The River and The Rock: Acceptance and Commitment Therapy

Emily Brady (0:15): Hi, everyone. I'm Emily.

Unknown Speaker (0:17): And this is Eva.

Unknown Speaker (0:19): And you're listening to Speech Talk. We're your research book club so you

Unknown Speaker (0:23): can do evidence based practice in practice. So let's start talking. Eva,

Unknown Speaker (0:29): tell me about your week this week.

Unknown Speaker (0:30): Oh, everyone got sick for the second week in a row. So honestly, the best part of my week is this right now. So excited our episode. Oh, and we're celebrating season two of this episode. Emily, we've been doing this for

Emily Brady (0:50): a year. It's so that is so wild. And we need like, poo poo, confetti.

Unknown Speaker (0:56): Confetti cannon, t shirt cannon, balloons falling from the ceiling, all of those feelings.

Emily Brady (1:04): It is really crazy to think about, like, this being our season two because we've been, like behind the scenes working on this for even when did we January. It started

Eva Johnson (1:20): two years ago. Yeah. Just like wrote episodes for like a year and tried to do some research and development in terms of how we thought people would like it with our friends. No one listened.

Emily Brady (1:37): And our friends don't listen. Our one friend texts us in a in a group chat and says, hey, guys, I'm thinking about potentially switching over to the sniff life. You got any tips? Like, yeah, listen to our podcast. There's a bunch in there.

Unknown Speaker (1:55): Any episode, take a pic.

Eva Johnson (1:58): So, yeah, that's pretty big. And how about you, Emily? What happened this week that was big? Fun.

Emily Brady (2:05): Well, for starters, also, we have been sick over here. I didn't know that you did you couldn't like, it's not a thing all the time that strep throat goes away with one bout of amoxicillin. So I'm on my second round of antibiotics. But you know what? I got two days off of work for it.

Unknown Speaker (2:27): You know, you're feeling real burned out at work when you're like, oh man, I'm sick. Can stay home.

Unknown Speaker (2:33): I am highly contagious. Don't talk to me.

Unknown Speaker (2:39): That was terrible. So sorry you're on your second round there. Rough stuff.

Emily Brady (2:45): Yeah, rough stuff. So my voice sounds weird, that's why.

Eva Johnson (2:47): And when you guys hear me blow my nose, there we go. Okay. So part of the reason I'm so giggly is I'm so excited to talk about this episode. I really went down the research rabbit hole, but I've reeled it in. And I'm gonna start off with asking you a question.

Eva Johnson (3:06): Emily, do you ever feel like you're fighting your patients to do speech therapy?

Emily Brady (3:11): Real talk. If I have to fight them more than twice, we start educating on discharge. You may need this, like, the grass needs sun and earth, but if you are just like, meh, girl, me too. Like, I don't care either. If you don't want it, then that's perfectly fine.

Eva Johnson (3:33): Yes. And I just, I hate that feeling of being like, why are why am I fighting you to do speech therapy? It always makes me feel like I'm doing something wrong because therapy is supposedly helpful. And instead, people are telling me that this isn't helping. They don't think they have an impairment.

Eva Johnson (3:52): They won't do their strategies unless I'm standing over them aggressively. And I was just like, I'm done. I'm done with this life. And I was listening to this other podcast, How to Be Patient. And they have an episode on, it's called Acceptance and Commitment Therapy.

Eva Johnson (4:09): And I was like, oh my god, maybe this is it. My patients aren't in the space to do therapy because they haven't even accepted where they're at. And that's kind of what sent me into this internet spiral on speech therapy and acceptance and commitment therapy. Wow, Eva, I'm intrigued because

Emily Brady (4:33): yes, my patients have not accepted where they are. Holy cow. How many times have you gone into a patient's room and they're like, yeah, I'm gonna start walking again and they've been bed bound for years.

Unknown Speaker (4:48): I think you mean like how many times a day I do

Unknown Speaker (4:51): I hear

Eva Johnson (4:54): don't have memory problems. Okay. Where are you? I'm at home. No, you're in the hospital.

Unknown Speaker (5:00): Right. Yeah. You got memory problems.

Emily Brady (5:03): And you know, like to your other point, we just recently got a survey back about the helpfulness of therapy, and all the comment said was speech therapy isn't as helpful as other therapies. Right. And

Eva Johnson (5:19): feels like a knife in the back every time. And so then I started having like this other kind of meta thought about this, which is maybe I haven't accepted, that they haven't accepted. And I need acceptance and commitment therapy or ACT.

Unknown Speaker (5:41): Are you committed to this profession? Have you cried in your car enough?

Eva Johnson (5:47): Yeah. So that's why I wanted to call today's episode, the river and the rock because of that that saying, the river doesn't argue with the rock because the river just goes around it. You know? That's what I feel like I wanna be doing with my patients. I just wanna flow around the obstacles, and I want them to take in as much as they're willing to accept and keep moving.

Eva Johnson (6:09): I'm done fighting the rocks. So today we are exploring acceptance and commitment therapy, ACT, not as psychotherapy, but just as a guiding framework for how we conduct speech therapy.

Emily Brady (6:22): So before we jump into today's articles, Eva, I think you should explain what ACT is.

Eva Johnson (6:28): Okay. So ACT therapy is a part of CBT therapy or cognitive behavioral therapy. The underlying premise of CBT is that our thoughts influence our emotions and subsequently our behaviors. By intentionally, like very directly identifying and restructuring our disordered or unhelpful thoughts, we can improve how we feel and how we act.

Unknown Speaker (6:54): Have you watched the Olympics at all?

Unknown Speaker (6:56): Yes. Oakland in the house.

Emily Brady (6:59): So Aileen Wu was doing this interview, and one of the interviewers asked her if she even thinks before she speaks because everything comes off so eloquent. In their words. And she said that she spends so much time in her own brain, like structuring how she thinks and making sure she's thinking positively. So that's what you just reminded me of. She makes herself think positively and so she is positive.

Emily Brady (7:31): She makes herself think winning thoughts and so she is winning.

Eva Johnson (7:36): I love that. And yes, that is a lot of the essence of it. You're like, you can restructure how you think about things if you do it intentionally.

Unknown Speaker (7:43): It was a funny way

Unknown Speaker (7:44): that the

Unknown Speaker (7:44): reporter asked, but do you even think before you speak? Like, no. Do you

Unknown Speaker (7:51): even think about your words? No? Okay.

Emily Brady (7:54): So in our patient world, if a patient says, I'll never get better.

Eva Johnson (8:02): Yeah. Exactly. We want them to examine and challenge that thought and be like, well, you may not get to where you were pre stroke, but you can definitely get better from where you are. The statement, I'll never get better. That's just a huge statement to make.

Eva Johnson (8:18): And in a lot of ways, it's just empirically false. You're gonna make gains.

Emily Brady (8:22): Yeah. So what about ACT?

Eva Johnson (8:26): Yeah. So where CBT is trying to restructure your negative thoughts, ACT assumes that difficult thoughts and emotions are just part of being human. Like that's part of our lived experience, but that we can change our relationship to our thoughts and feelings. So the negative experience is there, but we can change how we feel about a negative feeling.

Emily Brady (8:51): So that would look like a patient saying, I'll never get better, but then the therapist doesn't argue with it. You just acknowledge and kinda try to move forward.

Eva Johnson (9:02): Yeah. Exactly. And I've actually done CBT therapy for myself in my twenties when I had a lot of early twenties depression, and I found it really helpful. But I think as a clinician, I like that ACT framework because I don't feel comfortable telling my patients, hey. Your thoughts aren't true.

Eva Johnson (9:21): Like, that does not feel like my place. On the other hand, I do feel comfortable acknowledging their feelings and trying to help them keep moving towards their goals.

Emily Brady (9:31): So in speech therapy, we're constantly asking patients to do things they are uncomfortable with. We're trying to get them to eat differently, speak differently, use strategies, slow down, stop between words, open your mouth wider, practice.

Eva Johnson (9:47): Yeah. And we're like asking them to be imperfect in public, and that's so hard. And even asking them sometimes to acknowledge that they have an impairment is hard. Especially if they have like anosognosia and they're like, I can stand. And you're like, you have bilateral leg impairments.

Eva Johnson (10:04): You cannot stand, my friend. So sometimes just acknowledging the impairment is really difficult.

Emily Brady (10:10): Okay. I think I get it. Time for some research. And let's do some acceptance and commitment therapy practice.

Eva Johnson (10:20): I know. I feel like we're about to do some, like, real wedding or marriage counseling for the two of us.

Unknown Speaker (10:25): Aw, that'd be so cute.

Eva Johnson (10:27): Aw, our acceptance and commitment therapy to each other.

Unknown Speaker (10:31): I commit my life to you in this podcast.

Eva Johnson (10:35): Yeah, exactly. Okay. So I really did try to limit the number of things I looked into for today's episode, and I kept it to three things, two articles in a CEU. The first article was group acceptance and commitment therapy for post stroke depression. Second one was adapting ACT to stroke survivors with aphasia.

Eva Johnson (10:56): And the last was a speechpathology.com CEU called ACT framework. Was it free? I have an account with them, so I actually don't know if it's free straight up. Alright. Quick pause.

Eva Johnson (11:10): We'll be back right after this break.

Emily Brady (11:15): Okay. So you may ask, why are we looking at therapy models for speech work? But remember, clinicians do have counseling as a component within our scope of practice, so understanding a particular way to approach counseling is something we wanted to get into for this.

Eva Johnson (11:32): Yeah. And especially since I oftentimes do not feel qualified to do the counseling aspect, it was nice to kind of see this principle at work. Alright. Article one was a randomized controlled trial looking at post stroke depression in patients who received group based ACT therapy. The study found that ACT intervention significantly reduced depressive symptoms at follow-up check ins compared to the usual stroke care patients, even when a patient's neurological impairment didn't change.

Emily Brady (12:05): So they're feeling better without necessarily getting better?

Eva Johnson (12:09): Yeah. Exactly. People are feeling better about how they're doing post stroke without necessarily having significant neurological improvement. The results seem to suggest that increasing a patient's psychological flexibility can improve their emotional adjustment during recovery. And what's important for us as clinicians is that the research demonstrates that ACT can be done within the medical rehab setting with, like, meaningful impact on patient well-being.

Eva Johnson (12:37): The study findings really show the role of emotional processes in engagement and recovery.

Emily Brady (12:42): That's really cool. Because normally in medical settings, it just it feels more emotionally heavy. Right? Like, a lot of times, this can be someone's very first run-in with a stroke, and it has been debilitating. Right?

Emily Brady (13:00): Like, the it has really knocked them on their butt. Like, this is a whole new change. We've gone from running daily to bed or wheelchair bound. So just being able to talk about some of the things in our scope that is a little bit more hard, but maybe is work aroundable and not really and the patient might not be giving that their highest focus gives them a good opportunity to, you know, vent out those psychological and emotional changes in their speech therapy sessions. Definitely.

Eva Johnson (13:45): And your point about, like, this is a heavy place to exist. You've just gone through a big change. It's also like when you're in the hospital, you might have your own room in a sniff. You might be sharing it with, like, one to four other people. You're not sleeping well.

Eva Johnson (14:00): You got none of the comforts at home. Like, this is not really usually a place where that I associate with, like, emotional healing.

Emily Brady (14:08): Right.

Eva Johnson (14:08): You know? So it's nice to know that by having targeted acceptance commitment therapy, you you can see improvements. This research specifically looked at group sessions where the researcher said patients could socialize with similar experience to peers, provide opportunities for altruism, and that it was cost effective. And I just wanted to see what you thought about that idea because I've had really limited access to group sessions, but you were like the queen of group therapy.

Emily Brady (14:39): Not the queen, but I

Unknown Speaker (14:42): Maybe the princess?

Emily Brady (14:46): I'm the jester of the speech of group therapy. So the groups that I've watched seem so supportive back and forth. And then I've had groups where people have volunteered information about their memory impairment and have been able to share that with each other. And it is it is really nice to see people bonding and talking about things that impact them together just by, you know, them in the same room and doing a craft or having a cookie.

Eva Johnson (15:17): Yeah, man. There was a stroke survivor volunteer at my hospital who comes in and talks with recent stroke survivors. And he and one of my patients were, like, just kinda chilling, talking about what it feels like to have the the sectioned skull from a craniotomy in your stomach. And they were just like kind of talking about it and like what it's like to have it sitting there, like waiting to go back into your head. And I was like, yeah, this is not a conversation that I could have started.

Unknown Speaker (15:52): Like, it really takes someone who's been through it to talk about it.

Emily Brady (15:56): I'm so confused. What goes on with their stomach? They put it on their stomach for like safekeeping?

Eva Johnson (16:02): Oh, yeah. I recently learned about this that sometimes in a craniotomy when they take out a portion of the skull to relieve pressure on the brain, while they're waiting for the swelling to go down, they can't just, like, keep it on ice, but it turns out your body won't reject it. So they'll just like put it on your stomach for safekeeping. Wild. The quick Google search says removing a craniotomy oh, it's a craniectomy.

Eva Johnson (16:31): There we go. A craniectomy involves removing a part of the skull to relieve severe brain swelling with the bone flap temporarily stored under the skin in the abdomen to keep it sterile, nourished, and alive for future reattachment.

Emily Brady (16:44): You learn something new every day. I'm shook us.

Eva Johnson (16:47): I am shooketh. Yes. Anyways, it's pretty intense. And having those opportunities to talk about it seemed like it really was beneficial in an organic space, not like me being like, so tell me about the bone in your tummy. Tell me about that.

Unknown Speaker (17:08): Do you still get ticklish in this spot?

Eva Johnson (17:12): Yeah. Let's go on to the second article. So the second article is actually a clinical trial that's still in progress, but I'm really excited about it because it specifically is looking at ACT therapy for the aphasia population. They've concluded the trial, but they haven't written their report yet. National Institute of Health Clinical Trials publishes their progress so you can read what they're doing and their preliminary results as it's being done.

Eva Johnson (17:44): The intervention modifies the language of traditional ACT techniques. It simplifies it to ensure that people with language impairments have good access. So this study is looking

Emily Brady (17:57): at whether ACT can realistically work for people with aphasia, whether patients can participate in it, whether they can find it helpful,

Eva Johnson (18:06): and whether it reduces emotional distress while improving real world communication. It reinforces the idea that emotional adjustment and communication recovery go hand in hand. And for us, it seems to suggest that ACT can be meaningfully integrated into speech therapy when adapted appropriately. And I'm so glad to see that somebody is trying this out because if a therapeutic process relies on people being able to express themselves well, then it would kind of cut out like a very large portion of our population.

Emily Brady (18:38): When you're working with someone with aphasia, you can see on their face that they're upset or distressed. And they wanna talk about it, but it's just stuck. And I feel like sometimes my therapy is just practicing that script. My words are stuck. My words are stuck.

Emily Brady (18:59): And then trying to compensate.

Eva Johnson (19:01): Yeah. Going back to the idea of group support and aphasia moments. I used to be a volunteer support for an aphasia art group. It was read by led by a stroke survivor, and she would be in the middle of explaining. And she'd just be like, word is stuck and then cuss like a sailor and everyone just laughed.

Eva Johnson (19:28): It was like, it was so awesome to see everyone just totally relating on the intense frustration of like, you're talking, you're showing and like, you cannot get around this phrase. And you're like, I wanna say it and I can't. And it was just this beautiful moment. I'd never been in a space where watching someone struggle resulted in everyone laughing together. Mhmm.

Eva Johnson (19:54): And at first I kinda felt uncomfortable because I was like, oh, I can't laugh at people. You know, that wouldn't be right. But then as the longer I spent with the group, the more I realized, like, these were moments where people were relieving their stress. They were relieving their tension through laughter. And it really helped me to see how just saying I'm mad Mhmm.

Unknown Speaker (20:15): Help people move through it. And that's that's kind of the point of what we're talking

Unknown Speaker (20:18): about

Eva Johnson (20:18): right now. Mhmm. Anyways, the final thing we're looking at is the CEU, which was actually presented by the same guy doing the National Institute of Health trial. His name is William S. Evans, and way to go, Will.

Eva Johnson (20:33): So in his CEU, he does a really good job explaining some of the key ideas within ACT. And I wanted to review them here because there are these concepts I think can really help us as clinicians or frankly in our personal lives. So let's get into them. Emily, can you read us some of the list?

Emily Brady (20:51): Eva, I got the word, you get the definition. Ready? Got

Unknown Speaker (20:55): it. Here

Emily Brady (20:56): are the things we can recognize in our patients.

Eva Johnson (21:00): First off, cognitive inflexibility. That's when you're stuck or really rigid in your negative internal experience.

Emily Brady (21:09): Next up, cognitive fusion. That's

Eva Johnson (21:13): when you're feeling really fused with your thoughts. They're real. They're true. Like, they are your existence.

Emily Brady (21:20): And lastly, we have experiential avoidance.

Eva Johnson (21:25): This is when you're trying to avoid or control or suppress an unwanted internal experience. And I don't know about you, Emily, but I have seen all of these in my sessions. People are like, I am never going to be able to, you know, spend time with my family in the evenings when we're having dinner. And I'm like, what? That's an absurd thing to say.

Eva Johnson (21:52): Like, you'll just eat slightly different food. It's fine. And they're like, nope, it can't be done. And you're like, oh, okay. So now we are inflexible.

Eva Johnson (22:01): We are fused with this belief that like, we cannot be someone who dines with our family. And then they start avoiding eating and you're like, well, dang, you really, really entrenched yourself there.

Emily Brady (22:14): Yeah. And we will link the CEU in the show notes so you can get a more thorough education on these three things via William S. Evans. Yeah. Thanks, Will.

Emily Brady (22:29): So if that's what we're seeing in our patients,

Eva Johnson (22:32): we wanna then look at what the ACT framework promotes to, like, kinda overcome them.

Emily Brady (22:38): So first up, we have psychological flexibility. So almost the exact opposite of that first one. When we can open up, be present, and determine how we do what matters the most in that moment.

Eva Johnson (22:51): And so what is kind of component? As Emily said, there's open up, be present, and do what matters. Opening up therapy is being able to experience your negative or uncomfortable thoughts without putting up defensive mechanisms. For me, that reminds me of when I talk to my kids and I'm like, it's okay to be sad. It happens.

Eva Johnson (23:09): And we'll find something fun to do when it passes. Like, I'm not trying to tell you to not be sad. You're three. It's gonna happen.

Emily Brady (23:17): Be present therapy. So experience what you're going through.

Eva Johnson (23:22): It's okay. Just live it. And do what matters therapy is ask your patients to identify their values. These are aspirations that help keep them moving forward. It's like, how do we show that we're a loving family member when our communication is impaired?

Emily Brady (23:36): Yeah. And I feel like for this one, especially, this is I pulled this kind of thing into all my treatments. I'd start off like, what are we working on today? What is your biggest hurdle? So we are actively trying to do what matters, keeping that ultimate goal in mind.

Eva Johnson (23:55): The hospital, on the patient boards, it has goals. And a lot of people, it's like being able to walk, you know, getting from my bed to my chair by myself. But I feel like so often it just says, go home.

Unknown Speaker (24:13): Go home. That's my goal. Just go home. Don't care how.

Eva Johnson (24:21): Exactly. And so, and then the last thing he talks about is workability. And from how I read this, it's kind of a sustainability metric. Like, if what you're doing is making your life better, then yes. Great.

Eva Johnson (24:34): Keep doing it. And if not, it's not workable long term. And we can help patients consider other more workable options. Let's take a look at what some of this might look like if we kinda used it with our patients. So I pulled together, like, a few little kinda case studies here, And they're just I know this is where I got really excited and nerdy.

Unknown Speaker (24:57): I just wanted to exemplify some of these concepts.

Unknown Speaker (25:02): This is the first time I'm seeing.

Eva Johnson (25:05): Emily has not seen these. So, my apologies. So I can't defend myself any further. I got real excited. And I hope, obviously I'm not a specialist in AZT.

Eva Johnson (25:18): So I hope I'm doing the concept justice. I have to ask Evan Williams or William Evans if I did okay. All right, Emily, you be the patient. The cognitive change scenario. The patient who says, I don't need these strategies.

Eva Johnson (25:35): What would an SLP say?

Emily Brady (25:37): So you don't feel like you need this?

Unknown Speaker (25:40): No, that's what I said, I'm fine.

Emily Brady (25:42): Okay, would you be open to trying one small reminder today? Not because you have to, but just to see if it makes anything easier.

Eva Johnson (25:51): Exactly. So we're not trying to put them in the position of telling them their feelings they're wrong. If they say they don't need it, we're not telling them they do. But we're just kinda opening it and saying like, hey, what if it just made some things a little bit easier? Would you be open to that?

Eva Johnson (26:06): Is that kind of just slight pivot to kind of not hit the rock river? We don't hit the rocks, we go around them.

Emily Brady (26:14): Okay. Last case study. So if the patient shuts down and

Unknown Speaker (26:19): says and this is

Emily Brady (26:22): an aphasia patient. The patient shuts down and says, I can't. Eva, what do you say? I'm gonna look at them

Eva Johnson (26:28): and just say, this feels really hard right now.

Emily Brady (26:33): Yeah. The patient would agree.

Eva Johnson (26:35): Yeah. That makes sense. And we don't have to get it perfect. Let's just try something less intense. Would you be up for looking at maybe some family pictures on your phone or just doing something less structured?

Eva Johnson (26:47): What might you wanna do? And letting them kind of redirect the activity. We don't wanna hit that wall. We wanna go around it. Okay.

Eva Johnson (26:56): I know I sprung role play on you, but No.

Unknown Speaker (26:59): I don't know about that. That's the weirdest script.

Eva Johnson (27:05): If you were actually in the moment with some of those patients, how do you feel like how do you think that would feel trying that in a session with one of those patients who you're like, I am fighting you over therapy.

Emily Brady (27:20): I definitely think that while, you know, I talk about having people come off my caseload if they fight me, it's you can definitely tell a difference between someone who is fighting you because, you know, they hate it or, they're not willing to accept it versus someone being just really frustrated and down about the situation. I think these situations, these specific scenarios was the latter. Right? Like, in these specific situations, it's it's going to be a lot easier to open up your empathetic your empathetic heart and, you know, your your caregiver side and just be like, okay. Like, this is this is this is hard.

Emily Brady (28:13): Let's throw this away. Let's look at pictures of cats.

Unknown Speaker (28:16): And we're just gonna talk about cats for a minute,

Emily Brady (28:19): you know, or dogs, whatever your tea is. And I think in those situations where the patient is just combative and not really up for whatever you're trying to do. Maybe it's they're just they just really aren't ready. Those opening scenarios to me sound like such a a good idea. And I'm sure it takes loads of loads of practice to be able to diffuse those situations because Oh my god.

Emily Brady (28:56): Yes. Even listening to this podcast now, like, as we're talking about it, I'm like, having a combative patient, like, this feels hard and I'm not patients don't exist. Like, I'm I'm stressed out about going into this session and it doesn't even exist.

Eva Johnson (29:17): Right. Because I think what you're pointing out is that these, like, tiny role plays, the following line the patient says is, no. I still don't wanna do it. Like, they're still arguing.

Unknown Speaker (29:28): To your

Eva Johnson (29:29): point about the person who is, you know, uncooperative versus like, I'm just having a hard time. And I think that brings us really well to my next part. The role play for us as clinicians.

Unknown Speaker (29:44): Oh, no. There's no there's more role playing. Oh my god. I just scroll more. What did you do, Eva?

Unknown Speaker (29:53): I got way too excited.

Unknown Speaker (29:55): You're not allowed to have days off work anymore. What?

Unknown Speaker (29:59): You sound like my husband.

Emily Brady (30:01): This is why my Internet is running slowly is because our episode today is like eight pages long, actually.

Eva Johnson (30:09): Okay. We'll tone this one down. But I think you bring up a really good point, which is that like, sometimes you just literally cannot win with a patient and those moments are so hard. But I think they drive us to something William Evans would point out, which is the avoidance aspect that we're feeling rigid. Like, this is a rigid situation.

Eva Johnson (30:34): I can't get out of it. This patient is hard to work with. I don't even wanna go in the room. I hate this part of my day. I have don't wanna do this session.

Eva Johnson (30:43): Like, these are all thoughts I've had about patients who were frankly mean to be. Yes. Well, not just mean, but, like, you're just, like, really trying, and they are just rejecting everything. You know that vibe.

Emily Brady (30:59): Oh my gosh. No. Honestly, there is a patient I have on caseload right now. Anytime I ask him a question, he's like, what do you think? This huge attitude.

Emily Brady (31:13): He said I was a part of the KKK. I was like, actually offended.

Unknown Speaker (31:19): Yeah. Pretty good chances.

Emily Brady (31:20): How do I go back into this this client's room who is struggling help them if they're accusing me of being a Nazi? Like I just said hello. You didn't like my tone. It's how

Unknown Speaker (31:36): you said hello. I don't know.

Emily Brady (31:38): Today, went into his room and his foot was hanging off the bed. I accidentally knocked into him twice and he reamed me a new butthole like it was so bad. I was like, let me just turn around and leave. I'll never I'll never show my face in here again.

Eva Johnson (31:53): Oh, I'm sorry. That is really tough. That is very hard situation to be in, especially since you have to go in there.

Unknown Speaker (32:02): So too.

Eva Johnson (32:05): And sometimes if a patient literally cannot engage in therapy, discharge is the right option. You're like, hey. You're not making progress. You're not engaged. It's no longer ethical for me to bill you because you're not making progress on your goals.

Eva Johnson (32:18): And that's not on me. You know? We do always have that in our back pocket as like a, you know what? This isn't working out. Maybe outpatient is for them.

Eva Johnson (32:30): Maybe this is something they're never gonna engage with, and that's okay. And that's kind of the point of this next concept of, like, how do we use an ACT check-in for us as therapy providers? So the first one, think I we've kind of covered, which is, like, notice the story your mind is telling you. Like, this is a waste of my time. They are too difficult.

Eva Johnson (32:52): I don't wanna do this. Then you can say, hey. I'm feeling frustrated. Maybe I feel like I'm not doing a good job. Then you move through, can I feel irritated and still be professional?

Eva Johnson (33:09): Now we're separating, like, who we wanna be as a clinician from what we're doing in the moment and, like, making that an active choice. This is us going from hitting the rock, who is the patient, because we never hit patients. We go around them.

Emily Brady (33:23): It's a reminder to self. Know.

Eva Johnson (33:25): Reminder to self. So we move away from feeling like, hey. I'm telling myself I'm an an incompetent clinician to, hey. I know I want to be calm and supportive and helping them, but I can't control that. What I can control is how I behave and what options I give them.

Eva Johnson (33:46): And if I do those things where I remain calm and I give them new options and they still reject it, that's not about me. We're good. You know? This is the level of engagement they can do. That's just reality.

Eva Johnson (34:01): You were the person you wanted to be in the room and you can feel good about that.

Emily Brady (34:05): That's real Eva, that's deep.

Eva Johnson (34:09): And now you see why I was a little obsessed with this concept.

Emily Brady (34:13): Very obsessed. I mean, yeah. Like, because it is it is it is so hard to try and make sure we're like keeping yourself in check. But but you I mean, you can be irritated and still act professionally. Sometimes have to take breaks and just say you're going to the bathroom or something and do a couple goose for bars and calm yourself down.

Unknown Speaker (34:42): Don't know what that word is.

Emily Brady (34:45): From anger management? Adam Sandler.

Unknown Speaker (34:50): I do know about that movie. I don't think I've seen that one.

Unknown Speaker (34:54): He makes him say goose for a while whenever he gets two men. Oh. It's just the saying.

Unknown Speaker (34:59): That's how

Unknown Speaker (34:59): you cover slow down. Someone stealing your woman, you say goose for ba.

Eva Johnson (35:05): Or you write a country song. I won't take a shot at country music. But, no, I like what you're saying that, like, it takes a lot of work. And while I think the ACT framework is cool, this is so much cognitive load Mhmm. To just be constantly thinking about, like, this is what I'm targeting.

Eva Johnson (35:25): I'm watching the patient. I'm looking at their impairments. I'm making adjustments. I'm doing the appropriate amount of cueing. And on top of that, I'm regulating their feelings.

Eva Johnson (35:32): And then on top of that, I'm regulating my feelings. Well, I shouldn't say we're regulating each other's feelings. We're helping them kind of move through their feelings, and we're moving through ours. Like, that is so much mental work. It's exhausting.

Eva Johnson (35:47): But I think that if we can practice it in little moments

Unknown Speaker (35:50): Mhmm.

Eva Johnson (35:51): It makes things easier. And if for no other reason, then we're, like, just being okay with stuff instead of being like, god. That session was a total waste. It's like, I did my best, and they did their best in terms of what they could bring to the table. So, like,

Emily Brady (36:09): everyone tried. Good job. Good job, team.

Unknown Speaker (36:12): Good job, team.

Unknown Speaker (36:13): That's right. Oh, the people in my head.

Eva Johnson (36:18): Okay. So does the whole river and rock thing make more sense after this forty minute discussion?

Emily Brady (36:23): It does, but I can't stop thinking about how smooth the river rocks are how much the river changes the rock over time. Yes, by flowing around it. By flowing around it. So but, like, that's what I keep thinking. When I think about the river and the rock, my immediate thought is this sharp, jagged, big boulder.

Emily Brady (36:49): And then my second thought is little pebbles.

Eva Johnson (36:53): You know what, I really like that in the metaphor, know? When the rock starts in the river, it's all jagged and stuff, but over time, over time, it will become a smooth, pretty pebble.

Unknown Speaker (37:07): We will wear you down.

Eva Johnson (37:11): That's exactly what I tell my patients when I walk in the room. Hi, Amoife, I'm here to wear you down. And you guys can try it too listeners. Just look for moments of inflexibility, a moment when you or your patient are like really fused with their thoughts. You're not able to like kinda get out of a rut.

Eva Johnson (37:30): And try some of these for our clinical recommendations this week. Notice a moment when you're like, feel like you're pushing and ask a values based question. Share this episode with a colleague so that we can have more listeners.

Emily Brady (37:46): And then talk about your small wins with your friends about how together you are both avoidant to your one patient and how each of you had overcome something. And then give each other a cookie for doing your darndest.

Eva Johnson (38:04): That's right. And you can be like, you know what? I'm a good colleague. And they're a good colleague because we gave each other cookies. See, we're all ACTA ing all over the place.

Emily Brady (38:15): Until next time. Be more river. Be less rock y'all. Thanks for listening. Bye.

Unknown Speaker (38:22): You've been listening to Speech Talk.

Eva Johnson (38:24): Thank you everyone for coming to listen to our research book club. Until next time, keep learning and leading with research.

Emily Brady (38:31): If you like this episode and you wanna give us some love, please rate us on your favorite podcasting app. Leave a review and tell the world because as podcasters, our love language is in positive affirmations.

Unknown Speaker (38:42): And if you like listening to us, you may like more podcasts from our network, human content, like how to be patient, bendy bodies, knock knock high with the glock and fleckens, and psychiatry boot camp. If you have a research topic you want us to cover or you have episode comments, clinical experience you wanna share, or just wanna send us

Unknown Speaker (39:00): some love letters, send us an email at hello@speechtalkpod.com. If you want even more speech talk content, check out our website at speechtalkpod.com, where you can find all of our resources we made for you, copies of articles covered, and Eva's blog following these topics and more. We're your hosts,

Eva Johnson (39:20): Eva Johnson and Emily Brady.

Emily Brady (39:22): Our editor and engineer is Andrew Sims. Our music is by Omar Benzvi. Our executive producers are Erin Corney, Rob Goldman, and Shanti Brooke.

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Emily Brady (39:43): Speech Talk is a proud member of the Human Content Podcast Network.