This is a transcript from our podcast episode published January 30th, 2023. 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. [00:00:00] Kate Grandbois:  Welcome to SLP nerd cast, the number one professional resource for evidence based practice in speech, language pathology. I'm Kate Gradnbois  [00:00:09] Amy Wonkka:  and I'm Amy Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast.  [00:00:16] Kate Grandbois:  Each episode of this podcast is a course offered for ASHA CEUs. Our podcast audio courses are here to help you level up your knowledge and earn those professional development hours that you need. This course, plus the corresponding short post test, is equal to one certificate of attendance. To earn CEUs today and take the post test after this session, follow the link provided in the show notes or head to SLP nerdcast.com . [00:00:41] Amy Wonkka:  Before we get started, one quick disclaimer, our courses are not meant to replace clinical. We do not endorse products, procedures, or other services mentioned by our guests, unless otherwise specified. [00:00:53] Kate Grandbois:  We hope you enjoy the course. [00:00:55] Announcer:  Are you an SLP related [00:01:00] professional? The SLP nerd cast unlimited subscription gives members access to over 100 courses, offered for ASHA CEUs, and certificates of attendance. With SLP nerd cast membership, you can earn unlimited CEUs all year at any time. SLP nerd cast courses are unique evidence based with a focus on information that is useful. When you join SLP nerd cast as a member, you'll have access to the best online platform for continuing education and speech and language pathology. Join as a member today and save 10% using code nerd caster 10. A link for membership is in the show notes. [00:01:45] Kate Grandbois:  Hello everyone. Welcome to this week's episode. We are so excited to welcome back a guest Nina Reeves. And today she brings along with her, her husband Lee Reeves. Welcome Nina and Lee. [00:01:56] Nina Reeves:  Thank you. We're glad to be. I'm [00:02:00] glad to be back. And I'm glad to tow this one along. Yeah. [00:02:03] Lee Reeves:  Nice to meet y'all. [00:02:04] Amy Wonkka:  Nina and Lee, you are here to discuss stuttering therapy, a view from both sides of the table before you get started. Can you tell us a little bit about yourselves?  [00:02:17] Nina Reeves:  Why don't you go, oh, I'll go first. You go for it. Well, um, my name's Nina Reeves and, um, I'm a stuttering specialist here in Texas and, um, I work in the public schools and in private practice and it's what I do all day, every day. Um, and this one.  [00:02:37] Lee Reeves:  Well, I'm, uh, Lee Reeves. Uh, I'm a retired veterinarian. Um, I've been in, uh, I had a private practice for over 40 years, 42 years. Uh, I am also, uh, a person who stutters. I'm actually pretty good at it. Um, uh, I can stutter on just about anything at any time. Uh, even though I don't stutter as much [00:03:00] overtly today as I did when I was a youngster or going through, uh, high school or college even, um, I still stutter every day and, um, uh, still work within the self-help community and, uh, excited about being here as well. And that's how we met. [00:03:14] Nina Reeves:  Yeah. We met through the national stuttering association when he was chairman of the board and I was a volunteer and, um, it was really kind of cool. And so we were friends for a long time and now we're married and have been for a while.  [00:03:29] Kate Grandbois:  I love that story. And I, as a person who knows you, it makes me wanna ask you more questions about that, but I will, I will refrain for the sake of your privacy. [00:03:34] Nina Reeves:  We'll do the love story after. Okay.  [00:03:40] Lee Reeves:  So great. I was looking for arm candy and, um, you know, there I am.  [00:03:45] Nina Reeves:  There you was [00:03:45] Kate Grandbois: . I love it. I love it. It's awesome. Okay. So, um, we are really excited to get into this topic with you today. Discussing stuttering therapy from, as you say, both sides of the table. But before we get into that [00:04:00] conversation, I do need to read our learning objectives and our financial and non-financial disclosures. Uh, so I will just go ahead and get that over with as quickly as possible. So learning objective number one, describe at least two ways that clinician experiential learning improves long term outcomes and stuttering therapy. And learning objective, number two, identify at least three roadblocks to therapeutic alliances and how to overcome them. Disclosures Lee Reeves financial disclosures. Lee is the part owner and CFO of stuttering therapy resources Inc. Lee Reeves non-financial disclosures. Lee is a public member for speech language pathology on the ASHA council for clinical certification and speech language pathology and audiology. Lee is also a former chairman of the board for the national stuttering association. Lee Reeve's financial disclosures. Sorry, Nina Reeve's financial disclosures. Nina is part owner and COO of stuttering therapy, resources, Inc. Nina Reeves non-financial disclosures. Nina is a [00:05:00] volunteer for the national stuttering association. Kate that's me, my non-financial disclosures. I am the owner and founder of Grandbois therapy and consulting, LLC. And co-founder of SLP nerd cast. My non-financial disclosures. I'm a member of ASHA, sig 12 and serve on the AAC advisory group for Massachusetts advocates for children. 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. [00:05:29] Amy Wonkka:  Amy that's me. My financial disclosures are that I am an employee of a public school system and co-founder of SLP nerd cast. And my non-financial disclosures are that I'm a member of ASHA, SIG 12, and I serve on the AAC advisory group for Massachusetts advocates for children. All right. Onto the good staff, Nina and Lee. Why don't you both start us off by telling us a little bit about clinician experiential learning. What is that?  [00:05:57] Lee Reeves:  Well, I, I, I told Nina when we [00:06:00] started to discuss this, uh, to maybe it would be good if I went first as the, the individual who actually stutters and, and grew up with, uh, fairly significant stutter and have had a variety of speech therapists through through the years. So from experiential standpoint, I'd like to share maybe just a couple of stories that I think have stayed with me and are, might be helpful.  [00:06:24] Nina Reeves:  And before you get started on that, uh, to, in, in direct answer to your question, clinician, experiential learning is really as simple, uh, as it sounds, it's learning from the experiences of, in this case, people who stutter, our clients are students, their families, and, um, learning more about the condition through that rather than all through academics and theory, but being, um, more receptive to listening to the experiences of those who stutter.  [00:06:59] Lee Reeves:  Yes. [00:07:00] Or even just having that understanding. Um, my first speech therapist, um, was, um, when I was nine years old, I was in the fourth grade. And, um, I don't recall what she looked like. Really. I think she had red hair, but I don't really recall. And I don't remember her name and I don't really remember very much about what we actually did in therapy on a regular basis. Um, except that she was a recorder. I, I did a lot of recordings, but. One day I walked in and this is what I remember. I walked into therapy and she said, she sat me down and she drew a big circle on a sheet of paper. And inside that big circle, she drew a little tiny circle down in one, one corner of that larger circle. And she said, Lee, I want you to look at this. She says, this large circle is you. I want you to think about that being you and this little tiny circle down in, uh, the bottom. That's your [00:08:00] stuttering. Now I was in the, I was nine years old and in the fourth grade, and that, you know, when folks ask me about my therapist, I say, well, they say what help? I don't remember any strategies or any therapies or any, anything that we did. But I remember that now that was important to me and it, and so to me, what that said is that, that she thought that I was more than my stuttering and that she wasn't just treating my mouth. Um, that's why I didn't know that at the time. But now, so that was an important thing to me as, uh, as, as, as a student and as a young person who was in therapy. And then the second example is jump ahead to the 11th and 12th grade. We had just moved, um, to the Washington DC area from San Antonio. Um, it was a tough move for me. Um, I didn't have any friends. I had no support system up there. My stuttering was fairly significant. Uh, [00:09:00] at that time, in fact, it was very significant at that time. And, uh, so I was enrolled in school late. We got there late in the summer and, um, I had to go meet the new therapist. So I was called out of class to go down, uh, in the first week or two to meet my new therapist. And I was wondering, you know, is this the one, is this the one that's gonna help me? Is this the one that's gonna fix this? You know, who is this? And so I walked in and. Um, she was interested in my move from Texas, et cetera. And, and in that conversation, I happened to mention that I didn't, I was really disappointed cuz I didn't get into the concert choir. I had sung in the choir was one of the things that I was also an athlete, but singing in the choir was really important to me. And we'd gotten there so late that I didn't, I didn't get into that choir. I was in the boy's glee club or something, which was, you know, was not interesting to me. So that was that. And a, a few days later I got called down to the office and [00:10:00] I thought I was in trouble. I mean, it usually took me at least a month, but I, it was, you know, I was there much earlier, so I get down to the office and they had me a new schedule and the new schedule has the concert choir on it. So what I learned and found out is that she had gone down after that conversation. After the first time we had met and she was able to change my schedule. So that was very important. That was one of the first things that happened. And again, in retrospect, I think what that said to me nonverbally is that she really cared about me about, you know, not just, again, my mouth, not just a stuttering. And then from that point, I remember that, um, she shared with me fairly early that, um, I was her first case, if you will, or her first student who stuttered, she was young and she was, uh, outta school, not very long now that might have had something to do with why I liked her so much. But the, the point was is that, um, [00:11:00] she was kind of vulnerable in that sense, but, but she said that, you know, we, we would learn kind of together in a way that we'd do this. And that created a lot of trust for me and, and, and her, um, willingness to be kind of vulnerable. Um, you know, we kind of talk about this therapeutic Alliance and I think that was what it, what it was is I, I, we, we, we began to, she began to listen to me and I found it to be a very safe place. I actually, for the first time in all of my therapies through school looked forward to going to my therapy session once a week. And again, strategies and things. I don't remember any specifics, but whatever the conversation was, it was, it was about life. It was about me. It was about support. Stuttering certainly played in to all of our conversations, but it was more about supporting me and, and being, [00:12:00] um, helpful. And then the last thing that she did this, these, these all occurred in that two, your time period was that, um, she introduced me to self-help, she, she, one day I went into therapy and she said that she had heard about this new group that was forming, uh, you know, downtown Washington, DC at Catholic university, uh, or for adults who stuttered and wondered if I might be interested in going to that group, which I did as scared as I was, because desperate people do desperate things. And I was pretty desperate. That's a D D D that just runs together, done it. um, uh, and so all of that combined told me and her name was Roseanne Clauson. And what that said to me, uh, in retrospect is that, is that she was listening to me and she was learning from me as I was learning from her. [00:13:00] Um, and so I think that that alliance, that understanding it, that trust, I, I had a great deal of trust in her, but it didn't happen overnight. It happened over time. And, uh, did it solve my stuttering? Uh, goodness, no. I mean, my actual overt struggle. My stuckness with my stuttering was just as significant. And in fact, maybe even became more significant when I left high school than went off to college. But it wasn't about my stuttering. It was about somebody who believed in me and encouraged me and said that I could do anything that I wanted to do regardless. Or in spite of, or regardless of how I spoke. [00:13:42] Kate Grandbois:  I've been taking notes as you were talking, and you touched on so many aspects of your experience that stuck out. And first I wanna point out that nothing you've mentioned was specifically about strategies, which is something that we've already learned from Nina, that there are so many [00:14:00] components to this outside of what we learned in graduate school. But one of the themes that really struck me about the stories you just told were really about the relationship that you developed with your speech pathologist or with your therapist. And in that relationship, there was bidirectional, there was a bidirectional relationship. So you knew something about your therapist. You were able to develop a trust, a sense of trust in that relationship, the person in the relationship with you, advocated for you for something that wasn't related to your stutter. So this is what makes him happy. I'm going to go advocate and try and make that change. Um, I wonder, you know, these are all, this is again, I guess something that we've talked about with Nina before, but these are not things that we learned in graduate school as clinicians. These are not things that if anything, I think at least for me, and I'm only speaking for myself and my experience, I was taught to establish boundaries with [00:15:00] my students and clients to not share personal information. And to uphold a more professional quote, professional relationship. That was more about probably power and knowledge, to be honest and, and knowing the things that I, that I knew. I don't know if either one of you wanna,  [00:15:17] Lee Reeves:  well, let me come back, lemme come. Yeah, let me come back to that. Um, cuz that's a very important point, but let me give you before I answer that, that question. Let me give you the opposite side of some of my therapy. Okay. So I gave you the two therapists that I had out of the five that were very, these are things I remember. I don't remember two of them, except that one of 'em didn't like me. And so I didn't go back anymore, but, uh, I don't think she liked me. She didn't act like she liked me. I don't know. But, but then there was one that, that, that had a huge impact on me and this, uh, again, I was in the 10th grade. This was before we moved, uh, to Washington. [00:16:00] And as I said, I sang in the choir and I stumbled onto this, this amazing concept one day in choir when the instructor called, uh, the choir director called on me. And I noticed that if I tapped my toe inside of my shoe, I was able to answer the question. Without stuttering. And it was incredible. I mean, I thought, wow, this is, this is cool. So I went to therapy that week and when I walked into my therapy session and I don't remember this therapist's name at all, or anything else about what we did except she was a reader and we can go at that later. Um, and so I said to her, she handed to me the newspaper to start to read. I read the first paragraph, just like this and was not stuttering at all, which was highly unusual for me because I was a good stutterer. I did it really well. And she, uh, she looked [00:17:00] at me and she said, oh my gosh, what's changed. What are, what are you doing? And I said, well, you don't know this right now, but I'm tapping my toe inside of my shoe. And she said, that's terrific. That's amazing. That's wonderful. Whatever you can do to not stutter. And so that said to me that, that that was not only okay, that those are the kinds of things that I should be doing because stuttering, I mean, I didn't like to stutter of course. And so she was encouraging me to avoid my stuttering in a sense, and that toe tap led to a foot pump to a hand fist, to a grimacing, to all of the different kinds of secondary behaviors and surface behaviors that, that as I recall, came out of that session. So here was someone in retrospect who was treating my mouth [00:18:00] and not treating me. And, and that's really kind of juxtapo-, juxtaposition to the other two that I talked about. So there's that. And then quickly getting back to your question, uh, about this idea of, of hands off and the boundaries. I was taught the same thing. When I went to veterinary school, we were told not to help, not to make decisions for clients, that we were just there to get to lay out the facts and it was up to them to make the decisions. And you learn this, you know, you try this out early and you know what you learn if you own a pet. I mean, if you, if you're a pet owner yourself, but in, in a professional stance over time, you do have an opinion. You do have some experience. You do. It's not that you're going, I'm going to tell them what to do, but I can be a lot more empathetic with that client. I can say, I understand where you're coming from. And when they legitimately legitimately asked [00:19:00] me, what would you do? What would you do Dr. Reeves? I could say, well, I'm not exactly sure what I would do. I would be struggling the same way you are. I would be facing the same kinds of questions as you are. I would be taking the information that I'm giving to you, and I'd be struggling with it to try to make that kind of a decision, whichever way you go. I'm on your side. You know, I'm here to do that for you. So it's, it's, it's giving in a little bit. It's not, it's not, um, breaking down to the barrier completely. I think you can maintain a very professional relationship and still have a relationship.  [00:19:40] Nina Reeves:  that's a good way to put it. Mm-hmm oh, let's write that down. [00:19:45] Amy Wonkka:  well, because we are, oh, go ahead. Go ahead. We are all people. So in, in, in both of these worlds, whether you're a speech language pathologist, you're a veterinarian, you're interacting with people about  [00:20:00] people things. And so to completely take away the humanity of it all just seems impossible and also wrong. I mean, I think the other piece Lee, as you were talking about kind of your, that third therapist who you don't really remember, you know, I think one thing that I was reflecting on while you were talking is just how, how impactful. The choices that we make in terms of what to say and do as clinicians can be even something that might seem small to us, if we're not reflecting on it, the way that we should be. Um, and I think that's probably really true for you in your veterinary practice as well. Um, you know, I think you’re probably giving people a lot of like helpful feedback that just makes them feel better.  [00:20:51] Lee Reeves:  Well, it's a, it's it it's, um, it's about relationships and, and you know, why did I [00:21:00] remember those three things out of all of my years of therapy and all of, all of my years of stuttering and all my years of living, why do I remember the circles? When I was nine years old. Why do I remember the, the idea of somebody changing a schedule for me that had nothing really to do with stuttering directly? Why do I remember that? And why do I remember the toe tapping incident? Well, those were major, uh, events that had really to do with my stuttering, but had nothing to do with strategies. Uh, and yet they were, they were on the one hand, it was a positive impact. But the one that actually had something to do with the strategy toe tapping, which some people, you know, finger tap, they do it, which could be construed as a strategy, had a real negative effect on me. Now that's not to say that strategies are bad. And, and I mean, we, we need [00:22:00] them both of course. But when one is emphasized in the absence of the other, I think, uh, we can run into trouble. And that's where learning, that's where understanding the phenomena of stuttering. Getting back to the, what we're talking about here, experiential learning and experiential knowledge is more than academic knowledge and a set of skills that you learn in graduate school that you forget like three weeks when you're, when you're out of graduate school. It is, it is ongoing learning and, and, and allowing yourself to, to understand the phenomena of stuttering, not just the term, not just, you know, what you see on the service, but what is it? What's the experience like, what is it like for me and others like me to live with this every single day. And how, how can you as, as caring individuals and caring therapists, uh, interact with that in a meaningful way, that is not just [00:23:00] about trying to fix something that you can't fit fix. [00:23:05] Kate Grandbois: I have a, a question, but before I get to my question about how clinicians who are listening can actively seek out experiential learning. I wanted to ask or at least make a comment, um, about something that I think is tied to your negative experience with the toe tapping. It makes me think of all of the implicit biases that we have or all of these implicit rules we have about what is accept, socially acceptable. What's not socially acceptable, what's quote good. And what's quote, you know, what is quote bad and, and that your therapist, in that instance, I don't wanna make assumptions about her intention, but I can imagine a lot of us with having the right intentions accidentally communicate these implicit biases about how that is bad. And we want you to do that less, or you know, where even if the intention is, I [00:24:00] know this is something that you would like to change or improve, and I'm here to support you in that it's these very nuanced messages, um, and the role of implicit bias that I. Leaks out. Do you agree with that? Is that, is that something that, that resonates with you? [00:24:15] Nina Reeves:  Well, I think, um, you know, you're gonna learn, you're gonna lead us right into objective number two, but before we get there, uh, I'll answer, I'll answer it this way. Um, you know, it's not truly an answer. It's a thought pattern. The, the experiences Lee has shared, and of course I know all of them and I've heard them before and I, I, I just think they're, so they, they really shine a light on the different, um, the differences in our training and the differences in our biases. And I'm not even sure. Um, I was speaking to some therapists. Um, I did a presentation just the other day and I was standing with them in this big room and I thought, you [00:25:00] know, I'm not even sure we actually believe that we're supposed to fix stuttering. I'm not sure that we came into this profession saying we are gonna get rid of that stuttering. That stuttering is bad. We're gonna get those people to stop that thing. Right. It's an aberrant behavior. I'm not sure anybody ever goes in thinking that. And so it's almost like I we're giving permission to therapists to go, wait a second, let me step back from the training or the social stigma or the messages we get as therapists and just people on the planet that fluency good stutter bad, you know, and you don't even have to say stutter bad. If you say fluency good. If you praise fluency, if you do anything to have fluency and, and Lee and I were talking, you know, before, before doing this today that, um, you know, that's considered fluency at all cost, that toe tap, that's a cost. there's a cost to that, right? So you [00:26:00] may see an an on the surface fluency, but it's gonna break down. It will. It'll stop working. Um, and then there's costs for that because the, the message is, as you're talking about the unintended messages, um, yes, let's do anything you can to not stutter, which then increases the struggle.  [00:26:23] Lee Reeves:  Stuttering is, is very hard. It's very difficult to explain in a meaningful way to people that don't stutter. And in fact, it's pretty difficult sometimes to explain to those of us who do stutter, um, because it's so variable and intermittent, it's a, neuromotor, you know, it's an inherited and developmental neuromotor condition that has to do with our neurology. And it, it, it is not something that is easy to explain to somebody that doesn't stutter because. People who don't stutter have never really felt that out of [00:27:00] control that, that inability to move forward or to get out of, um, uh, a long block or a repetition or a prolongation, those kinds of things, where we get stuck in our neurology gets stuck. And in our heads, we're saying just open your mouth, stupid. Just open up, just go, okay, just relax. Okay. Just let the air flow, come on. You know how to do this? And you've done it a million times. Just take a deep breath, you know, do whatever these are the things that are, that are cycling continually inside of our head that nobody else can see hear or feel except for us. And to try to explain that phenomena, to try to help people to understand the experience of living with that is incredibly difficult. And, and, and because it's variable, you know, I still stutter, but I don't stutter with the frequency or the severity that I did, uh, when I was young. [00:28:00] And you know, we talk about this, I talk about this some, when I give these lectures is that sometimes I feel like an imposter because I'm, I'm representing this community. And yet, sometimes people look at me and say, well, gee, you don't stutter. You know, I don't hear you stutter. Well, they don't realize that that's an insult to me, but it's, they're not trying to be mean. It's just that they don't know what it's like to have this variability and this intermittent unpredictable interruption in the flow of speech. And so it's a difficult con it's not like articulation, you know, that you fix , you know, this, we have to, we have to learn. It's so nuanced. As you said, we have to learn not only. How to, uh, accept ourselves and come to terms with the idea that, you know, we're probably gonna stutter some, you know, once we're older than six or seven or so, and that's probably gonna be with us and how that, how we [00:29:00] come to terms with that and come to learn that and understand it is gonna be, is gonna be based on age, age related information. I mean, you know, you're not gonna talk to a seven year old the same way you're gonna talk to a 13 or a 25 or 35 year old about their stuttering, but somehow. That's what you guys are so good at is being able to be creative and find ways to help all ages regard, you know, where you, whatever setting you're in, but finding ways to help us come to terms with, first of all, the fact that we stutter. And then that doesn't mean that we shouldn't do something about it or that we shouldn't, you know, want to improve our ability, um, to, to not, to, to, to improve that stuckness. It's not that we're not gonna get stuck. I just like to know, I'd like to not to get stuck as hard or as much. And if I do, which I'm going to. I need to know how to manage that emotion, [00:30:00] that feeling, you know, wow. That was a good one. You know, you know, easy for me to say, you know, I mean, things like that, that, that allow, allow not only me to be okay with the fact that I just had an interruption in my speech, but allows my listeners to allow the people that I'm talking with to hear that, that I know what I just did and that I'm okay with it. And that I'm happy to share with you what that is. Um, and in fact, uh, I don't do it to put you at ease. I'm doing it to put myself at ease, but in, in doing that, it also puts my listener at ease. Does that make sense? Uh, so it's, it's, it's about helping us to come to terms with that and then helping us to manage, uh, our lives with stuttering, cuz we're gonna stutter and, and it is okay to stutter that we get so confused about you know, saying, is it okay? And, and then, okay, if it's okay to stutter, does that [00:31:00] mean that we don't need therapy or we didn't want therapy or that, you know, it's just out there. Um, some people, you know, for some folks that works for them and that's fine, they, they they're, they're management, they're coming to terms with their own stuttering means stutter like it is, you know? Um, and, and that's fine. Others say, yeah, stuttering is okay, but, but I still would like to do something to communicate easier. I'd like to communicate easier. I would like to be less stuck if you will. And so that's okay too. It's it's I don't wanna throw the baby out with the B with the bath water. It's it's all part of you know what Aristotle said? There's an, there's an apoplexy, there's an internal seizing of some kind of a mechanism internally. And he also talked about, uh, um,[00:32:00] melancholy. See, that was so good. Sometimes you just get stuck and, you know, melancholy, melancholy, melancholy. I can say that. Come on Lee. Geez. So, but he talked about a melancholy, which was this emotional aspect of studying that was 365 BC. Come on. I mean, it, it's not like this is new stuff. So  [00:32:25] Nina Reeves:  I love my geeky husband who has the history of stuttering at a moment's notice. And, and I love that. I love that there are people in the world that remind us clinicians that it's not the technical stuff. It's not all about the technician. It's the clinical, which means relationships, which means more than just the stutter. You know, as we say, in our books that we write and you've had Scott on the podcast, you know, stuttering is more than just stuttering. It's more it's, it's the experience, not just the moment. [00:33:00] And certainly there are moments of stuttering that Lee has and that all of our students have that we're never gonna see. So counting those stutters. I don't know, chasing a grease pig, don't know, uh, variable, uh, situational, uh, under the surface on the surface, we don't even know how many times a kid stutter. So why are we trying to do progress in therapy? Um, based on percent of fluent speech, that's just, we've already done a podcast on that. They can go back and listen to that part. But you know, there are just too many nuances, as you said, tape  [00:33:37] Kate Grandbois:  well, and something that I am reflecting on having, you know, Lee, listening to your stories, you know, Hearing about the importance of this experiential component, but also thinking about our first learning objective with learn improving long term outcomes. It seems to me, and maybe, maybe I'm connecting the dots incorrectly, but those long term outcomes are not defined by the [00:34:00] therapists. Those long term outcomes are defined by the person that you are working with in therapy using a person-centered care approach. Right?  [00:34:11] Lee Reeves:  Yep. It's so funny. You should say that because one of the things that I think is so sad about your profession is that, is that you don't get to see the results of your work. Oftentimes you have a student, particularly if you're in the schools, uh, you have a student for maybe a year or two, if you're lucky, maybe three, uh, rarely four, but, you know, and, and changes, particularly in that age group, are not gonna happen that quickly and that frequently. So the groundwork of the foundation that you have that you're able to lay at that time can pay a lot of dividends later. And, uh, I had the, the great fortune of meeting up with Roseanne Clauson 25 years later, 20 years later, she actually worked for ASHA, uh, uh, because I went to high school in the, in that area.[00:35:00]  And so long story short, I had the opportunity to track her down, uh, and meet her. And, uh, I, I set up a lunch with her at an Asha convention. I actually took off work and went to San Antonio, uh, to meet her. And we had these yearbooks cuz we didn't look like each other. It's been a long time. And I went and, and I, I was just glowing because she made such an impact on my life. And so I took her to lunch. And uh, spent the whole lunch period kind of talking about there a whole lunch time talking about this and her eyes, her she jaw was on the table and her eyes were just open at the end of our lunch. She, she said, Lee, I just have to ask you. She said, what did I do? and I said, you did everything. So that's your point is that, um, yeah, the long term outcome was, was me, uh, those little things, the big circle, the little circle, the, um, the changing of the schedule, the introducing me to self health, the, the, [00:36:00] the sitting in that room in a safe place, and being able to talk about all kinds of things in life, but still somehow incorporating my stuttering into those conversations. Those are, those are short term events that, that have long term outcomes. And the sad thing I think for y'all is that you oftentimes, most of the time, never get to see the results of that foundational work that you are able to do. And I oftentimes tell speech that, you know, when I, when I was walking down to, to see Roseanne Clauson for the very first time in the 11th grade, what was going through my mind was, is this the one, is this gonna be the one. That's going to make this go away. That's going to, you know, that and what I, and she wasn't the one, nobody was the one that made it go away. But what I try to instill in speech pathologists is you [00:37:00] can be the one. You are the one, um, in, in laying that foundational work, that therapeutic alliance that trust that being able to help kids, um, and adults for that matter, not just, um, uh, know who they are and, and understand that stuttering doesn't define them. You know, it's just a small part of what they have to offer in this life and that yes, your skills can help them manage some of those tough times, both, um, physically tough times and emotionally tough times, and a really good therapist, uh, goes past that just knowledge and skill set that you came outta graduate school with a really good therapist, has an experiential. They, they get into it and listen to and learn from, from their students. They learn from the people who stutter and take in that knowledge, because. [00:38:00] While you can't understand fully the experience, the lived experience that we have, you can get it, you can learn how to get it. Uh, quote, unquote, if you listen to us. [00:38:15] Kate Grandbois:  I, I love that. And I, something you said actually brings us a little bit more into our second learning objective. It was, you've mentioned the term therapeutic alliance. I wonder if you could either define it or describe it. What is an ideal therapeutic alliance? What do you mean when you say that? [00:38:30] Nina Reeves:  Oh, well, that's a great question. And I think, you know, when, when we're talking about therapeutic alliance, we're talking about aligning expectations, aligning understanding of who each of the people in the therapeutic, um, I would call it the therapeutic circle would be, and for us in the public schools, especially, well, no, for us, anybody who [00:39:00] works with anybody who has a family or a teacher or a, uh, uh, an employer, there is a therapeutic circle that extends well beyond the therapy room. And so the idea is to align with the communication environments of the client that you're working with. Okay. The people in them and the understanding and perceptions of stuttering in those spaces, as well as with the understanding and perceptions of stuttering of the client that you're working with. [00:39:39] Lee Reeves:  Yeah. And it, it, you know, I, I think that terms comes, comes outta the psychology literature and, um, you know, for, for me, what it means is that the alliance is, is that it, that, that the barriers or the boundaries that you spoke about earlier, um, are not blurred, but they're expanded. And it it's, it's a, it's a team effort. I mean, an alliance that we're [00:40:00] doing this together, it's not me doing it to you or fixing you or telling you what to do or necessarily how to do it. It's it's us exploring this together. And, um, it's a, it's a give and take. So we have an alliance, it's a therapeutic alliance. That's based on trust. Um, I, as a, as a client or as a kid who stutters, if I don't trust you, , you know, if, if, if I don't, if I don't trust you, uh, to, to be open and you know, for me to be open, I'm not gonna be open and honest with you. You ask, you know, you ask any 13 year old boy. Well, does stuttering bother you? Nah, doesn't bother me. No, I'm not gonna tell you that , you know, and, but if you had that Alliance, if you had that, that trust, then first of all, you wouldn't phrase it. That question, that way you would phrase the question and another way to tease out, um, what, and you can only do that by getting to, by, by being [00:41:00] vulnerable, by allowing them in a little bit into your thinking and your think and you're into theirs. So I think that's, what's so important about that therapeutic alliance. It's it's really about trust, but, and I think the therapist has to. The client as well as student, [00:41:15] Nina Reeves:  bigbig, big difference. And I was gonna, I was gonna, he was already reading my mind. This is what we do every day. Every, every day over coffee, let's solve all the world's problems. um, mostly stuttering and speech language pathology profession, but you know, we're working on it. And one of the things that happens is the idea that, uh, that trust. And I don't wanna, I don't wanna minimize this if you don't trust the client, if us, as the therapist do not trust that that client can, um, be in this alliance with us, then, you know, it's gonna break down no matter how much the client trusts us. If we don't trust the student and the family and the, and the, the, the therapeutic circle to make [00:42:00] change or to be vulnerable or all of those things, then it, then that's what we'll get is mistrust. If we don't, if we don't trust  [00:42:08] Lee Reeves:   the, um, I think the three most important words for, for me, uh, as, as a clinician, um, as a clinical practicing veterinarian for all these years, and I think transfers over to speech pathology as well, the three most important words, I think that I ever relate to a client where I don't know. I, I don't know, but followed by I'll find out or I will, I will. Yeah. Or I will get you to somebody who knows. Um, you know, that's a very interesting issue. I haven't seen that in a long time. It's, you know, I know what this is, I think, but it's been a long time since I've seen that in your case. I had, um, a youngster who stutters in a while. So you know what, I'm not sure, but I'm gonna find out and that maybe you don't say that to the child, but you talk to the parents. I guess my point is, is that, is [00:43:00] that we have to get, we have to get off of this, this therapeutic view of the world, where, where I am intelligent, I am the purveyor of all knowledge and all things. And I am going to, to provide you with what I think is important for you in this situation I am going to now, even if I'm not going to fix you, I still am the purveyor of the knowledge. It there's no alliance there. And we have to get past that. We have to break that barrier down and, and find that that it's okay to trust clients with their information. And it's okay for us, me as a, as a veterinary practitioner and you as a clinician to say, you know what, I don't have all the answers, but I am more than willing to do whatever it takes to be on your team and to help you out.  [00:43:57] Kate Grandbois:  I'm just gonna say this back to you. It's, it's, it's [00:44:00] encapsulated in, um, in just a handful of qualities. I'm hearing the importance of vulnerability, the importance of humility. And the importance of humanity. So being a person and engaging in some shared space of vulnerability and how mu how far that can go to build trust. Amy, what were you gonna say? I'm sorry.  [00:44:23] Amy Wonkka:  I, no, I, I just think it's also helpful to clinicians, any clinician be a veterinarian in our speech pathologist permission to not know all the things, you know, we, we talk a lot on here about our scope of practice is really, really, really broad. We, we can't know all the things and I think, you know, often we're put in this position, whether it's because of the infrastructure in which we work, uh, or like kind of our own self-imposed limitations that we feel like we have to, we have to know everything. We have to have all the answers. And if we are coming into [00:45:00] a therapeutic interaction with somebody with that personal perspective, that could also give us some anxiety coming in, you know, I, I don't know all the answers and I'm not sure what to do, but I have to be the best. And I have to know all of the things. And I would think that if that's how you're entering, um, an interaction with a client, you're, you're never going to make it that that's gonna be a persistent roadblock. Like you're never going to have that opportunity to build the trust because you are not gonna feel comfortable being vulnerable. Um, and so I think part of it is, uh, is like explicitly giving permission to people, just practice saying it, just practice saying I don't. I don't know, but I'll find out, I don't know, but I'll look into that. It's okay.  [00:45:44] Lee Reeves:  And you're exactly right, because I think when, when it's not, when, when we, when we don't have that attitude, what it does is it sets us up, um, in kind of a lose, lose situation. I think because expectations and intent get kind of mixed and expectations on [00:46:00] both sides, uh, expectations from us. I mean, why do we come to you? We come to you cause we don't wanna stutter. I mean, it's real clear. I don't wanna stutter. Um, and so we're coming to you with an expectation that you're going to make this go away. Um, and whether that, and that's an unrealistic expectation, but nevertheless, that, that is what is in our mind, as, uh, as a clinician, some clinicians have an expectation that they're going to make that go away. Not all, but some, if you just do this thing or that thing, it's gonna make it better. And so there's, there's an intent of each one of us wanting to, I want to get help. You want to help. I have an expectation that's unrealistic. You may have an expectation that's unrealistic. And so what has to happen. And I think from y'all's perspective, the real expert, the real, the, the real, um, uh, uh, or the real professional, the one that's experienced says, [00:47:00] in a way, not says out loud, but helps us to reframe our expectations. So what am I really saying? Well, I'm saying I don't wanna stutter, but in the end point, it's that I wanna be able to communicate. I wanna be able to say what I wanna say when I wanna say it. And I only think that can be done if I don't stutter. And so what, what, what the underlying issue here is, you can help me over time to reframe that, to the idea that stuttering is. Okay. I'm gonna help you to, to maybe, um, com communicate a little easier. But that stuttering is okay. And let's deal with that emotional side of that as well, if that makes sense. So I think it's a, it's a real, it's a reframing of expectations on both sides, because otherwise it ends up with a we versus they, we, we, we come out of therapy with, um, a negative, [00:48:00] um, impact, not necessarily impact, but, but we don't feel like it was successful. Um, in many instances, not all of course. And so we're reluctant to go back into therapy again. Now I'm talking now as an adult, not as a child, um, a little reluctant to go back into therapy because we didn't have that great of an experience in our earlier years. Uh, and not all of us, I'm really talking in generalities here. So I think that if we have, if, if we can that experiential learning, I think, and understanding the experience of what it's like to stutter, um, if. If the clinician can, can, can get that, can understand that. Then I think it leads to a more positive outcome and a longer term outcome regardless of, of stuttering behavior, regardless of what we would call fluency. Um, we, we wanna stutter on our own terms in a way or come to terms with it  [00:48:58] Kate Grandbois:  and, and everything that you're [00:49:00] talking about, all of these different facets of the alliance, I, and, and the rapport building and the trust and the vulnerability, uh, it's making me think of, of one part, one barrier in particular, which is our infrastructure. So how much time do you have as a school based SLP to build this rapport. How many hours do you have before someone expects you to write an objective and define what the long term outcomes are when that's not even really there for you to define? Um, I, I, I have to imagine that, you know, just this marriage of being a person centered clinician with the balancing that with the realities of our job is, is, is so hard. [00:49:47] Nina Reeves: I think that's a great point is that the barriers pop up, um, and I've always been, and I think, I think clinicians, um, it can be helpful for us to [00:50:00] adopt a yes, there's the barrier. How do I move through it? Right. Instead of always seeing the barriers, because if you work in private practice, there's barriers, if you work in university or, um, hospital rehab, there's always barriers. If you work in the public schools, all you see sometimes are barriers. Um, speaking as a public school clinician and the, the, the point is, is that we can be surrounded by barriers. We can also take the idea of, wow, that's tough. I'm not gonna pretend the barrier's not there. I'm not gonna tell myself I shouldn't, you know, worry about it. What I, what I do is I accept that. I accept the feeling I have about it. And then I say, okay, what is my behavior gonna be, uh, within this barrier? How do I move through it? Move around it to the best of my ability for the benefit of my student and keeping that in the top of our minds all the time. Um, and I think most [00:51:00] clinicians do that. And sometimes that's why the barriers seem so tough is that we wanna work with people. We wanna work with kids who stutter and we would love not to have all this other stuff swirling around us, but keeping top of mind that the children who stutter and their parents are counting on us to, um, find ways around what's going on. Um, I think I have a few, uh, When we do the talk, both sides of the table, like in presentations and, um, our little, what we call our dog and pony show. Um, I have like 10, I talk about the 10 barriers, right. And how to get around them. What I did today was try to synthesize three that we can do in a timeframe like this, that sort of absorb a lot of the others. And I think one of the things we've already touched on is that when we come into a therapy, [00:52:00] uh, situation with, um, you know, kind of staying stuck in the, I don't know anything about stuttering, which we hear a lot from, from our colleagues. Um, if we stay stuck in a mindset that we don't know what to do, um, I think that's a barrier, an internal barrier because mindset matters and, um, there is a sort of a cycle that happens, like there's fear of the kid who stutters, even though it's not their fault. Right. It's fear because we don't know what to do or don't think we're good enough. That goes into guilt. That goes into shame. Right? That keeps us very stuck. You know, we start grabbing at things, desperate people do desperate things. Lee said, well, that that's, that's what happens to us. We get into this desperation mode and we start pulling things off of, you know, different sites off the, you know, [00:53:00] internet don't get me started. And, um,  [00:53:05] Kate Grandbois:  you know, I was waiting for you to get up on that soapbox.  [00:53:07] Nina Reeves:  You're not gonna get up on it. Yeah, no, the internet, um, we don't have enough time for that. Um, but   Let me just say that the internet can be a blessing and a curse because, um, sometimes there's some really good information. You know, the national stuttering association, the British Stuttering association there is we'll, we'll put those links in the show page will send everything. But the idea is that's great information, but other people are out there Googling stuttering, which is because, you know, that's the curse side. That's the, that's the place where if we get desperate, someone may have said tapping the toe metro no, no, no, no, no. Metro, no, no, no, no, no. But the point is, is that somebody said, oh, this works, you know, and the kid is fluent except you can't carry it over. And it's. Yeah, but we get desperate [00:54:00] because we stay stuck in, I don't know enough about stuttering. And, um, so that's a roadblock. The way around that roadblock is to realize that we have that mindset to become self-aware that, that mindset leeches into our therapy and that the kid who stutters is seeing that they're seeing our discomfort, our uncomfortableness with, they think it's with them. You know, I'm not sure that therapist didn't like Lee. I'm pretty sure prob more than likely. I'm telling myself a story that, that therapist didn't know how to help Lee. And it came across as I don't like you. I don't think maybe that was the case, but that can leach. And so I think our way around that is to realize, first of all, that it's happening and start to say to ourselves, You don't have to be a stuttering specialist to do fabulous stuttering therapy. [00:55:00] And to say to ourselves, we've got a lot of what we need to do. Great therapy with people who stutter. Yes. We'll need to go get a little more so it's, it's not our fault that maybe we didn't get a good enough training. It, it does become our responsibility though, to go get more training. Yes. Like this right now, the things that you guys offer, this is you are doing the service that we cannot possibly do. Like Scott says they can't do all of this in, in graduate school. And so we want them, we want everyone to do better, but we also wanna make sure that those , that those learning opportunities continue over time. But before we go on and say, we've gotta learn all about stuttering in a different way. We also have to say, I already know how to be a good therapist, a good clinician. I know how to be empathetic. I know how to, [00:56:00] I know, um, how to talk to parents about difficult, um, situations that their children are facing. I know language, I know communication. I'm a communication specialist. I don't know just speech. I know communication. And every part of that comes into stuttering therapy because stuttering therapy is life lessons in communication, more than it is just about the stutter. So keeping ourselves in that space of, um, you know, I don't know anything is the roadblock. And then realizing that we do know things that we can bring to the table and that we can have resources and become savvy consumers of what's out there for extra learning in stuttering specific issues. That's how we get around that roadblock. [00:56:55] Kate Grandbois:  I just wanna emphasize, I'm sorry, Amy. we're just, I'm feeling very [00:57:00] emphatic feelings about the, the component of being a savvy consumer of information. That's all I just wanted to highlight was that the internet, as you mentioned, blessing, and can be a blessing and a curse, but if you are listening and you're interested in seeking new additional information, particularly as it pertains to stuttering therapy, please be a savvy consumer, consider your source. Um, and Instagram is fun, but it is, it is, it is a place to sift very carefully through information. And that's all I'll say, Amy, go ahead.  Amy Wonkka:  I, I just wanted to  pipe in about something different that I feel comes up every time we talk to you, Nina. And that is also that yes, we know, we know all of these things about being a therapist, but also the pieces that we are talking about, um, in terms of being relational with our clients and building trust and incorporating their values. These are also things that are not unique to stuttering. These are important things that we should be doing. We should be [00:58:00] thinking about how, the little things that we're doing, what those messages are communicating to all of our clients. So I think it, it goes both ways. You know, we, we have all of these skills as clinician and likewise, all of these skills that we've been talking about today, we should be reflecting on. Everybody, everybody who we are, who we're supporting. So I just, I feel like every time I talk to you, I'm like this is universally applicable stuff. Um, so just my, my chance to say that. [00:58:26] Nina Reeves:  Yeah. And, and of course, you know, that piggybacks on the idea that stuttering therapy is life therapy and, and so many of the things that we're going to talk to talk about with people who stutter, um, are about communication and being in the world and being vulnerable and being authentic. Okay. Because, you know, there are roadblocks about authenticity. I can have managed fluency, but am I being authentically communicating spontaneously and freely? Or am I feeling [00:59:00] like I have to do it in the ableist perspective? Like an able bodied, able speeched, uh, person who doesn't stutter. And so, yeah, we could do a whole nother one on that topic. Uh, you know, Some other time  [00:59:16] Lee Reeves:  and, and I think basically still understanding that stuttering is, is, um, again, going back to saying that it's, it's rather difficult to explain and understand to, to explain to people don't stutter, but you know, the fact that there are those of us who have significant interruptions in our speech, um, significant, like I used to, but have a carelessness about the, uh, opinions of others. I mean, they, they could care less about what other folks think. And then there are those of us who have very little overt stuttering, you know, um, that so, so mild that we can hide it. We call that covert and yet we have incredible. Um, [01:00:00] uh, emotional impact from that, we are so afraid those of us that, that, that are in that category. We don't have a lot of, uh, observable behavior, but this under the surface stuff is incredible. It can be very incapacitating and very debilitating. So we have those two, two continuums that are in operation at the same time. And each of us falls somewhere on that continuum. None of us fall at the same place. Part of it is understanding those two aspects of stuttering. And the way to, to, to, to help manage that I think is to, is to learn and, and to understand that, but, and I agree with you, it's not just about stuttering, uh, and your scope of practice is so large that it's, you know, uh, it would be inappropriate to blame the speech pathologist for not having that kind of knowledge to not being the expert. Um, it's, it's not your fault. Um, it, but it is your [01:01:00] responsibility. I think that when you run across, uh, an individual who stutters and you haven't had that training, or you haven't had that in a while, uh, to, um, go out and get some, um, good information.  [01:01:14] Nina Reeves:  Yeah. And, and you know that, uh, it brings us to this the second, um, uh, sort of potential roadblock is that, and we've already discussed it. So I'll, I'll, I'll sort of highlight it and move on the idea that semantics matters, how we talk about stuttering matters. And so the roadblock of we've been taught that, you know, don't even say the word stuttering, use the word disfluency disfluency, right? That's stigmatizing that in itself is stigmatizing and awfulizing stuttering. Right? Cause if you can't even say the word, then, you know, it must be pretty bad. And so we've gotta get away from that and we've gotta [01:02:00] understand that semantics matters, it, they didn't have a bad day yesterday or a horrible time. Right. Let's get into descriptive. What does that mean? Oh, that there was more stuckness. I had more times I got, uh, I got stuck or I've got stuck bigger. And how we talk about it with the child who stutters internally as well, and with the people around that child or that person who stutters, um, we are the model. Okay. We can't just say it's okay to stutter and then go wait a second. That one was bumpy. Let's make it smooth. Hello? Like,  Kate Grandbois: that's such a good example.  Nina Reeves: That's just words, right? We have to say it's okay to stutter. Believe it's okay to stutter and exude that it's okay to stutter by what we say and what we do in therapy, that stuttering is not the problem. And fluency is not the [01:03:00] prize. Right. Because somehow it feels. In the old days, fluency was the prize. Like we were, you know, let's focus on that fluency. And so that is the change in the mindset and the, um, paradigm shift that we're all going, you know, neurodiversity, you know, we talk verbal diversity, stuttering is verbal diversity. And that doesn't mean that people who stutter don't need support from a good qualified, caring, stuttering clinician, or clinician who works with stuttering. It means that, um, it's okay to stutter and it's okay for us to be there as part of the team. And so, as we think about that, um, understanding the messages, the, the simple way around, I shouldn't say simple, but there's really one way around the roadblock of understanding the [01:04:00] messages that we're sending that are unintended. We just need to be more mindful of our discussions, more mindful of the words we use, the way we talk about it and the way we describe it. and I'm gonna, I think I'll just wrap up the, the, the roadblock part, um, with, um, something that has been, I think, replete throughout this entire discussion is that there's a roadblock that we think, um, that re that does definitely relates to roadblock number one, which is our thought that we don't know enough about stuttering is that we need a programmed approach, you know, is that we need somebody to tell us what to do in therapy. We wanna be doers instead of be-ers. I wanna be with my students in, in therapy. I don't need to do something all the time. Like what's step one, step two, step three. And that mindset is a roadblock that somebody has to tell me what to do, uh, becomes, [01:05:00] let me desperately search the internet for someone who can do, Um, I think I just posted on our Instagram page the other day. Any, any time somebody says, you know, I've got easy 1, 2, 3 idea of how you can do therapy. I want you to run the other way. I know it's trying to do a surface, uh, and it's probably click bait and maybe it's not easy. 1, 2, 3, when you get there. But the point is, is that easy 1, 2, 3 is not encompassing all of the experience of stuttering. I guarantee it. And so we want ourselves to, um, look for, um, as Scott and I have always said, when we started writing books together, the, the working title of our first book was the thinking clinicians guide to stuttering. And that's how we've worked. All of our, all of the things you see on our website, all of the things that we [01:06:00] offer in, in social media and in our clinical guides is that this is not a programmed approach, but it's a framework from which you can then problem solve on your own. For the individual as Lee was just talking about, for the individual person that you have, the individual family dynamic that that person is working in communicating within. And so we want that to be something that, um, clinicians can feel like they have permission to do. You know, program guides are fine, as long as we don't just give our brains over to them, it's it. We wanna know why we're doing what we're doing, that principle behind the practice, so that when you know, you've got something there that, and you go to page 12 and page 13, you know, oh, no way. It's not working well, why? Right. That's that framework, that problem solving. So we wanna [01:07:00] give, uh, we wanna give ourselves as clinicians a way to say, um, I know the underlying principle, I know why I'm doing what I'm doing. The, how will appear, how to do it is the art of therapy. You get your science and that's the why. Right. And the, how is gonna appear.  [01:07:21] Lee Reeves:  You know, I think that, um, that is so true. And, and I would say that, um, experiential learning, um, in terms of long term out outcomes and things of that nature, I think experiential learning adds to the knowledge and skillset that you learn didactically and you learn in graduate school. Experiential learning helps the clinician to understand the phenomena of stuttering or more than just the definition of stuttering. And if a clinician does that, if they allow themselves to learn with [01:08:00] individuals or from in individuals who stutter immerse, if you can, if not get that experiential learning so that you have an understanding of the phenomena, then. You can be the one, you can be the clinician, you can be the therapist that guys like me, 20, 30 years later, look back on and say, you know, I don't really remember her name very much maybe, or a lot of things we did, but she really made a difference in my life. That's what I think, um, can lead to long term outcomes. [01:08:36] Kate Grandbois:  Everything that you've both said is so powerful. And every time we talk to you, I feel like there's hours and hours of more conversation to be had, which is why you have a very robust platform where there are a lot of additional resources and we will list all of those resources in the show notes for people who do wanna learn more. Um, I shameless plug for a framework. We love a good framework. Frameworks are [01:09:00] wonderful tools for being flexible, being able to customize interventions. They give you footholds to help digest and navigate through lots of information, um, help you problem solve. So it's just another, just plug for a good framework. We love a good framework. And before we wrap up, um, I just wanted to ask if you had any closing words of wisdom, any suggestions for anyone listening, who might wanna learn more.  [01:09:32] Nina Reeves:  Well, you know, um, I think we'll put as many resources as we possibly can out there. Um, uh, in the, in the show notes and things, because I, my, my biggest thing is we can never cover in a small amount of time, everything that a clinician wants to know and hear and needs from the world of the stuttering community, but, um, [01:10:00] extra resources, things that are available are out there. Just, we wanna make sure that you know, that they're there, there are organizations that live and breathe to give you things like here's experiential learning. In every way, shape and form in person online, all the different ways. Um, and I am going to, uh, my final thing would be to say, don't forget the caregivers, the parents, the teachers, the stakeholders that are surrounding this person that you're working with, um, make sure that they have that support as well, because they're not only on the journey with the child who stutters, but they're on their own separate journey in acceptance and understanding and maybe feeling guilty or maybe whatever it is that they're bringing to the table. We wanna make sure that that is a part of what we do when we're in a therapeutic alliance.  [01:10:58] Lee Reeves:  And I [01:11:00] guess what I would say is to get connected, um, get connected if you want to, if you wanna learn, uh, and about the experience of stuttering, get connected with those who stutter. If there's a local chapter of the national stuttering association in your area, go to their meetings, they're open to everyone, not just people who stutter, but family members, speech language, pathologists, researchers, uh, community members employ. It doesn't matter. The only thing that that, that we request is that you take your therapeutic hat off and come as a human being, come to learn and to share your own experiences and, um, uh, and to learn from others. If you wanna know what it feels like, and to, to live with the stuttering go to a support group, um, meeting and not just one go to several. If you have the opportunity to go to, uh, an annual conference, uh, friends, uh, national study association, things like that. Join SIG four, if you wanna learn more, uh, about [01:12:00] stuttering as well. So I would just say, get connected, reach out and be open to learning.  [01:12:08] Kate Grandbois:  Those were, I don't think that we could possibly say anything to follow up. Those, those, those closing remarks. We love having you here. Every time you come, as Amy said, everything you say is so applicable across the board to so much of what we do as clinicians, as human beings. We're so grateful for your time, and we're so glad that you were able to join us. And, um, we hope to have you back again soon. Thanks again so much.  [01:12:35] Nina Reeves:  Thank you so much. Thank you guys. We appreciate it. Enjoyed it. [01:12:39] 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, [01:13:00] 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 September 5th, 2021. The podcast episode is offered for .1 ASHA CEU (introductory level, related area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime . A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. [00:02:03] Kate Grandbois:  We're so excited for the topic of today's episode. This is an area that's very near and dear to us, and we get to welcome a woman who we've worked with before and collaborated with before who we've learned so much from already. Welcome Tanna Neufeld. We're so happy to have you here today. [00:02:20] Tanna Neufeld:  Yeah. Thanks for inviting me. I've been excited to join you guys for a while. I'm glad to finally have the chance.  [00:02:27] Amy Wonkka:  We are too. We are so happy that you're sharing your time with us now, Tana, you are here today to talk to us about AAC and complex communicators in early intervention. But before we get started, can you please tell us a little bit about yourself? [00:02:41] Tanna Neufeld:  Yeah. So I live in Seattle, Washington, um, and my primary job is working as a clinical instructor at the university of Washington. So I get to work with graduate students, and I love that. Um, I also get to teach their AAC class, which I really love. Um, and I think that it has [00:03:00] really become, uh, evident to me how important it is to improve our pre-service education through my role in that class. So I'm excited to talk a little bit about that today. Um, in addition to that, I do some private work as an AAC consultant, um, with children and families over telehealth. And I am the founder and director of accessible.org Accessible Foundation, um, where we provide low cost and free resources to the community around AAC. Um, yeah. Other than that, I'm a mom. I have two kids who I love and who teach me all the time about how to be a better person and a better therapist. I might be leaving some things out, but, but these are the broad strokes, right?  [00:03:43] Kate Grandbois:  I'm just going to be the first one to say that you do so many things and you've contributed so much to this field already. So hats off to you, um, especially your foundation, the Accessible Foundation, accessible.org is so full of [00:04:00] resources and webinars. Anybody who's listening, we haven't even gotten into the topic of today's episode, but if you want to learn more, or join a community, around AAC education and support then that is the place where you need to go. And you guys have a conference coming up, right? You're doing like an actual conference.  [00:04:18] Tanna Neufeld:  Yeah, scary. Right. So we're taking a stab at what I believe is the first conference of its kind, really, um, coming up in February on the 16th and the 17th. We're going to be hosting two full days of an online only live conference on the topic of early intervention for complex communicators. So it's called the AAC early starts conference. Um, and you can see some workings of the initial information on that conference, on our website. Um, we have a call for papers open for that as well. We're looking for presenters. We really want it to be a conference for families and professionals across disciplines, uh, to come and present and share their knowledge and experience, and [00:05:00] also attend, uh, to learn how to support these really young, early communicators who have these complex needs a little bit better for longer term outcomes that really helped them be independent members of society. [00:05:12] Kate Grandbois:  I'm incredibly impressed for a variety of reasons. And I think it's a great segue into today's topic because as you and I were having conversations about, about AAC and early intervention, having not worked in early intervention, it became abundantly clear that this is really, um, an area that deserves a spotlight and deserves more discussion and continuing education. Um, and I'm so excited that you're here to give us a little, give us a little sneak peek, give us a little preview and teach us all the things. So before we really jump into it, the powers that be require that I read our learning objectives and disclosures, um, I will get through them as quickly as possible, and then we can get onto the good stuff. So here we go, learning objective number one, identify at least two barriers to AAC implementation in an early intervention setting, [00:06:00] learning objective number two, identify at least five strategies to overcome barriers to AAC implementation in an early intervention setting, and learning objective number three, identify at least two resources for expanding scope of competence in AAC for early intervention clinic. Disclosures Tanna Newfields financial disclosures: Tana receives a salary from the University of Washington and receives donations for consultation services, mentoring services, course offerings and products on accessible.org . A portion of these donations is used to subsidize overhead costs for an organization, which she founded and direct.s Tanna receives honorariums for speaking, at conferences and workshops in the Seattle community. She is a paid advisor and consultant for goalie and assistive technology company. She is also a seller on Teachers Pay Peachers and Boom learning for which she receives funds for her products. Tana Newfields nonfinancial disclosures. Tana is a member of ASHA and ASHA SIG 1, 11 and 12.  She is president on the board of accessible foundation and a volunteer [00:07:00] contributing editor for SLP nerdcast, Kate, that's me financial disclosures. I am the owner and founder of Grandbois therapy and consulting LLC and cofounder of SLP nerd cast. My nonfinancial disclosure is I'm a member of ASHA, SIG 12, and serve on the AAC advisory group for Massachusetts advocates for children. I'm also a member of the Berkshire association for behavior analysis and therapy, Mass ABA, the Association for Behavior Analysis International and the corresponding speech pathology and applied behavior analysis special interest group. [00:07:27] Amy Wonkka:  Amy that's me. My financial disclosures are that I am an employee of a public school system, and I receive compensation as co-founder of SLP nerd cast. And my non-financial disclosures are that I'm a member of ASHA, SIG 12, and I serve on the AAC advisory group for Massachusetts advocates for children. All right, we've done it. We've made it through the learning objectives that disclosures onto the good stuff. Tana, why don't you start us off by just telling us a little bit about the barriers to AAC in early intervention. [00:07:57] Tanna Neufeld:  Yeah. So I have been so fortunate to [00:08:00] spend a good part of my career working in early intervention, even though that's not really where I am exclusively right now. And so some of the thoughts I'll share today are coming from my own experience in that setting. Um, and also from the collaboration and consultation I do with a lot of the EI providers here in the Seattle area who, um, really struggle to feel confident in the care that they're providing for complex communicators. Um, and rightfully so. So I think that the first barrier that I, that I kind of discovered myself as an EI provider and also through my support of others, um, is that really these really young little guys and early intervention are so, complex some of them. Right? So in addition to being young infants, toddlers, and preschoolers, um, those with complex needs are still developing all of their skills, right? They have not had a chance yet to have a foundation in anything. So [00:09:00] these providers who are supporting these little ones are supporting them at the beginning of every journey that they are on. Right. And that's a huge, huge job. Um, one that we're, we're not very prepared for, I think, as providers across domains, but obviously as SLPs. Um, so I think for that first, and that leads me into kind of the second one where I think that despite our efforts to acquit our professionals with the skills, they need to be good at what they do when they graduate, our pre-service education, still tremendously lacks the skills and experiences needed to really serve birth to three populations in general and let alone birth to three populations with complex needs. Um, you know, we don't even have coursework in many of our programs that talk anything about parent coaching or partner involvement. So I think our, our SLPs operating in these contexts are really, um, trying their best to do what they need to [00:10:00] do when they've been thrown into the deep end of the pool pretty much, um, on two fronts. Right. Uh, so those would be my top, my top two barriers that I see. Um, I also think that in these settings, um, because early intervention is wonderfully, uh, programed that serves all families, right? No matter what their background, um, we do have a lot of families and areas in early intervention on districts, right? So early intervention is usually assigned to a certain part of the community. Um, and in certain communities, technology is not available. Um, resources are very limited. And so our EI providers are really trying to create, um, access to technology that will support the needs of these really complex little guys with very minimal budget or, or opportunity to do so. Right. Um, so we have limited access to technology. Um, and I think we also just have limited access to training that’s specifically around how [00:11:00] to implement AAC in this very unique and special setting.  [00:11:05] Kate Grandbois:  I was going to say, you know, this is something that we've discussed a lot in previous episodes that we've done, that access to AAC, content knowledge, and then confidence and competence in applying those skills is something that is an issue. It's an issue because there's these, you feel like you have to be a specialist. You feel like you have to have your ATP. There are a lot of barriers just in general to implementing AAC. And when you look at it through the lens of early intervention, I love how you laid that out. That these, these tiny, these little people are at the beginning of this journey and you're right. We don't get a lot of structured education. I didn't have a course in early intervention, actually. As a matter of fact, I didn't have any clinical experiences in early intervention either. Did you Amy? [00:11:54] Amy Wonkka:  I mean, I feel like it was tied in, we had some child development courses, but no, there was nothing [00:12:00] dedicated to EI. And I also did not have experience working with that population until my CF year. So it was not something that I encountered in grad school at all.  [00:12:12] Kate Grandbois:  And to, to sort of piggyback onto that. I think you're right. There are so many components of early intervention that are separate from working in a school and separate from working in an outpatient clinic where you're really wanting to focus on, not only person centered care, but family support and, and caregiver training. I mean, these are such tiny little babies. They're, they're a little tiny baby. I keep saying tiny, they're physically small, you know, they're, they're really young. Um, and supporting them in that environment is such a diff, I have to assume a very different skillset. I've never done it myself. Is, would you agree?  [00:12:49] Tanna Neufeld:  Yes. It's a, it's a super different skill set. Um, and in my experience, it's, it's a, um, a work setting that's highly protected in a lot [00:13:00] of ways. Uh, in some districts it's, it's protected, right? So similar to maybe if I’m a grad school graduate, and I like want to work in a NICU. Right. And, and the NICU people are like, yeah, you're gonna have to pay some dues before you get to do that. Right. Because it's a very coveted, you know, protected area of our field. And in some areas in some places, EI is like that too. And so you'll have some EI providing companies that are very particular about training their providers, but then there's also a shortage of SLPs willing to do a job that requires them to learn, really spend the majority of their day in their car. Right. So I think you've got this weird contrast that, that makes this the services, obviously not very uniform where you may get some younger providers who are just getting their feet out there. Right. Getting, hitting the ground running. Um, and now they're in their car, in the homes with minimal mentorship, from anyone who knows [00:14:00] anything about what to do with some of these more complex cases. So it's just a lot to, um, to learn on the job, I think. And, uh, I think a lot of providers get a little, um, burnout by the feeling that they're not doing what they should be doing or could be doing, learning, or they don't know what to do, mainly because of all the reasons we just talked about. Right. Just lack of support, lack of training, lack of time. There's high productivity demands in the EI setting because there's always kids waiting and they're not allowed to wait for very long because there's mandates on how long they can wait. And so, you know, all of that indirect service stuff, you guys talk about so much on this show, it applies here too. There's just, there's not enough time to create, you know, to build an iPad in your garage because the family doesn't have the means to do it. You know? We need to have that. We need to be able to build stuff, 3d printing time and that sort of thing. Well, [00:15:00] then you talked about  [00:15:01] Amy Wonkka:  Well, then you talked about not just knowing what to do with your client, but also in EI. So much of it you're in somebody's home. You're working with families, the entire family unit is your client, essentially. And I think that that adds, that must add another layer for the clinician who not only has to learn what to do with the actual child on their caseload, but how to best support that family in that context. Um, so there are, there are almost two layers of clinical skills, which you may or may not find as a demand of some other work settings to the same degree.  [00:15:38] Tanna Neufeld:  Yeah, absolutely. I mean, I remember as a CF, my first experiences were a clinic where the families never even came into the room. Right. And that was the way I learned in graduate school too. And so when I went and started a job at a really family centered practice, I was like, wait, they're going to be in the room with me. [00:16:00]  [00:16:01] Kate Grandbois:  As a grad student. Oh my gosh, please don't look, I'm making a mistake. You feel like such a, so under a microscope, your supervisor is there. And then the, you know, the parents and it's a really intimidating, setting. [00:16:14] Tanna Neufeld:  It is. And so, you know, I mean, we haven't gotten to this part in our talk yet, but I think speaking to what you asked Amy about this, this big job of not only learning yourself, but teaching families. I think one of the things we need to do as a, as a field is assure that our pre-service experiences for graduate SLPs include families being in the room and it is harder and they're going to mess it up. I've seen it, it, they just, they get so nervous, but you know, they, I think you have to learn by doing and what better place in your career to do that. Then when somebody is right there to help you be better at it. Right.  [00:16:53] Kate Grandbois:  Totally. We're like high-fiving Tana through the screen. This is just so brilliant. I wonder if you could tell [00:17:00] us a little bit about why it matters and stick with me for a second. Right? So. You have a person, a child. Um, I wanted to say tiny child again, but I stopped myself, uh, a young child under the age of three, who is, um, possibly medically complex or has a complex developmental profile who presumably you're working in a team environment. You have, potentially OT, PT, working on some basic skills, focusing on sitting, crawling, trunk support, walking all of these kinds of things. And at least, I don't know if this is true, but my, what, in many areas, but in our area, what I hear a lot is that there are not, SLPs aren't assigned to the team until later because of these, and I'm putting these in quotations, “developmental norms”, it's in quotations of not needing access to communication [00:18:00] support until they're 18 months or two year or whatever the cutoff is. I'm not really sure I'm speaking out of turn there, but, but in terms of AAC, knowledge and application of AAC knowledge, can you tell us a little bit about how important that is and, and why that matters, how that paradigm should, might need to shift a bit?  [00:18:22] Tanna Neufeld:  Yeah. And I can tell like a little bit of a personal experience too. When I first started in, in true EI in, in Florida, EI was a little different, which is where I started my career was in Florida. EI was not mandated to be in the home. And so I worked at a multidisciplinary center at the time where I was seeing little guys, little, little cuties and helping them in the center. But then when I got here, Seattle, I started in a home-based center and, um, they did something called a primary service delivery model. I don't know if that's a thing, other places. I've lived here for a while now, but anyway, primary service delivery is kind of what you're [00:19:00] talking about, Kate, and this idea that if I'm a little baby and I have just been born with cerebral palsy, for example, and I go to an early intervention setting and I get an evaluation, um, despite the fact that everybody on the team acknowledges that I am at risk for long-term speech and language challenges, the likelihood that I will have an SLP assigned exclusively to me as part of my care team is very small because for some reason there's a need a desire or a thought that the needs of every young communicator can be met by a non language trained professionals. So, although they're not clearly stating that, you know, they don't lead communication intervention, they're not, that's not the question or the key point here. The point I believe is that, well, of course they need it, but it can be provided by another professional. And I always had a hard time with that because, [00:20:00] um, I used to say to my superiors at the time, well, but you wouldn't look to me to help him walk. Right. So why are you looking to my wonderfully talented, amazing PT colleague to help him learn how to communicate? So, you know, I think the importance here starts and we need the best skilled professionals for each domain intervening and, um, and, and we know how essential birth to three is. This is, this is the window for language, for sure. Right. So why do we wouldn't have then a language expert on the team? Uh, just seems to, in my opinion, to be frank, another situation where limited resources and such and such are kind of interfering with care provision, right. Um, so, you know, in perfect teams that works really nicely for the SLP to push in and help. But I think what we're missing then is we're missing [00:21:00] all of this immersion in particularly AAC that needs to happen. From the time the child's born, right. We need to immerse them if we want them to learn any language. So whether they are actually going to use an AAC system at all themselves, before they exit EI, they need to be exposed to models, um, and PTs, OTs, and education. They don't normally have the skills to do that, to provide that service. I don't know if I answered your direct question or if I just got onto a little miniature soapbox?  [00:21:34] Kate Grandbois:  No, no, it was, I, I wanted you to get on the soap because I think it's such a great point. And I think Amy can probably speak to this a little bit more based on her experiences in the school. But my assumption is that without those supports and without that immersion and without that foundation you it's, I'm assuming you're at high risk for quote, graduating from [00:22:00] early intervention or transitioning into a preschool system without the communication system or supports that you need to continue your language learning journey. [00:22:12] Tanna Neufeld:  Yes. Yes. And one of the hugest challenges for preschool teachers when they receive children who don't have a solid functional communication system, is that they're now have shifted from being a preschool teacher to the person, does the, who is, who is in charge of now teaching our child language that their peers have entered into that setting already having, right? So no wonder our preschool teachers and developmental preschool and our kindergarten teachers, even when children enter public school at that point are so overwhelmed because it's not, they're not trained to teach children language. That's not their job. I mean, they, I think they, many of them embrace it and want to do better, but, um, it's no wonder, it feels overwhelming and hard because, that's not really the way that [00:23:00] school was designed to be. So I think that we do a better service to our teachers and our teams, families and kids when we try our best to see into the longer-term future and think about things in terms of typical development. Right? So if I am a 12 month old child, I have, um, I have some skills that I need to develop around communication. And if I'm not doing those with speech or sign, then I need to have the ability and the opportunity to build them some other way, even at 12 months old. So I don't know, it seems like a no-brainer to me, but, um, it's hard sometimes to get people to see it that way. Um, and I also think a lot of the time we're just waiting for skills to be present, right. Prerequisite skills to be present. Um, and, and that's where the myth comes in, right? Yeah. Kate's doing a fist bump, fist bump  [00:23:55] Kate Grandbois:  modeling. Enthusiastic. Yeah. Fist bump. There you go.  Fuck. Bump [00:23:59] Tanna Neufeld:  Yeah. [00:24:00] So yeah, you know, the prerequisite skill myth, even though I think that if you get a bunch of us in a room, we would all say how we don't think about that anymore. We know that that's not true, but our practice is not following that. Right. Because we're still waiting for these kids to show some magical unicorn cognition skill. Before we say, Hey, let's just do this. Let's just for lack of a better analogy. Let's throw some stuff at the wall and see what sticks, right? Like this is the time to do it.  [00:24:33] Kate Grandbois:  I go ahead, Amy.  [00:24:37] Amy Wonkka:  Oh, I would say, you know, and it all, it makes me think about something, we've talked about a fair amount on this podcast before, but the idea of a communication system, also, it doesn't just have to be this one high-tech thing that we bring in. And that seems like maybe it's too much for the situation. Just like you just said, Tana, you know, you could, if you give yourself permission to try these different [00:25:00] things at an early age, you can get a better feel for what is, what works best for the child, what works best for their family. Maybe something works best in certain situations, but not in others, but if you don't have the opportunity to model and  give that exposure and also give that practice for everybody, you're not, you're not going to have any of that information. And then the child's going to have a transition out of EI and the people who are familiar and do know the child aren't going to have been able to gather that information, to share with their receiving placement. And that's, that's another piece that's really unfortunate.  [00:25:38] Kate Grandbois:  And I think this is a great segue into our second learning objectives in terms of what we can do. So instead of waiting for an arbitrary developmental milestone or cognitive skill or arbitrary timeline, so, we provide speech therapy at 18 months just because, um, what, what can we do? I mean, what are [00:26:00] some proactive things that SLPs who are listening in an early intervention setting or interested in an early intervention setting, or maybe frustrated with their current early intervention setting, what are some shifts or different lenses that we can look through to improve on, on this problem? [00:26:18] Tanna Neufeld:  Yeah. And I, I just thought of another barrier, so I'm going to like, go back. It's not really going back more that it’s just like nudging another little one in between before we start talking about solving the barrier. But, you know, so when Amy mentioned this. The idea of multimodal communication rates. So not really being so narrow-focused on the AAC device as the system, but realizing that all this funky hand stuff that I'm doing right now is AAC. My vocal tone, my gaze, um, even my quirky behaviors, right? Those are all part of a system, but an EI team should be building. [00:27:00] And I do a lot of trainings on intervention. Um, and I think people get a little frustrated when they sign up at first, because they're like, why don't you talk about the actual devices? And I think it's because in my perspective, when I'm working with emerging communicators, the technology is like 10%, 90% has all the other things. And I think sometimes the EI providers have this barrier self-imposed or otherwise where it's like, well, we got to just teach them to use this device. Whereas they might feel more successful if they were thinking about typical development and what children need to gain in order to have better success with the AAC device or book or whatever we're doing. So teaching intention, I can't even tell you how many times I've gotten reports from EI and school districts. “This child has no intention, so we're not going to call in speech yet because they have no intention.” And I felt like well last time I checked, babies aren't born with [00:28:00] intention and it shaped through interaction and that's AAC like that is complex communication therapy, right? It's not an AAC device, but it's part of this little niche of our field of providing services to children who don't talk and don't have all of the precursor skills that we feel they need to have verbal communication that we expect. So, yeah, I think that barrier of just having that blinder on really limits the programming, because then what you see is goals that are just like jumping canyons, right? A child has no intention, but they want them to use a big Mack to say, “ore”. Big Macks are great. The word “more” is great. However, there's probably about 800 skills that you also should be working on to help that child actually have a strong foundation to move to symbolic communication. So on that note, I would say my first, my first strategy would be, um, recognizing the strengths in the child [00:29:00] and I, and I think it kind of not just the child, the child, the family, and the team. So starting with the child, I think recognizing strengths means focusing on goal setting and intervention strategies that really truly scaffold. And don't just say, you're two. So you should be making sentences. So I'm going to give you a pecs book that says, I want goldfish, because you're two, and you shouldn't be making sentences. So rewinding and saying, okay, well, what do you do really well? Well, you're really intentional. You have great gestures. But you only say “more” with your sign, right? So going from this to, I want goldfish, huge canyon leap and goal setting an introduction, but thinking about early childhood language development, we know, well, I really need to be building your single word vocabulary to a Brown stage one so that you have the building blocks that you need to make sentences and actually have that skill [00:30:00] stick. Right? So I think recognizing strengths help us not say, well, this is what you can't do. So I need to teach you this. It says, this is what you can do. And this is the next step. So I'm going to teach that so that I can get you to what you can do. Um, okay. I'm seeing excitement. So I don't know if I should keep going or not. [00:30:22] Kate Grandbois:  I think, I think that this is a really wonderful and important lens to look through. It's critical for early intervention. It's also a really important piece of being a person centered therapist in terms of looking at, per individual strengths and choosing targets and writing goals that are empowering and appropriate. Um, based on, you know, the individuals presentation, not because you just chose it because you think that's what they should do. And I think that that's a really important distinction and I'm really glad that you brought it up.[00:31:00]  [00:31:03] Amy Wonkka:  I also feel like when you're note-, when you're learning about somebody's strengths, you're also learning about who they are and all of our clients are people and everybody's different. And we all, you know, even, even down to, you know, some clients really appear to enjoy like high affect and, you know,really exuberant interaction style. And for some folks that's just the worst. Right. So I think that that's gotta be a piece that, that kind of tags along with that, recognizing the strengths, you're also kind of figuring out a bit about who your client is as a person and that'll serve you well with all of your, you know, later therapy with that individual and their family. [00:31:51] Tanna Neufeld:  Absolutely. And I was just giving a training yesterday because I'm preparing to do some talks in the future [00:32:00] on the power of joy and learning in general, but really just the power of joy and learning AAC because we have children, right, who are complex communicators that don't have typical sources of joy. And so. It saddens me sometimes, not just for the child, but for the professional. When I have a mentoring relationship with professionals where they're like, I've got this student and they just don't like anything. They don't like anything. And we know that that is not true. It is completely not true, but what a, what an overwhelming place to be as a professional when you got into this field and you know, how important joy is to children and learning, but you just can't tap into it. So, yeah, I think you're right. Making sure you're looking at those strengths. What across all domains, right? Like what are their sensory strengths? Meaning what are their preferences, right? What are their motor strengths? What are their cognitive strengths, social strengths. Right. We have a lot of kids who have social strengths, but [00:33:00] don't seem to have a lot of other skills, like good vision or good motor, um, as part of getting to know them and knowing what brings them joy so that you can model the right words at the right time. Um, so I've been encouraging my students and my families that I work with to really try to think beyond the traditional stuff that we think is supposed to bring joy. Right. Um, I was just doing a training yesterday where I challenged the audience to think about what core language could you model for a young one who likes to stick their head on the fan? Right. Like blowing their hair in the wind and brings them joy. Like what could you target during this activity rather than just saying, that's not play, let's come over here and do that. They came up with like 50 words.  [00:33:46] Kate Grandbois:  And I mean, who are we to say? What brings someone else joy? That's just the most, I don't know. That's clinician centered, not person centered that has nothing to do with you. You are there to support the other person, [00:34:00] not make decisions for them. I mean, think about how we would receive that as individuals. I love reading science fiction and fantasy. It's my jam. If someone came along a teacher or I don't know, I was taking some sort of cooking class and they were like, that's not really okay. I would, I would say forget you, I'm not speaking to you anymore. That's mean, why would we do that to children? [00:34:22] Kate Grandbois:  Sorry, maybe that was a weird personal soapbox to get on for a second. But I had to say it! [00:34:27] Tanna Neufeld:  Well, you're right. And I think to be clear, I personally don't believe we do this on purpose, but I think that one of the things I've learned about myself and I've learned about several other people that are SLPs, if I'm being gently honest is we tend to be a little controlling in our personalities. Um, and when you. When you don't feel confident doing something, I think you tend to be even more so. Um, and so I think it's harder to truly follow a complex communicator's lead, right? A [00:35:00] child who likes to play with vacuums. It's really hard to figure out how to make that work. It's a lot easier to just teach them not to play with vacuums and to play with something else. Right. So, you know, I think that we don't do it on purpose, but we do it. We all do it. Educators do it, everybody. I think OTs are the only ones who don't really do it, honestly, because I think OTs are like magical. I want to be an OT when I grow up, but you know, we do it and it's so crucial. So I'd say one of my strategies would be, and it wasn't even one I planned to share, but I think you're so right. The joy in getting to know the clients still applies when you're teaching them hard things like AAC. Um, that means we can't make every AAC practice opportunity contrived and boring. How many goldfish can I ask for? Right before I'm just over it, right? That's not an interaction or an experience. That's a ritual and a behavior practice. Right? So I think all this beautiful skill that a lot of our EDI providers bring to [00:36:00] naturalistic intervention for children who are not complex communicators, it's harder to translate to children who have complex bodies, visual impairments, sensory differences. And so bridging that gap, right, somehow by recognizing strengths, recognizing preference, and then figuring out how these skills can, can bridge that for these kids is, is a huge strategy. Um, it's an idea. I didn't really give you any actionables on it, but it's, it's, it's an approach that you can take.  [00:36:32] Kate Grandbois:  I think it, it creates a lot of really important self-reflection too about, you know, how you approach and what your guiding principles are in therapy. I think it's, it's, it's a, it's a covert actionable it's there. It's definitely there.  [00:36:47] Tanna Neufeld:  It's there. You had to dig it out of the cracker Jack box there. Um, but yeah, I would also say, you know, it's really important in this setting to recognize strengths in everyone. So I think a lot of the [00:37:00] time what happens right, is, um, and I get this a lot in trainings where I'll ask people what they want to learn, SLPs educators and stuff in the room. And I want to learn how I can get this classroom teacher to follow through and how can I get this parent to actually follow through. Right. And so I think we spend some time really focusing on what parents and teammates are not doing. Um, but maybe we could spend a little bit more time figuring out what the strengths are. And so like at the beginning of a consultation for a young child's family, what I will do is observe what the parent's doing well. And the first piece of home program I give is to have them do more of it. Right? So it's like, you do this really well. I love how you give him choices. Your homework is to give him even more choices. Right? So taking what they already do really well and building confidence through having them recognize how it's [00:38:00] helping, recognize how their child is showing them that it's helping them feel empowered. Right. Because so much of this AAC game is like all work, very little instant gratification. So you're asking a team to do really hard work. With very little instant reward. I think it was David Beukelman who quoted in a book somewhere. I read that, um, AAC is like putting money in the bank, right? Like much of what we do is just investing, investing, investing, and our EI providers don't even get to see the benefits usually because the child goes on, right. So thinking of money in the bank, money on bank, and then that return on investment, that's going to happen in the long game. Um, but it's helpful to help parents and teachers see, well, what does the little in return look like? Right. Helping them figure out what is it that happens in my child when I do this thing that I do well. And then building on that with, with other skills that [00:39:00] are not as easy for them to do. Um, yeah. So, and then thinking also, in terms of strategies, I think supporting those challenges, um, I think a lot of the time it's, it's tempting to want to wait for things to develop. Like we talked about in the beginning of the call, but we have to consider how to set the learning environment up to support challenge areas in order to have any sort of foundation for language learning. Um, and I just gave a talk yesterday to an EI center specifically on this. So no AAC device even considered, are we doing our best to support this child's ability to move around their environment? Right. Are we teaming enough to make sure they have some sort of mobility because mobility drives cognition. So if we're waiting for cognition to come to the table so that we can get going with the AAC, we've gotta be doing something to help it along. And that means urging mobility, right? Give them a little ride on car advocate [00:40:00] for, you know, um, we used to use a wagon or use some other form of mobility in their day, or how are we adopting their play materials? So I'll often support families and providers who have, um, bright children with really impacted bodies. And they've got their big macks out in there and they've got their iPad that they're playing with, but none of their toys have been adapted for them. They can't even reach them from where they're sitting and it isn't because they don't want to give the child toys they can play with. I think they just don't think about it. Like how can I help you as a two year old, do what other two-year-olds do that, help them learn communication language and social skills. How do I help you draw? How do we help you paint? There's tons of beautiful adaptations that can be made to just set the stage for learning. And I think that's a huge piece of what EI needs to do is really have that family understand. This is a lifelong differentiated [00:41:00] instruction job, where this child is going to need us to, to help them access their worlds so that they have something to talk about.  [00:41:08] Kate Grandbois:  I love that you are considering and continuing to remind us how important some of these other aspects are. I mean, they're important for our school aged kids and our high schoolers and our, even our adults, but it's, so it's so critical in these early years and to consider all of these other aspects of development and how they may be strengths, or there may be barriers there. It also makes me think of the importance of collaborative relationships because you're working so closely. I think I'm going to go out on a limb here and say, you're working more closely in early intervention with these collaborators. Then you are in a school setting or in a hospital setting where you all have your separate rooms and you just like maybe live on the same hallway. You know? So I love the picture that you're painting of this multifaceted approach and, and how important it is. Um, and I [00:42:00] wonder if you could tell us a little bit about what other things SLPs could do to sort of expand on that.  [00:42:07] Tanna Neufeld:  Yeah, I love that EI teams have this built-in collaborative kind of approach. Right. And I I'm going to allude to the training I did yesterday because it was an EI training, but it was, you know, that's one of the things they bring to the table as this beautiful capacity to work with one another and not just do it on a lunch break, but actually like push in and jointly treat right in the home with everybody, with grandma, with uncle so-and-so, with the dog. Um, so I think one of the things I would consider hugely important is to make that a habit, not an exception. So if you have a child with complex communication needs, you absolutely should be prioritizing joint treatment with a motor therapist and a vision therapist, at least on occasion once a month in your service delivery. Um, it's only through partnering with them that we're truly treating the whole child in that moment. But also [00:43:00] what I learned is by pushing in or having others join my sessions, I learned so much about other stuff that I didn't get taught in school. Right. So I learned about vision and vision approaches. I learned about OT stuff, sensory processing, and motor support. And so then I just became a more well-rounded therapist by being able to tap into the genius that was happening in front of me. Right. I also felt that I, that was an opportunity for me to share, um, what I thought could happen in that moment to promote communication. And my PTs and OTs, were, were so grateful that I was there to not only tell them what I'd like them to do to help communication, but to actually show them how to do it. Um, so yeah, I would make that a priority pushing in and joining each other's sessions for sure. I also think that one of the demands placed on an EI provider, um, whether they like it or not is the need to learn about things outside of speech pathology. Um, and [00:44:00] so I think that when you're serving complex communicators, it really behooves you to seek continuing education outside of just speech and language. Um, vision, motor, obviously sensory integration, um, even relationships and infant and toddler interaction, all of these things that are really going to help you be more well-rounded in solving these really complicated problems. [00:44:25] Kate Grandbois:  And just for the sake of plugging this, if you do see continuing education outside of speech pathology, it will still count towards your ASHA C’s. Because ASHA's definition is anything where you are the learner. You have proof that you attended the event and you have a certificate and it makes you a better speech pathologist will count and you can quote me it's on their website. So don't feel, I just want to second that, because it's so important and there are so many things that other fields have to offer that still make us better at our jobs. We are not disciplinary centers, centrism is real speech pathology doesn't know everything. There [00:45:00] are lots of other wonderful resources out there. And so thank you for mentioning that.  [00:45:04] Tanna Neufeld:  Yeah. And thank you for plugging the fact that it still counts because I know that's really important to a lot of us that it counts, and it's also can feel a little bit like stepping on toes to go into other realms. But remember that, just getting knowledge to make you a more well-rounded therapist doesn't mean that you now become the fine motor expert. That's not a burden you need to carry, nor should you right? Um, I'm not an OT and I don't pretend to be one. Um, however, I do realize that this is a whole child with a whole brain, um, and I can't just treat one piece of it. And, and I found in my practice just getting to know other aspects has really made me feel more empowered and confident, um, and really has helped me understand my clients so much better. Um, and I would also say another place to kind of address this collaboration piece. Um, is to really [00:46:00] make sure that you are involving the parent as a true member of the team. So I think in EI, it's kind of assumed, well, yeah, it's, it's family centered, but there, there are family centered sessions and then there are family centered sessions. Um, and I think we recognize how this work is largely to be done by families. So I think that to set the stage for longer-term progress in, in success for families, you have to set that precedent at the beginning. You have to go in, [00:46:34] Kate Grandbois:  I was going to say, and this brings us to a point you made earlier about how, you know, the early intervention provider doesn’t stay with the child for more than 18 months, two years, maximum three. So by really making the family and the caregivers and the parents an integral part of therapy, you are empowering them to be there for the child for their life.[00:47:00]  And that's so much more than we can do.  [00:47:03] Tanna Neufeld:  Absolutely. And I think that that takes considering the long-term pie in the sky goal, for sure. But remembering that not all families are ready to bite off a full AAC device. It doesn't mean you can't follow a best practice and development and give them the right tools and multimodal system that they need. Sometimes you've got to compromise what you think might be ideal because ultimately your job is to leave the legacy that this family is going to be able to carry into the next phase of that child's life.  [00:47:34] Amy Wonkka:  And it's not ideal if it's not meaningful and doable and what works for the client and their family. [00:47:40] Kate Grandbois:  Also as the speech pathologist, it's not your job to decide things for people. It's your job to facilitate decisions that are in line with other people's values and perspectives. So I think, you know, taking that as a lens, and I think a lot of times AAC has this [00:48:00] connotation of an iPad and it's not, you know, so you think, oh, we need AAC. So we have to go get this other thing. But you're talking about tiny young babies who are maybe going to be working on gestures or other, you know, conventional or unconventional. It doesn't necessarily, which is, you know, completely appropriate. It doesn't necessarily have to be this new app that you found that you think is going to be great. And therefore you spend all of your intervention time convincing other people that you're right. And I feel like that that doesn't help anyone.  [00:48:37] Tanna Neufeld:  Yeah. And I'd say, you know, at the end of the day, um, we need to provide exposure to the language. So the platform upon which we do that can really look differently depending on all the other variables pressing in on the situation. Right. I would not hold back in providing technology just because it's a young child, obviously, but we have to realize that there's other things going on in this environment that may [00:49:00] prevent that and that there are other work arounds to help you provide robust language when you don't have an iPad at your disposal. So, you know, obviously we don't have time to talk about all the strategies, but I think that the big part of EI really is tackling buy-in. How do I help the family and the child buy into this idea of communicating differently, right? And keeping demands, low, keeping naturalistic, joyful interactions paramount, and really that means modeling, modeling, modeling, modeling all day long. However, we can, even with all my hands, which I do a lot with my kids. Right. And, and realizing that your job is, is to keep learning about this stuff. You're the first person, a lot of the times that these complex communicators meet, and I think you have a role to play, a huge role in setting a legacy for them. Um, that doesn't mean you fix it, but you, you help their family see hope, you help them see a path. And you [00:50:00] give them hopefully a good foundation to enter into preschool and go on.  [00:50:04] Kate Grandbois:  Can I ask you a question that I have to assume you get this, or you've dealt with this question a lot, either with your mentees or in your own practice, how to counsel a family who is extremely resistant to AAC of any kind, or do you have, you know, suggestions or, or strategies to, to get people on the same page, even if it's not anti AAC, but there are some other, um, conflict. I'm only thinking that because you've, as we've described a lot of times in our complex communicators at a young age, there's a lot going on. So these families are emotionally continually processing. They have lots of people in their house. They have work schedules. They have, you know, they have lives as well. So some of those communication skills can, they must be really important. What, what can you tell us about that.  [00:50:59] Tanna Neufeld:  [00:51:00] Yeah, I think the first step that I take is trying to understand where the resistance comes from. So you described a couple of situations, right? Sometimes it comes from grief or fear, um, that this means you're giving up on my child's ability to speak. Sometimes it comes from conflicting information from other providers. And like you said, the family is just trying their best to take all these conflicting opinions in mind and make these big decisions. So I think it really behooves you to take the time to develop a trusting relationship with the, with the family, um, and gradually start chipping away at this facade of, of, you know, rejection to the technology. Um, I don't think dropping it ever works. Right. I think a lot of, um, clinicians get a little hesitant to have conversations when a family has expressed a dislike or, or a rejection of an idea. But, um, I think [00:52:00] that you can gently work with the family without trying to convince them or persuade them when you just take the time to try to understand why. So just first of all, why is this happening? Uh, once you understand why I think a lot of solutions unfold that you can explore, um, but they're not always going to fix the problem. So I think, I think you really need to hear what families want for their child. Even if it isn't exactly what you want for their child, right. And some families are perfectly capable and fine with their child communicating and using nonverbal communication right now. They just can't take in anything else. So I would take that strength in that goal, and I would just make it explode with positive outcome. Right. So if you, if this is the way you prefer let's work on partner assisted scanning, let's get your kids to be the best. yes/noer on the face of the earth. Right. And all the while in your discharge at EI conference day, I'm going to put a handout in there [00:53:00] about an AAC device. Right. But I think that our job has really, we've got to help them reach their goals for their children.  [00:53:09] Kate Grandbois:  That was so well said. I wonder if you could tell us a little bit more other strategies for helping a family who might feel very overwhelmed. So I don't know how to use the technology or, uh, how can I possibly model all day long or I'm supposed to do this, but we're have a wheelchair fitting. And I mean, in terms of, we've already discussed, how AAC gets a bit, could, has is at risk for being somewhat overlooked in the early intervention years. How do you navigate that conversation about prioritizing exposure when you have a very complex child with a whole lot of people trying to do a whole lot of things at once, because you're right. We know how important those three years are. [00:54:00]  [00:54:01] Tanna Neufeld:  What I've found through experience. Um, and I would say just to preface this, that aided language modeling is number one strategy. If that's all you teach the family to do, I think you're doing a really standup job in the EI environment. And so if we throw all the other demands away and that's the skill we focus on, what I have found is the more confident the family gets at that skill, the more they will do it without you imposing arbitrary goals on it. Um, so I would suggest going back to the other strategy that we talked about in meeting a family where they are in their strengths. It's the first place that I introduced the concept of modeling is when they're already having a successful interaction together. Because if we ask families to model during something that is already feeling hard, 9 times out of 10, it isn't going to feel successful to anyone, including the child. Right? So if we take our example of the choice-making, which I think a lot of families feel really good about their ability to do [00:55:00] that, um, that may be a, an environment where I would say, great. So during this choice making, I want you to find one word on this page, usually the front page of the system. So they don't have to do a lot of digging. One word that we can talk about during this routine either while they're making their choice or after they've made their choice. So trying to kind of expand it away from requesting, because what I see happen when we make it about requesting something is they think they're going in to model and it ends up just saying, what do you want? And then they feel unsuccessful because the child's having a huge meltdown. Um, and everybody just cries and it's not fun. So I think, um, you know, understanding that starting with something that feels good, where everybody's happy and things are happening anyway, and then just adding one little step to. You can slowly build a repertoire around that and then keeping them on the first page is sometimes helpful or going with really [00:56:00] powerful words that the child already loves like a personal core word or a core word, a general core that happens to be really versatile, even if it's deeper into the system can be a good place to start. Um, and then I would go from there to say, um, each week I check in on how things are feeling. I keep everything very small. Um, so if that's the one skill we're working on and we don't come in next week and work on the new one, we build on the success right. Until I get the sense from the family they're coming to me and recording that something's going better without me asking, then I feel that they're ready to take more on. Um, so that might just be let’s do more words, or it might be, let's now bridge into more interactions.  [00:56:46] Kate Grandbois:  I wonder if in the 10 or so minutes that we have left, if you could tell us a little bit more about how, how a clinician can increase their scope of competence in this area, because we've already outlined [00:57:00] the many, many barriers that clinicians face in this realm and our strategies. There are a lot of them. So I can imagine that this is, you know, and I'm so glad you guys are putting on a conference about this, because if there's, obviously, this is just the tip of the iceberg. And I wonder if you could, um, give us some additional resources or discuss other, other ways that clinicians could improve their scope. [00:57:26] Tanna Neufeld:  Yes, I can. So, um, the first thing I would suggest is getting a mentor, um, and that is likely not going to be somebody in your EI setting, or it might be. Um, but you, you need to have somebody that you can check in with. So, um, I think there's lots of places to connect with mentors. Um, I have an accessible, a directory that, uh, people have submitted their information because they are, um, specialists in AAC and are willing to connect with families and providers who want to learn more.[00:58:00]  ASHA has, um, their pro-find and pro-find can be a great place to go in and type in your state. Um, and look at people who specialize in the AAC. Uh self-proclaimed right. So, you know, buyer beware, you got to make sure not everybody has the skills to give you as a mentor, but you're going to shop around and you're going to find someone you click with, but super, super essential to have a mentor. And then I think on top of that, um, as I said before, attending CE opportunities that are related specifically to other, um, domains, not speech-language pathology is really going to benefit you. So I would say things like seating and positioning, um, Closing the Gap has a bunch of conference sessions coming up on that. Um, there's a conference locally here with Karen Kangas. I don't know if anybody in the room has ever been to the Karen Kangas training. She is. Um, it's actually virtual this year. It's the Northwest augmentative communication society conference. And Karen is [00:59:00] presenting, um, and just getting a better understanding of how the body impacts communication and learning can be a game changer for you in this EI realm. So anything in seating and positioning, I would suggest anything on vision, soak up the vision, uh, Perkins School for the Blind has this branch called CVI Now. So good. So good. So good. And some of their stuff is free, even if it's not free. If you see any majority of, or any portion of your caseload of children who have neurological insult, they probably have cortical vision impairment, even if they don't have the diagnosis yet. So just get in there and get educated on it. And I think, uh, Perkins School is a, is a really great place to do that. Um, I also think if you're working with children on the autism spectrum, which, who isn't right. Then it really serves you well, to get trained in things like DIR floor time or any relationship based intervention that feels like it matches your philosophy. Um, just [01:00:00] learning how to support engagement and social interaction and respecting sensory accessibility is huge for working with little ones on the autism spectrum. What am I missing? Um, anything that helps you figure out how to play? Because I don't know about you guys, but we think we know how to play when we graduate. We don't know how to play. We don't know if it makes me so tired.  [01:00:27] Kate Grandbois:  I’m too old to play. Which is why I don't work in early intervention. I feel completely comfortable saying defend, just defending myself here for a second.  [01:00:33] Tanna Neufeld:  Yeah. You know, Amy mentioned that idea of high affect earlier in our call. Right? And I, I learned this concept from an OT colleague when I got here to Seattle, she's, in OT, they call it therapeutic use of self. Right. I don't know if you've ever heard that sounds real fancy. Um, but really it's using yourself as an extension of the play to entice and engage and provide joy to the child. [01:01:00] Um, and man, that goes a long way. When, when you think it's an attention issue, it's usually an engagement issue. Um, if they're not paying attention to you it is because something else is more interesting and as your problem, not their problem. So, uh, anything that helps you learn how to play better, um, learn how to, um, think about play differently. Anything from Hannon on play totally worth reading. They have these books called Let's Rock Play. Um, and they talk about people, games and people, toys and  [01:01:35] Amy Wonkka:  super accessible books too. They have like cute little cartoon drawings. Like they're just a fun.  [01:01:41] Tanna Neufeld:  You do. And they're great for parents because Hannon is just great for parents, right? But I think a lot of the times in EI, a huge struggle with complex communicators is figuring out how to help their family interact with them. It's hard to play and talk to a child with so much going on. You don't get the natural [01:02:00] reward, right. That you get from interacting with a child who has more social strengths or more verbal strengths. So I think a lot of our work, even though it's not really AAC, right. It is, because they need to be able to have joy. Otherwise they're not going to have any time to model all the things you're asking them to model. So yeah. Anything around play, social engagement, um, huge, huge importance. I don't think I left anything out.  [01:02:24] Kate Grandbois:  Well, you, when you and I were talking before we started recording, you had also mentioned some, some literature. Um, and we will have, um, at least one of the references that you mentioned listed in the show notes and article by Light and McNaughton from 2015. Um, I don't know if you want to talk a little bit specifically about that article, but I also wanted to make sure you mentioned, um, the research library that you have available on accessible.org for people?  [01:02:55] Tanna Neufeld:  Yes, absolutely. So, um, because the Light and McNaughton article is like a [01:03:00] novel written for researchers and not practitioners. I still, I still recommend that you read it because my philosophy on how to kind of approach improving our service delivery really is rooted in these gurus of the field, their perspective. So it is in the show notes. I really highly recommend you read it, but I wanted to really direct you also to, um, we have a section on our website called the stacks like library stack, um, and we have tons of stuff in there, but, um, what I'm really excited to keep building is a research collection. And one branch of that research collection is specifically on early intervention with AAC. Um, and I think some of the prominent names in the field like Romsk and Sevcik, um, are noted quite a bit in that research collection. And they talk a lot about the importance of EI, uh, including AAC, but also how to approach the myths that are still very pervasive in that field. Um, so check it out. You can see it on our website, accessible.org under the [01:04:00] resource tab, uh, stacks, um, lots of research in there and, um, anything that is by Romsk and Sevcik, I think is worth reading also anything by charity, Robin. It's worth reading in this field of early intervention, just to give yourself a framework for coaching assessment. I could go on, but they're all in there. Just read them. We all have them. [01:04:20] Kate Grandbois:  This is a wealth of resources and we're so grateful in our last minute. Do you have any, any words of wisdom or closing remarks?  [01:04:33] Tanna Neufeld:  So I would say, [01:04:33] Kate Grandbois:  that was a really good sigh. Just letting you know,  [01:04:37] Tanna Neufeld:  Dear EI SLP, you are doing a good job. You really are. Um, this is hard, hard work, some of the most rewarding work, but so, so hard and you're doing awesome. So be gentle on yourself, be patient on yourself, be patient with your families and your clients, um, and do your best to keep [01:05:00] learning, knowing that every kid you see, every complex communicators is going to teach you volumes. Um, so that, that would be my, my word of wisdom to  [01:05:08] Kate Grandbois:  That was wonderful thank you so much for sharing. This was so great. I mean, we've worked with you before on a variety of projects, but you are always just such a wealth of information and I love listening to you and we've learned so much from you. Thank you so much again for coming on and chatting with us today. [01:05:27] Tanna Neufeld:  Yeah. Thanks so much for having me.  [01:05:30] Kate Grandbois:  And anybody who is listening, Tana is so accessible. You should find her on Instagram, send her a message, send her an email. If you're listening and you have questions, um, you are not only a wealth of information, but incredibly collaborative and supportive of other SLPs on their learning journey. So don't hesitate. Um, and again, Tana, just thank you a million a million times.  [01:05:54] Tanna Neufeld:  Thank you.

This is a transcript from a podcast episode. 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 may contain typos. Email us anytime  with suggestions or errors. A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. [00:01:39] Kate Grandbois:  We're so excited for today's guest because we love talking to people - content experts - , who are going to teach us about things we know nothing about. And this is one of those topics we're so excited to welcome. Jenna Muri-Rosenthal, welcome Jenna!.  [00:01:54] Jenna Muri-Rosenthal:  Hi, thanks for having me  [00:01:56] Amy Wonkka:  now, Jenna, you are here to discuss fitness for [00:02:00] recovery before we get started. Can you please tell us just a little bit about yourself?  [00:02:04] Jenna Muri-Rosenthal:  Absolutely. So I'm a speech pathologist. I'm also a certified brain injury specialist. I've worked in TBI and neuro recovery for a dozen years at this point. I worked at the brain injury unit. Adult neuro is really my thing. I'm also an adjunct professor at the MGH IHP where I teach the brain injury course and I guess lecture at Northeastern as well. And in addition to all of my sort of speech and brain injury kind of passions, I'm also a certified level two CrossFit trainer and what we call an adaptive and inclusive trainer. And I coach at Invictus Boston, and I also have a program I'm the founder of called Fit to Function Recovery.  [00:02:46] Kate Grandbois:  This whole question right off the bat there. So as a fellow SLP, I enjoy exercise in my personal human life. How did you come to merge these two, [00:03:00] these two things, like what, what part of your journey led you into this, this area of nerd Ville? This is really interesting.  [00:03:07] Jenna Muri-Rosenthal:  Thanks. And you know, that question very directly sort of answers the, how did Fit to Function come to be? Which was that, you know, I had a lot of folks in my inpatient years in rehab and recovery. And then at MGH, I had a lot of folks who would kind of come back to me after they had left the rehab world and kind of said, insurance has run out, I'm looking to continue my therapy. I'm sort of at this place where I need a little bit more, can we continue speech therapy? And that's how I sort of started acquiring private clients alongside that. I was, I got into CrossFit on my own as a former college athlete and just looking for something new and different. Started gaining interest in just like this is kind of for everyone. So many people can benefit. And along with seeing the clients I was seeing for their functional recovery in speech and language and getting them back to work, I thought, you know, the gym is a great place for a lot of these individuals, , [00:04:00] because people lose so much of their general sort of, , their endurance, their confidence. And I sort of thought, I bet a lot of these people could make their way in the gym. , and that's sort of how it got started.  [00:04:15] Kate Grandbois:  Interesting. I mean, of all therapeutic environments, we talk a lot about the importance of different environments and communication on this show. I don't think we've talked about the gym one time, maybe like a PT room. [00:04:28] Jenna Muri-Rosenthal:  Yeah. And, and, you know, I think when we do co-treatments and things like that, we have always had that ability to see like, wow, I see how we can work on your memory here in the gym. I mean, I remember. My early days as a, a young SLP getting sent to the MSK unit, the musculoskeletal unit for the elderly individuals, who've broken their hip. And I would sit in there and just drill with them the steps to using their Walker. Where do you put it? How do you stand? How do you transfer? And you would just do memory with that. And so that has functional carry over, right? It's teaching people how to move. [00:05:00] So it's not that different when you think there are ways that we need to move better, but we also need to remember how to do that. And that's sort of where the blend came from. But for me, it was taking it a little bit beyond that, you know, you know, I use the tagline Fitness's for everybody and every body. , and I think that as folks are recovering from things like a stroke or a brain injury, they get to this point where they're, we have kind of says, oh, you're good enough. You can walk. You know, they sometimes get discharged, being able to just walk. And what if, what if that's not good enough for you? What if you want to run?. What if you want to jump, what if you want to lift weights? , and it, it was seemingly off the table for a lot of individuals and I thought, how can we get people back into this environment? [00:05:45] Kate Grandbois:  Okay. I have like 70 more questions.  [00:05:47] Jenna Muri-Rosenthal:  I want to ask, take it away,  [00:05:49] Kate Grandbois:  We need to go through the boring stuff first. So, so, , I need to read before I assault you with curiosity. Uh, hopefully it's not an assault. Hopefully it's a, a gentle [00:06:00] trickle of curiosity. I love curiosity. Oh, good. I'm really just on fire today here, I guess. So I need, we need to read the learning objectives, , and disclosures. So some people do write in sometimes and say that, , this is boring and they want us to skip it. We can skip it. ASHA makes me read it. So hang in there. I'll get through it as quickly as I can. Learning objectives for the day. , learning objective, number one, describe the relationship between fitness, speech, language pathology, and brain injury, recovery learning. Objective, number two, describe the role of fitness and social engagement and community re-entry. After a brain injury learning objective number three, identify three movements and functional fitness and their real world application learning objective number four, describe three cognitive communication skills or domains and how they can be applied to treatment in the gym or fitness setting, financial and nonfinancial disclosures. Jenna Muri-Rosenthal's financial disclosure as Jenna is the owner of fit to function, a program for brain injury survivors in the gym. She is also a certified level two CrossFit trainer,  [00:07:00] Jenna Muri-Rosenthal's nonfinancial disclosures. Jenna has no nonfinancial relationships to disclose Kate that's me financial disclosures. I'm the owner and founder of groundwater therapy and consultant LLC, and co-founder of SLP nerd cast my nonfinancial disclosures. I'm a member of ASHA, SIG 12, and serve on the AAC advisory group for Massachusetts advocates for children. I'm also a member of the Berkshire association for behavior analysis and therapy MASSABA the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis specialist. All right,  [00:07:29] Amy Wonkka:  Amy, that's me, uh, financial disclosures. I'm an employee of a public school system and co-founder of SLP nerd cast. And my non-financial disclosures are that I'm a member of ASHA, SIG 12, and I serve on the AAC advisory group from Massachusetts advocates, for children. All right. Onto the fun stuff onto the good stuff. , Jenna, can you start off by talking to us a little bit about just what is the fitness and wellness continuum?  [00:07:54] Jenna Muri-Rosenthal:  Yeah, absolutely. So when we think about health, right, , everyone [00:08:00] wants to feel well.So we think about the things that we can do to control. So eating well, sleeping well, doing activities that, , help maintain our general feeling of healthiness and our general wellness. Right. And all of these things are great, but in reality, wellness is more than that. , if we think about our global health and wellness in terms of, so, so think of it like a, it's a savings account. Okay. , we want to continually deposit into that bank account so that it grows. And so that we have a little bit of a safety net. So if I can, for example, lose some weight, , lower, my blood pressure starts sleeping eight hours a night. Maybe I take something, you know, take my vitamins, I'm filling my bank account and I'm starting to move the needle towards well, right. We don't want to be sick. We want to be well. But if we think about what truly opposes sickness, the opposite of sickness, isn't just wellness, it's fitness. So if I'm healthy and well and fit and active, I've really fully loaded that bank. And that helps me [00:09:00] potentially battle illness.  [00:09:03] Kate Grandbois:  Oh my God. I need to be well and fit now. I know my, my savings account is depleted. Okay. We need to focus because, because I think, I guess what I'm curious about, I mean, I had a million personal thoughts run through my head, but when you're talking about the field of speech pathology and the concept of wellness and the fitness and wellness continuum, where does speech pathology, like, how is that related to the field of speech and language? [00:09:35] Jenna Muri-Rosenthal:  I mean, there are a couple of different ways, right? For one is that everyone, everyone, everyone can benefit from increased fitness. Right? We know that to be true, especially if we think about that sort of wellness continuum. , but if you think about, on a very simple level, like a brain injury survivor, , if we can improve their coordination and balance and the way that we move, we can , we can save off the potential for future injury, right? Like people who suffer a brain injury are, are twice as likely to suffer a second [00:10:00] one, , often because either because of their impaired cognition and they use poor judgment or because they fall because they don't have good balance. , if we can improve, for example, your cardiovascular health, your fitness, can we help you promote, excuse me, prevent further strokes or brain injury or bleeds. So when you think about what we do is speak to the biologists, we were treating the brain, but in order for the brain to be healthy, the body has to be healthy. And in a lot of ways, Interesting. I could say more, but I can see the questions on your face.  [00:10:31] Kate Grandbois:  I know I'm like drilling you with my eyes. I have so much inquisitive look so . But before you go on, I think it might be worth. Cause when you say the opposite of wellness, the true opposite of wellness is fitness. I imagine the true opposite  of sickness, the sickness,  sorry. The true opposite of sicknesses is fitness. I imagine like, uh, I want to say beefy, but that's not appropriate. Like, you know, muscly sort of really trim 1% [00:11:00] body fat kind of situation, but that's not really what you're talking about. When you say fitness, you mean, I feel like the word function belongs in there somehow.  [00:11:09] Jenna Muri-Rosenthal:  Yeah, yeah, yeah. And we can talk a lot about functional fitness, but you know, we talk about in, in CrossFit in particular, which is my brand of fitness, right? And every brand that fitness sort of has their own ethos and their, their own structure. , we talk about general physical preparedness in CrossFit. So one of the things that we do is we want to make sure that you are trained kind of across a realm of things. And so that's weightlifting, but that's also going for a long run, but also going for a short sprint, but also doing gymnastics and having core coordination. So it's a range of everything it's endurance and stability and coordination and balance and strength and all of those things. What that looks like on an individual varies from person to person. Absolutely. So to be fit, you don't have to have that sort of supermodel, you know, television painted version of, you're not going to use the word beefy.[00:12:00]  You could use beefy. You could, you know, you could, you know, it's, it's whatever, it's however you view it, but that's even some of those individuals just because their bodies look like that doesn't mean that they have all of the wellness right across the wellness continu. And one of the things that at least cross. , likes to train for and, and, or against is we'd like you to be trained for it, like kind of prepared for anything. So you're, you're weightlifters who only weightlift. What if I asked them to go run a mile? How hard would that be for them? Pretty hard. Now, if I'm just a runner and you asked me to deadlift a few hundred pounds, that's also going to be very hard. So the idea is that by like a better sort of range of, , preparedness, your, your cardiovascular health is better, your strength is better. Your poor coordination is better. Your bone density is better. You know, the list goes on and on  [00:12:50] Kate Grandbois:  and on. Is it fair  [00:12:51] Amy Wonkka:  to say you're better off being pretty good at a lot of things then really good at just one thing? [00:12:57] Jenna Muri-Rosenthal:  Yes, absolutely. All  [00:12:59] Kate Grandbois:  right. I'm getting the [00:13:00] picture. And at the intersection of all of these things, when we talk about the field of speech and language pathology in this fitness continuum, you're really, and there is this emphasis on. An overall function and wellness for brain health, for cognitive function for living your daily activities, walking from your couch. I was about to say, walking from your couch to the fridge, that's how fit I am. You know, walking, walking ad to get the mail, you know, functional activities of daily living is really what you're, what you're talking about.  [00:13:33] Jenna Muri-Rosenthal:  Yeah, yeah, absolutely. And so, you know, quite simply as a treating clinician, no matter, I feel like no matter which domain you're in, you want your clients or your survivors to be well. And if possible, you want them to be better than you. So recovery is hard work and we know that, , and in addition to wanting better life and recovery, we also know how hard it is to function. , if how hard it is for good to have good brain function when [00:14:00] you're not, well, if you're not taking care of yourself, if you're not sleeping well, if you're not eating well, we all know the experience of increased like word, finding difficulties, even if you've never had a brain injury under fatigue or under duress. , so if we're encouraging our clients to be, to be, well, why not take that a step further to be fit to also help foster better brain health, right. And what might the potential be with that? What can we do with our brains? And of course, with our bodies by just kind of pushing that, that needle along that wellness continuum towards it. [00:14:29] Amy Wonkka:  I think it's so interesting. We talk a lot, Kate, Kate and I work in AAC and we talk a lot on this podcast about thinking about the whole person in terms of all of their different communication environments and all of their different communication partners. And to me, this feels like an extension of that. And you're thinking about the whole person in terms of like all of their body systems and all of the different ways that you want everything to be sort of optimized so that, you know, you're, you're maximizing your speech and language, , outcomes and ability to be functional and independent with those  [00:14:59] Jenna Muri-Rosenthal:  skills.[00:15:00]  Yeah. That, that has a lot to do with it. And that's so let me, I'll backtrack a little bit and talk about what exactly functional fitness means. Cause that sort of speaks to exactly, you know, exactly what you're talking about. Right? So like I said before, any fitness routine is defined by the movements that prioritize it. So functional movements are in CrossFit. It's what we consider natural. Meaning it's a movement pattern that's using real life, not just. Okay. So these are movements that are sort of found everywhere. They're embedded into human behavior and they occur spontaneously in response to your life. So for example, getting up off the couch, out of a chair or on and off the toilet, what is that? It's a squat. Okay. Yeah. So it's a squat  [00:15:41] Kate Grandbois:  for thought about this book,  [00:15:42] Jenna Muri-Rosenthal:  right? Right. Lewis goes on and on. Right. So picking up groceries from the floor, sag publishers, that's deadlifts. Exactly. , if you have to pick up like a heavy, like a big jug from the floor or a bag of dog, food needs to like, get it up on the table. That's something we call a power clean [00:16:00] where you actually lean down, you braced views, hip drive lifted up and you voiced it up. So you don't hurt yourself. Right. And then something like putting something up on a shelf, you have to have shoulder health and shoulder strength to push something and get it up high. Right. And my favorite example is what is a burpee? It's getting up off the ground. If you've. Right. Very simply put it is a functional movement. We put it into workouts to make people suffer, but for any individual, regardless of age or ability, we all end up on the floor sometimes. And if we can train you to be able to get there safely and, or get out of it safely, then we're doing you a good amount of service. [00:16:38] Kate Grandbois:  So, I mean, now I'm thinking about this. I'm like, well, I need to join CrossFit, obviously, but, but aside from that completely, I'm thinking about the SLPs who are listening and could be working in a school or could be working in, you know, an outpatient facility. How does this, how does this, you know, touch our scope of competence, right? Because you're talking, I mean, you are how you [00:17:00] have this, you know, area of expertise with a separate set of credentials that you have, but, you know, is this really, because this, it seems to make a lot of sense in terms of what Amy was saying with supporting the whole person and supporting their, their whole wellness and, you know, moving that needle to fitness, but w as an S and there's obviously, you know, a lot that we can talk about in terms of working on. What is within the scope of practice of a speech pathologist in a gym. And I do want to get to that, but where does this touch our competence? And what is the role of a collaborative practice in terms of like reaching out to your PT and really having, because I feel like we, as a speech pathologist, we collaborate with OTs a lot, but I don't know that I've collaborated with PTs officially. So I feel like this is really a collaborative relationship. That's  [00:17:44] Jenna Muri-Rosenthal:  underexplored maybe. Yeah, absolutely. And so think about it like this, right? So let's let me, you know, we are an SLP nerd cast. So let me nerd out for you a little bit about great. And then we can talk about how that kind of fits into anyone's scope. So like I said, for anyone can [00:18:00] benefit from fitness, right? But there's also, there's a lot of research out there about fitness and mental health. There's a growing body of evidence. That's not quite as deep as those with mental health, but about cognition and fitness. So we know that on a very simple level, that when we work out, our neuro-transmitters are firing right. And all kinds of positive ways. So our, you know, our senses are heightened. Our mood is improved, our focus is better. We're motivated more invigorated, right? So those are some of the things that we know sort of fitness, , primes our state of mind, we know that from the mental health literature, add to that though, that this new body of evidence that talks about really how, , exercise directly influences learning at the cellular level. So there are studies that show, , that exercise can improve the brain's potential for new learning. , studies really particularly have shown like total nerd moment that, uh, BDNF, which is brain drive neurotrophic factor. , [00:19:00] it's a molecule involved in plastic changes related to new learning and memory, right? So neuro-plasticity specifically in the hippocampus, which is responsible for new learning are activated through fitness. So through fitness in a lot of ways, we're priming the brain to learn. So now to tie that back into, how does this fit into your scope? It could be at the most simple level, you're sitting in your outplay patient room with your fine, and you go for a walk, can you do some air squats? You do some pushups, you get those neurotransmitters firing, you get the endorphins rushing. , and the brain does its thing. And so we carry that into the gym, but it doesn't have to be in the gym. Moving helps us perform better.  [00:19:40] Kate Grandbois:  I am so sorry to every PT. I have never worked with listening to that because that makes so much sense. And I asked, I feel like, you know, there's probably a lot of room for collaboration when you are working with someone who may be. Has some safety issues around like air squats and all those kinds of things, you know, like I, [00:20:00] but it also speaks to all of the things that we have seen in our great collaborations with, with OTs and movement in terms of, you know, playing games, running outside, being on the playground. I mean, that, that duh, like that makes, that makes sense.  [00:20:15] Jenna Muri-Rosenthal:  A lot of sense. Right. You know, and I can say, so I have this certification, right? I'm an adaptive and inclusive trainer. Anybody can get that certification. It's a one day course. And it's with a bunch of really cool adaptive athletes who show you how to adapt fitness for anything. And the individuals that have come to the forest, I've taken it twice because I'm a nerd. , and then my place, uh, you know, there were folks there who are working with all ages, some with kids, so much children on autism, spectrum, some with down syndrome and they show you, how do you modify fitness on the simplest level for all levels? And so one of the examples they did, they were trying to, they were showing for, they call it their intellectual disability sort of training, , [00:21:00] doing so for a kiddo on the spectrum with, uh, some visual and hearing impairments. How do you make burpees? So you do them in synchro. So we look at each other, we go down to the ground and then we high five double high five, and then we stand up and then we high five at the top of my head. It's a social interaction too. Exactly, exactly. And so there are all these ways that you can adapt to the most simple of fitness without needing to have some sort of other fitness certification. CrossFit is my brand of fitness, but the adaptive component just helps me adapt and include in the CrossFit model. But you could do that with, with any kind of thing.  [00:21:36] Kate Grandbois:  So we're going to put a link to that in our show notes, I'm going to find it. And you're, I'm going to ask you to give it to me and we will put it in our show notes because I think that seems like a really wonderful low barrier, you know, easy entry point complimentary skill set too. I mean, if, if not, if what you're saying is true, I know what you're telling me is true cited literature, but you know, that [00:22:00] relationship between neurology and learning potential and movement is, is something that I think would be really, really critical to include in our therapy sessions. Yeah. And possible, and done safely, please. Don't like the giant disclaimer.  [00:22:17] Jenna Muri-Rosenthal:  Yes. I should have done more disclaimers for fitness. , yeah, but you know, I think so I work primarily with adults. Those are, those are my people. I did work in the schools for a little while, but, , you know, I think there are so many different ways to modify, adapt and include. So for this, in this example, working with the children, the, the, that they were giving for children, one of the things they did was they made pictures. They made visual schedules. They had various fun ways to count the number of repetitions. So there are all these ways of the things that we do in speech. Now you're taking something that potentially is very motivating, , to a child because it's a game and they're in the gym and they're in this new environment and you're finding ways to apply your speech, your [00:23:00] communication, your social interaction, all of the goal, whatever goals you're targeting now for if I can kind of go on a little bit, the way I think about it with adults, I use all of those principles that I was just talking about as I nerded out a little bit to prime for language and cognitive learning within the gym. So for example, I might ask you to do five rounds of five pushups, 10 air squats, 15. So I'm going to have him do a round of that. And then I'm going to pause for a minute and I'm going to drill you on language, whatever your goal is, it might be naming. It might be describing, it might be something more related to short-term memory. And then we're going to do another round of that. You're going to work out a little bit of prime your brain, and then sounds was intense.  [00:23:42] Kate Grandbois:  I was going to say  [00:23:44] Jenna Muri-Rosenthal:  it's intense, but what is really cool and it, you know, it doesn't always work. Just like everything we do it doesn't sometimes it's too much, sometimes it's overstimulating. But what tends to happen is all of those mood type things that I talked about. So now your adrenaline is [00:24:00] pumping. You're happy. You're invigorated. Your fitness is flowing. You're a little salt, little less. Self-conscious potentially about dripping  [00:24:06] Kate Grandbois:  sweat and grimacing in front of someone and making moaning noises. I do burpees. I know that's, they're tough. They're hard.  [00:24:14] Jenna Muri-Rosenthal:  Right. But, you know, and, and people kind of like, they just come and they just fire away and they do their drills and I'm like, all right, go work out. And then they do the next round and then they come back and we do a little bit more. And then. Ways that we're using how the body helps the brain to help the brain help the brain. It's an interesting,  [00:24:31] Amy Wonkka:  like social construct too, to think about that though, because when you're at the gym, you're sort of accustomed to like, oh, I'm going to do this kind of hard stuff because that's what I do here. And so that's interesting too, to kind of take an overlay, the speech and language tasks on top of that. Cause often, you know, when you're in just a speech therapy room, you're, you're not necessarily in that mindset. You're serving I'm here. I'm talking to this lady and she we're gonna have a conversation about stuff we're working on things, but it's not the same. I don't know, I guess [00:25:00] at least in my sessions, it hasn't been kind of that same vibe that same, like Jim, you're trying hard, you're striving toward things, just kind of feeling going into this space. , so that's really interesting too. Yeah. And,  [00:25:11] Jenna Muri-Rosenthal:  and I also think right. All of us in our practice, we try really hard not to make what we're doing boring. Like we try not, there's always that way where you're trying to kind of like sneak in a task where they don't know that they're doing a task. Like I always ask my clients like, what'd you do. And I'm definitely testing their memory and their language, but they don't need to know that that's the easy example. But within the gym, I asked them to name objects. I asked them to remember things like, oh, what did we just do over there? Oh, what comes next? You know, oh, do you remember what this piece of equipment is? And you sort of start to embed that in, you introduce them to people in the gym and they have to remember names. And, you know, we, we bridge that sometimes into, , fitness logs. So they have to like talk about what they did that day when they got home and you know, all these kinds of ways to just naturally, you know, I always say about one of the coolest things about treating cognition in languages that it's everywhere and it's in everything we do.[00:26:00]  So you can just kind of have a conversation and at the same time be working on the things you want to work on. But in  [00:26:05] Amy Wonkka:  your example, it's much more contextual. Right. Like, like that is, that is so much more real use of the scale then, you know, doing some flashcards or even if you try and come up with a nice engaging activity that doesn't feel as dry as flashcards. Like it's still not quite as functional as, oh, I, I literally just have to remember these exercises because that's what I'm doing right now. And so it's super relevant to my actual  [00:26:26] Jenna Muri-Rosenthal:  what I'm doing. Yeah. And one of the jokes with, I, you know, I have a lot of language clients where they're just learning to count again, not learning, learning is the wrong word, but counting and using automatics is one of the ways that they're getting back to. , and also, you know, you're going to do eight of these and they either forget, or they just keep counting or they just keep doing it. I always joke while you're just going to get more fitness, because if you don't know, if you don't get the counting down that you did 14 reps, but for you  [00:26:54] Kate Grandbois:  funny, I also feel like I keep thinking about how this is just a wonderful opportunity for [00:27:00] generalization and how as SLPs, you know, working in our sterile white rooms or in our speech rooms, or even in, , you know, it's, it's often difficult for us to think of or suggest or accommodate for generalization opportunities. And I wonder if you could tell us a little bit about, , I mean, as I'm an AAC person, so I'm thinking about visual supports, like, do you have additional visual supports in your, in the gym? Like what kind of accommodations do you often see in the gym? Because I think that's just a great example of accommodations you can make in other places, like in, in the home, because this is all related to functional tasks. [00:27:42] Jenna Muri-Rosenthal:  Yeah. I mean, I often often talk about it. The, the ways that we modify and adapt and scaffolds to make it easier for folks then become the, the, the treatment and the things that we're handing over them to be independent from an [00:28:00] independent perspective. So like counting, right? When you first come to the gym, I'm going to count your reps for you. But eventually you're going to count. We're going to kind of use that sort of staff where I'm helping you do something. Eventually you're doing it on your own. And I, you know, we always say that anything kind of going back to, , my sort of fitness is for everybody and every body we can modify anything, no matter how you need it. So you need a visual schedule. We'll make it. You need me to write it down for you. We'll do that. Sometimes we use posters. To count reps. So you have something that you tackle that you can use. , sometimes we take pictures and videos and put them into a little booklet to take home to help you talk about it later. I'm not sure if that answers your question, but  [00:28:39] Kate Grandbois:  no, it does. And I think that there, I I'm just imagining, you know, the other generalization opportunities that presents itself. So if they have practice counting poker chips, then maybe they need, they can use that strategy to facilitate remembering counting when they're looking at a recipe and it's three tablespoons of butter. Obviously [00:29:00] this fitness conversation is making me think about really delicious.  [00:29:03] Jenna Muri-Rosenthal:  Obviously we'll actually say here's that here's a, now that you said as a perfect example. So one of the first, one of the first clients that I brought into the gym, who, you know how those first clients are, they just stay with. He one of them moments that was like such a big aha moment was he had had a massive, , uh, intraparenchymal hemorrhage. , and he globally aphasic, wasn't speaking, you know, couldn't speak, couldn't eat, couldn't walk. All of those things in the early phases of his recovery. By the time I got to him, we were doing some language stuff.  And after a few weeks in the gym, his wife said to me, he helped unload the groceries and it was for her enormous. He took the initiative to go pick up the bag to bring it into the kitchen, to take out the items and put them away. Now it was that because of the fitness. I don't know, but I like to think so. I like to think that it coming in and moving better and it gives you a little bit of sense of [00:30:00] confidence and ownership to be like, I can participate. In my life, because I can do all these things. I'm going out into the world and go into the gym and picking stuff up, putting it back down again. I can do that.  [00:30:12] Kate Grandbois:  I love the intersection of the cognitive approach of planning, , you know, processing and the physical interaction, because I think so often we're speech pathologists to be done language, but we think of receptive and expressive language, but there are so many integrative components of language that lend themselves to these non-verbal planning tasks that are so relevant and important to our daily lives and have a such a positive, , that's a great story. I mean, it has such a positive impact on our communication partners on our environments, on our lives, like across  [00:30:46] Jenna Muri-Rosenthal:  the board. Right. And, and one of the things that like I do for my clients. I, I work towards them, scheduling their own sessions, getting to, and from the gym, you know, be it an Uber, the T finding their way and then like [00:31:00] paying for their sessions and navigating all of that in such a big, it's a small thing, but it's a big thing. , when suddenly the significant other or the parent doesn't have to be the point person for everything. And so that's also one of the ways that I like to think that there's better carry over because you're now leaving your home to come to this place, to do this thing. So my independently, you're going to get here and back and you're gonna be in charge of the whole, the whole thing of it. That's  [00:31:25] Kate Grandbois:  huge.  [00:31:25] Amy Wonkka:  All of those components are huge. And all of those things that you just talked about are things that are then opportunities to repeat those same things in other parts of their life. Right? If you can get to the gym, then where else can you get to, if you can pay for your session, what else can you pay for? You know, if you can plan your ride here, where else can you plan a ride to? I mean, that's, that's, that's a huge, that's, that's gotta be so huge and impactful for people.  [00:31:51] Kate Grandbois:  I also feel like that's something that you can do, even if you don't, I'm just thinking of all the SLPs listening who may not have access to a gym and may not be with their, with [00:32:00] their patients or their clients in a gym, but how all of these things can be functionally applicable across the board. , and, and how important that is and how social I love the social component of this. And I wonder if you could talk a little bit.  [00:32:16] Jenna Muri-Rosenthal:  Yeah. , you know, I, when I talk to people about sort of my practice, that's one of the things I say is that brain injury is so isolated. , because people will always talk about how they have all the support upfront and they're in the hospital or in rehab, they get home. And then slowly that support started starts to, to drift the drift away and people lose their work. So they lose their, their kind of work community. Oftentimes they lose their, their general social network because they can't engage the way that they used to. , and one of the things I liked so much about the idea of bringing people into the gym is that it gives them a place to be in a sense of community and CrossFit is very community focused. , and so I've sort of. My hope for most [00:33:00] clients is that they, while they're adapting the fitness a lot, they need, they may need some one-on-one support, but that eventually they join a gym. So if you've never stepped foot inside a CrossFit gym, and I promise I'm not just selling, selling the listeners on CrossFit, but most people will tell you, like, it's a cult. Like we all love what we  [00:33:15] Kate Grandbois:  do. Okay. It was done. I was, I did want to ask you about that.  [00:33:18] Jenna Muri-Rosenthal:  You can, you can  [00:33:20] Kate Grandbois:  we'll we'll table that for a  [00:33:22] Jenna Muri-Rosenthal:  second. Give you this example. So this, so say that workout that I said before, so you can do five, five pushups and you know, 10 air squats and 15 setups. And you're going to work for 15 minutes. Everybody in the room is doing the same thing. Maybe with a little bit of an adaptation, like you, I might need to do my pushups, like elevated to a box. If I'm not that strong, some people might need to squat to a box if they can't get to kind of just squat and free space, but we're all doing the same thing and what will happen in any CrossFit gym. Everybody is cheering everybody else on. So in that example, we're all working for 50 minutes, but say, I said, you're going to do six rounds for time of [00:34:00] that. Someone's going to finish in six minutes and someone's going to finish as wealth. And you better believe that every single person in the room is cheering on those individuals until they get to the finish. And that's sort of part of what CrossFit is. And so the idea with this was that I want these individuals to find community. My father does CrossFit. He's 72. He refers to it as a brotherhood of suffering. Right. But the idea that we're kind of like we're all in this together applies no matter what your scale or modification is. So that is, you know, for these individuals who are, , a little bit more isolated, that's the hope. And even in my practice, I have all these clients who don't know each other, but they very much support each other. I had a client come in and do a competition. And my one, two of my clients helped on zoom. So they could watch her do the competition. It forms community because again, there's that sort of shared stuff.  [00:34:52] Amy Wonkka:  I just feel like it's, I'm getting so excited about it. I'm just having so many feelings, just like nice feelings, picturing what this looks like and what this feels like for [00:35:00] everybody who's participating, whether through your clients or, or other folks just at the gym. , and I do, I think that that's social component, you know, we, that's another big back to Kate scope of competence, you know, point earlier, we, we do work on social pragmatics. That is a big piece of what we're doing. And I'm sure that that is an area of focus for some of your clients as well. That's probably part of what they're working, they're working on the memory, they're working on cognition, but probably also some of that pragmatic stuff and having those relationships. [00:35:32] Jenna Muri-Rosenthal:  Yeah. There's definitely the pragmatic aspect. And also for some individual individuals. Having the confidence to use their language skills again, especially adults. , you know, if you've suffered, you have now severe aphasia and you're like, I can't talk to anybody, even for people who are getting much better having that, the opportunity, right. Cause you go home and you just talk to your sneeze and other and your therapists. So that kind of novelty effect as well is really good.  [00:35:58] Kate Grandbois:  For sure. And I love the [00:36:00] point you made about how isolating brain injury is and how important community is. And I mean, I know the CrossFit is the example that we're using a lot, but there are fitness communities everywhere there. I view when my daughter was born, I went to the gym all the time. I'm being totally honest. I put her in the daycare and then I sat in the, I was in grad school for the second time. And I was, I was, did a lot of studying in the gym waiting room I exercise to do, but there were, there were groups of women who would sit and have coffee every Thursday at 10 o'clock before they went into their aerobics class. And they, they were like, they gossiped about all the other people in the aerobics class. I mean, they were a community of people. I don't often think about the social and community important component of, , re-entry into the community. I guess once someone is discharged out of your office and how you really, I mean, as an adult, it's really hard to make friends. [00:37:00] Sometimes it's brilliant. There is no, like, you know, you could join a community theater. I mean, there's not a lot of choices, but unless  [00:37:07] Jenna Muri-Rosenthal:  it  [00:37:09] Kate Grandbois:  right, and fitness is a huge industry. So there are so many opportunities. There's CrossFit, there's, there's Pilates classes. There's huge gyms with yoga. Exactly. So I love the idea of using fitness as a bridge to community re-entry to generalize all of these skills. It's just, it's  [00:37:29] Jenna Muri-Rosenthal:  awesome. Right. And I, and I think what's cool too, you know, uh, I've spoken at a bunch of support groups and. One of the neat things. Neat. One of the few good things to come out of COVID is the ability to connect people via zoom. And the fitness industry in particular has really found ways to, to continue and to bring people together. And so you can do yoga on zoom and CrossFit and all kinds of fitness, uh, entities that are an opportunity for community, for people who maybe don't leave their [00:38:00] homes.  [00:38:00] Amy Wonkka:  Yeah. I think that's such a great point. And I heard you mentioned earlier that you had two clients who were there by zoom just to cheer your other client on. And I think that, that is, I agree with you. I mean, silver linings of COVID I suppose, but like, we, we have become a lot more comfortable with some of these modalities that really help break down some of those barriers for people.  [00:38:18] Jenna Muri-Rosenthal:  Awesome. Yeah. Yeah. I spoke at the stroke support group at Spalding and they were saying how, you know, as soon as COVID hits there, This is it like, what are we going to do for our support groups? And their support group is stronger than ever. They had almost 30 people there, the day that I was on. And they said they would have never had that kind of turnout in person. So it's just a really cool that, you know, this opens the door and it enables us to reach more clients in general and to help connect clients together. I just connected one of my stroke survivors here with one of my stroke survivors in Germany, because they're about the same age and they're going through the same thing. I wonder  [00:38:54] Kate Grandbois:  if you have ever, and maybe this is a little off topic, but I know you mentioned [00:39:00] earlier, the relationship between fitness and mood, and I have to make some assumptions here. The isolation re-entry into the community, some risk factors for depression or anxiety. , do you find yourself as a speech pathologist or do you think it's within our scope as speech pathologists to really look at those risk factors through a communicative lens and, you know, embracing components like mindfulness, for example, in a routine or as part of the cognitive, you know, addressing cognitive deficits? Yeah, I, I, yeah,  [00:39:40] Jenna Muri-Rosenthal:  absolutely. I, you know, I tell people all the time that like, so I worked, there was a physician who I used to work with . He used to say that the brain is the final frontier of medicine. And, and I love that. And I always tell people, like I work with the brain, so I work with all of it. How do we [00:40:00] separate? What is mood versus cognition? How do you know what is memory or attention versus like something else is going on with this individual? Maybe they're fascinated that this neighbor that, that said within our scope, I think it's our job to connect the dots at a minimum. , and, and, and to sometimes being the communication experts, we are the only people who can really see that connection. , because we're reading between the lines of language, because we're reading between the lines of what the person may be able to express or even remember. And so I think. I do think it fits within our realm to say like, we've got to find other ways to kind of help support this individual's mood food in particular. And I think a lot of people, like I was saying, once they've left the rehab setting and they're not really in a clinic and they're not, they don't have close followup. Nobody's really quarterbacking care for them anymore. And so if you're the significant other of a stroke survivor and he's kind of feeling down, you kind of just [00:41:00] feel like, well, I, yeah, of course he feels down. He'd had a stroke and he can't communicate as well anymore, but there are actually changes happening in the brain that medication may play a role for. And I feel like that fits within our scope because we're the experts that can at least connect people back to the services. Even if we don't make a blanket recommendation, we can say you should probably talk to your physician about X, Y, and Z. Cause I don't think people are able to parse through all that.  [00:41:25] Kate Grandbois:  You know, what else this is making me think about is the, the importance of, I know you mentioned this briefly support groups and we interviewed, , Dr. David Luterman about six months ago. , and, uh, with, uh, we did an episode on counseling and the importance of counseling and how counseling and forming support groups is completely within our scope as SLPs. And we don't really embrace that as part of our workplace environments and workplace norms. And we think of them as like social skills groups, but that's different support group [00:42:00] is different than, you know, than a, a therapeutic group with, you know, has a different focus. , and I love the concept of these, you know, blending a little bit of all of this. So you've got this community of individuals who are supporting each other. , you've got the component of fitness, which is priming the brain for learning, improving mood. This really seems like. You're just, it's just like, you're just hitting all the, all the points with these, with these fitness groups giant,  [00:42:32] Jenna Muri-Rosenthal:  I'm trying. And, and, you know, I do think I almost, all of my clients say the same thing, that support groups aren't for them. , I think people struggle with seeing themselves in others. , they often show up to a support group and they're like, oh, they're way worse than me. Or everybody's older. I hear that all the time. Everybody's old, too old. They think of stroke. You know, like a stroke support group is everybody being 70 plus. [00:43:00] And they're too old. I have a 56 year old client who said that to me. I went to one of those stroke groups and everybody was too old. And I think helping people connect. Is more than just saying, Hey, go to that group. It's supporting them through other ways, through other things that they have in common, potentially, other than just their Schroep, , helping to find interest to connect clients, helping people just find the community, wherever that may be, because they need, they need the support in whatever way they find it. But I think there's a stigma, unfortunately, attached to just going through a support group. Well, that's  [00:43:32] Kate Grandbois:  what I was just about to say. So if you are, you know, as an SLP listening, making recommendations to find that community through a fitness group, Pilates, yoga, CrossFit, whatever, you're removing that barrier of the stigma. Yeah. I mean, you're really just like cutting through the, you know, and finding peers, you know, people the same age, people who have the same interests, just being out in the community. I mean, there's a lot of benefit to them.  [00:43:56] Jenna Muri-Rosenthal:  Yeah. And I think that's what is lacking for survivors. [00:44:00] Like said they come, they come home now from rehab and they don't, they don't work and they can't socialize like they used to, and they don't know what to do with themselves. And so whatever kinds of things we can be encouraging people to do, and it doesn't just have to be other stroke survivors, you know, it can be, or, or people with the same type of experiences you it's, it's about also piquing their personal interests. Who were you before this, your injury. And how do we get you back to that person? Did you love book groups? Okay. I don't care if you can't read anymore. Come to my book group, sit here and listen, you know, did you love cooking? Can we tend to do a cooking class? It doesn't really matter what it is, but I do think there is, there's a lack in connectivity for people. We don't know how to get them to what they need and what they need is to find a way back to feeling like themselves. [00:44:47] Kate Grandbois:  Yes, they do. I love the way that you just phrase that. I mean, that seems like it's such a critical piece of ethics and integrity. Yeah, it should be a cornerstone of what we're doing. [00:45:00] Right.  [00:45:00] Jenna Muri-Rosenthal:  You know, and I, and I think that people are individuals very much are delivered the message and rehab that they're good enough and people want to be better than good enough. And they deserve to be. , and so how can we help them do that? How, and it's even things like, you know, so many individuals with any level of cognitive or language disorder after an injury, they don't work because maybe they can't do the job that they used to do. But that doesn't mean they can't work. Right. There are things, there are jobs out there that could get them doing something, finding community, finding interests, finding passion, but they just don't people. A lot of people don't take that initiative because it's, it's hard to pull yourself out of your injured self, because most people are looking to get back to a hundred percent of what they were before their injury. And often until they feel like that's where they are, they're not going to move forward. Well, it's our job. As, as speech pathologists to say, like, there are ways you can exist out there in the world. I  [00:45:58] Kate Grandbois:  mean, I very inspired. [00:46:00] I  [00:46:01] Amy Wonkka:  feel like you have made so many good points about. Helping connect people and whether that's helping connect people with, you know, the appropriate referral, like if, if perhaps maybe medication would help, we don't know, we're not, uh, you know, a prescriber, but you can make that referral. If it's connecting people to a social experience, maybe that's exercise, maybe that's a Booker bird cooking class or all of those great things that, you know, you, you listed off. , but I think, I think that piece is really important. And I think that. I, I sometimes go off a little bit and get grouchy about like our, our medical system here in this country and how hard it is to get reimbursed for services and all that for that I know, but, but  [00:46:49] Kate Grandbois:  you, I support you. I didn't mean for that to sound condescending.  [00:46:53] Jenna Muri-Rosenthal:  That's how I ended up with this practice, but carry on. No, we'll do it. We'll  [00:46:56] Amy Wonkka:  just to say, like, if you do find yourself, whether you find yourself, you [00:47:00] know, in, in a private practice role where you're maybe able to be a bit more fluid in kind of making some of those connections and having a little flexibility, but you know, as I've listened to you speaking, even being someone who who's in primarily school-based environments, you know, we could be making more connections within those environments probably than we already are as well. You know, I mean, if you're a speech pathologist working in a public school, your kid is probably also needing to follow directions in gym class and follow directions in art class. And have you ever been to gym class or art class to even see. If, if those are interest areas or if there's like a nice, fun, different way, you could work on those same skills. I think some of those same ideas that you've been talking about that are so incredibly cool with your population are, are also really broadly applicable if  [00:47:46] Jenna Muri-Rosenthal:  you like zoom out a little bit. Yeah. Yeah. And that's my premise as a treating clinician has always been what is functional for you, right? What matters to you? One of my private clients, one of the first private clients I've brought into the gym before we even did that. [00:48:00] She was a PE teacher and she had a severe aphasia and she wanted to go back to work. And so we had one of her coworkers take pictures of all the things, all the games and the toys and the things in the PE closet. And we practiced naming those. Right. I can show you a book of standard aphasia therapy type things, but you want to name this weird little scooter, which by the way, I was like, I don't know what that's called, but we'll work with it. , but you know, it's, it's, it's gotta be functional for the individual to be motivating and that's true across age. I heard  [00:48:28] Amy Wonkka:  you talking. I have to, I have to say an apology to all the physical education teachers out there. I was raised in the eighties. I call it gym. I know it's wrong. Physical education.  [00:48:35] Kate Grandbois:  Sorry. Oh, we don't call it gym anymore.  [00:48:39] Amy Wonkka:  Physical education. It was always gym class for me too. And obviously old habits die hard anyway. [00:48:45] Kate Grandbois:  And I learned in the eighties, turned out it was all trash, but we're not going to talk about that because that's a whole other, but anyways, , I, I wonder if I'm going to refocus here, , in terms [00:49:00] of, so we've, we've covered a lot of really important concepts through this conversation in terms of, you know, the role of the role of fitness, the role of exercise, the role of, you know, we've covered a lot of things. So we, we, I, , I have a question. I mentioned this question earlier in the episode, and I said, we were going to shelf it, shelve it. We were going to put it to the side CrossFit. We've talked a lot about fitness in general. CrossFit is your, as you've said, your brand of fitness, I have this and I enjoy fitness. I enjoy exercising and I have heard extreme views of CrossFit. I have heard it's the most amazing thing on the earth. And then I have heard it's. Cause you mentioned that those were your words, not mine. So can you, for those of, for people who are listening and really appreciating the community aspect that you've described of CrossFit and are thinking about maybe making referrals for their existing clients or patients to CrossFit, what [00:50:00] can you tell us about the CrossFit culture or environment pluses  [00:50:06] Jenna Muri-Rosenthal:  and minuses? Yeah. Yeah, no, I'm, I'm glad you brought that up because I think that like, look, CrossFit gets a bad rap. Like we, we know that, , it's viewed as like, whoa, crazy. What are those crazy people doing? , and in my neighborhood, people always say like, I see people running up and down the street, like carrying plates, like plates and dumbbells and kettlebells while they run, like, what's up with that. You people are crazy right now. But if you take, dial back to what I said before, about things that are functional, sometimes we have to carry heavy things. Sometimes we have to like run across the street, like with a toddler or a baby under our arm. Right? Like you do things where you carry things. So that's the application. You know, like I said, a fitness routine is defined by the movements that it chooses to prioritize and CrossFit prioritizes functional movements. So what. The world sees is maybe what the elite athletes are doing. So if you tuned into a CrossFit competition, you'd be like, I'm sorry,  [00:50:58] Amy Wonkka:  there's a big tires or [00:51:00] ropes. This is what I think of.  [00:51:01] Jenna Muri-Rosenthal:  Yeah. Legless rope climbs. They're doing 600 pound deadlift. They're doing things that like your average individual doesn't do, which is what elite athletics are. And CrossFit is an elite sport. There. It has an aspect to it that's a week, but really what CrossFit is, you know, if you define it, take it a step further, define it by its three elements. It's constantly. Movements that are functional executed at a high intensity. We talked about this a little bit before where we talk about general physical preparedness CrossFit talks a lot about preparing you for the unknown than the unknowable. So we take all of those functional movements. We vary the stimuli and we make sure that you're kind of ready for anything is sort of the ethos behind it. So, you know, there are benefits embedded within that very nature of the workouts and those variations on load intensity duration, et cetera. So that looks wild to the outside individual. But if I can take it back to like an adaptive kind of thought process, so a ring muscle up is one of the hardest [00:52:00] movements, and it's something that as I'm going to try to describe it to you. So something that gymnasts do so you hold the rings, the two rings hanging from the ceiling. You pull yourself up sort of in a poem and you kind of pull yourself through the middle, into a, into a ring dip. So you're pressing, so you're kind of pulling yourself up and. The rinks. Does that make  [00:52:20] Kate Grandbois:  sense? A little bit glaring at you because that's physically impossible. It's very, very hard.  [00:52:25] Jenna Muri-Rosenthal:  Now that is one of those movements that you look at and you're like, that's not my brand. I'm never going to be able to do that. Now this adaptive course that I talked about, one of the things that they talk about for our seated athletes. So our wheelchair dependent level level athletes, if they can do a ring muscle up from a seated position, there's not a fall or a situation they can't get out of because what is it it's just pulling themselves up, leaning their body over and pushing their body into position. So you can take that view of, wow, that's crazy. And cult-like and why would I ever need to do that? [00:53:00] But everything we do in CrossFit, you can strip it down to its functional nature.  [00:53:05] Kate Grandbois:  Interesting. Yeah. Can I ask you one more question about CrossFit that I have a rumor that I heard and you can prove it or disprove it? I have heard a rumor that it's unsafe.  [00:53:18] Jenna Muri-Rosenthal:  So I always tell people this about CrossFit. There are two reasons that people get hurt in CrossFit. One is ego. Two is bad coaching, which just like any other profession. There are people out there who don't take their job as seriously as they should, but in any CrossFit gym, it is among the most safe. If you come in, you check your ego at the door, you learn the things you're supposed to do, and you follow the coach's instruction, just like in any other sport or any other exercise class, any other exercise class, right? You have to, you have to leave your ego at the door. And if the coach says, Hey, maybe that's too heavy for you today. You have to be able to accept that. And the coaches job when they teach us to coach, the first thing that we're taught is.  [00:53:57] Kate Grandbois:  That makes sense. I mean it's yeah, [00:54:00] but see, people  [00:54:01] Jenna Muri-Rosenthal:  get hurt, right? Like most of the people that I know who I work out with, they got hurt outside of the gym because they like turned an ankle on a rock. You know, like these things happen, blew my knee out, walking  [00:54:10] Kate Grandbois:  like three weeks. Amy did too. One time I'm going to, I'm going to blow up your spot. So people, people, people do get hurt. Okay. Well, so thank you for clearing that up. And I, I think, you know, I think there is something there is, like we had already mentioned earlier in the episode, it's hard to make friends as an adult. If you don't have a job to go to. I mean, I think of a friend of mine recently had to move to a new city with her spouse. And she was so concerned that she wasn't going to meet anyone. She was a full-time stay-at-home mom. How do you get out there? You need to, if you don't make friends at a job, if you don't make friends in the class, how do you, how do you establish a community in a new place? , and if we're identifying that reentering a community after a brain injury is very isolated. [00:55:00] I love the idea of using the fitness industry to establish that. And if there is a safe and non cult-like, now that you've cleared up those things, fitness community, , that really has a fundamental principle of a state of having community embedded in it. That's, that's really wonderful because I know a lot of exercise classes, you know, you walk in and you're just like, well, stop staring at me. You know, I'm not going to talk to anybody. I'm just going to look at the floor and sit my water bottle in my tight pants. So, you know, there's already this, this, this feeling of vulnerability when you're, when you're in a, in a group exercise and fitness, , you know, situation. So thank you for clearing that up. Of course.  [00:55:41] Jenna Muri-Rosenthal:  , yeah. Think about like walking into a Globo gym, like a planet fitness type, like a big, just a big, you know, like a type of franchise gym, you go in there and you're on your own. Like you go in, you do your own thing and then you leave. But CrossFit, you show up, the coach runs a class, everybody does [00:56:00] the same thing or some version of it. You celebrate your successes together and you leave at the end together. So it's, it's that sort of misconception of what is gym and not all gyms are created equal. Not all fitness programs are created equal, and even I don't, you know, I don't really spin or do yoga or anything like that, but I would imagine that some of those are very well done in a community centric environment. Others probably aren't so much. So it's all about it. You just got to find your people. Right.  [00:56:24] Kate Grandbois:  Right. And also I would imagine, you know, listen to the, the client and prospective values, like perhaps they did yoga pre-baked brain injury. Perhaps they really enjoyed X, Y or Z fitness. And I feel like a lot of the things that you're talking about could really be found in a variety of different community fitness-based activities, right. [00:56:44] Jenna Muri-Rosenthal:  Activities are just a bridge, right? Like you go into a community fitness and then you find that somebody else in the group. Sewing or whatever. It's all about. It's all about finding, finding your people. And, but in order to do that, you've got to get out of the house and get somewhere. So fitness is the way that we can do [00:57:00] that then. Great. Okay.  [00:57:01] Kate Grandbois:  So in the last couple of minutes that we have, I wonder if you could leave our listeners with some resources that you like. So in terms of, I don't know where they can go to learn more information, other things that you think would be beneficial to our listeners.  [00:57:15] Jenna Muri-Rosenthal:  Yeah. Well, since we were just talking about the cult that has crossed it, I will just say, go out and drop into a CrossFit gym, take a class, see for yourself what it's all about. So for, but at 95% of gyms, your first class is free. You just come, you get to experience it. You see if you like it, come see that. Try that community thing. , that's my CrossFit plug just cause I do think fitness is for everybody. , but as far as resources, go, go out and read the book spark by genre. , and that's the new science of exercise in the brain. And that's where these got a lot of really good information. , kind of the nerdy stuff I was talking about before you, you won't be disappointed and he covers all different ranges of things related to brain health and fit and just exercise. , [00:58:00] go look up the adaptive training academy. Uh, that's the place that does the adaptive and inclusive fitness certification that, like I said, anyone can take it's a one day seminar. It's really, really, really great. Uh, there's a podcast that I love, uh, it's called docs in the box. , and that's because we call CrossFit gyms, they're called boxes. , so a couple of PMNR physicians, so physical medicine and rehabilitation doctors, those are the doctors that run your rehabs, , who are involved in the fitness world, running this podcast. So it gives you a lot of, uh, sort of a medicine type scope, but from a fitness type perspective, , And honestly check out my Instagram page, not, not to, not to plug what I do, but just because I think that it's really hard to conceptualize that like functional fitness on like a stroke survivor in the gym, , until you see it. But I have, I put a lot of videos on there because I think that's what really helps people be like, oh, I can, I could do that. That's for me,  [00:58:54] Kate Grandbois:  that's tremendously helpful. , in our last little bit, before we, before [00:59:00] we leave you, or before you leave us, do you have any final words of wisdom for any SLPs who are listening and feeling either appropriately outside their comfort zone, because, and they're curious, or who would like to try and implement some of these things? What are your final words of wisdom and parting thoughts?  [00:59:21] Jenna Muri-Rosenthal:  You know, I think everything we do is trial and error, right? We're making it up as we go. And so much of the things that we do in rehab, and it's all about just trying until we find that thing that hits. , for each individual, every client that we serve. And so don't be afraid to try stuff. Don't be afraid to reach out and ask questions. , I don't know. I think always keeping what you do in your practice, functional for the client. The most important things that I can say no matter what that means, be it that they have a certain interest in a certain kind of game or a certain artist or a certain fitness find the thing that speaks to them and help, help bring them back to [01:00:00] who they were, where they want to be. [01:00:02] Kate Grandbois:  That's all. Thank you so much for joining us. This was really fun. Awesome. Thanks for having me really, really fun. If anybody is listening and would like to use this episode for Ashesi use, you can purchase a Ashesi. You processing on our website, www dot SLP. Now podcast.com . All of the references and resources listed in the episode will be available in the show notes. So if you're running or commuting, don't worry. You didn't write anything down. We'll have it all written there for you. , and if you have a second, please cruise on over to whatever podcasting platform you're using and leave us a review or send us a note. We love hearing from our listeners and thanks so much for showing up today and hope everybody learned a little something. Thanks everyone. Thank  [01:00:48] Amy Wonkka:  you.

This is a transcript from our podcast episode published February 2020. 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 . [00:00:00] Kate Grandbois:  welcome to SLP.  [00:00:14] Amy Wonkka:  Narrowcast I'm Kate and I'm Amy, and we appreciate you tuning in and our podcast. We will review and provide commentary on resources, literature, and discussed issues related to the field of speech-language language. You can use this  [00:00:28] Kate Grandbois:  podcast for Asher professional development. For more information about us and certification maintenance hours, go to our website, www.slpnerdcast.com as I'll be nerd cast is brought to you in part by listeners. Like you, you can support our work by going to our website for social media pages and contributing. You can also find permanent products, notes, and other handouts, including a handout for this. So my names are free. Others are not, everything is always affordable. Visit our website, www.slpnarrowcast.com to submit a call for [00:01:00] papers to come on the show and present with us. Contact us anytime on Facebook, Instagram, or at info at dot com. We love hearing from our listeners and we can't wait to learn what you have to teach us  [00:01:12] Amy Wonkka:  just a quick disclaimer. The contents of this episode are not meant to replace clinical or. SLP nerd cast its host and its guests do not represent or endorse specific products or procedures mentioned during our episodes, unless otherwise stated we are not PhDs, but we do research our material. We do our best to provide a thorough review and care representation of each topic that we tackle. That being said, it is always likely that there is an article we've missed or another perspective that isn't shared. If you have something to add to the conversation, please email us. We would love to hear. [00:01:46] Kate Grandbois:  Before we get started in today's episodes, financial and nonfinancial disclosures. I am the owner and founder of grand watt therapy and consulting LLC. And co-founder of SLP nerd cast. Amy Wonka is an employee of a public school system and cofounder of [00:02:00] SLP nerd cast. Uh, we're both members of Ashesi 12 and both serve on the AAC advisory group from Massachusetts advocates. I am a member of the Berkshire association for behavior analysis and therapy, mass ABA, the association for behavior analysis international and the corresponding speech, language pathology and applied behavior analysis, special interest group. Welcome to our first episode of SLP nerd cast. I'm Kate Grandbois I'm Amy Wonka. And today we are talking about collaboration with BCBS. Amy, why did we choose this topic?  [00:02:34] Amy Wonkka:  Uh, because you are a BCB. It's true. It's true because we personally learned a lot through collaborating with  [00:02:42] Kate Grandbois:  BCBAs. It's true because almost every SLP is going to end up working with the BCPA at some point in their careers. Fair  [00:02:53] Amy Wonkka:  points. Also sometimes they make us  [00:02:57] Kate Grandbois:  gravitate. That's that's the, it's the [00:03:00] unspoken truth. Yeah. That sometimes SLPs and BCPS do not see eye to  [00:03:05] Amy Wonkka:  eye. Yeah. It's hard to get along.  [00:03:08] Kate Grandbois:  It is. It is. But we are going to try and explore that a little bit today. Um, the content of our episode is going to be some background information about collaboration, uh, background information about ABA. And then finally some, uh, I guess you could call them tips and tricks for how to collaborate. Effectively with, we won't say the enemy. We will say the front of me or the other colleague and collaborator, the friend  [00:03:36] Amy Wonkka:  we haven't met yet.  [00:03:37] Kate Grandbois:  Yes. The friend, the BCBA friend that we haven't met yet. I love that. Okay. So. I guess moving on Amy, why don't you tell us a little bit about why collaboration is so  [00:03:48] Amy Wonkka:  important? Well, I mean, I think we all know that collaboration is important and regardless of where you work as a speech language pathologist, you need to work with other people. Um, if that's in the medical setting, you're working with a bunch of [00:04:00] allied health professionals. If you're in the public schools, you're working with teachers and other therapists. If you're outpatient, you're working with a bunch of different professionals as well. So it's an important part of the job. Um, being able to work effectively with other people can be easy and wonderful. It can also be challenging and frustrating. [00:04:20] Kate Grandbois:  That's true. Yeah. I think every single clinical professional out there has had at least one argument disagreement, professional disagreement, probably especially with this.  [00:04:33] Amy Wonkka:  I think that that's fair to say. It's a fair point when it's easy. It's clear that working together is the best option. Right? We learn about the other person's discipline. We learn about how it affects our work with our clients, how we can carry over their goals, how they might be able to carry over our goals. Shoot co treatment shoot, shoot shocks. I'm trying really hard. no, this is good. Clean, fun, nerdy, [00:05:00] clean  [00:05:01] Kate Grandbois:  SLP fun. That's right. Coach rates.  [00:05:05] Amy Wonkka:  As you were saying, grain brainiac. Yes. Continue. Coach rates are great. You know, I have had some of my, um, some really great clinical experiences working. Collaboratively in the same session with an occupational therapist or a physical therapist, I feel like I've learned a lot. Um, we've been able to maximize, you know, the positioning and location of the, of the client in space that helps with communication. Also, their activities can be more fun than not. Oh, teas have all the fun. They have a lot of PTs have lots of  [00:05:37] Kate Grandbois:  every single client I've ever shared. They hate coming to speech and they love going to OT. We maybe picked around any OTs out there. We have jealous feelings about your swings and your putty. I do love it.  [00:05:50] Amy Wonkka:  I do too. Um, so that's our love Fest for other therapists, but how about when it's bad? Right. When it doesn't work, which happens, it does [00:06:00] happen. Uh, and that's, that's not something that's unique to BCBAs. No, that can happen in general, but when. Doesn't just naturally happen and it's not magic and a love Fest. Um, I think it's helpful to remember that our code of ethics has a lot of components in there that talk about the necessity of collaboration. So if you read principle one section B of the Asher code of ethics, you'll see, it says individuals shall use every resource, including referral and or interprofessional collaboration when appropriate to ensure that quality services provided. So. Principle one, that's the part that talks about holding paramount, the welfare of the people that we serve professionally. Um, you know, sometimes we want to pack up our toys. We want to leave the sandbox and save man. Uh, but that really isn't in the best interest of our clients, patients, students, whatever word you use. Well, I  [00:06:50] Kate Grandbois:  think especially when you consider the majority of people that we see. Well, maybe not the majority, but a high percentage of people that we serve are also seeing other professionals, [00:07:00] um, you know, thinking about complex learners, individuals with autism individuals, with complex bodies, they almost always have a team of people. At least in my clinical experience, there are very few clients I've seen who just have one. Communication issue. So  [00:07:17] Amy Wonkka:  I feel like what you're saying is that as speech pathologists, we should figure out how to collaborate with other people.  [00:07:22] Kate Grandbois:  Yes. And I think based on our code of ethics, we  [00:07:24] Amy Wonkka:  sort of have to, that is what it seems like there's a whole nother principle principle, four that's about upholding the dignity and autonomy of the profession. Maintaining. Collaborative and harmonious inter and intra professional relationships and accepting the self-imposed standards in our fields. So that's also another really long sentence.  [00:07:43] Kate Grandbois:  The difference between inter and intra professional. I'm so glad  [00:07:46] Amy Wonkka:  you asked. So interprofessional talks about within your own profession. So among other speech pathologists in try. Uh, with across other professions. Okay.  [00:07:58] Kate Grandbois:  Okay. Probably have known that, [00:08:00] but I didn't know. It's a good question. I don't know everything, but I'm  [00:08:02] Amy Wonkka:  collaborating with you to learn. Look at us collaborating together, and we actually are inter ending. I guess, because not only are you a speech pathologist, you're a, and that is also true. Wow. Fancy stuff. Um, I mean, really, I think you can make the case for collaboration weaving its way through a lot of other areas of our code of ethics as well. So, you know, if we look at principle two, that's looking at the need to achieve and maintain the highest level of professional competence and performance. So if your job puts you in a situation where collaboration with ABA providers is part of the deal, some professional development in that area, Necessary, you know, I mean, you need, you need to know enough to be able to work effectively with these.  [00:08:44] Kate Grandbois:  And if you don't know enough, you have to have the wherewithal to know what you don't know, which it sounds like a repetitive, ridiculous statement, but that is a cornerstone of professional maturity. And one of the biggest things. Um, in learning [00:09:00] and continuing education is seeking out information and acknowledging that you don't know everything. Yeah. I  [00:09:05] Amy Wonkka:  think  [00:09:05] Kate Grandbois:  you make a good point. Yep. Um, so I think we've both been really fortunate to have a bulk of good experiences with BCBAs. Oh yeah. I mean, but we've also had a lot  [00:09:17] Amy Wonkka:  of frustrating ones, I would say. In my experience, the scales are firmly tipped in the positive, but I know that that's not the case for everybody else. I mean, I have BCBAs who I consider near and dear friends, you know, I think. I've learned a lot of really great things. And I'll talk more about that later, you know, when we're chatting, but, um, you know, it's, it's not, it's not always roses. [00:09:39] Kate Grandbois:  It's not. Um, and I think this is probably a good segue into our next section related to a history of ABA, my personal, not a history of ABA, but an overview of ABA, my personal. Um, transition into the world of ABA was because I had had so many frustrating experiences [00:10:00] that I was motivated to go back and sit for the exam. As a way of infiltrating the enemy camp and dismantling it from the inside, because I had had so many frustrating conversations, everything related to teaching language in discrete trial format, exclusively. To using vocabulary that I didn't quite understand, like Mandan tact. Um, and I'm here to tell you that having gone through the education that a BCBA gets and being certified, ABA has a lot to offer. It is not all terrible. And I think it has been, they just have a pretty bad PR problem. And, um, the more you learn about it, the more you realize that there's a lot that it can bring to. I  [00:10:46] Amy Wonkka:  agree. I mean, as somebody who, for you listeners out there, um, Kate and I actually did that core sequence together. I made her do it. It was good. It was good. I mean, I love learning things.  [00:10:56] Kate Grandbois:  It wasn't, it wasn't a hard, no, she was like, wait, go to school for two more [00:11:00] years for no reason. Yes, please.  [00:11:01] Amy Wonkka:  It sounds great. I opted not to sit for the exam, um, for a number of reasons, but I think, you know, even as somebody who chose not to go through the final process to actually become a BCBA, I took a little. Away from that experience, I've worked in a lot of ABA based settings and I've learned a lot. It's made me a better speech, language pathologist. There's no doubt about it. Um, so while there are frustrating parts, I think on the whole, there are a lot of wonderful, wonderful  [00:11:29] Kate Grandbois:  things. Yes. Um, which is again, great segue. Let's try and unpack a little bit about what ABA is, um, so that we can then talk about how best to integrate it into our collaborative practices. So, first of all, I think we need to acknowledge that as we've mentioned, sometimes ABA has a bad reputation. But there are things that we can do to look past the bad experiences, um, and [00:12:00] embrace some of the good qualities according to, um, a great resource. If you want to learn more about ABA, it's a book written by Cooper Heron and. Um, according to those authors, ABA is this is a quote from page 15. Um, uh, scientific ABA is a scientific approach for discovering environmental variables that reliably influenced socially significant behavior. And I think some of the key takeaways from that quote are that it's a science, um, and that it is a science applied to influencing socially significant behavior. So these are behaviors that are, um, ha. A R very important to the individual have, uh, an, a significance in terms of improving their quality of life, um,  [00:12:46] Amy Wonkka:  also for society in general, right?  [00:12:48] Kate Grandbois:  Yes. Yeah. Yes, absolutely. I think that, you know, ABA is often associated with autism far too often. The principles of ABA are [00:13:00] applied to dieting, um, that they are applied to, um, exercise making me exercise. Um, they're applied to smoking quitting smoking, um, drug addiction. And I say this a lot when I'm working with families. If I got paid and rainbows and smiles, I would probably not keep going to my job. So there are, there are principles of ABA at work. Um, ABA uses what's called the opera and model, um, which is, um, learning. It's the concept that learning is the result of consequences that follow a behavior. Um, and that those consequences determine the likelihood that a behavior will occur again in the future. Um, that's a reference to an article by Donaldson and steamer in 2014, which is a great article that we will have posted on the web. [00:13:52] Amy Wonkka:  And I was just going to say, if you want to read more about these articles, check out our website. Yes.  [00:13:56] Kate Grandbois:  We will have a list of all of these references and resources on the [00:14:00] website. Um, so that's a little bit about what ABA is, but I think it's also important to acknowledge what ABA is. So ABA often gets misinterpreted as being only discrete trial training. And I think most of us have seen what discrete trial looks like. Particularly when teaching language it's a field of three and the student or client or individual is being asked to engage in a really specific. Response 10 times in a row, and then they get a cookie or a gummy bear. I feel like that's the, that's like the classic model, what you see in like a school or a  [00:14:32] Amy Wonkka:  clinic. Yeah. And I feel like you've also, I've heard that referred to as mass trials, right. You're doing the same thing over and over and over again, drilling,  [00:14:40] Kate Grandbois:  um, doing drills language do is, I mean, I think ABA is off also misinterpreted as teaching rote communication or memorization, which is. That happens sometimes, but that's not what ABA is in general. Um, ABA is not necessarily teaching at the table. ABA is not only for autism as we've already reviewed. [00:15:00] There is literature for the positive impacts of ABA across general education, stroke, dementia, health, and fitness, public health environment, and sustainability addiction. Um, it's even used in the business world, which is really interesting. Um, ABA is not a curriculum and it, my favorite ABA is not bribery or manipulation. Um, I think those are casual terms that we use. Um, Um, less structured settings like parenting. So, you know, I bribed my kids with a piece of chocolate or what have you, ABA is not any of those things. ABA is a science and it can be provided in naturalistic settings. Um, there are a lot of resources if you'd like to learn more about ABA and we are definitely going to have some of these listed on our website. The two, um, one that I already mentioned is the book applied behavior analysis by Cooper, Heron, and Heward. A lot of the people in the eighties. World, very casually referred to that as the white Bible, which it is not a religious text, but [00:16:00] I think in terms of it as a good comparison, it's very much like the language disorders book by ramp hall in the speech world, which I feel like most, most speech pathologists know what the Ray Paul book is. We still have the Ray Paul book. I love my ramp hall book. It's like, it's my, it's my purple Bible. See, so the applied behavior analysis by Cooper Heron, and he, it is a really wonderful reference if you'd like to learn more about ABB. The BACB website is another great resource. Um, the BACB is basically an HSA for ABA. It stands for a behavior analyst certification board, and they have a lot of resources on their website. I  [00:16:36] Amy Wonkka:  also like, uh, the VB map, which is actually an assessment tool, but the guide that comes with that assessment tool contains so much information about. The behavioral interpretation of different functions of language. I find it really concise and easily  [00:16:51] Kate Grandbois:  readable. Um, yes, I'm not as familiar with that, which is probably something I should be embarrassed about. I have not used that tool as [00:17:00] much as I should have. See no, but everybody doesn't know everything. That's  [00:17:03] Amy Wonkka:  totally cool. Can't read every book. That's why we're here. You can't.  [00:17:06] Kate Grandbois:  That's exactly right. Um, so. In terms of thinking about what ABA can bring to the table. Um, ABC VA's look at this same problem from a different angle. So often when we're meeting with a client, we're looking at vocabulary or syntax or quality of communication, um, and BCBAs don't necessarily have that educational background in terms of developmental skills. But they typically don't. Yes. They typically don't. However, they do focus on quite a bit on the function of language, which when I went through, um, my I'm sure when we both went through our BCBA training, I think we found to be pretty interesting. So instead of thinking about why are you using the word cookie or should we talk about Graham cracker versus cookie versus. Toll house. You know, what vocabulary word are you using? The BCBA is [00:18:00] looking at what reinforcer is in place that is motivating the individual to use that word in general. So it's more about the interaction between the use of language and its impact on the environment and what consequences are, what consequences follow, um, that make that communication exchange happen. Um, There is a lot, BCBS get a lot of education in measurement and how to measure these kinds of things, which is something that I think is very, um, Uh, contributing factor in terms of what they help me out here. Oh, I  [00:18:36] Amy Wonkka:  feel like the data collection piece. I mean, that was my jam. Right. I love data. Um, and so for me, that's one of the pieces where I've connected with the PCPs in my life, um, is the ability to manipulate and consider different ways. Solve the problem of the clinical question that you're posing at that time. Right. So what is a way to collect data that's [00:19:00] unobtrusive and gives me the actual answer that I want. And doesn't take away from the therapeutic integrity of, you know, the interaction I'm having with a client. That's, you know, your BCB is, can really help you out a lot. There. I feel like, you know, I mean, I'm like medium old, but when I, when I went to grad school, there was, you know, there, there was a lot of emphasis on, you know, kind of trial by trial data and, you know, Became the criteria for a lot of goals and objectives. Um, that's, that's not always the best way to think about it and that doesn't always get at the skill that we actually want our clients to achieve. And so I think that the, the different ways that BCBS are able to look at and, um, considered collection and analysis of data, uh, All all allied health  [00:19:43] Kate Grandbois:  practitioners practice. I think it's a really nice way to bring a BCPA into the conversation. If you're, especially if you're having a disagreement is to talk about their skills and how to make. Certain behaviors. Um, to be honest, they get a much better education in this [00:20:00] than speech pathologists. Do it's much more detailed  [00:20:02] Amy Wonkka:  wouldn't you agree? Yeah. I mean, if I had to like, be a bit crass about it and break it down, I would say that speech language pathologists get a lot of information about content. We are content experts, right? We're not experts, we're experts. Um, and when you think about BCBS, I feel like they get a lot of education, an application, right? So they can help us take the information that we know and apply it in a way that lets our client be successful in acquiring the skills that they, we want them to have, um, where they fall short. Typically, you know, in my estimation, Around that content. So I think, you know, when we have successful collaboration, it really is the best of both worlds for the people who were supporting.  [00:20:42] Kate Grandbois:  Definitely. Um, and I think when you do end up bringing in those qualities, bringing those qualities into the fold in terms of looking at function, you know, How better you can measure an individual's communication. You're really looking, you are meeting those ethical standards. You're holding the [00:21:00] needs of the student or client most paramount, and you're improving services across the board. And that's not just for the client or student. That's also for the family. So keeping in mind, particularly for our students, with autism or clients with autism, a lot of these individual. 30 40 hours of ABA a week. And how confusing is that? If your speech pathologist is saying work on core vocabulary and your behavior analyst is saying no madman meant that is incredible. Disjointed in terms of a collective treatment package. So when you're bringing the BCPA in and collaborating with them effectively, not only are you improving services for the client, but you're really helping to ease that burden for the entire family, not to mention the sheer number of hours and the way that BCBAs bill. So speech pathologists, we typically do. If you're in a school, a handful of, you know, you know, 30 minute sessions based on the documentation and the IEP. Um, maybe if you're in private practice, you're getting 1 30, 40, 30 minute, [00:22:00] 45 minute, one hour session a week. Um, The BCBA is outnumbering you in terms of the number of hours that the student is getting, they're getting 30 to 40 hours. So if you can make that collaboration happen, you have this wealth of time where you can get your student or client to be practicing some of this. That you want to be practicing.  [00:22:21] Amy Wonkka:  And I would say in most of my experience, you know, it's not the BCBA who's providing that like large aggregate number of hours. It's, uh, it's a paraprofessional level staff. Um, but the difference between, you know, the speech language pathologists and the BCPA would be that the BCBS. Is actually able to bill for those indirect hours of providing supervision to that staff. Whereas we're more jealous feelings.  [00:22:43] Kate Grandbois:  I know, big jealous feelings I'm listening out there who feels like taking on an advocacy project. Right. We need more boots on the ground to advocate for different billings director.  [00:22:53] Amy Wonkka:  For sure. It's a separate podcast, mate. It is a different podcast. Yeah. But, but if, you know, if you can get in with the BCBA and you guys are aligned and you're on [00:23:00] the same page, that's one more person who's making sure that the paraprofessional staff who's working with your client is also following through, you know, with your, with your goals and your recommendations. So, you know, another big piece of that. Often, you know, the is in the home. I know Kate you're in private practice. So you might have the opportunity to be in the homes more than, you know, those of us who are in outpatient or schools. Um, but if you have a BCB who's going into the home, being connected with them is going to help, you know, your, your client generalize those skills across environments, and they can bring back new information for you to about, you know, maybe this thing is meaningful. In terms of, you know, connection to the third grade curriculum, but there's this other piece at home that would also be super meaningful for this client and their family. Um, so, you know, the BCBA can really be a very helpful liaison. Well, I  [00:23:49] Kate Grandbois:  agree. And that sort of brings us to another point. The, there, the correlation between individuals who have. Uh, communication disorder and the behavioral [00:24:00] issue is really high. I can't tell you. I have a, I'm having coffee with, um, a fellow colleague of ours next week because, um, in her private practice, her clinicians are having a really hard time just getting her clients to crawl out from under the table. There are so many refusal behaviors or noncompliant. Because for so many of our, I guess, pediatric clients, they develop unwanted or maladaptive behaviors in place of communication, because communication is so hard. So, um, there are probably millions of instances out there where the client you're working with also has behavioral needs.  [00:24:39] Amy Wonkka:  And this is where, you know, I think back I'm sure everybody who's listening. Who's who's a bit longer in the tooth. Can think back to [00:24:54] Kate Grandbois:  No every  [00:24:54] Amy Wonkka:  day to folksy horsing. Um, so, you know, you can think [00:25:00] back to when you were first out of grad school and you look back on things and you're like, oh my gosh, I can't believe I did that again. Right. So, so I think behaviorally that's true for me as well. I, I definitely, you know, to use the terminology from ABA, I reinforced problem behaviors completely inadvertently, cause I didn't realize it. Right. So, you know, a good example is I have a client and they're in on the swing and. Pushing on the swing and they get upset. And I can tell that they're upset and you know, maybe they, maybe they hit me because they're feeling so upset and I can tell. You're upset because you want more swinging. And so, you know, what I do is I I'm, you know, maybe model more swing and then I pushed them on the swing. Um, you know what my behavioral colleague might say is like silly mughelli you just, you know, read  [00:25:44] Kate Grandbois:  them more, give them more  [00:25:45] Amy Wonkka:  swing for hitting you. Right. So you just made it more likely to in the future, because back to what Kate was saying earlier, you know, when you look in the behavioral paradigm, you're thinking that what happens after behavior makes it more or less likely that it will happen in the future. So when, you know, I [00:26:00] think back to that moment where, you know, I pushed the client on the swing because they hit me because I knew what they wanted. Um, I just made it more like. Because that was what they wanted. Um, but if I were working in concert with, uh BCPA or somebody else, you know, who had that behavioral background, um, you know, and even having that knowledge now I would, I would do that differently. So I think, you know, there, there are behavioral challenges where it impacts your effectiveness as a therapist, but also. Just like other people may undo what we want to do. We could be undoing. There are these totally by accident.  [00:26:33] Kate Grandbois:  And I think, you know, there are other that's, you know, the spectrum of problem behaviors is so wide. So there are problem behaviors that. I guess we'll say mild, you know, they're not dangerous. They're not negatively impacting the individual or a family quality of life to a significant degree. If anybody has any toddlers, we know what that looks like, you know, typically developing toddlers. Um, but you know, in terms of the spectrum of special [00:27:00] education, um, at least in pediatrics, there are more severe problem behaviors. And this is, this is my personal clinical area. Um, when you have an individual who's engaging in significant problem behavior that is unsafe, or that is, um, you know, dangerous to other individuals or themselves, there is a time where you may need to take a back seat and as a speech pathologist. And, um, that can be really tricky. I've had a handful of instances in my career where I've been asked by the parent. Um, some else, someone else in the school to come in and facilitate, try and make some recommendations for better language, because they want the individual to be commenting where they want them to be using core vocabulary. And I arrive and the individual is head hitting at such high rates that they've given themselves concussions and they're breaking their facial bones. And, you know, there are extreme situations out there where yes, I would love that individual. I would love to be able to teach that individual to make comments and to use core vocab.[00:28:00]  However I have enough wherewithal to say, okay, but that's not the most important thing for that individual from a safety standpoint, and being able to acknowledge that and sort of support the behavioral team. As a primary person for intervention, because that's, what's most important for that. I mean, I, and I know that's like the more extreme side of things, but there are times where behavioral needs supersede communication needs. [00:28:27] Amy Wonkka:  Well, and I know the focus of this podcast is BCBS, but, you know, thinking about our collaboration with occupational therapist also, you know, I mean, I think we know. When you're regulated and when you're available for learning, you're available for learning. And that, that runs the gamut. That's, that's true for adults. That's true for young children. Um, and so, you know, in the case that you're describing Kate like that, that person's not available for learning, right? So whether those are the ultimate goals or not like first, the team needs to work together to make sure they're at a place. They're in a place where they [00:29:00] can learn, like, you know, none of us is doing our best work when we're at crisis level 20, you know, it's just not, it's not compatible regardless of, you know, your unique characteristics as an individual. Right. And  [00:29:11] Kate Grandbois:  that's a, that's a by-product of being human. I mean, I know my husband was recently in a meeting where he was so nervous that he lost his words because he, his anxiety was really high. He was working at a level 12, like you said, he was not available to perform his best work. And I think that relationship between emotion and communication is true for everyone, um, to a certain degree. Um, so now that we've sort of covered why we should collaborate with BCB CBAs. I think it would, maybe this would maybe be a good transition to talk about strategies for when that collaboration, when you, when you, when you, when you as a professional have acknowledged. That collaboration is important that you see the players involved and that you're willing to collaborate, but either that person is a prickly pear [00:30:00] or they're recommending things that you think are inappropriate, or maybe there's a third party, like a teacher or a paraprofessional or parent who is making that collaboration more difficult. [00:30:10] Amy Wonkka:  Yeah. Yeah. So, I mean, how do you wake up? Make it work? I feel like for me, if I had to classify it, I would put it in like three big. Buckets of barriers, right? So there are, you know, logistical barriers. I feel like logistical barriers are real, even if you know, I know some of your terminology, um, and I'm, I'm on board, you know, emotionally with trying to be flexible and like Columbia. If we don't have time, we don't have time. Like effective collaboration takes time. Uh, no matter who you're collaborating with, no matter what the context is like, you, you need time. That's a real, that's a real barrier and it varies by setting. It does. It does. And, and I feel like the solutions to that problem depend on the setting too. I mean, when you're outpatient, it's hard to make time for when I worked out here. [00:31:00] Most recently I was per diem. I was at night. So I'm trying to collaborate with school providers, but I can't. Cause I have a second job during the day,  [00:31:06] Kate Grandbois:  plus they're not going to pay for that. You're not going to see not part of your  [00:31:09] Amy Wonkka:  productivity. No. So it's so it's really hard. So when you're in a productivity driven model and perhaps you're working offset hours with the people who you're trying to collaborate with, you know, I mean, what are your options? I, I personally think face-to-face is best, especially if you're going to have a potential disagreement. Cause when you see someone's face, I'm looking at Kate's face someone's face, you know, it's, it's harder to be really grouchy with them. Right. But it's even if you want  [00:31:38] Kate Grandbois:  to be grouchy or you feel grouchy, it's so much easier to do that over email. Than it is to a person's face, correct? Correct.  [00:31:46] Amy Wonkka:  So, but let's say you can't do that, right? Because you work nights and the school people work days and nobody's paying you for it anyway. Right. So second phone call. Can you coordinate a phone call? Do you have like a cusp hour where like, you've just gotten to your second [00:32:00] job and they're just wrapping up their job. Maybe you can call that's better than emails, which are an option. And technology's great. But like, have you ever tried to navigate a frustrating experience over email? Get the worst so bad. It's I just did it. I just got in a fight with my health insurance company. Do  [00:32:21] Kate Grandbois:  you sometimes, do you write an angry email and I just let it sit in your draft box because you can't send yes. That's my only, that's my only choice because I have no other way to effectively. Dismantle the argument and use some of the other strategies that I have to be like. Sometimes if you're having a prickly pear disagreement and you just smile or you just say, Hey, I like your pants. You can diffuse a lot of the disagreement and just have a human moment and you can not do that over email. [00:32:51] Amy Wonkka:  Emojis only goes so far and they're  [00:32:53] Kate Grandbois:  cheesy. They're, there's no place for those in a professional exchange sometimes.  [00:32:57] Amy Wonkka:  No. So, so those, I mean, I think that those [00:33:00] are, those are real challenges. Those are real barriers. They're logistical. Um, you know, I think thinking about making connections with other people and kind of all the pieces that go into that, you know, making it as in person as you can, would be. Uh, tip, um, if you can't do it, be cognizant of the fact that emails don't carry tone and emotion as effectively as you'd like them to. Um, so, you know, then, then like having worked in schools, it's a little different, like in, uh, in private schools, I've worked in a couple of private schools. They tend to program that time into their day. You know, like it might be, everybody comes in at seven 30 on Tuesdays. You  [00:33:39] Kate Grandbois:  mean private schools for substantial. Separate special ed. So not necessarily private, like regular privates, well, general education, private schools. Correct. But private schools for a substantially. Separate am I saying that right? Yeah. Substantially separate setting. Yeah. Substantially every center, um, and a more  [00:33:56] Amy Wonkka:  restrictive setting.  [00:33:57] Kate Grandbois:  And I also feel like, um, [00:34:00] You know, for Amy, you have done a really great job advocating with your administration to make sure that collaboration, that they acknowledge that collaboration is important. I know Asher has some literature on their website about embracing the three to one model. I don't know if you want to talk about that a little bit. Cause I feel like. Especially if you're doing consult once a week, once a month  [00:34:21] Amy Wonkka:  or whatever. So when you think about public schools in public schools, you know, you're documenting your time and your consultation time and the IEP, I would definitely advocate for people to think about what amount of consultation they really need to be effective. Thinking about the three, one model, the three, one model, Asher has a lot of great resources about the workload approach to caseload, which I have found is difficult for public school administrators sometimes to wrap their heads around. Um, the three, one model is a way to sort of encapsulate all of the indirect services that would be captured in a workload approach approach to caseload, uh, in.[00:35:00]  Three of the weeks within a month, you're providing direct service. So that would be your B and secret service for the IEP. And then in the fourth week, you're providing indirect service and it sort of set aside your designating that time in the acre, that indirect service grid of the IEP, um, and your, your making time for all of those services, which are really essential. Um, and I think looking to Ashleigh, looking to their resources on workload approach to approach to caseload is a really great tip. They have a lot of, they have a lot of information there  [00:35:34] Kate Grandbois:  and if you're not in the schools, if you are in an outpatient setting, Advocating to your administration or to your supervisor, particularly if you're working with complex learners, individuals with autism individuals, with complex medical backgrounds, being able to set aside a certain amount of time to collaborate with their physician or their OT, outpatient, OT, or. You [00:36:00] know, any, any of the home ABA service providers, being able to make sure that that time is set aside for you can not necessarily increase your productivity productivity from a monetary standpoint, but can do a lot of other really great stuff for your  [00:36:14] Amy Wonkka:  clinic. And I don't see any reason why the workload information that's on the actual. Couldn't be utilized to have a conversation with administrators in different employment settings as well. Fair  [00:36:24] Kate Grandbois:  point. This is what best practices. And if you need to translate it to your administration for budgetary rules. Customer service, um, you know, making sure that the families feel that you're putting in the extra time to help collaborate and, um, integrate things across different settings. Yeah, for sure.  [00:36:42] Amy Wonkka:  The next big barrier. So we've got our three buckets of barriers, bucket. Number one is logistics. I would say the next big barrier would be knowledge based, right? So, you know, I'm not a BCBA, Kate's dual certified. We did both take the coursework and which we've not mentioned multiple, multiple times, multiple times. So we're, we are, [00:37:00] uh, we, we took the classes and we learned things. Um, I think, you know, I think when you, when you make a commitment like that, it really helps you with your collaboration. I think it was very helpful for me to learn what their words mean. And now I can use those words in a conversation. And feel pretty confident that I know that I know what they're thinking. When I use those words, it allows me to redefine my terminology using their terminal. You don't have to make that commitment. Um, but I think, you know, thinking about doing a little reading so that you can use the same jargon, I do feel like professional sometimes. Like when we get our hackles up, we just go, we go all in with the jargon. [00:37:38] Kate Grandbois:  I think that the ABA world in particular has so much Turkey left. We have jargon, like most people don't know what a UV light. But I don't, I wouldn't say the dangly thing the back of your throat. I wouldn't say uvula because I know that the lay person does not know what that is. And for some reason, the ABA world, you know, Skinner, he was, he was a genius in so many ways, but when he made up all [00:38:00] these words, he, um, when he made up all these words, he really sort of threw a, threw a wrench into things. Um, and I think that. Just to your point earlier about having your hackles up, you know, when you have these difficult conversations or you have a BCBA you're working with that is, is a little bit of a prickly pear. It might be a great idea to ask them. So what do you mean when you say. If you don't have the resources or the time to go take a course or a do flashcards or read verbal behavior, you know, we ask them, you know, make, you can disarm their anger or defensiveness by trying to engage in a collaborative discussion so that you can learn so that you can sort of say to them, I don't know everything. I'm hoping that we can collaborate so that I can learn something from you. And by doing that, you might be able to disarm them a little, not disarm them. Okay. Make the exchange a little bit more [00:39:00] friendly instead of defensive.  [00:39:01] Amy Wonkka:  Yes. And I mean, we could also be the prickly pear. Like sometimes, maybe I'm the prickly one in the commerce could be, you could be, you could disagree with. I could always write, accept an email and then I'm just to ground Shannon, you  [00:39:16] Kate Grandbois:  leave it in your Dropbox, right? Like a rational, sane, human being.  [00:39:20] Amy Wonkka:  No, my, my poor health insurance lady got up to email. Um, but, but I think, you know, thinking about, I, I work in, in my current role, I work with augmentative and alternative communication and we talk about. About using core vocabulary. So using high-frequency vocabulary to define fringe vocabulary so less, less frequently used in more specific terms. And I think, you know, that's a helpful exercise to, you know, w what is a manned, um, how would you define it using  [00:39:49] Kate Grandbois:  so request, but it's a very specific definition and is not always the  [00:39:53] Amy Wonkka:  no, and I, and I think, you know, an exercise like that is helpful because then we could together. I [00:40:00] realize that, you know, in, in speech language pathology, there are like three or four terms that a BCBA would consider a man. Right. So they would consider, you know, uh, reject protest refusing, like all of these things that I would consider. As, as different Lee classified, um, functions, they all kind of group under this one term of man. So going through that exercise can be helpful because then it also helps them have the perspectives that we're thinking about it in all of these different ways. Um, you know, we mentioned earlier, I think the biggest benefit for me in collaborating with and learning about ABA has been the data collection piece. I mean, Thinking about, you know, is, is 80% really the criteria I want. Do I want this person to just increase their frequency of doing something? Do I want them to increase their independence and their frequency? Thinking about different ways to collect that data and the idea that like, maybe I don't need to write a million pluses and minuses on a post-it note.[00:41:00]  I can just collect data on the first time you did it. And if you did it independently and accurately, the first time we looked at that page in the story, I can just be in the, in the therapeutic moment with you and a don't need to be. Half present, because I've got to scratch all these things on a post-it note. I think that  [00:41:19] Kate Grandbois:  the, I think that the data collection piece is also a really great way to diffuse arguments. So how many times have between the two of us been in a situation with the BCPA, um, where they think. Nope. I don't think that this student should use touch chat. I don't think they should use lamp. We were both EAC people. Um, I think that they need to use sine. I think they need to use PEX or they have some other recommendation and there's this big to-do over whose territory it is. And who's making the right call. But you have to work with this person because the parents think that they're great or because they're in the home or because they work at your school and you [00:42:00] have to work together as a team. And this is something that I learned from me. Take the data, do it, just let the numbers speak for themselves. If you feel like you don't have it in your wheelhouse to you to design the data collection system, let the BCB do it. Listen, BCBA, you are so super smart with all of this data collection system. Just tell me what kind of data to collect. And then I will take data on my tool and then we'll take data on your tool and we will see what happens. It's a great way to flush out. Without making it a pissing contest. It's  [00:42:31] Amy Wonkka:  also really good practice because one of the things that I love about data and I do, we've had this, we've had a version of this conversation multiple times, but I feel like, you know, data does take, take your kind of beliefs that out of it, there are times when I've thought that something would be very effective and then we collect the data and it wasn't. And so that's, that's my job. That's what I want to know.  [00:42:54] Kate Grandbois:  Great. Is that BCBAs are driven by data. So if you're having that argument or discussion. [00:43:00] Then the numbers speak for themselves and they sort of have to acquiesce depending on, you know, how it flushes  [00:43:06] Amy Wonkka:  out. Well, and then you were collaborating to solve the problem together instead of like having a sassy battle. Right. I don't  [00:43:13] Kate Grandbois:  like sassy battles, but I like that phrase  [00:43:16] Amy Wonkka:  sassy battles. Yeah. It's battles. Nobody wants fun, but it's fun to say just like uvula. No, you didn't want to yellow, but it's also fun. It's just the UVA. Should I know that speech science people could tell us that if somebody  [00:43:27] Kate Grandbois:  wants to email us and tell us what the uvula does, that would be great. You  [00:43:32] Amy Wonkka:  feel would be helpful.  [00:43:36] Kate Grandbois:  Oh, oh, they're so  [00:43:39] Amy Wonkka:  good. So, so barriers, we've got logistical barrier. We have terminology and like knowledge barrier. Our last barrier I would say would be kind of the social relational barrier. Okay. That's fair. And that's real, right? So you have the information. You allocated the time in your schedule, but you still, like, it's not working. It's probably a social, it's probably a social barrier. [00:44:00] Um, collaborating with the  [00:44:01] Kate Grandbois:  meaning. The person doesn't have great social skills. No, or  [00:44:05] Amy Wonkka:  no. I mean, I suppose that could be part of it, but more just like you don't like the person types, you just don't really like people that's fair. Right? Like that's real. I, I have a very socially focused job and I'd like it to be real quiet and just me and my daughter.  [00:44:21] Kate Grandbois:  Um,  [00:44:23] Amy Wonkka:  no, I feel like, I feel like it's more just like sometimes you, you meet people and you're like, we could be friends.  [00:44:28] Kate Grandbois:  Right. And that's so much easier to collaborate and easier to disagree. Yes. When you're friends, I think more importantly. Yes.  [00:44:36] Amy Wonkka:  Just grants.  [00:44:36] Kate Grandbois:  Yes. We disagree quite a bit. Yeah. That's why I was saying earlier that you argue with a smile, I disagree  [00:44:41] Amy Wonkka:  with a smile. Cause you do pay on time. We do fight. Yeah. So I feel like, you know, if you, like, you're not going to like everybody, not everybody needs to be your friend, not everybody's going to like, you know,  [00:44:52] Kate Grandbois:  No, that's just a that's just  [00:44:53] Amy Wonkka:  life. I know. And so, you know, you have to find a way as a professional to like work around that and be like, all right. I don't [00:45:00] really like you, we will never go out after work together ever. Um,  [00:45:04] Kate Grandbois:  you feel like sometimes it helps to make an effort for social niceties. And I want to, I keep saying I like your pants, but you are not necessarily complimenting their aesthetic, but how was your weekend? Did you have a nice break? Just taking a humid, a moment to be a human, a moment to have a human connection. Yes. Not necessarily take a vested interest in their life, but find some sort of common ground to have a nice exchange outside of the topic that you're collaborating  [00:45:33] Amy Wonkka:  around. So like be a person, not a jerk,  [00:45:37] Kate Grandbois:  be a person don't be a jerk. Don't be a jerk. I think that's a  [00:45:40] Amy Wonkka:  great expression. Yeah. So, so I think that there are two back to these terms, like there's an interim professional challenge, right? So when you're coming full circle, I know it's like within yourself, right? So within myself, It's an, it's really an interpersonal issue, right? Like I'm making an active choice. I've identified. I don't like Kate [00:46:00] so much. Right. But I know I have to put so sad and I love it. It's okay. Um, but like we have to work together, right. So we have to work together. So it gets a challenge, a professional challenge within myself to like find a way to be kind of see you and like cultivate. Nicer thoughts toward you recognizing that we're, you know, we might never be friends, but I have  [00:46:21] Kate Grandbois:  to say, I feel like this bucket, this interpersonal bucket is a cornerstone for successful collaboration. So even if you don't agree, just finding a way, finding the strength or emotional bandwidth within yourself to be kind, to be professional, to be human and to not be a jerk, especially when the other person is maybe a jerk. [00:46:42] Amy Wonkka:  Well, too, like, you know, Use your perspective taking skills, right? I, I see sometimes what I'll see is I'll see disagreements between, let's say a veteran speech, language pathologist, and somebody who's new to the field as a behavior analyst. And I think back to my example, like I can look back on things that I [00:47:00] did as a brand new speech pathologist when. Knew so many things, you know, like I was, I was graduating. Like I can do  [00:47:06] Kate Grandbois:  everything. I'm going to change  [00:47:08] Amy Wonkka:  the world. I had a lot of confidence. I had a lot of like grand views. And I think even just that piece of being able to like reflect back to maybe what that moment felt like for you as a professional, as a person, and see that maybe part of like when someone is coming on really strong, like that's also probably coming from a place of like all of this passion and excited. For their field, you know? So just so trying to do a little bit of that perspective, taking and thinking about, you know, maybe what it feels like as this person is being rigid and pushy and bossy, but perhaps the way that they're thinking about it is like, they so much want to help this client. And they really feel so passionately that like, this is the best way to do it. Um, and, and not. Taking their perspective, like changes everything. But I find for me, it helps me cultivate kinder feelings. [00:48:00] And that leaves me open to creating the structure where we can have a better relationship.  [00:48:05] Kate Grandbois:  And I think that that's a really nice way to avoid being territorial because if you, and if you approach any exchange, particularly one that might be contentious with an email. All bets are off, nothing functional, nothing collaborative, nothing positive is going to come out of that exchange. Um, and, and especially when you're working with BCBAs, who. To be honest, feel that communication is within their scope of practice. Um, you know, there is this debate about whether or not that's true, um, which is probably a whole, I'm looking at the time. That's probably a whole other podcast we could do. But when you're working with a professional, you know, when you're collaborating with an OT, you're not entering the exchange thinking, oh, well I know a lot about sensory integration or I know a lot about fine motor skills. Oh.  [00:48:51] Amy Wonkka:  But we fight about feeding. But, but feeding.  [00:48:53] Kate Grandbois:  Okay. So perfect. Feeding is maybe that one shared area and the shared area with [00:49:00] BCBS, I feel like is, is much larger and, and goes across feeding and AAC and language development and communication in general. You're talking about an exchange that has a lot more potential to be explosive because you're sharing so many or quote, unquote sharing so many more areas of your scope of practice. Well, and I  [00:49:21] Amy Wonkka:  think that gets at the second piece of that kind of interpersonal social component, which is, you know, the, the social aspect of the interprofessional relationship, um, which really is, you know, that knowledge. And, um, vocabulary piece that, you know, is a barrier for us in not knowing their, you know, their jargon and not understanding their terminology. They, the BCBA is have that gap for us as well. So the social burden on us is to be able to have cultivate, uh, a solid enough working relationship that we can provide that education, even if it's not [00:50:00] necessarily something that, that BCB would have sought out on their own. So kind of demonstrating, you know, We, we did lots and lots of credits in school where we learned a lot about language. We learned a lot about phonetics phonology. We can write in this magical language of IPA. You know, we have all of these, you know, components that they're not even aware, um, potentially are. And from our information that we keep. And so, you know, by having an established relationship where you're able to share that in a way that doesn't feel like you're jamming it down their throat, but it's also assertive. Like, I mean, collaboration is not. Just giving up and like letting some other professional rule the roost, like the other big piece of our code of ethics is we need to do what's best for our client. And if that means having a professional disagreement that that's that's and it's  [00:50:48] Kate Grandbois:  okay to disagree. I think this is another thing that I've learned from you over the years is that disengage disagreeing doesn't have to mean fighting. Disagreeing can be a professional. Hey, man. It's cool. We can [00:51:00] still be friends. We can still work in the same place. We can still have social niceties and not agree on this one thing. And that is  [00:51:07] Amy Wonkka:  okay. So I had a boss a few years back who, who provided me with this bear, very powerful phrase that I continue to use to this day, which. We can agree to disagree and that's okay. Yeah. That's okay.  [00:51:21] Kate Grandbois:  It's it feels uncomfortable. I feel like conflict is not something that we culturally embrace and it's not something that people enjoy. It's not, it's not something that's pleasant. So I think a lot of times it becomes contentious by accident just because it just because it that's the default, but it doesn't have  [00:51:39] Amy Wonkka:  to be that way. And I find that to be. I mean, I use that phrase a lot. I've used it multiple times, but you know, I think it's a nice, if you feel like the conversation is getting too heated, it's a good stopping point to just say, you know what? I think we're just going to agree to disagree on this and that's okay.  [00:51:57] Kate Grandbois:  Okay. And making sure that they know that that's okay. [00:52:00] Um, I also think that by doing that, you're modeling mature. Your mom, you're providing an opportunity for, for learning for additional learning between yourself and the person that you're disagreeing with your modeling. Um, you know, you're providing an opportunity to show other A's or other younger speech pathologists, or maybe not even younger, but greener speech pathologists, new graduates on how to navigate some of these tricky waters. So. It's a nice way to identify that as an area of professional development and go into the difficult conversation, knowing that you, you might just have to  [00:52:38] Amy Wonkka:  disagree. They're also in the resources on our web page, there is a link to, um, a book called difficult conversations, uh, which is also a very helpful. Just about having difficult conversations with other  [00:52:51] Kate Grandbois:  people. Yeah. It's difficult. Conversations are real. They happen. Um, okay. So I think  [00:52:56] Amy Wonkka:  that pretty  [00:52:56] Kate Grandbois:  much concludes the, um, [00:53:00] three, the background information background information about ABA. And, um, the, um, strategies for how to collaborate. Um, I guess in summary, collaboration is really important. It's part of our ethical code. Um, even though ABA may have a little bit of a PR issue and you may have had some difficult conversations or difficult experiences with BCBAs, um, ABA is not, is not the devil's work. have a lot to offer. Um, the science of ABA is something that's pervasive everywhere. It is not related just to, um, autism or discrete trial. And we definitely encourage you to have, um, a little bit of an open mind and going into collaborating with BCBAs. Um, and we of course are here to get feedback. There is an issue that you would like some guidance on or [00:54:00] something else that you would like to talk about. Where can you guys find some more information? So, as Amy mentioned, we have additional resources posted on our website. Um, there is a great article that we referenced, um, called team collaboration, the use of behavior principles for SU for serving students with ASD, which was published in language, speech, and hearing services in schools, um, by Donaldson and steamer, there's the Cooper heroine, Howard Cooper, Heron and Howard book, the BACB website, the Ash code of ethics. And  [00:54:33] Amy Wonkka:  you can look on Ashleigh, sorry. On Ashleigh. There's also going to be links on our website to their information about workload approach to caseload. Uh, and then the difficult conversations book by stone Patton and heme will also be listed on the website. Okay,  [00:54:46] Kate Grandbois:  excellent. Um, and finally, if anybody out there is interested in becoming a BCBA, the BAC B the BACB changed their rules for taking the seven courses. Just this past year. So if anyone out [00:55:00] there is interested in becoming a PCBA or has considered it, definitely reach out and send us an email, um, I, we would both love to talk more about it. I think while we have the same education, I sat for the exam, Amy didn't, but I think we can both agree that it added quite a bit to our clinical practices and was worthwhile. Definitely. For sure. Definitely. So in closing, just to review this podcast can be used for continuing for certification maintenance hours. Just go to our website, www.slpnerdcast.com . Click on the episode and then click on get CEOs. You will be guided to a quick three question post-test and then we will email you a certificate of completion attending. Anything else? No. Nope. That's it. Thanks for joining us. Thank you so much for joining us. Stay tuned for our next episode on aided language stimulation. Very exciting. [00:56:00] Well, thanks again, everybody for joining us and we will see you next time.

This is a transcript from a podcast episode. 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 may contain typos. Email us anytime  with suggestions or errors. A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible. [00:01:40] Kate Grandbois:  I'm so excited for today's topic. This is going to be so interesting today. We have the great pleasure of welcoming Dr. Aimee Kotrba to talk to us about selective mutism. Welcome Aimee! [00:01:52] Aimee Kotrba:  Thank you. I'm so excited to be here and join you. [00:01:56] Aimee Wonkka:  ,  You are here to discuss selective mutism before we get started. Can you please [00:02:00] tell us a little bit about yourself? [00:02:02] Aimee Kotrba:  Yeah, absolutely. I'm a psychologist, a child psychologist. I own a practice in Michigan called thriving minds. And we specialize in seeing kids with selective mutism. I, when I was in graduate school, I'd never even heard of selective mutism. It never came up in any of the trainings that I did. And then right after I got out of school I started working in a clinic and a little boy with selective mutism came in the doors. And he was a really severe case, but I loved working with him and his family. And just got really involved in lit reviews and learning about selective mutism and training on selective mutism. And it sort of snowballed into where I am today where I get to work with all kinds of kids across the country with selective mutism.  [00:02:54] Kate Grandbois:  This is going to be so interesting. So I, we learned about Aimee, Aimee. I'm not sure what your experience [00:03:00] was with learning about selective mutism from, but from the speech pathology perspective, I heard about it in graduate school, but recieved zero training on it. As a matter of fact, I think I may have been told that it was not something that I could address. Aimee was your experience.  [00:03:15] Aimee Wonkka:  I think I was told something similar. I remember learning about it. I remember learning that it was a good time to refer to a different professional. So I'm super excited to have this conversation today and learn more about selective mutism and about the role of the speech language pathologist with respect to selective mutism [00:03:35] Kate Grandbois:  It's going to be so good. Great. I can't wait. Okay. So before we can get into the fun stuff, the powers that be required, that I read our learning objectives aloud as well as our disclosures. Sometimes people ask me to skip this part. I can't ASHA makes me read it. So bear with us while we get through this as quickly as possible.  Learning objective, number one, describe the evaluative and diagnostic process for selective mutism. Learning objective, number two, identify at least one [00:04:00] strategy or action that caregivers, educators, and communication partners can do to support children with selective mutism learning. Objective number three, list the overall components of an intervention plan and learning. Objective number four, identify appropriate social and academic expectations for students with selective mutism.  Disclosures Dr.Aimee Kotrba financial disclosures. Aimee is the founder of confident kids camp and the owner of thriving minds. She has authored two books. The first of which is titled selective mutism and assessment and intervention guide for therapists, educators, and parents. The second of which is called overcoming selective mutism, a field guide for parents. She's also the instructor for an upcoming workshop titled unlocking the mystery of selective mutism offered through thrive, offered through thriving minds. umAimee's nonfinancial Aimee's  [00:04:49] Aimee Kotrba:  Aimee coach buzz, nonfinancial  [00:04:50] Kate Grandbois:  disclosures. Aimee does not have any non-financial relationships. Kate that's me, my financial disclosures. I'm the owner and founder of grand watt therapy [00:05:00] and consulting LLC. And co-founder of SLP nerd cast my nonfinancial disclosures. I'm a member of ashes, 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.  [00:05:21] Aimee Wonkka:  Aimee that's me. My initial disclosures are that I am an employee of a public school system of grandpa therapy and consulting and co-founder of SLP nerd cast. And my non-financial disclosures are that I'm a member of Asher and SIG 12, and I serve on the AEC advisory group for Massachusetts advocates for children. Okay. We did it. We got through the boring bits onto the good stuff. umDr. Quarter, why don't you start us off by giving us just some general information? Like - what is selective mutism?  Yeah. It's so interesting. I feel like, again, a lot of people don't really understand maybe because of the [00:06:00] name. I think it's funny because I'll meet people and I'll tell them about, you know, well, I specialize in selective mutism and they're like, oh, that's when kids are choosing not to talk. Right. It's probably due to some sort of trauma. And I'm like, no, no, not at all. So selective mutism is considered one of the anxiety disorders. It used to be sort of this like other disorders of infancy and childhood, like off on its own little island of lost toys somewhere. But in the most recent DSM, they finally put it where I think it belongs, which is the other anxiety disorders. So I think it's nice to think of it kind of like, umany sort of specific phobia. umso for instance, if you think of specific phobias, you might think of things like fear of Heights, fear of animals, fear of blood. Selective mutism is really the fear of speaking in public settings. And it can even sort of generalize [00:07:00] to just general communication. So even things like non-verbals nodding, shaking their head, shrugging, pointing to things, making choices, even written communication can be difficult for some kids. We know it's not due to a primary or at least diagnostically. It's not due to a primary language disorder, but it's a really co-occurant with language disorders. Hence one of the reasons why I think SLPs are incredibly valuable. In the intervention piece, you know, depending on what study you look at, it seems like more than 50% of kids with selective mutism have some sort of co-occurring language delay just broadly. It's relatively rare. You know, it's only about 1% of kids in, in school settings, but I think either we're getting better at diagnosing it. I hope that that's what's going on or [00:08:00] rates are increasing because we're sort of seeing this creeping up of the prevalence of selective mutism.  you know, I think rates of anxiety are increasing across the board nationwide.  so I don't know if this is just sort of like one of those things it's, it's increasing along with everything else, but  we do see a little bit of increase in selective mutism. So it's certainly something that SLPs are gonna come across and they're in, you know, in their day to day of working in schools, working in private organizations or private clinics and in hospitals as well. Well,  [00:08:30] Kate Grandbois:  you, you answered my next question, which was obviously going to be why, what is the role of the SLP in, in, in terms of intervention and diagnostics evaluation? And it sounds like there is a role, there is room for us at the table here, which is totally contraindicated, but Aimee and I were told in graduate school, which by the way was a long time ago. So [00:08:56] Aimee Kotrba:  yeah, no, I think so. I think SLPs are incredibly [00:09:00] valuable as a part of the team, partly because of the co-occurrence of the language delay. Like I don't know how to assist in language development. And so I need somebody on my team who can help with that piece. But to be honest, even in the kids who don't present with a language delay, I think SLPs play this great role because they know they sort of know the trajectory of speech. They know how to help elicit speech in like slow steps.  maybe you could think of it similar to like stuttering, perhaps like there's this development of increasing speech when you're treating stuttering.  the similar to what we're asking kids to do in selective mutism, which is sort of like practice small steps towards increased speech. And you guys are the experts on speech. So it's super helpful to have an SLP as part of the team.  [00:09:55] Kate Grandbois:  And before we get too down a rabbit hole, because now I have a thousand more [00:10:00] questions I want to ask. I'm thinking about the reality of the environments that we work in. So I know that you mentioned that it's relatively rare, less than one, 1% or less than 1% of the population in a school setting and the role of the SLP in terms of identifying or triaging for a student who may get referred to them for a blanket communication disorder, or, you know, any other, any other reason, and the potential lack of resources available within that school team to effectively support the student. At least in the school environment. I know you're in private practice and there are probably going to be external resources, but I've got to assume that that's, that's a real  [00:10:42] Aimee Kotrba:  problem. Yeah, and I think it's tough. And, you know,  I would say that this SLP is not usually the first person in the school setting who recognizes that there's an issue to be very honest, even though a lot of these kids will demonstrate symptoms [00:11:00] kind of from birth. Like when we look at the trajectory of these kids development, oftentimes parents are saying things like they were difficult to sooth when they were babies.  they were scared, you know, there was more like stranger danger and separation anxiety than we would typically see in development. They didn't speak in public settings, but, but none of these things. Really concerning, right? You don't expect a three-year-old to be ordering in a restaurant. And none of these things are really concerning until the kids start in school. And then the teachers are having a really hard time evaluating them. So oftentimes teachers are sort of like the first eyes, seeing these kids, recognizing that something is going on. Sometimes there's a concern that these kids are autistic. Cause they're not speaking.  sometimes there's a concern that they're oppositional, like they're just choosing not to speak.  but then at that point, sometimes the kid gets know referred to special education, at least for an evaluation. And that's oftentimes when the SLP becomes part of the picture, [00:12:00] but you're right. I mean, it's tough with SLPs are pulled in multiple directions and this might not be the kind of case that falls in the lap of an SLP naturalistically. It might be the kind of case that an SLP might even have to sort of,  be assertive to try to get on the case, knowing that they would be a valuable member. [00:12:22] Aimee Wonkka:  Can you talk to us a little bit? Just, I feel like this is a nice segue into our first learning objective. What does that assessment look like? Who does it, what types of like, is there a standardized assessment for selective mutism? What, what is, what does that process look like? Yeah,  [00:12:41] Aimee Kotrba:  so I would say unfortunately, unlike some other things where there's a very standard procedure of do this, give this questionnaire, do the standardized test and you will know magically, you will have your answer. You know, evaluating for selective mutism is a little bit more nuanced.  having said that it's [00:13:00] not terribly hard to diagnose because when it all boils down to it, if a kid talks at home and they don't really talk in school, I mean, you at least have your antennas up right. For something going on. But what I typically see. In terms of like in the school, in the clinic setting, how are we evaluating for this one is we're trying to find out more about how the child uses communication. Right? So do they speak, who do they speak to? In the school setting, you know, there's a lot of quirky, interesting things about kids with SM where sometimes they'll speak to adults, but not kids or vice versa. Sometimes they'll talk to women, but not men. Sometimes they'll not speak at all, but they're very sort of like non-verbally communicative sometimes they're totally frozen, but finding out more about their methods of communication in the school is, is really. Helpful, not [00:14:00] only from a diagnostic perspective, but when we start talking about intervention, it's going to sort of tell us, like, where are we starting with this kid? What are we working on? You know, are we starting with a whisper? Are we starting with the kid who doesn't talk at all at school? Are we starting with a kid who will answer a question if you're like point blank asking them in a private area, but they're never going to be the kind of kid who would initiate to you or, or willingly willingly talk to you. Right. So I would say the first step is just asking the teacher, asking the parents, try doing an observation in the classroom, trying to find out more about. This kid's communication behavior. And then above and beyond that, you know, there are some questionnaires that are valuable and helpful. There's a new one out actually this last year, it's called the Frankfurt scale of selective mutism. it's available for free online. So if you just search Frankfort scale of selective mutism it's age [00:15:00] normed, and has a lot of questions about the child's speaking behavior in public scenarios. So like, Did they talk to the pediatrician? Do they order at a restaurant  at home, you know, do they talk to extended family? Do they talk to babysitters? Do they talk to parents in public settings? And then at school, do they talk to peers? Do they talk to teachers? Do they speak in front of groups? And I think combining those things sort of information observation about the child's communication behavior plus the questionnaire piece. and then I, I really find it valuable. If you can get a video of the child at home speaking comfortably, I think it's a really eyeopening, right? Like this is the, the difference between the kid at home and the kid at school. I think if you can get those three pieces and what you see as a kid who either doesn't speak or doesn't speak very much in the school setting and does at home, you can sort of feel comfortable that that's [00:16:00] probably selective mutism. [00:16:03] Aimee Wonkka:  Well, you answered a question that I had, which was, is there sort of a continuum of maybe severity is not the right word, but different kind of profiles that you'll see with students.  and I guess one thing that I'm wondering is it's, it sounds like from what you're saying, it's really more about looking for those patterns of communication behavior and kind of those patterns tied specifically to the communication environments and tasks. Is that, is that fair to say?  [00:16:31] Aimee Kotrba:  Yeah. Yeah. I think the environment would be including like the people who the child might be communicating with. And then I usually say demands, but tests. So speech demands, speech tasks. Yeah. How do they communicate? Given different kinds of demands and kids was selective. Mutism are so fascinating because maybe this isn't fair, but I say they're kind of like rigid and rule-bound because you might have a kid with selective mutism who [00:17:00] in school does not speak at all. Almost looks kind of frozen, like a statue. They don't speak to peers, they don't speak to adults. And then they walk off the school grounds. And I mean, literally like they cross the boundary. Truly crossed the boundary. They step outside of the school and they're just like, blah, blah, blah, blah, blah. Just talkative talking to mom, talking loud all the way home in the car. And I think that  I think that people can get frustrated by that because they're saying like, well, the kid is totally capable of talking. I saw them talking as they walked outside with them. They're totally capable of it. Or sometimes kids will talk to peers, but not adults. Right. And so teachers will say, they're talking to their friends and then they stop talking when I come over. And I think it's because they're oppositional when the truth is, is that there's just interesting, kind of rigid. Rule-bound quirks about kids with selective mutism.  and it's not, it's not in that [00:18:00] positionality. It's it's anxiety about certain, like you said, environments, people in demands.  [00:18:06] Kate Grandbois:  I, I mean, this is so interesting. And I'm thinking about the role of the SLP. Let's say there's a situation where there is a profile of a student who's been identified as having selective mutism and has also been identified as possibly having a co-occurring communication disorder or language disorder. how do you evaluate that student? If they, you know, - how do they do that? How does the speech pathologist do that? [00:18:40] Aimee Kotrba:  It's so hard. It's so hard. So, okay. What I will say is that there are kids with selective mutism that if you were to pull them into your office, give them some adequate time to warm up and get used to you and then ask them specific questions. There are a lot of kids with selective mutism who would answer. Yes.[00:19:00] having said that there are a lot of kids that would, right. And then you're trying to do this sort of standardized evaluation for communication delay, with a kid who doesn't talk to you.  and so what I say, and I know that this isn't like, I know that this isn't as standardized as people would like it to be, but I think that you can get a feel for the communication delay via watching videos of the child, speaking at home in a comfortable setting. So asking parents to bring in as many videos as possible. Sometimes I will ask parents to do some of the communication evaluation, like tests, with the kid at home. Now, they're not going to be scoring them. And obviously they're not incredibly reliable or valid evaluators, but you can get a little bit of a feel of the way that the kid would answer if they were completely comfortable. And you can sort of hear some of the disfluencies or communication delays. but it's not an exact science because yeah, you've got this like [00:20:00] anxiety all tied up in it as well.  [00:20:02] Kate Grandbois:  And I also have to, I mean, as a, as a dually certified behavior analyst, I also feel like being mislabeled as oppositional or having a behavioral. I mean, that's, that's, that's rough. And I have to assume that there is a significant amount of counseling and educating that needs to happen across the school team or across the school environment to address the social, emotional and anxiety related piece and not slap a label. And just because that that's got to compound the problem. That's absolutely. that's something definitely to be aware of. Do you have, how do you recommend that people go about embracing that counseling and educational component?  [00:20:44] Aimee Kotrba:  Well, I think I come from it from the perspective of just describing to them the way that the sort of cycle of selective mutism works. So because no one can see me right now and try to talk you through this. But basically what happens is these kids, [00:21:00] these kids already, we know have some genetic components of anxiety, usually anxiety runs in the family, right? And then they have some neurological differences. When we do research on kids with selective mutism, we find that there are McDilla is highly over-reactive and takes a very long time to habituate. And so that part of their brain that's like the, the guard dog, I guess you could say that tells them that they're in danger, tells them that they're in danger too much, too quickly. And for too long, And so these kids are coming into a school setting, a public setting with this sort of like overactive Aimeegdala, a genetic predisposition towards anxiety. And they're put into situations where they're asked to speak or engage or communicate. And I mean, that happens like a hundred times a day for, for a typical kid, right? Like another kid talks to them or the teacher asks a question or just happens [00:22:00] repeatedly in school. And when they are in this situation, they get anxious and they do it. We all do when we get anxious, which is a void, right? Like if you can think of something that you felt really nervous about, I guarantee that your first response was, how do I get myself out of this? Do I not do that thing 1000%? they avoid. But interestingly, we, as adults tend to step in and help them avoid, right. Because we don't, I mean, they're like cute little kids. They tend to be really sweet. And so we sort of step in and help the avoidance to occur. And then the kid learns, I was right. That was too hard. I can't do that thing. And the adult learns, well, we shouldn't ask him questions and we shouldn't put them on the spot. And, you know, and the cycle continues where the child is more likely to avoid. The adult is more likely to [00:23:00] rescue them. And so what happens in a school setting then is that people see this avoidance from the child. And they swing one of two ways. They swing either to, oh my gosh, that poor little like shattered glass. We can't ever ask him a question. We don't want to do anything. That's hard or swing the other way of like this. Kid's just oppositional. And you know, I just won't give them their lunch until they tell me what they want for lunch. [00:23:29] Kate Grandbois:  Well, that person needs. So if you're listening and you know, someone who's doing this, please correct them immediately. That's just terrible. Yeah,  [00:23:36] Aimee Kotrba:  exactly. So I think the beginning is just trying to educate people on that. Why this avoidance is occurring. And I think that that makes it understandable, right? Like I totally want to avoid things that I'm afraid of. I can't always, but I totally would love to. And the avoidance is out of fear. It's not out of manipulation or oppositionality, it's a hundred percent out of [00:24:00] anxiety about the situation. Well,  [00:24:03] Kate Grandbois:  and as you're, as you're telling this story and describing it this way, I mean, how much compassion do we have for a tiny little person, a small human being who doesn't have self regulation skills who doesn't necessarily have the ability to think about their own thoughts or, you know, embrace a lot of the strategies that we adults use to manage our anxiety and, you know, self-talk and all those kinds of things. How much compassion do you need to have to create safe spaces? For a little person to feel more comfortable and to learn. I mean, we're talking a lot about this as, as the school setting.  but also through any therapeutic setting where you're learning new skills or your, you know, improving upon a certain level of skill, you have to have a safe space to do that or not if it's going to happen. And so I. That's that's just a lot.  [00:24:57] Aimee Kotrba:  Yeah, it is. And, and, you know, when I, [00:25:00] when I talk about sort of like the first steps of intervention and what parents and schools can do to help the very first step, like you said, is just being empathetic, that these kids are struggling. And oftentimes these kids are going home and telling their parents, I love my teacher. I love my therapist. I want to talk to them. I'm to talk to them tomorrow. And then they just literally can't get the words out the next day. So, um, yeah, having empathy and then just developing relationships with these kids is, is really powerful in sort of like the first steps toward helping kids feel more confident to speak. [00:25:37] Aimee Wonkka:  I do want to zoom back for just a second  because I feel like. There are also times where speech pathologists might be the person saying, I think that this is what's going on.  and I just wanted you to talk a little bit about, because it's so connected with this anxiety piece.  should we also be referring to a psychologist to make sure that that's what's [00:26:00] going on and also to have somebody on the team who can speak to all of these communication partners about that anxiety piece? Probably a little bit better than a speech pathologist might be able to  [00:26:10] Aimee Kotrba:  just based on our training. Yeah. Yeah. And I think, I think that that's a great point. And when I think of having a team  selective mutism, maybe more than a lot of others  mental health disorders that I work with really requires a team. Like I C I, as a mental health professional can not do this myself. The teacher cannot do this themselves. The parents can do this themselves. So to me, the best case scenario for a team would be a mental health professional who can sort of speak to the anxiety piece, a speech pathologist who can assist with the communication piece. Not again, just the communication disorder that might be there, but just generally, how do we help shape communication for this kid? And the teacher would be fantastic and the school, and then the parent, I feel like [00:27:00] if we have those people on our team, that's like best case scenario for this kid, because they're really getting sort of a, a well-rounded approach and intervention for selective mutism. [00:27:12] Kate Grandbois:  Okay. So let's, let's fast forward a little bit and imagine a perfect scenario where this has been identified. You've got the teams import, you've got a compassion and a learning environment. That's rich with empathy and a team that's well-educated and counseled on, on what is going to go into this? What do you do? What does the, what does the intervention look like?  [00:27:38] Aimee Kotrba:  Yeah, so the intervention, and this is where I was saying before we started videotaping, but I love selective mutism and I love selective mutism treatment and intervention. And I could go down a rabbit hole for six hours with you talking about like tips and strategies intervention. So this is where I have a hard time keeping I'm going to try so [00:28:00] broad strokes  this like other kinds of anxiety disorders  research shows is the benefit and the sort of like the gold standard evidence-based intervention is behavioral intervention. So again, broad strokes, if you haven't  a fear of, or a phobia of any what needs to happen, you have to sort of face that fear in little steps. Right. Or you could think of it from more of a learning perspective. You can think of it. Like if you're learning any, anything, any sort of skill you're learning how to read, you're learning how to do math. You're learning how to play soccer. You start with the small steps, but eventually over time, you build up to the more complex steps. Right? And so that's exactly how it works with kids with selective mutism. We start them trying to do things that are more kind of where they're at currently in a communication sense. And we're asking them to do increasingly challenging [00:29:00] facing their fears, increasingly challenging communication over time. So I'll give you a for instance of one thing that parents will tell me all the time that I'm like, and you as a speech pathologist will probably understand what I'm saying here. Parents will say things like, well, I have a kid who doesn't talk at school. And so I said to them  I'll buy you a pony. You will just go in and say hi to your teacher tomorrow morning in the classroom. And they didn't do it. I can't understand why offer them a pony and a trip to Disney. And I can't understand. And I try to explain to parents. Coming in at the beginning of the day with no warm up time with a huge group of people milling around and then initiating, right, like initiating is harder than responding and initiating something to the teacher. It's going to be really challenging. So we as professionals have to start setting these appropriate steps of communication where maybe at first the [00:30:00] response is just consistent, non-verbal responding. And then we're starting to look for maybe a one-word answer, but we're doing that with forced choice questions because forced choice questions are going to be easier than open-ended questions. Right. If I said  what did you bring for lunch today? A sandwich or salad. That's a lot easier for a kid to answer. Then what did you do over, you know, vacation this summer? That's such a huge question. Any kid for any kid to answer? So we sort of started. And build up.  [00:30:34] Kate Grandbois:  I have a comment and a question. So my comment was you used a word before, which I think is a really great word for all speech pathologists to know which is shaping. So the concept of providing reinforcement for successive approximations of a behavior that you want to see. So the exam, I love the example you gave about, why didn't you just say hi and I take you to Disney world, right? So that's not a, that's not a [00:31:00] successive approximation. That's not a baby step. You're jumping all, you're jumping off within the water. We got to dip the toe in first. Right? So I, if you  if you're listening and you want to learn more about shaping, it's a great  we do it in speech therapy all the time without knowing the scientific word for it, I think. But it's a, it's a really wonderful way to sort of look at your treatment targets. That was my comment. My question. Is, and I'm not sure this is going to take us down a rabbit hole, or maybe it's a really terrible question. And you can tell me that it was terrible question, Aimee and I both work as  AAC specialists. And so as you're talking, I can't help, but think about the use of visual supports as you're creating these successive approximations or these small baby steps came to my mind when you said closed ended question  or increasing nonverbal communication as a, as a small step. So do you see the use of choice boards or  other other support, other visual supports [00:32:00] to facilitate more communication in, in this type of intervention?  [00:32:05] Aimee Kotrba:  Yeah, it's a great question and really hard to answer because it sort of depends on where the kid is at. So again, if I think of this in sort of a stepwise process where generally we're always trying to sort of encourage a kid to do something that's a little out of their comfort zone, a little out of their comfort zone, a little out of their comfort zone, then using something like a seize or choice boards might be great for a kid who doesn't communicate at all in the school. But if you have a kid who is communicating a little bit in the school, giving too many non-verbal options might actually. Stagnate that, that stepwise process. Right. So I love it as a step in getting more communication, but it has to be thought of as a step that will eventually be the expectation will be raised to actual verbal communication, because we I've, I've worked with some teenagers who were given  like [00:33:00] iPads or computers eventually to communicate. And they were able to type everything that they wanted. Right. They were able to do well in school. They were able to type to peers. Now that's great in terms of communication, but is it really like where we want to go? Is that really vocationally appropriate, you know, socially appropriate in the real world? No. And so it's hard sometimes to sort of pull those things away eventually and, and expect increasing verbal communication, but it can be definitely be used as a step [00:33:34] Kate Grandbois:  interesting. I  [00:33:35] Aimee Wonkka:  mean, I dunno, it makes me think I had any, I don't know anybody who's listened to right now. I'm like super duper afraid of airplanes. And if I could take a  [00:33:43] Kate Grandbois:  train duper  [00:33:44] Aimee Wonkka:  afraid of airplanes, right? Like if I could take a train everywhere, I would never fly in an airplane. I just want to do it.  [00:33:51] Kate Grandbois:  I'm also afraid of airplanes and take drugs to fly. So I'm not ashamed of it. I'm not throwing a stone, stone etching, Aimee,  [00:33:56] Aimee Kotrba:  but  [00:33:56] Aimee Wonkka:  no, I think, I think it's just like, I think that that's, that's an [00:34:00] interesting analog that I was thinking about in my mind. Like, like sometimes, and we talk in AAC and this may or may not be true  for selective mutism. Like sometimes there's an accommodation that needs to be in place and that's the way that you can access your world. And that's that. It's like the glasses, you know, I wear glasses or contacts or I can't see, like, that's my opinion. No amount of ponies is going to change that.  so yeah, I think, I think, again, that's another place where having a team is super important because as the speech pathologist, I don't want to be the person responsible for making that choice because I might think in my mind, this is a great idea and it's a great way that I can help this student to access their school day without having the perspective of the psychologist or the mental health professional, who is able to say, oh yeah, but have you thought about XYZ? So I think just one more plug for collaborative team  [00:34:52] Aimee Kotrba:  work. Yeah, absolutely. Yeah. And I think, you know, I think a different perspective that maybe I have as the [00:35:00] mental health professional that people perhaps in the school, or maybe SLPs don't have is one of my supervisors once told me that if in a session you have not made a child uncomfortable, you have wasted their time in yours. And that's a really hard right for me to think about because I am compassionate. I love kids love working with kids. I'm super compassionate and empathetic to what they're dealing with, but it's like an educator, right? If I'm like consistently and just expecting what they can do right now, I'm not helping them to grow. And so as a team, how do we continue to help this kid to grow? But at a pace that the kid can participate in, feel confident in make gains. And there's always that like balance and that helps with the team. The team piece helps with it.  [00:35:48] Kate Grandbois:  I, I w as you were talking, I was just going to say, for me, that goes back to creating a safe space for growth, because, you know, there is that slippery slope where you want to push them to the edge of their comfort zone, [00:36:00] but you don't want to become punishing. You don't want to go into that rule of, well, you're done. I don't want to talk to you anymore because you're a meanie pants and you make me feel uncomfortable.  so there really is that sweet spot and that all comes down to rapport and safety and, and empathy, and just creating that environment where someone can be vulnerable, can feel fear and, and move through it. And that is, that is so important. That's like the  [00:36:27] Aimee Wonkka:  number one. So, so this is big, right? Because we don't want to, we D we don't want to stop pushing art students or clients. We don't want them to reach that plateau where we've said like, okay, here, here you go. But like, how, how do we help? How do schools or parents speech pathologists, how do we make sure that we're helping, you know, kind of with that zone of proximal development, if you will, or like comfort zone, you know, and making sure we are [00:37:00] finding that sweet spot. And are there other things, you know, that you would advise that people do kind of as strategies, like, should we be helping with some like relaxation strategies or other things, I guess just tell us more, please, please tell us more  [00:37:14] Kate Grandbois:  things. It just keep talking. This is so.  [00:37:17] Aimee Kotrba:  Okay. More things. Here's some more things. Uh, so yeah, in general, I think the first step is sort of trying to decide, okay, where is the child currently? What are some strategies we can use to try to help them take the next steps? Now here's where I could go down the rabbit hole. And I'm gonna try not to, but encourage you to maybe read my book, do some more research on selective mutism. there is shaping, right? So we're asking the kid to increasingly  communicate with us through successive approximations. There's something called fading.  it's called stimulus. Fading is the behavioral  name for it. But the idea that a new person fades slowly into the existing speech that a kid already has.[00:38:00]  So it's different from normal interactions. And here's how  so typically in a normal interaction kid, mom, or at the store, a stranger comes up and says, oh honey, you look at you. You're so cute. I love your shirt. How old are you? And it's very quick. Right? And then the kid has sort of taken off guard and they avoid, they hide behind parents, parents talk for them and so forth. What's different about stimulus feeding is it allows a child through slow little steps to get comfortable with somebody, overhearing them, talk, and then interacting with them verbally. And so the way that you do this and it's, I will tell you right now, it might sound kind of silly, or it might sound like that's not going to work. So, well, it works so, but you have mom and kid in a room by themselves. So maybe in the school, maybe they're on the playground. COVID I know is making it hard for moms to come into school. Mom and kid are on the playground. Mom and kid are in the office and they're talking, they're playing a [00:39:00] game that might elicit some speech. So guess who UNO headbands.  there's all kinds of fun games here. Again, SLPs, you guys know the games, the OLIS that speech right. Kid and mom are talking that mom's eliciting speech and the new person just slowly enters into that interaction. So at first they just come into the room and they're like in the back doing something busy on their computer, you know, writing some notes, cleaning up. I had become very good at pretending like I'm busy when I'm really not busy or busying ourselves in the back. And then eventually kind of coming a little closer and sort of starting to pay attention to the child. And then starting to reflect what the kid is saying. So if you're following me in terms of like step wise, exposing the kid to  different levels of  their speech, it's like, I'm not paying any attention, but now I'm in the room, I'm paying some attention. Cause [00:40:00] I'm reflecting you. Right. So you know that I'm hearing what you're saying. I heard what you said. I heard what you said. I heard what you said. I'm just reflecting what you're saying. The kid says to mom  does your person have blue eyes? And I say blue eyes. What a fantastic question. All it is. All it is, is me saying, I heard what you said. I heard what you said. I heard what you said. Then  [00:40:20] Aimee Wonkka:  eventually  [00:40:20] Aimee Kotrba:  I'm kind of up closer to the kid and parent, and then I'm starting to pepper in some questions myself. And so in a, in a kind of sneaky way  I'll start to lean over to mom's guests who board and I'll start answering the kids' questions. So kid is really asking them like, does your person and blue eyes, and I'll say blue eyes. What a fantastic question. They do have blue eyes. Thanks for asking me now the kid wasn't asking me, but it's again, it's sort of the step towards. Your TA I'm hearing you talk, you're talking to me, we're having a [00:41:00] conversation and then I can start asking some small questions, then start asking the guests who questions. And I've like, kind of taken the board away from mom now at this point. And so I'm slowly fading into this existing speech and transitioning the speech to myself slowly. And mom has now kind of faded out. She stops paying as much attention. She goes to the other side of the room, and eventually now I'm the elicit or speech. And the kid talks to me and not just mom. So that's like an amazing tool that works with a lot of kids with selective mutism. That  [00:41:39] Aimee Wonkka:  was a really good description. And I got an awesome picture in my mind of what that probably looks like. I guess a question I had was.  [00:41:49] Aimee Kotrba:  Is  [00:41:50] Aimee Wonkka:  it different from kid to kid? Like how long does that take? Does that all happen in like one session? Does that happen over time? Does it depend?  [00:41:59] Aimee Kotrba:  Oh, [00:42:00] Aimee, I'm such an expert. It happens in 10 minutes every time. No, I'm just kidding. I totally depends. So I have kids who I can feed into their speech pretty quickly. And when I say pretty quickly, I mean, probably within 30 minutes or so, and then I have kids who it would take me. Six one hour sessions to truly fade into their speech and allow them to maintain speech because they're so anxious. And so when I entered the room, they stopped talking or they stopped talking very much and I can't take the next step. And then eventually their speech increases because they kind of get used to me being in there. And then I start reflecting and they stopped talking or they stopped talking as much, or they start whispering in mom's ear. And I have to sort of wait that out and continue to reflect, but not take the next step. So it does take time. What I will say is that a lot of kids get used to this idea of stimulus speeding. They find comfort in it because it's predictable and it's sort of slow and [00:43:00] rapport building just generally in its nature. And so over time, maybe I'm the first one fading in to this interaction, but now I'm going to fade in the teacher. Now I'm going to fade in some peers. Now I'm going to fade in the art teacher. and every time it gets faster because kids, they just start to get it, they just start to get it. And what once took five hours for me takes one hour with the teacher and 20 minutes with the students and then like five minutes with the art teacher. Quick, quick, quick.  so it, it depends on the kid and it depends on how many times they've done it, to be honest. So  [00:43:41] Kate Grandbois:  aside from stimulus fading, what are some of the other, I mean, just thinking about the lack of resources that are really out there, because this is such a rare presentation.  you know, there are li I'm, I'm making the assumption that there are not a lot of in-house resources for selective mutism. I had schools across the country.[00:44:00]  so someone who is listening, who is interested in exploring these kinds of things, what other.  easily achievable or easily attainable skills or  things can teachers and team members do to sort of help when they've identified a student with selective media.  [00:44:17] Aimee Kotrba:  Yeah, one very easy thing that people can do. that helps a lot and it doesn't work with every kid, but it helps a lot is just starting to ask close ended questions or forced choice questions, however you want to call it.  and then giving the child a latency in which to respond. Now, this can be socially awkward sometimes, but when they, when they look at research on how long people give for somebody to respond, once they ask a question, it's about two seconds. I ask you a question and if you don't respond in two seconds, I feel super awkward and I move on or I ask a different question, stop talking to you because it's really weird.  [00:45:00] we try to ask a forced choice question and then gives a child are what we usually say is at least five seconds, but maybe longer to respond because a lot of times these kids have communication delays, and they're trying to think of like the correct way to say it. What does she want to hear? How do I pronounce that? What's the right answer. Uh, and so it takes them a while to get the response out. The other piece though, is that it helps to give that delay because what it says to the kid is like, no, I really mean to follow up with this question. I'm willing to wait for you. I really mean it. When I ask, I'm not just going to sort of flippantly move on. And so asking a question is close ended or forced choice and then waiting five seconds. And then if the child has an answer asking again, and again, that's like kind of socially awkward, but I'm asking the same question again. Maybe. Slightly easier. So here's a for [00:46:00] instance  let's say that  I'm, I'm talking to the kid about what they had for lunch, right? That was the example I gave earlier. And I said, what did you have for lunch today, a sandwich or a salad. And the kid doesn't answer. I wait that super uncomfortable. At least five seconds. I probably actually avert my eyes at this point because a lot of really concentrated eye contact can make kids with selective mutism really uncomfortable and maybe even prohibit them from responding. So I might kind of look down. Look someplace else. If the child doesn't answer, I ask again, and maybe I need to change the way that I ask because kids was selective mutism, probably aren't going to correct you if you were wrong. So maybe I have to say, oh, did you have a sandwich, a salad or something different? Cause like, maybe I'm wrong. Right? They're not going to be like, actually I had a brownie for lunch. So I re-ask the question. And I wait at least five seconds. Just that alone increases the [00:47:00] likelihood that kids with selective mutism will respond to my question. And then of course, I also have to be sort of cognizant of like, are there a lot of other people around that the kid might feel anxious about responding in front of, right. I might want to pull them aside and have them kind of privately answer me. I would want to be somebody who has a good relationship with the child. So I want to be kind of aware of those factors as well. That  [00:47:23] Kate Grandbois:  makes so much sense.  and I am thinking more about some of, I know we're talking a lot about schools and what the expectations are for students in school. And how many do, as you said earlier, demands, there are demands, subtle demands placed on kids all day, sit on your carpet square, raise your hand. Don't poke Johnny in the arm. You know, it just  not to mention here's your math worksheet. You have seven minutes to do it. And then the Bell's going to rain and there's pressure everywhere. So how do [00:48:00] these, how can we make accommodations for these kids across the board? Not only socially and in our, you know, structured therapy that we've identified in this fictitious school with tons of resources in our well-trained team, what other accommodations can we make for them across the school? [00:48:19] Aimee Kotrba:  Yeah. And I think accommodations are a really important piece, you know, to me, I feel like whenever I'm working with a kid with selective mutism, it's sort of a two-pronged approach. There's the intervention piece, right? Like let's, as a team, come up with some ideas of things that we can do to help a kid feel encouraged to take the next steps, to be brave, that might include a reward system. you know, it might include  behavioral practices. It might include needing a special education plan so that the SLP can pull them out of the classroom or push into the classroom. But the other piece to that you're right, is accommodations because a lot of these kids, there's a high expectation to speak and [00:49:00] be engaged in school and so forth. So how can we come up with a plan for the things that the kid's not ready for yet? Right. So that might include things like  sitting next to a communication partner in the classroom I'm sitting next to, or in a group with somebody that they already talked to or feel comfortable with.  it might include things like scheduled bathroom breaks because kids are not usually going to ask to go to the bathroom. Right. Johnny to have a potty accident because he couldn't come up and tell you, then you'd go to the bathroom. It might include things like coming in and meeting their teacher prior to the school year starting so that they feel comfortable with that person. And maybe can even get verbal with them before the school year even begins. it might mean things like  preferential seating up by the teacher, because what I wouldn't want is, you know, little Johnny starting to try to use this brave voice, but we usually call it  eventually in the school year, but he's sitting in the back of the classroom. And so like 30 little heads swivel around whenever he says anything. So sitting up next to the teacher where [00:50:00] maybe she would be able to overhear him speaking more quietly  and 30 heads are not going to turn and look at him.  we have to have some sort of accommodation for presentations or show Intel or  participation points for older kids. Like how do we, how do we accommodate that now? Accommodation, as you know, doesn't mean like it's just excused. You just never have to do a presentation for the rest of your life, but how do we help the child be successful where they're at and sort of grow. A presentation might be that the child videotapes themselves at home doing the presentation and just the teacher watches. And then maybe the teacher watches with the child they're watching with them. So the kid kind of gets the idea of like, well, the teacher heard me talk and then the teacher watches with two friends that the child gets to pick. And that, and so we're sort of like increasing the challenge level, but, but still accommodating that we know that like the kid's not gonna be able to do a presentation tomorrow. That's not realistic. So how do we help [00:51:00] them take those steps?  [00:51:02] Kate Grandbois:  Do you find that kids with selective mutism are at a higher risk for falling behind or getting flagged with special education, academic, special education needs? When in fact that's not the case, it's just been an unsupportive environment or the right accommodations haven't been made. So in other words, just in that example, the teacher doesn't provide corrective feedback on the presentation or doesn't, you know, assign it. The, it gives an excuse or doesn't provide the learning opportunity because there's just this assumption that they can't do it.  [00:51:34] Aimee Kotrba:  Yeah, definitely. Yeah. We do see kids falling, but we see kids falling behind academically. part of that is that there's so much like group work  teaching that happens within classrooms now that if a kid's not participating in the group project, the group work  then they're not really learning. They're not really learning those skills.  kids, because they can't ask questions to the teacher, oftentimes we'll fall behind. So let's say [00:52:00] mathematics, right? If you don't understand something and you don't ask the teacher, you don't clarify. And the teacher can't really evaluate how much you understand math builds on itself. And so eventually you're lost a year or two later. You're completely lost. So we see kids falling behind academically. We see kids falling behind socially.  we tucked so much, like, I'm sure you do about early intervention, early intervention, because as kids get older with selective mutism, they begin to sort of identify as the kid that doesn't talk. Everyone else identifies them as the kid that doesn't talk. Right. And everyone's going to make a big deal out of it when they a talk. and socially they start falling behind because like in kindergarten, if you don't talk to your best friend, okay, that's reasonable. You guys are still playing in swinging together, but like intense. You don't have a best friend that you don't talk to. And so eventually these kids start falling behind socially. And then just in terms of mental health, if they don't get good treatment, we tend to see increases [00:53:00] in depression. We tend to see increases in just general anxiety. Overall, their world just kind of get smaller and smaller because what they learn over time is if I avoid something, it feels good, at least in the moment, right. I avoided that. I'm not going to do those hard things. I can't can't do those hard things. And so then not only does it become an issue of not speaking now, it becomes an issue of not being on social media, not texting, not hanging out with friends, not going to doctor's appointments, not driving, not getting a job. Right. And so it almost compounds itself. And so having that early intervention. Incredibly important.  hence why I love to do these talks and educate people on selective mutism so that we can work as a team to, to try to deal with this as kids are younger, rather than, you know, when they're teenagers and it's really, really hard. [00:53:55] Kate Grandbois:  I'm wondering if you could tell us a little bit about  [00:54:00] some more of those expectations, so, or I guess, let me reframe that. I'm wondering if you could tell us a little bit about what documentation you might recommend. So, you know, if a family, or if a speech pathologist is listening and wants to begin advocating for the family or making those referrals. We've discussed a lot of different accommodations and my understanding, and you can tell me if I'm wrong is that we still have academic expectations that are appropriate, and we still have social expectations that are appropriate. And we're using all of these strategies like stimulus, fading, and  shaping, but what can  how can we advocate for these families to make sure they have the documentation to make sure that those accommodations are being implemented properly? Because these are, this is a very unique situation where we have the, you know, reasonable, social and academic expectations with a whole lot of accommodations, which is sort of a unique situation. [00:55:00]  [00:55:01] Aimee Kotrba:  Yeah. And, and I find that a lot of the kids that I work with end up needing some kind of special education plan. and it's incredibly helpful if the SLP is again, part of that team.  and so kids will usually  have no problem really getting a 5 0 4 plan because it's a diagnosis that can be made by a medical doctor and sort of necessitates accommodate accommodations within the classroom setting.  a lot of the kids that I work with need IEP in order to access the SLP or the social worker school psychologist, or whomever is the mental health professional in the school. And the most typical designation that I see with IEP is for kids with selective mutism is either emotional disturbance or emotional impairment, which my spin is. I'm not as crazy about that one.  Maybe that opens the door   [00:55:52] Aimee Kotrba:  speech and language impairment. If there is evidence of a communication disorder, some, some SLPs that I've  [00:55:58] Aimee Wonkka:  talked  [00:55:58] Aimee Kotrba:  to have actually been like, [00:56:00] well, I, I was able to  make the argument for speech and language impairment because of social pragmatics, because the kids weren't using. Speech in a socially pragmatic way, right? They weren't asking questions. They weren't starting conversations. They weren't interacting with their peers conversationally. And so I was able to sort of make that argument that that was a delay that they were experiencing and then otherwise health impaired or OHI  because it is considered a chronic health condition. Anxiety is a chronic health condition that impacts the child's alertness. So kind of like the flip flop of ADHD, kids who have anxiety are hyper alert to what they're fearful of and therefore are less alert to the other things going on in the classroom. Like if you can imagine Aimee, you said that you're terrified of, of, you know, airplanes. I mean, imagine being on an airplane and then trying to learn, no, it's not  [00:56:55] Aimee Wonkka:  happening, right. It's definitely not happening. I'm just counting down until we get  [00:56:59] Aimee Kotrba:  to land. [00:57:00] So, but that's what these kids are experiencing. And so you being, you would be hyper alert to the, all of the fear stimuli on the plane, all the sounds that people  [00:57:10] Aimee Wonkka:  that captain. Oh  [00:57:11] Aimee Kotrba:  yeah, yeah. Does that mean that we're crashing? Does that mean, oh yeah,  [00:57:18] Kate Grandbois:  I heard, I heard a bump. We're going down. We're going down. [00:57:23] Aimee Wonkka:  I can't imagine how exhausting, like having experienced, you know, a very close approximation of what you just described every time I fly.  it's exhausting, that's exhausting. That's like an exhausting experience to be that hyper alert. And to imagine how hard that must be for a child, if that's their entire school day or, or even if that stretches beyond that, that's like when you go to the grocery store, it's just, you know, it's, it's gotta be just very draining, a very draining experience. [00:57:59] Aimee Kotrba:  A lot of [00:58:00] parents will say, you know, my child comes home and they fall apart and they're a hot mess the rest of the night, or they're exhausted. And I don't know why. And it is because of that chronic, we know the impact of chronic over arousal on the brain and on the body. And that's what these kids are experiencing. So to some degree, I got a lot of respect for these kids because they're, they are usually managing, they're keeping it together. They're learning, they are learning in school. I mean, they're doing better than I might do to address  [00:58:31] Aimee Wonkka:  that piece though. Are there, I guess, back to those strategies, are there any. Universal strategies that might be helpful to kind of deal with that piece. And is that something that would usually be addressed, I guess, by the mental health professional in the school setting or, or if a child is receiving, you know, outpatient services, like kind of to communicate that piece too, just maybe building, I don't know if it's a thing where you build in breaks or you build [00:59:00] in opportunities for just a moment of relaxation. I don't know if that's even possible for some of these  [00:59:05] Aimee Kotrba:  kiddos. I  [00:59:08] Aimee Wonkka:  mean, certainly teaching  [00:59:09] Aimee Kotrba:  relaxation strategies can be really useful for these kids and giving them breaks during the day can be really useful for these kids. But to be honest with you, a lot of it is the, the school setting or the, or the parents and the family and the private therapist, starting to understand appropriate expectations for this kid. That lots of times what happens prior to understanding that this is selective mutism, is that our expectations are so high. And we're peppering this kid with questions that they can't answer yet, and we're not allowing them to be successful. And so a lot in a lot of ways, it's like, okay, now we know that this is the level at which the kid feels comfortable communicating. So we're going to do it here and we're going to do it one step above. And that's it. We're not going to ask them to present [01:00:00] anymore in that, in the way that we're asking the rest of the class, because we know it's too hard, right. And that's what causes this increase in anxiety. So for a lot of kids, as we all become more educated in what to expect and how to prompt a child, we're allowing the kid to be more successful. And we're not over asking there. There's not like the lunch monitor. Who's like, well, if you don't order, then I'm not going to give you your lunch today, which actually has happened to separate with my kiddos.  we're not over asking anymore and that just brings their anxiety level down too. So I think it's a mix of both. [01:00:31] Aimee Wonkka:  And I'd imagine that you'd see, once everybody scales their expectations to a level that's appropriate and doable for the child, that's also a nice chance. Although it's a stretch for the child to feel confident about, oh, I did this thing and it was hard and I did.  [01:00:46] Aimee Kotrba:  Absolutely. The kids build. I think kids build momentum and they feel so good about being successful because most of these kids want very much to speak. They want very much to speak, but what they found [01:01:00] is repeated failure. And so being able to be successful and having people be impressed by them and happy for them, maybe earning some rewards is in itself really internally motivating and makes them feel good and confident. Yeah,  [01:01:16] Kate Grandbois:  this is so, so interesting. I, I feel like I could talk to you for a whole other hour, but since our time is pretty much coming to a close, I wonder if you have any parting pieces of advice for anyone listening, who either is interested in exploring selective mutism a little bit more, or is faced with a student who has selective mutism for the first time. [01:01:39] Aimee Kotrba:  Yeah, I guess my parting wisdom would be, get involved and get educated and do something. I think a lot of people see kids with selective mutism and they, they either don't know how to help or they maybe feel like it's not the role of an SLP is not part of the team for kid with selective mutism.  but the truth is, is that the interventions that we [01:02:00] use are very effective  and you can change a kid's life. I mean, there's, there's nothing better in my personal opinion than seeing a kid who never talked through kindergarten, first grade, but finally got a plan into place and a team on board. And then they talk and they have friends and they are, you've like opened up their lives in this way that you don't get the opportunity too much anymore. And the parents cry and it's so sweet. So get involved, get educated  It's so I, I love working with this population,  [01:02:34] Kate Grandbois:  such a pleasure having you. This has been so tremendously informative.  Some of the resources that we listed today, we will put hyperlinks and they will be available for you in the show notes.  you can also find additional resources on the episode page, Dr. . Kotrba you so much for joining us. This was so great.  [01:02:54] Aimee Kotrba:  Oh, good. It's my pleasure. Thank you for having me.

This is a transcript from our podcast episode published September 25th, 2021. 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. [00:02:04] Kate Grandbois:  We're so excited for today's episode today, we have the great pleasure of welcoming Uri Schneider. Welcome Uri [00:02:15] Uri Schneider:  Hey, it is such an honor to be here, so great to see you guys.  [00:02:19] Amy Wonkka:  We're so happy to have you, , you are here to discuss transcending stuttering before we get started with that? Can you please tell us a little bit about yourself? [00:02:29] Uri Schneider:  Absolutely. Well, first of all, thanks for having me and as excited as you are. , I'm super excited to see you guys and to have this conversation and to share this with your listeners. , it's also nice to be on this side of the conversation, you know, being grilled with questions. So thank you for that opportunity. A little bit about me. I think transcending stuttering pretty much captures it. , I was born and raised, , with my mom and dad. And my dad is known to many of our colleagues and friends as Dr. Phil Schneider. He was the original Dr. Phil [00:03:00] before Dr. Phil and, very much has that has that personality of being a very memorable mentor friend colleague, and he's still doing it. He's still doing what he loves to do: teaching mentoring and doing therapy and helping people, even as he's living with Parkinson's now. , so he's expanded his understanding of living with, with challenge and living with things where you want to go a certain way and your body doesn't cooperate. And so he's thought of as very much a guru in the true sense of the word when it comes to stuttering, but he says that when he got Parkinson's that's, when he really started to understand that at a whole nother level, that like stuttering and Parkinson's having, Parkinson's informed his understanding of stuttering because suddenly his body wasn't cooperating. So he started to appreciate what it must be. Like, someone knows what they want to say, but their mouth, their voice just isn't ready to make the moves. , so anyway, I grew up with pictures [00:04:00] of laryngeal mechanisms hanging on the wall and my father talking about the heroism of his clients, the exhaustion of his days, but the satisfaction of his work. And for me, that was an inspiration as a six-year-old kid. I couldn't even say speech language pathologist, you know, I would front on most of those sounds, but, , I kept coming back to it again and again. So this is my life, you know, and transcending stuttering for me is a platform for my own human experience of being a husband, being a dad, being a friend, being a good citizen. So, , I enjoy being a dad. I enjoy being a husband. I love the work we do. If I won the lottery tomorrow, I would just try to help more people. I still do the work that we do and, and help more therapists to great work and feel great about the work they do. And, , in my free time I enjoy running and as Kate has been encouraging me. Some comedy, some comedy on the side here,  [00:04:55] Kate Grandbois:  I was wondering what was going to come out of your mouth. So we've [00:05:00] had, I've had the pleasure of chatting with you a bunch over the last couple of weeks as we prepare for this, as we collaborate around other things, , and talking with you is always such a joy. And I wonder if you could tell our listeners before we sort of get into the learning objectives, tell our listeners a little bit about transcending stuttering, , as, as an entity, is there a place just before we get into the meat of it, a place where people can sort of touch base about it or learn a little bit more about it, I've had a chance to learn a little bit about it just through our conversations, , which is one of the reasons we wanted to bring you on to share some of that knowledge. , but if you could tell us a little bit more about some of the basics and what it is that would, that would be.  [00:05:42] Uri Schneider:  Absolutely. Thanks for the opportunity. I think, , it might be the first place that I'm sharing that we do have a new, a new address for all things. Transcend transcending, stuttering. So www.transcendingstuttering.co .. Someone else grabbed the.com . , so [00:06:00] www.transcendingstuttering.co ,, and essentially transcending stuttering started off as a documentary film. In 2004, my father had recorded all of his clinical work for decades, like actual footage back when video cameras were like, I dunno, the size, the size of a suitcase. Exactly. And believe it or not, his clients tolerated it. So both, , you know, in, in any clinical setting that he was working. So what he ended up with is, is. Tens of thousands of hours of video. And you literally can see people grow up in front of your eyes. So an eight year old kid becomes a ten-year-old kid, becomes a 13, 20 year old, 30 year old, and it's all real footage. It's not staged and it's not B roll. So transcending stuttering is a documentary that documents the journeys of several people who stutter men, women, black, white coming from all different sorts of places. But what's amazing is the universality of the experience. And, , also the [00:07:00] stages and chapters that people go through and the triumphant stories of how they end. They all go differently. Some of them continue to stutter. Some of them don't, but they all become exceptional human beings who discover great meaning and great purpose. That documentary came out. And some of us on the team, Joy Kling being one of them a colleague of ours. So we've got to do something with this. We got to create a curriculum. We've got to create a way for people to learn and grow through this in a way that kind of unpacks. Well, how did, how do you do that? The second film is going with the flow. Another documentary, these were on PBS, very, very well received. These are two documentaries. Awesome. And then in 2020, we start with an online course. It's like a self-help course for people who stutter a group therapy for people who stutter and then in partnership with some great people at SLP nerd cast who will remain nameless. , you know, we've been able to put together a CEU offering. That's pretty significant. And unlike many [00:08:00] others, both in terms of how many ASHA CEUs can be earned 1.2, five ASHA CEUs, holy smokes. If you're listening to this, this is just like a little, little like crumb, you know,.1 CEUs.. But 1.25 that out of the three that you need every three years. Pretty hot. And it's, what's cool about it is it's a cohort based course, which is also different. So really quickly, we usually go to CEUs you go for a lecture, you hear some things, hopefully it's worth your time, worth the money. You get the CEUs, you come in, you learn something, you write some things down, you leave. Hopefully you remember something, but generally whether it's the next day or the next week, you're back to doing therapy the way you were before and whatever. Flash of brilliance or inspiration, it's somewhat fleeting or at best, it's hard to integrate. And what's cool about cohorts based courses, which this transcending stuttering, you know, CEUexperiences for SLPs is it's lasting over time. So we meet periodically there's content that can be processed. That's prerecorded, [00:09:00] that's, that's written and printable and usable in therapy for all the therapists. But we meet with space in between for consolidation and processing. And we have an asynchronous community online where the conversations just keep going and the support keeps going up to keep each other on fire, so there's this peer mentor community where people are growing together around the country and was super exciting to seeing people that have very little experience in stuttering very early in their career, as well as people who are hall of fame, ASHA Fellows,, and specialists also kind of jamming around the same campfire and everybody has something to gain and everybody has something to give. So I see myself as a, as a conductor, as a steward on the ship and the ship is sailing and we welcome SLPs who are interested in learning more and really having a great experience and finding the dignity and the pride and the confidence, but also feeling that they can be change agents, you know, [00:10:00] really helping others take ownership of their own journey and communication, no matter what. And it goes beyond stuttering. And that's why it's transcending stuttering. It's beyond stuttering. It's about the people, but it's also using stuttering as a platform, as a springboard to leverage growth and courage and humanity.  [00:10:21] Kate Grandbois:  I love it. I want to unpack something that you said in that, first of all, every time you speak it's it demands my attention and there's so many little nuggets in there, but what you said about a cohort learning experience, I just want to emphasize that because I, at least speaking, personally, I have had that experience where you have. Sort of one sided staring at a screen, being left to digest it on your own. You take notes and then, you know, the 15 minutes after the lecture stops and then you go about your life and you, not that you forget some of it, but your mind is a sieve, right? We all have those moments where we go and we put our attention elsewhere into our life, into our regular lives.[00:11:00]  And what I love about you, what you've created in this community is there is so much more of an interactive learning component, , which is so important when we're really trying to be vulnerable enough to acquire a new skill or admit that we don't know something or seek more, , seek more information from a peer. So kudos to you. And thank you so much for creating that platform. , and I'm so excited for people to learn more about it as we sort of go through the course or go through this episode,  [00:11:33] Uri Schneider:  I was remiss. I forgot to mention. SLP nerd cast what? A podcast, huh? Podcasts. Talk about innovation. Talk about changing the way people consume, you know, good professional content. It's both got personality, but also substance. I mean, podcasts are also amazing. So I want to give you a lot of credit and everyone out there, who's consuming podcasts, everyone out there who is producing them, it is not easy. [00:12:00] There's also a transcending, stuttering podcasts. We've got tens of episodes. They're interviewing people who, stutter researchers, professionals, influencers from around the world. Just bringing those conversations to life and making them available for free. But yes, I think all of us as professionals and also as we work with families, with clients, with young people and older people, we should think about innovative ways to reach people, innovative ways to share information and also create opportunities for transformation. And in particular, the key of the cohort based learning is that multi-directional learning. It's not just interactive. It's literally, you know, I will share something. The group will be able to share back. We have breakout rooms, we have collaborative documents in real time where we put our contributions together. So there's this multidirectional learning and exchange that goes on, which makes for really healthy give and take. And for all of you listening to this podcast, if you're an SLP and you want to take part so just go to transcending, stuttering, excuse me, [00:13:00] www.transcendingstuttering.co go to the SLP page. If you want to register for a cohort for the SLPs, if you put in the code SLP nerd, SLP nerd. If you're an SLP nerd, you can use that discount code for a hundred bucks off for the next event. And they're also free events and opportunities. So it's not just a sales pitch, but a little courtesy to the amazing stuff that you guys are doing. Well,  [00:13:22] Kate Grandbois:  thank you. That's very generous of you. And, , as a person who participated in registering all of your content for ASHA CEUs I can definitely say it's, it's worth the while. It's a really great experience. , and we're so excited to get into this, into the actual components of transcending stuttering. So let's, , we're going to move forward quickly with learn, reading our learning objectives and our financial and nonfinancial disclosures. Sometimes people write in and ask me to skip this part. I can't ASHA makes us read it. So stick with us. We're going to get through this as quickly as.  [00:13:55] Uri Schneider:  I'm just going to take a nap. Can you just buzz me when you're done,  [00:13:59] Kate Grandbois:  then just [00:14:00] go ahead and mute your camera. That's no problem. No problem. Okay, here we go.  Transcribing... Transcribing...  [00:14:03] Kate Grandbois:  Learning objective, number one, explain the speech mechanism and neurophysiology of stuttering learning. Objective number two, identify more than one speech fluency strategy  learning objective, number three, define at least two aspects of the transcending stuttering framework.  [00:14:19] Kate Grandbois:   Disclosures Uri Schneider's financial disclosures: Uri is the owner founder of transcending stuttering, and the director of Schneider speech nonfinancial disclosures. Uri is a faculty member at the university of California, Riverside school of medicine, Kate Grandbois financial disclosures. That's me, I'm the owner and founder of Grandbois therapy and consulting LLC and cofounder of SLP Nerdcast my nonfinancial disclosures. I'm a member of ASHA, SIG 12, and serve on the AAC advisory group for Massachusetts advocates for children. I'm also a member of the Berkshire association for behavior analysis and therapy, Mass ABA, the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis, special interest group.  [00:14:59] Amy Wonkka:  Amy [00:15:00] that's me. , my financial disclosures are that I'm an employee of a public school and I received compensation as co-founder for SLP nerd cast. And my non-financial disclosures are that I'm a member of ASHA SIG 12, and I serve on the AAC advisory group for Massachusetts advocates for children. All right, uri why don't you start us off with you? Tell us a little bit about the landscape of centering intervention in our field.  [00:15:27] Uri Schneider:  That's a pretty Rocky landscape. Don't lose your footing. , you know, I think stuttering finds itself in an interesting time and interesting place. We have a president of the United States. Who's a person who stutters, , no politics, but just to recognize that someone it's very emotional, I'm getting emotional, like to think that this was a person who grew up that as a teenager, his nickname was dash. , so he says, because not because he was fast, but because they, they teased him that he talked like Morse code, , to think that he says that it [00:16:00] was, it was more likely that he, as a teenager, he thought it was more likely he would grow up and get the Nobel prize in science. Then become a politician, a career politician, let alone president why he hated science. He wasn't very good at it, but to think that he would make a living as a public advocate, as a politician speaking as a professional. That's amazing. So on the one hand, we have this incredible example of the sky's the limit. There is no ceiling for people who stutter and at the same time, we're still dealing with a lot of misunderstanding, lack of understanding, a lot of fear, , and stigma surrounding stuttering and people who stutter and as professionals, as speech, language pathologists, we should be leading, leading this charge of being allies for people that stutter, doing great advocacy for people who stutter of doing great supportive guidance or therapy with people who stutter and in reality about one percent of all speech therapists are showing [00:17:00] interest in stuttering or feel able and ready to step up. So out of 150,000 SLPs in the United States, at 1% show an interest in stuttering, we've got to step up, we've got to do better and we've got to make it doable so that more therapists can show up. Otherwise we're leaving many, many young kids and families and adults behind. [00:17:20] Kate Grandbois:  This is something that we talk about a lot on our show, , about how wide our scope of practice is in the field of speech pathology and how it puts SLPs in this position where we sort of have to know almost too many things. I mean, it's no one can know everything. And when you're a new grad or you have a job that sort of throws everything at you, you know, you're expected to treat whoever walks through your door or whoever gets put on your caseload, regardless of your scope of competence. It can really put clinicians in a pickle to be honest, I mean, really upping, butting up against [00:18:00] our ethical code in terms of operating outside your scope of competence. , as a matter of fact, Amy and I were working as, , "AAC specialist." We use, , stuttering as an example, a lot. I, I, that isn't nowhere near my scope of competence. I have not worked in that area of academia or clinical application since, I don't know, 15 years ago when I was in graduate school. So what are you, or what are your perspectives on this issue? As it relates to an SLP who is maybe listening, who has a caseload of 140 in a school, which by the way, is a real person that I know with a caseload of 140 students in the school. You know, there are a lot of components here. There's unreasonable working conditions, there's unreasonable caseload size. What is your perspective on how to support clinicians who are in that situation?  [00:18:59] Uri Schneider:  [00:19:00] It's tough one. I think just acknowledging that it's a tough position. The first thing I think, to recognize all the efforts of many great people, I don't want to leave anyone out, but there are some people that have dedicated tremendous amount of time to improve the amount of training that goes on in grad school. So that more of the next generation SLPs will have better preparation, but there is that fundamental problem. The big nine or whatever is going to be the scope of practice, the number of things that students and programs are expected to train in it's impossible. So I think credit to them, I think that's a slow moving process, but it needs to continue to move forward. And again, many thanks and hats off to them. What we're doing here is taking people where they're at wherever they're at, whether they're still in grad school or just out of grad school or further on, like you described your friend. And if we can find a quick way to equip them with a tool belt of ways that don'tmake stuttering therapy, overly complicated, overly scary, but like [00:20:00] very doable, very touchable. I think the first thing we all need to do is stop making everything so darn complicated. Like we need to be committed to the highest level of professionalism. We need to be up to date with best practice and latest research. We need to have mentorship. We need to have supervision. Those are all things that I look for at the same time when you meet Jane or Jack in school, and maybe they're even in a group of kids with different things that they're dealing with, or maybe you're meeting them alone in a private practice in the hospital clinic. It really doesn't matter where don't look at them as a pair of lips. Don't look at them as a diagnosis, look at them as a person, look at their family as a family, every family has their own multiculturalism. Every family has their own set of values, their own set of circumstances and challenges. And we got to meet everybody where they're at and bring the humanity back into the room. And when you do that and you get enough of the professional [00:21:00] training and professional access and professional supervision and support with peers and mentors, the sky's the limit, and you can make a huge difference in someone's life  [00:21:09] Kate Grandbois:  And can, I just say how that fits so well with the title of what you're talking about is that, but that does transcend stuttering. I mean, bringing humanity into your, you know, into your clinic room or into your speech room is going to benefit you as a human and your entire caseload. , and I also want to say that if you're listening to this episode, then you are obviously seeking continuing education and more information so that's a great place to start. And I wonder if that sort of leads us into the first learning objective related to the speech mechanism and neurophysiology of stuttering. , can you tell us a little bit more about that? And I'm going to learn here for the first time, cause I haven't reviewed this in 15 years, so lay it on me and tell me all the things  [00:21:52] Uri Schneider:  So, I want to frame that, I think one of the, just we'll pull back and put it into the frame of this transcending, stuttering. We have a [00:22:00] framework with four parts and what you're asking Kate, each of those objectives are going to tie into one of these pieces, because I think as SLPs, most of your audience, I assume our speech language pathologist or SLP A's or SLTs, depending where you are in the world. I don't know how much of a British audience you have, but, , hopefully some, some good who  [00:22:19] Kate Grandbois:  knows, right? As in, if you're, if you're in Europe, send us a note, we have no  [00:22:23] Uri Schneider:  idea. Right? That's right. Good. Ima, , that's down under. But, , what I was going to say was, I think we, one of the challenges as a speech language pathologist, and again, this goes to how we learn in school and how we continue to learn. We ended up with a lot of bits of information and they're all over the place they're scattered, like, you know, like a piece of glass that got shattered and it's all over the place But it's like looking up at the sky and you got all these stars and what did people do? They started to connect the dots. And the first step is you gotta collect the dots. You can't start connecting the dots before you have all of them. I think I heard that from Michelle Garcia winner. I don't know if that's an original of hers, [00:23:00] but you got to collect the dots and then you got to connect the dots and connecting the dots starts to give meaning and purpose to what you're seeing this constellation. So before I give you the speech mechanism, which I'm going to do, cause I think it could be one of the most mind blowing things to open up this whole stuttering thing for clinicians and for people who stutter, let's just put it into the frame of their four parts of the framework. Self knowledge is the first thing a person should have a chance to know what stuttering what's communication. What are my strengths? What are my challenges? What are my weaknesses? What's my profile. What's my picture. And how do I put that together as it is. What can I leverage that I already have? What can I bring out of me that I got inside of me? And I'm talking to speech therapists and also people who stutter and parents, right. Nothing brings out the best in us and the worst from us as being parents and caretakers. , but it also brings out things we didn't know we had inside of us. We didn't think we had the capacity to care for another living being. , and suddenly we find herself [00:24:00] in that position. So we do things we didn't think we could do, but self knowledge, knowing ourselves, knowing the landscape of what we're up against and what it takes. Self adjustment will be the strategies self-acceptance I think is somewhat self-explanatory and self advocacy. So we got these, , the four parts, but again, we got to keep it human and I just want to highlight the four parts are self known. Self adjustment, which is learning different things that you can do that can make your situation or your performance easier or make it more challenging. So when it comes to stuttering, we're talking about helping people discover what are the things that make me stutter and get stuck more, more, often more dramatically. And what are the things that make it easier? Less effortful, self acceptance is accepting what I can't change. Like what are the circumstances that I can't like? I have brown hair. I'm also losing my hair at this point. Like I just got to accept that, trying to fight that does not look good. And I promise my kids comb over is not happening. It's just not, it's not. [00:25:00] Thank you. Feel the same way. Thank you. Thank you so much. So I have many colleagues, I won't name them who are balding beautifully and boldly and. And I followed their lead. , and then self self-acceptance is that, and then self-advocacy, I think is the most important thing we don't do enough is, is how do we tell our story to others? How do we make sure that what we've come to understand and come to grips with and lived with on our terms, how do we share that with others so that they treat us, listen to us, support us in the way that we wish, because so many parents want to support their young, you know, young or not. So young children, teachers want to help their students, but they don't know what the kids really want. So let's go back to your question, Kate, which I think is will we'll drop one concept or bomb for each of these units. , that will be an insight as a concept and will also be helpful as a practical tool. How's that sound?  [00:25:53] Kate Grandbois:  That sounds wonderful. Drop them.  [00:25:58] Uri Schneider:  So I told you and Amy [00:26:00] about something very powerful. I've uncovered. Yeah. But we could do another talk about that, about how respiration and phone nation is a very significant, , intersection where kind of a laminar airflow, you know, it turns into pulse, their flow and starts to create these sound waves in the world. I won't go into the cabalistic insights on that, which we talked about before. If you're interested, hit me up with a DM, but what is cool is that with step one, it is cool to understand. Stuttering is to understand it is a neurophysiological thing. One of the most important misconceptions is to think it has to do with some psychological or emotional feebleness or weakness or some lack of knowing what you want to say. People don't stutter because they're nervous people don't stutter because they, , they have a lack of intelligence. They may also have social anxiety. They may, they may have anxiety, but not all people who are anxious. And not [00:27:00] all people who stutter are anxious. So the first thing is to just recognize that in terms of self knowledge, your temperament can be the shy, timid type, or it can be the extrovert. Who's acting in a shadow personality of a person who's shy because they don't want to be the extrovert that they really are because they think they'll stutter. So they put on this facade and you don't see them talk as much, but they really have this extrovert waiting to come out of their shell. What's happening in stuttering. If you can break it down and neutralize, it demystify, it it's so helpful because it takes the stigma away for others and for the person themselves. So essentially the vocal folds, as we all know, are moving at thousands, hundreds of times a second, right? The coordination of respiration to phonation, to resonance, to articulation is this unbelievably coordinated ballet. I often think it's more incredible that we don't stutter, that it usually goes off without a hitch. Right Amy,  [00:27:56] Amy Wonkka:  right? Yes. I mean, it's amazing when you stop and think all of [00:28:00] the things that have to go well for us to effectively generate any type of speech at all.  [00:28:06] Uri Schneider:  So the sequencing of that is remarkable. So essentially what's happening in stuttering is the vocal folds, we know, move in their positioning. So if you are holding your breath or if you're locking your, you know, let's say you're picking up a heavy table, or I'm thinking of women's tennis, you know, all the grunting there, it's all about getting leverage on the core, right? To lift something heavy, or if you're going to the bathroom, or if you're giving birth, you're going to lock the larynx. So the closing of the larynx that bringing the vocal folds together tight has that purpose. Also, when we swallow, we know that the closure is part of that. , the other position is when you're listening right now, probably you're sitting there breathing hopefully. And your vocal folds are open. Voice happens when they're. Approximating, , the adjacency one to the other, and they're not too tight. Now, if you think about when Amy's talking, when Kate's [00:29:00] talking, when I'm talking, there's no breaks between the words, there's this constant flow that creates a sound signal. That's pretty much uninterrupted a voiced and unvoiced sounds. And then somehow I just put that out into the world and you guys are picking it up in your ears and hopefully for the most part, you have good hearing. And then auditory processing kicks in, sends that signal over to the language processing. And somehow the listener is able to decipher where words begin and end, where sentences begin and end, and then create meaning from that fluid sound signal remarkable. But within all that on the production side, is this voice on voice off. Most of us take that for granted, but if you think about it, it's two extreme positions. You have wide open when you're just taking a breath, inhale, you have tight. At different times. And then you've got the approximation of volts when they have to move from one extreme position to another, from no voice to voice or from voice to no voice. That's where [00:30:00] people who stutter have a, a physical sensitivity, you could think of it like an allergy. Okay. So similar to like, I know how to breathe, but if there's enough dust in the room, I look like I can't breathe. I start coughing and going into some sort of allergic situation. So I'm not suggesting that it's a breathing problem. I'm just using an analogy. They know how to talk. Their voice works. They're there. Their neurology is wired, just fine, but there's a sensitivity and they have these hiccups and it's specifically, and understandably when there's a voice onset or coming off of that. So just think about it. Where do people get stuck? They get stuck often at the beginnings. They don't get stuck at random places. If you think about someone whose name, my dad had someone come in, his name was Sam. And he says, Hey, Dr. Phil, you know, I can't say S I can't say ass. My dad says, show me what you mean. He says, my name is Sam. See, but dad says, what are you talking about? You got, you got a gold metal S [00:31:00] over there, you got a longer, stronger S than I heard in the whole, the whole month. Your problem is not the S probably moving off the voiceless. S so the voiced, , a vowel right after it. So it's that transition from the S to the vowel. What needs to happen there when you're doing the voiceless? I don't know if this is on tap with what your listeners would appreciate, but you just visualize this. Your, your vocal folds are wide open, right? Because it's voiceless and then they need to come, but not shut. And what happens for many people who stutter is they might get just, they don't want to cooperate. They stay open, the vocal folds stay open so they don't get any. So that's, what's happening with him, stretching out the S his brain is saying, move on, move on. And that should happen, subconsciously. It's not a volitional control kind of thing, but it's not cooperating, or what happens instead of being able to approximate one another, the vocal folds and go into the phone atory position, they end up shutting and, and no air comes out. And that's [00:32:00] when you get those silent blocks there, the same thing could happen on the starting of like, let's say my name and open vowel, like apple or Adam or Uri. So there's this silent hesitation. You see their lips moving, but you don't hear the sound coming out. So what's happening there. When you've got an open tract, the vocal folds are where the closures at. They need to go from a tight shut position to adjust open, but, but able to let the air come through and do that passive isolation. And that's where the that's where the hiccup occurs. When you do that, you demystified stuttering  [00:32:34] Kate Grandbois:  just about to say, you're getting into that level of detail as a person who was very novice in this, in this academic area, you would not only appreciate as you described it, the ballet of what happens, but you also, it gives you a better framework through which to analyze what's happening when you, it doesn't. It seems to me that you can't really do this work without having an appreciation for all of that finite [00:33:00] physiologic physiology.  [00:33:02] Uri Schneider:  Or you could just let me tell you that. And then you're set, meaning I don't want people to leave this thinking, oh, I need to understand like the neurophysiology of voice physiology of voice. No, you don't. But what you do need to do is you have to have some working understanding. And I think this speaks to also when you're working with kids and you're working with young people and you're helping parents. Okay. Here's your practical tip on this whole. Nobody needs a 14 page PDF that you downloaded from the best organization that has all the tips that you could imagine. It's, it's actually like information overload and parents and all of us. When we have something we're looking up on the internet, Internet's very powerful, very helpful. Gives us access to a lot, helping finding communities of support, helping find information fantastic. But information overload in and of itself is not always actionable and it's not always emotionally helpful. It can be overwhelming. So I think our job is to figure out [00:34:00] how do we provide this kid, this parent, this young person, enough information that they have, like a working understanding that is practical, that's meaningful. It's significant. So I think when you've got that list, you should take that PDF. You should become very knowledgeable about the kind of tips that are recommended. Even if it's not your scope or area of expertise you become acclimated. And then you make the best decision you can as to what tips you might want to offer this person. What anatomical physiological insights. You want to give this person, but when you explain it the way I did, you just, you explain it in a way that, oh, that's at least plausible. Now I can say, yeah, there's a physical basis to stuttering. It's not emotionally based. It's not cognitively. Oh, but wait, why do I start her more? When I'm nervous? I always told her more. Of course you do. Of course she do. And all of us that have things like I eat when I'm nervous, other people go shopping, other people gamble. I won't say what other other people do. But generally when do those things act up more, when do they [00:35:00] flare up? When we're in a state of stress. So stress exacerbates, stuttering being nervous, exacerbates stuttering is not the cause of stuttering. So the allergy to peanuts is not a peanut problem. You know, it's a problem with a certain threshold of something and the peanuts are a trigger and that's the response. So you have a sensitive system that has that response to that trigger. So people who stutter are sensitive and this'll bring us to the next one. And I'll pause for your next thought. People who stutter, what are the two things that are most sensitive to overall in general is, is pressure. And speed. Speed is the speed with which one speaks and coordinates all this ballet, right? I often say if you asked me to do one move in the Nutcracker from one end of the stage to the other, I would fall on my face at least five times. , and if you asked me to do it in rapid fire succession, like speed it up one and a half speed. As many of you might be listening to this podcast, , you know, I'm gonna fall over more. If you do something to change [00:36:00] the speed, I might have more alacrity and more fidelity in my movements. Similarly, with the articulatory speech stuff and intensity, we know his speech, language pathologists, and a little bit maybe voice therapists, right. Intensity has to do often with volume. So glottal pressure is often related to volume. , so those are the two parameters that can often, , , more stuttering or more intense  [00:36:24] Kate Grandbois:  stuttering. Well, my next thought was going to be exactly sort of what you alluded to and how that's, if you know, I think of intervention as first, you identify the problem or you do your assessment, right? And then you design your intervention to support an individual through the problems and strengths that you've identified. So having those components as a backdrop and thinking about exactly, as you said, as this leads into this second learning objective related to, to, , strategies and fluency strategies, how do those two relate to one another?  [00:36:59] Uri Schneider:  I [00:37:00] spaced out for a second. Can you just remind me what were those two things? I was listening to every word, but you got me thinking about something else that I would share that. Okay, let's go there. I was thinking about one of my other passions and I got this from my mentors, , in grad school. , Sima Gerber, Joel Stark, Renee Toueg, Arlene Kraat Pat McCall. My father, Dr. Phyllis Schneider, Stanley Gelfand. I think I got most of them. , the concept is assessment is dynamic and ongoing. I think, I think we need to rethink the concept of what is assessment and what's treatment. That's what you got me thinking about. I just wanted to share really short on that as speech, language pathologists. I think number one, we think about assessment as like this activity that's separate from treatment. And then we think about treatment it's on a separate from assessment, and I think we need to find more ways. Number one, to connect the two that there should be far more connectivity. And that means in both directions, [00:38:00] our treatment should follow our assessment and our assessment should be relevant to treatment. So here I am with two women. And I don't know the listening audience, but I would say like one of my most uncomfortable questions that I was taught to ask on an a Val, but I don't. So tell me about delivery, natural delivery or C-section of what relevance is that going to have on my treatment plan, right. Of what relevance or impact is that going to have in my comfort and my ability to create rapport with this mom or dad, it's just sticking my nose, where it doesn't belong and it's not relevant and it's not going to change my therapy. So I think do assessment, that's going to inform you in ways that are going to be helpful and shaping a way to understand the constellation of what matters here and then build your treatment off of that, and then build your assets. To build your treatment and recognize it doesn't begin and end after the first visit, it's ongoing and use this feedback [00:39:00] loop of how therapy goes to kind of revisit update your assessment, which is a working understanding of what you're dealing with. And to recognize it changes over time. You know, the kid at the beginning of the year, different than the kid at the end of the year, he's a different kid, same kid, but different kid. Kate and  [00:39:16] Amy Wonkka:  I talk about that. We talk about that so much because we have big feelings about data collection and just making the point that really, when we're collecting data throughout our sessions, we are doing a bit of that assessment. When you're collecting the data. You're, you're taking a moment. In your treatment to get a little bit of that assessment data, and that's going to inform what you're doing. So I think, you know, all like high fives through the internet, but, , it really, we did it guys. , I think, you know, I think that that is such an important point to make for kind of any application within the field. There is that thing that you do that is assessment, this formal process, that's usually tied to funding [00:40:00] and eligibility and all of that stuff, but that, that really isn't where it ends and your treatment should continue to be informed by little bits of assessment. And that's why data  [00:40:09] Kate Grandbois:  collection is so important. All right. I just want a second Amy's thoughts. I loved the concept that you just mentioned that assessment is ongoing because that's very true and it sort of loops me back to my original question. , I hope you're paying attention now, so I'm gonna, I'm going to reply. I'm going to, I'm going to repeat the two things. So you had mentioned. That two things that people who stutter struggle with our speed and pressure. , and I'm wondering if as your assessment is ongoing, what are, and thinking about our second learning objectives of, , which is identify more than one speech fluency strategy, is it safe to assume that those strategies are related to speed and pressure, or are there other components and other fluency strategies that, , should be looked, should be looked at more [00:41:00] thoroughly? [00:41:02] Uri Schneider:  Just a shout out to all my ADHD, brothers and sisters out there. , the fact that I got distracted. Yeah. So I'm going to just, I'm going to answer your question. Little preview dropping little self-advocacy here. So I have something called ADHD. It doesn't mean I'm not interested in what you're saying, but sometimes my mind sparks connections that you might not have realized. So I might ask you to repeat, just know it's not an indication that I don't care or said I'm not paying attention. It's actually a sign of, I really value what you're saying. , so just, , I appreciate if you can entertain me and repeat the question sometimes. So I got it this time. I'm going to come back to that. You did not, and there's no reason to feel bad. There was nothing apologetic there. That's the whole point we're going to get to that in self-advocacy we're going to circle back to that. Okay. Okay. , so the question of understanding and assessment and then strategies for [00:42:00] fluency. So again, principal, we don't teach strategies. You don't teach someone how to do something that should be automatic. Speech should be spontaneous. Speech should be within the context of communication. If we are doing therapy that is plastic and sterile and stiff, and yet we think we're taking data, we're taking the wrong data for measuring wow. In the laboratory of my clinic room or in my therapy room. We're able to achieve fluency of this percentage on this percentage of words, this percentage of the time. Yeah. Ooh. Well, that's one way to fill out your paperwork, but that's not a way to make a difference in someone's life. Now, what if there's a way to make difference in someone's life and inline with SLP nerd cast and in line with the best of our profession, find ways to take data on meaningful change. You can do that and it doesn't have to be complicated, but we're not going to dive into that. But my point is don't teach strategies. It's not about teaching them. It's about leading [00:43:00] them on a journey of self-discovery. And that's why each of the units is self self, this self, that it should be like a science experiment. I meet kids 8, 9, 10 years old. Those kids are not coming because they want therapy. They generally don't care about their stuttering. Parents are sending them or someone else is sending them generally. Okay. , but the point is you can engage them. You don't need to teach them. You have something wrong in your speech. It's called stuttering. You need to talk like this, but you can engage them and say, wow, what a treat I get to hang out with you. Tell me a little bit about you. What makes you tick? What are you into? What gives you delight? Oh, anything, anything hard, you know, anything different, you know, anything anyone ever says to you that bugs you and you get an idea what's going on from that, from their perspective for those kids, motivation and buy in is not going to be around something that you're going to convince them of, but it can be, Hey, can I, can I interest you? And becoming really smart about this whole speech communication thing. Like you could use this for [00:44:00] your science project at the fair later this year, and you could teach them what we talked about a few minutes ago, and then they become the expert. And then you say, Hmm, let's do an experiment. Let's see if we talk like this and you say, Hey, you know, which lane of the highway do you go in? The lane on the far, right? Is about 40 miles an hour laying in the middle about 50. The left lane is about 60. Which lane do you like to drive in? So that also gives you a sense of temperament. Could you sense a processing speed? Right? And it legitimizes all of them. You don't say the good lane, the bad lane, you think about your language. That would be something else we talk about and transcending, stuttering and self knowledge. What's the language we use. , so you talk about speed like that. You make it real life, use analogies, like driving a car. You make it very matter of fact and very touchable and no stigma and no shame and no, no words of, of jokes. But words of description. So you asked me how fast do you think you talk? And it he'll be like, oh me, I'm like constantly getting speeding because I [00:45:00] go like 80 miles an hour. , I'm constantly getting pulled over by my mom, you know, whatever. Okay, cool. Let's see what would happen? Tell me about the Yankee game last night. I just had to throw that in there, Kate, because I am from the Bronx. I'm gonna make sure you know that and we're in bombing  for anybody listening, who doesn't know the, the red Sox Yankees  we're not done yet. Okay. Or tell me about the super bowl with, , giants. Yeah. Eli Manning. Yeah. , so New York giants, totally new England Patriots book, even, even your quarterback left. , so yeah, Tom Brady knows what's up. , so the bottom line is like this. You got to talk to the kid and their language, but the kid says I like to go 80 miles an hour. I would say great. Tell me about last night's game and this time, what if you would go like 15 miles an hour faster. And then you say to the kid, okay. I say like, how was that? Did that feel easy? Did that feel hard? Or you might ask in terms of data, here's a quick data hack one to 10. [00:46:00] How easy was that? Or how hard was that? Boom. Now you've got metrics that you can take your own data. You can check in with this young person, teen or adult, and then you can also do something if you need to with calibration between the numbers. But if you're plus minus and agreement of one with one another, you're good. , but it could be interesting if they have a different number, I would not jump in and convince them that they're given the wrong numbers. Okay. But you listen to their story and you use these numbers and use this kind of like interviewing style, conversational, chill kind of style. And then you say to the kid, okay, what if we tried like this? You can drive from New York to Boston with no stops. Okay. This is what I would say to the kid, but you do a family road trip and everybody gets in the car and mom and dad. Everyone go to the bathroom. Okay. You know, we're not stopping until we get to grandma's house. Now another family gets in their car and they say, guys, go to the bathroom, but don't worry. We're going to stop at those three, you know, three big stops in Connecticut. And then right as you enter a mass pike, right before that, , easy [00:47:00] pass thing over there, you know, so which of them are going to get to grandma's house first? Probably the ones that don't make a stop. What are the, what's the family going to look like when they jumped out of the car? They're all got their bladders exploding. They're all at each other's throats running. And what did they get for it? They got a few minutes, but they're all hyped up, stressed out at each other's throats. The other family, I don't know, in a, in a drive to Boston, how much time did they lose? But the key is by making those stops, the pressure, the Amherst is different. Another analogy you get on a plane, transatlantic plane. I do that sometimes like New York Tel-Aviv Tel-Aviv New York, for some reason, it's a different psychological experience than getting on the L I R R train from long island to New York. I packed the same bag. It's like a pack of book pack my computer. I really don't pack that differently in terms of the carry on, but there's this mental stress that I feel when I know it's a long trip. So the strategy for stuttering that we like to lean on is pausing. If you could [00:48:00] put your words into these packets, into these buckets and put, put bigger pauses between phrases, you're like the family driving to Boston, but you stop at the pit stops. It makes the load and the press. If you want to get into the neurophysiology, I'm happy to go there or we can leave it, but just think like Amazon, how many of you ordered from Amazon? You guys order Amazon?  [00:48:20] Kate Grandbois:  Oh, of course. I feel, I feel like I should be ashamed to say so, but  [00:48:24] Uri Schneider:  yes it's. Okay. You shouldn't feel ashamed. We can talk about that in counseling later that we'll do another one of these on counseling. , seriously, so listen, Amazon, you ordered 10 things from Amazon. How many boxes does it come in? You order one order. One shipping address. You're one person you paid for it in one transaction. It never comes in one box. Right? Right. Anyone ever think of that? Like why do they pay for extra boxes, extra shipping? Let's assume they're all at the same packing plant. The reason is the more things you're going to put in a box, the higher, the chances something's going to drop the [00:49:00] fewer items you put in the better, the chance you're going to get a successful delivery of the right items and the right number of items. So the fidelity of the delivery is going to be impacted by how many pieces are stacked into one box. So we know that the more words you pack onto a breath group, that is the packet of information sent from the brain to coordinate respiration, foundation articulation and everything. It's a much heavier packet, but if you have fewer words, if you use a little bit of pausing just to punctuate the phrases, no robot speech. But just learn to take these steps in between the phrases. It can sound natural. It can be a tool that effective communicators use. You can sit in school or in your clinic and show the kids videos of great speakers from around the world, from Obama to others. You want to message me. I'll give you a link to a whole demo of what sites I use and how we do that. And you can take a transcript of a speech and a video of a speech, and you can show how [00:50:00] great communicators this is, what they do. So the strategy would be could this young person experiment, explore, discover what feels more comfortable, pushing your limits, driving 90 miles an hour, or what if you did this, where you drive a comfortable speed, whatever feels natural, but you do stop at the guest stops. So that's an example. [00:50:21] Kate Grandbois:  I love the analogies that you use. I think it really helps. I don't know, harking back to something you said earlier in the episode about how clinicians are scared of treating stuttering or, and I'm one of those people. So I feel comfortable saying that, you know, it's not something that, , a lot of us feel comfortable in, but when you use those analogies and you have a better, , you know, thinking about the neurophysiology as a backdrop, thinking about components of speed and pressure, thinking about assessment as an ongoing, , component. And I know we haven't even talked about counseling, but counseling being such a huge part of this, , I think the analogies really help [00:51:00] us to digest stuttering, which can feel like such a, a large, , a large and overwhelming thing to address and tackle in our therapy rooms if we don't feel equipped to do it. So thank you. So, I mean, the analogies are great and it really helps me. So thank you for that. , and I wonder if we could spend our last 10 or 15 minutes. Sort of carrying over that thread of counseling and self-advocacy and thinking of N T tell us a little bit more about the transcending stuttering framework. You've mentioned it a couple of times, , that it's a multi-pronged approach and I know you've mentioned some components of it, like self-advocacy , what, what else can you tell us about the transcending stuttering framework?  [00:51:45] Uri Schneider:  Perfect. So I think one thing that you said, , we did touch on counseling a few minutes ago. I think. So we said that word, but, , I loved what you said that it's helpful to you, which made me think we should think in therapy, like what's helpful to the other person [00:52:00] shouldn't come in and give them what we did last time or what we did for the previous, , therapy appointment. We should really think about what's good for this person. So I was joking about the new England Patriots, but we're going to come back to using that because I do know that Kate's in Boston. So that's the context of where she is. So we're going to use that and I encourage you when you ask people that you're meeting, like, what are you all about? What makes you delight? What do you do on the weekend? What's your favorite subject that informs you as to what are the harbors of safe space and of analogies and of connection that you can have with this young person? So I think you use that information, not just as a feel good. Let me check that off and get that out of the way that informs the understanding of this person. And then it helps guide you in what you're going to do with them. So that leads us to self-acceptance. You asked me about the four parts of the framework, and I'm going to turn the table on you for a moment in a second, but for all the listeners, no notes. That's what [00:53:00] we have to take away. The oh no, there comes the stuttering case. Oh no. I just thought I just  [00:53:05] Kate Grandbois:  said, oh no. Cause you were going to put me on the, in the hot seat  [00:53:09] Uri Schneider:  who said it's hot. Maybe it's one of those seats in the car where you got like the air conditioning center. This is a seat with the air conditioning on your back. And also under your bottom, you got air conditioning coming everywhere. No hot seat, cool seat. , we all need courage as SLPs. We need courage to step into, to being present for people that may present with things that, that give us the heebie-jeebies. , and we need to be able to hold space when people get emotional and cry, whether that's our thing or not our thing, we gotta have the courage to lean in. So I think courage is very important because it also is what we're asking them to do for the young person, the teen or the adult or the parent. So much of what we ask them to do is asking them to go again. Like their first response. The first response is I want to be safe, fight or flight I'm out of here. I'll avoid, [00:54:00] I'll do anything, but, and we're asking them to do things. We have to be ready to do the same. And that's the best way to help someone, you know, flex their own courage and show them, us, ourselves, doing things that are outside of our comfort zone. I think that's very powerful and it becomes something you can do in different settings with different students. And in a group setting, you know, the kid who's got, the ADHD kid has got language processing stuff going on, the kid who has other, a different profile and the K2 stutters, they're all working on different things, but you can find that common ground anyway, in transcending stuttering, I tell all the SLPs, I want to be able to wake you up in the middle of the night. And you remember these four things because they're that helpful? So self knowledge, self adjustment. Okay. Strategy type stuff. Things I can do, and I can change. I can influence making it a bit easier, making it a bit harder. Self-acceptance somewhat [00:55:00] self-explanatory but not necessarily. And then self advocacy. Let me show you how helpful these four parts of the framework are. So I'll toss it up to you guys. Okay. And then I'll count 1, 2, 3, and you could say, is it part of self knowledge? I'm going to say something now, if it's self knowledge, self adjustment self-acceptance or self-advocacy and if you're listening, we'll give you a little pause, time to process and think which bucket would you put it in bucket? One bucket to bucket three and bucket four. Feel like we're at Yankee stadium, they have a part where they do this. They throw out a question and everybody has to answer, you know,  [00:55:32] Kate Grandbois:  like the jumbo Tron.  [00:55:34] Uri Schneider:  Absolutely. Absolutely. So here we go. So, , the kid says, oh, , I really wish Mrs. Smith wouldn't call on me to read out loud. I really wish she wouldn't call on me to read out loud. Which bucket would you put that in? Is that self knowledge, knowing about speech and self and all that is about self adjustment. How to change the way I talk or different mechanics [00:56:00] to make it more challenging or more easy. Is it about self-acceptance tolerating myself, loving myself, giving myself the care and regard that I deserve, or is it about how I tell my story to get the treatment that I want from others? Self-advocacy is it bucket 1, 2, 3, or four? 1, 2, 3, 4. What do you say  [00:56:20] Kate Grandbois:  I was going to go with with self knowledge? Oh, Amy, what was your I always going to go  [00:56:27] Amy Wonkka:  with self-advocacy  [00:56:29] Uri Schneider:  and you're both good. Here's another one. Yeah. Wait, I need one of us to be  [00:56:34] Kate Grandbois:  right.  [00:56:36] Uri Schneider:  I'm just kidding. I'm just used to altering therapy is going to require no rights and wrongs gotta be flexed. Truly, truly there are going to be things that go in two buckets at the same time. Why don't you tell us Amy, why you thought it was self-advocacy and then Kate, you could give your rationale why you thought that and they could both be good. .  [00:56:53] Amy Wonkka:  I was thinking I'm self-advocacy because your client was identifying their [00:57:00] preferences in terms of how somebody else would communicate with them. [00:57:04] Uri Schneider:  Yeah. Cool. Well, that's an opportunity that student is telling you. I don't yet have aligned with my teacher. My teacher doesn't know the way that I would like to participate or have a pass. And so to me, that is a ding ding ding, in, in, in a certain way of an opportunity to look into activities related to self-advocacy. How can we explore the channel of an issue ready for that? And what is she ready for? And how does that look? It's not a black and white, but at least I know. When you asked me Kate, what's the terrain, at least I know kind of my navigational intelligence clinically, where am I leaning here? What was your thinking, Kate, in terms of self knowledge? Cause I think there's something there.  [00:57:43] Kate Grandbois:  My, my thought was about it being self knowledge was related to the end of eligible the individual being aware that they were avoiding, they were avoiding that demand. They were avoiding that task in the environment and sort of knowing that it brought them [00:58:00] uncomfortable feelings he didn't want and they didn't  [00:58:01] Uri Schneider:  want to do it. Great. Great. I love that. I think that's great. And what I would think as I keep thinking about this is like, there's the experience of the person who stutters or the client for any of us. And then there's our experiences as professionals, you know, how's our avoidance management going, how aware are we have our own avoidance of certain things, stuttering therapy and among them. So I just think it's fascinating when we could start just looking, being more mindful. And, and watching ourselves go through the things we think about our clients and what we want to tell them and just reflect it back. So one more example would be the kid says I had such a bad day, you know, that's such a bad day. And it was like, it was a stellar day. It was like Disneyland day. There was just a lot of stuttering. So the kid says, I just had such a bad day. I'm such an idiot. So is that self not? What does that tip off in our mind? Self knowledge, self adjustment, [00:59:00] self acceptance, or self-advocacy 1, 2, 3 or four. I'm  [00:59:04] Kate Grandbois:  going to go with self-advocacy. [00:59:07] Amy Wonkka:  Oh, interesting. I'm going to go with self-acceptance because it's an opportunity to sort of think about maybe reframing.  [00:59:18] Kate Grandbois:  Perfect. And I would have self said self-advocacy because they're, they're seeking support from someone saying I had, I don't know, saying that you had a bad day. Connecting with another person to get, to get that support or express their feelings. [00:59:33] Uri Schneider:  It's both, but guess what? It's not here's what's as helpful is Kate. Why it's not about what's right, but it's about what's wrong. The wrong thing for that kid is to serve up some strategies. The wrong thing for that kid is the self adjustment. Okay. Don't worry. Yesterday was a big stuttering day. We're going to have a great, smooth talking day in the office. Now let's go, right? That is the most harmful thing any of us could do. And this is what I want to drive home. You don't need to be a [01:00:00] stuttering specialist to figure that out. You just gotta be human. You just got to think for a second, be that middle school kids step in their shoes. You don't need to be a psychologist. It's not counseling as a fancy. You're talking about having a tough, uncomfortable time. You're sharing that with another person. What do you want them to do? Do you want them to listen? Do you want them to pry deeper and like dig and dig and dig and put you under the interrogation? Do you want them to tell your parents right away that you're having a really hard time and you sound depressed. Do you want them to fix everything and tell you, oh, don't worry, honey. You know, be a cheerleader. Sometimes it's just a human thing to reflect and think of how we would wish a friend would treat us. So coming back to it, what I'm trying to say is the four-part framework empowers, simplifies and helps both the person who's going through stuttering and the guide, the parent, the teacher, the therapist, everybody can share the same language and you both gave great reasons. Why it's those things, Kate, I love what you said. If [01:01:00] he's saying it's a bad day, it was a no good day. He needs to recognize the language he uses is going to impact how other people see him, treat him, think of him. And he has something he can do about that. He can say it was a really rough talking day. It was awesome. Disney was great. I couldn't enjoy it as much because it was really distracting for me that I had so much stuttering going on. That's legit. And for Amy's point, absolutely. At the core you can't sell or tell the story that you're not living or, or buying or drinking yourself. So we can't advocate in a way that we're not ready to give ourselves the patient's love tolerance. So I think for that person, it's about recognizing, well, what were the other parts of the day? You know, give me the full picture. Not just that little snapshot or one angle.  [01:01:47] Kate Grandbois:  I love this, but I feel like this is. So helpful for us as people, because I think sometimes we, as clinicians, we get our fixer hat on, like, I'm, I know have all this content knowledge and here I am, I'm [01:02:00] going to fix you and I'm going to help you. And you're here to get better air quotes, you know, quote unquote, get better. , and we lose sight of the fact that we are also humans and we are there with another human. And there are so many components of our work that are not in the textbook. They're not rooted in content. They are rooted in these components of human connection and understanding, , and doing that to ourselves. You know, how important that is to do that to ourselves, to break it so that we can bring our best selves, our best human selves into our therapy room. And when we don't do that so much as lost. , so thank you so much for going into that. And I wonder if in our last minute or two, if there are any. Any parting words of wisdom that you can leave, , our audience or things that you might add. Anything else that you want to carry home that you haven't quite mentioned  [01:02:54] Uri Schneider:  funny? You should ask. I think, I think back to the biggest [01:03:00] influences in my life, and I ask you to think of yours. You know, if you're a speech therapist listening to this SLP nerd cast, you give you listening to a lot of other podcasts. Trust me, there's a lot out there, but something brought you here, but probably you here. It means you must be an SLP and you nerd out about SLP stuff and you love listening to SLP nerds, casting their SLP nerd out. But my point is something keeps bringing you back. Right? So I think what brings you back? What inspired you to get into this in the first place? And I don't know if it was. You know, the recurrent laryngeal nerve and the fascination with the route it takes, or if it was broken or were Nikki, or if it was ABA or floor time, I don't know. But I got a feeling that some of you like me, it had to do with something else it had to do with something that touched you. Maybe it was someone you knew in your lifetime. Maybe it was something a teacher professor shared for me, it was seeing my dad, [01:04:00] the joy, the relationships, the long lasting perspective of a lifespan of seeing someone who at one moment seemed so disabled, so unable, but believing in them and hanging in and seeing them shine. That's what brings me back again and again. So I think I want to take that for all of you. Think about what brought you here. Probably wasn't something technical and informational probably sound emotional. So when you're working with a young person who stutters or a family, as Kate was saying, get off the, fix it horse and get on the carrot horse. Carrots care care. And my, my, my mentor, when I think back to Joel stark, he taught me a lot. He passed away in the past 12 months or so he was the head of the department at the Queens college. And every year the students would make a plaque of 10 Joel isms, 10 quotes. And none of them were like the technical gobbledygook of our work. Two of them, I'm going to share it with [01:05:00] you. And these are things to take with you, but think about what you wish your students think of you five years from now, if you're teaching as an instructor in college or university, or if you're a therapist, what do you want your students to say five years from now about what they did with you? It probably is not about pausing and it's probably not that you saved their life with such and such technique, but they probably will say, you really cared. You really listened. You really showed up. You were really vulnerable. I could tell you didn't know what you were doing, but it was really great to see you struggle just like. As we both tried to find our way. So I would just leave you with these two. Joel isms love them up in a ethical way. In a professional way. He was a person who was demanded the highest level of professionalism and intellectual rigor, but he also made it clear if you don't really care about the person you're working with, get out. Cause nothing good is gonna come of it. You've got to care about the people you work with, even when they're really difficult, second kiss, keep it [01:06:00] simple. Don't over-complicate things. And yeah, and I just want to leave you with a feeling of confidence. You can do this, you can do this with, with the right support and a bit of, you know, leveling up and refreshing yourself with a good heart and a reasonable head and, and some professional judgment. You can be the difference for acute who stutters and don't just pass the buck on the one hand. If you don't feel you can help them, you feel like. Do you get out of there, but don't be scared to make a difference because you could be the difference. It takes one caring adult to make the difference between a kid's life and the kid becoming a statistic. [01:06:36] Kate Grandbois:  Got them. That was beautiful. Thank you so much. You're I love talking to you. I said that at the beginning of the episode, I'm going to say it again. Now we always learn so much from you. , and I know everyone listening has learned a ton, , through the course of this episode. So  [01:06:50] Uri Schneider:  we'll see what they fill in on their, a quiz at the end. You  know,  [01:06:52] Kate Grandbois:  there we go. , if you want to learn more, you can find more of Schneider speeches work and work [01:07:00] at, , on Instagram. , there's sending stuttering podcasts. There's also, , the transcending stuttering course where you can be a part of this cohort and to learn a little bit more www dot transcending, stuttering dot C O is the new website. So, , thank  [01:07:16] Uri Schneider:  you again, or www.schneiderspeech.com . There you go. And all, most of the content is a hundred percent free and obviously there are opportunities to dive deeper. So if anyone needs anything, we're here to serve and to help others, you know, get on fire and help others launch their own journeys, their own stories. Thank you so much, guys. Thank you so much for  [01:07:36] Kate Grandbois:  joining us. Thank you.