Dancing The Macarena On An Iceberg - Ep. 047

What do icebergs and the Macarena have to do with speech therapy? Episode 47 describes a case history of a fluency client, underlying issues that needed to be addressed before stuttering therapy could be effective, and how mindfulness can be one of your best tools.  

--- Podcast Links ---

Free Tool: A Story About Me - sign up for the free resource library.

Stuttering Foundation 
NORD 
The Mysterious Cause of Stuttering in the Brain 
PROMPT 
Voice Meter Pro 
Story Champs 
The Importance of Crossing Midline

Music: Simple Gifts performed by Ted Yoder, used with permission

Transcript

Denise: That's five things I talked about. None of her previous therapists had observed this, any of these, according to her mother and not even when she participated in a special study on stuttering to get some ideas on how to help her.

Dan: Nobody caught it.

Denise: Nobody caught any of these five things. I don't say this to toot my own horn, but why did I notice this and other therapists not?

Dan: That's what we want to talk about today. How do you, as a therapist increase your skill to notice these types of things?

Denise: 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 of 30 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: Today is going to be a little bit of a mind bender. What does the Macarena and an iceberg have to do with therapy? Today we're going to be covering an abstract skill. This is going to be something that's really, it's not like a sequence. This isn't going to be as easy to talk about. This abstract skill, it's not like dancing. So we're not actually talking about how to do the Macarena

Denise: Macarena is in there for a reason. So listeners hang on to the end.

Dan: But it's more like iceberg spotting when you're, when you might notice something that has a bigger context or a bigger import that you need to take care of first, and how do you do that? So to do that, we decided to structure this in a case study. And this is a stuttering client that Denise had. First set up the analogy.

Denise: Yes, many of you are probably familiar with the iceberg analogy. Dr. Joseph Sheehan came up with it and I'm just reading a quote from the stuttering foundation. Dr. Sheehan was a giant in the field and helped future clinicians to look at the person who stutters as a whole. Direct work on helping one gain fluency can be helpful in the short term, much like blasting the top layers of an iceberg and not being aware of the dense body of ice below. However, a focus on thoughts, attitudes, and feelings, which is melting beneath the surface features of an iceberg can bring about long-term change and self adjustment.

So that's why we talk about the iceberg when we're talking about stuttering, but sometimes it's more than thoughts, attitudes, and feelings. As important as those are, there can be other things to the iceberg. And with this particular client that I had, I just kept uncovering more and more and more and more things.

And I was following little clues that I just happened to observe and pick up on and discover that there was a lot to that. I mean, it seems so obvious in hindsight. Well, yeah, of course, that's part of what she needs to work on before we can actually address fluency. But at the moment they happened, it wasn't like someone was beating the drum and tooting the horn and saying, hey, Denise noticed this. That skill we're going to talk about, mindfulness, is what really helped me slow down and notice in the moment, something that was super important.

Dan: And that's what we really want to talk about today, developing that skill of being able to recognize those things as they appear and actually doing something about them because they are fleeting. You may not recognize it right in front, but it is an important thing, it's there, but you've got to grab onto it and act on it. Now tell us about the client.

Denise: When I first began working with her, she was in first grade. She had had previous speech therapy for stuttering, but she still struggled. And her parents were looking for a different approach.

She stuttered ever since she began talking. She was a born artist and she drew equally well with both hands. She didn't have a dominant hand and the whole time I worked with her, she never chose a dominant hand.

Dan: That's fascinating to me.

Denise: Well, and what is interesting, she had a condition called partial agenesis of the corpus callosum. So I will explain that, but that might explain that the lack of hand domination. So agenesis of the corpus callosum is a rare disorder that's present at birth. It's characterized by a partial or complete absence of the area of the brain that connects the two hemispheres. And so hers was partial. When I look this up, cause I was like, whoa, what is this, I found very little research on it. It's very rare. But she didn't have a full expression of that condition. Genetically, it could have been much, much, much worse. So she pretty much looked like a typical first grader, little bit underweight. I know they struggled to keep her weight up. Other than that, and her stuttering, she looked like a typical first grader.

So I researched this, as I said, trying to find is there a connection between this and stuttering? All I found was this quote, no differences were detected in the corpus callosum area or white matter volume between children with persistent stuttering, children who recovered from stuttering and typically developing children.

Really, that was all I was able to find. But this study is talking about children without the partial agenesis of the corpus callosum or my children with a normal, if you will, corpus callosum, I kept thinking there's gotta be some connection, but just as I was preparing this podcast, I recently found this article that was published in 2020.

Someone is studying this, someone named Dr. Chain. Unfortunately, this client is long gone, but for you, people who want to nerd out on this and read this article is fascinating. Chain has also observed structural differences in the corpus callosum, the big bundle of nerve fibers that links the left and right hemisphere of the brain.

These findings hint that stuttering might result from slight delays in communication between parts of the brain. So that's all this background knowledge because she did have this rare condition that was really puzzling to me. And I thought it might have something to do also with her handedness lack of a dominant hand.

Dan: You started off the therapy with this claim. You had this, this diagnosis out there that you were sure how that was going to impact everything, but you knew that you were working on stuttering. And so you've got the top part of the iceberg that you can see, the stuttering. Now you got to start trying to figure out what's the bottom of the iceberg look like.

Denise: And I didn't really dig so much as these things just became apparent. So the first thing I noticed as I was sitting across the table from her, and I noticed her posture was so rigid, her face was rigid. She was like, kind of like a robot almost. And then I noticed that her volume did not change and it was rather loud. She was talking to me like this the whole time. I can't even do it. That doesn't sound good. That doesn't sound like her, but she didn't modulate her voice. She didn't go up and down. And I thought, well, if you can't even control the volume of your voice, you know, we can't begin to work on fluency.

I pointed that out to her and she actually wasn't able to change it until I got an app that showed volume levels. And when she could see that visually and we worked on two different volume levels, then she was able to modulate her voice. Okay, so got that out of the way, but I thought, whoa, I just had to notice that it's like all of our checklists that we have as a speech therapist, check this, check this, check this, check this.

I mean, we do look at voice. We're supposed to look at voice. But I'm used to thinking of voice, okay are they raspy? Do they sound like they have vocal nodules? You know, that kind of stuff. Not can they not change their voice volume, right?

Dan: Right. But that rigidity, that was the first thing and you worked on that. And then the next thing you noticed.

Denise: Her jaw was so tense and because I'm PROMPT trained, I noticed this. She just didn't have, it will be called freedom of movement. And so, so tense. And we know that tension is part of stuttering. So I thought, well, until we can resolve some of this jaw tension, oh, we can't work on her fluency. So we worked on that and she didn't really have an articulation issue. She did have problems with L, but she could say it sometimes not other times. But when she did attempt to say an L, sometimes her tongue would go way off center to come out of her mouth. And it was just really, really uncoordinated. We worked through that, just getting some better oral motor control and getting her, uh, her jaw loosened up. Okay. So I thought, okay, now we got that out of the way.

Dan: Now we can work on fluency.

Denise: And then I noticed she couldn't tell a cohesive story. I think a clinician could be distracted by all her stuttering that went on as she tried to tell a story and not really notice that her story lacked complexity, sophistication, the kinds of things you would expect from a first grader.

It's like, oh, okay, well, she's needs to be able to tell stories because stories inherently involve cause and effect. Right, and she didn't understand cause and effect. She couldn't explain to me, she didn't know how to answer a question with the word because, and she was poor at making inferences. So because fluency therapy, once you're past the preschool age, I mean, preschool fluency therapy is sort of a separate way that you do it.

But once they are in elementary school, they're doing a lot of analysis, meta linguistics, meaning thinking about language itself, thinking about how they talk, if you don't understand cause and effect, you know, you cannot do this kind of fluency therapy

Dan: That's a very basic one, yeah. Not being told a cohesive story then led to, you know, seeing the cosmic effect, inability to recognize that.

Denise: And her lack of inferencing. So these are all language issues.

Dan: Okay. So obviously then you pulled out one of your normal techniques, which was...

Denise: Yeah, we did Story Champs and we worked on all that and I thought, okay, now, now we can start to edge into fluency therapy, which we did. And we started to talk about feelings and emotions a little bit around fluency. And I have these journal pages I created for her to talk about her feelings. It's called a story about me. She can start a story like once or today or yesterday or one day, I've got these little choices up here. She can tell me something that happened, and then what happened there and how she felt. And so I did this.

So that's her feeling, that's her action, then I, and that's her resolution. So I've got all these little prompts. This is a freebie, I'll put this on the free resource library, very simple, and then it's got a little place at the bottom to do a little sketch because of course she was a born artist. And if she filled this out, then she could sketch.

But there's one thing I do want to mention when you're talking with a client about their feelings and having them do this kind of stuff is that, as a clinician, I like to model too. So I would tell a story about something that happened to me. Something that made me frustrated or feel bad, a problem that I solved because they don't necessarily want the spotlight full on them.

You have these emotional problems, don't tell me about them, right? You have these fillings and they might not feel great. It wasn't easy for her to talk about them. And writing actually helped her.

Dan: That's the whole point of the journal pages, to help get that.

Denise: But I just want to say model, model, model, and be human with them. Yes, I have problems. So do you we can solve them. I told you all that about writing the journal pages. So I can tell you this. Okay. Now I mentioned how she didn't have a dominant hand, right? She could draw equally well with both hands and switched all the time when she was drawing. I didn't care about that, that's a right brain thing, right?

But when she was writing, I didn't want her to switch hands. And I did mention to her mother, it would be nice as he chose the dominant hand when she writes, never could get that to happen. Using both hands was kind of like her superpower. She was really proud of being able to do that. But from what I read is the brain, the two parts of your brain, left and right hemisphere, one's like the president and one's like the vice-president, if you have a dominant hand, right. And things just work better when you have a vice president and a president, if you don't have hand dominance, it's like, you've got two presidents.

Dan: And they're fighting each other.

Denise: Things just don't work as well. But her condition was still unusual to me. I didn't push it too hard. I mean, this was her superpower and I'm saying, well, you can't use this superpower. So I tried to encourage her to choose the dominant hand for writing, but what I finally came down to was in here. In therapy, what hand are you going write with today? And that's the hand you're going to use the whole time we're writing and don't switch. So that was my little compromise. Now this is where it gets really fascinating. So I was watching her write one of these journal pages, and I noticed that she switched hands on me, but I noticed where she did the hand switch.

She started with her left hand, went right to the middle of the page and then her right hand picked up and took it over to the other side. Slack jawed, I think is the only term I can think of. I looked at her mother who was in the room. I said, she's not crossing midline. It was like, oh my goodness, midline crossing, a really important skill. And the occupational therapist or physical therapist will tell you that. And I was like, whoa, whoa, whoa. I just noticed that. How long have you been working with you, and I just noticed that this hand switching thing is because you don't want to cross midline.

Dan: Okay, help me out here, why is crossing the midline, such a big deal?

Denise: When children can do this, they are using both sides of their brain to coordinate smooth, controlled, complex movement. Okay. It's important to combine movement patterns that cross the body for daily tasks, such as reading, writing, tying shoelaces. And I might add, speech.

Dan: Uh, huh, really? She would do everything with their left hand up to the middle and then the right hand would take over and do everything over to the other side.

Denise: Well, not all the time. She didn't do it consistently, but when she did do it, that was in the middle. And I was like, she wasn't crossing the midline.

Dan: Interesting. And so, wow.

Denise: Well, this is where the Macarena comes in. I thought to myself, what kind of warmup activity could we do where she could get some practice with crossing midline? Cause she could do it, it was just not natural for her, it wasn't ingrained. And I thought, well, there's the Macarena...

Dan: Because you're touching your left shoulder with your right hand, your right shoulder with your left hand. That's crossing midline.

Denise: Yeah, and your hips and your back and everywhere. You're just going, crossing midline lots. So that's why I dance the Macarena in therapy. I also had her do things like write on my white board with one hand. She couldn't switch, she had to write all the way across. Things like that.

What was interesting to me is that's five things I talked about. None of her previous therapists had observed this, any of these according to her mother and not even when she participated in a special study on stuttering. I mean, they flew across the country. I think it was one or two weeks. And she participated in a special study on fluency to get some ideas on how to help her.

Dan: Nobody caught it.

Denise: Nobody caught any of these five things. I don't say this to toot my own horn, but why did I notice this and other therapists not?

Dan: That's what we want to talk about today. So we told you this whole story so that we can talk about how do you, as a therapist, increase your skill to notice these types of things?

Denise: I intentionally practice mindfulness, and that has propelled me from being a decent therapist to a better therapist. I just, I can see the difference in myself. And of course I don't compare myself to other therapists, I compare myself to myself and I've grown so much as a therapist since I started being intentionally mindful.

Dan: Let's talk through this a little bit because we sat down and talked about this last night. What are some of the things that as a therapist you need to be able to do? What do you do when these little bits of inspiration strike?

Denise: I act on it. I just notice it, it's there in the back of my brain. And somehow I know to bring it to the front.

It's saying, notice me, notice me. And for some reason, now I can notice much more than I used to. And I still wonder about what I miss, by the way.

Dan: Of course, but the fact is mindfulness has helped you be able to detach yourself a little bit more from the mechanics of the therapy session, to be able to have part of you, that's kind of just sitting there, okay, what am I missing? What am I missing? What am I missing? And so while you're actually doing therapy, you're also watching yourself do therapy to think, what are you, what are you not noticing?

Denise: Well, that's a good description of it. I never thought of it that way, but yeah, as part of my brain is doing that.

Dan: And that comes with practice, obviously. I mean, when you're first out of college, you're surviving and it takes time to develop the skill. And so it's not something that you can just say, okay, today I'm going to do this. No, this is something you have to work out over time, but it's something to be aware of so that it becomes part of your routine. Now, how do you break yourself out of the mindset that thinks inside the box?

Denise: Well, this is how I practice mindfulness. This is what works for me. I take time to be still. I especially take time to be still in the morning. For me, it looks like I study my scriptures. I pray. I write in my journal. I ask myself lots of questions in my journal that I just put out there for God to answer.

But because I asked the question, I'm ready for the answer. It's made me a better person and that's made me a better therapist. Now, whatever it looks like for you, however you interpret practicing mindfulness, I just can't recommend it enough. It is such a valuable tool for your whole life. Not just for therapy.

Dan: So that morning routine for you is very, very important to help prepare yourself for the rest of the day.

Denise: Yes. It's, I mean, you might miss some mornings and of course don't beat yourself up, but make it a daily habit as much as you can, and you will start to notice a difference in your life.

Dan: Now, another thing I've noticed about you as a speech therapist, you're always reading. You're always researching. What part does that play, do you think?

Denise: I think it alerts your brain to notice those little moments when they happen. Because you're putting some input into your brain to think about this. For example, all the reading I did about this little girl, one about the partial agenesis of the corpus callosum and about dominance, that prepared me to notice that she wasn't crossing midline. I already had that information swirling around in my head somewhere. So, always be learning.

Dan: Yeah. As I think about always learning. You know, I always studied the things that go on in my business as well, but it, it prepares you for things that are not even related, sometimes. I kind of think of it as like a farmer plowing the field. You can throw the seed out on top of the hard dirt and it's not going to do well. It's not going to catch, and it's not going to grow. Some might, but not a lot of them. But by preparing the field, preparing your mind by learning something, not necessarily what you're trying to do, but just by plowing that field and making sure the dirt is ready to go, then the seeds will actually sprout and grow. And so studying one thing might allow you to, your mind to be ready to take on something else.

Denise: Absolutely, everything's connected. Everything's connected. So always be learning, observe, observe, and observe again. So I didn't see this iceberg of hers all at once. The iceberg below the ocean level. It was revealed to me in pieces.

Dan: And I think that's the critical thing is that you're always looking for what else is out there and, and treating your clients as a whole and find out what else besides just the 'I'm going to just work on fluency, they're here to work on fluency.' There's other things that they need to learn as well. And I think treating them with a whole, that comes with practice and is very important.

Denise: And one thing I want to mention about mindfulness, as we're saying, always be thinking, always be learning, always do this, always do that. Don't feel like, oh man, one more thing to do. I've got to do this, this, this, this, mindfulness is not that way at all. It's just deciding what time you have to practice mindfulness.

It's a very relaxed way to approach life and therapy, actually. You sit back, you take the time. If your session's not going exactly like you want it to today, observe why and make the changes. It's not a pressure just because I am aware of being mindful in therapy. I don't have extra pressure on me. It's actually less pressure, if that makes sense. I don't know if it does. But I want therapists to think of it this way. If you're interested in doing this, don't think like is another burden placed on you. We have enough pressure as it is.

Dan: You've got a lot of things to think about, and I can see how it'd be very helpful to develop that skill of just having a calmness, because that'll help your clients calm down as well, but just allowing things to go, but knowing where you need to go. And then as things progress, noticing what needs to be changed and just flow into that.

Denise: Flowing, that's the word. It makes things flow. That's a great way to end this podcast. Make things flow by practicing mindfulness and when we come back next time, we're going to talk about what I actually did with this client once we did get to working on fluency.

Dan: All right. Thanks for listening. And now everybody let's dance the Macarena!

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