Transcript Strategic Use in Context: AAC, Supported Conversation, and
Part IV: Integrated Therapy Approaches
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A. Introduction
The challenge: How do we enable people with aphasia to participate meaningful life activities ?
once again in
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:
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 activities into contextual communication
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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
1. Pragmatic Approach 2. Functional Therapy Approach 3. Life Participation Approach 4. Supported Conversation 5. 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 face to-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:
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
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) In terms of clinical implementation, is MORE structured than the general participation philosophy
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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”
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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.
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d. Populations:
communicators with aphasia who
can self-correct in some situations;
aren’t below the 10 th PICA, %ile on the
can sustain attention
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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
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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
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 is most appropriate for the client (conversational narrative, procedural) that
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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:
Nothing specified. Could use ASHA-FACS, etc., language samples, functional communication scales
h. Summary of this approach:
Pros Cons With whom
When
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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).
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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 .
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c. Populations
All people 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)
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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
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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)
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
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
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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.
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Sample page from Kagan et al.’s Pictographic Communication Resources
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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
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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]
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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
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.
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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
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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 -
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f. Implementing the Treatment Task
1) 2) 3) Modify the individual possible as much as Focus on the family or communication partners
Teach strategies
Educate Modify the environment
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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gif
Example of Architectural Modifications to Enhance Communication/Social Roles: Steinfeld, E. (1997)
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Example of Architectural Modifications to Enhance Communication/Social Roles Steinfeld, E. (1997)
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C. Specific Individual Therapy Techniques to Improve Communication Skills in Meaningful Contexts
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1. Basic Strategy Learners
Emerging (Basic Choice) Communicators Contextual Choice Communicators Transitional Co mmunicators
“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
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…..
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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!” 53
a) Basic Deixis
For turn-taking For requesting additional information
“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.
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b) Tangible Referent Identification
To request visible items (e.g., water) to answer questions
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
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!”
Example: Photo Album
Conversations point to pictures to answer autobiographical questions “Where was your favorite vacation?” 57
Results of current research project on referential communication in aphasia & matched peers
(Garrett et al. 2004)
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
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
Expect full conversations Expansion on a topic Completion of an entire transaction
(e.g., buying EE shoes – not done communicating until the shoes are in the bag)
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Tx Strategy #4. Use VOCAs to teach independent message initiation
Use hand-over-hand assistance (HOH) to assist PWA to activate 1 message in motivating context -- maximize success. Examples:
“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
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STEP 2: Access sequence of messages to convey “NEWS”
on a Voice Output Communication Aid (VOCA) no symbol selection/discrimination demands (all are activated) Minimal sequencing demands 65
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 66
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
Well done
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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 68
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
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….
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 76
Video Illustrations
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…
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…
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 Set up scripted conversational routines – practice then “do it!” Develop roleplays – assemble vocabulary, make choices, practice script, invite novel partners
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
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Video Example – Embedding Strategy Instruction in Contextual Therapy
Jerry/Kim OR Jerry & Ben OR Ben & Cliff
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2. Advanced Strategy Learners
Purpose of instruction at this level is to increase PWA’s independence and ability to think purposefully about using communication strategies
Transitional Communicators Stored Message Communicators Generative Communicators
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Tx Strategy #11: Ask PWA - “Which strategy could you use?”
“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:
prestore a message
explain how you communicate up front
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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 88
Mike talking about his WWII medal
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Tx strategy #12. Tax the communication with additional discourse demands
Increase interactional demands
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.
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Video Illustrations
Asking spouses out for a date
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
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Rationale for Group Therapy
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 long term rehabilitation services
Current Practices: England and the U.S.
Do you offer group therapy in your facility?
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2.
Description of Group Models
A) General Types of Groups
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
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Marshall’s Problem Holland & Beeson’s Solving Approach Convers. Groups Avent’s Cooperative Group Treatment Aphasia Center of CA Kagan’s Toronto CommunityProgram Family Based Intervention (Univ. of WA) Nebraska Scaffolded Discourse Approach 96
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
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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
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Problem-Solving Approach cont.
Examples of Activities
communicating in an emergency
meeting new people
preparing for a doctor’s visit
self disclosure
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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
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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
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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 moderate severely impaired communicators
home program set up prior to discharge
funding structure unknown
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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.
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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
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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
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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)
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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
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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)
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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
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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
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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
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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.
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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.
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The Aphasia Center of California (Elman & Bernstein Ellis) 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
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The Aphasia Center of California (Elman & Bernstein Ellis) 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
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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
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The Aphasia Center of California (Elman & Bernstein Ellis) 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
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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
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Family Based Intervention for Chronic Aphasia: (Univ. of Washington) continued *************************************
Facilitatory Behaviors
comment
clarify
cue
Nonfacilitatory Behaviors
interruption
interrogation
repetition request
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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
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Discussion
Which aspects of these group models appeal to you?
Who might benefit from these approaches?
Cautions???
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g) Group Therapy – The Nebraska-Pittsburgh Model
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History
University of Nebraska-Lincoln - 1993 1997: Garrett & Ellis
Student training programs Adults with a wide variety of aphasia types, ages, backgrounds
Duquesne University (Pittsburgh) - 1998 present: 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 social pragmatic 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
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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)
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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?
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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
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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
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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
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Communicator:
Figure *.*
Aphasia Group Conversational Competence Rating Scale (C) Garrett & Sittner, 1996 Context: Rater: Date:_____________
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
Instructions:
1.
Observe the communicator in an interactive group context. Circle your rating.
How much did the communicator participate in the interaction? none some a lot 7. On a scale of 1 to 5, how would you rate Communicator X's overall communication ability? <-------------------------------------------------------------------------------------------------------------------------------------------------> 1 poor communication ability 2 3 4 some ability communication 5 6 7 good comm. ability <-------------------------------------------------------------------------------------------------------------------------------------------------> 1 2 3 4 5 6 7 none some a lot 2. How much of the time was Communicator X able to get his/her message across? <-------------------------------------------------------------------------------------------------------------------------------------------------> 1 2 3 4 5 6 7 none 3. comments, or expressing opinions? some a lot How much of the time did Communicator X take an active role in the interaction by asking questions, generating unsolicited <-------------------------------------------------------------------------------------------------------------------------------------------------> 1 2 3 4 5 6 7 none some a lot 4. How frequently did Communicator X use different ways of communicating when trying to get his or her (i.e., speaking, writing, AAC system, etc.)? message across <-------------------------------------------------------------------------------------------------------------------------------------------------> 1 2 3 4 5 6 7 didn’t use used some used many methods different methods different methods 5. How flexible and strategic was the communicator when trying to convey messages that were not understood <-------------------------------------------------------------------------------------------------------------------------------------------------> by listeners? 1 not flexible 6. 2 3 4 some flexibility 5 6 How many communication functions (e.g., asking questions, arguing, giving advice, greeting, 7 very flexible commenting) did the communicator use when conveying messages? <-------------------------------------------------------------------------------------------------------------------------------------------------> 1 2 3 4 5 6 7 Group measurement scale found in your handout packet on page 60 138
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: Butterworth Heinemann. Pp. 85-96.
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Part V: Professional Issues, Future Directions, Discussion
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A. Programmatic Issues
1. Funding for Therapy 2. Funding for Equipment 3. Reestablishing our role 4. Measuring Change/Effectiveness
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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
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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
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www.aac-rerc.com
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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”
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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)
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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
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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.
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Is AAC is unique, or is it just another enhancement to overall language therapy?
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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
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B. Delivery of Therapy
1. Increasing contextual opportunities 2. Implementing group therapy
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C. Research questions and future directions
Measurement of use of strategies in real life 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?
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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?
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Goal = Communication
The End
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Discussion!!!
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