Communicating With Someone With Aphasia: What Helps, What Hurts, and Why

Communicating with someone who has aphasia works best when you reduce the noise, slow down, keep sentences short, give real time for an answer and use every channel you have, gesture, pictures and writing included, while speaking to the person as the capable adult they still are. Aphasia is a language disorder, not a loss of intelligence, and it affects roughly 25 to 40% of stroke survivors in the early stages¹.

For the first two days after my stroke I could think a full, clear sentence and not get it out. I knew my wife’s name and could not fetch it. My aphasia was mild and it cleared quickly, which I know makes me one of the lucky ones, but those two days taught me something I have never forgotten: the person on the other side of the conversation decides a great deal of how it goes. My wife slowed down, sat where I could see her face, and stopped asking me how I felt, which I could not answer, and started asking whether I wanted the window open, which I could. This piece is written mostly for partners, parents and children who are on that side now. The recovery side is in aphasia recovery.

What aphasia is, and what it is not

Aphasia is damage to the brain’s language systems that can affect speaking, understanding speech, reading and writing, in any combination, while thinking, memory for people and events, and personality are often much better preserved. It is a problem with language itself, how a person uses and understands words, and not a loss of intelligence.

That distinction is the single most important thing for a family to hold on to, because so many unhelpful habits come from forgetting it. People talk louder, as if the problem were hearing. They speak slowly in a sing-song voice, as if to a child. They talk across the person to the nurse. MedlinePlus puts it plainly: talk to people with aphasia in adult language, and do not shout, because shouting does not help unless they also have a hearing problem².

Aphasia also varies enormously. Some people mainly struggle to find and produce words but follow conversation well. Others speak fluently but with words that do not make sense, and may not realise it. Some find understanding the hardest part, especially in groups. A speech and language therapist can tell you which pattern your person has, and that is worth asking for directly, because it changes which of the tips below matter most.

Set up the conversation before you start it

The easiest gains come before anyone speaks: a quiet room, the television and radio off, one conversation at a time, and you sitting where the person can see your face. Background noise and competing voices take up processing capacity that someone with aphasia does not have to spare².

This sounds trivial and it is the thing families most often skip. A kitchen with the radio on, a child asking for juice and the kettle going is a hard place for anyone to hold a conversation, and close to impossible for someone whose language system is already working flat out. Timing matters too. Language is one of the first things to go when someone is tired, and post-stroke fatigue affects around half of survivors. A conversation about something important will go far better at ten in the morning than at the end of a day of appointments.

Change how you speak

Use short, simple sentences in a normal adult tone, give one idea at a time, break instructions into small steps, and then wait, longer than feels natural, for a response. MedlinePlus recommends breaking instructions into small and simple steps and allowing time for the person to understand².

The waiting is the hard part. Silence in a conversation feels awkward and most of us rush to fill it, usually by repeating the question in different words, which gives the person a brand new sentence to process just as they were getting hold of the first one. Count to ten in your head. If you need to repeat, repeat the same words rather than rephrasing. And watch your pace; most of us speak faster than we think we do.

Questions deserve their own thought. “What would you like for lunch?” is an open question that needs the person to find and produce several words. “Would you like soup?” needs one. “Soup or a sandwich?”, with the two held up or written down, needs a point. MedlinePlus suggests asking questions that can be answered yes or no and giving clear choices, though not too many². Be aware that some people with aphasia mix up yes and no, so if an answer surprises you, check it with a nod, a thumbs up or a written YES and NO they can point to.

Use more than words

Gesture, pointing, facial expression, drawing, writing, photographs and objects all count as communication, and using them yourself gives the person permission to use them too. Encouraging pointing, gestures, drawing and writing, and making a picture or word book of common topics and people, are among the core recommendations for families².

A small notebook and a thick pen will do more than most apps. Write the key word as you say it (“Tuesday”, “Doctor”, “Sarah”), draw a rough clock for a time, sketch a map for where you are going. Some people with aphasia can read single words better than they can understand them spoken; others are the other way round, and you will learn which quickly. A communication book with photos of family, rooms, foods and regular places gives the person a way to start a conversation rather than only answering one. A speech and language therapist can help make one that fits, and NICE recommends providing communication aids to people who could benefit from them after a stroke, with training in how to use them³.

The habits that backfire

Pretending to understand, finishing every sentence, correcting each wrong word and talking about the person rather than to them all tend to increase frustration and reduce how much the person tries to say. MedlinePlus is explicit that you should not pretend to understand if you do not, and should not correct the person when they remember something incorrectly².

Pretending feels kind and is not. The person can usually tell, and it teaches them that what they say does not really land. It is far better to say “I have not got it yet, can you show me?” and try another route. Finishing sentences is the other big one. Sometimes it helps, especially when someone is exhausted, but as a reflex it takes the turn away and often supplies the wrong word, which then has to be undone. The fix many couples use is a simple agreed signal, a raised hand or a tap on the table, that means “help me now”.

The last habit is the one that stung me most when I saw it happen to others. A consultant asks a question, the patient starts to answer, and the wife answers for him. It comes from love and worry and a wish to get the right information across. It also tells everyone in the room that the patient is not part of the conversation. Keep the person involved, ask them first, and let them hand over to you if they want to. MedlinePlus recommends always trying to keep people with aphasia involved in conversations².

How this fits with therapy

Good communication at home makes everyday life easier and gives the person more practice using language, but it is not a substitute for speech and language therapy, which is the treatment for aphasia and works better at higher total doses. The Cochrane review of speech and language therapy for aphasia found it improves functional communication compared with no therapy, and that more intensive and higher-dose therapy tended to do better⁴.

NICE’s stroke rehabilitation guideline recommends offering training in communication skills, such as slowing down, not interrupting and using props, gestures or drawing, to the people who regularly talk with someone who has aphasia³. If nobody has offered that training, ask. Many therapists are glad to have a partner sit in on a session, see what the person can do with support, and take home a few specific strategies. That is worth more than any general list, including this one.

The emotional side matters as well. Losing easy conversation is a grief for both people, and frustration, anger and withdrawal are common. The emotional side of stroke recovery covers some of that ground. If low mood, anger or hopelessness are persistent, tell the stroke team, because those need their own support.

When my words came back, the thing I remembered was not which tricks my wife had used. It was that she had never once made me feel stupid. Everything above is in service of that. What your own person needs, and which strategies suit their particular aphasia, is a question for the speech and language therapist who has assessed them.