Archive for March, 2010

I visit nurseries to train staff as part of my job; we aim to support the language development of all the children by improving the communication environment. I observe the staff and complete a check-list about the communication environment; it covers areas like adult-child interaction, the listening environment, snack time, and story time. I discuss my observations with the nursery manager and we decide what to focus on.

I’ve recently trained several practitioners in adult-child interaction, with varying degrees of success!

Training package

The training package I offer is still evolving. I usually:

• give the practitioners some written information about adult-child interaction from Elkan Early Language Builders;
• discuss the dual strategies of following a child’s lead and commenting rather than questioning;
• model these strategies; and
• make a brief video of the practitioner interacting with a child, and give feedback.

Effectiveness

I have used this package with five practitioners over the last month. Three of them responded really well: they asked thoughtful questions, reflected on their skills as they watched the video, and were able to adapt their interaction styles to become better communication partners. Result!

What about the other two? Well, one was able to identify that she asked a lot of questions; with support she began to think about how she could use comments instead. However, at the end of the session she still seemed unaware that she was being directive. The other practitioner felt she was already using both strategies, but didn’t notice herself asking questions when we watched the video. Hmm.

Reflecting on the sessions that didn’t go so well, could I achieve more by fine-tuning how I use the video? There’s lots of useful information on this topic in the Hanen “It Takes Two To Talk” programme. After reviewing it, I’ve found three ideas to try:

• considering the adult’s stage of learning,
• using coaching methods, and
• asking rather than telling.

Stages of learning

The Hanen programme describes three stages of learning: pre-aware, aware, and active. A pre-aware learner might be able to explain the strategies, but doesn’t realise that she’s not applying them. An aware learner knows the strategies and knows that she’s not yet applying them. An active learner has applied her knowledge and changed her behaviour.

So the practitioner who thought she was using the strategies but didn’t notice that she asked questions was at the pre-aware stage of learning. I should try to move her on to the next stage: to increase her awareness of her own behaviour. The Hanen information suggests making tentative statements about what you see and then “letting the tape do the talking.” I’ll try it.

Coaching

Hanen suggests coaching as another way to support an adult’s learning process, by improving the specific interaction. You can do this while the camera is running, during a brief break in filming, or by demonstrating the strategy.

So for the practitioner who was unaware of how directive she was, I could try some coaching: while the camera is running I could say something like, “don’t suggest what to play with: wait for him to show you what he wants to do.” Something else for me to try out.

Feedback: ask, don’t tell

Reflecting on the feedback I gave, I think it started well, but could be improved. I asked what the practitioner thought about the interaction, and then offered a specific focus; for example, “let’s look at when you made comments.” So far so good. But then I told them my own observations, rather than asking for theirs! By asking rather than telling, I could provide a more active learning experience, to increase the chances of learning new skills. Looks like I’ve got lots to practise!

Any ideas?

Do you use video as a teaching tool? What techniques have you found work well with pre-aware learners?

Clare Grace raised a great question in response to my post from 2009, Clinical Risk vs. Clinical Need: managing workload and throughput:

My biggest conundrum at the minute, is that the risk assessment tools are very medical model – and don’t seem to reflect anything within the tools/structures of education – and 80% of our caseload is working into an educational setting – any thoughts or ideas would be greatly appreciated.

Although I’m no longer working in the same service, I can remember discussions about how the approach fitted with our work in education.

I’m looking at Malcomess’ “risk” and “clinical risk” grids. The risk assessment requires judgements about functional impact on Activities for Daily Living (ADL) and environmental adaptation. We can consider ADL in the classroom. In terms of environmental adaptation I’ve found a note I wrote on one of the handouts saying: “score environment which is least adaptive (and central.)” So a child in an educational environment which is significantly contributing to risk would score highly on the context column.

In terms of clinical risk we discussed thinking about school staff as well as carers in the first column: motivation for change / carer responsibility. We need to consider who in the child’s life is primary, in relation to impact. A teacher who is unable or unwilling to collaborate in the treatment process would cause a child to score lower in this column (if the SLT service was entirely school based.)

What do you think about using the tools in education settings?

I’m interested in how Speech and Language Therapists (SLTs) use counselling in clinical work. I’m also drafting targets for my Personal Development Plan (PDP) and want to include one about counselling; perhaps writing this will clarify my thinking!

What is counselling?

The British Association for Counselling and Psychotherapy uses this definition:

Counselling takes place when a counsellor sees a client in a private and confidential setting to explore a difficulty the client is having, distress they may be experiencing or perhaps their dissatisfaction with life, or loss of a sense of direction and purpose. It is always at the request of the client as no one can properly be ’sent’ for counselling.

By listening attentively and patiently the counsellor can begin to perceive the difficulties from the client’s point of view and can help them to see things more clearly, possibly from a different perspective. Counselling is a way of enabling choice or change or of reducing confusion.

Why do SLTs need to use counselling skills?

SLTs work with clients (and their parents or carers) who may be experiencing denial or grief. We might need to use counselling skills if our clients:

• are unable to engage in therapy,
  
• demonstrate strong emotions,
  
• tell us they’re feeling low,
  
• are tearful, or
  
• struggle to adjust to their difficulties.

(List taken from Sparkes and Simpson, see below.) Sometimes we need to address these feelings explicitly before we are able to move forward with therapy.

One particular session with a parent left me feeling uncomfortable: her son had just been diagnosed with autism, and she spent the therapy session in tears. When I reflected on the session, it felt like I’d been unable to support her; so I decided to develop my counselling skills.

Resources and training

I searched Amazon for some books to get me started. I ordered Counselling Skills for Health Professionals by Philip Burnard and Person-Centred Counselling in Action by Dave Mearns and Brian Thorne. I found Counselling Skills for Health Professionals relevant and easy to read; it has practical ideas, short case studies, and an interesting chapter on culture and communication. In contrast, I found the language in Person-Centred Counselling in Action complicated and difficult to follow. Although it contains lots of interesting ideas—and it made me think—SLTs are not really the target audience.

I also attended a one day course called “Feeling out of your depth? Innovative approaches to using counselling skills within speech and language therapy” at University College London. The course was led by Cathy Sparkes and Sam Simpson. It was great! I took away lots of practical ideas for working with clients and families, and learnt more about my own skills and boundaries.

Using “blob people”

One of the ideas Cathy and Sam shared was using the blob people pictures. At work we use the “blob tree” as part of our initial assessment for people who stammer. I liked the list of possible questions that Cathy and Sam discussed: I can easily see how to use them in my clinical work.

The pictures show lots of blob people (who are neither male or female, young or old) in different situations; check out the blob bar! Possible questions to initiate discussion include:

• Which one are you?
• With friends, which one are you?
• Which one would you like to be?

The pictures and questions are a great resource, check them out.

Personal development target

I was prompted to think again about using counselling skills during a recent initial assessment. During the session the parents seemed to move from denial that there was a problem to grief that their son’s language was severely delayed. There was another family waiting, so I couldn’t explore the parents’ distress. Looking at the definition above, I did try to help them see things more clearly, and to reduce their confusion, but maybe I could have done more.

Is there a personal development target here somewhere? How about:

To practise using counselling skills in assessment and therapy sessions, in order to help parents think clearly and be ready to engage with therapy.

What do you think?