What happens when a group of scientists who develop medical treatments come and watch relationship-based therapy up close for the first time? Tracy brings the story back from her clinic, and it turns into a conversation about why the most powerful therapeutic moves are often the quietest ones, and why co-regulation is something you feel in your own body before you can explain it.
This one started off-mic, and we decided to keep talking because Tracy had just had one of those days. Five scientists who work on medical treatments for Fragile X and autism had come to Developmental FX to watch therapy in action, and what they saw stayed with them. We talk about the moment two of them visibly flinched when a child got big and loud, while the therapist beside him never wavered, and what that says about co-regulation as something embodied rather than theoretical.
From there we wander, in the best way, into Tracy’s own frozen moment treating in front of a crowd years ago, Deb Dana’s idea that you just need a foothold in ventral, and a couple of Jean Ayres quotes Cory had been sitting with, including the one we reckon belongs on a t-shirt: therapists dash in where scientists fear to tread. We finish on the real value of therapists and prescribers working as partners, and how the SPIRIT model helps us track what medication actually changes. It is, more than anything, a celebration of the quiet, masterful, deeply skilled work our teams do every day.
Lightly edited for readability. Speaker labels and chapter markers match the published episode.
Lightly edited for readability. Speaker labels and chapter markers match the published episode.
Cory: So we’ve just been off mics and now we’re hot mics, as the really famous podcasters would say. I don’t know if I’ve ever said that, but anyway, here we are. Tracy has shared some really fun discussion from her day to day, so serendipitously we’ve decided to chat about it, because who knows, people like to listen. And shout out to Shivank. I don’t know if that’s how we say your name. Tracy, have you met Shivank?
Tracy: I have met Shivank.
Cory: Am I saying Shivank’s name right?
Tracy: I believe so.
Cory: I’m pretty sure I’ve met Shivank too, but I don’t know if I’ve ever said your name out loud, so feel free to message me and correct me. Way back when we started this podcast, Shivank sent us an email talking about our trialogue instead of dialogue. I don’t know if that’s an official word, but we really like it and it gave us a good laugh. So thanks so much, mate, for sending that to us and keeping us hooked in.
Michelle: Love it.
Cory: So maybe share, Tracy. What happened today?
Tracy: At Developmental FX today we had five scientist visitors who came to learn more about what therapy actually is. These are scientists working on new medical treatments for individuals with Fragile X syndrome, autism, and other conditions that affect how our brains process information. They’re really dedicated to figuring out how, if a new medication were made, it would interact synergistically with really high-quality therapy. None of us can work alone, and medication is the same: it shouldn’t work in a silo. We shouldn’t think of it as an agent making profound changes for someone if they don’t have the other supports around them.
Tracy: Our clinic specialises in Fragile X syndrome as well as lots of other conditions, and we have a lot of trust built with our parents and our kids. So these folks were able to come in and observe some therapy. One of the visitors said, at the end of the day, that in his whole professional career it was one of the most meaningful days he’d ever had. He saw a range of children working with therapists, one session with a child who was more engageable and playful, another where the child was more stressed and dysregulated, another working with augmentative communication. None of them had ever seen kids like this before, and it brought the work to life. It also showed what happens when you provide the integrated models of care that complex kids really need. Several times they said, it’s so nuanced, so subtle, and yet what’s happening is profound. It’s not in the task so much as in the whole of the relationship, the attitude, the play, the access to capacity. I was very proud of my team.
Cory: What people don’t know is that these scientists had spent some time with Tracy beforehand, just to give them a bit of a preface to the theories that sit behind the work, before they even got to the treatment space. It made me think maybe everybody should spend an hour with Tracy before watching any sessions, so they can understand the tools and therapeutic adjustments we’re making in the moment.
Tracy: One of the speech and language pathologists was in a couple of the sessions, and they really noticed how in one session the therapist was quiet and subtle, continually co-regulating, offering an augmentative device, regarding the child through moments of frustration. And then in another session, a big, playful attitude, still always herself, but meeting the child where they were and bringing her affect and playfulness to match what was needed. When I described relationship-based therapy to them and how we make these adjustments, and then they saw it, it was like, wait, what just happened there?
Michelle: Often when we work with families, they see us match to the child in front of us and they say, you’re so good with them, you’re a good match. And beautifully, they don’t get to see that we’re all so different, adjusting our therapeutic use of self to be the just-right match for some other child at the other end of that range. As clinicians, that’s what we’re doing all the time, dialling up and down all the facets of the interaction. It’s fascinating having an outsider look in and acknowledge that the work we do is so critical.
Michelle: Cory, what you said made me think about watching the Olympics, or someone do a cartwheel, and you go, yeah, I can do that, and then you have a go. I was watching the swimmers swim so smoothly, and I thought, oh, I just have to go a little smoother. And no, that is precision on precision on precision, but it looks attainable. You try doing five breaths a whole lap and it’s like, well, that didn’t work out. So people go, she’s just playing with him. There’s a whole lot of doing laps at the pool behind it, and it’s so lovely that they saw that, Trace.
Cory: Props to the DFX team. To do that, and to do it in front of people, is pretty epic. It’s a whole other level of control when you’re treating. I’ve treated in front of what felt like crowds of people. As a naive new therapist I thought, it doesn’t matter if I get it wrong, I’m new, no one expects me to be good at this. But once you’re in a bit further, there’s more pressure, pressure to feel like you’re doing treatment that’s effective.
Tracy: This is one of the worst moments of my whole career. We were doing a clinical dialogues session at a clinic in Australia, a forum where you’re treating a child with a group of people watching. It was early in my coming to Australia. I was supposed to jump in with this child, but I didn’t know the child, and there were lots of people in the room. My stress level got heightened enough that I thought, I don’t think I can treat, I think I can observe and coach. There was another therapist treating the child, and I was going to push in and join, and I froze. Literally, I couldn’t move my body. On a few occasions I’ve had this kind of dorsal experience, pretty sympathetically charged but with a bit of dorsal energy, to use polyvagal as a lens. I had enough availability to think, take your time, get some breaths, but I couldn’t work through it quickly, and it was horrible. Everybody was gracious, and I could coach enough to say try this, but I felt disembodied. It happens to all of us sometimes.
Cory: If I was there, Tracy, I was completely oblivious, because I was in love with you, so please don’t stress about that. I’ve never been anything but gobsmacked watching you in a treatment space. So intuitively you knew: in that moment you were the treating therapist, that wasn’t a good match, and you weren’t going to go in.
Michelle: It’s interesting whether people pick up on that internal disconnect. I’ve had to do a few TV interviews recently, and I’ve had out-of-body experiences where I knew I was in the flow with what I was saying, embodied, but I was also coming out going, oh my God, that camera is really big. I watched it back and I don’t think you can tell, but it was this internal sense of, I’m not quite right, I’m not wholly present. I wonder, Tracy, if your intentionality of, I really intend to do my best here, held the space enough that the child wasn’t more dysregulated by your energy.
Tracy: It could be. Some of that is connected to my whole career in Fragile X syndrome, because these individuals can be so dysregulated. I had to learn to hold a very steady, even presence in some of the most challenging moments, conveying a sense of ease even when I wasn’t really feeling it.
Tracy: In the polyvagal world, Deb Dana often says you just need a foothold in ventral. You just need the tiniest sliver of a hook in there to allow your nervous system to have that reference point. It’s a funny skill that we develop. Connected back to today: these folks were watching a session, and one individual with Fragile X gets pretty dysregulated. He’s doing so well that I’m gobsmacked at my team and at the progress of these kids. But in this moment, as he starts to get dysregulated, he gets louder and his gestures get bigger. It isn’t that he’s threatening or going to swipe out at you, he’s just big in his body, and he’s funny. They were doing a little rhyme and he was gesturing in a big way, and the therapist sitting next to him was so calm and present, never a flinch. Two of the visitors were sitting at a table through the observation window, right in front of me, and I saw them visibly flinch when he got big. So I commented to them.
Tracy: I said, tell me about that. And they asked, how did she stay so calm in there? So we talked about what co-regulation means, that proverbial thing about putting your own oxygen mask on first. We get so practised at being fully present and available, a harbour of safety, and that allows the other person’s nervous system to hook onto it and stay, oh, I’m okay, even when they’re getting a little big or a little over-responsive. They really noticed that moment and could feel it in their own bodies. They felt the tension rising as his arousal went up, but they didn’t know what that meant. Then they saw the therapist managing it so masterfully, and that was something they really got, from watching it. Some of these folks had come to a conference I spoke at in Florida in July, where I’d talked about these ideas more conceptually. But now they got it, because they saw it and felt it in their own nervous systems. Several times they said, how do you do this work, I don’t know that I could. It was one of the times I didn’t take exception at someone saying it takes a special person to do this work, because there is a beautiful quality in therapists that we then cultivate and grow.
Cory: The reps in the pool thing resonates, Michelle, because until you do the reps, you can’t refine it. It’s so dynamic, what comes up in front of you in a session, and you have to build skill around managing a moment until it arises, being really uncomfortable when something happens that you’ve never had happen before. The place I felt most challenged early on was trying to explain concepts to parents, and it’s in that discomfort that I’ve continually sought how to do that explanation in a different way.
Michelle: It’s like what happened with the scientists. They heard Tracy’s theory and went, yeah, that makes sense neurologically. But that’s different from having their own nervous system co-regulated by the child, feeling uncomfortable, having their own stress response, and then being co-regulated by the therapist when they saw how masterfully she held space. That’s what our podcast is about: how do we take abstract concepts and theories that we cognitively tick off as making sense, and actually have an embodied sense of them and put them into practice in the clinic. They got to see the clinical reasoning we go through.
Cory: This is the translation of science into practice. You had scientists who don’t spend time in a clinical setting come in and see it, and they could see the science backing the therapists’ actions. Your therapists are attuned, working a theory and embedding it into a session. It’s backed by science, but it’s not like administering a protocol.
Michelle: Administering the protocol, yeah.
Cory: I found this quote that I shared with Michelle and Tracy beforehand, from Ayres. I have a fascination with Dr Ayres, and I was trying to get her boxes of notes from the university to read online, which of course you can’t, except physically in the library. In frustration, I read a review of Ayres’ work written after she passed away, and I came across this quote, which is in Ayres’ blue book, Sensory Integration and Learning Disorders, on page 265.
Cory: On page 265, Ayres says: It would be far easier and more impressive to provide treatment through methods that appear more scientific, such as placing a child on a table, attaching some apparatus and turning some knobs to start the apparatus working on the child. Such a procedure would avoid most of the disadvantages of using a natural procedure. But that is not the way to further neural integration. The brain must organise itself, and must do so through receiving information from self and environment, integrating that information for use, and then using it for adaptive action upon the environment. Society may respond more favourably to the spotless, chrome-clad treatment office, but sensory motor integration proceeds best with simple, unimpressive, often makeshift equipment, which, furthermore, is often generously sprinkled with dirt, carried in from playground or street on shoes or pant cuffs. Thank you, Dr Ayres, for being so amazingly ahead of your time.
Tracy: So true. I want to use the other quote, because it totally connects with our experience sharing the work with these scientists.
Tracy: In a letter to Sieg in 1988, Dr Ayres says, therapists dash in where scientists fear to tread. That was exactly the experience today. These scientists said, I don’t know that I could do this work, and they talked about how centred and present you have to be. One of them said that if they weren’t meditating, they were always multitasking. In a session you have to be present. We’re translating theory into lived, real moments, not translating theory just to translate it.
Cory: Go for it, finish the quote.
Tracy: Therapists dash in where scientists fear to tread. It’s a dangerous thing to do, but it’s what builds theory. Theory is not the facts. Theory is putting the facts together so you can use them, and in our case, to enhance the development of children. This is always my end objective. Thank you, Dr Ayres.
Cory: I want to circle back to the start, where you said we’re working in a very integrative model. So many of our kids are supported by pharmacological supports. I’m hoping most therapists in this space have had the experience where a child had the right match in terms of medication, and it completely changed their presentation and capacity to do the therapeutic work, or just their life in general. And we’ve had the opposite experience too, where it reduced their function in almost all areas when it was a bad match. We’re in the trenches seeing that play out, so being able to give that feedback, and to have scientists in the space watching, is impressive.
Tracy: Absolutely. If a child is going to be on medication to harness attention, I need to know that as a therapist, so I can make sure the adaptive response is more focal, even while following the child’s lead and staying with where they are developmentally. To tie it back to the SPIRIT model, which I shared with these folks and they were excited about: if they’re suggesting to a physician to use a class of medication, the therapist can be a partner in harnessing that adaptation. Advancing our practice to the point where we collaborate in treatment planning feels like very important progress, the kind Dr Ayres hinted at. It’s about making sure the child is organising their own brain, but for the purpose of higher-level integration.
Michelle: Hopefully the collaborative partnerships, too. When we’re in a strong multidisciplinary team, we might know there’s a paediatrician appointment coming, and a trial of intervention hasn’t achieved the functional gains we’re hoping for at school or across contexts, and carers want to discuss trialling medication. I love being part of that early stage, doing the baseline clinical assessments. What’s the primary thing you want to change? Attention. Right, let’s measure that: how long can he stay attended on a task he’s motivated by, and on one he’s not? Using the SPIRIT model, we can assess the rest too. So afterwards we can say, attention definitely increased, but social connectedness decreased, and ask whether we can tweak that.
Cory: As the occupational therapist, looking at broader timelines, in context and environment, with whom and with what, and being able to feed that back. It can be tricky to get your foot in the door, so it’s useful to have discussions with parents and whoever’s working with the child, so I can be as precise and as useful in progressing their development as possible.
Tracy: That’s right. Do you think you’d say something like, Mum and Dad, I think if you and I and your physician could have a trialogue, it would be really helpful?
Cory: Yes. Oh dear.
Tracy: It’s also really good to take moments like this for celebration, bringing my team into this forum and celebrating the magnificent work they’re doing. What a beautiful cup-filler for all of us. Sometimes, when we’re intrepid therapists marching forward where scientists would never go, you pause at the end of the day and realise there was some incredible thinking happening, some incredible gains, some incredible hurdles we ran smack into. All of that is the work, and we have to find ways to share it. I love that we’ve created this forum for talking with each other about it, and that it lets us foster a community of practice that’s so rich and beautiful.
Tracy: I love doing this 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!