Unmotivated Patients (And Other Tricky Situations In Speech Therapy)

I remember feeling defeated the first time a patient’s family disagreed with my therapy recommendations. It was uncomfortable and confusing for everyone involved.

Although you can’t avoid all disagreements, there are things you can do to help them go more smoothly.

In this article, we guide you through 3 common but tricky situations in speech therapy:

• How to discharge a patient who doesn’t want to be discharged
• What to do when a family doesn’t buy into therapy
• How to handle unmotivated patients.

This is the final installment of our New Clinician FAQ series. Read Dysphagia For New Clinicians and How To Deal With Difficult Patients for more helpful tips.

For step-by-step guidance to all of your frequently asked questions, visit our shop and online course. Now eligible for 1.55 ASHA CEUs!

How to Handle Tricky Situations in Speech Therapy

Despite all of your training and good intentions, there will be situations where patients or their families push back on your treatment plan.

Keep scrolling for practical tips on how to move forward ethically and respectfully in these situations.

For more on navigating difficult conversations, read speech-language pathologist Kelli Marshall’s helpful post on Communicating In Difficult Situations.

1. How To Discharge A Patient Who Doesn’t Want To Be Discharged?

As much as you enjoy treating a patient (especially if they love speech therapy), you know the time will come when you have to discharge them from your services.

But what should you do if your patient doesn’t want you to go? When should you discharge a patient from speech therapy?

When To Discharge From Speech Therapy?

When to discharge a patient depends on several factors. The American Speech-Language-Hearing Association has criteria to guide you through this decision:

• The patient is back to their prior level of function
• The patient no longer has any deficits in speech, swallowing, cognition, and/or voice
• The patient has met their therapy goals
• The patient’s speech, cognition, and/or language abilities are similar to those of the same age, ethnicity, gender, or cultural and linguistic background
• The patient can communicate effectively in a variety of settings
• The patient’s deficits no longer affect the individual’s overall quality of life
• The patient can use an AAC system to communicate effectively in a variety of settings
• The patient is safely meeting their nutrition and hydration means either via tube and/or by mouth.
• The patient is independent with their speech therapy program
• The patient refuses to participate in treatment or has poor compliance
• The patient/family/caregiver requests to discharge
• The patient is moving to another location
• No progress is being made despite modifications to therapy
• The patient is unable to tolerate therapy (medically fragile, lethargic/not alert, etc.)
• The patient has behaviors that interfere with therapy despite attempts to correct them

(Adapted from Admission/Discharge Criteria in Speech-Language Pathology by the American Speech-Language-Hearing Association, 2004)

How To Make Discharge Less Uncomfortable

Before Treatment:

Emphasize on assessment day that therapy is not forever, and the goal is to discharge.

During Treatment:

Check in with your patient every session about their goals, their progress, and your therapy plan, including future discharge.

At The Time of Discharge:

• Educate your patient about your reasons for discharge based on the above guidelines. 
• Provide a robust home exercise program. 
• Explain how future re-assessment and/or a follow-up may be helpful, especially if they’re worried about regressing.

2. What If The Family Doesn’t Buy Into Therapy?

Families are a crucial part of therapy, and patients often rely on their support. 

But what do you do if their families don’t buy into your treatment plan?

Slow down to ensure they understand that: you’re listening, you respect their wishes, and your goal is to improve the patient’s quality of life.

Practice Active Listening

Practice active listening to validate their thoughts, feelings, and desires (Tennant & Toney-Butler, 2023):

• Be aware of your tone and body language. Be kind and respectful when discussing your therapy plan. 
• Give your full attention to the speaker and listen for what they’re saying (vs for what you want to hear).
• Repeat back what they said to ensure you understood their message and the intention behind it.
• Ask for clarification whenever you don’t fully understand their message.
• Avoid distractions and assumptions. Again, give your full attention to what they are saying.
• Listen fully before responding.

Check The Advance Directive and Living Will

Patients have the right to make their own healthcare decisions, although families often play a role in decision-making. 

If your patient can’t make their own decisions, be sure to check their Advance Directives and/or Living Will to see what their healthcare preferences are (House et al., 2023). Bring in a social worker or another member of the medical team as another witness. 

Educate and Document

One of your jobs as a speech therapy professional is education. 

Once you’ve practiced active listening, educate the family about your reasons for recommending speech therapy and the potential risks and benefits of not participating. 

Clearly document your education and the family’s decisions.

3. How to Handle Unmotivated Patients

Lack of motivation can be a big barrier to progress in speech therapy. Learn the source of their lack of motivation to help you come up with solutions.

For example, maybe they’re just bored! Or maybe they can’t understand how your treatment will make an impact on their daily life.

Complete a patient interview to understand their likes/dislikes, hobbies, occupations, and goals. Use what you learned to modify your tasks to be more engaging, personally relevant, and functional.

Sometimes a patient needs more time to process the information and your recommendations. Give them space and time to think. They typically don’t need to make a decision or agree to a plan right away.

But f they remain unmotivated, here’s what you can do:

• Listen respectfully.
• Educate extensively about the benefits of your recommendation and the potential risks of not participating in therapy. 
• Answer their questions and give them time to decide.
• Document your education, recommendations, and the patient’s/family’s decision.

Per the U.S. Patient Self-Determination Act of 1990, patients have the right to direct their healthcare decisions to the extent State law permits (Congress.gov, 1990). If they don’t want to participate or are not motivated, that is their right and choice (Teoli, D., & Ghassemzadeh, S., 2023).

If, despite your efforts, the patient is still unmotivated and progress is minimal, it may be time to discharge. Provide them with a thorough home exercise program and document your recommendations (American Speech-Language-Hearing Association, 2004).

More Speech Therapy Materials

References

• American Speech-Language-Hearing Association. (2004). Admission/discharge criteria in speech-language pathology [Guidelines]. Available from www.asha.org/policy.
• American Speech-Language-Hearing Association. (2023). Code of ethics [Ethics]. Available from www.asha.org/policy/.
• Brewer, C., Aparo, M. (2021) The Adult Speech Therapy Starter Pack. Harmony Road Design Publishing.
• Congress.gov (1990). H.R.4449 – Patient Self Determination Act of 1990. Retrieved November 2024, from https://www.congress.gov/bill/101st-congress/house-bill/4449
• House, S. A., Schoo, C., & Ogilvie, W. A. (2023). Advance Directives. In StatPearls. StatPearls Publishing.
• Teoli, D., & Ghassemzadeh, S. (2023). Patient Self-Determination Act. In StatPearls. StatPearls Publishing.
• Tennant, K., Long, A., & Toney-Butler, T. J. (2023). Active Listening. In StatPearls. StatPearls Publishing.Varkey B. (2021). Principles of Clinical Ethics and Their Application to Practice. Medical principles and practice : international journal of the Kuwait University, Health Science Centre, 30(1), 17–28. https://doi.org/10.1159/000509119