Counseling is a broad term that refers to assistance provided in an interactive manner to individuals (i.e., clients, patients, and/or students) and their families/caregivers dealing with challenging emotions and life situations in an effort to facilitate realistic and clearly understood goals and improve quality of life (Flasher & Fogle, 2012; Tellis & Barone, 2018).
Counseling can fall into varied categories, two of which are informational and personal adjustment counseling, both of which fall within the purview of audiologists and speech-language pathologists (Flasher & Fogle, 2012). Informational counseling, also referred to as client and family/caregiver education, involves discussing with individuals and their families/caregivers the nature of a disorder or situation, intervention considerations and techniques, prognosis, and material and community resources. Personal adjustment counseling addresses feelings, emotions, thoughts, and beliefs expressed by individuals and their families/caregivers (e.g., realization of the pervasive impact of a communication disorder on day-to-day life).
Counseling is an important clinical skill that helps individuals and families/caregivers adjust to and cope with feelings about a disorder or situation (Flasher & Fogle, 2012). Counseling can empower individuals and families, encouraging them to self-advocate in their efforts to adjust, strive, and grow.
Counseling is an integral part of clinical work, and counseling skills are used intentionally or spontaneously in every clinical encounter (Luterman, 2008). Counseling services provided by audiologists and speech-language pathologists should occur in the context of comprehensive service delivery. It is important for audiologists and speech-language pathologists to recognize when referral to a related professional is warranted to best meet any additional counseling needs.
The professional roles and activities in audiology and speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment), prevention and advocacy, education, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology and Scope of Practice in Audiology.
Counseling individuals and their families/caregivers about communication disorders and related conditions and providing education aimed at preventing further complications falls within the purview of audiologists and speech-language pathologists.
As indicated in the Code of Ethics (ASHA, 2016), audiologists and speech-language pathologists should be specifically educated and appropriately trained to provide the services that they offer, should engage in only those aspects of the professions that are within the scope of their practice and competence, and should use every resource, including referral to ensure that quality service is provided.
According to the Preferred Practice Patterns for the professions of audiology (ASHA, 2006) and speech-language pathology (ASHA, 2004), counseling involves providing timely information and guidance to clients, families/caregivers, and other relevant persons about the nature of the disorder(s), the course of intervention, ways to enhance outcomes, coping with disorder(s), and prognosis. Counseling may address the following:
Although counseling is integral to the clinical services provided by audiologists and speech-language pathologists, there are situations and behaviors that warrant referring individuals to and collaborating with mental health professionals. ASHA's Code of Ethics (2016) includes principles and rules that contribute to determining when referral and collaboration are appropriate:
There are numerous theories of counseling, with many being particularly applicable to audiologists and speech-language pathologists. Aspects of the following theoretical frameworks can be integrated and/or combined to address the wide range of issues across age groups, disorders, and associated co-morbidities. These theories and the clinical methods associated with them may require additional training and/or collaboration with a mental health professional. The application will vary based on individual needs.
Health literacy is the degree to which an individual can obtain, communicate, process, and understand basic health information and services needed to make appropriate health decisions and follow instructions for treatment (Patient Protection and Affordable Care Act of 2010).
Health literacy principles for clinicians include the following:
(U.S. Department Department of Health and Human Services, n.d.)
The person with the communication disorder or related condition and their family/caregiver can benefit from family therapy and counseling by using the family systems approach. Masterful counseling skills include the ability to leverage family strengths into the therapy regimen to firmly involve the family in addressing the issues at hand (Holland & Nelson, 2014). Having family or other support people present during explanations of the diagnosis and proposed treatment can help with the overall management of their circumstances. For example, if a family/caregiver is having difficulty coping with the disorder or situation, the person with the impairment may feel isolated or rejected, which can lead to anxiety and depression. Counseling with the family/caregiver may alleviate some of the stress that the individual is experiencing (English, 2002).
Families differ in how they view and engage in counseling activities. Some will want to be intimately involved, whereas others will not want to be involved in any way (Tellis & Barone, 2018). Depending upon the individual's age and cognitive/communicative abilities, they may need a family member, proxy, or client advocate to provide information to the clinician and to support emotional needs. All of these considerations also should be made relative to cultural beliefs and values, linguistic diversity, and language mode (e.g., sign language).
Clinicians, individuals, and family members/caregivers present with their own unique perceptions, values, feelings, experiences, expectations, needs, and expertise that may positively or negatively influence their relationship with one another and therapy outcomes (Flasher & Fogle, 2012; Tellis & Barone, 2018). Building a good therapeutic relationship can help alleviate distress and lay a foundation of trust and cooperation between the clinician and the client and family/caregiver (Flasher & Fogle, 2012). The development of the therapeutic relationship is a reciprocal process during which the behaviors of each person in the ever-changing dynamic influence the others involved. There are several considerations and communication factors that affect the ability to build a therapeutic relationship (Flasher & Fogle, 2012; Luterman, 2008; Tellis & Barone, 2018).
Clinicians use questions to better understand individuals and their families and to help focus on issues that need further clarification. The goal is to enter into the world of the person and to understand the person from his or her own perspective—how the person sees, hears, and feels the world (Flasher & Fogle, 2012; Tellis & Barone, 2018).
Note: Why questions often put people on the defensive and cause discomfort because they feel they are being attacked or criticized and that they must justify their thoughts, ideas, opinions, or actions. Carefully worded what questions can often be used to get "why" information; for example, "You seem to be having a little extra difficulty with your voice today. What do you think is going on for you?" What questions are typically perceived as being friendlier and less judgmental than whyquestions.
It is important to note that although the use of questions is most often to gain information and understanding, questions may be perceived by some as judgmental and may prompt defensive responses—or, the use of questions may be perceived as rhetorical, with no response required or expected. Questions also may stimulate nonverbal responses that are misconstrued or that give mixed messages to the clinician.
Making accurate observations and listening to an individual's and family members'/caregivers' verbal and nonverbal messages is foundational to (a) demonstrating that you have understood the person and (b) creating an environment that will allow them to expand their story.
Observation and listening techniques include the following:
Through the use of selective feedback, the clinician attempts to influence the individual's or family member's view of self, problems, or circumstances.
Selective feedback techniques include the following:
The group approach to counseling/communication therapy is used commonly, such as when providing aural rehabilitation for adults (Boothroyd, 2007; Hawkins, 2005) or individuals who have had strokes and their families (Flasher & Fogle, 2012). The group dynamic allows clients and their families to (a) see other clients improve, which instills hope; (b) realize that they are not alone in feeling uncomfortable thoughts and feelings; and (c) build self-esteem through sharing opportunities that provide reassurance and insight to other group members (Luterman, 2008). Therapy in groups also allows an individual to practice what they learned in individual sessions and provides a structured, supportive venue allowing clients and families to reintegrate into society through conversations with individuals other than family members/caregivers and the clinician (Holland & Nelson, 2014). Group therapy is a service delivery model that can naturally incorporate support networks because of the alliances that clients form (Tellis & Barone, 2018). In some cases, clinicians may start a separate support group for clients in group therapy (Tellis & Barone, 2018).
Support groups comprise individuals experiencing similar issues and are forums for building helpful alliances (Holland & Nelson, 2014; Tellis & Barone, 2018). Members of support groups can focus discussion on feelings such as anxiety and apprehension. Clinicians closely monitor interactions within support groups to identify any dynamics that need to be addressed, such as conversations that undermine therapy focus and goals (Tellis & Barone, 2018).
It is normal for individuals and families to go through stages of grief (Kubler-Ross, 1969) when the disorder diagnosis is made and when the nature of the disorder and prognosis are discussed. These stages include
When in the denial stage, the individual and/or family/caregiver do not accept or believe there is a problem. Once the person enters the anger stage, they may exhibit strong emotional reactions about what they may feel is an injustice to them ("Why me?!"). Behind the anger are the emotions that trigger the anger—such as fear, uncertainty, embarrassment, and other normal feelings. In the bargaining stage, the person searches for a way to avert or get around the loss that has been experienced. Once the reality of the communication impairment sets in, many people experience depression, which is characterized by a feeling of emptiness and loss over what could have been. In the final stage, acceptance, the individual sets on a path that embraces the reality of the communication impairment and situation. Ideally, attempts are made to do whatever can be done to meet realistic goals in managing or improving the issues associated with the disorder or situation. Progression through the stages varies from person to person in that it may not be linear, and stages may be skipped. For example, some people stay in one stage for a long time, whereas others may be in a combination of stages, simultaneously going into and out of different stages—in particular, when confronted with new and challenging life situations (Flasher & Fogle, 2012; Luterman, 2008).
Audiologists and speech-language pathologists need to know when an individual is presenting with mental health challenges that are beyond the clinician's scope of practice and professional expertise. It is not necessarily the professional responsibility of the audiologist or speech-language pathologist to have extended conversations with individuals and their families about their struggles with uncertainty, sense of meaninglessness, and isolation. Refer to a licensed mental health professional individual or family dynamics are outside of the professional's knowledge or comfort level. Other indications that require referral to a mental health professional are as follows:
It is critical that the privacy and security of documentation are maintained in compliance with the regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Family Educational Rights and Privacy Act of 1974 (FERPA), and other state and federal laws. For more information regarding documentation, see ASHA's Practice Portal pages on Documentation in Health Care, Documentation in Schools, and Documentation of Audiology Services.
Cultural competence includes an awareness and understanding of any cultural influences that may impact clinical interactions, including acceptance of informational counseling and participation in personal adjustment counseling. See ASHA's Practice Portal pages on Bilingual Service Delivery, Collaborating With Interpreters, and Cultural Competence.
Having and/or caring for a child with a disability can have significant to devastating effects on a family/caregiver. Sometimes, the disability is evident at birth. At other times, the disability may not be apparent, recognized, or discovered until the child enters school. Being prepared to explain the disorder, prognosis, and treatment plan to parents and/or caregivers in comprehensible and clear language is essential to their understanding and acceptance of the communication impairment. Parents' and/or caregivers' understanding and involvement in their child's treatment is essential to achieving the best possible outcomes for their child as the child grows and develops. Further, parents and/or caregivers may express feelings, emotions, thoughts, and beliefs about their child's diagnosis and treatment plan that warrant use of counseling techniques.
It is not uncommon that audiologists and speech-language pathologists are the professionals who must give potentially upsetting information to children about their disorder or situation. It is wise to judge carefully how much information should be given, at what stage of development, and by whom (Flasher & Fogle, 2012). Counseling children usually involves other caregivers/members of the family. Being aware of family dynamics and being mindful of cultural considerations are important. When working with children, select words based on a child's age. Keep sentences short, and use simple words and concrete language—including simple sentences and questions when conducting an interview. Speak to the child at eye level as appropriate, which can help the child feel more comfortable and less intimidated. Check for different signs that the child is engaged in the conversation. Is the child attending to you—both looking and listening? Be careful to monitor whether you are acknowledging (e.g., "You have said that you think . . .") versus agreeing (e.g., "You have a right to feel . . .") with a child's statements in order to avoid conveying any unintended messages.
Inherent in counseling adolescents is accepting the responses that they provide to counseling questions, with the understanding that the clinician can always use additional question prompts to elicit targeted responses. For example, the clinician may want to use the advance–retreat–advance method (Zebrowski, 2003), as described above. If a conversation becomes uncomfortable for an adolescent, move on to another topic. Sometimes, an adolescent will re-initiate a conversation about a topic that was previously uncomfortable or that they did not have much to say about at the time. These moments may be used as a platform for continuing the conversation.
Be careful with the use of humor, making certain that it is not used inappropriately or excessively to make light of an adolescent's difficulties and feelings. Also, the use of slang words and profanity can diminish the adolescent's perception of the clinician's professionalism.
Characteristics of an individual (e.g., age, education, employment status, and occupational or professional background) can inform how you engage in the clinical session, including selection of counseling techniques and methods. Be clear, concise, and precise with word choice. Use ordinary and vivid words to characterize the mood of adults. Consider reflecting the feelings of the adult to clarify subtle experiences and emotions.
Elderly adults may be more prone to speak forthrightly about feelings and beliefs (Flasher & Fogle, 2012). It is important to consider that some individuals enjoy conversations, whereas others may want to be left alone. There may be cultural influences in how individuals and their families and/or social networks view a disability; for example, they may view the disability as a curse, a burden, or the result of fate. Be aware of how individuals and their families view the causes and effects of chronic or debilitating diseases and conditions because these views will influence the outcomes of counseling (Payne, 2015). See ASHA's Practice Portal page on Cultural Competence for more information.
When communicating with elderly individuals, keep in mind that the person's psychological and sociological ages may be significantly different from their chronological age. Some individuals who have been placed in a residential institution may be passively compliant because they feel a lack of control of their lives, may have hearing losses that are undetected, and may be experiencing other comorbidities affecting their health.
Be careful not to "talk down" to elderly adults by using baby talk, overly personal talk, or directive talk, (the last of which can be perceived as the clinician being controlling and uncaring). In addition, superficial talk may be interpreted as disrespectful and inappropriate. Including elderly adults in the decision-making process and seeking their input will ensure that they feel intricately involved in the process of addressing their needs.
Depending on the type and progression of a disorder, certain feelings, emotions, and behaviors may arise in individuals and their families (Flasher & Fogle, 2012; National Alliance for Caregiving & AARP, 2009; Payne, 2015; Rivera, Elliott, Berry, Grant, & Oswald, 2007). Clinicians should listen for the following information that can affect therapy progress and related counseling when engaging with a person and their family/caregiver:
Clinicians, by nature, attempt to fully understand the intricacies of clients' communication disorders and their impact on daily life. The level of combined emotional and physical investment involved can result in compassion fatigue, which is deep exhaustion as a result of providing assistance in a skillful, passionate, and compassionate way (Barrett & Olswang, 2014). Associated symptoms may include being overwhelmed, feeling a loss of self-worth, questioning one's competence, and feeling depleted.
Key steps to prevent or alleviate compassion fatigue include
Cheng is a 31-year-old Asian man with bilateral noise-induced hearing loss. Until the age of 30, Cheng had normal hearing. During a New Year's Eve fireworks show, a malfunction occurred with the fireworks. Unfortunately, Cheng was sitting in an area where the blast of fireworks caused immediate hair cell damage, resulting in moderate to severe sensorineural hearing loss.
Although his immediate family—his wife and 7-year-old daughter—are supportive and comforting, his parents displayed signs of embarrassment when the family was in social settings, such as dining together in a restaurant, because of Cheng's difficulty understanding speech in background noise. Day-to-day life was a challenge, and Cheng fought to stay socially engaged when he really wanted to withdraw.
With his wife's encouragement, Cheng was seen for an audiologic evaluation. He requested small, in-the-ear devices that he felt would be less conspicuous. However, because of the severity and configuration of his hearing loss and his very small ear canals, Cheng is not a good candidate for this style of device. Instead, receiver-in-the-ear (RITE) style hearing aids were recommended. Cheng expressed concern that his parents would not be supportive.
The audiologist listened to Cheng's concerns and encouraged him to bring his parents to the hearing aid fitting. The family members were asked to share what their goals and hopes were for Cheng's communication abilities. With Cheng's permission, the audiologist provided an overview of Cheng's hearing loss and its impact on his ability to hear and understand, especially in challenging listening environments such as noisy restaurants. The audiologist used a hearing loss simulation application to allow Cheng's parents to experience the impact that his hearing loss has on speech understanding. The audiologist reviewed Cheng's communication abilities when using the hearing aids and outlined the goals that he and Cheng had established; this was done in order for his family to understand appropriate expectations, given the hearing loss that Cheng has experienced. Together, they discussed a number of possible strategies that might help Cheng and his family communicate more effectively in certain situations.
Lily is a 3-year-old Hispanic girl who was diagnosed with autism. Although Lily is verbal, is speaking Spanish, and is learning English, her ability to convey and understand others' emotions and facial expressions is severely limited. She and her parents, bilingual speakers of Spanish and English, recently immigrated to the United States. Lily began receiving speech and language therapy soon after she arrived in the United States. The speech-language pathologist noticed that Lily's parents are very protective of their daughter—for example, they will sometimes interfere with therapy by completing tasks requested of Lily by the speech-language pathologist, or they will respond for Lily when the speech-language pathologist prompts Lily to communicate in a certain manner or context. The speech-language pathologist thinks that the parents believe that their methods are the best way to support Lily. Over a series of sessions, the speech-language pathologist heard Lily's parents mention the pain associated with their child's diagnosis and how lonely they felt in their small community—one in which no other parents they knew of had a child on the autism spectrum.
Rather than telling the parents that their behaviors may be considered overprotective and may be an impediment to advancing Lily's communicative abilities, the speech-language pathologist decided to better integrate the family into therapy by developing an Individualized Family Service Plan (IFSP) that included a contract with the family and identified the family's strengths and needs, desired outcomes, and treatment methods. In addition, the speech-language pathologist recommended and helped the family find a support group for families with children on the autism spectrum. Over a few sessions, Lily's parents were able to see how their behaviors were impeding her progress. Lily began to be more independent in her ability to recognize shifts in emotional states. Her parents talked about how they had more hope for Lily's future after talking to some parents of older children on the autism spectrum.
This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.
American Speech-Language-Hearing Association. (2004). Preferred practice patterns for the profession of speech-language pathology [Preferred Practice Patterns]. Available from www.asha.org/policy/.
American Speech-Language-Hearing Association. (2006). Preferred practice patterns for the profession of audiology [Preferred Practice Patterns]. Available from www.asha.org/policy/.
American Speech-Language-Hearing Association. (2016). Code of ethics [Ethics]. Available from www.asha.org/policy/.
American Speech-Language-Hearing Association. (2017). Issues in ethics: Cultural and linguistic competence. Available from www.asha.org/Practice/ethics/Cultural-and-Linguistic-Competence/.
Barrett, M., & Olswang, L. (2014, November).Compassion fatigue: Balancing and managing energy. Presentation at the American Speech-Language-Hearing Association Convention, Orlando, FL.
Boothroyd, A. (2007). Adult aural rehabilitation: What is it and does it work. Trends in Amplification, 11, 63–71.
Cohan, S. L., Chavira, D. A., & Stein, M. B. (2006). Practitioner review: Psychosocial interventions for children with selective mutism: A critical evaluation of the literature from 1990–2005. Journal of Child Psychology and Psychiatry, 47, 1085–1097.
English, K. (2002). Counseling children with hearing impairment and their families. Boston, MA: Allyn and Bacon.
Family Educational Rights and Privacy Act of 1974, Pub. L. No. 93-380, 20 U.S.C. §§ 1232g et seq.
Fernando, D. M. (2007). Existential theory and solution-focused strategies: Integration and application. Journal of Mental Health Counseling, 29, 226–241.
Flasher, L. V., & Fogle, P. T. (2012). Counseling skills for speech-language pathologists and audiologists. Clifton Park, NY: Thomson Delmar Learning.
Hansen, J. T. (2006). Counseling theories within a postmodernist epistemology: New roles for theories in counseling practice. Journal of Counseling & Development, 84, 291–297.
Hawkins, D. B. (2005). Effectiveness of counseling-based adult group aural rehabilitation programs: A systematic review of the evidence. Journal of the American Academy of Audiology, 16, 486–493.
Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, 42 U.S.C. §§ 201 et seq.
Holland, A. L., & Nelson, R. L. (2014). Counseling in communication disorders: A wellness perspective (2nd ed.). San Diego, CA: Plural.
Kubler-Ross, E. (1969). On death and dying. New York, NY: Macmillan.
Lipsitz, J. D., & Markowitz, J. C. (2013). Mechanisms of change in interpersonal therapy (IPT). Clinical Psychology Review, 33, 1134–1147.
Luterman, D. (2008). Counseling persons with communication disorders and their families (5th ed.). Austin, TX: Pro-Ed.
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National Alliance for Caregiving & AARP. (2009). Caregiving in the U.S. 2009. Retrieved from http://www.caregiving.org/data/Caregiving_in_the_US_2009_full_report.pdf
Patient Protection and Affordable Care Act of 2010, P.L. 111-148, 42 U.S.C. § 18001 et seq.
Payne, J. C. (2015). Diversity among caregivers. In J. C. Payne (Ed.), Supporting family caregivers of adults with communication disorders: A resource guide for speech-language pathologists and audiologists (pp. 35–62). San Diego, CA: Plural.
Rivera, P., Elliott, T. R., Berry, J. W., Grant, J. S., & Oswald, K. (2007). Predictors of caregiver depression among community-residing families living with traumatic brain injury. Neurorehabilitation, 22(1), 3–8.
Robbins, B. (2008). What is the good life? Positive psychology and the renaissance of humanistic psychology. The Humanistic Psychologist, 36, 96–112.
Rogers, C. R. (1951). Client-centered therapy. Boston, MA: Houghton Mifflin.
Rogers, C. R. (1959). A theory of therapy, personality, and interpersonal relationships, as developed in the client-centered framework. In S. Koch (Ed.), Psychology: A study of a science (Vol. 3, pp.184–256). New York, NY: McGraw-Hill.
Söylemez, A. (2017). Cognitive behavior therapy with couples and family relationships. Journal of Family, Counseling, and Education, 2, 72–76.
Spillers, C. S. (2007). An existential framework for understanding the counseling needs of clients. American Journal of Speech-Language Pathology, 16, 191–197.
Tellis, C. M., & Barone, O. R. (2018). Counseling and interviewing in speech-language pathology and audiology: A therapy resource. Burlington, MA: Jones & Bartlett Learning.
U.S. Department of Health and Human Services. (n.d.). Quick guide to health literacy. Retrieved from https://health.gov/communication/literacy/quickguide/Quickguide.pdf
Zebrowki, P.M. (2003). Understanding and coping with emotions: Counseling teenagers who stutter. In Effective Counseling in Stuttering Therapy, Publication No. 18. Memphis, TN: Stuttering Foundation.
Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Counseling for Professional Service Delivery page:
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association. (n.d.). Counseling for Professional Service Delivery. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Professional-Issues/Counseling-For-Professional-Service-Delivery/