Therapeutic relationships in aphasia rehabilitation: Using sociological theories to promote critical reflexivity

© 2020 The Authors. International Journal of Language & Communication Disorders published by John Wiley & Sons Ltd on behalf of Royal College of Speech and Language Therapists Background: Therapeutic relationships are fundamental in aphasia rehabilitation, influencing patient experience and outcomes. While we have good understandings of the components of therapeutic relationships, there has been little exploration of how and why therapists construct and enact relationships as they do. Sociological theories may help develop nuanced understanding of the values, assumptions and structures that influence practice, and may facilitate critical reflexivity on practice. Aims: To explore the potential for theoretical approaches from outside speech–language therapy to enable a deeper understanding of the nature and enactment of therapeutic relationships in aphasia rehabilitation. Methods & Procedures: An explanatory single case study of one speech–language therapist–patient dyad in an in-patient stroke rehabilitation setting. Data included observations of five interactions, two interviews with the client and three interviews with the speech–language therapist. Analysis was guided by analytical pluralism that applied aspects of three sociological theories to guide data analysis and make visible the contextual factors that surround, shape and permeate the enactment of therapeutic relationships. Outcomes & Results: The analysis of this dyad made visible individual, interactional and broader structural features that illustrate the dynamic processes that practitioners and patients undertake to enact therapeutic relationships. Clinical practice could be viewed as a performance with each person continually negotiating how they convey different impressions to others, which shapes what work is valued and foregrounded. The patient and therapist took up or were placed in different positions within the interactions, each with associated expectations and rights, which influenced what types of relationships could, or were likely to, develop. Organizational, rehabilitation and individual practitioner structures assigned rules and boundaries that shaped how the therapist developed and enacted the therapeutic relationship. Whilst the therapist had some agency in her work and could resist the different influencing factors, such resistance was constrained because these structures had become highly internalized and routinized and was not always visible to the therapist. Conclusions & Implications: While therapists commonly value therapeutic relationships, social and structural factors consciously and unconsciously influence their ability to prioritize relational work. Sociological theories can provide new lenses on our practice that can assist therapists to be critically reflexive about practice, and to enact changes to how they work to enhance therapeutic relationships with clients. What this paper adds What is already known on the subject Therapeutic relationships are critical in aphasia rehabilitation. We have a good understanding of the different components of therapeutic relationships and how relationships are perceived by patients and practitioners. What this paper adds to existing knowledge This study is novel in its use of sociological lenses to explore contexts and complexities inherent in building and maintaining therapeutic relationships. These are often invisible to the practitioner but can have a significant impact on how relational work is enacted and what forms of relationship are possible. What are the potential or actual clinical implications of this work? This study will support clinicians to critically reflect on how they enact therapeutic relationships and may enhance awareness of the often-hidden factors which influence the ways in which they work

Exploring clinical management of cognitive and behavioural deficits in MND. A scoping review

Objectives: Little is known about how cognitive and behavioural decline in MND is managed clinically. This review aimed to summarise clinical management approaches of cognitive and behavioural decline in MND reported in peer-reviewed and grey literature. Methods: A scoping review was conducted across Embase, Medline, Psychinfo and Emcare in October 2022. Grey literature was also searched across Google Scholar and Google in October 2022. Results: A total of N = 26 studies and 8 documents were included. Thematic analysis revealed six key areas of clinical management: i. Assessment, ii. Education, iii. Advance Care Planning, iv. Adaptation of Care Plan, v. Communication and vi. Carer Support. Conclusions: The literature on management of cognitive and behavioural decline in MND is sparse. Most peer-reviewed literature consists of expert commentary and there is a lack of primary data to guide practitioners and families on how to manage cognitive and behavioural change in MND. Practice Implications: Determining as early as practicable the presence of cognitive and behavioural changes in pwMND will enable practitioners to make adaptations to communication, provide education and supported decision-making for forward planning. This will enable individualised care, planned in partnership with families with MND, which incorporates personal needs and wishes

Cognitive impairment, fatigue and depression in multiple sclerosis: Is there a difference between benign and non-benign MS?

INTRODUCTION Multiple Sclerosis (MS) is a chronic inflammatory and degenerative disease of the central nervous system (CNS). The severity of disability in people with MS (PwMS) is generally measured with the Expanded Disability Status Scale (EDSS). A variant of MS known as 'benign MS' (BMS) has been defined as an EDSS score of 3 or lower, combined with a disease duration of 10 years or longer; however, there is disagreement in the field about whether BMS really exists. Given that the EDSS does not capture cognitive issues, communication dysfunction, fatigue, depression, or anxiety properly, its ability to accurately represent disability in all PwMS, including BMS, remains questionable. METHODS In this study, 141 persons with BMS (PwBMS) were included, consisting of 115 females (82%) and 26 males (18%) with a mean age of 50.8 (±8.68). A computerized test battery (NeuroTrax®) was used to assess cognition, covering seven cognitive domains (memory, executive function, visual-spatial processing, verbal function, attention, information processing, and motor skills). Fatigue was measured using the Fatigue Severity Scale (FSS). The Beck Depression Inventory (BDI) was used to assess symptoms of depression. Cognitive impairment was defined for this study as when someone has a score lower than 85 in at least two subdomains of the cognitive test battery. Rates of impairment were compared to 158 persons with non-benign MS (PwNBMS; with a disease duration of 10 years and longer and an EDSS score higher than 3) and 487 PwMS with a disease duration of fewer than 10 years. RESULTS Cognitive impairment was found in 38% of PwBMS and in 66% of PwNBMS (p<0.001). In PwBMS, the lowest rate of impairment was found in the verbal function domain (18%) and the highest rate of impairment in the domain of information processing (32%). Fatigue and depression were found in 78% and 55% of all PwBMS, with no difference in these rates between PwBMS and PwNBMS (p = 0.787 and p = 0.316 resp.) CONCLUSION: Cognitive impairment, fatigue and depression are common among people with an EDSS-based definition of benign MS. These aspects should be incorporated into a new and better definition of truly benign MS

International students in Speech-Language Pathology professional placements: experiences, competency development and outcomes.

Practice placements are a key component of speech-language pathology professional education programs but these learning environments may be challenging for international students (IS). This research explored the background of IS in speech-language pathology placements in Australia, investigated the nature of IS’ learning, experiences and competency outcomes in placements and the strategies utilised to facilitate their learning by IS and the clinical educators who supervise them. Four studies were conducted using a mixed methods approach. University coordinators were surveyed to collect information about IS and their competency development on placement. Then the perceptions of IS and clinical educators about placement experiences and learning were explored using focus groups. Finally, regression analysis was used to identify whether being an international student predicted placement outcomes. In Australian speech-language pathology programs IS were 8 to 12% of students. Learning and developing competency in placements were perceived to be complex for IS, as many adapted their learning, cultural and communication behaviours to participate. The extent of these adjustments may depend on the IS’ background and coping strategies, but may also add cognitive processing beyond that for other students. ‘At risk’ placement outcome was predicted by being an international student, which may relate to these adjustments and associated cognitive load. Clinical educators may also experience more cognitive load as they adjust to facilitate IS’ learning whilst delivering complex services to clients. This may contribute to their perceptions that IS are complex and time consuming. However, IS and clinical educators were also positive and developed mutual intercultural skills from their experiences and identified strategies to facilitate IS’ learning in placements. Training that reinforces these benefits and integrates strategies may assist to reduce perceptions of complexity and load

Supervising international students in clinical placements: perceptions of experiences and factors influencing competency development

© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Background Health professional education programs attract students from around the world and clinical supervisors frequently report that international students find learning in clinical placement contexts particularly challenging. In existing literature clinical supervisors, who support international students on placement have identified concerns about their communication and interactions within clinical environments. However, clinical supervisors’ perspectives about their experiences with international students on placement and the strategies they utilise to facilitate international student learning have not been described. As a result we have little insight into the nature of these concerns and what clinical supervisors do to support international students’ competency development. Methods Five focus group interviews were conducted with twenty Speech-Language Pathology clinical supervisors, recruited from 2 Australian universities. Interview data were analysed thematically. Themes identified were interpreted using cognitive load and sociocultural learning theories to enhance understanding of the findings. Results Four themes were identified: ‘Complex teaching and learning relationships’, ‘Conceptions of students as learners’; Student communication skills for professional practice’, and ‘Positive mutual learning relationships’. Conclusions Findings indicated that clinical supervisors felt positive about supporting international students in clinical placements and experienced mutual learning benefits. However, they also identified factors inherent to international students and the placement environment that added to workload, and made facilitating student learning complex. Clinical supervisors described strategies they used to support international students’ cultural adjustment and learning, but communication skills were reported to be difficult to facilitate within the constraints of placements. Future research should address the urgent need to develop and test strategies for improving international students’ learning in clinical settings