Counseling Skill Development in Audiology: Clinical Instruction Considerations

Abstract

Audiologists play a critical role in supporting patients as they provide diagnostic information about their hearing and in the delivery of treatment services. Graduate training related to counseling, however, varies among programs in the extent students are prepared to engage effectively and intentionally with patients. Instruction is needed to provide students with a framework that supports their ability to learn and implement evidence-based counseling services. This article addresses the impact patients can experience when counseling gaps exist, shares clinical instruction strategies that can support students' acquisition of counseling skills, and discusses considerations for integration of counseling education into graduate training programs.

Learning Outcomes: As a result of this activity, the participant will be able to (1) describe opportunities for improving counseling in audiology; (2) list three supervision strategies to support counseling skill development; and (3) describe how counseling education can be integrated into graduate training.

Counseling is an important element of service delivery, recognized by audiologists and included in the audiology scope of practice professional practice guidelines and in the American Speech-Language-Hearing Association document of Preferred Practice Patterns for the Profession of Audiology. ^{1 2 3 4 5} Guidance from accrediting bodies related to counseling competencies lacks specificity in expectations for graduate training. Furthermore, recent research has demonstrated gaps in counseling practices, ^{6 7 8 9} even though there is broad agreement about the essential role of counseling in helping patients adjust to diagnoses and adopt recommended treatments.

The audiologist-patient relationship is a critical element of the service delivery process. Services provided within a therapeutic relationship build a foundation for trust and an environment where patients feel comfortable sharing their concerns and challenges. Intentional implementation of counseling strategies facilitates communication that can help patients uncover the source of their barriers and identify solutions that will be effective in their daily lives. When audiologists neglect to attend to the counseling aspect of their role, they may unwittingly undermine their patients and impede intervention progress.

Research has revealed various counseling deficits in audiology. During hearing device–monitoring encounters with adult hearing aid and cochlear implant patients and parents of pediatric patients, audiologists were found to minimally use counseling skills (e.g., reflection, assessment of psychological variables, development of an action plan). ⁹ During encounters with adults with hearing loss, audiologists were found to provide technology-focused responses when patients raised emotion-based concerns; dominate the conversation, reducing opportunities for patients to voice their concerns or raise questions; and frequently multitask when talking with their patients, interfering with their ability to observe their patients and to display effective attending behaviors. ^{6 7 8 9} Patients may not directly share their emotions and challenges, but rather offer clues to how they are coping through their body language (e.g., eye contact, posture), verbal behavior (e.g., tone of voice, issues raised), or actions (e.g., not wearing their hearing aids). If audiologists do not provide space for their patients to engage or are not attuned with their patients' needs, they may miss opportunities to accurately target their support.

Variability in counseling education may contribute to this apparent mismatch in audiologists' recognition of the importance of counseling and communication behaviors observed in clinical settings. Coursework and clinical instruction are both critical elements of counseling education; however, not all audiology graduate programs include a required counseling course in their curriculum. ¹⁰ Furthermore, not all clinical instructors provide supervision for counseling skill development, and few clinical instructors in Au.D. programs report consistently using structured strategies to teach students counseling skills. ¹¹

Development of counseling skills is a process that occurs through intentional instruction. For students to gain necessary skills and the confidence to use the skills with their patients, they need foundational knowledge, opportunities to practice, and targeted supervision. As observed in findings from recent research, it is a disservice to the profession and those seeking audiology services to assume counseling skills either come naturally or develop over time with experience after graduation. In fact, audiologists who had a counseling course were found to be statistically significantly more confident and reported using skills more often than audiologists who had not had a course and who had been practicing audiology longer. ¹¹

A variety of factors can interfere with counseling supervision. Given the inconsistency in counseling training in audiology, there is likely variability in the training supervisors received, potentially limiting their scope of knowledge and confidence in teaching these skills to others. Additionally, there is a lack of clarity in practice guidelines and from accrediting bodies for counseling competencies to effectively address patient needs, contributing to the existing variability. Other factors, such as feelings of discomfort addressing emotions or concerns that there is not enough time to address patient emotions, can interfere and lead to avoidance of counseling and gaps in teaching students.

Clinical Instruction Strategies

Incorporating a variety of clinical instruction strategies can provide students with multiple opportunities to understand the implications of counseling and to gain confidence using skills. For example, talking about counseling during planning for a session can help students consider how to ask questions that will facilitate understanding of their patient's needs and can improve students' ability to develop a shared agenda with their patient. Talking about counseling after the session can give students an opportunity to ask questions and share how they felt about talking with the patient during the encounter, and it gives the supervisor an opportunity to provide timely verbal feedback. Written feedback after the session can help students reflect on their counseling skills, observe how they are improving, and identify areas that need more focused attention.

Performance feedback is a critical component for skill development. Finai et al (this issue) found that individual performance feedback that included replaying audio examples from the session increased students' use of counseling skills. Feedback not only needs to be timely, it needs to be specific, constructive, and sensitive. Receiving feedback about counseling can feel personal, and students may feel vulnerable or defensive. When supervisors reflect on how they approach students and observe how students respond, they can recognize if they are helping or hindering growth and if changes in their supervision style are needed to better individualize learning support.

Group supervision is another strategy that can facilitate students' ability to accurately reflect and consider their learning process. Bringing students together for group supervision can provide an opportunity to help students explore challenges that interfere with their counseling skill development and discuss challenging situations they experienced. They can recognize that feeling nervous is common, reflect on how they respond when they feel nervous (e.g., do they avoid patient emotions?), and explore alternative behaviors or strategies they can use to be more effective. This is also an opportunity to practice challenging scenarios in a safe environment using role-play activities or simulated experiences.

Teaching counseling also includes addressing students' attitudes about counseling. Students need to recognize the importance of understanding their patients' needs broadly, within the context of audiology service delivery, for a successful intervention process. If services are focused solely on technology-related topics, patients' emotional experiences will be overlooked. Emotional experiences exist for all patients, positive (e.g., joy, relief) and negative (e.g., denial, guilt, sadness, anger), and they can influence patient success. Building relationships and considering patients' needs more fully benefit the audiologist, as well as patients and families.

Opportunities for Growth

Teaching counseling must fit within the audiology curriculum without increasing the length of the program, and this can be approached by identifying how to effectively include critical components strategically within an existing curriculum. Even though many Au.D. programs require a counseling course, they are offered at different times within the curriculum, with the majority occurring during the second year. ^{10 11} Regardless of when the course occurs, students can be introduced to basic concepts and terminology from the beginning of their program. When clinical and classroom instructors use a common language to talk about counseling concepts and skills, students can more easily build their understanding and make connections across experiences within the program. One opportunity to introduce counseling is when students learn how to complete a comprehensive hearing assessment. This course commonly occurs early in the course sequence, is a natural place to explicitly introduce basic counseling skills and terminology, and can broaden students' views of assessment.

As students gain familiarity with basic concepts and skills, they can more easily expand on those skills to address more complex situations. Incorporating activities (e.g., role-play, simulation) can help students practice challenging scenarios, such as breaking difficult news. Simulation is relatively new to audiology and can offer benefits to students, including supporting development of professional dispositions and competencies and addressing characteristics that may interfere, within a safe and controlled learning environment. ¹² Activities can help bridge concepts learned in courses to clinical practice and facilitate the students' ability to gain confidence within the supervisory relationship.

Improving the intentionality of counseling education in audiology will require programs to take stock of their current approach, strengths, and resources, as well as existing challenges. The following are questions that may assist programs in reviewing their current approach to counseling education and considering opportunities for improvement:

• Does your program require a counseling course for Au.D. students? If so, when does it occur in the program, what works well with the current timing, and what are the challenges?

• Are students intentionally introduced to basic counseling concepts and skills from the time they enter your program? If so, how consistent is the mechanism in reaching all students? What works well with your approach? In what ways could it be improved?

• Have all clinical instructors received counseling training? What continuing education is needed to support your clinical instructors?

• What tools or strategies do your clinical instructors use to instruct and provide feedback to students, specific to counseling skill development? How consistently are the methods used? What works well about the methods and in what ways could the process be improved?

• What specific counseling competencies are students graded on in their clinical practicum? How consistent is grading related to counseling skill acquisition across clinical instructors?

Counseling is a critical component of education in audiology, and having a systematic structure in place within Au.D. programs for instruction is long overdue. Attending to program strengths and areas that can be improved will benefit future audiologists and the patients and families they serve.