family-centered vs. medical model in speech and language pathology

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“Family-centered therapy” has become such a widely used phrase in all sectors of speech and language pathology. When I was in graduate school, it was weaved into all of our coursework; however, there didn’t seem to be much depth to the process. It was almost implied that you would make the family a primary part of your service delivery, with little discussion on how to achieve this.

As I transitioned to the workforce, I heard mentors speaking negatively about other clinics being “medical model.” I listened to staff in-services about the importance of being family centered.

I got the general idea of it. Obviously, involving families leads to better generalization and improved outcomes (if this doesn’t seem so obvious, do a quick literature search). I also was given the impression that “medical model” meant ripping a child away from their parents in the waiting room, working on “fixing” them for an hour, and then returning them to their regularly scheduled programming.

Umm. That sounded terrible.

What do these terms actually mean?

According to an oldie-but-goodie article written by Elizabeth R. Crais in 1991, family-centered therapy involves the principles of: making families and clinicians equal contributors to assessment and intervention, fostering and expanding families’ skills in line with their personal wishes and recognizing the individuality of all families while adjusting yourself accordingly. (Crais, 1991).

The medical model, across disciplines, involves the professional diagnosis of disorders and designing a treatment plan with appropriate implementation. This is not necessarily ripping the child away from their parent for an hour! A parent can just as easily be in the room observing this model.

In other words, “family-centered therapy” is more than having the parent in the room, and the “medical model” doesn’t mean the family isn’t present.

Put into practice

Research shows both better generalization and more functional outcomes with a family-centered model. This, for me, is particularly strong for the research surrounding parent-implemented milieu instruction (which deserves its own article one of these days), and with the DIR/Floortime and Sensory Integration research (both of which will most definitely be getting their own posts).

That said, the medical model is not the devil. We are highly educated in the areas in which we treat (my Sallie Mae account likes to remind me JUST how educated I am), and our skills as diagnosticians and treating therapists should not be discounted.

Putting these principles into practice, however, is easier said than done. It is largely setting-dependent, as few parents come to their child’s speech sessions in schools. Even in the outpatient world, many view it as their time to run to the grocery store. In home-based services, it’s dishwashing time.

In the outpatient setting, parent involvement can be emphasized from the assessment onward. Problems can be encountered, however, when you inherit a child from another clinician or when the assessment was completed elsewhere.

In schools there is the wonderful opportunity to develop goals with the parents in the IEP meetings, but you are restricted to academic-based outcomes. This one time a year is also often the only time you see the parent.

It comes a bit more naturally in EI settings, but varying levels of family stress and routine play a role here, as well.

So, what’s my point?

My point is that we all have to do the best we can with what we’ve been given. There is a continuum ranging from parents not being present, to parents being informed of what they can do, to parents observing, to parents participating, to parents co-treating. Every case in every setting falls somewhere on that continuum.

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Our goal, I think, isn’t to bring them all the way from the left to the right. Our goal is to nudge them along until we reach a place where everyone feels the family and child is reaching maximum benefit from their current resources.

If you only see the parent once a year, try giving them a call once a month or sending home an update on what you’re working on and how to implement it at home.

If the parent is in your session, but texting the entire time, ask them how things are going at home and provide suggestions from there.

Taking these small steps to move our treatment up the hierarchy can help us involve families more and more, without feeling overwhelmed about the process. It also takes a lot of stress off of you to “fix” things in the short amount of time you see them. I think we can all agree we could use less stress.

 

Citations:

Crais, E. Moving from parent involvement to family-centered services. American Journal of Speech-Language Pathology, 1, 5-8.

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