20Q: Counseling Families of Children with Communication Disorders

From the Desk of Ann Kummer

The field of speech-language pathology is very broad. Some of us work with infants, some work with school-aged children, and others work with adults. Most of us tend to specialize, or at least focus, on certain areas of the field (i.e., apraxia, dysphagia, language disorders, speech sound disorders, augmentative communication, etc.). In addition, we work in a variety of settings, including hospitals, schools, and skilled nursing facilities. Although we, as speech-language pathologists, vary greatly in the populations that we serve, the disorders that we treat, and the settings in which we work, we all have one thing­­ in common—we all are called upon to counsel our clients and their families.

There can be no argument that effective counseling is an important part of our practice and that it can make a big difference in the success of our treatment. However, few of us have actually been trained to counsel families. That is why I am particularly happy that Dr. David Luterman, a specialist in counseling families of children with communication disorders, has submitted a 20Q article on this important topic.

David Luterman, EdD, CCC-SLP, is a professor emeritus at Emerson College in Boston, Massachusetts and Director of the Thayer Lindsey Family Centered Nursery for Hearing Impaired Children. He is the author of many articles and several books, including his seminal book called Counseling Persons with Communication Disorders and Their Families, now in its 5th edition. He has done several podcasts and a DVD through the Stuttering Foundation called Counseling People who Stutter and Their Families. In addition to authoring many books, he is a well-known teacher, researcher, consultant, and lecturer. Dr. Luterman is a fellow of the American Speech-Language-Hearing Association and recipient of the Frank Kleffner Clinical Achievement Award (2011).

I think you will learn some important counseling strategies as a result of this edition of 20Q.

Now...read on, learn and enjoy!

Ann W. Kummer, PhD, CCC-SLP, FASHA
Contributing Editor 

Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q

20Q: Counseling Families of Children with Communication Disorders

David Luterman

1. What is the primary goal of counseling?

The primary goal of counseling should be to empower our clients and their families to help themselves. We do this by being supportive and compassionate. We need to trust that those who we counsel have the wisdom and the ability to apply the information and skills provided by us as counselors. This is a hard concept to employ because clients are often floundering and feeling overwhelmed at the outset. Our goal is not to rescue clients because if we do that, we are teaching helplessness and we may even lower the self-esteem of the client. Instead, we must find the therapeutic equator of the relationship and be sure that the client participates actively in the therapeutic encounter. We must ensure that as a result of the clinical interaction, the client begins to take ownership of their feelings and reactions to the disorder. This can be done by not having a set lesson plan for the session but instead, jointly deciding what to discuss at the beginning of the therapy session. I always start my individual and group sessions by asking the participants what they hope to accomplish that day.

2. Is counseling just giving information?

Although giving information is an important aspect of counseling, it does not define what we do in counseling. When emotions are very high, the person cannot process information adequately.  This is because our brains are structured so that in high anxiety situations, we can act, but we are limited cognitively. We all experience this phenomenon when we are upset and trying to read something. We can read the words, but they do not connect in our brain. So giving information when a client is upset is usually not helpful. Therefore, we need to address the feelings first and then provide information as the client can absorb it.

3. Is giving advice a good counseling strategy?

No. Giving advice to the client is seldom helpful in a counseling session. Although it is tempting to give advice, and clients often expect it, advice tends to create a dependency in the client. This reminds me of the well-known proverb that says: “Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime.” Advice is the “fish” in the case of counseling. The goal of counseling should be to create an independent client who “knows how to fish” for himself. When people seem to be seeking advice, they are often really looking for confirmation of a position they have, but are not ready to reveal. Treating a confirmation query as a question seeking advice or information often results in a miscommunication. It is often better to respond to a question with a counter question. For example, if the client says, “If this was your child what would you do?” a good counseling response would be “Tell me a bit about what you have been thinking.”

4. What is reframing?

Reframing is a wonderful psychological tool that we have to change our perception of situations or events. Events in the actual world have no meaning except that to which we choose to give to them. The operative word here is “choose.” This is the glass half full or half empty conundrum. The answer is how you choose to see it. Most of the time we don’t realize that we have a choice. As a clinician, I can gently point out that there is another way of looking at the situation. To the parents of a child with autism I might comment, “Your child has guaranteed you an interesting life.”  To a parent group in concluding remarks I often tell them that “your child comes bearing a gift and I hope in the course of raising your child, you find that gift.” Timing and context are important here. If done too early, it may be seen as being Pollyannaish and dismissed by the parents. The astute reader will also note that I have reframed mistakes into learning occasions and the difficult client into a teacher. It is all a matter of how we choose to look at them. 

People often ask me how I maintain my emotional balance in the face of so much revealed pain and suffering from my clients. The answer is: I reframe my clinical experiences. Out of the pain and suffering that I observe from them comes personal growth. Helping clients find skills to deal with adversity that would otherwise lie latent makes this work personally fulfilling.

5. What is the predominant feeling that most clients have about their child’s communication disorder?

Underlying many of my clients’ feelings is a feeling of grief. Some clients have lost the life that they thought they would have with their child, and to them, this is a significant loss. As a consequence, they are in mourning. Therefore, when we counsel of family member, we are often “grief workers.” We must understand that grief is not pathological. Our clients are upset and appropriately so given their life situation; they are not emotionally disturbed. They need a compassionate human being who listens nonjudgmentally to their pain of loss and validates their feelings.

6. How can I best help my client with their feelings?

The feelings that clients have are often very intense and painful. This is especially true around the time of a diagnosis and the beginning of therapy. The tendency of professionals is to try to make the client feel better. Often, they do this by using positive comparisons, such as “It could be worse. He could have (name some other disorder).” Professionals may also try to make the client feel better by instilling (usually false) hope by saying something like “People are working on a cure” or “Technology is wonderful these days and it will minimize the disability.” These are conventional responses and in the long run, they not very helpful because they tend to invalidate the client’s feelings. The result of this is to leave the person feeling guilty because they still feel the pain. The reality is that grief is painful and that needs to be acknowledged. We need to give our clients permission to grieve. Having them embrace their painful feelings is actually the first step in healing. So while it seems counter-intuitive, trying to cheer up a grieving client is a mistake. Instead, listening and acknowledging the pain is the most helpful response we can make.

7. What role does listening play in counseling?

Active listening is a fundamental skill in counseling and will enhance the counseling relationship. In addition, listening needs to be seen as an active clinical endeavor. All clinical encounters need to begin with the clinician listening closely to the client. In this way, the client will better reveal his feelings and the clinician can then find the best way to help the client. Active listening does not mean that the clinician is just silent. In active listening, the clinician has no agenda, does not pose questions, but instead, is witnessing and listening selflessly. The mantra for the clinician at the inception of the encounter is “This is not about me.”  Listening deeply is a gift we give to our clients because what clients need the most is to be heard.

8. How can I help a client who feels guilty?

Listening is the first step and with listening, there should be no judgment. We have to convey to the client the notion that feelings just are; they are not good or bad. This creates emotional safety so clients can reveal their deepest, and often their most painful, feelings. Guilt is one of those deep feelings frequently seen in parents. For mothers, it is usually around causation. For fathers, the guilt is often in being powerless to protect the family from pain. When guilty feelings emerge, it is often a marker of the support the clients feel. Parents need an opportunity to explore the basis of their guilt and ultimately to forgive themselves. It is often helpful to explore the behavior that stems from the guilty feelings. Behavior can be judged as being self-enhancing or not. Guilty feelings often lead to the overprotective parent or the overindulgent one; neither is in the best interests of the child. When a parent can say, “I feel guilty but I will not let the feeling interfere with good management of my child,” then therapy has been successful.

9. Is it OK to cry with a client?

Crying is often seen as a weakness when in reality it can be a strength. Weeping with a client shows your compassion and vulnerability. It is often very bonding. Clients need to feel that the clinician cares and is invested in their therapeutic journey. Crying with a client does just that.

10. How do I help parents who seem to be in denial?

Parents of children with communication disorders often display signs of denial. Denial plays an important psychological role in coping with adversity. When we feel overwhelmed by situations or events, we often cope by denying their existence, even in the face of evidence to the contrary. An example of denial is when parents won’t put hearing aids on their child with a hearing impairment.

The failure to understand denial is often a major source of conflict in the therapeutic relationship. Therefore, denial needs to be understood and addressed in the counseling sessions. If the clinician admonishes the parents for not having their child wear hearing aids, for example, it will only increase the parents’ feelings of inadequacy. Instead, attention should be paid to the underlying source of the denial, which is fear and feelings of inadequacy. Therefore, instead of admonishing the parents, the clinician should work to enhance their self-confidence and self-esteem in dealing with the issues. There is no greater clinical intervention than enhancing a client’s self-esteem. A remark that “it must be so hard for you to see him with hearing aids” can also be very useful. With increased self-confidence, clients will take ownership of their feelings and become true collaborators in focusing on the needs of the child.

11. What do I do with an angry client?

Probably the most dreaded client is the angry one. This is because most clinicians are programmed to please clients and are averse to confrontation. The strategy with an angry client is to not be defensive but to understand and help articulate the source of the anger. This is not an easy thing to do, but is often very fruitful. Typically, the major source of anger is failed expectations and as such, is almost inevitable in the therapeutic relationship. Once we understand the underpinnings of the anger, the encounter with an angry client can be more successful. Most expectations are implicit and seldom articulated. Clients have a reasonable expectation that their life would be like everyone else’s, but it is not. That failed expectation generates an underlying anger. This generalized anger is often displaced on the clinician. Clients often expect the clinician to “fix” the problem without them having to do too much work. When clinicians refuse to accept the rescue role and expect a collaborative relationship, anger often ensues. However, the emergence of anger is a good opportunity to negotiate an explicit contract with the client that defines each role.

The importance of staying with the angry client came home to me as a graduate student, observing my mentor counseling the parents of a child with Down syndrome. The father, a burly steelworker, said, “If anybody tells me my child is retarded, I’m going to punch him in the nose.” Dr. Gene McDonald, my mentor, looked at the father with compassion and said, “You must love your child very much.” This reduced the father to tears because somebody had finally heard and understood him.

Some clients feel frustration more than anger. This can actually be good in that mild frustration can provide motivation to change. Happy people are invested in the status quo and have no incentive to change. I often tell students, somewhat “tongue in cheek,” that if your client is not angry with you, you are not doing your job well. Frustration is common when the client’s child has a communication disorder and that in itself is a motivation to change how they respond to the child. In addition, the clinician needs to push the client to continue to acquire adaptive skills in response to their frustration.  

12. How can I deal with difficult or unlikeable clients?

There are those clients who seek help that are unlikeable to the counselor. As a result, the counselor may find it hard to develop an unconditional regard for them. I like the Dali Lama’s quote that says “We are all seeking happiness.” This thought enables me to see the humanity in each client. I have found that if I look at the client with eyes of compassion and non-judgment, most clients respond in kind. It is not easy and many times I have failed. However, I have found over the years that these difficult clients have been my best teachers. By taking me out of my comfort zone, they have made me a better clinician.

13. How does counseling account for multiculturalism?

From a counseling perspective, we are all multicultural. No two people are alike in any ethnic group and trying to account for the characteristics of a group often leads to stereotyping. Instead, each client should be considered as a wonderful experiment of one. This is why we need to begin each encounter from a listening stance with no expectations, therefore, allowing the clients to reveal themselves.

14. How do I get the father of my client to come to therapy?

Embedded in this question is a cultural insensitivity. It is a projection of the middle-class values of the clinician. Some families work quite well with the father not directly involved in the clinical activities. As long as the father is supportive of his wife’s efforts and she has no expectations of his involvement, the family can do well. That said, I think all programs need to have elements of family-centeredness and programs need to provide opportunities for family members to participate in the clinical activities. This would include siblings and grandparents as well. A family is a system in which all of the parts are interconnected and when one person in the system has a disorder, everyone in the system is impacted. For example, clinicians need to recognize that they don’t have just a child with autism to treat; they have autism in the family. However, if they choose not to participate or cannot participate, that also needs to be respected.

15. What do I say when I do not know what to say?

There is the parable of the king who asked his wise men what to say for all state occasions. After much thought, they came up with “This too shall pass.” So too with counseling, there are words for all occasions known as affirmations. To encourage a client to continue talking and indicating you are listening, a well-placed “Uh huh” would do.  A response, such as “That’s OK,” gives permission. “That must be so hard” is an empathetic response. To be effective, these responses need to be heartfelt, consistent with body language, and appropriate within the context of the communication.

16. How do I avoid mistakes? 

Mistakes are an unavoidable aspect of professional growth. However, if you always stay within your comfort zone in your clinical endeavors, then you will not learn and grow in your skills. Mistakes are markers for what you need to learn and as such, they are immensely valuable to your clinical growth. Hopefully, the first mistake is a learning occasion so that the same mistake is not made again.

In the realm of counseling, clinicians are often more risk-averse because they feel the client is most vulnerable in the emotional area. So mistakes seem to count more and fearful clinicians tend to play it safe. The fallback strategy for professionals is often information and advice giving which seem safe responses. However, as indicated earlier, they are usually not helpful. The counseling model proposed here of listening to and valuing a client is mistake free. You cannot hurt a client by listening and valuing them. Yes, painful feelings will emerge when you do this, it should be noted that the clinician just needs to acknowledge and accept the feelings. The clinician is allowing the feelings to emerge; people have wonderful capacities to make themselves feel better.

17. Are support groups important?

A communication disorder, by its very nature, is socially isolating. This is true for the family members as well as the identified patient. Therefore, the opportunity to meet with other people undergoing the same stresses can be very liberating. Group members have often said to me, “This is the one place that I feel understood.” Support groups are a vital programmatic ingredient because they attenuate the loneliness that all clients experience. We all need community, and a support group becomes an important vehicle for providing a community. Within the support group, individuals also get the opportunity to help one another. The group leader is not the sole source of information and a group becomes a vehicle for enhancing the self-esteem of its members.

18. When should you refer to a mental health specialist?

A client should be referred to a mental health professional when the issues presented by the client are clearly outside our scope of practice and do not relate to the child’s communication disorder. Clients who are mentally unstable or have other issues, such as marital problems or financial difficulties, should be referred to a mental health professional. The biggest issue is not when we refer but instead, how we refer the client. A clinician-initiated referral has the potential to be highly emotionally disruptive to a client who is not ready for mental health counseling or might be culturally appalled by the referral. It is best to say to the client that “this issue is outside my scope of practice and I am not prepared to help you with this.” It is preferable for the client to understand the reasons for the additional referral so that a joint decision is made for him or her to seek additional counseling. If the client chooses not to seek further help however, that decision also needs to be respected.

19. Are there people we cannot help?

Emphatically yes. There are clients who come with a different set of expectations than the clinician is able to meet. This variance in expectations is usually around their responsibility in the counseling process. There are clients who expect the clinician to fix their child, without much involvement on their part. Of course, this is incompatible with the clinician’s expectation of high family involvement. Therefore, at the outset of the relationship, it is necessary to make both parties’ expectations explicit and when they do not match, therapy should not be initiated or continued.

20. How can I further my education in counseling?

Aside from the obvious places to further education, such as continuing education workshops and reading literature, counseling expertise stems from good self-care and continued personal growth. To be effective, the clinician needs to be maintained at peak efficiency. You cannot counsel well if you are running on empty! It is also the little things during the day, such as giving yourself a bit of time to center yourself between clients. I always tell clinicians that they must take some time to breathe, eat lunch, and maintain a healthy life regimen.

Every few years, I seek out a personal growth opportunity. Recently, I have taken workshops in Buddhist philosophy. I have found that as I become more comfortable with myself, my scope of practice has expanded, and I think my competency has grown. I recognize that increasing counseling skill is a lifelong process.