Transcript Strategic Use in Context: AAC, Supported Conversation, and

Part IV:
Integrated Therapy
Approaches
1
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:

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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
3
This is not an entirely new
philosophy

Let’s 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
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1.
2.
3.
4.
5.
Pragmatic Approach
Functional Therapy Approach
Life Participation Approach
Supported Conversation
Environmental Communication
Therapy
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The “granola”
approaches….
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1. Pragmatic Therapy Approach
Promoting Aphasic’s Communicative
Effectiveness (PACE)
 a. History:
Albyn Davis and Jeanne Wilcox promoted
this approach in the 1980’s.
 Thought that goal of tx was to improve
patient’s 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 faceto-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:
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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 sender’s
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 clinician’s
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
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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)
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In terms of clinical implementation, is
MORE structured than the general
participation philosophy
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2. Functional Approach
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a. History: - 1980’s and 1990’s.
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Systems theory took hold; rehab dollars
became tighter.
b. Description:
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Any activity that seeks to improve the
patient’s 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:
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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;
 aren’t below the 10th %ile on the
PICA,
 can sustain attention
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e. Principles
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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
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1) Eliminate Negative Communication
Behaviors e.g., impulsive patients
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have to “wait”, patients who fake
understanding have to signal comprehension
breakdowns, patients who don’t 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 there’s
a meaningful communication goal
with a real communication
partner
6) Train significant others
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g. Measuring progress:
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Nothing specified.
Could use ASHA-FACS, etc.,
language samples, functional
communication scales
h. Summary of this approach:
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Pros
Cons
With whom
When
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3. Life Participation Approach
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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:
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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
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All people with aphasia and their
partners
anyone else affected by aphasia
d. Research Bases:
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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:
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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)
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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
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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
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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:
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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
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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

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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.
We’ll 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: (416)
226-3706, Website: www.aphasia.on.ca.
Email: [email protected].

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
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a. History:
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1980’s and 1990’s. Systems theory took
hold in U.S.; rehab dollars became tighter.
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b. Description:
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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:
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Mostly conceptual/theoretical to date,
although some “systems theory”
research exists for other populations.
(e.g., dementia)
d. Populations:
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all communicators with aphasia
KG - especially our nonspeaking
communicators or people in long-term
care facilities
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e. Principles:
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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 41
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f. Implementing the Treatment Task
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1)
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2)
Modify the individual as much as
possible
Focus on the family or
communication partners
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3)
Teach strategies
Educate
Modify the environment
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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 – there’s
a tablet on the T.V.
Explain what’s coming
up…point to my schedule or the
calendar.
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Example of Architectural Modifications to
Enhance Communication/Social Roles:
Steinfeld, E. (1997)
gif
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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
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Emerging (Basic Choice) Communicators
Contextual Choice Communicators
Transitional Communicators
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“anyone who doesn’t 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
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Some communicators with
severe aphasia (across
modalities) appear to have an
elemental challenge in
referencing ability
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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 another’s 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 individual’s 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
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For turn-taking
For requesting additional
information
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“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.
55
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b) Tangible Referent Identification

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To request visible items (e.g., water)
to answer questions
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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
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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!”
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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)
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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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Tx Strategy #2. Teach clear signals
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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 it’s a bad idea too”)
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Teaching John “Yes” and
“No”
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Tx Strategy #3. Gradually
extend interactional length

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Expect full conversations
Expansion on a topic
Completion of an entire transaction
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(e.g., buying EE shoes – not done
communicating until the shoes are in
the bag)
62
Tx Strategy #4. Use VOCAs to teach
independent message initiation
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Use hand-over-hand assistance (HOH)
to assist PWA to activate 1 message
in motivating context -- maximize
success. Examples:
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“Welcome everyone” at the beginning of group
therapy
“Tell me about school!” when grandchildren
visit
“Did you hear that we’re 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!”)
Big Mack by AbleNet -- $92.00
64

STEP 2: Access sequence of
messages to convey “NEWS” on a
Voice Output Communication Aid
(VOCA)
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no symbol selection/discrimination
demands (all are activated)
Minimal sequencing demands
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Example
Guess
what! We
went
gambling
and I won
$500!
I spent it
already - a
necklace
for my
wife, and a
lobster
dinner.
I’m such a
great guy…
#1
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
STEP 3. Access semantically specific
messages to answer specific
questions – must discriminate
between messages and then choose
I’d like to
order….
STEAK
rare
LOBSTER
PORK
CHOPS
Welldone
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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
House’s 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 don’t CARE! It’s 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
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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….
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
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 communicator’s pocket.
 Use verbal or physical cues to
trigger presentation of remnant in
response to peer question “What’s
new?”
 Fade cues as appropriate
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Video Illustrations
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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…
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Vocabulary selection
System design
Identifying communication
opportunities in the community
Participating in partner role-plays or
real interactions
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John & wife Judy – adding info to
Dynavox about a story
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Tx Strategy # 9. Add new
strategies 1 at a time. Ex…

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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
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Set up scripted conversational routines –
practice then “do it!”
Develop roleplays – assemble vocabulary,
make choices, practice script, invite novel
partners
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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
83
84
Video Example –
Embedding Strategy
Instruction in Contextual
Therapy
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Jerry/Kim
OR Jerry & Ben
OR Ben & Cliff
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2. Advanced Strategy
Learners
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Purpose of instruction at this level is
to increase PWA’s independence
and ability to think purposefully
about using communication
strategies
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Transitional Communicators
Stored Message Communicators
Generative Communicators
86
Tx Strategy #11: Ask PWA -- “Which
strategy could you use?”

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“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:

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prestore a message
explain how you communicate up front
87
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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Mike talking about his WWII medal
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Tx strategy #12. Tax the communication
with additional discourse demands

Increase interactional demands

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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 shoe’s return
From telling 1 item about weekend to telling a story
and answering questions about it.
90
Video Illustrations
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Asking spouses out for a date
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Speech/gestures (Steve)
VOCA (John)
Conversation with Dynavox – (Don)
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THINK…DISCUSS
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D. Group Intervention
Approaches for Long-Term
Aphasia
1.
2.
3.
Rationale for Group Therapy/Discussion
Descriptions of Various Group Models
(note: apology)
The Nebraska-Pittsburgh “Thematic
Discourse” Model
1.
Rationale for Group Therapy

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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 longterm rehabilitation services
Current Practices: England and the U.S.
Do you offer group therapy in your facility?
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2.
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Description of Group Models
A) General Types of Groups
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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
************

Marshall’s ProblemSolving Approach

Holland & Beeson’s
Convers. Groups

Avent’s Cooperative
Group Treatment

Aphasia Center of CA

Family Based
Intervention (Univ. of WA)

Nebraska Scaffolded
Discourse Approach

Kagan’s Toronto
CommunityProgram
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a) Marshall’s Problem-Focused
Group Tx – Oregon & Rhode Island
Veteran’s Hospitals



targets independent
persons with mild
aphasia
designed to help
individuals cope with
day-to-day problems
clinician serves as a
facilitator only
97
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

98
Problem-Solving Approach cont.

Examples of Activities
communicating in an emergency
 meeting new people
 preparing for a doctor’s visit
 self disclosure

99
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

100
b) Avent’s 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
101
Avent’s 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 moderateseverely impaired communicators
home program set up prior to discharge
funding structure unknown
102
Avent’s 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.
103
Avent’s 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
104
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
105
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

106
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)

107
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

108
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
Ryff’s 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)
109
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
110
Arizona Conversation Groups (Holland & Beeson) cont.

Organizational Structure
serve approximately 40 individuals with
aphasia (8 groups of 5-7 individuals @)
 1 X per week/1 hour sesssions
 facilitated by graduate students with
supervision
 separate groups for family members
 private pay - $10 per session

111
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

112
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.
113
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.
114
The Aphasia Center of California (Elman & BernsteinEllis) 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

115
The Aphasia Center of California (Elman & BernsteinEllis) 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
116
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

117
The Aphasia Center of California (Elman & BernsteinEllis) 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

118
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
119
Family Based Intervention for Chronic Aphasia: (Univ. of
Washington) continued
*************************************

Facilitatory
Behaviors



comment
clarify
cue

Nonfacilitatory
Behaviors



interruption
interrogation
repetition
request
120
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

121
Discussion



Which aspects of these group
models appeal to you?
Who might benefit from these
approaches?
Cautions???
122
g) Group Therapy – The
Nebraska-Pittsburgh Model
123
History


University of Nebraska-Lincoln - 19931997: Garrett & Ellis
 Student training programs
 Adults with a wide variety of aphasia
types, ages, backgrounds
Duquesne University (Pittsburgh) - 1998present: Garrett & Staltari
 Ever-increasing demand for services at
the post-acute rehabilitation phase
124
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 socialpragmatic 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 don’t feel the same”
125

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
126

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 they’re
talking about; attending to relevant
info/conversational partners; engaging in
reciprocal exchanges
127

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
workman’s comp or Office of Vocational Rehabilitation
Sertoma scholarships for individual clients
Private pay – reduced fee schedule option
128
Purposes (4) of Therapy Groups

1) To improve linguistic skills



Semantic
Discourse
2) To improve interactional skills in


Conversational Contexts
Transactional Contexts
129

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)
130
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
131
 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
132
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?
133

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
134
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
135
Structure of the Model – 4 phases




1) Conversation
2) Context-Building
3) Language Mediation
4) Discourse
Turn to the grid representing
the group model – Section on
group therapy
136
VIDEO ILLUSTRATION –
GROUP in ACTION
137
F igure *.* A p h asia G rou p C on versation al C om p eten ce R atin g S cale
C om m u n icator:
R ater:
In stru ction s:
1.
(C ) G arrett & S ittn er, 1996
C on text:
D ate:_____________
******************************************** *****************
O bserve th e com m u n icator in an in teractive grou p con text. C ircle you r ratin g.
H ow m uch did the com m unicator participate in the interaction?
< ------------------------------------------------------------- ------------------------------------------------------------------------------------ >
1
2
3
4
5
6
7
none
som e
a lot
2.
H ow m uch of the tim e w as C om m unicator X able to get his/her m essage across?
< ------------------------------------------------------------------------------------------------------------------------------------------------- >
1
2
3
4
5
6
7
none
som e
a lot
3.
H ow m uch of the tim e did C om m unicator X take an active role in the intera ction by asking questions,
com m ents, or ex pressing opinions?
generating unsolicited
< ------------------------------------------------------------------------------------------------------------------------------------------------- >
1
2
3
4
5
6
7
no ne
som e
a lot
4.
H ow frequently did C om m unicator X use different w ays of com m unicating w hen trying to get his or her
(i.e., speaking, w riting, A A C system , etc.)?
m essage across
< ------------------------------------------------------------------------------------------------------------------------------------------------- >
1
2
3
4
5
6
7
didn’t use
used som e
used m any
m ethods
different m ethods
different m ethods
5.
H ow flex ible and stra tegic w as the com m unicator w hen trying to convey m essages that w ere not understood
by listeners?
< ------------------------------------------------------------------------------------------------------------------------------------------------- >
1
2
3
4
5
6
7
not flex ible
som e
very
flex ibility
flex ible
6.
H ow m any com m unication functions (e.g., asking questions, arguing, giving advice, greeting,
use w hen conveying m essages?
Group
measurement
scale found in
your handout
packet on
page 60
com m enting) did the com m unicator
< ------------------------------------------------------------------------------------------------------------------------------------------------- >
1
2
3
4
5
6
7
none
som e
a lot
7.
O n a scale of 1 to 5, how w ould you rate C om m unicator X 's overall com m unication ability?
< ------------------------------------------------------------------------------------------------------------------------------------------------- >
1
2
3
4
5
6
7
poor
som e
good
com m unication
com m unication
com m .
ability
ability
ability
138
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: ButterworthHeinemann. Pp. 85-96.
139
Part V:
Professional Issues, Future
Directions, Discussion
140
A. Programmatic Issues




1.
2.
3.
4.
Funding for Therapy
Funding for Equipment
Reestablishing our role
Measuring Change/Effectiveness
141
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
142
2. Funding for Devices


1. State Technology Projects Loaners
2. Private Insurance





Aetna - SGD’s
Tri-Care (military)
3. Medicaid (some states)
4. Medicare – SGD’s
5. Private Pay
143
www.aac-rerc.com
144
Special Issues



DME - devices should be described as
being “durable medical equipment
You need to find an authorized vendor
of DME equipment - usually can’t have
it in same hospital
Outside vendors of “orthotics and
prosthetics”
145


Only certain devices are covered.
Only certain manufacturers are on
the list of Medicare and insurance
providers - BECAUSE they are not
reimbursed in full (they’re
reimbursed at Medicare level rates)
146
Work of Medicare AAC Implementation
Team – through ASHA

Joanne Lasker – p. 61

Good organization schema for
ordering Speech Generating Devices
(SGD’s) for people with aphasia
“No Technology”
 “Low Technology” – digitized devices
 “High Technology – combine symbols,
writers

147
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.
148
Is AAC is unique, or is it just another
enhancement to overall language
therapy?
149
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
150
B. Delivery of Therapy


1. Increasing contextual
opportunities
2. Implementing group therapy
151
C. Research questions and
future directions





Measurement of use of strategies in reallife 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?
152
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?
153
Goal
=
Communication
The End
155
Discussion!!!
156