Introduction and Overview
I appreciate the opportunity to be with you today. You will see that the course title says, “Facilitating personal adjustment.” We will see that it has importance in how it is we conduct clinical practice. First and foremost, I need to disclose that I am receiving compensation for today's presentation, but there are no other financial relationships to provide you with.
We have an ambitious set of learning objectives, including looking at positive psychology as it may apply to communication sciences and disorders; looking at depression, which may very well be the result of the communication disorder that is present. We also will look at Audrey Holland's work, along with that of David Luterman. Holland has suggestions for promoting optimism and resilience among clients and families, and we will pay attention to those.
Goals
Some of the topics I will cover include, reviewing the scope of practice in speech language pathology because in the 30 years or so that we have had a scope of practice, it has been upgraded several times. The last iteration, in 2016, has more specificity than previous versions. As we evolve as a profession, we recognize emerging strengths and limitations that may be present in our collective skill profile. At this point in time, we are in a position to do a lot of good work with regard to communication counseling. We want to understand communication counseling, because that is the basis for our involvement in counseling at all. I would note that on a number of campuses, there is still some political pushback from other departments when they hear speech pathology and audiology using the term “counseling.” In our case, we are to follow the scope of practice with respect to what we have expertise in, and that is communication. We do not want to tread in the territory of our brothers and sisters who may be in psychology or departments of counseling, etc.
We want to appreciate, in terms of our goals, the role that emotions play with respect to communication disorders. As I mentioned previously, we also want to carefully look at the work of Audrey Holland and David Luterman. Holland is a speech language pathologist and Luterman is an audiologist, and they have both been in the professions for 50 years. They have done a good deal of groundwork for our work to follow, in helping individuals with problems related to communication.
I mentioned that depression may be a sidebar emergence around a communication problem, so we will spend a few minutes discussing where to get information for how we should be dealing with that clinical attribute.
Certainly, we want to spend a reasonable amount of time, if not most of our time, discussing how we can facilitate or assist clients and their families in dealing with the communication issue. Lastly - and I think it is an inherent expectation - if you have an interest in increasing skill and/or gaining greater confidence in the delivery of counseling, I have some ideas about continuing education that may be looked at beyond this course to help raise your bar and improve your bag of skills.
Assumptions
I would make these assumptions, and hope that they are legitimate for all of us. Perhaps your interest is in broadening skills, and that would be a great thing. We are going to watch the scope of practice and pay attention to that. Thirdly, and perhaps this is as important as anything, we are making an assumption that the individuals that we will be talking about are persons who are otherwise free from major mental health issues. We are not talking about persons who may be involved with other helpers who would be responsible for work in counseling; for example, psychologists or social workers or psychiatrists.
ASHA Scope of Practice in Speech-Language Pathology
The basis for this course is the scope of practice in Speech Pathology, shown in Figure 1.
Figure 1. ASHA Scope of practice in speech pathology.
Let's consider the first paragraph about providing education, guidance and support to families and caregivers and the person with the disorder regarding acceptance, adaptation, and decision making about communication, feeding, swallowing, etc. The decision making and feeding and swallowing are issues that occupy our collective speech pathology attention. In the second paragraph, you see that the process includes emotional reactions, thoughts, feelings and behaviors; that is where the facilitation of personal adjustment comes in.
Mandates
In essence, we are talking about providing information. Helping to empower individuals and families to make informed decisions and become self-advocates, of course, follows the provision of information. Oftentimes, a model that is employed is informational counseling, personal adjustment counseling. If, in fact, we have these two categories, I would argue that information counseling - the sharing of information - helps to build the relationship that will be terribly important in the facilitation process. So they really are not independent of one another; rather, they feed each other and are important in their own rights. Historically, when you ask professionals about their skillsets, they often feel much more adept at information provision than at the personal adjustment facilitation. There is a piece by Lieberman in the February 2018 American Journal of Speech Language Pathology - the reference is in our bibliography - that is a tutorial on counseling. He notes that it is not unusual to hear reports from professionals that they are not very confident with provision of some facilitative activities; this may be, in his estimation, due to a lack of formal preparation and then actual practice. It will not be surprising to you that in a few minutes, we will come back and make the recommendation that, in looking to advance our skillsets, we might consider finding other colleagues to practice with. We might simulate conditions or scenarios where we are sitting across from a would-be client and going through questions like, “How does this make you feel? How are you doing with your emotions, with regard to this issue?” and so forth.
We certainly do, among the Scope of Practice mandates, provide support to individuals and their families. After all, we are involved because we know the disorder. We recognize issues of onset. We have helped, oftentimes, in defining what the issue is. We provide information about what people ought to consider with regard to clinical management.
Lastly, we will oftentimes make referrals for individuals to seek the help of other professionals, particularly when we have a sense that some of their needs may exceed what we are prepared to provide comfortably and with integrity.
Shared Perspective
As this is a shared perspective, I am going to make an assumption that when dealing with persons having communication disorders and their families, we need to understand the issue professionally. Again, we intervene because we know communication. We assist clients and families in making plans. We provide advice about where the individual might go next. Certainly, we appreciate what the condition means, and we are in a position also to make suggestions about accommodation or adjustment. Our expertise in providing communication counseling is related to that knowledge about communication.
Emotional Circumstances
Here is a quote from Margolis (2003) in reference to what I am making assumptions about: “Because of the emotional impact of the information, personal adjustment counseling may be necessary to assist the patient and family so they can take positive measures to manage the condition.” Alongside this, I would simply state that I have been a practitioner in both speech- language pathology and audiology over my 45-year career, and I would be hard-pressed to recall an instance where there was not at least the strong prospect of there being some emotional piece to the problem that I was addressing. I worked for a period of time as an educational audiologist for the community schools where I was living, and it allowed me to talk to families of hearing impaired students and to get to know them over time. We talked about experiences they had had. Because I was teaching courses in counseling, I was interested to be able to report on experiences that people were aware of. I cannot count the number of times that parents reported to me - particularly after the initial case conference committee meeting - that they had barely made it to the parking lot before breaking down. They had been in an event where the table was full of professionals, each of whom gave their reports person by person to tell Mom just how much delay there was. There was hardly ever any talking about upsides. For the parent, that was devastating. I, of course, wanted to mitigate some of what may have been professional overkill, but at that point, it was a bit late.
Consider these emotional circumstances, if you would. We will just move through several of these, because I think we can all identify with, for example, the loss of a perfect child. Not that we expected perfect children, but the news about some shortfall can be hard to hear. In terms of a severity scale issue, it may be something that is rather limited in terms of impact or potential devastation. But if a parent has not heard “downside” information previously, there may be quite an initial shock factor. It may take some time for individuals to get past the delivery of, and make adjustment to, what is certainly necessary in terms of information giving.
There is another category, of course, which has to do with students being frustrated over peer reaction. The topic of bullying has gotten more attention over the last several years. Kids with communication issues are certainly more likely to be picked on and receive negative feedback in some shape or form, as they work their way through their school careers.
Stroke and/or other traumatic events, including traumatic brain injuries (TBIs), etc., may cause a sudden change in the relationships that were otherwise moving along just fine. Those who work in adult settings can appreciate and recognize that both the patient and significant other, as they become able to recognize deficits, are in a position to experience a great deal of negative reaction to the “downside.” The family now has to begin making accommodation or adjustment to the injured loved one, who is now different. As time moves along, the loved one may change or improve, but perhaps may not regain his or her previous status.
Part of our value is that our understanding of time course and progression in treatment allows us to give feedback to individuals who may be expressing frustration and a negative reaction to what is unfolding before them. After all, due to our expertise, we are likely to have seen similar situations before, and we are in a position to understand what may be coming, and to read signals about how quickly progress is being made or not made.
That is a segue to the point about degenerative conditions. In terms of our caseload types, we are more and more frequently treating individuals who are living longer but may have degenerative involvement. Alzheimer's disease is a prime example of that. As experienced professionals, we need to be in a position to promote adjustment to that. While the prognosis for retention of diminishing communicative skills may be on an individual timetable, we will be there to provide support for the individual and his family.
Lastly, we do encounter individuals whose expectations about treatment outcomes have not been met, or are not moving at a pace that was anticipated. We need to be prepared to hear questions and provide feedback along the way as we are working with different folks.
Needs for Personal Adjustment
We have loss, which can be intended or not so intended parting with things of value, including personal relationships and connection with loved ones. We see children going through developmental disabilities, for whom certain circumstances or certain behavioral challenges may not yet be emerging when we anticipated they would be. Loss is what drives the need for making adjustment.
There is deprivation, a lack of opportunity, which comes about from loss. Part of the definition of loss has to do with that deprivation.
There are primary and secondary examples of loss. Certainly, for someone having a stroke, the loss may be of the communication skills; whether the issue is increased difficulty with word finding or other forms of engagement challenge, it may rate as a primary loss element. Secondary loss may be the fact that Grandpa is not in a position to tell grandchildren that he loves them at this point in time. So secondarily, there is a lack of some of the familiar family engagements that people were accustomed to.
Of course, there is always the piece about loss that is idiosyncratic. It is about how we are feeling, the pain about what has transpired.
Facilitating
We are here to talk about facilitating. The definition of facilitate is to make easier, or to help bring about. We have known all along that we are change agents. “Facilitate” is a way, I think, to suggest that there may be different philosophical approaches to helping make things easier.
Resources – Audrey Holland and David Luterman
In fact, that is the reason for the examples of Audrey Holland and David Luterman. They are respected professionals who have long histories of providing the basis for counseling that we do in communication disorders. Odds are that we can look at their work and we are likely, at the end of the day, to develop our own translation of information and develop our own eclectic position. I have profound respect for both of them and I have worked with both of them.
Holland’s Grounding
Audrey Holland’s belief is that people who show up in front of us, the ones with communication disorders, are likely to have been moving through life coping with life rather well. Audrey is noted professionally for working with adults, and so she would explain the communication issues of children as being very much about helping facilitate adjustment for the parents. Her perspective comes from the positive psychology movement, and it focuses on what is right with people.
We are interested in helping with understanding, with explaining, with advising, and then with translating into action. The long-range objective is to foster optimism and resilience. In her mind, optimism and resilience will be the keys to moving on through life, regardless of the circumstances.
There are a variety of elements to the adjustment process. Grieving what has been lost and grieving is an important reaction to what she and Luterman would consider catastrophes. Whether it is the birth of a child with craniofacial anomaly, or the traumatic brain injury as a result of an automobile accident, family members grieve in the aftermath of what may be lost: the perfect child, the skills that are immediately at risk after the accident, and so on.
It is important to be able to provide these individuals with information that will help them understand what has taken place. Some of you are in clinical circumstances where you engage with families of persons who have had a TBI or stroke -- someone who has been moving along in life perfectly fine until now. At bedside, you can expect several questions from family that are almost universal: “How bad is it?” “Can it be helped?” “How long will it take?” Families are going to be pursuing that information because it helps them reconcile, and helps them begin to cope with what has taken place. In the delivery room, similar questions will be asked. When you are dealing with an infant or a toddler who has been, for example, identified as having significant hearing loss, you know that the questions will come. “How will he learn to talk?” “Will it keep him from being successful in school?” “Can he get a job?” “Will he go to the Prom?” There are all kinds of questions that come about as adults grapple with coping.
