«Anthony DiLollo, PhD, CCC-SLP Robert A. Neimeyer, PhD CONTENTS Foreword vii Preface xi Acknowledgments xvii Contributor xix Part I. Getting Oriented ...»
Anthony DiLollo, PhD, CCC-SLP
Robert A. Neimeyer, PhD
Part I. Getting Oriented 1 Chapter 1. Counseling in Communication Disorders 3 Chapter 2. What Does Counseling Really Mean 15 for Speech-Language Pathologists and Audiologists?
Chapter 3. The Leadership of Therapy: 31 How to Integrate Counseling into Your Clinical Practice Part II.
Theoretical Foundations 45 Chapter 4. Overview of Approaches to Counseling 47 Chapter 5. Constructivism 57 Chapter 6. Narrative Therapy 65 Chapter 7. Evidence for a Constructivist Approach to 71 Counseling in Speech-Language Pathology and Audiology Chapter 8. A Theory-Based Framework for Counseling 89 Part III. The Process of Counseling 107 Chapter 9. Listening for Thick Descriptions 109 Chapter 10. Facilitating Reconstruction 127 Chapter 11. Externalization and Relative Influence 143 Questioning: A Case Illustration v vi Counseling in Speech-Language Pathology and Audiology Chapter 12. Adaptive Counseling and Innovative 161 Moments: A Case Illustration Chapter 13. The Credulous Approach and 171 Reconstruction: A Case Illustration Part IV. The Clinician’s Toolbox 181 Chapter 14. A User’s Guide to the Clinician’s Toolbox 183 Chapter 15. Autobiography of the Problem 187 Chapter 16. The Story Mountain 195 Chapter 17. Drawing 205 Chapter 18. Dear John Letter 213 Chapter 19. The Downward Arrow 219 Chapter 20. Self-Characterization 227 Robert A. Neimeyer, Chris Constantino, and Anthony DiLollo Chapter 21. Experimenting with Experience 239 Chris Constantino, Robert A. Neimeyer, and Anthony DiLollo Chapter 22. Chair Work 255 Robert A. Neimeyer, Chris Constantino, and Anthony DiLollo Chapter 23. Play Therapy 273 Chapter 24. Therapeutic Documents
It is a pleasure to be asked to prepare a foreword for any good book.
But it is a special pleasure to do so when you are familiar with the authors’ work and look forward to reading chapters that you know will be thoughtfully and skillfully prepared. Students and professional clinicians in the professions of speech-language pathology and audiology will find this book an essential tool in their therapeutic practice. As I read through the concise and engaging chapters, I often found myself thinking of the many clinicians who—as the research indicates—are hesitant about counseling their clients. Although all readers and their clients will benefit from this book, it is the hesitant clinicians who will find this book especially useful.
DiLollo and Neimeyer provide the clinician with a clear theoretical rationale and intuitively appealing processes for connecting with and assisting clients with communication problems. Readers will be moved by the case illustrations that document the heroic journeys that are possible as a result of effective counseling for communication problems.
The authors explain in the preface that their goal in writing this book is “to provide an empirically informed and practically oriented manual for counseling clients with a broad range of communication disorders” (p. X). Their many years of counseling experience are necessary for achieving this goal. But it’s their thoughtful sequencing of the 26 chapters and their clear and engaging writing style that make it happen.
The early chapters provide a model that includes counseling as a natural and essential feature of the therapeutic experience for those with communication problems. The authors also document that counseling is clearly within the scope of practice for professionals in our discipline and that effective therapy and counseling are inseparable. They make the essential point that, in the vast
viiviii Counseling in Speech-Language Pathology and Audiology
majority of cases, we are assisting essentially healthy people who must cope with specific communication problems rather than people who need help with more basic personality issues. Of the four levels of progressively more concentrated counseling outlined in Chapter 2, the first two levels of counseling, focusing on a greater understanding of the client’s situation and the client’s ability to experiment and adapt to more effective coping, are all that is necessary for most individuals.
In Chapter 3, the authors describe the unique stance of the clinician as one of “adaptive leadership” rather than providing a service intended to “fix” the client. Rather than considering the person through the lens of the medical model where a breakdown in the system needs to be repaired, a more holistic approach is offered that considers the person as a complex adaptive system where changes to one part of the system results in changes to other parts. The primary goal of the clinician is to mobilize the client to do the work that is necessary for change to occur. Adaptive leadership by the clinician leads to adaptive change by the clients, with clients experimenting, not only with new ways of behaving, but also with new ways of conceptualizing themselves and their situations. In this chapter and throughout the book, the authors provide vivid examples of clinical experiences that illustrate the concepts and techniques that are necessary for change.
Part II (Chapters 4–8) provides clear descriptions of the theoretical foundations of counseling (humanistic therapy, behavior therapy, and cognitive therapy) and introduces the reader to the primary focus of the book, the constructivist-narrative approach.
Part III (Chapters 9–13) describes the processes that are part of the constructivist-narrative approach, with each process accompanied by a case description that is both vivid and moving.
The reader begins to appreciate that at the core of the constructivist-narrative approach is a focus on the “client as the expert” and each client’s personal narrative. Rather than being in the role of the expert or the “fixer,” the clinician has the opportunity to share an adventure with clients as they alter their relationship with their problems. The clinician’s stance is that of a curious observer and listener of the client’s current narrative. As the client’s dominant narrative is deconstructed and externalized via activities that are a natural part of the therapeutic conversation, ix Foreword the conceptualization of the situation moves from “the person as the problem” to “the problem as the problem.” The therapeutic experience becomes more about the development of a dynamic therapeutic alliance and the meaning of the activities as much or more than it is about the behavioral techniques that are a necessary but not a sufficient aspect of successful therapeutic change. The goal is to help clients to experiment with their relationship with the problem and to develop an agentic life style. Along with providing supporting empirical evidence for the effectiveness of the constructivist-narrative approach, the case illustrations in Chapters 11 and 12 bring home informative and touching examples of the power of adaptive counseling centered on the client and client’s resources and values.
Part IV (Chapters 14–25) describes the rationale and procedures associated with a variety of “tools” for working with clients from the constructivist-narrative perspective. These 12 chapters in Part IV are intended to be stand-alone chapters that can be read by the clinician as the need arises. The final section (Part V, Chapter
26) is a thoughtful addition intended to help instructors teach the constructivist counseling framework to students.
As a clinician and a person with a history of stuttering, I have often witnessed two essential changes that occur during a successful therapy experience—clients’ abilities to reconstruct their cognitive view of themselves and to successfully manage their communication problem. This book provides a concise, engaging, and effective way for the client and the clinician to facilitate those changes and create an agentic and autonomous lifestyle. I recommend it to both students in the discipline and seasoned professionals who are looking for a theoretically elegant, empirically informed, and immensely practical way of helping clients revise constraining stories of their relationship to their communication problems in the course of responsive counseling.
What is the role of counseling when working with people who have communication disorders? The answer, it seems, depends on who you ask! On the one hand, the official position of the American Speech-Language-Hearing Association (ASH A) and the American Academy of Audiology (A A A) is to regard it as a mandatory dimension of clinical practice, as we will see below. On the other hand, more than a few students and practitioners are leery of stepping into a territory they associate more with psychology or psychiatry than with speech-language pathology or audiology. Our goal in this brief chapter is to provide a general introduction to the concept of counseling in our fields by exploring the “disconnect” between policy and practice, and to consider prevalent myths about clinical practice that act as barriers to counseling.
A number of years ago, I was teaching a course on counseling to speech-language pathology and audiology graduate students. We had just finished a discussion of the importance of counseling and the need to get to know your client’s story when, during a break, one of the students came up to talk with me. “I have an aphasia client,” she said, “and, based on
34 Counseling in Speech-Language Pathology and Audiology
what we have been learning in this class, I wanted to spend our first session together getting to know her and how she feels about her life now.” “That sounds like a great idea,” I said, feeling rather pleased with myself for making an impact—until she finished her story: “But my supervisor told me that I had to follow my lesson plan because the client came here for therapy, not counseling.”
A Mandate for Counseling
As speech-language pathologists and audiologists, what we do is at least in part directed by a series of documents that have been carefully drafted by committees of our peers through our national accrediting agencies, ASH A and A A A. These documents provide detailed descriptions of the role of speech-language pathologists and audiologists, including the skills and practice patterns that are deemed appropriate given the goals of the professions.
scope of Practice and Preferred Practice Patterns
The term “counseling” is specifically and extensively referenced in key documents officially regulating practice for both speechlanguage pathology and audiology. For example, in the ASH A Scope of Practice for Speech-Language Pathology (ASH A, 2007), the wording related to counseling clearly states that clinicians should engage in “counseling individuals, families, coworkers, educators, and other persons in the community regarding acceptance, adaptation, and decision making about communication and swallowing.” Furthermore, ASH A’s document titled Preferred Practice Patterns for the Profession of Speech-Language Pathology (ASH A, 2004) notes that counseling should be “conducted by appropriately credentialed and trained speech-language pathologists” and that it should involve “providing timely information and guidance to patients/clients, families/caregivers, and other relevant persons about the nature of communication or swallowing disorders, the course of intervention, ways to enhance outcomes, coping with disorders, and prognosis.” 5 Counseling in Communication Disorders Similarly, ASH A’s Scope of Practice for Audiology (ASH A,
2003) specifically mentions counseling in its description of “what audiologists do,” and The Preferred Practice Patterns for the Profession of Audiology (ASH A, 2006) lists counseling in Section IV, Item 23, and provides a detailed description of the process of counseling as “interactive and facilitative, wherein the communicative, psychosocial, and behavioral adjustment problems associated with auditory, vestibular, or other related disorders can be ameliorated.” Furthermore, A A A’s Scope of Practice (A A A, 2004) document describes the role of the audiologist as providing “counseling regarding the effects of hearing loss on communication and psychosocial status in personal, social, and vocational arenas.” Likewise, A A A’s Standards of Practice for Audiology (A A A, 2012) indicates that audiologists must provide counseling to “improve a person’s use of residual auditory and/or vestibular function or cope with the consequences of a loss of function” and to “provide support to patients and their caregivers to address the potential psychosocial impact of auditory and vestibular deficits.” In addition to scope of practice and preferred practice patterns, both A A A and ASH A provide a code of ethics that also guide clinicians in what they do. Both of these Code of Ethics documents (A A A, 2011; ASH A, 2010) mandate that clinicians should engage in all aspects of the professions within the scope of practice and provide all services competently, using all available resources to provide high-quality service.
What emerges from study of these guiding documents is that we as clinicians have a mandate to provide clinical services beyond the simple teaching of behavioral techniques or use of technology.
Moreover, it is our ethical responsibility to seek further education to ensure that we are providing services commensurate with our scope of practice and preferred practice patterns.
A Disconnect Between Principles and Clinical Practice As might be gleaned from the vignette at the start of this chapter, despite the clear mandate to engage in counseling embodied in the scope of practice and preferred practice patterns for both 6 Counseling in Speech-Language Pathology and Audiology audiology and speech-language pathology, many clinicians historically have been reluctant to provide such services (Citron, 2000;
Clark, 1994; Crowe, 1997; Erdman, 2000; Garstecki & Erler, 1997;