Counseling (SR, chs. 4, 7, and 9)

1. Counseling(SR, chs. 4, 7, and 9)

2. Need for counseling • No need for counseling if they: • understand (example of not understanding “I don’t understand why…”) • accept (example of non-acceptance “This can’t be happening to me….”) • have heard enough (example of needing to hear more “What happens next?) • What we counsel about: • Making changes • Accepting and living with CD Lots of our model from fluency disorders

3. Roles of counselor • During diagnostic process • Interviewing client for their reactions to the Dx • Teaching/giving information • Modifying attitude/belief • During therapy process • Facilitating change • Encouraging adjustment/coping • Providing opportunity for emotional relief Practical suggestions include: Don’t give out your phone number…don’t spend a whole hour listening!

4. Example cases, counseling scenarios MR (example of not understanding) Disagreement over use of term, put SLP on spot, they may interpret MR differently Autism (example of not accepting) Denial of label. Wants child’s “speech” to improve. (We all have denial.) Aphasia (example of no longer hearing) Severe aphasia; request increase in treatment freq. when no change expected. “I wish that were the answer. I asked myself the same question earlier. More therapy won’t influence recovery” Voice– (muscle tension, dysphonia….referral?) “Let’s talk about what’s going on with your voice. How do you manage stress?” (referral to psychologist; need for getting att’n?)

5. Setting Boundaries Rigid boundaries “I’m not supposed to talk about this” “It’s not in my scope of practice / not my job” No boundaries “You’re not depressed, just sad” (outside scope of practice) “You shouldn’t put her in n.h.” (not your choice; but you can still call adult protective services…) “3-year-olds are too old to sleep with parent” (not my choice) “I will not let this happen to MY patient” (possession of client, too enmeshed). Better: I’ll do all I can do, but not take responsibility” Good boundaries (next slide)

6. Setting Boundaries Rigid boundaries No boundaries Good boundaries “I can’t help. I will refer if needed” “I can share information with them, but not decide what’s right for them” “I respect their decision” “I adapt my style and approach to the person” e.g. indirect approach with Hispanic mom “I’m wondering….” “I’ve seen this work….”

7. Variables That Influence Counseling(a few of the thousands!) Rapport – Immunity to litigation Type/severity of disorder Age (relative) --But don’t immediately believe you’re not qualified Family system and its nature—Social workers taught us this Emotional status Culture—high vs. low involvement cultures Resources/SES—no money even for coping mechanisms Expectations—”Fix the problem” Attitudes Previous experiences

8. Approaches to Counseling Directive: Clinician takes responsibility (clinician-led) High context cultures, lots left unsaid—e.g. Asian…we’re supposed to be expert For traumatic and highly stressful—flight attendant when crashing When fast change is necessary—child about to flunk Non-directive: “Client-centered approach”, self-explanation and education (In the past the same set of language stimulation recommendations were given to everyone. No longer.) Low-context cultures, much is directly stated—e.g. NYers, less concern for effect of words on “relationship” or feeling” When dealing with chronic problems When coping/adjustment important (give time to self-express) Behavioral (next slide) Cognitive (next slide)

9. Approaches to Counseling (cont.) Directive: Clinician takes responsibility (clinician-led) Non-directive: “Client-centered approach”, self-explanation and education Behavioral approach Attitude is changed by reinforcement and natural consequences associated with action. Specific goals are set and can be tracked through behavioral observation Works well with clients who are reluctant to share feelings and who expect specific advice. Cognitive approach “Thoughts create emotions”—Emphasis on changing thoughts. Change how they think about the issues, and they will feel better as a result. Actively refute irrational beliefs, such as “my life is ruined”

10. Approaches to Counseling (summary) Directive Non-directive Behavioral approach Cognitive approach BAG OF TRICKS. THE BIGGER YOUR BAG, THE BETTER YOU CAN HELP THE CLIENT

11. Structure of Counseling Session Formal: Planned, structured Informal : Unplanned, unstructured Components of session Opening (Look back and look forward) Re-establish rapport State purpose Set tone Middle: Biggest mistakes that all people make Guiding principles Closing Summarize Allow time to express self Give gime to process info

12. Structure of Counseling Session Formal: Planned, structured Informal : Unplanned, unstructured e.g., all of a sudden, one day, mom comes in: “You know, I was thinking again about my child’s performance in school” e.g. woman with aphasia arrives one day and is down in the dumps about progress: (structure your counseling into each session)

13. Incorporating Counseling Into Info Session Opening (Look back and look forward) Re-establish rapport: Start with positive “I see that..”“Thank you…” State purpose—also re-state what they came in for Set tone— “If you have questions, stop me at any time…” (discussion, not lecture). “I don’t have all the answers, but I’ll tell you what I know” Middle: Biggest mistakes that all people make: Child 2 SD below. Don’t say “a little low”! Say: “This is an area of concern. We’ll want to follow up with this” Guiding principles—Watch for non-verbals, engage them, summarize and simplify, don’t want the client to write you off Closing: Summarize, allow them time to express themselves, and give them time to process.

14. Some cultural examples: How to counsel in these cultures? Type A, goal/time oriented Sign on the foot of the bed _______ + ________ + _______ = go home _______ + ________ + _______ = go to n. h. Hispanic “He’s tired, he’s had a stroke, no therapy today”

15. Difficult Situations • Resistance • Denial (coping mechanism, e.g. child not autistic) • Questioning (lots of Q’s, another coping mech) • Discrepancies (pointing out discrepancies in information they have received) • Anger (displaced anger on therapist) • Overprotection (parent hovering over child) • Entitlement (this shouldn’t take this much work)

16. Coping With Difficult Situations 1) Stay calm. Recognize it for what it is. Don’t react. Don’t engage. 2) Understand their issues/motives (empathy) 3) Stay positive 4) Identify the issues that are key. Only a fine line between identifying issues and maintaining hope.

17. What you can’t ignore • Substance abuse • Abusive behavior- Must report by law • Threats of suicide— “Have you thought about suicide?” “Do you have a plan” A ‘yes’ = big red flag. Ask them how they’re coping. Invite discussion. Don’t confront.

18. Why you should strive for excellence in counseling • Better outcomes • Better job satisfaction • Expanded understanding of human condition