Counseling Adult Neurogenic Disordered Patients and Their Families Scott A. Jackson, M.S., CCC-SLP

Counseling Adult Counseling Adult Neurogenic Neurogenic Disordered Disordered

Patients and Their Patients and Their FamiliesFamilies

Scott A. Jackson, M.S., Scott A. Jackson, M.S., CCC-SLPCCC-SLP

A “Shout Out” to my A “Shout Out” to my InfluencesInfluences

Dr. Sonya Wilt (influenced by Dr. Sonya Wilt (influenced by Virginia Satir)Virginia Satir)

Dr. Audrey HollandDr. Audrey Holland

Jean GlattkeJean Glattke

Dr. Celeste Roseberry-McKibbinDr. Celeste Roseberry-McKibbin

Fears of CounselingFears of Counseling ““It’s really not in our scope of practice.”It’s really not in our scope of practice.” ““That should be done by a psychologist.”That should be done by a psychologist.” ““I don’t have enough experience to do I don’t have enough experience to do

it.”it.” ““I never know what to say.”I never know what to say.” ““We didn’t have very much training in We didn’t have very much training in

that area is school.”that area is school.” ““I feel like I need to be doing ‘speech’ I feel like I need to be doing ‘speech’

stuff in therapy…there’ s no time for stuff in therapy…there’ s no time for counseling.”counseling.”

““It’s non-billable!”It’s non-billable!”

Scope of PracticeScope of Practice

ASHA’s “Scope of Practice” ASHA’s “Scope of Practice” states that we as SLPs can/should states that we as SLPs can/should provide counseling for those provide counseling for those individuals we see for therapy individuals we see for therapy with communication/swallowing with communication/swallowing disorders.disorders.

ASHA Scope of PracticeASHA Scope of PracticeClinical ServicesClinical Services Speech-language pathologists provide clinical Speech-language pathologists provide clinical

services that include the following: services that include the following: prevention and pre-referralprevention and pre-referral screeningscreening assessment/evaluationassessment/evaluation consultationconsultation diagnosisdiagnosis treatment, intervention, managementtreatment, intervention, management counselingcounseling collaborationcollaboration documentationdocumentation referralreferral

ASHA Scope of PracticeASHA Scope of Practice

Examples of these clinical services Examples of these clinical services include: include:

counseling individuals, families, counseling individuals, families, coworkers, educators, and other coworkers, educators, and other persons in the community persons in the community regarding acceptance, adaptation, regarding acceptance, adaptation, and decision making about and decision making about communication and swallowing;communication and swallowing;

Why Us as SLPs?Why Us as SLPs? Budget cuts. Many hospital/facilities are Budget cuts. Many hospital/facilities are

cutting back on services including social cutting back on services including social services, etc…services, etc…

Many insurances don’t authorize Many insurances don’t authorize therapy/counseling with a therapy/counseling with a psychologist/social worker unless there is psychologist/social worker unless there is a significant depression associated with it.a significant depression associated with it.

Also…people are living longer as a result Also…people are living longer as a result of better medical care/medical of better medical care/medical advancements. Therefore, our caseloads advancements. Therefore, our caseloads should increase! There is expected to be a should increase! There is expected to be a huge shift in the age statistics of our huge shift in the age statistics of our population with elderly individuals population with elderly individuals increasing in numbers (the baby increasing in numbers (the baby boomers).boomers).

Why Us as SLPs?Why Us as SLPs?

Everyone on the interdisciplinary Everyone on the interdisciplinary team should be providing counseling team should be providing counseling to some extent.to some extent.

Ideally social workers and Ideally social workers and psychologists are the most psychologists are the most specifically trained for it.specifically trained for it.

How many of us have easy access to How many of us have easy access to one of these? Outside of acute rehab one of these? Outside of acute rehab facilities, most patients don’t have facilities, most patients don’t have easy access.easy access.


MDs often don’t have the time to MDs often don’t have the time to provide counseling or even provide counseling or even education to either the patient education to either the patient and/or family.and/or family.

PT/OT are focusing on physical PT/OT are focusing on physical difficulties and have such limited difficulties and have such limited time to do that.time to do that.


Anderson & Marlett (2004) cites several Anderson & Marlett (2004) cites several others in their article “Communication others in their article “Communication in Stroke: The Overlooked in Stroke: The Overlooked Rehabilitation Tool”Rehabilitation Tool”

Clark (2000) and Pound et al. (1994) Clark (2000) and Pound et al. (1994) found that patients felt that it was the found that patients felt that it was the role of doctors and hospitals to provide role of doctors and hospitals to provide information, explanation, information, explanation, encouragement, and advice but almost encouragement, and advice but almost half believed that this need was not half believed that this need was not being met.being met.

Wellwood et al. stated that over 70% of Wellwood et al. stated that over 70% of caregivers had to ask for information.caregivers had to ask for information.


It makes sense for us to be the ones It makes sense for us to be the ones to take a counseling role. to take a counseling role.

When asked why it’s easier for them When asked why it’s easier for them to get some counseling in Speech to get some counseling in Speech Therapy, a patient of mine stated Therapy, a patient of mine stated “because you actually listen to me “because you actually listen to me and understand me and take the and understand me and take the time. My doctor and physical time. My doctor and physical therapist don’t give me enough therapist don’t give me enough time.” time.”

Education Vs. CounselingEducation Vs. Counseling

Both are extremely important.Both are extremely important. I feel most of us do a good job in I feel most of us do a good job in

the education part…providing the education part…providing patients and families information patients and families information regarding the deficit(s).regarding the deficit(s).

It’s the counseling aspect that It’s the counseling aspect that many times gets overlooked or many times gets overlooked or ignored. ignored.

ResearchResearch

Clark, Micheal S. (2003) ran a study Clark, Micheal S. (2003) ran a study looking at education and counseling looking at education and counseling intervention for families after stroke. intervention for families after stroke.

Two groups. One control and one given Two groups. One control and one given stroke information and sessions with a stroke information and sessions with a social worker.social worker.

Conclusion: An education and Conclusion: An education and counseling intervention maintained counseling intervention maintained family functioning, and in turn led to family functioning, and in turn led to improved functional and social patient improved functional and social patient outcomes. outcomes.

ResearchResearch Evans, R.L. et. al. (1988) had two stroke Evans, R.L. et. al. (1988) had two stroke

groups with their families.groups with their families. One received information only and the One received information only and the

other received counseling only. other received counseling only. 18 months post stroke, findings showed 18 months post stroke, findings showed

both groups significantly improved both groups significantly improved caregiver knowledge and stabilized some caregiver knowledge and stabilized some aspects of family function better than aspects of family function better than routine care.routine care.

Counseling was consistently more Counseling was consistently more effective than education alone and effective than education alone and resulted in better patient adjustment at resulted in better patient adjustment at 1 year. 1 year.

General Ideas/ThoughtsGeneral Ideas/Thoughts

Like all clients we see in the Like all clients we see in the Speech Therapy, we need to make Speech Therapy, we need to make sure to build a rapport with them.sure to build a rapport with them.

Find a way to “connect” with them.Find a way to “connect” with them. Reciprocal learning.Reciprocal learning. Laugh at their jokes!!! Laugh at their jokes!!! Family is a great topic….so is food!Family is a great topic….so is food! Don’t be afraid to discuss personal Don’t be afraid to discuss personal

things about yourself!things about yourself!


Open-Ended QuestionsOpen-Ended Questions Allow a lot of latitudeAllow a lot of latitude

Draw a client outDraw a client out

Encourage answers that may be Encourage answers that may be more accuratemore accurate

They can be time-consumingThey can be time-consuming


It’s important to try and get a sense of “what It’s important to try and get a sense of “what the client/family needs” in terms of the client/family needs” in terms of counseling/support:counseling/support: Teacher/education providerTeacher/education provider An ear/sounding boardAn ear/sounding board Someone to help them feel calmSomeone to help them feel calm Someone to give them encouragement (cheerleader)Someone to give them encouragement (cheerleader) Someone to motivate them (military sergeant)Someone to motivate them (military sergeant)

*Find the balance as a therapist between *Find the balance as a therapist between providing awareness of deficits and providing providing awareness of deficits and providing hope.hope.

Be flexible!!!!Be flexible!!!!


Anderson & Marlett (2004): Professionals Anderson & Marlett (2004): Professionals debate whether their communication debate whether their communication gives stroke survivors and families ‘hope’ gives stroke survivors and families ‘hope’ and recovery after stroke and recovery after stroke versusversus creating creating over-optimistic expectations of ‘recovery’ over-optimistic expectations of ‘recovery’ and ‘unrealistic expectations’’. and ‘unrealistic expectations’’.

““I can’t predict how far your progress will I can’t predict how far your progress will go.”go.”

Focus on the things that they can do.Focus on the things that they can do. Let them discover with time rather than Let them discover with time rather than

us trying to predict. us trying to predict.


Family and/or Patient in SessionFamily and/or Patient in Session?? Most counseling sessions should Most counseling sessions should

involve both the patient and familyinvolve both the patient and family However, some sessions should However, some sessions should

involve just the patient. It’s amazing involve just the patient. It’s amazing how different he/she acts when how different he/she acts when around familyaround family

Some sessions or time should be Some sessions or time should be spent with just the family too. This is spent with just the family too. This is where a student intern comes in where a student intern comes in handyhandy


Don’t let people wanderDon’t let people wander ““Speaking of that….”Speaking of that….”

““That reminds me of something That reminds me of something you said earlier”you said earlier”

““Along those lines…”Along those lines…”

““That brings up a good point…”That brings up a good point…”


Facial ExpressionsFacial Expressions According to Glass (2002), 55% of According to Glass (2002), 55% of

nonverbal communication is facialnonverbal communication is facial

Frowning or looking disapproving Frowning or looking disapproving reallyreally shuts people down shuts people down

Fight those yawns!!!!!!Fight those yawns!!!!!!


Eye ContactEye Contact People generally appreciate People generally appreciate

direct eye contactdirect eye contact

However, this is very cultural; if However, this is very cultural; if people are uncomfortable, we people are uncomfortable, we should not gaze at themshould not gaze at them

General Ideas/Thoughts General Ideas/Thoughts

Head NoddingHead Nodding Positive head nodding Positive head nodding

encourages a person to keep encourages a person to keep going and say moregoing and say more

However, too much of it can However, too much of it can indicate that you are insecure indicate that you are insecure and overeager to be likedand overeager to be liked

General Ideas/Thoughts General Ideas/Thoughts

Body PostureBody Posture Leaning backward often conveys Leaning backward often conveys

negative feelings and disinterest negative feelings and disinterest (this may be gender specific (this may be gender specific though)though)

Leaning forward indicates Leaning forward indicates interest, respect, and likinginterest, respect, and liking

Don’t cross your arms…may Don’t cross your arms…may indicate disapproval indicate disapproval


SilencesSilences For Americans, this can be For Americans, this can be

uncomfortableuncomfortable In many cultures, silences are expectedIn many cultures, silences are expected Research shows that silences longer Research shows that silences longer

than 5 seconds result in shorter than 5 seconds result in shorter verbalizations from intervieweesverbalizations from interviewees

Short silences of 5 seconds or less can Short silences of 5 seconds or less can be helpful, because people are given be helpful, because people are given time to think and are often encouraged time to think and are often encouraged to say moreto say more


SummariesSummaries VERY useful for keeping things VERY useful for keeping things

moving!moving! At the end of the session, it helps to At the end of the session, it helps to

highlight and review major pointshighlight and review major points Consider taking detailed notes. You Consider taking detailed notes. You

can then refer back to them and can then refer back to them and give the patients and family the give the patients and family the exact words they said.exact words they said.

This makes them feel heard and, This makes them feel heard and, often, special—I care enough to often, special—I care enough to write down what they tell me. (Don’t write down what they tell me. (Don’t let them get suspicious)let them get suspicious)


Touch Touch This should be used very This should be used very

carefullycarefully Sometimes I will briefly touch Sometimes I will briefly touch

someone on the arm, hand, or someone on the arm, hand, or shoulder to convey sympathyshoulder to convey sympathy

When used appropriately, this is When used appropriately, this is quite helpfulquite helpful


Self DisclosureSelf Disclosure This is when we reveal This is when we reveal

something personal about something personal about ourselvesourselves

We need to keep it shortWe need to keep it short Often, people feel more Often, people feel more

comfortable and understoodcomfortable and understood


Running Out of TimeRunning Out of Time ““I’m so sorry—I have another meeting I’m so sorry—I have another meeting

in 5 minutes. Why don’t we continue in 5 minutes. Why don’t we continue during our next appointment so I can during our next appointment so I can hear the rest of what you want to say?”hear the rest of what you want to say?”

““I hate to cut this short, but there is I hate to cut this short, but there is another patient waiting. I want to hear another patient waiting. I want to hear more.” more.”

Some people give their business card Some people give their business card and email address and encourage and email address and encourage further communication that way.further communication that way.

DEFENSE MECHANISMSDEFENSE MECHANISMS

A. A. RationalizationRationalization Logical but untrue explanation of an Logical but untrue explanation of an

attitude or behavior that allows an attitude or behavior that allows an individual to explain why an expectation individual to explain why an expectation has not occurredhas not occurred

Rationalization not only prevents anxiety, Rationalization not only prevents anxiety, it may also protect self-esteem and self-it may also protect self-esteem and self-concept. When confronted by success or concept. When confronted by success or failure, people tend to attribute failure, people tend to attribute achievement to their own qualities and achievement to their own qualities and skills while failures are blamed on other skills while failures are blamed on other people or outside forces.people or outside forces.


B. B. DisplacementDisplacement Person transfers hostile feelings Person transfers hostile feelings

from the person or problem that from the person or problem that caused the hostile feelings onto a caused the hostile feelings onto a “safe” person or object“safe” person or object

Rather than express our anger in Rather than express our anger in ways that could lead to negative ways that could lead to negative consequences (like arguing with our consequences (like arguing with our boss), we instead express our anger boss), we instead express our anger towards a person or object that towards a person or object that poses no threat (such as our poses no threat (such as our spouses, children, or pets).spouses, children, or pets).


C. C. ProjectionProjection The person shifts responsibility to The person shifts responsibility to

someone else; feelings or motives someone else; feelings or motives that belong to the individual are that belong to the individual are attributed to another personattributed to another person

For example, if you have a strong For example, if you have a strong dislike for someone, you might dislike for someone, you might instead believe that he or she does instead believe that he or she does not like you.not like you.

DEFENSE MECHANISMSDEFENSE MECHANISMSD. D. Reaction FormationReaction Formation People experience emotions that are People experience emotions that are

so shocking or contrary to their so shocking or contrary to their previous thoughts that the new previous thoughts that the new feelings are considered feelings are considered unacceptable; individuals develop unacceptable; individuals develop positive attitudes that are opposed positive attitudes that are opposed to their new, shocking, real feelings to their new, shocking, real feelings about a subjectabout a subject

An example would be treating An example would be treating someone you strongly dislike in an someone you strongly dislike in an excessively friendly manner in order excessively friendly manner in order to hide your true feelings.to hide your true feelings.


E. E. RepressionRepression People People consciouslyconsciously keep thoughts keep thoughts

and feelings under control and out and feelings under control and out of view of others; they may hold of view of others; they may hold their true feelings inside and even their true feelings inside and even deny themdeny them

F. F. SuppressionSuppression Like repression, only the person Like repression, only the person

is not conscious of emotions or is not conscious of emotions or feelings--these are feelings--these are unconsciousunconscious

Disarming an Angry Disarming an Angry PersonPerson

Compliment the person on Compliment the person on something they did rightsomething they did right

Disarm them by finding Disarm them by finding something to agree withsomething to agree with

Encourage people to talk openly Encourage people to talk openly about why they are angryabout why they are angry

Feedback and negotiationFeedback and negotiation Acknowledge their Acknowledge their

anger/frustrationanger/frustration

ChangeChange

As we age, we face many As we age, we face many changes. This is the case for even changes. This is the case for even healthy individuals.healthy individuals.

One of my clients put it this way:One of my clients put it this way: ““Part of growing old is letting go of Part of growing old is letting go of

the things that you love.”the things that you love.”

ChangeChange Now imagine, in addition to growing Now imagine, in addition to growing

old, how some also suffer from a old, how some also suffer from a medical event, accident, or decline medical event, accident, or decline that may results in mild-severe and that may results in mild-severe and acute/chronic life-changes.acute/chronic life-changes.

Some examples include:Some examples include: Stroke (aphasia; dysarthria; dysphagia)Stroke (aphasia; dysarthria; dysphagia) Dementia (AD; PD)Dementia (AD; PD) TBITBI

CommonalityCommonality

Neurogenic disordered patients Neurogenic disordered patients all have suffered a loss!all have suffered a loss!

It can be a loss of It can be a loss of communication skills, swallowing communication skills, swallowing skills, social activities, memory, skills, social activities, memory, identity, roles in the family, etc…identity, roles in the family, etc…

It may be beneficial to include It may be beneficial to include “stages of grief” with your “stages of grief” with your counseling.counseling.

Stages of GriefStages of GriefThe stages are:The stages are: Denial: Denial:

Example - Example - "I feel fine.""I feel fine."; ; "This can't be happening, "This can't be happening, not to me!"not to me!"

Anger: Anger: Example - Example - "Why me? It's not fair!""Why me? It's not fair!" "NO! NO! How "NO! NO! How

can you accept this!"can you accept this!" Bargaining: Bargaining:

Example - Example - "Just let me live to see my children "Just let me live to see my children graduate."graduate."; ; "I'll do anything, can't you stretch it "I'll do anything, can't you stretch it out? A few more years."out? A few more years."

Depression: Depression: Example - Example - "I'm so sad, why bother with anything?""I'm so sad, why bother with anything?"; ;

"I'm going to die . . . What's the point?""I'm going to die . . . What's the point?" Acceptance: Acceptance:

Example - Example - "It's going to be OK.""It's going to be OK."; ; "I can't fight it, I "I can't fight it, I may as well prepare for it."may as well prepare for it."

Stages of GriefStages of Grief

DenialDenialAt first, we tend to deny the loss At first, we tend to deny the loss has taken place, and may has taken place, and may withdraw from our usual social withdraw from our usual social contacts. This stage may last a contacts. This stage may last a few moments, or longer. few moments, or longer.


AngerAngerThe grieving person may then be The grieving person may then be furious at the person who furious at the person who inflicted the hurt (even if she's inflicted the hurt (even if she's dead), or at the world, for letting dead), or at the world, for letting it happen. He may be angry with it happen. He may be angry with himself for letting the event take himself for letting the event take place, even if, realistically, place, even if, realistically, nothing could have stopped it.nothing could have stopped it.


BargainingBargainingNow the grieving person may Now the grieving person may make bargains with God, asking, make bargains with God, asking, "If I do this, will you take away "If I do this, will you take away the loss?"the loss?"


DepressionDepressionThe person feels numb, although The person feels numb, although anger and sadness may remain anger and sadness may remain underneath.underneath.

DepressionDepression

Men vs. Women in terms of Men vs. Women in terms of depressiondepression Men tend to show their depression Men tend to show their depression

via anger and anxietyvia anger and anxiety Women tend to show their Women tend to show their

depression via sadness and mopingdepression via sadness and moping

DepressionDepression Organic depression vs. depression Organic depression vs. depression

from lossfrom loss Since our neurogenic patients have all Since our neurogenic patients have all

suffered a loss of some sort, it is logical to suffered a loss of some sort, it is logical to assume that there will be some depression assume that there will be some depression because of that loss. because of that loss.

However, depression (or part of it) may However, depression (or part of it) may also be a part of changes that occur in the also be a part of changes that occur in the brain as a result of injury (ie., stroke). brain as a result of injury (ie., stroke). This is organic depression. This is organic depression.

Pt’s may benefit from understanding Pt’s may benefit from understanding this.this.

Depression and MedsDepression and Meds

Many patients are reluctant to Many patients are reluctant to start antidepressants. start antidepressants.

I feel it is our job to help them I feel it is our job to help them understand how depression may understand how depression may also impact their performance also impact their performance and therapy progress.and therapy progress.

Meds may help “clear away the Meds may help “clear away the fog”. fog”.


AcceptanceAcceptanceThis is when the anger, sadness This is when the anger, sadness and mourning have tapered off. and mourning have tapered off. The person simply accepts the The person simply accepts the reality of the loss. reality of the loss.

Loss of Identity/Loss of Loss of Identity/Loss of SelfSelf

Most of the adults we see for Most of the adults we see for therapy have suffered a therapy have suffered a traumatic event that has caused traumatic event that has caused many changes.many changes.

They feel a sense of loss…a loss They feel a sense of loss…a loss of identity…a loss of self.of identity…a loss of self.

Some of these changes happen Some of these changes happen rapidly (CVA) and some slowly rapidly (CVA) and some slowly (PD, AD)(PD, AD)

Loss of Identity/Loss of Loss of Identity/Loss of SelfSelf

The person whom the client once The person whom the client once knew is no longer present to knew is no longer present to him/her.him/her.

Areas that help define us may Areas that help define us may include:include: CommunicationCommunication MemoriesMemories SocializationSocialization Family RoleFamily Role Career/job RoleCareer/job Role Hobbies/interestsHobbies/interests

Domains of SelfDomains of Self

Barbara Shadden, PhD @ Univ. of Ark. Barbara Shadden, PhD @ Univ. of Ark. *From “Advance…” November 2008*From “Advance…” November 2008People draw from at least four People draw from at least four

domains of self to tell their life domains of self to tell their life story:story:

1. Biographical1. Biographical 2. Role-based2. Role-based 3. Interactional3. Interactional 4. Cultural4. Cultural


Biographical DomainBiographical Domain:: Facts of a person’s lifeFacts of a person’s life

AgeAge Marital StatusMarital Status ChildrenChildren PetsPets ProfessionProfession

* “Surface self”* “Surface self”


Role-based DomainRole-based Domain:: Household/family duties such as:Household/family duties such as:

DrivingDriving Bill payingBill paying CookingCooking CleaningCleaning


Interactional DomainInteractional Domain:: Also known as “relational domain”Also known as “relational domain” Dr. Shadden states that “self is Dr. Shadden states that “self is

constantly created with other people, constantly created with other people, the interaction part of the puzzle is the interaction part of the puzzle is huge.”huge.”

Typically our interactions change Typically our interactions change with whomever we are with whomever we are communicating with (ie., spouse, communicating with (ie., spouse, neighbor, children)neighbor, children)


Cultural DomainCultural Domain:: ““How do you fit into the world around How do you fit into the world around

you?”you?” Shadden: Cultural and self “get to the Shadden: Cultural and self “get to the

big picture of policies and practices big picture of policies and practices that help or hinder the social that help or hinder the social engagement of a person with a engagement of a person with a communication impairment.”communication impairment.”

Ie., Are some restaurants more Ie., Are some restaurants more friendly and accommodating?friendly and accommodating?

The Pie of “I”The Pie of “I”

Dr. Sonya Wilt (who has been Dr. Sonya Wilt (who has been influenced by Virginia Satir) influenced by Virginia Satir) talks about the importance of talks about the importance of discussing role changes in discussing role changes in therapy as part of counseling.therapy as part of counseling.

She uses a pie graph. I have She uses a pie graph. I have named it “The Pie of I”.named it “The Pie of I”.

Barbara Shadden calls this Barbara Shadden calls this “Role-based Domain”“Role-based Domain”

Counseling for Loss of Counseling for Loss of SelfSelf

We must help redefine oneself or We must help redefine oneself or recreate his/her “Role”! recreate his/her “Role”!

Help them realize that “they are still Help them realize that “they are still that same person…that same pie…but that same person…that same pie…but with just different pieces”.with just different pieces”.

The pieces may shift and become The pieces may shift and become smaller or larger, but for the most smaller or larger, but for the most part, they are still there. part, they are still there.

Other “slices” might also be created.Other “slices” might also be created. Some may even need to be removed to Some may even need to be removed to

some degree.some degree.

Prior to EventPrior to Event

After EventAfter Event

Health-care Professional Health-care Professional Communication with Communication with

Patients/familyPatients/family Bendz 2000: “professionals communicate Bendz 2000: “professionals communicate

about bodily impairment, problems of about bodily impairment, problems of reduced functions, and treatment of reduced functions, and treatment of patient’s disease, whereas stroke survivors patient’s disease, whereas stroke survivors portray themselves as individuals with a portray themselves as individuals with a life in society that they wish to recapture.”life in society that they wish to recapture.”

““Stroke survivors portray themselves as Stroke survivors portray themselves as individuals w/ a position in society that individuals w/ a position in society that they are trying to recapture, whereas the they are trying to recapture, whereas the medical care personnel categorize them by medical care personnel categorize them by their deficits.”their deficits.”


Patients/familyPatients/family Our goal in stroke communication, Our goal in stroke communication,

from the outset, should be to support from the outset, should be to support individuals and families in creating a individuals and families in creating a positive post-stroke identity. Four positive post-stroke identity. Four key factors have been correlated with key factors have been correlated with the improved outcome in stroke and the improved outcome in stroke and are also associated with improving are also associated with improving self-image and identity. They include:self-image and identity. They include: Family supportFamily support Ability to solve problemsAbility to solve problems Social supportSocial support Perceived controlPerceived control


Patients/familyPatients/family Life after stroke is about rebuilding, re-Life after stroke is about rebuilding, re-

establishing, or recreating a coherent establishing, or recreating a coherent sense of self, and the roles that fit this sense of self, and the roles that fit this new identity.new identity.

Ellis-Hill & Horn (2000): “When Ellis-Hill & Horn (2000): “When individuals cannot create a clear sense individuals cannot create a clear sense of future self, they experience anxiety of future self, they experience anxiety and become unsure how to act…and become unsure how to act…individuals who have had a stroke may individuals who have had a stroke may settle for a restricted future self with settle for a restricted future self with limited physical and social activity, limited physical and social activity, because this is what they expect of a life because this is what they expect of a life with a disability.”with a disability.”


Patients/familyPatients/family Professionals cannot redefine Professionals cannot redefine

identity for stroke survivors and identity for stroke survivors and their families after stroke. Stroke their families after stroke. Stroke survivors and families must do survivors and families must do that work on their own, with the that work on their own, with the collaboration of professionals. collaboration of professionals.


Couple or Family Counseling:Couple or Family Counseling: Since most of the domains contain Since most of the domains contain

aspects related to the individual’s aspects related to the individual’s family/spouse, it is important to family/spouse, it is important to include them as well.include them as well.

They also need to understand the “pie They also need to understand the “pie pieces”.pieces”.

They will be an integral part of They will be an integral part of helping him/her re-create or re-helping him/her re-create or re-establish one’s self.establish one’s self.

Prior to EventPrior to Event

After EventAfter Event

RelationshipsRelationships

Maintaining relationships Maintaining relationships Vanhook (2009)Vanhook (2009) Maintenance of relationships Maintenance of relationships

within the family and those within the family and those within the community provide a within the community provide a support system for anyone with a support system for anyone with a chronic illness. When these chronic illness. When these relationships become estranged, relationships become estranged, there are both physiological and there are both physiological and psychological manifestations.psychological manifestations.

RelationshipsRelationships The relationship change for both stroke The relationship change for both stroke

survivors and their families is sudden. survivors and their families is sudden. Pound et al. (1998) did a qualitative Pound et al. (1998) did a qualitative

study showing the descriptions of study showing the descriptions of relationships post-stroke vary from relationships post-stroke vary from support to alienation.support to alienation.

The variation is not explained as a The variation is not explained as a consequence of the stroke; findings consequence of the stroke; findings indicate that the previous state of the indicate that the previous state of the relationship influences the relationships relationship influences the relationships after stroke.after stroke.


Support groups may be very Support groups may be very beneficial. They provide:beneficial. They provide:

Emotional supportEmotional support Practice with their impairmentsPractice with their impairments A sense of belonging/CommunityA sense of belonging/Community A chance to be one’s selfA chance to be one’s self A chance to create/re-establish A chance to create/re-establish

one’s selfone’s self

Support GroupsSupport Groups

Mackenzie & Chang (2002) found Mackenzie & Chang (2002) found statistical significance between high statistical significance between high social support and functional social support and functional abilities at the end of 3 months. abilities at the end of 3 months. Those stroke survivors perceiving Those stroke survivors perceiving less social support experience a less social support experience a decline in functiondecline in function

Online resources/groups can also be Online resources/groups can also be great for stroke survivors and great for stroke survivors and families.families.

Counseling at Various Counseling at Various Levels of CareLevels of Care

The focus of our counseling may differ The focus of our counseling may differ greatly depending on the LOC.greatly depending on the LOC.

As the patient progresses through the As the patient progresses through the various LOCs, their counseling needs various LOCs, their counseling needs will change.will change.

At the ICU, we may focus mainly on At the ICU, we may focus mainly on the education part of counseling. We the education part of counseling. We tend to “treat and street people.”tend to “treat and street people.”

Many times, it’s not until outpatient Many times, it’s not until outpatient therapy that feelings about loss of self therapy that feelings about loss of self and role changes come out.and role changes come out.

Cultural & Religious Cultural & Religious ConsiderationsConsiderations

We all must be aware of and sensitive to the We all must be aware of and sensitive to the various cultures and religions. various cultures and religions.

Some religions and cultures view disease, Some religions and cultures view disease, disabilities, accidents as fate. This will impact disabilities, accidents as fate. This will impact how we do therapy and counseling.how we do therapy and counseling.

Some frown upon physical contact.Some frown upon physical contact. Some religions may find it difficult to listen to a Some religions may find it difficult to listen to a

female’s ideas versus a male’s. female’s ideas versus a male’s. Some cultures find it rude to question authority. Some cultures find it rude to question authority.

They may agree with you verbally, but truly don’t.They may agree with you verbally, but truly don’t. Some may seek other, non-westernized, Some may seek other, non-westernized,

treatments.treatments. Roles may vary greatly within different cultures.Roles may vary greatly within different cultures. Family support may also vary.Family support may also vary.

How can I bill for this?How can I bill for this? I feel that your entire session should I feel that your entire session should

not be spent doing counseling.not be spent doing counseling. You need to balance with your other You need to balance with your other

therapy tasks.therapy tasks. This doesn’t mean that you can’t use This doesn’t mean that you can’t use

counseling as part of therapy.counseling as part of therapy. I sometimes even make a goal to I sometimes even make a goal to

include counseling aspects (ie., Pt. include counseling aspects (ie., Pt. will have zero paraphasias during a will have zero paraphasias during a dialogue regarding his/her dialogue regarding his/her relationships.)relationships.)

Referring OnReferring On

We need to know that we are limited We need to know that we are limited in our abilities to serve as the client’s in our abilities to serve as the client’s sole “counselor”. sole “counselor”.

Often, we need to be sure and refer Often, we need to be sure and refer them on for a psychology consult or them on for a psychology consult or social worker. social worker.

Talk to the MD. Let him/her know of Talk to the MD. Let him/her know of your concerns.your concerns.

Social services may also be a great Social services may also be a great resource.resource.

Dr. Robert Buckman’s Dr. Robert Buckman’s QuoteQuote

“…“…the skill and effort that we put the skill and effort that we put into our clinical communication into our clinical communication (counseling) does make an (counseling) does make an indelible impression on our indelible impression on our patients, their families, and their patients, their families, and their friends. If we do it badly, they friends. If we do it badly, they may never forgive us; if we do it may never forgive us; if we do it well they may never forget us.”well they may never forget us.”

Questions!Questions!

Case Case ExamplesExamples

Documents

Counseling Adult Neurogenic Disordered Patients and Their Families Scott A. Jackson, M.S., CCC-SLP