Coaching questions with people with aphasia

Lucy Maran is a Speech and Language Therapist for the acute and community stroke teams at Royal London Hospital and an Associate Trainer with Bridges Self-Management.  Lucy was trained to deliver solution focused brief therapy for people with varying presentations of aphasia post stroke as part of the SOFIA project (SOlution Focused brief therapy In post-stroke Aphasia).  Here she shares her top tips for using coaching questions with people with aphasia:

• Ask people about information not related to their problems. 

This will help to put them in a positive frame of mind.  It is important to establish from the outset that it is the person who is important, not their problems. For example, you might comment on something you see around the house, such as family photos or certificates that can support a conversation about positive aspects of the person’s life and their achievements.

• Provide options to support people to talk about their personal resources.

For example, if you know that someone was an avid golf player, google the characteristics of a golf player and provide a list to see if the person recognises any of them in themselves.  This also works with a person’s job.

• Break down ‘unrealistic’ goals into small steps.

People with aphasia may have a goal to talk normally again, or to get back to normal.  By asking them what is possible in the next few weeks you will focus them on a shorter time frame without invalidating their hopes. Using visual timescales with calendars or diaries can help. You can also ask ‘What else?’ for example ‘Of course you would like to speak normally again, and what else what be helpful/useful?’ In addition, it is important to recognise that aphasia is a life situation rather than a problem that needs to be fixed and as such, coping, managing and living with aphasia can be the focus of therapy.

• Provide options for goal areas.

For example, the kinds of work other people have found useful such as focussing on energy, optimism, friends, family, feeling useful and coping. Provide pictorial support and allow people to physically place the pictures on a scaling mat. You can talk about why the person has placed the construct where they have on the scale to support them to reflect on their progress (what’s already working?) and think about their next steps.

• Ask about a ‘better tomorrow’.

You can support a person with aphasia to list their actions in a typical day and juxtapose it with an imaginary better tomorrow – how would each action be or feel different to them? Hypothesising can be difficult, so it is useful to have a visual comparison and to use images or gesture to indicate that you want the person to imagine a better day.

• Visual scales are fabulous!

You can use them for everything, and they help to move away from focussing on impairments. Some examples are coping scales, confidence in ability to progress scales, and scales where ‘10’ represents living with aphasia as best you can.

• Use your skills in supported conversation strategies.

This is an obvious strategy that can get overlooked.  Use pen and paper for writing key words, making drawings, diagrams and visual scales; supplement speech with use of gesture, facial expression and body language; and finally check back and clarify.

• Allow time.

It may take several sessions for you to understand the person’s communication profile and for them to understand what you are trying to get from them. They may never have been asked coaching questions, even before the stroke. Coaching questions can take some getting used to, even more so with the added challenge of aphasia.

• Persist (with gentle perseverance).

You really can use coaching questions with people with aphasia, even those with severe receptive and expressive aphasia.  The key is to ensure the person does not feel threatened or unsettled by the process. People tend to explain their problems rather than talk about what they want and it’s OK to listen to their problems. This will help them to feel validated and that they can trust you, but it is very important to move on to helping them imagine a future where the problem is less or not impacting. Observing the impact of a person with aphasia enjoying the mastery experience of engaging with coaching questions is a wonderful motivating factor to persevere with sensitivity and the necessary scaffolding and support.

The SOFIA project is led by Dr Sarah Northcott, Research Fellow at City University of London.  For more information please download the protocol paper https://amrcopenresearch.org/articles/1-11 and visit the project blog https://blogs.city.ac.uk/sofia/.