Transcript Turin Talk November 2013

RELATIONAL APPROACHES IN
APHASIA AND
ACQUIRED BRAIN INJURY
REHABILITATION
1
Kate Meredith
Speech and Language Therapist
Family Therapist
[email protected]
MY CONTEXT AND POSITION

White British middle-class female

Partner, mother, daughter, sibling, step-daughter…

Speech and Language Therapist working with people with
acquired brain injuries and neuro-disability for 10 years
Medical model of disability
 Social model of disability
 ‘Both/and’ approach

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MODELS OF DISABILITY

Medical model: diagnosis, impairments, activity limitations,
participation restrictions

Social model: disability only exists when society fails to
support difference; removal of barriers can mean people can
experience independence and equality

Both/and: identifying how trained professionals can
contribute to successful rehabilitation across impairments,
activity limitations and participation restrictions, while
considering and influencing societal perception and
integration of disability
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FAMILY THERAPY TRAINING
Family Therapist
 “Family and Systemic Psychotherapy helps people in close relationship
help each other. It enables family members to express and explore
difficult thoughts and emotions safely, to understand each other’s
experiences and views, appreciate each other’s needs, build on family
strengths and make useful changes in their relationships and their
lives” (Association for Family Therapy and Systemic Practice)
Services commonly employing Family Therapists
 Child and Adolescent Mental Health Services
 Older Age Psychiatry
 Eating Disorders
 Couples Therapy
 Addictions
What can be brought into the field of ABI and communication
disorders?
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FAMILY THERAPY AND APHASIA IN THE LITERATURE
Family therapists with experience of working with
communication disorders such as aphasia, or joint work
between family therapists and speech and language therapists
can produce results that are very meaningful for families living
with communication disorders following ABI
(Bowen et al., 2010; Herrmann, 1989; LarØi, 2003; Nichols et al., 1996; Stiell
et al., 2007; Währborg and Borenstein, 1989; Währborg, 1989).
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RESEARCH INTO SPECIFIC APPROACHES WITH
ABI / APHASIA
Emotionally focussed therapy with couples



Stiell & Gailey (2011)
Yeates (2013)
Yeates et al (2013)
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SOCIAL CONSTRUCTIONISM
Key figures: Cecchin, Boscolo, Tomm, Andersen, Anderson and
Goolishan, Burr.
From Vivien Burr (2003):
 Knowledge of the world is constructed within a social
community, through language

Belief systems are highly influenced by social interaction

Interaction occurs through language (verbal and non-verbal
communication) in conversation (spoken and written)
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SOCIAL CONSTRUCTIONISM (2)

Truth is not discovered but constructed

Not constructed by individuals but by communities in
conversation

Useful constructions of objects, events and relationships are
retained in conversation; non-useful constructions are
discarded

Language is a pre-condition for thought

Language can be seen as a form of social action
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SO WHAT HAPPENS WHEN SOMEONE ACQUIRES AN
ABI OR APHASIA?
In worst case scenario:

Not able to contribute to conversation

Not able to influence beliefs held in community (including
family)

Not able to participate in constructing truth and reality

Disempowerment

Isolation
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FAMILY LIFE CYCLE

Families develop through key stages, such as leaving home,
becoming a couple, starting a family, a family with
adolescents, launching children, later family life (including
retirement, illness, death)

Moving between stages involves transition, which can be
challenging and requires family adjustment

The FLC can be disrupted by stressors



vertical stressors such as family secrets, rules, taboos
horizontal stressors such as illness, divorce, bankruptcy
Families can experience stress and anxiety when either type
of stressor is present, which may affect emotional
transactions and the emergence of individual symptoms
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SO WHAT HAPPENS WHEN SOMEONE ACQUIRES AN
ABI OR APHASIA?

ABI can be conceptualised as a horizontal stressor that the
family is required to adapt to and move on with, in order to
fulfil further life cycle goals.

If the family becomes stuck, it is harder to grow and complete
the development tasks necessary to move on to a following
stage (Leaf, 1993).

Do we have the resources and skills to effectively support
these families?
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RESILIENCE

Perlesz et al (1999) – ABI research attends more to relatives’
stress and burden than exploring resilience and positive
family outcomes

Partner coping during chronic illness is influenced by many
factors, including the ability to communicate reciprocally with
one’s partner (Revenson, 2003)

Rolland (1994) believes couples who can communicate
openly, directly and sensitively can better cope with chronic
disorders

Reciprocal communication and affective relations are
important factors in family coping (Anderson et al 2002;
Florian et al 1989, Kreutzer et al, 1994a)
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SO WHAT HAPPENS WHEN SOMEONE ACQUIRES AN
ABI OR APHASIA?

Open, reciprocal communication is associated with coping,
but this is not always possible.

How do couples and families managing communication
difficulties following ABI manage issues such as establishing
boundaries around the illness and achieving balance in their
relationships?

How they can best be supported?
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WHAT CAN WE DO?
Work to:

Avoid silencing of a person with aphasia (PwA)

See the aphasia as a problem for the family rather than
the individual

Promote family growth

Promote resilience
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INVOLVING FAMILY MEMBERS

Invest in therapeutic relationship, considering how our
context influences us

Make invitation clear from the start – this is the way we work

Frame the family as united against the communication
disorder

Problem-free talk: gain understanding of communication in
family prior to the ABI, family strengths, activities, jokes…
what characterises them other than the communication
disorder?
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NARRATIVE THERAPY

What language do we use?
 Victim
 Patient
 Client
 Survivor
 Person

Do we situate people in relation to their ABI forever more?

How can we model a different way of thinking about
communication disorders?
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NARRATIVE THERAPY (2)

People make sense of their world by telling, and listening to,
stories about their lives. These stories are enormously
powerful.

Conversations can shape new realities

Weak voices have little power to change stories

How are PwA’s stories told? What narratives do these begin
to create for them, their partners and their families?

(Can you think of a story told about you by friends or family
that doesn’t fit with your reality? Have you been able to
challenge it?)
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USING NARRATIVE IDEAS IN REHABILITATION







Hear problem fully, understand how it makes them feel.
Separating problem from person – “he’s aphasic” vs. “the aphasia”
Understand the influence of the problem on the person, the couple,
the family. When is it most or least powerful, silencing, or
disruptive to family life?
What influence can they all also have on the aphasia? What
happens to the aphasia when Sarah draws a picture for her father?
Or when Daniel gives his mother more time in conversation?
Have there been other times that the family had to unite against
something difficult? How did they do this?
Reflect on times in recent past where communication has been
easier. Where else can we see this happening? How could we all
work against the aphasia to see more examples of this in the
present and future? More often in this context, moving to other
contexts, different relationships…
Therapeutic letters – witness subjugated stories, give permanence,
historicise progress,
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USING NARRATIVE IDEAS IN REHABILITATION (2)

Consider the power balance in the room. We may have
useful clinical expertise, but our clients are experts in their
own situation, their own story

Reauthoring lives and defining themselves in nonpathologising, non-problem saturated ways

Good examples of externalisation in healthcare:


Race For Life 2013: “Cancer, we’re coming to get you”
Anti-Anorexia league: Epston and Madigan, 1993. "Communities
of people who have taken a stand against the
oppressive regimes of anorexia and bulimia in their own lives
and are prepared to share their stories with others who are
struggling with these problems."
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GENOGRAMS AND ECOMAPS

Largely non-verbal

Permanence of writing and drawing supports comprehension
and retention

Enables understanding of who else to involve, understanding
priorities, functional goals for communication therapy and
potential for isolation

Enables understanding of family life cycle stage and
transitions that may be affected by ABI
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
Genogram example
Dementia
Depression
Lives with May
Visited by Tom most days
Plan to move to care home
Bob
74
Brian
40
May
72
Tom
36
Tom – Stroke 2013
Severe expressive aphasia,
moderate receptive aphasia
Teacher, book club, plays cricket
Due to
commence
privately funded
IVF
Lives in Australia
Alice
34
Mike
78
Sue
70
Kay
30
Ben
28
Teacher
Running club
Sam
10
Final year of primary school
Emergent difficult behaviour
Not wanting to visit father in rehab unit
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
Ecomap example
Bob’s care
home and
professionals
Friends, book
club, cricket,
running club
May’s GP
and
Community
Psychiatric
Nurse
Tom, Alice,
Sam, Bob,
May
Fertility
experts
Tom and
Alice’s work
Sam’s
school
Tom’s
healthcare
professionals
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WHAT NEXT?

Is a new profession of people with skills in family therapy and
neuro-rehabilitation is required? (Johnson and McCown,
1997)

Should there be more professionals working in neurorehabilitation services to complete the 4 year masters-level
training in Family Therapy? (Bowen, 2007)

Without professionals qualified to work in neurorehabilitation and family therapy, will developments in
services will be hindered? (LarØi, 2003)
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FURTHER READING








Bowen, C., Yeates, G. N., & Palmer, S. (2010) A Relational Approach to
Rehabilitation: Thinking about Relationships after Brain Injury. London:
Karnac.
Burr, V (2003) Social Constructionism, 2nd Ed. Routledge: London.
Herrman, M (1989) On the Possible Value of Family Therapy in Aphasia
Rehabilitation. Aphasiology 3 (5).
LarØi, F., 2003. The family systems approach to treating families of persons
with brain injury: a potential collaboration between family therapist and
brain injury professional. Brain Injury 17, 175–187.
Leaf, L.E. (1993) 'Traumatic brain injury: Affecting family recovery.' Brain
Injury 7, 543–546.
Monk, G., Winslade, J., Crocket, K., & Epston, D. (Eds.) (1996)
Narrative Therapy in Practice - The Archaeology of Hope. San Francisco:
Jossey-Bass.
Nichols, F., Varchevker, A., & Pring, T. (1996) Working with People with
Aphasia and their Families. Aphasiology 10 (8).
Shadden, B. (2005). Aphasia as identity theft: Theory and practice.
Aphasiology, 19: 211-223.
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FURTHER READING

Stiell, K. & Gailey, G. (2011). Emotionally focused therapy for couples living
with aphasia. In J.L., Furrow, S.M. Johnson & B.A. Bradley (Eds.), The
Emotionally Focused Casebook (pp.113-140). New York: Routledge.

Währborg, P., 1989. Aphasia and family therapy. Aphasiology 3, 479–482.

Währborg, P., Borenstein, P., 1989. Family therapy in families with an
aphasic member. Aphasiology 3, 93–98.

White, M., Epston, D., 1990. Narrative Means to Therapeutic Ends. Norton,
New York.

Yeates, G.N. (2013). Towards the neuropsychological foundations for
couples therapy following acquired brain injury (ABI): A review of empirical
evidence and relevant concepts. Neuro-Disability & Psychotherapy, 1(1),
117- 150.

Yeates, G.N., Edwards, A., Murray, C. & Creamer, N. (2013). Couples therapy
as social cognition intervention following acquired brain injury: Single case
evaluations of emotionally-focused couples therapy (EFT). Neuro-Disability
& Psychotherapy 1(2), 151-194.
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