JCPSLP Vol 18 No. 1Mar 2016

and cultural diversity, and family supports. This list is of interest considering the evidence cited above that only stroke severity, lesion size, and location have been shown in the research literature to be predictive for recovery. In practice, however, the clinicians interviewed in both studies felt that a much wider range of issues was important to consider. Motivation was frequently mentioned as a critical factor in decisions about potential to benefit from therapy, how much therapy to offer, and in discharge decisions. Motivation was very closely tied to improvement, enthusiasm, and the ability to set goals and to do the required work to support reaching those goals. Being motivated and making change were viewed as cyclical, and if people were judged as lacking motivation, they were not retained for therapy. There was some suggestion in Study 1 that people judged to be motivated would be seen more frequently in the acute setting, and suggestions from both studies that client motivation impacted on the quality of the interaction in that it was more satisfying to work with someone who was stimulating, interested, and enthusiastic. The degree to which families were viewed as motivated to support their family member with aphasia was also reported as important for a successful outcome. Interestingly, some SLPs commented on potentially unreasonable pressures on their clients to remain motivated at a stressful time when other physical and emotional concerns might be overwhelming. Discussion The data presented in this paper confirms that SLPs make judgments about motivation in their patients with aphasia (along with many other factors), that these judgments influence what is done in therapy, and for how long it is offered. SLPs do consider motivation in their predictions about someone’s potential in rehabilitation. Having motivation appears to be an expected behaviour in a rehabilitation context that requires client participation and enthusiasm for therapeutic success (Gold, 1983). Clearly, this is within a context where people with aphasia may not fully understand their own condition, the nature of their treatment, or expectations for rehabilitation. They may be facing considerable communicative, physical, cognitive, psychological, perceptual, and emotional changes including mood issues and fatigue, which together may impact on their ability to demonstrate the energy and enthusiasm their SLPs are looking for. Moreover, anxious family members may not be aware of how crucial their contribution might be to the overall impression of motivation for the therapist. These are very subtle issues; clinical judgments which are difficult to explain or make explicit. And yet, they contribute to the decision-making within rehabilitation. Of interest also are the comments in our results about motivated patients leaving SLPs feeling energized. This reciprocity of relationship has been raised by Kayes, Mudge, Bright, and McPherson (2015) and Bright, Kayes, Worrall, and McPherson (2015) in their discussion of engagement in rehabilitation. These authors note that engagement, which overlaps with the concept of motivation discussed here, can be viewed both as a patient state but also as a co-constructed process reflecting the quality of the relationship between the clinician and patient. Effectively, the work by Kayes et al. (2015) and Bright et al. (2015) suggests that a therapist who fails to engage a patient well (perhaps because of ineffective goal setting, poorly chosen therapy tasks and materials, or insufficient rapport and relationship building) will perhaps then judge that patient as

unmotivated. Our participants in this study have judged such a lack of motivation through a range of behaviours including non-attendance, passivity, or not completing home practice. We need to recognize that judgments of motivation may perhaps be about behaviours which reflect patient satisfaction with therapy – although within a particularly complex context of post-stroke rehabilitation. SLPs need to step back and consider how judgments of motivation might be impacting on their practice. We suggest that, in the context of aphasia rehabilitation, this is particularly crucial because language impairments can have such a profound impact on patients’ ability to make sense of therapy and of rehabilitation as a whole and, along with all the other variables discussed in this paper, could impact on how motivated they appear to be. Aphasia rehabilitation services are often time and resource limited – so there is certainly pressure to direct such resources towards the most benefit. However, how to make decisions regarding the potential to benefit from therapy at an individual level remains a difficult issue – but one which would be assisted by further discussion and reflection. References Becker, G., & Kaufman, S. (1995). Managing an uncertain illness trajectory in old age: Patients’ and physicians’ views of stroke. Medical Anthropology Quarterly, 9, 165–187. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. Bright, F.A.S., Kayes, N.M., Worrall, L., & McPherson, K.M. (2015). A conceptual review of engagement in healthcare and rehabilitation. Disability and Rehabilitation, 37(8), 643–654. Burton, C.R., Horne, M., Woodward-Nutt, K., Bowen, A., & Tyrrell, P. (2015). What is rehabilitation potential? Development of a theoretical model through the accounts of healthcare professionals working in stroke rehabilitation services. Disability and Rehabilitation, 37(21), 1955–1960. DOI: 10.3109/09638288.2014.991454 Ciccone, N., Armstrong, E., Hersh, D., & Godecke, E. (2013). Speech pathologists’ clinical decision making in the provision of services to people with aphasia. International Journal of Stroke, 8(Suppl1), 44. Code, C., & Herrmann, M. (2003). The relevance of emotional and psychosocial factors in aphasia to rehabilitation. Neuropsychological Rehabilitation: An International Journal, 13(1–2), 109–132. Gialanella, B., Bertolinelli, M., Lissi, M., & Prometti, P. (2011). Predicting outcome after stroke: The role of aphasia. Disability and Rehabilitation, 33, 122–129. Gold, S. J. (1983). Getting well: impression management as stroke rehabilitation. Qualitative Sociology, 6, 238–254. Hersh, D. (1998). Beyond the “plateau”: Discharge dilemmas in chronic aphasia. Aphasiology, 12(3), 207–218. Hersh, D. (2003). Experiences of treatment termination in chronic aphasia. (Unpublished PhD Thesis). Flinders University, Adelaide. Kayes, N., Mudge, S., Bright, F. A. S., & McPherson, K. (2015). Whose behavior matters? Rethinking practitioner behaviour and its influence on rehabilitation outcomes. In K. McPherson, B. E. Gibson, & A. Leplège. Rethinking rehabilitation: Theory and practice, (pp. 249–271). Boca Raton, FL: CRC Press. Lazar, R. M. & Antoniello, D. (2008). Variability in recovery from aphasia. Current Neurology and Neuroscience Reports, 8, 497–502.

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JCPSLP Volume 18, Number 1 2016

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