Therapy is On-Going Diagnosis

By Pam Marshalla

Q: Many SLPs write to me with questions about sibilants that are distorted––inter-dental, frontal, whistled, palatal, lateral, and so forth. I have given lots of advice about these errors, but sometimes I can’t. Why?

Sometimes I can give no advice for fixing errors on the sibilants because the errors are distorted in such refined ways that there is no way to determine what exactly is going on without seeing and hearing the error myself.

If you have taken classes of mine, you know that I often ask participants, “Can you make the sound exactly like your client? Can you model it for us?” I do this because I have to see and hear the error myself. Then can imitate it myself in order to figure out what to do. This is a reflection of Alexander Graham Bell’s methods. He said that if we can’t figure out what the client is doing wrong, we should imitate the client’s error. He said we should study the path of change from the error production to the better production as we make these changes ourselves. Then we should teach the client to make these subtle changes himself.

Another old saying that helps here is this: “Therapy is on-going diagnosis.” I am not sure who first said this but perhaps it was Van Riper. This concept is relevant to all types of speech-language problems, but it is especially helpful with the sibilants. We have to try a method and then watch/listen to what happens as a result. Then we try something else and observe what then happens next. Then we try a third thing, and so forth. Each tiny step tells us more about what needs to change in order to make the phoneme sound better.

The critical need for figuring out methods through the process of trial-and-error is one of the reasons I continue to rail against the notion that we can only do in therapy those things that have been “proven.” There is never going to be any research on what will work with the client sitting across the table. The client sitting across the table has never been studied by anyone but his attending therapist. Therefore the therapist has to have the freedom to try one thing and then another in order to determine what will work best for him. The therapist also has to have the freedom to invent methods on the spot to find out something that will be helpful for that particular client at that particular time. It is “trial and error” and “on-going diagnosis” and “thinking from the seat of one’s pants” that determines what methods work in treatment for individual speech students.

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