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Living with communicative impairments can be life-changing for clients and their families. As clinicians, we diagnose, treat and counsel about those communication-related and social experiences. Each stage of the rehabilitation process—diagnosis, treatment and discharge—calls for its own counseling techniques. Here are some suggestions.

As clinicians, you know your clients and their families. You know their struggles, insecurities and motivations. Speech-language pathologists and audiologists play a significant role in counseling within clinical practice. Counseling people with communication impairments is part of our job description. It is a necessary part of our clinical responsibilities. However, many clinicians may feel they need more training in counseling patients (see resources below). In his 2001 book, “Counseling Persons with Communication Disorders and Their Families,” David Luterman found that 82 percent of graduate students reported a need for further training and more experiences in counseling. It’s important to understand that there are counseling techniques that can be used during clinical practice to acknowledge the emotional needs of the client and family.

As counselors, clinicians must acknowledge their own beliefs and feelings regarding clinical practice. According to a 2011 article by Nina Simmons-Mackie and Jack Damico in Topics in Language Disorders, clinicians may purposefully avoid addressing emotional topics with clients. In this study with aphasia clients, clinicians favored discussing facts, used humor to deflect emotional reactions, and shifted directly to intervention tasks. These tactics were often used to avoid:

Difficult social interactions.

Issues of emotional intimacy.

Confusion with job description (clinician versus counselor).

Diagnosis

Despite these worries, transitioning from clinician to counselor can be an effortless shift during clinical practice. Counseling techniques are valuable in both diagnostics and intervention. When first meeting the client/family, in fact, clinicians act more as counselors. In her 2007 book, “Counseling in Communication Disorders: A Wellness Perspective,” Audrey Holland suggests four key principles to establish a rapport with clients:

1. Promote a safe place for communication.

2. Use unbiased listening to different cultural views.

3. Center topic discussions on client’s disorders (definitions, symptoms, feelings).

4. Explain the information that will help clients with acceptance and promote successful actions.

Holland also suggested that clinicians should help clients and families to:

Understand the cause of events that led to trauma (discuss events that happen pre- and post-trauma).

Grieve over loss of skills and accept the situation (embrace the emotional moments).

Identify personal goals and develop strategies (explore the client/family struggles and motivations).

Treatment

We act as counselors when we motivate our clients to co-develop a plan for intervention. In his 2006 book, “Counseling the Communicatively Disabled and Their Families: A Manual for Clinicians,” George H. Shames suggests that becoming a good listener and skilled interviewer allows clinicians to coordinate with clients’ emotions and to promote a strong clinical rapport. Clinicians can structure discussions to focus on clients’ understanding of and reflection on the situation. Shames recommended the use of attending behaviors, invitations to talk, and minimal encouragement to talk.

Attending behaviors include:

Silent listening:

Full engagement by clinician.

Clinician is quiet but actively listening to clients/families.

Verbal following:

Clinician tracks the client’s comments and repeats the client’s responses (“Eating in public is frustrating”).

Nonverbal communication:

Note eye contact, posturing, personal space, and body movements (Is the client avoiding eye contact during emotional topics or sensitive with personal space?).

Invitations to talk:

Open invitations:

Facilitate opportunities where the client leads the discussion.

Prompt client to expand comments (“Tell me why,” “Tell me more” or “What did you feel?”).

Closed invitations:

Structure the client’s response to a few words (“Do you agree…” or “This is ____ for you.”).

Minimal encouragement to talk:

Use verbal and non-verbal cues to maintain conversation:

“Uh-huh (said with a head nod).

“I understand.”

“And then ...” (cue for client to continue).

“Because …” (cue for client to continue).

During intervention, counseling is a vital aspect of treatment. People’s actions are a reflection of their feelings and beliefs. Clients and their families will experience an array of emotions during rehabilitation, such as anger, denial and grief. Clinicians can promote the client’s self-reflection of communicative behaviors and feelings. In their books on counseling, both Audrey Holland and David Luterman suggest highlighting the client’s awareness of both the therapeutic progress and related feelings:

Paraphrasing words:

Clinician repeats the client’s words or phrases.

This opens opportunities for clients to hear and revise or confirm the information.

Summarizing discussions:

Clinician paraphrases longer pieces of information.

This provides opportunities to:

Initiate a specific topic.

Explore a particular subject.

Explain a conclusion.

Treatment sessions that are strictly focused on tasked-oriented discussions may not promote opportune moments for counseling. To avoid missed opportunities, Simmons-Mackie and Damico proposed strategies to incorporate counseling into treatment.

Integrating the session:

Increase response time for answers (give clients time to process feelings).

Use multi-modality response options (include gestures, drawing, writing, and/or using key words).

Use pictographic systems (use faces or symbols to represent feelings).

Verify understanding (confirm your perception of client’s feelings, i.e., “You feel ___”).

Discharge

Another important part of counseling includes the discharge process. In their 2010 article in the International Journal of Speech-Language Pathology, Patricia Quattlebaum and Mary Steppling propose that a successful discharge starts at the very beginning of treatment. The authors suggest that when considering discharging clients, clinicians should acknowledge the client’s support system, ability to access resources and maintain follow-up meetings. It may be beneficial to help some clients interpret “discharge” as transitioning to another step in treatment. Quattlebaum and Steppling acknowledge that due to different clinical settings, guidelines for discharge vary according to many factors (caseload, service delivery, funding). However, counseling clients and families before and during discharge is a continued and necessary part of the therapeutic process.

There are times when referrals to mental health professionals are necessary and ethically important. The American Counseling Association (ACA) developed an integrated definition for counseling in 2010: “Professional counseling is a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals.” As clinicians, we must acknowledge when clients’ emotional concerns progress outside of our clinical scope of practice. If a client’s emotional and mental behaviors continue or the client’s safety is of concern, make an immediate referral to a mental health professional.

Counseling is a listening process. As clinicians, we must recognize our own emotions, as well as those of the clients. When we listen to our clients, we validate their feelings. Clients, who feel acknowledged, can feel empowered in all struggles.

Sources

American Counseling Association. (2010). Re: 20/20: A Vision for the Future of Counseling (Online forum). Retrieved from http://www.counseling.org/about-us/about-aca.

Holland A. (2007). Counseling in Communication Disorders: A wellness perspective. San Diego, CA: Plural Publishing.

Friehe M. J., Bloedow A., & Hesse S. (2003). Counseling families of children with communication disorders. Communication Disorders Quarterly, 24(4), 211-220.

Kaderavek J. N., Laux J. M., & Mills N. H. (2004). A counseling training module for students in speech-language pathology training programs. Contemporary Issues in Communication Science and Disorders, 31, 153-161.

Luterman D. (2001). Counseling persons with communication disorders and their families. Austin, TX: Pro-ed.

Shames George H. (2006). Counseling the communicatively disabled and their families: A manual for clinicians. Mahwah, NJ: Lawrence Erlbaum Associates.

Simmons-Mackie N., & Damico J. S. (2011). Counseling and Aphasia Treatment. Topics in Language Disorders, 31(4), 336-351.

Quattlebaum P., & Steppling M. (2010). Preparation for ending therapeutic relationships. International Journal of Speech-Language Pathology, 12(4), 313-316.

Author Notes

Janet Bradshaw, ABD, CCC-SLP, was a clinician in the New Orleans School System before starting the doctoral program in communication sciences and disorders at Louisiana State University, which she will complete this month. Her research interests include child language disorders with a focus on pragmatic language skills and children’s social-emotional understanding.

Kyomi Gregory, MA, CCC-SLP, was a clinician in public schools, early intervention, hospitals and long-term care in the New York City area. She is a doctoral student at Louisiana State University with research interests in child language acquisition and assessment in culturally and linguistically diverse populations, teacher training and prevention models in speech language pathology, and nonmainstream dialects.

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