The Role of Counceling in Practice

Client-Clinician-Family Relationships At Heart Of Counseling In Professions

By Robert Trace

The role of counseling in the field of communication disorders has had different meanings for practitioners through the years, but professionals today are supporting a stronger humanistic view of the client-clinician relationship.

In the early days of the professions, clinicians used the term "counseling" to refer to the factual, hands-on clinical instruction and intervention provided for remediating a communication disorder, stated Ellen Silverman, PhD, CCC-SLP, a private practitioner in Whitefish Bay, WI, and a former associate professor of speech-language pathology at Marquette University in Milwaukee, WI.

"The professional knowledge or how-to information we provide is an essential part of what we do," she said. "But today we also refer to counseling as the therapeutic aspect of our work and the close interpersonal relationship we share with our clients."

Eugene McDonald, PhD, research professor emeritus at Penn State University, State College, PA, was one of the first speech-language pathologists to explore components of counseling within communication disorders. Dr. McDonald, who was a school psychologist prior to becoming a speech-language pathologist, said early research in communication disorders drew on work in linguistics and psychological processes.

"There was an association between early speech-language pathology and psychology in terms of how some researchers viewed communication as a matter of behavior," said Dr. McDonald, a fellow of the American Speech-Language-Hearing Association (ASHA) and the American Psychology Association.

Much of Dr. McDonald's work centered on counseling parents and families of younger clients with communication disorders.

"It is virtually impossible to have a child with a disability without having some emotional stresses within the family unit arise in response to that," he said. "Feelings of confusion, worry, disappointment and frustration occur almost universally in these parents."

He wrote several books based on his observations of parents and families, including Understanding Those Feelings (Stanwix House, 1964), a guide for parents of children with disabilities and their caregivers.

"My awareness of the parents' role in these cases developed early on in my career. I soon realized that there isn't just a child with a handicap; there is a whole family with a handicap," he noted. "For example, if a neighbor makes a big deal about the child and/or his condition, the parents are embarrassed and may eventually feel negatively toward the child."

He said most parents of children with disabilities never really learn to accept their son or daughter's impairment—they learn to cope with it.

During the early years of the professions, very little was published on the role counseling played in speech-language pathology and audiology.

However, "all clinicians were aware of the function of counseling within their practice in some way," he said. "It was only as we worked with these persons that we saw broader implications for counseling. Over the last four decades, we have seen much more work by speech-language pathologists who are addressing the fears and concerns of parents and families, which is good."

Dr. Silverman said the client-clinician-family relationship is at the heart of counseling within the professions, and speech-language pathologists and audiologists should sharpen their listening/attending skills to get the most information out of interactions with clients and their families.

Clinicians must be active listeners. They should be tuned in not only to the speaker's verbal message but to nonverbal cues as well. A client's voice dynamics can reveal emotional messages, such as anxiety or depression, Dr. Silverman noted.

Practitioners should maintain a "suspension of judgment" when working with clients. "We should have an open mind when discussing matters with a client and/or his or her family and accept our clients as they are," she said. "That unconditional acceptance can make the client and his or her family feel more confident, self-assured and open to suggestions and intervention."

Speech-language pathologists and audiologists should encourage a flow of information between themselves and clients by being an active participant in conversations and asking pertinent and timely questions.

"As speakers, we notice right away when someone isn't really listening to us or asks irrelevant questions at the wrong times," she said. "We need to be informed about our area of clinical work and make a conscious effort to absorb everything that our clients tell us."

Providing essential and appropriate feedback to the client or "reflecting feeling" in the conversation also can make a lasting impression on clients.

"We must model active listening skills and respond appropriately according to the situation at hand," such as passing a tissue to a tearful client, Dr. Silverman explained. "Patients need to feel as if they are being heard, and clinicians can help this by asking questions periodically during the conversation and interpreting body language to have a better understanding of what the individual is feeling. It's a matter of learning how to use language and basic interaction skills more effectively to influence clients positively."

However, speech-language pathologists and audiologists should be careful not to overstep their professional boundaries.

"I have had some counseling training, but I know my limits," Dr. Silverman said. "I am doing my patients a service by being sensitive to deeper emotional needs while also having the skills to change speech and voice behaviors. But I recognize that I am not a certified counselor, and there are certain areas I am not prepared to enter into, such as grief management."

She noted that clients seek her services as a speech-language pathologist, not as a psychologist or counselor.

"The idea of facing a counselor can be intimidating, especially for patients seeking changes in communication behavior," she said. "They may not be ready to address certain psychological issues.

On the other hand, they may be mentally prepared to work on some of the accompanying communication problems that are causing immediate frustrations for them."

Counseling can be provided to augment services in speech-language pathology.

Lori Katz-Amon, MA, CCC-SLP, PD, assistant director of the Speech-Language-Hearing Center at the Saltzman Community Service Center, in Hempstead, NY, and adjunct professor in speech-language pathology at Hofstra University, also located in Hempstead, said she maintains a balanced caseload of counseling and speech-language pathology services.

She said counseling in speech-language pathology involves three elements: educating the client and his or her family; advocating and supporting the client; and facilitating behavioral change in the client.

Her focus is on the family's role in rehabilitation and how the attitudes of spouses, parents, siblings and children can either motivate a client to make a monumental effort in therapy or give up, she said.

"If family members are helpful and involved in the recovery process, the patient is motivated to make improvements," said Katz-Amon, who holds a professional diploma in counseling. "If they are disinterested and apathetic, therapy can be hindered."

To encourage family involvement in the recovery process, she sets real-life goals for the client. "I talk with the family to find out what the client's surroundings are like so I can make therapy more pragmatically-oriented," she said. "This is especially important for children who need that sense of familiarity and family support."

Adult clients also should receive pragmatic-oriented therapy, Katz-Amon noted. "They had a life pre-morbidly. As a clinician, I need to find out what that life was like. Their motivation improves when you tie rehab objectives into real-life applications."

Counseling also means addressing coping and grieving issues among family members.

"They often go through a mourning period after the diagnosis of a loved one's communication or cognitive problem, much like they would if their loved one had died," she said. "When speech-language problems arise, they don't occur in isolation; everyone is affected."

Spouses and children may become frustrated because they have to shoulder new responsibilities. When older adults are diagnosed with brain injury, stroke or dementia, for example, the children often become the adults in the relationship and may be forced to play a more nurturing, caretaking role in the relationship, she observed.

Likewise, parents grieve when their child has been diagnosed with a severe communication disorder. "Families must deal with the shattered images they have for their child," she pointed out. "If we are to help their child, we have to help the parents get past their difficulties accepting their child's imperfection."

How well family members react to and cope with a client's impairment is not necessarily correlated with the severity of the disorder, she pointed out.

"From a counseling point of view, it really depends on the family members and their personalities and use of coping mechanisms," she said. "The most difficult cases are those in which the individual and/or his or her family are not progressing through stages of grief. A lot of that depends on what each person brings into the situation from the past, such as the ability to deal with former trauma and losses."

The elemental and critical foundation for the intervention provided by speech-language pathologists is defined in terms of humanistic psychology, stated Kathleen R. Jones, PhD, CCC-SLP, assistant professor of speech-language pathology at the State University of New York (SUNY) in Geneseo. These terms are self-actualization, unconditional self-regard, congruency, present orientation and relationship.

The client is at the epicenter of the humanistic approach, she said. In keeping with this client-centered approach, clinicians should counsel clients to bring about changes in themselves outside of the therapy room and "take the challenge of recovery into their own hands. We can't just look at ourselves as speech-language interventionists, but as agents to facilitate changes among our clients."

To become agents of change, clinicians should promote unconditional self-regard and congruency.

Unconditional self-regard is the perception of self in such a way that no self-experience can be discriminated as being more or less worthy of positive benefit than any other. Each life experience is a learning opportunity, and clients who are effectively motivated to bring about changes in themselves learn from these experiences and become self-reliant.

The client is also congruent when "there is no dissonance among his or her acting, thinking and feeling states," she noted. "The person has a realistic view of him or herself and what areas need improvement. Likewise, the individual recognizes positive traits and values his or her self-worth."

Self-reliant clinicians and clients focus on the present and on those changes that can be made now in the pursuit of personal growth. "Growth occurs when one feels the control and the power in the present and begins to challenge a perceived self-image which is stagnant or blocked," she observed.

Finally, following a humanistic approach to service delivery means solidifying the clinician-client dyadic relationship. If the clinician fosters a positive attitude and stresses the importance of bringing about positive change now, the client can recognize the potential for change and model positive behavior, she said.

The humanistic approach is particularly applicable in counseling people who stutter, she pointed out. As director of the Starbuck Fluency Clinic at SUNY-Geneseo, she spends nearly half of her time counseling participants and their families about their fears and concerns and ways to facilitate behavioral and self-image changes.

"These persons carry a lot of guilt and negativity toward themselves and their disfluency," she said. "Helping them accept themselves as productive individuals is a major step in overcoming their stuttering."

Establishing and maintaining a strong therapeutic alliance through the demonstration of deep empathy and trust with young children and adolescents is necessary before a strong clinician-client bond can exist, said Barbara Ellicott, EdD, CCC-SLP, a private practitioner, learning consultant and developmental/school psychologist in New Jersey.

"You need to establish rapport with them. Resistance and fear of trust are problems with many clients who have been exploited and/or betrayed in the past," she added. "We need to treat them with respect regardless of their presenting pathology, intellectual or socioeconomic level."

It is equally important that clinicians use prudent judgment in defining the terms of the clinician-client relationship.

"There are some clinicians who don't know how to draw the line between comradery and maintaining an appropriate distance between him or herself and the student or client," she said. "The student doesn't really need a best buddy; he or she needs a caring and compassionate speech-language pathologist or audiologist who can be trusted."

Many speech-language pathologists have intuitive skills to become good counselors because of the close, hands-on therapeutic work they do with clients and their families, she said. However, counseling requires training and experience.

"In response to this need, an increasing number of graduate speech-language pathology and audiology programs are incorporating psychotherapeutic and counseling techniques as a concomitant part of the training," she said.

In recognition of this comprehensive preparation, most states permit licensed speech-language clinicians in private practice to incorporate counseling strategies in their treatment plans, Dr. Ellicott added. Some states, however, impose restrictions on incorporating counseling techniques, and such techniques are permitted only when dealing with persons who stutter or have voice problems and their families.

For More Information
Barbara Ellicott, EdD, 41 Brookwood Rd., Byram Township (Stanhope), NJ 07874; (201) 347-8959

Kathleen R. Jones, PhD, Department of Speech Pathology, Sturges Hall, SUNY-Geneseo, 1 College Circle, Geneseo, NY 14454; (716) 245-5133

Lori Katz-Amon, Saltzman Community Service Center, 131 Hofstra University, Hempstead, NY 11550; (516) 463-5263

Eugene McDonald, PhD, Research Professor Emeritus, Penn State University, Department of Communication Disorders, 110 Moore Building, State College, PA 16802; (814) 865-5414

Ellen Silverman, PhD, 5567 N. Diversey Blvd., Whitefish Bay, WI 53217; (414) 228-9530