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The First Session: New SLP Experiences

New School, New Communication: Working with AAC
January 12, 2017 8:24 AM by Dana Wetmore
I have been placed in my first practicum placement! Yee haw! I've waited for this day since I entered graduate school, anticipating what it's like to have a job and take on a full caseload. I've daydreamed about the crafts, the group time, and the co-workers that will help me achieve my goals. I thought about learning hands-on with a professional that would eventually (hopefully) become a mentor and a peer. Then the day came, and I regretted wanting to hurry through my studies.

Once put on the job, I again had to become familiar with a new type of practice, new people, new students and a new learning experience. My placement is in an elementary school that ranges preschool to sixth grade, in which my supervisor sees more of the younger population. Many of the classes include fully self-contained classrooms of different grades, a preschool setting, and a medically-fragile classroom. I will be doing evaluations, IEPs, meetings and eventually (meaning next week), taking on a full caseload.

The incredibly different and wonderful part of the experience my supervisor introduced to me is working with AAC (augmentative and alternative communication) as the bulk of the therapy. iPads from the school are programmed with applications dedicated to communication such as LAMP. The important aspect here lies within the main purpose of the iPad: communication. What may seem like an intellectual gap between cognition and technology becomes a special relationship of language and visuals.

Even the preschoolers use iPads and have proven to me the effectiveness of knowledge of language and expression through the use of technology. A student who can say only one sound can tell us that we are playing with green frogs and big cats. The child can form a three-word utterance by selecting the appropriate words using syntax and semantic knowledge otherwise unknown through limited verbalizations.

Recently ASHA published an article reporting the benefits of providing younger children with AAC titled "AAC with energy - earlier" by Beth E. Davidoff. Davidoff covers the pros and cons of AAC introduced during early intervention through research and standards requiring the necessity to give children the means to talk. As stated earlier, Davidoff covers the concern of screen time with young children, but if screen time is used in a functional, social manner with other people, it becomes less of a time burner for parents and more of a communication modality.

The catch-all of AAC is about the buy-in. Students can be successful using an AAC device, whether the type be communication cards, sign language or high-tech iPad applications, the method only becomes truly useful when it is capitalized as a method of communication by everyone: parents, teachers, teacher aids, sibling - essentially anyone and everyone communicating with the child.

After "AAC with energy - earlier" was published, a blogger part of ASHA made the observation that AAC is not as simple as sitting an iPad in front of a child and expecting them to brilliantly communicate. It takes time and effort for clinicians to model, teach and scaffold the use of AAC before it becomes functional for the child to use. The next step is teaching school staff, family, and friends how to use and edit the device. Finally, making the device available for all communication purposes is fundamental to the child. Of course, for this to happen has to be the ultimate buy-in, and expectations for everyone to be on the same page may be unfathomable.

Maybe I can prove the effectiveness of AAC with just one child during my practicum and make my opportunity of starting something new less intimidating for myself - and perhaps one of my students, too.

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Another Type of ABCs
October 19, 2016 3:35 PM by Dana Wetmore

By Dana Wetmore

 

The treatment note I wrote from my last session included the subject line: “in 1 instant __ ran out of the therapy room during the 50 minute session” and I was proud of it. Simply put, my client is what we call a “runner.” Where functional language lacks, replaced behaviors exist, and in order to provide any communicative feedback my client often jumps, gestures, cries, screams, squeezes my legs, or, in many cases, runs.

 

I have had clients in the past that did not have the language to produce wants and needs distinctly, and in an attempt to communicate, acted out in behaviors not considered appropriate for a structured setting like therapy or school. Luckily, I have had a wonderful educational background regarding the behavioral aspects of therapy to guide me in my practice.

SEE ALSO: Functional Communication

I have a supervisor that always emphasizes the ABCs of all actions: “A” being the antecedent, “B” being the behavior and “C” being the consequence. Pulling out some classic behavioral psychology here, but essentially everyone does this contingency in forming behaviors and attitudes. Your mom asks you to clean your room and you don’t, so she’s going to get upset and ask why you didn’t clean it. Perhaps you take your dog out for a walk and he goes to the bathroom, so in approval of his actions you say, “good boy!”

 

So let’s actually talk about something relatable here: Let’s say I want my client to sit in his chair (A), and in response to my request, he does it! (B) I will reward him with verbal gratification like, “good job!” and, “I love your sitting!” (C)

 

Based on research, people are more responsive to positive feedback than negative feedback, which totally makes sense! So in turn, this is where prompting comes in. Let’s say I want my client to sit in his chair (A), but instead he runs away (B). I am going to make sure he observes my disapproval with a verbal response such as “no” or “uh uh” or maybe something visual like crossing my arms, or my favorite, the stink eye (C). The next time I want him to sit in his chair, I will give him the most prompts available in order to make him successful. I ask him to sit in his chair again (A), guide him to the chair and point to the seat. If he sits! (B), I’ll respond, “Wow! Great sitting! Good Job!” (C)

 

Sitting in a seat may sound incredibly unrelated to speech therapy, but really how unrelated is it to children with intellectual disabilities struggling in class to follow one step directions? The line between behavioral therapy and speech therapy can sometimes be thin and perhaps touchy. Yes, behaviorists can assist with language, and yes, speech therapists can enforce good behaviors, but where there is overlap, there is opportunity to work with more professionals.

 

As a guest speaker, a BCBA (Board Certified Behavioral Analysis) therapist came into our class to talk about behavioral therapists and speech therapists working with the same patients. Often, the overlap occurs with children with Autism Spectrum Disorder (ASD), in which behaviors may cloud the ability to communicate academically and functionally. Their services often include using an AAC device or perhaps a picture exchange system.

 

In conclusion, no other professional has the linguistic basis and background knowledge to guide a child through language and speech development that speech-language pathologists and speech therapists do, while certified behavioral therapists have the understanding and knowledge to reinforce self-care, motor development and play skills. While these aspects are all equally important in daily activities and academics, the ability to make the individual therapies overlap could be incredibly beneficial to the child to increase carryover of the many types of therapies learned.

 

Sources: Maul, C. A., Findley, B. R., & Adams, A. N. (n.d.). Behavioral principles in communicative disorders: Applications to assessment and treatment.

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Concussion Recovery and the Love of the Game
August 1, 2016 2:09 PM by Dana Wetmore

My life has been surrounded by sports since I can remember walking. I tried playing everything imaginable when I was in elementary and middle school, finding myself loving the competition and finesse of little league games. Field hockey stole my heart quickly, as I found myself dedicating most of my time to training during the week, weekends and sometimes (I could swear), in my sleep. In fact, I played field hockey in college, meaning I dedicated my college career not only to academics, but to my team, my coach and my school.

As soon as I graduated college, I no longer had the opportunity to play, and living in Hawaii has put boundaries on my love for the sport — there isn’t much field hockey in the middle of the Pacific Ocean. As every graduate student may understand as well, I don’t have much time outside of academics to enjoy field hockey like I used to.

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But then I began studying concussions, and I found my love for athletics and competition again in the willingness of players recovering from concussions sustained while playing sports. The study also revealed my own connection, as a collegiate athlete getting head-butted during a heated competition and losing consciousness for a few seconds, to then find myself suffering a concussion for weeks. I laugh at some of my experiences, like when I fell asleep on my front porch after I forgot my house keys or when I would cry whenever I forgot where I had put my keys. In other instances, I shake my head about all the things I wish I could take back, like trying to participate in class when I could barely keep my eyes open or continuing to play in the same game I lost consciousness.

While I recovered from my concussion, I could have sworn I remembered the six-step return-to-play program in my sleep, dreaming of the day I could play field hockey again. My athletic trainer pushed me to be honest and monitored me carefully while recovering to physical activity and contact practice. The following are the steps recommended in several studies, as well as from the NCAA:

  1. Light aerobic exercise — For example, I rode a stationary bike for 20 minutes. If I didn’t show any signs of symptoms of a concussion, I moved onto the next step.
  2. Duration and intensity-dependent exercising — In this portion, the athletic trainers had me ride a bike for a longer period of time (say an hour, since field hockey is considered an endurance sport and demands the ability to run for a long amount of time).
  3. Activity specific to sport with no contact — In practice, I participated in passing drills where there was no contact with another person, but I slowly was guided back into the intensity of the game.
  4. Non-contact drills and continuing resistance training — Along with practice, our team lifted five days a week. During this step, I was able to participate in drills where there was no physical contact, such as shooting drills as well as beginning the lifting regimen the rest of the team followed.
  5. Full Practice — Finally, a full practice to prove that all symptoms of the concussion are gone. This includes contact and noncontact drills.
  6. Game Ready — Once the player has been able to do steps 1–5 without any symptoms of a concussion, they are allowed to participate in games again with an OK from a physician. In my experience, my coach slowly let me back in games as to be incredibly cautious getting me back into the typical full-game routine I was so used to. I swear by the third game, my teammates could hear me whisper “put me in coach … ”

For any symptoms shown throughout the increments, the player would digress to the step prior. For example, the first time I tried riding the bike I felt my head hurting again and had to return to rest the next day. The step-by-step aspects of returning to play are efficient and organized, and although there are guidelines and recommendations,  there is no step-by-step program in recovering to academics.

I personally discovered this issue after returning to class from a concussion sustained a few days before midterms. At this point, I was not even attempting the six-step program to return to play, because I still had symptoms such as a consistent headache, irritability and tiredness. Yes, I stupidly attempted to take my midterm (I like to think my executive functioning aka decision making was affected also). And yes, I failed miserably. My team’s athletic trainer was focused on my recovery, but I was still lacking the carryover to academics.

According to research regarding academic recovery, the following is recommended by the American Medical Society for Sports Medicine: “Students will require cognitive rest and may require academic accommodations such as reduced workload and extended time for tests while recovering from a concussion.”

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Although this is recommended and I had a whole group of people supporting me in my recovery, I didn’t have a designated person to help me understand the cognitive deficiencies associated with concussions. In fact, my injury affected my test scores and academic abilities following the three weeks after my concussion because of my inability to concentrate and remember small details, while I also fatigued incredibly fast throughout the day. Looking back now, I wish an SLP could have helped me understand the small incremental steps in returning to academics that coaches, athletic trainers, academic advisors and professors may not understand as thoroughly. I felt that I understood the steps returning to play, but no one had the knowledge of regaining the ability to work again like SLPs do.

Maybe in the future, there will be SLPs assigned to work with college or professional athletes returning to daily living and academics in order to promote the recovery process. In my opinion, another specialist on the team for recovery could do no harm, but provide greater support to a person with mTBI. The scope of our practice may be broad, but no one knows those aspects quite like we do. Although I did not recover to academics appropriately when I sustained my concussion, I feel as if I have learned through personal experience, and have grown to be an advocate for a healthy brain.

References

Giza, C. C., Kutcher, J. S., Ashwal, S., Barth, J., Getchius, T. S. D., Gioia, G. A., … Zafonte, R. (2013). Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology.Neurology, 80(24), 2250–2257. http://doi.org/10.1212/WNL.0b013e31828d57dd

Harmon K.G., Drezner J.A., Gammons M., et al. (2013). American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med, 47, 15–26. doi:10.1136/bjsports-2012-091941

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Choose One
June 15, 2016 1:13 PM by Dana Wetmore

By Dana Wetmore

 

My favorite day of the week is Friday. I know that’s a slightly generic statement, but there’s more to it than just the beginning of the sweet, sweet weekend. Stroke support group happens at our school’s clinic on Fridays and I am never happier than when I get to work with such a great group of people.

 

Everyone comes in the clinic and sits around a long table. With canes and wheelchairs, some of the most courageous people I have ever met share stories of their strokes. I value their ability to be candid about such a life-changing event, but in spite of how compelling each story may seem to me, it is the source of daily struggle for each stroke client and their families.

 

Most people come in pairs, though some come alone. Typically sessions serve as a venting and coping activity, but after a somewhat somber gathering, our supervisor decided we would be playing games this past time.

 

We played a very therapy-worthy game of “Choose One,” much like the better known “Would You Rather.” We gave each person who attended a packet of questions, each with the two options listed as possible answers. Questions typically read, “Choose one fruit: apple or banana?” or “Choose one flavor of ice cream: chocolate or vanilla?” The visuals helped guide each member through the game, and it was fun to hear everyone’s opinions explaining their choices.

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Then we threw in a curveball and played the game in a style similar to newlyweds, in which the couples guessed their spouse’s answer. With the help of good communication partner strategies, the group didn’t stop laughing the entirety of the activity. The activity also encouraged conversational speech for aphasic clients at higher levels, but still invited the simplicity of repetition or gesturing for communication. The use of visual options like pictures, as well as written words also offered an array of guides to understand the question. “Choose One” also presented an opportunity for communication partner skills to be fine-tuned, while observing the techniques of other caretakers.

 

Overall, the activity was a success for many reasons pertaining to therapy. Sharing life events and getting to know one another was more of a reason to enjoy the activity, as everyone in the room experienced the human connection that is sometimes difficult to feel while facing aphasic symptoms. My hopes are to bring this activity to therapy as perhaps a baseline aspect, while getting to know my clients that much better!

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The Value of Specialists
May 20, 2016 10:26 AM by Dana Wetmore

As a final project in Motor Speech Disorders class, we were required to complete a case study on a make-believe client that presented with different stages and severities of a dysarthria. My partner and I were assigned a child with cerebral palsy that presented hypotonic characteristics such as weakness in oral muscles and difficulty swallowing, but normal cognition. In order to find treatment process and evidence-based practices, we began the long haul of research that would lead us to many dead ends.

 

For example, a majority of the articles that prove this particular treatment process effective do not provide the actual treatment. The frequency was often provided, so the article may say “treatment occurred three times a week for 50 minutes each session for a total of six weeks,” but contained no additional information on what the treatment was. I found this research incredibly frustrating — I didn’t know how the heck they were dealing with their patients, and I don’t know if this is a rookie statement, but I would love for the actual treatment detail to be included in research articles!

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There was one woman I found connected with many articles dealing with cerebral palsy named Lindsay Pennington, MD. Located in England, she contributes to a lot of research I found that included treatment details. The articles led me to do more research on this fantastic woman, and it turns out she is helping to develop an app for phones that can record parent interactions with children who have cerebral palsy and send these directly to their speech therapists. This technology sounds incredibly exciting, as this process helps with parent training as well as any new conflicts that may arise with the child when the therapist is not around.

 

When I thought I was in a dead end place for research, I found hope in one researcher. I now realize that once you find a specialist in a field that has contributed to a study, whether they are a main researcher or supporter, you will be guaranteed to find many useful resources. The end of the presentation I gave for my class included a majority of Pennington’s research that I initially did not think I would find, but it’s hard to miss out on all that research proving how much she cares about her work.

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Saying Sorry
April 21, 2016 11:58 AM by Dana Wetmore

My motor speech disorders class this semester covered the sometimes uncomfortable and personal task of giving an oral mech. So every class, we prepped with a different checklist for facial and oral structures with accompanying disordered physiology, practicing on other classmates to become more comfortable with the process. At the end of each sheet was the unfavorable, gasp-worthy gag reflex. My classmates and I chickened out every time we got to that task and assured each other, “we can just skip this one.”

 

As part of our midterm in motor speech disorders, we all had to give our instructor our very own oral mechanical examinations. When we completed the written exam, we met up with our instructor in her office where all the essentials were laid out: tongue depressor, gloves, wet wipes, flashlight and — gasp! — a cotton swab.

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A day before the test, I took some materials home to practice with my roommates and my wonderful mother, who just happened to be visiting. As I got through the test practicing on my mom, the exam was winding down to the portion I didn’t warn her about.

 

“You better not gag me,” she said, wagging her finger at me. Without hesitation, I put the stick right back in the packaging and said, “Great, thanks mom. Looks good!” and scurried away.

 

So with minimal gag reflex experience going into the exam, fast forward to the midterm and the final aspect of the oral mech:

 

“Umm so now I’m going to test your gag reflex. It shouldn’t hurt ... ” I couldn’t help but fumble over my words completely as I added, “but it might feel a little uncomfortable.” My instructor, pretending to be a patient, shook her head to provide some kind of feedback. “I’m really sorry, but it might feel just a little uncomfortable. I promise after this is done the whole thing is over.” I literally didn’t know when to stop. “It honestly doesn’t hurt, though, but I’m really sorry this is just part of the routine check.” I think I said “sorry” about four more times.

 

My wonderful instructor sat patiently as I rambled on until I finally halted my speech to begin the gag reflex test officially. I unwrapped the packaging around it, stumbling on my purple gloves.

 

“Okay, say ‘ahhh.’”

 

Only a couple months later, and I know that the clinician is the person who makes the oral mech either successful or incredibly awkward. I promised myself I would work on my oral mech so that as a professional (after having done them enough),  I’ll only have to apologize once through the examination.

 

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In Their Shoes
March 9, 2016 1:57 PM by Dana Wetmore

By Dana Wetmore

 

This past week, our department hosted a communication disorders program from a university in Japan. All 12 students were freshmen studying speech-language pathology and audiology. The students and their two professors attended our lectures, observed our therapy sessions and participated in events we hosted for them throughout the week — including hula lessons, a special Hawai’ian lunch and an autism lecture. The whole itinerary was planned weeks in advance as professors and some students worked incredibly hard to organize all the events.

 

But my fellow classmates and I didn’t realize that the students hardly spoke any English. We were told they spoke some, but never had clarification until the day we met them and could only exchange “hi.”

 

For the first time, I felt as if I was experiencing a communication barrier similar to what many of my clients — current and future — encounter. Unsurprisingly, it’s frustrating. I would get blank stares when talking about my session with a client they had just observed. Even simple conversation was disorienting, or simply nonexistent.

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In one of my classes, we did a hands-on activity with communication boards to talk with our assigned Japanese student buddy and I managed to find out really incredible information about my buddy! We had similar interests and honestly, just learning his favorite color was exciting!

 

Throughout school, we are trained to mend the broken communication system between disordered folks and their environment. We know strategies to improve simple yes/no communication as well as manage the chaos a lack of communication brings to a person’s life. We train the families and friends of our clients how to be good communication partners with an emphasis on flexibility and understanding of the impairment. For the first time, I experienced that barrier and can finally empathize with my clients.

 

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I now understand that any form of communication can happen with a lot of hard work — from writing, pointing to desired words and letters, using Google Translate (my go-to for the week) or gesturing with a body part. More than anything, a smile can communicate one of the most desired functions a human possesses: happiness.

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'Please Sit in Your Chair'
February 12, 2016 7:13 AM by Dana Wetmore

By Dana Wetmore

 

My supervisors typically come into the therapy room for only a short amount of time, as they watch the sessions from the monitor in a nearby room in most cases. But sometimes, I need direct help from them. For instance, I have a client who is young, fast and wiggles around in his chair more than a worm. He makes it seem like I have no idea what I’m doing as I chase him around the clinic trying to get him to sit in his chair.

 

We began therapy and he would slide right out of his chair, pull his shirt over his head or even drop therapy items in order to go pick them up. “Please sit in your chair,” I repeated over and over again, even prompting with a gesture towards his chair or a warm pat on top the chair. Sometimes he would throw toys and laugh. “Please sit in your chair.” There were instances when he would even hide under the table. “Please sit in your chair.” Obviously, he displayed challenging behaviors.

 

I kept him cornered with a special table so he could have a chance of succeeding at more tasks; in therapy, you want your clients to succeed! I knew he could do it if he could just listen, but that table didn’t even work keeping him sitting.

 

My wonderful supervisor came in to save the day a few sessions later. There at the little kid’s table I sat parallel from my client, about a foot away with him closer to the wall so he was in a small corner. My supervisor said “no, you need to be closer.” So I scooted my chair up to the client and began to continue.

 

“No, no. Closer. You need to get closer.” I moved my seat just about six inches away in my little kiddie chair next to him.

 

She asked me to stand, pulled the chair immediately next to my client and looked back at me. “There’s no where he can go. See?” I realized my idea of closeness in proximity was never going to be the same after I started practicing with kids.

 

But I will say, the phrase “please sit in your chair” stopped haunting me in my sleep after that lesson.

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'Fake It ‘Til You Make It'
February 4, 2016 1:34 PM by Dana Wetmore

This is quite literally the best advice I have gotten throughout my graduate school career studying speech-language pathology.

I'm not a phony, nor am I incompetent. I'm just trying to learn through experiences and for me, my experiences are working with people who attend our graduate school speech and hearing clinic. Every semester I'll get my assignments for clients and do an extensive case history, call the patient for a quick chat about their first appointment and understand their problems as thoroughly as possible without meeting them in person.

Every time I meet a new client, it's like being set up on a blind date who's page of information I can see and access whenever convenient. I put together an image of the client and their family. I picture the worst possible first session scenario, and then I picture the best one as well. I chat with my supervisor, putting together a plan for the semester and try to sound professional as possible, but inside I'm screaming, "Fake it ‘til you make it."

Within the last hour before my session I collect all the necessities. For the toddlers, it's always the cookie monster toy, the ocean magnet board and Playdough. My tool belt for adults consists of magazines I've collected in the last year and a current newspaper. I print out my lesson plan, grab my personal folder and set up my therapy room.

Within the last ten minutes I try to peek through the window on the door that leads to the waiting room. I attempt to pick out my client from the bunch and put a name to a face. I pace around the clinic making sure everything is ready, repeating the name of a client that I just can't seem to pronounce right. My fellow students begin to take back their clients, some holding the hand of young children and some guiding a limping adult to the rooms of our clinic.

"Fake it ‘til you make it. Fake it ‘til you make it." I keep repeating it over and over in my head until the clock has hit the hour.

I open up the door to the waiting room, and call out the well-rehearsed name of my client. A person, a real-life human being, looking for help and love and sympathy looks my way. All my troubles simply melt away, and I know this is what I was meant to do.

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