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Part IV: Integrated Therapy Approaches


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Title: Part IV: Integrated Therapy Approaches

Part IV Integrated Therapy Approaches
A. Introduction
  • The challenge 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?

My 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

This 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.

B. Introduction to Wholistic Therapy Approaches
  • 1. Pragmatic Approach
  • 2. Functional Therapy Approach
  • 3. Life Participation Approach
  • 4. Supported Conversation
  • 5. Environmental Communication Therapy

The granola approaches.
1. Pragmatic Therapy Approach Promoting
Aphasics Communicative Effectiveness
  • 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.

  • 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.

  • 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

  • d. Populations
  • all communicators with aphasia however, must
    have some expressive ability and awareness of

  • 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)

  • 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
  • 5) Emphasis is on the communication of meaning
    within a naturalistic context.

  • 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.

Sample P.A.C.E. Stimulus Pictures (Edelman, 1985).
  • g. Implementing the Treatment Task
  • see principles.
  • KG/student Demo
  • h. Progress see 5-pt. scoring system on your

  • i. 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
  • 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

2. Functional Approach
  • a. History - 1980s and 1990s.
  • Systems theory took hold rehab dollars became
  • 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

  • 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.

  • d. Populations
  • communicators with aphasia who
  • can self-correct in some situations
  • arent below the 10th ile on the PICA,
  • can sustain attention

  • 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
  • 4) new and personally relevant information is
    preferred to arbitrary language exercises

  • 5) communication environments are natural ones
    (or as natural as possible)
  • 6) emphasis on reducing behaviors that block
  • 7) increase the frequency of patient
    communication first, then the accuracy of
    information exchange in later stages

  • 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
  • 3) Target a specific level of discourse that is
    most appropriate for the client (conversational
    narrative, procedural)

  • 4) Work within a topic/theme
  • 5) Set up the situation so theres a meaningful
    communication goal with a real communication
  • 6) Train significant others

  • 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

3. 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).

  • b. Description
  • Life concerns are at the center of all decision
  • 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

  • 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)

  • 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

  • f. Measuring Effectiveness
  • Life satisfaction indices,
  • scales of well-being,
  • of activities
  • of hours engaged in meaningful communication
    and participation
  • depression scales, etc.

  • 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.

Additional 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.

4. Supported Conversation Approach (Aura Kagan,
  • 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
  • Aura Kagan is presently the director

  • 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
  • In the Pat Arato model, partners consist of
    community volunteers who gently facilitate group
  • 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

  • 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
  • Communicators with aphasia are the leaders, the
    volunteer is a facilitator only.

Sample page from Kagan et al.s Pictographic
Communication Resources
  • 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

  • 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.

  • Resources/references
  • Kagan, A., Winckel, J., Shumway, E.
    Pictographic Communication Resources Enhancing
    Communicative Access. Pat Arato Aphasia Centre,
    53 The Links Road, Toronto, ON, Canada M2P1T7
    Fax (416) 226-3706, Website Email
  • Kagan, A. (1998) Supported conversation for
    adults with aphasia methods and resources for
    training conversation partners. Aphasiology, 12,

5. 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
  • In general, tx starts with the assessment of
    environmental (systems) factors.

  • 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 or
    people in long-term care facilities

  • 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 -

  • f. Implementing the Treatment Task
  • 1) Modify the individual as much as possible
  • 2) Focus on the family or communication
  • Teach strategies
  • Educate
  • 3) Modify the environment
  • Example - architectural design of room, visual

Sample Environmental Chart with Communication
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.
Example of Architectural Modifications to Enhance
Communication/Social Roles Steinfeld, E. (1997)
C. Specific Individual Therapy Techniques to
Improve Communication Skills in Meaningful
1. Basic Strategy Learners
  • Emerging (Basic Choice) Communicators
  • Contextual Choice Communicators
  • Transitional Communicators
  • anyone who doesnt think to turn to external
    symbols/strategies to convey meaning when unable
    to do so verbally

Tx 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..

  • Attending to others (especially speakers)
  • Pointing to request
  • Pointing (indexing) an object, picture or written
    word to clarify the referent when
  • Gesturing deictically to request info or indicate
    anothers turn
  • Searching for tangible information when answering
    questions (e.g., in communication notebooks,

  • Abbeduto, Short-Meyerson, Benson, Dolish,
    Weissman (1998) described physical referencing
  • understanding that an item that is present
    in an individuals proximal life space may be the
    topic of conversation or concept under
  • Their research indicated that referential skills
    (particularly physical referencing) are present
    in young children as well as older children with
    developmental language delays.

My 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)

My Hypotheses cont.
  • 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.

Target Basic Referential Skills
Where did your husband wreck the car?
It happened right here in Pittsburgh!
  • a) 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

John now pointing independently to ask Sara a
  • b) Tangible Referent Identification
  • To request visible items (e.g., water)
  • to answer questions
  • Example Show us what you bought this weekend
    visual prompt to encourage Jane to point to her
    own new sweater

  • c) Point to objects or photos to answer
  • To teach basic deictic skills with external
  • There are no wrong answers
  • Partner responds contingently (oh, you went to
    Nova Scotia! I love it up there!
  • Example Photo Album Conversations - point to
    pictures to answer autobiographical questions
    Where was your favorite vacation?

Results of current research project on
referential communication in aphasia matched
peers (Garrett et al. 2004)
  • In photo-reminiscing task, PWA are as referential
    as peers with no aphasia -- no difference in
  • Perhaps less able to think to communicate
    referentially in group communication situations
    -- more demands are placed on linguistic and
    cognitive resources in dynamic conversational

(No Transcript)
Tx Strategy 2. Teach clear signals
  • Tag yes/no questions provide graphic
    cues/gestural model for y/no
  • Hand-over-hand (HOH) assistance 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)

Teaching John Yes and No
Tx Strategy 3. Gradually extend interactional
  • 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)

Tx Strategy 4. Use VOCAs to teach independent
message initiation
  • Use hand-over-hand assistance (HOH) to assist PWA
    to activate 1 message in motivating context --
    maximize success. Examples
  • Welcome everyone at the beginning of group
  • Tell me about school! when grandchildren visit
  • Did you hear that were getting a new car?
  • Later, pause before HOH wait reinforce
    independent activation

  • STEP 1 Access single message VOCA to greet, say
    1 target message (e.g., Happy Birthday, I love
    you, Go Steelers!)

  • STEP 2 Access sequence of messages to convey
    NEWS on a Voice Output Communication Aid (VOCA)
  • no symbol selection/discrimination demands (all
    are activated)
  • Minimal sequencing demands

  • Example

  • STEP 3. Access semantically specific messages to
    answer specific questions must discriminate
    between messages and then choose

J.V. telling Sara he wants to watch a movie by
pointing to a photo choice after she asked Well,
what do you feel like doing right now?
Addition of dental floss and cigarette symbols
helped John learn to discriminate between
pictures vs. pick them at random
Tx Strategy 5. Gradually increase complexity
and number of choices in partner-supported
  • Written choices shift from egocentric topics
    (your hobbies) to world events (How improve
  • VOCA - increase number of levels/pages for
    situational messages

  • Point to semantically specific written word
    choices to answer conversational questions
    (Written Choice Conversation Strategy -- Garrett
    Beukelman, 1995)
  • Example Egocentric choices
  • Where do you live?
  • Squirrel Hill
  • Oakland
  • East Liberty

  • Example Complex topics/choices
  • What do you think of the White Houses policy on
  • I am against war stay out.
  • We need to be there to fight terrorism
  • See what the other countries say
  • George Bush 2 is at it again how ridiculous!
  • I dont CARE! Its all politics as usual!

Typing out choices on the economy for Dr. D.
Tx Strategy 6 Asking questions/becoming an
  • Teach PWA to ask questions by pointing, using
    rising intonation, and approximating You?
    Eventually shift to asking with semantically
    specific key words Wife?
  • Goal increase range of communication acts
    (i.e., not just responding) and provide means of
    communicating linguistically difficult question

Tx Strategy 7. Teach PWA s/he is responsible
for setting the topic.
  • And must bring/show SOMETHING
  • All is quiet until they signal/gesture/reference

Sample topic setter Travel Brochure
  • Teach family members to place REMNANT of an
    outing or activity in view or in communicators
  • Use verbal or physical cues to trigger
    presentation of remnant in response to peer
    question Whats new?
  • Fade cues as appropriate

Video Illustrations
  • Pointing to ask a question
  • Using a tangible topic setter
  • Telling a story via prestored symbols on simple
  • Making simple requests via pictures
  • Using a VOCA to access conversational phrases

Tx strategy 8. Involve client, family, and
partners in
  • Vocabulary selection
  • System design
  • Identifying communication opportunities in the
  • Participating in partner role-plays or real

Tx Strategy 9. Add new strategies 1 at a time.
  • 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
  • Then teach PWA to find a list of family members
    and point to it to answer who questions etc.

Tx Strategy 10. 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

  • Gradually lengthen roleplays
  • Change setting leave clinic room
  • Add partners
  • Withdraw cues and script after repeated
    rehearsals (if possible)

Sample Script
(No Transcript)
Video Example Embedding Strategy Instruction in
Contextual Therapy
  • Jerry/Kim
  • OR Jerry Ben
  • OR Ben Cliff

2. Advanced Strategy Learners
  • Purpose of instruction at this level is to
    increase PWAs independence and ability to think
    purposefully about using communication strategies
  • Transitional Communicators
  • Stored Message Communicators
  • Generative Communicators

Tx Strategy 11 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
  • prestore a message
  • explain how you communicate up front

Chart 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
Tx strategy 12. 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.

Video Illustrations
  • Asking spouses out for a date
  • Speech/gestures (Steve)
  • VOCA (John)
  • Conversation with Dynavox (Don)

D. Group Intervention Approaches for Long-Term
  1. Rationale for Group Therapy/Discussion
  2. Descriptions of Various Group Models (note
  3. The Nebraska-Pittsburgh Thematic Discourse

Rationale for Group Therapy
  • Interactional contexts can promote generalization
    and functional use of communication skills
  • Groups provide opportunities for peer
    socialization and cooperative attainment of
  • Efficient and effective way to deliver long-term
    rehabilitation services
  • Current Practices Scandinavia and the U.S.
  • Do you offer group therapy in your facility?

Description 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

3. Contemporary Models of Aphasia Group
  • 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

a) 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

Problem-Solving Approach cont.
  • Organizational Structure
  • meet 1x per week for 60-90 minutes
  • 8-10 participants
  • no predetermined discharge date
  • No charge VA supported

Problem-Solving Approach cont.
  • Examples of Activities
  • communicating in an emergency
  • meeting new people
  • preparing for a doctors visit
  • self disclosure

Problem-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

b) Avents Cooperative Group Treatment for Mild
Aphasia (Jan Avent, California State
  • emphasizes dyadic communication, inquiry and
    discovery, reflection on performance
  • clinician facilitates a group member to
    facilitate the target communicator

Avents 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
  • home program set up prior to discharge
  • funding structure unknown

Avents 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.

Avents 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,
  • significant increases in SPICA, WAB, CADL scores
    for moderate to severe participants at 2 mos and
    4 mos

c) 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

North 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

North York Pat Arato Aphasia Centre (Toronto,
Canada -- Kagan et al) Continued
  • Organizational Structure - Funding
  • funding is obtained from various sources,
  • Ontario Ministry of Health
  • fundraising
  • Suggested donations for participants is 160
    (Canadian per term)

North 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

North 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
  • 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

d) 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

Arizona Conversation Groups (Holland Beeson)
  • 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

Arizona Conversation Groups (Holland Beeson)
  • Examples of Activities
  • topical conversations
  • PACE types of activities
  • games
  • use of memory books
  • discussions about former occupations
  • roleplaying
  • educational/informative lectures
  • self-evaluations

Arizona Conversation Groups (Holland Beeson)
  • 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.

e) The Aphasia Center of California (Elman
  • built on the premise that natural social
    interaction motivates persons with aphasia to
  • work on learning strategies, using multiple

The Aphasia Center of California (Elman
Bernstein-Ellis) continued
  • Organizational Structure
  • 70 members
  • community based (located in Senior Center)
  • 6 conversational groups weekly (90 minutes
  • 5 to 8 persons per group
  • caregiver groups bimonthly
  • SLPs facilitate

The 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

The 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

The 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

f) 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

Family Based Intervention for Chronic Aphasia
(Univ. of Washington) continued
  • Facilitatory Behaviors
  • comment
  • clarify
  • cue
  • Nonfacilitatory Behaviors
  • interruption
  • interrogation
  • repetition request

Family 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

  • Which aspects of these group models appeal to
  • Who might benefit from these approaches?
  • Cautions???

g) Group Therapy The Nebraska-Pittsburgh Model
  • 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 Moir
  • Ever-increasing demand for services at the
    post-acute rehabilitation phase

  • Constituency of Groups (3)
  • Mild 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.
    Are back to most routine life activities but
    complain that they just dont feel the same

  • Moderate Aphasia Group
  • Difficulties with fluency, semantic flexibility
    and specificity, grammaticality, phonologic
    retrieval, repair of online communication
    breakdowns, organization of discourse, timing,
    and integration of language with high level
  • Some comprehension challenges.
  • May communicate by speaking or supplement speech
    with alternative communication strategies

  • 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

  • Organizational Structure
  • University-based clinic
  • weekly sessions/1.5 hours
  • 4-8 members all severity levels
  • SLP graduate students facilitate sessions (with
  • break out sessions/individual instruction as
  • minimum of 5 per session max of 25 per
  • some insurance payment for a portion of the
  • workmans comp or Office of Vocational
  • Sertoma scholarships for individual clients
  • Private pay reduced fee schedule option

Purposes (4) of Therapy Groups
  • 1) To improve linguistic skills
  • Semantic
  • Discourse
  • 2) To improve interactional skills in
  • Conversational Contexts
  • Transactional Contexts

  • 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)

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

  • Prepare for challenges to resource allocation
    practice compensating for situational demands in
  • EX Practice standing up, walking to movie
    counter, asking for a ticket, being bumped,
    getting back on track and requesting a ticket

  • 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?

    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

  • 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

Structure of the Model 4 phases
  • 1) Conversation
  • 2) Context-Building
  • 3) Language Mediation
  • 4) Discourse

Group measurement scale found in your handout
packet on page 60
  • 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.

Part V Professional Issues, Future Directions,
A. Programmatic Issues
  • 1. Funding for Therapy
  • 2. Funding for Equipment
  • 3. Reestablishing our role
  • 4. Measuring Change/Effectiveness

1. 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

2. 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

Special 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
  • Outside vendors of orthotics and prosthetics

3. 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.

Is AAC is unique, or is it just another
enhancement to overall language therapy?
4. Measuring Change/Effectiveness
  • See Garrett, K., in Elman, R. (Ed). Chapter on
    Measuring Outcomes of Group Therapy. Group
  • My current practices and ideas
  • Triangulation
  • NOMS, ASHA-FACS, Observ. Tools
  • Tests
  • Criterion Referenced Measures
  • of Life Activities that PWA is participating in
  • Discussion

B. Delivery of Therapy
  • 1. Increasing contextual opportunities
  • 2. Implementing group therapy

C. Research questions and future directions
  • Measurement of use of strategies in real-life
  • 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?

D. 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?

Goal Communication