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From: Dr. Kay Monkhouse
Date: 22 Oct 2004
Time: 16:22:04 -0500
Remote Name: 141.150.106.133
Dear Judy, Thank you for your response to my paper. I enjoyed reading your comments. The MSAM can be applied with clients who have the cognitive ability to self-correct (level 3a on the horizontal plane) i.e., a level of conscious competence. You can literally see the person hesitate and say “whoops”, and restate what s/he just said in the “new” format. Most recently, I have seen preschoolers do this in the Lidcombe Program, where they become highly aware of what constitutes “smooth” and “bumpy” talking without anxiety and where, with appropriate parent training, they appear to internalize their own personal “rules” for “smooth talking”. I have also observed these preschoolers move with apparent ease to the step 3b (pre-hoc plan) at the conscious competent level – and all with only the positive feedback that is the basis of Lidcombe (where the child never experiences feelings of “failure”). “Perception” is everything, isn’t it, when dealing with who is “right”? Just as the model is based on subjective judgments, so is perception of “rightness”. So, both parents are right to the extent that they can agree with each other (even if it’s a mustard seed’s worth of agreement) and the elements of those subjective feelings can be discussed openly and compared, in order for there to be sharing of expectation levels. Moving between levels is determined by the client’s responses. The clinician sees evidence of behaviors such as the post hoc whoops or the pre hoc plan (the former, where the client purposefully self-corrects and the latter, where you see the client “treading on egg shells” to give a “new” response). Often, step 3b is accompanied by a self conscious giggle or a look of purposefulness. The client will say – “But it feels (or sounds) wrong” and the clinician responds, “That’s great!” (It has to feel “wrong” to be “right”, because you’re comfortable with the old way and the “new” way must feel uncomfortable or strange at first until you force the change often enough that your comfort level increases and then it becomes a new habit.) In answer to your question about how I work with all 4 contexts: I work only on the clinical level until I have responses that can be reproduced at > 90% criterion level (100% preferred) and that requires very careful planning of goals/objectives, with very small increments of change. Understanding of the goal/objective is paramount so that the client’s comfort level is high in completing the assignment. There must be no frustration in completing an assignment – if it’s not fun and reproducible with vigilance, then the complexity level is too high. If the client can achieve 100% accuracy in the clinic at any step, then I will set that activity as a home assignment, with very specific instructions to the parent about how to reinforce responses and achieve that 100% success rate. The value of private practice is that a parent or responsible adult is always there and participates in at least part of the session, so that they understand what the client is doing and why s/he is doing it. Incorporation of the treatment plan in school depends on who can work with the child and when. Because many of my clients also receive treatment at school, many of the school clinicians and I coordinate our goals and we are each able to reinforce each other’s programs. In a school setting, the school SLP will often coordinate with a teacher who can reinforce certain assignments whether individually or in the classroom setting where all of the students work on the assignment. Step 3 is highly significant, because then the client can be assigned goals and objectives which s/he can complete independently. Step 3 at the clinic level is usually the time when assignments are set for home or school, but only if there is very careful supervision and a guarantee for success. Assignments are never set outside the clinic setting unless there is that 90 – 100% criterion level for success within the clinic first. Assignments at Step 3 at school will depend upon the support systems available. Note that it is not necessary to complete Step 4 before entering Step 3 of a higher complexity environmental setting. In actuality, treatment is usually terminated when the client is at level 3 in the “outside world” setting, where s/he is operating conversationally with some vigilance in a high-anxiety environmental setting (which has been determined for each client at intake). Suffice it to say, that for sanity to rule in any clinical setting, clinical judgment must always be the final decision maker in moving through both the horizontal sequences and the vertical hierarchy of complexity. What to read? I have covered some of your questions in my responses to other reader’s comments which you might also like to read. You could email me at kmm@stutteringinstitute.com for some of my favorite authors.