Transcript Language and Cognition Colombo June 2011

Language and Cognition
Colombo June 2011
Day 7 Working with conversational
partners
Models of Service Delivery
• Impairment based approach
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Restorative/rehabilitative
Reliant on formal testing
Little generalisation to everyday life
Gains made may be small and not functionally relevant.
Gaps in linguistic measures and real-life functional
performance
• Functional Skills approaches
– Ability to utilise compensatory strategies
– Reliant on tasks used in everyday life e.g. Using phone
– Still does not account for personal experiences/lifestyle
adjustments
Rationale for Social model
approaches
• Aphasia
– chronic disorder
– Long term communication deficits impacting on
daily life
– Need to acknowledge impact of aphasia on
psychosocial aspects
– Self-esteem
– Role and identity within a family unit
– Relationships
– Acknowledgement of PWA limitations in rights
and opportunities
Values Supporting the Social Model
• Disability if a consequence of disabling
attitudes and barriers imposed by society, not
just an impairment within the individual.
• Aphasia is a diagnosis but also a socially
constructed way of being that is created
through the experiences of the person with
aphasia, those around the person and society
(Penn 2004 p292 in Chapey 2008)
• PWA and their families share control and
decision making with clinicians
Principals of a Social Model
Approach (Chapey 2008)
• Addresses both information exchange and social needs as dual goals. Less
focus on transaction of a specific message, and more on the interactive
process
• Addresses communication within relevant and natural contexts
• Views communication as dynamic, flexible and multidimensional
• Focus on the collaborative nature of communication
• Focus on natural interaction particularly conversation
• Focus on personal and social consequences of aphasia
• Focus on adaptations to impairment
• Embrace the perspective of those affected by aphasia
• Encourage qualitative as well as quantitative measures.
Objectives of Partner Training
• Speaking partners learn strategies to support
communication when aphasia interferes.
• Use of augmentative tools by the partner to
encourage the PWA to use the same
• Altered expectations and perceptions of PWA
• Expand opportunities for conversation by
alleviating embarrassment, helplessness, fear
• Encourage life participation and reinforce joint
responsibility for success
Creating Authentic Communication
Events
• Relevant life activities:
– Leisure, exercise and conversation groups, e.g.
Book club with adapted materials and facilitated
group discussion.
• Relevant client centred life situations
– Cooking, gardening, volunteering
• NB Not aiming for pre-aphasia lifestyle. Aim for
satisfying life with aphasia Simmons Mackey in Chapey 2008
Providing support systems within
the community
• Training of family and friends of the individual
to build expanded support systems
• Set up of peer mentors: PWA + PWA pair
• Community education through church groups,
businesses, education institutions to increase
public knowledge
A review of Conversational Partner Training
Turner and Whitworth 2006
• Review of current literature to examine:
– The reported success of studies adopting
conversational partner training approaches
– What aspects of communication were being improved
and how these were being measured.
– How participants were being selected and
subsequently reported.
– The nature of the participants’ involvement in the
intervention, examining how influential (if at all) their
individual characteristics were considered to be to the
outcome.
Methods
• Extensive literature review of databases
• Reviewed; data extracted on:
– Participants,
– CPT approach used
– Outcomes
– Maintenance of effect
Results
• 9 papers included
• 3 intervention approaches used:
– Conversational Analysis
– Supported Conversation for Adults with Aphasia
(competence of PWA exposed through skilled CP)
– General total communication approach with
conversational coaching (examines message
exchange plus social communication skills
appropriate to specific events)
Characteristics of the Person with
Aphasia
• Mean age 58yr
• 4-178m post onset of stroke
• Functional comprehension in conversation
(Mild/mod receptive impairment)
• Mild-severe expressive difficulties
• Medically stable with few cognitive
impairments
Characteristics of the Conversation
Partners
• Family members (spouse) or volunteers (often
university students = younger)
• Factors influencing selection of participants:
– Carer availability
– Marital harmony
– Motivation
– Potential to change communicative behaviour (of
both parties)
Focus and Format of Training
• Information was given initially on the nature of
aphasia, followed by information specific to the
person.
• Raising awareness of maladaptive conversation
behaviours via the use of video feedback
• Experiential teaching, allowing the opportunity
for practice (role-play situations) with feedback.
• Volunteers: teaching of generic conversation skills
to provide participants with the skills to offer
conversational support for any person with
aphasia in their volunteer role
Outcomes Used
• Conversational Analysis parameters (turns in a
repair, proportion of successful repairs)
• Story telling (% of utterances using supportive
communication)
• Scales by Kagan et al (1999) (assess partner skill
and level of participation of PWA)
• Confidence and satisfaction questionnaires
• VASES and HADS
• BDAE, CAT, and CADL-2
Efficacy
• Very favourable outcomes:
– Positive changes in interaction of familiar partner
(reduced interruptions & use of test questions,
Increased number of successful repairs etc)
– Volunteers increasingly able to reveal
communicative competence of PWA,
knowledgeable about aphasia and useful
strategies
– Increased attempts at interaction for PWA
But...
• Despite clear efficacy demonstrated it still
remains unclear as to whether one particular
approach may be more successful than
another...
• Or whether the stage in a person’s
rehabilitation is influential in the success of
the programme.
Long Term Effects of CPT
• Many articles did not follow up.
• Those that did found maintained effects up to
3m post training
Possible Factors Influencing Outcome
• Relationship harmony between spouses and
premorbid communication styles
• Impact of age, cultural background, education
and motivation on volunteers as
conversational partners
Conclusions
• Favourable outcomes for CPT schemes
• But:
– Poor information regarding conversation partners
esp. volunteers (e.g. Selection criteria, success of
communication prior to training)
– Methodological weaknesses in some studies
– Functional state of relationship and mood, partner
attitudes may influence outcomes
• More research in these areas = better
understanding into what makes communicative
success.
Summary
• The training of communication partners falls
within a social model approach to
intervention.
• Based on the belief that communication is a
social act expressive of ideas/values
• The ultimate aim of a social approach is to
enhance the living of life with aphasia.
Simmons-Mackey in Chapey 2008