Research by Hersh et al. (2012), in plain language
What’s this study about?
This study looks at what counts as a “goal” in rehab for language impairment after stroke.
Why did they do this study?
Goals are an important part of rehab. But, what counts as a goal? Even though goals are usually set by the therapist and the patient together, some things can get in the way of this process. For starters, the therapist and the patient can have quite different ideas of how goals should be set. They could also have different ideas of what to expect from rehab. It might be that the patient’s expecting a fast and full recovery, while the therapist is less hopeful. In other cases, the patient might not be very involved in setting goals at all, because they’re limited by their condition. Patients with aphasia (language impairment) after stroke, for example, can feel confused about why they’re working on the things they’re working on in rehab.
Another point is that a goal isn’t just one thing. It’s an endpoint, but it’s also the journey of getting to that endpoint. It can be short-term, long-term, or somewhere in between. Compared to more general values and beliefs, which tend to stay the same, goals can change depending on the situation. One way of thinking about goals is that they should be ‘SMART’. This stands for Specific, Measurable, Achievable, Realistic, and Time-bound.
Knowing what counts as a goal can give therapists a better idea of how to set goals with patients. So, the researchers in this study wanted to know what counts as a goal in rehab for aphasia.
How did they do this study?
The researchers interviewed 34 speech pathologists about their experiences of doing rehab with patients with aphasia after stroke. The speech pathologists were from Adelaide, Brisbane, and Newcastle in Australia. 32 were female and 2 were male. They were 21-60 years old. They were working in a range of settings, including in hospital with patients who’ve just had a stroke, and in rehab with patients who’ve returned home after their stay in hospital. The researchers looked at all the interview responses to find patterns in what the speech pathologists said.
What did they find in this study?
Based on what the speech pathologists said, the researchers found six key messages about goals in rehab for aphasia. There was some overlap between the key messages, which shows that they all tie in together to explain different aspects of what counts as a goal.
I. Goals as desires
The speech pathologists said a goal is something that the patient wants. They said it’s not just getting there, but the process of working towards it. They said a goal could be anywhere from “concrete” to “airy-fairy”. A more concrete goal is one that’s tangible and motivating, achievable through rehab, and suitable for the patient. All in all, they said a goal should be something that the speech pathologist and the patient comes up with together, even if it takes time and effort to do so.
II. SMART goals
The speech pathologists said a goal should be ‘SMART’. They said making a goal Specific, Measurable, Achievable, Realistic, and Time-bound is what they’re taught to do as professionals. But, they also talked about how this can conflict with making a goal something that the patient wants, because sometimes what the patient wants isn’t ‘SMART’. You can see this point being made here:
Speech pathologist: My definition of a goal is something that’s important to the patient… in real terms, and is achievable in one way or another…I wouldn’t accept a goal that was not achievable in any way.
Researcher: Okay. So what would you call that if it wasn’t achievable?
Speech pathologist: A dream.
On the one hand, a goal needs to be something that the patient wants and hopes for, but on the other hand a goal needs to be realistic and practical. Clearly, both are important, but can make setting goals quite complicated when they’re at odds.
III. Impairment or functional goals
The speech pathologists said there’s a difference between a goal that’s about impairment and a goal that’s about function – impairment being what’s wrong in terms of the condition itself, and function being day-to-day things the patient can or can’t do. They said a goal that’s about function is usually closer to being something that the patient wants.
In the hospital setting, goals tend to be about impairment because the focus is on the medical side of things. Later, when the patient goes home and sees what day-to-day things they can and can’t do, goals shift to being more about function. But the question is, in the hospital setting, how can speech pathologists make sure goals are what the patient wants, but also what the patient needs?
IV. Goals as steps
The speech pathologists said a goal is usually broken up into smaller steps. These might be based on when to do different parts, or how hard to do different parts are. Together, the smaller steps form a clear path towards the bigger goal, which makes it more manageable.
What’s interesting is that other studies show that therapists tend to avoid discussing long-term goals and instead focus on the smaller steps at hand. The speech pathologists said that smaller steps are easier for patients to understand and more motivating. Even the process of breaking up a goal into smaller steps is important, because it’s part of turning a goal into tasks that you can work on in rehab.
Another point is that breaking up a goal into smaller steps makes it possible for the goal to be both ‘SMART’ and what the patient wants. The speech pathologists said having ‘SMART’ steps that work towards the patient’s goal, which may be less ‘SMART’, is a good way to “smarten” a goal.
Again, where the patient is in their rehab journey has an effect on goals. As patients move from hospital into rehab, they start to adjust their goal from being purely what they want, to being more manageable ‘SMART’ steps for rehab. This shows that what’s done in rehab isn’t just decided by goals, it shapes them.
V. Goals as contracts
A few of the speech pathologists made the point that a goal needs to be clearly spelt out. This is so that the patient knows exactly what they’re trying to achieve in rehab, which helps them judge whether rehab is working. As before, speech pathologists prefer discussing smaller, ‘SMART’ steps that can be worked on in rehab as opposed to the patient’s long-term goal. Because of this, what’s spelt out as a goal in rehab is probably closer to the therapist’s idea of a goal than the patient’s.
VI. Implicit goals
The speech pathologists said sometimes they’ll have a goal in mind that they don’t necessarily spell out for the patient and the other therapists treating that patient. They might do this on purpose if the goal is something invisible, not taken seriously by the patient, or involves changing family members’ behaviours. The therapist might also keep a goal to themself if they think it’s not what other therapists expect speech pathologists to work on, or if it’s something that’s hard to measure. For example, one speech pathologist said that she might have in mind but not spell out a goal to “have people know more about aphasia”.
Recently, with more research showing that invisible goals are still valid goals, speech pathologists have started feeling more comfortable with spelling out these types of goals. The speech pathologists pointed out that it’s important to actually have the words to spell out invisible goals. For example, the I.C.F. is a model created by the World Health Organisation that shows it’s not just a condition itself but things in a patient’s environment, like how much support they have, that affects how disabled a patient is in their day-to-day life. This is helpful in giving speech pathologists the words to spell out an invisible goal like “have people know more about aphasia”.
What do the findings mean?
When thinking about what counts as a goal in rehab for aphasia, speech pathologists try to make a goal both something that the patient wants and ‘SMART’. Finding this balance is hard, especially when a goal is long-term or invisible. But, it’s an important thing to do because patients with aphasia can suffer psychological and social difficulties that are long-term and invisible. Thinking more broadly about how the patient’s situation or their environment might affect them can be a helpful thing to do.
Particularly for patients with aphasia, where the condition makes it harder for the patient to be involved, therapists need to think carefully about how to set goals together with the patient. This might mean using more simple language, using pictures, and allowing more time to help the patient understand and express themself. This is important because the patient has a right to have a say in their treatment, which shouldn’t just be generic. In this way, the process of setting goals can help patients feel more in charge of their treatment and their health.
Where can I learn more?
This blog post is based on the following paper:
Hersh, D., Sherratt, S., Howe, T., Worrall, L., Davidson, B., & Ferguson, A. (2012). An analysis of the "goal" in aphasia rehabilitation. Aphasiology, 26(8), 971-984. doi:10.1080/02687038.2012.684339
You can read the original paper here: