Part IV: Integrated Therapy Approaches

1. Part IV: Integrated Therapy Approaches

2. A. Introduction • The challenge: How do we enable people with aphasia to participate once again in meaningful life activities? • Teach communicators to use AACandnatural communication strategies in a purposeful and understandable manner?

3. 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

4. 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.

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

6. The “granola” approaches….

7. 1. Pragmatic Therapy ApproachPromoting 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.

8. 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.

9. 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…

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

11. 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 sender’s message out of view of the receiver (pictures face down) • 3) Free choice of channels: (any modality at any moment – whatever works)

12. 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.

13. 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.

14. Sample P.A.C.E. Stimulus Pictures (Edelman, 1985).

15. g. Implementing the Treatment Task • see principles. • KG/student Demo • h. Progress – see 5-pt. scoring system on your handout.

16. 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

17. 2. Functional Approach • a. History: - 1980’s and 1990’s. • Systems theory took hold; rehab dollars became tighter. • b. Description: • 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”

18. 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.

19. d. Populations: • communicators with aphasia who • can self-correct in some situations; • aren’t below the 10th %ile on the PICA, • can sustain attention

20. 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

21. 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

22. 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 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)

23. 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

24. 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

25. 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).

26. 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.

27. c. Populations • Allpeople 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)

28. 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

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

30. 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.

31. 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.

32. 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

33. 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

34. 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.

35. Sample page from Kagan et al.’s Pictographic Communication Resources

36. 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

37. 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.

38. 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: aphasia@aphasia.on.ca. • Kagan, A. (1998) Supported conversation for adults with aphasia: methods and resources for training conversation partners. Aphasiology, 12, 816-830.

39. 5. Environmental Approach • a. History: • 1980’s and 1990’s. 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.

40. 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

41. 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 -

42. 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

43. 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.

44. Example of Architectural Modifications to Enhance Communication/Social Roles Steinfeld, E. (1997) Jpeg

45. C. Specific Individual Therapy Techniques to Improve Communication Skills in Meaningful Contexts

46. 1. Basic Strategy Learners • Emerging (Basic Choice) Communicators • Contextual Choice Communicators • Transitional Communicators • “anyone who doesn’t think to turn to external symbols/strategies to convey meaning when unable to do so verbally”

47. 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…..

48. 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.)

49. 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.

50. 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)