Abstract
Therapy for school-age student children and adolescents is most effective when they are actively involved in changing their behaviors. The more a student is able to recognize the need for changing a behavior (e.g., becoming more intelligible, engaging in coherent communicative exchanges with others, managing stuttering), the more likely they are to exhibit progress. School-age children should be capable of actively seeking change and making decisions regarding change. Clinicians can provide more appropriate therapy if they know how their students think about their need to make changes and their ability to make those changes. This Idea Swap describes a method called journey mapping that enables clinicians to gain an understanding of their clients’ views on change: where are they on their journey to make changes in their behaviors. Such knowledge enables the clinician to better counsel the student and plan relevant lessons.
While working with persons with addictions, Prochaska and DiClemente (1983) developed the transtheoretical model (TTM; also called the stages of change model). The model describes behavioral change as an intentional process that unfolds over time and involves progressing through a series of stages. The TTM focuses on the decision-making of the individual and is a model of intentional change. People do not change behaviors quickly and decisively. Rather, change in behavior, especially habitual behavior, occurs continuously through a cyclical process. The TTM is a model rather than a theory. It is called transtheoretical because it employs a variety of different behavioral theories in various stages of the model where they may be most effective. The TTM is endorsed by the World Health Organization (WHO). (Speech-language pathologists [SLPs] are to employ the WHO’s International Classification of Functioning in all assessment and intervention). Since its introduction, the TTM has been widely applied to many habilitation and rehabilitation situations where a change in a person’s behavior or attitudes is desired. Sometimes this approach is called journey mapping because one is documenting a person’s journey of change. A review article in this issue of Word of Mouth describes its application for adolescents who stutter.
Change involves a series of stages, from being unaware that there is a need for any change to having made and maintained the change in behavior. Table 1 displays the six proposed stages of change and a phase of possible relapse (Prochaska & DiClemente, 1983),
Stages of Change.
Source. Copyright 2022 by Carol Westby. Shared by permission of the author
The clinician should determine where the student is on this change journey and assist the student in understanding where they are on their journey. Client journey mapping gives clinicians a better understanding of their clients’ experiences when dealing with a communication impairment and the stages of change they go through in their habilitation/rehabilitation. By knowing where clients are in their journeys, clinicians can better counsel and design interventions based on a student’s/client’s specific stage in their journey.
Table 2 gives examples of two students’ journey change: MG, a 12-year-old boy in sixth grade with a bilateral moderate hearing loss, and AV, a 15-year-old male high school freshman with a history of developmental language impairment.
Student Behaviors at Stages of Change.
Note. DLD = developmental language disorder; SLP = speech-language pathologist.
Source. Copyright 2022 by Carol Westby. Shared by permission of the author.
MG wore his hearing aids inconsistently, insisting he did not need them. Students with hearing loss frequently do reject wearing hearing aids, particularly if they do not see other students with hearing aids. Initially, MG rarely wore his hearing aids and was unaware of what he was missing in class. His therapist that year, who had a significant hearing impairment herself, worked with MG to make him aware of what he was missing and why what he was missing was important in the classroom and with his friends. By the end of the year, he was regularly wearing his hearing aids. When he was re-evaluated at the beginning of high school, however, he had relapsed and was not consistently wearing his aids.
AV had been diagnosed with developmental language disorder (DLD) in early elementary school and had been receiving language services since that time. Upon entering high school, both AV and his parents requested that he no longer receive services. Initially, AV saw no need for language therapy support. As the year progressed, however, he became aware he was having difficulty keeping up with his academic assignments.
Requesting dismissal from speech and language services is common for students entering high school who have had a history of language impairments throughout elementary and middle school. High school Individualized Education Program teams have been quite willing to accept the students’ and their parents’ requests and to dismiss them from services. High school SLPs, however, are aware that a number of these students begin to flounder as the school year progresses. If students are dismissed from services and then began to experience difficulties and even fail, it is difficult to requalify them in a timely manner. For that reason, some high school SLPs have requested that those students be placed on “monitoring” the first semester of their freshman year. The SLPs can check in briefly with the students each week and can monitor students’ academic performance on Power School, a computer system that documents students’ attendance in classes, completed assignments, and current grades. The high school SLPs also let these students know that they have open office hours over the lunch periods. Students could drop in if they needed some assistance with a task or wanted to talk. Gradually, a number of these students who initially rejected services begin to recognize their need for them if they are to achieve their post high school goals.
Journey mapping is typically accompanied by motivational interviewing (MI; Rollnick et al., 2016). MI, which focuses on improving a person’s motivation to change and does this through conversation, is founded on the conviction that students can change. MI consists of a set of skills clinicians use to have a conversation in which they talk with the student about the case for change—the pros and cons of changing their behavior. Students are more likely to change their behavior if it involves what they want or need. MI involves a shift in a clinician’s conversational style, from informing/instilling to eliciting, that is, acting more like a guide than a teacher. MI is not a behavior management technique but rather a way of helping someone make decisions. There are four steps in MI:
Engaging: The clinician actively establishes a connection and a helpful working relationship with the student. In this step of the MI process, clinicians should ask themselves: How comfortable is this person in talking to me? How supportive and helpful am I being? Do I understand this person’s perspective and concerns?
Focusing: The clinician and student decide what change to talk about. In this step, clinicians should ask themselves: What goals for change does this student have? Do I have different aspirations for change for this student? Are we working together with a common purpose?
Evoking: The clinician draws out the student’s ideas about why and how to change. The clinician evaluates the student’s pros and cons or benefits and costs for changing or not changing a behavior. Using a 1-to 10-point scale, students indicate how important it is for them to change and to what degree they think they can change. In the Preparation Stage of Change, AV (the student mentioned earlier), began to acknowledge he could use assistance, but he was ambivalent about attending language therapy. AV reported that upon graduation from high school, he intended to join the military. To do so, the clinician explained he would need a score of at least 31 on the Armed Services Vocational Aptitude Battery, which would require better reading skills than he currently possess. AV was participating in Junior Reserve Officers’ Training Corps (JROTC), but he had to have passing grades in all subjects to remain in JROTC. Table 3 displays AV’s benefits/cost chart of attending or not attending therapy. AV rated the importance of his doing well in his classes as a 6, and the degree to which he thought he could do better in his classes as a 4. AV appeared to underestimate how important it was for him to do better in his classes if he was to remain in JROTC. His low confidence rating on being able to change likely influenced his ambivalence about attending therapy. The clinician needed to support him in recognizing that he was capable of making the necessary changes. In this step clinicians should ask themselves: What are this student’s own reasons for changing? Am I trying to move the student too far or too fast in a particular direction?
Planning: The clinician helps the student decide how to make the change, what to do, and when. In this step, the clinician considers: What would be a reasonable next step for the student to make changes? What would help this student to move forward? Am I evoking the plan from the student rather than prescribing a plan? Am I offering needed information or advice with permission?
Cost/Benefit Analysis of Attending Therapy.
Note. JROTC = Junior Reserve Officers’ Training Corps, SPED = special education.
Source. Copyright 2022 by Carol Westby. Shared by permission of the author.
Journey mapping and MI have been done with elementary school students.
In the process of conducting an MI, clinicians use four skills called OARS ([ask]
Open-ended questions invite a wide range of possible answers, not just yes-no. They invite clients to “tell their story” in their own words without leading them in a specific direction, for example, “What happened? How did you react? Tell me more.”
Affirmations: These are statements that shine a light on student/client strengths and achievements, no matter how big or small. Affirmations build clients’ confidence in their ability to change. Examples: “Even when you’re upset, you make careful decisions”; “When you are focused, you get things done.”
Reflective listening: The clinician tells the student/ client, in different words, what they heard the student say or mean. There are three levels of reflective listening:
Repeating or rephrasing: Clinician repeats or substitutes synonyms or phrases and stays close to what the speaker has said. Paraphrasing: Clinician makes a restatement in which the speaker’s meaning is inferred. For example, the student says, “And I just lost it.” And the clinician responds, “You were really upset.” Reflection of feeling: Clinician emphasizes emotional aspects of communication through feeling statements. This is the deepest form of listening. For example, the student says, “I had done nothing to upset her. She just wants to be the queen bee around here and makes it hard for others and I don’t want a friend like that.” The clinician reflects, “You don’t want to hang out with those girls and yet you don’t want to be alone on the playground.”
Summarizing: Notes the student’s/client’s key points during the conversation and then produces the points in a summary. Give special attention to change statements. Use “you” and include aspirations and strengths along with concerns. Ask the student if what you said was accurate and if you missed anything.
Journey mapping requires students to have language skills characteristic of typically developing mid-elementary school students. They must be able to converse with the clinician about their experiences and cognitively understand the concept of change. Consequently, journey mapping may not be appropriate for some elementary school students with developmental language impairments. For middle and high school students, it can be a strategy to promote executive functioning.