Abstract
BACKGROUND:
The quality of the counselor-client relationship, as defined by the therapeutic or working alliance (WA), has long been known to impact therapeutic outcomes (Horvath, Del Re, Flückiger, & Symonds, 2011; Lambert & Barley, 2001). Within the Vocational Rehabilitation (VR) process, a strong working alliance has likewise been shown to result in better vocational and/or independence outcomes (Lustig, Strauser, Rice, & Rucker, 2002) due to more active client collaboration in vocational planning and follow-through with planned services, a strong predictor of outcome in therapy (Gomes-Schwartz, 1978).
OBJECTIVE:
As bonding between therapist/counselor and patient/client is one essential element in the construct of the WA (Bordin, 1979), the sub-elements of bonding are considered in this review as they apply to the critical role of communication (Egan, 2013) between the generalist VR counselor (Cook & Bolton, 1997) and client who is hard of hearing or late-deafened.
CONCLUSION:
Communication challenges peculiar to these populations are explored, and how they impact the development of bonding and a functional relationship in the counseling setting. Finally, ways to reconsider and accommodate these challenges are reviewed.
Introduction
The quality of the counselor-client relationship in the Vocational Rehabilitation (VR) process can impact client collaboration in vocational planning, and the client’s follow-through with planned services toward a vocational and/or independence goal (Lustig et al., 2002). One useful construct employed to identify, describe and study the counselor-client relationship over the last fifty-plus years is the therapeutic or working alliance (WA) (e.g., Frieswyk, Allen, Colson, Coyne, Gabbard, Horwitz, & Newsom, 1986). The WA, as posited by Bordin (1979), is comprised of three basic components, two of which are: a) counselor-client agreement on goals to be pursued and attained through counseling and/or service provision, what the client hopes to achieve (or change) through the relationship; and b) counselor-client agreement on tasks, i.e., the work acknowledged as necessary to achieve identified goals. For example, a counselor and client might collaborate and agree to pursue a vocational goal of “Licensed Practical Nurse (LPN),” with post-secondary education and a major in Nursing identified as a task necessary to achieve this goal.
The third component of WA is bonding (Bordin, 1979), characterizing the interpersonal relationship between counselor and client. When bonding occurs, it implies a trust that agreed-upon tasks will help the client achieve the desired goal through the relationship (Horvath & Greenberg, 1994). The level of counselor-client bonding can vary, however, with what is required to achieve the goal. Bordin (1979) gives an example–not altogether unlikely in the early phases of the VR process—in which the only task given the client is to complete some forms. The level of bonding necessary for this task will differ considerably from one involving more intense review, discussion, negotiation, planning, and decision-making over the course of several sessions. Whatever the level, if a functional WA (with bonding) is to occur at all, it is important that it develop early, as there is a point at which the opportunity for WA diminishes (Horvarth, 1994). In fact, Henry and Strupp (1994) suggested that the WA that correlates with successful outcomes either forms, or fails to form, within the first three sessions.
This speaks to the importance of establishing a bond as soon as practically possible in the VR process, especially if closer collaboration is necessary for the client to achieve a successful outcome. Horvath and Greenberg (1994) stated that “it seems reasonable to think of alliance development in the first phase of therapy as a series of windows of opportunity, decreasing in size with each session” (p. 3). So even at the outset of the relationship, typically the first meeting in the counselor’s office, the bond can begin to form. Bonding then may be strengthened in following sessions as the VR process is validated for the client through genuine counselor attention, interest and follow through, as communicated through interaction, service provision such as vocational evaluation and subsequent counselor review and discussion. Over time, Horvath and Greenberg (1994) indicated that WA–including its bonding component–may develop, decay and renew, depending on the challenges encountered: “Once workable levels of alliance have been developed, the relationship component of the therapeutic journey may become a roller coaster” (p.3). However it should stabilize and even increase (Kivlighan & Shaughnessy, 2000), as counselor competence, reliability and support is validated for the client through positive, counselor interaction (Saunders, 1999; Sexton, Hembre, & Kvarme, 1996) and the process of service provision—i.e., information provided and activities performed (or assigned) by the counselor (Henry & Strupp, 1994), to include case management, advocacy, and related services.
The importance of adequate communication to the bonding process can hardly be overemphasized, and this is as true for persons with hearing loss (Pollard, 1994) as it is for the hearing client (Ahn & Wampold, 2001; Atkinson & Karskadon, 1975; Hill & Corbett, 1993). To the client, the face of the VR process is the VR counselor who orients, informs and navigates the client through the system. For persons who are culturally Deaf or Deaf-Blind, challenges to communication are obvious, if not fully and always addressed (Williams & Abeles, 2004). But with the VR client who is hard of hearing or late-deafened, challenges to communication for the VR counselor are frequently as subtle as they are critical, and can easily be overlooked or ignored (see e.g., Boone, Trychin, Battat, Conway, Tomlinson, Hamlin, Berry, & Smith-Olinde, 2012).
According to the Hearing Loss Association of America (HLAA), the term “Hard of Hearing” is intended to be descriptive; it is generally understood to mean there is some useable hearing, or a hearing loss short of deafness (HLAA, “Glossary,” 2012). According to the 2012 report from the National Health Interview Survey (HIS), 37.5 million Americans aged 18 and over reported hearing losses (Blackwell, Lucas, & Clarke, 2014). Most of these are hard of hearing, rather than deaf (National Institute on Deafness and Other Communication Disorders [NIDCD], “Quick Statistics about Hearing,” 2016). These constitute a significant pool of clients and potential clients of the state-federal VR program.
To be “late-deafened” is to be distinct from those with prelingual deafness because their personal experiences differ considerably (Meyer & Kashubeck-West, 2013). These are individuals who have lost significant hearing at approximately 13 years of age or older (Mason, 1996), after acquiring speech and language as the primary mode and habit of communication (Watson, Jennings, Tomlinson, Boone, & Anderson, 2008). Prevalence of adult onset deafness among our general population is relatively high (Watson et al., 2008); onset was reported to be older than 19 years of age among those with no measurable hearing or, at best, hearing shouted into the ear (Ries, 1994).
In this review, I will (a) consider the elements of bonding, (b) describe primary populations with hearing loss and their predominant modes of communication, and (c) discuss communication challenges to bonding with persons who are hard of hearing or late-deafened. Finally, I will (d) suggest ways to address these challenges in the early stages of the VR process in order to promote a functional counseling relationship toward a successful outcome.
Bonding: Liking, trust, respect, common commitment and shared understanding
Bordin (1994) has described “bonding” as “partner compatibility.” Between counselor and client, bonding is characterized as “liking, trusting, respect for each other, and a sense of common commitment and shared understanding in the activity” (p. 16). A brief review of these concepts and their relevance to the construct of bonding will be presented.
The concept of “liking” or interpersonal attraction
Research on “Liking” or its synonym, “interpersonal attraction,” flourished in the 1960s–70s (Finkel & Eastwick, 2015). In their review and summary of attraction literature over the last 50 years, Finkel and Eastwick (2015) maintained that theories from that period and into the 1990s tended toward one of the following, general perspectives: (a) domain-general reward, (b) domain-specific evolutionary, and (c) attachment. The domain-general reward perspectives focused on the individual being drawn to someone who can satisfy fundamental needs, such as pleasure, belonging self-esteem, and consistency, which may be accomplished through friendship, work, family interaction and activities, and mating. Domain-specific evolutionary perspectives see interpersonal attraction linked to needs specific to reproductive success which can only be addressed in specific ways, e.g., a spouse exhibiting sexual attraction toward the individual; these needs can include hedonic pleasure, self-esteem, belonging, consistency, and self-expansion. Attachment perspectives tend to include elements of both domain-general reward and domain-specific evolutional, but generally view interpersonal attraction as an attempt to reestablish a sense of security in times of distress (Bowlby, 1969).
Ultimately Finkel and Eastwick (2015) suggested the instrumentality principle as the best explanation for interpersonal attraction, subsuming other theories; it is the notion that “people become attracted to others who help them achieve needs or goals that are currently high in motivational priority” (p. 4). Fitzsimons & Shah (2008) stated that it is the tendency to “draw closer to instrumental others, evaluate them more positively, and approach them more readily, while distancing themselves from noninstrumental others, evaluating them more negatively, and avoiding them more readily” (p. 320).
Implications for the VR counselor-client relationship are obvious. The basic purpose of a rehabilitation relationship is to address an identified client need, and to accomplish an agreed-upon goal. The client who meets a VR counselor for the first time and is willing to assume—at least at the outset–that needs and goals will be addressed and achieved, is open to liking that counselor. The instrumentality principle can also apply from the counselor’s perspective—i.e., the counselor liking the client. Viewed from the perspective of job satisfaction, the VR counselor will enter into a relationship with the client for myriad reasons, not the least of which is to satisfy an employer and earn a paycheck (Szymanski, 1995). But Andrew, Faubion, and Palmer (2002) noted that once extrinsic job factors (e.g., administration, work environment, pay and benefits, and supervision) are satisfied, intrinsic factors (e.g., talking, helping, serving clients) are the primary ingredients to job satisfaction, which also appeared to be the conclusion of Szymanski and Parker (1995): while a primary reason for staying with the job was “security,” the most frequently reported reason VR Counselors sought work with the agency included “working with people” (p. 56). Wright and Terrian (1987) similarly determined a higher degree of intrinsic over extrinsic satisfaction in their study of rehabilitation counselor job satisfaction.
Importantly, Capella and Andrew (2004) also found evidence that VR counselor job satisfaction is significantly related to VR client satisfaction. When the client is satisfied, the counselor is likely to be satisfied as well. The instrumentality principle (Finkel & Eastwick, 2015) is evident here as both client and counselor satisfaction occur in the expectation that each will meet the needs of the other.
The concept and development of trust
Trust is “the client’s perception and belief that the counselor will not mislead or injure the client in any way” (Fong & Cox, 1983, p. 163). Where a client questions the counselor’s capacity to understand, or competence to intervene effectively, a working relationship can be impeded or even halted. And as time is of the essence in developing an effective working alliance (Henry & Strupp, 1994), a delay at the outset due to a lack of client confidence in the counselor, is counterproductive to client engagement and collaboration. Horvath and Greenberg (1994) stated that a “…lack of development of trust within the first three sessions will probably lead to disengagement from therapy” (p.2). A not uncommon example of such an occurrence might be that of a counselor working with a client of a different ethnic or cultural background (Smith, Soto, Griner, & Trimble 2015). In recent years, ethical guidelines were developed to ensure counselors are aware of their responsibility to become competent in serving clients of cultures other than their own; e.g., CRCC and ACA Codes of Ethics provide cautions and guidance regarding the need for cultural sensitivity, respect for values, and competence in addressing needs (CRCC, 2009; ACA, 2014).
Recognizing that trust in a counseling relationship does not occur automatically (Smith et al., 2015), especially where the issues are particularly sensitive, and/or there is wide cultural diversity between counselor and client, then trust may need to be developed or enhanced to be functional. Fong and Cox (1989) suggested that the development of trust may be conceived as a series of exchanges, called “tests of trust,” between the counselor and client. They identified these “tests” as predictable in form and, importantly, need to be well addressed by the counselor, without serious misstep, in order for trust to build and solidify. The steps include (a) requesting information, (b) telling a secret, (c) putting oneself down, (d) asking a favor, (e) inconveniencing the counselor, and (f) questioning the counselor’s dedication and motivation (Fong & Cox, 1989).
Important to this discussion, it may be noted that each test of trust is inherent in an early phase of the state-federal VR process (cf., Maki & Tarvydas, 2011, pp. 98–100, and Scope of Practice for Rehabilitation Counseling, CRCC, 2010, Appendix B.III-IV). The client (a) requests information about services and the likelihood that such services will address an identified need, then makes application through a state-federal VR program; (b) the identified need is presented via medical or functional details not generally privy to the public, but shared with the counselor to demonstrate eligibility for the program–i.e., medical diagnosis, constituting a handicap to employment, with a need for services—and enlists the counselor’s help; (c) intake and related discussion encompass client’s self-view of limitations and hardships; (d) services are discussed and requested to address identified needs and limitations; (e) counselor will often, at some point in the rehabilitation process, be asked or required to take on unexpected challenges to advocate or intervene for the client in order to keep the program moving or modify the plan; and (f) counselor commitment may be periodically questioned or challenged by the client or advocates with delays or missteps.
The concept of respect
The third component of bonding, “respect,” is often linked to qualities of liking (Bordin, 1994), confidence, understanding and trusting in the literature (see e.g., Lietaer, 1992; Raue & Goldfried, 1994). However Egan (2013) maintained that respect is “such a fundamental concept that, like most such concepts, it eludes definition” (p. 46); it is viewed as foundational to the counselor-client relationship, the basis upon which all helping interventions are built.
Egan (2013) listed behaviors exemplifying respect by counselors for their clients that imply many of the same attitudes and perspectives of liking and trusting in the counseling setting. Respect is demonstrated when a counselor: (a) becomes competent, (b) is genuine (no pretense), (c) makes it clear that the counselor is there “for” the client, (d) assumes the client’s goodwill, and (e) keeps the client’s agenda in focus.
Of note, parallels to these behaviors of respect are generally but easily evident in the “primary values” identified for the VR counselor in the Preamble to the Code of Professional Ethics for Rehabilitation Counselors (2009). Ethical values include: (a) Enhancing the quality of professional knowledge and its application to increase professional and personal effectiveness; (b) Ensuring the integrity of all professional relationships, and respecting human rights and dignity; (c) Advocating for the fair and adequate provision of services; and (d) Acting to alleviate personal distress and suffering, and appreciating the diversity of human experience and culture.
Sense of common commitment
Bordin (1994) indicated that in addition to liking, trusting and respect, bonding is likely to be expressed and felt in terms of a sense of common commitment to “change goals” (p. 17). Basically, as a component of WA, a change goal is the reason for which counseling is sought. In a rehabilitation context, a change goal may be the outcome expected of an employment or independence plan to change the client’s current circumstances in some way. Within the construct of bonding, a sense of common commitment to the change goal is critical. “Common” means shared by both client and counselor. Once the client’s goal is decided, the client should feel a shared sense a commitment to the goal by the counselor. Bordin (1994) calls this a “key process in building an initial, viable alliance” (p. 21) between client and counselor.
The actual level of commitment necessary to achieve a goal will vary, however, with the difficulty required to achieve it (Bordin, 1979), as well as the client’s individual ability and personal resources (Gomes-Schwartz, 1978; O’Malley, Suh, & Strupp, 1983). But whatever level of commitment is necessary, while the client should know the counselor agrees with the goal and believes in the client’s capacity to achieve it, actual ownership for its achievement belongs to the client (Egan 2013). Egan (2013) described three possible levels of client commitment to the goal: (a) compliance (e.g., “Well, I guess I’ll have to…”); (b) buy-in (e.g., “Yes, I know it’s in my best interest to change…”); and the highest level of commitment (c) ownership (e.g., “It’s not someone else’s, it’s not just a good idea, it’s what I want to do”).
In the VR context, through whatever means are employed by counselor and client to explore, negotiate and establish a meaningful, feasible goal to change a client’s circumstances, it will be important to assess and encourage the highest level of commitment possible from the client. For if the goal is suggested or directed by someone else (e.g., the counselor or significant other) and accepted by the client, ownership (and commitment) of the plan shifts away from the client, as does responsibility for its outcome–especially if the outcome is failure (Egan, 2013).
Shared understanding in the activity
Beyond the client’s perception of the counselor personally, in terms of liking, trusting, respect, and a sense of common commitment, Bordin (1994) indicates that bonding will also be expressed/felt in terms of shared understanding of the activity or task(s) to achieve the goal. This differs from the third general component of WA—agreement on tasks (Bordin, 1979)—in the same way the concept of “understanding” differs from that of “agreement.” In the context of rehabilitation counseling, the first, “most important component of the VR process is the collaborative development of the Individualized Plan of Employment (IPE), as that document specifies the type, quantity, and nature of goods and services that are to be provided to assist the individual to reach his or her vocational goal” (Fabian & MacDonald-Wilson, 2012, p. 60). Inherent in the collaboration required to develop the IPE is the expectation that the client is not just a participant in the plan, but a partner (note e.g., CRCC’s Code of Professional Ethics of Rehabilitation Counselors, 2009, A.1.b, p. 3; and A.3.b Informed Consent, p. 4, uses terms such as “work jointly,” and “mutually agreed upon,” to characterize the activity of plan development).
Obviously, the extent to which the client is involved in planning will depend on how well the client understands the tasks necessary to achieve the goal (Bordin, 1994). Recognizing that understanding may not readily or easily occur if there is a disability constituting a barrier to comprehension, the Code of Professional Ethics of Rehabilitation Counselors (2009) nonetheless emphasizes the right of clients to understand, i.e., to be presented information in such a way as to promote understanding. For example, “Rehabilitation counselors have an obligation to review with clients…in a manner that best accommodates any of their limitation…” (A.3.a, p. 3). Further, “…counselors communicate information in ways that are both developmentally and culturally appropriate” (A.3.c, p. 4) and, in cases where the client is “unable to give voluntary consent, rehabilitation counselors seek the assent of clients and include clients in decision-making as appropriate” (A.3.d, p. 4).
For the VR client who is hard of hearing or late-deafened, these ethical considerations take on special significance for the counselor. It is important to forge a collaborative bond to achieve successful VR outcomes (Lustig et al., 2002) with these populations, and communication is likely to be a predominant barrier to doing so (Boone et al., 2012). Yet the ethical guidelines are clear; the VR counselor is obligated to overcome this barrier (CRCC, 2009).
Overcoming barriers to communication can be challenging, however, especially as these challenges may vary considerably among individuals with hearing loss. Eng and Lerner (2011) stated: “Although inferences can be made from interpreting the test results, the degree of impairment is affected by a variety of other factors, including the type, degree, configuration of hearing loss, age of onset, cognitive status, educational background, and the individual’s personality” (p. 217). Still, to provide a basis for this review, a brief overview will be presented of these populations—i.e., those who are hard of hearing, and those who are late-deafened–and how they differ from the culturally Deaf. With variation in hearing function, there can be vast differences in communication and intervention needs.
Hard of hearing and late-deafened: Two distinct populations
Watson et al. (2008) stated that “hearing loss is the most prevalent, chronic, physically disabling condition in the United States today” (p. 3). A brief description of major populations of those with hearing loss who are hard of hearing and late-deafened will be provided. But to avoid confusing these with perhaps the more visible population who uses sign language to communicate, it may first be useful to briefly describe characteristics of this group, the culturally Deaf. A caveat to these reviews: from individual to individual, people with hearing loss might loosely identify with more than one population in terms of degree/type of hearing loss, communication and/or social preferences (Leigh, 2009). For example, someone who is culturally Deaf (defined below) may have a capacity for speech adequate to socialize with hearing people and float in and out of professional or social functions in mixed social settings; likewise a person who is functionally hard of hearing may use American Sign Language (ASL) and socialize as an accepted member of the Deaf community, or “Deaf World”—as indeed may a hearing person–etc. (Leigh, 2009). Still, with acknowledgment that there may be some overlap from individual to individual, general group descriptions are helpful to the extent they assist in a review of common communication problems among populations with similar characteristics, their impact on bonding, and accommodations to address their barriers and promote collaboration.
The culturally deaf
Acknowledgement in professional literature that there is a unique, distinct culture called the Deaf, came about in the early 1960s (Glickman, 1996), following “the then-radical claim that the gestural system used by Deaf people was in fact a fully grammatical language capable of abstractions, subtleties, and linguistic development” (p. 3). This group has since been recognized in print as “capital-D Deaf,” to distinguish the descriptive term deaf from the Deaf, a distinct group of people sharing common characteristics:
Deaf refers to a member of a linguistic and cultural minority with distinctive mores, attitudes, and values and a distinctive physical constitution. We refer to the members of that culture as Deaf and to the culture itself as the Deaf-World; these are glosses of the signs in American Sign Language with which Deaf people refer to themselves and their culture, respectively. We also follow the Deaf-World practice in referring to children of any age as capital-D-Deaf who have, for whatever reason, the physical constitution characteristic of this minority—that is, they rely so much more on vision than on hearing that they communicate most readily, given the opportunity, in a natural sign language. (Lane, 2002, pp. 367-368)
It should be noted that hearing loss is not necessarily criteria for membership in the “Deaf-World.” In fact, since adult Deaf people usually have hearing children (Calderon & Greenberg, 2003; Mitchell & Karchmer, 2004), whole families intermingle in their social circles whether hearing or not (e.g., Deaf Clubs, places of worship, etc.), and the only basic criteria for membership is the ability to communicate in American Sign Language (ASL). The mores, attitudes and values (Lane, 2002) that further characterize the culture are acquired through socialization, as they are in any culture or society (White House Conference on Handicapped Individuals, 1977).
It is also noteworthy that, unlike persons who are hard of hearing and late-deafened (Luey, Glass, & Elliott, 1995) the Deaf do not typically consider themselves “disabled” (Humphries, 1993). Lane (2002) stated, “Whereas people with disabilities seek total integration into society at large, Deaf people cherish their unique identity and seek integration that honors their distinct language and culture” (p. 369). This is an important point. To facilitate bonding with persons from this culture group, communication needs are addressed as they are for any other culture group where language is the barrier (e.g., Thomas & Donovan, 2015).
The client who is hard of hearing
According to Watson et al. (2008), “persons who are hard of hearing include those with a hearing impairment resulting in a functional loss, but not to the extent that the individual must depend primarily upon visual communication” (p. 6). Because hearing loss may not be readily observed in an individual, the disability has been labeled the “invisible condition” (HLAA, “Basic Facts About Hearing Loss,” n.d.); indeed, persons who are hard of hearing will often seek to blend in as much a possible with their hearing community to avoid identification and embarrassment, often with mixed success (Armero, 2001; Gomez & Madey, 2001; Hallberg, Erlandsson, & Carlsson, 1992).
In general terms, people who are hard of hearing consider a hearing loss to be a medical problem (Eng & Lerner, 2011; Luey et al., 1995); if they are inclined (or believe they can afford) to seek remedy, they will begin with their doctor, audiologist or a hearing aid professional for help to resolve it (e.g., National Institute on Deafness and Other Communication Disorders [NIDCD], “Hearing Loss and Older Adults,” 2016). Their goal is to hear better so as to more fully enter or re-enter a society of hearing people—e.g., their family, friends, workplace, social groups, etc.—with whom they consider their community (Luey et al., 1995; HLAA, “Hearing Loss Association of America’s Public Policy and Advocacy Agenda: Ten Key Goals and Outcomes,” n.d.).
Functionally, there is wide disparity among persons of this population because, apart from other factors (reviewed below), the inability to hear adequately will vary by intensity (loudness) and/or frequency (pitch) of the individual’s hearing loss (DeBonis & Donohue, 2003). Therefore appropriate individual solutions will also vary. Stone (1993) noted that “along the spectrum of hard of hearing people, there are many different problems, and the method of alleviation may vary. What works in one case may not work in another” (p. 8). But when attempts at remedy through medication or surgery are inadequate, solutions are typically sought in amplification technology. Eng and Lerner (2011) stated “amplification is central to a treatment program of aural rehabilitation. Amplification includes hearing aids that intensify the speech signal to a comfortable listening level for the hearing-disordered person” (p. 218).
To initiate and facilitate the process of bonding with persons of this group, the VR counselor will first consider and address the barrier of communication by improving and/or enhancing the quality of what is heard by the client, supported by visual cues (see e.g., Watson et al., 2008). Specific communication factors will be considered in greater detail below.
The client who is late-deafened
The individual who is late-deafened will have acquired a significant hearing loss by adolescence or later in life (Mason, 1996), with the level of functional communication dependent on many of the same factors as those for persons who are hard of hearing—e.g., degree and type of loss, age at onset, aptitudes, level of education, extent of adjustment to loss, etc. (Eng & Lerner, 2011). However late-deafness is unique because it “…is adventitious, meaning that it is generally unexpected and acquired later in life rather than at birth, and therefore it will require psychosocial adaptation” (Meyer & Kashubeck-West, 2013, p. 124).
The need for psychosocial adaptation is a critical characteristic of many persons—especially older adults–suffering late onset deafness (Meyer & Kashubeck-West, 2013). For an acquired disability, adaptation is a process involving progress through psychological stages of adjustment (Livneh & Antonak, 2005), and the struggle may be long and arduous if, in fact, it is achieved at all. A number of professionals contend that “…late-deafened adults never really accept the hearing loss, but rather come to acknowledge it and engage in constructive action to cope with it” (Rothschild & Kampfe, 1997, p. 6). This is because a significant communication barrier—one that presents suddenly or progressively–will impact a lifestyle, separating these individuals from family, social affiliation, and status in the community. The barrier can be a constant reminder of a break from all they know, and may be emotionally devastating (David & Trehub, 1989; Luey, 1980; Rutman, 1989). But speed and degree of acceptance, if not adjustment, will vary considerably from individual to individual depending on such factors as age at onset of hearing loss, various aptitudes, available personal supports, and the individual’s success with coping (Rothschild & Kampfe, 1997). Lucas (2007) determined that adaptation to an acquired disability is not always achieved, and that it can impact happiness, quality of life and well-being.
For the VR counselor to initiate a bond with a late-deafened individual, communication strategies may well require enhancement of both audio and visual cues, with emphasis on the visual (Watson et al., 2008). Specific barriers and accommodations to/for bonding for the late-deafened client will be reviewed below. Once a functional bond has been established, in light of probable psychosocial issues (Meyer & Kashubeck-West, 2013), the VR counselor may need to consider encouraging a change goal (Bordin, 1994) to address adaptation to the disability prior to (or at least concurrent with) a vocational goal.
Communication challenges to bonding with hard of hearing or late-deafened
Verbal communication—i.e., basic expression and reception of a spoken language—is the primary tool for bonding with hard of hearing and late-deafened people, with all its elements of liking, trusting, respect, sense of common commitment, and shared understanding in the activity (Bordin, 1994). However, verbal communication can be significantly labored when there is a hearing loss with which to contend (Eng & Lerner, 2011). For communication to occur there must be certain elements in place; and the degree to which these elements are present or functional determines the adequacy of the interaction (Boone et al., 2012), and of bonding—i.e., “liking, trusting, respect for each other” (Bordin, 1994, p. 16).
Communication and the counseling setting: Factors and suggestions
Strong (1968) conceptualized counseling as an internal influence process, similar to that of opinion-change. Opinion change is an important topic in mass communication and public opinion research (e.g., Mutz & Young, 2011), and verbal communication a critical tool in that process, as it is in the counseling process. Strong (1968) posited:
In opinion-change research a communicator attempts to influence his audience in a predetermined direction; in counseling, the counselor attempts to influence his client to attain the goals of counseling. Verbal communication is the main technique used by an opinion changer in influencing his audience; verbal communication is also the counselor’s main means of influencing his client. For both these communications present opinions or conceptions different than or discrepant, from the opinions or conceptions of the audience or client. Finally, characteristics of the communicator as perceived by the audience, characteristics of the audience, and characteristics of the communication affect the success of influence attempts. (p. 215)
Boone et al. (2012) confirmed two of these three characteristics, calling them categories with factors that influence how well a client understands verbal communication: (a) speaker factors and (b) listener factors. These echoed Strong’s (1968) characteristics of (a) communicator as perceived by the audience and (b) characteristics of the audience…,” i.e., speaker-communicator, listener-audience. Strong’s (1968) third characteristic, characteristics of the communication appears conceptually addressed in Boone’s et al. (2012) speaker factor, i.e., how communication is conveyed (e.g., language style, accent, dialect or other cultural distinction).
Finally, Boone et al. (2012) specified a third category, that of environment, which refers to those factors specific to neither speaker nor listener, but rather concerns the context or environment within which communication is attempted. I will briefly review these three categories of factors before addressing the issue of bonding between VR counselor and client with a hearing loss.
Speaker factors
Basically, speaker factors are those activities (or inactions) by a verbal communicator that impact how well the spoken message is received. The overall counselor-speaker strategy then is to maximize the usefulness of the listener-client’s residual hearing, as well as the listener-client’s capacity to speechread.
Speech reading is often used synonymously with the term lip reading. Speech reading is using what you see on the speaker’s lips as well as facial expressions and gestures to understand conversation…People with hearing loss can use speech reading to supplement understanding when they have trouble understanding or hearing speech. Often those speech sounds that are hard to hear are easy to see, like a softly spoken “p” sound. The more severe the hearing loss or the more noisy the environment, the more likely one can benefit from speech reading” (HLAA, “Speech Reading [AKA Lip Reading],” n.d.).
Unfortunately, only about one third of the speech sounds in English can be distinguished on the lips (Eng & Lerner, 2011); so speechreading alone is, at best, only a help for the listener. But together with the client’s residual hearing and amplification, it is a critical help:
Combining speechreading with wearing hearing aids is very important. In a study at the University of Manchester researchers found that hard of hearing people just using their residual hearing understood 21 percent of speech. If they combined their residual hearing with either a hearing aid or with speechreading, they could understand 64 percent of speech. This is a significant improvement. However, if they used their residual hearing and both hearing aids and speechreading, their speech comprehension soared to 90 percent. (Center for Hearing Loss Help.“Speechreading [Lip-Reading],” 2016).
Boone et al. (2012) identified the following basic activities the counselor-speaker can do to minimize the guesswork in speechreading: (a) get the listener’s attention; (b) face the listener while talking; (c) do not cover face while talking; (d) speak normally, not too rapidly or slowly, and not too softly or loudly; (e) enunciate clearly; (f) use natural facial expression and body language; (g) keep facial hair trimmed away from lips and throat; and (h) minimize distracting mannerisms. Other speaker factors to consider include distinctive foreign accents or regional dialects, and a boring (e.g., monotone) delivery or message (Module “Who,” Boone et al., 2012).
Listener factors
Listener factors are those on the part of the client-listener that assist in understanding the spoken word. Factors specific to hearing itself are considered in more detail below; they include the type and severity of the loss, and whether hearing aids and/or assistive listening devices (ALDs) are employed to support it. But there are also various subtle and intangible factors relevant to understanding speech. For example, sustained attention to a speaker’s face for clues to understanding can be stressful, wearying, frustrating and, if unsuccessful, embarrassing (e.g., Bauman, n.d.; Stephens & Hétu, 1991), so a client-listener’s (a) attention level, (b) emotional and psychological well-being and confidence, (c) exposure to distracting sensations or thoughts while listening, (d) fatigue, (e) motivation, and (f) speaker expectations, can all influence the degree with which understanding occurs (Watson et al., 2008). More specific to hearing itself are the client-listener’s (a) type and severity of hearing loss; (b) use of hearing aid, and (c) use of assistive listening devices (Boone et al., 2012).
Type and severity of hearing loss
Eng and Lerner (2011) pointed out that degree and type of hearing loss “…is a convenient method of interpreting audiological results and aids in determining the effect of the hearing handicap on communication” (p. 217). Indeed it is the first step and point of reference in determining one’s functional, communication capability (e.g., Hull, 2014).
A conductive hearing loss is one in which sound is not effectively transmitted because of barriers to the middle and/or outer ear (Stach, 2008). Blockages may be due to malformation of the middle/outer ear, infection, the presence of foreign body, or simply ear wax build-up, among myriad other issues. A conductive hearing loss is usually temporary and/or treatable via medical intervention (e.g., medication, minor or major surgery) and, when necessary, largely restored or remediated through hearing amplification (Stach, 2008).
Sensorineural hearing loss is the result of damage to the inner ear and sound is unevenly blocked, i.e., certain frequencies (high or low pitch) may be heard well, while others are not (Martin & Clark, 1997). This often results in speech itself being heard, while particular words containing high-frequency consonants lack sufficient clarity to be understood; the result is the oft-heard complaint, “I hear but I can’t understand” (HLAA, “Symptoms of Hearing Loss,” n.d.). A sensorineural hearing loss is permanent, the result of a prenatal and/or genetic condition, pathology or trauma, or even ototoxic medication administered to treat a life-threatening condition (Martin & Clark, 1997). Also, many people acquire a noise-induced, sensorineural loss through prolonged exposure to loud noise. The NIDCD reported that approximately 15% of Americans between the ages of 20-69—or 26 million Americans—have a hearing loss likely caused by exposure to noise at work or in leisure activities; and as many as 16% of teens (ages 12-19) reported hearing loss that could have been caused by loud noise (NIDCD, “Noise-Induced Hearing Loss,” 2016).
A mixed hearing loss refers to a combination of both sensorineural and conductive hearing loss. The Better Hearing Institute explained it this way:
A mixed hearing loss can be thought of as a sensorineural hearing loss with a conductive component overlaying all or part of the audiometric range tested. So in addition to some irreversible hearing loss caused by an inner ear or auditory nerve disorder, there is also a dysfunction of the middle ear mechanism that makes the hearing worse than the sensorineural loss alone. The conductive component may be amenable to medical treatment and reversal of the associated hearing loss, but the sensorineural component will most likely be permanent. Hearing aids can be beneficial for persons with a mixed hearing loss, but caution must be exercised by the hearing care professional and patient if the conductive component is due to an active ear infection” (Better Hearing Institute, “Mixed Hearing Loss,” 2016).
Use of hearing aid
“Difficulty understanding speech is the primary complaint that leads individuals with hearing loss to seek hearing help, and thus the primary goal of audiologic rehabilitation is to improve everyday speech understanding” (Ferguson, 2012, p.779) through amplification. Watson et al. (2008) confirmed that most individuals who are hard of hearing do not communicate via sign language, so hearing aids are often an important component in communication. However, Kochkin (2009) determined that fewer than 25% of individuals with hearing loss actually have them, and HLAA reported that “80% of people who could benefit from hearing aids do not get them” (HLAA, “Hearing Health Care and Insurance,” n.d.).
Important to this review, the NIDCD noted hearing aid usage in 2006 by working aged adults (20–69 years) was approximately 160 per 1,000 persons with moderate-to-severe hearing loss (NIDCD, “Use of Hearing Aids in 2006,” 2012). HLAA indicated that “there are many reasons why people do not seek help for their hearing loss but we should not underestimate the impact of the cost of hearing aids” (HLAA, “Hearing Health Care and Insurance,” n.d.). If 160 per 1000 represent 20% of those who had sought help from hearing aids, then the implication is that there are as many as 800 of every 1000 working-age Americans with hearing loss who could benefit from hearing aids on the job (Kochkin, 2010), and therefore benefit from financial assistance provided by public VR services toward their purchase. Indeed, financial assistance toward purchase of an aid is the primary service provided VR clients with hearing loss (Kosovich, 1993).
Use of assistive listening devices (ALDs)
Availability and use of assistive listening devices (ALDs) are another factor that could increase the capacity of the client-listener to hear and understand. ALDs are devices or equipment designed to assist in specific listening situations where a hearing aid may be inadequate or inappropriate alone. Watson et al. (2008) noted that hearing aids alone “…do not totally correct or restore normal hearing. In fact, the success of use often depends on the specific situation in which the device is used” (Watson et al., 2008, pp. 74-75), and Kochkin (2005) also noted that only half of those with hearing aids say they are satisfied with the benefit received in noise, i.e., when trying to hear in the midst of other sounds. These are situations in which ALDs may be helpful in addition to, or in lieu of, hearing aids.
For one-on-one counseling sessions with a client-listener who has no useable hearing and does not sign, by virtue of commonplace, digital technology, ALDs are plentiful today for the counselor-speaker today, and vendors can be readily googled to find multiple options (search e.g., Assistive Technology for Hearing Loss; or Assistive Listening Devices). Watson et al. (2008) summarized several basic communication strategies for the office to include handwritten notes, speechreading, and a couple, practical ALD approaches, e.g.: computer terminal with monitor facing the client-listener while counselor-speaker types message; two text-telephone devices connected with a display facing both client-listener and counselor-speaker; or augmented communication devices (see e.g., website AbilityHub: Assistive Technology Solutions, http://abilityhub.com/aac/aac-devices.htm) featuring augmentative and alternative communication (AAC) aids that send messages from one person to another via language boards on which objects may be represented by pictures, drawings, letters, words, sentences. AAC devices are flexible and can be a practical communication tool for clients with multiple disabilities, including cognitive, physical, and speech as well as hearing (AbilityHub, n.d.).
Environmental factors
Environmental factors are those that influence understanding between the counselor-speaker and client-listener (or counselor-listener and client-speaker) in the physical context of the counseling setting, usually the VR counselor’s office. Given that a VR applicant or client with significant hearing loss will rely on residual hearing, possibly with a hearing aid and/or ALD, together with visual cues, there are a few simple, common sense factors to consider. A few of these include (a) background noise, (b) lighting, (c) room acoustics, (d) proximity to source of sound, (e) presence of visual or auditory distractions, (f) presence of objects between speaker and listener, and (g) seating arrangements (Boone et al., 2012).
Background noise, distractions
Any extraneous noise in a room with speaker and listener can constitute a barrier to communication. “Despite tremendous advances in hearing aid technology, even with the latest digital noise reduction circuitry, background noise continues to be a problem. Problematic background noise is any noise that interferes with your ability to hear, understand, and/or pay attention to the signal that you want to hear” (Kricos, “Tips for Hearing in Noise” on BHI website, n.d.). While wearing a hearing aid and trying to listen to a speaker, background noise inside or outside the office could include traffic noise, music, reverberation (sound that echoes when reflected off room surfaces) voices of children playing and laughing, people talking at once, or even one person talking nearby in a way that prevents or distracts from listening to another talker. As hearing aids are designed to amplify sound, they can pick up extraneous sounds in the room that may compete with the speaker’s voice (Martin & Clark, 1997).
Inside an office, such as a VR office with counselor-speaker and listener-client, background noise can include that which is often ignored or otherwise disregarded by hearing people. Public address system, background music, air conditioning or heating fan, even paper-rustling, shifting or movement in the chair, some types of (buzzing/humming) lighting, or noises outside the door (people talking, laughing or moving heavy objects, vacuum cleaner, traffic if office window is on street side), could interfere with desired listening (Watson et al., 2008).
Visual distractions refer to those activities that divert the attention of a client-listener away from the counselor-speaker. These could include movement behind or peripheral-to the client-listener—e.g., people walking, curtains blowing, flickering lights or, from the counselor-speaker, distracting mannerisms by the counselor-speaker such as excessive gesturing or hand movement, leg or foot movement, facial tics (Watson et al., 2008).
Other factors
Lighting, acoustics, proximity to sound source, and seating arrangements are important factors as well (Atcherson, Franklin, & Smith-Olinde, 2015). Adequate lighting is necessary to illuminate the speaker-counselor’s face, without shadow or glare from the light source, to maximize capacity for speechreading. Acoustics may be a problem in a counseling setting with multiple hard surfaces (e.g., floor, ceiling, walls, desk or table tops) from which sound reverberates, which reduces the intelligibility of speech (Sanders, 1982), as the client-listener may hear the sound more than once, differently or distortedly. Proximity to sound source refers to the distance speech sound must travel to reach a listener’s ear or, in the case of a client-listener relying heavily on speechreading, the distance from which one must watch the counselor-speaker’s face. Also, the further a speaker-counselor is from the listener-client, the more possible it is that sound can suffer interference.
Similarly, seating arrangement needs to be considered; important in group situations, it may also be a factor in one-on-one sessions where seating configurations have a counselor-speaker positioned at a desk with client-listener sitting to the side. In this configuration, the counselor-speaker’s face may appear at a 3/4 angle to the client-listener. Another problem may be that the counselor-speaker looks down to take notes while talking, or at a computer monitor to type information, both of which could hinder speechreading for that brief time. Care should also be taken to ensure there is no object between the counselor-speaker and client-listener—such as a decorative item (e.g., flower vase, centerpiece) on the table or desk both for the effect it would have on sound transmission as well as a full-face view of the counselor-speaker (Watson et al., 2008).
Bonding with the hard of hearing or late-deafened client
The elements of bonding which, when present, contribute to the achievement of positive outcomes, include interpersonal attraction, trust, respect, common commitment and a shared understanding in the activity (Bordin, 1994). Positive VR outcomes resulting from a strong WA of which bonding is a part, are competitive employment and independence for clients with disabilities (Lustig et al., 2002), including persons with hearing loss.
In order for the bonding process to begin in any counselor-client relationship, there must be adequate capacity for communication (e.g., Ahn & Wampold, 2001; Atkinson & Karskadon, 1975; Hill & Corbett, 1993). Unlike many state-federal VR offices, however, who have taken steps to seek and/or hire a VR counselor who signs, to work with clients who are Deaf and use ASL, VR offices around the country vary in their staff structure and “consumers who are hard of hearing or late-deafened are often served by counselors from different caseload backgrounds and various skill levels related to these populations” (Module “How,” Boone et al., 2012). Called generalists, these VR counselors are educated to serve only a general caseload of persons with disabilities as both case manager and therapeutic counselor (Cook & Bolton, 1997). For this reason, Boone et al. (2012) suggested that the generalist VR counselor assigned the role of serving hard of hearing or late-deafened clients, seek to become a “communication specialist,” to gain a repertoire of communication skills, knowledge of alternate methods for communication access and ability to adjust to specific needs and preferences” (Module “How,” Boone et al., 2012).
The bonding or partner compatibility construct (Bordin, 1994) begins at the outset of the counseling relationship. Since the best, functional bond is established early in the bonding process (Henry & Strupp, 1994), it is critical to determine and address client communication needs at or even before the first meeting. From here, and likely to the extent confidence is generated in the VR counselor’s ability to understand and address their needs, a frank discussion can begin of the actual reason(s) for the client’s application for VR services (i.e., specific employment).
In the following review, I consider the bonding process in what might typically be the first three meetings between counselor and the hard of hearing or late-deafened applicant/client in the VR process. It has been established that by then bonding will have either occurred, or fail to form (Henry & Strupp, 1994). Aside from differing communication strategies, both the bonding process and the VR case management system are assumed to be the same for clients of either population—however, with the caveat given earlier that there could be significant variety in individual communication needs and preferences (Stone, 1993). My focus in this review is on the VR process utilized by the VR state-federal program, but note that the steps to promote bonding may generally apply with these populations in other rehabilitation or general counseling settings.
Planning for communication factors
Before the first meeting, once the generalist VR counselor becomes aware that a client with a hearing loss has been assigned to him or her, it would be helpful to glean as much relevant information as possible from application material regarding the individual’s communication background and needs; helpful information will include medical, audiological and speech, educational, vocational, and psychological reports (Watson et al., 2008). Is the individual hard of hearing or late-deafened (cf., degree/type of hearing loss, onset, educational background, remediation or personal amplification device)? As with any VR client, other medical issues should also be noted. For the hard of hearing or late-deafened individual, visual acuity takes on greater significance since speechreading is dependent on adequate vision (Atcherson et al., 2015). With this information, the generalist VR counselor can know how to arrange the counseling setting to maximize residual hearing and/or hearing aid function, speechreading capacity or other accommodation (e.g., ALDs not already in the office).
The VR office in which the first session is to take place, should be smaller, and ideally carpeted, with acoustic tile and curtains, to reduce reverberation (Atcherson et al., 2015). Common background noise for the office (e.g., proximity to outside road or pedestrian traffic, break room, public address system, music, ventilation fan, etc.) should also be considered and minimized (Watson et al., 2008). If the VR counselor’s working office is not conducive to meeting with the hard of hearing client, there is time to consider and/or make arrangements to meet elsewhere if possible.
If ALDs would be helpful, and the counselor is aware of what these are ahead of time, it is best to have these available and in working order ahead of the first meeting to avoid either (a) putting off the first meeting, or (b) taking the time to find, equip (batteries, etc.) and set up the devices while the client waits. Many times, however, the appropriate ALD or accommodation for a specific client will require a conversation with that client (Watson et al., 2008) or the client’s significant other in order to know what will work. Therefore it would be ideal if, ahead of the first meeting, the client or client’s family is contacted to ask what accommodations might be necessary, so the counselor has the time to appropriately arrange the counseling setting.
The first meeting
“At the heart of any relationship is communication” (Egan, 2013, p. 19), and from a practical standpoint when they meet for the first time, this will be the first order of business for the VR counselor with an applicant who is hard of hearing or late-deafened. The client should be invited into a quiet, well-lit, distraction-free, environment, with face-to-face seating at eye level and at a comfortable proximity, with appropriate ALDs to hand as necessary (Atcherson et al., 2015). Whatever adjustments or other arrangements need to be made, should be initiated until the client is satisfied with communication arrangements. If the meeting needs to be postponed due to inadequate arrangements, it need not have been a waste of time if better communication arrangements are identified and can be made available later.
Most VR applicants begin their relationship with their VR counselors at the point of intake, a first meeting at which the VR counselor begins the process of eligibility determination for VR services (Maki, 2012). The first meeting is also the point at which the client who is hard of hearing or late-deafened assesses the counselor’s capacity for “partner compatibility” (Bordin, 1994), at least to the extent such compatibility is necessary to achieve the desired outcome. VR applicants obviously approach the VR agency to acquire services and/or technology they hope or expect will benefit them in some way, normally an employment outcome (Watson et al., 2008). But their needs, and therefore services requested, will vary in number, cost, complexity and length (Fabian, MacDonald-Wilson, 2012), so the extent to which they expect to “like” their counselor—one component of bonding—will, according to the instrumentality principle (Finkel & Eastwick, 2015), depend initially on how well they believe the counselor will satisfy their needs. If the client’s perceived needs are minimal (e.g., simply financial assistance toward purchase of hearing aid), the expectations for partner compatibility may be minimal as well; it may be the client’s view in this case the counselor need only say “yes” or “no” to either continue or conclude the relationship. Actually the purchase of a hearing aid may be a familiar scenario in VR offices (Kosovich, 1993), but clients who are hard of hearing or late-deafened are on a “hearing loss journey” (Boone et al., 2012), and needs will vary at different points in time of adjustment, often broader than a hearing aid.
Those who have hearing loss vary in terms of how long they have been aware of their hearing loss and what steps they have taken to deal with it. Some people are only in the beginning stages of recognizing that there may be a hearing problem, while at another extreme are those who have been wearing hearing aids for many years—successfully or unsuccessfully…What people are ready to accept in terms of information, advice, and hearing aids or other helpful equipment depends largely on where they are along their hearing loss journey. Those people who have only recently become aware of the presence of their hearing loss may or may not be ready to take steps to deal with the condition. They may, at that time, be more in need of information and support until they are ready to take action to deal with the hearing loss. (Module “Who,” Boone et al., 2012)
Once good communication is established, whatever the perceived or real need, bonding ideally begins here with “liking” the counselor—i.e., there is the expectation that the counselor will satisfy this need (instrumentality principle, Finkel & Eastwick, 2015). The VR counselor will have (a) asked pertinent questions regarding the client’s communication, educational and vocational background, interests and aspirations (Rubin & Roessler, 2008), (b) explained the counselor’s own role and qualifications (per Professional Disclosure Statement, A.3.a, CRCC Code of Professional Ethics, 2010), and oriented the client to the VR process—i.e., what is required to be successful by VR agency standards (e.g., competitive employment)—and the range of services available (Rubin & Roessler, 2008). Finally, relevant “homework” (tasks) (Henry & Strupp, 1994) may be assigned the client (e.g., to search resources, discuss potential goals with family, consider risks and benefits, clarify interests), and arrangements made to further explore client capabilities and interests through vocational evaluation. By the conclusion of this first meeting, the client should believe there is a: (a) shared understanding of the tasks necessary to achieve the goal; (b) commitment by the counselor to the goal; and (c) the expectation that the counselor has the capacity to fulfill this commitment. Bonding takes shape through this discussion as eligibility is sufficiently determined, or further arrangements are made to conclude the eligibility determination process.
The second – third meeting
The second and third meetings will continue the process of eligibility as necessary—e.g., reviewing the results of outside evaluations (e.g., medical, psychological, vocational)—and of discussing ramifications of evaluation results on client interests and goals (Rubin & Roessler, 2008). With all relevant information in hand, planning for services can begin (Maki, 2012). The bonding elements of trust, respect and confidence in the counselor’s capacity to fulfill this commitment continue to grow through positive, supportive interaction (Saunders, 1999; Sexton, Hembre, & Kvarme, 1996). Again, as the VR process continues over coming months, the bond may undergo some challenges from time to time if timelines or meetings are misunderstood, overlooked or delayed raising questions and possible frustration, as part of the “roller coaster” effect of the bonding experience (Horvath & Greenberg, 1994). But to maintain trust especially in the beginning, formative stage of the relationship, violations to trust need to be quickly and appropriately addressed (Fong & Cox, 1989).
Obviously, if client abilities, interests and service needs are accurately identified, planning becomes a relatively simple process of researching resources and arranging services. The VR case management system is structured for this process (see e.g., Individual Plan of Employment [IPE], 29 U.S. Code §722(b) et seq., of the Rehabilitation Act of 1973). But Hansmann, Parker, Saladin, and Thomas (2012) noted that the actual goal of rehabilitation counseling is to “empower people with disabilities to achieve their highest personal, social and work potential…To ameliorate each consumer’s unique set of problems…The variability of consumers’ characteristics, needs, values, aspirations, cultures, environments, and other factors dictates that counselors must be flexible in their approach to rehabilitation counseling” (pp. 125-126).
For the hard of hearing or late-deafened individual this is no less true. Watson et al. (2008) identified myriad services that could be useful in the goal of empowering clients with hearing loss on an individual basis, specific to degree and type of hearing loss, educational or vocational aspirations, location and availability of services, family situation, cultural identity, financial status, etc. Services to address these are equally myriad and will always involve vocational counseling and guidance. But specific to the individual’s situation, these may also include financial support for hearing aids, ALDS specific to school or job, job specific training (postsecondary education, on-the-job, etc.), job readiness training, independent living skills training, rehabilitation technology for the home, job shadowing opportunities, job coaching and job placement services (Watson et al., 2008).
Frank, open discussion of the range and reason for services with each individual, with a focus on risks and benefits, constitutes respect for the client’s autonomy—the ethical principle of encouraging each client to make independent decisions and act in his or her own best interest (Gatens-Robinson & Rubin, 2008). But to be honest with information the client may not wish to know—in order to guide goal-setting in more productive or realistic direction—it is critical to have in place a good, basic bond of liking, trust and common commitment. Egan (2013) asserted that the counselor should “challenge only after you have spent time and effort building a relationship with your client” (p. 190). But it is important to get to this point as quickly as possible to ensure bonding begins for a functional counseling relationship. Respect is a critical element in bonding (Bordin, 1994), and useful in the overall goal of rehabilitation counseling to empower the client (Hansmann et al., 2012). Informed choice is simply the provision of relevant information, pros and cons, about service options and goals and allowing the client to choose (see e.g., CRCC Code of Ethics, A.3.b, 2009). To respect the client via informed choice, the VR counselor needs to be clear with the client about (a) assessment results (e.g., from interview, medical/psychological reports, vocational evaluation), (b) time, cost, location, and other logistics regarding services undertaken, and (c) the VR counselor’s own role in service provision, i.e., what he or she will and will not do, when, for how long, etc. With this information, the client can make the best choice for him- or herself (Watson et al., 2008).
By the conclusion of the second meeting, the client should be armed with information necessary to consider and make some decisions by/at the next meeting. And by the third meeting, activities related to eligibility and planning (Maki, 2012) may be well underway or nearing completion depending on the extent of research and complexity of expected services (Hansmann et al., 2012), and time and activity between meetings. Bonding will continue to stabilize (Kivlighan & Shaughnessy, 2000) as counselor competence, reliability and support are validated through positive, counselor interaction (Saunders, 1999; Sexton, Hembre, & Kvarme, 1996), and service provision (Henry & Strupp, 1994).
Conclusion
I have presented the elements of bonding in some detail, as well as an overview of the special problem of bonding with persons who are hard of hearing or late-deafened due to communication challenges. Lustig et al. (2002) have shown that a positive working alliance, of which the construct of bonding is a component, has the capacity to improve employment outcomes and job satisfaction. Bonding, described as “partner compatibility,” is characterized as “liking, trusting, respect for each other, and a sense of common commitment and shared understanding in the activity” (Bordin, 1994, p. 16); it is the essence of the interpersonal relationship between counselor and client (Henry & Strupp, 1994). And Egan (2013) emphasized that communication is at the heart of the counselor relationship. Failure to bond may present as delays, plan changes, and/or client drop out, wasting counselor time, VR funding, and community resources.
For the individual who is hard of hearing or late-deafened, the first order of business in bonding is communication (Pollard, 1994). Yet a generalist VR counselor may overlook or disregard practical, communication considerations if the client’s needs are subtle or unvoiced, as may be the case with the client who is hard of hearing or late-deafened (Boone, Trychin, Battat, Conway, Tomlinson, Hamlin, Berry, & Smith-Olinde, 2012). I presented practical ways to address communication challenges with these populations in the early, bonding-forming stages (Henry and Strupp, 1994) of the VR process in order to promote a functional counseling relationship toward a successful outcome. It is important to recognize however that solutions need to be individually considered, discussed and applied as there could be significant variation in the communication needs and preferences within these populations (Stone, 1993).
Finally, in the VR context, I provided an overview of how bonding might present in typical, early meetings of the VR counseling process with clients who are hard of hearing or late-deafened. Initially, the focus must be on communication, through which the bond is developed and strengthened as the client comes to believe he or she is understood and respected, and that the counselor is committed to shared tasks and goals. Ideas were presented as to how these elements may be conveyed and enhanced through interaction and service provision, to promote the bond with clients who are hard of hearing or late-deafened.
There are multiple, practical resources available to the generalist VR counselor who is serious about developing a functional, in-depth relationship with the hard of hearing or late-deafened client. I suggest a best start—because it’s free, comprehensive, and begins with the basics—might be the website “VR4hearingloss” (http://vr4hearingloss.net/getting-starte/), a series of video training modules directed at the generalist VR counselor. The focus is on expanding knowledge about hard of hearing/late-deafened clients, to include basic audiology, their communication needs, hearing aids and ALDs, eligibility issues, job development, pertinent legislation, and resources. Of particular interest might be an in-depth explanation and approach to Order of Selection (OOS), sometimes a barrier to timely services for the eligible client who is hard of hearing perhaps wrongly assessed as not significantly disabled by a naïve VR counselor. For VR management, as well as the counselor, the Model State Plan for Rehabilitation of Persons who are Deaf, Deaf-Blind, Hard of Hearing or Late Deafened (Watson et al., 2008) is also an important resource, cited frequently in this paper.
Conflict of interest
None to report.