Opportunity Cost - Ep. 042
There are a lot of different treatment options in our profession, and let’s face it, often the experts don’t even agree. Added to that, every treatment choice comes with an opportunity cost.
I get it. It’s valuable to have different treatment approaches, BUT when it comes to helping our clients learn to make and reciprocate eye contact, I’m a dyed-in-the-wool believer. I’m such a firm believer that I can’t stay silent when it’s suggested that eye contact can hurt, rather than help, our clients.
This episode explores
- the opportunity cost of not working on eye contact, and
- the unexpected benefits of treating eye contact
- how eye contact can help our clients develop a growth mindset
--- Featured Links ---
Mindful SLP episode 15: Keeping an Open Mind ,
Simple Tools with Denise: BINGO activity,
Simple Tools with Denise: You and Me and ABCs ,
Realizing Their Authentic Selves By Siva priya Santhanam and Hope Gerlach,
Freedom: My Book of Firsts by Jaycee Dugard,
The Road not Taken Robert Frost,
Hanen More Than Words ,
Equipped for Reading Success
Music: Simple Gifts performed by Ted Yoder, used with permission
Transcript
Denise: I remember one day, we were passing a ball back and forth. He held the ball in his hands and he was standing like maybe six feet away from me on the other side of the room. And he looked at me and he just kept holding the ball and he looked at me. And he was just like staring at me, like he was learning, like he was building new neural pathways and I started counting quietly in my head.
I'm like, how long is this going to go on? Because before it had been like milliseconds, it was like 28 seconds. He just stood there with the ball and he was looking at me. He was learning things about the human connection. It was so awesome.
Welcome to The Mindful SLP, the show that explores simple but powerful therapy techniques for optimal outcomes. I'm Denise Stratton, a pediatric speech language pathologist at thirty years. I'm closer to the end of my career than the beginning, and along the way I've worked long and hard to become a better therapist. Join me and I'll do my best to make your journey smoother. I found the best therapy comes from employing simple techniques with a generous helping of mindfulness. Joining me in the conversation is Dan, my technical wizard and office manager.
Dan: Welcome back to The Mindful SLP. This week, we're going to be talking about opportunity cost and how this relates to an article that Denise read. Now, just to catch everybody up in case you don't know, an opportunity cost is the cost of choosing one thing at the expense of others. So for example, I might choose to buy a Ferrari, but the opportunity cost might be that I wouldn't have anything left to eat with or, you know, when you choose to do something, for example, when you choose one career, then you have to give up the choice of any other career to do that. So, you know, there are costs to all of our choices and the things that we do. So Denise, why are we talking about speech therapy and opportunity cost? What's the connection today?
Denise: I'm going to tell you, but I just had this thought first, for those of you who love Robert Frost? The Road Not Taken? It's all about opportunity cost. I love that poem. Okay. Let's get back to speech therapy. Well, I read an article in the ASHA Leader, it got me on my soap box a little bit.
Dan: Uh oh, when Denise gets on a soap box, watch out.
Denise: It's an opinion article in the ASHA Leader, September 2021, called Realizing Their Authentic Selves. It's about how some people with communication disorders try to hide some of their behaviors, which can lead to them not valuing themselves.
And let's be clear. I agree with many points in this article, but what got me up in arms is something I've seen popping up frequently in the past few years. Things about eye contact with clients with autism, ideas about not causing our clients any discomfort, because then they might not value themselves.
It seems that there's a prevalent idea that expecting certain kinds of behavior, such as eye contact from clients who aren't neuro-typical is damaging to them. So I understand, and I do agree that we shouldn't expect typical, and you can't see my air quotes here, typical behavior from all of our clients. Of course not.
But when it comes to eye contact, I'm a firm, dyed in the wool, I'm an evangelist about this. I bought helping clients with autism learn to experience eye contact, and I'm going to read a few passages from the article to further our discussion. Okay. Again, I'm not disagreeing with every point in this article, this is what I take issue with. So quote: "By situating neuro-typical communication standards as the goal, speech language pathologists may be unintentionally devaluing communication diversity and planting the seeds of shame. For example, we may teach an autistic client to maintain eye contact or to use quiet hands in the classroom, or to use facial expressions, smiling and agreement, nodding, head and acknowledgement during a conversation. These practices imply that we want the autistic child to appear non-autistic", end quote. There's another quote further on in the article, under Suggestions For Therapists. I quote: "Notice when you reward client's attempts to pass, that means passing as neurotypical, like praising fluent speech or forced eye contact and reflect on what that might imply about the value of their neurodivergent identity", end quote.
There's a lot of buzzwords in there. So, a lot of really emotion words, like neurotypical, is one of those words. It just do we really know what that means? Anyway, it causes a lot of, it's what they call an emotional word when people write. So I want to respond to these comments in four ways. We're going to talk about accommodations, or building neural pathways. We're going to talk about why, why am I an evangelist for eye contact? Is it because this merely a typical behavior? We're going to talk about do SLPs force eye contact. I want to talk about rewards. Do we say, hey, great job, you made eye contact with me. Is that something we do?
Dan: Okay. Well, what's the difference between an accommodation and building a neural pathway?
Denise: In the podcast that we did, podcast 15, about keeping an open mind, Dr. Penny Stack talked about this and she was talking about dyslexia. She gave us some background information when she started this conference and said that she came from a medical background and working with clients who had impairments in the motor, she's an OT.
They worked on building new neuropathways, on actually repairing things that were damaged, or neuropathways that hadn't been built. And she got into the education world and it was all accommodations. arranging things around the child to give them more time to take this test, give them extended time to turn in homework, lots of accommodations. And she said, well, you do need some accommodations, but what about building these neural pathways so they can function better. I mean, that's really, really important, and you can do that. But I guess there's a way to do therapy where you tend more to the accommodations then building neural pathways. So I'm saying, well, if you're neurodivergent, maybe we should build some neural pathways just to have overall better function.
Dan: That's an interesting one to me because I'm not quite sure what's what are we calling neuro-divergent versus neuro-typical, what's typical and what's diversion, who gets to decide?
Denise: Yeah, I wonder about that. Even someone with ADHD could be called neuro-divergent. Now for those of our listeners who don't know, Dan is a little bit ADHD, so therefore, are you neuro-divergent?
Dan: I personally think it's an advantage and I don't call, I wouldn't call myself a divergent. I mean, that's, that's almost a little insulting to me, but I have a hard time with that word.
Denise: And the thing is, whether someone is what we call neuro-typical or neuro-divergent, it's a really gray area. It's this huge category that you could put almost anyone in for at some point or other.
Now people who are really clearly autistic. You can see them and you can say, oh yeah, I can tell that their brain functions a little bit differently. But the problem with just saying we shouldn't treat anyone this way who's neuro-divergent, you're not looking at the individual, right? You're not looking at what does this particular individual need at this particular time. The point I want to bring out, if a client comes to you, it's for a reason, and it's for a desired change that the parents are seeking, anyone can accommodate, but what's our role as speech language pathologists?
Dan: Yeah. I mean, I don't come to a speech language pathologist to be accommodated. I could stay at home and do that.
Denise: Yeah. And we should certainly educate and support accommodations, but our real work is in helping the brain change and that applies to every client I see. Not just those that we might call neuro-diverse because every client I work with, I can see new neural pathways. Well, see, yeah. I realize it's happening.
Dan: Well, let's get back to our topic here. The eye contact, I find this interesting. Why are they so concerned about eye contact? I guess I wouldn't say that that was something you'd want to accommodate.
Denise: I thought that we had sort of puts this idea to bed years ago. I remember going to a conference, it was probably 20 to 25 years ago. Um, I was trying to learn about autism. And believe it or not. SLPs, when I went through college, we barely talked about autism.
Dan: You must have went to college in the Stone Age.
Denise: A long time ago. So trying to learn about it and the presenter says, studies have shown that people with autism have discomfort when they look at your eyes, they tend to look at the mouth more. So don't expect them to make eye contact with you, and I was like, oh, I do that a lot. I remember even going back and telling the other SLPs, this is what I learned. I'm like, oh yeah, we've heard that. But then I couldn't stick to it. I never could.
I, if I was reading a book with a child and I was holding the book up, I would wait until they looked at me before I turned the page. I mean, it was just natural, right. So I don't know why it's such a concern, but the idea has come back, like let's not cause discomfort with eye contact, but let me explain to you about Hanen More Than Words, which is a training I've taken.
Hanen has a way of engaging the client and eye contact is a really big part of it, but it's never in a way that's really uncomfortable for the client. You wait for them to look at you. You introduce a very engaging activity, you know that they love, and you just wait. And if they want something to happen, they're going to make a motion toward you. They're going to look at you. They're going to come towards you, and you position yourself. Positioning is huge. So you get on the floor, you're at their eye level. You position yourself so that they can hardly not make eye contact, right? And then the magic happens. They look at you and you continue the activity and there's a light in them that lights up.
So it's not really discomfort, it's really, really valuable, it starts to establish that human connection between the child and you.
Dan: To me, that's important to have that human connection. We all need it. I mean, we know body language is more than half of the communication process, but making that eye to eye contact that is so much more important than, than even body language. I mean, you're, you're really acknowledging the other person.
Denise: Yeah. Well, let me give you some stories so you can see the opportunity costs perhaps of not pursuing eye contact. Okay, I had a little client, three years old, came to me, obviously on the spectrum. We started working on eye contact and I remember one day we were passing the ball back and forth.
He held the ball in his hands and he was standing like maybe six feet away from me on the other side of the room. And he looked at me and he just kept holding the ball and he looked at me. And he was just like staring at me, like he was learning, like he was building new neural pathways and I started counting quietly in my head.
I'm like, how long is this going to go on? Because before it had been like milliseconds. It was like 28 seconds. He just stood there with the ball and he was looking at me. He was learning things about the human connection. It was so awesome. I was like, this is just going on and on and on. And then later on, his mom said, and this is so sweet, she said, he looked at me with adoration. I mean, she was saying, he looked at me with love and she had never experienced that before. Never. So what's the opportunity cost of not working on eye contact? And I have to say, um, I didn't force eye contact, but it was a little bit tricky to get it with him. I think people might be misled by an opinion piece like this, that if it's not easy to get eye contact with a client, they should leave it because I will have to force it. Well, I didn't force it with him, but I had to work and work and figure out what activities really going to work for him. Another cool story about him. He used to get up like at 5:30 in the morning and terrorize the house. So his poor parents, you know, into everything.
You worry about his safety, is he going to go out the front door, is he going to figure out how to undo locks? Autistic kids are really good at undoing locks. You know, he'd get everything out of the kitchen and you know, and then the house is a disaster. And shortly after he came, he had only been coming just like maybe a month or something, and just barely started to work on some of these things, and eye contact was a big part of it. His mom said he still woke up at 5:30, but he played quietly in his room for 45 minutes. He played with his toys, and for her that was huge because he really didn't play with his toys before, he just kind of got things out and made a mess.
Dan: And that's a total change that never would have expected.
Denise: I know, it's a side benefit. It's the side benefits that you get from eye contact and our last podcast with Kelly Vess, we did talk about locus of control and how clients with communication disorders, even when they're, like in their early thirties, don't feel that they have locus of control. Like they feel, they don't feel like they have control over their lives.
And in my mind, you can't really separate some of these skills, like eye contact with them forming a locus of control. So what's the opportunity cost of not teaching eye contact, if you're sacrificing locus of control. See that's what this little boy did when he learned how to play in his room with his toys, he was getting locus of control, besides symbolic play and a few other things. It was huge. You get huge benefits from, eye contact. And there might be initial discomfort when you start to work on eye contact. I mean, I really haven't seen it a lot, but you could, but I think it's rare if you're willing to wait.
Dan: And really that's the key, right? For this according to Hanen and that, it's like you said, you're not forcing them to look at you. You're not grabbing their face and holding them still and forcing them to look right at you. You're just waiting for them. They figure it out.
Denise: And I just wanted to say something about introducing discomfort into my clients' lives. It's something I do on a regular basis. And I'm proud to say it. But there's discomfort with change. How else will they change if you don't? And then this article, it's not all about autism. She talks about fluency and discomfort. I just know that there's some discomfort with lots of ways my clients have to change.
There's a client I have who is dyslexic, really dyslexic. I have been doing, Dr. David Kilpatrick's Equipped With Reading Success with her, had huge benefits. Sometimes it's pretty hard for her. And the other day I said, okay, we're going to do our word list, and she looked at me like 'that again'. And I said, you know, because of this, this is why you are reading these books.
She's reading books at a much higher level than she was before. She was, I said, this is why you're reading the Harriet Hamster books. This is why you can read these books. And this is why you could write this story on the board for me. And she looked at me, she said 'yeah, I know'. So she knows it's helping her, but there was some pain there.
Dan: Yeah. I mean, let's face it. Everything that requires change, not just for autistic kids, us too.
Denise: Yes. And for her, the auditory pathways, those were the neural pathways that needed to be built. She could not hear how words are supposed to sound. She could not. And therefore she couldn't read and spell them. Yeah.
Dan: And that takes effort to get there.
Denise: Yeah. On the fluency side, I just have a couple of real short stories. I've been fortunate enough to, go to a couple of conferences where, some professors who were people who stuttered were the presenters. So Dr. Barry Guitar, this was years and years ago, this is anecdotal, but this is what I remember him saying, that he finally sought therapy for his stuttering, probably when he was college age, Dr. Charles van Riper. He's the big grandfather of stuttering, big hero of mine, said to him, do you really, really want to do this, because he knew it would be uncomfortable for him. He said, if you're not ready to do this, you know, then don't come. But then he said, do you need anything? Do you need any money? Can I help you out?
Dr. Guitar said he would give you the shirt off his back. He was that generous of a man, but he wasn't going to start stuttering therapy with you, if you weren't ready to change, to be have some distant. And I'm not sure I'm saying his name right, but Dr. Peter Ramig, I went to a conference where he presented, he talked about how the speech therapy he had when he was in school never really helped him. But when he, again, got to college age, sought speech therapy on his own, he said, standing here right now, the hair on my arms is standing up. When I think about the choice I made, whether to seek speech therapy or not, because it was, he would be facing his fears, right? It'd be very uncomfortable.
And just thinking about that choice, thinking about that opportunity cost, even years later, gave him those goose pimples, right there when he was giving that presentation. And so my point is, perhaps we shouldn't look at the neurodivergent population. If you want to call them that, as people who should be treated differently, as far as discomfort goes. But of course you can't force them, which this clinical does make the point, they have to choose it. But, but we need to have that in mind that we could explain to them that some discomfort could be part of it.
Dan: Right. You, you have to learn how to help them want to learn that, you know, like you do where you just sit there and wait for them quietly. It takes them to finally get to that discomfort level of nothing's happening before they realize, oh, I need to do something and then they can learn.
Denise: I've got a story for this about waiting. This is a great story. So, um, if you've listened to some of my previous podcasts about one of my clients named David, who has autism, this is a story about him. It had happened very early when I was treating him, he was probably still a preschooler. And I had just taken my Hanen More Than Words training.
So I knew about this waiting and he was playing with my play food set. I saw that he liked to cut the food with the play knife. So I held the knife and I was sitting very close to him and he was looking down, he wasn't looking at me, he was just looking down, and I waited and I waited and I held the knife, like in his field of vision, just at the edge of his field of vision.
Again, I did this thing, like kind of start mentally counting. I think it took like a whole minute and he didn't actually make eye contact with me, but he reached his hand out really fast, just like a flash. And he grabbed the knife from me. And that was huge, that was huge. So I didn't like in that moment, expect eye contact because just the fact that he reached out to me, I didn't hand him the knife, but he initiated getting it, was a really big step for him.
And his mom told me later that he played with a play food set for 45 minutes. She was just really impressed. Well, it had some kind of meaning for him beyond what happened at therapy session. And pretty soon we worked on eye contact too, but that was the beginning. That was the beginning. So I really didn't actually have to have eye contact at that moment, but I needed that initiation.
But waiting, again, I swear it was like a whole minute. Yeah, at least. And it's kind of uncomfortable for the SLP too. Cause you think nothing's happening, but something is happening.
Dan: It takes time to build those new neural pathways.
Denise: And here's another David story. And I just love this. He liked to play with bugs and we would make bug soup and he would pretend to walk the bugs on my finger and his finger. So I thought he's going to love the Hungry Caterpillar. I have this Hungry Caterpillar activity where there's a hole in the food. And I put this like, pretend caterpillar slipper sock on my hand, and the caterpillar eats the food. And you actually put your hand through the hole. Okay. So big pieces of laminated food with holes in them basically. He was having none of it. He didn't think it was fun at all. I don't know why I did this, but I held up a piece of food and I looked through it at him. And he did the same thing. And all of a sudden, his eyes just lit up and he looked right at me and he had made eye contact before but not this way, I tell you there was something different in the quality.
And it was like, maybe he didn't know where to look before with my face sort of framed, my eyes sort of framed by the cutout hole in the fruit. It was just amazing. He was like, and he had so much fun, we did that, we did that for a long time. We just looked through the pieces of fruit at each other. And what is so interesting is his mom said like a week or so later, she said, I'm really starting to work on eye contact with him now because he seems ready for it.
And I was like, well, maybe it's just that our clients don't know where to look.
Dan: Yeah, our faces are, are busy places of movement and emotion and everything, and he just needed to have that isolation of the eyes. That's really interesting. Oh boy. I can see all sorts of studies on that.
Denise: Oh, I know, I cut out other circles out of paper plates, put them on sticks. And for the next little while when he came into the room, I would have the door closed. I arranged this with his mom, um, and I opened the door and hold up that right in front of my face, just to get that going, to keep that going, I don't have to do any more. He's a great one for eye contact now. There's an idea for you SLPs.
Dan: That's interesting. And you say that his eye contact is not a thing for him now. He looks at your eyes all the time.
Denise: Oh yeah, he does. And he watches your face for cues and things like that.
Dan: Now he never would have made that shift without that discomfort initially of getting to the eye contact.
Denise: And I wouldn't even call it discomfort, I would just call it awaiting and then finding the right tool for him to know where to look.
Dan: But if he never would have worked on it...
Denise: The opportunity cost is too huge to think about it, it staggers me.
Dan: Because it's such a big thing for him now. That's cool.
Denise: And by the way, my Simple Tools video, You and Me and ABC, that's another thing I did with David and I've done with other clients and that works pretty well too. So check out that Simple Tools video, if you're interested in that, that works for some clients.
Dan: Yeah. We've got a link to that in the show notes. You can also find it on our YouTube channel and also on Teachers Pay Teachers.
Denise: And the one last point, the author this article mentions, you know, giving verbally praising someone for eye contact and I'm like that almost never happens. The reward for eye contact is intrinsic. It's the continuation of the activity. When they make eye contact, then you go forward. Yeah. In most cases, in most cases, you know exactly how it happens.
So that's sort of a, a moot point for me. Why would you add a verbal praise onto something that it will, sometimes it takes away from the moment. See, when that little boy held that ball for 28 seconds and just looked at me and I looked back, I'm not going to say, oh yeah, you looked at me. It totally unnecessary, right? Yeah. The things were just happening there that were awesome. And there no need to say anything. The use of the word force by the author of this article made me remember something that I read. So Jaycee Dugard, not 'du harr', Dugard.
Dan: She's the woman who was kidnapped and held for like 18 years, wow.
Denise: Yeah. She wrote a book called Freedom, about her overcoming things. And in it, she talks about horse therapy, which some of my clients have done. And she said something very interesting about why she liked horse therapy. She said, because the horse forces you to have a conversation with it. So, what does she mean? Well obviously she doesn't mean force in the way she was abducted, right? Right. That's a different kind of force. So it makes me wonder what kind of force the author of this article might be thinking about, you know, we need to talk about this because there's different ways of force.
Dan: Yeah. A horse forces you to have a conversation with it, that takes a little explanation. For those of us who've never had a conversation with a horse...
Denise: In my opinion, what she's talking about is in order for you to saddle the horse, to continue to work with it, to have it go where you want it to go, you need to make an emotional connection with it. I think that's what she was saying. And the horse is just quiet. It's waiting for you, but it's not going to let you continue until you also reciprocate. And in a way it's forcing it because you're highly motivated to ride the horse. And it works for someone who is highly motivated to ride the horse. Cause it's very rewarding. Jaycee, I imagine, had to overcome some discomfort just because of all her past traumatic experiences to, to converse. You know, she was overcoming some emotional things.
Dan: And the horse was just willing to wait.
Denise: To wait there and you know...
Dan: Which ties right into what the Hanen training...
Denise: So that's my take on annex thought(?), it was so interesting. So as SLPs, are we forcing eye contact, you know, when we do it right? I don't think so, when we do it right. It works.
Dan: And I think the important thing to remember too, is that it's the opportunity cost. We're going to cause some discomfort maybe by waiting for that eye contact, but what is the opportunity cost? I think the story with David is, is telling. How much more he has grown because of that ability and the way that he's able to communicate with others now.
Denise: Yeah, the opportunity cost is just too great to say, I'm not going to work on eye contact. There's this saying that eyes are the windows of the soul. whether you believe that or not, I will say that a client who learns to experience eye contact becomes more of their authentic self, which is the opposite of what this title of this article is, Realizing Their Authentic Selves. I think that eye contact is a huge part of them, experiencing some part of themselves that is hidden from them before. It brings joy, I can see it in their faces. So let's not say they're so neuro-divergent that they don't need this humanness.
Dan: Well, we invite you to take a look at the Simple Tools video...
Denise: You and Me and ABC. In addition to You and Me and ABC, I have another Simple Tools video around the song Bingo, B I N G O. It's a great eye contact joint interaction activity. So check that out too. Remember, eye contact is simple, but it leads to some very complex growth with our clients.
So again, when you master the simple, the complex takes care of itself, because I did not teach that little boy to play in his room for 45 minutes instead of terrorizing the house, right? We were just beginning to work on eye contact...
Dan: And it paid off. Well, thank you for joining us today. We look forward to talking with you and on our next episode of The Mindful SLP. Until then have a great week.
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