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Department of Audiology and Speech Language Pathology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
Department of Audiology and Speech Language Pathology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
Corresponding author. Department of Audiology and Speech Language Pathology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, 575001, India.
Department of Audiology and Speech Language Pathology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
Counseling is important in service delivery in the field of Speech-Language Pathology. The skills required for counseling can be utilised during the assessment and management of all communication disorders. To develop, validate and administer a questionnaire assessing current perspectives and experiences of working speech-language pathologists practising in India towards counseling.
Methods
The questionnaire consisted of 36 questions towards counseling which were completed by 116 speech-language pathologists. Statistical analysis was carried out using Jamovi 2.0.0.0 to determine descriptive statistics and the internal consistency of the questionnaire using Cronbach's Alpha.
Results
The participants perceived the importance of counseling and were comfortable with providing counseling. The most common source of knowledge on counseling was reported to be discussions with colleagues and friends. The participants considered all the suggested aspects of counseling to be extremely important. The most common area difficult to counsel was reported to be reading and writing disorders.
Conclusions
The questionnaire helped in providing insight into the current perspectives and experiences towards counseling in the field of communication disorders in India.
The term ‘counsel’ is a broad term that refers to some advice, opinion or recommendation given regarding some decision as well as a discussion of options for the future.
Counseling plays a crucial role in strengthening the client-clinician relationship. Studies in Speech-Language Pathology have identified different purposes and major aspects of counseling. These involve active listening, prevention, or reduction of disorder severity, conveying information, addressing clients and family's emotions, providing support, empathy, motivation, independence and different intervention options.
Counseling forms the basis of all interactions providing solutions to the clients' problems, indicating their mistakes, and providing suggestions and to create a positive change in their life.
Counseling clients and their families with speech, language and communication disorders about their diagnosis and treatment options are within the scope of practice of speech-language pathologists (SLPs).
The goal of counseling for SLPs involves facilitating the clients to explore and find their own answers, experience some sense of control, and have a new perspective and confidence towards self-care.
During counseling, SLPs need knowledge about the anatomy and physiology of the different speech, language and hearing structures. Further, understanding the condition, its disabling effect on the client and his/her family and their coping reactions are also extremely important.
Skills such as listening actively, knowledge of using open-ended and close-ended questions appropriately as per the requirement, ability to handle individuals' negative feelings and including non-verbal communication are considered to be important while counseling.
The clinician should focus on being a good communicator by understanding that individuals with communication problems have accompanying emotional disturbances due to which their emotions need to be acknowledged. Respecting and accepting clients’ cultural values, being optimistic and flexible are also other important personal characteristics required by SLPs during counseling.
Clinicians in India need to consider different multicultural aspects during counseling such as the importance of family members, as family plays a very important role in the decision-making process of a client. There is a dearth of information regarding understanding the perceptions and experiences of working speech-language pathologists on counseling in India. Thus, the purpose of the present study was to explore the perspectives and experiences of speech-language pathologists practising in India towards counseling by development, validation and administration of a questionnaire across different age groups, gender, experience, and work settings.
2. Method
A cross-sectional questionnaire-based online survey was carried out to explore the perspectives and experiences of SLPs practising in India towards counseling. The study was carried out after the Institutional Ethical Committee approval from Kasturba Medical College, Mangalore (IEC KMC MLR 03–2021/99). The sample size was calculated using the estimation of population proportion formula which is, n = (Z1-α)
as well as expert opinion. The questionnaire was validated by five SLPs with over ten years of work experience. The respondents had to rate each question using a four-point rating scale; not relevant, somewhat relevant, quite relevant, and relevant.
Those items which were given a rating of relevant and quite relevant were retained in the final questionnaire. The questionnaire was developed and administered in the English language. The final 36-item questionnaire included; demographic details, perceptions towards counseling, importance of various aspects during counseling, and experience towards counseling. The final questionnaire is available upon request.
2.2 Phase two - data collection and data analysis
SLPs with one year of work experience after their final degree, practising in India were included in the study. Undergraduate and postgraduate students pursuing their degrees in the field of Speech-Language Pathology and Audiology were excluded. SLPs who had studied in India but presently practising in other countries were excluded.
The questionnaire developed and validated in phase one was converted to an online Google Form which was sent via electronic mail to the participants. The contact details of the participants were procured from the Rehabilitation Council of India and/or Indian Speech-Language and Hearing Association. Approximately 500 SLP contacts were obtained and were requested to participate in the online survey, out of which 116 SLPs consented to participate in the survey. Data was collected during the month of April 2021 using Snowball sampling. No identifying personal information such as name, contact details were collected to maintain anonymity. The Google Form started with a brief description and aim of the study followed by the inclusion and exclusion criteria. This was followed by a formal informed consent form. Only those SLPs who gave their consent were able to take part in the study. Each participant required approximately 10–12 min to complete the questionnaire. All the responses were saved in Google Drive and were accessible to the investigators only.
2.3 Statistical analysis
Descriptive statistics were performed to summarise the demographic variables. Continuous variables were analysed using mean ± standard deviation and range while categorical values were analysed using frequency and percentages. The questionnaire also included one open-ended question whose responses were categorised to calculate the frequency and percentages. Internal consistency of the questionnaire was calculated using Cronbach's Alpha. The statistical analyses were carried out using Jamovi 2.0.0.0
A total of 116 SLPs participated in our online survey. The demographic details such as the age, years of experience, gender, degree, and work settings of the SLPs have been depicted in Table 1.
Table 1Demographic details of all the participants (n = 116).
This section included 15 statements where the participants were asked to express their opinions using one of the 5 options offered. The responses provided are shown in Table 2.
Table 2Perceptions towards counseling.
Statements
Responses
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
n (%)
n (%)
n (%)
n (%)
n (%)
I think counseling is an important aspect while treating clients
115 (99.1)
1 (0.9)
–
–
–
Listening to the client or their family member is an important aspect in counseling
108 (93.1)
8 (6.9)
–
–
–
I believe that my role as a speech-language pathologist involves counseling patients with speech-language and communication disorders
108 (93.1)
7 (6)
1 (0.9)
–
–
Good interpersonal communication skills are important while counseling
95 (81.9)
18 (15.5)
3 (2.6)
–
–
I feel comfortable providing counseling services to my clients/family members
93 (80.2)
21 (18.1)
1(0.9)
–
1 (0.9)
More emphasis is needed on counseling skills in the curriculum of graduate programs
91 (78.4)
20 (17.2)
4 (3.4)
1 (0.9)
–
I should be fully attentive emotionally and mentally during counseling
78 (67.2)
33 (28.4)
5 (4.3)
–
–
Understanding the clients/family members temperament is an important aspect in counseling
70 (60.3)
35 (30.2)
4 (3.4)
3 (2.6)
4 (3.4)
Empathy while counseling is an important aspect of professional practice
70 (60.3)
27 (23.3)
15 (12.9)
1 (0.9)
3 (2.6)
Non-verbal modes of communication are as important as verbal mode of communication during counseling
62 (53.4)
39 (33.6)
12 (10.3)
2 (1.7)
1 (0.9)
Effective counseling has no role in the client's prognosis
5 (4.3)
1 (0.9)
8 (6.9)
18 (15.5)
84 (72.4)
I feel clients should not be encouraged to ask questions during counseling
2 (1.7)
1 (0.9)
12 (10.3)
22 (19)
79 (68.1)
During counseling, the client need not be provided with an opportunity to reflect on his/her feeling or problems
11 (9.5)
8 (6.9)
13 (11.2)
33 (28.4)
51 (44)
Unrealistic expectations can be included during counseling
14 (12.1)
13 (11.2)
23 (19.8)
21 (18.1)
45 (38.8)
I have my own pre-decided judgements while counseling my client/their family
3.2 Importance of various aspects during counseling
This section included 6 statements and the SLPs had to indicate their opinion using a 5 point rating scale.
Table 3 shows that all the statements included in this section were considered to be extremely important by majority of the SLPs. The SLPs were asked to indicate their primary source of knowledge about counseling. Out of the given 4 options, majority (84.5%) of the SLPs reported obtaining knowledge by discussing with their colleagues/friends. Further, 69% of the SLPs obtained knowledge from their graduate coursework, 65.5% from seminars/workshops/conferences and 57.8% from journals/books.
Table 3Importance of various aspects during counseling.
Statements
Responses
Not important
Slightly important
Moderately important
Very important
Extremely important
n (%)
n (%)
n (%)
n (%)
n (%)
have a holistic approach
3 (2.6)
3 (2.6)
3 (2.6)
26 (22.4)
81 (69.8)
understand the level of acceptance towards the condition
2 (1.7)
1 (0.9)
2 (1.7)
33 (28.4)
78 (67.2)
know expectations of the client/family
2 (1.7)
2 (1.7)
2 (1.7)
38 (32.8)
72 (62.1)
respect the sociocultural diversity of the patient/family
2 (1.7)
2 (1.7)
5 (4.3)
35 (30.2)
72 (62.1)
explain technical terms in simple language
2 (1.7)
6 (5.2)
5 (4.3)
35 (30.2)
68 (58.6)
restate the clients/family's expression in own words
This section of the questionnaire included 5 statements and Table 4 shows the responses of the SLPs given using a 5-point rating scale. Majority (71.6%) of the SLPs reported of allowing their clients/family members to ask doubts, 50% of the SLPs referred their clients to other. Less than 50% of the SLPs reported of asking the clients/family members views, describing their emotional status and asking their clients/family members to restate/repeat the points to ensure that information is conveyed. The SLPs were suggested 11 components that could be included during a typical counseling session. Fig. 1 depicts that more than 90% of the SLPs provided information about the disorder, emphasised on the importance of patients and family members for an effective prognosis, provided intervention options and home-based activities to their clients. Combining all the responses of the participants, it was found that 24.1% of the SLPs reported including all the 11 suggested components of counseling based on the literature. 22.4–17.2% of the SLPs reported incorporating 9–10 components respectively.
Table 4Experiences towards counseling.
How often do you …
Responses
Never
Rarely
Sometimes
Frequently
Always
n (%)
n (%)
n (%)
n (%)
n (%)
ask your client/clients family to ask doubts/questions if any?
1 (0.9)
–
5 (4.3)
27 (23.3)
83 (71.6)
refer your clients/family members to other professionals?
2 (1.7)
2 (1.7)
19 (16.4)
35 (30.2)
58 (50)
ask your client/clients family to express what they feel about the condition?
3 (2.6)
9 (7.8)
30 (25.9)
41 (35.3)
33 (28.4)
ask your client/clients family to rate or describe their emotional status?
21 (18.1)
29 (25)
36 (31)
18 (15.5)
12 (10.3)
ask your client/clients family to restate/repeat the points you have mentioned, so as to get a better understanding?
The SLPs were also asked to indicate the disorders that they face difficulty with during counseling. Fig. 2 shows the areas of difficulty among the suggested 9 disorders.
The questionnaire included a final open-ended question where SLPs were asked to list the professionals to whom they refer their clients/family members. Majority of the SLPs referred their clients/family members to allied health professionals such as Psychologist (78.4%), Occupational therapist (68.1%) and Physiotherapist (52.6%). Other allied health professionals (Audiologist, Behaviour therapist, Social worker etc.) were also being referred by the SLPs. They also indicated referring their clients to medical health professionals (Paediatrician, Neurologist, ENT etc.) and other professionals (Special educator, Teacher, Vocational educators).
Apart from the commonly referred professionals, 13% of the SLPs also mentioned the factors that would influence their decision-making during referral. 9.5% of the participants believed that referral depends on the needs of each patient and 1.7% of the SLPs gave referrals depending on the rehabilitation team required for each patient. The SLPs (0.9%) also mentioned that they referred their clients based on the proximity of clinics and they (0.9%) believed in referring their clients to group therapies where they could interact with their affected peers.
4. Discussion and conclusion
4.1 Discussion
This study helped in understanding the current perspectives and experiences of speech-language pathologists practicing in India towards counseling. The questionnaire was developed and validated using standard procedures. S-CVI index calculated was found to be 0.97 which indicated that the developed questionnaire had an excellent content validity. Internal consistency was assessed using Cronbach's alpha. An alpha value of 0.78 was obtained for the questionnaire indicative of good internal consistency. The participants of this study reported working in different work settings such as clinical, academic, hospital and NGO. According to the Rehabilitation Council of India (RCI, 2015), different work settings for SLPs include health care settings (hospitals, clinics, medical rehabilitation centres etc.), multidisciplinary rehabilitation centres, academic settings, government and private settings and research centres. A survey also found that 51% of their participants worked in a private hospital setting, 35% in a private outpatient clinic, 16% in a university-affiliated clinic and 5% in school settings.
reported their participants to practice in training institute hospitals (43.63%), 38.18% hospitals, 30.9% ENT clinics, 21.82% private practice, 20% training institutes, 7.27% special schools and 5.45% in research labs.
Most of the SLPs reported requiring 16–20 min for each counseling session. In a survey done by Philips and Mendel,
, the SLPs reported providing 2 h and more than 8 h of counseling on an average in a week. They also found that as the number of counseling hours provided increased, comfort and preparedness of the SLPs to conduct counseling increased.
4.1.1 Perceptions towards counseling
The SLPs strongly believed that counseling is an important aspect while treating clients. They believed that it is important to listen to their clients.
It is important to have good interpersonal communication skills and being comfortable while providing counseling services to their clients and their family members.
Many SLPs felt the need to increase emphasis on improving counseling skills in the graduate programs' curriculum and it is the graduate school's responsibility to provide training in counseling.
Importance of being fully attentive emotionally and mentally during counseling was also strongly agreed upon. Literature suggests the use of body language is an important part of listening to portray the clinician as an attentive listener.
Other skills important during counseling include understanding the clients or family members' temperament as the clinician should accept it rather than attempting to change it
and empathy which helps to improve client-clinician relationships during the initial sessions of counseling allowing the clinician to accept the point of view of their clients without any judgements.
The SLPs in the present study agreed that non-verbal modes of communication are as important as verbal modes during counseling as it allows the clinician to respond appropriately after actively listening to the information their client and their family members wished to communicate and identify any mismatch between their non-verbal and verbal behaviour. The SLPs believed that effective counseling has a role in client's prognosis and they should encourage their clients to ask questions during counseling. Opportunities to reflect on their feelings or problems should be provided and unrealistic expectations and pre-decided judgements should be avoided during counseling.
It is important to understand their clients' level of acceptance towards their condition and is also considered to be one of the purposes of counseling.
The SLPs believe that it is extremely important to explain technical terms in simple language as it helps to clarify and improve client-clinician communication.
Another important aspect is restating clients/family's expressions. Studies have indicated that restating facilitates better clarification of messages being conveyed by the client indirectly.
4.1.3 Primary sources of knowledge about counseling
Majority of the SLPs in the present study indicated that they obtained information about counseling by discussing it with their colleagues and/or friends. Other sources of knowledge included graduate coursework, seminars/workshops/conferences, and journals/books in this order. It was found that SLPs with more work experience indicated the use of journals/books to obtain information on counseling as compared to those with lesser experience. Studies have indicated various training on counseling in new and experienced SLPs. New SLPs indicated receiving training during their course period, while experienced SLPs reported receiving in-service training.
found that 80% of their participants did not receive credit hours pertaining to counseling in their graduate school. Many participants in their study reported that counseling was not considered an integral part of the graduate coursework.
The SLPs in the current study indicated that they would frequently ask their clients to express what they feel regarding their condition. Exploring clients' feelings about their condition is one of the purposes of counseling and is within the boundary of the practice of SLPs.
Studies have reported that emotions are usually associated with the clients' communication problems, and it is necessary to address them for effective counseling.
However, emotions were sometimes reported to be addressed by the SLPs (31%) in the present study by asking them to describe their emotional status. Approximately less than 30% SLPs indicated frequently asking their clients to restate the points they have mentioned during counseling to establish better understanding. Duvivier et al.
has emphasised the importance of providing selective feedback to their clients during counseling such as reframing their clients’ statements to encourage a positive attitude towards their communication problems, increasing discussions and summarising the session highlighting the key points of the discussion.
4.1.5 Components included during counseling by SLPs
The SLPs indicated providing information about the disorder,
and including parents/family members of the client. Studies have suggested that family members influence each other and should be included during the assessment and management of any client.
The SLPs reported providing intervention options to their clients including the goals and approaches that are going to be focussed during the intervention
in addition to providing activities and strategies to be followed at home. A good counseling skill will help the client to follow the strategies provided by the clinician even at home following a discharge.
and overcoming the weaknesses of their clients. Addressing the clients underlying weakness associated with their communication disorder to reduce barriers to communication.
The SLPs reported including family viewpoints or reactions during counseling. Interviewing the client's family members, addressing their reactions to provisional diagnosis is considered to be within the scope of practice of an SLP.
Another important, yet unrecognised component of counseling is planning on health or educational requirements for the client beyond therapy which were being incorporated by less than 70% of the SLPs currently. This component is also considered to be within their boundary of practice and should be incorporated by the SLPs while counseling.
Less than 50% of the SLPs indicated using visual aids and involving others with similar experiences as their clients during counseling.
4.1.6 Areas of difficulty during counseling
The SLPs reported having more difficulty counseling individuals with reading and writing disorders, swallowing disorders and motor speech disorders in children. Some SLPs also selected the ‘none’ option and indicated that they did not face difficulty counseling in any of the given communication disorders. The least reported difficult areas of counseling were for voice disorders and articulation and phonological disorders.
4.1.7 Referral to other professionals in team
The SLPs indicated that it is important to provide appropriate referrals to other professionals. According to Holland and Nelson,
, there are certain boundaries of practice that should be followed by an SLP. The areas of counseling that are not within our scope of practice should be referred to another relevant professional. This was also indicated by ASHA
found that it is the role of an SLP to provide referrals where necessary. The role of SLPs includes detecting, diagnosing the communication problem as well as providing referrals to the respective professionals.
The SLPs in our study reported referring their clients commonly to a psychologist, occupational therapist or physiotherapist. Other professionals included paediatrician, neurologist, ENT, special educator, teachers, nurses, dietary staff, physicians and early interventionists.
The aim of the study was to understand the perspectives and experiences of SLPs practicing in India towards counseling using a developed and validated questionnaire. The SLPs believe that counseling is an important aspect in which they have an essential role. Being an attentive listener, providing empathy and showing good interpersonal skills are some of the necessary skills required for an effective counseling. They perceived it to be important for the clients prognosis and that it should be emphasised in the curriculum. Based on the survey, it is important to note that lesser percentage of SLPs made use of visual aids and involved others with similar experiences. During counseling, they felt difficulty counseling certain communication disorders such as disorders of reading and writing, swallowing and motor speech disorders in children. In general, the SLPs felt comfortable providing counseling and reported of incorporating majority of the aspects incorporated in the survey. There is a scope of strengthening the SLPs confidence, skills, and knowledge by providing training at their work settings which will also help them shape their counseling skills with experience. Providing more emphasis on counseling in curriculum programs will help in increasing the confidence and ability to counsel clients effectively in the upcoming graduates.
5.1 Future implications
The developed and validated questionnaire can be used to explore the perceptions and experiences of SLPs towards counseling on a larger scale among students as well as working professionals. Studies to compare the perceptions and experiences of the SLPs across the world can be carried out. Studies can be taken up to explore the current curriculum on counseling in the graduate and postgraduate programs in India.
Ethics approval
The study was carried out after the Institutional Ethical Committee approval from Kasturba Medical College, Mangalore (IEC KMC MLR 03–2021/99).
Source of funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
The authors declare that they have no conflict of interest.
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