Roles and Responsibilities

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, 2023), 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.

Preferred Practice Patterns

According to the Preferred Practice Patterns for the professions of audiology (ASHA, 2006) and speech-language pathology (ASHA, 2004), the expected outcomes of counseling are

• enhancement of client and family/caregiver understanding of, acceptance of, and adjustment to communication, swallowing, vestibular, tinnitus, or related conditions;
• increased engagement in management of disorder;
• increased autonomy, self-direction, and responsibility for acquiring and utilizing new skills and strategies related to their goals;
• enhanced physical and psychosocial well-being and quality of life;
• improved understanding of how to modify contextual factors to reduce barriers, enhance participation, facilitate successful communication, and manage related disorders;
• enhanced compliance with treatment recommendations; and
• enhanced benefit from and satisfaction with treatment.

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:

• Evaluation procedures
• Diagnoses and results of evaluations
• Problems experienced secondary to communication, vestibular, swallowing, tinnitus, and related conditions
• Effects of the disorder on psychosocial and behavioral adjustment, including interpersonal relationships, social activities, and occupational options and performance
• Affective/emotional reactions to communication/swallowing/balance disorders
• Development of coping mechanisms, problem-solving skills, compensatory behaviors, and systems for emotional support
• Development and coordination of individual and family/caregiver self-help and support groups

Ethics

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 (2023) includes principles and rules that contribute to determining when referral and collaboration are appropriate:

• Principle I, Rule B states, "Individuals shall use every resource, including referral and/or interprofessional collaboration when appropriate, to ensure that quality service is provided."
• Principle II, Rule A states, "Individuals who hold the Certificate of Clinical Competence shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their certification status, education, training, and experience."
• Principle IV, Rule A states, "Individuals shall work collaboratively, when appropriate, with members of one's own profession and/or members of other professions to deliver the highest quality of care."

Counseling Theories and Approaches

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.

Cognitive-Behavioral Theory

• Definition: This approach involves ensuring that individuals are aware of negative perceptions that could impact therapy progress and helping them evaluate the validity of those perceptions as well as using a systematic series of steps to reframe those perceptions and reinforce behaviors necessary to achieve specific therapy goals (Flasher & Fogle, 2012; Holland & Nelson, 2014; Luterman, 2008; Manning & DiLollo, 2018; Söylemez, 2017).
• Clinical Application: Focus on helping individuals and families (a) identify harmful behaviors and problematic thinking and (b) modify environmental factors that foster negative behaviors and thoughts (e.g., a student thinks college attendance is out of reach because of challenges with verbalizing complex ideas during presentations, an individual with a hearing loss avoids or restricts social interactions, or an individual with tinnitus doubts the impact of therapy because of a belief that their tinnitus cannot be effectively managed).

Family System Theory

• Definition: Family system theory and therapy consider the role of family/caregivers in the problems faced by an individual (Cohan, Chavira, & Stein, 2006; English, 2002; Flasher & Fogle, 2012). Audiologists and speech-language pathologists work with families to help them identify ways in which their behaviors impact communication difficulties (Flasher & Fogle, 2012).
• Clinical Application: The focus of clinicians' work is to facilitate family interactions and enhance communication in an effort to facilitate compliance with therapy tasks or management efforts and, thereby, to remove conditions that maintain communication disorders or barriers (Cohan et al., 2006; Flasher & Fogle, 2012; Holland & Nelson, 2014).

Humanistic Theory

• Definition: The humanistic approach involves the application of person-centered techniques to address issues in consideration of what it means to thrive as a human being and to realize one's potential (Flasher & Fogle, 2012; Robbins, 2008). Humanistic theory is based on the belief that people are good and can address their own issues when the therapy provided is caring, nonjudgmental, and considers and reflects the individual's feelings (Luterman, 2008; Rogers, 1951, 1959; Tellis & Barone, 2018).
• Clinical Application: Audiologists and speech-language pathologists are reflective and are led by the individual's and family members' needs versus confrontational and directive in their attempts to shape the individual's or family members' behavior (Flasher & Fogle, 2012; Hansen, 2006; Tellis & Barone, 2018). Clinicians strive to create emotional safety by using nonjudgmental, deep listening, which ultimately builds the therapeutic relationship (Luterman, 2008).

Interpersonal Theory

• Definition: Interpersonal theory and therapy stem from a belief that a person's behavior is a result of what was learned from previous interactions with people in their lives as well as the impact of current day-to-day interactions with people and situations—including major life changes, both positive and negative (Flasher & Fogle, 2012; Lipsitz & Markowitz, 2013).
• Clinical Application: This approach is particularly applicable when an individual is seen for multiple treatment sessions. In that context, audiologists and speech-language pathologists observe communicative interactions, share their observations with the individual, develop and implement a treatment plan that considers the individual's interpersonal style and any self-defeating communication patterns that need to be addressed, and close out clinical services by discussing improvements and anticipated future problems (Flasher & Fogle, 2012; Lipsitz & Markowitz, 2013).

Multicultural Theory

• Definition: Multicultural theory takes into account culturally diverse world views. The theory rests on the assumption of cultural relativism—that is, the belief that there are few universal standards for evaluation of "right or wrong" and "healthy or unhealthy" human behavior (Flasher & Fogle, 2012; Payne, 2015). Multicultural theory is integral to counseling, regardless of which other theory or theories are being used (Luterman, 2008).
• Clinical Application: Audiologists and speech-language pathologists recognize that cultural variables may influence an individual and their family's/caregiver's beliefs. Clinicians respectfully listen to varied views as part of culturally sensitive clinical decision making (Flasher & Fogle, 2012).

Existential Theory

• Definition: This theory is based on a tension between individual freedom of choice and aspects of existence, such as responsibility, death, loneliness, and meaninglessness of the universe (Luterman, 2008; Manning & DiLollo, 2018; Tellis & Barone, 2018).
• Clinical Application: In existential theory, the focus of the clinician's work is to promote the individual's self-awareness of their abilities (Luterman, 2008) while simultaneously acknowledging the impact of a communication disorder and/or related condition on daily life (Tellis & Barone, 2018). The clinician's efforts could foster or enhance the individual's mechanisms for creating meaning in their lives (Fernando, 2007; Flasher & Fogle, 2012) rather than assigning fault to themselves (Spillers, 2007; Tellis & Barone, 2018)—and, in turn, highlight the individual's options for the future.

Considerations in Service Delivery

Health Literacy

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:

• Monitor the rate of delivery, and take adequate time to communicate with the individual and family/caregiver.
• Use common language and limited technical terms that are specific to a profession.
• Include pictures to clarify concepts and emphasize key points.
• Provide manageable amounts of information and repeat what was communicated in an effort to facilitate retention and comprehension.
• Encourage questions to facilitate comprehension of information.
• Ask open-ended questions using the words "what" or how" versus asking questions that can be answered with "yes" or "no."
• When working with an individual who has limited English proficiency, use a trained interpreter who can use plain language in the individual's preferred language, providing examples that are relevant to cultural norms and values. See ASHA's Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators for more information.

(U.S. Department Department of Health and Human Services, n.d.)

Family Involvement

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).

Therapeutic Relationship

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).

• Show consideration for the individual and family/caregivers: When interacting with an individual and their family/caregiver, show respect for their dignity, privacy, autonomy, and vulnerability (e.g., using preferred titles and name[s], knocking before entering their room, introducing yourself to a new client and their family/caregiver, asking [in private] if they want their family/caregiver present during service delivery).
• Engage in joint decision making: Involve individuals and families/caregivers in decision making whenever possible (e.g., joint, functional, patient-centered goal setting). This demonstrates respect for them and their family that will help maintain their motivation to participate in clinical services as well as decrease the likelihood of resistance to service delivery.
• Motivate: Foster and maintain motivation to achieve positive outcomes by ensuring that the individual and family/caregiver understand that adapting to treatment is a process and not something that is turned "on/off." They need to (a) understand and feel that they have "ownership" of the recommended goals, strategies, and management techniques and (b) believe that the goals/strategies/management recommendations are purposeful, leading to growth and improvement. Learning their wants, needs, thoughts, and feelings can help them overcome any obstacles that they face as intervention progresses.
• Facilitate identification of barriers: Encourage individuals and families/caregivers to consider any beliefs and desires that may be negatively affecting motivation, use of strategies, or management. This requires tact and some advanced counseling skills.
• Trust your intuition: When an individual's or family member's body language or vocalizations seem inconsistent with their message about an issue, trust your intuition, and explore whether they want to share additional information.
• Address resistance: When addressing individual or family/caregiver resistance to services, determine whether
  • a treatment goal or strategy needs to be clarified;
  • dissatisfaction with progress needs to be addressed;
  • external issues are mitigating factors; or
  • there is an imbalance in motivational factors. Motivation can wane when goals are too difficult, are time consuming, or feel very inconvenient.
• Consider transference: Individuals and their families/caregivers may perceive a clinician as having certain intentions or tendencies based on their past relationships and experiences with other professionals. Be aware of this phenomenon and consider whether it is negatively affecting their clinical intervention. For example, an individual or family member/caregiver may have interacted with a previous professional who said "I understand" after each revelation discussed; however, the individual or caregiver felt that the professional actually did not truly understand. Therefore, the use of "I understand" by any professional seen by that person in the future may result in feelings of distrust.
• Consider countertransference: Clinicians may perceive an individual as having certain intentions or tendencies based on the clinician's past relationships and experiences with other clients or families/caregivers. Be aware of this phenomenon and consider whether it is affecting therapy. For example, a clinician who has worked with individuals or families/caregivers who display emotion when discussing the impact of the communication impairment or situation on their daily lives may assume that those who do not openly display emotion do not require as much support.
• Avoid blaming language: In some cases, individuals and families/caregivers do not complete the therapy tasks that the professional asks of them.Avoid using blaming language that can cause the person to become defensive or resistant. Instead, ask the person questions that address the issue while not projecting or attributing judgment (e.g., "I'm wondering if you feel uncertain about how to complete the therapy tasks.").
• Consider tone of voice: The clinician's tone of voice may be detrimental or beneficial to the therapeutic relationship (e.g., perceived as untrustworthy; exuding false confidence or arrogance; warm and friendly; confident; gentle and accepting).
• Consider nonverbal communication, which may include
  • physical appearance and proxemics (i.e., personal space and interpersonal communication distance);
  • seating arrangements (i.e., distance and positioning relative to the client);
  • eye contact (i.e., direct, indirect, or sustained); and
  • touch (i.e., seek permission before touching a client).
• Know when to refer an individual to mental health professionals: It is beyond the scope of practice of audiologists and speech-language pathologists to diagnose or treat individuals with psychological disorders (e.g., depression, anxiety). If a clinician notes behaviors that seem to suggest a psychological disorder, then they should refer the person to a qualified mental health professional.

Microskills for Counseling

Questions

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 their own perspective—how the person sees, hears, and feels the world (Flasher & Fogle, 2012; Tellis & Barone, 2018).

Considerations for Asking Questions:

• Asking appropriate and carefully considered and worded questions can be a tool for redirecting an individual or family member/caregiver if the conversation goes off topic or beyond our scope of practice. However, asking too many questions—in particular, quickly—may overwhelm a person, and the person may feel "badgered."
• Asking leading questions can be perceived as manipulative by a person and may give the clinician inaccurate impressions of how the person is feeling and what the person is thinking. For example, asking a client if they have been feeling anxious since their voice disorder began or asking a family member if they have been depressed since their husband's stroke would be considered a leading question.
• Speaking style can influence listeners' perception. For example, using an assertive questioning style can be perceived as intimidating and insensitive, whereas using a very tentative, too sensitive communication style may be interpreted to mean that the clinician does not feel competent or confident.

Question Types:

• Closed questions elicit a yes, no, or other brief response and often include the words is, are, or do. For example, "What is your name?" "How many children do you have?" Closed questions are often used initially in an interview; however, too many closed questions can sound like an interrogation.
• Open-ended questions do not elicit a specific response; instead they allow for varied and detailed responses. Frequently, the first word of an open-ended question helps direct the type of information sought. Open-ended questions include the following:
  • Who questions provide information about people involved in a situation.
  • What questions often lead to factual information or opinions.
  • When questions give information about time or sequences of events.
  • Where questions provide information about locations.
  • How questions often give "method" responses—that is, the person's thinking processes that illustrate problem-solving strategies.
  • Why questions provide information about reasons or causes.

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.

• Funneling questions narrow the focus of a broad conversation by enabling the clinician to ask increasingly specific questions until the discussion is focused on a certain topic. Funneling questions translate problems from abstract concepts into concrete language and break complex problems into more manageable, transparent elements.
• Requests for clarification explain the individual's or family's/caregiver's intended message by asking if the clinician's summary of what was said is accurate. Asking, "Is that correct, or have I missed something?" can help the clinician confirm that what was said was accurately understood.
• Comparison questions use comparison words (e.g., better or worse, more or less, easier or harder) to determine what improves or worsens a communication disorder or situation. Obtaining this information can help the clinician discover the patterns of symptoms and behaviors and develop an appropriate therapy strategy.
• Counterquestions involve answering an individual's or family member's/caregiver's question with a question. Counterquestions are important tools to help understand a person's thoughts, feelings, positions, and decisions. They may help the clinician avoid being "hooked" into answering a question that the person has already made a decision about. When a client or family member asks something like, "What do you think?", respond with a what or how question that includes repeating the essence of what is being discussed (e.g., in reply to the question, "How much longer do you think I need to continue therapy?" from a client who stutters, the clinician might ask the counterquestion, "What do you think about the progress that you have made so far?").
• The advance–retreat–advance method (Zebrowski, 2003) is a technique in which, if an individual or family member/caregiver responds to a clinician's question (e.g., "What do you find is a little scary about your stuttering?" or "What are some of the challenges you are having with your husband now that they are home from the hospital?") in a manner that indicates they do not want to answer or address the issue (e.g., "I don't know" or "There aren't any"), the clinician can retreat (e.g., "That's okay"), and then the clinician may later "advance" by saying something like, "Some people who stutter feel it is a little scary wondering about what others might think about them when they talk and stutter. Is that true for you?" or, "Many families find coping with someone who is having difficulty communicating to be somewhat challenging. Are you experiencing anything like that?"

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.

Accurate Observations and Listening

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:

• Paraphrasing: A brief restatement of what someone has said that captures the essence of their words and message to help assure the person that you have accurately heard the central meaning of their message.
• Reflection (echoing): Restating the last few words or a portion of a person's statement in the same tone of voice as the one that the person used. Clinicians do this in order to avoid turning the reflection into a question. Reflection can encourage the person to expand on the story or on a statement within the story.
• Verbal encouragers: Prompts, such as "uh-huh" and "okay" can be used to encourage a person to provide more information. Verbal encouragers are often used in conjunction with nonverbal encouragers, such as smiling and head nodding.
• Silence: Encourages the person to continue adding details (often, important details) to the issue at hand or to reflect on what has been said thus far. Sometimes, when a clinician uses a verbal encourager (e.g., "Okay," "Yes") while the person is still speaking or when the person appears to have finished, the encourager tells the person that the clinician has heard enough. It is often better if the clinician (a) waits several seconds after the person has finished and (b) wears a facial expression that indicates they are expecting more from the individual. Doing this often encourages the person to fill in the silence with more—and, often, very valuable—information.

Selective Feedback

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:

• Reframing: A technique that presents the individual with a new frame of reference in a positive light through which to view a problem or situation in an effort to better understand and manage the situation or problem.
• Interpretations/linking statements: The addition of new information to a paraphrase in an attempt to (a) understand the person's thoughts, feelings, and experiences and (b) relay the interpretation back to the person. The goal of an interpretation is for the person to achieve insight or increased self-awareness and self-understanding.
• Suggestion versus direction or instruction: A nondirective and nonmanipulative suggestion to help individuals develop a new perspective about a communication, swallowing, or balance impairment or related situation. Direction or instruction involves specific information as to what the clinician wants a person to do, such as a particular exercise and how to do it, or things that family members can do to help the person who is having difficulty communicating. (Note: There is an important distinction between (a) making a suggestion or giving advice on how a person's life should be lived and (b) providing an instruction or a direction about specific therapeutic processes. Avoid offering either unsolicited or solicited advice about broad life situations and family matters. We always aim to stay within our scope of practice.)
• Confronting: A term in counseling that refers to (a) noting discrepancies, incongruities, or mixed or conflicting messages in the individual's or family member's story and (b) presenting them back to the person in a gentle manner (i.e., not accusatory and not causing defensiveness). Confronting is tentative and nonjudgmental, encouraging the person to explore the discrepancy, such as, "Could it be . . ." or "You seem to tend to . . ." There are numerous types of discrepancies that clinicians may notice—discrepancies between what is said and what is done, between two or more statements, between verbal and nonverbal behavior, between nonverbal behaviors, and between the views of different people.

Group Therapy and Support Groups

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).

Grieving Process

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

• denial;
• anger;
• bargaining;
• depression; and
• acceptance.

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).

Referral

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:

• Topic of death is raised in multiple instances.
• Person reports recurrent thoughts of death.
• Person reports suicidal thoughts.
• Person shows signs of persistent depression.
• Person shows signs of physical abuse of either themselves or a family member/caregiver (this behavior also warrants alerting law enforcement).
• Person shows signs of self-inflicted abuse.
• Person has a drug and alcohol addiction.
• Person reports behaviors consistent with persistent and/or severe social and/or emotional withdrawal.
• Person indicates a deterioration in family relationships.
• Person reports behaviors/thoughts consistent with personality and character disorders.

Documentation

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 Considerations

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 Responsiveness.

Counseling Across the Lifespan

Counseling Parents of Infants and Young Children

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.

Counseling Children

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.

Counseling Adolescents

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.

Counseling Adults

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 Responsiveness 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.

Disorder-Specific Considerations

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:

• Is the disorder chronic, acute, congenital, or progressive?
• How much time post-onset is the individual? What impact does this have on their perspective?
• How might this affect the individual's self-image and self-concept?
• What feelings of anxiety, guilt, embarrassment, and so forth, might this disorder instill in the person and their family/caregiver?
• How does the disorder affect socialization and relationships with peers?
• How does the disorder affect academic performance and perceptions of teachers, employers, colleagues, and so forth?
• Is there any cultural stigma associated with the person's communication impairment that could affect how they are treated by others?
• How does the severity of the communication impairment affect the individual and family/caregiver?
• What kinds of situations may be challenging for the person and family/caregiver?

Compassion Fatigue

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

• being mindful of the effects of your efforts on yourself;
• recognizing when you expend energy and then acknowledging your need to replenish that lost energy;
• learning what reenergizes you; and
• writing and attempting to adhere to a wellness plan that considers your personal and professional visions.

Case Scenarios

Case Scenario 1: Man With Noise-Induced Hearing Loss

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 their immediate family—their wife and 7-year-old daughter—are supportive and comforting, Cheng's 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 they really wanted to withdraw.

With their wife's encouragement, Cheng was seen for an audiologic evaluation. They requested small, in-the-ear devices that they felt would be less conspicuous. However, because of the severity and configuration of their hearing loss and their 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 their parents would not be supportive.

The audiologist listened to Cheng's concerns and encouraged them to bring their 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 their 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 their hearing loss has on speech understanding. The audiologist reviewed Cheng's communication abilities when using the hearing aids and outlined the goals that they and Cheng had established; this was done in order for Cheng's 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 their family communicate more effectively in certain situations.

• Counseling Theory: Humanistic, Interpersonal, and Family Systems Theory
  • The role of family members was considered when discussing the problems displayed by this individual (Cohan et al., 2006; Flasher & Fogle, 2012), including how past experiences that are associated with cultural beliefs may be contributing to Cheng's desire to withdraw from family and society. The audiologist worked to facilitate family interactions. If the distress in the family becomes too great for this person, or if this person withdraws socially, the audiologist will refer Cheng to a mental health professional.
• Methods for Building the Therapeutic Relationship: Attending, Listening, and Using Therapeutic Communication
  • Attending to the individual's and family members' body language—as well as listening to verbal and nonverbal (e.g., a grunt indicating displeasure) messages—are key aspects of building a therapeutic relationship and customizing and modifying therapy plans.
  • The audiologist will use therapeutic communication (e.g., show respect for the person, engage in joint decision making) to build a good relationship with a person who is on the fringes of disengaging socially. Cultural considerations will play a key role in identifying which aspects of therapeutic communication will be attempted.
• Counseling Techniques: Accurate Observations and Listening; Family Dynamics and Involvement; Questions; and Selective Feedback

Case Scenario 2: Child With Autism

Lily is a 3-year-old Hispanic girl who was diagnosed with autism. Although Lily is verbal, is speaking Spanish, and is learning English, their ability to convey and understand others' emotions and facial expressions is severely limited. They and their parents, bilingual speakers of Spanish and English, recently immigrated to the United States. Lily began receiving speech and language therapy soon after they 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 Lily's progress. Lily began to be more independent in their ability to recognize shifts in emotional states. Their parents talked about how they had more hope for Lily's future after talking to some parents of older children on the autism spectrum.

• Counseling Theory: Family Systems and Multicultural Theory
  • The role of family members was considered when discussing the problems displayed by Lily (Cohan et al., 2006; Flasher & Fogle, 2012). The speech-language pathologist worked to facilitate better family interactions and enhance communication in an effort to increase compliance with therapy tasks and, thereby, remove conditions that maintain communication disorders (Cohan et al., 2006; Flasher & Fogle, 2012). The clinician recognized that cultural variables may influence clients' and families' beliefs and respectfully listened to varied views as part of culturally sensitive clinical decision making.
• Methods for Building the Therapeutic Relationship: Attending, Listening, and Using Nonblaming Language
  • Attending to the person's and family members'/caregivers' body language, as well as listening to verbal and nonverbal messages (e.g., a grunt, indicating displeasure) are key aspects of building a therapeutic relationship and customizing and modifying therapy plans.
  • In cases where individuals do not complete tasks as expected, it is important to avoid using language that can cause the client to become defensive or resistant. Instead, use nonblaming language, such as asking the person questions that address the issue while still maintaining their dignity (e.g., "I'm wondering if you feel uncertain about how to complete the task").
• Counseling Techniques: Support Groups; Accurate Observations and Listening; and Family Dynamics and Involvement

ASHA Resources

• ASHA's Scope of Practice in Speech-Language Pathology
• ASHA's Scope of Practice in Audiology
• ASHA's Preferred Practice Patterns for the Profession of Audiology
• ASHA's Preferred Practice Patterns for the Profession of Speech-Language Pathology
• ASHA's Code of Ethics

Other Resources

This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.

• American Association for Marriage and Family Therapy
• American College Counseling Association
• American Counseling Association
• American Mental Health Counselors Association
• American Psychological Association, Division 17: Counseling Psychology
• American Rehabilitation Counseling Association
• American School Counselor Association
• Association for Death Education and Counseling
• Association for Multicultural Counseling and Development
• The Care Project
• International Association of Counseling Services, Inc.
• International Association of Marriage and Family Counselors, Division of the American Counseling Association
• National Board for Certified Counselors

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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. (2017). Issues in ethics: Cultural and linguistic competence. Available from www.asha.org/Practice/ethics/Cultural-and-Linguistic-Competence/.

American Speech-Language-Hearing Association. (2023). Code of ethics [Ethics]. Available from www.asha.org/policy/.

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.

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Acknowledgements 

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:

• Kathleen M. Cienkowski, PhD, CCC-A
• Paul Fogle, PhD, CCC-SLP
• Emily Lund, PhD, CCC-SLP
• David Luterman, DEd
• Joan C. Payne, PhD, CCC-SLP
• Tommie L. Robinson Jr, PhD, CCC-SLP
• Johnnie Sexton, AuD, CCC-A
• Nancy Swigert, MA, CCC-SLP, BCS-S
• Barbara E. Weinstein, PhD, CCC-A

Citing Practice Portal Pages

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/