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TomBroussard, February 25,  2021  9:56am EST

Stroke and Aphasia Recovery: Withdrawing Help Isn’t the Same as Not Helping

Dear Friends and Colleagues,

“Hardening off” is the process of toughening vulnerable plants while still inside so that they can live outside successfully. The plants have to be exposed enough to feel the cold without damaging them overtly.

The metaphor of “hardening off” sounded to me like the process of helping people with aphasia by exposing them with a little bit of (therapeutic) stress. People with aphasia need sufficient stress (in a good way) to be prepared for the next day, and the day after that. That is the reason for the incremental exposure to the appropriate level of stress and the hardening off process. Like in the story of Goldilocks and the Three Bears, it has to be “just right.”

It is not unlike experience-dependent neural plasticity that converts thinking and cognitive activities into neural (brain) matter and learning. Plasticity doesn’t happen without experience-dependent activities that induce plasticity. If the appropriate, effortful, and (somewhat) stressful activities are not provided at the right level, the required plasticity might not provide the learning environment needed to improve. You need to have one to acquire the other.

Recently, I was leading a short discussion with several people with aphasia and their spouses. Each person with aphasia had their own communication issues and tried their best to express what they meant.

One client with aphasia had a spouse who had taken over the conversation. It was clear that she was dominating the dialogue. It was sad, because she wanted her husband to get better. She wanted her husband to get better so much that she would do anything to help, including helping on his behalf. That went on for several minutes and I finally interjected.

I had a question for her husband. I asked her not to respond and let her husband respond on his own. Like most people with aphasia, we need more time (and that induces stress for sure) to assemble our thoughts, more than our partner’s patience might allow. After a long silence, his spouse started talking again.

It was a teachable moment. I told her (and I tried to help her understand this) that her volunteering responses on behalf of her husband wasn’t the kind of help that was needed. This form of “help” would not help him to get better.

I was careful and sensitive during the conversation. She was the ultimate family caregiver, and I didn’t want to offend her in any way. I just had to explain to her what “just right” might look like. She seemed to understand and didn’t get defensive. She wanted to know how she could help, when all she would do was help in this way.

A Soviet psychologist, Lev Vygotsky, presented the same problem with education and learning. Vygotsky described the “zone of proximal development (ZPD).” The ZPD is the difference between what a learner can do with some amount of help versus what a learner cannot do at all. Vygotsky believed that experiences that are within their “zone of proximal development” advance their individual learning while the guidance is gradually diminished (Vygotsky, 1978).

I explained to the spouse that helping “in the zone” can be useful. Not helping doesn’t help. Helping a lot doesn’t help either. Family and friends, as well as therapists, have to create a “helper” contract that is designed to withdraw help as part of the process of helping. Withdrawing help isn’t the same as not helping. Constructing the zone of proximal development and providing the appropriate guidance is the challenge, and being aware of the challenge is half the battle.

Please see my full article and video at

Thanks…have a great aphasia day!



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