SLPworldview

Cultural empathy in clinical practice doesn’t require understanding your own worldview, but it can’t hurt. Dig deep with Will Farnham, MS, CCC-SLP.

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We’ve all got them: Pain points.

Sore spots.

Don’t-go-there’s.

Not just in our histories, but in our worldviews.

Things that make you go 🤔 just a little 𝘵𝘰𝘰 much.

Maybe it’s theodicy.

Maybe it’s the paradox of tolerance.

Maybe it’s free spontaneity vs altruism/compassion.

We looooove to point these out when we perceive them in others.

Not so much when we are shown them ourselves.

You can usually spot them in the moments when your instinct is to shout “NO U” in retort.

Inhabit the discomfort.

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In case you missed it, I had a guest spot on Meredith Harold and Ianessa Humbert’s “Evidence and Argument” podcast about the sorts of things I ostensibly talk about on this account.

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I’d be willing to bet there has been a lot of gazing long into the abyss lately.

We all know that eye contact it its various forms has multiple communicative implications.

What has the abyss been saying to you as you gaze?

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Clang Clang Clang

I’ve always had a problem with the trolley… problem. Such a concrete visual for such an abstract conundrum.

Who among us is going to have to decide between situations so dire that either one or five people will die?

Enter Spring 2020.

Enter questions like, “Should we use personal protective equipment to conduct instrumental swallowing exams?”

Or, “Should we speed up how quickly we go back to consuming because the most vulnerable among us are the most harmed by the economic impact?”

Should we switch to the track with one person so that five may live.

What makes this problem a problem is there is no correct response. There’s no protocol to follow. Are we ethically required to do what’s best for a single patient right here, if it means increased risk for five other patients in a different place or time?

Every response builds on a host of assumptions. Do the needs of the many outweigh the needs of the few, or the one? Is conscious deprivation of a necessary but insufficient cause for sustaining life tantamount to willful commission of a sufficient cause to ending a life?

Does life have value? Is life’s value quantifiable?

What do we owe to each other?

Who is my neighbor?

The only right answer to the trolley problem is to throw yourself on the tracks if you’re standing close enough to do so. That saves six people. But when the trolley is an infectious disease, we aren’t just pulling the lever, we’re the trolley.

So tired that I couldn’t even sleep

So many secrets I couldn’t keep

Promised myself I wouldn’t weep

One more promise I couldn’t keep

—Soul Asylum

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Those of us that were fortunate enough to have had a counseling and ethics component to our education were provided a hefty helping of unconditional positive regard. Of presumed competence.

Set personal preferences aside so that your  knowledge and expertise can mingle with patient preferences.

Approach each session as though the client is motivated and capable, and simply lacks the scaffolding to achieve their highest possible performance.

Probe for gaps in knowledge and areas of stimulability.

Do I exercise these same skills and principles with my colleagues?

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Call it compliance. Call it adherence.

What happens when two incommensurate things must both be true?

In our striving for what’s best in our clinical practice, we try to ground our practice in the evidence. We dig as far into the research as the paywalls will let us. We read summaries from people who have greater access and comprehension to that research. We consult mentors who are generally acknowledged to be experts. We use that knowledge to make recommendations, and we listen to feedback from our patients or clients or caregivers on how those recommendations align with their goals and preferences.

So what if it doesn’t align?

We tend to be comfortable with a hypothesis that we can accept or reject based on evidence. But what happens when we have both a thesis and its antithesis?

Enter Hegel and the dialectic. The unstoppable force acting on an immovable object.

A therefore not B. B therefore not A.

A. And B. 

We do not fall for the argument to moderation. There is no middle ground here.

The third part of that EBP triad is where we should be finding the synthesis from the thesis and antithesis. A and not A. B and not B. A and B.

Clinical expertise is not “I have a degree!” It’s not “I’ve been doing this long enough that you should take my word for it.”

It’s recognizing when the science is a hammer but the patient presents as a bolt. It’s finding out whether or not the right size nut exists. It’s guiding the client through the process of knowing when things have been tightened enough, and what might loosen them again. It’s staying vigilant for the science developing or revealing evidence that a ratcheting hex driver set exists.

It’s putting metaphors back into the tool chest before you break them.

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Setting Nietzsche aside for a moment, allow me to posit a propositional truth. If you disagree, tell me in the comments.

We as SLPs would not have entered this field to become übermenschen. We have not peered into the abyss beyond good and evil.

Maybe we accept general cultural norms of “acceptability.”

Maybe we grew up with “God and country” or “Faith and family.”

Maybe we have a creed, either inherited or of our own devising.

Maybe we honestly haven’t thought about it.

Or maybe we have gazed long into the abyss.

The abyss can blink.

Or we can leap into it with Kierkegaard.

But if we had let it stare back, we would not be who we are, where we are, doing what we are doing, for whom we are doing it.

Because speech pathology requires normative practice.

Whether we believe there’s an objective order and a force behind Right and Wrong, or believe that what we know as the good is just a reflection of what we owe to each other, as one strange epiphenomenal loop to another, we do not do what we do as an exercise of the will to power.

So, why do we let ourselves be beholden to new techniques? To dominant stakeholders?

Do we compromise for expedience? For security? For novelty?

From fear? From anxiety? From exhaustion?

We may not be the last men, but are we accomplishing the normative task set before us with every patient we encounter?

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Nietzsche’s Übermensch used to be frequently translated as “Superman,” (We’ll come back to superpowers later.) Action Comics cut short the life of that interpretation, giving way to the more common “Overman.” The Overman, who transcends constructions of Good and Evil and exercises their own Will to Power. SLPs frequently claim to be super-human. Are we Overmen?

The Overman is over many things. Over a need for self-preservation. Over a need for external motivators. Even over millennia of moral and ethical constructs that all began to unravel in the modern era.

Maybe we don’t need to be Overmen. But maybe we need to stop being Overman’s opposite, the last and most despicable ones.

Am I seeking first comfort and security? “I’m so burnt out but this job is all that’s available where I live.”

How often am I enthralled with my own accomplishments? “I’ve been doing this a long time, and I’ve learned a thing or two.”

To what am I clinging that fosters complacency? “I guess another year without a norm-referenced assessment is going to have to be fine.”

When or to whom have I been obsequious? “I understand that you talk just fine.”

Where am I settling for existence rather than flourishing? “I need two more free CEU hours this year to keep my license.”

Have I confused flourishing with extravagance? “I’m making more money than ever. That speaks for itself.”

“What do they call that which makes them proud? Education they call it; it distinguishes them from goatherds. That is why they do not like to hear the word ‘contempt’ applied to them. Let me then address their pride.”

Thus spoke Zarathustra.

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It is a truth universally acknowledged that an SLP in possession of a patient must be in want of a protocol.

Okay, maybe not universally acknowledged, but it’s true for even many of us that are not wound quite so tight as some.

We like to solve problems. After all, as we are so keen to remind others, we’re pathologists.

We find the appropriate diagnostic tool, and administer it. We do our best to stay on top of the current research, and we poke and prod at treatment methods to see if they’re right for our patients. Some of us do that on our own, others of us are paralyzed at the mere thought of clinical conjecture when we don’t have it spelled out explicitly. But wherever we fall on that continuum, generally we are looking for an answer.

We don’t like ambiguity. 

We may have enough confidence in our knowledge and scope to refer to another discipline when we don’t have an answer. We may be okay with a poor prognosis. We may have a satisfactory explanation for slow progress. But what we aren’t satisfied with is uncertainty.

We talk in terms of fear, and risk. Or, if that doesn’t suit us, we embrace fear’s twin, brazenness. We have a harder time with courage and freedom because we are beholden to certainty.

We’ll say, “I don’t know, but I’m going to find out.”

But when there’s no finding out to be had, what is left for us?

We turn back to Hofstadter, because for now, what is important is not finding the answer, but looking for it.

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The last post was prefaced with a quote from Socrates: “Ought we to inquire into the truth of this, or simply to accept the mere statement on our own authority and that of others?” And we focused on the unreliability of our own authority.

This time, I’d like to redirect our attention to the authority of others.

We all know that “expert opinion” comprises the bottom rung on our hierarchy of evidence. In rational debate, we go further than that, and call it a logical fallacy. In this case, it’s better referred to “argumentum ab auctoritate,” or the argument from/appeal to authority.

If you want to participate in a little exercise in humility about how good you are at reasoned discussion, take a look at Wikipedia’s List of Fallacies entry. Go ahead and take them one by one. Click through to the individual entries if need be.

This whole entry is a red herring. I don’t want to talk about authority today. Instead, I want to think about the times I’ve appealed to my own authority, and the authority of others. Or an argument to the absurd. Or that I’ve moved the goalposts. That I’ve confused possibility with necessity. That I’ve appealed to probability. That I’ve presented false dichotomies. That I’ve rejected an idea for being imprecise. That I’ve argued for a single cause in a multifactorial case. That I’ve claimed fallacy as an indication of a false conclusion.

I’ve done it with patients. I’ve done it with colleagues. 

How often have I swung low because I wanted to come out on top?

How often have I compromised a correct conclusion out of deference to an authority because that authority pushed back?

How many more of these am I going to exercise the next time a colleague comes to me for assistance, especially if doing so makes me seem more authoritative?

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To make a gross generalization and oversimplification, much of the history of Western philosophy can be boiled down as attempts to answer either—or both—of the following questions: How do we know things, and does that even matter?

Most thinkers (woof—I’m definitely coming back to that term down the road!) up to and including the modern era were principally consumed with the former question.

The idea that our senses may be unreliable is not a strange thought to us SLP’s. We’ve all known a patient with hemineglect, a person with hearing loss whose “spouse always mumbles,” or a neurodiverse child that just needs some different input. But what about the rest of us within a standard deviation of the mean? Can we we trust that the world is as it seems? And if so, how?

Call it imprisonment in the cave. Call it the evil genius hypothesis. Call it the Matrix. Ultimately there’s always a possibility that we are all just characters in The Sims ∞, or maybe are constantly mistaking our wives for hats, just doing so less frequently than an Oliver Sacks patient. If there is a “we” in any sense of the word at all.

That this is not the case is frequently one of those assumptions mentioned last time. We take them a priori, but to do so means that we’ve been complacent in the answers we give ourselves when we stop to think “how” or “why.”

Assuming we stop to ask ourselves that at all.

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How often do we make what seems to be an innocuous comment only to have it turn into a complete dumpster fire, particularly online?

Some of it is the medium, as well as the effect of strangers interacting via ambiguous communication modalities, and making assumptions based on incomplete data.

But sometimes, it’s about a different kind of assumption. It’s about a priori assumptions, sometimes referred to as first principles.

Think of it like this: Every time we make any kind of assertion, that simple statement sits on top of a mountain of other ideas that we have already assumed to be true, whether we are aware of it or not.

At its core, some things have to be assumed. At one level, the truth that 2 + 2 = 4 must be assumed. It can’t be proved, but if you’re going to tip your barista, do your taxes, perform an appropriate regression on your study data, or debate Keynesian vs Austrian economics, you’re going to accept that basic mathematical concepts have immutable meaning and properties.

We assign the same level of certainty to all sorts of ideas of multiple complexities until those ideas are challenged. And correspondingly, we tend to assign them the same level of universality. We’ll delve deeper later, but for today, I’ll just leave you with some examples of propositions that SLPs may frequently assume but which are by no means universal.

Communication is meaningful.

Interpreted and applied appropriately, valid and sound interventions will be reproducible.

I will eat today.

Human behavior is quantifiable.

Two individuals with similar capacity and knowledge fund may be anticipated to exercise similar choices.

Most people will do the best they can within their ability.

“Best” in the sentence above has meaning.

Reasonable people will agree on what that meaning is.

What else are we assuming?

#speechpathology #speechtherapist #slpsfollowslps

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As speech-language pathologists, we spend a lot of time thinking, thinking about thinking, and thinking about others. When we find ourselves pushed to the brink, sometimes we start thinking about ourselves as well, and call it self-care.

We know more than so many about the who, what, when, where and how of thought. We can be the point person for these matters if there’s not a neurologist or psychiatrist around. And sometimes if there is.

But how often and to what degree do we think about the why of thought? Particularly of our own thought?

I’d be delighted if you’d join me on a (very!) casual tour of some of the basics of western philosophy and worldview formation (as well as some dalliances in other traditions) with that peculiar angle that only SLPs seem to grok.

Part blog, part experiment, part completely unaccredited continuing ed opportunity, my hope is that we will end up asking questions that maybe we answer for ourselves, maybe we don’t, but if we’re lucky it will help us better understand where we are coming from so we can better meet others where they are. Excelsior!