Change talk when talk has changed; theoretical and practical insights into motivational interviewing in aphasia

Background: After stroke, people may need to make diet, smoking, physical activity or lifestyle adjustments. One method used widely in encouraging behaviour change is Motivational Interviewing (MI), a counselling approach that attends to people’s “change talk”, language that indicates their readiness to change (Rollnick, Miller & Butler, 2008). MI is collaborative and guiding, useful in contexts where there is ambivalence to change. Evidence from a range of health fields suggests that, where people are ambivalent, MI is more effective at changing behaviours than traditional approaches of advising and directing towards an expert’s solution to a problem. However, people with aphasia may not be offered MI in clinical contexts and tend to be excluded from studies using MI (for example, Krishnamurthi et al., 2014) because their language impairments are assumed to prevent participation in the interviewing process. This is unsatisfactory and denies them the same opportunities to make the lifestyle adjustments offered to people without aphasia. Aims: This presentation aims to show how MI can be adapted to be an accessible approach for people with aphasia using evidence from a single case where the goal was increased physical activity. It seeks to demonstrate how MI can be offered as an alternative option within rehabilitation goal setting, and beyond, for people who may be finding it hard to engage, and be a useful way for speech pathologists to support allied health colleagues working with people with aphasia. Methods and Procedures: This study draws on a single case of a 61-year old woman, J, who had suffered a left middle cerebral artery cerebrovascular accident 6 years before, resulting in a persisting moderate-severe non-fluent aphasia, apraxia of speech and a right hemiparesis. J had a complex previous medical history including longstanding schizophrenia, depression, epilepsy, osteoporosis with several previous fractures, hypothyroidism and gastro-oesphageal reflux. As part of a PhD study on increasing physical activity in people with neuromusculoskeletal conditions (carried out by the second author, an exercise physiologist (EP)), J attended the Adapted Physical Activity Program (APAP), a lifestyle intervention that includes MI. J attended sessions 3 times each week over a 15-week period at her local community rehabilitation service, and local gym, although several days were missed due to health issues. The data for this case study are based on qualitative analysis of field notes through the APAP, a video-recorded evaluation session, records of collaborative session planning between the EP and the speech pathologist, the subsequent adaptations made to implement MI for J, and outcomes of the APAP and MI program. Outcomes and results: Through a supported MI intervention, J was able to transition from reluctance to regular gym attendance during the APAP. MI adaptations allowed ways of judging and building on “change talk” through a range of ratings, visual timelines, values card-sorting, and supported conversation techniques. The EP supported J’s attitude change to the APAP, offering genuine, client-driven choices about attendance, exercise frequency, intensity, time and type. She demonstrated progress, and individualised the program sufficiently to keep J motivated. Conclusions: This case offers an innovative demonstration of interprofessional collaboration, of making MI accessible, and of resolving ambivalence in a person with aphasia. Moreover, despite MI being an accepted, evidence based counselling approach, this is one of the first examples of its use in aphasia. People with aphasia, judged as disengaged or unmotivated by health professionals, are at risk of being discharged or overlooked but this case highlights theoretical arguments and practical solutions to encourage lifestyle adjustment and behaviour change