Research by Lawton et al. (2018), in plain language
What’s this study about?
This study looks at how the relationship between a patient and their therapist works in aphasia therapy.
Why did they do this study?
‘Therapeutic alliance’ is the relationship between a patient and their therapist. Studies show there’s a link between how strong a therapeutic alliance is and how effective therapy is. But, what about aphasia therapy? Aphasia is a communication disability that can happen after stroke. Since communication is key in relationships, how does the therapeutic alliance work in aphasia therapy?
The researchers in this study wanted to look at the therapeutic alliance in aphasia therapy from the patient’s point of view. Knowing how the therapeutic alliance works can give clues about how to form a strong therapeutic alliance, and how to measure the strength of a therapeutic alliance. Ultimately, this could make therapy more effective.
How did they do this study?
The researchers found 18 patients with aphasia in England who were willing and able to be interviewed. Six were female, 12 were male, and they were aged 45-88 years. They had been going to aphasia therapy for one month to six years and had had at least four sessions during that time. The interviews lasted 40-90 minutes and loosely followed the same list of questions. During the interviews, the researchers used a range of communication strategies to help the patients understand the questions and express themselves.
What did they find in this study?
The researchers found five key messages in what the patients said.
I. Readiness to bond
The patients said the therapeutic alliance depends on how ready they are to bond with their therapist. Patients deal with many difficult emotions after stroke, like anger, frustration, and low mood. Until they’re ready for it, therapy can feel pointless. They could be holding on to hope that things will return to normal, or they could be unaware of their difficulties and not understand what aphasia is. In order to care about the therapeutic alliance, they had to care about therapy. But, it could work the other way too: feeling ready for therapy can come out of having a strong therapeutic alliance.
II. Level of closeness
The patients said that the therapeutic alliance depends on how close they feel with their therapist. It could be anywhere on a scale of ‘emotionally close’ to ‘professionally distant’. Patients with an ‘emotionally close’ therapeutic alliance said their therapist was genuine, friendly, non-judgemental, and caring. This made them feel connected to their therapist and relaxed in therapy. In particular, patients appreciate when their therapist takes time to get to know them, and treats them as a person as opposed to an illness. It’s also nice when the therapist tells the patient a bit about themself, because it makes the relationship more equal. But, this shouldn’t dominate the session and take the focus away from the patient.
Whether or not a patient feels heard and understood by their therapist depends on how good their therapist is at listening. Speech therapists in particular seem to be good at listening closely, showing care and concern, and paying attention to patients’ feelings and what they need. This builds trust and makes the patient feel less isolated. But, there’s also a point at which the patient can become dependent on their therapist. One patient said he was devastated when therapy ended because he was so close with his therapist that he had pinned his hopes directly onto them.
At the opposite end of the scale, a ‘professionally distant’ therapeutic alliance is one where there’s little to no small talk in sessions because the focus is on doing the therapy. Some patients aren’t bothered by this because that’s what they expect therapy to be like. Others said that when their therapist didn’t show they cared about their feelings and what they were going through, it made them feel less engaged in therapy.
How close a patient is with their therapist can also depend on each patient’s own preference as well as how far along after stroke they are. Normally, a ‘professionally distant’ relationship doesn’t work well at the early stages after stroke because that’s when patients feel most vulnerable and in need of a human connection.
III. Being in tune with the patient
The patients said that the therapeutic alliance depends on how in tune their therapist is with them. This means knowing when to push and when not to push, so that therapy can be pitched at just the right level for them. For example, the therapist needs to know when to move on to easier tasks if therapy gets too hard so that the patient can stay in good spirits. Patients also appreciate when their therapist tells them about the progress they’re making because it gives them confidence and hope, especially if progress is slow and barely noticeable.
On the flipside, when their therapist isn’t in tune with them and doesn’t pick up on and respond to subtle things in the right way, the patient can feel not only uneasy, but frustrated and hopeless. For example:
Patient: When I laughed and I did things wrong, she didn’t laugh.
Interviewer: How did that make you feel?
Patient: It made me feel stupid for laughing at myself.
IV. Being kept informed
The patients said that the therapeutic alliance depends on how they’re kept informed about what they have, whether they’ll get better, and how they’ll get better. Most felt that their therapist was forthcoming about whether or not they’d get better, and had the sense that getting better fully was unlikely. The patients said even though it’s devastating to know, they wanted to know. On the other hand, dodging the subject makes patients trust their therapist less. Still, it’s important for the therapist to say the right thing, to the right person, at the right time, so that the patient can have hope while having realistic expectations.
A few patients said that in the early stages after their stroke, they didn’t get much information, or couldn’t understand the information. Either way, it left them feeling lost about what was going on and where they could get help. During this time, some said their therapist was a symbol of hope for them, and even the act of having a conversation about getting better made them feel better.
Whether or not a patient is kept informed depends on how good their therapist is at giving information. One patient said her first therapist bombarded her with too much information, which left her feeling lost and alone. Her second therapist, however, gave information in a way that was understandable and relatable, which is what started their strong therapeutic alliance. It’s also important for the therapist to be able to explain why they’re doing what they’re doing in therapy, otherwise it can all seem pretty pointless to some patients.
V. Working as a team
The patients said that the therapeutic alliance depends on how they work as a team with their therapist. For some parts of therapy, like setting goals, many patients were happy for their therapist to be in charge because they saw them as the expert. They felt that what their therapist decided generally matched what they needed.
Again, whether or not a patient and their therapist is truly working as a team depends on how good their therapist is at listening. This means listening to the patient’s story and making therapy about what’s important to the patient, so that it’s meaningful and motivating. But, some patients did say that it’s better for their therapist to take the lead during the early stages after stroke when things are chaotic and uncertain.
A few patients said their therapeutic alliance had more of a ‘do what I say’ vibe, which made them feel anxious both during and before their sessions. For example:
Patient: I tried not to do it and I got told off so I had to do it. It was that simple, I had to do it.
Interviewer: How did that make you feel?
Patient: Like a naughty schoolgirl.
This type of therapeutic alliance was bad for the patient’s self-esteem and made therapy feel irrelevant.
What do the findings mean?
This study shows that the therapeutic alliance in aphasia therapy depends both on what the patient and the therapist brings to the relationship. The patient needs to feel ready for therapy in order to be ready to bond with their therapist. The therapist needs to make sure what’s done in therapy is what’s important to the patient in order to have a strong therapeutic alliance, which, in itself, can make the patient feel more ready for therapy. All this can depend on timing, because a lot changes in the months after a stroke and the early stages are particularly overwhelming. Overall, depending on its strength, the therapeutic alliance in aphasia therapy can either give or take away hope for the patient, and make the patient feel more or less engaged in therapy.
Where can I learn more?
This blog post is based on the following paper:
Lawton, M., Haddock, G., Conroy, P., Serrant, L., & Sage, K. (2018). People with aphasia's perception of the therapeutic alliance in aphasia rehabilitation post stroke: a thematic analysis. Aphasiology, 32(12), 1397-1417. doi:10.1080/02687038.2018.1441365
You can read the original paper here: