A Crucial Alliance: SLPs and Mental Health Professionals

This is a transcript from our podcast episode published March 1st, 2022. The podcast episode is offered for .1 ASHA CEU (introductory level, professional area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime.

A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible.

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Kate Grandbois: We're so excited for today's episode. I know I say that every single episode, but today Amy and I are welcoming a dear friend who we've worked with for a long time.

And before we introduce her, I want to tell a little story. You can see everybody's look, we're in a zoom room. Everybody's looking at me. Of course they are. But the little story is in, oh gosh, I think it was 2000. It was over 10 years ago. It was over 10 years ago. We were attending a talk, Amy, do you remember this?

And then we remember this cause we just talked about it. We were attending a talk about executive functioning and this woman, Beverly Montgomery was doing the talk and I was completely floored by how much knowledge she had, just so intelligent, so eloquent, so respectful and answering people's questions.

It was one of the best talks I've ever been to. And [00:03:00] I made her be my friend and Amy made her be her friend. And so we're so lucky to have her here today to talk to us about collaboration with mental health professionals. Welcome Beverly, 

[00:03:11] Beverly Montgomery: thank you so much. I'm so excited to be here. This is a big treat for me.

So thank you. 

Amy Wonkka: This is a very nice way to end the week 

[00:03:20] Kate Grandbois: and for dealing with that very long intro, that was quite personal. Maybe what you weren't expecting. That's okay. We'll move on. 

[00:03:30] Amy Wonkka: Beverly you are here to discuss various aspects of interprofessional collaboration within our field. Specifically the SLPs role in the area of mental health.

Before we get started. Can you just tell us a little bit more about yourself? 

[00:03:44] Beverly Montgomery: Yeah. So I am not actually super involved in mental health, per se. If you look at my kind of job description, it's not that I work in a specific clinic or hospital, it's just that to do my job, um, I have found that [00:04:00] this type of collaboration is essential.

So, um, I started off with a team approach because I was in the public schools for about 10 years, um, in a district-wide program as the speech pathologist, and then, um, had two kids and began my own private practice and decided to focus just on what I'm most passionate about, which is social communication and cognition and executive functioning.

And right now that private practice is Let’s Communicate in Lexington. And, um, I absolutely love what we do. 

[00:04:31] Kate Grandbois: You're so passionate about what you do. And I have reached out to you so many times as a colleague in the area, looking for guidance and advice, and you're always so generous with your time and knowledgeable and answering all of my potentially annoying questions.

So I'm so excited to take your knowledge and share it with whoever is listening. And before we sort of jump into the, all the fun stuff, I have to read our learning objectives and disclosures. So I will try and do that as quickly as possible, a learning [00:05:00] objective number one, state the purpose and benefit of interprofessional collaboration. Learning objective number two, define interprofessional education and interprofessional practice. Learning objective number three, describe a decision-making process for when and how to make mental health referrals. And learning objective number four, identify a variety of collaborative partners, both within and outside their organization.

Disclosures Beverly Montgomery's financial disclosures. That really is the owner and operator of Let;s Communicate. Beverly's nonfinancial disclosures, Beverly has family members with diagnoses discussed in this course and has a professional bias towards integrated collaborative social communication treatment.

Kate Granbois financial disclosures. That's me. I'm the owner and founder of Grandbois therapy and consulting LLC. And co-founder of SLP nerd cast. My non-financial disclosures. I'm a member of ASHA SIG. I serve on the AAC advisory group for Massachusetts advocates for children. I'm also a member of the Berkshire association for behavior analysis and therapy, [00:06:00] mass ABA, the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis, special interest group.

[00:06:07] Amy Wonkka: Amy that's me financial disclosures. I am an employee of a public school system and co-founder of SLP nerd cast. And my non-financial disclosures are that I am a member of ASHA's SIG 12, and I serve on the AAC advisory group for Massachusetts advocates for children. 

All right now, to the exciting stuff, Beverly, why don't you start us off by telling us just a little bit about this first learning objective?

What are some of the benefits for an SLP who's collaborating with mental health professionals? 

[00:06:37] Beverly Montgomery: Well, first I think number one, you can feel good that you're just doing your due diligence and following the ethical mandates as set by ASHA and other organizations. Um, it's, it's a mandate that ensures that you're providing the best possible care.

And I absolutely couldn't do my job without this kind of collaboration right now for my current [00:07:00] caseload. I probably am collaborating with 15 to 20 different professions. And a lot of those are in the realm of mental health. Um, I think that if you are treating anybody who is a child and you have family systems things going on, you have grief.

You have, um, co-parenting conflict going on. The, if you have, or if you're treating voice, if you're treating, um, you know, anybody with fluency, if you're treating anybody in geriatrics, in a medical setting, cancer, I actually can't really think of a setting where you would be isolated from the need to, um, reach out to a mental health professional at some point, because we can't operate in a vacuum.

Right? So communication is by nature, social enterprise, um, which means that it has to do with our relationship with ourselves, but also our relationship with other people. And as soon as you've got both of those [00:08:00] things at play, I think mental health is going to come into the picture at some point. We also know that people with emotional and behavioral difficulties are hugely underserved and underdiagnosed when it comes to speech and language difficulties. So, um, there's also a very good chance that someone who is being seen by a mental health professional as their primary provider in fact has a challenge that would fall under our scope of practice.

There was a meta analysis that was done that suggested that 81% of individuals with emotional behavioral disorders have at least below average expressive language abilities, if not language disorders, we've also seen really disturbing studies come out of, um, juvenile detention centers and things like that.

So we know that this is an area where a lot of times, because of behavior or things, um, language disorders are being [00:09:00] misdiagnosed and missed and when they come to us and they already have a mental health concern, we can't really treat without understanding where their treatment journey has started. So that's another reason to collaborate.

[00:09:14] Kate Grandbois: That makes so much sense. And it's reminding me a little bit of some of the things we've talked about in previous episodes related to counseling and how we don't necessarily get explicit counseling as speech pathologists, but, and I'm literally quoting David Luterman here. And what he said in a previous episode with us is so much of what we do is grief work.

And without the direct training to provide better counseling service, I have to imagine that engaging in some of this transdisciplinary work, when you are collaborating with a mental health professional, to either help you with those skills, provide you with those skills, train you in those skills, give you a referral is a critical piece to bridge that gap between the work we [00:10:00] need to be doing and our own competence in this area.

[00:10:03] Beverly Montgomery: And I think that, you know, we'll talk about this a little bit later, but I think that that's a really key indicator for a referral is if you feel like a significant amount of the work that you're doing with your client or patient or family is mental health counseling, instead of, you know, within the scope of practice of speech pathology, that's a great time to get a second opinion.

You know, there is so much gray area, no, especially when it comes to the type of work, um, that many of us do in terms of identity and in terms of social and pragmatics and, um, you know, fluency and how people see themselves. And then the coping mechanisms we develop and the anxiety and depression that often go with those that it's, it's really hard to know, you know, where those lines are.

And in my experience, they're very very, you know, gray it's, it's not a [00:11:00] clear picture. And one of the ways that I have found to be most effective in making sure that I feel like I'm operating a hundred percent within my scope of practice and expertise is by having that discussion with a mental health provider who will then say, Nope, that's not what I do.

Or, uh, yes, that sounds very much like what I do. And I can take on this part and then you can take on this part and we'll work together on where they overlap, which to me, as a clinician feels much better and less overwhelming than feeling like it's all on my shoulders. Another great David Luterman point is just that, you know, a clinician who needs to be needed is setting themselves up for trouble, right?

And our goal as clinicians is always to not be needed. And if I'm feeling like as I'm working with someone they're needing me more and more and more and more, that's another good sign that it's time to bring in another provider. I think another reason to do this is because our jobs are really hard [00:12:00] and no matter what setting we're in, there's not enough time to do what we're expected to do.

The, I think the biggest barrier to doing this is time and funding, right? You know, indirect service doesn't get funded, um, in the same way and tracking down people, making phone calls, setting up times to talk. Those are all things that we're not given time to do no matter what our setting is. What I will say is that the amount of time I spend in the effectiveness of my treatment is absolutely proof that it pays off and it's worth it because I save more time in the end with that collaboration, just because I'm so much more focused in my treatment because of it.

And because I don't spend the hours and hours researching and doing things to make sure I'm doing things right. If I'm worried that there is this kind of counseling piece that I'm addressing 

[00:12:53] Amy Wonkka: well, and we've talked a lot on the podcast too, just about the idea of us having a scope of practice. And then within that scope of practice, [00:13:00] we have our own scopes of competency.

And so I think you brought up a lot of really good points. Like sometimes it's very clearly just not even within our scope of practice. Right. And there may be times where some of the work you're doing could be in your scope of practice, but it's not in your scope of competence. Um, and so. We're big proponents of collaborating with other professionals so that our clients get the quality service that they need.

Can you talk to us a little bit just about interprofessional education? An interprofessional, I think that that's going to help us talk a little bit more about kind of what this looks like and how you may collaborate differently with different mental health professionals.

[00:13:39] Beverly Montgomery: Yeah. A lot of the collaboration I do is not even kind of, um, direct consultation regarding an individual student.

So what it might be is more what would be considered interprofessional education. So that's the IPE part, which the world health organization defines as activities [00:14:00] that are two or more professions or professionals from different fields coming together to learn about, um, learn from, and learn with each other so that there can be effective collaboration and, um, outcomes can be improved for the individuals and families that you serve.

So I do a lot of that when it comes to the social work that I do in terms of not as a social worker, but social cognition and social communication work that I do because a lot of. People in the mental health field, don't understand why I'm seeing people to work on social and I'm seeing them individually.

And so there's a lot of education that goes on about how, you know, it, it could be that if I'm working with someone, for instance, who's really struggling with impulsivity that having them with peers that may be reactive to that impulsivity may not serve them best in learning the skills they need to then be successful with peers or that, you know, if anxiety is a major issue, being in a group with other dysregulated [00:15:00] individuals that have similar challenges might not be setting that individual up for success.

So on the surface, a group might be the recommendation, but you know, after a discussion that professional might say, you know what, actually individual would be great because that would be starting from success. They do really well with adults right now. So if we could build the skills they don't have starting from that point of success, then we could work them into a group.

Oh, I see what you're saying. And then they can help me figure out. Okay. So what does set them up for success in terms of challenging them? You know, like what are the motivators for this individual or, you know, a lot of what we get into with individuals who've have a history of social challenges is there's a lot of shame.

And, you know, a lot of times I don't recognize that that's, what's at play. I had a little guy in my office and, um, he had a super hard time with a game and it turned out it was because he had played that [00:16:00] game two years ago in school and kicked a peer. And there was a lot of problem solving around it and he was still feeling so much shame about it, that just seeing the game on the table really dysregulated him. 

And my framework for behavior is much more in terms of looking at what the antecedent was like when he's like walking into the room. And I wouldn't have known the two year antecedent piece that would have helped inform how I responded to that behavior. So that education piece is really important. Um, another huge piece is psychiatrists and medication.

So if you're in long-term care, this is a really, really big one. Um, understanding what medications your patients are taking and how that impacts them. And, you know, may even be at the level of like a chemical restraint at that point. But a lot of the school age, people I see are on medications that are off label for them that have side effects that impact [00:17:00] their functioning across the day. I absolutely am not up on medications that are coming to market and I'm definitely not up on off-label use for prescription medications. Um, so I really look for help. And get a lot of help from, um, psychiatrists in that area. So those are, that's kind of a little bit more around like the education piece.

The, uh, IPP is the interprofessional practice. Um, which again, if we use the world health organization definition, that's where you're having people from different professional backgrounds, um, kind of as a treatment team. So, um, people are providing a comprehensive healthcare or educational service by working directly with individuals and their families.

So that's more of what you might see in a school or hospital setting where you've got a multi-disciplinary team of providers that are all working with the individual. And so really your [00:18:00] collaboration is around that individual versus around, you know, Tell me about what Ritalin does when taken by somebody with really high anxiety.

Right? In one case, I would be asking you about a specific individual and the other I'm seeking to understand a little bit more, what stimulants do to somebody who's stimulated by anxiety. 

[00:18:22] Kate Grandbois: I think that discussing medications and with our students and clients is so critical and something that I'm not sure is discussed often, at least not in the works places where I've been, unless there's, you know, a significant change in medical status where, oh, it's, this is new information, but some of our students and clients maybe, maybe have been on medications for a long time or the information isn't forthcoming from the caregiver or parent.

And it can have such an impact on communication and alertness and fatigue. And. Everything. I had a student whose [00:19:00] medication was making them really thirsty and they started having some toileting accidents because they were so full of water all the time and using, needing to use the bathroom more frequently, but their communication system was not set up.

So they weren't asking for the bathroom. And all of a sudden it became this huge problem, but really stemming for the medication. The educational team attempted to address this from an educational lens at first, before, and I think maybe like a whole week or two went by before it was like, oh, there was a note in the L in the home lab.

Oh, by the way, we're going to see so and so for all the, all the urination and all the, the, the thirst they have pervasive there is. And it was because of this medication. And as soon as the medication got changed, it was no longer an issue. But just thinking about the educational resources, the clinical resources that went into this, and if we ha, you know, by some miracle had different workplace restrictions or a different workplace settings, and more open channels of communication [00:20:00] with mental health professionals, medical professionals, so much of what we do, it's sort of like we're in the dark with a flashlight, but we need a floodlight to sort of see some of these other variables.

I wonder if you have any thoughts or suggestions around communicating with mental health professionals, particularly I think psychiatrist is where they, where my head is that because, or where my question is coming from, because they can be very difficult to get a hold of not only that, but as SLPs, depending on our workplace, we don't necessarily have, you know, just the 30 minutes to burn in the middle of the day where maybe we can make a phone call.

I mean, do I need to make comments about how we're being told to cry in our car? Probably not, but I just did anyway. I mean, we just don't have the time. So when you start talking about these critical conversations with mental health, it seems like it's even more insurmountable. I wonder if you have any thoughts or suggestions on that? 

[00:20:56] Beverly Montgomery: Yeah. So as school based setting, it [00:21:00] can be really hard, the medication piece, because, you know, unless the medication is administered at school, we may not even know. And that's true obviously in private practice too, in the sense that it is, you know, up to the parents to disclose the medication piece.

Although I think it's, there seems to be more of a barrier between, um, parents and school-based providers sometimes then, um, private practice just because they're not individually selecting those providers they're assigned to them. So in that case, the school nurse can be a really good advocate for you and help you with that.

And what you can do is just jot down three or four words that you're noticing during your session that either seem off or different. I've seen kids with, you know, definitely hunger and thirst differences because of medications. Um, definitely behavioral changes, definitely things like ticks throat clearing, like a horse, a raspy quality to their voice fatigue.

You know, there's lots of things. If it seems off for what you are used to for that given [00:22:00] individual, and you're seeing it across more than three or four sessions, then it, it bears, you know, investigating. And, um, if you can ask the nurse, if they're aware of any medications that the student is on, very often. what I find is that if I don't have more than five minutes, and if I have one question for a psychiatrist and it's about a medication that's specific to their client, not that I want to consult with you about X student, they usually find a way to make that five minutes for me. And neither of us has more than five minutes to talk.

So, um, you know, I think if usually with few exceptions, They have actually been very appreciative because it's not necessarily something the parents have seen because they're not seeing them in that setting. They're not seeing them consistently at that time of day it's information they don't have. So, um, you know, if you can make it very focused to what they're providing for your students and keep it really short and sweet, I have [00:23:00] found more success, but if not, then having the school nurse reach out through the pediatrician can also be a really good way to go.

Um, and then you kind of get the communication through trickle down, but the point is you're still getting the answer to your question. 

[00:23:14] Kate Grandbois: I love that suggestion of going through the school nurse. 

[00:23:17] Amy Wonkka: I also, you know, I think it's, I think it's always an interesting conversation that's worth having and the separation that we sort of do in our culture between like physical health and mental health.

And I think the medication is a really interesting example of where something that we may be doing. Something we've sorted into the mental health box affects something in the physical health box, but ultimately the more information we have to, whatever degree is necessary for our client and like, based on their preferences and their family's preferences, if there are pediatrics, um, in terms of what they want to share.

But that, I mean, that is going to help us, depending upon what our collaborative goals are, you know, what their goals are, what we're all working on together. [00:24:00] Um, and so just having an awareness of all of those things, just like we want to know, we want a recent audiogram or hearing screening, or we want to know, you know, what's going on with somebody's visual system.

Those are all going to affect what we're doing and how we're presenting information in therapy. I dunno. I think it's, it's an interesting thing that we do here to, to separate those things out and make them very separate and different.

[00:24:25] Beverly Montgomery: Yeah. And I think it's a challenge, you know, that we're, that we all have to deal with.

I think the other, the other piece is that if you are coming from a truly curious and student or patient centered place, and you are asking a specific question based on your observations, that does not communicate judgment about whether or not there's medication involved, that's going to lead to a much higher chance of success than if the parents feel like this is a litmus test as for whether or not they're doing the right thing for their kids by medicating or not medicating. I cannot [00:25:00] prescribe medication. Therefore I have no opinion on whether or not you should be giving your child medication. What I can tell you is what I have seen through my clinical practice and what research tells me about medication. So, you know, that is my answer to parents is that, you know, what I can tell them is what I have seen and what I've read and, and what we know from the science.

And then, you know, ultimately my job is to support them as parents, but whatever choice they make, the reason I need to know is X. And when I, again, I'm very specific about the types of things. Parents aren't necessarily aware that something like hydration and a 30 minute session would matter. Right. Like, why would it matter if they're more thirsty?

They have a cup on their chair, so why does it matter? Like it's not their job to know what I need in my session. And so again, the more I can keep it very specific and focused to why I need to know versus asking a broad question. Like, does the student take any [00:26:00] medication? The more likely I am to be successful and communicate to the parent that this is a treatment oriented question and not a, um, judgemental or, or booby trap kind of question.

[00:26:13] Amy Wonkka: I think that's such a good point. And we've had speakers on before who have made the point that like, we don't necessarily need all of this nitty gritty information about people when we're doing an assessment or something like that. We don't need to find out the intricate details of what a family does in terms of medication or different things like that, unless it's relevant to our treatment.

And by having a conversation about why and how it's relevant, that's going to help us with the families. But it's also going to help kind of circling back to our first two learning objectives, like in maybe the interprofessional education that we're seeking out. If we have a lot of questions about medication and how that might be affecting our clients and all of these different ways like that could be, maybe we go to a talk on that.

Maybe we listen to some [00:27:00] pharmacology podcasts and try and make our way through understanding. Yeah. But we're looking for that information. Outside of our field, but to inform our practice within our field, um, you know, it brings us back to the recommendations around evidence-based practice. Part of what we're doing when we're doing evidence-based practice is we're formulating that clinical question.

And so we may be wondering, geez, I have a lot of people on my caseload who might be taking a medication. I want to know, maybe I want to know what types of medications are more likely to result in X type of effect on my client, because I've seen these different things. So that would help us pursue that IPE piece.

And then the interprofessional practice is more what I think of when I think of interprofessional collaboration. I think about that like collaborative team and part of that's probably just places where I've worked in my professional experience. Um, but that might help ask, help us, like better collaborate with those members of the teams as well.

I had questions [00:28:00] about, so if you have that team in place, then we know how to like form those thoughtful questions for those people. But what if you don't have that team in place, but you feel like maybe you should.

[00:28:08] Beverly Montgomery: Yeah. So I think, um, One of the, uh, this is going to obviously depend on who the person is.

So I'm going to start first because I tend to see more pediatric clients than adults. I see both, but I have more pediatric clients. I'm gonna start there and then we'll, we'll switch to adults. But I think for pediatric clients, you start with the parents, right? And the, and the question there that we might have is, you know, you do need to know if there's other providers.

And again, the more you can tell people why you need the answer to a question when you ask the question, the more freely they may be able to give you the answer. So for example, when I say, I want to make sure that, you know, my treatment approach is consistent with other providers. Are there other providers that the individual is seeing and then, you know, obviously they would need to [00:29:00] sign consent for you to communicate with those people.

One of the reasons why I have a social worker on staff is because I feel like the vast majority of my caseload, which are usually people who have been unsuccessful other places and have been labeled as difficult or too complex or a mystery or whatever else. That's kind of how they usually end up on, on my doorstep.

And at that point, you know, a huge amount of those individuals need two services. And so you, you build the team because you see a need for it. And that can happen either through, again, going back through the pediatrician. Their school systems often have, um, you know, uh, contracts with, um, mental health search providers so that they can call one number and then that individual helps them find somebody who takes their insurance. And, um, and then, because you've kind of been on the journey with them, they're much more likely to share that information when they find a [00:30:00] provider with you. I have a lot of mental health providers that refer to me because they get the individuals and they realize this actually isn't a mental health concern.

It's a speech and language challenge. So it goes both ways. Another way that you build that is by being interested. So when you get a neuro-psych report, if there's a significant portion of that report, that's addressing a mental health concern. And the individual who did the testing is probably, you know, a neuropsychologist, follow up with them.

I just read a report again, get your consent. I just read a report by that you did by so-and-so. Is it going to be easy to get ahold of them? No, but if you let them know the specific question that you want an answer to, when you leave the message on your, on their voicemail, I have never had someone not get back to me eventually.

You know, like we're all super busy. None of us have the time, but again, I also don't have the time for a long conversation. So it's not that I'm looking to consult for a half an hour on a [00:31:00] on a student either. I read this report, all of the ratings on these behavioral or emotional ratings were clinically significant, but I didn't read anything in the presentation that suggested that what was the followup like with the parents?

Because they weren't clear on it. I asked the parents first, if they're not sure I get permission to, so you start building kind of your own team, even if it's somebody you only talk to once. The fact that a speech pathologist reaches out to a neuropsychologist, sticks out to the neuropsychologist too. And so I've also had it be where people are much more likely to, um, assume there's going to be a communication with me if they hear that I'm one of the service providers, because they know that I'm annoying.

And I'm going to follow up with a question that I had, um, but, but the point being that they also know what's going to be short and brief and that I don't have time for more, you know? Um, so I think the way that you build the team is curiosity and focus, staying [00:32:00] really focused on that clinical question and then being a little dogged about it.

You know, you might have to leave two or three voicemails, but in my experience, the voicemails don't take very long. So that's, you know, and then once it's scheduled for the five minutes, you do your five minutes and you're done, then you have your answer. 

[00:32:17] Kate Grandbois: You've mentioned as we've been talking, you've mentioned a variety of different kinds of mental health professionals.

So we've talked about psychiatry. You've mentioned social workers. I wonder if there are other flavors of mental health professionals that you've worked with that you want to tell us a little bit about aside from the obvious ones we've mentioned. 

[00:32:37] Beverly Montgomery: Sure. Um, so depending on what family you're working with, there may be addiction specialists involved.

You may also have equine specialists who are in the mental health field for a lot of kids who are doing like hippotherapy and using horses. And, um, there's also a licensed marriage and family therapists that are doing similar work. Um, there's guidance counselors at [00:33:00] school are school psychologists, um, and, um, I think I also, I also kind of consider mental health to be wellness in the proactive sense.

So, um, it may be, you know, a yoga instructor. It might be a, you know, a mindfulness coach that the family uses. It could be a, um, you know, I actually had a conversation recently with an aroma therapy specialist who works with one of my students, um, because I wanted to find out what that was about. 

[00:33:33] Kate Grandbois: And I think the, I think one of the points that you're making that I absolutely love is that it's not our place to decide what the other professional is, is providing.

So when you say aroma therapy specialist, it's like, oh, well, that's significantly different than anything I know about. That's not in the realm of science that, that we are aware of in our profession, but if it's a stakeholder for the family, it matters. And that's, that's the [00:34:00] point is that when you're really engaging in person centered care and family centered care, if it's an individual that is providing service, no matter what, the services that the family has stake in, or that they have stake in, in the family's wellness or the student's wellness or the child's wellness, then it matters. And it's worth your efforts to collaborate. I also, I actually recently in a different podcast episode, it came up that sometimes, um, we do share this scope with, with mental health professionals, like sharing language with neuro psych or sharing executive functioning with the school psychologist and how sometimes that relationship can be more prickly than it needs to be.

In terms of, you know, who is, who is out of the two of you is treating the issue. And I also love the perspective you bring up, you know, sharing an area. And I wonder if you have any, um, before we move on to our next learning objective, if you have any suggestions [00:35:00] for managing some of those relationships for a shared scope of practice?

[00:35:04] Beverly Montgomery: Yeah, I think it may sound a little bit simplistic, but again, nobody owns these scopes of practice, right?

There's a reason why they overlap and that's because we have different perspectives on it. So if you can, um, approach it from a place of curiosity and not assume that, you know, your way of doing it is the more correct way. If you genuinely want to find out how the person is working on executive functioning, I have not had, I've had a person tell me they don't time to tell me, but I've never had a person who is prickly about my asking if that's genuinely why I want to know if the reason why I'm asking is cause it's like kind of a passive aggressive way to tell them, I don't think they're doing a good job, then that's going to meet with a prickly response.

Right. So I think if you can approach the work with curiosity that has something to do with it, I think also you can agree to disagree. So you do have different professions and it's okay to be. Like [00:36:00] the way someone's addressing it in their work and to like the way that you're addressing it and your work, and to be like, wow, I wouldn't do it that way.

I'm really glad he's getting both, you know, like it's not your job to make the school psychologist work on speech pathology stuff. They don't have the training and we don't have their training. So there's plenty of work to go around and there's plenty of kids who need help. So nobody needs to own the work.

You know, I think, um, I think the other, the other part of that, that you mentioned earlier was just about, it's not our job to judge, you know, I absolutely give my science-based opinion whenever I'm asked for an opinion, but if someone's just sharing that this is a provider that they have, um, then they're not asking for that.

And I think it's my ethical obligation. Obviously, if I think there's any potential harm to indicate that. But otherwise I think it's kind of due diligence to find out. Evidence-based is based on the progress of the individual. So if, even [00:37:00] if we don't have a scientific base saying that best works for people with this profile in general, but we have individual data that for this individual, it works, then, you know what that's evidence-based like for that individual, we have evidence that this is working and we need to learn about it.

[00:37:19] Kate Grandbois: We’re fist pumping. Nobody can see us. We're like, yes, internal data collection is still EBP.

[00:37:25] Beverly Montgomery: I love data. And that's a way that honestly, that I help a lot of mental health professionals. They have that, um, they have not had the training in their field around data collection and writing measurable objectives around, uh, you know, the work that they're doing.

Um, and often there's overlap with the work that I'm doing and that's an area that I can help with where, you know, I, I can help them with the language that they're using and, and really being specific around what it is that they're measuring. How do you know? Um, because it is a different type of work. 

[00:37:56] Amy Wonkka: It really is.

And that integration of the internal and external [00:38:00] evidence is ultimately, I mean, if there is external evidence and there are studies that show something's effective, we still want that internal evidence to make sure it's actually effective for our clients. Um, we've talked a lot on this podcast just about the fact that most of the research studies are not done through the lens of imitation science they're done in a research setting.

And so it may have been effective for those people who were in that study and that doesn't necessarily translate to our clients. So these are, these are important things to do, whether or not you have that external evidence.

[00:38:36] Beverly Montgomery: Yeah. And the more complex your individuals are, the less like the study participants that are going to be, because we, you know, in a study, we want to be as careful as possible, not to have confounding variables.

So many of our patients, students and clients are confounding variables. They have lots of complexities, which [00:39:00] make them not ideal for a study. Um, which makes it really hard if we need to find research based evidence, um, on them specifically. 

[00:39:09] Amy Wonkka: Yes. And when we're talking about lower incidence populations and everybody has their unique variables that may or may not make this approach in this study, be a perfect fit. That's, that's part of why we're there as the clinician and part of why data collection is so important. And I love data collection too.

[00:39:28] Kate Grandbois: I also wanted to bring in what, since we're talking about the EBP and our evidence-based practice triangle and speech language pathology is just to sort of remind our listeners what it looks like and the three components.

So we do have this component of evidence, which is comprised of external evidence and internal evidence. So the research articles and the internal data that you collect, we have our clinical judgment. So based on our experience and the best available information, what our is, our clinical opinion. And then the third piece is client and family values.

And this sort of speaks [00:40:00] to what you were saying earlier about not placing judgment, because if it is incorporating client and family values in, into our practice is still evidence-based practice. And I think sometimes we get hung up on the external rev- evidence, and we think of EBP as a research article.

So like where's the research. I need to find an article that says X, Y, or Z, but that's not, it's an integration of all of these things. So I, I love your perspective. Just sort of anchoring this back to our learning objectives and topic, your perspective of collaborating with mental health professionals, across a variety of perspectives and across a variety of trainings and making sure that we’re understanding how our EBP triangle and client family values and internal evidence relates to that collaboration.

And that's really important.

[00:40:57] Beverly Montgomery: And I think that's again where we're going to save time. [00:41:00] Right? So treatment planning is a significant amount of my time. And the more I have this information, the more informed my treatment planning can be versus spending lots of times kind of trolling through articles and things like that.

Looking for what should I be doing with an individual with X, right. Instead saying, this is what's working. This is, what's not, what's my clinical question. How do I answer that? And then there's my treatment plan, right? I think it's a different approach than many of us were taught. So it can feel a little uncomfortable, but at the same time, from a time perspective, it can be much more kind of cost saving when you bill yourself for your own time.

[00:41:43] Kate Grandbois: 1000%. I wonder if you can just, I'm just looking at our learning objectives. I'm wondering if we can start talking a little bit about decision-making in terms of working with families who are experiencing grief, [00:42:00] experiencing trauma, seeking additional help, or maybe you've identified that they might need additional support, but maybe don't know it.

Or there is a lot of tenderness and there's a lot of, you know, they're in a, in a fragile place. What are some of the decision-making procedures that you go through to tackle or address these issues and potentially make a referral? 

[00:42:24] Beverly Montgomery: Well, I think I spoke earlier about, we're gonna speak about adults late here, and I'm not sure I circled back to it.

So I'm going to tie that in here too. I, um, I think the way that you build a team for adults is, is different, right? Cause you're not going to go through a pediatrician or something like that. So with adults, what I do is, um, again, um, have that intake or that evaluation. So as part of that process, I'm going to find some information.

And then the first few sessions, um, you know, aren't going to be diagnostic sessions too, to see if kind of my clinical hypothesis is correct based on the evaluation or in tech [00:43:00] intake. And that's where I will kind of hold up a mirror for the individual and say, you know, I hear you talking a lot about how hard it is to do the homework between sessions.

And I'm wondering what you think gets in the way. And if they're talking about the fact that it's just really hard to do anything, but get themselves out of bed and to work. And then, you know, like they have to force themselves to eat dinner and then they just, it's just one more thing they have to do, boy, that, that sounds kind of like a depressive, you know, individual to me that, that sounds like something I might want to ask more about.

If they're saying that the reason they can't get to whatever the tasks are in between sessions is because, you know, they're taking care of an aging parent themselves at home. And, you know, there's just not enough time in the day. That's a beautiful invitation for me to say, so who do you have for you?

Because I'm X and then describe what your role [00:44:00] is, but who do you have for you? Because you're a caregiver and, and that, so that's kind of how you build that team is, is in partnership with the adult. Or you can even say, you know, have, has there been any. Of therapy that you've ever done, that you found either effective or ineffective and really listen to their responses.

Um, A. it can give you really good information if you hear about lots of awful treatment providers they've had in the past, that's really good information to have. Um, if they tell you that they had this really fantastic person and then it never really worked with anybody else. Well, okay. That's good information too.

Um, or if this is the first time as an adult, that they're getting any sort of support, that's super important information, too. So just being able to, being willing to ask that question, but ask it broadly enough so you're not just asking about speech therapy and again, indicating you know, why it's helpful for you to know that you could probably shorten the, um, you know, potentially shorten the [00:45:00] number of treatment sessions, if you know what's most effective for the individual. 

Thinking about, um, parents, I think about it from two lenses, right? You might be making a mental health referral for the parents themselves or the family as a unit. I am a strong advocate for sibling groups. I think a lot of our really complex individuals have siblings that have really complex lives that need support. And there's a couple of good sibling groups out there for that type of support.

So I share those resources with families. I also think that being a parent is really, really hard. I was a great mom until I became one and figured out that I wasn't, 

[00:45:42] Kate Grandbois: oh my God. Can we both say that at the same time? Because that is the truest statement of the year. Parenting is just hard. I think about some of the things I recommended before I became a parent to other parents and I just didn't know how hard it was.

It's exactly what you just said. Sorry. It's just this [00:46:00] personal soap box. I couldn't help but stand on for a second. 

[00:46:03] Beverly Montgomery: So true. And then, you know, you're, co-parenting with, it doesn't even have to be, you know, a spouse or a partner. You, you could be co-parenting with a nanny or co-parenting with, you know, um, uh, extended family that all lives in your house.

If not, everyone's on the same page, that's a whole nother, you know, there are so many dynamics and, and we don't learn anything about family systems in our, in our training, um, which is a whole nother reason kind of to refer, but also just grief. You know, everyone's grief process is different. And I talked to so many clinicians who are like, oh, the parents are just in such denial.

And I, and I understand why that's frustrating as a clinician, but it's also information, um, for you and rather than being frustrated with the fact that they're in denial, maybe giving them some resources. You know, and, and so then the next question is, well, how do you do that [00:47:00] without saying, oh geez, you seem messed up.

You, you know, you need some help. Strike that one. Um, but like, how do you say that without seeming like you're going outside of your scope of practice or, you know, I think it's coming from, again, an observation holding up a mirror, you know, what? You look so tired and, and like, you know, I know that X, Y, and Z are things that Jimmy or whatever the kid's name is requires, but that takes such a toll.

It's easy for me because it's my job. And I don't have the emotional piece. What's it like for you? If they identify to you that they are significantly struggling, it's okay to meet them in that place and kind of bear witness to that pain and say, how about we see if we can get you some more. And just leave it there.

You don't have to know who the right person is in that moment or whatever, but just, I think we, we, as clinicians want to solve things. [00:48:00] And so it's really hard to see somebody who is in a challenging place if we don't have the solution, or if we know that that's just comes with the package, right. Kids with really significant needs are going to be even more challenging to parent.

Right. So some of that's to some extent expected that doesn't mean we can't do what we can. And honestly, I've never had anybody be insulted. That's everyone's fear is like, what if they're insulted? If it doesn't feel like a good fit for you, it probably isn't. So that probably isn't the way you would say it.

The point is to take the cue from the parent, right? You're not coming and saying, you know, I think it must be tough having this child, so you should probably get some. You know, you are again, holding up a mirror or reflecting things that you have observed just like you do in your reports or in your soap notes or whatever.

You're making a direct clinical observation and sharing it, and then creating an opportunity for [00:49:00] that parent to share if they don't, they don't, and you don't need to go beyond your kind of scope to make guesses about what's going on, but if they do share, it's also okay to be with them in that vulnerable moment.

I think that's part of working with the family is the closer you can stay to your therapeutic agenda with the child. The more authentic this request or advice is going to become. So, you know, oh, it came up in the session that, you know, so-and-so is having a really, really rough time with their sibling and that, um, You know, they're feeling really badly because they've said they're going to kill their sibling so many times in the last, and we know sibling relationships are tough, but have you noticed that that's been tougher than, than usual? That pertains directly to my work and yet is also in invitation for more information, right?

[00:50:00] Again, I'm not looking for more people to give therapy to or to, to, you know, refer, refer out. But when something lands in my lap, I feel the need to address it. Um, and I guess that's the way I feel about, um, about this is if you had a sense that your progress is limited because something is getting in the way of their ability to access the work that you're doing and that something is depression, anxiety, identity issues, family, you know, systems, sociological issues, you know, poverty, your home conditions, all of these things are things that we can get the child help with. And then you can get back to focusing on your therapeutic agenda. I think you also have to, when the only caveat to that is not getting too far ahead of the parent.

So would I have any of these conversations the first time I meet with them? No. You know, I think you have to have a relationship with the parent first and maybe they're having an off day. Right? Like [00:51:00] I'm not going to tell every parent that walks in the door they look tired. Cause I look tired all day, every day of my life.

Like, that's 

[00:51:05] Kate Grandbois: I was just going to say, can anybody see me right now? Or are you talking about me? That's also a human condition. 

[00:51:11] Beverly Montgomery: You know, I, I think, um, I, and then the other caution I would say is just to. Maintain as much as you're going to a somewhat personal place, maintain your professional role. So, um, as you're doing that, you're doing it as a professional who yes cares. Um, but it's not their buddy or their friend or, or, you know, um, you're not there to provide comfort in that moment. Um, as much as you are to be a resource in that moment, which may provide comfort, right. But then there's this kind of a subtle distance. It's not your job to kind of jump in and problem solve.

And this is a really hard one for me, because like I said, I, I, I want to solve it. Right. I, but I think that's where we can sometimes get a little ahead of where the parent is. And then with adolescents, [00:52:00] I address it with them and with their parents. And, um, I talked to them about, you know, I hear a lot of, I had this conversation, I'll give an example of a conversation I had, um, this week with one of my teens and, you know, he was really conflicted about the fact that he knows what the quote unquote right thing, or, you know, expected thing to do would be, but it just feels wrong to him.

And he said, you know, is this my autism? Is this, you know, is it my autism that makes us feel wrong? And he's like, or maybe it's my add. Or maybe it could be the anxiety too, you know? And, and I said, well, I'm not sure it's super productive for us to try to figure out why it feels wrong. I think it's pretty profound that, you know, it feels wrong. So do you know what feels more right? And he said, yeah, I think I need to tell this teacher that it's not professional to be giving students resources that were published [00:53:00] before they were born. Like that is just bad educational practice. And I said, okay. So if that feels right, what feels like the right way to do that?

And he's like, well, if you're not being direct, you're not being honest. And I know we've talked about honesty and feelings and all that, but that's just how I feel. And I said, okay, so again, we had this sort of counseling session right about it. But what he's struggling with is, you know, this is what feels right to me.

I'm old enough to know what the rules are and what I'm expected to say, but I have this internal conflict. Right. And so, and then at the end of the session, you know, he said, um, I think maybe if I tell the teacher that because of my autism, it's really hard for me to get over some things, she might take the news better when I tell her that her resources are crap.

And I said, and, and I said, well, I'm not [00:54:00] sure you can absolutely put it that way if you want to. But I think the more important part was that you were being honest about how it felt to you and you had a suggestion and how that would help you learn. And I said, you kept it about you. You didn't make it about the teacher.

And he said perspective taking, I know, I know. And this is the guy I've been working with for 12 or 13 years. So he's known me for a long time. So, and then, um, and he's like, this neuro-diversity stuff is really tough. And I said, um, and I said, it is. Um, he's like, cause everyone says you're supposed to be you, but then you're also supposed to be like, who the world wants you to be.

And I said, you know what? That is really tough. And I said, and if you ever want somebody else to talk to about that, you know, I'm sure that there are people that are really good at that. 

Kate Grandbois: What a profound statement. 

Beverly Montgomery: And I said, and he's like, really who? And I said, well, I don't know who the right match for you would be, but there's a lot of counselors and stuff who really help [00:55:00] teens with that.

And he said, oh, I think I'm going to talk to my parents about that. You know, again, what teen says, I want a counselor, like, but it's something he's significantly struggling with. And he saw it as a tool or a potential resource and sure enough, his parents emailed me and said, you know, do you have any names?

So, um, it doesn't have to be a, a very emotional experience. It can be very organic and come from the moment. 

[00:55:26] Kate Grandbois: I just want to reflect back, something that you said that I found to be really important, which is being there for the family and not just being there for our clients. Right. So, and, and, and I think that's important for so many reasons.

Not only because we're treating the whole family ready, we're really being present for the whole unit, but also because our, the parents are stakeholders, we're transient, they're permanent, hopefully permanent, right. They're going to be with the child for first grade, [00:56:00] second grade, third grade, when you are gone and no longer at that practice or with the next therapist or with the OT, they are a permanent, hopefully permanent.

There are a, there is continuity there that we can not provide. So if you have a parent that's struggling or a family dynamic that is struggling, being able to address that will open so many doors for additional work that we can do as the communication specialists. So showing up for making recommendations that are reasonable within the home, making homework suggestions or home programming suggestions, that don't feel overwhelming knowing what to target in your therapy room, that has a good chance of being carried over because you've taken the time to show up for that family and have a deeper understanding of what their family dynamic is like, what their home life is like.

And I feel that this is particularly true on the younger, you know, the [00:57:00] younger you go because the older you get, you get more independence and they're out of the house more just like, you know, that the student that you were describing before, I think showing up for the family is not something that we do just to be nice.

It is part of our clinical work. And it will move, help us move our clinical work forward. Unfortunately, I think based on our field and some of our workplace settings and infrastructure norms showing up for the family and showing up to the parents and integrating them as part of our therapy is really difficult.

Again, plug for funding for indirect service, but also in the schools. I mean, how often do you see the family, right? What's your family communication? Like how often do you have time to sit there with a grieving parent or caregiver and let them have the space and the moment of safety to tell you about how difficult things are at home or a big win that they had and how happy they are.

I mean, we, we don't really get an [00:58:00] opportunity. To have that level of clinical intimacy with our families, and I just wanted to reflect back to you how important I thought that was. And, and it's something that I think we should all consider trying to do more or I know we all have a million things on our plates and it's almost impossible to do more, but it's, I guess, a different lens to look through or a different perspective to consider.

[00:58:20] Amy Wonkka: I think just also to, to value the moments we do have as somebody who has worked in a lot of different environments, but many of them have been school-based, you know, even there, you may have a parent teacher conference or you might have something, you know, where you're getting these brief check-ins and just valuing that moment, even though it might not be all of the moments that you wish it were for what it is.

And it's also an opportunity to make those connections. 

[00:58:47] Beverly Montgomery: Or, you know, yes. Using the moments that you have and then making new quick opportunities. So I think back to when I was in the schools and I had a lunch bunch with kids, cause that was like, you know, a thing. Um, [00:59:00] and I would stick a little note in the kids' lunch boxes because some caregiver is going to be emptying those lunch boxes and filling them in all likelihood.

Um, about two things we chatted about. And then, um, you know, I just put an invitation at the bottom. Let me know what you'd like to chat about at home. And I'd say twice a quarter, uh, you know, most of the kids would bring something back. It didn't always come, you know, it wasn't weekly. It wasn't. Um, but that probably would have been more than I could handle anyway.

But the point was, I had an insight in a communication with the parents that was much more about getting to know them as a family than it was about, you know, the IEP process. And that helped me with communication with them, but also with the, with the kiddo, like if the kiddo needs to be talking about vocabulary, that is not what I'm teaching and they have trouble saying those words then, you know, I don't know that because I'm not a part of that culture.

So [01:00:00] it's really helpful that I have that information from the family. The other piece I want to talk about with adults is also, um, you know, talking about progress and if you feel like, you know, um, I've also had conversations with adults where I feel like, you know, I think we have a great professional therapeutic rapport, but I feel like our, you know, and I, I love data.

So I usually have some sort of nice visual that I can show. I feel like our progress is kind of plateauing or stagnant. Like I feel like we're not moving forward the way that we were, and you know, that can happen sometimes in therapy. But if I think that it's not just a normal ebb and flow, then I would also share that with the adult and say, you know, I'm wondering if it's time for a different type of work.

And I said, you know, you've gotten to this place and what I think might be getting most in the way of your connecting with other individuals right now is [01:01:00] X. And again, this is based on a clinical observation you have made, you're not pulling it out of thin air or making a judgment it's data-driven. And you're saying, you know, would it be helpful if we brainstormed, you know, what the best way to address that is because I may not be it. And that's okay. You know, I think what I have found is that sometimes if there has been progress made, it's hard for adults to pause or add service providers because they feel almost like they're, I don't want to say cheating on you, but it's like a, it's almost like they think you're going to take it as an insult.

If you're adding to the team and sometimes they need your permission to know that it's helpful, that you can't do it all and you don't want to do it all. And that, you know, there's, there's work here to be done. And there's some great people to do it. Um, but I'm not it, you know, um, it doesn't have to [01:02:00] mean leaving you, it could mean adding, but sometimes it does mean leaving you.

And sometimes people need permission to do that. If they've made progress with you, because I don't, you know, it's not their job to know our work. And if our work isn't moving forward, we're the ones that need to tell them that they need a different lens or a different approach. 

[01:02:21] Kate Grandbois: I love that. And I wonder if in our last couple of minutes you have any parting words of wisdom or pieces of advice for our clinicians who are listening and maybe considering some of these things for the first time, or maybe they're masters of their domains, but they've learned a little something from you.

[01:02:38] Beverly Montgomery: I would just say that, you know, you can do this and still be yourself. And, and what I mean by that is nobody is suggesting that you collaborate with mental health professionals, the way that Kate or Amy or Beverly would. Right. We're saying, think about this when you have questions. Because you may not have considered it as an [01:03:00] avenue for answers.

And, um, I guarantee you there's somebody on your caseload right now that you could brainstorm a collaborative partner for, um, that is somewhere within this, this realm. So, you know, in the last couple of minutes, as you're doing whatever paperwork or turning things off, do that thinking and figuring out who that person is and who you might reach out to in a 30 second next step.

[01:03:26] Kate Grandbois: I love that. Thank you for sharing all of your wisdom with us today. Beverly, 

[01:03:31] Beverly Montgomery: thank you for having me, 

[01:03:32] Kate Grandbois: we really appreciate you being here. If anybody is listening, um, and is wanting to learn more, there will be more, there will be additional resources listed in the show notes. Thank you again for being here and we hope everybody learned something today.

Thanks again. Thank you. Thank you so much for joining us in today's episode. As always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, [01:04:00] depending on the regulations of your governing body. To determine if this episode will count for professional development in your area of study, please check in with your governing bodies or you can go to our website, www.SLPNerdcast.com.

All the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@SLPnerdcast.com. Thank you so much for joining us, and we hope to welcome you back here again soon. Thank you to our corporate sponsors Vooks who helped to make this episode possible.

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