Why talking works?
My patient nicknamed Sarah Lee was a great successful patient. Unfortunately, she is the only patient with increased impulsivity I have ever discharged back to home with full independence. So why?
Let me tell you about Mr. Y
Mr. Y:
When I was at a Skilled Nursing Facility (SNF), I met Mr. Y. The first time I met him: He was sitting in his wheelchair and running towards me all at the same time.
He was on the rush.
From my personal experience as a therapist, when a patient is rushing, the patient had impulsivity. Mr. Y had massive impulsivity.
When I asked him to stand with a walker, he grabbed the walker as if it is a ladder. (That is dangerous because the walker is unstable.) I stopped him immediately. I pushed him and his wheelchair to a table. Then I used the exact strategy that I used on Sarah Lee.
“How do you stand up safely?” I asked him.
He put his hands on the armrests of his wheelchair, and then stood up.
Perfect.
“I see that you put both of your hands on the wheelchair armrests before you sit.” I said, “How about sitting back down safely?”
He put both of his hands on the armrests of his wheelchair before he sat.
Perfect.
“I see that you put both of your hands on the wheelchair armrests before you sit.” I said, “Now how about safely standing up with a walker?”
Instead of pushing off from the armrest of the wheelchair, he grabbed on to the walker again!
What went wrong?
1) Mr. Y did not transfer what he learned from the table to the walker.
2) Unlike Sarah Lee, who spoke out loud to think through the steps, Mr. Y remained silent. As a result, Mr. Y did not think thoroughly before he stood up.
Through having this experience, I discovered that if therapists want to use strategy training, they must ask patients speak out loud, so the patients THINK.
I thought the self-instructional training was popular because by just asking patients to speak to themselves, they have better functional performance. Unfortunately, when I searched self-instructional training, the latest research paper went all the way back to 1980s. I thought I was old, but the 1980s…….. That was before I was born! Also, the only participants in the self-instructional training were children with impulsivity trying to succeed in school (Bryand and Budd, 1982). Well, the paper may deem as irrelevant now, but…… Why not use this strategy on geriatrics, when my patient's cognition may be at the children’s level?
I was working in the Skilled Nursing Facility on the weekends (If you are a new grad, do not ever do it. I was doing it as a new grad, and it was horrible). The nurse appeared frightened and angry. They reported that Mr. Y charging to the front desk at full speed with his mini-steps without a walker. (He is about to clash to the ground.)
When I saw him later that day, I decided to use Strategy training and self-instructional training. As usual, I brought my pen and paper.
“Isn’t it annoying when the nurse told you not to stand and walk?” I asking him from his perspective.
“YES!” Mr. Y answered with much frustration and annoyance, “They are noisy.”
“Well, what can we do to stop them from being noisy?” I asked.
Mr. Y looked at the walker.
“Let’s write using a walker at all times on the paper,” I said while pointed at the paper.
“Used a walker to walk,” He said as he wrote.
After that, whenever I met him in the hallway, he was always using a walker to walk.
In short:
Strategy Training: Goal. Plan. Do. Check
and
Speak Out Loud.
Reference:
Bryant, L. E., & Budd, K. S. (1982). Self-instructional training to increase independent
work performance in preschoolers. Journal of Applied Behavior Analysis,15(2), 259-271.
doi:10.1901/jaba.1982.15-259
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