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JCPSLP Volume 18, Number 1 2016 6
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
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illness trajectory in old age: Patients’ and physicians’ views
of stroke. Medical Anthropology Quarterly, 9, 165–187.
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in psychology. Qualitative Research in Psychology, 3(2),
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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.
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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
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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