30 Clinic-Based Scenario: Sam Raises Expectations

As we discussed in earlier chapters, every interaction and communication is an opportunity to strengthen a relationship. As you read through the clinic-based scenario below, write down what you notice. What words are said? If you can imagine this playing out in real life, what might you observe? Think about the tone potentially conveyed, the facial expressions and body language that accompany the words, and the proximity between Sam, the clinician, and David, the important adult.

Sam, a new case manager and therapist in an outpatient therapy clinic, meets Michael’s parents, uncle, and grandfather for the first time. He reviewed Michael’s file in advance of their meeting and feels comfortable beginning the conversation. He introduces himself by his first name, shares his role, and invites the family to sit down in chairs around his desk. They sit down. “Thank you so much for your time. I look forward to working with you so Michael’s growth isn’t interrupted.” Sam continues to share the summaries from the other providers who support Michael. He then takes a breath and says, “Based on everything I’ve read and shared, I think we can help Michael reach a place where he can function just like all of the typically developing children.” Michael’s important adults exchange glances as his father, David, slowly responds, “What do you mean by that?” Sam, realizing he may have said something that didn’t land as he intended, rephrases, “ I just meant that your son is doing so well! I think that if we push him a bit, he’ll surpass your expectations.” David responds with a very firm tone of voice, “We have known Michael since he was in utero. We’ve worked with every doctor, nurse, therapist, and educator available for the past three years since he made his entrance on this earth. Michael’s development isn’t, as you put it, typical. He won’t be typical. But he will be him. You have no right to show up here now and tell us we aren’t doing enough.” The family stands up and walks out together.

What happened here? When we introduced Michael in chapter three, we shared that he received early childhood interventions and supports. That means that Michael has one or more disabilities and is eligible for support from both public services and through private health insurance. Children who receive these supports have varied disabilities and possible outcomes. Let’s imagine that Michael’s family was told that Michael’s disabilities were not life threatening, but required managing his environment and providing additional supports as he would not develop in ways that most children did. Let’s imagine that Michael’s family, hopeful that he would have a good quality of life and immediately bonding with their sweet, smiling baby boy, inquired about best and worst possible outcomes. Perhaps as Michael grew, they noticed differences between him and other children of the same age. Perhaps they also noticed similarities. They may have sought guidance from medical providers and clinical staff, as well as through family support groups they joined. Perhaps they accepted the reality of Michael’s disabilities and established realistic goals centered on helping Michael have equitable access to the world and to be a loved, valued member of his family and community. These are some of the basic tenets of the disability rights community, yet Sam implied a lack of understanding. The foundation of early intervention services (as described for Michael and his family in chapter 3) are rooted in the family’s goals for their children. When Sam led with his priorities, he unintentionally negated family wisdom and experience. However well intended, Sam’s words had a negative impact.

Let’s consider Sam’s intent and thought process.

Sam had developed a positive mentor-mentee relationship with a more experienced clinician named Carolina. Shortly after Michael’s family leaves his office, he walks down to Carolina’s office, relieved to find her there. “I don’t suppose you have a few minutes to talk?” Sam asks. Carolina invites Sam to sit down. Sam recounts the situation, asking Carolina to help him understand what he did wrong or if David was the one who was wrong. Carolina pauses for a moment. She asks, “Tell me what led you to think someone was wrong or right.” Sam considers her question and slowly says, “Well, I guess I assumed that in arguments, someone is usually wrong, and the other person is right.” Carolina reassures him that there are some scenarios where that might accurately reflect behaviors and interactions. For example, behavior deemed illegal in the workplace is a fairly clear line we don’t cross. But she then says something he hasn’t considered, “If our goal is to strengthen a relationship, then it really doesn’t matter who is wrong or right. In fact, focusing on that might only serve to weaken a relationship.” She then invites Sam to share more about his thought process, “Tell me what led you to encourage the family to consider new goals?” Sam immediately describes the historical inequities that children and adults with disabilities face and his goals as a case manager to do whatever he can to reduce those inequities. He describes his own motivation for his career: growing up with a disabled brother who wanted to have greater autonomy and independence, Sam and his family wished that their perceptions were valued, particularly after his brother transitioned from early intervention to outpatient clinical support. Sam explains that there was one case manager who did and his brother’s skills expanded during that time. Carolina repeats back what she thought she heard him say by summarizing, “So it sounds like you approached the situation the way that your family would have wanted someone to approach you. Do I understand that?” Sam responds yes and adds, “It’s my job to ensure that we’re raising expectations in the disabilities community. I guess I always follow the Golden Rule: treat others the way you want to be treated.” Carolina pauses again and asks, “What if they want to be treated differently than you do?”

Let’s consider what Carolina kindly shared and what she graciously modeled during this exchange. She approached Sam’s difficult conversation with curiosity. Instead of evaluating his choices, she provided opportunities for him to share more; by asking him to tell her what instead of asking why, she allows her to share her thought processes and creates a psychologically safe space to do so without judgment. She modeled exactly what researchers and practitioners in conflict mediation suggest: Approach other humans with curiosity. Seek to understand instead of to reply. Now let’s consider her guidance regarding the Golden Rule. Without telling Sam that he was wrong, she asks a question with embedded guidance: consider how someone else wants to be treated. If we focus only on what works for us, we miss the opportunity to learn with and from those around us. We reference only our cultural and structural experiences, not those of the families we aim to serve. We, the authors of this text, invite you to consider an updated version: treat others how they want to be treated. By doing so, you create the space for culturally responsive practices as you de-center yourself and your experiences, centering instead the members of our diverse communities who bring a wealth of wisdom to the conversations. As a clinician, this is particularly important as IFSP goals are determined in conversation with the family. Even if the EI therapist or provider feels strongly about a certain goal, it is not written down if the family doesn’t agree it is a priority.

Before we re-imagine this conversation ending more positively, let’s take a moment to think about what went well. At the beginning, Sam invited the family to sit in chairs around his desk. This proximity and invitation is important. After all, everyone wants to feel seen, valued, and heard. Now let’s consider three important steps when emotions are strong:

Let’s consider how Sam might put all of this together in this re-imagined version:

Sam, a new case manager and therapist in an outpatient therapy clinic, meets Michael’s parents, uncle, and grandfather for the first time. He reviewed Michael’s file in advance of their meeting and feels comfortable beginning the conversation. He introduces himself by his first name, shares his role, and invites the family to sit down in chairs around his desk. They sit down. “Thank you so much for your time. I look forward to working with you so Michael’s growth isn’t interrupted.” Sam continues to share the summaries from the other providers who support Michael. He then takes a breath and says, “Based on everything I’ve read and shared, I think we can help Michael reach a place where he can function just like all of the typically developing children.” Michael’s important adults exchange glances as his father, David, slowly responds, “What do you mean by that?”

Sam takes a slow breath to calm his nerves, remembers that it isn’t helpful to respond defensively, and apologizes. “I’m sorry. I can see that you’re upset” In this brief response, he validates the family’s emotions. Sam then says, “Let me take a few steps back. Please tell me about your child and what’s worked well for him these past few years. Then, perhaps you can tell me what goals you have at this time.” David responds, “We established a number of effective strategies with his early intervention therapists and providers. You can see the established goals right there in your files.”

Sam takes another slow breath to maintain his composure. He reminds herself that being right isn’t important. It’s about establishing trust and a collaborative relationship with a family. He then apologizes again, “I’m sorry,” and asks David, “What should I know about Michael and how can I, as your new case manager, make sure I support your goals?”

David describes Michael as an amazing child. Michael’s mom, Leslie, and his grandparents, Eric and Barbara, begin to talk almost concurrently. “He’s very curious. His favorite toys are firetrucks and he could play with everything about firefighting all day. He smiles so much and he has such joy. But if he doesn’t feel loved, he’ll cry so loudly. He has to know he’s loved. He has a few favorite foods. We’re introducing new foods, but he’s very particular. He likes to play with other children, but in smaller groups. He doesn’t love too much loud noise. He gets overwhelmed. We want him to know that he’s loved and to be able to do things kids enjoy doing. And sometimes that means he has to do them a little differently or at different times. He liked the community theater event a few weeks ago. They had a special afternoon for children with sensitivities to loud noises and too many lights.” Sam asks focused questions to verify some of what he hears from the family and what he’s read in the notes across the five domains: cognitive, motor, communication, self-help, and social or emotional. He clarifies existing goals and asks about new goals by saying, “So what I hear you saying that you want for Michael this year is…..” And then he makes sure that he writes it down and allows the family time to review it. He then says that he will send all of his notes, including their goals, for them to review at home. “Should I email you or print it out for you to take with you?” He then explains that some of the goals must be written in a certain way for insurance. He offers to provide the very clinical language and what he thinks of as “a normal human version” for clarity. The family laughs and says, “Yes, please. We would appreciate that.” Sam then translates the clinical jargon into plain language for the family.

At the end of the conversation, all family members thank Sam for being so responsive. They end the conversation calmly smiling at once another, everyone feeling better about the situation and about their future interactions.

What worked well here? Sam used a basic, yet effective, strategy to regulate his own emotional response. He reminded himself to respond calmly, rather than react defensively. He then used the three steps to deescalate the situation: 1) apologize, 2) validate emotions, and 3) invite a conversation. He approached the conversation from a place of curiosity, rather than defensiveness. He wanted to understand, rather than to reply. This avoided the game of who’s right and who’s wrong. And finally, he asked the family to collaboratively construct a way forward.