ACQ Vol 12 No 2 2010

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ACQ Volume 12, Number 2 2010 61
understanding and involvement for family members. Rachel
reported that time was short and she was restricted in what
she could offer by service constraints, particularly working in
a rural area. Having to deliver therapy from a distance meant
a reliance on home practice but this was difficult for Rachel,
and previous therapists, to tailor or monitor. It appears that
home practice was not underpinned by sufficient explanation
or shared understanding and the couple’s failure to view
home practice seriously was not fully evaluated. At Rachel’s
handover session, she advised the couple to continue doing
what they had been doing. This was flawed because she did
not understand the implications of this directive in the light
of Ruth and David’s attitude to the homework. Within three
months, the couple were discharged from therapy.
On the one hand, speech pathologists are recognising
the importance of family involvement in rehabilitation
but on the other, they are not always being resourced
to do what is necessary to make this possible. Involving
family in goal planning can be difficult (Levack, Siegert,
Dean, & McPherson, 2009). Both time and family-centred
approaches are needed to build trusting relationships
and develop understandings, not only with the client with
the communication disorder, but also with the family.
Detailed case studies like this one are useful in revealing
the realities of practice and highlighting what can go
wrong, especially when the signs and consequences of
misinterpretation, miscommunication, and misjudging are not
immediately obvious. Involving families means exploring their
interpretations about therapy, spending time communicating,
answering questions, sharing information, and judging how
the client can be most appropriately assisted in therapy.
Ultimately, such an investment is surely worthwhile.
References
Avent, J., Glista, A., Wallace, S., Jackson, J., Nishioka, J., &
Yip, W. (2005). Family information needs about aphasia.
Aphasiology, 19(3/4/5), 365–375.
Cunningham, R., & Ward, C. D. (2003). Evaluation of a
training program to facilitate conversation between people
with aphasia and their partners. Aphasiology , 17, 687–707.
The second issue is that as well as being a gatekeeper,
Ruth was a potential resource for the speech pathologists.
Certainly, she sat in on sessions both at the rehabilitation
unit and within her own home. She found this useful and
her inclusion in sessions was clearly encouraged by the
therapists. From her perspective, however, there was
inadequate effort put into helping her really understand the
nature of aphasia and therapy, what her role was, what
she was entitled to, what decisions she could share, how
the various services functioned, and what they could offer.
Her involvement in David’s rehabilitation might have been
more productive had she been well informed, included in
decisions, and convinced by the benefits of therapy. Her
understanding and knowledge of her husband could have
been tapped in order to tailor therapy to him more effectively.
A third issue was that Ruth’s own needs were not
adequately addressed during the different stages of her
husband’s rehabilitation. She reported receiving little
information from the health services and therefore gathered
it from people around her and made assumptions about
recovery based on her beliefs and previous experience.
These assumptions, including how to reconcile her belief
in full recovery with the reality of having a husband with
severe aphasia a year post onset, had not really been aired.
She obviously had to deal with the frustrations of daily
communication breakdown, manage the appointments for
a range of allied health services, including physiotherapy
and occupational therapy, drive long distances for non-
domiciliary appointments, and act as full-time carer. Her lack
of interest in homework may have been related, at least in
part, to her own fatigue and time pressures but this was not
fully explored. Pushing David to do something that he did not
enjoy may have had a negative impact on their relationship.
Perhaps if Ruth had been better supported and if her
religious beliefs, reluctance to initiate contact and concerns
about the value of therapy had all been understood, she
could have played a different role in therapy.
The final issue is that speech pathologists are perhaps
not sufficiently supported in developing this level of
Table 1: Summary of the themes relating to the different family and clinician perspectives in this case study
of a man with severe aphasia
(mis)interpretation (mis)communication (mis)judging aphasia therapy
Ruth’s (wife’s) Full recovery is possible; Felt unable to make requests to therapist More, but different, therapy would have
perceptions religious conviction for explanation of rationale of therapy; resulted in change
Private services are better than assumed you have to do what you are told Pointing and gesture only detract from
public ones Superficial understanding of aphasia the real aim of talking
Hands-on treatment is the only real Was willing to drive David to a centre if it Being with disabled people in groups is
service and therefore Rachel had done meant more service but had not not helpful
nothing despite her telephone follow-up discussed this option A friend’s child had speech therapy and
Funding issues were the reason Reluctant to use the telephone to ask for improved so David could too
for discharge information, nervous about phoning people The homework was useless and had
Confused by service structures, no relevance
transitions between agencies and
multiple health personnel
Rachel’s (speech Assumed that Ruth would be happy Assumed that no telephone calls from Ruth Frustrated by Ruth’s attitude to non-
pathologist’s) to continue what she had been doing meant that everything was okay verbal strategies
perceptions with the previous therapist Not aware of Ruth’s view of home practice Busy with case meetings and
or consultancy model negotiating group services but no
funding for direct provision
Influences from Metropolitan services assuming and Domiciliary therapist did not hand over any No apparent discussion about changing
previous services recommending more intensive rural complaint and therefore unaware of Ruth’s therapy direction or homework options
provision than is possible view of therapy