Hands on the Wheel Clinicians who set up their clients as the drivers prime those clients for the moment when they no longer need a navigator and can find their own way. Features
Features  |   May 01, 2015
Hands on the Wheel
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Speech, Voice & Prosodic Disorders / Fluency Disorders / Voice Disorders / Hearing Disorders / Audiologic / Aural Rehabilitation / Special Populations / Healthcare Settings / Professional Issues & Training / Normal Language Processing / Language Disorders / Attention, Memory & Executive Functions / Traumatic Brain Injury / Speech, Voice & Prosody / Features
Features   |   May 01, 2015
Hands on the Wheel
The ASHA Leader, May 2015, Vol. 20, 38-43. doi:10.1044/leader.FTR1.20052015.38
The ASHA Leader, May 2015, Vol. 20, 38-43. doi:10.1044/leader.FTR1.20052015.38
Rachel Sievers, an audiologist at Arkansas Children’s Hospital, has the same conversation with each of her first-time clients: “I explain to them that they are the ultimate decision-maker. It is their ear, their hard work.”
Years of practice seeing clients “from the cradle to the grave” have taught her that each person has to feel empowered to put in the work to get the best out of treatment. The need for clients to be the drivers of their own recovery is true across all disciplines, but many clinicians see clients coming to treatment expecting to be passive recipients instead of active change agents. How do clinicians help them make that transition?
When clients first arrive, they may be looking for answers, thirsty for a fix. The clinician is often seen as the repository of knowledge. And yet, as disfluency treatment pioneer Charles Van Riper once wrote, the client—not the clinician—must be the guide. Put another way, good clinicians are client-directed, rather than treatment-directed. According to Van Riper, the clinician’s role is critical, but not prescriptive; clinicians must show their clients how to assume the responsibility for their own choices and changes.
To be client-directed, clinicians must draw on the tenets of counseling, alongside their teaching capacity. The initiation of treatment, and its ultimate success, rest on clinicians’ ability to create a supportive, working alliance with their clients, as indicated in a meta-analysis published in 2000 in the Journal of Consulting and Clinical Psychology. To do so, they must foster three core elements: a positive bond, an agreement on goals and tasks, and a team approach.
Positive bond
The first key to a productive client-provider relationship is the creation of “unconditional regard” from the clinician toward the client, notes Diane Kendall, director of Washington University’s Aphasia Laboratory, in a 2000 article in Counseling in Communication Disorders. “The clinician must develop an attitude of unconditional regard, so that the client feels able to discuss all aspects of the disability,” she writes.
This unconditional regard comes from the understanding that the greatest wisdom resides within the client, according to Joseph Donaher, program director at the Children’s Hospital of Philadelphia’s Center for Childhood Communication. “Clients are experts on their stuttering,” Donaher says. “They know themselves better than anyone else.”

“Clients have to want to be there and want to work with you. It has to be valuable to them. So who are they and what do they want? What are they driving toward?”

If you listen closely enough, often the client will, perhaps unknowingly, reveal the best way for him or her to be taught. To tap into this wisdom, the clinician needs to practice judgment-free and focused listening, says Angela Ciccia, assistant professor in the Communication Sciences Program in Case Western Reserve University’s Department of Psychological Sciences. Empathy, she says, is key. It comes down to a simple mantra: “I see you. I hear you. I know this is hard.”
At times, developing this trusting relationship may take precedence over the active diagnostic process. Clients and their families often have to confront feelings of grief and loss. In the case of an infant diagnosed with hearing loss, Sievers explains that there is a “delicate balance of weighing the urgency of intervention with the delicacy of the parents’ process.” In this situation, the audiologist gives families the necessary information about available hearing technologies, while also explaining that the technology is not a miracle fix. The importance of offering hope is not overlooked, but parents are made aware of the challenges that lie ahead and are given the necessary time to resolve the loss of the life they imagined for their child.
Often the way to bond with clients has little or nothing to do with their disorders. “I don’t scream that therapy has to be fun, but it has to be something they want to go to,” Donaher explains. His love for sports often gives him an easy form of camaraderie with clients, although, at times, it takes a little homework on his part: “I don’t know much about wrestling but I have a client who loves wrestling, so I always do a little research on recent wrestling matches before I see him.”

“I know our bond is strong when I challenge kids, and they tell me what’s working and what isn’t working—when they have their own ideas—and I listen.”

Once Donaher and the client have discussed various subjects that they agree and disagree on, he introduces the subject of stuttering. Beyond creating a trusting relationship—one that will increase the client’s capacity for experimentation—this mutual respect prepares both parties for the difficult conversations ahead.
As with many of the most successful relationships in our lives, a productive therapeutic relationship is not always idyllic. There are times when a clinician might ask things of clients that they do not want to hear or do. A base level of trust is necessary to weather those disagreements. As Donaher explains, “I know our bond is strong when I challenge kids, and they tell me what’s working and what isn’t working—when they have their own ideas—and I listen.”
Joint agreement
When it comes to indicators of clinically significant change, “clients need to have a voice in determining the forms of change they consider worthwhile,” writes Walter Manning in a 2010 article in Seminars in Speech and Language. Before a therapeutic approach is mapped out together, the clinician must ask one key question: What is important to you?
Ciccia relates this to her work with children and adults with traumatic brain injury. “It is easy for clinicians to focus on their own training and what goals they would pick for the client,” she says. However, changes that the clinician may consider meaningful are not necessarily changes that are valuable to the client. To combat that tendency, Ciccia sees her job as eliciting what she describes as buy-in. “They have to want to be there and want to work with you,” she says. “It has to be valuable to them. So who are they and what do they want? What are they driving toward?”
Ciccia remembers working with a young adult with TBI who was desperate to go back to college, away from home. She could see that he was not yet cognitively ready, so they agreed that he would go to a local community college as practice. He was able to see which classes, papers and relationships were a struggle; they could work together on the specific areas he wanted to work on to achieve his goals.
When working with clients who stutter, Donaher sees collaboration as key. “Together we answer, what is success? We determine concrete signs of what it looks like when things are getting better,” he says. “We create clear and concise ways to measure how clients are doing in real life, beyond just fewer moments of stuttering.”
If one of his clients has not been able to succeed at something, Donaher will explain that it is his fault, because they designed the plan and the goals together. However, he will hand the reins of responsibility back, asking, “How we can make it better together?”
Across all disciplines, it is key that the conversation about goals and tasks continues beyond the initial meetings, spurred on by the clients’ self-assessment. Effective treatment is likely to alter the speakers’ views of themselves and their situations. A client who stutters may first arrive determined to stop stuttering, but as the treatment progresses, that client may decide it is more important to improve his or her ability to interact with others or make lifestyle changes.
This evolution of tasks and goals is particularly notable in patients with TBI and other medical conditions, when the evolution of treatment coincides with the evolution of their recovery, Ciccia says. At first they are healing from a traumatic medical event and, as Ciccia explains, “What we want when we are not feeling well is totally different from what we want when we are feeling better.”

“Together we answer, what is success? We determine concrete signs of what it looks like when things are getting better. We create clear and concise ways to measure how clients are doing in real life.”

As treatment progresses, the client may feel better and may lack full awareness of his or her own cognitive difficulties. They may feel that they no longer want help to recover. Here, Ciccia explains that the clinician may need to take the driver’s seat temporarily: “There is a fine line between what they want and what they need to get their cognitive conditions back on track. At these times, we have to reflect on what drives them and focus on their goals.”
Finally, in the later stages of their recovery, when clients are more aware of their cognitive deficits, they often want their old life back. For some that is possible. For others it is possible with modifications and, “for others we need to set new expectations together,” Ciccia says.
Team power
When we talk about the client as the driver we must be careful not to imply that the client is left to navigate the path alone. Rather, the search for understanding, change and recovery is a partnership. The clinician takes on the role of a constant ally, there to persevere alongside the client when the process of change slows or becomes difficult. Clinicians typically describe themselves as guides and coaches. They inform, connect and motivate. They are compassionate and understanding, playing different roles as necessary.
These ideas are in line with the pioneering client-centered theory of the late Mark Ylvisaker, a brain injury rehabilitation theorist to whom ASHA Special Interest Group 2, Neurophysiology and Neurogenic Speech and Language Disorders, devoted a tribute issue of Perspectives in 2014. However, in keeping with client-centered theory, the clinician must be careful not to over-help.
In the December 2003 issue of Perspectives on Fluency and Fluency Disorders, David Luterman writes that, “When we over-help, clients learn helplessness.” Luterman, professor emeritus at Emerson College, goes on to note that, “It is often very difficult to find the therapeutic equator of supportive helping without inducing dependency. It is a matter of being responsible to the client rather than being responsible for the client … one of the hardest things professionals have to learn is to allow clients the dignity of making mistakes.”
Ciccia explains how she walks this tightrope. “I have the knowledge to shape what you want, and to put it in a way that helps you do it right now,” she says. “And then you have to do it.” To keep clients in a role of responsibility, she asks them to notice the differences in their performance from session to session. To ensure that they are constantly engaged in their recovery, she turns their abstract goals into meaningful activities. For clients who are having trouble with word retrieval, she covers their room in Post-its that name each object, as well as the day’s activities.
For many, this team approach goes beyond the solo relationship with their clinician. Often the success of any rehabilitation program depends on the active participation of all in the family. This participation means that spouses or parents are enlisted as collaborators, not just as passive recipients of clinician expertise, according to Luterman.
For infants and preschool clients, the decision-makers in treatment are the parents. In these cases, the goal of treatment becomes the development of informed, independent and empowered families who have the ability to make good decisions for themselves and their children. To make that goal possible, clinicians provide the parents with specific and digestible information; they ask the parents to talk about the daily behaviors, experiences and interactions of their child; and they help them to understand and clarify their own ideas, attitudes and emotions, as described by Elizabeth Webster and Louise Ward in their 1993 book “Working With Parents of Young Children With Disabilities.”
When first meeting with the parents of a child with hearing loss, Sievers explains that they are the driving factor in success. “I encourage them to work hard, and I applaud them when I see any level of progress,” she says. As a mother herself—in particular the mother of a son with hearing loss—she knows how hard their position can be, and how the lion’s share of the work falls on their shoulders. Whenever possible, she works with the hospital’s psychologists and social work team to lighten the load in other areas of their life so they can focus on making the necessary alterations.
This assistance could be “anything from helping with behavior modification to helping them with their transportation to and from the session,” Sievers says. Often the best way to support the parents is to introduce them to other families. Within these family support groups (such as Hands and Voices), they can validate one another’s experiences, and the sharing of information can empower them outside the walls of the clinic.
As children get older and their comprehension starts to increase, it is important to include them as much as possible in the feedback and decision-making, Sievers notes, starting with small steps. In the case of children with hearing loss, Sievers may ask them to select the color of their hearing aid or to touch the equipment and learn how it works. The aim is to keep them informed so they learn greater independence and enhanced self-esteem over time. Eventually, as Donaher puts it, “The teen, clinician and family are all co-pilots in the treatment and each person has a specific role and goal.”
Their own road
Unfortunately, there may be times when relationships with clients become adversarial, and it is impossible to create the necessary connection with a client or the client’s family. In those cases, it’s OK to recommend that they work with someone else, Ciccia says. As she concisely puts it, “This isn’t about me.”
In thinking about the client as the driver, it seems to boil down to one simple truth: Treatment is about the client. It is not about the clinician.

There may be times when relationships with clients become adversarial, and it is impossible to create the necessary connection with a client or the client’s family. In those cases, it’s OK to recommend that they work with someone else.

As Diane Kendall writes, we must allow “the client and family to assume responsibility for choice and change in the client’s behavior. [We] as clinicians feel the need to be the information provider in the white lab coat, and often we want to be the rescuer. The result of this type of approach leaves the client feeling powerless, such that any change that will occur will come from an external source rather than from within. Clients and families must be empowered to assume responsibility for their own behavior and subsequent recovery, so that continual improvement will occur long after the formal therapy relationship has dissolved.”
In setting clients up as the drivers, we are preparing them for that future moment when they no longer have a navigator to guide them and they are compelled to find their own path.
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May 2015
Volume 20, Issue 5