Language and Cognition Colombo June 2011

1. Language and CognitionColombo June 2011 Day 7 Working with conversational partners

2. Models of Service Delivery • Impairment based approach • 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

3. 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

4. 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

5. 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.

6. 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

7. 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 aphasiaSimmons Mackey in Chapey 2008

8. 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

9. A review of Conversational Partner TrainingTurner 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.

10. Methods • Extensive literature review of databases • Reviewed; data extracted on: • Participants, • CPT approach used • Outcomes • Maintenance of effect

11. 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)

12. 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

13. 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)

14. 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

15. 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

16. 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

17. 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.

18. Long Term Effects of CPT • Many articles did not follow up. • Those that did found maintained effects up to 3m post training

19. 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

20. 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.

21. 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