The paradox of helping: Contradictory effects of scaffolding people with aphasia to communicate

Abstract

When interacting with people with aphasia, communication partners use a range of subtle strategies to scaffold, or facilitate, expression and comprehension. The present article analyses the unintended effects of these ostensibly helpful acts. Twenty people with aphasia and their main communication partners (n = 40) living in the UK were video recorded engaging in a joint task. Three analyses reveal that: (1) scaffolding is widespread and mostly effective, (2) the conversations are dominated by communication partners, and (3) people with aphasia both request and resist help. We propose that scaffolding is inherently paradoxical because it has contradictory effects. While helping facilitates performing an action, and is thus enabling, it simultaneously implies an inability to perform the action independently, and thus it can simultaneously mark the recipient as disabled. Data are in British English.

Full text

RESEARCH ARTICLE
The paradox of helping: Contradictory effects
of scaffolding people with aphasia to
communicate
Alex Gillespie*, Julie Hald
Department of Psychological and Behavioural Science, London School of Economics and Political Science,
London, United Kingdom
*a.t.gillespie@lse.ac.uk
Abstract
When interacting with people with aphasia, communication partners use a range of subtle
strategies to scaffold, or facilitate, expression and comprehension. The present article anal-
yses the unintended effects of these ostensibly helpful acts. Twenty people with aphasia
and their main communication partners (n= 40) living in the UK were video recorded engag-
ing in a joint task. Three analyses reveal that: (1) scaffolding is widespread and mostly effec-
tive, (2) the conversations are dominated by communication partners, and (3) people with
aphasia both request and resist help. We propose that scaffolding is inherently paradoxical
because it has contradictory effects. While helping facilitates performing an action, and is
thus enabling, it simultaneously implies an inability to perform the action independently, and
thus it can simultaneously mark the recipient as disabled. Data are in British English.
Introduction
‘The gift not yet repaid debases the man who accepted it . . . Charity wounds him who
receives, and our whole moral effort is directed toward suppressing the unconscious harm-
ful patronage of the rich almoner.’
([1]: p.63)
Helping is a social activity that must be analysed both in terms of the activity being helped
and the meaning of receiving help. Providing help aims to enable the recipient to perform an
action; but, simultaneously, helping indexes assumptions about the ability of the recipient, the
authority of the helper, and their relationship. Most of the literature on helping has focused
on facilitating activities. A smaller literature has shown that people often resist receiving help–
echoing Mauss’ statement, in the above quotation, that any form of gift creates an imbalance
that wounds one’s identity. The present article combines these literatures, arguing that helping
entails a very specific communicative entanglement in which the practical and relational
effects of helping are contradictory; while helping can empower, it can also simultaneously
index disempowerment.
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OPEN ACCESS
Citation: Gillespie A, Hald J (2017) The paradox of
helping: Contradictory effects of scaffolding people
with aphasia to communicate. PLoS ONE 12(8):
e0180708. https://doi.org/10.1371/journal.
pone.0180708
Editor: Ian McLoughlin, University of Kent, UNITED
KINGDOM
Received: August 27, 2016
Accepted: June 20, 2017
Published: August 14, 2017
Copyright: ©2017 Gillespie, Hald. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: The anonymised
numeric data used for the three analyses are in the
Supporting Information file.
Funding: The research was funded by the
Economic and Social Research Council, UK (RES-
000-22-2473). The funders had no role in study
design, data collection and analysis, decision to
publish, or preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.

We analyse conversations between persons with aphasia (PAs) and familiar communication
partners (CPs). The helping behaviour is scaffolding communication, for example, reading
aloud, breaking down sentences, speaking for, prompting, and facilitative gestures. Our first
analysis describes the scaffolding that is provided, showing that it is most frequently done by
CPs and usually effective. Our second analysis reveals an unintended effect of scaffolding,
namely, positioning CPs as dominant. The third analysis reveals PAs alternating between
requesting and resisting scaffolding. To understand why PAs simultaneously request and resist
scaffolding, we introduce the concept of the paradox of helping.
Aphasia within informal relationships
Aphasia is a communication disability that can be caused by stroke, brain injury, brain
tumours, infection or a progressive neurological condition. In terms of communication, apha-
sia usually impairs a person’s ability to speak, write, read, and understand speech. In terms of
identity, the potential outcomes of dependency upon others, unemployment, and social isola-
tion [2] can result in a diminished sense of self [3].
Close social relationships are an important resource in adapting to aphasia [4]. However,
these relationships can also be undermined by aphasia [3]. First, becoming an informal care-
giver is a challenging transition, entailing a vulnerability to physical and psychological strain
[5]. Second, maintaining these social relationships becomes more difficult due to the commu-
nication impairment itself [6].
Given the importance of close relationships in adapting to aphasia, a lot of research has
focused on enhancing communication within these relationships [7]. For example, PAs can
receive training to maximise use of retained capacities [8] and video feedback can be used to
enhance communication within relationships [9]. Also, taking advantage of the relational
nature of communication, some interventions have focused on communication partner train-
ing [10–11]. The evidence indicates that training communication partners to facilitate the PAs
expression and reception is effective [12–13], with a general correlation between communica-
tion strategies and communication success [14]. However, communication partner training
can have diverse outcomes [15], and efficacy depends upon the extent and type of language
deficits. Accordingly, any training in facilitating communication needs to be individually tai-
lored to the particularities of the PAs aphasia [16–17].
Scaffolding communication
‘Scaffolding’ is a metaphor initially used in child development research to describe how an
adult or expert can provide cognitive support to enable ‘a child or novice to solve a problem,
carry out a task or achieve a goal’ just beyond their ‘unassisted efforts’ ([18]: p.90). The concept
of scaffolding is also evident in Vygotsky’s [19] observation that children are better at perform-
ing tasks when receiving support from an expert who guides attention, augments memory,
and structures the task [20].
Stone [21] identifies four aspects to scaffolding. First, scaffolding involves the recruitment
of a learner to typically valued activity. Second, the expert’s support is not fixed but titrated in
response to the learner’s changing capabilities over time. Third, strategies of scaffolding can
vary widely given their contingency to whatever should arise. Fourth, support is gradually
removed resulting in a transfer of responsibility from expert to learner.
The concept of scaffolding has proved useful beyond child development [22], being applied
to adults who have learning disabilities [21], dementia [23], cognitive impairment [24], and
aphasia [25]. The concept of scaffolding, in these domains, focuses attention on the way in
which interaction partners provide help that is relational, temporary, and contextually
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calibrated [4]. However, the idea of removing the scaffolding, enabling independent task per-
formance, is often inapplicable when conditions are chronic or deteriorating.
Research on aphasia has identified a broad range of scaffolding strategies used by commu-
nication partners, including: Checking agreement, repetition and demonstrating understand-
ing [10]; speaking-for, steering the interaction and correcting [26]; reformulating, offering
options, praising and using assistive technology [27]; controlling the task or environment and
giving simple directives [28]; third-turn repair [29]; responding to problematic talk [30]; read-
ing aloud and spelling-out [31]; prompting [32]; and pointing and gesturing [33]. Despite the
preponderance of scaffolding strategies that have been identified, there has been little system-
atic examination of the extent to which PAs use these strategies, the efficacy of the strategies,
what effects they have on dominance within the relationship, and the extent to which these
strategies are requested or resisted.
Overview of research: Examining the effects of scaffolding
We take a sociocultural approach [34] that assumes a perspectival social world [35]. Meaning
arises from the situated and historical interaction of different perspectives [36–37]. Emergent
meanings are only partially shared [38]; each action or utterance within the social interaction
affords multiple, often unexpected, interpretations in the social world [39–40]. Accordingly,
our aim is to examine not only the practical efficacy of scaffolding communication, but also its
unintended effects.
Our methodological strategy has been to draw freely on any qualitative and quantitative
techniques that can advance the analysis. While we have found conversation analysis proce-
dures useful in conceptualising and transcribing the interactions, we are not intending to
report a conversation analysis study. Specifically, while we agree that it is problematic to specu-
late about motivations within an interaction sequence, we nevertheless assume (in line with
our sociocultural approach) that motivations do exist and that they are an important compo-
nent of the concept of helping.
The data we analyse are problem-solving conversations between PAs and their main CPs.
Three analyses are reported, examining, in turn, the effects of scaffolding on enabling commu-
nication, on dominance, and on the relationship.
Analysis 1 asks: What scaffolding strategies are evident, who uses them, and are they effec-
tive? Scaffolding research has focused almost exclusively on ‘the expert,’ glossing over the ‘the
learner’s’ capacity for agency [21]. PAs are active in scaffolding, using gestures [27,33] and
assistive technology [41]. Moreover, PAs try to guide CP scaffolding, requesting CPs to repeat,
slow down, wait, or read aloud [10,42]. A second limitation of the scaffolding literature, that
we address, is the assumption that scaffolding is effective when evidence is emerging to suggest
that it is not always effective [43].
Analysis 2 asks: What effects does scaffolding have on dominance within conversations?
While the literature has generally been enthusiastic about the potential of CP scaffolding, one
study has observed that CPs tend to dominate conversations, holding the floor, and acting as
primary speaker [44], while PAs have trouble making initiations [45].
Analysis 3 asks: Why do people with aphasia both resist and request scaffolding? Extensive
literature demonstrates a widespread reluctance to receive help [46]: People with depression
fear stigmatization [47]; people in organisations worry about appearing incompetent [48]; and
children in school want to avoid looking dumb [49]. In relation to aphasia, CPs’ attempts at
speaking-for are often resisted [26]. Our third analysis explores the idea of a tension between
the potential of scaffolding to simultaneously facilitate communication and make salient
disability.
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Methodology
Twenty-four PA-CP dyads were recruited through a Speech and Language Therapy Service
within the NHS. An NHS Research Ethics Committee reviewed the project, procedures, and
documents and approved the study (07/S0501/73). Participation was voluntary and no remu-
neration provided. Participants provided written consent for participating in the study, being
video recorded, and allowing us to use the verbal and visual data in publications. Four dyads
dropped out for health reasons. Among the 20 dyads that completed participation, the average
number of months since onset was 30 and the aetiology was stroke (n= 18) and traumatic
brain injury (n= 2). Speech and language therapists rated participants’ aphasia as: 5 mild, 2
mild/moderate, 6 moderate, and 7 severe; 11 were mainly expressive and 9 expressive and
receptive. Fifteen PAs had concomitant hemiplegia and/or dyspraxia. The PAs (11 male, 9
female) had an average age of 59. The CPs (13 female, 7 male) were partners (n= 16), adult
children (n= 2), and parents (n= 2). All dyads were living together.
Piloting with unstructured conversation showed dyads falling into routine and non-chal-
lenging exchanges that were non-comparable. Accordingly, we developed an artificial task
designed to be challenging enough to elicit scaffolding and equally unfamiliar to all dyads. We
created the ‘inviting a friend or relative for a meal’ task as a culturally-familiar activity judged
appropriate for the population. The task (Fig 1) was introduced as a “joint activity.” There
was one A4 sheet with the task and participants were asked to write answers directly onto the
sheet.
The task was conducted during home visits by a speech and language therapist, with a first
visit explaining the study and consent procedure, and a second visit to gather the data. Home
visits ensured the talk elicited occurred in a natural setting even if it would not have occurred
without the researchers’ intervention [50].
Fig 1. The joint task.
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All 20 conversations were video recorded. The mean duration was 7:02 minutes (range 2:19
minutes to 16:29 minutes). Verbal data (2 hours 34 minutes) were transcribed using the con-
versation analytic conventions set out by Gail Jefferson [51] with nonverbal data added where
salient.
Three analyses were conducted corresponding to the three research questions. The first
analysis began trying to code the data according to the scaffolding strategies identified in the
section ‘Scaffolding Communication.’ These were then refined to have clearer textual operatio-
nalization and minimal overlap (see Table 1 for coding categories). Scaffolding efficacy was
assessed, where possible, by examining whether it was accepted by the recipient and/or
whether it resulted in a communication accepted by the initiator. The second analysis followed
the procedure of Initiation-Response Analysis [52] (see Fig 2 for coding categories). The third
analysis coded instances of both requesting help and resisting help, along with the more gen-
eral indicators of resistance, namely, interrupting and disagreeing (see Analysis 3 for coding
categories). Three excerpts, selected because they had multiple illustrations of the coding cate-
gories, are presented and analysed. This final analysis then used Peirce’s [53] ideas about para-
doxes to interpret the observed tension between requesting and resisting help.
To assess reliability, 20% of the data was double coded by an independent MSc graduate.
Applying a Cohen’s kappa, the interrater agreement was found to be moderate for the analysis
of scaffolding strategies (k= 0.527), repair initiations (k= 0.580), Initiation-Response Analysis
Table 1. Usage and efficacy of scaffolding strategies.
Scaffolding strategy CP (n) PA (n) CP/PA
†
(%)
CP %
††
Efficacy
PA %
Efficacy
Checking agreement: often a question, sometimes reformulating or other-repetition 79 1 99/1 84 100
Speaking-for: completing or ’filling out’ the interlocutor’s inadequate adjacent turn 40 1 98/2 85 100
Reformulating: modifications of original that reduce complexity, increase redundancy, or
chunk elements
164 11 94/6 57 91
Praising: any positive verbal feedback, such as ’that’s it good’ or ’right’ 16 1 94/6 50 100
Repair initiations: utterances treating as problematic a second turn misunderstanding of a
first turn
89 12 88/12 67 67
Offering options: any suggestion of single or multiple possible solutions to the task
questions
147 25 85/15 70 92
Correcting: utterances that correct an aspect of the interlocutor’s preceding utterance or
action
12 2 86/14 50 0
Steering: moving to the next question or changing topic forgoing any mutually agreed
transition
228 57 80/20 68 84
Reading aloud: loud-reading without amendment to the original task text 120 32 79/21 59 81
Prompting: seeking to elicit a response, e.g. ’who’ and ’when’ questions, excluding offering
options
165 50 78/22 64 90
Sounding-out: loud letter-by-letter spelling out of problematic lexical items 22 7 76/24 73 86
Directing: directives that issue an order, e.g., ’just read it from the beginning’ 16 9 64/36 56 89
Other-repetition: unmodified repetition of an adjacent lexical item or clause 38 35 52/48 * *
Demonstrating understanding: engagement with adjacent turn, often prefaced with ‘so’ 43 58 43/57 * *
Assistive technology: using an artifact for communication, e.g., writing-out, using symbol
cards
9 12 43/57 67 50
Gesturing: nonverbal communication e.g., pointing, nodding, head-shaking, shrugging, and
tracing
122 215 36/64 * *
†
Percentage of all instances of the scaffolding type performed by CP vs PA
††
Percentage of instances of the scaffolding type that were effective
*Efficacy could not be assessed because the scaffolding has indeterminate responses.
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(k= 0.508), and instances of resisting and requesting help (k= 0.458). Coding of repair initia-
tions was done separately to other scaffolding strategies because it involved a greater unit of
analysis (three turns-at-talk).
Analysis 1: Usage and efficacy of scaffolding strategies
Table 1 shows that CPs and PAs engaged in scaffolding 1,310 (M= 65.5, range 29 to 149,
SD = 33.08) and 528 (M= 26.4, range 7 to 67, SD = 16.2) times respectively. Table 1 collapses
CPs and PAs into groups, and it is important to note that there was considerable variability in
how frequently the strategies were used between dyads (see data in S1 File). Specifically, while
most CP used all strategies (although 3 CP never read aloud, 2 CPs never initiated a repair,
and 2 CPs never gestured) many PAs did not use particular strategies (17 PAs never used an
assistive technology and 13 PAs never read aloud, however, only 1 PA did not gesture). This
variability likely reflects the nature and extent of the aphasia [16], participants’ attitudes
towards strategies [54], the particularities of the dyad’s relationship and trial and error experi-
ence with the strategies. We will consider the strategies used by CPs and PAs in turn.
Scaffolding by communication partners (CPs)
Starting with the CPs, it is important to note that few strategies were used by all CPs. This
likely indicates that CPs, on the basis of their familiarity with the PAs, were making selective
use of strategies [17,54]. The most common scaffolding strategies used were steering, reformu-
lating, prompting, offering options, gesturing, reading aloud, repairing, and checking agree-
ment. Less frequently, there were also episodes of teacher-like correcting and praising. We will
consider these strategies in turn.
‘Steering’ refers to attempts to ensure the activity’s optimal progression. These turns would
often use phrases such as “right,” “alright” and “so then” as the CP took control of the task and
moved the dyad from one question to the next. CPs’ control of the progression through the
task compares to how dominant parties in institutional settings (e.g., doctors, interviewers,
judges) utilise their greater allowance of discursive resources to direct the other’s contributions
[55]. Such control implies a lower status for the PA [56].
Fig 2. Mean frequency of utterance strength (with standard deviations).
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‘Reformulating’ entailed simplification either in real time (i.e., whilst reading aloud) or ex
post facto as part of a repair. Reformulation was dominated by CPs (93.71%) and had poor effi-
cacy (56.71%) relative to the other efficacy scores. While some substantial chunking of commu-
nication was evident, the majority of instances entailed minimal changes to the syntactic
structure of the task questions. For example, CPs tended to exchange the impersonal nouns
and deictic references with more proximal ones. While apparently well-intended and occasion-
ally even an expression of solidarity (e.g., “you” for “we") [57], such minimal reformulation
can imply that the PA’s marker of trouble (e.g., “um”) had been a product of inattentiveness or
even idleness [58].
‘Prompting’ usually entailed CPs asking questions about “who,” “when,” “what” and “how”
to solicit answers. Problematically, the person who does the prompting significantly deter-
mines the way in which an interaction can sensibly proceed [59–60]. CPs tended to prompt to
help the PA arrive at a solution without providing it directly. Their implicit assumption might
have been that their role was not to provide answers but, instead, to facilitate the PA to provide
the answers.
‘Offering options’ entailed introducing ideas which the other presumably would or could
not have summoned alone. Most frequently, the options offered were names of people to
invite, days when the meal could be scheduled, and possible dishes (e.g., “chicken?” and “what
about stir-fry?”). At the outset, a distinction must be drawn between those scaffolds which con-
sisted of two or more options and those which consisted of one. The latter stood for 89.32% of
effective offerings. While such single options give less room for PAs to exercise choice, these
yes/no interrogatives enabled PAs to express their position with “yes” to close topics and “no”
to keep topics open [61]. Offering multiple options was more challenging given it required
PAs repeat one of the options named. PAs would regularly agree instead (e.g., “yes”), forcing
the CP to offer each option again singly. As with reading aloud and sounding-out, offering
either single or multiple options, especially when they failed and had to be repeated, made
salient the communication difficulty.
‘Gesturing’ was most prevalent among PAs (see below), but, when used by CPs it was usu-
ally to unobtrusively augment communication whilst speaking. CPs, for example, would ges-
ture while reading “bringing the food out,” “putting it on the table” and it getting “knocked
over.” Due to this augmentative function of gesturing it was not possible to evaluate efficacy;
with the benefit that it likely improved communication without ever resulting in overt failure.
‘Reading aloud’ refers to any reading of the task-text verbatim (without reformulation) that
was sufficiently loud to be communicative. Although widespread among CPs, it was relatively
ineffective (59.17%), possibly due to the task-text’s low redundancy. CPs’ persistence likely
sought to spare PAs struggling to read the text. Nevertheless, reading aloud can imply that the
PA needed to be read aloud to, echoing the genre of asymmetrical interaction used with young
children in classrooms [62].
‘Repair initiations’ were carried out to restore misunderstandings, usually following prob-
lematic demonstrations of understanding, repetitions or responses. While repairs usually fol-
low misunderstandings [63], in our data they often followed non-understandings. A typical
example is a CP offering two food options and the PA responding “yes,” leading the CP to reit-
erate the options more slowly. Having such non-understanding made salient risks positioning
the PA as conversationally incompetent. Moreover, as reported elsewhere [64], the dyads often
took more than three turns to re-establish mutual understanding, thus adding salience to the
communication failure.
‘Checking agreement’ assessed whether participants’ partially shared intersubjectivity
had endured the most recent sequence of turns. Although explicit checking is rare in typical
conversation [65], it occurred relatively frequently in our data and was almost completely
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dominated by CPs. Arguably, by implication of doing the checking, this strategy consolidated
CPs’ authoritative role within the task [66]. These yes/no questions were particularly effective
(83.54%). However, it should be noted that agreement is not necessarily understanding [65].
In fact, agreeing is a robust way of feigning understanding when there is a desire to avoid
embarrassment, support a respected interlocutor or close an unstimulating topic given that it
requires no proof of understanding be provided [67].
CPs also dominated ‘speaking for,’ ‘praising,’ ‘correcting,’ and ‘directing.’ While each of
these strategies was relatively infrequently used, together, they suggest a pattern of interaction
that is very asymmetrical. Speaking-for [26], correcting [68], and directing [69] evidently
claim an entitlement over the recipient. But, even paying compliments, especially between
adults, can reproduce and solidify a perceived asymmetry in competence [70]. Phrases such as
“look how you spelled fish” (correcting), “no, try again” (directing) and “right, well done”
(praising) suggest a genre of interaction more closely associated with parent-child or teacher-
child interactions than with adult-adult interaction.
Scaffolding by persons with aphasia (PAs)
Turning to PAs it is important to note that collectively they used all scaffolding strategies, but,
many were used very infrequently, and no strategy was used by all PAs. Again, this diversity
underscores the fact that strategies are selected and tailored according to the particularities of
the aphasia, relationship, and history of interaction [17]. The majority of their scaffolding was
gesturing, demonstrating understanding, steering the interaction, and prompting. Although
PAs engaged in less scaffolding than CPs, their efficacy was higher (83.18% vs 66.21%), per-
haps indicating a high degree of responsiveness of CPs to scaffolding attempts.
‘Gesturing’ accounted for 40.72% of all PA scaffolding. It was mainly used to supplement
verbal utterances and facilitate CP comprehension of information and feelings nonverbally
[71]. PAs’ gestures were adaptive and rich. For example, when the word ‘drink’ escaped a PA,
he motioned putting a glass to his lips. Common gestures included pointing to the person who
would perform a task or pointing to a word on the task sheet, as an indirect attempt to recruit
help [72].
‘Demonstrating understanding’ refers to rephrasing of the preceding turn so as to demon-
strate comprehension and, as such, is more robust than either checking agreement or other-
repetition for establishing intersubjectivity. Overt demonstrations are exceedingly rare in ordi-
nary conversation [73] and none were found in the data. Rather, there were what may be called
‘tacit claims of recognition’ ([73]: p.257). By virtue of their tacitness, these claims fulfilled the
preference that intersubjectivity be verified without unnecessary interruption to a conversa-
tion’s progressivity [73]. Demonstrating understanding let PA independently close sequences
and preface next-position matter by showing sufficient interest in the other’s preceding turn
[74–75].
Although ‘steering’ was dominated by CPs (see above), 14 of the PAs also engaged in steer-
ing. These were often assertive interruptions, sometimes resistive attempts to claim control
over some aspect of the task, often accompanied by taking the task sheet, and trying to read
the questions or write an answer. For example, in one dyad the conversation began with the
CP taking the task sheet saying “okay” (i.e., clearly steering the task), and then the PA saying
“it says who will we invite,” thus making a claim to steer the task.
Similarly, although ‘prompting’ was dominated by CPs, it is also a strategy that 19 of the
PA engaged in. However, while CPs tended to prompt to help the PA arrive at an answer
without providing it directly, PAs tended to prompt to convey non-understanding or to
check their understanding. Thus, for example, PAs would suggest answers (i.e., “chicken?”)
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or interpretations of the task-sheet (i.e., “go shopping?”) as tentative suggestions, almost
checks of comprehension, and thus inviting correction. This recurring difference in how
prompting was used bolstered participants’ epistemic asymmetry at the expense of the PA
[66].
Summary of the first analysis
The first analysis has three main findings. First, scaffolding is variable but two-sided; every
strategy is used by at least some CPs and PAs. Second, scaffolding is generally effective. Third,
CPs engage in scaffolding 2.48 times as frequently as PAs. These findings beg the question:
Might CPs’ frequent scaffolding interventions, especially their use of strategies reminiscent of
teaching young children and frequent steering, lead to asymmetrical domination within the
conversations?
Analysis 2: Interaction dominance
A simplistic way to assess communication dominance is to compare the number of words spo-
ken by each party. Taking this approach to our data appears to show imbalance, with CPs
speaking on average 412.4 words (range 186 words to 656 words; SD = 133.74 words) and PAs
speaking on average 156.05 words (range 27 to 323; SD = 101.71 words). It also shows hetero-
geneity, as 5 PAs spoke less than 50 words and 7 spoke more than 200 (see data in S1 File).
But, this overall imbalance could be a by-product of the fact that PAs often find speech produc-
tion difficult. Accordingly, we focus on what Linell, Gustavsson and Juvonen [52] term ‘inter-
actional dominance,’ that is, one person managing to direct and control the other party’s
actions and utterances whilst also avoiding being directed and controlled.
Linell and colleagues [52] developed the Initiation-Response Analysis to assess interaction
dominance, it entails assigning each turn in a verbal interaction to one of 18 mutually exclusive
and exhaustive categories. Turns are distinguished in terms of responsiveness to previous
turns, initiation of something new, strength or assertiveness, adequacy, scope, focality, and
whether they link to the previous utterances of self or other. Each of the 18 codes is assigned a
turn strength score on a 6-point ordinal scale, ranging from the weak and minimally respon-
sive with no initiation (1 point) to non-responsive and strongly initiating (6 points).
Fig 2 shows the interaction dominance distribution, grouped by overall strength score,
revealing that PAs were mainly responsive while CPs were making much more initiation.
While the modal turn for PAs was the adequate minimal response, linking to the preceding
turn (scored 2), for CPs the modal turn was a strong initiative, ignoring all preceding turns
(scored 6).
The median utterance strength scores, termed the ‘IR index,’ for CPs was 3.58 (range 3 to
4.5 points, SD = 0.52) and for PAs was 2.08 (range 1 to 3 points, SD = 0.41). The difference
between these IR indices, termed the ‘IR difference,’ was 1.5. Linell, Gustavsson and Juvonen
([52]: p.433) report IR differences for diverse interactions, ranging from informal conversation
between friends (IR difference = 0.07) to a court trial (IR difference = 1.97). Fig 3 compares
the IR difference that we found with some of their data.
To explore the source of the large dominance asymmetry we used the IR methodology to
calculate coefficients for balance, obliqueness, solicitation, and fragmentation (Table 2). The
balance-coefficient is the percentage of turns that responded focally to a preceding turn and
which also contained some initiation. It indicates how conversation-like the dialogue was. The
CP and PA balance-coefficients of 10.46% and 10.05% do suggest a good deal of balanced talk.
Indeed, these balance-coefficients are comparable to those reported for other atypical dyads
[76–77].
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The obliqueness-coefficient reveals non-cooperation between participants; it is the percent-
age of initiatives which ignored, challenged or commented upon their preceding turns. The
obliqueness-coefficient for CPs was much higher than for PAs (16.42% vs 3.14%). This shows
that CPs sometimes ignored or criticized their partners, partially accounting for the IR differ-
ence. An example of a weak initiative with a challenge, is after the PA tried to write “go to cafe
´
for meal” and the CP said “well, that’s not ‘meal’ you’ve written there, it’s ‘menu’ you’ve writ-
ten there.”
The solicitation-coefficient is the percentage of turns which demanded a response. Not only
was soliciting common, but, CPs did it over ten times more frequently (38.58% vs. 3.14%),
thus making a significant contribution to the IR difference. The CP utterances coded as strong
initiations soliciting a response included: “Do you want me to phone them?” “Would you like
to put it in some kind of sauce?” “Right, who are you inviting?” and “Right, what would you
do?” Such instances of solicitation suggest that CPs oriented to the activity as one of trying to
get their partner with aphasia to talk. Indeed, it is as if the CPs were siding with the task, and
taking responsibility for administering the task to the PA.
Finally, the fragmentation-coefficient is the percentage of non-locally linked initiatives
which did not pick up on an adjacent turn but which linked to an earlier one, therein weaken-
ing the dialogue’s coherent flow. Such turns constituted 34.42% of CP turns and just 11.68% of
PA’s. That is, CPs often treated their partner’s contributions as off-topic or inadequate. This
even occurred in some instances when the PA contributions were entirely on-topic. For exam-
ple, one PA had just finished reading the first question, about who to invite, and said quickly
and clearly “Alex.” The CP then said: “Right, who would you invite, first name only?” thus
ignoring the PA’s turn.
Summarising the initiation-response analysis, we can say that although participants were
asked to treat the task as a “joint activity,” many CPs positioned themselves as soliciting
responses and coordinating the task. Their initiatives were not asking for information but try-
ing to elicit a response that would demonstrate the PA’s understanding of the locally-relevant
Fig 3. CP-PA initiation response difference compared to other interaction types (data from ([43]:
p.433)).
https://doi.org/10.1371/journal.pone.0180708.g003
Table 2. Initiation-response indices and coefficients of interactional asymmetry.
IR-index Balance Obliqueness Solicitation Fragmentation
Communication partner 3.58 10.46% 16.42% 38.58% 34.42%
Person with aphasia 2.08 10.05% 3.14% 3.14% 11.68%
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matter [77]. Indeed, when these initiating/responding roles reversed, CPs would usually try to
turn the job of answering back to their partner. Most striking, however, is that despite solicit-
ing responses, CPs sometimes ignored the responses they received or treated them as insuffi-
cient (indicated by the high fragmentation-coefficient).
Analysis 3: Resisting and requesting help
The third analysis examined the effect of scaffolding on PAs. Specifically, how do PAs respond
to both the effectiveness of scaffolding and the potential interaction domination that it can
result in? We coded both explicit requests for help and explicit resisting help, along with more
implicit indicators of resistance, namely interrupting and disagreeing. Table 3 summarises our
findings, showing that although PAs often request help, they also frequently resist it.
‘Requesting help’ included any verbal or nonverbal solicitation of support. It was done almost
exclusively by PAs (97.78%; 6 PAs never requested help). The one time a CP requested help was
inadvertent; he asked himself how to spell “substitute” only to have his partner provide the cor-
rect spelling. The number of requests is low considering the frequency of scaffolding observed
(45 vs. 1,838). This suggests a high degree of coordination in which scaffolding is often being
provided (and accepted) without PA having to explicitly request it. While requesting help posi-
tions the PA in control of what scaffolding they receive and when, too many such requests
would risk positioning them as dependant and incapable. Arguably, CPs are thus trying to pre-
empt requests by responding to what Kendrick and Drew [72] term ‘projectable troubles.’
‘Resisting help’ included express refusals of help, hushing to silence it, and head shaking.
Some resistance was subtler, for example one PA simply ignored her partner’s help in spell-
ing “meal,” opting instead to write “food.” The majority of resisting help was done by PA
(72%; 8 PAs never resisted help), but, taking account of how often scaffolding was offered
(1,310 vs. 528 times) reveals that both PAs and CPs were equally likely to openly resist help
when it was offered (2.72% vs 2.64%). However, focusing only on explicit resistance underes-
timates the extent of PA resistance which also manifested indirectly through disagreements
and interruptions.
‘Disagreeing’ comprised of adjacently positioned action-opposition turns. The typical for-
mat of disagreeing-thru-agreement was often replaced with participants’ unconcealed orienta-
tion to ‘the prior turn as arguable’ ([78]: p.23). Whilst 71.43% of caregiver ‘disagreeing’ was
modulated by, for example, the preface “well” [79], its interpolation by laugh particles [80], or
weak modalization (e.g., “maybe” and “I think”) [81] to soften and work up its reluctance, only
half of PAs did the same. That is to say, 50% of PAs’ disagreeing utterances were unapologetic
and aggravated [78] for directly stating “no” or declaring the exact opposite. Thus, not only
were PAs much more likely to disagree (69.57% vs 30.43%), but the way they disagreed was
also much more vociferous and direct, arguably positioning themselves as independent. How-
ever, again, we found variability, as 5 PAs never disagreed.
Table 3. Indicators of request or resistance.
Indicator CP
(n)
PA
(n)
CP/PA
(%)
Requesting help: Explicit verbal or nonverbal request for help, excluded
creating opportunities for help
1 44 2/98
Resisting help: Direct verbal or nonverbal refusal of help provided in the
previous turn
14 36 28/72
Disagreeing: Explicit disagreement, does not include suggesting alternative 14 32 30/70
Interrupting: Overlapping speech, excluding nonverbal communication 82 133 38/62
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Excerpt 1 illustrates disagreeing. It begins after the mother with aphasia and her daughter
have read the task question (“what food will you prepare?”). The daughter prompts her mother
“what d’you reckon?” (line 01) and the mother tries to say “spaghetti bolognese” (lines 02–03).
After some shared laughter about this, with the daughter being particularly animated, and
leaning into her mother while looking at her (lines 03–04, Fig 4a), the daughter turns to the
researcher to ask, in a joking manner “h(h)ave you set aside a lot of ti(h)me "for "her?”. The
reason, she states, is because “w(h)e’re a special case” (lines 06–09). The use of “we” is ostensi-
bly an attempt to share ownership over the problem she has just highlighted (i.e. taking extra
time). However, these turns clearly draw attention to the mothers aphasia: it is directed at the
researcher and pertains to the mother’s prior attempt to say “spaghetti.” The mother, then,
with apparent concentration clearly enunciates the problematic phrase “Spaghetti>bolog"ne
(h)se!” (lines 11–12). The exclamatory quality as well as the rising intonation with which it is
produced both suggest the mother’s relief at having clearly articulated the phrase. When her
daughter then turns to her asking whether she would like to spell it out (line 15, Fig 4b), the
mother blurts out “n(h)o!”. The daughter takes the sheet and begins to write while, in passing,
suggesting that their guest might not like mince (lines 20–25). Throughout the preceding turns
the mother’s impairment has been made salient. Now her judgement about what food to cook
for her chosen guest is being called into question in front of the researcher. She openly dis-
agrees with her daughter twice (lines 22–25, Fig 4c).
(1) Mother(PA) disagreeingwithdaughter(CP) (03:24)
01 CP whatd'you reckon? Prompting
02 PA em:(1.8) spa::(1.2)I-I knowthat heh(0.9)
03 skabetti[heh hehheh!(Fig 4a)
04 CP [heh heh!(Fig4a)
05 (0.7)
06 CP h(h)aveyou ((lookingatthe researcher))set
07 aside a lot of ti(h)me "for"her? (0.8)
08 w(h)e're a special case "h(h)erew(h)e'reheh
09 heh!
10 (1.2)
11 PA <whatfood willyou make? (0.5)Spaghetti> Reading aloud
12 bolog"ne(h)se![hehheh heh
13 CP [hehheh hehheh!
14 (0.3)
15 CP d(h)oyou wantto writeit?(Fig 4b) Prompting
16 PA n(h)o![heh hehheh!
17 CP [hehheh
18 ((CPtakes sheetandwrites answer))
19 (1.1)
20 CP °I don't howmuch helikesmince mum°
21 (1.0)
22 PA wellhe hadit herebefo:re(Fig 4c) Disagreeing
23 CP °no:I thinkhe wasbeingpolite° [heh Disagreeing
24 PA [well Interrupting
25 #I::'llspeak to"him heh heh! Disagreeing
26 CP .hhright whowill prepare it? Steering
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‘Interrupting’ was defined as the annexation of one person’s speaking rights by another
[78,82]. Interrupting may be affiliative or disaffiliative with the other’s stance [83], but
always forces abandonment so as to fulfil the conversational norm of minimal overlap [84].
As with disagreement, interrupting often followed a sequence in which the PA was negatively
positioned.
Excerpt 2 illustrates interrupting. It begins with a wife leaning into her husband and writ-
ing their agreed-upon answer that she would set the table (lines 01–02, Fig 5a). After writing,
she turns to her husband, looking him in the eyes, and rationalises the agreement, telling her
husband with aphasia he would “probably .hhh (0.6) forget” (lines 04–05, Fig 5b). The hus-
band interrupts (line 06), suggesting she could also do the dishes. The CP abandons her pre-
vious turn and disagrees in a friendly way, but the PA interrupts, again, insisting that she
will do the dishes. This creates some nervous laughter, the bodies briefly separate, and the
husband rubs his head (lines 11–13, Fig 5c). Arguably, the husband’s interruptive insistence
is a response to the wife’s steering of the interaction and the remark that he would probably
“forget.”
(2) Husband(PA) interruptingwife(CP)twice (04:45)
01 CP °so I'lldo thetable°((CP writes Demonstrating
understanding
02 answer))(Fig 5a)
03 (0.9)
04 CP causeyou wouldprobably(Fig 5b)
05 .hhh(0.6) forget[what
06 PA [dothe dishes Interrupting;
Steering
07 (0.3)
08 CP uh no you((touches PA's arm)) Disagreeing;
Gesturing
09 [do=
10 PA [you c'dothe dishes Disagreeing;
Interrupting
11 CP = the dishes[heh hehhehheh!
12 PA [hehheh heh((CP’s
13 bodysways awayfromPA)) (Fig5c)
Fig 4. a-c. Anonymised video stills from excerpt 1 (CP is on left).
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Taking stock of the analysis so far, it is clear that there is a knot at the heart of scaffolding: It
is generally effective, but sometimes fails; it is widely accepted, but often creates domination; it
is requested but also often openly resisted. In order to explore these contradictory effects we
introduce Charles Saunders Peirce’s theory of paradoxes.
According to Peirce [53] a sign, or representational meaning, arises out of a tripartite
relation between an object, the sign, and an interpretant. The object is the thing or state of
affairs being represented. The sign is the actual representation; either an icon, index or sym-
bol. The interpretant is the semiotic system that interprets the relation between the sign and
its object. Most other theories of meaning rest upon a binary between the sign and the signi-
fied [85]. Peirce’s theory is distinctive because signs do not signify anything except to an
interpretant. Consequently, the meaning of any sign is as diverse as the interpretants that are
brought to it.
Consider Excerpts 1 and 2. Arguably, what is being resisted in these excerpts is a shift from
interpreting the interaction as progress in a joint activity to interpreting the interaction in
terms of the PA’s disability. The utterances that refer to the PA as “a special case” and someone
who will “forget” shift the focus from the task to the disability. Interpreting the interactions in
terms of the PA’s disability is an ever-present option, but, it is not always salient. The question
is, what actions and utterances might make this interpretant salient? While clearly, referring to
the PA as a “special case” or likely to “forget” makes this interpretant salient, we also argue that
the mere act of helping can index this interpretant.
Signs in context usually have multiple potential interpretants. Choosing to invite Bob for a
meal might be interpreted as both Bob being a friend and living nearby. Choosing to cook
chicken might be interpreted as both liking chicken and having experience cooking it. All
these interpretations can co-exist without contradiction. However, sometimes the salient inter-
pretants are contradictory, and then, Peirce argues, a paradox arises.
Peirce [86] considers the classic liar paradox, namely an utterance such as ‘this statement is
false’ [87]. While normally such statements are considered meaningless, Peirce [86] argues
that ‘far from being meaningless . . . it means two irreconcilable things’ [p.282]. First there is
the interpretant relating to the propositional content. Second, there is the interpretant relating
to the act of making a statement, the assumption being that what is said is intelligible and true.
The paradox arises because the propositional content conflicts with the implicit assumption
about intelligibility and truth. It follows that the paradox dissolves if one changes the second
interpretant to: ‘What I say is un-intelligible and false.’ Thus while others have tried to solve
the liar paradox in terms of hierarchical categories [88], Peirce solves the paradox using a the-
ory of communication with multiple and conflicting interpretations. For example, statements
such as ‘the apple is big and small’ are contradictory from the standpoint of classical logic, but,
from Peirce’s point of view such statements are possible provided one acknowledges multiple
interpretants (such as that of an ant and a human).
Fig 5. a-c. Anonymised video stills from excerpt 2 (CP is on left).
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We propose that scaffolding may produce paradoxical effects, in exactly the sense
described by Peirce. Consider the utterance ‘let me help you.’ The propositional content
appeals to an interpretant that frames the activity as helpful. However, from the standpoint
of what it means to receive help, the utterance could imply incompetence and dependency;
in short, helplessness. This is different from referring to a PA as a “special case” or someone
who will “forget” because those statements are not paradoxical; they do not appeal to contra-
dictory interpretants. Helping activities, on the other hand, can be simultaneously empower-
ing and disempowering.
Excerpt 3 illustrates requesting and resisting help, and thus the paradoxical effects of
scaffolding. It is from a married couple in which the wife has aphasia. The excerpt follows
on from a sequence with ‘test’ questions [89] in which the husband had been teaching his
wife how to spell “fish”–scaffolding that she resisted and then accepted. The excerpt begins
with CP watching over PA’s shoulder as she is writing (Fig 6a) and then pointing to PA’s
misspelling of “both” as “boht” with a pen (lines 01–02, Fig 6b). PA interrupts first with a
glaring look and then, while shaking her head, an explicit resistance: “Don’t correct me . . .
don’t want to be” (lines 04–07, Fig 6c). CP, ignoring this resistance, demonstrates the cor-
rect spelling and PA proceeds to correct her spelling with CP again looking over her shoul-
der. As she writes CP explains the mistake and praises her efforts (lines 12–13). PA, while
accepting the help, simultaneously resists by saying “shhh!” (line 14). CP then reads the text
aloud slowly, and this scaffolding is not requested or resisted (lines 18–25). However, when
CP tries to solicit a response (lines 31–33), PA interrupts and resists, again insisting
(“shhh”) on reading herself (line 32). But, then, in the subsequent turn (lines 34–35), PA
gets stuck, and uses her pen to point to a word on the page, indicating a nonverbal request
for CP to enunciate the word (lines 36–37, Fig 6d). CP obliges and confirms her comprehen-
sion (lines 39–40). PA continues reading, but gets stuck again, and nonverbally requests
help once more (lines 47–49). This time, however, CP directs her to “just read” from the
beginning (lines 54–55), and PA in an implicit act of resistance begins reading further on in
the text. CP, evidently exasperated that his offer of help has been rejected again, looks away
and drops his hands in a gesture of despondency (line 65, Fig 6e). PA then requests and
receives confirmation of her comprehension of “gets” (lines 70–71) and “knocked o(h)ver”
(lines 73–75). The excerpt ends with the couple reminiscing about a similar event that
occurred before PA had a stroke, both are laughing (especially PA) and her body leans in to
touch his (line 82, Fig 6f).
(3) Wife(PA) accepting,requestingandresisting help (11:06)
01 CP rightsee whatyou'vedone again? Correcting
02 ((pointswith pen))(Fig6b) Gesturing
03 (1.1)[your writing
04 PA [don't correctme Interrupting
05 CP holdon
06 PA don'twant tobe ((shakeshead; Resisting help;
Gesturing
07 pointsat questionsheet))(Fig 6c)
08 CP °( ) ° ((CP takes question sheet
09 andwrites; PAtakespaper and
10 correctsown text;CPlooks over
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11 PA'sshoulder asPAwrites))
12 CP °rightyeh t-comes before theh- Sounding-out
13 (.)same asthe s-(.)
14 PA shhh! Resistinghelp
15 CP beforethe h-in fish°.h((PA
16 glaresat CPbeforecontinuing to
17 write))
18 CP ((PAholds uppaper and CPreads))
19 >onceyou're satisfied<(2.1) Readingaloud
20 imaginethat youha:ve(1.3) almost
21 finishedpreparing(2.7) andyour
22 friendor relativeisexpected to
23 arrivein tenminutes.hh (3.1)but
24 "then((points withpen))as you're
25 bringingthe food(1.8)[it gets=
26 PA [( ) Interrupting
27 CP = knocked over
28 (4.3)
29 PA °right°((studiespaper)) Demonstrating
understanding
30 (0.8)
31 CP rightwell [ifBob'sarriving in= Reformulating
32 PA [( ) shhh Interrupting;
Resistinghelp
33 CP = ten minutes what do youdo?
34 PA ((readsunder breathtoself))
35 °asyou are°(7.2) () (3.7)
36 ((PApoints towordon question Requestinghelp;
Gesturing
37 sheet for CP to see)) (Fig6d)
38 (7.5)
39 CP bring
40 PA °bring°((continuesto readunder
41 breath toself))(1.0) ( )
42 CP °mhm°
43 (5.1)
44 CP °um°((CP pointsat page withpen)) Gesturing
45 (1.7)
46 PA But"then "a:s(4.8) you (0.5) Requestinghelp
47 "bring:(0.3) thefood(12.4) I
48 don'tknow thisone((PA points Gesturing
49 onquestion sheet))
50 (1.0)
51 CP .hh
52 (0.3)
53 PA [( )
54 CP [>just-justreadit< (0.3)>from Directing;
Interrupting
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55 but-<(0.3) >readjustread<
56 (3.4)
57 ((PApoints atquestionsheet Requestinghelp;
Gesturing
58 withpen))
59 CP >readit outloud<
60 (1.6)
61 PA butyou started°( ) ° Disagreeing
62 ((PApoints atquestionsheet;
63 PAbegins readinglaterin the Resistinghelp
64 sentence))
65 CP hhhh((looks away,dropshands))
66 (Fig6e) (3.0)you can ifyou
67 [wantedto
68 PA [( ) Interrupting
69 PA ((PA readsto self))it(0.4) Readingaloud
70 gets(0.6)
71 CP mhm
72 (0.3)
73 PA knockedo(h)ver
74 (0.3)
75 CP right Praising
76 (1.1)
77 PA hehheh hehheh [hehheh!
78 CP [rememberwhat Interrupting
79 youdid with[the turkey
80 PA [hehheh! ((nods))
81 CP thatyou droppedin the kitchen
82 PA hehheh heh!((nods))(Fig 6f)
83 CP that was [before you hada stroke
84 PA [itwas onthe floor! Interrupting
Fig 6. a-f. Anonymised video stills from excerpt 3 (CP is on left).
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Excerpt 3 demonstrates a knotted to-and-fro between help offered, help resisted, help
accepted, and help requested. Help is offered several times, explicitly resisted thrice, accepted
several times, and explicitly requested twice. This entanglement, we suggest, can be unpacked
by distinguishing the interpretants.
Scaffolding, as a social action, is an indexical sign; an action that is meaningful from several
standpoints, or interpretants. The act of scaffolding indexes, or implies, something about the
recipient, the provider, and their relationship. One could interpret scaffolding as variably
indexing: A focus and commitment to the task; care and concern for the recipient; the recipi-
ent’s lack of ability; the provider’s impatience; or, a relationship of dependency. Moreover, it
might be that some scaffolding behaviours are more likely to index a certain foci (i.e., correct-
ing is particularly focused on the recipient’s lack of ability, and thus perhaps, most likely to
lead to resistance, as evident in excerpt 3). Nonetheless, all of these interpretants are available
to all parties for all the scaffolding behaviours, but, there seems to be different emphasis placed
on these interpretants by PAs and CPs.
Although both PAs and CPs generally focus on getting the task done, projecting positive
identities, and sustaining the image of a normal life, PAs seemed more concerned with provid-
ing answers, rather than giving the correct answer, and moving the task forward, rather than
getting hung up on small communication errors. CPs, on the other hand, seemed concerned
to be good at facilitating communication (leading to solicitation) and at rehabilitation (leading
to teaching sequences). These different orientations explain why PAs repeatedly wanted to
move the task on, while CPs were repeatedly drawing attention to trivial communication
errors.
The salient interpretants can also wax and wane during the course of an interaction. Spe-
cific interpretants come to the foreground when directly appealed to by interaction partners
(such as referring to the PA as “a special case”). Also, interpretants based on the disability are
likely to become salient when scaffolding fails, as it does about one third of the time (Table 1).
Rather than indexing poor scaffolding (i.e., speaking too fast, inappropriate strategy) failure
might index that despite receiving help the PA ‘still doesn’t get it.’ However, we want to argue,
that these interpretants that frame the interaction in terms of disability are also indexed by the
act of helping itself. This is the paradox of helping; the very act of helping, because it is a visible
social act, indexes the need for help.
While previous research has shown that scaffolding risks positioning recipients as depen-
dent and child-like [90], we have taken such analyses a step further by showing how helping is
inherently paradoxical. Why do PAs simultaneously request and resist scaffolding? Because
the effects of scaffolding are both positive and negative, simultaneously enabling communica-
tion within the relationship (evident in analysis 1) and creating an asymmetrical relationship
(as revealed in analysis 2). Scaffolding, ostensibly an act of helping, is thus caught in a web of
contradiction. It simultaneously facilities communication and indexes problems in communi-
cation; it simultaneously empowers and disempowers.
Discussion: The paradox of helping
Across three analyses we have mapped out the range of scaffolding strategies evident in PA-CP
conversations and examined their unintended effects. While scaffolding ostensibly improves
communication, it can fail, creating a teaching-like genre of interaction, resulting in interac-
tion dominance, and making salient disability.
Our first analysis builds on the literature that describes scaffolding strategies [91], espe-
cially in relation to communication [28]. Our analysis is distinctive because it examined
both parties as equals within the scaffolding process, finding that PAs engage in all the
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scaffolding strategies observed, albeit usually with less frequency and considerably more var-
iability. We also added to the literature by examining efficacy, finding that about a third
of CP scaffolding initiatives fail. This latter finding, we suggest, is particularly important
because scaffolding failures have the unintended consequence of making salient the commu-
nication disability.
Our second analysis builds on the literature that has documented the asymmetry in
PA-CP conversations [26,44], contributing a systematic analysis of the extent and type of
interaction dominance. The observed asymmetry was mainly a result of CPs taking it upon
themselves to solicit responses from the PA and to engage in teaching-like episodes–a genre
of interaction far removed from the normative ideals of close social relationships, and, when
combined with testing exchanges, identified as potentially problematic [89]. The concept of
scaffolding originates in the field of child development [19,92] where teaching-like episodes
are less problematic. As the concept is broadened to apply to adults [4,21], our results advise
caution due to the unintended meanings of doing teaching episodes within close personal
relationships.
Our third analysis identified a knot at the heart of scaffolding. On the one hand, scaffolding
is widespread, usually accepted, and often requested, but, on the other hand, it can lead to
asymmetries, resistance, and explicit rebuffs. To make sense of these tensions, we conceptual-
ized helping as potentially paradoxical in Peirce’s [86] sense. Specifically, we suggested that CP
scaffolding can have contradictory interpretations, simultaneously facilitating communication
and marking the communication as problematic; simultaneously enabling and disabling. The
literature on helping has found that people in diverse domains do not like being helped, specif-
ically they worry that it will make them look incompetent [46]. Our introduction of Peirce and
our examination of alternations between receiving, resisting, and requesting help show that
helping is often a peculiarly paradoxical social activity. In trying to overcome a limitation it
can make the limitation more salient.
The paradox of helping can be better understood if one conceptualizes helping as a gift.
The literature on gifts shows that receiving a gift entails either obligation or subordination [1].
Accordingly, people will, as noted in the opening quotation from Mauss, often try to avoid
receiving gifts [93], in much the same way as they resist requesting help. Of course the giver
might not be interested in reciprocation; but, as with helping, there can be a divergence of per-
spective, and even if the feeling of obligation or subordination is one-sided it is still consequen-
tial. Arguably, a further complication with receiving help to communicate is that it often fails
(Table 1), and one thing worse than being indebted for help received, is being indebted for
help that was a hindrance.
Although the paradox of helping may be inherent in the semiotic structure of helping, con-
ceptualizing helping as paradoxical in Peirce’s sense, does open some avenues for amelioration.
First, scaffolding failure could be reduced. Scaffolding failure exacerbates the paradox of help-
ing because it makes salient the help being provided and the problems that the disability is
causing for the relationship. To this end, our findings support more research on training inter-
ventions for CPs [7,10–13,54]. We would also advocate the use of redundant scaffolding, such
as gesturing while speaking and demonstrating understanding, because these strategies do not
result in explicit failures.
Second, the quality of CP scaffolding could also be improved by giving PAs more control
over the scaffolding they receive. PAs often blame comprehension problems on CPs speaking
too fast or incorrectly supporting their comprehension [94]. We suggest developing a system
of simple nonverbal signals that PAs (who have capacity for expression and gesture) could use
to direct the scaffolding they receive. For example, gestures for ‘stop talking,’ ‘slow down,’
‘rephrase,’ and ‘repeat’ would help the CP tailor their scaffolding to the needs of the recipient.
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This would facilitate the tailoring of strategies not just to the PA, but to the particular needs of
the PA in a given context [17]. Moreover, such signals would have the significant secondary
benefit of reducing CPs’ interaction dominance because PAs would be exerting more control
within the conversation.
A third way to ameliorate the paradox of helping is to enable PAs to reciprocate the gift not
yet repaid [1,93]. Thus, ironically, what would help PA is if CP were to ask them for help, or,
at least create opportunities for PA to repay help received. Although rare in our data, there
were isolated instances, such as the PA who helped their CP spell “substitute.” Of course, the
reciprocation does not need to be in the domain of communication; it could be in another
domain which plays to the strengths of the PA. Relatedly, when PAs do engage in scaffolding,
CPs should, perhaps, avoid resisting. Each of the 14 occasions when CPs resisted help was a
missed opportunity for the PA to reciprocate.
Finally, the paradox of helping can, to some extent, be side-stepped, by raising the
salience of alternative interpretants that focus on the quality of the CP-PA relationship.
Given that receiving help with communication can be an identity threat, it is unsurprising
to find that effective CPs focus on face-saving by redressing power imbalances, joking, and
restoring dignity [10]. Eight of the 20 PAs never resisted help in part due to these subtle
techniques. Particularly important, here, is humour leading to joint laughter. Laughter is a
sequentially-organised activity that constructs intimacy [95] and is a common characteristic
of informal caregiving relationships [2]. Laughter makes salient the interpretation that the
relationship is enjoyable for both parties; pushing the interpretant of disability to the back-
ground. Mutual laughter indexes shared understanding, connectedness, symmetry, and
enjoyment. However, humour itself can be asymmetrical, with CPs initiating most of the
humour [96].
The current research has important limitations. The extent and types of aphasia among
participants was diverse, as were their relationships. This likely resulted in the variable
numbers of words spoken, variability in the frequency of strategy use and variability in the
frequency of requesting and resisting scaffolding. Each dyad should be seen as having devel-
oped their own conversational style, with associated scaffolding strategies, through much
trial and error experience [12–13,17]. The limited size of our sample meant that we could
not subset the data to systematically examine how types of relationship or aphasia profiles
impact on scaffolding or interaction dominance. Another set of limitations concerns the
task, which was ultimately artificial, and, with the presence of a Speech and Language Thera-
pist, might have elicited genres of interaction associated with teaching and rehabilitation
[89] (which is quite distinct from actual rehabilitation sequences [97]). Finally, the concept
of scaffolding that we have used tends to assume an expert-novice relation with a power
imbalance. This approach could be contrasted with research focused on conversation as a
collaborative achievement [98]. By analysing the scaffolding done by both CPs and PAs, and
systematically analysing initiation and responses, our research empirically documents the
nature, extent and variability of the asymmetry.
There has been a lot of research on the scaffolding processes that CPs can use to facilitate
communication with PAs. A neglected aspect of scaffolding, which we draw attention to, is the
potential for multiple intended, unintended and contradictory effects. We have connected the
literature on scaffolding with the literature on resisting help. While previous research has con-
ceptualized resisting help in terms of identity threat, we used Pierce’s [86] semiotic approach
to paradoxes to show that resisting help is a very peculiar communicative entanglement that
can be conceptualized as a paradox; namely, an attempt to help, which is meant to empower,
can simultaneously mark the recipient as powerless.
The paradox of helping
PLOS ONE | https://doi.org/10.1371/journal.pone.0180708 August 14, 2017 20 / 25

Supporting information
S1 File. This file contains the numeric data for the analyses of scaffolding strategies, inter-
action dominance, and resisting and requesting help.
(XLSX)
Acknowledgments
The authors would like to acknowledge the assistance of Morag Place and Joan Murphy with
collecting the data and the support of a research grant from the Economic and Social Research
Council, UK (RES-000-22-2473).
Author Contributions
Conceptualization: AG.
Data curation: AG JH.
Formal analysis: AG JH.
Funding acquisition: AG.
Investigation: AG.
Methodology: AG.
Project administration: AG.
Resources: AG.
Supervision: AG.
Validation: AG JH.
Visualization: AG JH.
Writing – original draft: AG JH.
Writing – review & editing: AG JH.
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