, which is why I thought, holy cow, this is a lot of loss for the same clinicians. Um, different, you know, reasons, mostly traumatic, also illness, depending on some of the little ones that come with certain syndromes, but the loss is still genuine for the team. And if we want to keep our staff employed. And, you know, you spend all this [00:37:00] time meeting these clinicians that are fabulous, and to lose them because we're not supporting their mental health, their emotional health doesn't make sense. Thank you. So that's where I came this year and said, okay, this has got to change. Kate Grandbois: Those are great suggestions. I wonder if there are any final suggestions that you have for our audience, Julie?  Bebe Marin: Um,  Julie Swanson: no, I think all I would say is get curious. Hold space for the families. What does that mean? It could mean something different each time. Maybe just ask how they're doing. Change the atmosphere that you're in. Remind them that right now is a bad, bad day, bad minute, but it's not like this forever. Um, provide resources if you can  Bebe Marin: and give them a hug for sure, for sure. Plenty of those, um, as an [00:38:00] administrator, something we did with our county director who was very passionate about this topic was we hired a professional to focus a training for E I providers for early intervention providers, Pam Pressler. And then we met her through Emma's footprints. And she custom tailored. A one, a two hour training on how to support parents. Uh, teach us a little bit about grief, the grief process, um, you know, best practices for working with families, um, and so that training work towards our 24 hours of continuing ed was wonderful. And so our next topic is going to be a little bit more on the self care for clinicians. Um, that have experienced grief as well. And if you are the clinician and not the administrator, get talking, get your county to be aware of these subjects, you know, we need help as clinicians families need [00:39:00] informed clinicians. Start talking and make some changes within your work environment and in your county because it will affect everyone and it does make your county a better, more supportive place to be. Thank  Kate Grandbois: you so much. Thank you so, so much for sharing everything with us today, your words of advice, your stories. We're very grateful for your time. All of the references that you mentioned will be listed in the show notes for anyone who is listening, um, and including the contact information for Emma's footprints. Thank you again so much for being here and. Just thank  Julie Swanson: you.  Bebe Marin: We really appreciate that you find this, um, subject as important as we do. So thank you for putting it out there for all the other EI clinicians.[00:40:00]  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 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 Intro Kate Grandbois: Welcome to SLP nerd cast the number one 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 Sponsor Announcement Yeti Stereo Microphone: Welcome to the first episode of season five. We recorded about 25 episodes this past summer to share with you throughout the course of this year. This season, our focus was to bring you content that covered a wide range of topics all with clear clinical application.  Yeti Stereo Microphone-2: The [00:02:00] biggest news from the summer is we built an app.  After years of planning and so many requests from our audience, we finally created an app where you can find all of our podcast episodes, webinars, resources, and take the post tests to earn Ashleigh CES.  Yeti Stereo Microphone-3: Learning and earning ashes CEOs on the go has never been easier. Yeti Stereo Microphone-2: Our app is available to download for free, and you can find it in the app store or using the link in the show notes. Yeti Stereo Microphone: We also launched our resource library this summer. We partnered with Melissa Berg from speech therapy store. To bring you therapy, materials, discounts, and exclusive resources to help you connect research with practice, stay tuned for podcast, episodes and videos from our resource specialist, Corey Clemens. To put research, informs materials at your fingertips. Kate Grandbois: One Change to expect this year is our schedule of courses for graduate credit. This year, we will be offering a winter session and a summer session, just like you might find at a university. In both our winter session and summer [00:03:00] session, we will offer a handful of courses for graduate credit, giving you the opportunity to do a deep dive in a clinical topic of your choice. Our graduate credit courses are generally four weeks long and cover topics, including complex pediatric assessment, childhood apraxia of speech AAC in schools evaluating bilingual, multicultural and multilingual children and progress monitoring and goal writing. Check out our website, www.slpnerdcast.com to learn more about registration for courses for graduate credit. Finally before we start this first  episode Of season five, we wanted to say a special thank you to our members. Our members make it possible for us to bring you the content that matters in your clinical work. We have so appreciated getting to know our members over the last few years. To those in our membership who are listening. Thank you for being a part of this community. Yeti Stereo Microphone-4: Please don't hesitate to go into our member community, say hello,  ask a question of one of our expert guests.   Or connect with other members  now you can easily get access to the member community [00:04:00] in the app. Just download it from the app store and sign in.  We can't wait to connect with you. Enjoy the episode. Episode Kate Grandbois: Hello everyone. Welcome to S L P Nerd Cast. We're so excited for today's episode. We are here with our expert guest, Jenny Traver. Welcome  Jenny Traver: Jenny. Thank you so much for having me today,  Amy Wonkka: Jenny, you're here to discuss current research and best practices in concussion slash mild TBI care. Now, before we get started, can you please tell us a little bit about  Jenny Traver: yourself? Absolutely Amy. So I am a speech language pathologist and a brain injury specialist just outside of Boston. Um, I have a virtual private practice where I provide virtual cognitive therapy and executive function coaching. So I spend all day thinking about the cognitive side of things in our S L P world. And that is why I'm here today to talk to everybody about cognitive [00:05:00] therapy and how we can better support our students with concussions and traumatic brain injuries, especially as they're getting back to school. So in my practice, I, um, do a few things. I provide direct therapy, uh, I provide coaching for families to make sure all their questions are answered. And I also. Provide education to other professionals and school teams, um, including SLPs. Um, I'm actually quite excited this fall I will be hosting a course all about helping students get back to school with a concussion. So stay tuned for more about that because, um, I'm quite excited about it and in fact, a lot of what we'll be talking about today will, uh, be a part of that course as well. So really, my goal today is my goodness to see how much information I can pack into an hour for you all, um, to help shed some [00:06:00] light on, up to date concussion information and debunk some of these concussion myths that are still out there floating around. And highlight the role of the S L P and what we can do to support our students with concussions, um, because more awareness is needed about our role and why we deserve a seat at this concussion table. So thank you for having me today, and I, I can't wait to dive in. We're  Kate Grandbois: so excited to learn from you. For everyone who is new listening to this podcast, this is actually Jenny's second episode with us.  You've been with us once before talking about individuals with A T B I transitioning back into a school setting, and that was incredibly helpful and I'm, we're so excited for you to launch your learning platform and have more resources available for SLPs. We will be sharing all of that information with everyone listening. For now, I need to get through our learning objectives and disclosures, so I will read those [00:07:00] quickly before we hop right on in learning Objective number one, list at least two key signs and symptoms of a concussion slash mild tbi. Warning signs and recovery timelines learning objective number two, describe the role of the SS l P in concussion slash mild TBI care and learning. Objective number three, describe how cognitive therapy plays a role in the concussion slash mild T B I recovery process.  Disclosures, Jenny's financial disclosures. Jenny is the owner of a private practice called Cognitive, S l p, and is also an instructor at Emerson College. Jenny also received an honorarium for participating in this course. Jenny's non financial disclosures. Jenny is a member of Asha and the AC and the Academy of Brain Injury Specialists.  Jenny also manages the social media accounts for her private practice. Cognitive SS l P. Kate, that's me. My financial disclosures. I'm the owner and founder of Grand Bot Therapy and Consulting, L L C, and Co-founder of S L P [00:08:00] ncast, my non-financial disclosures. I'm a member of Ashe SIG 12, and I serve on the A A C 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 am an employee of a public school system and co-founder of SS l p 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 participate in the A A C advisory group for Massachusetts Advocates for Children. All right. Good stuff coming up. Jenny, why don't you start us off by telling us a little bit about why you wanted to talk about concussion and mild T  Jenny Traver: B I with us today? Thank you, Amy. I think the first thing, aside from how passionate I am about this topic, the first thing that comes to mind is that we don't learn enough about this. Graduate school. In fact, if your [00:09:00] experience was similar to mine, you had a traumatic brain injury course where perhaps you learned a little bit about concussions or traumatic brain injury, and a little bit about the pediatric population in one segment of this course, Um, and it really deserves more time and attention, especially when we consider the fact that about 80 to 90% of traumatic brain injuries every year are mild traumatic brain injuries. Also known as concussions. So it really deserves more of our attention, especially when we look at the research. It shows that this connection between the medical system and the school system is how we can best support our students when they get back to school. And being able to bridge this gap between the hospital and the school systems, being able to support the child and the family as they return to school and. Is really what's gonna give this child their, the [00:10:00] ability to reach their learning potential long term. So it's a topic that really more awareness, as I said earlier, more awareness is needed about the SOPs role in this topic. And there's so much that we can do, so much that we are uniquely qualified to do to help these students. Um, and that's what I. I wanna  Kate Grandbois: start by pointing out, um, a question that I had even before we hit the record button, which is that concussions and mild T b I are the same thing. I know nothing about this, so I'm very new to this topic and I didn't know that.  Jenny Traver: Thank you for bringing that up. So concussions are in fact a type of traumatic brain injury known as mild traumatic brain injury, and it's a bit of a, a misnomer in a way because. Even though we call it a myo traumatic brain injury, the effects can be quite debilitating on a student physically, cognitively, and [00:11:00] emotionally. Um, so when we think about traumatic brain injuries, we wanna think back to any bump, blow or jolts to the head that can really cause the head and the brain to move rapidly back and forth. That can cause. The neurons to stretch and the brain cells to be damaged and chemical changes in the brain to occur. So when we have a mild version of this traumatic brain injury, um, we might not actually seek medical care. Initially. You might not be going to the hospital like you would be if you had more of a moderate or severe brain injury. And that's part of the challenge is that a lot of the mild TBIs and concussions. Might not reach a medical provider, might not be going to the emergency department. Um, however, medical care should be sought out, right? Because all concussions, all traumatic brain injuries should be taken [00:12:00] seriously. And there's a lot that we can do to help this recovery process, even if it seems like it's just a little bump  Kate Grandbois: to the head. Little bump to the head. I, uh, this is making me wanna tell a personal story. My daughter fell down the stairs a few years ago. She's fine. I will preface with it all ended up okay. I wanted to take her to the emergency room and I had to, had to have an argument with my husband, who's wonderful and lovely. So this is not a throw under the bus story, but it sort of is. He was like, it's not a big deal. She doesn't need to be seen. And I was like, she just felt this is you. She just fell down the stairs. We have to take her to the emergency room. And I remember having this argument because he felt like, eh, it's just a bump to the head. And I, while I preface this with, this is not a throw of the bus story, even though there goes the bus and he's under it. I feel like there are a lot of myths about T b I just like that. I mean, just that you don't really need to go seek medical care unless you can't remember your name [00:13:00] or can't see or don't know what day it is. You know, these things that we see in the movies. Do you feel that those myths still persist? I mean, outside of my household where I've  Jenny Traver: clearly corrected the problem. There are so many myths that are still out there. Um, I think the first, first, I'll address a few comments that you just made in your story. Um, the first one being that even if you don't go to the emergency department, you should certainly reach out to your primary medical provider, whether that be the pediatrician or your P C P. Um, And do a full workup, right? Have them take a look neurologically at what's going on, and if they observe or notice any symptoms that they'd be concerned about. Second from that is there are some warning signs that you can be on the lookout that will tell you when you should definitely go to the emergency department or call 9 1 1. And those are more of what you see in the movies, right? Those are, if you see, um, repeated [00:14:00] vomiting or nausea, slurred speech, confusion, uh, weakness, a sudden headache that keeps getting worse. Um, any sort of loss of consciousness or seizures that are occurring, all of these would be an indication that more severe medical, sorry, that more medical care is recommended, um, because it could be a sign that, uh, more severe brain injury is present. So if you do not see these warning signs still go to your pediatrician, your P C P, um, and you'll notice a lot of the symptoms. Um, really fall into four major buckets. Physical symptoms, cognitive symptoms, emotional symptoms and sleep. Changes in sleep. So physical you might see those. Headaches, lightheadedness, dizziness, sensitivity to light and sound. Um, neck pain, blurry vision. [00:15:00] We hear a lot about these physical changes. The second bucket of cognitive changes. You might notice memory changes, um, difficulty paying attention or concentrating. Complaints, some brain fog zoning out a bit more than usual, having trouble remembering words or finding the right words, difficulty making decisions, and that's the cognitive realm and that's why we're here today, right? This, for everyone listening, this is when we want to get involved, right? This is when the S L P should be on the team, and we should be getting a closer look at what's going on cognitively. The emotional piece is, um, you might notice some changes in mood. Uh, more irritability or sadness come up, depression, um, changes in personality even. And then sleep disturbances is the last category, and that's difficulty falling asleep, staying asleep, sleeping at weird times. So these might be, [00:16:00] these are common signs and symptoms that you would expect to see after a concussion. Um, now, Back to your original question, um, about the myths out there. My goodness, there are so many myths, and I'll highlight a few in particular. One, again, relates to your story, which is that we just need to give it time and the concussion will heal to just give it time. Now, in many cases, the majority of concussions and mild TBIs will. Heal right within a couple weeks, let's say two to four weeks. However, getting early care with a skilled concussion provider, it's is what's going to reduce the likelihood of prolonged symptoms. Right, so a concussion provider can help identify these common signs and symptoms, can provide that education about the [00:17:00] warning signs even, and guide you as you meet with your medical provider, go back to school, slowly, increase activities and things like that. Another common myth, Is to stay in a dark room until symptoms resolve. And this, I've heard this myth. Yes. So this used to be so, so popular because that's what the research used to tell us, right? Because the research is always changing, which is why we need to stay up to date. So this idea of staying in a dark room sometimes is referred to as cocooning. Cocooning in a dark room until symptoms subside. And now we know that this idea of complete rest of doing nothing in a dark room actually hinders our progress and might prolong recovery. What we want to do is to do [00:18:00] more relative rest, which is rest for the first day or two, and then gradually re-acclimate to our physical and cognitive activities, monitor our symptoms. Expect. Expect a symptom exacerbation because that's normal. We'll see the symptoms increase slightly as we reintroduce activities, but we want to be reacclimating so that we don't make it harder on ourselves later when we've spent so much time away from all the stimulation that's causing this trouble. Kate Grandbois: I have a question. What about the myth? Or maybe it's not a myth. I don't know. Uh, don't fall asleep. You have to stay awake because if you fall asleep, you're gonna go into a coma. And, uh, you know, you see cartoons of like people in showers, like, just like try throwing water in people's faces, trying to get them to stay awake. Is that true? Jenny Traver: So this, um, [00:19:00] For the first four to six hours after you have a T B I, you a mild T B I or concussion, you wanna be monitoring for symptoms and monitoring for those early warning signs that I mentioned after that four to six hour period, you want to be prioritizing sleep. Sleep is what helps the body and the brain heal. So you do not need to be staying up for a full 24 hours afterwards, but keeping an eye on those symptoms early is key. Same with, you know, not taking medications right away because we wanna see what the symptoms are, right? We wanna make sure we understand what's presenting, because that's gonna guide us in what type of care we need, how emergent the care might be, and who we wanna start getting involved on our team. Amy Wonkka: So an observation I have as you're going through some of these myths, it's just not only that the myths are incorrect, but in a lot of these instances, [00:20:00] what the myth tells you is the exact opposite of what you're actually supposed to be doing. So the myths are not only. Not accurate. They're super misleading and could lead a patient to do the completely wrong things. I, I'm wondering, as an SS l p, how, how soon are you seeing patients in this process? And I'm like jumping like a little bit out of order, but  Jenny Traver: like if you are,  Amy Wonkka: if you are working with people, are you seeing them ever in these like initial stages or are you helping guide people through, Hey, this isn't, don't, don't put yourself in the cocoon. Don't do it. It's not  Jenny Traver: good for you. So that's a great question, Amy. I'm, I'm starting to see more as I am raising more awareness about some of these concerns and sharing the research, what the research says. Um, often people will reach out to me when they're getting back to school, and that's, that's the initial point of contact when the S L P [00:21:00] could get involved and really be supportive. Um, so. But really we want, as early as we can get a concussion provider involved, the better. That might not be us, that might be a physical therapist, that might be a, a medical provider, but somebody who's seen a lot of concussions and TBIs, um, who can guide this healing process is, is really helpful. So as early as two weeks, as early as two weeks, I've seen patients. Typically cognitive therapy wouldn't begin until that, um, four weeks or later. But in those early stages, we can be doing more of the brain health and education understanding of concussion, dispelling these myths. Um, so really focusing on the education piece and then also helping with the school reentry piece, right? Being able to support the student in getting back to school and identifying accommodations. Um, that piece starts early and then the longer term support is, [00:22:00] is, um, more of the cognitive therapy. And I know we'll be talking more about this later as well, but great question. That  Kate Grandbois: leads me to my next question, which is sort of starting to talk about the role of the SS l p in all of this. You've mentioned cognitive therapy. This is something that I learned in graduate school almost 20 years ago and don't really remember anything about it at all. Um, I have to imagine that there are many professionals who are supporting these patients. You've, you've mentioned the term concussion specialist or what, what was the term  that  Jenny Traver: you used? Uh, skilled concussion provider, I think skilled concussion  Kate Grandbois: provider. Right. So I have to assume that there is a, there are, there is a group of individuals who are likely supporting these individuals two weeks out, four weeks out, et cetera. Can you talk to us, before we get into the role of the s l P, can you talk to us a little bit about the kind of supports and the kind of care that these [00:23:00] patients need when they're ready for care? Jenny Traver: Absolutely. So the first point of contact should be a medical provider, right? So reaching out to your primary care physician or pediatrician, um, would be the first step to do a full evaluation and workup and, and determine what the signs and symptoms are, determine if we need any specialists involved early on, and really begin that conversation about what. We what the recovery plan will be, right? What the next couple weeks look like. Um, they will also be able to start the conversation with the school and provide you with information about do's and don'ts of what exercise you can do, what you can, and, and how to slowly increase your return to school. After that, it's really gonna be based on your symptoms and what's presenting. So for example, if you have a lot of physical symptoms, we wanna get a physical therapist involved. And it [00:24:00] depends on what physical symptoms you're showing, on what type of physical therapist we would want. So this goes back to that idea of the skilled concussion provider. Is, we're not looking for a generalist here. We're looking for a physical therapist that's skilled in the neck, if that's the pain you're having or skilled in vestibular therapy, if you're feeling dizzy and having trouble balancing or feeling that lightheadedness. Um, so, and, and again, if we see the cognitive symptoms come up, that's when we wanna get the cognitive therapist involved. But another big piece aside from the, the doctors and the rehab professionals is the school team now, everyone's school team is, it's functions slightly differently. Their concussion protocol. It differs based on what school you're in. But often your school team will involve a combination of your school nurse, um, a learning specialist, um, maybe your [00:25:00] athletic trainers or coaches, depending on what age you are and your teachers and guidance counselor. Right? And again, building this team and this communication between these professionals is what we're aiming for, because that's, That's really what the gold standard is in concussion care is this interprofessional team approach where collaboration flows seamlessly through all of these numbers. Um, and the s l p, whether this is as a rehab professional or the s l p in the schools, um, ideally both so that we can be communicating would also be involved. Kate Grandbois: Thank you for that. It's making me think about just some barriers to communication, just because indirect service and um, extra time to communicate can be such a challenge. So maybe at some point towards the end of this conversation, we can talk about ways to overcome or some strategies to overcome some of [00:26:00] those barriers. But for now, I wonder if you could talk to us a little bit about. The SLPs role in all of this? I mean, I just thinking about our scope of practice being so wide, I could imagine that our role could really differ depending on the presenting symptoms. Is that an accurate assumption? Um, yes.  Jenny Traver: Yes. Uh, when we're providing care, like in any area of our field, it certainly will differ depending on who's sitting in front of us. I said, I think there are big picture categories that we can think about. That will help us all provide better care for this population. So the first one being that education, right? That psychoeducation that happens early on in the recovery process. Um, being able to help somebody understand what is going on in their brain, what, how the healing process might look and feel like to them. Uh, why they need to [00:27:00] be prioritizing rest, why things might be harder right now. But also holding that space for hope and, and a positive mindset about their recovery. Being able to say, this is hard now, but it will get better and we expect a really good recovery with this, but let's give it time, I think can be really, really big. Um, especially when we look at the research which says that somebody's mindset about their recovery impacts their recovery. So I think that's the first role that we can play as SOPs is with the education around the brain, around cognitive communication skills, around, um, my goodness, what types of accommodations are important for students in school? How we can support somebody's cognition and communication skills in the classroom setting. Um, and who else might be necess or who else might. Want [00:28:00] to join the team. Who else? We might want to join the team. I think I said that correctly. Um, so that's the first piece. The second piece of our role is, again, thinking about these, uh, symptoms. So when the cognitive symptoms are spiking, when we see a lot of challenges with attention and memory and word finding, energy management is a big one. That's again, where we want the s l p to be involved. So we have the education as our number one. The second one is taking a closer look at this, uh, the cognitive skills, and I might even separate this further to say that early on it would be symptom and energy management. So even things like helping somebody understand what the symptoms are and ways to track their symptoms can be huge, helping them. Understand their energy and, um, especially in the [00:29:00] recovery process when they're experiencing so much fatigue can be really helpful. Um, so that symptom and energy management systems can be a key part and key role of the S L P and then the specific strategy instruction for their cognition. So finding ways to strengthen their attention in memory and executive functioning, whether this be with assistive technology, right? Introducing compensatory strategies like using a Google calendar or alarms and reminders on their phone to support their memory and organization. Um, or a pen to help them while they take notes. That also records the what's happening in the classroom to help with note taking. Or to use more of a metacognitive strategy instruction approach, where we are directly teaching individuals to regulate their own behavior by monitoring their performance and um, identifying when [00:30:00] behaviors need to be changed to optimize their performance longer term. So in summary, high level that brain health and psychoeducation, the symptom and energy management component, assistive technology and compensatory strategies for cognition, and then specific strategy instruction of your cognitive skills. That  Amy Wonkka: was really helpful. Thank you for that. I, I am, as I'm listening to you talk and you're talking about, you know, kind of the four different key types of symptom presentation we might see with people who have a concussion, mild T b i. Um, I'm looking here in the notes you had sent over to us, and I'm wondering if that maps onto different types of concussion phenotypes. Like are there. As an SS l p, who's doing this more often? Can you look at certain clients and think, oh, I think that you kind of fit into this type of profile where I anticipate supporting you  Jenny Traver: more in these different ways. [00:31:00] Thank you for bringing this up, Amy. So this, um, con, the concussion. Phenotypes is also not very well known right now, but there are in fact multiple types of concussion and those fall into seven main categories. So one of them is cognitive. So often we are working with individuals that present with a cognitive concussion phenotype. That being said, there often individuals will have multiple types of concussions, so we might have somebody. That has cognitive difficulties, but also presents with changes in their mood and, uh, vestibular challenges, right? Having trouble with balancing or dizziness, um, and having difficulty with their vision or their ocular motor. So that would be four different types of concussion, the cognitive, the, a mood, the vestibular, and. So [00:32:00] this really, we use the, the seven different types of concussions to help us identify what's going on with our client and build our team, right? Identify who else, what other providers should be part of our team and where they're trying to get to the root cause. So if I see somebody with a headache, for example, I'm not quite sure why they're experiencing that headache. So I wanna do a screen to figure out if the headache is simply be, or just because of the cognitive challenges, or if it could be due to neck pain, right? A cervical component, in which case I want a cervical PT to look at that. Um, or if it could be due to sensitivity with light in the room or when you're reading something, which might be more of a vision component, um, or if it's something completely different. They didn't drink enough water that day, and that's more of the brain health and [00:33:00] education that we wanna look at. Kate Grandbois: You mentioned four phenotypes. I gonna see if I can repeat them back to you and then maybe you can tell us the other three, or maybe I didn't, maybe I didn't catch on this. Okay. So you mentioned cognitive, vestibular, ocular motor. Uh, I'm not  Jenny Traver: really remember the fourth one. That's okay. Effective or mood? Oh, mood.  Kate Grandbois: Mood. And  Jenny Traver: then what are the last three? So I mentioned cervical two, so that's the neck component. Gotcha. Um, pain and then headaches actually is one of the categories as well. Really? So there's overlap. Yes. So that's, so that's the seventh. Um, and then the first one is physiological or autonomic. And that's when we hear more about the, um, exercise intolerance or changes in your heart rate variability. Interesting nervous system. So what, what's interesting about these [00:34:00] seven is that there is a lot of overlap, which again, is why we wanna be understanding the root cause and really working with a concussion provider to make sure we're treating the root cause and not just the symptoms. And often we will see people who have multiple phenotypes of concussion. So when  Amy Wonkka: we think about recovery from concussion, I know you mentioned one of the myths was if you just wait it out, you'll get better. And sometimes that's true, but sometimes not necessarily. And in any regard, having somebody to support you through the process is going to be beneficial. Are there other. Are there risk factors that people who do this regularly are able to identify that might make it more likely that you'll have a longer recovery or a more challenging recovery?  Jenny Traver: Absolutely. So typically, um, according to the research, [00:35:00] most people recover from their concussion within two to four weeks. That being said, clinically, I typically see more like one to three months. Um, or longer. Now, the longer recoveries, as Amy's question gets at, is really for people who have these preexisting conditions that might make it more likely for them to experience a prolonged recovery. And those are things like a history of concussions, right? If they've had concussions in the past, um, and their recovery from those, if they were, if they actually went to a rehab professional or saw medical care, or if. They just went about their life can play a role. Um, preexisting learning differences, um, or language differences. Um, mood disorders like anxiety of depression, and even a family history, either personal or family history of migraines can play a role in [00:36:00] prolonged recovery. So these, I often, um, again, this is one of the things that all of us SOPs can help with is identifying, um, when we meet with an individual who's had a concussion or might've had a concussion, making sure we ask these questions initially in our initial evaluation. To help with that education piece and giving them a general recovery timeline can be really helpful. Um, especially if the concussion doesn't happen on school grounds. So sometimes we as professionals, especially in the school system, um, or in private practice, we might be the first to hear about changes with their attention and memory and schools all of a sudden harder, and we're not sure why. Or we're having these headaches and we don't know what's going on. And I think that's when we can dig a little bit deeper as well to [00:37:00] figure out if there was an event, and then make sure the appropriate channels know about it, right? Making sure we let the, the team know, the family know, um, and make sure it's documented in the school records so that we can monitor this student longer term as well. I  Kate Grandbois: have a question just about the collaborative process with all of this. I'm just thinking about SLPs listening who are interested in this line of work or, you know, maybe work in a school or work in private practice, and how much of this might really be, how much of our work as SLPs is enhanced through an interdisciplinary model. I mean, you're talking about. You know, the cervical phenotype and wanting to get a specific kind of PT involved. How do you bridge some of these gaps given that this is, these are individuals who are not in a hospital, right? But at the same time, they need to be supported by an interdisciplinary team of [00:38:00] professionals that might not exist in a school setting or in a private practice setting. How do you  Jenny Traver: do that? Oh my goodness. I, you know,  Kate Grandbois: that was not supposed to be a trick question. Jenny Traver: I, I think the, my best advice is to always ask the questions of who else could be involved. Right? Always ask ourselves what is presenting in this student? Um, Who else could be a part of the team to help this student? I mean, one of the things, a lot of what I do when I first meet a student is ask a ton of questions. Right? And I have, and for anyone listening, being like, but Jenny, what are those questions? Reach out to me because I will get you a list. But I have, um, but some of the ones I mentioned, right? Have you had concussions in the past? Have you experienced headaches [00:39:00] or migraines before? Um, you know, it can really help us understand what's going on with the student. And it's always better to be proactive. So if we think that, you know, someone does have a history of mood, mood disorders, reaching out to, if they see a therapist, reaching out to them to try and collaborate or getting the school counselor involved early on can be really key. Um, right leaning on our team whenever possible. So that they can ask questions that we wouldn't even think of, I think is, is the best advice I have, knowing, recognizing that this takes time and this takes effort. And, um, my goodness, we all, I, I wish we all had more time and, um, and abundance of effort to share. Amy Wonkka: So Jenny, I've got a question. How, how do we know a student is ready to go back? I know that we've learned that we shouldn't just [00:40:00] be cocooning away in a dark room, and that it's a process where you are, you know, trying to expose the person to more of their regular life. Um, you kind of expect an exacerbation of their symptoms, but is there, is there sort of a process there in how to figure that out and kind of what our expectations  Jenny Traver: should be? Absolutely. So those first two days after concussion is when we wanna prioritize physical and cognitive rest. So 24 to 48 hours after the concussion. And then we wanna start to introduce light activities at home. So activities of daily living, your normal routines of cooking meals, and eating meals, and going about your day. And then introduce some cognitive activities, um, even some schoolwork, so some reading, and see how that goes. If you have worksheets available, do some light homework, um, to see how your symptoms are presenting [00:41:00] after we're able to do some of those activities at home. Increasing the symptoms too much, we can then go back to school part-time. And it depends what that looks like for everybody. Um, usually it would be. An hour or two, maybe a few hours a half day, but a partial day at school, um, initially and with supports in place, right, with those accommodations, with the ability to take rest breaks whenever they need to. Um, I often say access to a quiet space, whether that's the nurse's room or even your office or the guidance counselor's office, um, but some quiet space so that they can rest when they need to. After the partial day at school, we can slowly build up to a full work day. Um, with accommodations. And then the last step is reducing those accommodations, and that's usually the [00:42:00] longest step. So when I mentioned that it takes a few months for many people that what I see clinically, they're still in school, but they're in school with accommodations, with a modified workload, a modified schedule in some way, um, when the ultimate goal is to get them back to school. Full time with their full academic load and homework without the supports in place. So that's kind of the high level stages. Um, and in this process, as we move from one stage to the next, we would expect to see some symptom exacerbation, as I mentioned earlier. Right. That's quite common. Um, as we reintroduce some of these activities, If we see more than a mild symptom exacerbation, we wanna slow this process down. So the way we can think about mild exacerbation is actually if we use the zero to 10 point scale, um, where [00:43:00] zero is no symptoms and 10 is the worst symptoms manageable. We don't want to increase by more than two points. If we do increase by two points, we wanna go back to where we were within an hour. So that's what we can use as mild symptom exacerbation, which is normal in this process if it. If you do an activity and you feel two out 10 to start, and by the end of reading that page or paragraph you're at a five out 10 or six outta 10, then we're going too fast and we need to slow down before progressing to the next stage. And this idea of mild symptom exacerbation, it might be referred to as the two point rule, you might hear it as. Um, but this was actually one of the things mentioned in this recent consensus statement that I wanted to share with you all. This was a statement that was, um, [00:44:00] So this was actually one of the things mentioned in the most recent sports concussion consensus statement that I wanted to share with you all. So this was back in October of 2022. The sixth International conference on concussion in sport was held in Amsterdam. And 31 expert panelists representing multiple disciplines from nine different countries, including the US gathered to develop this new consensus statement on sports concussion, and it was just released in June of 2022. Now, this paper, I would highly recommend to anyone listening who's interested in this population because they do a wonderful job of dispelling a lot of the myths. I mentioned today and some more, um, and they mentioned this two point rule. They de define for the first time in research what this mild exacerbation looks like. And they say that when we go [00:45:00] past mild exacerbation is when we need a slow down this return to learn process. Um, so I'll send Amy. And Kate this, uh, the report. You can read the research article. I also have a blog post that I wrote about the key takeaways for those that are. So busy with time, as limited as I know it is for so many of us. Um, but in this article, you'll be able to read a lot of the new research out there, um, and you'll be able to see the new, uh, sports Concussion Assessment tool and the the Sports Concussion Office Assessment Tool. And these can be used both on the sidelines. But also in the office, um, in private practice after concussion. So this is the sixth edition that, so I'll make sure to get you all of these resources.  Kate Grandbois: That would be awesome. Thank you. Okay, so  Amy Wonkka: I'm an S L P I. Let's say I'm working in the [00:46:00] schools. I have a student, they've had a concussion. They're coming back to school.  Jenny Traver: What, how do I help them? So early on, um, advocating to be on the team mm-hmm. Reaching out to see what's, what symptoms are present is key, and helping with the team's initial creation of these accommodations. And I wanna point out at this point that, you know, these accommodations early on are temporary. So they're often not written into a 5 0 4 plan or created a more formal process through an I E P at this stage. That being said, One of the roles of the SS l P can really be to support the student in identifying what accommodations are helpful and when we can modify them longer term, and ultimately whether we need to make this more [00:47:00] formal, which might be the case, especially for some of our individuals who perhaps were. Had some under underlying difficulties before that weren't necessarily diagnosed or, um, noticeable to their performance, but are now quite affecting their learning, um, and overall performance in school. And that's when we certainly, that shift is key for us to be able to provide more support in the school system. And helping our colleagues monitor that progress, uh, is, is key to determine, you know, when we modify, when we add, when we subtract, and how to keep them moving in their recovery overall. Do you have  Kate Grandbois: any suggestions for. Terminology or statements that, um, SLPs could use to advocate to be on a team? For someone who's returning with a T B I, [00:48:00] do you find that to be a difficult process or something that requires a lot of advocating? Jenny Traver: Hmm. It can. Um, it really, it really depends on your school setup. Um, there. Their willingness and, and the foundation they have to collaborate and provide this interprofessional care. I also think that this is an opportunity for education. Um, being able to explain what the research says about concussion, um, using that. Article that I just mentioned will be huge, will be huge. So please look in the notes for that. Um, to really show them what the research says and what our role of an SS l P is, uh, and how we can support an individual, I think is, is the first step. Um, and finding creative ways to, to provide support, um, you know, I think can [00:49:00] be quite helpful. I, I also, you know, wanna mention that there is this wonderful referral tool that we can all use, um, that's called the cognitive communication Checklist for acquired Brain Injury. And this can be a, a great way for us to quickly show our teammates. Um, or hand out to the family to have them identify if there are any cognitive or communication differences since their brain injury. And help to, uh, point out the need for cognitive communication support through an SS l P. So this tool is actually created by Sheila McDonald's. Um, for who's an SS l p, um, specifically to help families describe what they're experiencing after brain injury and [00:50:00] help healthcare professionals and administrators understand, um, how to detect a communication difficulty and refer to a speech language pathologist. And it's quite a wonderful tool. Um, we can link it as well for you. Um, but it's a free tool that breaks down difficulties into categories of auditory comprehension, expression and social communication, reading comprehension, written expression, um, and then thinking and executive function skills. And it's a quick checkbox, you know. A quick checklist where you can have, again, whether the family fill it out or the teachers fill it out so that you can better screen for individuals who might need your support more directly. I was just wondering  Amy Wonkka: when you're, because you are in private practice and you're supporting families, you're supporting students who are returning to school,  Jenny Traver: um, When, when  Amy Wonkka: you're having a really successful team experience for a student, can you just talk to us a little bit about what that [00:51:00] looks like? And I'm sure it will be different for every student, it will be different for, you know, their unique recovery phenotype, but, um, as, as a student is going back to school, are there patterns where you're like, oh, it's, it's super helpful. If we have the nurse and the classroom teacher and the speech pathologist, are there any trends that that might be helpful for our  Jenny Traver: listeners? I. Hmm. Um, absolutely. So I think the first one is early communication with the medical provider would be key. Um, and understanding the, the concussion management team at the school, because it varies. Yeah, it varies. And it's not always as interdisciplinary as we are hoping and pushing for. Our advocacy efforts, um, understanding who is involved and then based on what we're seeing, making recommendations for who else should be on the team. So what this would look like is early communication with the doctor. [00:52:00] Um, Communication with usually the learning specialist and or the school nurse, but usually learning specialist and or the school counselor to share what we're seeing. Um, and, and then depending on how the, the student is presenting, um, reaching out to, uh, trainers and, and, uh, coaches as well. Amy Wonkka: I am just wondering as a speech pathologist or just thinking, I guess as a speech pathologist who has done a lot of school-based work, if you are listening to this podcast and thinking, okay, one thing I could do, you know, to maybe help make sure that I'm included in the thought process when we have students who are coming back after concussion mild, t b I. It could be just form some relationships with the coaches. Like I know in most of the schools where I've worked, the coaches are also teachers in the school. Right? So perhaps it's just reaching out to those people, forming a connection, letting them know, as a speech pathologist, you're here maybe sharing the, I've forgotten the name of it. Now, [00:53:00] sharing that tool, the C C C A B I, um, you know, with those different school-based providers. Who might be more likely to be part of that team might make it more likely for you as the S L P who's working in the school to be invited to sort of support those students.  Jenny Traver: So for when we're thinking about what this great communication and interprofessional team looks like, um, it really involves the collaboration between the medical system, uh, the school team, and then other rehab professionals. So if you're the outpatient s l p, getting in touch with the school, SS l p would be wonderful to share some knowledge and support with them. Um, if you are the rehab part of the rehab team, being able to communicate with the medical providers and the school, um, the point person in the school, since we did mention that those. Each concussion protocol is varies per school, and their concussion management team might look very different. [00:54:00] Understanding what your school's team looks like and who the point person is, whether that be for the team or for this individual student as they return, will help you to figure out who to share this information with. And as Amy mentioned, you could share the cognitive communication checklist with them. You could share some. You could share the consensus statement on sports concussion to debunk some of these myths and highlight the current research on concussion care. And of course you could highlight our, um, our role as SOPs in cognitive communication skills in general. I  Kate Grandbois: have one last question before we wrap up, and it is related to something you said in the lab in when we during, when you answered the last question. Is working closely with the families. I have to assume that some of the families that you're working with, you know, they're dealing with [00:55:00] a, something that was unexpected or something that creates a lot of fear, or on the other side, oh, it's no big deal. It was just a bump on the head. Do you find that counseling tends to be a big piece of this, particularly in the beginning when you're doing some of this foundational education?  Jenny Traver: Counseling and education. Absolutely. Um, and again, it's really helpful to share what the research says about the recovery timeline, about the how Most students, more than 75% of students require accommodations initially. So again, being able to validate, um, and normalize some of these. These things can be really helpful when working with families. Um, and then of course, taking some of the stress off of their shoulders by facilitating this communication and collaboration is one of the, I, I would say the biggest ways that I support families early on is to, to really [00:56:00] triage this communication and say, these are the people we need to get involved. These are the questions we're gonna ask. I'm gonna call these people first and let you know, you know, and again, that's part of the. Uh, luxury that I have of being in private practice and, and in private pay. Um, not being, you know, dictated by insurance that I can spend more of my time, uh, providing this support for the families, provide this counseling and education and, um, communication between key team players. Thank you  Kate Grandbois: so much for sharing all of your knowledge with us. Do you have any parting words of wisdom or anything else you'd like to leave our audience with before we say goodbye?  Jenny Traver: Absolutely. I think, my goodness, I, I would say if you're feeling. Whether you're feeling inspired or overwhelmed by this information, please know that you are not alone. There is so much to learn out [00:57:00] there. There's so much that we can be doing, but let's support each other in doing this and, and this is really one of the main reasons I'm creating this. Course in community on helping students get back to school with a concussion, because I wanna better support parents and families. I wanna support other SLPs, other educators and rehab professionals to really get this information out there. So if you are listening and you're excited to learn more, or you're feeling like you're overwhelmed by all of this and want, um, some more, a slower pace of a conversation perhaps, or more handholding in this process. Please reach out. Please visit my website for more resources and consider joining us for the course this fall. I would love to have you, um, so that we can all stay up to date on concussion care and support our students and advocate for the role of the SS l p. Thank you so much, Jenny. Thank.  Kate Grandbois: Thank you. It, it was really, really wonderful to have you today. Thank you so [00:58:00] much for being here. For everybody listening, we will link all of the resources in the show notes as well as on the landing page on our website. Thank you again, Jenny, for sharing all of your knowledge, and we hope to see you here  Jenny Traver: again soon. Absolutely. It was my pleasure. Thank you for having me. Sponsor Outro 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. . [00:59:00]  [01:00:00]

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 . Kate Grandbois: [00:00:00] Welcome to SLP nerd cast the number one 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 SLPnerdcast.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 Kate Grandbois: Hello everyone. Welcome to SLP Nerd Cast. I am without my amazing co-host Amy Wonka today, but I am not alone. I am here to welcome Danielle Green to the podcast. Welcome, Danielle.  Danielle Greene: Hi. Thanks so much for having me.  Kate Grandbois: I [00:02:00] love talking with you. We have been chatting in this Zoom room for half an hour before we hit the recording button, so I'm very excited to share your wealth of knowledge with the rest of our audience. You are here today to discuss special education law and how it relates to speech language pathology. Um, you have, you've done a webinar for us before, which I'll mention in a minute. But before we get started, can you tell us a little bit about yourself?  Danielle Greene: Sure. So again, my name is Danielle Green. I'm a special education lawyer. Uh, I started, got into my practice, um, you know, as many of our special education lawyers do because of personal experience. Um, and I work with families, uh, and, and their, their children to help them get special education services in the public schools. Um, I do everything from, you know, for, from three year olds all the way up to, uh, students who are returning 22. Um, I also work with, um, families that are having discipline challenges, [00:03:00] um, in schools. Um, and so the practice really runs the gamut. Um, but again, got started because, you know, my son, um, needed services and I was sitting in that i e p meeting. Actually it was the pre i e p meeting, um, before I even got to the i e P table. And I literally felt like I was on like candid camera, um, because obviously my son was having challenges and. You know, um, we weren't really, it didn't feel like we were like getting anywhere. Like no one wanted to say it, you know? And so I was like, I went home that night and I was like, something has to give here. I must not be using the right words. And, um, kind of my practice started from there.  Kate Grandbois: I've learned so much from you, from working with you over the last year and a half. And every time I talk to you, I walk away with so many nuggets of wisdom and I'm really, really excited to share it with everybody. And I wanna take a quick minute to just talk about some of the work that you have done. So you did a [00:04:00] webinar with us about special education law about a year ago. It's available on our platform for our members if. If anyone out there hasn't seen it, I highly recommend it. I learned so much from you. I will link a, um, I'll put a link in our show notes and I also wanna give a special shout out to one of our listeners and members, Kate Andress. So Kate took your webinar and wrote in with all of these questions, how do I apply this? What do I do in this situation? And Kate is, um, a really big reason for why we decided to publish this follow-up episode. So just a quick shout out, A big thanks to Kate Andress for helping us create this episode and draft all of these follow-up questions for you. Um, again, anyone who's interested, I will link the original webinar in the show notes. Before we launch into some of this information, I'm gonna quickly read our learning objectives and our financial and non-financial disclosures learning objective. Number one, identify at least one of the purposes stated in the Individuals with Disabilities [00:05:00] Education Act or I D E A learning objective Number two, describe the difference between an I E P and a 5 0 4. Learning. Objective number three, list at least two legal considerations for recommendations of service, delivery and learning. Objective number four, list two strategies for advocating within a school setting when administration is not supporting compliance with an I E P disclosures. Danielle's Financial Disclosures. Danielle is the owner of Exceptional Children's Special Education Advocacy, L L C,  danielle's Non-Financial Disclosures. Danielle is a member of the Massachusetts Bar Association Council of Parents, attorneys and Advocates, or C O P A A and the Special Needs Advocacy Network, Inc. Kate, that's me. Financial Disclosures. I'm the owner and founder of Grand Wa Therapy and Consulting L L C and Co-founder of S L P Nerd Cast. My non-financial disclosures, I'm a member of Ashes SIG 12, and I serve on the A A C Advisory Group for Massachusetts Advocates for Children. I'm also a member of the [00:06:00] Berkshire Association for Behavior Analysis and Therapy. Okay. So we have some interview questions for you about mm-hmm. What happens when things don't go well? Right. But before we get into that, I wonder if you could tell us a little bit about I d E A, maybe some fundamental components of the law in and of  Danielle Greene: itself. Yeah, of course. And before I do that, I just wanna give, um, my little legal disclosure that all the information that's being presented is for information purposes only. I am, you know, neither providing legal services or our conversation is not, um, creating a attorney-client relationship. Um, if you have personal questions or concerns, always consult with your own lawyer. Um, okay. So now that all that is out of the way, um, we can, that  Kate Grandbois: seems like a very  Danielle Greene: important disclosure. Yeah, it's a very like lawyerly, you know, disclosure. Anyone that's, uh, it fits though. It fits. It does. It totally fits. It fits. Yep. Okay. [00:07:00] Carry on. Okay, so, um, so relevant laws for our discussion. So there's federal laws and state laws. Um, the federal law is the Individuals with Disabilities Act, I D E A. There's a statute that you'll find at 20 u s c section 1400. Um, and then regulations which generally provide just a little bit more detail than the statute is 34 C f r part 300. Um, I mean, in reality, what you're gonna be doing is searching like child find special education law, but just to give you, you know, more relevant, um, the actual numbers and, and things like that. The other, um, law that we're gonna be discussing is the federal law Section 5 0 4 of the Rehabilitation Act of 1973. Um, and that is kind of where Section 5 0 4 plans come from. That's 29 U S C section 7 94. Again, most [00:08:00] people just say 5 0 4 section 5 0 4, um, the Americans with Disabilities Act, things like that. So, um, where in Massachusetts, uh, so Massachusetts has its own, um, set of, of laws around special education. They can be a little bit different than the federal laws. So it's always really important for you to know kind of where you are in your jurisdiction, um, and what the, what the differences could be. Like, for example, the federal law timelines allow for 60 days, um, 60 calendar days for an evaluation to take place in Massachusetts. Um, our law says 30 school working days, um, from the date of receiving consent. So again, it's just important to know, um, your state law as well. So from my perspective, um, there's five key sections of I D E A. Um, the first section is the [00:09:00] findings section and the purpose section. Um, the next is dis is definitions, state responsibility, evaluations, and i e p, and then procedures and due process. So just to kind of frame the, the federal law, um, I think it's important to understand that the findings from the congressional testimony for when I D A I D E A was founded, talk about how important it is to ensure equality of opportunity, full participation in independent living, economic self-sufficiency for individuals with disabilities. They also talked about how it was important to have high expectations for our children, right? And to ensure their access to the general education curriculum. Right? I mean, there's tons of case law, um, for how I d a came about where basically if a student had a disability, they were basically told to go home, right? They were [00:10:00] not educated way back, you know, in the day. Um, and the, the, the findings from congressional testimony basically, you know, address that to say, no, these are, these are students that we just need to figure out how to help them, right? Like, how do you make their puzzle piece fit so that they can, they too can sit in the class and, you know, become whatever they wanna become. Um, so I just think it's a really important framework for how this needs to start.  Kate Grandbois: I just wanna, I don't wanna interrupt you cuz I know you have more to teach us. I just wanna comment that. So much of that is news is news to me. Right. I mean, we think as clinicians working in a school or as municipal employees, you know, we are often the component, there are components of that law that are really highlighted mostly. Yes. Access to the curriculum. Yes. Needs based access to the curriculum. But I haven't heard a lot about economic independence. Yes. I haven't heard a lot about, what was the one that you said right before Economic independence? There was another  Danielle Greene: one. Um, independent living.  Kate Grandbois: Independent living. This [00:11:00] is another one that I, I don't hear emphasized a lot within an educational setting, so I really appreciate you sort of giving us a scope of the breadth of, of what this this law is. Danielle Greene: It's broader than, than just, and I don't mean just in like, in a way of minimizing it, but it is the, the purpose of the law, which is what we're gonna talk about next, which is one of my favorite sections of the law is just so much broader Right. Than, you know, can, um, Can Danielle sit next to her peer and listen to a math lesson, right? Like, it's just so much broader than that. Um, and I, I realize that I'm really, that was very simplistic. Um, so in terms of the purposes of I D E A, and of course no one's reading these things, right? Like it's just the nerdy lawyer, um, that is interested in it, right? But that's why you're here telling  Kate Grandbois: us Cause we're not gonna read it. No one's  Danielle Greene: gonna read this though, right? [00:12:00] Um, and so, um, but like, where did it come from and why right? Is, is super important. So one of the purposes of, of special education under I D E A is to ensure that all children with disabilities have a free, appropriate public education fape, right? Everybody working in a public school has heard that, I'm sure, you know, almost e you know, maybe every meeting somebody comes in and says, you know, my child's not getting a fape, you know, whatever, right? So like, that's obviously in there. However it goes on to say, designed to meet their unique needs and prepare them for further education, employment, and independent living. So again, how Congress and the congressional testimony went as they, you know, they heard testimony and then they took that and turned it into, okay, so this is really the purpose of our statute here, right? Like one of the important sections, um, one of the important purposes, [00:13:00] um, another purpose is to ensure the rights of children with disabilities and their parents are protected. And that's why parents have these procedural safeguards that, you know, in Massachusetts, um, we give out at every um, i e P meeting and. People joke about how, you know, they've had so many, they can wallpaper their house with them and things like that. But there's a purpose, there's a reason why, um, you know, we, we give those out. Um, we have to ensure that educators and parents have the necessary tools to improve educational results. That's also one of the purposes of special of I D E A. And then to assess and ensure the effect effectiveness of efforts to educate children with disabilities. So, very high level, right? But taking a huge step back, like that's what all of you know you are doing, you know, in, in the school system, right? With your, with all of your colleagues. Um, and so again, I just feel like those [00:14:00] things are so important to highlight. Um, and frankly, I. When I'm looking at an i e p when I'm talking to, to parents, I'm, I wanna know, does this i e p help them? Either further education, uh, employment or independent living. Right? I mean, that's, that's the bigger picture of this down the line. Um, so I used  Kate Grandbois: to have it as a sticker. I'm sorry that I interrupted you. I love coming back to the bigger picture. Yeah. Uh, again, because I think working in a school system, so many of us, we get very focused on our one job. Right? Right. So as a speech pathologist, my one job, we have many hats, but yes, for the purposes of the I e p, your, your, you know, your job, your quote unquote role is to provide services, to be in compliance with the I E P. And that might mean direct speech services. It might mean training, it might mean indirect service depending on what the I E P looks like. Right. Um, but I, I love just the idea or [00:15:00] reminder that their parents are a part of this team, that this law is overarching, um, that there are safeguards for all members of the team. Yeah. And that might Right. But you  Danielle Greene: need to be trained as well too. Right. As new things come out. Right. So how do you maybe get your administrators if you need to, right. Um, to help you bring somebody in to do training. Right. Or allow you to do training for the paras, right. That are working with these students real time every day. Yes. Right? Yes. Like, could you use the purpose of I d E A, one of the purposes of I D E A to help that argument, to say, you know, listen, like we're, we're all part of this bigger, you know, wheel, right? Like we each do our individual cog kind of section. Right. Right. But like this, there's, there's a bigger, there's a, there's a bigger, um, there's a bigger reason behind all of this. Yes. Right? Yes.  Kate Grandbois: Um, [00:16:00] and I, I love just to sort of, Pin it back to something you said earlier. I think, and we're gonna get into this later, but I think many of us work in settings where we don't have an attorney at our fingertips. We don't have someone who has a deep understanding of the law. And often we are told by our administrators who are not lawyers, right? Danielle Greene: Yeah.  Kate Grandbois: We are told things that are maybe half-truths or we are told things that are myopic compared to the larger picture. Yes. Um, so keep zooming out for us. Keep going cuz I, I think that this is really, it's a wonderful to set the stage before we sort of get into the minutiae of what to do. Yeah. The details when, when these things don't  Danielle Greene: go well. Right. So another great section and the next section that I think is really important for people to understand is, is truly the definition section, again, not a sexy section right. Of the law. Right. Like, not something that people are like gonna dive into, but it has so many importance. Um, You know, definitions that we work with every day, right? So one of them is a [00:17:00] child with a disability, right? There's an actual definition for what that means, and there's a list of things. It means a child with an intellectual disability, hearing impairments, speech and language impairments, visual impairments, serious emotional disturbances, orthopedic impairments, autism, traumatic brain injury, or other health impairments, um, and specific learning disabilities. And who by reason thereof because of their disability, they, they need special education and related services. So what's important to understand and uh, sometimes more important maybe for families to understand is that the mere fact that your child has a disability does not necessarily qualify them. For special education services or related services under, uh, the special education laws I I D E A or your state law. Right. It's, there's a [00:18:00] combination that you have to kind of keep in mind. So you, you have a disability and because of that disability, you require specialized instruction. You require a speech and language pathologist to help you with articulation, social pragmatics, um, you know, any other of the social pieces, um, or comprehension, you know, all the, all the amazing things that, that you, you guys do. Um, but it's a, it's, it's not, it's not just, again, not saying just as, um, a simplistic, um, or, um, or anything like that, but it's, you have to, you have to marry the two pieces. Um, Again, the definition of free, appropriate, appropriate public education, or a FAPE means special education related services that have been provided at public ex expense, under public supervision and direction and without charge. It meets the [00:19:00] standards of the state education agency. It includes appropriate preschool, elementary, and secondary school education in the state, and then they're provided in conformity with an individualized educational program. Um, so that's, that's, you know, just the, the standard definition of, uh, a FAPE as it's called. Um, another definition that I think is important is called related services, and that's also where speech and language pathologists are included specifically in the definition. Um, it says transportation and such developmental, corrective, or other supportive services. Including speech and language pathology, audiology services, um, interpreting services, psych, psychological services, physical and occupational therapy services from the nurse, um, services that are designed to enable a [00:20:00] child with a disability to receive a free, appropriate public education as described in the individualized education program of the child. Um, so again, we're kind of tying definitions, you know, back together, um, for how can you, how do maybe speech and language pathologists provide services that are designed to enable the child to access their education?  Kate Grandbois: And I think a lot of times, at least in my professional experience, Those definitions can get sliced and diced a little bit. Like, so, you know, and the semantics really, really matter. Yeah. So going back to the way that the law is written, I think for those of us who are arguing with our administrators, or for those of us who are put in difficult positions or maybe don't quite understand why it's contentious, going back to what the law says, I would assume is a very powerful thing. Because again, if you've [00:21:00] been told a half truth or something, that's a little right myopic compared to the grand scheme of things, that can be a very powerful  Danielle Greene: tool. I think it can be. And I think that, right, it's, it's the black and white. It's kind of like what I say for, for you guys from a speech and language perspective is use your data, right? Like in a lot of ways, the black and white of the law is your data, right? And it can be as easy as saying, So this, I, I just happened to see this, or I looked it up, or I saw this on, on a Facebook group or whatnot, and it was posted. And so I was just curious, can you help me understand what that means? Because to me, that makes it sound like I should be doing X, Y, and Z. Right? And I maybe the, the help, can you help me understand is a great way, I think of kind of benching your ego at the door, um, and hopefully helping somebody else do the same thing, [00:22:00] um, while opening lines of communication, right? I feel like in these situations I'm constantly looking for ways where that's a possibility because I think that's where a lot of good work can get done, or that's when a lot of good work can, can get done. And so I feel like I'm constantly looking for phrases and ways that are, um, that can diffuse things. Yet still prove the point.  Kate Grandbois: I love that you said that checking your ego at the door is one of the, my favorite expressions. I feel like we need to now do a whole podcast on conflict resolution. Right. It's conflict management because it's so important. It is. And of course we're talking about this in the context of a contentious I e P meeting or when something has not gone well and there are big feelings in the room and there are people who have, you know, are bringing very different strong beliefs and feelings to the table. So I think that that's such a wonderful suggestion. I'm so glad you said that. And  Danielle Greene: I think, I mean, [00:23:00] listen, I guess I would say too that in some cases maybe the meeting's not, doesn't even start out feeling contentious. Right? I think but I, I think in any way I. When I'm going into these meetings, um, and I'm thinking about like, there's a child that I'm, I'm trying to see how can I help them a little bit more. And so if you're a parent, that's, that's always gonna weigh a little heavier on your heart, right? So it's just gonna, it's just gonna make it a little bit more like the ante is up a little bit, right? And so, even if it's maybe not contentious, there's still this like feeling of, but something's not working and I need to figure it out. Right? And so, again, I, I and I, I, I mean, listen, I wish that phrase or phrases like it, or written on every wall in every meeting room across the, you know, across the world, right? Because it's, it, it, it [00:24:00] gets a lot of us in trouble. And I think it's also important for everyone to understand that we, everyone play is playing a role and they have a role at that table. Right. The administrators have a role at that table, right? They're not just i e p members, not only i e p members, um, per the law because there has to be an administrator there or someone that's there, um, to be able to commit resources for the district as a team member, right? But parents are there, they're required members of the I E P team, a general ed teacher is a required member, a special ed teacher, someone who's providing services. These are all required members of the I E P team. And we all have egos and we all have a reason for what we are trying to be there for, right? And I, I, I, I do talk to my families about that, to kind of help everybody just realize, right? And like, this is, [00:25:00] this is, this is our data that we're looking to use in order to show, you know, Danielle needs some additional assistance here. Because it, what what we're doing isn't, isn't working and it's through no fault of anyone. It's just not, it's not working for her. Mm-hmm. So now what? Right. So, I don't know. I felt like I went off on a bit of a tangent, but, um, it was an important  Kate Grandbois: one. It was a good one.  Danielle Greene: Keep going. Um, okay. So, um, so back to your point about just knowing kind of what definitions are and maybe having a little bit more information. So there's in the regulation at, um, 34 c f r, 300.34 related services. There's something, uh, specific to speech and language pathology services. And it, it says it includes identification of children with speech and language impairments, diagnosis and appraisal of specific speech and language impairments, [00:26:00] referral for medical or other professional attention necessary. For the rehabilitation of speech and language impairments, provision of speech and language services to prevent communicated communication impairments and counseling and guidance of parents, children, and teachers regarding speech and language impairments. That one, which is a really important, no one talks about that. Holy  Kate Grandbois: moly. I have a million things to say about that last one. Yeah, I bet. I mean, training of communication partners. Yes. Indirect service delivery. Yes. Training of of families. Yeah.  Danielle Greene: Training of all in the consult section of the grid.  Kate Grandbois: Yes. Yes. I, I feel like I wanna ask you a million more questions now, but I'm gonna hold myself until we get to the questions section so that we can, we can finish some  Danielle Greene: of this. Yeah. But I feel like that's a really important, a really important piece. Right. Um, so there's other definitions, um, supplementary aids and services, you know, AIDS and services and supports that [00:27:00] provide, that are provided in the regular education classes. Right. So you might be providing services maybe outside of the class, but also thinking about, hey, what could help this student in the class? Right. Especially communication devices, as you were just saying. Or, you know, other types of, um, accommodations, you know, things like that to help them participate in extracurricular and non-academic settings too. Um, so we we're kind of, the law also allows you and requires you to, to think about those things. So again, that can be helpful if you're recommending something and someone's pushing back to say, well, do we really need that? Do they really need that? You know, um, if you feel strongly about it and you have your data to support that, then you know, yes they do. And oh, by the way, I happen to see that there's a section that says this is one of the things that we're required to, uh, to think about. Um, okay, so evaluations is another [00:28:00] area that I feel like, um, you know, warrants discussion. Um, there's all different, um, pieces of the law that talk about this. Um, what's required to be in the notice and description of the procedures? No single procedure. Is the sole criterion for, um, for you to use. So you can do observations, you can do informal, formal, right? It's not just, oh, we have to use the castle and that's all we can use, or whatever happens to be. Um, you are required to assess the child in all areas of suspected disability. So let's say you're, you're doing, you're, you're doing an assessment and you're like, gosh, I'm hearing some things that maybe I wonder if there's something else going on. Um, you may be told by your administrators, All you're gonna do is this, right? Or you might feel like, all I have time to do is this [00:29:00] one assessment. Right. Which is real. Right. That's, that's a, that's probably a big part of what's happening too, is that your caseloads are huge. Right. Um, and so, but I just would like to remind that the law does require for a child to be sued in all areas of suspected disability. So if you feel like, even though parent didn't say on the form, oh, I'm worried about articulation. If you, as the professional help happen to notice that and you wonder if that's holding them back from being able to participate, like their peers, then let's, let's do a subtest or something right. To get more information about that and report, report that out. Kate Grandbois: I love, I just wanna emphasize again for everybody listening, that assessment does not necessarily mean a standardized test, right? You may be in a district where to prove eligibility, you might, your state might mandate that you use a standardized test. But for clinical purposes, there are so many ways to collect and information [00:30:00] and often standardized tests don't give us the clinical information that we need. And we have so many courses on assessment on our platform. If anybody wants to learn more about that, I will link those in the show notes as well.  Danielle Greene: Yeah. Cuz I, and I, and I actually think, I know, you know, again, even from a lawyer perspective, it's like, okay, so what's the standardized testing state? Because a lot of times that is what we're arguing right about in terms of, um, you know, the student is not doing well in class, but then they did a standardized test with you and they're all, and they came out all average, right? And so, but still, something's not. Clicking for them. And, you know, it's, it's, it's, it's very encouraging when I can, when I sit in meetings and the related service providers, the speech and language patho, pathologists will, will say, you know, one-to-one, the student did pretty well. But I can tell, and I know that, that they would, they are having problems from [00:31:00] an observation that I did or from talking to the teacher or, you know, even in how they interacted with me, that even though they scored in the quote unquote average range, they are still someone that does need some support and services. And you're doing that based on your clinical experience. Like you're doing that based on your expertise. And that's exactly what we wanna see, what the law requires, you know, you to do. But I realize that we're working in a system as well and that can be challenging. Um, okay. So, um, Let's talk about, um, sometimes I think it's, it's helpful for, for people to understand that there is a section of the law that includes educational records, um, and what that means. And, and especially for, uh, for related service providers who feel like they're producing a lot of data on a student and, you know, is that [00:32:00] data, information that parents get or not? Obviously. Um, there's specific definitions in, um, the Family Educational Rights and Privacy Act or ferpa. Um, and actually the special education law includes, um, the FERPA law in, in its, um, Incorporates it by, by reference in the definition. Um, but I, I think educational record is records, files, documents and other materials which contain information directly related to the student and are maintained by the educational agency or institution. So I just bring that up as a, um, as a reminder, you know, um, that's important for people to understand. Um, and  Kate Grandbois: I, I, I think one big takeaway for me when I hear, when I hear that definition, is paying a little bit of more close attention to my documentation. Mm-hmm. [00:33:00] So, you know, the data sheets that I'm writing on, right? The, the notes that I'm, the progress notes, obviously there are some pieces of documentation that are obviously part of a legal record, but if you are scratching your data on a piece of scrap paper or keeping it in a notebook, By that definition, I could see some circumstances where that becomes part of their educational record. I have had families request my data sheets  Danielle Greene: before. That's right. I was gonna say I, it depends on the situation and it depends on what's happening. Um, you know, I've had situations where that information is requested, it's redacted for other, from another, you know, any other student's names that are included on the same page or redacted for that student from a privacy perspective. But yes, it's, it's just an important piece. And if you have questions about that, you know, I'm sure that your, your school district, um, counsel can also provide, you know, information and, and things like that about, um, [00:34:00] what, how you should keep that records, you know, from, from your, your district's point of view. So in terms of an, the individual education programs or an i e P, um, there are several, several sections within the law. Of course. We already talked about the, um, one of them, the required team members in an I E P team meeting, the parents, at least one regular education teacher, at least one special education teacher or provider, a school official who can commit resources if you have test results. A professional required or qualified to interpret the test results the student. If they're between the ages of 14 and 22, but they can also be excused. And if you have any outside agencies that are representing, um, responsible for transition services for the student, then they should also be invited, uh, to the I E P team meeting. Um, you can be excused from an I E P [00:35:00] team meeting. Parents can excuse you if you're not able to participate. The law does say that, um, the consent has to be in writing. And then, um, if your, if your team, if your content area or related service is modified or discussed, um, then you should provide something in writing beforehand so that that's kind of your contribution as the team member. And then the team will discuss that during the meeting. Um, there are certain parts of the I E P I know that you all are well, um, acquainted with, uh, writing all the time. Um, but parents and, and student concerns, which is one of, you know, my. Most important, I feel like parts of the I E p, um, student strengths, key evaluation results, of course, the present levels of, um, educational, academic, functional performance. They're called different things throughout different states. IEPs are also sometimes called different things throughout the states as well. Um, you're writing [00:36:00] measurable annual goals, both academic and functional, um, designed to meet the child's needs that result from the child's disability to enable to them to make progress in the general education curriculum. Uh, I know we have some questions I believe on, on those things. Um, service delivery is another really important, um, part of the I E P, um, about, you know, when the student will get services, where they will get services and again, services to parents as well as necessary. Um, IEPs are in effect when the district, when the, they, um, sorry. They must be, once they're put into effect, they have to be made accessible to the special ed, the general ed related service provider, and any other provider who's responsible for their implementation. So hopefully your district or, you know, has a, has a, a program or something where you kind of get, um, the i e p and you know, there's some sort [00:37:00] of, um, tracker or something maybe, uh, so that it, it shows that you reviewed it and, and had that information. Um, okay. And then section 5 0 4 is the civil rights law that prohibits discrimination against individuals with disabilities. It's ensuring a child has dis that, that has a disability, has equal access to education. It requires that reasonable accommodations and modifications be made for the child with a qualifying disability. There are a list of qualifying disabilities in the law. Uh, 5 0 4 plans do not require public schools to provide an individualized educational program that meets a child's unique needs and provides the child with educational benefit. So that's, that's a big difference. Not to say that Section 5 0 4 plans are not useful or helpful or, um, appropriate or exactly what a student needs, um, for them, but it's just a, one of the [00:38:00] differences. Some of the other differences are that 5 0 4 s are technically not required to be written plans. Although, you know, in every district that I've seen that they are, you, you aren't required to provide progress reports like you are for an I e P. Uh, there's no annual team meeting requirement in the law. There's no requirement for transition planning like there is on, on IEPs. Um, So, uh, but you can still get in, uh, you can still get related services on a 5 0 4. It's just that, those 5 0 4 s generally, although I have seen some, so unfortunately, you know, it, it is kind of district dependent where they will write almost like a service delivery into the 5 0 4. Um, those are rare that I've, that I've seen anyway, but I, I have seen where that has happened. Kate Grandbois: Okay. Now that we have the lay of the land, You've given us [00:39:00] such a wonderful overview of the law, which I think so many of us don't truly understand because we're not attorneys, right? Yeah. We're clinicians. We're not supposed to know the law. But knowing all the nooks and crannies, I think gives us a really good picture for the field that we're playing on. Right. And all of my analogies. Yeah. Um, I wanna lead this conversation with a question that has, that our listener Kate asked, but also it's something that I've experienced. I have multiple colleagues who've experienced it. And the, the question is, what do we do as professionals when our clinical expertise is not in line with what our administrations expect us to do? And I'll, I'll give you an example. I have heard multiple times that students are, maybe they're given an AAC device, but they're just given an iPad with this one program because it's, quote, what we do here. I've, I've heard that a lot. Or, yeah. [00:40:00] We don't provide direct services on our i e P or indirect services on our I E P because quote, that's not what we do. Right? Yes. So there's this cookie cutter, um, approach to service delivery, but we as clinicians, we know we may know better, right? We may have a better understanding of how best to help our students, but we are in conflict with our own administrations over, over what we have the resources to do. Right? How would you, what do we do in those situations to be in compliance with the  Danielle Greene: law? So I think that, um, one, I think it's important to say what the student needs in the I e P team meeting. I, I do think that sometimes what happens is there's a hesitancy to say all the things that the student needs. Um, but that's the place to do it, right? So when you are suggesting [00:41:00] services to say, this student needs an AAC device, it, it's, it might, the parent might be thinking, right, and you're gonna train me on that, right? Um, or the teacher might be thinking, you're gonna train me on that, right. Um, the general ed teacher, and, you know, if you don't say it in the meeting, then it, it will likely never be done. So, I mean, that's just like, that's just how I operate a little bit, is like, if it's not said, if it's not written down, then it was never, it was never done. It wasn't never said, right? So say it in the meeting, make sure it's part of your service delivery. Um, uh, recommendations. Make sure it's part of your recommendations. So you're thinking about the recommendations to the family, um, to the other teachers, right? Your consults, the indirect, um, support that you're gonna provide for the student in the classroom in specials, right, in electives [00:42:00] or whatever it happens to be, um, in lunch, right? Like all of these areas, you know, have to be thought about, right? So that's the B grid service. The, A grid is the consult to parents, to other staff, and then the direct service is the C grid. So when you're thinking about your recommendations, if you, you, if you think about all of those areas, then um, I. You're making that as part of the i e P team discussion, right? Which is where it should be done. Maybe provide you a little bit of cover, um, and hopefully parents pick up on the fact that, okay, so these are things that should be in the I E P, right? Um, if you're looking for more information about like where, like what we were just talking about, right? Like, um, sometimes there's FA FAQs by your state that deal specifically with AAC devices or people have asked questions before to other websites. Like Rights Law is a, is a great, um, it's a very, [00:43:00] uh, dense website. You can search it. There might be information there for you to find some, um, articles on or things like that. They also have trainings very accessible to non-lawyers. Um, there's a group called a website called Wrights Law, um, where Pete Wright and, uh, who is a lawyer and then, uh, does trainings, um, that are very accessible to non-lawyers with his wife. Um, and they talk about kind of the marriage for prac, uh, pardon the pun of between, um, advocacy and the law. Um, I think, which can be very helpful. They have a lot of books as well. They have a website, um, that you can search. Uh, I don't spend a ton of time in the Facebook groups because sometimes I find that you're not getting the full facts. You might not be getting, um, you know, the full set of circumstances and you sometimes really need those in order to help you answer your question. Um, if you're in Massachusetts, the [00:44:00] Special Needs advocacy Network provides trainings, the Federation for Children with special needs. Um, Is another, uh, free, they do a ton of free trainings as well. They also have, um, uh, a Facebook presence. Um, each state, I believe has some sort of parent clinic, um, that you don't, you know, necessarily have to be a parent Right. To, to sign on to one of the webinars or things like that. Um, so, so those are some just other areas where you can maybe learn some more information to help you advocate for your students, um, and also help you even feel more empowered. Right. Similar to what we were talking about, of like bring in the definition from the law and just say, you know, this seems like this would relate to me and what I'm doing. Can you like, help me with that?  Kate Grandbois: I, I, I so appreciate all of these resources and for anyone listening, we will link all of these resources in the show notes. I think you bring up such a great point that there is a. [00:45:00] A lack of access to good quality information about the law, which is different than legal advice or having a, a relationship with an attorney. Um, the law feels like this big scary thing that's cloaked in mystery that we just hope we're not screwing up somehow. Right. Um, and I also just wanna mention that you are, you have resources available for clinicians and families as well. Yeah. Um, on your website, some low entry, low barrier to entry in pieces of information and consultation. So we will, not to put you on the spot, but we will list your information in the show notes there as well, cuz I've learned so much from you. Um, so I wanna move on to some more questions about what we can do when things don't go well. So we've, we've reviewed when we are in the hot seat and our clinical expertise is not aligned with what our administration says we can offer. Mm-hmm. I'm wondering about when the tables are turned. If we have [00:46:00] recommended services, we feel confident that what we've recommended is in line with our clinical expertise, with best practice, with research. Let's, for the sake of argument, say we have our ducks in a row and we have data, hard data to support what we are recommending. But the parents refuse the I e P services and refuse to sign it, and there's contentions on the end of the family. Right. What are the legal procedures involved there and what are some things that we need to keep in mind as the professionals sitting at this quote unquote hypothetical table? Danielle Greene: Yeah. Um, again, I, not to continue to say the same thing, but I think what's important is that you, you as the, um, speech and language pathologist for the student are providing and recommending the services that you believe will ensure that they can make progress in the general education classroom slash curriculum. Right. Again, that can be social emotional, that can be academic. IEPs are [00:47:00] not just for, um, academic reasons. Right? Um, so I think that's the most important thing to kind of keep in mind. And then from a parent's perspective, They have options. So, so they can accept the i e P and the services in full. They can partially reject the I E P or they can reject fully the I e P. Um, I, you have to tell if you're going to partially reject, you have to be very specific. These are the areas that we're partially rejecting you can reject for omission. So let's say, um, you know, you're, you know, Kate, you're recommending one times 30 in the sea grid for Danielle. And, and I'm like, actually I want, I, I think that that really what she needs is push-in services as well. You didn't recommend that I'm partially rejecting the omission of the B grid service, [00:48:00] right? Or I'm rejecting the omission of a consult to parents to help learn the AAC device. Right. Or whatever it happens to be. So you can also reject the omission of goals, the omission of services, the omission of, um, accommodations, you know, things like that. Um, so anything that you do not reject will be accepted and the services will begin immediately, um, is what the law says. Um, then obviously if you partially reject, if there's some services that you reject, those services will not, will not start. Um, if there's a service that was removed or reduced, you can then stay, put that service from the prior accepted service slash  Kate Grandbois: iep. That was gonna be my next question about stay put, because that's a phrase that's used a lot that is sort [00:49:00] of, I've heard it used different ways. Yeah, I, I it's, it's a little confusing. Can you talk a little bit about the stay put concept and how it's applied  Danielle Greene: and it's different? The federal concept is different than the Massachusetts concept, which is even more, um, I think confusing. Um, so it can apply to individual services to an I E P or to a placement. Um, and you are asserting as the parent, the stay put rights for a specific, you know, service or, um, goal, or cuz you don't think that the goals were achieved right. Then you would stay put for, and those goals would remain. Unfortunately, what happens is that the goals remain the same. You don't get to update those. So you're basically kind of working off of the same information. Um, but at least [00:50:00] the service is staying with your child during that period. Okay. And then that happens until, until the dispute. Yeah. And then it's until the dispute is, cuz that's basically right. You're, you're disputing No, the student, no, Danielle doesn't need that service. You know, says the teacher, you know, the parent says yes. So you have a dispute. So until that dispute is, um, is mediated. Um, and there's a couple ways that that could be done. You can have a meeting and you can resolve it. Um, another team meeting and resolve it. You can go to mediation, um, or you can, you know, file for, for due process. I'm gonna, and federally it has to be through due process. Okay. I'm gonna,  Kate Grandbois: I wanted to skip ahead. Yeah. A question or two, um, just because it's related to what we're talking about. When there is a disagreement over the proposed service delivery, can a chairperson or team member or administrator change the services on a [00:51:00] grid without the consent of the certified professional? So, for example, if in your example, the S l P recommends one times 30 in the C grid and there is, you know, some dissent from the family or some rejected, can a non S l p chairperson administrator change it without checking in with the S L P either to like push in or pull out or, you know, some other service delivery model? Danielle Greene: So what, what I would say is that no, um, that, that should be a team decision. The service delivery that is being suggested should be dis discussed within the team meeting environment because the parent is a member of the I E P team. Um, presumably the speech and language pathologist who made the recommendations, they know the student, right? They have some sort of understanding of, from a clinical perspective, the expertise perspective plus what the student requires that, you [00:52:00] know, one could argue the administration does not have. Um, and so I think all of those things are really important to, to be taken into account. And so that's, Um, one of the reasons why I say it has to happen, it should be happening in a team meeting, um, not after, because you're denying the parent the right of meaningful participation, which is a procedural safeguard for them. That being said, I, I'm a hundred percent sure that this happens, um, either in pre-meetings or post meetings, right? And if it's happening post-meeting and we've, we've already had a discussion, um, at the meeting that the student's going to receive two times 30 or, you know, two times 15, whatever it happens to be, then I'm, I'm gonna say administrator, you're not even involved in this. You weren't even at the meeting. You, you can't make that call. Um, so I, I, and I, but I know a hundred percent that that's, that's happening, [00:53:00] uh, you know, throughout the country. And I'm sure that there's a lot of pressure put on clinicians, um, related service providers. Um, In this process, you know, I mean, I get, I get calls from friends of mine that are teachers that are like, listen, you know, I'm wondering, I, I wanna, I'm doing everything. I've done everything I can for this, for the student in the general ed classroom, and they're still not getting it. They need more, I suggested a tutor, which is a word that they might use, right. For special education support. Um, and, you know, may, may or may not have been told, well, we don't really wanna  Kate Grandbois: say that. Uh, this was, you're leading right into my next question too. Oh, well, there you go. Keep, no, keep going.  Danielle Greene: Keep going. Yeah. So, you know, the conversation that we had was, How can I, because it's a delicate balance, right? I mean, you still, you have to work still. [00:54:00] Um, right. You have bosses, obviously they have not checked their ego at the door. They did not listen to the podcast and like got that information. Um, you know, but so what my advice was, one is you have to give all of the data that you have and say all the things that you are doing in the general education classroom and say, and he's still not getting, or it's still not enough, right? Because you, you have to, you have to, you have to go that far. Right? It, it's in, it's. One, there are compliance requirements, right? Like if you are not able to provide what the student needs and you do not feel they're making progress, then you do have an obligation under child find. Um, which literally means, you know, says means what? It says find a student with disabilities and, you know, evaluate them to see if they need services, [00:55:00] then that's, that's what you need to do, um, better if you have some data. Um, but if you feel like you can't go so far as to say they need a special education teacher, um, because of your administrators or your situation. Say that without saying it. Like, we see all those memes, like, you know, tell me you have kids without telling me you have kids, you know, or whatever it is or whatever bad example I'm trying to give. Right. Like, what are some ways that you can say, like I, I said, I also said like, give some examples. Mm-hmm. Right? Like this was the student's math quiz and this was it before, if you can, this was it before I sat with them. Right. They got one problem done in 45 minutes and it was wrong and they couldn't show their work correctly, couldn't even write it in a way that anybody could read.[00:56:00]  And this was after I sat with them for two days throughout, you know, um, kind of the free periods during, during, uh, school.  Kate Grandbois: So showing that customized intervention as the data. Yeah. More of like a, sort of like a dynamic, that's another dynamic, another example assessment. Yeah. Right. Um, so, and this, this was gonna bring me, my question was going to be around this needs versus benefits. Yeah. Bene needs versus benefits from question. And, um, one of the questions that, um, Kate brought to the table, which I wanna emphasize is how do we answer questions when a family asks us an innocent meaning question, such as, do you have, do you know anywhere, anyone I can send my child to for outside speech services? Yeah. Or do you have any additional resources for x, y, z deficit? And yeah. The que we are in at times paralyzed by these questions [00:57:00] because, If we answer them, then it looks like there's, do they need services? Services they're supposed to be getting. Um, so how would you recommend we navigate some of this needs versus benefits language when it accidentally arrives on our, on our professional doorstep, doorsteps, so to speak? Danielle Greene: Yeah, I guess one, I would say it's such a shame that, you know, providers, teachers feel like this. Like, like, you know, you can feel like, um, you're heart racing, you know, like when you get asked this question from a parent because you wanna, you wanna say, you know, these are the services, these, you know, um, but you, you feel put in a, in a, between a rock and a hard place, which I, I can, I can appreciate. So I guess what I would say is, um, you might have to say, Although the services that we're, we're, we're providing, um, Danielle in [00:58:00] school are, are what she needs in order to access her education in school. I can see how outside of school maybe you would want to, um, get her, you know, more repetition or extra support or maybe look at these areas, right? So you might have to start by kind of doing a little bit of, especially if you are providing them service, you know, this is something that we are doing and this is why we're doing it. And we're happy to work with that outside provider too, because there's only so many minutes in the school day. And we know, we also wanna make sure that the student is having some time, right. With their peers in their classroom, you know, or for whatever it happens to be. Um, So I guess I feel like that could be one way, right? Like, you know, call out the fact that, you know, you are providing the services that you think are appropriate in this, in the school setting. Sometimes [00:59:00] there are things that aren't gonna be worked on in the school setting. Right. Um, I feel like this happens all the time with OTs and PTs as well, and it's, it's really challenging. And I'm sitting on the parent side of the table. I'm sitting on the, um, attorney side of the table. It's really challenging to hear, you know, and somebody say, we're not providing your student services, maybe because they're, they're not failing enough. Right. Or, or something like that. And the law doesn't require a student to fail. Right. But, and, and really it's, again, you have to bring it back to you. Are they making progress? Um, in the general education curriculum, and there's a lot of ways that progress is measured. In Massachusetts, we also have a concept of effective progress, and there's a definition relating to that. Um, and there's case law, some case law about that. Um, but it's, it's tricky. It's really tricky. I'm, I'm not [01:00:00] sure that I, I answered that in a helpful way, um, at all, and I can appreciate that. It's, it's, it's, it's a very tricky situation for clinicians. I was  Kate Grandbois: muted. I'm sure that all of the. Answers are rooted in the specifics of a situation too. Yes. Especially, you know, depending on whether or not you have the backing of your district. Yes. Depending on how the question is asked, what the skill is, you know, there's a difference between getting additional supports for extra practice for articulation versus Yes. Training for an AAC device. That is the main way through which you get access to a curriculum. So yes, I think there are, I'm, I'm sure that questions like that are just difficult to answer across the board, depending on the specifics. I am so grateful for your time. I know that we do need to wrap up and I, I just wanna say thank you for spending the time with us for answering some of these questions to anyone who is listening, if you're [01:01:00] anything like me, you probably have more questions because this is such a deep well, um, and an intersection that we don't often talk about in our field. You know, how we interact with the requirements of our jobs and our workplaces and how we interact with the requirements of the law. Yeah. So we really appreciate your time in, in highlighting some of these things. If anyone does have additional questions, we will put Danielle's website in the show notes, um, as well as all of the additional resources that she mentioned. So go ahead and take a look, get in touch. Um, there is more help out there for you if you need it. Thank you again so much, Danielle,  Danielle Greene: for joining us. Oh, thank you so much for having it was,  Kate Grandbois: it was wonderful. Thank you so much for being here. You're welcome.  Danielle Greene: Thanks for having me. Outro 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 [01:02:00] 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 . Louise Pinkerton [00:00:00]  Intro Kate Grandbois: Welcome to SLP nerd cast the number one 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 Sponsor 1Episode Kate Grandbois: Hello and welcome to S L P Nerd Cast. I am here alone today without my co-host Amy Wonka, but I am not alone or lonely. I am here with a whole panel of guests. It's not often that we get to welcome multiple people here [00:02:00] for a discussion, and I'm very excited today to welcome Louise Pinkerton, Jenny Brodel, Elisa Green, and Stacey Robinson. Welcome all. Hi everyone. Thank you. We're happy to be here. I would love to start off by having you all tell me a little bit about yourselves. Um, I'll go ahead and  Louise Pinkerton: start first, um, I actually took the long way round to get to speech pathology. Um, I was accepted to a master's program after my undergraduate music and decided to do other things, um, specifically singing and, uh, teaching voice at universities. But, you know, I wanted something a little more stable. And speech pathology is amazingly stable with lots of employment opportunities versus being a soprano. Um, so I did my master's in 2016 and then have worked in a variety of settings, um, outpatient, acute hospital, rehab hospital, and now I'm returning to [00:03:00] university teaching and continuing to do supervision like I did in the workplace. But I'm an assistant professor and I run the voice team for our in-house clinic. That's wonderful. Thank you, Louise.  Jenny Brodell: Um, so I, oh wait, I'm the opposite of Louis. I always wanted to be an S L P and I just went straight through right when I got to college. Um, I have always been interested in pediatrics and autism. I originally worked at a nonprofit outpatient clinic where I specialized in evaluation and treatment of pediatric, um, pediatric clients with developmental, um, disorders. Now I am here at the University of Iowa and I am also a clinical assistant professor. Um, and I specialize in, um, still specialize in pediatrics and autism, but now I'm supervising graduate students regularly. Thank you. Jenny,  Kate Grandbois: how about you, Stacy?  Stacy Robinson: Um, yes. So, uh, similar to [00:04:00] Jenny, I wanted to be an S L P for a long time. Went straight through. Um, I moved out to Baltimore to start my career at Kennedy Krieger Institute, um, their autism center out there. And then took a brief detour in the schools before, um, ending up in, um, Iowa, um, to supervise. And I still specialize in pediatrics. I'm a more, a bit more generalist than, um, when I was doing autism. And then, um, I also have been developing a little bit of a specialty in literacy lately. So that's been  Kate Grandbois: fun. Thank you. And how about you, Elisa?  Elisa Green: I am Elisa Green and I am the clinical director at St. Ambrose University. About 45 minutes down the road from the other three on the panel here at University of Iowa. And, um, while I'm the clinic director here, I never actually saw myself in academia. I worked in a skilled nursing facility and I worked in a rehab hospital. [00:05:00] Um, and I loved working with students in CFS while I was there. And it was actually a student who suggested that I apply for a position at St. Ambrose. Um, they said, oh, you're so good with students and you can relate. And, um, even though students have changed and I have changed because I'm not as close to their age as I once was, um, in the last couple decades. But, um, I still love working with students. Um, I love their energy. I love sharing our passion about our field with them. Um, my specialty is adult neurogenics and, um, I just love working with students and helping my clients and their family members.  Kate Grandbois: I am really excited to hear more from you all today. Mental health is something that we talk about a lot on this podcast. We've also talked about supervision on this podcast, but I don't think we've ever had an opportunity to marry these two concepts and do a little bit of a deeper dive talking about mental health in supervision, [00:06:00] particularly with graduate students. So I'm very excited to have this conversation. Before we get into all the super fun stuff, I do need to get through some housekeeping things. So I'm gonna read our learning objectives and everyone's disclosures, and then we will kick off the conversation learning objective number one, describe practices that support the mental health needs of graduate students learning. Objective number two, describe Anderson's continuum and how feedback changes throughout the clinical education process and learning. Objective number three, identify at least six characteristics of effective feedback. Disclosures. Louise's Financial Disclosures. Louise received an honorarium for participating in this course. She also receives a salary from University of Iowa and the University of Iowa Hospitals and clinics, Louise's Non-Financial Disclosures. Louise is the Continuing Education Administrator for the Pan-American Ology Association, jenny's Financial [00:07:00] Disclosures. Jenny received an honorarium for participating in this course. Jenny receives a salary from University of Iowa and the University of Iowa Hospitals and Clinic Jenny's Non-Financial Disclosures. Jenny has no non-financial relationships to disclose Elisa's financial disclosures. Elisa received an honorarium for participating in this course. Elisa receives a salary from St. Ambrose University, Elisa's Non-Financial Disclosures. Elisa has no non-financial relationships to disclose Stacey's, Stacey's financial disclosures. Stacey received an honorarium for participating in this course. Stacey receives a salary from the University of Iowa, Stacey's non-Financial Disclosures. Stacey is a member of the Iowa Board of Speech Language Pathology and audiology. Kate, that's me. My financial disclosures. I am the owner and founder of Grand Watt Therapy and Consulting, l l c and co-founder of S L p Nerd Cast. My non-financial disclosures, I'm a member of ASHE SIG 12 and serve on the a a C advisory group for Massachusetts Advocates for Children. I'm also a [00:08:00] member of the Berkshire Association for Behavior Analysis and Therapy. That was a lot. You all are a wonderfully experienced group of people, so thank you to everybody who sat through that with me. Um, I would really like to kick off this conversation with a question related to what you have listed here as the modern student. So I was reviewing all of your notes that you sent in before we hit the re record button. And you have a lot of information here about the quote, modern student. What is that exactly? I. Elisa Green: So the modern student is actually six times more likely to experience anxiety and depression, and stress can be a cause of that. Anxiety and depression. I can see Kate's face. I was also shocked when I found out and read that research of how much more anxiety and depression is incurring with our students. And so we can't just say, well, in my [00:09:00] time, or maybe they need to tough, you know, tough it out. I toughed it out. It is different. Our world is different. Our current students are different. Just like we treat our clients as individuals, we need to be treating our students as individuals as well. And so that'll be one great thing about learning the different kinds of feedback and information that you can provide these students because you really do need an arsenal of different supports depending on the student that you have. Um, so not only across campuses are we seeing the trend that, um, anxiety or mental health in general. So, anxiety, depression are kind of the two that speech pathology students have the most of. But in general, mental health is becoming more and more of a problem across college campuses, and that's undergrad and grad students. Um, but our grad students are faced with even more challenges as they enter this kind of [00:10:00] adulthood, um, phase of their life. Also, the rigor of our coursework increases. They're actually seeing real people where they are making decisions that impact these people's lives. And so it's adding to their, um, stress, which increases their anxiety and depression. Kate Grandbois: So I, straight out of the gate, I am blown away by these statistics. I'm not surprised, but I don't think that I had a good understanding or a good grasp on how much of a problem it was. And I really appreciate, I guess, all of you taking a moment to hold space for that because graduate school is extremely stressful in and of itself. And I think if you map on, you know, I know the, the point of this podcast episode is not to talk about the complexity of our society and our broken world right now, but there are a lot of stressors out there. And I, I, I just really appreciate, I really [00:11:00] appreciate, um, you taking space for that. I wonder if you could tell us a little bit about, um, how that stress impacts the graduate school experience? Elisa Green: Um, yes, I can. So we ask our students to work with clients. We ask them to meet productivity. We ask them to make quick decisions and write down exactly what they did and what they saw in a very fast paced world. And if somebody is experiencing significant, um, mental health deficits, They are going to struggle to do just the basic things, let alone what we're asking them to do clinically. Jenny Brodell: And  Elisa Green: so, um, we might ask them to,  Jenny Brodell: um,  Elisa Green: uh, you know, build a relationship with a client, [00:12:00] but somebody who is experiencing mental health disorders has challenges creating that relationship to begin with. And so those things that we're expecting and asking them to do clinically are going to be more challenging based on what we know about those who are experiencing mental health  Jenny Brodell: deficits. I also think we can't, you know, discount that we're not that far away from the pandemic and how that has really impacted our students. You know, something that Elise has been saying, which really rings true for the students, you know, we've seen recently is just this switch from, you know, one, like you had said, going from just sitting in a classroom to now you're in clinic and you have to actually apply everything you've been learning for years. Um, but you know, they, this, you know, new generation of student has had so much of their learning put online and virtually [00:13:00] to where they, you know, now those interactions almost get taken out of the learning process. So it's almost like they have to have this crash course and like, what does it mean to truly collaborate with someone? It's more than just kinda sharing a Google Doc back and forth. Um, it's more than just, you know, here read this and then you'll know how to do it. Um, I think. What we've noticed is that just some of those, um, those skills and working with other people in general, um, need a little more support because they've had this period of isolation where they haven't had as many opportunities to expand their just kind of general, um, you know, collaborative skills. So  Kate Grandbois: in relation to the, in relation to the statistics that you mentioned earlier about how anxiety and depression are on the rise in this age group, just in universities in general. Mm-hmm. Would you say that this problem is particularly [00:14:00] difficult for students in communication sciences and disorders when compared to other forms of student bodies or other tracks, other disciplines? I.  Elisa Green: That is what the research is showing us. And so there was a study that had different health sciences, um, and they compared, and speech students led the way, for lack of a better term, in signs of anxiety and depression, um, across the board. And when asked, you know, why they thought this might be some perfectionism came into play. And so, you know, I think about my college professor, um, we were on a committee together years after I had graduated and I was saying, well, we need to do this and this and this, you know, and kind of make it the best it can be. And his remark to me was, your Type A has been driving me crazy for decades, but we're getting stuff done with it. Right? And so I was able to use my little dose of [00:15:00] perfectionism. I'm by no means a perfectionist, but a little, a little dose of wanting to do things just right. Four positive outcomes. But if I am somebody who has perfectionism and anxiety and depression, that's gonna make adverse outcomes. I'm not gonna be able to lead my group to get things done. I'm going to be putting things off, worrying about things, overthinking things, not sleeping at night, and just making my problems even worse.  Kate Grandbois: It also makes me wonder about the culture within the graduate program. So, um, I mean, I, I'm hearing you say the word perfectionist. I am sure. Mm-hmm. There are many of us who bring that to the table as part of our natural personalities. Mm-hmm. Uh, but that's not everyone. Not everyone identifies as a perfectionist. So, but if we're quote, as you said, leading the way in anxiety and depression in [00:16:00] graduate school, what does that say about our academic institutions and our professional culture? That cultivates this, this, I don't know, extra special anxiety and depression skill. Stacy Robinson: I think part of it is just the rigor to get into graduate school in the first place. If you think about what students have to do to even be accepted into an SS l P graduate program, I mean, I'm on the admissions committee at our university and the excellence of students that just apply but are not gonna get in because they're not excellent enough. Because there's just so many,  Kate Grandbois: you know? I was gonna say, what contributes to that? As someone who went to graduate school almost 20 years ago, don't tell anyone. What is that like now? I mean, why is it so competitive?  Stacy Robinson: I don't, I don't know. But I mean, it's the students that are getting [00:17:00] into top programs are, they need to have, they. Basically a 4.0 g p a. They need to have research experience, they need to have some kind of clinical or, you know, volunteer experience. They need to show leadership capabilities. I mean, the number of things that students in their undergrad programs are doing just to be able to get into the graduate program. And a lot of times I have to tell our students, Hey, you've already shown us that you are excellent. And they're still trying to prove it to us, and they're still putting that same level of pressure on themselves that they did to get to this place.  Jenny Brodell: I do think another, um, you know, roadblock to is that we just, you know, we're limited in. I say we as you know, the collective we and how many programs there are out there and how many students, you know, are coming through undergraduate to graduate programs. And you know, this is an issue we talk [00:18:00] about in-house all the time is just that we, we really struggle to take on more students because of the type of experiences we want them to get clinical or otherwise. And we don't have enough faculty to take on more students. And so I think there's just issues at all levels that really create roadblocks and then, you know, increase this, this stress surrounding just getting into the program. This  Kate Grandbois: is wild. I mean, you hear about things being stressful, but this is just remarkable. Louise Pinkerton: Yeah, and I'll, I'll run back to, they've gone through all that stress just to get into the program and we do a lot of talking to people about, we're a collaborative group now. It's not competitive. You're working together. And that is a huge mindset shift. And I know I've had lots of discussion with students, especially the last couple years about being excellent or being [00:19:00] competent and what the differences are and that it's okay to be a competent clinician. That's our baseline, that's our bottom line. That's good. And just determining that, you know, not every session has to be peak. Excellent. Every session has to be good and solid and show progress in their skills and help their client. And that's a really hard thing for our students to get used to because not perfect is bad. So then what is competent? 'cause competence not perfect. Competence what ASHA asks for and competent is what we ask for, and so it's a real change.  Jenny Brodell: That kind of gets into the, the issue of changing from just classroom, like coursework to clinic where in classroom, like Louise was saying, competent is an A or an a plus. That's in their mind is what competent is because that's what they need, you know, to be at the top of their [00:20:00] class to get into graduate school. Now you get into this world of gray that is clinic and like Louise said, what is competence? They think it means I must know everything. I have to know how to do everything before I do it. Um, and I think that again leads to so much stress and we really have to, you know, kind of keep telling them over and over again, like, we don't know what we're doing. A lot of the time it's okay to not know a humongous part of our job is going on that search for more information, not. Knowing everything ahead of time because that's impossible. Elisa Green: And then if you take to Jenny's point, we're expecting them to have clinical inquiry and see what happens and try things out. But if you are somebody who is already lacking self-confidence and having anxiety, you aren't going [00:21:00] to feel comfortable and you aren't maybe going to try those things that we expect our students to do. And so I, I had a student sitting in my office and they were telling me right after the dysphasia test, all of the stages of the swallowing, all the anatomy involved, everything with it, what you would do to assess it, what you would look for on the swallow study. And I said, so what'd you write for your test? Nothing. She wrote nothing down. She said she got there and her head just went completely blank. And she has significant anxiety and she has accommodations for test anxiety. If nothing's coming to your mind, she couldn't share her knowledge. And we're expecting our students on internship or our CFS to share their knowledge, to try new things to explore and their mental health may impact what we're seeing. Kate Grandbois: Well, and it's making me think about what science says about learning. The science of learning is [00:22:00] operating on the fringes of your competency. It requires vulnerability, it requires discomfort and anxiety. Just shuts all those things right down. I I am, I am shocked. I'm wondering if you could tell us a little bit about what this looks like. Are there signs and symptoms for anybody out there listening? I and I, we mentioned this before we hit the record button, but I suppose it's, it begs, you know, it's worth saying. This applies not just to graduate students, but to anybody else that you're supervising, fully certified SLPs individuals in their clinical fellowship. Anyone who's new-ish to the field. Um, I think we're, we are living in a sort of perilous time. Identifying signs and symptoms of anxiety and depression in our supervisees and our colleagues and our coworkers is, is really important. What can you tell us about signs and symptoms? Um, to be on the [00:23:00] lookout for, in a workplace? So  Elisa Green: it's an individual I. Kind of thing. And so you might want to get to know yourself if you have anxiety or depression, but also your student. Um, I work with my students all the time on what are your symptoms, what are your signs to try to catch things beforehand. Um, but in general, irritability would be noted. Maybe difficulty controlling your emotions, like having extreme worrying about something, maybe constantly seeming like they're on the edge. Um, exhaustion can be a big one. You know, they always seem tired and sometimes I. Um, supervisors will say they don't wanna be here. They don't seem like they wanna be here. They're yawning. They seem disinterested. Those things might manifest. Um, the students might feel guilt, like they're not giving their best to this client, this actual human that's sitting across from them, that they are, quote, in charge of, [00:24:00] um,  Jenny Brodell: helping, um,  Elisa Green: feeling low about their, you know, low self-esteem, about their own worth. Um, there could actually be physical manifestations, so like physical pain or headaches, you know, those, those kinds of things without known causes. Um, it's also worth noting that the signs and symptoms and anxiety and depression in general occur more often in women. Which our profession has a lot of,  Jenny Brodell: but  Elisa Green: also in those gender non-conforming individuals as well. And so those two, um, types of people, um, are where we're gonna see those anxiety and depression in increase the most. And we have a lot  Jenny Brodell: in our field. Um, from that. Elisa, I  Louise Pinkerton: was gonna say, I know you have some really good ideas for then how to deal with these in the clinical setting. We've, the four of us have done some presentations [00:25:00] together, and I know in particular there, there were some acronyms that I wanna be sharing with my students, and I was wondering if you could tell us about those. Elisa Green: I can, so they're actually from the ASHA leader in 2017. Um, their, their acronyms, I love them. I think because of me, they're like memory strategies and easy to remember. Um, so the first one they talked about was the surf model, and that's really, um, you know, self-care understanding, so like seeking to understand someone else's perspective. Um, relationships, there's so much with just relationships, having a relationship with the client, having a relationship with the student, having a relationship with the university so that you can get that, that kind of support. So, um, and then the f is for focus, like a clear focus. And so many of our students now are asking for clear expectations. What do you expect of them? I'll [00:26:00] tell my students, I can't expect something from you if I, you know, you don't know about it. And so trying to be as clear as possible in what it is that you are expecting of them.  Kate Grandbois: Another note that I see here is that there's some evidence in the research that those who report symptoms of anxiety and depression also report multiple issues with supervisors. Yeah. So there's a relationship between the supervisee and the supervisor relationship. Can you tell us a little bit about that? Um, yeah,  Elisa Green: so about half of the people who have some kind of disclosed mental health issue report that they felt unsupported, their supervisor didn't care about them, they didn't provide any, um, good feedback, which again, is gonna be so wonderful to hear about. Ways to provide good feedback and support. Um, and they just in general, Don't feel that we have as supervisors [00:27:00] provided that support for them, um, which is why it's important to know what feedback to  Kate Grandbois: give. You mentioned acronyms. Do you have more acronyms for me? I love a good acronym.  Elisa Green: Well, just one more. And as much as we might try to provide them feedback, you know, your question was how do we support people and when they report that they're not feeling supported or cared about, um, It can still go wrong, right? So we think we're providing great support. We think we're providing great feedback. We've used all the tricks that we have in our supervision bucket and it's not working. And so then the last acronym is dare uh, again, this is from the Asher leader in 2017, um, from Rice, I believe. And it's, you know, Des the D is design your mindset carefully. So really assume positive intent from the people that you are talking to, um, and supervising. And then the A is for [00:28:00] approaching yourself, but also others with compassion. As a supervisor. Don't forget to breathe. Take a deep breath. Their future is not entirely on your shoulders. And I think we as supervisors sometimes feel that way, but it is not. You are one piece. A very important piece, but one piece of their, their future. Um, and then going on with the acronym, the R in DARE is for requesting feedback from others. I only know what, I know other people have had different experiences and they can maybe shed light or think of something from a different perspective than what I thought. And then finally, um, for the e it's about expectations. Um, expectations and relationships are gonna drive our outcomes in clinical settings. And so letting others know what you expect of them, and then also having [00:29:00] that relationship with them so that they may feel more comfortable to try things, they may feel comfortable to disclose to you that they have, um, some anxiety or depression or other kinds of mental health so that you can support  Louise Pinkerton: them. I wanna add to the expectations. It's also that we need to work on learning how other people understand our expectations. 'cause there are many times where I feel like I've been very clear and I've laid it out and I've given step-by-step. Or maybe I didn't write it out, but we did it verbally and I thought people understood, but I find out after the fact that they were missing key points or there wasn't follow through or the, the format I had chosen to share it just did not get through. So it's not, it's important to have the expectations and to communicate them, but also make sure that communication's been received, which I think is kind of a tenant of the whole idea of communication. It's not talking, it's being [00:30:00] understood. Kate Grandbois: Thank you for that delineation. And I'm, I'm thinking about everyone listening who now feels a tremendous responsibility to mitigate all of these factors, not only for a graduate student that you might be supervising, but a CF that's you're supervising, um, or, you know, feedback that you wanna give to your own supervisor who's creating maybe a more toxic environment than is necessary if this feels really overwhelming for people as supervisors. I'm just moving ahead to our next learning objective 'cause I love a good framework. Are there any, are there any structured approaches that we could take to improve. Our ability to move through this and support graduate students.  Jenny Brodell: Yeah. And I, I love Kate how earlier you had mentioned just like what's, what are general processes for learning? Because those are, um, definitely things we look to when we think about how do we support people, how do we support their learning in general? [00:31:00] One that we use a lot, um, at the University of Iowa, and I know this has been adopted many places, is Jean Anderson's Continuum of Supervision, which has three main steps. One is, you know, an evaluation feedback step, and that's one we're, we're really giving lots of direct and consistent feedback to a learner. Then we kind of move into a transitional stage where our student is gaining more independence, they're needing less direct feedback. We become more collaborative in nature until we move into the last step of the framework, which is self supervision, where the student is able to. Um, you know, really just use us as a consult where they're engaging in independent learning, they're motivated to make changes, they have more tools to support themselves and to reflect themselves. And what's really nice about thinking about a framework like this is that we can [00:32:00] individualize it not only to each individual student, but to each individual learning opportunity that they have. You know, the, the goal is not that every student should be starting in the evaluation feedback stage and needing much more support until they move along the continuum to self supervision. It's that we as supervisors need to take a little bit of time to figure out, you know, where this student falls within this particular learning episode. Um, so maybe we have a student who has. Worked as a camp counselor before. They have lots of experience with kids. They were a teacher previously and they're coming back. So they already know a lot of, you know, different learning strategies in general and working with children. So maybe they're starting in this continuum and the Andersons continuum a little farther down on, on the scale. They're in the transitional stage. They're almost to self supervision, but you know, we have to look [00:33:00] at. A different situation in a different way. Let's say they get to the hospital and they're now gonna be working with a patient with dysphagia, and they might be in that evaluation feedback stage where they need more support. Um, we, we really just kinda like this framework because they think it makes us slow down and think about each student as an individual. And considering that they're not gonna know everything as none of us do, um, they're gonna feel more comfortable and more knowledgeable and competent in cer certain situations. Um, so we need to kind of take the time to just recognize that and think through, okay, what do they know? It's my job to kind of figure that out, set up the relationship so we can kind of get that information and then use the support that's necessary within each of those different situations. And I  Stacy Robinson: think that. Not only is that framework really helpful for us as supervisors, but I think it's [00:34:00] also incredibly helpful for the students. Mm-hmm. So we share this continuum with students. I have my students Mark, where they think they are on the continuum when they start a placement with me, um, to see what their perspective is of their own learning and what they are gonna feel comfortable with. Um, and just like Elisa was talking about, that helps create an expectation of this is what we're kind of looking at across this next semester or even across this specific evaluation that we're preparing for, or something like that. Um, because I think we mentioned this earlier, students sometimes think that they need to be able to do everything perfectly the first time. Um, and so even if, you know, I have a student who's pretty independent in their treatment sessions that they've been doing every week, well then we get to an evaluation and I. Suddenly, I think they sometimes have the perspective that I'm gonna be just as uninvolved in that evaluation as I have been in their treatment sessions. And it's important to tell them, oh no, I'm gonna be in it [00:35:00] with you because I recognize that this is a different, um, stage of your learning and I don't expect from you in this situation what I have maybe come to learn that you can do and now expect from you in another situation. Elisa Green: And I, I love that idea, Stacy, of having them mark where they think that they're at in the continuum. You know, self-assessment, self-evaluation is a skill that we really want our students to develop and that I think will help them, but it could also help them to see that they have shown progress, and then it leads to those great conversations where you're being supportive and you're telling them, I don't expect you to be way over here in the continuum with this kind of client. And helps them to see that you have different expectations based on different clients because of their  Jenny Brodell: different experience levels. Right. That really brings us to, you know, one of the most important feedback strategies if we're kind of keeping this framework for supervision in mind is that it's [00:36:00] really essential that. You know, you set up these expectations and you set up this environment that's really accepting of what the learning process is. The student has to know, again, that this is much different than just, I'm gonna tell you information and you will memorize it, which is what they know thus far before they get to clinic. That's what coursework is. Um, hopefully it's a little more than that, but you know. It's just different. Um, so just letting them know like, Hey, we're all gonna make mistakes together. Me, myself included, as a supervisor, we are all on this journey of continuous learning. We expect questions. We want you to ask questions. We do not expect that you know everything, and that is okay. You don't have to know everything. And I feel like I constantly want to remind my students like I do not know everything. I have to go on this [00:37:00] continuous journey of learning with you. I do not know it all.  Louise Pinkerton: I think some of the best learning opportunities for my students have been when the treatment protocol we decided to do for voice therapy wasn't a good match. 'cause we had a client that came in with an advanced neurological condition I was less familiar with. We were doing the things that should have worked theoretically, research-wise, evidence-based, but they just weren't a match for the client. They didn't fit her. And so for them to see that, frankly, we crashed and burned and had to completely reevaluate and find a different approach that would, was still evidence-based but would get her where she needed to be, was I think an incredible process to go through because I'm the one that guided them to make those choices in the beginning. And then we had to reevaluate and really start over. And I think it's exactly what would've happened if I was treating the client on my own. Because I [00:38:00] started with the tried and true and it was great how those students could see, again, that process and how you reassess and how you maintain a relationship with a client when you're having trouble with them. Seeing that we are not perfect. Yeah. Very, very good point.  Kate Grandbois: It reminds me of my, one of my favorite quotes that I say to myself privately, quietly, in my mind all the time, failure is data. Mm-hmm. That's all it is. It's in more information for us to reconsider our goals, reconsider our approach, tweak, rinse, repeat. I love  Stacy Robinson: that. I love that. Yeah, I love that too. I'm gonna start using that with. Um, I think it's also important for us to, kinda like what Louise was saying, like she guided them on that treatment path. Um, and it wasn't their quote unquote mistake because I have so many students that do exactly what I tell them to do and it doesn't [00:39:00] work, and then they feel like they've messed up. And so part of creating that environment is being really honest and saying, no, you did everything I told you to do. I wouldn't have expected you to do anything else. It just didn't work. And I now, you know, now we together can come up with a new strategy, but even just to kind of help ease some of that stress, sometimes it helps for me to just go ahead and take the lead and say in owning up to like, Hey, that was what I told you to do and it didn't work. But that's okay.  Jenny Brodell: Yeah, and I think that really kind of. Bridges into this. Next point I wanna make, we're, we're kind of getting into some more evidence-based feedback strategies from this paper by Laura Mogenson and Markins from 2016. Um, I was talking about creating and accepting environment. One is definitely, we wanna normalize mistakes, but then also discussing what is feedback and discussing that process upfront because that is another area where [00:40:00] before I was a supervisor, I don't think I even thought about it. Um, it was just, I remember having a meeting with my students and offhandedly saying I take written feedback 'cause I'm old school. I don't, I don't like to type. I write by hand. Um, um, and I just remember someone had said, some had commented on the length of my written feedback and I had said to the group, you know, it's the length of my notes has. Usually has nothing to do with what you are doing in a session and has everything to do with what I am paying attention to, to what I am thinking about. It's not, if you have a full page of feedback, it's not a mark of failure. It may be just meant I was in your session for longer, or I, you know, we were doing something newer that day. Um, and they were like, no one has ever told us that before. And since that moment I'm like, I really need to [00:41:00] dedicate. You know, so more, much more time to talking about what is feedback, what can it look like, what does it mean? And that is part of creating this accepting environment and getting students to understand, again, this new way of learning, because they don't get constant feedback again in classrooms, they might get a note here or there. They might see a minus one or a letter grade on a paper. But in clinic, man, we're watching them, we're writing down notes. We're sending them things. We're putting in long comments in their clinical documentation. And so just letting them know, here is the expectation. Here is what my feedback will look like. Here is what it means. It's a tool for learning. It's a tool to help you think a little more critically. It is not a mark of failure. Where, you know, unlike, again, in, in your different learning [00:42:00] experiences, having more notes does not mean, oh, this is a failure. It just means, wow, there's lots of learning opportunities here. And really, once I've seen students. Kinda grasp that. And I, you know, I feel like those have been the most successful, um, partnerships I've had with students is when we, I present, I make it more clear what this learning relationship will look like, and they kind of understand that, and then it, it kind of helps 'em feel a little more free and in asking questions and saying they don't know something and trying to write something in their documentation and then putting a little note and saying, I don't really know how to say this. Let's brainstorm. And I feel like those are the best learning partnerships where we can, you know, both be vulnerable with each other because we know the expectations. We know that part of it is figuring it out together, not knowing at all, and recognizing that feedback is not punitive. It's a learning tool. [00:43:00] I also just  Kate Grandbois: wanna point out as I'm listening to you talk, That when you take this approach, it sounds like you are modeling humility, you're modeling a lot of professional humility. You're modeling a lot of vulnerability, right? Mm-hmm. And we know that these are the things, this is the environment. This is the culture that is required to operate on that fringe of competency and take those risks and feel uncomfortable and sit in your discomfort. Um, and I love the idea of harnessing that as the supervisor to shift that culture through providing it as a model  Jenny Brodell: yourself. Right. And I don't, you know, maybe it's, uh, probably a lot of this is generational, but I just remember thinking back, you know, when I was in, in undergrad and graduate, like, gosh, those professors know so much. Those are the smartest people I've ever known in my whole life. And they probably were, but I never thought, oh, they [00:44:00] must make mistakes. They don't know it all. They have to continuously learn until you're the one working and you realize like, yep, we're all just, we're all having to figure it out day by day. We, there's new research coming out. There are different. Client or patient or student presentations that I need to, um, you know, do more research in or I've never seen this type of patient before. And I think it's so important to let students know that that's not just their expectation as a student. That's the expectation as a working clinician is that you never know at all. Your job is to continuously learn and to always be thinking about, you know, is there new research? Do I need to, um, you know, compile different approaches, reconfigure what I am doing rather than just. Looking at the learner in the situation when you're the clinician, which is your patient, and saying like, oh, it's them. They need to do something different. It's [00:45:00] us. We, we usually need to do something different. Yeah.  Elisa Green: And Jenny, I love that like lifelong learner approach. That's what we all have to do. And I know when I started my very first student supervising, the advice I got was, do not try to teach them everything. You know, because it took you all these years to learn that information and you can't shove it into their head in a very short amount of  Louise Pinkerton: time. I am gonna jump right of that off of that Alisa, because two of the points we wanna make later about effective feedback, or maybe we'll make those points now, is about appropriate amount and self-directed learning and starting with the self-directed learning and that lifelong learning part. I'm finding that's a really difficult one right now that a lot of my students need a little bit of a push or an impetus to take control of what they wanna learn, make decisions about what [00:46:00] directions they're gonna go actually go look things up. Um, I was kind of surprised about that in a couple situations. It's like I said, go look at this website, read these three pages. They're like, yeah, I opened the page. Well wait a second. You're the one that has to see this client. Here's all this information that you could use. So getting people to, to take ownership over that and become those lifelong learners that we know they have to be to be good SLPs and a good s l p again, is a competent s l P, not an excellent SS l p I suppose. They're both, um, and the appropriate amount part. I love what you said about that because in the beginning I kept thinking, you know, I have all this stuff I've learned through my clinical work and through my prior profession, and it's just like, I wanna download it into their brains and I can't do it. And I remember the situation where we were rearranging a clinic room and I thought, well, why don't I explain the logic behind why we're rearranging this and how I wanted the [00:47:00] client and how I wanted them. And then I got into the idea that, well, you know, you always should make sure you have a way out of the room, which is something you really push in medical settings and in hospitals and in psych wards. And then all of a sudden the students are just staring and looking at me and going. Are those concerns for our client? It's like, no, wait, no, your client's fine. We're, we're not worried about behavior, we're not worried about needing to escape. I was just giving them too much. Um, and so I think that idea of appropriate amount and yeah, we took a lot of time to learn this and they'll learn that lesson when they're in that setting. I don't have to tell them that we're putting the table this way. So I always have a door or the client's never between me and a door that can come later.  Stacy Robinson: I love those, uh, lessons that we get as supervisors too. Um, that makes me think also, Louise, of being really specific in your feedback. [00:48:00] Um, Because a lot of times, you know, I know what I'm thinking when I wrote something down, but maybe the student doesn't understand what I was thinking. Um, so oftentimes I just try really hard to be very specific. I, even, the way I take feedback, I separate it by activity in the session so that the students know like, oh, I'm talking about this point while you were reading a book with them so they can like think back maybe to the exact moment when I wrote that piece of feedback. Um, And then I also try to use a lot of like rationale and examples when I'm being specific. So explaining to them why I'm telling them that. Like in your example, Louise, like, Hey, I'm telling you this because I just thought of it, not because, um, I actually think it's a concern for our patient or giving them an example. You know, if I tell a student that, um, I'd like them to phrase something differently or that their language is too complex, I'll often try to take an example of something they said that was too complex for that [00:49:00] client, and then give an example of what they could do to change that. Um, and I think that really helps increase the clear communication between the supervisor and supervisee, um, which is so important for, again, that relationship that's gonna support good supervision and good mental health, um,  Jenny Brodell: in your students. Just piggybacking off of that idea of. You know what can kind of support their mental health. Another thing to keep in mind with feedback is that it really helps to focus your feedback on, you know, this is in line with being specific, but focus it on that behavior that you're seeing, not making statements about the individual. So instead of saying, you did this, you did that, those are just. Ringers for, you know, for people to take personally as we all would, right? If someone wrote like, [00:50:00] you didn't do this. Now I'm thinking, oh my goodness, I did a bad job. I'm in trouble. I, I have to do it differently next time, which may be effective, but that does nothing for, for my positive, you know, my, my kind of, um, self-esteem that makes me feel terrible. Like, oh, I failed. So instead of phrasing statements about the individual, keeping it, about that, that behavior, that action, that was great or that maybe needs a little more thought for the next session. So this, this activity was really successful because X, Y, Z or when this type of a statement was used, the client was, you know, that supported the clients. Whatever skill you're working on versus you did this, you did not do that. And I think sometimes  Stacy Robinson: the standards that we have set up for students can [00:51:00] help us focus on those behaviors. 'cause it's almost like a list of behaviors that you should hopefully be looking for and cultivating in your students. So at the grad student level, you have the cost of competencies. Um, some of those are delineated by Asha At our university. We also have other things that we're looking for and a lot of times I try to revisit those, um, competencies. We do it minimally twice a semester in the middle and at the end. But I try to revisit it more than that because that also sometimes helps me give more summative feedback. A lot of times I can give a ton of specific feedback and then the students still won't really have a sense of whether or not they're doing well. So taking that moment to focus on the standards that you have for them and discuss how well they're doing to meet those standards can really help decrease some of that anxiety as well. Because a lot of times we think that we're being clear in our, you know, day-to-day feedback. Um, but students don't really know [00:52:00] what we're thinking in a more summative  Jenny Brodell: sense. I know Louise is going to talk about this strategy soon about your, your own self-reflection and collecting your own feedback. But that point about reminding students about standards is something I have to actively work at. I forget because I just have those casa competencies stamped in my mind because it's what I do all the time. Um, but a once a student asks me in a meeting, kind of like you just said, Stacy, so how am I doing? Am I, am I gonna pass this clinical rotation? And I was thinking like I. Well, yeah. All I write is positive feedback in every, after every single session and every single note. But I'm like, oh, I haven't, we haven't done our midterm yet. I haven't, you know, this is your first semester, so I need to give you a detailed discussion of these are the specific skills I'm looking at. Because feedback that you give for weekly sessions or weekly documentation [00:53:00] is much different than the evaluative feedback you give when you're grading someone or doing a performance review. So just keeping that in mind is so powerful and recognizing like, I have a different thought process than this person I'm working with.  Louise Pinkerton: Yeah, absolutely. And I think that communication is really important and that feeds in to creating that open and honest environment that's really helpful for mental health and helpful for communicating. And it's a really important part of requesting feedback, what you were just referencing that I will touch on now. Um, but as a supervisor, it's very important that we get feedback. I. From the people we're working with. And we all know that we are never a finished product. We will be working on our clinical skills and our clinical knowledge and our supervision skills and our personal relationships until the end of our career and probably beyond that.[00:54:00]  And part of that needs to be informed by the people we're working with. I think of evidence-based practice and you know, we've got the research, we've got our own experience, and then we've got the client preferences. We need to include the student preferences almost in our evidence-based practice triangle for supervision. Um, and that open and honest environment is essential. Um, and also opportunity. I find that students say a lot of things to other students, but if we don't give them the opportunity to share it with us, we don't hear about it. And I often end my supervision sessions with, what else do you need? An open-ended question and. Hopefully they understand it's an opportunity to say, I need to know more about this technique. I really don't understand why we're doing this. Um, I'm horribly stressed and need to, it's just an open opportunity to, to share what they're needing at the moment. And we usually start with an open-ended question about how things are going, [00:55:00] but, but it can lead us different directions and let them actually direct our supervision session. Um, but some of the things we certainly wanna do is model receiving feedback. Well, um, if we get feedback from students and don't take it well and become defensive, we've kind of defeated the purpose. I do find my students have a hard time with the difference between things under my control and things not under my control. I'm gonna start being more speci specific about, you know, there are things I can and will change and they're not a big deal that I'm glad to flex on. There are things I can't change. I cannot change Casa Casa requirements. I can't change a Asha ethics. I can't make your clients show up when they're canceling. Um, you know, I appreciate the feedback, but there's very little under my control. And then there's another group of things that I won't change because I know that this is good educational practice and as uncomfortable it [00:56:00] is for a student to sit in, in those, um, desirable difficulties as it doesn't matter that they don't like it, they're still learning from it. I am finding I need to do some more clarifying of what I can change for the students. Um, and also one of the things I found the last couple semesters, and I think this relates to some of the things with Covid and what Elisa was mentioning about the modern student being different, is that I'm doing the things that have created an open, honest environment in the past. And I've been doing collegiate teaching since 2000. So I have a lot of experience with it. But what I'm finding is students will sit with me, we have a problem, we figure it out, we create a solution, we develop a plan, we agree on it. And then I am skewered in my final anonymous course evaluations. And I think this is part and parcel of learning how to communicate and not having [00:57:00] some of those fundamental experiences where you disagree with people. And just the whole idea of, you know, we need people to understand. They can tell us. That this doesn't work. You know, I wouldn't have had a problem with any of the things that were said. What I have a problem with is that some of the students agree to one thing when they really want something else. Um, and so it makes that feedback really important and I've been doing a lot of reflecting on that and how I am gonna find a way for these students to feel comfortable. It's a challenge.  Stacy Robinson: Yeah. That is so difficult. And I think it goes back to what you're talking about, Louise, about creating those opportunities for feedback. Um, you know, that's hard to do on both sides of the equation, you know? So there's so much that we're often talking about in our individual meetings that's just, okay, how are we gonna get to through the next session? Um, but spending some of that time you have with your student, whether that's in [00:58:00] scheduled meetings or between sessions, whatever, I. Setting you're in and what that allows for, to give them an opportunity to let you know how you, how they think things are going. Um, I often. At least at midterm, uh, require my students to give me, um, non-anonymous feedback because I always tell them, I'm like, this feedback is for you. The feedback you give me at the end of the semester doesn't help you because you're going to a new supervisor, but the feedback in the middle could help you as an individual. Um, so I really try to encourage that for them. Um, but then it's also important to make sure we're creating opportunities for us to give feedback to the students, um, and making sure that that feedback is timely. You know, some students myself include, well, really myself, so people in general, um, just to have short memories and they might not remember what happened two days ago. So if the student does a session and we don't get them their feedback for a couple of days about that specific session. [00:59:00] They might not really remember what we were talking about. And sometimes a student will ask me a question about feedback that I gave them a week ago, and I have to say I don't really remember what was happening in that session. Um, which is why being specific can be helpful. 'cause then that usually triggers my memory better. Um, but yeah, but finding times to be timely with your feedback. So whether that's something that you have to do in the moment, in the middle of the session because it's impacting the client's care or if it's something that you need to say right after the session so that it's fresh in both of your memories. Um, or if it's that more summative feedback that I was talking about before and maybe that only happens once a week or once every couple of weeks. Um, all of those things are important to take into consideration when you're giving students feedback. And again, if we pull back to that mental health piece, if you have a student that has a lot of anxiety, They just finished the session and they're not hearing anything from you that can real, just the, the [01:00:00] not knowing of how the supervisor thought that went can really increase anxiety. So a lot of times I'm running from one session to another. I don't have time to do a long verbal debrief with a student, but I'll at least say like, Hey, that went really well, or, oh yeah, he had a hard time with that. You know, your client had a hard time with that. We'll make sure to talk about that in your meeting. So they at least get something from me before they go to read my, uh,  Kate Grandbois: written feedback. And I have to assume that in those situations, you know, kindness and a smile go a long way, even if it was a really rough session or even if, even if, regardless of the situation. Um, being a graduate student is so you, you're so vulnerable. I remember that feeling of being looked at through the one way mirror. Oh my Lord. And it was very uncomfortable. You're just being creepily, like, just observed, you know? It's, it's really uncomfortable. So I have to imagine that just the [01:01:00] delivery, embracing a little bit of kindness and a smile, and even, even commenting on one praise you. This went really well. The other parts, well, let's talk about it at your meeting. You know, I just, I I have to imagine that that really, you know, counts.  Louise Pinkerton: Absolutely. I remember one session where the clinician mentioned to me right at the end as we were all wrapping up and the client had left, well, that was a dumpster fire. And I'm like, no, actually, it was exactly what I expected, and it was exactly where we needed to be. We were co clinician together. You did, you did everything. That you were capable of doing at this moment. Um, so it, that can be so important for that client not to have lived with their dumpster fire.  Kate Grandbois: You all have shared so much with us today. We've talked about workplace culture, components of mental health, everything as a supervisor you can do to improve this journey for graduate students. You've brought a framework to the table. We've [01:02:00] talked about how you can model things. You've shared so much knowledge. Do you have any parting words of wisdom for our audience or words of advice for anyone who is listening who is currently supervising a graduate student or thinking about supervising a  Louise Pinkerton: graduate student? Yeah, I will take this one. Um, the first thing is don't do it all at once. Um, take some time, reflect on what you're doing, acknowledge yourself for what you are doing well, and then think about some small achievable changes you can fit into your practice and your setting and your situation. So maybe if there are one or two ideas from this that you think would make meaningful changes, implement those. See how it goes. And then reflect again, do I wanna continue doing these? Do I wanna add another one? Have I made these a habit enough? I've got the mental space to add something new. And I think it's just a process of wash, rinse, and repeat. Um, keep doing this as you go and adding [01:03:00] and dropping strategies as you find that they do and don't work for you. But, you know, one to two at a time is plenty to try and change in the moment. Um, The next idea is that good super supervision is fundamentally about collaboration and communication. Uh, I am very used to a model where all the knowledge comes from the teacher. This needs to be a collaborative process with the students these days, and it gives us the opportunities to hear what they need. Um, and it's a chance for us to continue to get feedback and grow and develop and meet these students where they need to be. Um, the last one I wanted to add here is that, you know, we can't manage our supervisees mental health. Most of that is things they need to be dealing with and they need to be working with professionals on and developing their own strategies for. But what we can do is create an environment that doesn't make it worse at a minimum, um, and actually help support them. [01:04:00] To, to be more proactive and, you know, the things that help us with our mental health and managing burnout and, and all of that are probably good for our students too. So making those connections between what we do for ourselves and and helping support them. And then the very last thing I wanna say is, uh, the four of us have two virtual presentations at ASHA this November. So if you wanna join us for a more lecture style, uh, information, we're gonna be talking about mental health and Anderson's continuum and these feedback strategies in more detail. And then at the University of Iowa Communication Sciences and Disorders YouTube channel, we have a webinar that Stacy, Jenny, and I did on again, Anderson's, uh, continuum and the feedback strategies that you're welcome to watch anytime. And we'll make sure you have that web page for the show notes.  Kate Grandbois: Thank you so much for [01:05:00] sharing those resources. Yes. We will link everything in the show notes. You've also sent this beautiful reference list, so anybody who would like to do some additional reading or learning, we have many places for you to go. Thank you all so much for being here. This was really wonderful. I really appreciate it.  Louise Pinkerton: Thank you, Kate. It was great to be here too. Stacy Robinson: Yeah, thanks for having us. Thank you. Sponsor 2Outro 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.[01:06:00]