The Invitation

Tonight, this inspired me. 

It doesn't interest me what you do for a living. I want to know what you ache for and if you dare to dream of meeting your heart's longing.

It doesn't interest me how old you are. I want to know if you will risk looking like a fool for love, for your dream, for the adventure of being alive.

It doesn't interest me what planets are squaring your moon. I want to know if you have touched the centre of your own sorrow, if you have been opened by life's betrayals or have become shrivelled and closed from fear of further pain.

I want to know if you can sit with pain, mine or your own, without moving to hide it, or fade it, or fix it.

I want to know if you can be with joy, mine or your own; if you can dance with wildness and let the ecstasy fill you to the tips of your fingers and toes without cautioning us to be careful, be realistic, remember the limitations of being human.

It doesn't interest me if the story you are telling me is true. I want to know if you can disappoint another to be true to yourself. If you can bear the accusation of betrayal and not betray your own soul. If you can be faithless and therefore trustworthy.

I want to know if you can see beauty even when it is not pretty every day. And if you can source your own life from its presence.

I want to know if you can live with failure, yours and mine, and still stand at the edge of the lake and shout to the silver of the full moon, 'Yes.'

It doesn't interest me to know where you live or how much money you have. I want to know if you can get up after the night of grief and despair, weary and bruised to the bone and do what needs to be done to feed the children.

It doesn't interest me who you know or how you came to be here. I want to know if you will stand in the centre of the fire with me and not shrink back.

It doesn't interest me where or what or with whom you have studied. I want to know what sustains you from the inside when all else falls away.

I want to know if you can be alone with yourself and if you truly like the company you keep in the empty moments.

I truly feel that as I get older, I care more about the rundown - age, job title, education, rather than experiences, passions, street skills, life skills, wisdom, and heart. This is a good reminder that challenges me to think otherwise.  

[Source]

End of Life

Death and dying. Why is it so taboo? After a thought-provoking guest lecture by on palliative care, here were my takeaways:

• Palliative care is about maximizing quality of life for whatever amount of life the patient has.
• Palliative care is not only limited to geriatrics, nor is it only limited to hospice care.
• All hospice is palliative care, but not all palliative care is hospice. Try to wrap your mind around that.
• The concept of "death cafe" and "dinner and death," where people meet up over coffee or dinner to chat about death. People actually do this, and I kind of want to too now!
• There are fascinating games to get the conversation going about death. A few we were exposed to include: My Gift of Grace, Go Wish, and Natural Dying Living Will Cards (specifically for dementia)
• Ask your patients the following questions: What do you understand about your health condition? What do you anticipate treatment to look like? This not only allows for clear communication, but you more often than not, you find that the patient and family are extremely uninformed. It is our job to educate!
• Arrange an advanced directive to make it easier for loved ones. It is not technically a legally binding document, and you do not need the presence of an attorney - only two witnesses over age 18.
• Above all, hope for the best but plan for the worst. Isn't that what life is all about?

I Am Intelligent

In listening to Peyton, we are compelled to ask ourselves how many souls have been daily cast away from meaningful life because we do not know how to reach them, recognize their potential, afford them opportunities to have their voices heard? As clinicians, educators, and parents, we have to question whether our own perceptions about those who rely on us for assistance are accurate, and whether, as a society, we are doing the best we can for those who are unable to speak for themselves (Goddard & Goddard, 2012, p. xiii).

Throughout Peyton Goddard’s life story, one thing was clear: Peyton is aware and intelligent, despite being a non-verbal communicator who is severely autistic. One thing that was not as clear is that Peyton’s experiences are not singular, just as abuse, depression, exclusion, and misdiagnosis are more common among individuals with autism than not. The above excerpt implores clinicians, educators, and parents to reconsider their beliefs and practices. Based on Peyton’s experiences, four actions SLPs can take to ensure other individuals with autism do not experience the same injustice include: 1) counseling, 2) presuming competence, 3) ensuring equal access, and 4) providing appropriate strategies for communication.

Firstly, there is an unsaid responsibility for SLPs to reach out to students who may have experienced inexplicable prejudice or trauma, whether as a byproduct of their disorder or as a result of others taking advantage of their disability. Autism is often associated with a plethora of psychiatric disorders, such as anxiety disorders, bipolar disorders, depression, obsessive-compulsive disorders, phobias, and sleep disorders (Kluth & Shouse, 2009). According to the American Speech-Language Hearing Association, one of the roles of SLPs is to actively partner with families in assessment and intervention in individuals with autism spectrum disorders (ASHA, 2006). The scope of practice for SLPs extends beyond speech and language, to counseling, education, training, service coordination, and family advocacy (ASHA, 2006). If warranted services are beyond the scope of practice for SLPs, collaborating with a multidisciplinary team of professionals, including psychologists, counselors, and autism consultants, is even more essential.

Secondly, SLPs must engage in an active and conscious pursuit to presume competence and recognize the potential of individuals with autism, which may be easily overlooked in the face of other competing behaviors. Despite setbacks, it is important to focus on small gains, perceive strengths, and provide waiting time. Like Peyton, individuals who are severely autistic may not be able to provide visual indicators demonstrating competence; however, Peyton writes, “Ultimately, teachers and parents, in heart of cool love, must dare assume each person is competent and has intellectual potentials that can and must be reached” (Goddard & Goddard, 2012, p. 141). The label of autism should not lead professionals or even the general public to view behaviors through a lens of deficit and dismiss the potentials and abilities of individuals with autism. Though Peyton was fully competent of her surroundings, she exhibited behavioral impulses as a result of her autism, and sometimes out of frustration of being a nonverbal communicator. As SLPs, one way to presume competence is to talk to individuals with autism rather than about them in their presence. More often than not, individuals with autism are perceptually aware and cognitive intact. For example, Dr. Friedman, whom Peyton refers to as Dr. Freed Me, spoke directly to her and validated her behaviors. To Peyton, Dr. Friedman’s actions spoke volumes about his presumption of her competence, as he saw her as worthy of his clinical efforts.

Thirdly, SLPs are to ensure equal access to learning curriculum, which is a basic human right. As Peyton writes, “All students must be supported and accommodated to facilitate their success—in learning and in life; without the right involvement in the choices of one’s life, one lives in fear and frustration and will never know the joy of independence (Goddard & Goddard, 2012, p. 144). One of the roles for SLPs in assessment and intervention in autism spectrum disorders is to provide “access to literacy and academic instruction and curricular, extracurricular, and vocational activities (ASHA, 2006).” For Peyton, access to education included special accommodations, such as: communicating with professors beforehand, establishing an emotional connection with test proctors, reserving classrooms free of distractions, providing extra time for exams, enlarging presentation of test material, and allowing certain movement strategies to cope in the classroom. By providing individual accommodations, Peyton was able to access the curriculum and graduate from community college. In addition to accessing the academic curriculum, access to the informal, hidden curriculum involves explicit instruction and extracurricular inclusion and is as important as formal education (Hinkle, 2012).

Lastly, SLPs are to provide appropriate strategies for communication, which is another basic human right. All too often, speech therapy for individuals with autism revolves entirely around behavior management. However, behavior management is a reactive approach and may not be as proactive and preventative as simply reaching out, recognizing potential, and providing different strategies. Providing different communicative strategies may mitigate problematic behavior and allow for more effective therapy and more independent clients. One strategy is facilitated communication, which involves “facilitating movement with physical, verbal, and emotional assistance” for individuals with autism who struggle with challenges in controlling, initiating, inhibiting, and transitioning between motor movements (Goddard & Goddard, 2012, p. 171). Although there is not enough scientifically controlled evidence to support facilitated communication, it is impossible to ignore the fact that it has been an effective tool for Peyton to successfully communicate and achieve what was previously unfathomable. Said Peyton, “The journey of life cannot be traveled without a clear mode of successful communication and listeners who caringly support. Of utmost importance is the insurance that a system of communication supplies me… With [facilitated communication], I finally gained a mode of dependable communication, which allowed me to tell the truth of my life and begin to relieve the fear which plagued me. (Goddard & Goddard, p. 174-175).” Despite Peyton’s success with facilitated communication, more research is needed to demonstrate its scientific validity and reliability among individuals with autism who are nonverbal (ASHA, 1995). For SLPs, it is important to consider what is effective for the particular individual in conjunction with evidence-based practice.

Peyton’s experiences relay the importance of counseling, presuming competence, ensuring equal access, and providing appropriate strategies for communication to individuals with autism. In particular, I Am Intelligent provides a personal, mother-daughter account on achieving educational inclusion via higher education and facilitated communication for individuals with autism (Goddard & Goddard, 2012). One of the most important lessons for professionals is that assessment and intervention in individuals with autism spectrum disorders is not as black-and-white as may be presumed from textbooks. In spite of this, the lessons behind this book are far-reaching and not limited to professionals working with individuals with autism. Rather, others that may benefit from this book include individuals who are unfamiliar with autism, families with individuals who have autism, policymakers and practitioners, and other individuals with autism. Individuals unfamiliar with autism may benefit from reading this book to gain awareness and acceptance about the unimaginable characteristics and challenging struggles that individuals like Peyton who have severe autism face. Family with individuals who have autism may identify with and find solace in the experiences of Peyton and her mother Dianne, and how far they have come in their mother-daughter relationship. Policymakers and practitioners may benefit from being educated about sensitive, oft overlooked issues in individuals with autism, and act as the driving force to make education for individuals with special needs more inclusive. Individuals with autism may identify with Peyton’s diagnosis and experiences, and feel inspired by her ability to overcome myriad setbacks and attain personal and professional success. Despite who reads the book, one conclusive takeaway from Peyton’s account is to never lose sight of the intelligence behind the individual with autism. In the words of Peyton Goddard, a severely autistic, nonverbal communicator, and college graduate: “I AM INTLGENT (Goddard et al., 2012, p. 173).”

-----

References:

• American Speech-Language-Hearing Association. (1994). Facilitated communication [Technical Report]. Retrieved June 29, 2014, from www.asha.org/policy 
• American Speech-Language-Hearing Association. (2006). Roles and Responsibilities of Speech-Language Pathologists in Diagnosis, Assessment, and Treatment of Autism Spectrum Disorders Across the Life Span [Position Statement]. Retrieved June 29, 2014from www.asha.org/policy
• Goddard, P., & Goddard, D. (2012). I Am Intelligent: From Heartbreak to Healing--A Mother and Daughter's Journey through Autism. Guilford, CT: skirt!
• Hinkle, S. (2012). The hidden curriculum: social understanding, social skills, and belonging in k-12 settings, post-secondary, and beyond [PowerPoint slides]. Retrieved June 29, 2014, from California State University San Marcos Seminar in Autism Spectrum Disorders: http://cc.csusm.edu
• Kluth, P., & Shouse, J. (2009). The autism checklist: a practical reference for parents and teachers. San Francisco, CA: Jossey-Bass.

Language and Literacy

Over the summer, I had the opportune pleasure of being placed at an intensive language and literacy camp for kinder and first graders in Vista, CA. Sixteen kids, eight student clinicians, two supervisors, and five short weeks to do it all. In dividing each week by thematic unit, we were able to tackle various behavioral, social, and language objectives while keeping it fun and engaging.

Here is a glimpse of what we did and what worked:

Week 1: Assessment 

The first week consisted of meeting the kids and conducting a speech and language screening. We informally screened speech and language ability by having the students do tasks involving word association, color naming, sentence repetition, sentence segmentation, articulation, naming categories, rhyming, story paraphrasing, expressive vocabulary, and analogies. For example, kids who gave functions of items rather than name the category the items belong in, demonstrated more rudimentary cognitive skills. Therefore, appropriate goals might focus on providing an item and having the kid name the category the item belongs in (e.g., a shark is an ocean animal, a grasshopper is an insect, milk is a beverage). 

However, the most telling baseline measures came from language sample analyses collected from story retell of wordless picture books. The wordless picture books we used included the frog book series by Mercer Mayer (in particular, we used Frog Goes to Dinner and Frog, Where Are You?). These books were excellent for baselining story sequencing, past tense -ed verbs, and irregular past tense verbs, especially since most of the kids were English language learners. The SALT Software proved to be a useful tool in comparing our language samples against norm-referenced peer samples reading the same frog book series.  

After working with the adult population for a year, there was quite a bit of mental shift that had to be done. But the most important lesson I learned is this: building rapport with the client, regardless of their age, is so important. The way I develop rapport with my clients is by reading their non-verbals, going with my intuition, and mirroring them naturally. Developing that relationship and trust really sets the tone for diagnostics and treatment. It's so important for clients to know that you genuinely care for them, want the best for them, and are working for and with them.

Week 2: Ocean Theme

My favorite book from our print awareness activity was the classic children's story, Rainbow Fish. It is such a simple book but with so much potential - social stories on sharing, past tense -ed, irregular past tense verbs - you name it! My favorite arts and crafts was a two-day activity, which consisted of comparing and contrasting Rainbow Fish before he shared his scales and after he shared his scales. The first day, the kids each decorated their own fish on paper plates with scales made out of colorful construction paper and shiny aluminum foil. Then, they described attributes of Rainbow Fish before he shared his scales (e.g., beautiful, sparkling/shimmering/shiny, proud, silent, lonely). The second day, the kids each decorated another fish on paper plates with scales made out of just colorful construction paper. Each kid was given only one scale made out of shiny aluminum foil. The kids then had to share their shiny scale with another kid to carry out the moral of the story. Finally, they described attributes of Rainbow Fish after he shared his scales (e.g., sharing, happy, friendly, playful, one shiny scale).

An awesome experiential learning activity that worked really well was going on a "field trip" to the beach. We set up a blue tarp in the middle of the classroom, with toy ocean animals of various sizes and species. Around the tarp, we set up beach chairs, beach towels, beach bags, floppy hats, buckets and shovels, and the like. First, we asked whether any of the students had gone on a field trip, and what is needed before going on a field trip (e.g., parent permission slip). Next, we talked about cautionary signs one might see around the beach (e.g., high tide, sharks, strong current, tsunami). Then, the kids were able to explore the makeshift beach and talk about what they found, which worked on irregular past tense verbs. Finally, one of the student clinicians pretended to be the mailman and mailed a post card for each student (This was tied to a small-group activity during the week, in which each student randomly chose another student's name out of bowl. The students learned about the components of a postcard, wrote a postcard greeting, and decorated a destination postcard). This incredibly meta activity was actually a hit, and it reinforced several objectives, including learning each others' names, sharing with peers, and snail mailing a letter.

The Guest House

Wow, I cannot believe that it is my last semester of grad school. Oh, how fast the time has flown by! I am going to sound like a total nerd, but I am so excited to finally be taking Counseling this semester. I came across this poem in my textbook and felt that it was was an appropriate perspective-changer not only for our clients and their families dealing with the ramifications of communication disorders, but also for us as practicing clinicians and everyday humans. For me, the takeaway from this poem is to appreciate and entertain every situational feeling - to not necessarily dwell on it, but to at least be grateful for it and what it is bringing.

This being human is a guest house.
Every morning is a new arrival.
A joy, a depression, a meanness,
Some momentary awareness comes
As an unexpected visitor.
Welcome and entertain them all.
Even if they're a crowd of sorrows,
Who violently sweep your house
empty of its furniture.
Still, treat each guest honorably.
He may be cleaning you out
For some new delight.
The dark moment, the shame, the malice,
Meet them at the door laughing,
And invite them in.
Be grateful for whoever comes,
Because each has been sent
As a guide from beyond.
-Jalal al-Din Rumi, from The Essential Rumi

A Common Language

"I have always felt that the action most worth watching is not at the center of things but where edges meet. I like shorelines, weather fronts, international borders. There are interesting frictions and incongruities in these places, and often, if you stand at the point of tangency, you can see both sides better than if you were in the middle of either one."

-Anne Fadiman, The Spirit Catches You And You Fall Down

Language is a pivotal cornerstone in the job description and identity of speech-language pathologists. But as medical professionals working and interacting with patients from other cultures, what is the common language with which we speak? At its crux, The Spirit Catches You And You Fall Down by Anne Fadiman prompted me to think about biases and perspective, empathy and patient care, cultural barriers and cross-cultural differences. What resonated me was the quote, "We do not see the world as it is. We see the world as we are." Ingrained within all of us are our own cultural biases that form our frames of reference, thereby affecting how we perceive and interact with the world around us. In the case of Lia Lee, cultures clashed with horrifying repercussions. At the time, the Western doctors in Merced, California, thought they knew best about providing optimal care to Lia, as they had knowledge and education on their side. They viewed Lia's parents as unfit for parenthood, and the Hmong culture and its twix neeb as unsound doctrine. On the other hand, Lia's immigrant parents interpreted major medical and social events surrounding Lia's illness and hospitalizations in the context of Hmong religion. This was all they knew, and most importantly, what they believed in. This also was the source of tension and contention, as each side misinterpreted the other's intentions. There was no common ground and no common language. How then, does one avoid prejudice and discrimination if each culture unknowingly cultivates its own biases? How does one cultivate empathy towards a person or group of persons whose background and culture is so unfamiliar and foreign? As Fadiman stated, "What you choose to call it, the ability to deal with patients from unfamiliar cultures shouldn't be a political stance but a human stance, as well as a strategy that save lives." I think speaking the common language means adopting a professionally loving and empathetic human stance towards the patients who are under our care. A common language means standing "where the edges meet" - at the "point of tangency" where both sides can be better seen and fully understood.

First Year Musings

So it's official: I just finished my first year of grad school. Granted, it ended three days earlier than anticipated in the form of hectic and horrifying wildfires, but what's done is done. And what more? I survived. Here are a few lessons I learned along the way:

Lesson 1: Collaborate. The thing about grad school that is so fundamentally different from any other educational experience is the level of support from professors and peer colleagues. In undergrad, I felt lost in a crowd of overachievers and top performers in a research-based institution. In post-bacc, there was an "every man for himself" mentality because of the intense competition for graduate admissions. Perhaps my experience is specific to speech pathology, and if it is I am even more certain that this is the field for me. I do believe that collaboration is not only important but also resourceful as a speech pathologist, and I am eternally grateful for peers who blast email oral mech evals specific to dysphagia assessments or share study guides for final exams. Furthermore, I think it is so important to remember that peers will be future colleagues, so work on building and maintaining strong working relationships!

Lesson 2: Commit to memory. Remember in undergrad when course content could be purposefully (and easily) forgotten after each quarter? Well, this concept simply does not apply to grad school. In fact, it is the polar opposite because all course content should be committed to memory. Every course, regardless of how unrelated you think it is, relates to each other and builds upon each other. Neuro is the basis for aphasia, dysphagia, motor speech, and so much more, and this means that something as fundamentally painful as the cranial nerves simply cannot be deleted from memory. My first year of grad school demonstrated to me that mastery of course material in a holistic context is of paramount importance, as course content ties together in unexpected ways. This is a lesson I am still learning and applying.

Lesson 3: Clinical application. The clinical application piece, to me, is the most intriguing, enjoyable, and rewarding part of grad school. I am so thankful that I feel this way because it means that I have found my purpose, which is my passion, my mission, my vocation, and my profession combined. Oh, that elusive purpose! Admittedly, it is also undeniably difficult, because in practice, diagnoses and assessment results are not as clear-cut as is oft presented in textbooks. Patients may quickly become lethargic or move to another room during mealtime, and it is important for clinicians to obtain the most accurate assessment results while considering patient wants and needs. The most important takeaway is learning to use my best clinical judgment while remaining flexible.

Ironically, the three most pivotal lessons I learned this year all start with C. One more year until I receive my actual CCC's! Five more days until summer sessions commence again, so wish me luck because much is needed. What are some lessons you learned along the way in grad school?