Midweek musings – managing the lows

 I promised to blog about the highs and lows of being a Speech Therapist and recently there has been a period of lows.

My case-load is constantly changing.  I might have a settled period of the same case-load and then someone goes back to uni, someone else is discharged, someone has a setback and it’s all change again.

As it’s August, lots of my usual case-load are on holiday and I’ve been doing some new assessments. Everyone who has had a brain injury has a story to tell of a life changed in an instant. Every story is shocking and sad.  However, I’ve recently assessed quite a number of the saddest cases I’ve come across in my 10 years of practice. You just cannot make up real- life sometimes.

When you are a community speech therapist working in people’s houses, you become immersed in their world for the time you are there. I think that is very important for making therapy work. When you meet a new client and learn their story, I feel I take that person and that family ón’. I will be investing my time and my thoughts to get them the best outcome possible  That is what makes the job so rewarding – however, sometimes I wonder how many more stories I can hear, how many worlds I can immerse myself in before I can’t cope any more. I feel emotionally drained at the end of the day and my two little girls get a snappy and frankly horrid mummy putting them to bed some nights. I don’t dwell or brood on cases but I do try and feel and understand what they are going through so I stand a chance of building a relationship and making a difference in therapy. My emotional energy is not boundless, and at times when it is being used a lot at work, I feel like by the time I get home I have nothing left to give.

I have been on the receiving end of healthcare. Thankfully nothing major. I’ve had a c-section and a natural birth. My youngest daughter had septicaemia at 5 months old and was dangerously ill but recovered after a week of IV antibiotics. My oldest daughter broke her arm recently and needed a general anaesthetic and an overnight hospital stay to sort it.

I’ve experienced good and bad healthcare. The best healthcare professionals I’ve experienced were empathetic, took time to understand me and my children, were positive without giving false hope, had a can-do attitude and made me feel like I was the most important person in the time they were with me.  They were knowledgeable and did their job-role properly.

My daughters broken arm happened just as I was just starting this period of taking on some new cases.  The care from every member of the team was exemplary. And that experience helped. I remembered what is important to the patient and their family. I remembered it is OK to achieve tiny steps and not huge ones. I remembered how stoical people can be in the face of adversity. I remembered that I can put one foot in front of the other for my clients and do what I need to do, because even if I can’t magically make everything better, I can do something positive. And I’ve done this long enough to know that my case-load will settle into a manageable equilibrium again soon.

The Interview Series – 2. My Mentor

jeannie

Jeannie was my first mentor when I started my career in adult speech therapy.  She was so inspirational and set me firmly on my path into acquired neuro rehabilitation.  My head was turned slightly by the chance to start some training in the field of head and neck (which is just so medical and exciting – having your fingers inside someone’s larynx is quite mind-blowing!) but Jeannie helped me develop my skills and love for the less glamorous but hugely rewarding work I do now.

I could not do an interview series without including her – I’m sure she is responsible for launching many careers over the years and I thank her from the bottom of my heart!

Can you tell me about your pathway into speech and language therapy as a career?

I grew up in the United States where my father was a maxillofacial surgeon and did a lot of work with a cleft palate team.   He always spoke so highly about the speech therapists on the team and the work they did so that was a definite inspiration from my childhood.  After earning a BA in child psychology I was still unsure about an actual career choice so checked out some possibilities, one of which was speech and language therapy.  I still remember how helpful and encouraging the people in the Communication Disorders Department at the University of Minnesota were when I went to visit.  That sealed the deal!

Tell me about a stand-out moment in your training as a speech therapist:

Probably a huge turning point for me was when our profession became so involved with the assessment and treatment of dysphagia.  I learned to do modified barium swallows and never looked back!

What is your current role and what was the pathway to that role?

I’ve had a long and rewarding career spanning several decades and two continents.  Although most of my work has been with adults, I also have accumulated a considerable amount of experience in paediatrics along the way.  In the US I owned a private practice that provided services in many hospitals and facilities throughout the area.  We also had an outpatient clinic.  Since I came to the UK eleven years ago I have worked primarily as a dysphagia specialist in acute care and in neurorehabilitation.  For the past two years I have been working in a variety of hospitals as a locum SLT.  I love the fast pace and unique challenges of locum work.

What do you love most about your job?

The amazing combination of great colleagues and new clinical challenges is hard to beat!

What do you find the hardest about your job?

Leaving it – I know I will need to retire one of these days!

Who/what inspires you in your job?

Patients and families who are facing such difficult challenges with courage and positivity – they are truly inspirational.

What 3 top skills do you think are paramount in acquired neurology?

Intuition

Motivational ability

Patience

Can you share a funny SLT-related story?

Back in the US I once worked with an acquired brain injury patient who had been a lumberjack.  We did a lot of cognitive communication work including some deductive reasoning “brain teasers”.  Although he hadn’t even finished high school, he became incredibly good at them.  At the end of each session I gave him several to do at home and one day when he returned he challenged me to do a particularly difficult one he had just completed as homework.  I foolishly took him up on it and the glee on his face as I struggled to find the solution still makes me smile!   

What job do you think you might have done, if not speech therapy?

Medicine – I actually considered going to medical school at one point when my two children were quite young but in the end I decided against it because my life was already way too hectic.

How do you relax/switch off from your job?

Travel, outdoor activities, and photography although most of all I love visiting my family in the USA twice a year.

jeannie2

Thank you Jeannie.

10 things I remember about being an SLT student

  

Recently I returned to my old university to work as an examiner for student VIVAs for a day (shameless selfie above taken on the day!) I hadn’t actually been back to the speech therapy department since leaving 10 years ago the same month, so it was very poignant! The building had changed quite a bit over the 10 years (glass atrium overlooking a courtyard, decent coffee – lucky students!) but the essence was the same. 

All the memories of being a speech therapy student just came flooding back- it seemed to be such a unique university experience compared to my friends on courses such as history, languages or English. Here are 10 of my strongest memories of my time as an SLT student: 

1. Library wars:

The instant a new piece of work was introduced with a recommend reading list, everybody ran for the library and if you weren’t there within five minutes of the lecture ending then you missed out. I ended up having to buy the most obscure titles because I couldn’t get hold of them in the library. This was before Amazon, so it meant ordering through the Waterstones on Gower Street and waiting an age before it arrived.  I had come from an environment where it wasn’t cool to show you were interested in studying, so the library wars baffled me initially! 

2. ALL DAY lectures:

Your friends on other courses are in the student union eating cheesy chips and nachos and having fun. You, however, are stuck in one room for the entire day, trying to get to grips with an obscure linguistic concept. I remember one teaching room resembling a prison with out of reach windows covered in bars. Caffeine and chocolate were required to fuel the day and by the time you stumbled out onto the street at 1730 all your friends on normal courses were drunk and you had to go home to complete a phonetic  transcription. 

3.  Friday lectures:

All the SLT students in my year were super keen and no one skipped class. Apart from Fridays. People would come in with wheely suitcases. At every break, less people would return, so by 1630 only a handful of people would be in the room. On Fridays we often had visiting lecturers, and if you were one of the few who stayed it was often mortifying as the lecturer would clearly think they were delivering a lack lustre lecture! 

4. Placement envy:

Most of my placements were absolutely miles away, requiring a 5am start to catch a tube, train, bus plus an on-foot hike at the end just for good measure. As placements happened on the Autumn and Spring semesters, I just have an over riding memory of being cold all the time. The majority of students had placements like these. However, there was always one or two people that lucked out. Either it was a placement that was 5 minutes walk away, or they scored a lift from their supervisor, or they got the amazing hospital that everybody else wanted! Placement envy abounded! 

5. Placement clothes:

I had a wardrobe of clothes I only wore for placement. Whilst my house mates are throwing on jeans and a t-shirt, I was pulling on horrible formal trousers and a blouse. I used to feel so uncomfortable. I wore my placement clothes well into my first job. Then I realised that as long as I didn’t wear denim, I could pretty much wear the normal clothes that I felt comfortable in – skinny trousers and throw on tops usually- and the placement clothes thankfully are long gone! 

6. Written exam fear:

I still have dreams now that I am sitting an SLT exam and haven’t been to any of the lectures. Written SLT exams are just so incredibly hard and require such a depth and breadth of knowledge. The added stress at UCL was were are not campus based. The university would rent out massive halls all over London. So you would also have the stress of having to travel to a hall you’ve never been to before. The exams were HUGE. The SLTs (around 60) would make up a tiny proportion of the hall, so it was completely overwhelming. 

7. Placement visit:

The awful day when one of your UCL tutors would travel to wherever you were on placement and they & your supervisor would watch you with a patient. Shudder. That is all. 

8. Phonetics

My husband, who I met at uni, was studying Italian. He had to do a weekly translation of Italian literature. I had to do a weekly transcription of how I would pronounce a long and obscure piece of text. Phonetics was not my best subject. I hated that task with a passion. I wish someone had told me you can still be a good therapist without perfect skills in transcribing the way someone has said something. 

9.  Vivas:

I’ve never forgotten the feeling of waiting to go into a viva. The cold sweats, the feeling of dread in your stomach. Frantically trying to work out if you’ve correctly labelled the aphasia type you’ve just seen on two repetitions of a short video…

 
10.  Finally being unleashed into the real world:

I started my first job as an SLT quite soon after I finished at UCL. The most amazing bit was how much easier it was compared to studying! I still say now, training to be an SLT was the hardest thing I have ever done. But I don’t regret one minute, because it’s given me a brilliant and rewarding career. 

5 things to do if you forget your bag!

  

I read this really interesting blog post the other day about a paediatric speech therapist making a decision to ‘go bag less’ and seeing really positive results. 

It reminded me of a day last year, when admist a busy morning rush I managed to remember school book bags, PE kits, packed lunches, school assembly costume etc etc but forgot my own stuff. 

I was 50 miles from home at my first patients house when I first noticed. I searched the car in vain, and went a bit clammy! I had 5 clients to see that day, including one new assessment. I didn’t have any resources at all, not even pen or paper. 

I did survive the day, and it was a good lesson that I could rely on myself and  what was around me to provide quality speech therapy. 

  1. Beg, borrow or steal pen & paper as soon as you can! My first client was a really lovely lady (an ex occupational therapist) who I was able to come clean to! She lent me a pen and a wodge of plain paper that lasted the day!   
  2. Use the environment around you. Working on naming? Name things in the room. Want to drill down to sub categories- name things in a kitchen drawer, name plants in the garden, name things in the bathroom.   
  3. Look for magazines/newspapers/books/leaflets that you can use for reading comprehension or picture description work.   
  4. Working on comprehension? Give instructions- name things in the room, body parts, ask the client to draw something that you describe…
  5. When I came to the assessment client I was amazed how much I remembered off the top of my head! The client had higher level language difficulties and I was able to do the spoken comprehension and expression parts of the Mount Wilga from memory. Add in all the extra bits- case history, oro-motor exam etc and I covered the first assessment session with ease!

Safe to say, I’ve not forgotten my bag since then, but if it happened again I know the day is not lost! 

    App review 2: Language Therapy 2.0 from Tactus Therapy

      Language Therapy was the first app where I took the plunge and spent more than a couple of pounds on an app for work. It costs £39.99 in the UK, although sometimes it is on offer, and you can buy the different modalities separately (comprehension , reading, naming and writing).  However, I can hands down say it is so worth it, and it is my most used app- cost per use would be getting into fractions of pennies territory! I have been using it almost daily for a few years now.   It was developed by Tactus therapy, a Canadian based speech therapy app company, started by Megan Sutton. She wrote an amazing blog post about the Life Participation Approach to Aphasia which explains why she started to produce apps.  I’m not going to go into detail about how the app works as the link at the beginning of this post explains it more succinctly than I ever could. However, it essentially allows your client to drill language skills over 4 modalities, either in a session with you, or at home (with results being emailed to you).  We know that drilling is required to bring about impairment level change and a case that most stands out in my mind is a young (in his twenties) man who had a stroke. He had only recently come to the UK from Poland and could not speak English. When assessed through an interpreter he was severely globally aphasic. (One of those cases where object recognition goes out of the window too and razors are used as combs- eeek!). I worked with David Brown on this case (featured here) and we often still mention him years later. Between us we saw him daily, with a interpreter. Due to all sorts of issues, sometimes we only had very short sessions, so we focused on drilling the same set of 20 object picture cards. (This was pre iPad days, so they were colour cards from memory). We drilled spoken & written word to picture matching and naming.  Slowly,slowly we saw improvement, and when we re- tested spoken word to picture matching on a different set of pictures he had improved significantly and he was beginning to say a few general conversation words that the interpreter could understand. Somehow the language barrier made the whole experience purer for us as therapists- we were drilling in a different language and bringing about change in that language! Anyway, back to the point!  You can drill with any words. But honestly sometimes a pack of the same pictures you use again and again are more sleep inducing for the therapist than a hot bath and a mug of camomile tea and our patients deserve us to be vibrant & present! Also, the client is going to need someone to help them practice outside of Speech Therapy sessions and that is not always possible.  This app brings a new dimension to the drilling process. My iPad is fast becoming my number 1 tool and I love the fact I am carrying about such a fantastic resource without dragging about a huge bag! (In my first job as a speech therapist I swear my bag was bigger than me and I used to have red strap marks on the shoulder I carried it on by the end of the day!) Here are a few features I love about this app:

    • I love the fact that the app works without needing to be connected to the internet so you can take it into deepest darkest no wifi territory and have a fantastic tool up your sleeve
    • It’s easy to use- one morning I was woken up to the sound of ‘dinging’ which indicates a correct answer when using the app. In my half awake state I wondered if I had perhaps horrifyingly fallen asleep in a therapy session (happened once when pregnant!). But no, my six year old had woken early, grabbed my iPad and was working the app independently!
    • The app has recently been updated to a full UK version (plus also French, German and Spanish). Previously parts of it were UK friendly, but not the whole app- This was my only bugbear with the app – sometimes my clients were thrown by some of the more American/Canadian pictures/phrases, especially  my older clients not so immersed in American culture.

     When I used the new version with my very English, retired, mostly non- verbal client with severe aphasia/apraxia he verbally said ‘that’s better‘,which says it all!

    • The app has clean, uncluttered look, moves smoothly from page to page and does not crash like some other apps I use. 
    • Just an anecdotal observation, but I often use the naming part of the app when working with people with severe aphasia & apraxia.   I often find that the ‘app voice’ as opposed to my voice brings better results when the clients are trying to name from phonemic cue or whole word copying – I think because I can turn up the volume to a more intense level than my voice and it’s a deep male voice, there’s  something a bit more to ‘grab onto’ for the client. 
    • I love the way you can use the app creatively in therapy sessions – once you’ve worked in each modality with an aphasia client you get a feeling of the depth and breadth of the resources on the app and I now feel confident about quickly changing the settings to pull out what I need to work on with a particular client.

    A recent study by Stark and Warburton 2015 (to be published later this year) has shown that people with chronic aphasia who used the Language Therapy app on their own for just 20 minute a day over 4 weeks have made and maintained significant improvements on standardized language tests. See here for a handy poster detailing the results.  My first thoughts on hearing this was ‘I’m not surprised’. I have used this app as the primary tool for impairment based therapy for many clients and have found the same when re-assessed formally- I’ve also found a positive knock-on affect on general conversation (as you would expect).  So, if you are dithering over whether to splash out on this app, I wholeheartedly reccommend it.  Last notes! : Check out other Tactus Therapy apps here. I have most of them and you can tell they’ve been developed by someone who knows aphasia therapy inside out.  I’ve recently read a couple of interesting posts about using iPads with older people- here and here.

    The interview series- 1. Boardroom to Boston Naming Test 

      
    David Brown is the equivalent of a unicorn in the speech therapy world i.e. a rare beast! He is a male in a predominantly female profession. His background is in banking. He is also a neurology and a voice specialist. 

    I have known him since 2009 and he’s one of those people who make you laugh until you hurt! He’s the only speech therapist I’ve met who has come from the corporate world and that brings huge positives. Speech therapists have a tendency to over discuss/over complicate issues at times (!) and David has a gift for cutting through that and moving things on. His clients absolutely love him. 

    I’m so pleased to feature him as the first therapist in my interview series:


    David, can you tell me about your pathway into speech and language therapy as a career?

    After working in banking for several years I decided I wanted a more rewarding career and one that allowed me to really make a difference. I spent around two years researching careers in the caring professions and attended university and NHS departmental open days and decided that speech and language therapy closely matched my skills and interests.

    Can you think of a stand-out moment in your training?

    I was on a student placement and as part of a multidisciplinary team had to give a diagnosis of autism to the parents of a child we had assessed. I was extremely worried about communicating my assessment results in a sensitive and clear way. After the meeting the paediatrician took me aside and told me I had done a “great job” and said I should really consider a career in that area.

    What is your current role and what was the pathway to that role?

    I have recently returned to the acute hospital trust that I originally joined when I qualified and see inpatients and also outpatients for voice therapy. Prior to that I worked for another acute trust and also in older person’s mental health services seeing patients with a diagnosis of dementia.

    What do you love most about your job?

    Meeting new people, the variety and working in great teams!

    What do you find the hardest about your job?

    Managing patients with terminal illnesses and supporting their families.


    Who/what inspires you in your job?

    My colleagues – past and present!



    What 3 top skills do you think are paramount in when working as a speech therapist in acquired neurology?

    1. Excellent observational skills
    2. Patience
    3. Flexibility


    Can you share a funny speech therapy related story with us?

    When I first worked on an acute ward I was assessing a gentleman. I was speaking quite loudly and everyone on the ward began replying to my questions. It got very confusing!

    What job do you think you might have done, if not speech therapy?

    Counsellor/psychotherapist

    How do you relax/switch off from your job?  

    Fun and laughs with friends and boating on the Thames on the rare occasion the weather is kind!

    Thank you David.  Here is a section of The Thames that David regularly navigates in his boat (as seen from one of my favourite bars!) 

     

    10 things I’ve learnt about running a social communication group

      
    I’ve been running a monthly social communication group for adults with brain injury since 2011.  The group has evolved so much over 4 years – here are 10 useful things I’ve learnt:

    1.  Remember that you, as the SLT, are not the expert on social communication difficulties post brain-injury – the attendees are the experts.  Don’t make the group about ‘teaching’ – take a step back and let the clients attending take the lead.  We’ve witnessed magical things happen – peers taking feedback from peers about more difficult aspects of their behaviour, in a way that never would be tolerated if it came from us.  We usually have 15 minutes at the start of the session where client’s talk about what has happened over the past month and this usually sparks a story related to social communication issues.

    2.  You can mix abilities in groups – skill sets will surprisingly complement each other – we’ve paired people who are very verbose with clients who do not initiate communication at all.  Someone who is back at work but struggling with verbal presentations may find talking to clients at a lower level a gentle way to practice.  As long as you hold a client’s individual needs and goals in your head and draw them out, you can work with a very mixed group.

    3.  Projects are the way forward for groups – since we switched to purely project working, the reported satisfaction of attendees went up significantly.  You can pick any project – but present ideas to the group so they can choose, and make sure you have their buy-in.  Successful projects to date in our group include: writing a leaflet to give to others at the start of the brain injury rehab process, making short videos showcasing client’s skills, a book club, a social media project – tweeting and instagramming about life in general…  These projects have allowed us to work on client’s individual goals such as turn-taking, initiation, planning, talking in groups, keeping comments appropriate etc but in a practical and meaningful way.

    4.  Breaks – group work can be draining for both therapists and attendees – we run for 45 mins, have a half an hour break and then run for another 45 minutes.  Great things happen in the 30 minute break – the attendees go off together for coffee and amazing friendships have formed that have brought extra benefits for those attending that we had not anticipated.

    5.  At it’s biggest our group has been around 10 clients, at it’s smallest 3. Up to 10 is a good number as long as there are 2 therapists. When we’ve had 10, we’ve split off into 2 groups for some tasks. 

    6.  Keep the group relaxed and casual- our clients report they hate really structured groups that take themselves seriously. We do not talk down to our clients and, as mentioned in point 1, set them up as the important people with crucial & helpful information to share. Tea, coffee and biscuits are also very important! 

    7.  All of our clients have needed reminders about the group date & time each month. We now email everyone a week in advance. Sometimes a group member will call another at the start of the session to remind them to get out of bed! Bottom line, if you want people who’ve suffered a brain injury to turn up to your group,you’ll have to remind them! Save memory goals for something different! 

    8. Linked to point 7- don’t expect any homework you set to be completed! Again, email reminders are helpful, but expect to do most of the work that needs doing in the group itself- anything else is an unexpected bonus! 

    9.  Don’t talk formally about how the brain injury happened- in the early days we used to do group introductions and asked people to give a brief history of what happened to them. It just didn’t sit right with us- we leave clients to share their stories if/when they want to- we just remind each other of names if required and crack on. 

    10.  Be flexible – sometimes the group session will take an unexpected turn. Our group can often descend into giggles/bring out anger/make someone frustrated/go off on a tangent. We have to make judgements all the time- sometimes great things come out of unexpected turns- sometimes we remind clients that the break/end is coming up and steer everyone back to task.