Summer Reading List

One of the best things about summer is finding time to read!  During the school year, my reading time is limited to a few minutes before falling asleep at night.  But in the summer, busy though I am with lots of chores and activities, I still make it a point to carve out some time each day to read, especially on rainy days which I feel Nature provides specifically for that purpose.  Getting lost in an exciting mystery, an inspiring biography, or illuminating historical fact or fiction book clears my head and recharges my batteries.  And as much as I relish the escape from work, I do try each summer to read one book related to our field to gain new insights and renewed compassion for people whose lives are very different from mine due to disability.  Here are some of the books I’ve read over the past few years that I would strongly recommend.  I’m linking the titles to Amazon so you can read more about the books, but encourage you to visit your local library or patronize your local bookseller, both so very worthy of our support!

My Stroke of Insight:  A Brain Scientist’s Personal Journey by Jill Bolte Taylor, Ph.D.  41xxS5wUJtL._SX330_BO1,204,203,200_This is the brutally honest biographical account of a young, healthy, brilliant neuroscientist who was devastated by a massive stroke.  Amazingly, she was able to regain functioning through incredible determination and countless hours of therapies.  The account of her eight-year journey to recovery includes her memories of being completely helpless and unable to communicate, yet perceiving the attitudes and emotions of caregivers, even when she could not comprehend their words.  I always share this information in my workshops with school staff who deal with students who have significant disabilities.  You can view Jill Bolte Taylor’s TED Talk here, but read the book, too!

Ghost Boy:  The Miraculous Escape of a Misdiagnosed Boy Trapped Inside His Own Body by Martin Pistorius.

Screen Shot 2018-07-19 at 9.35.36 AMWell, the title pretty much says it all!  Martin was a perfectly normal and healthy boy until he was completely debilitated at age 12 by an unknown virus that left him locked in his body for 10 years.  I did a review of this book on this blog in 2015;  you can read it here.  I always include information from this book in my workshops, as the memories of Martin as a profoundly disabled school-age boy are eye-opening and shocking, and serve as a reminder to all educators to always presume competence.  Through Martin’s recollections, we also get a glimpse of the effect his condition had on his parents — another important insight that I share.  Martin Pistorius also has a TED Talk entitled “How My Mind Came Back to Life — But No One Knew,” but read the book first so you are even more blown away by his recovery.

51HsAQlyqFL._SX321_BO1,204,203,200_41QZ3WNoKNL._SX329_BO1,204,203,200_Two other uplifting come-back stories are “In an Instant: A Family’s Journey of Love and Healing” by Lee and Bob Woodruff, which recounts the recovery of this ABC News journalist after a devasting head injury in Iraq, and “Gabby: A Story of Courage and Hope” by Gabrielle and Mark Giffords, about the US Congresswoman who survived an assassination attempt but was left with lifelong challenges.

31-E5HeYuEL._SX334_BO1,204,203,200_A fictional story that I really enjoyed — and would recommend for young teens as well — is “Out of My Mind” by Sharon M. Draper.  This is the compelling story of a young girl with CP who is the smartest girl in her school, but is considered by all to be mentally challenged because she is unable to speak.  Her determination will warm your heart and change the way you view people with disabilities.

41fxsXxLq9L._SX322_BO1,204,203,200_There are scores of books about autism.   Any book by Temple Grandin is worth reading, as she generously shares her “insider’s view” of being autistic and offers valuable advice to parents and educators. The writing of “The Curious Incident of the Dog in the Night-time” by Mark Haddon perfectly captures the voice and thoughts of a young man with autism who relates well to animals but has no understanding of human emotions, who hates to be touched and can’t abide the color yellow.

 

This immensely popular story was made into a Broadway play.  Unlike some of the others I’ve mentioned, this book makes for light reading but will keep you thinking, long after you close the book.

519TerFSCjL._SX331_BO1,204,203,200_I am currently reading the 560-page tome, “Neurotribes:  The Legacy of Autism and the Future of Neurodiversity” by Steve Silberman.  The author presents a fascinating and sometimes horrific history of autism research and treatment from its earliest days, and spotlights many people on the spectrum who have used their unique talents and perspectives in important, but often invisible, ways (think computer programmers, NASA, etc.).  Indeed, he makes the argument that autism and ADHD are not errors of nature but rather natural variations in human development.  I’m only half-way through the book, so I’m just about done the section devoted to the history of autism and look forward to reading about the author’s view of the future of neurodiversity.

41JNxY4tU-L._SX326_BO1,204,203,200_For a compelling and honest account from a parent’s perspective, I recommend “The Child Who Never Grew” by Pearl S. Buck.  Pearl Buck’s daughter, Carol, was born with disabilities at a time when such children were hidden away in institutions to avoid shame on the family.  Ms. Buck was determined to provide the very best care for her daughter and others like her, championing the rights and acceptance of people with disabilities.  She candidly shares her struggles as a parent in this story that still offers timeless wisdom and encouragement, nearly 70 years after its publication.

These are just some of the books that I have found to be entertaining, enlightening, and thought-provoking.  What books would you recommend to your SLP colleagues?

 

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Summer Freebies!

travelGuidesI’m sure that, for the first few weeks of summer vacation at least, school will be the last thing on your mind. But did you ever consider that summer could provide a treasure-trove of free therapy materials that you can use throughout the school year?? Here are some ways to make therapy fun and functional, and relevant to the curriculum for all of your artic, language, fluency, and voice students:

 

  1. Tourist brochures – Hotels, rest stops, and tourist destinations always have racks upon racks of cards and brochures that promote all of the attractions in the area, and they are FREE. Help yourself! These provide interesting stimulus material for reading aloud, discussion, and writing activities.
    1. Our fourth grade studies Pennsylvania history, so brochures from historical sites in our state are very relevant to their classwork. And it’s always surprising (in a sad way) to learn how many students have never visited local historical sites. Maybe sparking their interest will lead to family day trips in the region.
    2. Brochures from outside the state offer the opportunity to talk about history, geography, distance, and observable differences in the photos compared to your immediate environment. What do you see? What do you think it’s like there? Does it remind you of any place you have already visited? How long would it take to get there? What would be the best way to travel there? What would you have to pack for that trip?
    3. Provide brochures from a variety of locations and have the students discuss the pros/cons of each from their point of view.
    4. Use brochures as a reference for writing activities, such as writing a letter or postcard to someone about an imaginary trip or writing an ad to promote a tourist destination. Video the students presenting their ad – lots of fun, great carryover for artic, and useful for self-monitoring via playback.
  2. Postcards – not free, but usually cheap. Use as above, and also as creative story starters about “my best” or “my worst” summer vacation. Sort by common features (location, type of attraction, etc.). Locate the places on a large wall map.
  3. Maps and regional travel books – free to members of AAA. Maps alone offer so many language opportunities! Older students will enjoy learning how to look up tourist destinations and then plot them on the map to create an interesting itinerary. Read the hotel and restaurant listings, comparing amenities and price. Create math word problems related to these materials for students who struggle with that language. And don’t forget the maps that are often provided in amusement parks, zoos, historic villages, etc. With just a little thought, I’m sure you can come up with all kinds of storytelling, describing, categorizing, auditory memory, and sequencing activities that the students would really enjoy.
  4. Menus – lots of restaurants have take-out menus so, again, help yourself! With your artic, language, social skills and life skills students, use menus for:
    1. artic practice with multisyllabic words
    2. discussion of likes/dislikes and healthy vs. not so healthy choices
    3. role play ordering and taking orders in a restaurant – good for social skills, auditory memory (can the waiter repeat and/or write down what the customers ordered?)
  5. Bus and train schedules – available at all stations and depots. These provide practice with functional life skills, in addition to artic and language. Can they locate the quickest route to their destination? How much will it cost? How long will it take?
  6. “This Week in (vacation location)” booklets — use for planning a daily or weekly itinerary, comparing/contrasting and expressing opinions about listed activities, writing and then verbally delivering “ads” to get folks interested in the various events. (My students love to do news, weather reports, and commercials on video — motivating speech and language practice that provides playback for self-monitoring).
  7. Photographs of your travels — use for labeling, describing, writing captions.

Students love using these unconventional materials in therapy. Beyond the activities I create to support their goals, these materials spur the students to share stories from their own travel experiences, giving me the opportunity to assess their conversational artic, vocabulary, grammar, and ability to tell a story in sequence and with sufficient detail.

So, while you are out and about this summer, be on the lookout for these materials and ask your friends and relatives to do the same. Then create a “travel agency” nook in your therapy room and enjoy using these materials throughout the year!

Your Moment of Zen: Becoming One with /r/

In my last post, I wrote about how various technology – from free and cheap apps to expensive high-tech equipment – can be used to help students improve their articulation of vocalic /r/. But that’s not all I use. There are lots of useful, hands-on ways to increase a student’s awareness of position and tension, some as old as our profession itself.

image_20813The first tools I always use – and ones we revisit time and time again – are the trusty flashlight and mirror. Looking inside the mouth becomes a lesson about the “speech helpers.” Kids love exploring the structures and tongue movements, laying a solid foundation for all future instruction. We talk about how the lips, tongue, and jaw move for each speech sound, then work on motor imitation skills, beginning with obvious movements, such as popping one’s lips for /p/, then to more difficult and subtle movements, like raising a wide tongue up to the back molars. We explore the contexts of /k/ and /ee/ as a way to get to /er/.   Tongue Elevators (raising the tongue from low, mid, high) and Train Tracks (elevating the tongue, then sliding back on the molars) are part of the drills I’ve developed in my /r/ packet, and exercises that we use as warm-ups at every session. All of this is done with the flashlight and mirror. Old school still works.

A-427_Totally_Zen_FrogOnce we’ve gotten good visual information about the articulators and their expected position/movement/tension for /r/, we do all of the above….but with our eyes closed. This allows the students to really focus on proprioceptive feedback as I lead them through a variety of speech sounds and tongue movements. “Where’s your tongue? What do you feel?” This “moment of Zen” is invaluable in increasing their focus on and awareness of what their tongue is actually doing. This is a technique we revisit often. It’s amazing to see how much information the students get and can convey when their eyes are closed.

Screen Shot 2018-06-03 at 3.34.54 PMSometimes we need to “wake up” the tongue. The Speech Gizmo (really, a dental flosser) can be used for this. We rub-rub-rub on margin of the tongue, then the other, then lift the tongue to the molars. This is a useful strategy to start each session. The Speech Gizmo can also be used to gently guide the tongue up and back for /er/, as described in a previous post. I send these home with students and ask that they use them 10 times, each time they brush their teeth.

SW-032717-SillyPutty-Map1To further increase awareness of tongue shape and position, we make tongues out of Silly Putty. I use them in mouth molds from the dentist. This opens up discussion and awareness of wide/skinny, high/low, front/back.  See my previous post about this.

Earth_globe_stress_ball1Tension is critical for /er/, so we do tense/relax exercises with hands, arms, shoulders, jaw, tongue. We explore all of the vowels, again with eyes closed – which are tense, which are relaxed? Where do you feel the tension? When working on /er/, I often give the students stress balls to squeeze. This is especially helpful for students who have low tone. Standing up also helps increase tension.

IMG_0188And, in an activity that is both instructive and fun, we take a whole body approach as each student “becomes a tongue.” One by one, they step into the mouth (the doorway to the speech room), spread their arms and press hard against the molars (the sides of the door jamb). We notice how far away the tip of the tongue (their head) is from the front teeth (top of the door jamb). Again, words like “wide, back, tense” are used. As the student presses against the door jamb, he tries to replicate this with his tongue, making his best /er/. With this experience fresh in their minds, we return to the mirror and flashlight to see if our real tongues can do what the “student tongues” just did

Of course, there are many other tried-and-true techniques that might be needed: pressing up with the thumb at the root of the tongue, lying backwards over a therapy ball to let gravity help, working in contexts they can do to get to once they can’t, etc. As mentioned in a previous post, Char Boshart’sChar Boshart’s seminars, video presentations, and publications are a wealth of information about how to get inside the mouth and tame the tongue for /r/. Be sure to visit her site for /r/ and other invaluable information. I learn something new every time I visit! What tricks work for you? Please leave a comment so we can all benefit from your experience!

Tackling /r/ with Technology

A /t/ is a /t/ and a /k/ is a /k/. But, oh, that vocalic /r/ – the most complicated phoneme in the English language! Volumes have been written about how to fix an /r/ distortion. My go-to bag of tricks includes Char Boshart’s “The Easy R Therapy Program” and “The Entire World of R” books and cards. I’ve learned so much from Char’s books and presentations about how to facilitate tongue movement and tension; her website is a treasure-trove of great information, including free materials, videos, books, and blog posts.  Char Boshart’s “The Easy R Therapy Program” comes in hardcopy and digital versions, and there is even a condensed version for quick reference.   From “The Entire World of R” I learned that there are more than 20 allophones of /r/, each depending on the vowel context and position in the word, and that students can have some of these /r/ sounds perfected, while others remain stubbornly distorted.   Indeed, as part of my own /r/ remediation packet, I developed “Hit the Mark with /r/,” a quick screener to help me determine the vowels and positions in which the student can produce a good vocalic /r/ and those in which production breaks down.   “Hit the Mark with /r/” presents three words for each of the vocalic /r/ sounds (initial, medial, final) and a rating scale that breaks down production into 3 categories: “vowel and /r/ are distorted,” “vowel is OK but the /r/ is distorted,” and “acceptable vowel and /r/.” I follow this up with more in-depth probes, using Artic-U-Checks, which uses a similar rating scale of “incorrect,” “close,” and “acceptable.” A pattern I see over and over in my students: most initial and medial vocalic /r/ sounds are acceptable, but /er/ in all contexts is distorted, and so are all final /r/ sounds.

So, once I have assessed the type, place, and severity of a student’s /r/ distortion, therapy begins. In my experience, there is no one-size-fits-all approach to /r/ that will work for every student. Therefore, I am constantly expanding my bag of tricks, searching for that one cue, one technique that will flip the switch for each student. Multimodality instruction is key.

Screen Shot 2018-06-03 at 12.43.09 PMBecause vowel context is so critical to producing acceptable /r/ sounds, my favorite app is Vowel Viz Pro by Complete Speech. This awesome app analyzes vowel production in real time. As the student produces words with vocalic /r/, the spaceship zooms to and hovers over high, middle, or low planets, representing the various vowels. The visual feedback is very reinforcing to the students and is definitely a motivator. The effort I’ve seen students expend in achieving the goal with this app is amazing – far more than I could ever get with flashcards or word lists. You can read more about Vowel Viz Pro in my blog post, “Apps for Vocalic /r/.” If you use an iPad in therapy, you definitely want this app.  Another app from Complete Speech that you might find useful is “Speech Racer.”

smartpalate_system-1Another very useful piece of technology, also by Complete Speech, is a palatometer, called the SmartPalate System. A custom-built mouthpiece shows students exactly where their tongue is touching the palate (or not). I wrote about my experience with the palatometer in my post, “Watch that Tongue: A Trial with a Palatometer.” This tool is not only very useful for /r/, but was also great for lateral and frontal distortions of /s, z, sh, ch, j/. The downsides for school use: (1) the software is expensive, and (2) each student has to have a mouth mold made by a dentist, then a custom-built palate with sensors – also expensive. The best approach is to see the students every day for short periods of time. Research done by Complete Speech indicates that 20 sessions is the average for fixing a speech sound error. Imagine cycling students through 4 weeks of intense therapy with the palatometer, and it could actually mean a cost-savings or break-even, compared to traditional weekly therapy that could go on for months or years. Still, it could be a tough sell to most school districts.  A new product by CompleteSpeech is the TargetPalate:  a custom-made plastic palate that has bumps where the tongue should be touching for sounds that the student is making in error.  I haven’t yet tried this with my students, but imagine the tactile feedback could be very helpful.  Please leave a comment if you have already had experience with the TargetPalate.

Students can get good information from seeing and hearing themselves on video, using a free program like PhotoBooth on my Mac. I just had a fourth grade boy who was convinced his /er/ was pretty good, until he heard the playback on PhotoBooth. The look on his face when he heard the distortion reflected an important “aha” moment for him. Another student with a wicked /r/ distortion heard the app, “Talking Tom,” repeating the /r/ words spoken by him and other, more advanced, students. I’ll never forget the puzzled look on his face when he asked, “Why is Tom saying their words correctly and my words wrong?” (Note: Talking Tom apps are available for iOS and Android, but I caution their use as they have gotten to be a bit raunchy for school use).

In my next post, I’ll share my no-tech tricks for working on /r/. By combining these “tried and true” old school techniques with new technology, students remain motivated and make measurable progress.

The “Therapy Voice”

In grad school way back when, SLP majors were partnered with a classmate and sent out to observe SLPs in a variety of workplace settings.  We observed in a nursing home, a rehab center, a public elementary school, a hospital, a residential facility for clients with multiple disabilities, and a state school for the deaf.  Of course, the goal was to gain insight into each of these settings, into the types of clients who were served, how treatment was delivered, and personal reflections of each of the practitioners.  Following each visit, we were to write up our impressions.  This exercise was one of the most valuable experiences of my education, as it helped me to determine my future goals — the type of setting in which I did or did not want to work and how I envisioned my future self delivering services.  Much of this experience has faded from memory, having taken place over 25 years ago, but one observation has never left me:  the “therapy voice.”

It was in a hospital that my partner and I first heard the “therapy voice.”  The SLP met us in her office and we had a lovely conversation about the profession and her experiences with inpatient and outpatient therapy.  Then we followed her to bedsides and into the clinic.  While her therapy activities seemed appropriate to our novice eyes, what really struck us was the way her voice changed whenever she addressed her clients.  Louder, slower, and higher pitched, her voice took on a whole different persona — one that signaled, to us at least, the message that “you are so impaired, you don’t know what I’m saying so I will shout it at you.”  My partner and I looked at each in disbelief, that her friendly, conversational voice could immediately become so seemingly condescending.  Now, mind you, I fully understand that she had years of communicating with people who presented with strokes, brain tumors, neurological disorders, hearing loss, and dementia, and I fully understand that one’s communication style has to accommodate those conditions.  But we observed this same “therapy voice” when she was treating outpatient children and adults in the clinic for articulation, language, and fluency.  It was amazing to us, the way she could switch back and forth when treating clients with the “therapy voice,” then turning to us with comments in a conversational manner.  This wasn’t the last time I heard the “therapy voice” but it certainly was the first, most dramatic, and most memorable.  My partner and I vowed, as we walked out of the hospital, to never, EVER, use the “therapy voice” in our practice.

The bulk of my 25-year career as a public school SLP has been spent with students who have moderate to profound disabilities.  Obviously, I have had to adjust my language level with these students — shorter sentences, simplified vocabulary — but I have held to my promise and ALWAYS speak in a conversational tone of voice, one that presumes that “I know you understand what I am saying,” even when there is little or no outward sign of this.  In other words, presume competence!

Two books I read recently bear out my intuitive use of conversational tone:  “My Stroke of Insight” by Jill Bolte Taylor, and “Ghost Boy” by Martin Pistorius (reviewed on this blog HERE).  Both authors were suddenly stricken with profound injury to the brain, one by stroke, one by an unidentified virus, and were essentially trapped inside bodies that would not, could not respond or be controlled.  Both eventually recovered to a remarkable degree, thanks in no small part to their own strong will and the support of therapists, caregivers, and family.  Both relate horror stories of how they were sometimes spoken to by people (family and medical staff) who didn’t think they could hear or understand.  Jill Bolte Taylor includes a list of “do’s and don’ts” in her book, including the importance of communicating presumed competence and respect through words, but also through tone of voice and body language.  I highly recommend these two books to all SLPs in any treatment setting, as they provide a rare, detailed, and highly personal account from people who experienced traumatic loss of communication.

Beyond reading these books, I really haven’t given much thought to the “therapy voice” in years, but this spring, I saw how damaging it can be.  On May 10, my dear father suffered the first of several strokes.  He was flown by helicopter to a nationally ranked medical center and was given the “clot-buster” drug within the “golden hour.”  The stroke was on the left side of his brain, which initially caused right side paralysis and the inability to speak.  Twenty-four hours, he had regained movement on his right side and could speak, although aphasia was obvious in the “word salad” and word-finding problems he exhibited.  Within a few days, the aphasia lessened, and he was able to speak in longer, more accurate sentences.  We were so encouraged by this and assured him that progress would continue.  Unfortunately, less than a week after the first stroke, he had a second that required emergency surgery to clear a blocked carotid artery and to remove some of the new clots in his brain.  Clots from the first stroke were left in place, due to the risk of bleeding.  Dad again regained movement on his right side, albeit with weakness, and again could talk, but the second stroke wiped out the progress he had made and he was back to being more significantly aphasic.  One only had to look in his eyes to know that he was fully aware of what had happened and was very afraid.

Once medically stable, Dad was released to the local hospital in a small town near his home for two weeks of rehab — OT, PT, Speech.  Dad was evaluated by the SLP and therapy began immediately.  Due to work obligations and distance (85 miles from my home), I could not be with my dad during these first few days, but I did get out there on day 4 so I could meet with the SLP and observe therapy.  This observation was welcomed by the SLP and the rehab director, and I had a good conversation with the SLP about Dad’s status and goals.  Then, when we walked into his room, I heard it — the “therapy voice.”  “HELLO, RICHARD!  DO YOU REMEMBER ME? I AM HERE TO HELP YOUR SPEECH.”  This was said just inches from his face.  Dad immediately recoiled and looked stricken — facial expression, eyes, and body language all expressed this.  After a few minutes of this, I gently told the SLP that Dad’s hearing was fine and that his intellect had not been affected, only his ability to produce spoken language, and said that she could speak to him conversationally.  I also said he was having trouble with yes/no questions, but I was sure that he understood.  Dad shot me a grateful glance, but it didn’t change her approach.  She opened up a book of aphasia therapy exercises and asked him “WHAT GOES WITH —” questions.  When he couldn’t answer, she said, “YOU CAN’T DO THIS SO WE’LL DO SOMETHING ELSE.” She moved on a series of yes/no questions.  When he answered “yes” to “ARE YOU A WOMAN?,” she answered, “NO, YOU ARE NOT.  YOU ARE A MAN” and closed the book.  Dad looked even more stricken.  The next activity was naming photographs. He failed on the first three, so that activity ended, again with “YOU CAN’T DO THIS NOW SO WE WILL TRY AGAIN ANOTHER DAY.”  By this point, it was all I could do to keep from taking the cards from her and modeling, “Look at this picture, Dad.  What is this?  I’ll help you, it’s a ball.  What do you do with a ball?  Can you show me?   Yes, you can throw a ball like this; now you do it. You throw a ball.  You can kick a ball, too, like this. Now you show me, kick a ball.  Look at the picture again — see it is a ball, a red ball.  Can you say that with me?  Ball.”  But I didn’t.  After a few more failed activities, Dad watching all the time as data was collected, the session ended with Dad looking devastated and Mom in tears.  I left the room with the SLP and repeated, very calmly, that Dad’s hearing was fine and suggested that he’d respond better to a conversational tone of voice and instruction, rather than just data collecting (the eval had already been done, remember) to show what he couldn’t do, and perhaps she could be more instructive when he couldn’t name pictures. Dad was a very intelligent and proud man, and failure at questions a toddler could answer cut him to the core.  When speaking with the SLP,  I was very aware that I am NOT a hospital/rehab SLP and did not want to say or do anything that would make Dad’s next two weeks more difficult.  But I know how I would teach my students with disabilities — key word is “teach,” not just collect data.  It’s very easy when people have impairment to only focus on what they can’t do.  My approach is always to focus on abilities, no matter how limited, and build from there.

Well, according to my mom, nothing changed in those two weeks.  Dad responded very well to the OT and PT, gaining skills and trying again with positive effort when he didn’t perform to his highest level, but became increasingly despondent as speech therapy time approached.  After two weeks, he was sent home with in-home therapy.  Because I was up to my eyeballs in the crazy end of the school year, I was not able to get out to their home during the week when the new SLP was there, but after a few frustrating sessions, Mom told her I was an SLP and she immediately asked for my phone number.  We had a very good discussion in which she revealed that Dad would become emotional and even hostile when she was taking data on the same kind of tasks that he had been exposed to in the hospital.  Mom had already told me this, saying that the OT and PT did not take data in front of him and worked on skills that were functional in his home and related to his personal interests and goals, whereas speech therapy was limited to drilling him with questions.  I suggested that she put away the aphasia therapy book and cards for a while, and instead engage him in conversation about his family, his career, his hobbies, his dog, etc.  I told her that Mom had many photo albums of family members, present and past, and brochures from many places that they had traveled;  these would be great conversation starters for him.  Dad was an accomplished woodworker, so I suggested that she take him to his workshop and talk about the tools and the things he had built.  Dad lost the ability to read due to the strokes, but he was still able to put together jigsaw puzzles, an activity that he and Mom did every winter to pass the time;  that would be another way to work on language skills in a relaxed context. And I stressed that, although Dad was 85 years old, he was 100% independent in all areas of life prior to the strokes — drove a car, cut his own grass, handled affairs without any difficulty.  When I visited Dad weekly throughout this time, we had many great conversations about people and events in the past, conversations that he initiated and participated in fully, even if a word or two was wrong here and there.  He talked about his concerns for my mom and the future.  He could tell time and knew when his favorite shows were on.  I’ve never seen so many episodes of “American Pickers” as I did this past spring and summer, and Dad was always able to make insightful and relevant comments about this and other shows we watched together each evening.  I did not evaluate my dad and did not want to be his therapist, but it was very evident to me that his intellect was not affected. When we went out for a drive in their rural area, Dad was able to give me directions all over the countryside to point out places of interest, to get to a farm stand he particularly liked, and always found our way home — an errorless and most enjoyable change of scenery for him that gave him a sense of control.  All of this, I shared with the SLP, giving lots of therapy suggestions that Dad would respond favorably to.  I said I totally understood about the need for data (the bane of my school-based therapy existence), but suggested it could be done more discreetly.  The conversation ended very well, with the SLP expressing her gratitude for my suggestions, as it was clear that she wanted to do her best with Dad and that she was as frustrated as he was.

Well, I’d like to say it ended well, but it didn’t.  The picture cards came out again;  Dad blew up and refused any more therapy from anyone — no OT, PT, or speech.  We hoped after this meltdown that he would relent, and we encouraged him as much as we could to try again, but it was clear to him, and to Mom and I, that he was actually going to make more progress on his own, engaging in daily functional activities, having conversations about things that interested him, commenting during his TV shows, giving us directions when driving or about how to change the water filter, than he would be getting from an aphasia therapy book. And so, I started giving my mom strategies to help Dad that didn’t feel like therapy.  That Dad was so soured on speech therapy, right from the beginning, just killed me, as you can imagine, and I have to think that a more conversational approach that presumed competence would have yielded a more positive outcome.  I completely understood and explained to both of my parents that Dad’s anger and frustration was a very common bi-product of stroke and that it would ease with time and healing.  However, Dad was too demoralized by his experience with speech therapy, and then extended that to all therapies and medical interventions.  He didn’t feel any of it was helping him, and he was done with it all.  Once he made this decision, his anxiety level dropped noticeably and he had a good month of small steps forward.  I could see a positive change in his abilities and attitude every week and we were all greatly encouraged.  Unfortunately, Dad suffered additional TIAs and complications from which he could not recover.  On August 14, this proud, wonderful, admirable, and loving husband and father passed away.

Please understand that I write this not as an indictment of the SLPs who treated Dad.  SLPs are the most caring, compassionate people I know.  These SLPs were no exception. Both seemed to be genuinely nice and caring people, and I’m sure they have helped many patients in their careers. I especially appreciated the home-based SLP who reached out for ideas when she saw Dad shutting down.  As stated earlier, I’m not a rehab therapist, so my practice is not shaped by years of dealing with adults with strokes, dementia, etc.  Maybe rehab SLPs are more strictly bound to certain therapy materials and lessons;  as a school-based SLP, I have free reign to do whatever I think will be helpful to my students, be it traditional therapy or materials/strategies that are highly personalized and even unconventional.  That didn’t seem to be the case with the SLPs who treated Dad. I acknowledge that data must be collected to satisfy insurance requirements; it drives the IEP in schools, and I work hard to keep a balance between measuring progress and actually teaching.  I certainly acknowledge that Dad’s strong personality and damage caused by the strokes also contributed to his very negative reactions.  All that said, I guess I felt the need to write this for a few reasons.  I am still very much hurting over the loss of my dad.  I’m very saddened to know that he wasn’t helped by speech therapy and, in fact, was turned off to all therapies and medical treatment as a result.

This is the first time I’ve been a close observer of therapy with a loved one — very different from being the SLP treating other people’s loved ones.  It was an eye-opening experience;  I viewed the therapy professionally and my dad’s reactions to it personally, and found that very hard to reconcile.  While a person’s prosody may seem inconsequential, Jill Bolte Taylor and Martin Pistorius would disagree, and so would Dad and I. Even if he hadn’t been able to understand the words that were spoken to him, he immediately sensed that the “therapy voice” was an affront to his status as a successful, intelligent, dignified man, and that was his introduction to speech therapy.  I witnessed how Dad perceived each session as a series of tests on which he was found deficient, and saw how badly this wounded his pride and confidence. And I have to agree with him — the activities were rote and without instruction, strategies, or prompts to help him succeed.  No amount of encouragement from me could convince him that he would improve if he would just cooperate and try. This was heartbreaking for my parents and for me;  more than anything, I wanted to do whatever it took to help my dad recover his independence and dignity, and obviously, my mom desperately wanted that, too.   Mom and I saw how Dad watched data being collected after every question, visibly wincing and withdrawing more and more with each tally mark, and that has made me much more aware of the way I keep data with my students. I feel guilty that I didn’t speak up more strongly with the rehab SLP when I saw how offended and saddened my dad was by her approach and tone of voice.  I am not good at confrontation, I never pass judgment on a colleague, and I was in a very fragile place myself.  As a result, I feel that I was overly cautious in expressing my concerns. I also knew that the SLP was not trying to do any harm;  she was just unaware of the effect her manner was having on Dad.  If I had been more clear about my observations, would therapy activities and the relationship have improved?  Would Dad have been more accepting and willing to go along with therapy?  That’s all water under the bridge now for Dad, but maybe by voicing my concerns now in this post, an SLP somewhere might rethink his/her approach and somebody else’s loved one will benefit.  Indeed, shouldn’t we always engage in self-reflection about our practice and do our best to adapt our manner and therapy to each individual? That’s the first lesson in speech 101:  “Establish rapport.”  Right?  If nothing else, maybe the reason I felt compelled to write this post is to finally release some of the feelings that have been bottled up all summer.  It’s been a tough one.