“Good,” “Hopeless,” and “Alright”: People with Aphasia Expressing Their Opinions on Their Rehabilitation Experiences

Abstract

Treatment for people with aphasia mainly concentrates on facilitating the communication of needs or providing facts. This focus is in danger of downplaying the significance of the expression of attitudes and emotion. Evaluative expression is critical for recreating identity and social interaction. However, the linguistic expression of emotions following aphasia has been insufficiently explored. This study aimed to determine which semantic-lexical devices people with aphasia used to express their opinions and views about their clinicians and rehabilitation. In-depth interviews with 50 people with aphasia describing their emotions during their rehabilitation were analyzed using the appraisal framework comprising appreciation, affect, and judgment. Speakers also graded their attitudes toward people, things, or events. Almost half of instances expressed appreciation, over one-third expressed judgment, and about 16% expressed affect. Amplification of emotions was used frequently, in over 40% of instances. Affective difficulties following aphasia and other brain injuries are among the most important factors for rehabilitation, social reintegration, and the burden on family members. To ameliorate these issues, the focus of rehabilitation in aphasia needs to shift from expressing needs toward facilitating the expression of opinions and feelings and providing people with aphasia with the opportunities and means to express their views on their healthcare.

Keywords

aphasia - evaluation - rehabilitation - emotional expression - appraisal - attitudes

Learning Outcomes: As a result of this activity, the reader will be able to:

• Explain why emotional expression is significant to people with aphasia.

• Summarize one approach to analyzing emotional expression.

• To discuss how to facilitate emotional expression for people with aphasia and to develop more appropriate means of providing feedback regarding their treatment.

The focus of treatment for people with aphasia (PWA) is frequently based on the communication of basic needs, naming pictures, or expressing useful concepts (e.g., name, food items, family names; Berube & Hillis, 2019; Brogan et al., 2020). This may be due to concrete objects (e.g., cup, wheelchair, coffee) being more easily imageable and basic facts about individuals being more easily obtained (e.g., address, family structure). While being able to provide factual information is naturally important, as speakers we also need to be able to reveal our feelings, opinions, and views about our experiences. PWA expressed the need to be able to communicate their basic needs as well as to convey their feelings and opinions (Worrall et al., 2011). For example, one individual with aphasia stated “No. Needs, yes, but talk … my [points to head], I want to talk is politics and religion” (p. 314). This woman wanted pictures that depicted her needs (“toilet, stick, money, make-up”) but also her feelings (“frustrating,” “angry,” “awful”) (Sherratt, 2014). This treatment focused on needs is in danger of sidelining or downplaying the significance of the expression of attitudes, opinions, and feelings.

Aphasia research has widened its focus to explore the experiences of PWA regarding their identity, emotions, and attitudes from a psychological or quality of life standpoint (e.g., Brumfitt, 2010; Hilari et al., 2015; Shadden & Koski, 2007). However, how PWA convey these emotions (i.e., the lexical devices used) has not been extensively investigated, despite these devices being of interest in linguistics for decades (e.g., Labov, 1972). In personal recounts, PWA used less evaluative resources in terms of verb usage than non–brain-damaged speakers (Armstrong, 2005). In recounting their stroke narratives, individuals with mild to moderate aphasia were able to use evaluative language to convey their attitudes and feelings (Armstrong & Ulatowska, 2007a, 2007b; Ulatowska et al., 2006). In these narratives, they were able to use a variety of linguistic devices, including evaluative words/phrases, repetition, direct speech, and metaphor. However, these individuals simplified their language by using repetition and a restricted range of evaluative words. The variability in the extent and nature of evaluative devices used may reflect the severity of their aphasia, premorbid style, gender, and education level. These studies have provided significant preliminary information on the use of lexical devices in the narratives of PWA.

Analyzing Emotional Expression

Analyzing the verbal expression of emotion is complex and few relevant analysis procedures are available. The appraisal framework (Martin & White, 2005) has been used to analyze the expression of attitudes in a wide variety of discourse types (e.g., media, casual conversation, medical discourse, childhood discourse, academic writing, and legal discourse) (Eggins & Slade, 1997; Macken-Horarik, 2003). The term “appraisal” is used for “the semantic resources used to negotiate emotions, judgments and valuations, alongside resources for amplifying and engaging with these evaluations” (Martin, 2000, p. 145). Thus, appraisal indicates how speakers are feeling the judgments they make and the value they place on the various phenomena they experience. While evaluation is complex, it can be reduced to a small number of basic sets of options (Martin & White, 2005). There are three categories or dimensions of attitudes delineated within the appraisal framework, as well as a resource for amplifying the evaluations (Martin, 2000; Martin & Rose, 2003; see [Table 1]).

Table 1 Categories of the appraisal framework

Category	Definition	Lexical expression	Example
Affect	Identifies emotional states, both positive and negative. Describes how people feel. Can be probed by the question “How did/do you feel about it?”	Often as adjectives but also as nouns, adverbs, and verbs	I'm very happy. He did it angrily
Judgment	Refers to judgments about the ethics, morality, or social values of other people. This is how speakers evaluate whether people's behavior conforms to or transgresses speakers' social norms. Can be probed by “How would you judge that behavior?”	Lexically or in clauses	They are freaks. She is brave
Appreciation	Expresses reactions to and evaluation of things, whether concrete or abstract and either positive or negative. Answers the question “What do you think of that?”	Adjectives, nominalizations, adverbs, or verbs	One of them is alright. She has beautiful eyes
Amplification All three categories can be amplified	The choice to turn the emotional volume up or tone it down. An attitude can be augmented/intensified or mitigated/downplayed	Nouns, repetition, prosodic stress, or adverbs	Intensified: incredibly big. Sweet sweet girl Mitigated: hardly tall

All three categories encode feeling. Affect can be considered as the basic system, with judgment evaluating behavior, and appreciation appraising the products of behavior and the wonders of nature (Martin, 2000). The resource of amplification or grading allows the speaker to indicate the depth or extent of evaluation by turning the volume up or down. This form of evaluation can be expressed in various categories of words (verbs, nouns, adjectives, adverbials, intensifiers, and modal adjuncts) as well as in phrases or sentences.

The appraisal framework has been used to analyze the spoken narrative and procedural discourse of individuals with right-brain damage (Sherratt, 2007). It has also been used to determining the ways in which PWA express their opinions and feelings within a conversational group setting (Armstrong et al., 2012). Individuals with all severities of aphasia were able to participate in all categories of evaluation. The complexity and variety (e.g., the lexical variety of verbs and adjectives) of the evaluation used by the interviewees varied depending on the severity of their aphasia.

The appraisal framework as proposed by Martin and his colleagues (Martin, 2000; Martin & Rose, 2003; Martin & White, 2005) offers a far more detailed and complex in-depth analysis than that presented here. Only the three broad appraisal categories and amplification were considered to be appropriate for this study to determine the opinions and views of PWA about their rehabilitation experiences.

Why Is Emotional Expression of Importance to PWA?

The expression of attitudes, opinions, and feelings is an intrinsic aspect of all communication (Thompson & Hunston, 2000). From previous research, expressing their attitudes and opinions may be considered significant to PWA in at least four ways. Firstly, aphasia can have a devastating effect on a person's sense of identity; aphasia has been described as “identity theft” (Shadden, 2005). Change to identity and the loss of a sense of self following aphasia have been relatively frequently described (Anderson & Whitfield, 2013; Bronken et al., 2012; Corsten et al., 2015; Simmons-Mackie & Damico, 2011b). Usually, these changes are negative (e.g., feeling vulnerable; Moss et al., 2004) or cause uncertainty (e.g., “Who is that woman in my body?”) (Hill, 2004). As Boazman (1999) states, “With my ability to communicate destroyed, it seemed as if the very core of my personality had been wrenched from me. In retrospect, not being able to express my feelings and emotions verbally was the biggest loss of all” (p. 15). Evaluative expression is critical for the formation and manifestation of one's identity and to express that identity to others (Hunston & Thompson, 2000; Martin, 2000). Emotions determine our individual awareness as human beings because “they govern the conscious feeling of whether we lead a full and happy life” (Schwarz-Friesel, 2015, p. 158). Individuals may have to renegotiate their identity post-aphasia; however, with the loss of language, PWA are often hindered or have lost the essential tools for reconstructing their identity (Shadden, 2005).

Secondly, having aphasia profoundly affects a person's social networks and relationships (Hilari & Northcott, 2017). Relationships with family, friends, and work colleagues may deteriorate or disappear altogether (Dalemans et al., 2008; Davidson et al., 2008; Northcott & Hilari, 2011). Loneliness, depression, and social isolation are also frequently noted (Cruice et al., 2006; Laures-Gore et al., 2020; Parr, 2007). The expression of emotion is of great significance in building solidarity and rapport. Evaluation plays a constructive role in “organizing sociality—how we share feelings in order to belong” (Martin, 2004, p. 341). It constructs and maintains relations between speaker and listener by informing the latter about the speaker's attitudes toward things and people (Thompson & Hunston, 2000). Bonding between speaker and listener occurs when the listener shares those feelings (Karow, 2003; Martin, 2000, 2004). By indicating how he/she feels, a speaker invites empathy. The absence of the articulation of feelings is considered to be a cool, excluding, faceless stance (Martin, 2004). It is difficult to relate to someone if you do not get any indication of their feelings, thoughts, and opinions, whereas the expression of strong or intensified feelings can be more involving for interlocutors (Martin, 2004). To negotiate the complex process of rapport-building effectively, individuals need access not only to evaluative resources but also to the various categories of evaluation because different feelings need to be expressed in diverse types of discourse and at varying stages.

Thirdly, the ability and opportunity to express opinions and feelings plays an important role in rehabilitation. Motivation to engage in rehabilitation is affected by the rehabilitation environment, relationship between client and clinician, and the clinician being seen as approachable, professional, and competent (Maclean et al., 2002). It is also influenced by clear and revisable goal-setting and ensuring the clients feel that their views on rehabilitation are valid and welcome (Lawton et al., 2018; Lequerica & Kortte, 2010). To be engaged in rehabilitation includes emotional involvement with treatment providers (Lequerica & Kortte, 2010). Increasingly, the views of PWA regarding their healthcare are being considered noteworthy (Kagan & Duchan, 2004; Worrall et al., 2011). They indicated that they wanted healthcare treatment that met their needs and that was relevant to their life (Sherratt et al., 2011), as well as a positive and respectful relationship with their speech-language pathologists (SLPs) and other health service providers (Lawton et al., 2018; Tomkins et al., 2013). These individuals themselves also spoke of their desire to be able to express their opinions and feelings (Worrall et al., 2011).

The participation of patients/clients in health care has become increasingly important and reflects the move toward person-centered care within health services and specifically for individuals with communication disorders (Forsgren et al., 2022). To engage fully with rehabilitation and become and remain motivated, PWA need to be able to express their views on the clinician, the nature of the therapy, and the healthcare system. Providing feedback on rehabilitation may be particularly difficult for PWA (Lawton et al., 2018; Tomkins et al., 2013). Many of the feedback channels (e.g., patient satisfaction surveys) may be inaccessible to these individuals, particularly those who have more severe aphasia or limited caregiver support. They may be excluded from patient satisfaction surveys and research due to the difficulties which may be associated with obtaining opinions and information from them (Eames et al., 2010; Gayet-Ageron et al., 2011). However, using interview and narrative methods, feedback on their care can be elicited from them (Pound et al., 2007; Tomkins et al., 2013; Worrall et al., 2011). Although eliciting narratives from these individuals may be challenging, they must be seen as an important source of information (Forsgren et al., 2022; Penn, 2002). These narratives must be elicited continuously throughout the acute and rehabilitation process to gather feedback as needs change (Brown et al., 2012). In order to provide both positive and negative opinions and views within interviews or narratives, they need to be able to express their emotions.

Fourthly, the ability of individuals to disclose more about their emotions has been shown to be positively related to mental and physical health (Pennebaker, 1995; Tedeschi et al., 1998). An increase in the ability to express emotions and engage in self-disclosure is also found among people who have experienced loss. In addition, verbal emotional disclosure supported greater posttraumatic growth, defined as a significant positive change arising from the struggle with a major life crisis (Calhoun et al., 2000; Slavin-Spenny et al., 2011). Recounting or discussing their stroke experience can act as a coping mechanism to deal with such a major life-changing event (Alaszewski, 2006). By expressing their emotions, PWA noted an increased ability to connect emotionally with other people, resulting in stronger interpersonal relationships (Sherratt, 2019; Sherratt & Worrall, 2021). Individuals who report an increased ability and willingness to express themselves tend to regard it as a positive change (Tedeschi et al., 1998). Thus, by enhancing their ability to express emotions, PWA may improve their personal relationships and thereby quality of life.

Although emotional expression by means of facial expression, gestures, and prosody has been investigated (Laakso, 2014), the linguistic expression of attitudes, emotions, and feelings following aphasia has not been extensively explored (Armstrong & Ulatowska, 2007a; Ulatowska et al., 2006), particularly regarding their rehabilitation. Therefore, this study aimed to assess how (using which semantic-lexical devices) PWA expressed their opinions, views, and attitudes toward their treating clinicians and their rehabilitation experiences.

Methodology

These data are analyzed qualitatively and exemplified by quotations from the participants. Additionally, numerical content analysis (tallying of each appraisal theme) is used to document and verify conclusions, and to increase rigor (Allsop et al., 2022; Sandelowski, 2001). Using this approach, the results have the potential to inform clinical aphasia practice and healthcare policy (Houghton et al., 2017).

The Participants

Fifty participants (24 males, 26 females; mean age: 63.9 ± 10.8 years) with post-stroke aphasia (mean duration: 54.9 ± 43.6 months) and English as their first language were included in this study and interviewed in their own homes. The participants had a mean Western Aphasia Battery-Revised Aphasia Quotient (Kertesz, 2006) of 69.6 (± 24.2) (range: 5–98). The major types of aphasia represented by the participants were anomic (23 participants) and Broca's (13 participants) with other types less represented (conduction 8, Wernicke's 4, transcortical motor 1, transcortical sensory 1). They were recruited through an aphasia registry, in addition to community contacts in three Australian cities. Ethics approval was obtained from the Behavioural and Social Sciences Ethical Review Committee, University of Queensland, Australia (2006000005) for all phases of the research. Informed written consent was obtained for all participants prior to conducting the study. Participant consent forms were developed using aphasia-friendly principles (e.g., larger text, short sentences, simpler vocabulary, additional spacing; Rose et al., 2011) and limited symbols/pictures. In addition, the SLP read and explained the consent form to the PWA.

The Interview Data

The three SLP interviewers had extensive experience of treating and interviewing PWA. Supported conversation techniques (Kagan, 1998; Simmons-Mackie & Kagan, 1999) were used to ensure the interviews were accessible for the participants. Modified conversational techniques of questioning and responses (open and closed questions, simplified questions with key words, additional time and gesture, drawing, writing, and back-channeling) were used. In addition, paper and writing materials were supplied for both participants and interviewers. Participants were also provided with a comprehensive folder of visual materials, including information and pictures on a wide variety of topics (e.g., numbers, calendar, rating scales, medical settings, people such as health professionals and family members' maps, activities, feelings). The interview schedule ([Table 2]) explored the participants' experience of having aphasia, their rehabilitation goals and needs, their involvement in rehabilitation, and their desires regarding other aphasia services. These questions were used to probe the participants' experiences at each stage of their recovery (first onset of aphasia, in the hospital, in inpatient rehabilitation, discharge home, further rehabilitation, later on at home, now). An aphasia-friendly version of the interview schedule was provided to all participants prior to and during the interview.

Table 2 Interview schedule for participants with aphasia

Interview schedule for participants at each time period

His/her experiences of aphasia e.g., What was it like with your aphasia?

Rehabilitation goals and needs related to his/her aphasia e.g., What was important to you? What were your concerns? What did you want to work on?

Experiences of aphasia rehabilitation and services e.g., Tell me about your therapy for your aphasia? What did you do? What other therapy did you get for your aphasia?

Specific speech therapy goals and needs related to his/her aphasia e.g., What did you want to do in speech therapy?

Aphasia rehabilitation and services they would have liked to have had e.g., What aphasia services would you have liked? What would you have liked to work on for your aphasia?

Data Analysis

All semistructured in-depth interviews were video-recorded and transcribed verbatim by professional transcribers and checked by the SLP who conducted the interview. The data for this study are part of the complete data collected for a larger study of person-centered aphasia rehabilitation (Howe et al., 2012; Sherratt et al., 2014; Sherratt et al., 2011; Worrall et al., 2011). The transcribed interviews were analyzed using qualitative content analysis based on Graneheim and Lundman (2004), recommended for qualitative descriptive studies (Sandelowski, 2000). After becoming familiar with the transcripts, the transcribed interviews were imported into NVivo qualitative data analysis software (QSR International Pty Ltd, 2020). NVivo is designed to facilitate researchers to organize, analyze, and visualize their data. Using open coding, text (words, phrases, sentences) was identified and recorded in a code that reflected what the interviewee was discussing. In this study, coding was inductive and emerged from the data. In NVivo, these codes or meaning units are gathered into one place called a node. In the larger study referred to above, the SLPs identified nodes that referred to participants' major concerns, needs, priorities, and goals concerning their experience of having aphasia and the treatment they had received. The nodes with related content were then grouped together hierarchically to form emerging themes or high-level categories (e.g., goals during treatment, support for family members, information regarding aphasia; Allsop et al., 2022; Doyle et al., 2020). The three SLPs and two research advisors conducted ongoing review and scrutiny of the analysis in order to ensure trustworthiness in the links between the data, codes, and categories. Credibility, or the congruence between the observations and the way the researcher represents them, was achieved through peer debriefing, prolonged engagement with the participants, and ongoing review and scrutiny of the data collection and analytical processes (Mertens & McLaughlin, 2004). Recording details about the data analysis procedures, research decisions, and keeping data in a well-organized, retrievable format fulfilled the construct of dependability (Allsop et al., 2022). Providing details of participants' quotations in this paper allows other research to confirm the study results (Mertens & McLaughlin, 2004).

From many themes arising from this extensive data of 50 interviews, the theme of “emotions” was extracted for further NVivo analysis. As the analysis was complex, the procedural steps for analyzing appraisal as provided by Eggins and Slade (1997) were used. Thus, the appraisal items in the data were identified and classified in terms of the three appraisal categories and amplification ([Table 1]). The instances of each type of appraisal (appreciation, judgment, and affect) and grading/amplification were coded. Within NVivo, the number of times each code occurs is tallied, thus providing evidence to confirm the findings (in place of the usual “most,” “some,” or “few” used in qualitative research). The aim of using numbers is to complement and supplement the findings, rather than to quantify them, and this adds methodological rigor (Allsop et al., 2022; Houghton et al., 2017). The relative proportion of each appraisal dimension to the total appraisal resources used was also determined. In the final stage, the patterns of appraisal choices were interpreted (Eggins & Slade, 1997). This same procedure has been fruitfully employed previously in the use of appraisal resources by individuals with right-brain damage (Sherratt, 2007).

Results

The relative proportions of each of the three appraisal categories are depicted in [Fig. 1]. In addition, amplification was used with 41.4% of instances of appraisal, to either augment or mitigate their reactions. Most participants were able, to some extent, to draw on all three appraisal categories during the discussion of their experiences, despite their communication impairment.

Figure 1 Percentage of appraisal categories of total number of instances.

Appreciation was used most frequently (almost 50% of appraisal) to reflect the participants' reaction to their rehabilitation experiences and was predominantly expressed as adjectives. Participants expressed their reactions toward their clinicians predominantly positively (“She was a nice sort of person,” “She's a hell of a lady,” “I thought he was patience”), although some negative reactions were noted (“He was a bugger,” “He's a bloody useless chap”). They used appreciation to express both positive and negative emotions regarding their treatment. Participants expressed positive feelings toward their treatment (“It was very good,” “It was helpful,” “I suppose it's relevant”), as well as negative feelings (“Everything bad,” “I found it really boring,” “I suppose it was alright,” “I'm not going back there because it's useless”). A few participants expressed their ambivalence toward their treatment (“That's because it's good but not good”).

Participants also used judgment over one-third of the time to express their evaluation of clinicians' capabilities or behavior in terms of socially desirable standards. Participants were usually positive about the clinicians and often used “good” or “great” (“They were very very good at their work,” “They must have been the pick of the bunch,” “She is nice spoken,” “I thought she was productive”). Some did express negative judgments regarding their clinicians (“She was far too extended,” “I thought he was good. No good to me,” “No hopeless, hopeless”), as well as using sarcasm, indicated by laughter (“Yes, was just great”).

The category of affect was least used (around 16%) to describe participants' reactions to their clinicians and treatment. Affect was appropriately limited in participants' evaluation of their clinicians (e.g., “I liked her,” “I was happy, very happy,” “I love [name]”). However, participants rarely expressed negative feelings regarding either their treatment (e.g., “I didn't like what I was doing and I was quite relieved to get out of it,” “I'm not happy”) or their clinician (e.g., “Don't like her. Hate her”).

Amplification was used in over 40% of the instances of appraisal, either increasing or decreasing the level of the evaluation. Most of the instances of amplification used to describe their clinicians and treatment were positively augmented, usually using adverbs like “very” or “really.” Predominantly, participants used adverbs (“A great help,” “She was just really good,” “I could be totally wrong”), adjectives (“She was excellent,” “Big tall one, massive tall Sheila” [“Sheila” is Australian slang for “woman”], “She was fabulous,” “A delightful lady,” “She was butch”) and nouns (“He was a bugger,” “Yeah, bitch”). Expletives and interjections can be considered as outbursts of amplified or intensified evaluation. Participants mostly used these forms to negatively react to their clinicians (“Bloody useless chap,” “They made me bloody bloody sick”) or their treatment (“Grrrr,” “F—ng boring”).

Repetition of a lexical item was used to indicate the strength of evaluation. Participants used repetition relatively frequently to intensify their evaluation of their clinicians (“Lovely, lovely person,” “Bloody bloody bloody … they made me bloody bloody sick,” “They were very good, very very good”) or treatment (“Alright, alright,” “This very hard, hard,” “No hopeless, hopeless”). This repetition may be contiguous or can occur at intervals throughout the discourse. One participant repeated the word “terrible” 18 times during her interview, usually as an interjection (“Terrible, terrible”). Repetition of a response as an instance of evaluation needs to be differentiated from perseveration which is often observed in PWA. Perseveration is the inappropriate recurrence or uncontrolled repetition of a previously produced or heard response in place of the correct response (Stark, 2011). Within the narrative/conversational context (rather than picture-naming), it is more difficult to distinguish repetition from perseveration (Martin, 2011). In the examples expressed by the participants, repetition was considered to serve the function of emphasizing their opinions, within the context of anomia.

Despite their communication impairments, participants were able to express their views, opinions, and feelings using simple syntax (“They were good,” “I liked her”) or agrammatic syntax (“Everything bad,” “Hate her,” “Was wonderful,” “Sentences – yeah hard”). They also used adjectives (“Big tall person,” “A very nice person”), adverbs (“very,” “really”) and repetition of adjectives and adverbs.

Discussion

As part of a larger study, 50 PWA were interviewed about their rehabilitation experiences. Their attitudes, opinions, and feelings regarding their clinicians and their treatment were analyzed in terms of three appraisal categories (affect, appreciation, judgment) and also in terms of amplification.

All participants were able to draw on the three appraisal categories and amplification to provide their opinions of and attitudes toward their clinicians and their treatment. Speakers with a range of aphasia severity have also been reported to use all types of evaluation in narratives and conversation (Armstrong et al., 2012; Armstrong & Ulatowska, 2007a). Some individuals were able to use complex syntax, less frequently used adjectives (“delightful,” “relevant”) and adverbs, and were not as reliant on the use of repetition to indicate their evaluation. However, most individuals were restricted to simple syntax, common adjectives and adverbs, as well as the frequent use of repetition. One participant's appraisal was restricted to single adjectives (co-constructed in response to questions) and interjections. The participants were mostly able to provide only simple evaluations independently and they were limited in terms of the variety of lexical terms available to them. The most frequently used adjective was “good” and the most frequently used adverb was “very.” Limited lexical variety in verbs and adjectives was also noted in the narratives and conversational exchanges of individuals with aphasia, including those with severe aphasia (Armstrong et al., 2012; Armstrong & Ulatowska, 2007b). Even the most severely impaired participant used adjectives and therefore had access to one of the most frequent ways in which types of appraisal can be expressed (Martin & White, 2005). However, participants used a significantly lower proportion of adjectives compared to cognitively healthy speakers (Meltzer-Asscher & Thompson, 2014).

Most participants used simple syntax of the form subject–verb–adjective or subject–verb–object, with few embedded clauses. This may reflect the dominant types of aphasia of the participants being anomic and Broca's. Even though some participants' syntax was agrammatic (“she good,” “is awful”), their meaning was clear, indicating that intact syntax was not necessary to convey meaning. A number of PWA with more severe aphasia relied on co-construction with the interviewer to express their views. For example, in response to interviewer's question “so verbs were difficult,” one participant responded “is terrible.” Thus, she relies on the interviewer to provide the subject of her utterance as a scaffold for her evaluation and thereby expresses her opinion even though she does not predictably have access to the grammatical frame commonly used.

Appraisal Categories

In response to the questions posed to them, participants appropriately and most frequently used the appraisal resources of appreciation and judgment. Appreciation was used most frequently by the participants in this study and also in conversation by PWA (Armstrong et al., 2012). This type of evaluation expresses the speaker's reactions to, and evaluation of, things (concrete or abstract) and this category of appraisal was aptly used to evaluate the participants' treatment (rather than their clinicians). Appreciation can have a distancing effect (Martin, 2004), creating the situation in which the speaker is an observer rather than a participant in the experience. The relatively frequent use of judgment reflects the participants' evaluation of how able or competently clinicians have accomplished something. Judgments of social esteem (how people's behavior is evaluated in terms of socially desirable standards) often occurs in conversation (Eggins & Slade, 1997). It is encouraging that PWA are sharing values like this because judgment is critical to the formation of social networks with family, friends, and colleagues (Martin & White, 2005).

The limited use of affect in response to the questions was also appropriate. In a conversational group setting, affect was used by individuals with aphasia to a greater or lesser extent depending on whether the evaluation occurred independently or as part of a co-constructed evaluation (Armstrong et al., 2012). Affect is explicitly subjective in that it indicates emotional states and responses (Martin & White, 2005). It is also particularly important in establishing solidarity and empathy, as it gives an indication of how an individual feels (Macken-Horarik, 2003). However, participants were not directly asked how their rehabilitation made them feel. Nevertheless, some participants did express their emotional responses (positive and negative) to their clinicians and to their actual treatment in terms of happiness, enjoyment, affection, and loathing.

Amplification or grading of emotions was used frequently by most participants. More amplification than other categories often occurs (Eggins & Slade, 1997) and has been documented in the conversations of PWA (Armstrong et al., 2012). In the latter study, amplification was considered as a compensatory device, particularly for individuals with more severe aphasia. Common strategies were the use of simple adverbs or repetition to indicate the strength of their feelings, particularly those with more severe aphasia and thus more limited syntactic and lexical resources. In many cases, these two strategies were used together (e.g., “she was very good. She was very good, very good yeah.”). PWA with more severe aphasia used repetition in response to the interviewers' questions (co-construction) in order to intensify their responses (e.g., “hopeless, hopeless,” “nothing no no”). Such repetitions may act as a compensatory technique because of lexical and syntactical limitations. The frequent use of repetition by PWA was reported in stroke narratives as well as in conversations, especially co-constructed sequences with individuals with more severe aphasia (Armstrong et al., 2012; Armstrong & Ulatowska, 2007a). Speakers with aphasia have been noted to use repetition strategically in order to express affective meanings (Leiwo & Klippi, 2000). Some individuals similarly used interjections and expletives in co-constructed responses to grade their evaluation (e.g., “yeah,” “oh God,” “oh f—k”).

Despite these limitations, most participants were able to convey their evaluation of their rehabilitation experiences. Their use of appraisal resources indicates that these individuals had a relatively intact system of evaluation, despite the range of severity of their aphasia. Although some of the strategies used to communicate evaluation (e.g., repetition, interjections) are relatively simple, they are nonetheless effective in expressing attitudes and feelings.

This study as well as previous studies have found that individuals with aphasia and other forms of brain damage may produce less evaluative language as well as less variety of appraisal categories (Armstrong et al., 2012; Armstrong & Ulatowska, 2007a; Heilman, 2014; Sherratt, 2007). PWA may still be restricted in fully expressing their identity, as a key function of evaluation is to form one's identity and express that identity to others (Hunston & Thompson, 2000). Those with severe aphasia relied on co-constructing their evaluations with the interviewer during the interview. This meant that their evaluative expressions were limited by the nature of the questions being asked. The participants were also similarly restricted in expressing co-constructed sentiments, as it was possibly easier for these speakers to agree with the interviewer, rather than disagree and then be unable to explain their reasons. However, in these interviews, PWA were more willing to express negative emotions regarding their treatment than toward the clinicians themselves, probably reflecting the fact that the interviewers were all clinicians. Furthermore, due to the frequent use of common adjectives (e.g., good, nice) and simple syntax, the potential range of their emotions could not be communicated. While the use of nonverbal behaviors, such as gesture, facial expression, and intonation, could supplement the expression of emotions, the restricted evaluation strategies available to PWA impair their ability to fully participate in social situations.

Clinical Implications

As conveying opinions and feelings is clearly critical to PWA for the re-construction of identity and to ameliorate social isolation, the expression of evaluation should be an integral part of rehabilitation. The first step is to gain an understanding of how and to what extent an individual is able to convey feelings and attitudes appropriately. This may lead to more appropriate, relevant, and person-centered treatment, and thereby improved social interaction. Assessment should include a variety of topics, interlocutors, and situations in order to determine not only the quantity and types of appraisal used but how appropriate they are and what syntactic structures dominate. A detailed assessment as conducted in this paper is not necessary. Clinicians could identify the most frequent strategies used, such as, does the individual use adjectives, repetition, interjections, expletives, or direct speech and how extensive and varied are the lexical items used? What syntactic structures is the individual able to use? Furthermore, any relevant strategies already being used by the speaker should be identified as they could be harnessed for the expression of appraisal.

Using existing and developing strategies to express opinions and emotions can facilitate the rehabilitation experience. PWA wanted positive relationships and interactions with their clinician, and clinicians emphasized the importance of establishing a trusting relationship (Lawton et al., 2020; Sherratt et al., 2011; Worrall et al., 2011). PWA wanted to feel respected and acknowledged and not be talked over (Parr et al., 1997). Satisfaction with healthcare, particularly for PWA, was consistently associated with the relationship with the healthcare provider (Fourie, 2009; Tomkins et al., 2013; Webb & Gearing, 2020). If the relationship is ineffectual, clients may feel disengaged and hopeless (Lawton et al., 2018). For PWA to be satisfied, motivated and engaged requires them to be able to express their views and opinions on their treatment.

Treatment would focus on including more emotive words and concepts (adjectives, adverbs, nouns, and verbs) alongside more traditional objective items at all stages of rehabilitation. Appropriate strategies already being used by the individual could be reinforced and extended. Additional new strategies for increasing the quantity and types of appraisal could be introduced (e.g., employing an interlocutor's utterances as a scaffold). Syntactic structures (e.g., adjective–noun, subject–verb–adjective) could be included in the treatment. These strategies would be tailored according to the individual's other communication skills and deficits as well as personal communication style. While some PWA may be comfortable using a variety of verbal and nonverbal strategies to express themselves, others may prefer to limit their evaluative output to one or two strategies. Adjectives were used most frequently by the participants in all categories of evaluation. Recently developed programs have been effective in improving the retrieval of emotive adjectives and may provide PWA a greater opportunity to express their opinions and feelings as single words, in sentences, and at the discourse level (Milman et al., 2014; Renvall & Nickels, 2019).

It is especially difficult for PWA to give valid and complex feedback about their therapy because of their language difficulties (Kagan & Duchan, 2004; Tomkins et al., 2013). A more formal strategy to facilitate PWA to provide feedback on their healthcare, rehabilitation, and clinicians would be using modified patient satisfaction surveys. Surveys relating to various aspects have been successfully modified for PWA using response format modifications and external support from the examiner/survey provider (Pompon et al., 2018; Tucker et al., 2012). The scaffolding provided by the survey framework may promote the spontaneous expression of concerns and opinions by PWA.

A possibly more fruitful strategy to elicit the views and opinions of PWA would be for clinicians to use their knowledge and skills to co-construct narratives (Forsgren et al., 2022). Co-constructed narratives can provide individuals with a way to participate and collaboratively construct a version of an event that gives greater insight and understanding on what has taken place (Ellis, 2008; Vickers et al., 2012). Co-constructed narratives regarding treatment may lead to better care (Beach & Dixson, 2001). There is now an extensive literature on, as well as training in, supported conversation partner techniques which can be used by SLPs as well as other healthcare providers (Jensen et al., 2015; Kagan, 1998; Kagan et al., 2001). These techniques can be further supported with pictures/photos, pens, paper, and other supported communication tools.

Clinicians are uniquely qualified to help PWA express their concerns, feelings, and opinions, and counseling should be an integral part of clinical responsibility (Holland, 2007; Simmons-Mackie & Damico, 2011a). The expression of evaluation is therefore critical to these more all-encompassing aspects of therapy. However, the emphasis on communicating basic needs and information during treatment for aphasia may reflect the fact that SLPs felt under-skilled to address psychological well-being and may avoid counseling opportunities and emotional issues (Holland, 2007; Sekhon et al., 2015; Simmons-Mackie & Damico, 2011a). This is an area that requires greater focus in training and continuing education so that practicing clinicians have better access to materials and resources to build their knowledge and skills in counseling. As DiLollo (2023) states “counseling remains a rather elusive topic” (p. 2).

Limitations of the Study

Participants were not asked directly about their opinions, views, or feelings regarding their clinicians and their rehabilitation experiences. This may have limited the extent of evaluative comments obtained. However, the fact that the comments were not directly solicited and were largely unanticipated may enhance their credibility. Furthermore, not all participants expressed their opinions about their rehabilitation experiences because their treatment was minimal or non-existent. Nevertheless, the participants may have provided additional evaluation regarding their rehabilitation experiences because they were given the opportunity during a conversation, rather than by direct questioning or a survey. Using patient narratives is considered to be an important means of obtaining feedback from PWA (Forsgren et al., 2022).

The clinicians conducting the interviews were well-known in their respective communities and participants may have felt reluctant to provide an evaluation of other clinicians and their rehabilitation. Furthermore, participants may have been hesitant to criticize any member of their interviewer's profession. This may reflect the fact that participants expressed more positive than negative evaluations.

Conclusions

Increasing the quantity and types of evaluative language accessible to PWA may enable them to re-negotiate their identity and participate more fully in social interaction and activities. The significance of emotional expression cannot be ignored. Affective difficulties following brain injury are among the most important factors influencing the outcome of rehabilitation; these impairments often produce the greatest burden for family members and rehabilitation staff, as well as causing the greatest difficulty for the long-term social reintegration of these clients (Borgaro et al., 2004; Karow & Connors, 2003). If aphasia therapy aims to provide people with the communicative tools to express their identity and to interact in a more satisfying way with others, the focus of rehabilitation needs to shift toward facilitating the expression of feelings, opinions, and attitudes, whether verbal or non-verbal.

Conflict of Interest

None declared.

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Publication History

Article published online:
26 February 2024