20Q: Counseling Skills for Speech-Language Pathologists

From the Desk of Ann Kummer

Speech-language pathologists (SLPs) are called upon to counsel their clients and families regarding the diagnosis, prognosis, and treatment plan. However, very few SLPs have had education or training in counseling skills. As such, they rely mostly on their intuition and suggestions from colleagues. Fortunately, Dr. Paul Fogle is an expert in counseling. In this article, he provides information regarding the basic concepts of counseling skills and how to apply them in a clinical setting.

Paul Fogle earned his PhD at the University of Iowa and minored in psychology throughout all his degrees. He had additional extensive education in counseling psychology, educational psychology, and family therapy. He has been a speech-language pathologist for over 50 years and was a university professor for 35 years. Dr. Fogle has presented all-day seminars on Counseling Skills for Speech-Language Pathologists in cities throughout the U.S. and in several foreign countries. He is the main author of both editions of the textbook Counseling Skills for Speech-Language Pathologists and Audiologists (available through Amazon). He is the author or coauthor of four other textbooks and four therapy materials. Dr. Fogle has maintained a private practice since 1980, specializing in adults and children with neurological disorders, stuttering, and voice disorders.

This article provides great information about counseling and applies to all SLPs who work in a clinical setting.

Now…read on, learn, and enjoy!

Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Contributing Editor 

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

20Q: Counseling Skills for Speech-Language Pathologists

Learning Outcomes

After this course, readers will be able to: 

• Discuss the importance of speech-language pathologists learning principles of counseling and counseling techniques that apply to the various populations they serve and the settings in which they work.
• List at least two approaches to counseling that are most relevant to our professions.
• Describe the “microskills” we use during client interactions.

Paul Fogle 

1. I am a speech-language pathologist. Why do I need to learn about counseling?

That is an excellent question!  When I was teaching the required course on Counseling Skills for Speech-Language Pathologists at my university, many students asked that very question. I have made scores of presentations at national and international conferences and have presented all-day (6-hour) seminars in cities throughout the U.S. and in several other countries on counseling skills for SLPs. Most SLPs who attend my presentations have 5 to 30+ years of professional experience and work in every setting. I always ask at the beginning of a presentation, “How many of you do counseling in your work with clients and families?” Every single therapist every time raises their hand. ASHA (2016) recognizes the importance of counseling and specifically states that counseling is within our scope of practice. (Counseling has been within our scope of practice since the early years of ASHA.)

(Note: If you review the ASHA Portal on Counseling for Professional Service Delivery (Counseling For Professional Service Delivery (asha.org), you will see that much of the information provided comes directly from my textbook (often verbatim) Counseling Skills for Speech-Language Pathologists and Audiologists, Second Edition (Flasher & Fogle, 2012).  I chose Dr. Lyda Flasher, a clinical psychologist, as my coauthor because the book could contain information about counseling that cannot normally be addressed authoritatively by an SLP alone, for example, the threat of suicide or self-harm. I wrote about 75% of the book and Dr. Flasher wrote about 25%, but everything I wrote she made sure was accurate from a clinical psychologist’s perspective, and everything Dr. Flasher wrote I made sure was applicable to speech-language pathologists.

The reality is that SLPs use counseling skills in every interaction with every client, patient, or family, from the initial phone call, email, and our first face-to-face encounter with a person to our last encounter. Our tone of voice, choice of words, phrasing, body language, gestures, and facial expressions all give important (and often subtle) messages to the people we work with. All those messages include counseling skills.

Regretfully, very few university departments in the U.S. or around the world have a dedicated course on counseling for SLPs. Some departments say they “infuse” counseling in their various courses. However, that is not really sufficient because students (and then later, professionals) never have the foundation in counseling that allows them to apply counseling skills to the many disorders and people we work with (Johnson & Hall, 2023).  It would be like starting your graduate education without the necessary undergraduate courses that lay the foundation for working with the disorders. Most SLPs learn their counseling skills via OJT (on-the-job training), but that means they are making countless counseling errors before they eventually learn the skills they were never taught in their education.

2. Can we say we are “counselors” or “doing counseling”?

That is a very important question. Although we incorporate counseling and counseling skills into all our work, it is not appropriate to identify ourselves as “counselors.” We can only identify ourselves with the professional titles related to our education – our degrees. We are not psychologists or counselors, even though we study, understand, and use concepts of psychology and counseling. Rather than saying we are "doing counseling" with a client or family, it is better to say we are educating, training, or conferencing.

3. Do you think counseling is an art or a science?

Counseling is both an art and a science. The science aspect involves understanding psychological and counseling theories, principles, and skills. The art lies in understanding when and how to use those theories, principles, and skills. Sometimes just listening carefully to a person about their suffering and helping them overcome their aloneness and isolation is the best gift we can give a person. The science aspect of our care is unique to professional helpers and differentiates us from nonprofessional helpers. 

4. What are the differences between informational counseling and personal adjustment counseling?

Counseling can be divided into various categories, two of which are informational and personal adjustment counseling, both of which fall within the purview of speech-language pathologists. Informational counseling, also referred to as client and family education, involves discussing with individuals and families the nature of a disorder or situation, intervention considerations and techniques, prognosis, and material and community resources. The majority of SLPs do informational counseling.

Personal adjustment counseling addresses feelings, emotions, thoughts, and beliefs expressed by clients and their families, such as the realization of the pervasive impact a communication disorder on day-to-day life. For speech-language pathologists, personal adjustment counseling is the process of helping people cope with and manage the daily emotional components of their communication or swallowing problems (or both). This is where we use our most sophisticated counseling skills. It is also where the real art of our counseling comes into play and our best insights and personal and professional maturity are needed.

5. What are some of the challenges to our boundaries and scope of practice we need to be aware of when we are counseling clients and families?

This is a very important question. Challenges to our boundaries can occur in our first interactions with a client or family. We cannot avoid possible encounters with situations that challenge our boundaries, so we need to recognize them and have the tools to respond to them appropriately.

Usually, the longer we work with a person in a heavy counseling situation, such as with people who stutter and adults with voice disorders, the more likely challenges to our boundaries will show up. We can find ourselves on a slippery slope. For example, when a person leads us into trying to help them with their marital difficulties. Other challenges can occur when a parent wants us to help them with the behavioral problems of other children in the family. Stone, Shapiro, and Pasino (1990) provide the following rule of thumb: If a clinician is feeling tense, anxious, uncomfortable, or develops headaches while working with a particular client, patient, or family, it may be a “red flag” that the clinician is in a beyond-boundaries area for our profession or the clinician’s level of training and expertise.

If both the clinician and client bring considerable strengths (professional knowledge, experience, understanding, insight, patience, and maturity) to the working relationship, more issues may be addressed. We need to ask ourselves, “What ‘baggage’ (inner emotional turmoil, fatigue, personal biases, etc.) may potentially affect my therapy and counseling with this client or family?” Some days we can work with certain emotional issues more easily than others, but we still must do our professional job no matter how we are feeling and maintain stable, predictable boundaries and therapeutic environments. Sometimes, the client or family’s emotional pain will be similar to the pain we have had or are currently experiencing. During those occasions, we need to stay focused on the other person’s experience and not on our own.

6. What are some of the counseling theories or approaches that are important to SLPs?

Good question and a rather involved one, but I will limit the discussion. There are over 400 counseling theories and approaches in counseling, psychology, and counseling psychology literature (Prochaska & Norcross, 2018). (Note: There are differences in the education, training, and focus of professional counselors, psychologists, and counseling psychologists.)  There are several theories and approaches that apply directly and commonly to our profession, but I will discuss only a few.

• Family System Approach is probably the single most important approach we need to become very familiar with.  Family-centered therapy and person-centered therapy (which have been emphasized in our work only in the last decade or two) are based on the family systems approach that emerged in the 1950s and ‘60s. (Search 'family system theory' and 'family system techniques' to get a lot of good information).

Relatively few of the people we work with have significant psychopathologies. Most are just ordinary folks with typical anxieties, fears, and problems of life who are now dealing with a significant communication or swallowing disorder in themselves or a family member.

Some basic concepts in family system therapy are:

• Each family member affects all other members of the family. Within the family, there are subsystems: father-mother, brother-sister, father-son, mother-daughter, grandparent-grandchild, etc. When one person in a family changes (or a problem is identified), other members of the family are also changed and affected. For example, we talk about “a stroke in the family.” A child with a language delay or disorder affects the parents, siblings, and grandparents.

(When I do counseling seminars, I hold up a baby crib mobile with Mickey and Mini across from one another, and below them are Pluto and Goofy across from one another. When I move Mickey up and down a little, Mini of course moves too, but below them, both Pluto and Goofy also move. This demonstrates that when we help one member of a family, all the other members are helped too.)

• When interviewing or talking with parents or two or more individuals, don’t let one person talk for the other person. You want to get each person’s own information and points of view. You can do this by looking directly at one person and asking the person what you want to know, maintaining good eye contact, and leaning slightly toward the person. Avoid saying “Okay,” “I got it,” or some other words that tell the person you don’t need to hear anything more. When the person stops talking, wait, and wait some more, as if you are expecting more information. The person will often fill in the silence with important information or feelings you would not have gotten if you had not waited patiently and expectantly.  

When you feel you have gotten as much of the information as you can from one person, turn to the other person and ask the exact same question in the same way and with the same listening techniques.

• Always assume there is more to a person and family’s story than you will ever know. Avoid making assumptions about the person’s thoughts and feelings. Check them out. If you have an insight into a person’s thoughts and feelings, tell the person what you think, and then ask if that is about right. It is better for us to be corrected than to have erroneous assumptions.

• Families often give mixed messages (verbal vs nonverbal) to the person who is officially our client, and the nonverbal messages are often negative, such as a lack of acceptance of our client’s problems. When we notice a family member is being incongruent, we may gently make them aware of it. It is important for our clients to both hear and see the same positive messages. Clients with communication problems can easily become very confused.

• We are all familiar with Kubler-Ross’s (1969) classic stages of grief (denial, anger, bargaining, depression, acceptance). Although we use the word acceptance, for many people, it is more of a resignation than acceptance. We hear people say, “It is what it is,” but usually not in a warm or excited tone. They have resigned themselves to making the best of a bad situation, but if they could make things different, they would.

• Denial is the first (and automatic) response to loss. Denial may be seen as minimizing impairments or disabilities. Denial is built on fear of change or, more specifically, the inability to cope with change. We can help the person who is in this stage by providing information about the problems they are experiencing. We cannot talk people out of denying a problem, they will move on to the next stage when they have developed more coping abilities.

• We want families to participate in assessments and therapy. They are more likely to accept an invitation to participate when it is made clear that they can be helpful to their child or loved one by being involved from the initial evaluation and throughout therapy.

• As clinicians, we need to pay attention to the labels that family members give to one another (e.g., my “bright” child, my “problem” child, my “handicapped” child) and the way those labels affect our perceptions of our client. Negative comments or innuendoes from family may bias us in subtle ways about our clients.

• Triangulation refers to the process in which one or more family members try to get another member to side with them. (We all did that when we were children. When Mom would say “no” to us, we go to Dad and ask him. That way, we can say, “Well, Dad said it was okay.)  As clinicians, we need to be aware of when a family member tries to get us to side with them, either for or against another member.

• Each family has a particular pattern of behavior that serves to maintain its balance or homeostasis. Serious illness or injury inevitably disrupts the family’s homeostasis. We can sometimes help clients and families regain some of their homeostasis by listening to and understanding their struggles and saying something like, “Have you considered …? That might be helpful.” We want to help the family manage and cope with what they are dealing with.

• Cognitive-behavioral theory involves helping individuals become aware of their negative perceptions that affect therapy progress and helping them evaluate the validity of those perceptions. This is followed by taking steps to modify those perceptions and reinforce behaviors that are helpful to achieve the therapy goals.

We can help clients and families identify their negative perceptions of themselves and therapy and then help them rethink or reframe their perceptions to more positive and therapeutic views. For example, a person with a stroke who thinks he can never get better or a wife who says her husband isn’t getting any better. Affirmations (a therapeutic technique) can be very helpful here. Using more positive ways of talking to themselves about the aphasia can help them start thinking – and acting – differently.   

• Multicultural theory considers culturally diverse world views and is integral to counseling regardless of which other theories are used. The cultures of our clients and their families, as well as our own cultures, influence the counseling process both pervasively and profoundly. Culture plays an important role in a person’s belief system about health and illness and the experiences and beliefs professionals hold may be in stark contrast to those held by our clients and their families (Salas-Provance, Erickson, and Reed, 2002). As always, clinicians respectfully listen to varied views as part of culturally sensitive clinical decision-making.

7. I have heard the term microskills. What are they, and are they important to us?

I am glad you asked that question.  Microskills is a counseling psychology term that refers to “tools” we use to obtain information from clients and families and for understanding and working through challenging situations. Closed questions and open-ended questions are the types of questions we are most familiar with.

• Closed questions elicit yes, no, or other brief responses and often include the words is, are, or do. For example, “What is your name?” “How many children do you have?” However, if we ask too many closed questions, it can sound like an interrogation.
• Open (open-ended) questions (WH questions) are generally preferable to closed questions because they encourage longer and more expansive responses. Open questions usually include:
  • Who questions that 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 process that illustrates 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 why questions.)

8. What other kinds of questions are considered microskills?

There are more microskills than I can discuss here, but these are some of the most useful during interviews and counseling.

• Funneling questions guide the conversation from general to specific and are particularly helpful during an interview. For example:

  • Clinician: “How can I help you?”

  • Client: “I’m having trouble with my speech.”

  • Clinician: “What kind of trouble are you having?”

  • Client: “My boss thinks I get tangled up with my words sometimes.”

  • Clinician: “What do you mean tangled up?”

  • Client: “I’m having more trouble talking to customers on the phone than I used to.”

  • Clinician” “What happens when you have trouble talking on the phone?”

  • Client: “I have a hard time getting my words started.”

  • Clinician: “Can you show me what you do when you have a hard time getting your words started?” (Note: You are getting at the problem the client really came to you for. – He stutters.)

• Requests for clarification are helpful when you are not certain you understand what a person is trying to say. Requesting clarification involves either (1) paraphrasing what the client just said and then asking if you understood him correctly or (2) occasionally summarizing the conversation in order to clarify or confirm what has been said. After you summarize what you think the client said, ask if what you said is accurate. For example,

  • “Let me try to clarify. You’re saying that . . .”

  • “Could you try to describe what happened again? I’m not sure I’m understanding.”

  • “Let me see if I can sum up what we have talked about so far...." "What have I left out that is important?"

• Comparison questions help us understand what exacerbates or alleviates the client’s problems. Comparison questions tend to use phrases such as “better or worse,” “more or less,” “hardest and easiest,” “this situation or that situation,” and “with this person or that person.” (Much like going to the eye doctor and he asks, “Which lens is better, number one . . . or number two?”)  Ultimately, comparison questions are trying to answer more specifically the “wh” questions of who, what, when, where, and how.

• Counterquestions involve answering a client's or family’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 decided on. When a client or family 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 with a voice problem, you might ask the counterquestion, "How much longer do you think you need to be in therapy?")

Remember though, clients and families can ask us counterquestions. For example, “Why do you need to know about my work and how I get along with coworkers?” “Why do you need to know so much about my family?

• Sometimes we might want to make a declarative statement such as, “Please describe your child’s speech problems for me” rather than asking, “What kind of speech problems does your child have?”  Wachtel (2007) talks about the art of “gentle inquiry,” which is how we want our interviews to be. Our tone of voice, body language, gestures, and facial expressions (all being congruent) help our clients feel comfortable with us. More often than we might expect, a client or family will say to us, “You know, I have never told anyone this, but . . .” and then disclose some rather personal and often relevant information.

9. You have mentioned incongruent and congruent a couple of times, why is that so important in counseling?

Thank you for asking about that. Carl Rogers (1951, 1957, 1961, 1980) developed what is known as humanistic therapy and client-centered (person-centered) therapy. Along with the concepts of self-actualization (realizing one’s potential) and unconditional positive regard (love and acceptance for others (i.e., we should accept the person but not necessarily their behaviors), he emphasized congruence. That is, to be in touch with our own thoughts and feelings and to communicate with our words, phrasing, tone of voice, facial expressions, gestures, and body language the same verbal and nonverbal messages whenever we are communicating.

This is very important when working with clients, patients, and families. Although the people we see in therapy may give mixed messages, we should not. We cannot (and should not) say everything we think and feel, but what we do communicate verbally needs to be consistent with what the person sees. The proverbial saying “seeing is believing” transcends cultural, educational, and professional boundaries. If we are observing a person closely, we can usually detect when a person does not really believe what they are saying. Our clients and their families are “reading us” as much as we are reading them, and the reading is of our nonverbal communication. For the people we work with to trust us, they must believe us – and that means being congruent.

10. Are there any cautions when asking questions in interviews? 

That is an insightful question, and yes, there are a couple of cautions.

• Bombarding or grilling: Too many questions coming too fast (particularly the WH questions) can overwhelm clients and families and put them on the defensive. When a person feels defensive, they are more tense, and we want the person we are talking to to feel relaxed and comfortable with us. Keep in mind that the person asking the questions is usually in control of a conversation.

• Multiple questions: If we ask several questions at once or have a question embedded in another question, the person can become confused. It is better to ask a single question and wait patiently for a response.

11. What does “normalizing” refer to?

I am glad you have heard about normalizing.  Normalizing is an attempt to help a client or family recognize and accept that however they are feeling and thinking about whatever has happened is normal.  When they hear that how they are feeling or thinking about something is normal, they can begin to accept that they are not bad a bad person for thinking or feeling a certain way – That they are normal.  For example, the parents of a child who has had a serious traumatic brain injury or the wife of a husband with a stroke may have a lot of anger about what has happened to a person they love. You can read that in their body language, facial expressions, words, and voice. You can say, “Yes, it is normal to be very angry that your child was hurt so badly.” Or, “Yes, it is normal to be angry when a person you love has so much difficulty understanding and talking.” (Remember that behind anger is often fear – fear of the unknown.) Other “normalizing” phrases are: “It’s understandable that . . .” “It frequently happens that . . .” “I have had other clients feel like you do.”

12. Does counseling mean giving advice to someone?

That is a really important question, and I am glad you asked.  Professional counselors avoid giving advice (nonprofessional counselors give lots of advice).  It is much better to introduce thoughts and possible solutions by asking questions. For example, “Have you considered . . .”  “What do you think would happen if... ?”  “What do you think are the possibilities of . . ?”  “It’s possible that (X …) could work (happen). What do you think?” That way the person can take his own advice; we are simply providing something to consider. We can also help the person work through the decision process so he can still take responsibility for his own decisions and actions.

In therapy, though, we need to be direct in what we want the person to do, such as practice these exercises, make an appointment with the ENT, take smaller bites, eat slower, etc.

13. As therapists, we normally think talking or doing something is therapy, but how does silence play a part?

Our silence after a client has spoken can encourage him to say more than he would have had we jumped right in with more information or another question. Silence can give the client time to really hear and process at a deeper level what we have just said. And it can give the client time to process at a deeper level an insight he has just considered for himself. Therapists need to be comfortable with silence during times of counseling (Rogers, 1951).

14. I have difficulty telling clients and families the bad news when it is serious. Any suggestions?

Yes, you are having a struggle that a lot of therapists have.  The nature of our work is that we often must give “bad news” to clients and families when we are explaining the results of our evaluation or that we have to discharge a patient because insurance will no longer cover therapy. Bad news may be defined in practical terms as any information that significantly and negatively alters a person’s view of himself and his future (Hallenbeck, 2022).

Communicating difficult or bad news to clients and families can be an unpleasant and stressful task for us, particularly when it is about a child.  If bad news is communicated poorly, the person may never forgive you. But if bad news is communicated well, the person may never forget you.

SLPs present information that affects a person’s quality of life, in the present and sometimes for their lifetime. When the impairments are severe (as in TBIs and CVAs), and the prognosis is guarded or poor, the challenges of presenting the information require particular sensitivity. Most patients and families feel that the attitude of the one who gives the bad news, combined with the clarity of the message and the knowledge and ability to answer questions, are the most important aspects of giving bad news. The following is a discussion of principles from Buckman and Kason (1992) (The first book written on this important subject and was written by an oncologist and family practitioner.) and Monden, Gentry, and Cox (2016).

• A patient- and family-centered approach keeps the patient and family at the center of this difficult communication process. It conveys the information according to the patient's and family's needs. Identifying these needs considers the cultural, spiritual, and religious beliefs and practices of the family.

• The basic principles are: (1) deliver the news in person, (2) find out what the person already knows, (3) share the information clearly and straightforwardly, (4) assure the message has been understood, and (5) make sure there is follow up and follow through with the patient and family.

• The physical environment and presentation of yourself: The location should be quiet, comfortable, and private. Shake each person’s hand to reduce perceived emotional separation. Everyone should be seated when talking. The therapist should appear relaxed (at least not tense) and warm, with good eye contact, open body language (arms and legs uncrossed, hands open), and leaning forward slightly. Use a gentle but not faltering tone of voice with moderate loudness. If you are asked to repeat something, say it again with the same words and tone of voice so the person does not have to try to compare new words or word order. The therapeutic goal is to assist the person in processing what will likely be unsettling information. (A box of tissues nearby can be helpful.)

• What does the person already know: If appropriate, ask the patient or family what they know about the problem. This gives the opportunity to assess the accuracy of the person’s understanding and the level of sophistication of communication the individual has, which allows you to adjust your level of communication so you are not speaking either above or below the person’s language level. Reinforce accurate information using the person’s own words if possible.

• Communicating the news: It is helpful to alert the person that something serious is coming using a statement such as, “Mr. and Mrs. Z., the evaluation results on your (say the person’s name) indicate that she is having problems in several areas.” Then tell the patient or family the news straightforwardly and objectively. Disclosing the bad news may only take a moment, or there be several areas that must be covered.

If there is a moment or two of silence after you have spoken, say in a gentle and empathic tone, “What questions do you have?” (not “Do you have any questions?”). After you have answered their questions, make an empathic statement such as, “This is a lot of difficult information to take in at one time.”   Or, “You have heard a lot of people in the hospital talking about your child’s problems today. It can be overwhelming to hear so much at once.”  It is critical to promote hope and optimism (but not false hope). Focus on what you are going to be doing to help the person and family.

There are some things to avoid saying:

• “I understand what you are going through.” (We never really know. Even if we have had a similar experience, we don’t really know what this person is going through.)
• “I’m certain that some good will come from this.” (Let the patient and family decide that later, probably much later.)
• “I’m sure your son’s friends will welcome him back, and he will be just as popular as ever.” (We don’t know how his friends will react, particularly if the child has been seriously injured.)
• “Your child is a survivor. He is going to come out of this better than any of us might expect.” (Yes, the child has survived, but we cannot predict early on what the recovery will be.)

15. You mentioned “affirmations” earlier. What are they, and how can we use them in therapy or counseling?

Affirmations are wonderful tools, and I am glad you want to know about them. Affirmations are conscious, positive thoughts that help change a particular image or belief a person has about himself. They help people believe in themselves and put their thoughts into actions. No negative words are used in affirmations. We want clients to focus on what they want, not what they don’t want. For example, “My voice is smooth and relaxed.” vs. “My voice is not hoarse and tense.” Or, “My speech is easy and relaxed.” vs. “I don’t stutter now.”

16. How do people change?

That is a fascinating question. People change in essentially three ways.

• “Evolution” – A person slowly, almost imperceptibly changes over time.  It takes almost two decades to grow to adulthood. Our education is evolutionary over decades where we slowly gain our knowledge and understanding of the world. It can take years to become proficient and develop excellent skills in our profession. Affirmations work as an evolutionary process.
• “Revolution” – A significant event in a person’s life changes the way he or she thinks, feels, believes, and behaves.  A good example is when a person gets married – one moment, we are not married and the next moment we are a husband or wife. A cognitive shift occurs in our brains, and we start thinking and feeling like a married person. Another good example is when we have a baby. The moment the baby is born, the cognitive shift of becoming a parent is profound and pervasive, and we are never the same afterward.  For many of us, when we finally found speech pathology, we realized that this is what we wanted to do in our lives – and we were changed.
• “Resolution” – A person decides that it is now time to change. Some students who had not been taking their education seriously finally decide to really start studying. People resolve to lose weight or go to the gym to exercise. Some people resolve to stop smoking or taking drugs, or doing something else that is self-destructive.

As therapists, we know that rehabilitation is an “evolutionary” process. It can take months and months to make significant gains. But what do our clients, patients, and their families want? They want “revolutionary” changes. They want to get better and go back to work – like next week!  What all our clients, patients, and families need, though, is the “resolve” to stick with therapy, to put in the time and work to get the results they want.

17. I have heard about “transference,” but could you please explain it?

Transference is a very important concept in counseling.  The basic idea is that people view others through the lenses of their past experiences. Transference, then, simply refers to the lens through which we perceive new situations and people.

Clients and their families inevitably have feelings about their therapist, sometimes based on some previous positive or negative experiences with another therapist or authority figure. The feelings a person comes into therapy with about us are known as transference. The transferred feelings of the client may have nothing to do with how we are as a professional and a person, but the feelings are there nonetheless, although unaware or unacknowledged, by the client. If a client takes an immediate dislike of us, it is most likely from some difficult experience with a previous therapist.  As SLPs, we need to do the best job we can, no matter how a client or family feels about us.

On the other hand, there is also countertransference.  This occurs when we have an initial internal reaction (good or bad, conscious or unconscious) to our new client based on our own previous experiences. The experiences may have created unacknowledged or unconscious personal or professional biases from positive or negative experiences with a similar kind of person.  If we find that we have an instant like or dislike of a client, we should realize that we have already had some countertransference and need to be cautious about it influencing our work with them.

18. What are some challenging emotions and thoughts of clients and families that we might have to deal with?

Excellent question and things we all deal with no matter what work setting we are in.  First, our responsibility is to work with our clients and families in ways that their emotional states do not interfere with or hinder therapy progress. 

We need to avoid “pathologizing” and labeling clients and family members by saying they are depressed, anxious, paranoid, schizophrenic, narcissistic, histrionic, have a dependent personality, etc. Psychologists can do that, but we cannot. However, we can describe situation-specific behaviors that suggest a psychological or emotional problem. We need to keep in mind that even though a person has certain behaviors in an unusual situation for them, it does not mean these are typical of the person.

• Anxiety in a client or family is a common emotion we see.  But a lack of anxiety in response to a loss would be abnormal. There are different kinds and levels of anxiety that are a common component of communication disorders, such as acute anxiety, chronic anxiety, situational anxiety, and social anxiety. There is a continuum here: Anxiety → Fear → Panic.  Some people are more prone to anxiety and reaching the panic level than others. Fortunately, SLPs tend to have calming effects on people, which is why our conversations and counseling can be so helpful.

• Feelings of inadequacy are common when a person feels overwhelmed with a major new problem or challenge in their lives. We all know what it feels like to be inadequate and even overwhelmed with some new or difficult experience.

• Guilt is a frequent feeling clients and families have when they think they have done something that caused the problem they are dealing with, such as smoking, drinking, or taking drugs during pregnancy, causing the child to have speech, language, or cognitive problems, or driving drunk and causing the accident that seriously injured someone (or themselves), and so on.

• Resentment toward the person who has the communication disorder is seldom expressed directly, but it may be an underlying feeling that affects how family members treat the person, particularly when so many family resources (time, energy, money) must be used to help the person.

(Guilt is a feeling turned inward, resentment is a feeling turned outward.)

• Feelings of confusion are common when people are dealing with strange new and difficult experiences or are given more information than they can deal with. And we all know what it’s like to feel confused.

• Combined emotions are the reality.  People do not just feel anxiety, fear, inadequacy, guilt, resentment, or confusion. They can feel all of these at the same time – and more.  Most people have some means or strategies for coping with crises in their lives. We need to facilitate whatever inner strengths people have. Asking how they have coped with other crises or difficult situations and then helping them draw on those same resources can help them feel not so all alone and deal with the new situation that confronts them. If necessary, a referral to a psychologist or professional counselor may be needed.

The professional’s (our) feelings:  Like our clients and their families, we can feel all the same emotions they have. We can feel anxiety, fear, inadequacy, overwhelmed, guilt, resentment, and confusion when confronted with difficult and challenging situations, disorders, and people. We usually can be helped by our professional colleagues and even our families to talk through what we are struggling with. But do not think it is a personal or professional stigma or failure to seek professional help. It can be the best thing we can do to help ourselves.  (I have been in counseling more than once in my life.)

Remember: Take care of yourself so you can take care of others.

19. I have just heard the term dysthymia. What is it, and why is it important for us to know?

Not many speech pathologists are familiar with the term dysthymia, even though it can play a role in many of our clients and families' lives than we know about. Dysthymia is a low-level depression that, according to the DSM-5, must last at least two years before it can be officially diagnosed. Dysthymia affects women twice as often as men. Many factors are thought to contribute to the condition, including environmental, psychological, biological, and genetic factors. Chronic stress and trauma have also been linked to this condition. People with dysthymia at times tend to have bouts of major depression (a mood disorder).

How does it affect our clients and their families?  We may try to work with the parents of some children we see in the schools and wonder why the parents are never very motivated to help or work with their children. Or we may try to encourage the wife of a patient who had a stroke to try and do a few things at home that could help her husband, but she does not seem to have the energy or motivation to do anything. The reason behind the lack of motivation and energy may be an undiagnosed and untreated dysthymia. A person may have dysthymia for years, and it may never be diagnosed because the person cannot bring themselves to seek help. Realistically, it is very difficult for us to recommend the parent or spouse seek help for their low-level depression, but it is helpful for us to understand why some people seem much less motivated than what we might expect and not put our expectations on them that they cannot handle.

20. What part might post-traumatic stress disorder (PTSD) play in our work?

That is a very insightful question.  Many more of our clients and families than we might imagine deal with PTSD in their lives. PTSD is a mental health condition (not a disorder) that is triggered by a terrifying event, either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety, avoidance of similar experiences or situations, and uncontrollable thoughts about the event that may last for months or a lifetime.

Some of the children we work with in schools have had horrible experiences in their homes that can affect how they feel about themselves and life for years, if not forever. Children and adults who have been in terrible accidents may always suffer some emotional trauma from the accident. The husband or wife or the children of a seriously injured spouse or parent who was in a motor vehicle accident may always have some level of stress disorder from seeing or being with the injured loved one.  

And we don’t want to forget ourselves.  Many of us have had traumatic experiences in our own lives that still play a part in how we think and feel about ourselves and our lives. (Personally, I still deal with on a daily basis experiences I had in Vietnam in 1969 when I served as an Army Combat Medic. I used to think they would go away, but after so many decades I have realized they are with me for life.)

Addendum

As speech-language pathologists, we seldom know the long-term (life-long) benefits of the work we do with children and adults we have helped. After many years of work, we may occasionally come across a person we had in therapy years ago, and they may remember us. Often, we are gratified with how well they are doing. Although we should not try to take credit for their successes in their education, work, and life, we may feel that we were a small part of all the help they needed to get to where they are.

For the want of a nail, the shoe was lost; for want of the shoe, the horse was lost;
for want of the horse, the rider was lost; for want of the rider, the battle was lost;
for want of the battle, the war was lost – all for the want of a horseshoe nail.
Sometimes, we might be the nail.

There is so much more to counseling than what can be presented here, and I hope you search for the many resources that are available - particularly family therapy techniques.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th edition). Washington, DC: Author.

American Speech-Language-Hearing Association. (2016). Scope of practice in speech-language pathology. Rockville, MD: Author.

Buckman, R., & Kason, Y. (1992). How to break bad news: A guide for health care professionals. Baltimore, MD: Johns Hopkins Press.

Flasher, L. V., & Fogle, P. T. (2012). Counseling skills for speech-language pathologists and audiologists, 2nd edition. Clifton Park, NY: Delmar Cengage Learning. (Available through Amazon.)

Hallenbeck, J. L. (2022). Palliative care perspectives, 2nd edition. New York, NY: Oxford University Press.

Holland, A. L., & Nelson, R. L. (2018). Counseling in communication disorders: A wellness perspective, 3rd edition. San Diego, CA: Plural Publishing.

Johnson, L. W., & Hall, K. D. (2023). Counseling confidence in preservice and early career speech-language pathologists. Perspectives of the ASHA Special Interest Groups, 8(5), 1027-1038. doi.org/10.1044/2023_PERSP-22-00224  

Kubler-Ross, E. (1969). On death and dying. New York, NY: Macmillan Publishing Co.

Monden, K. R., Gentry, L., & Cox, T. R. (2016). Delivering bad news to patients. Baylor University Medical Center Proceedings, 29(1), 101-102. doi: 10.1080/08998280.2016.11929380

Rogers, C. (1951). Client-centered therapy. Boston, MA: Houghton Mifflin.

Rogers, C. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95-103.

Rogers, C. (1961). On becoming a person. Boston, MA: Houghton Mifflin.

Rogers, C. (1980). A way of being. Boston, MA: Houghton Mifflin.

Prochaska, J., & Norcross, J. (2018). Systems of psychotherapy: A transtheoretical analysis, 9th edition. New York, NY: Oxford University Press.

Salas-Provance, M., Erickson, J., & Reed, J. (2002). Disability as viewed by four generations of one Hispanic family. American Journal of Speech-Language Pathology, 11, 151-162.

Stone, J., Shapiro, J., & Pasino, J. (1990). The boundaries of counseling: Strategies for habilitation/rehabilitation professionals. Paper presented at Counseling for Rehabilitation Professionals Conference, Reno, NV.

Wachtel, P. L. (2007). Relational theory and the practice of psychotherapy. New York, NY: Guilford Press.