Interview between Speaker 1 (Meg) and Speaker 2 (Rachel Dorsey)
Episode 93: Strengths-Based Goal Writing in Action
[Introductory music]
Welcome to the Two Sides of the Spectrum Podcast. A place where we explore research, amplify Autistic voices, and change the way we think about autism in life, and in our professional therapy practices. I’m Meg Ferrell, formerly Meg Proctor, from learnplaythrive.com broadcasting to you today from unceded Tsalagi territory.
Meg:
Before we get started, a quick note on language. On this podcast, you’ll hear me and many of my guests use identity-affirming language. That means we say ‘Autistic person’ rather than ‘person with autism’ because this is the preference of most Autistic adults. Being Autistic is a part of their identity that they don’t need to be separated from. Join us in embracing the word ‘Autistic’ to help reduce the stigma.
Welcome to Episode 93 with one of our favorite returning guests, Rachel Dorsey. Rachel is an Autistic SLP and the instructor of one of our flagship courses at Learn Play Thrive, ‘Goal Writing for Autistic Students’. On the day of this podcast released May 1st, 2024, we have just released a brand-new version of this course that Rachel has worked so hard on, along with her course contributors, OT’s Kelsie Olds, who you may know as the Occuplaytional Therapist, and Jess Miles, as well as SLP’s Karina Saechao and Maribel Serrano-Holder. This is an on-demand continuing education course that’s 8.75 contact hours and registered for AOTA and ASHA CEU’s. In this course Rachel teaches a framework that you can use to write individualized affirming goals for your Autistic clients. She then walks you through how to apply it to really complex true-to-life case studies, and then supports you as you apply it to case studies outlined in the course to create your own affirming goals so that you can take this into your practice with ease and confidence. This course is truly transformative, you can check it out at learnplaythrive.com/goals. In the meantime, you’ll love this conversation today where we explore Rachel’s approach to goal writing, how it’s changed over the years, how she writes affirming goals for her Autistic clients, and how to make sure that the goals are billable to insurance and that they’ll be accepted by the IEP team. Here is the interview with Rachel Dorsey.
Hey, Rachel.
Rachel:
Hi, Meg.
Meg:
I’m so happy to have you back on the podcast.
Rachel:
Thank you for having me once again. I hope you’re not sick of me.
Meg:
Never. Never, ever, ever. You’re like my first collaborator on continuing education courses, and one of our regular contributors. And I always learned something new even though I I’ve taken your courses and interviewed you a bunch of times, every time I talk to you, we add some level of nuance that I’m really excited about. I want to start, and since we’re talking about goals today, I want to start with your own goal writing story, Rachel. How has your approach to goal writing sort of shown up in your work and changed over the years?
Rachel:
Yeah, I think I used to have an outlook on goals as these are ways that the targeted skills are things, and the way that we write goals can be done to protect the student, which is still true. It can guide therapy in an affirming direction. We don’t want to do harm. And so, all of that is still true. But, yeah, over the past few years, I’ve really expanded, really, where I think that goals can and should, can go. Goals are an opportunity for everyone. They are an opportunity for the clinician to — I call it, I think of it as like developing a proposal where we are trying to figure out what’s going on here with our clients, like, what’s the difficulty; is there a difficulty? Why is — why might it be happening? Do we know why? Sometimes we don’t know why. And then thinking of some ideas of how to solve, or how to, you know, solve this problem or approach in some way. And then, we measure it. So, we hold ourselves accountable to what we say we’re going to do. And I think that thinking of goals as a way to not only help your clients, but to also help yourself, I guess the biggest sort of a change I’ve had over time, is writing goals that are not only affirming for our clients, but also affirming for clinicians.
Meg:
What does that mean? What does it mean for a goal to be affirming for the clinician?
Rachel:
Clinician affirming in the context of goals means that what you’re hoping to see in your students or your clients is something that you feel pretty good, that you are able to do given the emotional state of everyone, given the time period that we have. Because if it’s like the student doesn’t meet the goal, like, if you write a goal that isn’t attainable, which I’ve definitely been guilty of, like, for sure. I’m just expecting way too much. You’re setting the client up for failure, and you’re setting yourself up for failure, and that feels — that’s a loss for everyone.
Meg:
Yeah, that makes a lot of sense. I think that especially happens when we write goals based on developmental milestones instead of writing goals based on the client in front of us. And that’s a nice segue into common mistakes. So, I know people listening want to really focus on how do we write affirming goals, and I promise we’re gonna get there. But it’s useful to examine first, what are the common mistakes that people make in writing goals?
Rachel:
Yeah, I think of it as like a few types of categories of mistakes. This isn’t exhaustive, but I think the one that people are more and more aware of is goals that are ableist. And goals that are ableist, I hesitate to say that goals themselves are inherently ableist because, like, ableist is — ableism is contextual. And it’s possible to have an ableist goal, a goal that could end up being ablest, but to interpret it in a way that is affirming. But they’re, like, there are some goals that lend themselves to being ableist therapeutic practice. So, common examples, like an eye contact goal. It doesn’t really matter if we’re aiming for like the client being able to show other people that they’re attending, which some people, that might be the goal. That might be why they’re writing that eye contact goal. But some people are writing that eye contact goal because it is like, you know, one of these lists of things that people need to do.
So, yeah, I think of goals, like, that goals that are, I think of like some masking types of goals. You know, there is a way to really kind of delicately go about working on how a student or client wants to show themselves, but there are goals that are just like, we are going to try to normalize how you act and socialize. And that, you know, that’s ableist. Another common mistake that I think, out of all of them, I think this is the one that I’ve been the most guilty of, is attainability. You mentioned that attainability can become a problem if we’re looking just like trying to match Autistic milestones or Autistic development into neurotypical milestones. That’s definitely true. Like, they are — they’re not attainable; they’re not aren’t gonna progress in that sort of a way. But also, well-intentioned goals can just like not be attainable. Like, if we have a really depressed 16-year-old client who’s Autistic and like pretty burnt out, I’m knowing how much healing, you know, some mental distress takes and how much work that — I’m not going to be expecting this 16-year-old child to suddenly start self-advocating all of the time. I’m not going to be expecting them to manage and process their emotions. But something that I would perhaps work with this client on is, okay, so you seem to be, you know, you don’t like a lot of things. What’s something that you used to like, like a while ago? Okay, let’s revisit that. Let’s see what you like about it. And then, that would turn more into a life skills-y type of a goal, or perhaps a coping skills goal related to discriminating just the differences between feelings.
Oh, yes, I mean, there’s another common mistake. I mean, I won’t touch on it too, too much. Just like the measurability. Yeah, I mean, I’ve made this mistake, too. I guess it’s important to try to think creatively about like, what are we measuring here and to be mindful that we’re actually measuring the thing that we aim to measure. Sometimes we think we’re measuring, you know, social skills, but we’re actually measuring ability to comply. So, yeah, those are some common mistakes that I’ve made and others make, too. We all make mistakes.
Meg:
Yeah, I think I remember another example from your course that you give about measurability is where we think we’re measuring receptive language with somebody following instructions. But there’s so many other things happening with executive function. And I love this because I think these are things we do kind of rote sometimes. Goal writing in general can just feel like this irrelevant, extraneous like pain, hassle of a thing that we do for reasons beyond the deepest meaning of our work. And I love that you’re bringing it back in and saying this is a practice of what we hope for, what we think is realistic, what we together with our client have determined is attainable, and meaningful, and truly supportive. Taking things from rote and stressful and frustrating to meaningful is one way we can learn to love our work in the ways we hoped we would. And I love that your work around goal writing is doing that for people, I know early on, you’re like, “Meg, I’ve chosen the hardest topic to teach on but somebody has to do it.”
Rachel:
Yes, yes, I — yeah. And I’ve grown, I’ve grown to kind of love it because I love looking at situations and analyzing them and like figuring out where are we going to go and then trying to translate that into something that parents, students, insurance companies, IEP teams actually believe in.
Meg:
So, people have the question just screaming in their head, “How do I make affirming goals work for IEP teams, or for insurance companies?” I want y’all to know we are going to get to those questions in this interview today. But first, I want to talk to you a little bit, Rachel, about what makes a goal affirming and I know you could talk about that for seven hours and we would learn something at every moment of it. So, I want to just zoom in on the most important thing. What would you say the most important thing is for professionals who are writing goals for their Autistic clients to keep in mind?
Rachel:
Yeah, I mean I have — this was always an important thing. So, safety and security, our client’s sense of safety and security, it was always something that was important to me. And through, you know, seeing the impact of COVID and the high mental unwellness statistics and for students in general, but, you know, particularly our Autistic clients. A lens of that, of like does this client feel in some way in some setting a sense of safety and security? Do they know what that feels like? Or are they stuck in a crisis state. And it doesn’t have to be one or the other, right? We can be — you don’t have like our one little safe place and then the rest is like as scary. There’s kind of a range of things. But getting a read on that is super important.
Because I’ve seen the difference in rate of progress in clients that are really struggling and it’s going to seem, it’s seeming like they’re going to struggle for a while in terms of their mental health. And I’ve seen clients that have had for a while some difficulties on the way, but a while, like, they’ve had a felt sense of safety and security. And they’re able to make a lot of progress and makes SLP’s and OTs, clinicians, able to do our jobs. I’ve also seen clients that have gone through so, so much, faced so much adversity, and then have time for respite or leisure, healing, and then make so, so, so much progress. And it’s really beautiful to see. But it requires a mental shift of instead of mental health being one of the components, like it is, it is the foundation, and then everything — and it really just paints, I’m very visual, it really like paints how we kind of look through everything else.
Meg:
This is such an important point. It makes me think about all of my Autistic clients in the past to have been in crisis or been in burnout, sort of nearing crisis, and I’ve written a fine motor goal. And it’s awful, right? Like the sessions are really stressful. They don’t feel right. But, you know, I’m thinking, “Oh, I’m supposed to be getting them to do something. I’m supposed to be teaching them something and helping them meet this next goal.” And when you overlay this, ‘Are they feeling safe and well? And if not, what goals could I write to move towards that?’, it completely changes everything. I think that’s a really, really important point. I’m gonna ask you to walk us through a case study for a school aged child with an example or two of goals that you might write, and how you get there.
Rachel:
Okay, well, goodness. So, let’s make up a case a case study of an Autistic eight-year-old who, let’s say, has had a pretty regimented therapy plan for ever since early intervention. So, EI, SLP, OT, PT. And even going off of what I often see after that type of a thing is I see kids that are — so, this eight-year-old in my head that I’m making up right now is making very slow progress kind of across the board. Maybe it’s flatlined in some areas. And the team is trying to come up with a lot of like crisis management, like, parents are on edge because they, like, when is next meltdown going to happen? What is the next crisis going to happen? So, let’s pick that child? So, well, I would take a look at the situation. The child, what does the school think? What do the teachers think? What do the caregivers think? I would try to get a read on what the student thinks. But given the situation, it could be quite challenging to get something very concrete.
Take all that and think, okay, what are the problems here? Are there problems here? Well, yes, there are. And go and think through what is causing this? And then, how do we — also, the student is in a lot of distress, how do we calm this distress? And then, the goals that would come after that, you know, I would probably have some sort of a communication goal in there. The communication goal that I would select for that particular case, well, first, I would see, like, what are the past goals? Have they made any progress in any which way? And if they haven’t, then I’m going to start thinking creatively about all different types of modalities and AAC programming. And so, I guess the goal I would write for that case would have to be a little bit more general, because we would not know exactly what combination of modalities is going to work.
So, I would probably write a general goal for like functional communication, and really specify in there that we’re going to build upon the child communicating in several modalities, whatever seems to work and click. And I would embed within that goal any supports that would help this child feel safe and secure. And so, this is a child who, like, they need to be holding like an action figure, a little action figure, like that is their ride or die — fantastic. That goes in the goal, because it’s necessary. But that’s just one example for a communication goal, I would say.
Meg:
I love that you’re focused on, okay, are they having a really hard time? In that case, let’s give them a long time to achieve a smaller goal, and/or let’s write goals that are going to help them feel well. It is really affirming. I want to move towards this question about the goals being accepted. I know we get this question a lot, and you get this question a lot. People want to know, okay, how do I write goals that are going to be accepted by the IEP team, that are going to be billable to insurance, and are still affirming to my Autistic client?
Rachel:
Yeah, I get this question a lot. I would say, if you isolate what, like, what is the problem here, what is going on, if you identify that correctly, and that’s your target skill, and then incorporate how you’re going to get there, as well as how you’re going to hold yourself accountable to what you hope to see, what you expect to see, then everyone’s happy. Like, then IEP team is happy, administration is happy, insurances are happy, student is happy, parents are happy. So, I think it’s I think that that we need to think creatively about the thing that we’re working on, and ways to measure that thing, and be sure that we’re measuring the right thing. And I haven’t had any problem with that sort of mindset when writing goals.
Meg:
I think that that’s something that you do you really, really well in your course, that you show how to write goals for a child whose parents have put them in an intensive ABAT program, how to write goals for a child who you’re working on last year’s evaluation done by a different provider in a really deficit-based model. You really put all of those real-life variables in and then say, “Okay, here’s how I would write this goal in a way that’s going to be affirming for the child and pass for the team.” It’s hard to bring up every possibility in a short conversation. But I will say that that’s a real strength of your course. I have one more question that I know you get asked a lot. People say, “Rachel, how do we make sure that our goals are neurodiversity affirming?” What’s your response to that question?
Rachel:
Yeah. Well, I, first of all, I understand why people are asking that question. Like, we don’t want to be ableist. We all want the best for our clients. We’re hearing ‘neurodiversity affirming’ as a word going around, you know, much more now as compared to five years ago. It’s very exciting. At the same time, I would caution against thinking, “How do I make sure this goal is neurodiversity affirming?” Because with that type of thinking, there’s a fear, we don’t want to be ableist. And it ends up being really limiting, actually, if that is the lens that you’re going in with. It limits the ability to truly be client-centered; it limits the ability to really try to actively listen to the family and team members. So, and so, it ends up like acting kind of against what we originally want. So, I would like to encourage providers to think of how can I make this goal client- and family-centered, while being mindful of some of these other variables at play, and I think you will end up having affirming goals automatically through that type of shift and, and mindset.
Meg:
I love learning from you, Rachel, because often, for all of us, when we first start learning about something, it can feel really black and white. And then, over time, we’re able to add a lot more nuance. And you’ve kind of reached this next level of nuanced thinking about how to determine what an affirming goal is for the person in front of you, not generically. And this really shines in the new version of your course. It’s really, really brilliantly structured. And you have an awesome neurodiverse team of OT’s and SLP’s helping teach and come up with some of the content for the course. Can you just give us the rundown of how it’s all set up and how it works?
Rachel:
Yeah, okay. Yay! Yes, I’m very, I’m very proud of it. It was a lot. And I did it. And I love it. I love what I ended up putting out. And I love what my collaborators did with it as well. Yeah, so the course is structured in a way where I, after some explanations of some Autistic traits and like more lecture-based types of content, it goes into several case studies, six case studies, where we go from IEP and perhaps your observations as their provider, all the way to affirming goals across communication, fine motor, life skills, and coping skills. The case studies are, as you said, capture a variety of real-world types of situations. And I tried to make it pretty, like, there’s a case — even if not every student resonates with your caseload, there will be like one or two that you’re like, “Yes, I’m gonna take this and apply it in real life.” So, I really think there’s lessons to be learned in all of the case studies. The fine motor parts are done by Kelsie Olds, occupational therapist, who has such a, such a brilliant way of thinking about the, like, I learned so much from Kelsie just like talking to them, thinking about how occupationally meaningful to our clients are, you know, certain fine motor skills. And Kelsie provided in the goal bank, in addition to the course, so many great fine motor goals. Some goals that are like, oh, the parents, like, working on handwriting is like their ride-or-die thing, like they want that so much, and maybe they have a lawyer with them. Okay, then let’s write a handwriting goal. And here’s a way to address handwriting, still make it client-centered, and affirming, and incorporate the family’s very strong viewpoint.
Okay, other — I went off on a thing about Kelsie just because they’re so great. I mean, I’ve other collaborators, too. Jess Miles, another OT, did a lot of executive functioning, kind of life skills-y types of types of things, and so and a lot of applicability, particularly for older students. Maribel Serrano-Holder is knowledgeable about gestalt language processing, but in bilingual families, or if you’re working with a client and their parents don’t speak the same language you do, how do you navigate that? And Karina Saechao who — everyone’s brilliant, I respect them all so much — Karina Saechao, SLP, collaborated regarding a more medically complex AAC, situation. And because these are all areas, each of these, like, fine motor, executive functioning, GLP but bilingualism, AAC, they’re not really my areas of expertise. But they’re theirs. So, anyway, you go through the course and you arrive at affirming goals, and you’re given the goal bank right in the beginning of the course. I’m not like, gonna, you know, just give it to you upon completion. I really see it as a visual support, as a lot of modelling of here are all the different types of ways that affirming goals could look like. Yeah, I love it.
Meg:
Yeah, I kind of love that we arrived at you creating a goal being together with your colleagues, because initially, I know we had a lot of conversations years ago about, “Well, it’s not so cookie cutter, right?” And then, you’re kind of to this level of nuance of, okay, so people need a framework that they can use to look at the person in front of them, and write the right goal for that person at this time in their context. And people need more examples of what affirming goals can look like, because a lot of us have never seen it modelled. And we are drawing from nothing. And so, I love that you’re giving folks both things. You’re giving them the framework, you’re giving them a lot of really dynamic case studies and examples; and you’re giving them resources like the goal bank, while teaching them how to use it flexibly in a way that’s really client-centered. So, I’m so grateful to all of your thoughtfulness and work and your collaborators’ thoughtfulness and work to create the new version of this course. We are very proud to help you share it with people.
Rachel:
Thank you. That means a lot. I’m excited, too.
Meg:
Yeah. Yeah, so people can find it at learnplay thrive.com/goals. It’s self-paced, online, you get six months access. And we really 100% stand behind it. So, go check it out and enjoy a lot more Rachel, a lot more learning from Rachel and her team. Thank you so much, Rachel.
Rachel:
Thank you, Meg.
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