Applied Motivational Theory in Aphasia Patient Therapy


Motivational theories and concepts play a pivotal role in better understanding the needs of aphasia patients, and to facilitate their speech recovery to the fullest extent possible. The importance of motivation cannot be understated when approximately 90% of clinicians in a survey cited low motivation as the most commonly reported discharge criterion, second only to plateau reached. Also, low interest/motivation was the most common reason for not prescribing home practice to persons with aphasia (PWAs). Clearly, the insights provided by examining motivation have significant clinical applications that aid in restoring not only communication skills, but also in reaffirming and renewal of compromised quality of life issues (relationships and activities). A useful definition of motivation is provided to assist in understanding the aspects of the motivational theories that follow.

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A brief discussion on aphasia is given to fully appreciate the difficulty and challenges these patients face. Studies on motivation have yielded valuable observations with theoretical, as well as, practical clinical applications. Positive outcomes are obtainable when patients actively engage and participate in the rehabilitation process; and apply motivational strategies working with their speech therapist. Identifying what the aphasia patient wants and needs offers to the speech therapist a possible template or guide to follow in order to incorporate those patient specific desires into a collaborative treatment plan. Nine broad categories are listed that describes important goals to the patient.

Evidence based motivational theories mentioned will be Self-Determination Theory (SDT) and Social Cognitive Theory (SCT), that delve into the psychological basis for what stimulates and satisfies one’s inner needs. An of equal importance, what factors may suppress those needs and lead to negative feelings of depression, anxiety, amotivation, and treatment failure. Though focussing on SDT and SCT, and the attributes of each, there are other theories: Attribution, Self-Worth, Control, and more that have made valuable contributions and are worthy of inclusion when formulating therapeutic goals, although not detailed in this paper. Combining various aspects of different motivational strategies is often done in specific cases, sometimes with greater success than one strategy used alone. Counseling and intervention support strategies are presented that incorporates and supports the motivational theories.


The ability to communicate is essential in today’s world, and it can be accomplished through a variety of means including, but not limited to, spoken words, written words, gestures, and facial expressions. If one considers the possibility of losing language abilities and the trickle-down effect on speech and overall communication, the impact would be traumatic to say the least, yet this is the reality of aphasia. Aphasia is an acquired language disorder resulting from brain injury, most often stroke, that impairs one’s ability to process language in a receptive or expressive way. As a result of aphasia, language processing is inefficient and ineffective with negative impacts on the quality of life and activities of daily living.

Persons with aphasia may not be able to follow simple commands or respond to yes/no questions about their personal lives. To complicate matters the events leading to aphasia, such as stroke or acquired brain injury often result in other limitations. For example, aphasia often co-occurs with other communication disorders, such as apraxia (i,e., impairment of motor planning and programming of speech), dysarthria (i.e., impairment of motor execution of speech), and dysphagia, a swallowing disorder, is another potential complication. Persons with aphasia may also present with limb weakness on the side opposite the brain lesion, visual impairments, and impairments of memory (not to be confused with loss of intelligence or dementia, neither of which is associated with aphasia (Morrow-Odom, 2019)

The Nature of Motivation

Motivation has been referred to as energy, direction, persistence, and resilience-all concerned with activation and intention; and is at the core of biological, cognitive, and social regulation (Ryan & Deci, 2000). The concept of motivation has been well-debated and discussed within the margins of many motivational theories, with current focus on the relationship between beliefs, values, and goals set to action (chap12,4); and grounded in developmental psychology. Motivation, therefore, covers the psychological determinants of behavior, such as a person’s consciously held goals and priorities-to which they direct their behavior-and their beliefs about how well particular behaviors will serve these goals. It also includes an individual’s confidence in carrying out behaviors effectively despite potential obstacles. Less-conscious influences on behavior are also incorporated into motivation, (i.e., a person’s identity, habits, outlook, and emotions), according to researchers Johnson, Best, Beckley et al (2017).

Self-determination theory (SDT)

Humans have a potential for growth, integration, and well-being, while also being vulnerable to defensiveness, aggression, and ill-being (VanSteenkiste & Ryan, 2013). SDT addresses the mechanisms that are involved in the integration of these elements and forms the organismic foundation upon which it is based . The term organismic is associated with the latin verb “to arrange in coherent form” (Vansteenkiste & Ryan, 2013, p263), and means that people have a tendency to develop toward more coherent and unified functioning that can be observed at both intrapersonal and interpersonal levels. To accomplish this level of functioning SDT attributes a form of regulation referred to as autonomy, or volition; an integrative tendency observed when people are healthy and strive to enhance their integration through a process of internalization. The striving toward increasing intra- and interpersonal skills does not take place automatically, and in order to satisfy basic psychological needs, SDT states that three specific components are required: autonomy, competence, and relatedness. Autonomy refers to self-endorsement of one’s activity,; competence refers to experiencing a sense of effectiveness in interacting with one’s environment, and relatedness satisfaction is concerned with the experience of love and care by significant others (Vansteenkiste, 2013) On the other hand, need frustration is experienced when basic psychological needs are thwarted within social contexts where one may feel low relatedness to friends, family or colleagues resulting in less vitality and excitement for work or activities previously enjoyed.

According to SDT, there are three different types of motivation: amotivation, extrinsic motivation, and intrinsic motivation. There is no regulatory mechanism for amotivation because behavior is unintentional and controls are not required to regulate totally passive behavior. For extrinsic motivation, there are four types of regulation: external regulation, introjected regulation, identified regulation, and integrated regulation. For intrinsic motivation, there is high internal regulation (Zivani, Poulsen & Cuskelly, 2013).

Intrinsic Motivation

Intrinsic motivation is considered the hallmark of volitional functioning because these behaviors are associated with a sense of spontaneity that the individual finds interesting and enjoyable. When people are intrinsically motivated they engage in explorative behaviors that are inherently interesting and appealing to them. And, by following their interests they are being themselves and contributes to a sense of autonomy and authenticity, which promotes a sense of well-being (Vanstenkiste, 2013). In addition to autonomy, competence satisfaction is critical for the intrinsic enjoyment of an activity. When curiosity is guiding discoveries and learning, people are more likely to experience a sense of astonishment and sincere surprise, which forms a catalyst for the quick absorption of new material and skills, thereby building competence. Although autonomy and competence supports are important aspects of intrinsic motivation, a third factor, relatedness, also factors into its expression. SDT hypothesizes that interpersonal relationships that thrive are more likely to reinforce one’s sense of security and relatedness (Ryan & Deci, 2000).

Extrinsic Motivation

Extrinsic motivation occurs when another person (i.e., parent, teacher, therapist) attempts to influence and foster a certain behavior in others. Because extrinsically motivated behaviors are not typically interesting, the primary reason people initially perform such actions is because the behaviors are prompted, modeled, or valued by significant others to whom they feel (or want to feel) attached or related. Extrinsic motivation, therefore, is outcome driven not done by the individual for inherent interest or enjoyment. (Ryan & Deci, 2000). The result can range from amotivation, or unwillingness, to passive compliance, to active personal commitment. Extrinsic motivation is an outcome driven action and not done by the individual for inherent interest or enjoyment. The consequences of relying on strictly extrinsic motivation is the individual subject will not seek optimal challenges, feel a lack of connectedness, and experience a disruption of natural actualizing and organizational tendencies. Other manifestations may include: distress, anxiety, and depression (Ryan & Deci, 2000).

Social Cognitive Theory (SCT)

Bandura proposed a social cognitive model of motivation focused on the role of perceptions of efficacy and human agency. SCT identifies self-efficacy or the belief in one’s ability to perform actions towards a goal as an important psychological process that could be applied to setting and achieving goals during rehabilitation. He characterized it as a multidimensional construct that varies in strength, generality, and level (or difficulty). Thus, some people have a strong sense of self-efficacy and others do not; some believe they are efficacious even in the most difficult task, whereas others believe they are efficacious only on easier tasks (Eccles & Wigfield, 2002).

SCT focuses on expectancies for success, and Bandura distinguished between two kinds of expectancy beliefs: outcome expectations-beliefs that certain behaviors will lead to certain outcomes (i.e., the belief that practicing will improve one’s performance)-and efficacy expectations- beliefs about whether one can effectively perform the behaviours necessary to produce the outcome (i.e., one can practice sufficiently hard to accomplish a certain goal). The two kinds of expectancy are different because individuals can believe that a certain behavior will produce a certain outcome (outcome expectation), but may not believe they can perform the behavior (efficacy expectation) according to Eccles & Wigfield (2002). As a result, Bandura proposed that individuals’ efficacy expectations are the major determinant of goal setting, activity choice, willingness to expend effort, and persistence. Strategies to enhance self-efficacy are based on the following four sources: mastery experience ( to configure treatment so that a patient has frequent experiences of meaningful success and that the patient interprets as being due to his own effort and ability), vicarious experience (observing other people perform an activity successfully to strengthen a patient’s belief that they can perform similar actions if the patient judges the model to be like themselves in relevant ways-severity of aphasia, time post-onset, age, etc.), verbal persuasion (encouraging patients to believe that they are capable of success or by using feedback to influence how they interpret their performances), and physiological and affective experiences (people tend to interpret physiological and affective states experienced before, during, or after an activity to manage the demands of the activity-such as fatigue, anxiety, depression) (Biel, NItta & Jackson, 2017).

The terms self-efficacy, as used in SCT, and competence in SDT, are related in that they both refer to a subjective sense of ability. SCT focuses on the self-efficacy beliefs that essentially are predictions about one’s ability to perform specific tasks. SDT focuses on the innate need for competency, that when satisfied, leads to a positive affective experience (Biel, Nitta & Jackson, 2017).

Motivational Interviewing (MI)

Motivational interviewing is a person-centered and direct means of supporting behavior change. During the MI process, the client and the therapist explore current behaviors and goals for the future, and address ambivalence and discrepancies between the individuals values and behaviors according to Zivani et al (2013). The aim of a study by Medley & Powell (2010) was to evaluate the potential of MI to create optimal conditions for individual case formulation, improved self-awareness and goal-setting, and constructive engagement in clinical rehabilitation. The importance of which is the observation that those individuals who do not recognize their own impairments are not likely to feel motivated towards treatment. Self-awareness is fundamentally a cognitive process that facilitates self-reflection, which in turn, assists in guiding and adjusting behavior towards practical and social goals. A key goal in MI is to increase the importance of change from the client’s perspective. This is accomplished using specific types of questions, along with selective reflections, that direct the client toward the discrepancy between his or her problem behavior and broader personal values (Burke, Arkowitz & Menchola, 2003). The researchers stated there are four underlying principles that guide MI:

  • Express empathy– by exhibiting skillful reflective listening and acceptance to help resolve ambivalence about change.
  • Develop discrepancy– client rather than clinician should present the arguments for change. Change is motivated by perceived discrepancy between present behavior and valued goals.
  • Roll with resistance– resistance is not directly opposed and is interpreted as a signal to respond differently. New perspectives are invited not opposed.
  • Support self-efficacy– client’s belief in the possibility of change is an important motivator. Clinician seeks to enhance client’s confidence and self-determination in coping with obstacles. Understanding that the individual’s belief in the possibility of change is the prime motivator and this is enhanced when the practitioner affirms this belief.

Goals Aphasia Patients Find Important

Goal setting with stroke patients with aphasia can be difficult; their language impairment naturally makes expressing their needs difficult; and discussing their experiences and needs can be a long and convoluted process for both the therapist and the client. The goal setting model of Bradley (Worrall, Sherratt , Rogers et al,2011), provided a framework within which to conceptualize the expressed values and unmet needs of these patients, with the “goals” used to encompass these concepts. The following nine categories of goals were identified as important to aphasia patients:

Return to pre-stroke life– desire to be normal again and return home to the security of their old life.

Communication– recovering communication function and be relieved of feelings of frustration, hopelessness, isolation, and depression

Information– wanted information about aphasia for themselves, family, and friends. Also, information about their therapy and goals.

Speech therapy and other health services– wanted speech therapy that met their needs at different stages of recovery, and was relevant to their life.

Control and Independence– wanting to be discharged from an institution and to their home, and wanting to do things by and for themselves.

Dignity and respect– wanted respect and stated they were competent people despite their communication difficulties.

Social, leisure, and work– wanted to converse with family, chat with friends, read to grandchildren, and feel comfortable in a crowd, upset by boredom and isolation.

Altruism and contribution to society– goal of improving the lives of others, including others with aphasia.

Physical function and health-general health was closely tied to success of other goals, understand that physical improvements would determine whether they could manage at home (Worrall et al, 2011).

Counseling Considerations

Mastery Goals

Studies have shown that mastery goals serve as a strong predictor of positive psychological outcomes when those goals are enacted in an autonomy-supportive context and with the experience of choice. With mastery goals, individuals try to improve their level of competence, develop new skills, or achieve a sense of mastery based on self-referenced (intrapersonal) standards (Benita, Roth & Deci, 2014).

Building Autonomy in Clinical Practice

Autonomy support, as suggested by Benita, Roth & Deci (2014), is the degree to which socializing agents take the target individual’s perspective; act in ways that encourage choice and self-initiation; provide meaningful rationales and relevance; and refrain from using language or displaying behaviors that are likely to be experienced as pressure towards particular behaviors. Additionally, supporting autonomy in these ways has been found to promote autonomous regulation, effective performance, and psychological well-being. In contrast, the use of rewards, deadlines, threats, surveillance, and pressuring language tend to be experienced as controlling and undermine autonomous regulation and result in poorer performance and greater ill-being (Benita et al, 2014).

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Understanding the aphasia patient in regard to his/her emotional state, familial, social, speech, and physical disabilities are important for accurate assessment and are factors that impact the likelihood of successful rehabilitation. Also to be considered are various independent variables such as, the stroke/injury site and the extent of the lesion(s), etiology, severity of the aphasia, duration of the disability, age at onset, general health factors, education, and type, intensity, and duration of treatment, all factors to help when indexing the patient’s motivation (Shill, 1979).

To build motivation takes time and patiences, and foremost among considerations is for the SLP to practice reflective listening to determine the patient’s personal goals. By listening, asking questions, and deliberating over what’s ultimately most important to the patient supports open channels of communication and sets the stage for change and effective goal planning. Adopting this approach of patient-centered directed therapy empowers, the patient to take responsibility for reaching those goals that are meaningful to them. When a patient’s actions are based upon autonomous reasons-greater effort is expended toward reaching their goals, and a higher degree of progress is realized. In a sense, support for autonomy allows individuals to actively transform values into their own (Ryan & Deci, 2000).

Competence Support

The need for competence refers to the desire to feel effective; not necessarily actual ability, but the desire for the feeling of effectiveness. In SDT, three factors are relevant to supporting the need for competency. First, are goals that are neither to easy or difficult, but ones that set an optimal level of challenge; second, patients should get feedback about their performance; and third the feedback should not be offered in an evaluating/controlling way, but instead should provide objective and useful information about progress or adjustments that could augment therapy (11,18) Also, important for building competence is preparing PWAs and their families for rehabilitation by discussing the role of other healthcare professionals, therapy scheduling, and orienting them to the rehabilitation setting. In the acute stage of recovery, PWAs and their families may be overwhelmed by the experience, so discussing potential barriers to participating in rehabilitation and how to manage them can also satisfy the need for competency in being able to meet the demands and challenges of therapy.

Relatedness Support

Relatedness involves feeling meaningfully connected to others, rather than feeling alienated or ostracized. In addition to autonomy and competence support, clinicians can reinforce relatedness by emphasizing the uniqueness of each individual and how that may translate into a different learning style. In other words, we care about you, so please share past experiences that can guide therapy specific to that style. Such inclusion facilitates intrinsic motivation and has been demonstrated in studies by Baumeister and Twenge (Sheldon & Filak, 2008), that found the opposite, social exclusion, increases self-defeating behaviors, reduced performance and intelligent thought.

The need for relatedness refers to the desire to have the experience of caring for and being cared for by other people-both individuals and communities, such as aphasia therapy/support groups.

In SDT, clinicians establish a close relationship with patients and satisfy the need for relatedness by demonstrating sincere involvement in promoting their patients’ welfare, and through unconditional positive regard and acceptance that can only exist in an atmosphere of trust (Palmer et al, 2012).

Social Participation

For people living with aphasia, achieving satisfying social participation can be challenging. In addition to language and communication limitations, people with aphasia can experience a decrease in their activities, quality of life, and quantity and quality of social contacts (Laliberte, Gauvreau, & LeDorze, 2016). Personal factors, including identity-based factors like fears or avoidance behaviors, lack of motivation, as well as language disability, can also be barriers to social participation. Four life habits are significantly affected by language deficits in stroke patients: communication, responsibilities, community life, and recreation (Laliberte et al, 2016). Their relationships can also be altered: some of their friendships may end, others are often transformed; furthermore, most people with aphasia do not return to work.

Speech and language therapy approaches promoting social participation of patients and relatives within their environment, or in the community, have been developed (Laliberte et al, 2016). Some barriers seemed to be generated by the patients themselves as lack of spontaneous interest towards social interaction, The degree of participation is not determined by a defined set of activities, and is a highly individualized concept, although anyone, regardless of his or her sociability level, is at risk of experiencing a decrease in social contacts, that could be addressed in speech-language therapy. A participation-centered approach to rehabilitation in not intrinsically related to patient motivation but possibly to that of rehabilitation professionals. To encourage patients in taking on the the challenges associated with this kind of therapy, SLPs could consider the higher value to patient perceptions, goals,and life environments associated with these social contacts.


A question to consider in regard to motivation and aphasia rehabilitation is… what counts as success in aphasia therapy? Recent and past research has attempted to answer many such questions, and has analyzed a multitude of variables that have been postulated, conjectured, theorized, debated, and argued in order to provide insight into the complex world of the aphasia patient. Do patients with ABI require a particular combination of therapeutic and motivational therapy? Which treatment modalities provide the greatest therapeutic gains across all motivational and therapy conditions? Where and how to begin the first therapy session when meeting the patient and family for the first time? To such important questions the patient and family deserve answers. The importance of undertaking this research became clear as more time was spent pondering the theories, concepts, insights, and conclusions of the various studies. Aphasia patients are looking towards the clinician to pry open the door of lost communication that because of an unfortunate event (stroke, ABI, or organic origin) has been fully, or partially closed. A world once represented by family, friends, employment, and activities of their choosing, is now reduced to an unfamiliar life of uncertainty; where family and friends may not visit as often, one’s employment is at risk, less active socially and physically, and with little or no hope for successful rehabilitation.

The SLP arguably becomes to varying degrees-clinician, mentor, coach, instructor, and counselor. Before any significant therapy gains can be realized, assessing the patient from a holistic standpoint that includes a psychological profile is essential; with the individuals motivational status evaluated. In order for the SLP and patient to establish and build a relationship of trust, incorporating the tenets of motivational theories such as SDT, SCT, and others, provides a fundamental understanding on how to approach therapy in a meaningful and productive way. The strategies of autonomy support, competence support, relatedness support, mastery goals, and motivational interviewing, reflective listening all lend proven guidelines for effective patient-centered action plans. Positive outcomes stemming from a therapy relaqtionship between the SLP and aphasia patient are possible and attainable, and may hopefully return balance, hope, and joy into the patient’s life.


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