March 21, 2006 Features

The Counseling Relationship

As a neophyte audiologist, I essentially used the medical model of conducting the testing: I took a careful case history, sat family members in the waiting room while I conducted the test, and afterward "counseled" by providing the test results. I was cautioned by my supervisors not to get into feelings as this was not my responsibility. In fact, there was a social worker on staff to whom we were instructed to refer clients if they showed any emotion.

As a young professional, I found that when I delivered bad news to a client, even when they were expecting me to tell them that, for example, their child had a hearing loss, their emotions seemed to overwhelm them. Shortly after giving them the bad news, their eyes would glaze over, heads would nod and, on subsequent visits, I found they retained almost none of the information I had provided.

The fact that clients retain little of the information has been well-documented (Martin, Kreuger, and Bernstein, 1990; Margolis, 2004). Physiologically, when our affect is high we operate in our right brain and cognition is limited. We get into a fight-or-flight mode and our ability to absorb information becomes restricted. I found it necessary, especially in the early stages of the diagnostic process, to provide emotional support first and then gradually provide information.

As a profession, we must give ourselves permission to enter the affect realm with our clients. What has been helpful for me is the awareness that our clients are not emotionally disturbed; they are emotionally upset. This is quite appropriate to their life situation. We would feel the same way if we were in a similar situation. I have had to learn that my role is not to try to make the client feel better because to do so invalidates their experience. Most clients come to us feeling emotionally isolated because the conventional response is to try to make someone feel better. Usually this is done by trying to solve the problem or, if that is not feasible, using positive comparisons by suggesting that "It could be worse," i.e., "You are so lucky your child is just hard of hearing. He could be deaf." The parent is usually not feeling lucky and is probably feeling bad that he or she has a child with any hearing loss. Now the parent starts feeling bad because they are feeling bad and they have been denied permission to grieve their loss.

An Unconventional Role

As helping professionals we have an obligation to both teach (provide information) and counsel (provide emotional support to) our clients. The teaching aspects of our responsibilities are relatively easy to provide as they conform to client's expectations and are well within the scope of practice as taught in most training programs. For many audiologists "teaching" was considered "counseling" (Flahive and White, 1982). The counseling aspect, which provides emotional support, is not prevalent in most training programs and therefore seems out of the scope of practice to many professionals in our discipline (Crandall, 1997).

The counseling relationship is not a conventional one; it places a different set of demands on the professional. It is a relationship that requires deep, selfless listening. The professional must be willing to put aside his or her agenda and listen to the client. Therefore, the professional can have no point of view other than trying to hear and understand where the client is coming from, and in many cases, reflect that back to the client. Within a counseling relationship, there is the understanding that wisdom resides within the client; therefore, all professional judgments are suspended. Because nonjudgmental listening offers a high degree of emotional safety for the client, he or she can begin the process of resolving problems.

When interacting with clients, professionals must learn to listen for the "faint knocking" that is the client's affect because clients are often unaware of how they feel. By listening deeply we can elicit the feelings and provide the support. Other clients may launch a "trial balloon" indicating a feeling. Early in my audiology career, when I was very much into counseling as teaching mode, I was working with an elderly couple in which the husband had a severe hearing loss. After explaining the audiogram, in the midst of talking about how the hearing aid functioned, the wife interjected that they had a severe problem. It seemed that every time they left the house she had to return two or three times to check on whether or not she had remembered to lock the door and shut off the gas stove. At the time I thought this comment was strange and out of place. I just said, "uh huh," and proceeded with informational "counseling."

In retrospect, I can see her remark as a trial balloon. I think what she was trying to tell me was that she was overwhelmed. She couldn't remember to lock her door and shut off her gas, and here I was asking them to manage a complex piece of equipment. I think I would have helped this couple more if I had stopped informing and elicited their feelings. The information they needed could have then been interspersed over time.

The Realm of Feelings

The ability to recognize teaching moments from counseling moments is the hallmark of the complete professional. Distinguishing between them is a learned skill that requires sensitivity and mindfulness. For example, the parent who asks, "What causes hearing loss in a child?" is usually not seeking information. What the parent may be seeking—or dreading—is confirmation that they may have done something to cause their child to have hearing loss.* This parent might be helped more by responding: "Do you think you did something to cause your child to have hearing loss?" rather then engaging in a discourse on the causes of hearing loss. If parents perceive this is an emotionally safe relationship they might begin to talk about their feelings of guilt, which may be more fruitful for the parent than information.

Entering the realm of feelings usually strikes fear in the hearts of most speech and hearing professionals because it seems so out of the scope of practice. Yet not to enter this realm limits our ability to help our clients. To have a communication disorder or to live with someone who does generates a great many emotions. There is always an underlying feeling of loss, and with loss, there is usually anger because life expectations are violated. Anxiety and confusion are generated by feeling overwhelmed by the new reality, and there is a loss of identity which is one of the hallmarks of the grief experience. There is always a feeling of vulnerability.

These feelings need expression and validation. If not expressed, they can lead to unproductive behavior. The unexpressed feelings of guilt, for example, can lead to overprotection. The parents feel that they let something bad happen once to the child and now they are not going to let it happen again. It often interferes with the parent/clinician relationship as the parent is unwilling to fully let go of the child even to the care of a professional.

Clients are often loathe to disclose their feelings. Their role expectations for professionals in the area of communication disorders do not necessarily include discussions about their feelings. What we can do is invite them to talk about their feelings by making a counseling response. Some clients will not accept our invitation to talk about their feelings and that is OK. The medical model in which "counseling" is seen as a separate entity completed after the diagnosis is a poor one for our field. We must never charge for counseling; this is inappropriate. Instead, we must infuse client interactions with both counseling and teaching responses. We must move seamlessly between these types of responses and clients should not realize that they are being "counseled."

With help, the feelings associated with a communication disorder can be transmuted into productive behavior. The confusion becomes a spur to learning; the recognition of vulnerability leads to a re-ordering of priorities; anger becomes the energy to make changes; and guilt transforms into commitment. The grief becomes compassion for all suffering, but in particular for people and families dealing with disabilities.

These feelings recur as trigger events unfold, but they are never as intense as they were in the early stages of diagnosis. What clients need most is someone who will listen compassionately and deeply to their feelings and not prescribe solutions. Information needs to be given judiciously, when families are receptive to receiving it. They need emotional support in a safe, non-judgmental relationship that enables them to work out their own solutions for themselves and their families. They need empathy and never sympathy.

I do not see communication disorders as a tragedy, but as a powerful teacher and if I allow the counseling relationship to happen, by not rescuing clients, growth will be promoted.

David Luterman, is professor emeritus at Emerson College in Boston and director of the Thayer Lindsay Family Centered Nursery. Contact him by e-mail at

cite as: Luterman, D. (2006, March 21). The Counseling Relationship. The ASHA Leader.

References and Resources

From the ASHA and NSSLHA Journals

Contemporary Issues in Communication Science and Disorders (2002), volume 29. Focuses on counseling in speech-language pathology and audiology. Visit

English, K., Mendel, L. L., Rojeski, T., & Hornak, J. (1999). Counseling in audiology, or learning to listen: Pre- and post-measures from an audiology counseling course. American Journal of Audiology, 8(1), 34-39.

Grunblatt, H., & Darr, L. (1994). A support program: Audiological counseling. Language, Speech, and Hearing Services in Schools, 25, 112-114.

Halpin, C., Hermann, B., Whearty, M. (1996). A family with autosomal-dominant progressive sensorineural hearing loss: Rehabilitation and counseling. American Journal of Audiology, 5(1), 23-32.

Margolis, R. H. (2004, Aug. 3). Boosting memory with informational counseling: Helping patients understand the nature of disorders and how to manage them. The ASHA Leader, pp. 10-11, 28.

Stone, J. R. (1992). Resolving relationship problems in communication disorders treatment: A systems approach. Language, Speech, and Hearing Services in Schools, 23, 300-307.


Crandall, C. (1997). An update on counseling instruction in audiological programs. Journal of the Academy of Rehabilitative Audiologists, 30,1-10.

Flahive, M., & White, S. (1982). Audiologists and counseling. Journal of the Academy of Rehabilitative Audiology, 10, 275-287.

Martin, E., Kreuger S., & Bernstein, M. (1990) Diagnostic Information transfer to hearing-impaired adults. Texas Journal of Audiology and Speech Pathology, 16(2)29-32.

Resources Related to Audiologic Rehabilitation and Counseling

  • The Aging Patient: New Perspectives on Audiology Service Delivery. This virtual conference on the Web scheduled Sept. 6-21 focuses on audiologic service delivery to a growing population. Experts in audiology, psychology, sociology, and geriatrics will present multidisciplinary perspectives on the aging patient, with emphasis on audiologic service delivery.
  • Access Audiology. This ASHA e-newsletter, written by and for audiologists, highlights current clinical topics. Members have access to a complete archive of past issues, including "Current Trends in health Literacy/Plain Language" (Jan./Feb. 2006) and "Current Trends in Adult Audiologic Rehabilitation" (March/April 2005).


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