Measuring therapeutic alliances in aphasia rehabilitation

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Abstract

Background: The development of a positive therapeutic alliance has been shown to be a strong determinant of treatment outcome in psychotherapy and evidence is emerging from a range of healthcare and medical disciplines to suggest that this construct may in fact be a variable component of treatment outcome, adherence and satisfaction. Although there is a surfeit of therapeutic alliance measures, these measures have yet to be validated with people with aphasia and evidence suggests that conceptualisations of the alliance, rooted in psychotherapy, do not encapsulate all of the characteristics of the construct relevant to specialisms such as rehabilitation and medicine. This thesis therefore, aimed to develop a theory-driven measure of the therapeutic alliance, which could then be used to determine whether the therapeutic alliance is a variable component of aphasia therapy in and of itself. Method: A systematic review and meta-ethnography was conducted to explore how stakeholders experience therapeutic alliances in stroke rehabilitation. Given the paucity of research in aphasia rehabilitation, two further empirical interview-based studies were conducted examining speech and language therapistsâ€Â™ (SLT) (n=22) and people with aphasiasâ€Â™ (PWA) (n=18) perceptions of therapeutic alliance construction and maintenance. Interviews were analysed through thematic analysis. A further Q methodological study examined which aspects of the therapeutic alliance were valued by people with aphasia. The theoretical understandings gained from these four studies informed the development of a robust therapeutic alliance measure, the Aphasia and Stroke Therapeutic Alliance Measure (A-STAM). The reliability and validity of the A-STAM were investigated with 34 therapist-patient dyads engaging in aphasia therapy following a stroke. Results: The findings from the meta-ethnography suggested that marked power imbalances between professionals and patients persist in stroke rehabilitation, despite professionalsâ€Â™ attempts to redress this balance. Further qualitative insights demonstrated that SLTs employ multiple strategies to establish purposive alliances, with the aim of recognising personhood, sharing expectations and activating ownership. The findings revealed that SLT value judgements are implicitly intertwined into alliance development. For both SLTs and PWA therapeutic responsiveness to the situational and relational context was central to maintaining effective alliances. For PWA, goal congruence was dependent on listening to the PWAâ€Â™s narrative and identifying goals concordant with individual priorities. The findings from the Q study highlight considerable diversity in individual viewpoints; whereas some people valued acknowledgement and understanding, others prioritised challenge and direction. Preliminary findings suggest the therapeutic alliance measure (A-STAM) has good reliability and validity with a pilot sample. Conclusion: This thesis contributes to our theoretical understandings of this construct in aphasia rehabilitation and presents a novel measure of the therapeutic alliance which can be adopted in a clinical and research context to quantify this potential variable of change.

Keyword(s)

Aphasia; Therapeutic alliance; stroke rehabilitation; therapeutic relationship; working alliance

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