People with aphasia's perspectives of the therapeutic alliance during speech-language intervention: A Q methodological approach

Therapeutic relationships in speech-language pathology: A scoping review of empirical studies

PURPOSE

This scoping review provides an overview of empirical studies investigating therapeutic relationships between speech-language pathologists (SLPs), clients, and caregivers across all ages and clinical areas, and identifies areas of future research.

METHOD

The Joanna Briggs Institute's (JBI) scoping review method was employed. Systematic searches were conducted across seven databases and four grey literature databases. Research published in English and German until 3 August 2020 was included. Data were extracted for the primary aim, terminology and theoretical foundations, research design, and focus. Central findings concerning the input-, process-, outcome-, and output-level of speech-language pathology were categorised.

RESULT

Of 5479 articles, 44 articles were included in the analysis. Psychotherapy was the leading discipline for the theoretical foundation and measurement of relationship quality. Most findings focused on therapeutic attitudes, qualities, and relational actions to build the basis of a positive therapeutic relationship. A small number of studies indicated connections between clinical outcomes and the quality of the relationships.

CONCLUSION

Future research needs to address precision of terminology, expansion of qualitative and quantitative research methods, development and psychometric examination of measuring instruments specific to SLPs and the development and evaluation of concepts to support professional relationship building in speech-language pathology training and everyday work.

'It's been an extraordinary journey': Experience of engagement from the perspectives of people with post-stroke aphasia

BACKGROUND

Engagement is recognized as an important factor in aphasia treatment response and outcomes, yet gaps remain in our understanding of engagement and practices that promote engagement from the client perspective.

AIMS

The purpose of this phenomenological study was to explore how clients with aphasia experience engagement during their inpatient aphasia rehabilitation.

METHODS & PROCEDURES

An interpretative phenomenological analysis approach guided the study design and analysis. Data were collected through in-depth interviews with nine clients with aphasia, recruited through purposive sampling, during their inpatient rehabilitation admission. Analysis was completed using a variety of analytic techniques including coding, memoing, triangulation between coders and team discussion.

OUTCOMES & RESULTS

The analysis revealed that for clients with aphasia in the acute phrase of recovery, the rehabilitation process resembles travelling on a journey through a foreign land. Successful engagement in the journey was accomplished when one had a therapist who served as a trusted guide and was able to be a friend, invested, adaptable, a co-creator, encouraging and dependable.

CONCLUSIONS & IMPLICATIONS

Engagement is a dynamic, multifaceted and person-centred process involving the client, provider and rehabilitation context. Findings from this work have implications for measuring engagement, training student clinicians to be skilled facilitators in engaging their clients and implementing person-centred practices that promote engagement within clinical settings.

WHAT THIS PAPER ADDS

What is already known on the subject Engagement is recognized as an important factor in rehabilitation treatment response and outcomes. Prior literature suggests that the therapist plays a critical role in facilitating engagement within the client-provider relationship. Communication impairments associated with aphasia may negatively impact a client's ability to develop interpersonal connections and participate in the rehabilitation process. There is a dearth of research directly exploring the topic of engagement in aphasia rehabilitation, particularly from the perspective of clients with aphasia. Capturing the client perspective can provide novel insights regarding practices to foster and maintain engagement in aphasia rehabilitation. What this paper adds to existing knowledge This interpretative phenomenological study revealed that for individuals with aphasia in the acute phase of recovery, the rehabilitation process resembles travelling on a sudden and foreign journey. Successful engagement in the journey was accomplished when one had a therapist who served as a 'trusted guide' and was able to be a friend, invested, adaptable, a co-creator, encouraging and dependable. Through the client experience, engagement is seen as a dynamic, multifaceted and person-centred process involving the client, provider and rehabilitation context. What are the potential or actual clinical implications of this work? The current study highlights the complexity and nuance of engagement within the rehabilitation context, which has implications for measuring engagement, training student clinicians to be skilled in engaging their clients and implementing person-centred practices that promote engagement within clinical settings. It is necessary to recognize that client and provider interactions (and thus engagement) are embedded in and influenced by the broader healthcare system. With this in mind, a patient-centred approach to engagement in aphasia care delivery cannot be achieved through individual efforts only and may require prioritization and action at the systems level. Future work is needed to explore barriers and facilitators to enacting engagement practices, in order to develop and test strategies to support practice change.

'Talking Very Properly Creates Such a Distance': Exploring Style-Shifting in Speech-Language Therapists

BACKGROUND

In the governmental delineation of the speech-language therapist (SLT) profession and in preservice SLT education, Flemish SLTs are considered as gatekeepers of the standard language in Flanders. Yet, most Flemish clients typically use a colloquial language style. Following earlier research on how teachers' language style affects teacher-student interactions, an SLT's strict adherence to standard Dutch may potentially evoke perceptions of inequality in their clients. As a result, Flemish SLTs may find themselves torn between on the one hand adhering to the standard language and on the other hand adapting to the sociolinguistic style of their client and establishing trust. In the present study, we explored SLTs' views on using standard/colloquial language varieties in their practice.

METHODS & PROCEDURES

Individual semistructured interviews were conducted with 13 Flemish SLTs who worked with children, adolescents and adults in special schools, private practices and hospitals. Interview transcripts were analysed with reflexive thematic analysis.

OUTCOMES & RESULTS

Analyses yielded three themes. Switching between styles was (1) triggered by client characteristics (age, style, therapeutic needs), and it was shaped by (2) the need for establishing trust and (3) a balance between the SLT's professional and personal identity. Notably, most SLTs described partially converging with their clients' colloquial style, effectively reconciling their professional identity as expert speakers with their personal identity as a colloquial language user.

CONCLUSIONS & IMPLICATIONS

Despite consensus on the role of the SLT as gatekeeper of standard language, many SLTs felt that colloquial language also plays an important role as it bolsters therapeutic alliance and rehabilitation of functional communication. By implementing reflective mixed methods and integrating the client perspective, future studies should further examine how authentic style-switching occurs and how various styles used by the SLT are evaluated by clients in different contexts. These findings may guide the development of style-switching as a communicative strategy that can be addressed in preservice education.

WHAT THIS PAPER ADDS

What is already known on the subject In Flanders, the existence of various (non-)standard varieties of Dutch may evoke some tension regarding the preferred variety in a given context. Flemish teachers switch between standard language and colloquial language (style-shifting), depending on the foregrounding of the transactional or relational nature of the context. Moving towards students' colloquial speech builds trust and perceptions of equality. Despite the importance of alliance in speech-language therapy, little is known about how speech-language therapists (SLTs) feel about using colloquial speech given that they are considered expert speakers. What this paper adds to existing knowledge While 'talking properly' is part of the SLT's professional identity, many Flemish SLTs felt that strict adherence to the standard language variety hinders therapeutic alliance. While standard language was strongly associated with professionalism, strict adherence to standard language was used only when SLTs felt they had to prove their clinical competency or when language scaffolding was in the foreground. Partially converging with the clients' language use allowed SLTs to reconcile their professional identity as expert speaker with personal identity and authenticity. What are the potential or actual clinical implications of this work? Both colloquial speech and standard speech serve a function in SLT practice. Therefore, switching between standard and colloquial speech needs further consideration as a communicative strategy rather than instilling in therapists an ideological, normative stance towards language.

Humor in rehabilitation professions: a scoping review

PURPOSE

Studying humor in the rehabilitation professions is important given its positive effects on health and well-being. We conducted a scoping review to understand how the use of humor has been explored in the existing literature in four rehabilitation professions. The rehabilitation professions included audiology, speech-language pathology, physical therapy, and occupational therapy.

MATERIALS AND METHODS

The five-stage method identified by Arksey and O'Malley was used to conduct this review. Six databases were searched. We included 57 articles in our final review, summarized in a narrative synthesis.

RESULTS

We generated seven themes in our analysis: (1) humour as a management strategy in therapy; (2) humour as a power establisher vs. equalizer; (3) humour as a coping mechanism in rehabilitation; (4) conceptualizations of non-verbal humor cues in therapy; (5) Is humour trainable? (6) Humor used to foster group cohesion; and (7) Attitudes and beliefs surrounding humor practice.

CONCLUSIONS

Our findings emphasize the importance of using humor in the rehabilitation professions, and the ways in which humor is conceptualized in a multitude of ways for both clinician and client. Future work is needed to further understand the presence and use of humor in rehabilitation professions.IMPLICATIONS FOR REHABILITATIONIn a scoping review of the literature, this study showed that humor was used mainly positively in rehabilitation by the included professions of audiology, speech-language pathology, physical therapy, and occupational therapy and contributed to a sense of belonging.Humor may be an effective way to improve management of client/clinician relations as well as improving group cohesion in rehabilitation settings.In the rehabilitation professions of audiology, speech-language pathology, physical therapy, and occupational therapy, non-verbal humor cues were used in instances where communication was difficult or impaired for clients.

Masking care: A qualitative investigation of the impact of face masks on the experience of stroke rehabilitation from the perspective of staff and service users with communication difficulties

BACKGROUND

Face mask use has become widespread as a means of reducing transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Research suggests face coverings can impact speech discrimination, therapeutic alliance and the interpretation of non-verbal cues. However, there is little research into the impact of face masks on people with communication difficulties (pwCD) post-stroke.

AIMS

To explore the perspectives of service users and staff on a stroke rehabilitation unit in order to understand the impact of staff wearing face masks on the experience of rehabilitation for pwCD. Strategies that might improve the experience of rehabilitation for pwCD were also explored.

METHODS & PROCEDURES

Semi-structured interviews and a focus group were conducted with six pwCD and five health professionals (HPs) on a stroke rehabilitation unit. The data were analysed using reflexive thematic analysis.

OUTCOMES & RESULTS

Four main interacting themes were identified from the data: (1) face masks as a barrier to effective communication; (2) face masks as a barrier to human connection and therapeutic relationships; (3) the impact of face masks on an individual is influenced by multiple internal and external factors; and (4) there is a need for service provision to evolve to meet pwCD's needs when using face masks.

CONCLUSIONS & IMPLICATIONS

Findings shed light on how face masks can act as a barrier for pwCD within the rehabilitative process, and emphasize that each individual with communication difficulties is likely to be affected to a differing extent, as a result of multiple interacting factors. HPs are encouraged to consider the individual holistically, tailor strategies and adapt to each individual's needs. Further research is required to understand how to optimize rehabilitation outcomes when face masks are used.

WHAT THIS PAPER ADDS

What is already known on the subject There is evidence face masks can affect speech discrimination, therapeutic alliance and interpretation of non-verbal cues. The existing literature predominantly considers people with hearing impairments, mental health needs or the general public. The potential for face masks to impact pwCD post-stroke is high, given pre-existing communication barriers and evidence of increased social isolation. What this paper adds to existing knowledge This study is the first of its kind to explore how face mask use by HPs impacts the experience of rehabilitation for pwCD post-stroke. The authors consider the need to tailor compensatory strategies to each individual and adapt them to meet service users' needs. What are the potential or actual clinical implications of this work? HPs should monitor closely the impact of face mask use on pwCD with whom they are working, and consider what adaptations to delivery are required. It would be helpful for clinicians to have a discussion with pwCD post-stroke to understand the impact of face mask use on them personally and what strategies they would find most helpful within rehabilitation. Additional training by speech and language therapists on supporting effective communication and successful interaction with pwCD may be indicated in the context of face mask use.

It takes two to tango: The therapeutic alliance in community brain injury rehabilitation

Objective:

A positive therapeutic (or working) alliance has been associated with better outcomes for clients in the psychotherapeutic and traumatic brain injury (TBI) rehabilitation literature. The aim of this pilot study was to gain an understanding of the therapeutic alliance in community rehabilitation from the perspectives of adults with TBI and their close others who have completed a community rehabilitation programme.

Method:

This study used a constructivist, qualitative methodology which applied grounded theory analysis techniques. Using purposeful sampling, three pairs of participants (adults with TBI and close others) who had finished a community rehabilitation programme completed separate in-depth interviews which were transcribed verbatim and progressively analysed using a process of constant comparison.

Results:

A preliminary framework illustrating participants’ experience of a therapeutic alliance was generated, comprising three interconnected themes: being recognised as an individual, working together and feeling personally connected. All participants viewed being able to work together as important in their experience of community rehabilitation and described features that helped and hindered the alliance.

Conclusion:

These pilot study results demonstrate the importance of the therapeutic alliance to the rehabilitation experience of individuals with TBI and those close to them.

Therapeutic relationships in aphasia rehabilitation: Using sociological theories to promote critical reflexivity

BACKGROUND

Therapeutic relationships are fundamental in aphasia rehabilitation, influencing patient experience and outcomes. While we have good understandings of the components of therapeutic relationships, there has been little exploration of how and why therapists construct and enact relationships as they do. Sociological theories may help develop nuanced understanding of the values, assumptions and structures that influence practice, and may facilitate critical reflexivity on practice.

AIMS

To explore the potential for theoretical approaches from outside speech-language therapy to enable a deeper understanding of the nature and enactment of therapeutic relationships in aphasia rehabilitation.

METHODS & PROCEDURES

An explanatory single case study of one speech-language therapist-patient dyad in an in-patient stroke rehabilitation setting. Data included observations of five interactions, two interviews with the client and three interviews with the speech-language therapist. Analysis was guided by analytical pluralism that applied aspects of three sociological theories to guide data analysis and make visible the contextual factors that surround, shape and permeate the enactment of therapeutic relationships.

OUTCOMES & RESULTS

The analysis of this dyad made visible individual, interactional and broader structural features that illustrate the dynamic processes that practitioners and patients undertake to enact therapeutic relationships. Clinical practice could be viewed as a performance with each person continually negotiating how they convey different impressions to others, which shapes what work is valued and foregrounded. The patient and therapist took up or were placed in different positions within the interactions, each with associated expectations and rights, which influenced what types of relationships could, or were likely to, develop. Organizational, rehabilitation and individual practitioner structures assigned rules and boundaries that shaped how the therapist developed and enacted the therapeutic relationship. Whilst the therapist had some agency in her work and could resist the different influencing factors, such resistance was constrained because these structures had become highly internalized and routinized and was not always visible to the therapist.

CONCLUSIONS & IMPLICATIONS

While therapists commonly value therapeutic relationships, social and structural factors consciously and unconsciously influence their ability to prioritize relational work. Sociological theories can provide new lenses on our practice that can assist therapists to be critically reflexive about practice, and to enact changes to how they work to enhance therapeutic relationships with clients. What this paper adds What is already known on the subject Therapeutic relationships are critical in aphasia rehabilitation. We have a good understanding of the different components of therapeutic relationships and how relationships are perceived by patients and practitioners. What this paper adds to existing knowledge This study is novel in its use of sociological lenses to explore contexts and complexities inherent in building and maintaining therapeutic relationships. These are often invisible to the practitioner but can have a significant impact on how relational work is enacted and what forms of relationship are possible. What are the potential or actual clinical implications of this work? This study will support clinicians to critically reflect on how they enact therapeutic relationships and may enhance awareness of the often-hidden factors which influence the ways in which they work.

Creating therapeutic relationships through communication: a qualitative metasynthesis from the perspectives of people with communication impairment after stroke

PURPOSE

Communication between patients and clinicians influences the development of therapeutic relationships. Communication is disrupted when the patient has communication impairments after stroke. However, how these communication disruptions influence therapeutic relationships is not well-understood. This qualitative metasynthesis explores the perspectives of people with communication impairment to understand how interpersonal communication influences therapeutic relationships.

MATERIAL AND METHODS

Four databases were searched for qualitative studies which discussed how communication influenced therapeutic relationships from the perspectives of people with aphasia, dysarthria or apraxia of speech. Additional papers were identified through citation searching and subject experts. Nineteen eligible papers were included and analysed using thematic analysis.

RESULTS

Four themes were constructed from the analysis: (1) Relationships provide the foundation for rehabilitation; (2) Different relational possibilities arise from "reading" the clinician; (3) Creating therapeutic relationships through validating interactions and connections; and (4) Creating therapeutic disconnections through invalidating, exclusionary interactions.

CONCLUSIONS

A therapeutic relationship develops, at least in part, in response to the clinician's communication and how this is received and experienced by the patient. Understanding the characteristics of relationship-fostering communication and knowing how communication influences relationships can help clinicians critically reflect on their communication and better develop therapeutic relationships with people with communication impairment.IMPLICATIONS FOR REHABILITATIONPractitioner-patient communication can facilitate therapeutic relationships or create therapeutic disconnections.Communication patterns that are commonly evident when a patient has communication impairments can impede therapeutic relationships.Clinicians need to attend to how their communication is received and how it influences people's sense of self.Communication partner training should address the existential and relational needs of people with communication impairment after stroke.

Aphasia and stroke therapeutic alliance measure (A-STAM): Development and preliminary psychometric evaluation

Purpose: The therapeutic alliance, also known as the therapeutic relationship, may influence treatment process and outcome in aphasia rehabilitation; however, we currently lack a reliable tool to measure this relationship. This study aimed to develop a novel measure of the therapeutic alliance applicable to this population and provide preliminary evidence of the measure's psychometric properties. Method: Statements were generated from the: (1) therapeutic alliance literature, (2) qualitative interviews with stakeholders, and (3) Q methodological insights with people with aphasia (PWA) (n = 455). A representative sample of statements was identified from the data set (n = 57) and reviewed by expert panels (professionals and PWA), culminating in a 42-item clinician and patient version of the aphasia and stroke therapeutic alliance measure (A-STAM). Reliability and validity of both the clinician and patient versions of A-STAM were investigated with 34 Clinician-patient dyads engaging in therapy. Result: Internal consistency and test-retest reliability were excellent for both clinician (α = 92; ICC = 0.93) and patient versions of A-STAM (α = 0.92; ICC = 0.97). In both versions, scores correlated highly with psychotherapeutic measures of therapeutic alliance, indicative of good construct validity (r_s = 0.75; r_s = 0.77). Conclusion: The findings establish the preliminary reliability and validity of A-STAM and support further investigation into the measure's psychometric properties in larger samples.