Starting hard conversations with parents and clients is so much easier when you know how to say difficult things honestly and gracefully. Here’s where the right turn of phrase, examples, and analogies smooth the way. 

 What this episode has to offer: finding the right words to introduce difficult topics

 Join me under the umbrella for tips on talking about

• Frequent absences and no-shows
• Insurance issues
• Dismissal
• Parents in the therapy room
• Suspected co-morbid conditions (like autism)
• Realistic time frames for progress
• Clear feedback to clients

— Useful Links —

Three Task Oriented Movement Activities for Executive Function

Impossible R Made Possible Video Course

Real Changes in Spoken Language with Sketch and Speak 

More Success with Cluttering Therapy, part 2

Seeing Autism Signs? Speak Up and Guide Parents to See Them Too

Music: Simple Gifts performed by Ted Yoder, used with permission

 Transcript

Denise: Welcome to the Speech Umbrella, the show that explores simple but powerful therapy techniques for optimal outcomes. I’m Denise Stratton, a pediatric Speech Language Pathologist of 30 plus years. I’m closer to the end of my career than the beginning, and along the way I’ve worked long and hard to become a better therapist. Join me as we explore the many topics that fall under our umbrellas as SLPs. I want to make your journey smoother. I found the best therapy comes from employing simple techniques with a generous helping of mindfulness.

Hello, this is episode 78 of the Speech Umbrella podcast. Whether you’re a regular or a new listener, welcome. I’m so glad you dropped in. Today’s episode is along the same lines as the last one, number 77. That podcast was all about ways to improve client and clinician and parent rapport. Well, today I’m going to talk about hard conversations with parents and clients because not skirting around difficult topics is another way to improve our relationships. The sooner these things are talked about, the better the experience is for everyone, and that includes SLPs as well as clients. . The problem is we don’t always know how to say what needs to be said, and that was certainly the case for me when I was a younger clinician and even after I opened my own clinic, as a somewhat experienced clinician.

Now I’ve had so much practice saying hard things. I don’t sweat it like I used to. As the saying goes, honesty is the best policy. I’ve garnered a few tips on my way, and that’s what I’m offering today. I’m calling this episode How to Have Hard Conversations with Parents and Clients. Now here are seven potentially hard conversations I’m going to cover.

The first three are applicable to private practice and the rest are generally applicable. So number one, frequent absences and no-shows. Number two, insurance coverage. Number three, reasons for dismissal. Number four, should parents stay in the therapy room. Number five, suspected the undiagnosed co-morbid conditions. Number six, realistic timeframes for progress, and seven, giving clear feedback to our clients. While I’ve listed the first three topics separately, the frequent absences and no-shows, insurance coverage, and reasons for dismissal, there is no way to avoid lumping them together a bit when I talk about ’em, especially when I talk about clinic policies, because your clinic policies and procedures are going to be a huge help for you dealing with these three things.

Now, these are not the only topics covered in my policies, but these are the areas that end up in difficult conversations. So first I want to emphasize again, if you have a private practice, write up your policies and procedures and follow through on them. I actually collect a signed copy of my policies when clients begin therapy, so they are aware of the expectations and following your own policies will make everything much easier, even if initially it’s really hard, for example, to charge someone for a no-show.

Now you might be thinking, sure, I can follow my own policies. What else is there to say? Well, there’s quite a lot, I’m afraid, with frequent absences and no-shows. The difficulty comes in when the client says, well, it was an emergency. Now I make exceptions for true emergencies. I’ve had clients, you know, break an arm the very day they’re supposed to come to therapy, things like that.

But I have had clients who claimed emergencies so frequently that I have to question their definition of an emergency. So what I do is rather than questioning them about what truly constitutes an emergency, I point out that their time and money is not being well spent because their child is not getting therapy regularly enough to benefit. They just can’t get traction in the direction they need to go. And I then suggest that they stop private therapy, at least for the time being because their resources could be better spent. If I need to, I can present them with a list of their absences and a copy of the clinic policies they signed. But usually just that conversation with them kind of gives them the out that they need.

A no-show now is when a client doesn’t show and doesn’t cancel, and my policy is to charge the full session price for a no-show so even with great parents who occasionally forget therapy, I still charge a now-show fee and this is why. The first time it happens, they’ll usually say, oh, I’m sorry. I understand if you need to charge me for today.

And you think, oh, they’re being so nice. I’m not gonna charge them today. But what happens when they forget again and you do charge? And then they have cause to wonder, well, why not then? And why are they charging me now? And they’re confused and you haven’t been consistent. And number two, the second reason is financial. Now, if I were to forgive all the honest no-shows, meaning the parents didn’t just write me off, but it was last December and Christmas was coming up and they honestly just forgot, if I were to forgive all of those, that would be a real significant hit to my bottom line because Christmas, and that happens when you’re in private practice.

So be tough, but fair in your expectations. You provide value. It’s a fair exchange of your expertise and time for their money. No-shows, frequent absences and late cancellations take your time and therefore it’s fair to be paid something. Now let’s talk insurance. When you’re billing insurance, there’s a lag time between therapy sessions and insurance processing. And in a perfect world, you wouldn’t begin therapy until you have a clear understanding about insurance coverage. And most of the time that’s the case and we just have smooth selling. But sometimes when you look at a client’s policy, it appears that they’re gonna pay for speech therapy. But then they end up denying once they process the claims, and this usually happens because they have certain limitations that they put around speech therapy that we don’t know what they are, and those are totally outside of my control.

But because of the time taken in processing claims, the client may end up owing money for therapy that they were not expecting, because they were expecting insurance to pay and it may have been a month, or it may have been six weeks that they’re coming to therapy thinking insurance is going to. So you really need to address this in your policies if you’re going to bill insurance, and I’m just gonna read you what my policy states. As a courtesy, we will check your benefits to verify speech and language coverage before treatment commences. This check of benefits does not guarantee coverage by your insurance company. In the event that your insurance company denies payment for services rendered, you’ll be responsible for the amount on your invoice. If efforts to appeal any denials or delays result in payment for services previously billed, you’ll be reimbursed on your next invoice.

You want to have something like this written up because some parents have a really hard time understanding this bit, and so I don’t get sidetracked into speculating why insurance won’t cover because I don’t know. I simply state the facts, I provide documentation and I make sure parents are aware that they may need to pay cash for a certain number of sessions, depending on how long it takes for insurance to process those first claims and whether they deny her, whether they approve. So we’re all clear there. Also, I have a policy that if insurance clients are no show or a late cancellation, they’re going to pay me cash for that because I can’t bill insurance for an absence.

Here’s one more area regarding cancellations. I require parents to be responsible for the decision about whether their child is well enough to come to therapy. I dunno what it is, but some parents kind of want you to decide as the clinician, and I’ll get texts with lengthy descriptions of all their child’s symptoms and asking whether I want ’em to come in.

And I find it’s best to reply that it’s their decision as the parent and let me know what they decide, and just leave it at that. It’s hard not to sound abrupt when saying this, but it must be done. So once you’ve figured out a good way to say it, save your wording and that way every time this comes up, you can just copy and paste that, send it to ’em, and there you go instead of spending five or ten minutes wondering, how do I say this and not sound mean?

Okay. Let’s move on to communicating about dismissals. I touched on this a bit with policies and procedures, but I have a couple of stories that’ll illustrate this point. I had a client who was really regular and on time for quite a while, just a dream client as far as the parents being regular, and while there were really no issues or hard conversations that needed to happen at that time, later on, as I thought maybe he was getting close to being released, his attendance just cratered and there were all sorts of scheduling problems and conflicts with his family and cancellations, and so I thought well, he’s got a little bit of work on articulation left. He’s got a little bit of work left on phonemic awareness, and he has a little bit of work left on fluency. So he had a lot going on, but was actually doing pretty well all things considered. And so I suggested to his mom, well, maybe the school speech therapist can finish this out.

So about a year later, she contacted me about all the problems he was having, and referred to me graduating him, and that’s when I realized, oh, I wasn’t clear enough. I wasn’t honest enough because she’d been such a good client and I didn’t want to sound so mean that you just need to stop coming because you were canceling all the freaking time. I was really soft about it. Oh, maybe the school speech therapist can finish him up, and her impression was, well, you graduated him.

So that didn’t reflect well on my clinical judgment because he wasn’t really ready to be released, and I knew that these things were going on and they hadn’t really been totally resolved. I was just hoping, it was a hope that he was close enough to being released that he didn’t need to continue with private therapy.

And so that came back to haunt me. Another reason for dismissal that can be hard to talk about is diminishing returns. And this is particularly pertinent to clients with severe disabilities, and when you see diminishing returns with clients, you need to communicate that clearly and show it if you can.

This story might have served to illustrate. Once I had a client with a rare chromosomal disorder. He was in his early teens and he had a AAC device, but his parents wondered if he could learn to vocalize more. And so he did make some really nice initial gains in learning to vocalize. And for him, honestly, just a few words would’ve been great. That would’ve been all of his parents asked for. And he was even trying to speak more at home and more at school. And this lasted for a few weeks, and then it just stopped. And my feeling was that he wasn’t motivated. So we tried removing a parent from the session to see if that helped and he didn’t. So I asked his parent to come back in because I wanted them to see what I saw, which was lack of desire.

And his dad saw it clearly, and he said, we realized he’s happy where he is at. And that’s a best case scenario for dismissing a client who isn’t progressing. And of course, parents are always free to keep looking and our field is such that they may find a clinician who has that special skillset set to help them progress more. But when you have done all you can, it’s best to communicate that.

Okay, moving on to topic number four, should the parent remain in the therapy room? And I know SLPs have varied opinions on this, some will always have the parent present. Some just don’t do that, and they never have the parent present. I like to determine it with the parent when we see how the child is acting in therapy, when demands are placed on them.

The hard conversation happens when you suspect that clients would do better without the parent in the room. So some clients will not bring themselves to do challenging things when the parent is there. In those cases, the easiest solution for me is to explain this to the parent and see if they’re willing to try stepping away.

And if they do want to try being out of the room, I always invite them to come in the last few minutes so we can talk about what we did and how they can offer support at home. So if this is a quandary for you, don’t be afraid to bring it up and talk about it. A parent may still decide to stay, but at least you’ve had the conversation.

And I remember the first couple conversations I had with parents. It was hard for me, you know, it was hard for me to say, I think that they’ll do better if you’re not in the room. But the results were obvious and they did do better and it worked. So that works for me. Now, number five, suppose you have a client with a suspected undiagnosed condition, and oftentimes this is autism.

What do you say to the parent who is positive their child is not on the autism spectrum, when you clearly see signs of it? First of all, I would say listen to their side. So why are they sure their child is not on the spectrum? They may have been told by a professional that it was unlikely. Some children with ASD have what I call a honeymoon period with a new person, and they really don’t exhibit many symptoms of autism until they know you better or until you present something really challenging to them, and I know I’ve had that happen to me. So I’ve learned to kind of shut my mouth and observe a child for a few sessions before I say something about autism. Suppose you’re seeing signs of autism when it hasn’t been diagnosed. You could talk about the symptoms. You could say, this is what I’m seeing. And these are characteristic of Autism Spectrum Disorder.

I mean, you’re going to be treating the symptoms regardless of the diagnosis. So you can surely talk about the symptoms that you’re addressing. And I tell you many times parents do suspect autism deep down. In one case, after I had this hard conversation with a parent with a box of tissues between us, she went from crying one week to being a strong advocate the next week, seeking the diagnosis and getting her child into OT, which he really, really needed. And ever since then, she has been a super advocate for her child. So knowledge is power. It’s the power to take needed steps for the child. So it’d be better to present the idea of autism even if you’re not sure so the parent can get the knowledge they need, get the diagnosis they need.

Number six, we’re gonna talk about realistic timeframes for progress and also questions about IEP service time. So school clinicians, if you’ve been cooling your heels, wondering when is this podcast ever gonna apply to me? Well, this next part does. Now, if you work with preschoolers in a school setting, see if this has ever happened to you. Has a parent of a preschool child with a significant speech and language impairment said, I want her to be ready for kindergarten.

This is their way of saying if you just give them enough time in therapy, they will be ready because that’s their belief. And by ready they mean they expect them to sound pretty much like their peers. Now, if this doesn’t seem like a realistic expectation, the following road trip analogy can be helpful.

They may see their child’s journey to kindergarten as a road trip with so many miles to go, and as long as you go with certain speed, that means give them enough therapy time. You’ll get them there in time for kindergarten. They may not understand that their child is the vehicle, and there may be several issues that take time to address before the child can even begin to travel at the speed they want. These may be neurological issues, attention issues, motor issues. These issues can exist even when a child has what we would call normal cognitive ability. So when you know you’re using the best techniques in addition to continually learning, and that’s what I hope the Speech Umbrella does for you. It’s easier to be realistic about speed of progress.

We don’t really know how quickly any of our clients will progress and we’re making educated guesses, but we do know the child’s neurocognitive state, that’s the vehicle, is a big part of the equation. So if you can share this analogy with a parent, they might begin to understand that just a certain amount of therapy minutes is not necessarily gonna get them ready in a certain amount of time.

Here’s another hard conversation specific for school clinicians. Some parents want more therapy time than is offered on the IEP. Now I’m gonna qualify talking about this with first, really, really think about whether they do need more time and whether you can figure out a way to give them quality time.

But that being said, when faced with the situation, you could say the school is a finite system and I have to work within that system so you don’t have an infinite amount of time. And also point out that they need to have access to all the school offers. That’s why they’re in the school, including other special ed services, PE, time in the regular class, and the SLP cannot infringe on those. Once again, when we are using the best therapy techniques, you can generally be confident about the student making progress.

Number seven, last but not least, is the hard conversations you have with clients themselves. For example, our feedback on how a client says R needs to be clear. You need to say yes, you said that R spot on, or no you didn’t.

Saying things like, on a scale of one to five that was a three, are really confusing for the client. If you want to know more about this, check out my Impossible R Made Possible video course cuz I talk all about that. And this same thing applies to any sound that is liable to distortions such as S and Z. It even applies to fluency clients.

In episode 69, More Success With Cluttering Therapy, I do have a really neat story about how when I was really honest with the client about his cluttering errors, it was a turning point for him and I’ll link that episode in the show notes. Now, your client may be initially disappointed that they didn’t get more positive feedback, but they also may stay in therapy forever without clear feedback.

Now, if you tuned into episode 72, Real Changes in Spoken Language With Sketch and Speak, you’ll remember how insistent Dr. Ukrainetz was about the child repeating the same sentence exactly once it was formed correctly, and there’s no room in the Sketch and Speak method for that was okay or that was close.

The goal is not to be negative, but to teach them to speak with precision. Because precision in language leads to precision in thought. I’ve had these hard conversations at least once with every client who is capable of self-reflection on my caseload because it keeps us on track and progressing. Let me explain what I mean by that.

If the child is working on R but isn’t saying it precisely, without clear feedback they don’t know they’re missing the mark. Without knowing how to say R with precision, they can’t master R. Then one of two things happen. They stay in therapy forever or they graduate without having really mastered it.

Neither of those is a great outcome. But when you have the hard conversations in a timely manner, you’ve given them knowledge and that knowledge leads to the power to change. My usual mantra at the end of this podcast is when you master the simple, the complex takes care of itself. Today, I’m tweaking it to when you master simple honesty and hard conversations, you avoid messy complications. Thanks for listening. Now go forth with courage to have those hard conversations.

Thanks for listening to the Speech Umbrella. We invite you to sign up for the free resource library at thespeechumbrella.com. You’ll get access to some of Denise’s best tracking tools, mindfulness activities, and other great resources to take your therapy to the next level. All this is for free at thespeechumbrella.com. If you’ve enjoyed this podcast, subscribe and please leave us a review on Apple Podcasts and other podcast directories.