Welcome to the show, Jerry really glad you're here. And looking forward to talking with you.
Oh, thank you. Thank you for inviting me. I'm happy to be here.
Yeah. I've been really impressed with your work on this. And so could you just give us some personal background, start by giving us a personal background and what kind of led you to doing research on the topics we'll be discussing today?
Yeah, I'd be happy to. So I'll just start by saying that I worked clinically for 10 years prior to returning for my doctorate. And at that time I was working in an acute care stroke and trauma center. At that time it was called Luther Hospital, now it's Mayo Clinic Eau Claire. And counseling was just a part of my everyday work there.
I will say that I had A great counseling course in my graduate program. And actually, I'm an alumni of UW Eau Claire. And that was really helpful from a foundational standpoint to have that kind of background knowledge and experience to go off of But, you know, that was really my start. When I returned from my doctoral program I was there at the same time that Eva Van Leer was there.
She's a voice expert from Georgia. And she got me really interested in motivational interviewing at that time. That really aligned well with my interest in cognitive rehabilitation. So I started doing some training incorporating motivational interviewing into my cognitive communication interventions.
Then I received some training did a lot of reading and counseling. And I had taught counseling for quite a while, actually, since I, came to UW Eau Claire, I started teaching I started teaching the counseling course there.
And it was always really well received from students. And one of my graduate students Aspen Dowd at the time, Aspen Townsend now did her master's theses on counseling practices which really solidified my interest in the counseling curricula. It was probably more in line with a PhD that don't tell us we're not yet, but then a master's thesis.
We were fortunate enough to have Audrey Holland on a, on her committee and conducted initially a, a nationwide survey of counseling programs. And might've seen that work that was published in 2020 looking at, the state of counseling programs at that time. And that was followed by a survey of practicing clinicians and then qualitative interviews of practicing clinicians specific to aphasia, but really kind of generic in terms of preparation you know, for anything that they might encounter in the field.
So so that really propelled me into this real interest about counseling. As a curricular issue. Since then had the opportunity. It was being chow. So reached out to me about developing the same 20 counseling group. And we worked with Tony Delalo. Yeah, Christopher Constantino, Laura Plexico and and later Rebecca Crowell.
to develop that group. And I think that has really kind of immersed me in a lot of conversations about counseling curricula and counseling practices throughout the discipline. The other thing was, is that I was on the doctoral committee for Jess Khan who has done some really fine work out of Australia in this area.
And Just really kind of embedded in that international conversation about counseling we've actually started just over the past fall, kind of just starting to get rolling on an international work group. looking at counseling training both that the graduate level or, or, you know, the training level, but also practicing clinicians.
It's specific to aphasia, but again, I think so many of those principles really just are universal across our discipline. So, it's funny how, Aspen's work really just kind of turned me in that direction with things that I was already doing.
But yeah.
Yeah, it's such an important area and I'm really thankful people like you are moving our field in a more holistic direction. As I was reading your work. I really appreciated your perspective on why counseling skills are crucial for speech-language pathologists and audiologists.
So could you start by laying that foundation for us?
Sure. And thank you for those kind words. I just, I always tell people that people with communication disorders have psychological and socio emotional adjustment needs either because they have some sort of a developmental impairment that affects their interaction with others or communication difference.
Or acquired communication and swallowing needs and parents have those same kinds of needs. Partners have those same kinds of needs as well. And because individuals with communication disorders have difficulty expressing those thoughts and needs that includes psychological and socioemotional kinds of needs as well.
We're going to come into contact with them on a regular basis. And they're going to have trouble expressing those needs. One of the things I encountered clinically was that I would make referrals back in the day for counseling and that, you know, they'd meet with the counselor and the counselor would tell me they didn't really say anything.
And I'd say, Oh my gosh, they've got, they've got so much to share. And that was with, you know, conversations leading up to it about using specific techniques and about how they could use them and so forth. But without a lot of collaboration and kind of working side by side. It's really tough for that training to transfer over to them to be able to use the techniques that they know well and to adjust them for, you know, a different set of needs.
And I just think we're uniquely qualified to meet those needs and to serve those needs. We have specific skills. That's our bread and butter. And typically we know that mental health counselors lack that skill set and certainly that's part of our role, right?
We have a role in training them and collaborating with them and working with Parallel just as they have a role in training us to enhance our skill sets. I've had the fortune of collaborating and interacting a little bit with Ian Kneebone, who is a psychologist and a counseling psychologist and his perspective.
And he's really well known in the counseling, education, counseling, implementation world. His perspective is always that. It's not so much about the degree that you have. So it's not whether you're a speech language pathologist or an occupational therapist or a nurse or whatever it has happens to be.
It's about your training and your preparation and confidence to deliver those interventions. So he said, I don't, You know, there's more than enough mental health psychosocial emotional needs out there to be met more than we can currently meet. So it's a matter of having people who are going to encounter those individuals really trained.
to deliver and that you're practicing at the level you're trained for. And I'm, I'm really a big advocate of that as well. So, I mean, if you're trained to do higher level interventions, you should do them and do them with confidence. And if you're not, then you should probably not be attempting them. Just think it's so important for us to recognize that we should be trained.
We're going to be in this situation a lot and we've got, you know, A lot of the skill sets we already need to be good counselors. It's a matter of building in some specific skills to enhance that.
Yeah, I think one of the first hurdles I see people running into is differentiating their role from say a counselor or a therapist. And, we were talking about using some counseling techniques, but we're not therapists. So how do you think about that differentiation between us and mental health counselors?
Yeah, that's a really good question. And something I meant to address earlier, too, was that scope of practice.
ASHA put out a scope of practice statement in 2016, which was really intentionally broad and vague to allow us to do what we need to do. And I think that's good from the standpoint of being flexible. But from the standpoint of having guidance for what to do, I think more specificity would be helpful to know what those practice boundaries are.
And to have a specific framework for understanding when we're in our area and when we're kind of out of our scope. That's something that the SIG 20 group is working on is developing new practice guidelines and drawing upon Ian Niebuhr. Ebone's framework for stepped psychological care.
Understanding when we're soundly in a level one intervention that, to be quite honest, all SLPs should be doing. It's the stuff we're trained in every single day. And when we're in a level two Where if you have specific counseling training, you should feel pretty solid, but also knowing when you get to those upper levels, those are areas that we don't have expertise in unless we have some specific training.
And we should be thinking about how can I work with a mental health counselor to address these issues? And I always say to my students, this is not a handoff. This is the beginning of a collaboration. There's a little bit of that sense that, Oh, well that's a, you know, that's a level three. That's I, that's not my stuff.
Like I'm just going to let them go to this other person, but it doesn't work that way. And it doesn't work if we're just handing things off because that mental health counselor needs some more support from us and, and they need us to be able to address issues when they arise in sessions. And we also need to be able to say, I know this is, you know, what needs to happen and, and why you need to talk to your mental health counselor about these issues.
It doesn't mean I'm not going to acknowledge them and I'm going to put up a stop sign and say, don't, don't say anything else. But it means that I recognize where those limitations are. And I think having those updated guidelines will be really helpful. There's been such a burgeoning of research on counseling across the discipline in the last six, seven years.
So it's time, right? It's time to have that specific information and a framework for understanding your place and in the world, so to speak.
Yeah, that's really helpful. I, that's that's, that's exactly what I was asking. So it probably would be helpful to move into some more specifics in terms of some of those specific clinical counseling skills that you really feel are essential for professionals.
Could you start by telling us a little bit more about those?
Absolutely. I kind of made a list of them and make sure I didn't miss anything. But I think training in active listening is really important and distinguishing, between what just listening is and what truly actively listening is, is really important.
I think a lot of people say, Oh, I listening is really important to me. Just listening alone. Yeah. There's power in that. Just feeling like you've been heard, but knowing you've been heard. Is that active counseling piece where you reflect and, and you affirm those feelings. So the person knows you've been listening, right?
It's one thing to sit there and nod your head, but if you don't show that you've actually taken in any of that information that loses its power. But really truly listening is verified. By that validation, those those statements of affirmations, those reflections, and that's when the person knows, Oh, like you're really listening to me evoking their needs and solutions really using those communication supports as a way to evoke and elicit those needs and solutions is important.
And I think a lot of people don't make the connect the dotted lines of. We've got these skill sets for eliciting communication and supporting communication. Those need to be used in that process of elicitation and evoking those needs. I think obviously being culturally sensitive and humble is really critical.
And that means being aware of those cultural differences, being aware of our own biases and You know, beliefs. And kind of being able to set those aside. Educational counseling is still really important. Counseling assessment. A lot of people don't necessarily refer to counseling assessment in our world, but counseling assessment is really finding out, you know, Is that person understanding the situation?
Are they understanding their needs? Are they able to convey the kind of information that we need from them? And then I think disorder or difference, specific knowledge is really important, right? So, how does this apply to individuals with fluency disorders or stuttering. How does this apply to individuals with swallowing disorders or palliative end of life care kinds of disorders and issues, child articulation, everything across the lifespan and across all of the areas that we have in our profession.
Having some understanding specific to those things, I think is really important. So some of its specific skills and some of it really distributed knowledge I think is really important.
Yeah,
definitely agree. Can you tell us a little bit what you've learned about the curriculum in communication sciences and disorders and how that's kind of evolved?
Yeah, absolutely. You know, I'd like to say that it's evolved a lot. But like a lot of things, unfortunately it has not. I do think we're getting to the point where we're starting to make some headway. And I think some of our next steps as a profession will lead us in that direction. And I know that Asha is doing some things from an advocacy standpoint to help with reimbursement and with agreements with other counseling professions about kind of where those muddy murky lines are between our professions.
But yeah, I, I know even some programs who had counseling courses in their curriculums have dropped them recently. And part of that challenge is just where to fit them in the curriculum. Because there's all kinds of other expectations being added too. And those expectations are important, like, you know, cultural diversity and humility among others.
So I certainly wouldn't argue to say, no, don't put those in the curriculum because they need to be there too. But making space and, you know, being able to figure out those priorities. Asha identifies counseling as one of the eight pillars of our clinical practice. And yet there's really not a requirement for courses.
when McCarthy and colleagues did their study, 76 percent of programs offered counseling courses. And yet graduate students really felt unprepared to address counseling moments. So even though they were there, they weren't really meeting the mark in terms of training students to be prepared.
And I think a lot of that has to do with including hands on opportunities for practice, just like anything else, right? You can't just hear about counseling to counsel. You have to have practice in counseling to be able to counsel and to feel confident with that. In 2017, when Aspen Dowd and Audrey Holland and I did our survey of the profession 59 percent of programs offered a standalone counseling course, which is actually.
step down. There were some improvements now at that point, ASHA required that counseling was a part of training. And I was going to kick out of the statistic. 97 percent of programs said that they embedded it somewhere in their programs. And I'm like thinking, okay, so 3 percent of you are not compliant with ASHA guidelines right now.
But yep, that's fine. I guess they were anonymous in their reports, but it always just kind of struck me as, shouldn't that be 100%? No, we don't do that. But yeah, in our, our forthcoming paper 47 percent of practicing SLPs had a course in counseling and interestingly enough, 66 percent of them had no further continuing education.
Education, training and counseling. And, and I think this number is remarkable. Only 26 percent had hands on training. And I think that's where the, do you feel comfortable and confident to deliver counseling comes in. If you, if only 26 percent of them have had hands on training, then it's just saying, here's this really complex idea.
Go ahead and use it in the future. That's pretty tough. We do know that practicing clinicians are much more comfortable with educational counseling because it's more concrete. It's more tangible than emotional adjustment counseling. But that's kind of where we're at right now.
Yeah. You had mentioned. The overcrowded curriculum or the important things that we need to teach students.
What are some other challenges that we face in terms of implementing of counseling training within
programs? Yeah. And I think, you know, the overcrowded curriculum is a part of it, but just not specifying that it needs to be in a course. That creates some flexibility, which I appreciate, right?
But it also limits that accountability. I think it's one of those things, if it's one of our eight pillars of practice, it should be a required course. And I think there's a way to work with curriculums and I, and I don't say that's an easy thing. Because obviously, you know, counseling is important to me acquired cognitive disorders and rehabilitation is important to me, so it'd be easy for me to say those have to stay but this has to go, but, so I don't think that's an easy conversation, but I do think as soon as you have that, you know, that flexibility being good, it just limits that accountability the other thing I think is true, there's a lot of different counseling approaches I have training in motivational interviewing.
I have some, a lot of knowledge about other counseling techniques, but prioritizing those is, is difficult. We all have different perspectives on how much of a role we should have in counseling. And they're not all the same there. And again, there's just no standards for designating specific elements for training.
I think having some of that, I mean, not being prescriptive so that People can't do what they believe is important but having some designation would be really helpful, I think. So I'm moving forward with the scope of practice paper updates and I think that'll be a step in the right direction.
But, I mean, I think those are the big factors that are limiting those incorporations into the curriculum.
Yeah, that makes a lot of sense. There really does seem to be a lack of standardization or consistency even in how it's being taught. And if it's being taught and what's being taught.
Agreed. And, and even from the standpoint of the training for the, the teachers,
I mean, in order to be able to teach this, there's really not a standard, you hope that people have training specific. to counseling to teach a counseling course. But that's not always the case. , having some, some standards, some consistency would be really helpful, I think.
Yeah. And you've written about the implications of this variability in counseling training. Can you talk about those?
Yeah. I go back to one of the, One of kind of the foundational papers in this area by Simmons, Mackey and D'Amico, and they really talk about how when you're not confident, when you're uncomfortable, when you're uncertain about things.
You avoid those things, right? It's true. I mean, their paper was about counseling moments. That's true about anything, if I don't know how to implement a specific strategy, I'm going to say, you know, probably do a little bit less of that. And I think that's true with all of us, right? Like I'm a speech language pathologist when I work clinically, probably Speech was like my least favorite thing to do.
Like I felt really confident and comfortable with language and cognition and swallowing. And it was kind of like, I want to work on high level speech stuff. And I'm like, are you sure? Cause you have more cognitive needs, right? So, I mean, I think that's just human to be like, okay, do we really want to go into high level speech when that's not my cup of tea or my level of comfort.
But I do think when, when we're not ready when we're not prepared for those moments. It's easy to say and moving on. And to be honest, some of the statements that we heard in our qualitative study were just remarkable that someone would say, you look like you're really sad right now. I'll come back in a half an hour when you are not.
And then we can resume therapy because we've got stuff to work on it. Like part of it is, it's amazing to hear that. It's amazing that someone and All respect to the person who said that in the study. I mean, it's kind of amazing that you would say that out loud, like, I'm not comfortable with this, so I'm going to leave or but there were a lot of comments about productivity and, you know, the balance of working on your other speech and language and swallowing goals At the, you know, at the sacrifice of counseling and vice versa, right?
Like it's hard. That's difficult to navigate, right? You still have to accomplish those things and and I think that accounts for some of it as well. Some people really feel like , this isn't billable. , as opposed to the work they're supposed to do on swallowing or COG or something like that that they don't, You know, kind of have the, the license or however you want to say it, that they should be doing this.
And I think that's one of the reasons we have to get it through, you know people's head that it is something that's billable. And we're working on ways to clarify that as well. And ASHA is doing some things to advocate for the discipline in terms of billing for counseling kinds of needs.
But I think the number one thing, as I said, comes right back to D'Amico Simmons Mackey, that idea of when you're not comfortable, you just redirect, we even know that in certain areas of the field we, we avoid it.
Like in the areas of, sexuality and difficult conversations about death and dying. We simply avoid it. We clinicians will remove parts of standardized surveys, where they're supposed to ask about those things like, Oh, you just had a stroke. You probably don't want to talk about sexuality. Right. Or.
We don't want to go down that road of talking about death and dying because that would make you feel sad. Well, it's a reality, right? And that could apply to a lot of different parts of our field as well. But our clients tell us, you avoid these things. You didn't give me the opportunity to talk about this.
And it was something I was going through. So. I think we have to be able to have techniques that put us in those situations. And there's good techniques that I think apply Across the of the lifespan and different disorders within death and dying and sexuality research and counseling There's this there's these approaches that essentially the number one piece is Offering that client permission like if you ever want to talk about this, I will talk about it
And you can say things like, we don't have to talk about this now, but if you're ever at a point where you want to talk about that I'm happy to have that conversation. And again, inside you might be thinking the exact opposite, but just saying that puts them in a position to say, Hey, remember a few weeks ago when you said, I want to talk about that now.
And that actually reduces the anxiety for the clinician as well, because they're like, yeah, I did say that. And the fact that you're telling me you want to talk about this makes it easier for me to talk about it too. So I'm not broaching something that that you're thinking you don't want to have a conversation about.
So it kind of breaks the ice and it It simplifies that process a little
bit. That's really interesting way to think about it. As I was listening to you, I heard two themes, comfort and compartmentalization, you know, first the comfort of knowing how to handle those situations. What are some ways that we can be.
Good counselors and being open to those topics, but then also compartmentalization, I think is part of what, we are up against a little bit in terms of thinking as counseling is separate from speech disorders or, you know, working on aphasia cognitive rehab or something. Would you agree?
Oh, completely agree. And that's just such a good point. When you understand, truly understand what counseling is, you'll see it in every moment of what you do. In teaching a graduate course on this for several years, it's always interesting at the beginning of the semester, you know, everyone is asked to find one of the clients that they're actually working with And identify the counseling moments and the counseling approach and, you know, It's classic at the beginning of every semester.
Well, I've got a four year old, so I'm not going to have any counseling moments. And by the end they're like, so I was wrong. Like there are a lot of these counseling moments and they just have a broader definition of what counseling is and what it looks like for those kinds of individuals. And then when you get that conceptualization, you start to realize like, Oh, This isn't two separate things,
so it's not as though I'm stepping away from language to work on counseling or speech to work on counseling. They are one. And understanding that is really important because then it, then it doesn't feel like you're trying to weigh like, how much should I work on this and how much should I work on something else?
I do think there are moments that are really pivotal moments where if you don't address the underlying upset, the counseling moment, it. you're not going to get anywhere on those other tasks anyway. So, I mean, it is a little bit deeper conversations and I think that's something as SLPs, you know, I always say we're classified as nonprofessional counselors and it doesn't mean we stink at it.
It just means that that we're not a mental health counselor. But that means we don't enter counseling moments in the same way that Mental health professionals do they go into it and saying, what are your issues today? Like, what do you want to talk about? We don't, we, these moments land in our lap, like by surprise.
And then we kind of have to deal with it. And if one of those big issues lands in your lap, You can't just say, Hey, how about we put that aside and talk about that later? You're not going to make any progress on whatever it was that you had planned to do. So it's really about following that client's agenda.
It's being person centered and saying, okay, so this is obviously more important. We're not going to try to talk about articulation when you're dealing with a deep psychological issue. We'll come back around to that, but I think that's important to recognize too. But yeah, you're absolutely right there.
They're one and they're not, it's not. Two things.
Yeah. As I listened to you say that, it reminds me, you know, we've all experienced the negative effect on outcomes of a resistant client, they're resistant to work for whatever reason, , we feel just fine setting up behaviorist plans, you know, in the therapy session, you know, setting up reward system or whatever. but for some reason, counseling, it's easy to compartmentalize. Whereas, there's no magic bullet in our field or in counseling, but if we can, stack the deck with a therapeutic alliance, that's going to feel more like winded our back in terms of getting that engagement , and subsequent client outcomes.
Absolutely. And I, I, I think the other key part of Therapeutic Alliance, and I always tell people, if I were going to add something to Borden's principles of Therapeutic Alliance, it would be that ability to acknowledge the individual's competence, and that is true of any age or any cognitive status,
people can see through an inauthentic, surface level kind of, I'm doing this because I have to. Three year olds can see that. 96 year olds with moderate to severe dementia can see that right? Like, oh, you're just doing this to get me to do something that that isn't the same. And I tell you what, from a motivation standpoint, when you've got a three year old who doesn't want to be in therapy,
or a 10 year old or whatever. And you're saying, you know, we're doing this because you have to, because your mom and dad say you have to write that. Yeah. That doesn't cut it. You want to find out like I'm listening to you. Like, what do you want to do? I see you as someone who has the right to contribute to this plan that changes things and that's huge from a therapeutic alliance
standpoint.
Yeah, that's a really great perspective on it. So you've mentioned some things that you recommend in terms of improving counseling training in our field. Do you have some others that you'd like to talk about?
Yeah, I think there needs to be training of instructors. There are some really wonderful teachers out there. But not everyone has that same set of knowledge and experience in terms of teaching counseling doesn't mean they can't be trained to. So certainly that's important. I think ensuring that interprofessional collaboration and practice is a part of that training is really important, beginning that dialogue and knowing where to begin.
Cause I think it can feel really territorial until you start the conversation. And then, and then when you begin that conversation, There's plenty to go around, right? No one's like, Oh, I don't want you doing my territory. They're like, I have no idea how to interact with someone with aphasia who has counseling needs.
So please, please, please be there in that moment. That's the conversation that you'll have once you begin those conversations. But I think the unknown is that you're thinking, no, they don't want me treading on their ground. Yes, they do. And vice versa. And then I think building up an evidence base for training programs.
Jazz Sakan has a really comprehensive training program that she's developed and she's working on implementing on a kind of a repeatable level, so to speak. I've done some work on collaborative counseling training with really hands on experience. And I, and I think that That kind of information will be really helpful for people.
So I think those are really the keys.
Yeah. I'm, I'm looking forward to seeing more of those and continuing to move our field forward here, Jerry. Again, I just really appreciate the work that you and other people are doing. You know, as we kind of get towards the end of our time, what are some key takeaways you'd like people listening to take from our conversation and your work?
Sure. And thank, again, thank you for the kind words. So we train and we have a lot of essential skills sets as speech language pathologists for supporting communication. And a lot of those are overlapping really parallel to what we need to do from a counseling standpoint. So some of that is just recognizing that we need to train those specific.
counseling skills and just the terminology that goes around it. I think one of the things that Aspen Townsend and I have noticed when we've been in sessions and doing some work together is that if you don't have the terms for it, you can't be intentional about it. So, I mean, I've been in situations where someone says, it's all just about listening.
And I'm like, Yeah, but it's a little bit more. You're right. Listening is huge, but it's more than just listening. Again, I think clarifying scope of practice and having some specific guidelines for that may help people to have a better understanding of their roles and those boundaries. And then developing some standards for training, I think will be a really important next step.
Yeah, I, I really love that perspective and it's really encouraging to see that coming in our field and continuing to be further developed.
I know there'll be people out there that would like more resources or more readings on this. Do you have some that you can recommend and I can get the links from you and put those in the episode description
as well? Absolutely. Well, not to self promote but I, I recently wrote a counseling book called Counseling and Motivational Interviewing Speech Language Pathology.
And I think that is a really comprehensive guide to implementing counseling. And there's some intentional work in there about training as well. There's a chapter on learning and training counseling. So I think that's important. The work that Aspen Dowden slash Townsend now, and I, and Audrey Holland has done on this, I think is important.
Aspen and I have a few papers out there and one forthcoming soon that should. Provide some more information. I really value the work of Jazza Khan. And she's done she's got a 2019 paper, a 2015 paper, a 2021 paper, as I mentioned before, Sarah Northcott out of the UK has a, has several really good papers, one in 2017 and one 2018 that really look at this.
Victorino and Hinkle have written some really good things about self efficacy and counseling. One paper that's really wonderful in 2019. And again, I really appreciate the Simmons, Mackey and D'Amico paper from 2011. It's oldie, but a goodie. But there's a lot of good stuff out there. If you, if you look at any of those papers, you'll get really a strong sense of the history of counseling.
in speech language pathology, audiology in the U S and in the UK and in Australia. So I think those are really good starting points. Yeah,
those sound great. And I'll link as many of those as I can in the description. So people can get their hands on those and, and subsequent work. So. Well, Jerry, I've really, really enjoyed talking with you about this.
I appreciate your experience and your thoughtfulness and the practical nature of your suggestions and just really appreciate your time and all the work you're doing. So thanks for joining
me today. Thank you. And thank you for the opportunity. It was a lot of fun talking about it.