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Speech Therapy

Speech Therapy Carer Training

5 June 2026About 8 min read

After a family member has a stroke or develops aphasia, what is often hardest for those around them is not the limited movement of the arms and legs, but the silence of someone who knows what they want to say and cannot say it. Carers naturally place their hopes on the patient, hoping that the person will practise hard and speak more. Clinical evidence, however, points to another key that is often overlooked. In home speech rehabilitation, the most underrated, most trainable and fastest-acting point of leverage is the carer's own way of talking, and not the patient practising alone. Using the evidence, this article goes through the three things home rehabilitation most needs to get right: communication partner training, home swallowing and feeding safety, and the mouth and voice exercises that have a real practical effect.

Training the carer's way of talking is a key part of speech therapy

The core difficulty in aphasia is not intelligence, but access to conversation. When the carer learns to open that access, the patient can get thoughts across even without receiving extra treatment.
Kagan et al., 2001

A person with aphasia who cannot speak is not a person who cannot think. In a controlled trial, researchers trained conversation partners in techniques that acknowledge and reveal competence. The trained partners performed far better than the control group, and, more importantly, the social skills and message exchange of the people with aphasia improved clearly even though they themselves received no training (Kagan et al., 2001). In other words, it was the carer's way of talking that was trained, and the patient who benefited directly.

How carer involvement affects home speech rehabilitation

The time a therapist can visit each week is limited, and most of the patient's waking hours are spent with the carer. The carer is therefore more than the therapist's assistant. The carer is the person who decides whether rehabilitation training reaches into daily life.

Where daily practice time comes from

  • A Cochrane review (57 RCTs, 3,002 people) confirmed that speech therapy clearly improves functional communication (SMD 0.28, 95% CI 0.06–0.49, P=0.01)
  • High-intensity, high-dose or longer courses work better, and the training hours come mainly from daily life and not from time in the treatment room alone
  • When carers build short, frequent practice into daily routines, this is how the training hours the clinical evidence calls for are reached (Brady et al., 2016)

Clinical research on communication partner training

  • An updated systematic review analysed 25 studies of communication partner training, and all 25 recorded positive change
  • The authors clearly recommend that communication partners of people with chronic aphasia should be offered training, to improve their skills in helping the person communicate
  • Together with the 2010 version, 56 studies in all were covered, and the conclusions point the same way (Simmons-Mackie, Raymer & Cherney, 2016)

Clinical data after communication partners are trained

Patients clearly improve too
When the communication partner is trained and the patient receives no extra training
Patients' message exchange F(1,36)=17.6, p<.001; social skills p=.023 (Kagan et al., 2001)
25 / 25 studies
All studies of communication partner training recorded positive results
Together with the earlier review, 56 studies in all (Simmons-Mackie et al., 2016)
Fidelity 87.2%
Pilot trial of communication partner training for progressive aphasia
Of 30 goals, 29 were met or exceeded (Volkmer et al., 2023)

This approach does not apply only to the stable phase after a stroke. A randomised controlled pilot study in the UK of people with primary progressive aphasia and their communication partners (BCPPA) showed that systematic training in carers' conversation is not only feasible but also well accepted: treatment fidelity reached 87.2%, and of the 30 intervention goals, 29 were met or exceeded (Volkmer et al., 2023). Even with a degenerative condition, teaching carers how to converse still has great practical value.

The four steps of communication partner training (SCA): acknowledge, reveal, verify, repair

Supported Conversation for Adults with Aphasia (SCA) breaks the abstract idea of good communication into concrete steps. A carer can practise the following four steps one at a time (Kagan et al., 2001; Simmons-Mackie, Raymer & Cherney, 2016).

  1. 1
    Acknowledge competence
    Through tone and attitude, let the patient know: "I know you understand, you just can't find the words right now." Respect the patient as an adult. Do not treat the patient like a child or assume the patient cannot understand.
  2. 2
    Reveal competence
    Provide aids that help the patient express what is in their mind, for example pen and paper, pictures, gestures, writing key words, drawing or offering choices. Research shows that trained communication partners did clearly better than the control group at helping patients reveal their competence (Kagan et al., 2001).
  3. 3
    Verify
    Narrow things down slowly with yes/no questions, and repeat back what you understood so that the patient can confirm it (for example: "Do you want a drink of water?"), making sure that what you received is what the patient meant.
  4. 4
    Repair
    When the conversation gets stuck, do not give up easily, and do not rush to finish the second half of the sentence for the patient. Try asking in another way, switch to an aid, or step back and try again, and keep the conversation going without brushing it off.

How carers talk and listen day to day

Slow down, one question at a timeSpeak clearly and slowly at a moderate volume, using short sentences as far as possible. Ask only one question at a time, and avoid giving a lot of information at once, which leaves the patient not knowing how to respond.
Allow enough time and do not hurryWait patiently while the patient organises their thoughts and expresses them, and do not jump in to say whole sentences for the other person. Often, with a little more waiting time, the patient is able to give a full reply.
Understand the meaning, not each wordThe point is to understand the overall meaning the patient wants to get across, and not to correct their pronunciation word by word. Use yes/no questions to check that you have understood, and give recognition and encouragement each time the patient tries to communicate.
Use aids wellPrepare picture cards, gestures, pen and paper or a tablet app, and put together a personalised communication book, to give the patient one more way to express their thoughts (Kagan et al., 2001).

Managing the risks of swallowing and feeding at home

For many carers, every meal feels like an exam, with constant worry that the patient will cough or even develop pneumonia. The key to safe feeding is to treat eating as a risk that can be assessed and managed, and not to keep adding thickener by instinct.

The most common problem among carers is often not a lack of feeding technique, but a mistaken belief that the thicker the drink, the safer it is. A randomised trial of 515 people showed that the rate of pneumonia within 3 months did not differ clearly between patients who drank thickened liquids and patients who swallowed with a chin-down posture. Patients who drank thickened liquids, on the other hand, had higher rates of dehydration, urinary tract infection and fever (Robbins et al., 2008).

What thickening drinks really does to swallowing safety, and its risks

Myth: the thicker, the safer
  • Honey-thick liquid does remove aspiration at the time of testing (under videofluoroscopy) most effectively (Logemann et al., 2008)
  • But in the 515-person RCT, the 3-month pneumonia rate with thickened liquids did not differ significantly from the chin-down posture (HR 0.84, 95% CI 0.49–1.45, P=0.53) (Robbins et al., 2008)
  • The cost: the thickened liquid group had more dehydration (6% vs 2%), urinary tract infection (6% vs 3%) and fever (4% vs 2%) (Robbins et al., 2008)
  • Patients found honey-thick liquid the least acceptable, and people with the most severe dementia did worst with every method (Logemann et al., 2008)
Evidence: individualised, with patient preference included
  • A speech therapist decides texture and posture for the individual, based on a swallow study or clinical assessment
  • Patient acceptance is taken into account: the chin-down posture and nectar-thick liquid were the most acceptable (Logemann et al., 2008)
  • Fluid intake and nutrition are looked after, avoiding the backfire of dehydration in order to prevent coughing
  • Posture, oral care and monitoring go together, and thickener is not relied on as a single measure

IDDSI and the Hong Kong Council of Social Service food texture standard

If family, care home and therapist each use their own standard to describe thickness, errors easily creep into daily care. It is advisable to follow the International Dysphagia Diet Standardisation Initiative (IDDSI) or the Hong Kong Council of Social Service guideline on texture-modified diets (《照護食標準指引》), which divide drinks and foods into standard levels. The therapist then sets the suitable level according to the patient's actual ability (Robbins et al., 2008).

Why drink and food textures are standardised

  • Drinks and foods are divided into standard levels, for example thin, mildly thick and moderately thick
  • This avoids miscommunication between family, care home staff and therapists who understand "how thick" or "how soft" differently
  • It helps daily observation and handover between places or people, for example on discharge, transfer between homes, or a change of domestic helper
  • Which level to eat must be set by the speech therapist according to the patient's swallowing ability, and carers must never raise or lower the level themselves

How a carer checks food texture and thickness at home

  • A fork, spoon or syringe can be used for a simple flow test to confirm that the drink or food meets the standard thickness
  • Check straight after mixing the thickener to make sure it has fully dissolved and has been left long enough to thicken
  • Avoid giving foods of mixed textures (for example a clear soup with solid pieces of vegetable), to lower the risk of choking
  • If a drink or food has changed in thickness after standing (for example thinned out or become lumpy), make a fresh one before feeding

Why daily oral care matters for swallowing safety

What really lowers the risk of aspiration pneumonia is often not the thickness of the drink, but the daily mouth cleaning that is often overlooked. It is the step that is easiest for a carer to do and the cheapest, and the one most often skipped.

Treat oral care as a daily routine as important as feeding:

  • Brush the teeth and clean the mouth after every meal—A randomised study of 417 older adults in nursing homes showed that when care staff or carers brushed the patient's teeth and cleaned the mouth after every meal, pneumonia, days with fever and deaths from pneumonia fell clearly (Yoneyama et al., 2002).
  • Older adults without teeth need it too—The study also pointed out that cleaning the mouth helps whether or not the older adult has their own teeth. Dentures, gums, tongue and the lining of the mouth all need cleaning, and the step should not be skipped because the patient has no teeth (Yoneyama et al., 2002).
  • Oral cleaning together with swallowing practice—A literature review also noted that in several randomised controlled trials (RCTs), cleaning the mouth and brushing the teeth clearly reduced pneumonia and deaths from respiratory disease. Combining this with swallowing training to improve the related muscle function can lower the chance of pneumonia further (Tada & Miura, 2012).

Home safety checklist before, during and after a meal

Safety checks before and after each meal
  • Before the meal: keep the room quiet with few distractions, and begin feeding when the patient is most alert
  • Before the meal: sit the patient upright at about 90 degrees with the head tilted slightly forward, and never let the patient tilt the head back to swallow
  • During the meal: feed slowly, one small mouthful at a time of about a teaspoon, and make sure the patient has swallowed a mouthful completely before giving the next
  • During the meal: follow exactly the food texture and sitting posture set by the therapist, and do not thicken or dilute by yourself
  • If the patient chokes and coughs: stop feeding at once, let the patient cough the food back up, and continue only when breathing is steady again. If choking happens often, tell the therapist
  • After the meal: keep the patient sitting upright for 20–30 minutes, and never lay the patient flat straight after eating
  • After the meal: brush the teeth and clean the mouth after every meal (including cleaning dentures and the tongue), to prevent aspiration pneumonia (Yoneyama et al., 2002)

Choosing mouth and voice exercises that have a real function

Many families equate home speech training with mouth movements such as sticking out the tongue and pursing the lips. A carer's time and the patient's patience are both limited, and the effort is better put into exercises that turn into practical function in daily life, and not into abstract mouth muscle drills.

Make the task itself the targetThe exercise should directly target speaking or the swallowing movement itself (for example saying everyday words, or swallowing a mouthful of food safely), and not simply be mouth movements unrelated to speaking (McCauley et al., 2009).
Enough dose and intensityThe Cochrane evidence shows that high-intensity, high-hour treatment works better. Short, frequent practice built into daily life works far better than a long drill done only once in a long while (Brady et al., 2016).
Build it into real situationsThe training methods shown by the therapist are done directly in real conversation and mealtimes (for example practising food names at a meal, or making sentences in everyday chat), so that the results of training carry straight into daily life.
Chosen by the therapist from the diagnosisWhich exercises suit the patient, how many to do each time and how often should be set by the speech therapist from the diagnosis and assessment, and should be reviewed and adjusted regularly.

Clinical evidence on plain mouth muscle exercises

A systematic review of 15 studies found that the existing medical literature does not contain enough evidence to support or reject the idea that non-speech oral motor exercises (for example simply sticking out the tongue or pursing the lips, movements unrelated to speech) improve speech performance (McCauley et al., 2009). In other words, spending all the precious time on plain mouth muscle drills may not make the patient speak more clearly. It is better to use the time on exercises that have evidence behind them and can really be applied in daily life.

How a home-visit speech therapist guides carers in training skills

Carer training is far from learning from videos alone. The therapist comes to the patient's home in person, teaches the carer step by step according to the patient's real daily routine, and keeps adjusting alongside.

The therapist's demonstration, feedback and adjustment on the spot

  • In the real home setting, the therapist demonstrates SCA conversation techniques and safe feeding postures on the spot, and has the carer try them straight away
  • Feedback is given from video recordings and corrected step by step, fine-tuning the communication skills to suit the patient as closely as possible
  • Research confirms that systematic carer training is workable in practice and acceptable to participants (fidelity 87.2%; Volkmer et al., 2023)

How to fit enough training hours into daily life

  • Carers are taught to build short, frequent practice into daily routines, reaching the high-intensity, high-hour training that the clinical evidence recommends (Brady et al., 2016)
  • Food texture levels, oral care steps and the safety checklist are set out clearly, so that family members have clear steps to follow in daily care
  • Rehabilitation progress is reviewed regularly, balancing enough training against tiring the patient and the carer

Frequently asked questions

A family member cannot speak after a stroke. How can the carer help at home?
The approach with the most evidence is for the carer to become a skilled communication partner first: slow down, ask only one question at a time, use yes/no questions to check understanding, use pen and paper or pictures, allow plenty of time to respond, and never finish the patient's sentences for them. A controlled trial showed that when partners used this set of techniques, which acknowledge and reveal the person's competence, the patient's exchange of messages and social skills improved clearly even though the patient received no additional treatment. A home-visit speech therapist can demonstrate on the spot, give feedback from a video recording, and adjust the techniques to suit the patient's level.
The thicker a drink is made, the safer it is. Is that right?
No. A randomised trial of 515 people showed no significant difference in the rate of pneumonia within 3 months between drinking thickened liquids and using a chin-down posture. Patients who drank thickened liquids, however, had higher rates of dehydration, urinary tract infection and fever. Another study of 711 people also found that honey-thick liquid was the best at preventing liquid aspiration at the time, but it was the least acceptable to patients. The right approach is for the speech therapist to decide the most suitable food texture and eating posture for the individual patient from a swallow study or clinical assessment, and not to add thickener blindly.
How should thickener and food texture be graded?
It is advisable to follow the International Dysphagia Diet Standardisation Initiative (IDDSI) or the Hong Kong Council of Social Service guideline on texture-modified diets (《照護食標準指引》), which divide drinks and foods into standard levels (for example thin, mildly thick and moderately thick). At home, a carer can use a fork, a spoon or a syringe for a simple flow test to check that the thickness meets the standard. Using one common language for texture avoids miscommunication between family, care home and therapist, and helps daily monitoring. The level a patient actually needs must be set by the speech therapist according to the patient's swallowing ability.
Are daily tongue and lip-pursing mouth exercises effective?
It depends on the purpose of the training. A systematic review found that non-speech oral motor exercises, which are unrelated to speaking (for example simply sticking out the tongue or pursing the lips), have not been shown to improve speech clarity. A carer's time is limited, and effort is better put into practice that directly targets the speech or swallowing movements themselves with enough repetitions, and into building the strategies shown by the therapist into real conversation and mealtimes. Which exercises suit the patient should be decided by the speech therapist from the diagnosis.
What is the step carers most easily overlook in preventing aspiration pneumonia?
Daily oral care. A randomised study of 417 older adults in nursing homes showed that brushing the patient's teeth and cleaning the mouth after every meal clearly reduced pneumonia, days with fever and deaths from pneumonia, and older adults with and without their own teeth benefited alike. This measure is the easiest and cheapest for a carer to carry out and also the one most often overlooked, and it should be part of the daily care routine together with a safe feeding posture.
How often and for how long does practice need to be for it to work?
A Cochrane review (57 RCTs, 3,002 people) showed that speech therapy, compared with no therapy, clearly improves functional communication, and that high-intensity, high-dose or longer courses of treatment work better. This means that short, frequent practice built into daily life is far more effective than an occasional long drill. However, drop-out was also higher in the high-dose groups, so the actual training dose must balance benefit against tiring the patient and the carer, and should be set for the individual by the therapist and reviewed regularly.

Speech rehabilitation often needs support from several directions. If the family member also has difficulty swallowing, read more about dysphagia treatment. For how home treatment compares with attending a clinic, see the advantages of home-visit speech therapy. Carers may also read the physiotherapy guide for carers, which together cover everyday communication, self-care and limb function in supporting a family member's recovery.

Would you like to help a family member communicate and eat safely at home? Our registered speech therapists can visit, demonstrate and teach carers the skills hands-on.

Book a home-visit speech therapy assessment

Disclaimer: This article is general health information and is not professional medical advice. If you have any health concerns, please consult a qualified healthcare professional.

References

  1. Kagan, A., Black, S. E., Duchan, J. F., Simmons-Mackie, N., & Square, P. (2001). Training volunteers as conversation partners using “Supported Conversation for Adults with Aphasia” (SCA): a controlled trial. Journal of Speech, Language, and Hearing Research, 44(3), 624–638. PubMed
  2. Simmons-Mackie, N., Raymer, A., & Cherney, L. R. (2016). Communication Partner Training in Aphasia: An Updated Systematic Review. Archives of Physical Medicine and Rehabilitation, 97(12), 2202–2221. PubMed
  3. Brady, M. C., Kelly, H., Godwin, J., Enderby, P., & Campbell, P. (2016). Speech and language therapy for aphasia following stroke. Cochrane Database of Systematic Reviews, (6), CD000425. PubMed
  4. McCauley, R. J., Strand, E., Lof, G. L., Schooling, T., & Frymark, T. (2009). Evidence-Based Systematic Review: Effects of Nonspeech Oral Motor Exercises on Speech. American Journal of Speech-Language Pathology, 18(4), 343–360. PubMed
  5. Robbins, J., Gensler, G., Hind, J., et al. (2008). Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial. Annals of Internal Medicine, 148(7), 509–518. PubMed
  6. Logemann, J. A., Gensler, G., Robbins, J., et al. (2008). A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson’s disease. Journal of Speech, Language, and Hearing Research, 51(1), 173–183. PubMed
  7. Yoneyama, T., Yoshida, M., Ohrui, T., et al. (2002). Oral care reduces pneumonia in older patients in nursing homes. Journal of the American Geriatrics Society, 50(3), 430–433. PubMed
  8. Tada, A., & Miura, H. (2012). Prevention of aspiration pneumonia (AP) with oral care. Archives of Gerontology and Geriatrics, 55(1), 16–21. PubMed
  9. Volkmer, A., Spector, A., Swinburn, K., Warren, J. D., & Beeke, S. (2023). Results from a randomised controlled pilot study of the Better Conversations with Primary Progressive Aphasia (BCPPA) communication partner training program. Pilot and Feasibility Studies, 9, 87. PubMed