EPISODE 252

[0:00:14] MD: Hi, folks, and welcome to First Bite: Fed, Fun, and Functional. A speech therapy podcast sponsored by SpeechTherapyPD.com. I am your host on this nerd venture, Michelle Dawson, MS, CCC-SLP CLC. The All-Things PEDs SLP. I am a colleague in the trenches of home health and early intervention right there with you. I run my own private practice, Hartwood Speech Therapy, here in Columbia Town, South Carolina. And I guest lecture nationwide on best practices for early intervention for the medically complex graduates. First BiteÕs mission is short and sweet; to bring light, hope, knowledge, and joy to the pediatric clinician, parent, or advocate.

[0:01:01] EF: By way of a nerdy conversation, so there's plenty of laughter, too.

[0:01:05] MD: In this podcast, we cover everything from AAC to breastfeeding.

[0:01:10] EF: Ethics on how to run a private practice.

[0:01:12] MD: Pediatric dysphagia to clinical supervision.

[0:01:15] EF: And all other topics in the role of pediatric speech pathology. Our goal is to bring evidence-based practice straight to you by interviewing subject matter experts.

[0:01:25] MD: To break down the communication barriers, so that we can access the knowledge of their fields.

[0:01:30] EF: Or, as a close friend says, ÒTo build the bridge.Ó

[0:01:34] MD: By bringing other professionals and experts in our field together, we hope to spark advocacy, joy, and passion for continuing to grow and advance care for our little ones.

[0:01:45] EF: Every fourth episode, I join. I'm Erin Forward, MSP, CCC-SLP, the Yankee by way of Rochester New York transplant who actually inspired this journey. I bring a different perspective, that of a new-ish clinician with experience in early intervention, pediatric acute care and non-profit pediatric outpatient settings.

[0:02:06] MD: Sit back, relax, watch out for all heart growth, and enjoy this geeky gig brought to you by SpeechTherapyPD.com.

[0:02:21] EF: The views and opinions expressed in today's podcast do not reflect the organizations associated with the speakers and are their views and opinions solely. 

[INTERVIEW]

[0:02:29] EF: Hello. I'm here with Karen McWaters. I'm Erin Forward, for those of you that don't know. This is First Bite. And today, we are talking about Therapeutic Use of Self and Affect: Your Greatest Tool in Therapy, which is one of my absolute favorite things to talk about because it really dives into my love of psychology and bringing people and learning more about yourself than you probably want to learn about and over-analyzing who you are. It encompasses all of those things. 

For those of you that don't know, I will introduce Karen again. What's your title again?

[0:03:08] KM: I'm Karen McWaters. I'm an OTR. If you want to go by credentials on OT/M, OTR/L, PPODT candidate, which is why no one can keep up with all those letters because it's just a lot right now. I'm finishing up my post-professional doctorate, which is what the tail end of that means. 

But I am on the faculty at Georgia State University. I'm a clinical assistant professor at Georgia State University in their OT Doctorate Program. I have been a pediatric clinician for a number of years. And Erin and I worked together for three years, which is where we got to know each other so well. If you guys want to hear the origin story, it's actually recorded in a podcast episode. So, you can go listen to an older episode that has me on it from a while back. 

Financial disclosures wise, I get paid through my job at Georgia State University. I will be compensated for these podcasts. And I have a consulting job through my clinic that I used to work at in Greenville. Non-financial disclosures. I do some volunteer work around the community with a number of non-profits, but that's pretty inconsistent. 

[0:04:21] EF: You all probably know me. If you don't, I work at Cincinnati Children's. I'm Michelle's First Bite partner in crime. I get paid by Cincinnati Children's. I get paid by Speech Therapy PD for First Bite and other lectures with them. Non-financial, I volunteer for Feeding Matters. Sometimes Dysphagia Outreach Project. I still volunteer a little bit with South Carolina Speech Hearing Association. And I am a contributor for Michelle's book, Chasing the Swallow. 

Now that we have that out of the way, like we said last time for those of you that were here on Tuesday, if you have any questions throughout, feel free to put them in the chat box. We can both see them just to kind of make this as interactive as possible. Especially, we're going to talk about the models. Like, which things I've learned about occupational therapy versus speech therapy, is occupational therapy, like, a model, and a diagram, and a chart. And there's a lot to learn from them in that aspect of especially how to kind of frame your clinical practice. 

And I've actually gotten very into yoga recently. And what I love about yoga is that they talk so much about like your practice that you do in yoga. What's your practice? And your practice may change from day to day. What movements you might do might change from day to day. It may depend on how your body feels, or the environment, or what happened that day. And I like to take that mindset into my practice as a clinician. 

We all have our own practice of interventions and theories and experiences that make who we are as a therapist. And that may change based on patient. That may change based on day. But getting to the core of like what is your practice, what are your values, what do you bring to the table is a big thing that we will talk a little bit more about today. 

I think what we'll probably start with is just going through what therapeutic use of self is and talk a little bit about the intentional relationship model also. Just curious. If you guys have heard about the intentional relationship model or the term therapeutic use of self if you could raise your hand? Because I know I didn't know of this until I started working with occupational therapists that helped develop this model. Just curious. If you want to start, Karen, and give us a little background. 

[0:06:57] KM: Yeah. If you have an OT friend in your life, you may know that we really like to, Erin said, make a diagram. We like to visualize things. And so, there's a number of models that have been created by the profession of OT but often speak to larger therapeutic principles. 

And the intentional relationship model is one of those models. It's a model for using yourself as a therapeutic tool and it talks about the interpersonal reasoning process and steps that go into thinking through how you're interacting with people. In fact, in a lot of the literature, which we can give you guys a couple of citations to go read about this model a little bit and how it applies to practice, you'll see like this cycle diagram where there's stages of reasoning and you move through them and then they're self-reinforcing, right? The cycle starts itself over again. 

And it's really beneficial to kind of have that tool for self-reflection. For me, personally, it has been. But then, also, on top of that, it makes you more confident in what you're doing and why because it gives you language to express so much of the intangibles of what goes into this job, which is we work in a caring profession where we help other people. And then we often are the overlooked factor in that, right? That you yourself as a therapist is often the agent for change. 

And that means modeling yourself and your interaction is a big component of that session. But we often think about the interventions, or the tools, or the environment, or the task at hand, or the position of a piece of equipment for OTs as interventions. And the thing is, is that in every session you go into, the one intervention that's always there is yourself. 

Yeah. We'll talk a little bit about this model. I'll talk through some of those stages. But, Erin, if you want to talk a little bit about therapeutic use of self in speech therapy in the role that that can play, that would be great. 

[0:09:03] EF: Well, the thing I remember Ð and you and I had this conversation a while back. I vividly remember being in grad school and you have your lesson plans of goals, and what you were going to use to work on those goals and what order you were going to do them. And we would have a reflection piece at the end of like what could have been done differently or what would you have changed? And it was never a how could your presence have been different. Your tone. Your facial expressions. Like, all these little things that impact the children that we work with so much. But, yet, it was, "Oh, I could have used a different tool." Or, "Oh, I could have created a different stimuli or something like that." 

And so, realizing that you are the best tool in therapy both for the children you're working with and the caregiver. I say to every family I work with, I am a tool. I am a member of your team and I'm here to help build your relationship, help build your comfort. Whether it is around feeding or around language and communication. Because my goal is for a family not to need me. 

And like Karen was saying, the way that you interact with a child can be such a model for a caregiver the way that you respond the language that you use them. From our perspective, I talked about in the last podcast, the fastest way to aid in regulation and to aid in that connection piece is through relationship. 

And so, building that relationship is the core or I think should be the core of that experience. And every child in every family has this huge story and that reasons for what they're doing what they're doing. And we also come to our sessions and this relationship with what we've gone through. 

It's really, really important to be able to think about the way you're reacting to things, the energy that you bring, the responses that you have. Because those little things are going to have such an impact. And that can be a scary thing and that can be a big shift to think about. Because we're not 100% every day. And we all have stuff that we go through. But the most important thing is showing up authentically. 

I'll have days Ð like, I'll even say to the kids I'm working with, "I'm having a hard day." And just being honest in that relationship can be so helpful because they're going to come across people that are having bad days. And they're going to come across people that aren't able to give them 100%. That's kind of the way I try and look at myself and how I show up to work with the kids I work with. 

[0:11:43] KM: One thing I would like to include into this conversation, because I know we're speaking to a bunch of working therapists as well, is the use of yourself as a tool. But then, also, the protection of yourself from burnout. Because that's a big component of this. Burnout is real when you're in a helping profession.

And using yourself as a tool is great so long as you do it in a mindful way that promotes longevity for yourself and growth for yourself. And not giving of yourself to the point where you don't have anything left to give. 

With that, let me kind of clarify on what we mean by what therapeutic use of self. The authors of this model defined it as the planned use of his or her personality, insights, perceptions, and judgments as part of the therapeutic process. 

I kind of want to pause for just a second and think about that. It's not just your personality, but it's the planned use of your strengths and weaknesses as an individual. And it's that mindfulness element that kind of sets this apart. Because it is mindful, right? It's not just walking in and saying, "Oh, I've got a great personality. Let me use that to my advantage." 

It's very self-reflective, which we know and we're used to thinking. OT is really used to thinking about reflecting on the environment, and the tools, and the occupation, and the task, and all of the other elements involved. And then it's easy to get wrapped up in the tangible things outside of yourself and neglect reflecting on yourself as a tool. 

The therapeutic model identifies six different modes of communication. And I'm going to kind of outline those because I think that they are really valuable to think about that you may be switching between a mode of therapeutic communication and making that choice more intentional comes first with like identifying what that mode is. 

The modes identified by this model, the intentional relationship model, are advocating, collaborating, encouraging, empathizing, instructing, and problem-solving. And the thing about this model is it identifies different things as well. It identifies a list of intrapersonal characteristics, things you might have inside of yourself. Like, your tone of voice, your gestural communication, your approach to your asserting needs, your level of trust. Those are within yourself and then also within your client. And that match between your intrapersonal and interpersonal really comes through those therapeutic modes of communication. 

And then the thing that we know happens in therapy all the time where you really start to reflect on yourself are sort of these therapeutic events. The model identifies interpersonal events that happen between a therapist and a client. In pediatrics, the most common one I think is boundary testing. That happens frequently. It happens every session, right? But usually multiple times during a session. 

And then when you're in pediatrics, you really have the kid client, right? And then you also have the parent client. And oftentimes, you'll hit things with the parent client and or the kid client, like, crisis points, or intimate self-disclosures, or resistance and reluctance to what's going on in therapy. Empathic breaks where you just misunderstand each other. And so, this model identifies those kinds of things and then talks about modes that can be used to address them through interpersonal reasoning. 

I mean, I can think of a million times. I feel like every time when I would Ð when I was working in an outpatient peds, every time I walked a kid out to the car, one of those interpersonal events would happen. Whether it was resistance and reluctance to the ATP I was giving them, or intimate self-disclosure with a parent ending up in tears over something that's happened somewhere else, or an empathic break where the parents just had a long day and I've also had a long day. And sometimes we just have a brief communication and we have to leave. We really can't check in on each other. Those things are really, really common. And for me as an OT, it's helpful to have a framework to think it through and to be intentional and evidence-based with it, too. 

[0:16:11] EF: Right. Because I feel like it can seem very overwhelming at first. Like, I will acknowledge that, for some people, some of this does come easier. For some people, that shifting. I will say, having to shift for other people's needs comes pretty easily to me because I did that as a child. 

For better or worse, I have learned very quickly how to read every single person in the room and figure out what they might need, what they might need. And that's something that I think helps me in the therapy session. But also, hinders me to a point that I might be too focused on everybody else's needs that I can't like be as present as I want to be. 

But for people that are like I haven't really thought about this, I am just trying to dive into it. And for people who Ð like, I will also acknowledge. Once you dive into this, you have to be more reflective on yourself as a person, which is not easy to sit and say, "Why am I reacting to this this way?"
 
In Floortime, which Karen and I are both trained in, when you look into a child's individual differences, you also look into your own. You look into your own sensory system, your own trauma, your own family history. Because if we're going to show up authentically, which I do love that this is I feel like a shift, where instead of me showing up as a therapist, and being super professional and having this role, like, there's more of a push to show up as who you are. But you have to know who you are to do that. 

And there would even be times where like Karen and I would share a kid and he'd be off. Or like I'd notice something and then we'd look at each other and be like, "Are we off today?" They can sense it. And the kids that we work with are much more in tune with like energies around them just because I think, sometimes, we learn as we get older to push off those energies. There's just so many more things in the environment that they're more in tuned to. 

What I like about this model is that, like Karen said, it breaks things down. So, you can better identify it. When something happens, you're like, "Instead of I did something wrong," or, "They don't like me," it's, "Wait a second. They were trying to push boundaries or they were trying to Ð they did disclose something to me that then impacted our relationship." And to start from that point as opposed to just saying, "Something went wrong. I don't know what to do from here," can be really helpful and can be helpful if you're working with somebody that's trying to start to focus on this. Because, otherwise, it's a lot. 

[0:18:53] KM: Yeah. And we're going to talk today about attunement and affect. And we started this series off with sensory. Because it's so important to be aware of sensory systems, both others and your own when you're trying to use yourself therapeutically. Because using your body and yourself in the wrong way to that client, it can become not therapeutic very, very quickly, right? 

And then, also, being aware of your own sensory system and knowing when you're going to have to drum up a little bit more out of yourself. Because in order to meet this client at their threshold, you may Ð for me, that's my particular challenge. Because I'm a pretty low arousal person. When I have a child who has high arousal, I know I'm really going to have to amp myself up for them to feel like I'm advocating, empathizing or collaborating with them. 

If I am not bigger than my natural resting state, they don't register it, right? That's a very intentional thought about my therapeutic communication mode as relates to their sensory system and kind of layering this model and sensory models on top of each other. Because that's what attunement truly is, is attunement to yourself as well as the client's needs and feelings in the moment. 

And when you're talking about therapeutic modes, too, like it's important for us to show up authentically and also show up self-reflectively. Because what we may naturally want to do may not be the right answer, right? Yeah, show up as yourself and show up as the best version of yourself that's reflecting on the goals of the moment and what you're in that session for. 

[0:20:50] EF: And how that caregiver [interacts 00:20:51] responds to that in that way, too, I have been able to have the confidence to have more conversations that I may not have been able to have before where maybe I did something and the caregiver had a reaction to it. Or I could feel that something Ð and I may bring it up and say, "Hey, this is where I was thinking with this. But I want to make sure that this is something that you're comfortable with." 

Or sometimes you have to be the one to start that conversation to allow the caregiver or child to advocate for a shift in that relationship. And it's because of the Ð looking at this model and having this experience that I've been able to say, "Okay. This may be what's happening." Instead of ignoring it and pretending that it doesn't exist, I need to change something or address it. 

[0:21:43] KM: And sometimes that's just having language to be able to identify what that weird feeling was, right? Sometimes you read something and resonate with it and then you can figure out what that feeling was. 

Which, Erin, that was a great segue because I really wanted to talk about what that like interpersonal reasoning process is. According to this model, it kind of starts at the top with anticipating what is going to happen, right? When you really start to use yourself therapeutically, it requires some amount of knowledge of that client, right? Whatever knowledge you have. 

You're trying to anticipate issues. Before they happen, you're going to identify and cope with them. Determine whether or not a mode shift is required, right? That's their third step in this process. Decide whether or not what you are doing is working or if you need a new way of approaching it.

After that, you choose a response mode and then you draw on the interpersonal skills associated with that and then gather feedback back from the client or the person that you're working with. Whether that'd be the parent or the child. And oftentimes, in pediatrics, it's challenging because you have to do that process twice at the same time especially if you work in an in-home environment where the parents are often in your sessions. And so, you have to react therapeutically to the child. And then, over the top, narrate in a very different voice, very different mode to the parent at the same time. 

But for me, when I started using this model and thinking through it more, I was able to do that more efficiently, and more productively and with less stress on myself. Because I felt like rather than trying to intuitively feel it out, I was just thinking through, " Okay, I've been trying to advocate. But maybe this parent needs me to switch to instruct. Right? Or maybe this parent needs me to switch to an empathizing mode rather than telling them what to do better, they just need to hear me out. Or they just need to be heard for a minute, right?" 

And same for the child. We get into these instructing modes commonly in sessions because we're supposed to be the one in charge, right? We're supposed to be the one making the therapeutic gains and the switches to go from instructing to collaborating and figuring out when to switch between those two. Because there's times for both of those. Within the same 30 seconds, there's time for both of those, you know? Yeah. That reasoning process is really important, but especially the gathering feedback part. 

[0:24:24] EF: And I think from Ð specifically, from like a speech therapy perspective, the way that I've started to be very intentional are the words that I use and the words that I model. Because I have very strong feelings about the role that your occupational therapists learn a lot more in regards to their role in mental health, which we don't learn as much in speech. 

I mean, I got a counseling class in my graduate degree, but nothing to the level of the role that communication can play in a child and a caregiver's mental health. And when I'm collaborating, when I'm using these modes, I try to be very intentional with the words that I use. Whether it is me modeling for the child. Whether it is me modeling for the child to the parent, which I will do a lot. Where I will narrate for the child to communicate to the parent what I think they're feeling and thinking. And why they might be doing what they're doing to build that relationship kind of on the outside, which is what I'm trying to advocate for the child. Slightly instructing the parent, but trying to collaborate with the parent to help this child problem solve if we're going to use all of these Ð talking specifically of these modes. 

And like Karen said, you're doing three different things at the same time. Like, this child's trying to do something. I'm advocating for them by narrating for them. Trying to collaborate with the parent to help this kid problem-solve what they might be doing. And if that collaboration isn't happening as much, I may then switch to instructing the parent of, "Hey, I think this is why this is happening," to help build that relationship. 

And we have this very significant role in Ð and I will probably bring up Kim in every single episode. But when Kim Barthel talks about how you cannot have Ð you cannot separate language from someone's well-being. Because the way that things are said in our head in our own language and how we talk about ourselves and to ourselves impacts the way that we feel. 

Making sure that when you're building this relationship. That you're trying to use strengths-based language. That you're not reaffirming these things and these negative feelings that these caregiver and child may be thinking when they're coming to see you is really, really important. And that can be a huge part of this model. 

Because whatever language you use to describe what's happening to a caregiver or child is whatever language they may then go and explain to somebody else or be able to advocate for themselves. That's really, really important. 

And I remember even in feeding sessions, I would use like medical terminology that the physician may use as well as explaining it in another way so that they can advocate and can tell the doctor, "I know what's going on," but also understand it in a level that they can process it a little bit easier. 

[0:27:30] KM: Yeah. And if you want to really apply this to us as therapists, too, having language to explain why you are even using the words that you're using, right? Or the tone of voice you're using. Or the way you're positioning your body on the floor. Or the way you are interacting with this patient and their sibling together. Because that's another common thing that happens that then creates an interpersonal event, right? These siblings come in. And, all of a sudden, the dynamic shifts. 

Sometimes having language, like the language we've talked about with these specific modes and this reasoning process, it made me feel more empowered. I hope that that also empowers you to know that there is research out there, right? That there is evidence-based practice about how you use yourself and that you doing what we spend 90% of our sessions doing, which is interacting with the client, right? 

There's 10% of the time where it's really the activity we've got going on that really might be doing the job. But like 90% of the time, it feels like we're carrying the weight. A session either is a success and I walk away feeling good about it or I walk away feeling not so good about it because of the way that I handled it, right? Or the way that that interaction went. 

And so, knowing that that 90% does have real evidence behind it. And then, also, research to tell you what you're doing and why you're doing it is so reaffirming. As a therapist, especially a therapist, who is not by training, a counseling therapist, right? Or is not by training. A psych therapist. Because we feel like sometimes, or at least OTs feel like, "Yeah, I get this far and then I'm stuck because I don't know what the next step is. How do I counsel somebody through this?" When, really, it may not even be counseling. It's just being intentional about how you're communicating and hearing flying out. 

[0:29:31] EF: And then the goal, the goal with using this model and the goal with building these relationships, is to have that attunement, and is to have that bond, and that connection and that reading each other. And having that flow, as we would call it in Floortime, is like what we try to put all this together to create. 

[0:29:56] KM: Yeah. A really tangible way to start doing that is to go back to the sensory episode. Really dig into sensory and then use sensory as your tool to start doing self-reflection, and therapeutic use of self-reflection and then reflection on your client. 

The reason I say that is that a lot of times, the language and the clinical application of sensory-based attunement is so clear. And there's a lot of verbiage to give yourself there, right? So, that way you feel like you know what you're talking about because there's so much literature to pull from. And it can help interpret your own experiences. This is a very tangible way to start this journey of attunement. 

When you hear trauma-informed or trauma-sensitive practitioners talk about attunement, they really talk about that magic moment. Floortime calls it the twinkle-in-the-eye moment or the falling-in-love look. And we can all relate to that with a client. We've all had those clients that like, all of a sudden, time kind of stands still. It feels like a magic recipe that you got to the spot where everybody was like truly in the moment and enjoying each other. That is attunement. That ooey, gooey love feeling that happens when you're really on the same page with somebody's attunement. 

And while it can sometimes naturally be occurring in the wild, sometimes it needs a little bit of a greenhouse and some TLC to grow, right? It's not that you can't find an orchid growing out in the woods. You probably can. But we all know those are temperamental plants that require a lot of time, and water, and special soil and the right conditions and humidity for them to eventually flower seven years from now, right? They're very temperamental flowers. 

And a lot of times, our therapeutic relationships with clients feels like growing an orchid. It feels like you put in a lot of time and you're trying to get the environment just right for one magic moment to happen. And when it does, it really pays off. But just waiting for the lightning to strike and the magic to happen, there's so much more out there to get if you start to reflect on yourself. And you start to really pull in multi-disciplinary pieces to understand the whole person, and the whole developmental process, and your whole self and how those two entities interact. 

[0:32:31] EF: And to find the joy in that process, too. Sometimes that can get lost a little bit when you're constantly looking for the joy and that perfect outcome to match. And so, a lot of the time, when I'm feeling the most joy, and excitement and attunement with a child is when we're like figuring something out. 

I remember I had one session with our Ð you're not supposed to have favorites. But our favorite patient. And we like Ð because Karen could see me from across the hallway. We had a scooter board and we were like pretending that the scooter board Ð like, at first, he just like fell off the scooter board and he like thought it was funny. And it was great. And then we like pretended that the scooter board was like a ship crashing and that we'd fall off. And we like did this over and over and over again and. I pretended that I fell off the scooter board and like needed to be pulled. 

And we had to process. We had to think through this. Because he was like, "Let's just pull you on the floor," which I let him do it because like we had to think why this wasn't going to work. But bless him. He found somebody else and they pulled me on the floor so it didn't like Ð we didn't have to problem solve in the exact same way. 

But it was like in that beautiful moment of like we're improvising and we're trusting each other. And we're realizing that we trust that when you bounce something off, I'm going to bounce off with you, is I think the most beautiful thing. 

And what I encourage speech pathologists to think about, too, is we are not just the sternum up. And it always bothers me when speech pathologists are like, "I just work from here up." Because you learn so much through moving your body and you develop language for the experiences that your brain and your body have. If we want children to develop language, they also have to develop these experiences with their body to have something. 

And Karen and I, we know neurons that wire together fire together. As you build these more experiences with more meaning, they're more ingrained in your brain. And that's when affect is like such an amazing tool. Because it creates more emotion and it creates more of these emotional memories that pull things in. 

I had one patient who he only remembered the things at school that had big emotion. And, unfortunately, those were the drills that they had to do. And that one time that kid was mean to him. Every time I would ask him what happened at school when he'd come see me in therapy, he would say, "Oh, we had the drill today." Because that's the only association you have because it had so much emotion behind it. 

And affect doesn't Ð there's this connotation that affect is like you're loud and super excited. But affect is just how you alter your tone and your emotion for the situation. I will be extra quiet and whisper, or pretend to be scared, or have these different reactions within the situation or the experience that we're having that, again, create these stronger connections in their brain to have these memories and to pull this language so that it resonates more so and they can use it again. 

[0:36:03] KM: I like the point you make about like the emotional salience of things. And that like affect and emotion are really tied together. One thing that sensory research is starting to point to and has pointed to for a long time, but is really starting to show more and more, is that every sensory experience is an emotional experience. We don't have experiences and then have almost no emotion about them. We always have an emotional reaction to our world and our things because we're emotional creatures. And so, using emotion as a tool for intervention is very, very effective and important to do. 

But also, before we get into affect, Erin, there is one more piece of like Attunement that we all need to be aware of. And that is that attuning with individuals also makes you very aware of their attachment style. Because when people start to relate to other people, that's really where attachment comes into play. Because it's how we first learned to interact with other people. 

And so, being aware that children with disabilities are more likely to have challenges with attachment. Because Ð I would argue. Because their sensory systems have a harder time interpreting their world. And even with the most caring, attentive parents, when you have a sensory system that is disorganized, it creates a disorganized interpretation of the world. Not necessarily a disorganized attachment pattern in the clinical sense of that. But it creates difficulty knowing that your world and your relationships around you are consistent. 

Attunement to children does require really self-reflective use of affect because that's your key into their attachment system in the way that you see how they interact with the world. We learn through relationship. We don't learn in a vacuum. There's so many studies that talk about the importance of an enriched, valuable, relationship-rich environment for learning and development. 

And if you wanted to take one takeaway message from the last 50 years of psychological research, it would be that relationship really does matter. And the way we perceive relationship is through attunement. And the way we perceive attunement is through affect that is meaningful to us. 

Erin, do you want to kind of define what we mean when we talk about affect? We've talked about it generally. And we really do mean affect with an A, right? Not effect. But affect. 

[0:38:50] EF: I feel like I'm going to Ð I will go around in circles. And I've done so many lectures on it and have like a very concise definition that I'm just going to find. Because, otherwise, you're going to get me talking for how long I could talk. 

[0:39:06] KM: While you're finding that very concise definition, I can say that when psychologists refer to affect if you've heard that term before, it's probably been in a psychology class. Because when you hear that word in a psychology class, they're talking about people's facial reactions. 

Particularly, you hear the phrase negative affect in relation to negative symptoms of schizophrenia. That's where most people are familiar with that term. And it means that rather than Ð when we think of schizophrenia, we think of all the hallucinations and the delusions. But there are negative symptoms. Meaning symptoms of things that are missing. 

One of those is negative affect. It means that people have a flattened affect and have less reaction, less emotional visible reaction on their face than you would expect, which is what psychologists call negative affect. When we start talking about affect, we're really referring to Ð 

[0:40:01] EF: The outward. 

[0:40:01] KM: Your face and your body. Yeah. But, Erin, your concise definition probably puts that way smaller. 

[0:40:08] EF: It's just a sentence. I really thought it was going to be longer. But it's basically the outward expression of our feelings and emotions. And the thing that I think, especially talking with mostly speech pathologists, is that it is the most important way you communicate the way another person feels about something. And it can be so, so, so subtle. 

And from a Ð I'm trying to understand how a child is feeling about something, you have to pay attention to like the crinkle of an eyebrow, or how they move their eyes, or it can be a slight movement in their face. I watch this Ð have you ever seen the show Lie to Me? 

[0:40:53] KM: No. 

[0:40:53] EF: It's like this show where this guy's a psychologist. And he sits in on like cases in the court. Oh, sorry. He can tell like the micro expressions and what they mean. And so, what I found so exciting but also made me be so much more conscious is that we can do such subtle things that people pick up on that demonstrate our affect. 

And children are very, very good at picking up on these subtle expressions, especially in your eyes. Because that's what teaches safety. Children, very early on, and think about the world that most of the young kids we lived in with masks, all of that information has come from eyes. 

And so, the way that we use our body, use our tone, use our facial expressions to communicate how we're feeling is that use of affect. And from a multi-sensory perspective, the more senses we can use to give that information to a child, the better we can develop that attunement. 

And I think, too, about the children we work with that have motor differences that maybe have a harder time expressing whether it's communicating verbally or even expressing some of their affect outwardly because of these motor differences. 

I find it very empowering, too, to know that there is so much information out there about how much we can develop these conversations and connections even without language. 

[0:42:30] KM: Erin, have you heard about the research Ð this is long-standing research from the Gottman's about the four horsemen that come into marital relationships. they talk about microexpressions and how you can tell whether or not a marriage will last or not. 

I mean, this is a husband-wife duo, ironically, that are a research duo that research marital conflicts and micro-expressions. If you're interested, please look up their research. It's very interesting. They are most famous for the four horsemen. But they categorized expressions down to micro-expressions of the eyes and the mouth to really identify what emotion couples are expressing to each other. And their research has gotten to the point where they can predict down to the year and the month. How long a couple will stay together based off of their micro-expressions. 

The attunement and the affect really does make a big difference in relationship. And it's just very interesting to me that we can break our faces down into such regions that signal either safety and trust or distrust and incongruity. And it's that incongruity, in my experience, that children really react to. 

When you are saying something positive in a negative tone or when you're saying something negative in a positive tone, which I will call out Ð 

[0:43:53] EF: Speech therapists. 

[0:43:55] KM: No. Not speech therapists. I was about to call out OTs and then I have to pause because I was thinking, "No. I just think it's people that work with kids generally." We all tend to be like it's time to go. And the kid is crying on the floor. And the kid doesn't feel heard or seen by the Ôsing-songyÕ time to go. I hear you're upset. That is not signaling that you hear the child, right? So, they automatically mistrust you because of that incongruity between what you're saying and what you're doing. 

And, especially, if you are children who have language delays, that incongruity does not help with receptive language processing because they can't use their other sources of information. 

[0:44:37] EF: And there's nothing that pisses me off more than when I'm ranting about something and somebody is like Ð I love my sister so dearly. But sometimes I'll call her and I'll like be really hyped up and I'll be pissed off with something. She's like, "Okay." And I'm like, "What? You can't give me anything? I need something more than just, "Okay." It makes me so angry. 

And so, to think about helping children Ð because I will say to caregivers, too. From my perspective, the most important thing for a family, especially when they first come to see me for a child, is for them first to feel understood and then to work on them communicating. My job first is to understand them and to be attuned to what they're feeling and to help them know that the way that they're communicating something and the affect that they're using is valuable and is honored. 

And so, what I also find beautiful is like, first, I was like, "Oh, my gosh. Every expression I make is going to be Ð" and Karen knows my micro-expressions are like less micro. I'm very, very expressive with my eyes when I'm feeling something. But it also shows like even just a smile with your eyes. 

I do swallow studies and I work inpatient. And those aren't situations that like Ð those are really hard situations for families. And sometimes even just smiling at them and showing them that this place that I'm a safe person can make the world of a difference. 

And, honestly, I've been re-watching Gray's Anatomy. And something about McDreamy that is really great is he always smiles with his eyes at all of his patients, which now that we were talking about this, I was like, "Huh. He does a great Ð very trauma-informed, McDreamy." 

[0:46:30] KM: Hats off. But, no. that's actually something Karen Purvis talks about in TBRI, too. She talks about when you ask a child for eye contact, which we have to be careful about with our neurodivergent friends. Hear that with a big grain of salt. But when you are making eye contact with a child or when you're asking a child to look at you because we often do that to make sure that children are tuned into what we're saying, right? That's a natural reaction to be like, "Hey, I need you to look at me to make sure that you're paying attention to me." 

Again, grain of salt with neurodivergent friends. But she talks about you can never ask a child for their eyes if you're going to show them shame, right? If you look angry and they take shame away from your face. Then you haven't helped them. You've put them into a shutdown spiral. 

And so, she always talks about like soften your face. Smile with your eyes. Never ask a child for their eyes when you are angry. Because that's a normal reaction as a human. You're going to get frustrated with these kids, right? They do some stuff sometimes that either scares you or makes you frustrated. And anger is a natural reaction out of that. But you cannot ask a child for their eyes when you're angry because you're signaling to them that you're not safe. Because you're not in that moment. You're not in control of your emotions. 

And so, I developed a strong practice of any time I felt myself about to say, "Hey, I need you to look my way," right? Or, "Can I have your eyes?" That's what I usually ask children. Can I have your eyes and can I have your hands? That's a TBRI thing. 

When I felt myself getting to that point, before I said anything, I made sure to kind of rub a hand across my eyebrows right here. Because I realized my eyebrows go up when I'm stressed. And then just like kind of rub it down and smile. It kind of manually relaxed my facial muscles and I smiled. And then my tone would soften because I was making myself shift my mindset. 

And I will tell you, that there are so many kids who get used to not making eye contact with adults because they're used to only making eye contact in a place of shame. It's powerful when you can soften your affect and use your affect to use it as a place of connection even when you may have to be correcting something that's going on, right? You cannot throw paint across this room. I get it, buddy, right? But I can say that with a smile in my eyes and a smile in my voice so that they can hear the correction and not go into a shame shutdown. That's a TBRI side chat though. 

The other thing though, Erin, and I really want you to kind of touch on this because it's really valuable for speech therapists I think. And then, also, I really like the language you use around this, is talking about using affect to mirror a child's affect and then putting words to it to help them understand emotions. Can you kind of talk about the power of doing that and how it can tie into interception and self-awareness for a child? 

[0:49:34] EF: Yeah. And I just took, again, Kim Barthel's trauma-informed class, which like really Ð or trauma-sensitive course she calls it. Really reiterated what I've already felt. And Michelle actually was the first person that taught me this because I had a patient that I saw when I was her student. 

And I remember one day, he got on the floor and he had this meltdown because he was frustrated because he couldn't have a toy. And Michelle got right next to him and she got with her voice and she was like, "I'm mad. I'm frustrated. I can't have my toy." And he's like laying there next to there and looks at her and it's like, "Oh, you think you're mad too? Me too." That's like Ð I get it. 

And so often, I think we're afraid of these big emotions and these big feelings. What you learn is children who have Ð a lot of times when they have sensitive sensory systems, they also have sensitive to emotions. Because those are very, very much connected. And the way that we describe and the language that we use when a child is in a certain state of feeling and emotion can really, really shape how the words that they use and their understanding of how they feel. 

What I try to do is mirror the affect that they're using. Get on their level. Because we also have to think about where we are positionally. Karen and I, because of our training, we try to never be too often above a child especially when we're having these moments of connecting. Because when you're above a child, that can be as Ð you're using your power. Whether you're meaning to or not. 

And then with the same emotion and the same intensity, whatever that be, modeling, I feel in their voice and what you think they may be thinking. Every once in a while, you might be wrong. But if you've built this trusting connection, they're going to tell you when they're wrong. And you will be Ð I'm always surprised at like sometimes the level that a child will be able to let go of that emotion when somebody labels it for them. 

So often, it's not necessarily I want that toy back that you took away from me. Or that's not usually the solution. The solution is to be heard, and be felt, and be understood so that I can feel that emotion and it can process through my body. And also, to know that that emotion is not unsafe. 

Because so often, if a child's feeling an emotion and we disregard it or we try to shut it down so quickly, it can teach them that an emotion is unsafe. And there's a child I work with right now whose mom is fantastic. She could be a Floortime therapist. I have told her. And he has these big feelings and she's asked Ð she's like, "How do I help with these big feelings?" And so often, my advice is to teach him that you're there to work through those feelings, to hold space, and to label it for him. And that can reiterate Ð the thing that I've learned, these big feelings aren't going to go away. This is the reaction that their body has. They feel deeply. As we work through their sense Ð help them with their sensory system, they may be able to prepare themselves a little bit more so it doesn't have this big reaction. But we're not going to stop these feelings by ignoring them. 

The more we can label them, the more we can give words to these emotions that they have, the more they can understand themselves and then be able to communicate that before it reaches that point where they have that meltdown because they've been able to have the words to say it. 

And like I have so many Ð I love when a kid will tell me I'm mad or I'm frustrated. And sometimes I'll bring an AAC really early. And sometimes if they can even tell me, then they can move on with it because they're like, "I need you to know this." And I didn't have the words to say it before. And now I do. So, let me tell you about it.

[0:53:39] KM: Yeah. And we have a special role to play in just our children who are experiencing the world a little differently than others, right? We have a special role to play in helping them make meaning out of what they're feeling and doing, too. And I say that as an OT who really appreciates it when my speech therapy partners help me find the language for them, too, right? 

I can help them make the play make more sense. To interpret their world a little differently. To work on those social skills. But I need help helping them find the words. Because that's not my specialty. But they need those words to be able to do all the rest. 

[0:54:27] EF: And Kim will set Ð like, she will say, "In those situations, they then Ð"say, a parent is modeling it. They carry their parent with them. When you model that, they carry you and that situation with them to that next experience because it was so emotionally charged. 

It's honestly in those moments where I'm even more Ð I really have to check myself and be even more intentional with how I respond because they're going to remember that experience because it was so emotionally charged. And so, if that means you have to take a step back, take a breather so that you can show up with them in using the language you want to be using and being attuned with them, then that's okay. It's okay to take a second to make sure that you show up in the way that you want to as opposed to reacting really quickly. And then maybe responding in a way that's not as thought out as you would have wanted it to be. 

[0:55:24] KM: Yeah. Now, as we kind of wrap up this evening, I think one thing that I would like to leave you all with is just like a few quick, practical takeaways. Erin, you got any that are like how do I start doing this, right? How do I start being more intentional? How do I use affect? 

[0:55:45] EF: I think number one is you have to take time to get to know that child. I will spend some of my first sessions like really observing and watching more. Because you cannot be attuned with someone that you don't understand. And the way I explain it to parents too is I say, "It would be unkind and unfair for me to say that I understand you and your child after one session. For the first couple of sessions, I'm really going to start to take time to watch your child. To learn how they learn. And to better understand them so that I can show up and be the best therapist for them." 

Because like we talked about, it's not just about having a good personality. It's about adjusting your therapeutic use of self for the family and the child that feels right to you. There are going to be times where you have families where you're like, "We're just not a match." And that's okay. 

And I also think we didn't talk as much about this today, but like touch is such a valuable tool. That has to be used very intentionally. Because we have so many kids that have negative experiences with touch. But you and Dylan taught me so much about like just a handhold. Just the value that holding a child's hand when you're connecting with them can do Ð if they're comfortable with that, it can be very powerful. 

[0:57:10] KM: Kim taught me Ð and I'll try and describe this in words so people who are not online tonight can imagine it. But Kim is an NDT-trained therapist. She is trained in therapeutic handling and positioning. And she was telling me that, oftentimes, if you're just trying to touch a kid but not signal control, sometimes just holding the ball of their thumb, what OTs call their thenar eminence. Right here. Underneath their thumb. Just holding that with your hands gives you an ability to touch but they don't feel like your hand is covering theirs or you're restraining their wrist. 

But then at the same time, you can signal to them which way to turn and which way to move. And just that touch allows attunement without control. Yes, you're right. Touch is a big one. We could probably spend three hours just on touch and how to use touch and when not to use touch. 

My big one is practice self-reflection. Being aware of yourself. But also, my big recommendation is a scary one, which is record yourself and then watch it back and reflect. No one else needs to see it, okay? You don't have to go show it to everybody else. But you putting your phone on video in the corner of the room. Even if you don't record the video. Even if you just turn it around to the wall, right? And it's just the audio. Hearing your tone of voice and the way you're interacting and playing it back, especially if you're a home health therapist and you have time between sessions to kind of use your travel time, harness it for self-reflection and decompression. That's a big, big help. 

I think Erin and I will both say that recording ourselves is the biggest way that we've grown and the way that we continue to grow. And we will oftentimes give those recordings to people we trust for feedback as well. 

[0:59:11] EF: It's weird. But you get used to it. 

[0:59:13] KM: It's weird. It's uncomfy. But it's really worthwhile doing. It's very like mindfulness reinforcing. And then also lets you pause and slow down and be like, "Okay. I thought I was empathizing. But really sounds more like I'm instructing. And I need to work on like delineating when I'm empathizing with somebody and when I'm instructing them." Yeah, that's my big takeaway. 

[0:59:38] EF: Well, if you guys have any questions, we'll stay on for like five extra minutes to answer them. For those of you that have to leave right now, just make sure, if you want live credit for tonight, that you go on to Speech Therapy PD's website and take the quiz before the end of the day today just to make sure that you get credit for it being live. I didn't want to forget before people started to sign on. But if you have any questions, if you want to find us, I said this last time, but we're both on Instagram. You can message me on the First Bite Instagram or erinforward.slp, or our First Bite email, which Michelle gets those. But she'll forward it to me if it's a me or Karen-specific question. 

Yeah, I feel like when you start to dive into this Ð I mean, our job never gets boring. But it taught me a lot about myself to have to reflect on all of that. The good, the bad. Karen see me cry a lot. 

[1:00:41] KM: Vice versa. Vice versa. 

[1:00:43] EF: Thank you, guys, so much for joining us. This is basically conversations we have regularly. Sometimes I'll voice memo Karen if I like think of something or have an idea. Sometimes I just sit here and listen to Karen and I'm like, "I'm so lucky to have her on speed dial." 

[1:01:00] KM: So lucky to have found each other. Find your OT, SLP Ð 

[1:01:05] EF: Yeah, that's our other tip. 

[1:01:07] KM: The big pro tip is find yourself a friend, especially an interdisciplinary friend. And print for you to explore these concepts. So the concepts are Ð I linked the two articles that we were talking about. 

[1:01:20] EF: I'm trying to think what the website is. There's a website that has a really good Ð I think it's like Chicago. If you start intentional relationship Chicago. There's a really good website. If you give us a second. The quiz for the podcast should be in like where you went in to sign in to take the course. It should be in there underneath it. 

If you have any issues with that, you can email Ð let me see if I can put the First Bite email out there. I think it's firstbite@SpeechTherapyPD.com.

[1:01:55] KM: Okay. That visual is the link I just sent as well. That's got a really good model. And then the two articles we were referencing I already linked above. They are both AOTA articles. 

[1:02:09] EF: I put my email in there if you guys Ð if you have any questions or if something comes up. Yeah. It might be when it ends. If there's an issue and you don't find it when it ends, email me and I'll forward it to you. 

[1:02:23] EF: Yeah. Thank you all for joining us on Thursday. We hope you have a good weekend. Yeah. And we'll be back Tuesday and Thursday of next week. We're talking about praxis and language on Tuesday. And then Thursday, we're talking about the just right fit in therapy and finding joy in your sessions, which is wonderful.

[1:02:45] KM: Yeah. And that one, we're going to go through what OTs call activity analysis, which just might be a helpful interdisciplinary tool for you guys to think. I don't know. Might not be. But it might.

[1:02:59] EF: Well, thank you, guys. Have a good night. Bye. 

[OUTRO]

[1:03:03] MD: Feeding Matters. Guide system-wide changes by uniting caregivers, professionals and community partners under the Pediatric Feeding Disorder Alliance. 

So, what is this alliance? The alliance is an open-access collaborative community focused on achieving strategic goals within three focus areas; education, advocacy and research. So, who is the Alliance? It's you. The Alliance is open to any person passionate about improving care for children with a pediatric feeding disorder. 

To date, 187 professionals, caregivers and partners have joined the alliance. You can join today by visiting the Feeding Matters website at www.feedingmatters.org. Click on PFD Alliance tab and sign up today. Change is possible when we work together. 

That's a wrap, folks. Once again, thank you for listening to First Bite: Fed, Fun, and Functional. I'm your humble but, yet, sassy host, Michelle Dawson, The All Things PEDÕs SLP. This podcast is part of a course offered for continuing education through SpeechTherapyPD.com. Please check out the website if you'd like to learn more about CEU opportunities for this episode, as well as the ones that are archived. And as always, remember, feed your mind, feed your soul, be kind, and feed those babies.

[END]


FBP 252		Transcript

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