Do you provide “therapy” or “training”?

A therapist guides a young girl through speech therapy exercises using a playful and modern approach.

Looking at the caption on this picture, I don’t know that I’d call it a “modern” approach. These types of prompts are pretty standard in speech sound therapy…

But, I digress.

Today’s question comes from a discussion I recently had with a PTA (physical therapy assistant).

A little background…In home health, you don’t cross paths all that often with your colleagues. It can be challenging to know what the other disciplines are doing, how you can support them, and how they can support you. You might see them in passing when families schedule appointments back to back. You might end up cotreating because you or PT or OT were running late and that’s just how it worked out. Sometimes, you might schedule an appointment to see one sibling while PT or OT is seeing the other, then you switch clients. But, most often, you’re on your own.

This particular PTA struggles with the pragmatic aspects of working with families in home based settings. While she’s mainstream culture, she often is at least 20-30 minutes late to scheduled appointments. Sometimes, she’s much later than that. I know. When I do run into her, it’s often because she’s so late that she’s run over into my appointment start time.

She also struggles with relating to the pediatric clients. When I’ve worked with her, I’ve tried to explain that the client she’s working with needs time to process what’s said and that she’ll get much further if she uses gestural prompts and/or models what she wants the clients to do. I’ve offered to make her visual supports and show her how to use them effectively. After about 6 months, the clients don’t respond well to her (e.g., tantrumming, refusing to participate) and the families are over the difficulty with scheduling/keeping appointments.

Most recently, she ran into difficulty with an adolescent client I also see. This client has high functioning autism, selective mutism, and anxiety. The client simply stopped participating, turned away from her, and closed her eyes to avoid looking at her. The client also locked her out of her room. I have previously suggested to by OT and PT that when this particular client stops talking they begin using writing prompts with her. That’s what I do – I take away the need for the client to respond verbally when she does not choose to engage verbally or when I need her to respond with more than a word or phrase. Because the last few PT sessions had devolved into the client screaming and locking herself in her room, the mother asked me to see if I could get any insight from the client about what the issues were. I used writing prompts to ask about what was challenging about PT (I don’t know), did she perceive a need for PT (no, she can walk if she wants), if it hurt (yes, her feet), if she was bored (yes), and what would she be willing to try (e.g., making a video, following a video, incorporating more dance or yoga moves [personal preferences], following a checklist she has input on, making a calendar, participating in scavenger hunts, etc.) I passed this information on to the supervising PT as possible suggestions to make the sessions go more smoothly.

As this news came down to the PTA, she asked to speak with me. I passed along the same suggestions I’d given the supervising PT – using writing prompts to get responses/answers from the client, the types of activities the client said she’d be willing to try, letting the client choose the order of activities, and to make sure the PTA gave the client up to 20-30 seconds of processing time. During this discussion, the PTA mentioned that she “demands” eye contact because, “I know you speech therapists like that.” I told her that in this client’s case, forcing eye contact was likely going to increase anxiety and increase the likelihood that she would not respond verbally. I suggested to the PTA that she ask the client to turn her body toward the PTA when they were talking. Again, that’s what I do with this particular client.

It was during this discussion that I noticed she kept referring to her sessions and my therapy sessions as “training.” She kept saying that the client won’t “do the training.”

I think that might be the root of the issue.

Since this conversation, I’ve thought a lot about this. “Training” implies a vested interest on the client’s part. We pay trainers at the gym to help us get in (better) shape. Professional athletes train to stay at the top of their game.

Because of their age or the severity of their disorders, most of my clients participate in therapy activities. But, they don’t actively “buy in” the way you would with a trainer. Their families might have that level of buy in, but the clients most definitely don’t. I don’t “train” or provide “training” to my clients.

I teach through therapy. Language and language acquisition isn’t like training big muscle groups to get stronger or have more range of motion. Language is fluid and flexible and requires that clients learn to generalize to the greatest extent possible to be able to use newly learned skills appropriately across environments. With this particular adolescent client, we are working on learning mental and emotive state vocabulary like fact/opinion, manipulate/ignore, and rigid/flexible and then applying these vocabulary to social inferencing situations. My therapy sessions look more like a high school or lower-level undergraduate lecture/discussion class. What’s predictable for the client is the format, but the content changes every session. It keeps her interested and provides additional opportunities for generalization. I follow this basic format for all of my language clients – the sessions have a predictability to them in terms of the structure, but the activities and opportunities to use targeted skills change from session to session. To me, that’s not “training”, that’s therapy.

What are your thoughts? Do you provide training or therapy supports to your clients? If you’re a parent, what do you think we, as clinicians, should provide?

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