The Aphasia Therapy File

Volume 2

Sally Byng, Judith Felson Duchan, Carole Pound, Sally Byng, Judith Felson Duchan, Carole Pound

• Publisher: Psychology Press
• Year: 2013
• ISBN:
  9781135426521
• Edition: 1
• Topic: Médecine
• Subtopic: Audiologie et orthophonie

The Aphasia Therapy Files represent a practical resource for people who work with individuals with aphasia, either as therapists or as researchers. An overview of issues associated with current practices is combined with a study of the practicalities of determining, designing and implementing therapies.

This second volume continues to explore the possibility of bridging the gap between therapy in a clinical setting and the practical issues faced by the person living with aphasia. Each author presents one or more of their clinical practices in order to share their therapy experiences and reasoning with others. These contributions provide an insight into the complex issues that face both the practitioner and the person with aphasia, including discussion of subjects such as:

Revealing competence and rethinking identity for people with severe aphasia using drawing and a communication book

Respecting the rights of a person with aphasia to their own life choices: a longitudinal therapy study

A group approach to the long-term rehabilitation of people with acquired head injury within the community

Lexical and functionally based treatment: effects on word retrieval and conversation

While each of the chapters is of considerable interest on its own, the final chapter offers readers a method of describing and capturing what happens in therapy and why, to enable comparisons between therapies and application by readers themselves.

Written by speech and language therapists working in clinical practice, the studies included in this unique resource reflect the realities of everyday practice and will appeal to therapists, students and researchers in aphasia.

1
Introduction: Describing therapies for aphasia

Sally Byng and Judith Duchan

This book is about different ways of thinking about, describing, and carrying out aphasia therapy. The authors present one or more of their clinical practices in order to share their therapy experiences and reasoning with others. The book's aim is to provide aphasia therapy practitioners with new therapy resources and to challenge them to reflect on their own therapy decisions, processes, and successes.

This is the second volume to grow out of the aphasia therapy symposia organised by the British Aphasiology Society. This has been a biennial event at which speech and language therapists/pathologists, clinical linguists, and psychologists from across the UK and beyond come together to discuss in detail their experiences of doing therapy with people with aphasia. Feedback on the first volume of The Aphasia Therapy File (Byng, Swinburn, & Pound, 2001) was positive. Many felt it served to fill a gap in the therapy literature, providing them with a forum for presentation of discussion to which both therapists and students could relate.

The papers here are slightly different from those published in the first volume. The first volume of The Aphasia Therapy File set out to provide a forum for the people who actually do the therapy, the therapists as opposed to the people who more generally get the opportunity to write, reflect, and talk about it, that is, academic researchers/therapists. This second volume has a slightly different authorship: More of the chapters represent collaborations between people in clinical practice and those working in academic practice. As a result some, but not all, of the chapters are closer to research papers than were those in the first volume. While different in format, this volume is like the first in that it is written with a spirit of exploration and with the intent of tackling difficult clinical issues. For these reasons the chapters vary considerably, reflecting to some extent the personal styles of the authors, as in the first volume.

About the Chapters in This Volume

Below is a brief synopsis of each of the chapters in this volume. Together they offer readers a vivid sense of how aphasia therapies and their descriptions differ depending upon the clinician, the client, the framework that clinicians work in, and the chosen writing styles. The final chapter, Chapter 15, offers a way to examine the commonalities across the chapters, despite their differences, and a way to uncover some of the rationales the authors used to select their therapies. The synopses are presented in alphabetical order by the first author. This ordering is deliberate, even though it has the effect of separating chapters that address similar issues. We are keen not to categorise these therapies because we are concerned that the literature on aphasia therapy is littered with descriptions, and polarisations, of "approaches". Rather, we want the reader to take each therapy at face value for addressing the issues it seeks to address, rather than labelling it as being an example of a type of approach. We deal with this issue in further detail in Chapter 15.

The synopses provided in this chapter are intended to guide the reader to identify which chapters may address similar issues; these issues may be tackled using different methods of therapy. The commonalities and differences between the issues addressed are summarised at the end of this chapter.

Deborah Cairns’ therapy with Tony (Chapter 2)

Deborah Cairns' story of her therapy encounter with Tony conveys how powerfully someone can communicate without language. So often therapists struggle to persuade people with aphasia to be prepared to use multimodal means of communication, and yet in Tony's case it seems that the initiative came from him. Deborah describes how she and the students working with Tony had almost to run to keep up with Tony's clarity about what he was trying to get out of therapy. She conveys how Tony seemed to know just what he wanted—the job of the therapist was to figure that out and respond creatively to it.

The contribution of the therapy group comes across powerfully. Tony uses the group context effectively both to understand the impact of his communication on other people, and also to regain some of his identity by playing a leading role in the group—a role that was familiar to him prior to his stroke. How Tony's therapy would have developed without the opportunity to work in a group is hard to imagine.

Tony's story also conveys how communication strengths can turn out to cause barriers that have to be overcome. Tony's familiarity with communicating across language barriers seems to serve him well in being prepared to use all the means of communication at his disposal. And yet, the intrusion of one language upon another also causes both him and his interlocutors frustration as they try to pick out and follow Tony's meaning. His enthusiastic commitment to therapy could also prove to be overwhelming. His impatience to move on and yet his absorption in some aspects of the process sometimes made the therapists feel that he had lost sight of the practicalities and rationale of the therapy. However, through this process he also conveyed clearly his own rationale, which was different from that of the therapists.

The dynamic nature of goal setting with people with aphasia is revealed in this story. In the process of working towards one goal—in this case, developing a communication book—a different more subtle goal is revealed; that of creating a personal portfolio for Tony to convey who he is and his own story. This goal was set in a context in which (a) the therapist did not consider that a communication book could be used to help form an identity and (b) Tony had difficulty conveying what he really wanted out of therapy. The eventual outcome grew out of the ongoing interaction between the therapist and the person with aphasia.

Tony's experience of bilingualism offers opportunities to use his second language as an alternative means of communication, but creates its own difficulties. The "therapy" related to his bilingualism, which aimed to investigate the conditions under which one language intruded upon another, led to further communication breakdowns, Deborah Cairns described this therapy with inverted commas around the term "therapy". That is because there wasn't any therapy as we usually think of it. Rather it was "an opportunity to consider his own language in a more experimental spirit".

This spirit of experimentation corresponds well with the experience of many therapists, who report that people's aphasia changes during the process of assessment or exploration (hence the need for a category called "checks" in the framework described in Chapter 15, to account for the exploratory nature of some therapies). It seems that some people with aphasia can use that process for themselves as an opportunity to understand what is happening with their changed language—to see what happens when they try different tasks in different structured contexts. The therapist's role is to set up the appropriate range of structured contexts and then perhaps to provide explanations about why they have done what they have. It appears in Tony's case that this process in and of itself was sufficient to enable him to gain enough information about what he was doing linguistically to change aspects of his language behaviour.

Deborah Cairns' chapter offers a number of ways to consider a therapist's role, but a principal one might be as a developer of contexts in which people can do their own changing. That is, the therapist does not have to set up repeated practice exercises for the person to engage in. Rather she created the conditions to enable Tony to use those contexts to find what he wanted. She has done this by communicating in a group, enabling the group to develop its own topics, and through provision of models. Throughout, she has responded to his choices and reactions, through careful listening and attention to how Tony reacts and responds.

The therapy summarised in the framework (see Chapter 15) illustrates how some of the negotiation around the communication book was achieved, but more centrally, the summary shows how the whole therapy process really represents the creation of the conditions for therapy to take place, enabling Tony to make his own choices and to use the materials to develop the therapy as he wished to achieve his own ends.

Claire Gatehouse and Liz Clark’s therapy with WL (Chapter 3)

The enormity of the impact of aphasia upon someone's life is underlined again in WL's story from Claire Gatehouse and Liz Clark. The list of positive factors and difficulties facing WL is daunting (see a summary in Tabic 15.3, Chapter 15). Yet this is the reality of aphasia for people who live with it. This story reveals the wide array of areas of work to be undertaken by the speech and language therapists trying to deal with that impact. The story chronicles the thinking of the two therapists principally concerned with providing therapy for WL's aphasia, and in so doing it also reveals the exclusion and isolation faced by people with aphasia.

Where do you begin when everything in someone's world has changed overnight? Gatehouse and Clark's chapter illustrates the pragmatic solution reached to deal with the small amount of time available to offer to WL. Therapy was carefully devised as language-focused tasks that could be done at home. However, this is not without its challenges—especially given the stigma of aphasia, which became apparent for LW as time went on. What must it feel like to work on language tasks at home, when the people around you do not understand what aphasia is and when the only other experience of doing this type of task is school-based?

The dilemma of managing it all—of trying to conduct well-controlled therapy, to monitor the effects of what you are doing, to see the impact of one aspect of language processing on another when you have one session available a week to see someone in an acute care setting and do not have the luxury of time to collect data, is well illustrated here. The therapist's frustrations are palpable. The difficulty of teasing out whether the effects are due to spontaneous recovery or therapy is enormous.

This is frustrating for a therapist wishing to understand the specific effects of the therapy or to illustrate the contribution of therapy to theoretical knowledge about language processing. This desire to know the impact of one's efforts is even greater in the professional atmosphere, where one is asked to provide evidence for the effectiveness of one's therapy. In situations where there is lack of service (presumably because of assumptions made by others about its relative effectiveness compared to other services), the pressure to prove the relevance and impact of your service feels all the more critical.

The story of WL's therapy includes how some of the social barriers that WL was facing were addressed through action by the therapist. The framework description (see Chapter 15, Table 15.3) reveals the different nature of the therapist's role in this type of therapy—involving negotiation. interpretation between people, explanation, preparation, and planning, to involve a much wider set of agencies. This role was carried out in a different setting, still involving just one session a week. However, the way that the session was used was very different—not necessarily involving face-to-face contact with the person with aphasia. This is very often the sticking point: Therapists are sometimes under pressure to monitor direct contact time with individual "cases". The results achieved by using therapy time flexibly, for interpreting, explaining, and negotiating, speak for themselves.

The long-term nature of the service WL required, the sense that issues revealed themselves over time, and that you cannot rush someone's coping process, are all important lessons from WL's therapy. One size doesn't fit all either: WL decided that counselling wasn't for him, and there is a clear sense that a lot more water has to go under the bridge with WL before he would be ready to develop a portfolio as Tony did in the previous chapter.

Debbie Graham’s therapy with KB (Chapter 4)

Debbie Graham's chapter is written trom the perspective of someone working in a busy rehabilitation setting, but who was able at that time to provide long-term and intensive rehabilitation— something few clinicians are able to do these days. This short report from a clinician in practice reflects the real-life imperative of needing to get on with therapy, with the urgency that acute stroke and aphasia bring. Debbie conveys clearly how, in practice, therapists are often guided by their own implicit theory of the priorities to address through therapy. For most therapists the reality is that there is neither the time nor the appropriate resources and materials to do thorough, theoretically motivated and well-controlled assessment, let alone before and after evaluations, to demonstrate "scientific" evidence for change through therapy.

This chapter reflects KB's need to regain the use of, and control over, his language that he had before his aphasia struck, given its importance to his identity. This challenged Debbie Graham to keep up with his changing language and to continue, in turn, to challenge KB. The report captures the pressures and complexities of working with people whom professionals might see as having only relatively "mild" aphasia, in the same way that we often construe the complexities that people with more "severe" aphasia offer.

The therapist's familiar dilemma—whether to focus on repairing language, on developing strategies to circumvent difficulties, or on facilitating the gaining of confidence to use newly emerging language and communication skills in real-life contexts—is also clearly drawn. This author spells out the decisions she took, but also opens up the questions for others to consider.

Julie Hickin et al.’s therapy with HM and PH (Chapter 5)

The complex impact of changes to communication is again illustrated in Julie Hickin et al.'s work with HM and PH. This chapter describes a controlled experiment to compare and explore the effects of providing therapy in different ways. Opportunities to use specific words in a range of structured communication activities provided a context for two people with aphasia to see if they could regain ability to use the names of the learned words, and to see what the carryover effects were. Would they be able to use the words they learned in a highly structured task in conversation and would they be able to find more words generally as a result of this therapy?

Both people showed positive changes in their ability to use the names learned after each of the therapies. Predictably, however, they showed different patterns of change following the two therapies, with one person appearing to make more gains after the first therapy than the other person, and only one of them making gains in finding names not learned in the therapy.

Interestingly, the person who made most gains from the two therapies was HM. The summary in the framework (see Chapter 15, Table 15.5) illustrates that, of the two of them, he is probably the person who has least opportunity in his day-to-day life to have conversations, and is possibly the more isolated of the two (although this is, of course, pure supposition). Could it be that having more opportunity to communicate purposefully in the therapy setting enables him to use latent communication skills, for which he has the potential but no opportunity to use?

The course of evaluating therapy never does run smooth, however. It is HM who has made the most measurable gains in naming and who perceives that words seem harder to find in conversation at the end of therapy than at the beginning. Is this because HM is attempting more conversation than he did previously, so could this perception of greater difficulty actually represent a positive outcome in some respects? This is an important issue forevaluators in an evidenced-based healthcare culture: From whose perspective are the outcomes that make up the evidence, and how do we interpret the potential meanings and complexities thrown up by those outcomes?

Sally McVicker and Leonie Winstanley’s therapy with a group of people facing communication and cognitive difficulties following acquired brain injury (Chapter 6)

Sally McVicker and Leonie Winstanley describe a group for people coming to grips with living with cognitive and communication impairments, including in particular memory and attention difficulties. Negotiating different levels of awareness, self-perception, and retention of material proved challenging, but was supported by careful preparation of a programme with accompanying materials.

MeVicker and Winstanley use a stringent gauge of the outcome of therapy, documenting not only whether goals have been attained but also whether group members have been able to apply the knowledge gained to make a difference in real life. For two of the group members this seems not to have been the case, representing a difference between knowing something about yourself and being able to act on that knowledge.

This further complicates the issues about assessing outcome that we referred to earlier. So much reha...