When a client with cognitive problems does not engage in therapy… Part two


In post one here, I covered what to do when a client is withdrawn/fatigued/turns away.  This part explores what to do when a client has attention/memory/behavioural difficulties that makes engagement in therapy difficult. 

I’m going to split the three out as it makes it easier to discuss, however clients can have a combination of all 3 difficulties, so you may find yourself blending approaches. 


Thinking back to child language acquisition, attention has to been in place first before language comprehension and expression can be acquired.  When rehabing an acquired speech and/or language disorder, it is the same- a client needs to have attention skills.  Clients with frontal lobe or right sided brain injury will be the clients who may exhibit poor ability to maintain attention. In my experience, if you can get ten minutes ish of focused attention with then needing to change the task or give someone a break, that is fine- you can get plenty done in ten minute blocks over a 45 minute to an hour session.  However what do you do when someone cannot stay in one place for more than a few minutes, or is distracted by any noise in the environment, or keeps going off on a tangent?  

Importantly, attention skills can be rebuilt. Here are a few things to try:

  • Consistency- run your sessions in the same order with the same activities so that the client knows what to expect- e.g start with greeting, exchanging names, discussion of something they have done that day. Move onto a iPad activity and then a pen & paper activity. Finish up with a task they really enjoy such as looking at family photos together. 
  • Brain injury education around attention. Explain their difficulties with attention linking it with the area of damage in their brains. Keep the explanation short but adult. Set achievable goals before each task- for example, we’re going to play tic-tac-toe on the iPad- last time you focused for one game. Let’s aim for two. Or, we talked about these photos for 1 minute last time before you changed the subject, can you do 2 minutes? 
  • Be engaging and suggest interesting activities- you do not have to do traditional ‘speech therapy’ when building up attention. If you have access to a kitchen, bake biscuits (you can buy ready made gingerbread dough that you roll out, cut and bake within 20 minutes- I’ve done this with a couple of clients with good results). Can you join in with a physiotherapy session and help them build attention skills whilst reaching for objects and catching a ball? 
  • Written prompts- instead of having to constantly use your voice to bring someone back to the task in hand, write down the task you are doing and keep it in front of both of you. If they lose attention, bring their attention back to the written prompt and then to the task. 
  • Reduce other distractions as much as possible. This is very difficult on a noisy ward, easier if you can go to a different room or you are in their home. 
  • Frequent breaks- if a client perseverates on asking the same question repeatedly (can I go back to bed? When is Pete coming? Where is my phone?) or frequently runs off on a tangential topic, firmly bring them back to the task for a short period of time, but them give them time to ask their questions/chat freely. It can be such a confusing time for clients as attentional problems occur usually in the early stages of brain injury recovery, along with a multitude of other difficulties such as poor insight and memory difficulties. If I don’t know the answer to their questions and can’t easily find out (or know that the answer will be one they won’t like, as in, sorry you can’t go back to bed yet) I use a validation and reflection technique. Make the break explicit and timebound (write it down if needed) and then refocus to the next task. 
  • If a client has difficulty physically staying in one place you will need to be willing to move with them around the environment. Usually these clients might be at risk of absconding so ensure you are following any instructions put in place to keep them safe. Try and engage them in each place- take photos with you, or discuss things going on in the environment they are currently part of. Be calm and friendly. 


Some clients I’ve worked with have very poor short term memory which makes rehab of speech and language extremely difficult. 

Orientate: very important and you may need to repeat this throughout the session. Written, verbal and pictorial prompts if possible. A board that stays in the room they spend most time in is very useful.  Remind them who they are, who you are. Where they are, why they are there. What your role is. What you plan to do that session. Keep information short but adult. 

Consistency: this word crops up a lot! But running a session roughly the same way each time helps with memory. 

Written/visual prompts: as well as someone having a orientation board, writing down their speech therapy goals and a brief summary of your session will be helpful. If the client has reading comprehension difficulties you will need to make these more visual or ‘aphasia friendly’ 

Find a memory aid that works- for a lot of my clients, their smart phone or tablet is their memory aid. One client said to me ‘my brain is in my pocket’. With a tablet or smartphone you have calendars, notes, to do lists, photos, diary apps- all sorts of ways to help someone with memory difficulties. However if someone has other difficulties that make the use of smart tech impossible, you may be looking at very simple paper based aids. 


The clients I’ve worked with who have behavioural problems usually have complex traumatic brain injuries with widespread damage.  These clients need the most help but are the hardest to reach. They might not see the point of speech therapy, have insight difficulties, feel sessions are not relevant to them, boring or treating them like a child.  It can be difficult for the therapist as it can make you feel vulnerable waiting for an angry outburst, and I’ve had clients who hit out, throw things, push things over etc. 

Safety first- ensure you are in a position where you can move away from the client into a safe area if you need to. Clients with severe behavioural issues will usually have 24 hour support – make sure others are with you in the session (or close by) who have the skills to step in if needed. However, remember that angry outbursts are not their fault and they are a person first. Once you’ve ensured your safety, just keep calm and carry on!

You will need to use all your skills to engage a client – you are likely to need to gather assessment information informally and therapy will likely need ‘hiding’ within other tasks. If other therapists have seen the client before you (speech or otherwise), speak to them and get a heads up about what they have tried in therapy and how it was received. 

Most if the clients I’ve worked with are aware of their speech and language difficulties at some level but will have a level of denying/ poor insight so if you directly mention things they can’t do, it may set off an angry outburst. 

See if you can find something that they will willingly admit to that you can work on directly. I use the approach ‘some people with a similar brain injury to you find that they may experience … ‘ and then you can mention speech/language/voice/cognition difficulties you are aware they have. You may find, for example, they admit dysarthria but not receptive difficulties. You can then work directly on the dysarthria and work in reception work as part of dysarthria therapy- increasing steps given in commands for example. 

You may need to be very flexible in your approach. Change the setting, make a cup of tea, go for a walk, accompany them to a task they enjoy such as shopping or playing sport. You might feel that you are not providing therapy, but do not underestimate your skills to make anything you do therapeutic. I help my children’s language skills all the time whilst walking, cooking, being in the car- I build their vocab, provide good grammar examples, help them practice tricky sounds.. And they don’t even notice! Just make sure you are clear in your head what you are trying to improve and have a baseline you can refer back to. Sometimes the goal might just be about engaging with you in the first place. 

Be positive but be balanced in any feedback you give if you are able to carry out therapy tasks. I’ve found that many of my clients why behavioural issues feel they are being babied if you just give them glowing praise all the time. Give 3 good things and 1 thing to work on and if they come to respect your input, you may find they work with you on other areas they denied having difficulties in.  

Show their improvement in therapy in a way they can understand- video or voice recordings, people around them saying they can understand them better, being able to do something new- link their success back to the joint work between then and you. This will help keep them engaged in the speech therapy process.

Wow, writing all that makes me realise what a difficult topic this is and I feel like I’ve only scratched the surface. I hope this helps in some way- feel free to comment below with what works for you or anything you’d like me to cover in more detail  

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