A few years ago, I had a major rethink about how I set targets for the students who I work with. Previously, targets were based on assessments, functional goals and discussions with parents and school staff. That sounds logical, right?!
I then found myself in a situation where I was working with a student using an AAC device who I felt was disengaging with therapy. No amount of fun, all-singing, all-dancing sessions were cutting it! I tried supporting them in the classroom instead, but found that the same issues existed in that environment and also with different communication partners. Scratching my head, I began digging into research, starting by exploring the Means, Reasons and Opportunities model (Money and Thurman, 1994).
If you’re not familiar with the model, it basically explains the reason why any of us communicate! Firstly, we need a means of doing so- speaking, signing, using a communication book or device. Next, we need opportunities to do so- people to chat with, communication friendly environments and topics of interest! Finally, we need reasons to communicate- to make choices, reject things that we don’t want, ask questions, tell stories, etc!
When we consider the three different aspects of the model, barriers to communication can appear at any level. As SLTs we are trained in identifying what those barriers might be- But our perception might be different to that of the person we are working with!
During this period of research, I stumbled on a fabulous piece of work by the Barnsley Assistive Technology team back in 2010. It’s like a symbolised questionnaire for AAC users based on the Means, Reasons and Opportunities model. You can download it for free here: https://www.barnsleyhospital.nhs.uk/assistive-technology/resource/means-reasons-opportunities-aac/
I immediately wanted to try it out with my teenage student. I adapted it slightly into a Talking Mats style format so that it was really led by the student. The outcome was fascinating…. It transpired that there were issues at every level of the model:
- Means- using the communication aid was difficult when the student felt tired,
- Opportunities- conversations could be too fast paced to join in with,
- Reasons- the student’s main reason for wanting to communicate was to gossip with friends! Without the right vocabulary and pre-stored phrases, this was impossible!
This information gave us a clear plan as to what we needed to do next-
1. Find an alternative, quicker means of communication for different situations,
2. Train communication partners in the ‘power of the pause’,
3. Create ‘Gossip’ pages for the device with useful words and phrases.
I had never included the word ‘gossip’ in a target before (!) but just using that word reminded me of a key aspect of our role- we support others to communicate about what they want to communicate about. Otherwise, what is the point?!
After this revelation, I began ensuring that all my assessments took into account the students’ perspective across all 3 areas of the model (where possible!) but also that they could actively choose at least one of their communication targets. As a result, students are much more engaged and also make incidental progress in other areas.
I’ll give you an example- A young man chose ‘telling jokes’ as something he wanted to prioritise working on. This 100% fitted his personality but in my head I was thinking, “But we still need to work on initiating communication”. My ‘therapy brain’ had missed the obvious- to tell someone a joke, we need to firstly gain their attention. The student was much more motivated to do this when he felt he had a reason to initiate communication!
An interesting study by Rohde et al (2012) found that the goals of the therapist vs the goals of the client (in this case, adults with Aphasia) often differ. As SLTs we can be impairment focussed or we might not see how the individual’s goal fits our remit. I am not a comedian by any means (!) but working on joke telling was less about the quality of joke and more about social interaction and turn-taking! If a goal is important to the individual, we need to value that and not impose our own agenda. An individual will ALWAYS make more progress with a goal they are invested in as opposed to a goal someone else feels is good for them!
Changing how I SET goals has also made me consider how I EVALUATE goals. About a year ago, I started using Goal Attainment Scaling (I may need to blog about this in more detail another day!). The idea is that when you review goals, you give them a numerical value as to progress made with the target. The great thing about this system is that it can also involve working with the individual to self-evaluate how they are meeting their goals. Working with students with complex needs, I tend to show them a simplified visual of 2 symbols to select from- ‘I can do it’ or ‘I need more help’. Sometimes our evaluations don’t match but that’s ok- it allows me to consider why they don’t match and how we might tweak the target based on that outcome.
In closing, I thought I’d review the statement that I made at the start of this post: “Previously, targets were based on assessments, functional goals and discussions with parents and staff. That sounds logical, right?!”
My new answer is: Partially! But first of all, what does the individual want to be able to talk about?! That’s where the journey begins!
P.S. A little bit of blatant self promotion…. I now offer supervision for SLTs. Happy to discuss and help with all things AAC!