As the number of trained speech-therapists is still insufficient to cope with all of the aphasic patients, every doctor who has anything to do with them must master the basic mechanisms for communication with these patients. In the long term, involvement of the relatives and others who are close is very important. To them, Martha L. Taylor's book "Understanding Aphasia" can be helpful (see References) .

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The most important initial step is to explain to the aphasic in simple language that he is suffering from a speech disorder, what is its cause and that this will most probably improve with time or completely disappear. It is often necessary to explain this problem many times. It is also just as important to make it clear to the patient that he is not mad or mentally disturbed. It should be explained next that certain speech exercises have been planned for him and they will begin soon, and will make it easier for him to make himself understood again as soon as possible. These steps reduce anxiety and aggression and give hope.

Automatic terms of frequently-used speech (such as "hello", "how are you?") can be achieved by many aphasics. Many are also able to count, recite the alphabet or sing songs. However this spontaneous ability is not necessarily of prognostic importance. Speech cannot be improved by means of singing. Of course an aphasic who previously enjoyed singing, and is attempting to sing, should be encouraged.

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Speech therapy should not exhaust the patient. Short, frequent exercises are better than those which are longer, and tire him. It is useful if the patient is motivated and enthusiastic about speech therapy, but if this is given under pressure, it can endanger rehabilitation.

The use of substitute languages has not been shown to be effective in adults. It seems to be even more difficult for the aphasic patient to learn a new form of communication than to build up a limited number of common words. The mother tongue is relearn most rapidly by those who have mastered several languages.

Success of speech therapy depends on the severity of the speech disorder, the underlying disease, the remaining intellectual ability, age and the motivation which can be aroused for speech training. There are patients who remain completely aphasic in spite of excellent speech therapy, and others who learn to speak almost normally once again (President Eisenhower, Sir Winston Churchill).

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At first, a small number of words should be learnt; those which are important for daily living, such as "bed", "chair", "toilet", "money", "watch", "bread", "butter", "tea", "phone", "doctor", "shoe", "mouth", "key", "soap", "hand", "leg", "table", "house". Words can be introduced later which have a particular relevance for the aphasic patient, for example "flowers", "seed", "betroth" for a gardener.

Furthermore it is important that the aphasic is taught words in a useful order, which is substantives, verbs and adjectives. Next would come adverbs, articles, prepositions and conjunctions. Many aphasic patients have greater difficulties learning the "small words" (prepositions, conjunctions and articles) than mastering substantives. This applies especially to patients with motor aphasia, but the reverse is true for those with amnesic aphasia.

Aphasic patients must be continually encouraged to speak. This is best achieved when speaking becomes a pleasant experience for the patient for which he is rewarded by praise or attention. In general, the aphasic patient should be offered plenty of opportunities to hear speech, although he should not be overwhelmed (listening to conversations, radio, television). As has been said, more frequent, short exercises are both more effective and more interesting than extensive speech practice for longer time spans. The aim of therapy should be realistic and dependent on possibilities which can be achieved in the short term. The aphasic should be treated empathetically, so that he recognizes that those around him understand how badly he is affected by his handicap.

Additional writing exercises can encourage both reading and speech. As the right side is usually affected in aphasic hemiplegic patients, the patient often has to use his left hand for writing. Writing exercises should be in script rather than capitals, as most people can manage script rather than printing letters. This would also result in the patient having to learn how to go on from printing to script later.

Reading practice is best carried out using printed or typed material as this is what most people read anyway. Aphasic patients are better at reading larger type than a normal size, possibly because the excessively large letters are more stimulating. Initially patients are not able to read for any length of time due to limited concentration. Many aphasic patients still spend time looking at their daily paper, even though they cannot read or comprehend it. Maintaining this habit can encourage the patient.

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It is also not useful to speak on behalf on the aphasic patient as this tends to extinguish self-trust, and increases his feeling of dependence.

It is always inappropriate to interrupt a person. This applies particularly to aphasic patients. He must be given enough time to seek his own words, without an impatient reaction of those around.

Initially it is of no great importance that the aphasic patient can pronounce each word perfectly, but he should be able to make himself understood. Every form of isolation leads to a reduction in the amount of speech he can manage, and every over-exertion to a disturbance of his confidence. It is most important that every attempt to converse with the aphasic motivates him to activity, and never blocks his self-initiative.

Ideally "speaking with those who cannot speak" would not only result in comprehension and partial relearning of speech, but would also lead to working through and conquering the disease which led to the aphasia.

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