A reflective, case-free episode on the tension every therapist knows: you plan the activities, but you never plan how you will show up. Michelle names it honestly, Cory and Tracy run with it, and the conversation lands somewhere quietly profound, that the relationship is not the warm-up to the real work, it is the necessary condition for the nervous system to change at all. It also traces, for the first time, where the Spirit model came from.
After several episodes on following the child’s lead, Michelle surfaces a tension she has been sitting with: she walks into every session with a list of what to work on, sensory discrimination, posture, the social-emotional piece, but never a plan for how she will show up. Therapeutic use of self is something she brings, but it is not at the top of the list. The three of them slow down and make this the whole episode, pausing the Spirit-model topics to talk about clinical reasoning and the journey of becoming a relational therapist, the dance between the doing and the being that nearly everyone in the field wrestles with.
Tracy reframes it through contemporary neuroscience: brains only really develop in the context of relationship, so the two necessary conditions for neuroplasticity are the presence of another and the opportunity for adaptation. Rapport, it turns out, is the shallow end; what they are really describing is attunement and mindsight, reading where a struggle is coming from before rushing to fix it. They get honest about how protocols feel mechanical until you own them and infuse them into the we-ness of a session, when to drop a protocol that does not fit, and why a connected, attuned version is neurologically richer than rote training. Along the way Tracy tells the origin story of the Spirit model, its Sensory, Affective and Motor (SAM) core drawn from treating children alongside Stanley Greenspan in the DIR approach, and why OTs tend to underweight the affective A in the middle. It sets up the next episodes on the A and interpersonal neurobiology.
Lightly edited for readability. Speaker labels and chapter markers match the published episode.
Michelle: Hello, Trace and Cory, welcome to episode 13. How are you?
Cory: Yeah, good. Hello Michelle, hey Tracy, how are you going?
Tracy: Hi, great to be here with you. Lucky 13.
Michelle: The last few episodes we have been reflecting on the children we are working with, how they are presenting, following their lead and honouring where they are at, particularly that social and emotional piece. I have been noticing some tension in myself about the doing of activities, where we are really thinking about use of self. Trace, you have really mentioned that we bring ourselves to it, attuning with where they are at, allowing it to unfold, holding back and giving them space, clinical reasoning outside the sessions about why they present as they do, trusting they may move to the next level of development in their own time. And I have had some tension around my own practice, because I come to every session with a list of things I want to get through, to work on sensory discrimination, posture, relationship, that social-emotional piece. But I never come with a list of how I am going to show up. I bring myself, and I am trying to hone and refine my therapeutic use of self, but that is not at the top of my list. I know other therapists, and I mentor some, we go in with a plan, and that plan does mention affect and matching, I am going to have bigger affect, more energy, so we do pay attention to that, but at the top might be vestibular activities, rotary. So can we dive into that today? How does that feel for you, Cory?
Cory: I think it is a great idea, because for so many of the therapists in our clinic, and some you and I help support in their clinical reasoning, there is always this pressure to feel, what is the thing I am doing in session that will facilitate the change? I want this parent to know I am doing the work, that they are here for a purpose. It feels a little less worrying, especially in the first few years of treating, to have a plan and specific activities you are working towards. Because the process of treatment is so complex in the moment with the child and family that you do not always notice the work you are actually doing, you do not always recognise what is unfolding, which is why we love these discussions, because you refine your ability to notice the minute things having an impact once you reason it out afterwards. I am sure many people have this same battle in their heads around how much do I do and how much do I allow the child to do this dance. You probably have thoughts on this, Tracy, it is probably your passion.
Tracy: On some level it is the core passion. It is that tension, and it is a visceral experience. Being a therapist is visceral, you bring your whole self to those moments, engaged fully with every child in every session, feeling and doing and being with them. Early in my career I had this burning, yearning desire to name the process going on. And at the same moment, in learning to do this work, there is also the doing, the use of the swing, the stairs, the ramp, a blow toy, why is that happening in a particular session. There was so much to learn and master, whether sensory integration, neurodevelopmental treatment and handling techniques, or oral-respiratory approaches in the suck-swallow-breathe synchrony. And what I kept realising in each session was that it was less about that stuff and more about being present, connecting and really seeing and feeling who is this person I am with, and what is going to help them move to the next step. Struggling with that led me on a journey of trying to articulate clinical reasoning approaches, and I have spent years putting together frameworks like the STEPPSI framework and the Spirit framework that we loosely use in our podcast. So it is cool for us to take an episode to pause from the Spirit topics and just talk about our clinical reasoning and that journey, because each of us has had a journey of coming into the frame of, how do I think about my work, how do I reconcile all that tension so I can show up in a way that is meaningful and impactful in each session and each life I am engaged with. I think the folks listening have had that same struggle and are on that same journey.
Tracy: Let me give a couple of frames. The core of what we come back to in this podcast relates to the work of Dr Ayres. In Ayres Sensory Integration, she used the definition, the organization of sensation for use. But in a more contemporary neuroscience framework, there is a really clear understanding now that all of our brains only develop and unfold in the context of relationship. So a cornerstone within occupational therapy practice, separate from sensory integration, is the therapeutic use of self in the context of meaningful, purposeful engagement. When I think about the roots of our profession, this idea of connectedness and relatedness is essential to our work, and it is essential in the developmental space of working with children, because the nervous system self-organises around capacity when it is given the chance to be in the presence of another. So there are two conditions necessary for neuroplasticity: the presence of another, and the presence of opportunity for adaptation. You do not have to know all of Ayres’ theory, or all of NDT, or all of development, but you have to stay true to those two things, creating opportunities for just-right challenges and adaptive responses, and being fully, wholly present, because the nervous system needs the presence of another for those capacities to emerge. There is a simplicity and beauty in that wisdom of the neuroscience.
Michelle: I do follow that, but I am a lot of years out of uni, and I think I used to believe that building rapport with a client meant they would want to do their work more if I was nice to be around and a good cheerleader, that they would achieve their goals if I coached them with a bit of enthusiasm to give them some juice. It is only in more recent times that I have understood the impact of that neurology, that I can change neurology, with my own babies as they were growing, with the children we work with, and with each other as adults. I am a really relationship-based therapist because it feels good to me, but I still fall into the doing. I do not know whether that is because I am a doer, or because when I went through uni, use of self was good, but it was a vehicle to be a cheerleader to coach the other, rather than the weight of shifting neurology, an essential part of shifting neurology.
Cory: I am having university flashbacks too, because I distinctly remember lectures on therapeutic use of self, but I also remember it being hammered in that it had to be occupation-based and task-focused. That was a huge overarching principle drilled into me. So I wonder if that is partly why we feel drawn to the doing. I am not bagging that out, because it is wonderful to have occupational performance in mind, it makes practice purposeful rather than drilling or just working on integrating a sensation, which even now sounds horrendous to me, not holistic at all. So, Tracy, you have helped me pull neurology into the being part of the doing, into those minute moments where I can be with and allow development to unfold purposefully, because I thought about how beforehand, but then I let go and take it in the moment and match it, which is the presence part, being wholly present. It takes a lot of guts to be with in the moment, because you are not always that confident when you first start, you think, gosh, I have got to be doing something, I am not doing anything. Most people would struggle with this dance, which is why it is great to talk about how we reason it out and come to a place of more confidence in treatment.
Tracy: Absolutely. Most of us drawn into these therapeutic fields have this idea of rapport, but it is so much deeper than rapport. Rapport is that trusting, respectful, I see you, we are going to be mutually engaged in a process together, I am on your team and I will help you feel understood and move forward. But there is something deeper. When we talk about attunement and connectedness, when I am with you and see you are struggling, I do not necessarily have to shift something right away. I might need to just notice, where is that struggle coming from, is it frustrating because you do not quite have the motoric skill, or the attentional space, or whatever the demand is. If I just try to fix it for you, that is not necessarily what you need. What you might need is for me to really notice it, or make a minor task or environmental or attitude adjustment. So with therapeutic use of self, each of us is always learning to tune into which one of those it is, because if we get that right we facilitate progress differently than if we blow it. There is a kind of mindsight involved, super tuning into the qualities of performance in the other, a lens into, why is that easy for you, why is that hard, why is this so elusive, little person, that you cannot quite figure out what your body or your ideas could do here. In that mindsight we are not making a decision for the other person, we are helping to craft what could be possible. That is a lot of work, and it is brave work, it takes a suspending of eagerness. Michelle, you talked a couple of times in the last episodes about that greediness, come on, let’s do more, let’s have you accomplish this thing. That is a beautiful goal, but it is also lovely to realise that sometimes if you just take a breath and allow for the mistakes and the repetition to happen, and proceed and learn from it together, a lot happens there. I feel so passionate about helping therapists come into the wholeness of what they have to offer, and yet it can feel like it is not specific enough, because it is this space of individual difference and tuning into that, so it is not any one thing, which makes it a little elusive to explain.
Michelle: It does shift it for me, Trace, because I just had a tear when you were talking, so I am feeling it in my body. I guess it is the way we evaluate our sessions, because I have a few kiddos I have greater capacity to allow.
Cory: You are so hard on yourself. Sorry, I laughed loudly, but Michelle is a fantastically relational therapist, just putting that out there. I think it is in your inherent nature, and you undervalue it because it is so innate for you. That is probably why you focused on the doing, because the therapeutic use of self felt more natural, and then you thought, well, how is this doing the thing we are wanting to work towards?
Michelle: Thank you, you are very generous. I feel like I am doing nothing if I just show up and be me. When I really allow it to unfold, truly following the child’s lead and giving them space, and they are going backwards through the tunnel for the fifth or sixth time, which happened recently, and the next week they still keep going feet first, it really feels like I have done nothing and wasted a bit of time. It took them 14 goes before I said, hey, some kids go through head first, and they still put their feet first and try to get their head in as well. When I reflect back, if I did not use my tricks or pull out any big guns, it is a bit like, we just hung out, I do not need to go to any more courses. I am being facetious, but you know what I mean.
Cory: What resonated with me in what you were saying, Tracy, is just how abstract this can feel for someone learning the journey of being a therapist. It is the art and the science, the art of it not being one distinct track we just follow, and that can feel really hard to learn, because it is, well, what am I actually doing? This is why I love clinical reasoning, because it is only on reflection afterwards that you look at what you did therapeutically, not just the tricks. When we say tricks, we mean deep pressure, or getting them in inversion, or pushing through their toes. It is fantastic to have the knowledge to pull those out when you need them, embedded in something bigger. But it is only on reflection that you realise how much of the impact you as the individual, being with and allowing, actually has. It was like my little friend a couple of episodes ago, I knew cool things were happening because I could feel it in my body, but I could not articulate it until we started to talk about it. That is why I love mentoring, because the first time I had to start thinking about this was when Colleen said, yeah, you can go in with a plan, but you have got to be prepared to drop the plan, always be prepared to let go of the plan. You want the plan because you are worried about what am I actually doing, but it is only with someone helping you go through it that you feel you can bring your questions and wonderings, which is why I love this discussion.
Tracy: It is so powerful and brave, and worth championing, that getting to clinical reasoning and reflective practice is where those insights come from, where you realise it is always both the doing and the being together. That is really what occupation is. So let’s think about it in reverse. Many of us have learned therapeutic protocols, rules of the road, particular powerhouse activities we employ for various purposes, whether a suck-swallow-breathe activity seen in lots of clinics, or helping a child activate their core, or land their body through a therapeutic use of pressure. When you learn those approaches, it always feels a little artificial, I am learning how to use a ball to put percussion into a child’s core to activate their abdominal muscles or respiratory pattern. When you are first learning it, it feels mechanical and artificial. And you cannot wait until you get to use those approaches with one or two or three kids and sink into the settled space of your authentic therapeutic use of self with that strategy. Suddenly you own it in a different way, and you never use it again in a really protocolised way, because you have taken ownership of it in a way that infuses it into the relationship, into your you-ness and how you bring that to the we-ness of the therapy setting. That is part of the journey. We have to learn the things to do, but the journey does not end with what do I do, it only begins there, and it lands when you can settle it and embody it and bring it into the relational space. So relationship-based intervention does not preclude the doing, it infuses the doing into being with.
Cory: It resonates so strongly, because when you first learn something like the Astronaut program, you do not know what it can afford you, so you do it really protocolised, exactly how they teach it. Then you realise what it can offer you, especially having access to conversations with Sheila, who is always adapting and embedding those things within what she can see is working, rather than doing it in a protocolised way. But you have to teach it, and to teach it you have to make it stepwise, because you do not know what you are doing when you have not done it before. So it is about understanding the underlying principles, why would I choose to do that protocol in the first place. If I understand the mechanisms of what I am trying to get out of it, then I can let go of the protocol-ness and see the opportunity to embed it in the flavour of what is juicy and fun for the child. But it is really hard to reassure someone going in unsure, when you just say, follow the child’s lead, that is so abstract, you need a bit more concreteness than that.
Michelle: The opposite side is following the therapist’s lead, where we do have a real plan. We have done the trainings, the protocols. Where I have not been able to find ways to help the child engage in a protocol, even when I add some flavour, and they have not wanted it, I have dropped the protocol, because I could not make it fit for that child in a way they were welcoming and wanting to be in. So the protocol gets dropped. There is a tension for me around, am I missing changing that part of the brain or sensory system by not doing that protocol? For people like me who feel I have to refine that piece posturally or breath-wise, I wonder, Trace, to help me trust the neurology of it. When I have been able to work with a child and we are really attuned and in flow and they readily engage with an adapted version of a protocol, it feels good, a win-win, I have maintained the relationship and we have had a shared experience of an activity that happened to be a little protocol-ly. So how does being in attunement and connection help, or why is it necessary, for me to achieve a result through the protocol, rather than just the protocol? Because if I go from a more behavioural approach where it is, first do that and then this, do the protocol and then we can do the juicy thing.
Cory: Let’s just say you do a bubble mountain, so it is, okay, you do the bubble mountain and then we can play your jumping-off-the-loft game, or whatever you want to do. Can I still impact the brain the way I want with that kind of negotiation, rather than when I am juicy and in flow and it just happens a bit more connected? Let’s say the aim of the bubble mountain was to get the extended breath, a deeper exhale, to pull them into a more regulated state, or to have access to their core. Whereas if you had not done the bubble mountain on purpose as a stepwise protocol, and you just met the child where they are at, and you did not see the breath, are you still going to get the similar outcome of the core activated, the diaphragm letting go, them a little more regulated? Is that the question, Michelle?
Michelle: Yeah, perfect.
Tracy: I love how you guys think, and how we dissect this together. A couple of things. In the relationship-based intervention approaches that are the core of what we are striving for, there is this attunement piece guiding you in following where this child is right now. If the child tends to come in pretty dysregulated, often involving dysregulation even of basic functions like breath, you are probably going to be prepared with a set of activities that might address that. But when the child shows up that day, you are going to be with them and see where they are at today, so one activity may lend itself better than another on a given day. That level of preparedness and availability of options is something we all should prepare for, we should not just show up in the absence of it. But it is attuning to where this child is today and following their lead. What you are doing is noticing what is going to allow you to be with each other on this journey of an hour together, tuning into their physiology, their sensory, affective and motor cues, the sparkle in their eye, the glimmer drawing them, their arousal state, what is available, what they are seeking out, what they are avoiding. We assess all of that moment to moment, to see where the opportunities are for the next level of adaptation, because it is less about the doing of a particular task and more about the level of adaptation we are going to get to today. The neuroscience research now tells us that if we do that in a shared, together, connected way, the progress of adaptation is far deeper, richer and more sustaining of the nervous system’s capacity than if I just teach you how to blow the bubbles. So there is a difference in the essential neuroplasticity if it is based in true connection and true meaning. It really does unfold differently and impact the nervous system differently than rote training would.
Michelle: Because we are being a regulator, regulating and matching where they are at, which allows them to stay in that optimum level of arousal, the stabiliser that lets them move to the next level of adaptation. We are holding that for them, not letting them slip too far up or down, so they have more capacity to do the adapting.
Cory: And you said you drop the protocol as soon as you realise it is not the right match, which is exactly what Tracy is saying. You come in with a plan and a thought about what might be useful given what you know about the child, you have it ready, but as soon as you notice it is not having the effect you are after, you adapt and change it.
Michelle: With the bubble-mountain idea, if I see the child a little dysregulated, eyes flitting around, not on me yet but eager to get in the room, I am going to go for big roars and jumps. When Tracy was talking, I was like, bubble mountain you are, you are going to get on the loft, we are going to do a big roar, an extended exhale, then a big drop down, and then I might squish you on the mat and have you resist to climb up the ramp again. So I think I am doing the protocol, but I feel less effective because I did not do the bits, the protocols, on purpose.
Tracy: It is totally true, but it is worth punctuating a couple of things. The basis of connection and safety allows your nervous system to move into adaptation, so that window of adaptation is available and you can grow your capacities when you are in it. The foundation is that felt sense of safety and connection. But it is both pieces: the adaptation itself, bumping into your edges, finding your power, your agency, your joy, your curiosity, those are real things, but they are enhanced in the context of you and me. Dan Siegel calls that the we space. It is additive. Contemporary neuroscience tells us that the raw neural circuits, we perceive and integrate and act, are all enhanced necessarily by the we, by the connection. So when we are in relationship and connection, the neural circuits actually hum and vibrate and work in a richer way, and that is what they need to get to the highest level of adaptation. So the relationship is not secondary, it is necessary.
Cory: All of this makes me think about how I personally started to move from activity-based doing when I first started treating, because you have to start somewhere, often by imitating what others are doing without really understanding why, but it seems helpful, to more of this attuned pulling of knowledge and approaches into moments with children as I needed them. It reinforces how lucky I have been to have fantastic mentors and the ability to fine-tune my clinical reasoning, because that is what has allowed me a really robust reflective practice. I want the neurology to lay on top of what is going on. The Spirit model has been amazing for me that way, Tracy, because there is such depth to this and it can feel overwhelming. Could you talk a little about how you came to the model, the steps that drew you to it? I know that is a 30-hour discussion, but just some pieces people could take away to start thinking about it, even without the training in the model.
Tracy: We have been talking so much today about this vitality affect, this felt experience of who we are and how we establish a grounded, embodied sense of, I am here for you, I see your journey, I am going to walk this with you, and we are going to understand each other and move forward. A lot of those words relate back to the core elements I was drawn to develop the Spirit model around, the sensory, affective and motor elements. In the work Dr Stanley Greenspan did developing the DIR model, the developmental, individual-differences, relationship-based approach, he talked about how when people were struggling with the development of their capacities, especially social-emotional capacities, there was very often some difficulty with sensory or affective or motor processing at the core of why that developmental unfolding was not happening. In studying that model for years, I had a chance to treat a couple of kids with Dr Greenspan, which was eye-opening, hearing him talk about sensory and affective and motor processing. What I realised was that in our domain we have a pretty deep understanding of sensory and motor processing, which let us enrich that, but the affective piece in the middle was something I felt I did not have as much depth of knowing from my OT tradition, and really had to seek out. In the basic neuroscience there is this idea of a vitality affect, or what people sometimes call a bias, a valence or tipping point, a biasing function that happens in the nervous system at a very basic chemical level, then in the neural circuits, particularly active in the affective processes. So the valence-based affective system, the A system, is often thought of as a big driver of the way we function as humans. I have heard Brené Brown talk about how, no matter what is happening in your world, your emotions are always in the driver’s seat. So affect and that driver’s seat of the valence is really foundational. In the Spirit model, I spent a lot of time thinking about the basic processing of sensation, affective biasing and motor processing, and started to realise there were relatively lower and higher routes of each that contribute to how our capacities unfold, which gave us a convention to figure out the whys of what is going on for a person, and that leads us to the what. For clinical reasoning, if we can get to the why, the what becomes far more evident, and that releases us to be fully present and available, not so caught up in the doing, and to be with through the lens of why. So the SAM function is one way of tackling that systematically, so we can get to the why.
Cory: I was thinking about that affective system neurologically. Just hearing the word affect, it was not always obvious to me what that even was. I had to go and learn about it, because I did not really understand it. In the most basic way now, that emotional, affective system, at the very basic level, is, am I safe or am I not? And at the very highest level it feels like, what am I interested in, what am I drawn to, what gets me going? That becomes so essential to my practice, because, as you said, Tracy, if you are safe and connected, which is that base of our affective neurology, it allows me into the adaptive response, it allows the possibility of that. So that is an overarching principle Michelle and I have going into session. And then at the top is, what am I interested in? That is where I want to figure out what is interesting to you today, where you are drawn, where you are getting a little buzz, and can I embed my why. That A system is the piece they always talk about as the glue between the sensory system and the motor system. As OTs, maybe we did, but I did not always think about the As. I knew more about the others and less about that one, but it is so essential and crucial, that is why it is right in the middle to me.
Michelle: I am going to bold mine. I think I thought he was a lightweight, I kind of did and did not. Personally, no, in my life relationships are everything, but in the clinic somehow I thought he was the little cousin. So I am going to bold it. I have a vision of S-A-M in lowercase and capitals, and I am going to make my A a little brighter and a little bolder, just to reinforce where I am right now, to let that shine through in my practice a little more, that all the protocols are of no more benefit than the As.
Cory: And maybe that is something we can dive more into in the next episodes, the A processing and the interpersonal neurobiology behind why that is so important, so we can make it a little less abstract for people and they can really see the value and refine the way they use it.
Tracy: I love that. Taking the time today to think about our own thinking, our own clinical reasoning and use of self, and how SAM informs that, is such a cool thing. Then we can explore through cases how all of what we are talking about comes together in our clinical reasoning, as we identify what is happening in those various functions, those neural capacities that we are always scratching at and moving forward with.
Cory: A perfect place to wrap up. Thanks, Trace, and thanks everyone for joining us on this one. We will see you next time.
Tracy: Great to be with you guys.
And that’s a wrap on today’s episode of Spirited Conversations. We hope this sparks something for you, whether it’s a new clinical idea, a fresh perspective, or just the reminder that you are definitely not alone in this work. If this conversation resonated, we would love for you to share it with anyone on their own learning journey. You can find information about the podcast on our website, and you can join us in the courses and communities the Developmental FX team have put together at developmentalfx.org. And if you’re enjoying listening, please subscribe or leave a review, it genuinely helps more people find us. Until next time, keep the conversations spirited!