Part IV: Integrated Therapy Approaches

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Part IV Integrated Therapy Approaches
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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?

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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

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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.

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B. Introduction to Wholistic Therapy Approaches

• 1. Pragmatic Approach
• 2. Functional Therapy Approach
• 3. Life Participation Approach
• 4. Supported Conversation
• 5. Environmental Communication Therapy

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The granola approaches.
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1. 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.

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• 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.

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• 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

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

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• 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)

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• 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.

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• 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.

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

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• 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
  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

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2. 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

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• 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.

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

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• 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

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• 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

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• 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)

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• 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

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• 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

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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).

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• b. 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.

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• 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)

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• 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

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

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• 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.

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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.

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4. 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

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• 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

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• 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.

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

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• 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.

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• 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 [phone], Website
  www.aphasia.on.ca. Email aphasia_at_aphasia.on.ca.
  
• Kagan, A. (1998) Supported conversation for
  adults with aphasia methods and resources for
  training conversation partners. Aphasiology, 12,
  816-830.

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

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• 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

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• 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 -

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

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Sample 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.
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Example of Architectural Modifications to Enhance
Communication/Social Roles Steinfeld, E. (1997)
Jpeg
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C. Specific Individual Therapy Techniques to
Improve Communication Skills in Meaningful
Contexts
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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

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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..

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• 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.)

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• 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.

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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)

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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.

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

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John now pointing independently to ask Sara a
question.
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• 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

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• c) Point to objects or photos to answer
  questions
• To teach basic deictic skills with external
  symbols
• 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?

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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
  pointing
• Perhaps less able to think to communicate
  referentially in group communication situations
  -- more demands are placed on linguistic and
  cognitive resources in dynamic conversational
  contexts

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(No Transcript)
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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)

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Teaching John Yes and No
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Tx 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)

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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
  therapy
• Tell me about school! when grandchildren visit
• Did you hear that were getting a new car?
• Later, pause before HOH wait reinforce
  independent activation

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

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• 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

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• Example

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

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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
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Tx 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 - increase number of levels/pages for
  situational messages

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• 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

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• Example Complex topics/choices
• What do you think of the White Houses policy on
  Iraq?
• 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!

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Typing out choices on the economy for Dr. D.
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Tx Strategy 6 Asking questions/becoming an
initiator

• 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
  forms.

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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
  SOMETHING!

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Sample topic setter Travel Brochure
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• 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

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Video Illustrations

• Pointing to ask a question
• 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

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Tx strategy 8. Involve client, family, and
partners in

• Vocabulary selection
• System design
• Identifying communication opportunities in the
  community
• Participating in partner role-plays or real
  interactions

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Tx Strategy 9. 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.

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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

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

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Sample Script
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(No Transcript)
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Video Example Embedding Strategy Instruction in
Contextual Therapy

• Jerry/Kim
• OR Jerry Ben
• OR Ben Cliff

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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

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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
  should
• prestore a message
• explain how you communicate up front

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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
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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.

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Video Illustrations

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

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THINKDISCUSS
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D. Group Intervention Approaches for Long-Term
Aphasia

1. Rationale for Group Therapy/Discussion
2. Descriptions of Various Group Models (note
   apology)
3. The Nebraska-Pittsburgh Thematic Discourse
   Model

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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
  goals
• 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?

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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

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3. 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

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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

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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

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Problem-Solving Approach cont.

• Examples of Activities
• communicating in an emergency
• meeting new people
• preparing for a doctors visit
• self disclosure

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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
  paperwork

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b) 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

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

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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.

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

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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

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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

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North 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)

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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

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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
  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)

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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

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Arizona 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

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Arizona 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

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Arizona 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.

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e) 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.

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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
  sessions)
• 5 to 8 persons per group
• caregiver groups bimonthly
• SLPs facilitate

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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

114
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

115
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

116
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

117
Family Based Intervention for Chronic Aphasia
(Univ. of Washington) continued

• Facilitatory Behaviors
• comment
• clarify
• cue

• Nonfacilitatory Behaviors
• interruption
• interrogation
• repetition request

118
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

119
Discussion

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

120
g) Group Therapy The Nebraska-Pittsburgh Model
121
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 Moir
• Ever-increasing demand for services at the
  post-acute rehabilitation phase

122

• 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

123

• 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
  social-pragmatic
• Some comprehension challenges.
• May communicate by speaking or supplement speech
  with alternative communication strategies

124

• 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

125

• 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

126
Purposes (4) of Therapy Groups

• 1) To improve linguistic skills
• Semantic
• Discourse
• 2) To improve interactional skills in
• Conversational Contexts
• Transactional Contexts

127

• 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)

128
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

129

• 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

130

• 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?

131

• 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

132

• 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

133
Structure of the Model 4 phases

• 1) Conversation
• 2) Context-Building
• 3) Language Mediation
• 4) Discourse

134
Group measurement scale found in your handout
packet on page 60
135
Reference

• 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.

136
Part V Professional Issues, Future Directions,
Discussion
137
A. Programmatic Issues

• 1. Funding for Therapy
• 2. Funding for Equipment
• 3. Reestablishing our role
• 4. Measuring Change/Effectiveness

138
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

139
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

140
www.aac-rerc.com
141
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
  hospital
• Outside vendors of orthotics and prosthetics

142
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.

143
Is AAC is unique, or is it just another
enhancement to overall language therapy?
144
4. 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

145
B. Delivery of Therapy

• 1. Increasing contextual opportunities
• 2. Implementing group therapy

146
C. 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?

147
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?

148
Goal Communication