The Independent Therapists Network

Stick It! Therapy™

Stick It! Therapy™ is based on a therapeutic concept and dilemma familiar to all Speech and Language Pathologists and Audiologists providing treatment with a view toward changing a behavior. All therapists, for that matter, SLP's, OT's, PT's and beyond, are faced with the problem of practice and generalization of learned skills. Practice simply refers to the patient practicing a newly learned behavior. Generalization is the term used for moving a particular learned skill from one arena to another. For example, if the therapist is teaching production of the "s" sound, her job is to help the patient move from production of the sound in isolation, across word positions, at the word level, at the sentence level and so on with the ultimate goal being that the patient use the new behavior, that is, producing the "s", at a conversational level, and the error behavior (in this case the error could have been deletion, distortion or replacement of the "s" sound) is to be ultimately eliminated. Practice is the redundant review of a newly learned behavior, done to some extent as a part of the treatment session, but more importantly refers to the work done outside of the therapy session itself. The dilemma of generalization is typically that the patient does well in the therapy session or the therapeutic environment but fails to utilize the newly learned behavior beyond that setting. The patient may even do well within their own practice sessions done between therapeutic interventions, but does not carry the skill over to other settings. This is most keenly felt when the targeted behavior or new skill has reached an advanced stage, such as conversation (continuing with our speech example), wherein the targeted skill is being utilized during treatment and practice but has not transitioned over to functional settings, such as talking among friends, at a restaurant, on shopping trips, etc., wherein the patient reverts to the habitual error behavior.

The problem with both practice and generalization falls into two main areas. The first is obvious on some level; we all know we have to practice something repeatedly to become proficient at it. The second aspect of generalization is a bit more difficult to comprehend. The conundrum is that if we have learned something proficiently, why can't we easily habitualize (make a habit of) the skill into everyday use. The problem is one of neurology rather than of cognition or intelligence. First, it is easier to make a habit of a new behavior if it is not replacing an old behavior. Learning to play the piano, then, is easier than learning it incorrectly and having to replace the incorrectly learned lesson with the right behavior. Similarly in speech errors, the behavior is not usually brand new, although in some cases it may be with very young children. Typically, speech, and language along with many other behaviors, are learned either as a course of development or imitation. If, for whatever reason, they are not learned correctly, a variety of aberrations may occur. Either the target speech behavior is omitted, distorted (an approximation of the actual speech sound but produced imprecisely in some way), or replaced by another sound (often in some way related to the target). The difficulty with generalization occurs because the new behavior or speech sound must replace an old behavior. The old behavior is a habit. Habits are strong. Habits are strong for a very important reason. Primarily, a strong habit requires no intentional thinking. The behavior has become automatic. The behavior has been imprinted as a body memory. This is very good, in most cases. Body memory, which allows us to behave automatically, allows us to build on a base of knowledge and add to it. For example, if you learn a dance step, say the basic box step of the Foxtrot, learning it to the point of memorization within your body, allows you to move through the steps without thinking about them. Remember, you don't want to think about steps, you want to dance! This will allow you to look at your partner while you dance, rather than looking at the floor to watch where to place your feet. In addition, once having learned the basic step well, you will be able to add movement within the basic step, to lead or follow in a turn within the dance, for example. Similarly, in the case of speech movements, the purpose of these movements is not to have to think about them. We need speech movements to be automatic, without much thought, so that we as speakers, can attend to the real reason we speak, which is to convey our thoughts. Remember, we don't want to do speech movements, we want to talk! Unfortunately, we sometimes don't get the initial lesson in dance or speech (or in many other areas for that matter!) correct, and we have to make changes, corrections, adjustments, etc.

Making changes to a behavior is not a big problem if done right at the beginning when an error first occurs. It's a lot harder to fix the problem, when the error movement or behavior has become a habit. Now we need to replace the error behavior with the correct behavior. To learn the correct behavior takes practice of the new behavior, to replace the old error habit takes lots of practice in as many different locations in which you plan on using the behavior. Wow! Not so bad for the dance example, you dance at the studio, maybe at a variety of dance clubs, etc. However, for speech, the number of places in which you speak and need to incorporate the new behavior and lose the error behavior is far greater.

Stick It! Therapy™ addresses both practice and generalization issues ongoing, from the very early stages of intervention, through carryover of skills, from one level of the treatment to the next to ultimately fully having incorporated the learned skill to everyday use. Not only will Stick It! Therapy™ address both of these therapeutically frustrating outcome roadblocks, but it will expedite achieving the therapeutic outcome in less than half the time!

You're probably wondering why it's so hard to replace a habit. I mentioned earlier that the 'problem' was one of neurology, not cognition or intelligence. Body memory, as we often refer to the movements we have learned well through repetition, once mastered, correctly or incorrectly, become automatic, meaning you no longer have to think about them to perform them. For the most part this is great; just what we want and need to move forward in most activities. You wouldn't want to have to think about differentiating the movements for driving with focused thinking forever, that would be cumbersome. Moving smoothly between steering, breaking, speeding up and slowing down allows for a smooth execution of the activity. However, when you learn it incorrectly, your body will do the same thing. In other words, "Practice doesn't make perfect�Perfect practice makes perfect!" Your neurological system is a redundant system, allowing you to learn whole patterns of information and then store them for automatic retrieval so you don't have to think about them. If you learn something and practice it repeatedly incorrectly, you will become very good at doing that activity incorrectly. Now what happens when you try to learn the activity correctly? While it may vary from person to person and depend, in some part, on what the activity is, it will most likely be similar in difficulty as it was to learn the initial behavior (in this case the incorrect behavior) in the first place. If you learned the initial behavior without great difficulty you will most likely learn the correction with limited difficulty. The real problem arises when you and your body try to replace the initially and incorrectly learned behavior. You remember the saying, "Old habits die hard?" That adage may actually be a law when it comes to neurology; however, you can expedite the change from an old behavior to the new replacement behavior if you understand what's going on.

Imagine that you had a clock that you hung up on the kitchen wall. After many years living in your home, you finally move the clock to what you have decided is a better location. When you come home, for the first time after moving the clock to the preferred location, where will you look to check on the time? Of course you will look at the old location first, then you will say to yourself, "oh right, I moved the clock," and then you will look at the new location to see the time. How long will it take before you stop looking at the old location? A couple of days? A week? A month? You will look at the wrong location for at least 6 months before adjusting to the new location without looking at the old location first. This is the result of neurology and automaticity. You have practiced the old location for a long time and "hard wired" your body to look for the time in this old location. Although you learned the new location with ease, you have had little experience or practice with the new location and have not yet replaced the old wiring. With respect to the new location, you will practice the new location exactly as often as you need to know the time. If you could somehow increase the number of times you needed to check the time, you would decrease the overall amount of time you spent looking at the wrong location first, when checking the time. My personal experience with this phenomenon of neurology and automaticity happened to me when I purchased a new car. The old car had the fuel gauge on the right side of the dashboard panel; the new car had the fuel gauge on the left. Inadvertently I was checking the fuel level in the new car, in the old location, which now had information on the vehicles temperature. As the temperature was always medium, neither hot nor cold, and as my habit was only to glance at the fuel gauge to assess fuel status, I was always checking my fuel level by my temperature gauge. Therefore, it always appeared to me that my tank was half full! I only got the message regarding the fuel level when a little image of a gas tank lit up upon having reached near empty status! This would happen time and time again for over a year! The reaction was the same every time. First I would be in a panic at my sudden and emergent reality, and then I would rush off to the gas station to refuel. Each time I was sure it was only a matter of time and I would surely adjust to the new location of the fuel gauge. While it certainly improved over time, I continued to look in the wrong area of the dash board for well over a year! Clearly this was a far greater dilemma than the scenario with the clock! Certainly I had the motivation needed to learn the new behavior! Nevertheless, I continued to follow the old habit because my body was running on automatic pilot. If, however, I had had therapeutic intervention, teaching me how to practice and systematically increase the number of times I practiced, I could have replaced the old behavior more quickly. Specifically, if I had filled my tank half way, I would have doubled the number of times I experienced (practiced) running out of gas and would therefore have had twice the number of reminders that the fuel gauge was now on the left instead of the right side of the dashboard panel. Just imagine how fast my body would have stored and hard-wired new information if I filled the tank only a quarter of a tank at a time. Naturally I did not "treat" myself in this way. I never filled the tank less than full at any visit to the gas station. I suffered for over a year and learned the new behavior slowly and replaced the old behavior eventually.

However, in the case of speech and other therapeutic interventions, time is of the essence. Not only is therapy expensive, but we're talking about talking, and everybody would prefer to be heard for the content of what they're saying not to how they're saying it. Sadly, when a person has even a small deviation in their speech, the listener's ear will track the speaker's speech and listen to how they are speaking rather than to what they are saying, until they get used to the deviation in the speech or speech pattern. Just think of how you listen to a film wherein all the actors speak a form of English other than your own. For Americans, a good example would be listening to an Irish film with Irish actors speaking English. For myself, it will take at least half an hour for me to adjust to the dialect and by then I've lost so much content that I am likely to start the film over again, if I haven't already rewound several times along the way.

Again, Stick It! Therapy™ addresses both practice and generalization issues ongoing, from the very early stages of intervention, through carryover of skills, from one level of the treatment to the next to ultimately fully having incorporated the learned skill to everyday use. Not only will Stick It! Therapy™ address both of these therapeutically frustrating outcome roadblocks, but it will expedite achieving the therapeutic outcome in less than half the time!

Stick It! Therapy™ was designed to increase the amount of practice occurring between one therapy session and the next. Everyone, therapists and patients alike, understands that to learn a new skill they will have to practice. The truth is, that once a behavior is learned, which may actually take very little time, it will take a lot of practice to make the behavior stick, or become hard-wired, automatic, or second nature. It will take a lot of practice before you will do the behavior without thinking about it. A good clinician will not end treatment if her patient is still thinking through the learned skill, because she knows the behavior is not automatic and requires treatment strategies to facilitate generalization.

Stick It! Therapy™ addresses both practice and generalization. First, practice has to take place a certain minimal number of times in order for the behavior to be learned well; well enough to move on and learn new items to be added to the old. Remember the dancing example? First basic dance steps are learned and practiced well, then a turn may be learned or a spin and changing places with your partner and so forth. When we're dealing with speech movements, remember, these will be executed far more often than dance movements and have a purpose that is beyond the speech movements, in particular, to convey thoughts or make one's wants or needs understood. A rule of thumb regarding practice has been taught and subsequently discussed in the varying therapeutic fields. Initially, at an academic level, we were taught that 30 minutes a day between therapeutic sessions would result in a behavior being learned well enough to hopefully move on in the next session. All new clinicians quickly discover how unlikely it is to find anyone practicing at this rate for more than a few consecutive days and that over time, home practice drivels down to a trickle. Many of us have settled for 10 minutes a day, but here too, consistency is hard to come by even in the most proactive patients and families. Why? For one thing, speech practice is boring. It consists mostly of drill work. For another thing, it is difficult to side-step the itinerary of anyone's day to set aside time for speech practice. Unlike learning something that you want to learn, that is new and exciting, like dancing, music, or a foreign language, speech is a corrective intervention, and while a person may want to achieve good speech or correct speech, it is not as much fun as learning a new skill of choice. Another standard amount of practice has been defined as 50 repetitions of the target per day. According to that standard, a practice session could take as little as one minute! Assuming that 50 trials per day would result in adequate practice to learn the target behavior, it would be better for generalization, if that practice occurred in smaller amounts, more frequently across the day and in different settings or locations. To accomplish this, the Stick It! Therapy™ method has arranged a way in which practice can occur in short amounts, more often across the day, in a variety of settings, within the activities of daily living. Through the use of sticky-notes, the practice plan between therapy sessions can be outlined and placed in a variety of areas in which the patient will trespass naturally as a course of the patient's particular daily schedule. The locations for placing the sticky-notes are based on locations that the patient frequents regularly across any given day. Typical locations would include the kitchen (on the cupboard and refrigerator), the computer station, the restroom, the bedroom, the front door (both sides preferably), the rear view mirror or dashboard of the car, the television, etc. These are high frequency locations that most people come across naturally. Patients may have other areas that they frequent on their particular schedules that they can share with the therapist and which can be incorporated on a case by case basis to individualize the program. The "look" of the sticky-note will vary from patient to patient and will differ depending on the age of the patient and the need for caregiver involvement. For example, a child that does not read might simply have cute pictures on them that they helped design and/or draw, to alert them to practice their assignment. An older child might have the actual assignment written out below the picture. For children, the pictures make the activity more fun and interesting to them as an individual. Adults may only need the assignment written out on the sticky-note. The frequency of any given practice when faced with a sticky-note along the patient's day, should always consist of a certain number of repetitions to occur at that particular encounter. A minimum of one or two repetitions may be appropriate for a young child starting out and 5-10 repetitions is adequate as they progress. For children, the practice is referred to as a 5 or 10 finger practice and is terminated with a "high five" or "gimme 10" as an integral reward for practicing. Therapists will have to individuate the need for additional reward systems based on the patient's need for encouragement.

Therapists can and should negotiate frequency per sticky-note practice on a case by case basis. It's always best to begin low with something exceedingly achievable to maximize success and hopefully encourage higher frequencies of practice per sticky-note based on previous successes and their desire to expedite outcomes. Sticky-notes may also be arranged hierarchically, such that certain warm-up exercises are practiced earlier in the day and more advanced practices later on in the day. For example, a child who is practicing lingual placement for "s" who can produce "it_ts" with accuracy, may warm-up with this exercise across the first three sticky-notes and advance to "it_tssssssss"-glides for the remaining sticky-notes. The first sticky-note exercise may be color coded or simply marked "1" and the second "2" and the patient can mark their sticky-note to determine that they've done three sets of exercise one before moving on to exercise two across the day.

In general it is best to keep the practice regimen given to the child, adult or family, simple and at a level that the therapist can be certain will be practiced accurately in their absence. A therapist may well advance further within a session than they would expect the patient to practice. Always have the patient practice correctly by keeping homework highly achievable.