What it means: Ensuring that each other’s perspective is understood, having real choices and negotiation, and some agreement resulting from the discussion.

How it can be done: Within a shared approach effort is made to prepare clients, including families and significant others, about what is on offer and what choices exist.

Example: L's goals are 1. to have better conversations Mo on the phone 2. to use clear speech strategies in conversation (speak louder, swallow saliva before speaking)

L's goals came up from information gathering (he said he had strategies from SLT in Hungary, where he had his stroke, and one of his regular communication partners is his mum, who he calls every day but who always asks him to speak up. We asked him if he would like to work on these and he said yes. His wife and main carer agreed these were good goals to work on.

L originally had 3 strategies from SLT in Hungary and we added the one on swallowing. We asked him which 2 he would like to work on.

Questions

What it means: Monitored denotes continuous evaluation, often as part of therapy itself. The idea is to reduce reliance on discreet periods of assessment to guide goal setting and encourage an iterative approach where small changes in performance, or different requests from clients, lead to a re-evaluation of therapy direction

How it can be done: Monitoring highlights the value of regularly discussing improvement or lack of it, updating on progress towards agreed goals, and making evaluation a part of therapy. The measurement of change on therapy goals does not have to be numerically based. Client self-evaluation and family evaluation are additionally ways of evaluating if goals have been reached. Choices for goals in therapy still need to be evidence-based but not rigid or driven by the results of an assessment that does not reflect client goals. A simple idea is to have a quick set of objects, phrases or maybe a video of the client that comes out every so often to allow for monitoring and checking on changes.

Example: L's goals are 1. to have better conversations Mo on the phone (?using strategies) 2. to use clear speech strategies in conversation (speak louder, swallow before speaking)

We used an adapted version of the Better Conversations Self-Rating Scale weekly to get L's reflections on a. conversation overall b. using strategy: speaking louder c. using strategy: swallowing saliva

Questions

What it means: Goal setting with people with aphasia needs to be in a format that allows ‘communication access’.

How it can be done: Information needs to be in an patient-friendly format, whether that involves extra time, a total communication approach, supported conversation, or careful adaptations to goal setting documents or contracts (Rose, Worrall, Hickson, & Hoffmann, 2011).

Example: L's goals are 1. to have better conversations Mo on the phone (?using strategies) 2. to use clear speech strategies in conversation (speak louder, swallow before speaking)

We gave L his goals and self-rating scales in an aphasia-friendly format (large text, few words, visual support). L keeps his self-rating scales for a physical tracker of his progress.

Questions

What it means: Therapy should be relevant to people’s lives.

How it can be done: For therapy to feel relevant for clients, the goal-setting process needs to be shared and worked through together. Home visits can allow both clients and clinicians to judge priorities for therapy from a broader life context rather than only from the results of particular assessments. Clients may also wish their goals to be relevant and set at a challenging or ambitious level (Baird et al., 2010; Playford et al., 2009). Clinicians should not assume the relevance of their therapy but check it regularly, involve family, and find ways to ground both impairment and functional work in the real needs of each individual client.

Example: L's goals are 1. to have better conversations Mo on the phone (?using strategies) 2. to use clear speech strategies in conversation (speak louder, swallow before speaking)

L chose his own goals. Better conversations with his mum is relevant as they call every day. Using strategies is relevant because he can use them with any communication partner and is easily generalisable e.g. to speak to GP on the phone.

Questions

What it means: There needs to be clear understanding of the goals and how therapy tasks relate to them.

How it can be done: Through the use of the SMARTER framework there should be clear, accessible records of agreed goals and sub-goals and, ideally, an understanding of the rationale for the therapy approach needed to achieve them. This process may involve time, supported discussion, and a solid understanding of the client’s life, needs, and interests.

Example: L's goals are 1. to have better conversations Mo on the phone (?using strategies) 2. to use clear speech strategies in conversation (speak louder, swallow before speaking)

Therapy tasks (e.g. scripting, using video to self-reflect) were explained to L e.g. scripting a hypothetical call with L's mum because that is what he wants to work on.

We haven't done this yet, but we will ask L if he has any more shot-term goals e.g. "by week 4, I will do a practice call with my wife from the other room, using my cell phone, and I will rate myself 4/5 on using my strategies"

Questions

What it means: Goals should change with time, as recovery occurs, as people become familiar with the realities of rehabilitation, and as they encounter the challenges of living life with aphasia.

How it should be done: The term evolving emphasises the need to revise and revisit goals regularly but also incorporates a process of explaining to clients, even early on, that they can ask to change therapy direction, that therapy goals are not set in stone, and that recovery is very individual.

Example: L's goals are 1. to have better conversations Mo on the phone (?using strategies) 2. to use clear speech strategies in conversation (speak louder, swallow before speaking)

We will tell L and his wife that L can change his goals as therapy progresses.

Questions

What it means: The term “relationship-centered care” has been used to highlight the centrality of the relationship in contemporary health care (Hughes, Bamford, & May, 2008) and is the focus of a client-centered approach to working with people with aphasia (Davidson & Worrall, 2011).

How it can be done: The relationship, sometimes described by speech pathologists as “rapport”, is core to this and takes priority before formal goal setting and prior to formal assessment where possible. A strong, therapeutic relationship may build quickly or may take time but realistically continues to develop over longer periods.

Example: L's goals are 1. to have better conversations Mo on the phone (?using strategies) 2. to use clear speech strategies in conversation (speak louder, swallow before speaking)

Working on what L wants to work on builds rapport because it helps him know that we are really supporting him. At the start of each session we usually have a chat to review how he has been getting on with working on his goals outside of sessions.

Questions

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