WHO-ICF, Counseling. the Diagnostic Interview, and Motivational Interviewing

CC2 Neuro 2

WHO ICF

World Health Organization International Classification of Functioning, Disability, and Health

WHO-ICF Components

• Body functions: Physiologic function and anatomic structure

  • the impact of health problem/condition on body systems (including cognition)

• Activities/Participation: Execution of specific tasks and participation in life events

  • How does the disorder impact the person’s ability to fulfill roles and interests?

• Environment: External factors influencing performance

  • the environment may inhibit or support functioning – Braille for the blind, rails and ramps for the physically impaired 

• Personal: Internal factors influencing performance (overall health, age, fitness, lifestyle, habits, etc.)

  • Inhibit or support functioning. Includes motivation, depression, SES, beliefs about illness, health insurance, education, and much more.

Purpose of Assessment

• Detect a problem if it exists

• Characteristics of the problem

• Go through the process of differential diagnosis

• Determine the impact on functions

• Determine the impact on participation in activities

• Determine how disabling and handicapping the condition is (how it affects function and life)

• Determine if the problem is amenable to treatment

• Establish treatment goals and prognosis

Assessment Process

1. Use available medical records and other available records to hypothesize nature of the impairment (right hemisphere stroke? TBI? LH stroke? Dementia? Parkinson’s?)

2. Plan the assessment: standardized and non-standardized, high and lower level (always have a backup plan!)

3. Implement the assessment (data collection)

4. Score tests

5. Use test results, clinician observation, informal measures, and client/family report to summarize strengths and weaknesses

6. Identify type and severity of the impairment

7. Make recommendations regarding progress

8. Recommend treatment goals

9. Write the assessment report. This is your interpretation and integration of testing results, clinician observations, and patient/family reports

SMART Goals

• Specific

• Measurable

• Achievable/Attainable

• Realistic

• Time-oriented

SMART Goals

• 1) Use the compensatory memory strategy of the iPhone calendar for prospective memory tasks with minimal verbal cues to input events into the calendar in 80% of trials across 3 sessions to address memory deficits.

• 2) Attend to a preferred task for 3 minutes with less than 2 verbal cues to maintain attention to the task 5 times over one session.

• 3) Recall tasks completed throughout the day by referring to the memory notebook with minimal verbal cues for details over one week to address delayed recall and use of compensatory memory strategies.

• 4) Alternate attention between two structured tasks with 80% accuracy for each given moderate verbal cues on 3 occasions.

The Diagnostic Interview

• The first opportunity to meet with the client/family

• Essential to know how to relate to, speak to, listen to, and gain trust of the individual

• Aims to be:

  • Knowledgeable 

  • Professional

  • Compassionate

  • Understanding

  • Self-confident

  • Willing to listen

  • Trustworthy

The Diagnostic Interview

• Create a safe space for sharing thoughts, concerns, and fears about the future

  • “I want to go back to work.”

  • “I want to eat what I want.”

  • “I want to sing at church.”

• Empower clients and families

  • Hear their feelings

  • Be present with them in their struggle 

  • We are focused on science, but we cannot forget the art of interpersonal communication – “catalysts in the healing process.” (Stein-Rubin & Fabus, 2013)

• “What do they want for themselves?”

• “What do I want for them?”

The Medical Model

A disease model/model of health in which disease is detected and identified through a systematic process of observation, description, and differentiation, in accordance with standard accepted procedures.

The Medical Model Criticisms

• Supports the false notion of dualism in health – biological and psychological problems are treated separately

• Focuses on disability and impairment rather than an individual’s strengths and weaknesses

• Encourages paternalism in healthcare, not patient empowerment

Historically, our field has been content centered

We fix what is broken

Medical model: tell, explain, and fix, while avoiding feelings of our clients

Leave the emotions to psychologists, social workers, and counselors

Or relatedly, telling and advising

Telling someone what to do rather than call forth answers from the client

Enforces client powerlessness, compounds insecurity, and creates dependence on clinician

ASHA Postition

• ASHA, 2006: “Content counseling is important for informational purposes , but emotional support and guidance through the grieving process must also be provided.”

• We are beginning to incorporate a mental health perspective into traditional content-based approach

• “Informational counseling, also referred to as client and family/caregiver education, involves discussing with individuals and their families/caregivers the nature of a disorder or situation, intervention considerations and techniques, prognosis, and material and community resources. 

• Personal adjustment counseling addresses feelings, emotions, thoughts, and beliefs expressed by individuals and their families/caregivers (e.g., realization of the pervasive impact of a communication disorder on day-to-day life).”

ASHA Position

“Counseling is an important clinical skill that helps individuals and families/caregivers adjust to and cope with feelings about a disorder or situation (Flasher & Fogle, 2012). Counseling can empower individuals and families, encouraging them to self-advocate in their efforts to adjust, strive, and grow.

ASHA Position

Counseling is an integral part of clinical work, and counseling skills are used intentionally or spontaneously in every clinical encounter (Luterman, 2008). Counseling services provided by audiologists and speech-language pathologists should occur in the context of comprehensive service delivery. It is important for audiologists and speech-language pathologists to recognize when referral to a related professional is warranted to best meet any additional counseling needs.” 

Detective Approach

results-oriented, based on content; to inform and advise

Nondirective Approach

based on deep listening; to validate and connect; process-oriented; focused on the relationship rather than the goal

3 ingredients for a successful therapeutic relationship

• Unconditional positive regard

• Empathy

• Counselor congruence

Unconditional Positive Regard

accepting the patient from a nonjudgmental respective stance

Empathy

feeling the client’s perspective as if you are in his/her shoes

Counselor Congruence

authenticity and genuineness

Affective Counseling

• focuses on expressing, identifying, discriminating between, and alternating or accepting feelings

• Affective counseling isn’t just within our scope; it’s our responsibility to the client to provide optimal treatment

• The emotional experience is a process. If we give too much or very technical information in our first encounter, you’ll see:

  • Eyes glaze over

  • Defensiveness

  • Resistance 

  • Difficulty absorbing information 

The Emotional Process

• More is revealed in the clinical interview and counseling session when we approach the client from an authentically curious place

• Remain open to what is present in the moment. What is the client verbally telling you, or telling you through their body language and nonverbals?

• We also learn more over time with a partnership relationship between client and therapist

• Trust the process

• Provide space and time for the client to process emotions, then get out of the way

Locus of Control

• The degree to which people believe they have control over the outcome of events in their lives

• External: believe events happen to them and people do things to them

• Internal: believe they have a choice; even though they can’t control certain life circumstances, they can choose the way they react to those events

  • Have the power to notice negative, self-critical thoughts that precede each emotion and challenge them

  • When positive things occur, they are more likely to attribute these events to their skills, attitude, attributes, or the choices they make

• To facilitate the shift from external to internal, we need to provide the space for negative emotions and help our clients identify and focus on their strengths

Positive Psychology

• We grow most in the areas of strength and slowest in areas of weakness (Buckingham and Clifton, 2001)

• Equally important to focus on amplifying strengths as it is to identify weaknesses

• Strengths may be used indirectly as a productive strategy to address weaknesses

• How well do you remember the last positive thing someone said to you? The last negative thing? Which had a more lasting impact?

Negative Feedback

should be delivered with sensitivity and in a foundation of acknowledging the client’s/family’s strengths to result in a positive response

Constructive Feedback

Solidifies trust and provides the client with the assurance that he/she is being given productive suggestions

The Medical Model

• We may group clients under a generic label

• This assumes a deficit perspective 

• Strips the client of individuality 

• Client becomes the problem named

The Social Model

• Emphasizes the importance of altering society’s perspective rather than trying to “fix” the client

• Kathy Snow: “Disability, like ethnicity, religion, age, gender, and other characteristics, is a natural part of life…a disability is not the defining characteristic of a person, any more than one’s age, religion, ethnicity, or gender is the defining characteristic. We must never use a disability label to measure a person’s value or predict a person’s potential.”

Inventory of Strengths

• Seligman (2002): “the father of positive psychology.”

  • The science of happiness, human thriving, and flourishing; described character strengths and virtues that are valued across races, cultures, and religions

  • Courage

  • Valor

  • Wisdom

  • Ability to see another person’s perspective

  • Kindness

  • Mercy

  • Empathy

  • Leadership

Inventory Strengths

• We are dealing mostly with normal people who have experienced life-altering crises

• We can help our clients focus on strengths, how they have used those strengths in the past, and how they can be used in the future

• Help them examine what has worked to get them where they are today, despite challenges

• Highlight these attributes to give clients greater access to their individual core virtues

How do i do this?

• “How would shifting your lens from one of labeling a client to seeing the core strengths of the individual empower your clients and their families?”

• Listen deeply without judgment 

  • Put your pen down

  • Look them in the eye

  • Don’t check your watch, look around, tap your fingers, shake your leg

• Hold no agenda other than listening to the client

• Ask open-ended questions

  • How have you felt about your speech/swallowing/etc since your stroke?

• Ask probing questions

  • Why do you think you feel like this?

  • What do you think would happen if…?

  • Tell me more about that.

• Paraphrase and repeat the message you hear behind the words to make the client feel heard and valued

  • “It must be hard. You know what you want to say but it just won’t come out.”

  • “It must make you feel really isolated and different to not be able to eat what your family is eating.”

  • “It sounds like it’s really challenging for you to not be working right now since you’ve always been the provider.”

  • “I bet it’s a hard adjustment going from being the one taking care of everyone to having other people take care of you.”

• Validate the client’s/family’s feelings:

  • “You have just had a major life change.”

  • “It is normal and expected to grieve during your recovery.”

• DO NOT SAY “I understand how you feel.”

  • No, you don’t.

  • Even if you went through the EXACT same thing (you had a stroke and have aphasia)…you and the client are different people. You don’t know exactly how they feel.

  • BE HONEST and say something like:

    • “I can’t imagine how you feel.”

    • “This must be so hard and overwhelming.’

    • “I bet you are scared and worried about the future.” (If they are directly or indirectly communicating this)

• We have to learn to be comfortable to sit with the negative emotions

We don’t stay there.

Once their feelings are validated and understood, then and ONLY THEN can we begin coaching the client to reframe the event to the positive and to what has worked in the past rather than focusing on what is weak

Find Strengths Through Values

• Values: the aspects of life important to a person – experiences, activities, settings, goals, or relationships that he/she wouldn’t want to live without

  • “What are you doing when you don’t even notice that time has passed?”

  • Tell me about a time or experience in your life when you felt strong.

  • How would your spouse/best friend/etc. Describe you?

The Role of Family

• Identify strengths of the family

• Hear family concerns/emotions

Developing The Therapeutic Relationship

• Counselor (clinician) congruence: we are obligated to develop our own congruence, the alignment between the intellectual and emotional components of self and the individual’s actions

  • Denotes that the person’s actions are consistent with their core values and the individual is centered

• For us to achieve congruence, we must:

  • Work on our own centering: are our actions consistent with our core values (spoiler alert…your actions reveal what you really value!)

  • Hone our listening skills

  • Sharpen our self-awareness

  • Be able to access our own feelings, strengths, and core values

The Co-Active Coaching Method

• Hallmarks: listening, curiosity, and use of intuition 

• Cornerstones:

  • Hold all human beings as naturally creative, resourceful, and whole

  • Design the alliance with our clients

  • Preserve the client’s agenda 

  • Address the client’s whole life

The client as naturally creative resourceful and whole

• “Nothing broken and nothing to fix.”

• All people possess inherent wisdom and the solutions to many of their life problems

• Coach/counselor (you as the clinician) trusts that the wisdom and solutions lie within the client

• Confidence that each person carries the seeds for his or her own transformation and is the expert on their own life

• Pay attention to what works rather than what is broken to adopt a strengths perspective 

• How does your paradigm shift when you don’t have to be perfect?

• What if you, as a clinician, were held as naturally creative, resourceful, and whole?

• What if you didn’t have to know everything? 

• How would the relationship look if your client didn’t have to be perfect?

Preservations

• Listen to our clients’ voices, honor their accounts, and resist superimposing our theories on their views

• Encourage the client to focus on what is most meaningful to them

• Self-manage our own reactions, judgments, and internal comparisons

  • Projection: tendency to subconsciously impose our own needs, history, feelings, and views upon what another person is expressing

  • The desire to interject our own story or similar life situation and solution

  • There is a time for appropriate self-disclosure 

  • But remember, “This is not about me.

• Maintain sincere curiosity about the client

Listening

• The foundation of the therapeutic relationship 

• Tone down the voices in your head to truly hear what the other person is saying

• Resist the desire to interrupt, take over the conversation, bring it back to you, or change the topic without agreement or warning

• View silences and pauses as an opportunity to invite a response

• Ask for clarification to better understand what the other person is saying 

The Co-Active Coaching Model: Levels of Listening Level 1

• The spotlight is on me

• Everything that is spoken is about me

• Egotistical

• Full of mind chatter – ongoing dialogue in my head that distracts from focus and is full of judgment

The Co-Active Coaching Model: Levels of Listening Level 2

• Requires attention to the other party

• Listen not just to the words but also to the meaning behind the words

• We are mirrors that reflect everything to our clients to allow them to hear themselves more clearly

• Assume a meditative state and quiet our mind chatter

• Use silent pauses creatively

• “Bundle up your thoughts with a string and put them in a drawer, then turn your attention back to the client.”

The Co-Active Coaching Model: Levels of Listening Level 3

• Listening with all of your senses

• Highest level

• Become aware of shift in client posture, changes in energy and mood, and tune into what is not verbalized

• Emotional intelligence and intuition 

  • Be aware of your gut reactions and be tactful

  • Express intuitive hunches: “I get the feeling that…”

  • Investigate intuitive hits with clients: “How does that sound to you?”

Levels of Listening

Level 2 and 3 must be practiced in everyday communication

• Cashier

• Child

• Classmates

• Family

• Friends

What effect does using level 2 and level 3 listening have on your relationships?

Factors that impact listening

• Judgment about what we observe and hear

• Language we use and how it shapes our internal and external reality

• Expectations or preconceived notions about ourselves and clients

Judegement

We all judge

Antidote to judgment is curiosity: remain open in our attitudes and authentically curious about the human being in front of us

Language: Word Traps

• “Should” makes us feel pressured and obligated

• “Could” opens up possibilities and moves us from an external to an internal locus of control

• Remove the pressure of “should” and provide the freedom of “could.”

• But”

  • “You did a good job, but…”

• Substitute “and.”

  • “I want to speak in public, but I am afraid.”

  • “I want to speak in public, and I am afraid.”

  • “Can’t”

    • Best avoided in clinical settings

  • Write down three “can’t” statements related to your own fears

  • Avoid the trap of insisting, “Yes you can!” or “You shouldn’t be afraid!”

  • Don’t turn our persistence into their resistance

  • Instead, ask:

    • “What are you willing to do?”

    • “What do you need help to try?”

    • “What do you think will be hard about this?”

The Language of Acknowledgement

• Recognize as being valid or having force or power

• Acknowledge an individual by highlighting his/her strengths to foster greater access to those gifts

• Acknowledge an individual by highlighting his/her strengths to foster greater access to those gifts

• A compliment is nonspecific and focuses on what the individual did for you

• An acknowledgement focuses on who the individual is “being” to you, is specific, and reflects admiration

The Diagnostic Interview and Post-Diagnostic Conference

• “The more we are willing to wade in the unknown without the security of a checklist, the quicker rapport will be established and the deeper the connection will be.”

• Refer only occasionally to a prepared list of interview questions

• Refrain from extensive note-taking during the interview

• Record if necessary

The Interview

• Pay attention to:

  • Missing links in the diagnostic puzzle

  • Client and family priorities and inconsistencies in between each other’s reports; incongruities between their reports and clinical data

Counseling/Coaching Tools

• Reflecting and clarifying

• Summary probe

• Clearing

• Powerful questions

• Meta-review

• Reframing

• Acknowledging

• Using silence

Reflecting and Clarifying

• Mirror back to the client what they just said so that the client sees themselves more clearly

• Gives the client greater access to their emotions 

• May lead to revelations for the client

• Involves paraphrasing and interpreting the client’s statement in our own words (more effective than just repeating):

  • Client: There are so many things to do and work on, and I’m so tired.

  • SLP: It sounds like you feel overwhelmed.

• Check in when you reflect to make sure the client agrees with your paraphrase

• If not, this is valuable feedback; it may lead to the client clarifying his/her own thoughts 

Summary Probe

• Used as a transition device

• Summarize in your own words what the client has told you

• Tactful way to consolidate or steer the conversation back on track

• Provides the opportunity to use the client’s thoughts to segue to next topic

Clearing

• Allow clients to release their emotions!

• Allow time for them to tell their stories, feel sorry for themselves, and release negative emotions

• Once people release emotion, they are generally more ready to emotionally and cognitively to receive information

• Remember, you may have worked with hundreds or thousands of clients and this may be your fourth evaluation of the day…but this is likely the first time this person/family has experienced a _____ (stroke, devastating diagnosis, TBI…MAJOR life change and many unknowns)

Powerful Questions

• Open-ended

• Curious

• Introspective

• Thought-provoking

• Prompt a person to look deep inside and search for an authentic response

• Limit use of yes/no closed ended or leading questions

• May be followed by silence - we don’t get these questions much

Examples of Powerful Questions

• What do you truly want?

• How will you know you received it?

• What about that is important to you?

• What’s next?

• What else?

• How would it look if your life were balanced?

• What’s working?

• How does this serve you?

• What are you willing to do?

• How do you give your power away?

Meta-View

• Helps the client gain perspective on their situation

• Bird’s eye view

• Mini-visualization exercise

• Have the client envision they are taking a helicopter ride

Reframing

• Helps the client redefine the problem into something positive

• Their view of reality may be causing them stress

  • “I can’t do anything now that I can’t work.”

  • “I’m a burden to my family.”

  • “I always took care of everyone, now everyone else has to take care of me.”

• Reframing shows the client there are various points of view offering opportunity

• Some perspectives may be true, but we always have choice

• Everyone has the power to choose the way they view their situation

• Moves from victimhood to being in control

• “What’s another way you can look at this?”

The post-evaluation toolkit

A funnel from general to more specific information

• Flow talk

• Highlight positive attributes and general strengths

• Clarify your role

• Highlight communications strengths

• Enlist the family in the diagnosis

• Written recommendations

• Question and answer period

• One important take-away

Highlight positive attributes and strengths

Acknowledge general personality or intellectual strengths of the client

“Thank you for you hard work and patience during this evaluation. I know you are probably tired of everyone coming in and poking and prodding you!”

Clarify your role

• How many of your friends/family members know exactly what an SLP does??

• Explain that we don’t just treat a mouth!

Highlight Communication Strengths

• Start with the positive and how those positive features will help in therapy

  • “You are great at getting your point across through gestures and signs, even when you can’t find the words.  This will be really helpful for you as we learn some strategies to get around not being able to find the right words.”

Enlist the Family in the Diagnosis

• Engage the client/family in reiterating areas of concern and their perception of the client’s difficulty

• Use what the client/family has said

• Tie in your own clinical impressions to give a complete diagnostic description 

• Approach the client/family as naturally creative, resourceful, and whole and having the answers to their own questions

• The parent is the expert on the child’s life

• The adult is the expert on their own life

• Ask what they noticed during the evaluation 

Enlist the Family in the Diagnosis

• State

• Discuss

• Elaborate on

• Be

• Don’t give

• Summarize

• Check in

• Provide

Provide Written Recommendation

Immediate handouts/information/suggestions at home

Motivational Interviewing (MI)

• A means by which patients can be encouraged by their health care providers to identify barriers and facilitators for effective health behavior change

• Who might we use it with?

  • Voice disorders

  • Neurogenic communication disorders

  • Fluency 

  • Dysphagia

  • Attendance 

• Evidence-based, generalization across problems, complementary to other treatment areas, can be delivered by non-specialists 

• Involves:

  • Asking open-ended questions

  • Reflective listening

  • Summarizing the interaction

MI

• Assist individuals to work through their ambivalence or resistance to behavior change

• Clear behavioral goal

• The client generates the rationale for change

• Clinician rarely attempts to convince or persuade, but may subtly help client recognize contradictions in their thoughts and behaviors

• Clinician guides the client to think about and verbally express their own reasons before and against change, and explore how their current behavior may impact their ability to achieve their life goals or align with their core values

• Encourages the client to make fully informed and contemplated life choices, even if the decision is not to change

• Reflective listening: demonstrates the clinician has heard and is trying to understand the client, affirms the client’s thoughts and feelings without judgment, and helps the client continue the process of self-discovery 

  • “If I heard you correctly, this is what I think you are saying…”

  • “Given what you said, you might feel…”

  • “You are having trouble with…”

• Resist the instinct to respond with questions or premature advice

Motivation

• The desire to change a particular issue, habit, or situation

  • Readiness

  • Willingness

  • Ability

Open-ended questions

• Elicit pertinent information to identify source of ambivalence or behavior change

  • What

  • Where

  • When

  • How

  • Tell me more about…

Reflections

• How the clinician summarizes information provided by the patient

  • Simple reflection: summary or repetition of what the patient said. 

    • Patient: I hate my voice.

    • SLP: You hate your voice.

  • Complex reflection: incorporates the affect and meaning of the client’s response in the summary reflection.

    • Patient: I hate my voice.

    • SLP: It sounds like you feel unhappy about how you sound.

Diagnostic Report Writing

• Provides analysis and synthesis of information

• Guides therapy recommendations and goals

• Used as written communication with other professionals (and possibly family)

• Used as basis for insurance reimbursement

• Serves as a reflection of the professional integrity and competence of you and your organization

Commas

• Compound sentence: 2 or more independent clauses are connected by a conjunction (but, and, or, for, so, etc.)

  • Mr. XX presents with moderate anomia, but he is able to communicate wants and needs with his family.

• Complex sentence: an incomplete sentence depends on the complete sentence that follows, connected by a comma when a dependent clause and a marker (though, unless, before, once, because, etc)

  • Although Mrs. XX read aloud monosyllabic concrete nouns with 100% accuracy, her reading comprehension for the same words was 50%.

• Qualifying clauses: require a comma

  • Mrs. YY presents with impaired pragmatics, as evidenced by her frequent interruptions and poor topic maintenance.

Embedded Clauses

can be removed from the sentence without changing the meaning

Transitional Element

word, phrase, or sentence that connects a preceding topic to one that comes after it (however, nonetheless, therefore, also, otherwise, finally, of course, above all, for example, in other words, in conclusion, in addition)

Semicolon

• Used to join two independent clauses when the clauses aren’t joined by a conjunction, especially when the sentences are closely related

  • TBIs can severely impact quality of life; they should not be minimized.

• Complex enumeration of items

  • A number of questions remain unresolved: (1) whether beverages that contain caffeine are an important factor in heart disease; (2) whether such beverages can trigger arrhythmias; and (3) whether their arrhythmogenic tendency is enhanced by the presence and extent of myocardial impairment.

• Series that contains internal commas

  • We tested three groups: (1) low scorers, those who scored fewer than 20 points; (2) moderate scorers, those who scored between 20 and 50 points; and (3) high scorers, those who scored more than 50 points.

Colon

• Used to introduce a statement/paragraph or series. If the statement begins with a complete sentence, use a capital letter; otherwise, don’t use a capital letter

  • He gave the following account: The client scored below the mean in the language test, and it was recommended that he begin speech and language therapy.

  • He exhibited the following behaviors demonstrating agitation during the evaluation attempt: cursing, shouting, throwing of objects, and refusing to participate. 

Quotation Marks

• When the clinician asked why he thought he was here, he responded, “I dunno. Everybody keeps telling me something’s wrong with me but I’m fine. I can remember stuff fine. I wish everyone would leave me alone and stop asking me stupid stuff.”

Possession

• John’s iPhone

• Subjects’ scores

• Julius’s right hand

• The Duke of Sussex’s title

• The Sussexes made a decision. It was the Sussexes’ decision. 

Sentences

• Don’t end a sentence with a preposition

• Whom: used after a preposition; the object of a verb or preposition

• Who: used as the subject

• Use active voice when possible

Sentences

• Use the positive form (clearer and more direct)

  • Less desirable: His mother said he usually did not turn in his writing assignments on time.

  • Preferred: His mother said he usually turned in his writing assignments late.

• Avoid unnecessary words

  • Less desirable: He said he was unaware of the fact that stuttering was treatable.

  • Preferred: He said he was unaware that stuttering was treatable.

• Parallel structure: elements should be similar in grammatical form

  • Incorrect: He presents with moderate impairments in understanding, writing, and expressive language.

  • Correct: He presents with moderate impairments in receptive, written, and expressive language.

  • Incorrect: Her goals are to drive, working, and exercise.

  • Correct: Her goals are to return to work, return to driving, and get back to exercise.

  • Correct: Her goals are to return to work, driving, and exercise.

• Fragments: not a complete sentence; missing subject or verb

  • Incorrect: Some clients provided with therapy last week.

  • Correct: Some clients were provided with therapy last week.

• Run-on sentence: two independent clauses are connected without punctuation to separate the clauses.

  • Incorrect: He wasn’t successful in therapy he didn’t practice at home

  • Correct: He wasn’t successful in therapy; he didn’t practice at home

• Rambling sentence: contains many independent clauses and is just too long!

  • Incorrect: The client came to therapy, and she forgot to bring her homework, so she was very upset and began to cry, but the clinician calmed her down, and the client was able to produce the words correctly.

  • Correct: The client came to therapy, but she had forgotten her homework; she was very upset and began to cry. The clinician calmed her down, and the client produced the sounds correctly.

Paragraphs

• Headings/subheadings in diagnostic report

• One idea per paragraph

• Introductory sentence

• May be:

  • Logical sequence of events

  • Statement of strengths, then weaknesses

  • Comparison of assessment results related to information from other parts of the evaluation

  • Any other clear connection between the additional information and the topic idea

• The issues in the paragraph should tie into the target topic, relate to each other, and relate to the main idea of the paragraph

Writing Tips

• Express information clearly; don’t assume information is implicit

  • Readers don’t have a chance to ask for clarification

• Check for redundancy in words (verbs and nouns), phrases, and sentence structures

• Use cohesive devices (transitional devices) – the glue that binds sentences together and connects one paragraph to another

  • Although you are writing a professional diagnostic report, you are writing a narrative that paints the whole picture of this client

• Alternate between name and pronoun

• Unless stated or demonstrated, don’t assume you know the client’s internal state

  • Less desirable: The client felt frustrated by not being able to speak.

  • Preferred: The client demonstrated frustration with difficulty speaking by cursing every time a word “got stuck.”

• With background and summary of evaluation, state the positive before the negative

• No first person – you are “the examiner” or “the clinician”

• Write a concluding statement for each paragraph or section

• Avoid “really” and “very”

• Read it out loud – does it sound cohesive? Professional? Redundant?

• Table

SOAP Notes

• Subjective: Impressions of the client – level of motivation, awareness, mood, willingness to participate; can list anything the client/family says to you during a session

• Objective: measurable information, data, test scores, percentages for goals/objectives

• Assessment: analysis of the sessions; interpretation. Compare client’s performance across sessions

• Plan: outline course of treatment; any changes to objectives, activities, reinforcement schedules.