Title: Strategic Use in Context: AAC, Supported Conversation, and Group Therapy Interventions for People with Severe Aphasia
1Strategic Use in Context AAC, Supported
Conversation, and Group Therapy Interventions
for People with Severe Aphasia
- Kathryn L. Garrett, Ph.D., CCC-SLP
- Duquesne University, Pittsburgh, PA USA
-
- March 6th 7th, 2003
- Newcastle-upon-Tyne, England, UK
2Day 1 Augmentative and Alternative
Communication Strategies for Individuals with
Aphasia
Completed
- Morning
- Introduction to AAC Strategies for People with
Aphasia - Categories of Communicators
- Afternoon
- Categories of Communicators Cont.
- Assessment
- Group Activity
3Day 2 -- Integrated Communication Approaches to
Individual and Group Aphasia Therapy
- Morning
- Introduction to Integrated Therapy Models
- Pragmatic
- Functional
- Life Participation
- Supported Conversation
- Environmental Communication Therapy
- Teaching Communicators to Use Communication
Skills and Strategies in Meaningful Contexts - Individual Therapy
- Afternoon
- Aphasia Group Therapy
- General Models/Other Models
- Nebraska-Pittsburgh Model
- Wrap-up and Discussion
4Emphasis mostly on people with.
- global aphasia
- symbolic deficits across modalities cognitive
decreases severe motor - severe aphasia with minimal expression
- (Severe Brocas or TMA, some less global
folks) but better comprehension than group 1 - Individuals with a nonlinguistic disorder, such
as perseveration or apraxia-of-speech, - that interferes with functional communication to
such a degree that they function well below their
linguistic ability levels
5The purpose of these talks is.
6Part III Assessment and Technique Selection
7A. Goals of Assessment!
- Identify underlying language and communication
skills - With no context true aphasia impairment
(standard aphasia tests) - With context functional ability
- Match client skills to appropriate strategies
- Criterion vs. Maximal Dx
8B. AAC Strategy/Device Selection
Cognitive-Linguistic Considerations
- What are
- The cognitive-linguistic demands of requesting a
blanket (patient in hospital) - The demands of talking about a movie with a
friend?
9In aphasia, its not as simple as...
- Substituting a novel symbol set J
- for an impaired language system
- (Great, I have mail!)
10- Aphasia disrupts the automaticity of information
processing and language use in general
And now add...
11Additional Demands Posed by AAC Strategies
- Physical Access (often nondominant limb)
- Novel Symbol Translation Skills
- Message Encoding Skills
- Working Memory
- Operational Skills for Technology
- Metacommunicative Ability
- To USE strategies in dynamic situations
- To ID need to use alternative strategy
12(No Transcript)
13Were asking people with aphasia to complete a
METACOGNITIVE task when using many AAC
strategies especially those that dont involve
partner support
14- Aphasia disruption of the automaticity of the
language/ communication process - AAC going outside of ones own language system
to communicate______________________________ - Clinical Challenge teaching people w/ aphasia
to use strategies effectively and
naturally
15Group Analysis of
Access Symbol Skills Memory Metacognition
Call light Y if limb apraxia No Y min/mod Y - min
Yes/No board Y - min Y Y min Y - min
6-message VOCA to request/tell story Y - min Y Y - mod Y - mod
Written Choices No Y - min Yes - episodic No
Multi-level multisymbol VOCA Y - min Y - mod Max Max
16What to do???
- 1) Match AAC strategies to communicators,
considering their abilities (cognitive, language,
motor, visual) and needs - i.e., dont expect a basic choice communicator to
initiate by pointing to a symbol-based VOCA - Dont ask someone who fits the profile of
controlled situation communicator to combine
symbols to create a novel sentence - Etc. etc.
17- 2) Teach strategy use
- component by component
- by modeling strategy use during real
opportunities - by embedding use of strategies within real-life
situations as you go
More to come on this approach to communication
therapy!
18Discussion why arent AAC strategies always
quickly adopted and used successfully by people
with aphasia?
19- For a more detailed discussion of the
cognitive-linguistic demands inherent in AAC and
language-based communication activities, see - Garrett Kimelman (2000). AAC Aphasia
Cognitive-linguistic considerations. In
Beukelman, Yorkston, Reichle (Eds.) AAC for
Adults with Acquired Disabilities.
20Now, lets engage in a diagnostic process to help
us match appropriate AAC strategies to specific
communicators
21C. Patient-based Capabilities Assessment
- Garrett Beukelman's (1992) Categorical
Assessment form (see attached) - Multimodal Screening tool symbol
comprehension/association, use of multiple
levels, message complexity symbol sequencing
(attached) - Spelling/Writing screening (First letter, whole
word, generative writing) - Standardized tools (RCBA, WAB subtests)
- Assess what you can't see reading,
comprehension - Look more carefully at decontextualized
performance - System Trials
221. Categorical Form
- Pp. and handout
- Available from Garrett Beukelman AAC Medical
Setting (1992) chapter - OR Beukelman Mirenda (1998) Aphasia Chapter
23The goal
- Differentiate between who requires
- Partner support/prelinguistic
- Partner support/emerging linguistic skills and
intentionality - Self-initiated communication
- Simple symbol systems
- Complex symbol systems
- Special adaptations for specific environments
242. Multimodal Communication Screening Test
Score form p. 35 or on-line at http//aac.unl.edu
25The goal
- Differentiate between who can
- Use simple symbol systems to request
- Symbols represented on multiple levels to
request, describe. - Manipulate symbols to communicate alternate
meanings - Switch between multiple modalities
263. Spelling screening
- P. 34 and 35 of handout
- Conduct as part of multimodal symbol assessment
OR - Use 1st letter/whole word spelling inventory
especially if the individual is indicating they
would like to use a regular computer for most AAC
needs
274. Vision screening
28Video Illustration
- Individual participating in multimodal assessment
- Additional clips if time
29D. Partner-based Assessment
- 1. Assess their literacy (informally)
- 2. Assess their vision and hearing skills
- 3. Assess their ability to anticipate and
provide opportunities (by watching them
interact, trying strategies)
30E. Communication Needs and Context Assessment
- 1. Needs assessment see form p. 36
- 2. Identify Environments and Potential
Participation Activities - 3. Topics
- 4. Messages and Vocabulary
311. NEEDS ASSESSMENT
322.Topics/Vocabulary/Message Inventory
- See materials from Garrett, K., Beukelman, D.
(1992) AAC in the Medical Setting. K. Yorkston,
Ed. Communication Skill Builders. - See phrases from new book by Barbara Collier See
what we say messages for adults. Brookes
Publishing company.
33Comment
- Nice to invite families to complete this info
gradually but steadily especially during
acute/early phase of recovery.
34Part IV Integrated Therapy Approaches
35The issue
- How do we enable people with aphasia to
participate once again in meaningful life
activities? - Teach communicators to use AAC and natural
communication strategies in a purposeful and
understandable manner?
36My hypotheses re limited intervention outcomes
in this population
-
- Individuals with severe aphasia are the least
likely clients to generalize communication
targets that are taught - in de-contextualized contexts
- as products (e.g., sounds, symbols, words,
gestures) vs. communication acts - Opportunities to use both AAC strategies and
practiced speech targets must be embedded into
contextual communication activities
37This is not an entirely new philosophy
- Lets discuss some of the current therapy models
that provide support for delivering therapy in a
more integrated manner.
38A. Introduction to Wholistic Therapy Approaches
- 1. Pragmatic Approach
- 2. Functional Therapy Approach
- 3. Life Participation Approach
- 4. Supported Conversation
- 5. Environmental Communication Therapy
39The granola approaches.
401. Pragmatic Therapy Approach Promoting
Aphasics Communicative Effectiveness
(PACE)
- a. History
- Albyn Davis and Jeanne Wilcox promoted this
approach in the 1980s. - Thought that goal of tx was to improve patients
ability to communicate in natural conversations.
- However, felt that tx approaches to date had not
corresponded with this goal. - Felt area of pragmatics (just emerging at that
time) supported this alternative approach.
41- b. Description
- a formalized structure of interaction between the
clinician and patient that incorporates elements
of face-to-face conversation. Clinician and
patient take turns sending new information to
each other.
42- c. Research Basis
- Philosophical work of Searle, etc.
- Child pragmatics research (important to focus on
USE of language, not just the FORM) - Some efficacy studies exist comparing pragmatic
tx to other tx approaches
43- d. Populations
- all communicators with aphasia however, must
have some expressive ability and awareness of
interactions.
44- e. Principles
- 1) The clinician and patient participate equally
as senders and receivers of messages - 2There is an exchange of new info this is done
by keeping the senders message out of view of
the receiver (pictures face down) - 3) Free choice of channels (any modality at any
moment whatever works)
45- 4) natural feedback the clinicians feedback is
based FIRST on communicative adequacy of the
message. Only then may clinician provide
feedback on the form of the message. Also,
provide feedback in a sequence from general to
specific. - 5) Emphasis is on the communication of meaning
within a naturalistic context.
46- f. Selecting Treatment Stimuli
- 1) Choose pictures that depict specific
relationships for barrier communication
tasks. Can buy some picture kits for this (see
PACE kit, my pics) - 2) Design roleplays.
47Sample P.A.C.E. Stimulus Pictures (Edelman, 1985).
48- g. Implementing the Treatment Task
- see principles.
- KG/student Demo
- h. Feedback is supposed to be naturalistic (based
on content) rather than direct correction of
form. - i. Progress see scoring system on your handout.
49- j. Summary of this approach
- Differs significantly from conventional
stimulation approach - Communication target is NOT predetermined
- Clinician is not in total control of output
- Focus is on the adequate communication of
intent/meaning - Elicits initiations as well as responses
- 5-point scoring system can apply to verbal AND
nonverbal behavior (see handout) - In terms of clinical implementation, is MORE
structured than the general participation
philosophy
502. Functional Approach
- a. History - 1980s and 1990s.
- Systems theory took hold rehab dollars became
tighter. - b. Description
- Any activity that seeks to improve the patients
reception, processing, and use of information
pertaining to daily activities, social
interaction, and expression of current physical
and psychological needs. - Some consider it task-focused
51- c. Research Basis
- Audrey Holland, 1982, and others. Work from
individuals with severe developmental
disabilities was applied, too. - More efficacy research is surfacing all the time,
but more difficult to measure because it is
defined in many different ways.
52- d. Populations
- communicators with aphasia who
- can self-correct in some situations
- arent below the 10th ile on the PICA,
- can sustain attention
53- e. Principles
- 1) aphasia is more than just a linguistic deficit
also includes nonverbal communication, impact
of environment - 2) Treatment of language is important, but in the
context of working toward a functional goal - 3) First goal is to establish communication
interchanges and reinforce all communication
modes - 4) new and personally relevant information is
preferred to arbitrary language exercises
54- 5) communication environments are natural ones
(or as natural as possible) - 6) emphasis on reducing behaviors that block
communication - 7) increase the frequency of patient
communication first, then the accuracy of
information exchange in later stages
55- f. Implementing the Treatment Task
- 1) Eliminate Negative Communication Behaviors
e.g., impulsive patients - have to wait, patients who fake understanding
have to signal comprehension breakdowns, patients
who dont initiate must try something. - 2) Establish a communicative set determine the
best kind of cueing, the best modality for
communication - 3) Target a specific level of discourse that is
most appropriate for the client (conversational
narrative, procedural)
56- 4) Work within a topic/theme
- 5) Set up the situation so theres a meaningful
communication goal with a real communication
partner - 6) Train significant others
57- g. Measuring progress
- Nothing specified.
- Could use ASHA-FACS, etc., language samples,
functional communication scales - h. Summary of this approach
- Pros
- Cons
- With whom
- When
583. Life Participation Approach
- a.Historical Background
- Consumer-driven service delivery approach
- Believes the goal of aphasia therapy should be to
help individuals achieve immediate and long term
life goals - Developed by several highly experienced
clinicians who were frustrated with a deficit
only approach to tx (Chapey, Elman,
Simmons-Mackie, Kagan, Lyon, Duchan).
59- Description
- Life concerns are at the center of all decision
making. - Consumer is encouraged to select and participate
in recovery process to collaborate on the design
of interventions that enable him/her to return to
an active life. - Goal to reduce the consequences of disease by
increasing life participation and reducing
handicap.
60- c. Populations
- All people with aphasia and their partners
- anyone else affected by aphasia
- d. Research Bases
- derived from social models of human interaction
and life satisfaction. - Now some data-based articles with outcomes out
there too (See Lyon reference - handout)
61- e. Therapy Activities
- identify important life activities (most have
some type of communication component) - inventory how that person could participate more
fully with therapy or supports - teach partners new skills
- modify the environment
- teach within and outside of the clinical
environment
62- e. Measuring Effectiveness
- Life satisfaction indices,
- scales of well-being,
- of activities
- of hours engaged in meaningful communication
and participation - depression scales, etc.
63- g .Other
- developed in direct contrast to disability-driven
therapy. (e.g., stimulation approaches). - Not fully accepted by some clinicians or funders,
but Medicare etc. have made changes in this area.
64Additional References
- Lyon, J. (1996) Optimizing communication and
participation in life settings for aphasic adults
and their primary caregivers in natural settings
A use model for treatment. In GL Wallace (Ed),
Adult Aphasia Rehabilitation. Boston
Butterwowrth-Heinemann, 1996 137-160.
654. Supported Conversation Approach (Aura Kagan,
Toronto)
- a. History
- Started by Pat Arato, spouse of a man with
aphasia, in 1979, after his discharge from
therapy. Originally called the Aphasia
Centre-North York now the Pat Arato Aphasia
Centre. - Aura Kagan is presently the director
66- b. Description
- Communication involves partnerships
- Partners must be taught to acknowledge and reveal
the inherent competence of adults with aphasia
within the framework of natural adult
conversation - In the Pat Arato model, partners consist of
community volunteers who gently facilitate group
discussions - Conversational supports are techniques and
resource materials that partners and people with
aphasia can use to build a communication ramp
to maximal/natural participation in conversation
67- Sample techniques include
- Augmented input (drawing, writing key words, use
of graphic contextual information) - Written choices
- Cues to choose modalities
- Cues to interpret vs. interrupt
- Increasing pause time
- Provide validation and feedback for communication
effort and message content
68- c. Populations
- All people with aphasia
- Some join Introductory Groups (12 weeks)
- Others participate in weekly activities
- No time criterion post onset
- Some people with aphasia on either end of the
severity continuum may not be included, but this
is relatively rare. - d. Research
- Outcome measures are underway
- Research basis for program is from social theory
69- e. Activities
- Primarily group conversation, with some family
counseling available as well. Referrals
generated from the larger community of
rehabilitation professionals. - Well discuss sample activities in more detail in
group therapy section.
705. Environmental Approach
- a. History
- 1980s and 1990s. Systems theory took hold in
U.S. rehab dollars became tighter. - b. Description
- Rosemary Lubinski (2001) summarized this
approach to tx in which environmental and social
factors are assessed and then targeted for
intervention. - In general, tx starts with the assessment of
environmental (systems) factors.
71- c. Research Basis
- Mostly conceptual/theoretical to date, although
some systems theory research exists for other
populations. (e.g., dementia) - d. Populations
- all communicators with aphasia
- (KG - especially our nonspeaking communicators)
72- e. Principles
- 1) individuals are affected by their environment
and their communication partners - 2) The communication predicament faced by elderly
and aphasic individuals escalates as their
environment responds minimally or in a disordered
way to their communication attempts - Example Fluent aphasia - confused/jargon output
-- nurse caregiver - dining hall - retreat -
73- f. Implementing the Treatment Task
- 1) modify the individual as much as possible
- 2) focus on the family/communication partners
- Teach strategies
- Educate
- 3) modify the environment
- Example - architectural design of room, visual
schedule
74Sample Environmental Chart with Communication
Instructions
Please point to what you are talking about. Make
sure you get my attention before you start
talking. Write down key words theres a tablet
on the T.V. Explain whats coming uppoint to my
schedule or the calendar.
75Example of Architectural Modifications to Enhance
Communication/Social Roles Steinfeld, E. (1997)
76B. Specific Individual Therapy Techniques to
Improve Communication Skills in Meaningful
Contexts
771. Basic Strategy Learners
- Basic Choice Communicators
- Controlled Situation Communicators
- Emerging/Transitional Comprehensive Communicators
- anyone who doesnt think to turn to external
symbols/strategies to convey meaning when unable
to do so verbally
78Tx Strategy 1. Teach referential
communication skills
- Some communicators with severe aphasia (across
modalities) appear to have an elemental challenge
in referencing ability - They need explicit instruction to engage in basic
referential skills..
79- Attending to others (especially speakers)
- Pointing to request
- Pointing (indexing) an object, picture or written
word to clarify the referent when
answering/commenting - Gesturing deictically to request info or indicate
anothers turn - Searching for tangible information when answering
questions (e.g., in communication notebooks,
etc.)
80- Abbeduto, Short-Meyerson, Benson, Dolish,
Weissman (1998) described physical referencing
as - ...an understanding that an item that is present
in an individuals proximal life space may be the
topic of conversation or concept under
discussion. - Their research indicated that referential skills
(particularly physical referencing) are present
in young children as well as older children with
developmental language delays.
81My Hypotheses
- That individuals with severe aphasia may not be
able to produce propositional, verbal (speech or
nonspeech modalities) communication until basic
referential skills emerge (either naturally or
with facilitation) - That the emergence of meaningful spoken or
alternative communication coincides/ parallels
the reacquisition of basic referential skills
such as pointing to others, shifting gaze to a
speaker, physically manipulating
externally-stored info (pictures, words, etc.) to
answer a question.
82Target Referential Skills - A Proposed Hierarchy
- A. Social-Pragmatic Referential Skills
- B. Semantic/Symbolic Referential Skills
- C. Discourse Level Referential Skills
83- A.Social-Pragmatic Referential Skills
- 1) Basic Deixis
- For turn-taking
- For requesting additional information
- Dean - ask Jerry what he thought of the
election...hand-over-hand assist to point to
Jerry to request info
84- A. Social-Pragmatic Referential Skills (cont).
- 2) Tangible Referent Identification- immediate
envirionment - Example Show us what you bought this weekend
visual prompt to encourage Jane to point to her
own new sweater
85Video Illustration
- Explicitly instructing an individual with severe
aphasia to - visually reference/demo joint attention
- Point to indicate a turn
- Show responses to audience
86- B. Semantic/Symbolic Referential Skills
- 1) Visual symbol referencing
- Example Photo Album Conversations - point to
pictures to answer autobiographical questions
Where was your favorite vacation?
87- B. Semantic/Symbolic Referential Skills continued
- 2) Point to tangible topics setters to
initiate a conversational topic (Weiss Ho,
1997) - Example Teach family members to place remnant
of an outing or activity in view or in
communicators pocket. Use verbal or physical
cues to trigger presentation of remnant in
response to peer question Whats new?. Fade
cues as appropriate
88- B. Semantic/Symbolic Referential Skills cont.
- 3) Access sequence of messages to convey NEWS
on a Voice Output Communication Aid (VOCA) - no
selection/minimal sequencing demands
89- B. Semantic/Symbolic Referential Skills cont.
- 4. Access semantically specific messages to
answer specific questions -- on VOCA
90- 5. Point to semantically specific written word
choices to answer conversational questions
(Written Choice Conversation Strategy -- Garrett
Beukelman, 1995) - Example Who do you want to win the election
Gore Bush You dont CARE!
91Video Illustrations
- Using a tangible topic setter
- Telling a story via prestored symbols on simple
VOCA - Making simple requests via pictures
- Using a VOCA to access conversational phrases
92- C. Discourse Level Referential Skills
(advanced communicators) - Answering questions with semantically specific
referents - Commenting
- Asking questions
- Time markers and (then)
- Continuers and, but
- Combine natural modalities (speech, gestures,
writing) with use of AAC strategies
93Construct opportunities for
- Explicit, referential communication to occur in
one or more modalities - Gestural - Vocal
- Verbal - Writing
- AAC or other external symbols
- An increase in self-initiated communication acts
increase - Discriminating between symbols to choose, request
or describe - Turn-taking and other pragmatic aspects of
interactional communication to kick in
94Mike talking about his WWII medal
95Video Illustration
- Comprehensive communicator participating in
conversation by accessing symbolized messages,
gesturing, spelling, and speaking/vocalizing - Note difference in initiations and conscious use
of strategies - NOVEL information transfer
96End of section on referential communication
(skill 1)
97Tx Strategy 2. Teach clear signals
- Tag yes/no questions provide graphic
cues/gestural model for y/no - HOH to help with point gradually withdraw
- Model use strategies yourself while conversing
- (look, this is what I think point to rating
scale I think its a bad idea too)
98Teaching John Yes and No
99Tx Strategy 3. Gradually extend interactional
length
- Expect full conversations
- Expansion on a topic
- Completion of an entire transaction
- (e.g., buying EE shoes not done communicating
until the shoes are in the bag)
100Tx Strategy 4. Add VOCA messages gradually
- HOH 1 message always successful
- Pause cues wait reinforce activation
- News, activity preferences, greeting
- Gradually add items to build up discrimination
of messages, add nonpreferred choices (e.g.,
dental floss)
101Tx Strategy 5. Gradually increase complexity
and number of choices in partner-supported
techniques
- Written choices shift from egocentric topics
(your hobbies) to world events (How improve
security?) - VOCA - same
102Several years ago.
103Tx Strategy 6. Tell PWA s/he is responsible for
setting the topic.
- And must bring/show SOMETHING
- All is quiet until they signal/gesture/reference
SOMETHING!
104Sample topic setter Travel Brochure
105Tx strategy 7. Involve client, family, and
partners in
- Vocabulary selection
- System design
- Identifying communication opportunities in the
community - Participating in partner role-plays or real
interactions
106Tx Strategy 8. Add new strategies 1 at a time.
Ex
- Teach PWA to show topic setter
- Then teach PWA to point and ask you? while
showing topic setter - Then teach PWA to point to choices to answer
- Then teach PWA to find a map to answer location
questions - Then teach PWA to find a list of family members
and point to it to answer who questions etc.
Etc.
107Tx Strategy 9. Focus on teaching use of
strategies in meaningful contexts from Day 1
- Set up scripted conversational routines
practice then do it! - Develop roleplays assemble vocabulary, make
choices, practice script, invite novel partners - Ex. Bank
- Embed new strategies into real life situations
- Ex. Wedding toast for daughter store on single
message device, have person practice, then access
it for real at the wedding
108- Gradually lengthen roleplays
- Change setting leave clinic room
- Add partners
- Withdraw cues and script after repeated
rehearsals (if possible)
109Sample Script
110(No Transcript)
111Video Example Embedding Strategy Instruction in
Contextual Therapy
- Jerry/Kim
- OR Jerry Ben
- OR Ben Cliff
1122. Advanced Strategy Learners
- Purpose of instruction at this level is to
increase PWAs independence and ability to think
purposefully about using communication strategies
113Tx Strategy 10 Ask PWA Which strategy
could you use?
- How are you going to get your message across?
- Is that information in your system? If not,
then maybe you should write/draw/pantomime - Is this person patient? Knowledgeable about your
communication disorder? If not, maybe you
should - prestore a message
- explain how you communicate up front
114Chart Approach Instead of verbally instructing
PWA to use a specific strategy, point to the
chart and ask. Which strategy will work best?
Modality Instruction Chart
115Tx strategy 11. Tax the communication with
additional discourse demands
- Increase interactional demands
- Partner pretends to not understand
- Partner interrupts or requests more info
- Deviate from practiced scripts
- Conduct discourse activities in other settings
with unfamiliar partners - Increase difficulty of discourse tasks
- From requesting a specific shoe size to
negotiating a shoes return - From telling 1 item about weekend to telling a
story and answering questions about it.
116Video Illustrations
- Asking spouses out for a date
- Speech/gestures (Steve)
- VOCA (John)
- Conversation with Dynavox (Don)
117THINKDISCUSS
118C. Group Intervention Approaches for Long-Term
Aphasia
- Rationale for Group Therapy/Discussion
- Descriptions of Various Group Models (note
apology) - The Nebraska-Pittsburgh Thematic Discourse
Model
119Rationale for Group Therapy
- Interactional contexts can promote generalization
and functional use of communication skills - Groups provide opportunities for peer
socialization and cooperative attainment of
goals - Efficient and effective way to deliver long-term
rehabilitation services - Current Practices England and the U.S.
- Do you offer group therapy in your facility?
120Description of Group Models
- A) General Types of Groups
- Conversational Groups
- Language Therapy Groups
- Functional Activity/Skills Groups
- Support (Psychosocial) Groups
- Drill and Practice Therapy Groups
- Spouse/Caregiver Support Groups
- Spouse/Caregiver Communication Instruction Groups
121B) Contemporary Models of Aphasia Group
Therapy
- Marshalls Problem- Solving Approach
- Avents Cooperative Group Treatment
- Kagans Toronto CommunityProgram
- Holland Beesons Convers. Groups
- Aphasia Center of CA
- Family Based Intervention (Univ. of WA)
- Nebraska Scaffolded Discourse Approach
1221. Marshalls Problem-Focused Group Tx Oregon
Rhode Island Veterans Hospitals
- targets independent persons with mild aphasia
- designed to help individuals cope with
day-to-day problems - clinician serves as a facilitator only
123Problem-Solving Approach cont.
- Organizational Structure
- meet 1x per week for 60-90 minutes
- 8-10 participants
- no predetermined discharge date
- No charge VA supported
124Problem-Solving Approach cont.
- Examples of Activities
- communicating in an emergency
- meeting new people
- preparing for a doctors visit
- self disclosure
125Problem-Solving Approach cont.
- Outcomes
- 14/23 showed overall improvement on the PICA
- 9 showed little or no change on the PICA or
discontinued tx before retesting - anecdotal reports clients began filling
prescriptions, ordering specialty sandwiches,
obtaining bids for repair work, completing
paperwork
1262) Avents Cooperative Group Treatment for Mild
Aphasia (Jan Avent, California State
University-Hayward)
- emphasizes dyadic communication, inquiry and
discovery, reflection on performance - clinician facilitates a group member to
facilitate the target communicator
127Avents Cooperative Group Treatment cont.
- Organizational Structure
- 2 individuals with aphasia in a treatment dyad
and an SLP facilitator - 45 minutes (1 story per session) to 90 minutes
(2-3 stories per session) - designed for mildly impaired individuals but has
been used with moderate-severely impaired
communicators - home program set up prior to discharge
- funding structure unknown
128Avents Cooperative Group Treatment cont.
- Examples of Activities
- summarizing target stories (narrative and
procedural story retells) facilitator with
aphasia assists the target individual to improve
their rendition. - narrative story topics have included Alaska,
American bison, exercise, dogs - procedural story topics have included planting a
garden, renting a movie, etc.
129Avents Cooperative Group Treatment cont.
- Outcomes
- multiple baseline study with 8 subjects conducted
3X weekly for 5 weeks - Measures included Correct Info Units (CIUs),
number of key words used by reteller, number/type
of cues supplied by the facilitator, SPICA, WAB,
CADL - significant increases in SPICA, WAB, CADL scores
for moderate to severe participants at 2 mos and
4 mos
130 3) North York Pat Arato Aphasia Centre (Toronto,
Canada -- Kagan, Gailey, Cohen-Schneider)
- emphasizes a partnership among members, families,
volunteers, and professionals staff - goals of increased independence,community
reintegration, social and emotional support - large program - 300 members and 100 volunteers
131North York Pat Arato Aphasia Centre (Toronto,
Canada -- Kagan et al) Continued
- Organizational Structure
- 12 week introductory program
- one session per week/105 minutes
- 20-25 members with aphasia
- 4-5 people per group
- separate groups for family members
- volunteers are trained extensively to facilitate
conversational interactions
132North York Pat Arato Aphasia Centre (Toronto,
Canada -- Kagan et al) Continued
- Organizational Structure - Funding
- funding is obtained from various sources,
including - Ontario Ministry of Health
- fundraising
- Suggested donations for participants is 160
(Canadian per term)
133North York Pat Arato Aphasia Centre (Toronto,
Canada -- Kagan et al) Continued
- Examples of Volunteer-Facilitated Activities
- natural topical conversation!!!
- barrier games/PACE strategies
- 20 questions
- watching video clips of news segments or humorous
advertisements, homemade videos of staff engaging
in embarrassing situations
134North York Pat Arato Aphasia Centre (Toronto,
Canada -- Kagan et al) Continued
- Outcomes
- members with aphasia and family members reported
changes in 5 of 6 dimensions on the Ryffs
Psychological Well Being Scale at 6 month
intervals - positive changes reflected in
- autonomy, environmental mastery, personal growth,
purpose in life, self-acceptance (members) - autonomy, personal growth, positive relations
with others, purpose in life, self-acceptance
(family)
1354) Arizona Conversation Groups (Holland Beeson)
- small group format
- goals are to provide communication
opportunities, to facilitate communication using
all successful modalities, and to teach strategies
136Arizona Conversation Groups (Holland Beeson)
cont.
- Organizational Structure
- serve approximately 40 individuals with aphasia
(8 groups of 5-7 individuals _at_) - 1 X per week/1 hour sesssions
- facilitated by graduate students with supervision
- separate groups for family members
- private pay - 10 per session
137Arizona Conversation Groups (Holland Beeson)
cont.
- Examples of Activities
- topical conversations
- PACE types of activities
- games
- use of memory books
- discussions about former occupations
- roleplaying
- educational/informative lectures
- self-evaluations
138Arizona Conversation Groups (Holland Beeson)
cont.
- Outcomes
- longitudinal data collected with formal (WAB) and
informal (CETI) measures revealed measureable
gains in communication abilities for most group
members who were many months or years post onset.
1395) The Aphasia Center of California (Elman
Bernstein-Ellis)
- built on the premise that natural social
interaction motivates persons with aphasia to
communicate. - work on learning strategies, using multiple
modalities.
140The Aphasia Center of California (Elman
Bernstein-Ellis) continued
- Organizational Structure
- 70 members
- community based (located in Senior Center)
- 6 conversational groups weekly (90 minutes
sessions) - 5 to 8 persons per group
- caregiver groups bimonthly
- SLPs facilitate
141The Aphasia Center of California (Elman
Bernstein-Ellis) continued
- Organizational Structure - Funding
- because tx is held in nonprofit community agency,
less overhead - Funding is primarily private pay (15 per session
with sliding fee down to 4 per session). - Several HMOs willing to pay first 10 sessions.
- Also conduct fundraising activities individual
contributions, corporate and private foundations
142The Aphasia Center of California (Elman
Bernstein-Ellis) continued
- Examples of Activities
- conversational activities
- reading and writing groups
- art class
- supplementary individual treatment
- not task or theme oriented/conversation emerges
in accordance with the interests of the day
143The Aphasia Center of California (Elman
Bernstein-Ellis) continued
- Outcomes
- 28 subjects - randomly assigned to immediate vs.
deferred group tx - dep. measures included SPICA, WAB AQ
reading/writing measures, CADL, CETI, affect
balance scale, connected speech and interviews. - scores on formal test measures (SPICA, WAB, CADL)
were better for immediate tx group
1446) Family Based Intervention for Chronic Aphasia
(Nancy Alarcon, Univ. of Washington)
- focus on direct tx of family members re
behaviors affecting communication - goals increase quality of communication
interactions in dyad, decrease breakdowns,
increase facilitatory behaviors
145Family Based Intervention for Chronic Aphasia
(Univ. of Washington) continued
- Facilitatory Behaviors
- comment
- clarify
- cue
- Nonfacilitatory Behaviors
- interruption
- interrogation
- repetition request
146Family Based Intervention for Chronic Aphasia
(Univ. of Washington) continued
- Treatment consists of
- general education (communication abilities of
person with aphasia, facilitatory behaviors) - conversational practice
- videotape, review, feedback
- additional practice of facilitatory behaviors
147Discussion
- Which aspects of these group models appeal to
you? - Who might benefit from these approaches?
- Cautions???
1483. Group Therapy The Nebraska-Pittsburgh Model
149A. History
- University of Nebraska-Lincoln - 1993-1997
Garrett Ellis - Student training programs
- Adults with a wide variety of aphasia types,
ages, backgrounds - Duquesne University (Pittsburgh) - 1998-present
Garrett Staltari - Ever-increasing demand for services at the
post-acute rehabilitation phase
150- B. Constituency of Groups (2)
- Mild-Moderate Aphasia Group
- Difficulties with fluency, semantic flexibility
and specificity, organization of discourse,
timing, and integration of language with high
level social-pragmatic skills - Participants tend to have generally good auditory
comprehension primarily communicate by speaking
(although enhancement through other modalities is
often a goal)
151- Severe Aphasia Group
- Participants have limited to no verbal
communication. Typically have some degree of
auditory comprehension breakdown as well -- from
mild to severe. - Have difficulties initiating communication acts
conveying novel,semantically specific
information referencing what theyre talking
about attending to relevant info/conversational
partners engaging in reciprocal exchanges
152- C. Organizational Structure
- University-based clinic
- weekly sessions/1.5 hours
- 4-8 members all severity levels
- SLP graduate students facilitate sessions (with
supervision) - break out sessions/individual instruction as
needed - minimum of 5 per session max of 25 per
session - some insurance payment for a portion of the
sessions - workmans comp or Office of Vocational
Rehabilitation - Sertoma scholarships for individual clients
- Private pay reduced fee schedule option
153D. Purposes (4) of Therapy Groups
- 1) To improve linguistic skills
- Semantic
- Discourse
- 2) To improve interactional skills in
- Conversational Contexts
- Transactional Contexts
154- 3) To increase communicators use of compensatory
strategies when appropriate - 4) To assist clients and significant others to
learn to live with aphasia (after Lyon, 1996)
155E. 3 Basic Tx Principles Communication in
Meaningful Contexts
- 1) USE language vs. practice
- Embed language targets in a connected sequence of
communication acts that have a purpose - EX Asking your wife out on a date vs.
practicing her name and I love you in an
isolated context
156- Prepare for challenges to resource allocation
practice compensating for situational demands in
tx - EX Practice standing up, walking to movie
counter, asking for a ticket, being bumped,
getting back on track and requesting a ticket
157- 2) Communicate at the level of discourse
- Have a GOAL (conduct a transaction, to tell a
story, to explain how to do something) - ORGANIZE the communication acts you need to
achieve this goal - Ex.Hi honey - come here gesture. Date?
158- Add enough REFERENTIAL/ SEMANTIC SPECIFICITY and
COHESION to convey ideas - Ex.Movies - you? or show newspaper
- Consolidate multiple communication modalities
into one communication act - EX Hand her flowers and say I love you
vs. practicing speech and gestures separately
159- 3) utilize thematic, situational activities in tx
- Examples
- Planning a party for group member
- Going to the bank
- Greeting trick-or-treater
- May facilitate retrieval of language associated
with episodic memory - Preliminary observations increased complexity
and automaticity of expressive communication
160F. Structure of the Model 4 phases
- Conversation
- Context-Building
- Language Mediation
- Discourse
161- VIDEO ILLUSTRATION GROUP in ACTION
162Group measurement scale found in your handout
packet on page 60
163Reference
- Garrett, K., Ellis, G. (1999) Group
communication therapy for people with long-term
aphasia Scaffolded thematic discourse
activities. In R. J. Elman (Ed.), Group
Treatment of Neurogenic Communication Disorders
The Expert Clinician's Approach. Boston
Butterworth-Heinemann. Pp. 85-96.
164Part V Professional Issues, Future Directions,
Discussion
165A. Programmatic Issues
- 1. Funding for Therapy
- 2. Funding for Equipment
- 3. Reestablishing our role
- 4. Measuring Change/Effectiveness
1661. Funding for Therapy
- Write objectives specifically
- Examples
- Will initiate request for medical needs or
favorite activities by selecting message from
8-item VOCA display in contextual situations in
assisted living environment - Note the communication function, strategy, and
environment that you are aiming for - Caveat about saying AAC
- Reapply for insurance coverage each year
1672. Funding for Devices
- 1. State Technology Projects Loaners
- 2. Private Insurance
- Aetna - SGDs
- Tri-Care (military)
- 3. Medicaid (some states)
- 4. Medicare SGDs
- 5. Private Pay
168www.aac-rerc.com
169Special Issues
- DME - devices should be described as being
durable medical equipment - You need to find an authorized vendor of DME
equipment - usually cant have it in same
hospital - Outside vendors of orthotics and prosthetics
170- Only certain devices are covered.
- Only certain manufacturers are on the list of
Medicare and insurance providers - BECAUSE they
are not reimbursed in full (theyre reimbursed at
Medicare level rates)
171Work of Medicare AAC Implementation Team
through ASHA
- Joanne Lasker p. 61
- Good organization schema for ordering Speech
Generating Devices (SGDs) for people with
aphasia - No Technology
- Low Technology digitized devices
- High Technology combine symbols, writers
1723. Reestablishing our Role
- Not just swallowing experts
- Not just stimulation therapists
- Work on the whole package of communication
whatever it takes to increase participation,
strategic communication in real-life contexts - Partner training is legitimate
- Other team members can be invaluable in rehab
setting e.g., rec therapists, religious
leaders, etc. - We can do something for these folks and we need
to see them.
173Is AAC is unique, or is it just another
enhancement to overall language therapy?
1744. Measuring Change/Effectiveness
- See Garrett, K., in Elman, R. (Ed). Chapter on
Measuring Outcomes of Group Therapy. Group
Treatment - My current practices and ideas
- Triangulation
- NOMS, ASHA-FACS, Observ. Tools
- Tests
- Criterion Referenced Measures
- of Life Activities that PWA is participating in
- Discussion
175B. Delivery of Therapy
- 1. Increasing contextual opportunities
- 2. Implementing group therapy
176C. Research questions and future directions
- Measurement of use of strategies in real-life
contexts - Partner training
- What types/quantity of referential communication
skills do same-age peers use when communicating? - Changes in language expression/comprehension
- Changes in comm. Competence with referential
communication training?
177D. Wrap-Up
- How will you change what you do as a result of
this workshop? - What concerns do you have?
- What goals do you have?
- Can you suggest additional directions for me?
178Goal Communication
179The End
180Discussion!!!