Improving Outcomes With the Ziggurat Model - Part 2

Kim Clairy, Ruth Aspy and Barry Grossman Author

04/14/2022 Added

13 Plays

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Conference 2022

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[00:00:00.090]Regulated. Got it.
[00:00:05.130]While we're working together,
[00:00:07.850]and from the perspective of the autistic individual,
[00:00:12.550]Am I anxious or uncomfortable?
[00:00:14.130]Is my body dysregulated?
[00:00:16.500]How can I address that at the sensory biological level?
[00:00:20.150]So on the next slide,
[00:00:22.260]we see some of the things that we consider
[00:00:24.450]at the sensory biological level.
[00:00:26.657]They range from sensory input, sound,
[00:00:30.460]light, texture, et cetera,
[00:00:32.230]to things like nutrition, appetite, pain,
[00:00:36.672]side effects to medication.
[00:00:39.080]And one thing that we always consider
[00:00:43.380]at the sensory biological level is regulation.
[00:00:46.480]And that's the question that we ask,
[00:00:48.800]is the individual regulated,
[00:00:51.220]and what do we need to do to help him be regulated?
[00:00:53.580]Because until the person is regulated,
[00:00:56.850]they're really not gonna be able to benefit
[00:00:59.150]from anything else that any other services
[00:01:01.490]they are provided.
[00:01:03.230]So in the next slide,
[00:01:04.610]you see some things that we've already talked about,
[00:01:07.150]things that can happen during a session,
[00:01:10.830]you can be flexible about how the session is set up.
[00:01:14.630]And there's absolutely no reason that a person needs
[00:01:17.700]to come in and sit down and be still while we work together.
[00:01:22.210]And so these are just a few of many ways
[00:01:27.330]that we could allow movement
[00:01:29.660]or different ways to be comfortable during the session.
[00:01:33.640]And it may require us to think about,
[00:01:38.030]we know that now we think about classrooms very differently.
[00:01:42.470]Often when I into a classroom,
[00:01:44.320]I see six different kind of chairs in one room.
[00:01:48.850]And some of the kids are sitting on the floor on blankets
[00:01:53.950]and some of the kids are sitting in desks,
[00:01:56.640]and some of 'em are sitting on therapy balls.
[00:01:58.830]And so it's just like we're used to adapting
[00:02:02.270]in school settings,
[00:02:03.730]we can adapt in therapy settings as well.
[00:02:06.250]And the way to help people figure out
[00:02:08.450]what their sensory needs are,
[00:02:10.780]is having them do a task in different environments
[00:02:16.400]and different setups,
[00:02:17.640]and having them charge
[00:02:20.030]or having an observer or provider or parent chart
[00:02:26.920]differences that they notice in how they're functioning,
[00:02:32.080]how their body feels, what their thoughts are.
[00:02:37.620]'Cause a lot of times people don't know
[00:02:39.000]what their sensory needs are,
[00:02:40.860]until, sometimes until they're introduced to a change.
[00:02:48.309]And you're gonna give an example of that,
[00:02:50.683]some examples of that in your own experience.
[00:02:53.570]And the next slide,
[00:02:55.800]this is something that I always ask him
[00:02:57.780]to share about her sensory experience.
[00:03:00.240]And so if you just want to share about thinking in pictures.
[00:03:05.761]Yeah.
[00:03:06.594]So I think in pictures, and when I get overstimulated,
[00:03:08.930]either from internal to much internal stimuli or external,
[00:03:14.750]those pictures develop holes,
[00:03:17.120]which I say is like Swiss cheese.
[00:03:18.820]And then I'm not able to interpret those holes
[00:03:24.020]and verbalize what it is that I'm seeing.
[00:03:27.100]And that is a lot of times when I start to struggle
[00:03:30.730]with my words and I can sometimes go mute.
[00:03:34.830]And I think that I'm learning more over time,
[00:03:38.580]how going mute, how losing the ability to speak,
[00:03:43.900]or at least to articulate what you're hoping to say.
[00:03:49.510]It is a real challenge for more people on the spectrum
[00:03:54.580]than I realized.
[00:03:56.750]And I think that recognizing that challenge,
[00:04:04.625]It just in general, is important to understand,
[00:04:08.440]and tying that challenge to the possibility
[00:04:12.200]that's caused by overstimulation.
[00:04:18.590]So next, these are some more things
[00:04:25.450]about your experience with sensory matters.
[00:04:29.927]"My sensory sensitivities are more than a dislike
[00:04:32.620]or a preference;
[00:04:33.453]a nuisance or something I can get used to.
[00:04:36.750]Often disorienting and painful,
[00:04:38.940]they make it hard to coordinate my body.
[00:04:41.300]They make carrying out tasks exhausting,
[00:04:44.190]and sometimes just impossible."
[00:04:50.060]Barry.
[00:04:52.880]No, Go back.
[00:04:55.840]Yes, something got-
[00:04:56.810]Oh, sorry. There we go.
[00:04:58.676]There you go.
[00:05:00.489]"Stimming is okay for me to do.
[00:05:02.750]It helps me to self-regulate so I can gauge."
[00:05:06.540]And a lot of people stim or they do things,
[00:05:09.470]stimming for me a lot of times is just a way
[00:05:12.230]to get my body into equilibrium on my mind,
[00:05:16.817]so I'm able to pay attention into focus.
[00:05:20.080]And when people say things like stop pacing,
[00:05:24.570]or stop flapping, or pay attention,
[00:05:27.150]is confusing because I'm doing those things
[00:05:30.820]so I can pay attention.
[00:05:34.090]So in this quote that's on the screen right now,
[00:05:38.327]"Pushing will make it worse and last longer."
[00:05:40.780]What do you mean by pushing?
[00:05:47.750]For me, it's forcing myself
[00:05:49.640]or somebody forcing me to continue
[00:05:52.710]to disregard that I need to take a break
[00:05:59.270]and continue an activity.
[00:06:02.787]Okay.
[00:06:03.620]And what happens is eventually...
[00:06:05.310]I do have autistic catatonia,
[00:06:09.450]and I find that when I'm pushing myself too much,
[00:06:13.640]that's when those symptoms come in
[00:06:16.050]and then I can get stuck in actions or freeze in positions,
[00:06:20.970]or I'm really, really slow,
[00:06:24.900]and it's like, just a complete shutdown.
[00:06:27.040]And that can last for a few hours,
[00:06:31.350]it could last for days or even weeks or months.
[00:06:35.180]So you have the form of catatonia that comes and goes.
[00:06:40.132]Yes.
[00:06:40.965]And if you get too stressed or pushed too hard,
[00:06:43.700]that's when the catatonia can come and sit down on you
[00:06:47.240]for a while.
[00:06:48.350]Yes.
[00:06:49.790]Before you move on, I do want to read just an example
[00:06:52.870]of what sensory stimulation,
[00:06:57.100]how it feels a like me,
[00:06:59.270]or when I'm over overstimulated.
[00:07:02.760]This is a journal entry that I wrote.
[00:07:07.550]This is my reaction to an exercise class that I went to.
[00:07:11.397]"I feel sick inside.
[00:07:12.760]My breathing is rapid. My muscles tensed.
[00:07:15.310]I feel frozen yet, I want to flee.
[00:07:17.390]My chest is heavy,
[00:07:18.900]and my brain is shuffling through unidentified pictures.
[00:07:22.510]I want to curl up and cry, but I need to be alone.
[00:07:25.310]I am embarrassed.
[00:07:26.150]I must stay awake, and in class until the end,
[00:07:29.650]until I can be in my safe spot.
[00:07:31.990]I'm in the days, my fingers plugging my ears,
[00:07:34.450]my eyes counting the dots on the ceiling,
[00:07:36.810]and my fists and toes tightly clench.
[00:07:39.020]It takes every bit of my energy to keep from screaming,
[00:07:42.730]flapping my arms and running away.
[00:07:45.690]The noise eventually stops, but the threat continues.
[00:07:48.790]I feel no different.
[00:07:50.350]The aftershock of this earthquake hits.
[00:07:52.900]My movements are slow. I follow what I see.
[00:07:55.690]I can't think on my own.
[00:07:56.867]I want to count and I want to light things up,
[00:08:00.150]but I also don't want to be noticed.
[00:08:02.520]So at the end of class,
[00:08:03.610]I just follow and recite the steps
[00:08:05.540]in the sequence of cleaning up.
[00:08:07.860]I'm like a turtle caught on a busy highway.
[00:08:10.780]I leave the scene in a days,
[00:08:13.030]and here I sit alone to my car calming my system,
[00:08:17.680]so then I can finally drive home.
[00:08:20.220]The aftermath effects will slowly dissipate,
[00:08:22.970]but it takes time.
[00:08:24.610]I'm exhausted and tired,
[00:08:26.250]my being though, endured the threat.
[00:08:28.960]I'm a survivor.
[00:08:30.550]I made it through the clashing tones,
[00:08:32.520]erratic beats, and stabbing music
[00:08:35.390]that played during exercise class that day."
[00:08:40.930]And I think that you also have shared
[00:08:43.190]that you were able to communicate
[00:08:45.990]with the person who leads the class
[00:08:48.450]and able to get them to play a different
[00:08:50.520]kind of music in the future, is that right?
[00:08:53.190]Yeah, I showed her my writing,
[00:08:56.210]and she said, she wouldn't play that.
[00:09:01.870]It was a particular, like, two songs,
[00:09:04.860]And she never played those two songs again
[00:09:07.090]when I was in class.
[00:09:09.470]That's when I was, this is...
[00:09:10.910]I haven't thought about this before,
[00:09:12.940]but do you deal with things like music in waiting rooms?
[00:09:20.300]I usually put my ear plugs in and my headphones on.
[00:09:24.540]Okay.
[00:09:25.920]But even now, it's a consideration that sometimes
[00:09:28.080]we just kind of take for granted
[00:09:30.150]that it's not gonna be hard on people, but it could be.
[00:09:33.860]Yeah.
[00:09:34.693]Yeah.
[00:09:35.720]All right, next slide.
[00:09:42.330]So this is another example of some of my sensory things
[00:09:48.980]that I discovered.
[00:09:50.880]So that picture that you see, the person's face,
[00:09:55.310]that's my husband, William.
[00:09:57.560]And that's how I saw for 30 years.
[00:10:04.750]I went around life,
[00:10:07.170]seeing everything kind of pulled apart
[00:10:09.670]most of the time and fuzzy.
[00:10:12.300]And I didn't realize that until my husband and I,
[00:10:18.010]at that time we were dating,
[00:10:19.230]we were visiting my sister and we were in an airport
[00:10:21.680]in a TSA line and it was getting too loud.
[00:10:24.500]And I had headphones at that time,
[00:10:27.470]but I never wore them in public because I was embarrassed,
[00:10:31.180]but I decided to...
[00:10:34.200]Well, I needed to put them on 'cause I was about to curl up
[00:10:37.220]in a ball on the floor.
[00:10:38.790]So I gave myself to my husband,
[00:10:41.200]took out my headphones and put them on and then I stopped,
[00:10:43.660]and I was like, "Oh my gosh, I could see.
[00:10:45.670]I can see details. I can see faces."
[00:10:49.130]And I didn't realize that noise makes my vision very blurry.
[00:10:59.090]Other things.
[00:11:00.150]Oh, click one time, Barry.
[00:11:02.084]Oh, there you go.
[00:11:03.180]Yeah.
[00:11:04.013]So with my headphones on, I was able to see.
[00:11:08.220]There's other things.
[00:11:09.280]So sometimes light,
[00:11:13.680]certain lighting makes me,
[00:11:16.000]makes the textures of food,
[00:11:18.440]it tastes differently in my mouth.
[00:11:22.260]So like, in one lighting,
[00:11:26.890]apple sauce might be lumpy texture,
[00:11:30.610]and another lighting,
[00:11:31.560]that same exact apple sauce will be very liquidy tasting
[00:11:35.930]in my mouth.
[00:11:38.770]And then there's the smell of bacon.
[00:11:42.910]So I hate that smell.
[00:11:44.830]It's a fire inside my nose, is what I say.
[00:11:47.810]And it makes me,
[00:11:49.820]my urges are to take off my clothes and run away.
[00:11:54.810]That's what I picture in my head,
[00:11:56.240]because the smell of it clings onto my clothes
[00:12:00.240]and then I smell like bacon all day.
[00:12:02.550]And like I said,
[00:12:03.383]it's like a fire inside my nose and it's painful,
[00:12:06.550]and it makes focusing on anything else really hard
[00:12:10.380]'cause I'm in pain.
[00:12:13.768]Sure.
[00:12:15.380]So one thing you've learned is some strategies
[00:12:21.270]that you can use that help calm your senses
[00:12:24.550]and help them to function better.
[00:12:27.010]And another thing you've learned is just how your senses
[00:12:30.850]function differently from other people's senses.
[00:12:33.900]Yeah, being aware of why some of my react,
[00:12:36.960]why I would run away all of a sudden sometimes like,
[00:12:41.300]so when I was in treatment centers,
[00:12:42.700]I would just bolt out of the center
[00:12:44.830]and usually go climb trees.
[00:12:47.460]And I didn't know why I was doing that at first,
[00:12:50.780]but after some self exploration, I noticed that,
[00:12:55.237]"Oh, I'm doing that every time I hear a blender go off."
[00:13:00.380]And so exploring what...
[00:13:04.490]Looking at some of the behaviors or challenges that I have
[00:13:10.470]and looking at, trying to figure out like,
[00:13:13.636]what is causing that?
[00:13:16.820]And for me, I do have a lot of sensory issues.
[00:13:18.760]So figuring out what those sensory issues were,
[00:13:21.250]and putting names to it was huge.
[00:13:23.810]Right.
[00:13:24.643]You know, I think that occupational therapists
[00:13:27.153]are really good detectives.
[00:13:29.700]And sometimes they draw the links between things
[00:13:32.970]before other people recognize them.
[00:13:35.400]So you have the advantage of having that training as well.
[00:13:40.206]Yeah. In the next several slides,
[00:13:41.872]we're gonna see strategies that you use in your,
[00:13:46.170]at the sensory level.
[00:13:47.580]So on the next slide, you want me to-
[00:13:50.547]So, I need to incorporate sensory strategies
[00:13:54.100]into my daily routine.
[00:13:56.894]So for example, certain smells are very energizing to me.
[00:14:01.740]So in the morning,
[00:14:03.080]I use a tangerine scented lotion
[00:14:06.560]'cause that helps to stimulate me.
[00:14:11.183]I am low registering,
[00:14:12.650]but also sensory seeking in proprioception and vestibular.
[00:14:18.320]So in the morning too,
[00:14:20.310]sometimes William will have to tickle me to get me up.
[00:14:27.490]At other times though, I hate light touch.
[00:14:29.850]And if it's unexpected, I tend to hit.
[00:14:35.580]I use lavender and vanilla lotion in the evening
[00:14:39.330]to help calm me.
[00:14:40.830]I wear sensory bracelets on my wrist
[00:14:44.090]whenever I go out and about.
[00:14:47.370]I bring my weighted vests with me, at which I have on now.
[00:14:50.960]So I have to incorporate these different sensory strategies
[00:14:54.800]and tools throughout my daily routine.
[00:15:01.210]So on the next slide, you see some more strategies.
[00:15:05.320]And part of feeding my daily sensory needs,
[00:15:09.050]is doing a morning routine.
[00:15:11.100]And for me, this is a must,
[00:15:12.940]if I want to be productive during the day.
[00:15:16.070]Without it, I am very disorganized in my thinking
[00:15:19.210]and in my actions,
[00:15:20.160]and I will need William to give me a lot of cuing
[00:15:27.320]and a lot of support in order to even do
[00:15:31.400]very simple activities.
[00:15:35.200]And he, William, if I do not take a sensory break,
[00:15:41.120]William will kind of urge me to get out the door,
[00:15:45.530]because otherwise, I will drive him absolutely crazy.
[00:15:50.622]And what happens if your sensory routine gets interrupted?
[00:15:55.400]I'm very, very disorganized.
[00:15:57.500]I have a hard time.
[00:15:59.580]I like to say it's like,
[00:16:00.413]I don't know up from down, left from right.
[00:16:05.310]Everything's just confusing.
[00:16:06.960]And then I can start to do...
[00:16:10.070]If I don't have a plan in place ahead of time,
[00:16:16.332]and that happens,
[00:16:17.830]I will get very disorganized in my actions
[00:16:22.470]and do a lot of starting and stopping of things.
[00:16:25.770]Never getting anything done.
[00:16:28.770]So a lot of disorganization.
[00:16:30.870]Right.
[00:16:31.703]So having sensory strategies planned and in place for you
[00:16:36.570]is essential to your ability to function.
[00:16:39.110]Yes.
[00:16:39.943]And I do wanna say, so with the pictures that you see,
[00:16:41.850]this is part of my morning sensory routine.
[00:16:46.370]I do a lot of proprioception activities.
[00:16:49.900]So giving my body a lot of pressure.
[00:16:52.070]I do bear crawls,
[00:16:53.790]which is the picture of me kinda upside down,
[00:16:57.460]and that's also inverting my head.
[00:16:59.730]And inverting your head is very,
[00:17:02.090]can be very organizing to your system.
[00:17:06.070]And I also do crab walks, which is that bottom picture.
[00:17:10.500]And I do a lot of cross body movements as well,
[00:17:14.700]'cause that tends to help organize me,
[00:17:17.780]and helps me sequence, it seems like.
[00:17:23.660]Right.
[00:17:24.650]So the next slide shows some more strategies.
[00:17:27.253]I think you've talked about some of these.
[00:17:29.127]Did you want to add anything?
[00:17:31.100]Yeah, when I go out and about in public,
[00:17:35.020]I have a sensory bag that I wear.
[00:17:37.010]And in that bag, I have different tools and strategies.
[00:17:41.930]I have my headphones. I have sunglasses.
[00:17:45.960]I have this thing called bongers, which I usually show,
[00:17:50.460]but I kinda broke it.
[00:17:52.270]But it's a massage tool,
[00:17:54.370]and it can give your whole body vibration.
[00:17:59.730]So yeah, when I go out and about,
[00:18:01.190]I have to bring strategies with me.
[00:18:06.110]But then I also, each place that I go, identify places.
[00:18:11.100]So if I'm going to a restaurant,
[00:18:13.510]I know that I can go to the bathroom and take a break,
[00:18:17.450]if I need a break.
[00:18:18.560]Or I can go outside and take a break.
[00:18:22.000]Or if I'm at the Renaissance fair
[00:18:24.930]and I need a sensory break,
[00:18:26.810]I go to a soap station,
[00:18:28.760]because I really like smells,
[00:18:31.320]and will stand there for about 30 minutes
[00:18:34.210]and smell soap while William walks around.
[00:18:39.640]And the next slide shows some strategies,
[00:18:41.960]I think that you work with your clients with.
[00:18:45.410]Yeah, so I made this with one of my clients
[00:18:50.450]who I was trying to help him identify
[00:18:54.420]what his internal signals
[00:18:59.440]and also how he can change his body states.
[00:19:07.220]So I had him do these different actions, like bear walks,
[00:19:13.250]crab walks, frog jumps,
[00:19:15.920]and afterwards, had him identify,
[00:19:21.860]is that calming for you?
[00:19:24.050]Is that stimulating, or energizing, or is that focusing?
[00:19:31.910]And then after that,
[00:19:35.800]before every session, I would go over with him;
[00:19:38.810]how is your brain feeling?
[00:19:43.110]And then what do you...
[00:19:45.580]How does your brain need to feel
[00:19:47.290]in order for you to engage in our session?
[00:19:51.440]Because I know that without doing that,
[00:19:53.490]he won't be able to get anything out of our session.
[00:19:58.050]And does he do the actions during the session?
[00:20:02.630]I do 'em with them.
[00:20:03.840]Okay. All right.
[00:20:06.661]So he's learning about the effect on his own body
[00:20:09.960]and how it helps him to regulate
[00:20:11.810]for whatever activities he needs to do.
[00:20:14.410]Yes, and his mom gave the school...
[00:20:18.670]This individual is in his last year of high school,
[00:20:23.430]gave his school this chart as well.
[00:20:27.720]And they incorporate some of these into his day
[00:20:35.610]when they notice that he's having a hard time.
[00:20:39.370]And they might have him do something,
[00:20:40.830]or he might choose to do a different action
[00:20:43.010]if he's about to take a test, then he would,
[00:20:45.380]if he's about to work on a different kind of task.
[00:20:51.075]Yeah.
[00:20:52.120]All right.
[00:20:52.953]So we're going to go to the next level,
[00:20:55.880]and I want everyone to take a deep breath.
[00:20:58.710]Often when we get to reinforcement,
[00:21:01.860]there's an emotional reaction.
[00:21:03.780]And I remember the first time, it's been a long time now,
[00:21:08.210]but Barry and I were in Atlanta,
[00:21:11.330]and we were presenting to a large group,
[00:21:13.430]and when this level came up,
[00:21:15.220]this contingent of people in the middle of the room
[00:21:17.280]got up and walked out.
[00:21:19.460]And I was the one speaking at the time,
[00:21:21.930]and I was kind of stunned
[00:21:24.080]and I didn't know what had happened.
[00:21:25.495]And certainly we've come along long way since then.
[00:21:28.010]And what we've learned is there are a certain group
[00:21:32.341]of autistic people who experience what they feel
[00:21:37.410]was abusive use of behavioral strategies
[00:21:41.310]at some point in their lives.
[00:21:42.970]And so they tie reinforcement to trauma.
[00:21:47.630]And just the word reinforcement makes them angry
[00:21:51.580]or trigger them.
[00:21:54.269]And so let me apologize if that's your experience here,
[00:21:59.320]and assure you that when we include reinforcement
[00:22:04.768]in "The Ziggurat Model" is included.
[00:22:07.630]Because autistic people are people,
[00:22:11.550]they're human beings.
[00:22:13.100]And reinforcement is something that we would use
[00:22:15.500]with any human being that we're working to help.
[00:22:20.083]I mean, when you go to work, you're working for money.
[00:22:23.870]And for a lot of people,
[00:22:24.940]that money is a reinforcement to work.
[00:22:28.470]Absolutely, Kim.
[00:22:29.650]And a lot of people would quit if their paycheck quit.
[00:22:35.110]Yeah, it's part of being a human being,
[00:22:38.700]is the need for, in response to reinforcement.
[00:22:43.870]So if you look on the next slide, what is reinforcement?
[00:22:48.060]What reinforcement is something that increases
[00:22:50.220]the likelihood of behavior.
[00:22:51.510]Increases the likelihood, as Kim says,
[00:22:53.717]"That you're gonna go to work."
[00:22:55.170]And when we're doing therapy with somebody,
[00:22:58.230]what are we doing?
[00:22:59.100]We're working on, or when we do self-help,
[00:23:01.900]what are we doing?
[00:23:02.733]We're trying to increase the likelihood
[00:23:05.260]that we're gonna use a new skill
[00:23:07.120]or that we're going to exhibit a behavior.
[00:23:11.880]And what is the key to that?
[00:23:13.460]I hate to sound like a behaviorist, but sometimes I am.
[00:23:17.270]And the key to that is reinforcement.
[00:23:20.090]So we have it on this level,
[00:23:22.230]because everyone needs something to pull them forward
[00:23:27.780]towards skills and behaviors that they need to increase.
[00:23:32.940]And that's what reinforcement is.
[00:23:35.310]So on the next slide, you see examples of reinforcement.
[00:23:40.270]Could go from activities that a person enjoys,
[00:23:42.970]and this shows a board game,
[00:23:44.700]but it could be video games, are very popular reinforcers.
[00:23:50.517]YouTube videos, some of the kids that I work with,
[00:23:53.540]this is one of their very favorite things.
[00:23:56.830]And then you just see the thumbs up.
[00:23:59.350]And Kim often talks about
[00:24:01.530]her reinforcement, being accomplishment.
[00:24:04.610]So we'll look at the next slide.
[00:24:06.110]Kim can talk about that.
[00:24:08.444]Yeah, for me,
[00:24:09.277]a lot of times it's just engagement in the activity
[00:24:14.710]is an accomplishment, and I just wanna get the task done.
[00:24:20.650]And that for me is very reinforcing.
[00:24:23.360]It can also be something
[00:24:24.530]I work towards like a preferred activity.
[00:24:26.210]Right now, my husband and I set up a reinforcement
[00:24:29.900]of I'm working towards building
[00:24:35.220]a little gnome garden outside
[00:24:40.480]to help with some regulating things
[00:24:46.750]that I'm having a hard time with.
[00:24:47.770]And it has been very, very helpful.
[00:24:50.110]With one of my clients,
[00:24:53.350]we set up a reinforcement for Mexican food
[00:24:58.840]when he helps set the table five times.
[00:25:02.490]I would not use that strategy,
[00:25:07.900]and his mom wanted to use it for him
[00:25:11.210]when he gets, to help him turn off the water in the shower,
[00:25:14.910]because he has a hard time turning the water off
[00:25:17.060]in the shower when he showers.
[00:25:20.440]But that to me,
[00:25:23.650]the reinforcement would not be very a helpful strategy
[00:25:28.520]for him in that case,
[00:25:31.370]because he needs more support for it.
[00:25:39.580]He's having catatonia moments in the shower
[00:25:41.970]and it's not a matter of him not wanting to do it.
[00:25:45.910]It's a matter of him being able to do it.
[00:25:50.002]Right. So that's a really good point.
[00:25:51.160]We don't want to ever make someone earn something
[00:25:54.260]that is something they need.
[00:25:56.440]And we also don't wanna put in reinforcement strategies
[00:25:59.760]when actually what's going on is a physiological event,
[00:26:05.700]and you can't reinforce somebody out
[00:26:07.530]of a physiological event, and that's what catatonia is.
[00:26:10.990]That stuckness is not a choice.
[00:26:14.170]It is something that's happening to him.
[00:26:17.480]Yeah.
[00:26:18.313]So the first two levels are sensory,
[00:26:21.400]biological, and reinforcement.
[00:26:24.120]And we include those in anytime
[00:26:27.130]that we're working with someone,
[00:26:31.380]and whether it's helping them
[00:26:33.410]with their own self-help strategies or in therapies,
[00:26:36.850]you really are not gonna have an effective plan
[00:26:40.530]if you don't include a sensory,
[00:26:42.090]biological, and reinforcement.
[00:26:44.290]And the next level, I'm gonna hand it over to you, Barry.
[00:26:47.530]Sure.
[00:26:48.730]It's structure, visual/tactile supports.
[00:26:51.730]And so the mental health practitioner needs to be asking
[00:26:54.620]like, is his world predictable?
[00:26:55.910]What does he need to see?
[00:26:57.740]And for, again, we wanna teach these skills.
[00:27:00.770]We wanna teach individuals on the spectrum
[00:27:03.090]to think in levels.
[00:27:04.120]And they can ask themselves, is my world predictable?
[00:27:07.790]What do I need to see?
[00:27:10.393]So that's what this is about.
[00:27:13.000]So we say that structure creates predictability, right?
[00:27:18.920]And so predictability for so many individuals
[00:27:22.550]in the spectrum is, they need their world to be predictable.
[00:27:25.970]They need to kind of understand what to expect,
[00:27:29.340]and that can help to reduce stress, anxiety, et cetera.
[00:27:34.670]And so we use visual supports
[00:27:38.520]to create structure and predictability.
[00:27:43.102]These tools-
[00:27:44.603]I wanna add,
[00:27:45.436]it also helps structure and predictability,
[00:27:49.960]and schedules helps,
[00:27:51.030]because when you go into different environments,
[00:27:55.413]the environment's never the same.
[00:27:59.060]And that takes a lot of mental energy,
[00:28:03.930]a lot of processing to figure everything out,
[00:28:07.530]to figure out the sensory environment
[00:28:09.290]and the social environment.
[00:28:11.210]And having a schedule and having something structured
[00:28:16.040]allows you, or takes away that demand
[00:28:19.930]so you're able to cope with the other demands,
[00:28:24.770]and then better be able to engage.
[00:28:28.252]That's such an excellent point
[00:28:29.871]and I'm glad you mentioned that.
[00:28:32.640]And you also did some cool foreshadowing,
[00:28:35.630]'cause we're gonna get in a minute to the next level,
[00:28:37.860]which is task demands.
[00:28:39.380]And you use the word removing obstacles, and it does.
[00:28:41.930]And there's some overlap here,
[00:28:43.490]and visuals can help remove those obstacles,
[00:28:46.330]can help individuals to be successful across settings.
[00:28:53.530]One of the questions we get sometimes is, why visual?
[00:28:56.920]Why visual?
[00:28:57.753]And visual is such a strength for so many on the spectrum.
[00:29:01.320]We say this is about access.
[00:29:03.350]And so, whereas others may kinda learn certain things
[00:29:07.330]just from, through osmosis, right?
[00:29:09.580]We just kinda pick up on these things.
[00:29:11.400]We might need to make these more visual, more discreet,
[00:29:15.960]more concrete for individuals on the spectrum.
[00:29:18.870]And so visuals help provide access
[00:29:22.830]to people on the spectrum.
[00:29:26.320]All right, this is as an example.
[00:29:28.890]So again, back to the mental health professional,
[00:29:31.190]although you could use this
[00:29:32.430]in other service providers as well.
[00:29:35.080]We use a visual agenda.
[00:29:37.460]And oftentimes I encourage my clients to come prepared.
[00:29:44.900]And so if there's something that they want to talk about,
[00:29:47.610]maybe if they could jot it down a little bit,
[00:29:50.420]at least as an agenda item,
[00:29:52.250]they don't have to write or script,
[00:29:53.820]but they could at least write down what's important to them.
[00:29:56.550]And so, again, when I'm meeting in person, I'll have my,
[00:30:00.780]the best tool a counselor can ever buy,
[00:30:02.990]a blank piece of paper,
[00:30:04.580]and I'll write down the agenda,
[00:30:06.330]and we'll we'll just write it down
[00:30:08.080]and just kind of keep it in front of us.
[00:30:09.690]But when I'm doing telehealth, I'll share my screen,
[00:30:14.260]and this is what I have on my screen,
[00:30:16.200]and I'll just type right in what topics
[00:30:18.628]that individual wants to talk about today.
[00:30:21.650]And sometimes I've had someone kinda get stuck, almost.
[00:30:24.870]he said, "Well, there's two things I want to talk about
[00:30:26.697]but I'm not sure we're gonna have time,
[00:30:28.560]and what can I do about it?"
[00:30:29.740]Well, let's problem solve.
[00:30:31.230]And so we actually say,
[00:30:32.147]"Well, about how long would you wanna talk about
[00:30:34.050]topic number one?"
[00:30:35.437]And he said, "Well, maybe 10 minutes."
[00:30:37.420]And I said, "Okay, and so from 1:00 to 1:10,
[00:30:41.750]we're gonna talk about around 1:00 to around 1:10,
[00:30:45.590]we'll talk about topic one.
[00:30:47.320]And then we'll talk about topic two around 1:11
[00:30:52.150]and so we can structure it more that way as well."
[00:30:55.570]And so visuals are very helpful.
[00:30:57.730]They create predictability.
[00:30:59.540]We can see what we're talking about,
[00:31:01.290]and that can help facilitate that session.
[00:31:06.150]Visuals can be used in other ways, so many other ways.
[00:31:08.780]In this way, it was helpful to communicate
[00:31:11.980]to teach a certain concept that might otherwise
[00:31:15.200]be hard to understand.
[00:31:17.840]Worked with a young woman;
[00:31:20.220]she was having difficulty understanding
[00:31:23.270]how social media was for her,
[00:31:27.940]not always a good, a healthy use of her time.
[00:31:33.720]And so we kind of said,
[00:31:35.267]"Well, let's, it can be good and bad
[00:31:37.010]and everywhere in between,
[00:31:38.460]and you can see that how we have a continuum there."
[00:31:41.737]And we just talked about what at aspects of it are good,
[00:31:45.310]and what aspects are kinda bad,
[00:31:47.350]and helped her to kinda figure out whether,
[00:31:51.310]for her right now, whether social media a healthy outlet
[00:31:55.990]or not a healthy outlet for her time.
[00:31:58.790]And so that, so again, we're using visuals
[00:32:01.210]to explore different concepts,
[00:32:03.050]to facilitate this conversation,
[00:32:06.240]to talk about things that are somewhat abstract sometimes,
[00:32:09.770]visuals are powerful tools and highly recommended.
[00:32:15.170]So Kim, we're gonna talk about some of your strategies
[00:32:18.420]and supports on the structure of visual,
[00:32:21.000]tactile support level.
[00:32:23.970]Tell us about this one. Yeah, here's,
[00:32:25.220]I want to just say, because I have autism,
[00:32:27.930]I have a very hard time with changes in the unexpected,
[00:32:32.310]and it's also difficult to process
[00:32:34.730]and organize multiple steps.
[00:32:37.200]So I need one direction at a time,
[00:32:38.900]and visuals for things that are auditory.
[00:32:41.810]So when there are changes, I need to,
[00:32:46.550]it's best if I can have those changes in advance,
[00:32:49.910]or know about them in advance.
[00:32:51.720]And a strategy that I sometimes use
[00:32:55.507]and that I use with or suggest to clients
[00:32:58.730]is having a whiteboard on their refrigerator
[00:33:02.280]and only using that whiteboard for a change
[00:33:06.570]that's gonna be coming.
[00:33:08.410]So no other words can be written on there
[00:33:10.760]except for a change that's gonna be coming on in that week
[00:33:16.350]or within the next two weeks.
[00:33:18.830]So that way it's known.
[00:33:21.893]And also with change,
[00:33:23.620]it can be helpful to problem solve with somebody
[00:33:27.320]on how to...
[00:33:34.360]I don't have the right word.
[00:33:35.570]On how to navigate through that change.
[00:33:41.760]Okay.
[00:33:42.810]And let's look at another one.
[00:33:47.510]Yeah, so some of the tools that I used,
[00:33:49.530]I used first/then cards.
[00:33:51.590]And actually, you can see,
[00:33:53.820]so I have this one that I used today, which has,
[00:33:58.140]once we had a break or after the first talk, this test.
[00:34:02.030]First, I will jump on my trampoline.
[00:34:04.410]Then, I will eat lunch.
[00:34:06.580]Next, I will give the second part of the talk.
[00:34:10.080]And that helped me to structure my time
[00:34:13.967]and gave me a visual so I stayed on task
[00:34:18.980]for after that first talk.
[00:34:21.580]And I also had to use with that a timer,
[00:34:25.100]which is right here,
[00:34:27.643]to help me keep track of time when I was on my trampoline.
[00:34:30.730]And this timer,
[00:34:32.290]it's really kinda cool because I can set it.
[00:34:34.890]So like after 10 minutes, the red goes off,
[00:34:37.600]and then five minutes, the yellow, and then...
[00:34:42.820]Wait, I did it opposite.
[00:34:44.140]Green for 10, then yellow and then red.
[00:34:46.470]But I can set it for each interval.
[00:34:49.300]And just that helps visually keep track of time.
[00:34:53.160]I also have a key chain, which you see on the screen.
[00:35:00.650]And each of the cards has different places or situations.
[00:35:07.840]And on the back of that card,
[00:35:09.730]it has the sensory tools that I can utilize
[00:35:12.850]when I'm in that situation.
[00:35:14.950]And I made this when I was first understanding
[00:35:18.040]my sensory needs and how to cope.
[00:35:20.350]So because there's so much to you learn and think about,
[00:35:24.580]and when I'm in a situation, like a social event,
[00:35:28.610]and I'm getting overstimulated,
[00:35:31.880]it's hard, especially at first,
[00:35:33.680]to know, "Oh, I need to use my headphones,"
[00:35:37.650]or "Oh, I can go to the bathroom and take a break."
[00:35:42.480]But with a visual support,
[00:35:44.280]I can look at my list and see it right there,
[00:35:49.800]and it's easier cognitively.
[00:35:53.686]I love the strategies you come up with
[00:35:55.550]and that you developed on your own,
[00:35:57.355]and you're not only-
[00:35:58.570]I might take a break card.
[00:36:01.440]Oh, you gotta push that one up.
[00:36:04.420]Did I?
[00:36:05.253]Yep. Oh, I'm on the wrong.
[00:36:06.086]Sorry. I understand.
[00:36:07.660]Here we go.
[00:36:08.770]Yeah.
[00:36:09.603]So I can get fixated on,
[00:36:12.670]especially when I'm working on PowerPoints,
[00:36:14.935]on the visuals of it,
[00:36:16.730]and spend way too long working on it.
[00:36:22.740]And when my husband, William, notices this,
[00:36:25.807]he used to come and tell me,
[00:36:28.337]"Hey, Kim, you need to take a break."
[00:36:30.120]I would get so angry at him for verbally telling me that
[00:36:34.560]because it really broke my concentration.
[00:36:37.220]And it took lot of effort to transition
[00:36:40.020]from doing something visual
[00:36:43.120]to having to process his auditory information.
[00:36:46.020]So we came up with a system where he puts a,
[00:36:49.600]take a break in 10 minutes card in front of me,
[00:36:53.040]and that works.
[00:36:54.450]It serves as a queue.
[00:36:56.470]And then if I don't take a break in 10 minutes,
[00:36:58.980]he puts another card that says, take a break now.
[00:37:02.870]And if I still don't take a break,
[00:37:05.263]then he turns off my computer,
[00:37:08.110]because I'm stuck and I need his help to get unstuck.
[00:37:12.600]And that's something y'all
[00:37:13.730]have obviously arranged beforehand,
[00:37:15.680]so it's not unexpected.
[00:37:17.960]It's part of the routine that you've created,
[00:37:20.859]and it's a predictable routine.
[00:37:23.630]Tell us about...
[00:37:24.463]I love these, you showed us these,
[00:37:26.560]the coping blocks and some of the other strategies
[00:37:30.200]that you have developed for yourself.
[00:37:32.730]Yeah, so my coping blocks, there's two different sets.
[00:37:38.260]One set, the green and yellow have emotions,
[00:37:43.479]and the other one, the blue and the orange have strategies.
[00:37:47.610]So when I was trying to learn to,
[00:37:51.364]well, I mean, I use these now too,
[00:37:52.980]but these were really helpful when I was trying to pair
[00:37:55.810]my emotions to strategies to use,
[00:37:58.860]because with blocks,
[00:38:01.230]yes, I have things written on each side,
[00:38:03.260]but I can only see limited information at a time
[00:38:07.380]which helps me not to get too overwhelmed,
[00:38:11.090]and also I can manipulate them.
[00:38:15.260]I can touch them, move them, feel them.
[00:38:17.520]Whereas so many strategies are flat on paper
[00:38:23.940]or on the computer.
[00:38:25.722]And for me, that doesn't work.
[00:38:27.730]I need to touch and feel.
[00:38:30.530]So it being 3D, really helped.
[00:38:34.040]That's great.
[00:38:36.210]All right.
[00:38:38.635]Would you like, which, do you want me to jump to the-
[00:38:43.790]Yeah.
[00:38:44.623]This one? Okay.
[00:38:46.260]This is something I use with one of my clients.
[00:38:50.130]So before, this is a virtual session.
[00:38:52.580]Before session, I send this to my client
[00:38:58.330]so they know What we're gonna focus on in session.
[00:39:05.230]I'm giving them structure of what to expect.
[00:39:10.570]I love it. I like that. Talk with William.
[00:39:13.300]Yeah, William, my husband, 'cause we're on social.
[00:39:16.880]I said he gets incorporated in that.
[00:39:19.270]I love the beard too. That's awesome.
[00:39:22.190]I have a quick question. Kim, how far ahead of the session
[00:39:25.810]do you share this with the client?
[00:39:29.971]Ideally, a few days before.
[00:39:35.330]I like, with this particular client,
[00:39:37.410]I need to kind of wait to see what is important for them
[00:39:40.000]to focus on that week.
[00:39:41.620]So I can't do it too soon because then it'll switch.
[00:39:44.570]So I have to wait till I get their update.
[00:39:46.530]I usually ask my clients to...
[00:39:49.716]I have a very structured form and have them fill out
[00:39:53.500]to help them identify what it is that we need to focus on.
[00:39:58.200]That's great. Yeah.
[00:40:01.600]So we're gonna move to the next level.
[00:40:04.040]So again, we're wanting to think in levels,
[00:40:06.010]but every level's really important.
[00:40:07.620]So we've talked about sensory differences, biological needs.
[00:40:11.060]We've talked about reinforcement.
[00:40:12.540]Remember we do reinforcement because we're human,
[00:40:15.410]and this is a different kind of enforcement,
[00:40:18.445]not the other kind.
[00:40:21.180]We do structure and visual, tactile support,
[00:40:23.790]and this is the fourth level,
[00:40:25.950]task demands and positive environment.
[00:40:28.750]And so the mental health practitioner or other practitioners
[00:40:31.310]need to be thinking, is she in over her head?
[00:40:33.820]What obstacles need to be removed?
[00:40:36.410]And there may be obstacles in the therapy environment.
[00:40:39.680]The fact that we we're seated,
[00:40:41.790]or the fact that it could be the lights
[00:40:43.740]or it could be communication obstacles, who knows.
[00:40:46.140]How can we remove those obstacles?
[00:40:48.350]And for the individual on the spectrum,
[00:40:49.880]we wanna teach them to use these levels so they can use them
[00:40:53.030]in their daily life.
[00:40:54.250]And they should ask themselves,
[00:40:55.480]is this whatever it may be?
[00:40:56.790]Is this too hard for me?
[00:40:58.520]What obstacles do I need removed?
[00:41:01.400]And so there may be some accommodations, modifications,
[00:41:05.620]different kinds of supports that need to be in place
[00:41:09.380]to help the individual.
[00:41:11.220]Oftentimes we get this question,
[00:41:12.700]well, we'll get this comment,
[00:41:14.197]"The real world doesn't,
[00:41:15.860]won't provide him with a schedule,
[00:41:17.210]or how is she gonna learn unless we push her?"
[00:41:19.700]And what we say is, our response is,
[00:41:22.540]"What we wanna do is remove obstacles for individuals
[00:41:25.460]while we're teaching skills,
[00:41:27.240]because we don't want to create a sink or swim moment."
[00:41:30.830]What do that mean?
[00:41:32.140]Here's what we're talking about.
[00:41:33.340]We like, the image of a balance here,
[00:41:37.440]we think really helps to capture the concept
[00:41:39.630]of the task demands level.
[00:41:41.320]And on the left hand side, you'll see,
[00:41:43.020]we have demands.
[00:41:43.890]On the right hand side, we have ability.
[00:41:45.750]And we never want this.
[00:41:47.440]We don't want a situation where the demands
[00:41:49.550]exceed the ability.
[00:41:50.560]When they do, this is a too demanding.
[00:41:53.460]And what does that look like?
[00:41:54.650]Shutdowns, meltdowns, lack of progress,
[00:41:58.010]maybe some behavior challenges.
[00:41:59.790]So this is what we want to try to avoid.
[00:42:03.050]So how do we address this?
[00:42:05.080]Well, on the left hand side,
[00:42:07.110]you can see, we can pull some of those rocks off, right?
[00:42:09.410]We can lower the demands, reduce some demands.
[00:42:12.900]And on the right hand side, we could try to add support,
[00:42:16.720]which would help to level this off,
[00:42:19.551]but we could also add ability.
[00:42:22.170]How do we add ability?
[00:42:23.210]Well, that comes next.
[00:42:24.360]That's our skills to teach level, right?
[00:42:26.530]And the more ability someone has, the more skills they have,
[00:42:29.290]then the more demands they can place on themselves
[00:42:33.450]and the fewer supports they're going to need,
[00:42:35.800]but all balances out.
[00:42:37.090]So we wanna kind of avoid this situation,
[00:42:39.083]because this is when we're overwhelmed, right?
[00:42:41.530]And we don't want that autistic burnout, et cetera.
[00:42:44.790]This is what we're thinking about
[00:42:47.362]when we hear those terms,
[00:42:48.830]something is overwhelming, too demanding.
[00:42:51.530]Here's an example in a counseling session,
[00:42:54.240]I had a young woman tell me, she said,
[00:42:57.037]"I'm afraid college is more than I can handle."
[00:43:01.690]And so boy,
[00:43:03.000]there were some lots of layers to unpack here, right?
[00:43:06.490]And so one of the first things I did
[00:43:08.640]was I kinda introduced that concept,
[00:43:10.660]how different thing, how college could,
[00:43:15.100]we could range from easy to too demanding.
[00:43:17.210]And what's it like for you?
[00:43:19.250]And they put the little red X right there,
[00:43:21.370]kind of at the edge.
[00:43:22.320]It's in the challenging area, not too demanding.
[00:43:26.100]And so we wanted to point out that challenging
[00:43:28.610]is we're learning is occurring, right?
[00:43:30.390]And which is good.
[00:43:32.040]Now how she said it was too demanding,
[00:43:33.920]well, then we would've had needed
[00:43:36.160]to have some conversations.
[00:43:37.770]What can we do to get this to go move from a too demanding,
[00:43:41.177]to the challenging zone?
[00:43:44.860]And so we got to talking about this more and more,
[00:43:47.950]trying to understand what about it was challenging.
[00:43:50.920]And then she said,
[00:43:52.457]"Actually, it's not the work that's hard. It's working.
[00:43:55.250]Keeping track of my assignments.
[00:43:56.820]Keeping track of things that have to be turned in.
[00:43:58.928]Logging into the system and all those things."
[00:44:01.450]Well, these are things we can work on, right?
[00:44:03.250]And these are things,
[00:44:04.330]maybe there's some different accommodations
[00:44:05.930]a college could provide, et cetera,
[00:44:07.520]or we could work on time management.
[00:44:09.620]And so that's we did
[00:44:11.460]from a practical problem solving perspective,
[00:44:14.600]but many of you mental health practitioners
[00:44:17.410]were probably tuned in as I was, to say,
[00:44:20.720]well, let's look at this, let's look at the thought here.
[00:44:23.190]The thought was,
[00:44:24.350]college is more than I can handle, and can we evaluate that?
[00:44:27.330]And we did that, visually here.
[00:44:29.360]And so I circle back around and I said,
[00:44:32.237]"Well, you know what?"
[00:44:33.340]We've said, "It's not too demanding. It's challenging."
[00:44:36.820]And you've specified, what's challenging about it.
[00:44:40.630]And the work for you isn't the challenging part,
[00:44:42.760]it's working.
[00:44:43.920]So what's a more accurate belief you might have
[00:44:46.640]or statement or thought about college?
[00:44:48.610]And she said,
[00:44:49.443]"Well, as long as I don't let things get away from me,
[00:44:52.260]I can do fine."
[00:44:53.690]And that's a healthier thought, right?
[00:44:55.710]Rather than thinking college is just too much for me,
[00:44:58.060]to really narrow it down and say, you know what?
[00:44:59.710]I can handle college as long as I can keep track
[00:45:02.988]of my assignments and things.
[00:45:04.960]And that's a different way of looking at that.
[00:45:07.610]All right.
[00:45:08.443]Kim, tell us some of your wisdom about task demands
[00:45:11.630]and obstacle removal.
[00:45:12.840]How do you use this level? What do you think about?
[00:45:17.270]I cannot be rushed. I need time to process.
[00:45:21.690]Sometimes I repeat actions, thoughts,
[00:45:25.110]and words because I'm stuck in a loop.
[00:45:28.170]And when this happens, I need help stopping.
[00:45:31.940]Not just telling me to stop, but actual help stopping.
[00:45:37.240]Verbal communication can become very difficult
[00:45:41.170]when overstimulated.
[00:45:43.380]So to remove that obstacle,
[00:45:45.670]I need, sometimes, prompts to do written communication
[00:45:50.750]or through pictures or symbol.
[00:45:53.840]I might not be responding to you
[00:45:55.510]because I just need a little bit of help starting
[00:45:59.430]or stopping a task.
[00:46:02.430]I am very literal in my thinking,
[00:46:05.340]I have strict word definitions,
[00:46:07.770]and struggle with open ended questions.
[00:46:12.310]So it's very important to...
[00:46:18.760]This kind of goes back to the self-awareness,
[00:46:20.440]like it's so important to understand for me
[00:46:23.590]what my autism traits are.
[00:46:25.340]So I can identify that these are the things
[00:46:27.340]that I have a hard time with.
[00:46:28.780]So when I'm looking at supports to create for myself
[00:46:34.220]or when somebody else is helping me to create supports,
[00:46:41.050]I need to keep these in mind,
[00:46:42.780]'cause these could all be potential barriers,
[00:46:44.940]and I need to problem solve through it
[00:46:48.780]in order to be successful
[00:46:50.300]with what it is we're trying to do.
[00:46:55.160]All right.
[00:46:57.251]And really thinking that through is something,
[00:47:01.180]it helps you to get a situation, whatever that may,
[00:47:04.510]that context from where we go from too demanding
[00:47:07.030]to maybe challenging,
[00:47:07.940]or challenging to easy, in some situations.
[00:47:12.470]And so tell us a little about this one here,
[00:47:19.080]some of your strategies.
[00:47:20.970]Yeah, so I have a number system that I use,
[00:47:24.160]from 1 to 10.
[00:47:25.970]And 10 means that I'm completely overstimulated.
[00:47:29.410]One, I'm never a one, that would probably be, I'm in a coma.
[00:47:33.822]I'm so calm.
[00:47:35.330]But I usually stay around a five or a six.
[00:47:41.530]But the number system is good,
[00:47:42.790]because at my communication starts to go away
[00:47:46.290]at around a seven.
[00:47:48.070]So at a 7, I can do my hands,
[00:47:51.440]and do a seven or eight with my hand.
[00:47:55.480]But not only does it help me communicate,
[00:47:58.430]it also, for my husband,
[00:48:00.510]it helps him know how he needs to help support me.
[00:48:05.830]Because at an eight,
[00:48:09.330]he can suggest, "Hey, Kim, maybe you need your headphones?"
[00:48:13.870]But at a eight, I can't physically go and get my headphones.
[00:48:18.010]I need him to do it for me.
[00:48:21.180]But at a seven, he can suggest it and I can go do it myself.
[00:48:28.260]I have signals from...
[00:48:30.450]I talk to my gym, so I can get stuck in actions,
[00:48:34.780]especially jumping and spinning,
[00:48:36.950]and I will do this until I pass out, sometimes,
[00:48:41.640]which is not good.
[00:48:42.473]So I talk to the gym about that and we have hand signals.
[00:48:46.430]So if I'm getting stuck, I can give them a hand signal,
[00:48:49.660]and they come and they help me transition to something else.
[00:48:54.020]I have an ID card on my purse or sensory bag
[00:49:03.050]and it's on the outside,
[00:49:04.070]because I found that if it was on the inside
[00:49:08.760]and I'm overstimulated and I need to show somebody my card,
[00:49:13.150]I can't fumble around looking inside my bag to find it.
[00:49:17.780]I need to have access to it right away, outside my bag.
[00:49:21.240]And I found that out because I was at a store
[00:49:27.520]and they thought I was shoplifting, but I wasn't,
[00:49:30.920]I was just very overstimulated
[00:49:33.460]and kind of pacing back and forth.
[00:49:35.650]I was in the jewelry section,
[00:49:37.490]which I guess is why they thought that.
[00:49:40.540]And I couldn't talk to them and let them know
[00:49:42.290]I have autism, I'm overstimulated.
[00:49:44.200]I need help.
[00:49:45.820]It was very traumatic experience.
[00:49:48.360]Sure.
[00:49:49.193]Yeah.
[00:49:52.480]When I'm down by the creek, I can get stuck in actions.
[00:49:56.260]I have a whistle that I use.
[00:49:58.447]And when I blow my whistle,
[00:50:00.060]then William knows he needs to come down there and help me.
[00:50:05.610]Very smart.
[00:50:07.090]So you really have put a lot of thought
[00:50:08.930]into developing supports to help you
[00:50:12.170]to be functional across a number of environments,
[00:50:14.650]everywhere from the gym to home environment and elsewhere.
[00:50:19.780]Yeah, I do want to mention real quick, with task demands.
[00:50:26.010]I'm working with an individual who,
[00:50:30.530]they have a visual support and structural support,
[00:50:33.240]we're working on communicating needs for emotions.
[00:50:38.390]So he has a key chain that has,
[00:50:42.500]like, what to do when he's feeling certain ways at school.
[00:50:47.480]And so he has the visual and structural support,
[00:50:54.120]but he doesn't have access to it.
[00:50:57.390]The task of him actually using it is too hard
[00:51:01.530]because he has it on his book bag, which is under his desk.
[00:51:06.240]So when he overstimulated
[00:51:08.010]or when he is having really high emotions,
[00:51:11.180]he's not able to actually access that key chain
[00:51:15.360]that would be very helpful for him.
[00:51:18.070]And so, what I talked to the school about doing,
[00:51:22.940]and his parents about doing,
[00:51:24.100]is having something laminated,
[00:51:27.097]so a little bit simpler laminated and having it on his desk
[00:51:30.830]so he has access to seeing it,
[00:51:33.300]to this visual support that would be helpful for him.
[00:51:37.470]That's a great, great strategy.
[00:51:39.790]And sometimes people ask,
[00:51:43.090]where does the strategy of teaching others?
[00:51:44.850]Where does that fall?
[00:51:46.190]This is an example of a task demand intervention.
[00:51:48.990]So for example, if the teacher could be taught,
[00:51:51.930]and it sounds like you've trained William as well,
[00:51:55.070]like, "Hey, put this thing on my desk,"
[00:51:56.730]or "Hey, prompt me if I get stuck."
[00:52:00.630]And so maybe the teacher could also be a prompt,
[00:52:03.560]either visual, verbal prompt.
[00:52:05.520]The teacher might say,
[00:52:06.887]"Johnny, you're looking like you might need a break,"
[00:52:11.600]or it could be,
[00:52:12.760]or perhaps could just point to that visual support
[00:52:15.650]you've created, something.
[00:52:17.130]And so that is also way.
[00:52:19.330]So adding support is removing obstacles.
[00:52:22.730]That's a task demand intervention.
[00:52:25.730]We're gonna talk about the last level of the Ziggurat.
[00:52:28.610]And so again, we wanna remind you all
[00:52:30.740]that we wanna think in levels.
[00:52:32.100]We wanna make sure that we have a whole rounded plan,
[00:52:35.210]and we need all five levels.
[00:52:37.200]And so we're thinking about what does this individual
[00:52:39.480]need to know on this level?
[00:52:41.780]Or of course, for individuals in spectrum,
[00:52:44.350]they need to be asking themselves,
[00:52:45.490]what do I need, what does I need to know?
[00:52:48.800]Sorry about that.
[00:52:49.633]What do I need to know?
[00:52:51.900]And so that's what we need to be thinking about
[00:52:55.430]on that level.
[00:52:56.330]And so I like this summary here, it says,
[00:52:58.257]"Learning skills allows for growth and independence.
[00:53:01.590]When the sensory system is calm,"
[00:53:03.420]see how we're building here, right?
[00:53:04.917]"Reinforcement is available,
[00:53:06.370]the environment is made predictable through structure
[00:53:08.520]and visual supports,
[00:53:09.800]and task demands are carefully designed,
[00:53:12.600]skills can be effectively taught and learned."
[00:53:16.920]And that's what we're doing.
[00:53:17.850]We're trying to...
[00:53:18.750]We need to make sure that in order for skills
[00:53:21.320]to be in place, to work on skills,
[00:53:23.730]we have to set that stage
[00:53:25.620]and make sure that those other levels are supportive.
[00:53:29.230]Those other levels are addressed.
[00:53:31.400]And so Kim, you have some wise words here.
[00:53:34.010]Tell us a little about skills to teach
[00:53:36.473]from your perspective.
[00:53:38.880]Yeah, instead of looking at my mess-ups
[00:53:41.540]or our behaviors as negative,
[00:53:44.360]I look at them as a missing skillset
[00:53:46.620]that needs help developing.
[00:53:49.110]So I used to do a lot of a negative self-talk,
[00:53:53.420]but that negative self-talk has turned around,
[00:53:57.120]and now it's more like,
[00:53:58.617]"Okay, I'm having a hard time with this.
[00:54:02.680]So why am I having a hard time with this?
[00:54:05.800]And what can I do about it?"
[00:54:08.150]So instead of looking at, when I have a hard time,
[00:54:13.380]or I don't wanna say, fail,
[00:54:15.270]but like, when something doesn't go right,
[00:54:18.550]it's just another opportunity to create a new system,
[00:54:22.220]to create a new strategy.
[00:54:25.813]What a great perspective.
[00:54:27.752]I think it takes people a long time
[00:54:30.060]to kinda turn that corner
[00:54:31.900]where they can see those things from this wiser perspective,
[00:54:37.277]and try to...
[00:54:40.695]I always like to say,
[00:54:41.528]"Not kick yourself in the tush," right?
[00:54:43.140]That's that negative self-talk where we're,
[00:54:48.021]were yeah, were we kinda kicking ourselves in the tush,
[00:54:50.240]is what I say.
[00:54:51.320]Well, kim-
[00:54:52.153]Can I read something about that,
[00:54:53.380]really quick? Yes, please.
[00:54:55.970]Along with that,
[00:54:56.970]so self-compassion was a really big skill
[00:55:00.240]that I had to learn.
[00:55:03.500]Had to learn that it was okay to mess up.
[00:55:05.250]That it was okay that I have a hard time with things.
[00:55:08.060]And I wrote something about that.
[00:55:11.647]"I am realizing that it is not the disability or illness,
[00:55:15.440]developmental, psychological, and medical,
[00:55:18.000]for me, that prevents me from doing things
[00:55:20.470]or moving towards my goals.
[00:55:21.950]But rather, it's the thoughts about what I should
[00:55:25.140]or should not be doing.
[00:55:26.380]And it's the expectation that I need to do things
[00:55:29.980]a certain way or by a certain time.
[00:55:33.060]These shoulds and expectations prevent me from even trying.
[00:55:38.240]I am realizing that sometimes I may need to take a step back
[00:55:42.420]or stay put in order to eventually move forward.
[00:55:46.920]I'm learning that some days, I might be able to do a lot,
[00:55:50.130]but other days, I am not.
[00:55:52.180]But that both days, I can still be doing something.
[00:55:55.490]I have to redefine my idea of being productive.
[00:55:59.240]It's not about how much I've accomplished
[00:56:01.900]or how many things I've completed that day,
[00:56:04.600]but rather, it's about doing the best that I can
[00:56:07.110]in the present moment.
[00:56:08.760]It means that working on a project for 4 hours one day
[00:56:12.720]is just as productive as only paying my bank bill
[00:56:16.690]on another day.
[00:56:17.960]Adapting self-compassion is essential
[00:56:22.070]and also another key to moving towards my goals.
[00:56:26.120]Without it, I become paralyzed
[00:56:27.980]with frustration and disappointment,
[00:56:30.640]which leads to self-doubt, and ultimately, self destruction.
[00:56:34.090]It's important to realize what defines capability.
[00:56:38.510]Disability or illness doesn't determine how capable I am.
[00:56:42.790]That's determined by me, and me alone.
[00:56:46.530]I decide whether I will be paralyzed
[00:56:49.500]by the shoulds and expectations,
[00:56:51.480]or whether I will be guided by self-compassion."
[00:56:57.610]There are lots of wisdom in that. A whole lot.
[00:57:02.793]Again, self-compassion is a skill
[00:57:06.752]that it sounds like you have worked on learning, Kim.
[00:57:12.530]I'm reframing those demands, that demand thinking,
[00:57:17.030]those shoulds is also a skill.
[00:57:23.250]Kim, I know that there were a few more slides
[00:57:26.170]that you wanted to be sure you talked about,
[00:57:28.260]and I'm just watching our time,
[00:57:30.530]and then you may- We can do questions
[00:57:32.170]'cause they're in the handout,
[00:57:33.440]so they can, people can see them.
[00:57:35.090]They have access.
[00:57:36.550]So are you saying you wanna switch to Q and A right now?
[00:57:39.470]Yeah, sure.
[00:57:40.680]Okay.
[00:57:41.513]So then, I will...
[00:57:44.080]Trying to see if there's anything else I wanted to do.
[00:57:45.630]We have the, of course, to contact us, and we have that.
[00:57:50.160]So if y'all have any questions, you're welcome to email us.
[00:57:54.090]And then just a quick reminder,
[00:57:55.740]there's that code,
[00:57:57.750]if anyone needed the coupon code for conference discounts.
[00:58:04.536]So we are gonna do Q and A,
[00:58:05.927]and I know there was already one question
[00:58:08.370]which I can read that was in the chat box.
[00:58:11.250]And then I think that we'll have a microphone
[00:58:13.720]in the room there too.
[00:58:15.160]Would it be okay if I just read the question
[00:58:16.890]from the chat box-
[00:58:19.330]Yeah.
[00:58:20.163]To get us started?
[00:58:20.996]Okay, it says,
[00:58:21.829]what are your feelings about repeated exposure?
[00:58:25.310]As a neurotypical, I try this with my students,
[00:58:28.720]and I won't any longer if you and others
[00:58:31.040]with the disability feel that it is detrimental.
[00:58:34.580]For example, go out to the bus barn.
[00:58:36.950]Next day, touch the bus.
[00:58:38.720]Next step, open the bus door, et cetera,
[00:58:41.390]in order to make riding the bus a possibility.
[00:58:46.340]It really depends on a lot of things.
[00:58:51.700]So I have done exposure therapy for,
[00:58:56.520]when I was in eating disorder treatment.
[00:58:59.300]They had me to exposure therapy for trying to sit still.
[00:59:02.710]So I had to go into a room
[00:59:04.090]and they wanted me to sit still for a minute.
[00:59:08.140]And it was torture, and I was not able to do it.
[00:59:11.500]My body needs movement.
[00:59:15.930]So in that case,
[00:59:17.350]exposure therapy was very inappropriate for me.
[00:59:24.110]I could see exposure therapy for,
[00:59:28.910]it depends on what the underlying challenge is.
[00:59:33.030]If it's something sensory,
[00:59:35.630]no, I don't think exposure therapy is good.
[00:59:41.410]If it's something where it's more...
[00:59:46.580]There's a difference between sensory and anxiety
[00:59:51.490]for a reason why somebody might be avoiding something
[00:59:55.800]for an anxiety reason, possibly if it's done correctly,
[00:59:59.950]exposure could be very helpful.
[01:00:02.950]But the key is trying to figure out
[01:00:05.610]what the reason is.
[01:00:09.278]That's a great point.
[01:00:10.111]Sometimes, and it sounds like you're chaining
[01:00:13.090]in your example.
[01:00:13.923]So it's like you're taking little steps,
[01:00:19.400]which again, that might be an inappropriate way to do it
[01:00:22.990]for what, but you have to look at other things.
[01:00:26.765]Is the riding the bus,
[01:00:31.220]is the reason why riding the bus is hard,
[01:00:34.070]is because it's too loud, or the movement of the bus,
[01:00:38.320]or is there something social going on, or is it the unknown?
[01:00:44.700]And in that case, incorporating in some other strategies.
[01:00:50.370]So if it's sensory,
[01:00:51.880]trying to incorporate some sensory strategies.
[01:00:54.250]If it's, the person doesn't really know what to do
[01:00:57.850]when they get on the bus and it's very confusing,
[01:01:01.080]create a structure of,
[01:01:03.560]this is what you do when you get on the bus.
[01:01:05.960]When you're on the bus,
[01:01:07.920]these are the things that you can think about,
[01:01:10.450]or these are the tasks that you can do
[01:01:13.720]while you're waiting for your stop.
[01:01:18.820]So it's, yeah. Did I answer that good?
[01:01:21.920]I loved your answer. I really did.
[01:01:24.910]The only thing I would build on is just that you're right.
[01:01:28.170]If it's kind of like a walkthrough,
[01:01:30.200]you're really trying to prepare them
[01:01:31.470]for something new or different.
[01:01:33.900]I don't know that I would necessarily call it exposure.
[01:01:35.510]And we do that all the time, right?
[01:01:36.750]Elementary students going to middle school.
[01:01:38.500]We schedule visits.
[01:01:40.030]Maybe during the summer they can walk the hallways
[01:01:42.580]and get used to that, that's great.
[01:01:44.930]But if it's a sensory kind of thing,
[01:01:47.660]as you, to your point,
[01:01:48.970]it can be a, that could be a challenge,
[01:01:52.110]and would not wanna do that. Like having me smell bacon?
[01:01:54.495]No. Yeah, we don't wanna train
[01:01:56.450]people to do something that's not good
[01:01:59.010]for their bodies that's dysregulating.
[01:02:02.530]I see a new question popping up in our chat box.
[01:02:05.880]Can you give a brief overview of what your resources are
[01:02:10.550]for "Ziggurat Model?"
[01:02:11.383]Are they generally checklists that help guide
[01:02:13.460]the development of strategies and supports?
[01:02:16.060]The "Ziggurat Model" starts with an assessment.
[01:02:17.890]We have the assessment tool,
[01:02:18.723]the underlying characteristics checklist,
[01:02:21.210]which can be completed by multiple respondents.
[01:02:24.915]So again, I might do a self-report,
[01:02:28.010]could get a parent, a teacher, et cetera,
[01:02:30.700]completing the UCC.
[01:02:33.126]And that that process also depends on what context
[01:02:36.120]you're using it.
[01:02:37.330]But then there are additional forms and tools,
[01:02:40.840]if you're using it
[01:02:41.690]for the formal kinda "Ziggurat Model" approach,
[01:02:44.310]where you're actually developing
[01:02:45.780]a whole written intervention plan
[01:02:47.300]that might be incorporated into an IEP, for example,
[01:02:50.110]or some other kind of a work transition plan, et cetera.
[01:02:56.610]But there's only one assessment checklist,
[01:02:58.470]but then there are other checklists that you use
[01:03:00.970]to help through each step of that process,
[01:03:03.500]from going from assessment to intervention.
[01:03:07.480]Are there anything to,
[01:03:09.570]as far as guiding the development of the strategies
[01:03:11.930]and supports, we kind of lean on you to know,
[01:03:15.590]to have ideas of different kinds of strategies
[01:03:18.960]and supports that might be helpful.
[01:03:20.670]Our book though,
[01:03:21.503]does have lots of examples for each level of the Ziggurat,
[01:03:25.740]of what kind of strategies and supports,
[01:03:29.360]examples of research supported supports and strategies.
[01:03:32.400]Yeah, their book,
[01:03:35.050]and I read that before I contacted Barry and Ruth
[01:03:38.670]for the first time,
[01:03:40.530]I found it very helpful, how it outlined the different,
[01:03:46.330]how it gave different examples of the supports to utilize
[01:03:52.300]in each of the different levels.
[01:03:55.340]I thought it really talked to autism neurology
[01:04:00.010]very, very well.
[01:04:01.910]What other questions do you all have,
[01:04:03.520]either live or online?
[01:04:05.500]Okay. We have a question live.
[01:04:08.650]Actually, I have two questions here,
[01:04:10.130]but the first one is, (faintly speaking)
[01:04:17.841]I couldn't hear that.
[01:04:19.745](participant faintly speaking)
[01:04:44.470]Okay, could you guys hear that at all?
[01:04:46.260]No. No.
[01:04:47.310]Yeah, our AC kicked on
[01:04:48.810]right as she began asking questions.
[01:04:51.250]So she said, "There was a slide that you showed
[01:04:54.750]right before we went into reinforcement
[01:04:58.040]and it was about some exercises
[01:05:02.150]and how it makes the person feel.
[01:05:06.750]Yeah.
[01:05:07.735]And so she was just asking
[01:05:10.360]for a little more clarification on that,
[01:05:13.380]and how you go about that exercise,
[01:05:16.210]for asking them how they feel.
[01:05:18.770]Yeah. I created that for an individual.
[01:05:25.470]Like I said, at first, I just started off with doing,
[01:05:28.280]okay, so one session.
[01:05:30.882]I didn't even have...
[01:05:32.460]The very first session I did this with,
[01:05:34.810]I only had a PowerPoint slide that had bear walk on it,
[01:05:40.310]and I had him do a bear walk.
[01:05:43.280]And then I asked a very specific questions.
[01:05:48.000]What do you feel in your hands?
[01:05:51.160]What do you feel in your body?
[01:05:58.586]What do you feel like doing?
[01:06:02.010]Do you feel like you can sit down and focus?
[01:06:07.150]This individual is minimally verbal.
[01:06:11.980]He is very articulate through writing.
[01:06:15.320]So he would write to me what his experiences,
[01:06:22.500]and then I would put an icon by it,
[01:06:26.870]and then the next session, we would do another one.
[01:06:30.490]Sometimes I might do two in one session
[01:06:33.500]and then be opposite.
[01:06:34.630]So I might have, okay, ball bounces.
[01:06:41.610]And then right after that, leaning back on the ball,
[01:06:45.100]how does that change your energy?
[01:06:46.800]What is the difference between those?
[01:06:50.950]And then eventually,
[01:06:52.520]I was able to create this chart on the right.
[01:06:57.610]And then I was thinking,
[01:06:59.167]"Okay, how can I have a guide to help him know
[01:07:05.840]when to do what?"
[01:07:07.600]So thought, "Okay, I need guiding questions."
[01:07:12.500]So how does your brain feel right now?
[01:07:14.480]He's able to identify these body states.
[01:07:19.780]And I put a list down
[01:07:21.270]because he needs that structure, the list.
[01:07:25.200]And then it just kind of morphed to the rest of it.
[01:07:31.050]And at the very end,
[01:07:33.380]so I do this in the very beginning of session.
[01:07:35.650]At the very end, number five,
[01:07:37.170]what strategies can you use to help you remain
[01:07:39.800]in this state?
[01:07:43.300]So I put that there,
[01:07:44.540]because a lot of times for him,
[01:07:47.490]he would know what he needed.
[01:07:51.350]He would pace. He would use fidgets.
[01:07:54.010]He would use putty.
[01:07:58.130]His parent, however, would tell him, "Sit it down"
[01:08:03.720]or "The put is distracting,"
[01:08:06.160]even though it wasn't distracting.
[01:08:08.380]It was helping him focus
[01:08:10.250]so I wanted to give him that control of,
[01:08:13.350]what is going to help you remain in this state
[01:08:19.870]throughout our session.
[01:08:22.130]And Kim, I want to say, I think this is an example,
[01:08:26.150]correct me if I'm wrong, but this is individualized,
[01:08:30.010]and you could not take this very same chart
[01:08:32.580]and use it with another person.
[01:08:34.970]Because what is focusing and alerting for this individual,
[01:08:39.140]might be calming to another individual.
[01:08:45.000]And so you would have to...
[01:08:47.400]And these take time to develop.
[01:08:49.070]You would never lift it from one person
[01:08:50.940]and share it with another.
[01:08:52.100]It's kind of a painstaking, but very valuable process.
[01:08:55.644]It is.
[01:08:56.477]This individual, to get a good gauge of his sensory needs,
[01:09:02.070]this is where I did a lot of detective work
[01:09:06.990]in the beginning.
[01:09:07.823]Giving a lot of questionnaires to the parents,
[01:09:13.850]as well as going over it with him in session,
[01:09:17.280]doing a lot of questions,
[01:09:20.750]and just trying to figure out when he's having a hard time,
[01:09:24.750]and when he's having not a hard time in tasks
[01:09:28.260]and what are the differences.
[01:09:30.730]This individual actually has a lot of the same sensory needs
[01:09:34.170]as I do.
[01:09:35.260]So for him, it was kinda easy for me to pick
[01:09:38.040]what actions to do,
[01:09:39.140]'cause these are a lot of the ones that I do.
[01:09:42.860]But some of them, like wall pushes or hand pushes
[01:09:47.620]and bottom lifts,
[01:09:48.453]those aren't necessarily ones that I use for myself,
[01:09:51.330]but for him, those are good.
[01:09:55.992]And so I had kind of,
[01:09:58.700]yeah, I needed to explore more than I needed
[01:10:02.480]to just explore different things.
[01:10:05.052]And let me point out too,
[01:10:06.100]this one strategy covers the sensory, biological level,
[01:10:10.540]the structure, visual level,
[01:10:13.087]the task demands level, and the skills to teach level.
[01:10:16.120]And depending what you did afterwards,
[01:10:17.740]it could also incorporate reinforcement.
[01:10:21.760]Yeah.
[01:10:25.420]Barry, can you go to my slide that has,
[01:10:27.830]like, the different,
[01:10:29.620]one of the ones that we skipped over.
[01:10:30.980]It's the charts.
[01:10:32.710]Okay. Let pull that one up real quickly.
[01:10:35.020]Was it the first one or the second one or about-
[01:10:36.986]That one.
[01:10:37.970]Okay. Yeah.
[01:10:39.120]So this is something I do to help kind of trying
[01:10:41.770]to figure out what's going on with individuals is,
[01:10:48.650]sometimes I have to ask a parent to do this,
[01:10:51.010]sometimes the individual can do it themselves.
[01:10:54.780]I take, like, an unwanted behavior, thought, or urge.
[01:11:00.260]So if, for this individual, pretending to bite the teacher.
[01:11:06.820]So then ask, okay, what were you doing during that thought?
[01:11:15.480]What did you do before?
[01:11:19.240]What did you want to do?
[01:11:22.180]What were you thinking about?
[01:11:23.890]And what is your environment?
[01:11:25.040]I'm very good at finding patterns and things.
[01:11:29.527]I think that's one of my autism superpowers.
[01:11:31.850]And so after I get a lot of different data entries,
[01:11:37.870]I call it, patterns start to pop out for me.
[01:11:42.380]For this individual, noticing that,
[01:11:46.240]okay, body sensations of prickly skin
[01:11:50.670]is constantly coming up,
[01:11:55.460]and it's also coinciding with wind, air touching his skin.
[01:12:04.430]So this individual is very hypersensitive to light touch.
[01:12:08.710]So that kinda,
[01:12:10.280]that didn't have anything to do with his behaviors,
[01:12:12.500]but it's still something that helped me to identify that,
[01:12:18.470]okay, he is over registering to light touch,
[01:12:23.190]and his desk is underneath an air vent, which is an issue.
[01:12:31.112]So yeah, just finding ways to analyze like this.
[01:12:36.220]And I've had to create different forms,
[01:12:39.610]different ways to present this to different people.
[01:12:42.800]There's one client I have who I need her,
[01:12:51.108]she lives with a friend.
[01:12:53.020]Her friend has to identify,
[01:12:56.540]give her the form and say what behavior
[01:13:01.970]or what situation during the day for her to write on about,
[01:13:06.943]because she needs somebody else to provide a concrete,
[01:13:13.250]something concrete 'cause she can't come up with it
[01:13:15.960]on her own,
[01:13:17.000]'cause there's too many things she could write about.
[01:13:21.510]I think we have-
[01:13:22.601]Okay, we have another question.
[01:13:24.420]Are we okay on time?
[01:13:27.120]Are we?
[01:13:27.970]No, it's time.
[01:13:28.980]Oh, sorry, we are not.
[01:13:31.190]If you-
[01:13:32.166](woman faintly speaking)
[01:13:36.200]Can we find any of those charts that you have created, Kim?
[01:13:41.720]Yeah.
[01:13:42.553]Is there a place that we could find any of those?
[01:13:44.830]Oh, find them?
[01:13:46.270]Yes.
[01:13:48.150]On the handout, I think.
[01:13:53.140]If they're not, I can-
[01:13:56.150]Was that one in the handout?
[01:13:58.190]That particular one wasn't in our handout.
[01:14:00.860]This is in there. Yeah.
[01:14:03.126]It's not?
[01:14:04.282]Oh, is this it here?
[01:14:05.633]Yes, I will give those to you
[01:14:07.690]and then you can give them out.
[01:14:11.050]Okay. All right, Thank you.
[01:14:12.710]We can email 'em out.
[01:14:14.120]Okay. Beautiful.
[01:14:15.680]Thank you all so, so much. Thank you.
[01:14:18.536]We really appreciated both parts of your sessions today.
[01:14:22.247]Thank you.
[01:14:23.164]Thank you all Thank you guys.
[01:14:25.924]Have a great group. Thank you.
[01:14:27.735]Bye friends.
[01:14:28.843]Bye.

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Improving Outcomes With the Ziggurat Model - Part 2

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