Collaborative participation in aphasic word searching: comparison between significant others and speech and language therapists

Background: Searching for words is a common phenomenon in conversations of people with aphasia. When searching for a word the speaker interrupts the emerging conversational turn with a pause, vocalisation (e.g., uh), and/or a question (e.g., what is it). Previous studies suggest that gazing and pointing can be used to invite conversational partners to join the search.

Aims: This study compares the collaborative actions of different conversational partners of people with aphasia (significant others vs. speech and language therapists) during aphasic word searching. The aphasic speakers’ actions inviting assistance from the partners in the search are also examined.

Methods & Procedures: The data for the study comprised 20 conversations, half videotaped at the participants’ homes and half in aphasia therapy sessions. The conversations were transcribed and analysed sequentially with a special emphasis on taking non-verbal actions into account. In the analysis, word search sequences were identified and the collaborative participation of the significant others, as well as the speech and language therapists, compared.

Outcomes & Results: The analysis showed that institutional and non-institutional conversational partners collaborate in different ways during word searching. When invited to join the search, often non-verbally, the significant others quickly offer words for the aphasic speakers to complete the search. When successful, these immediate completions solve the search and the core conversation can continue. On the other hand, even if invited non-verbally, speech and language therapists do not join in searching by offering words. Instead, they ask questions or offer their candidate understandings that are more elaborate than one word. Furthermore, they regularly shift the speaking turn back to the aphasic speaker encouraging the aphasic speaker to continue the search by him or herself.

Conclusions: The institutional and everyday practices of sequential resolutions of word searching differ to a great extent. Everyday conversational practices of collaborative completion appear more effective in solving the search and allow the aphasic speaker to experience smoothly flowing conversational interaction. Everyday practices could also be systematically used within aphasia therapy. Furthermore, if necessary, speech and language therapists should promote the use of these practices within daily interactions of the aphasic clients and their significant others.     

Implementing and evaluating aphasia therapy targeted at couples' conversations: A single case study

Background: In recent years conversation has become an area of interest for aphasia therapy, with several studies using conversation analysis (CA) to target and evaluate therapy. Most of these studies have focused on the main conversation partner of the person with aphasia, and in particular have targeted the partner's pedagogic behaviours in relation to the person with aphasia. Evaluations of therapy have primarily taken the form of qualitative analyses of change in conversational behaviours.

Aims: This single-case intervention study aims to advance research into interaction-focused intervention for aphasia in the following ways: by targeting intervention at the person with aphasia and the main conversation partner as a couple; by focusing on conversational behaviours where the person with aphasia can be seen to be restricted by the conversational actions of the conversation partner, in particular by recurrent questioning using closed questions and yes/no interrogatives; and by using a novel combination of qualitative and quantitative approaches to evaluate the intervention.

Methods & Procedures: CA was used to target and evaluate interaction-focused intervention for a couple where one partner has aphasia. Evidence for change was evaluated using qualitative and quantitative evidence of change in conversational behaviours; evidence from naïve raters of pre- and post-intervention conversation extracts; and interview/other feedback from the conversation partner.

Outcomes & Results: There was evidence that the intervention had changed the couple's conversational behaviours. In particular, the conversational behaviours of the non-aphasic partner were in general less restricting for the person with aphasia in that she was now using fewer questions and more instance of other types of turns, such as paraphrases. Following intervention the person with aphasia had also changed in that he was now producing turns that had more sentences, or attempts at sentences, and which developed the topic of talk across several of his turns.

Conclusions: The study provides evidence that directly targeting the conversational behaviours of the person with aphasia and/or a main conversational partner can produce positive change, and can achieve this in a way that is ecologically valid. In particular, it highlights the usefulness of targeting conversational behaviours that are proving to be maladaptive for the participants. It provides further evidence that creating change in the non-aphasic partner's conversational behaviour may facilitate change in the person with aphasia's conversational and linguistic performance.     

Multiple languages,memory, and regression: An examination of Ribot's Law

Background: Low-tech visual scene displays (VSDs) combine contextually rich pictures and written text to support the communication of people with aphasia. VSDs create a shared communication space in which a person with aphasia and a communication partner co-construct messages.

Aims: The researchers examined the effect of low-tech VSDs on the content and quality of communicative interactions between a person with aphasia and unfamiliar communication partners.

Methods &; Procedures: One person with aphasia and nine unfamiliar communication partners engaged in short, one-on-one conversations about a specified topic in one of three conditions: shared-VSDs, non-shared-VSDs, and no-VSDs. Data included discourse analysis scores reflecting the conceptual complexity of utterances, content unit analyses of information communication partners gathered from the interaction, and Likert-scale responses from the person with aphasia about his perception of communicative ease and effectiveness.

Outcomes &; Results: Comparisons made across conditions revealed: (a) the most conversational turns occurred in the shared-VSDs condition; (b) communication partners produced utterances with higher conceptual complexity in the shared-VSDs condition; (c) the person with aphasia conveyed the greatest number of content units in the shared-VSDs condition; and (d) the person with aphasia perceived that information transfer, ease of conversational interaction, and partner understanding were best in the shared-VSDs condition.

Conclusions: These findings suggest that low-tech VSDs have an impact on the manner and extent to which a person with aphasia and a communication partner contribute to conversational interactions involving information transfer.     

Preliminary results from conversation therapy in two cases of Aphasia

Background: Few studies have investigated conversation therapy between a person with aphasia and a clinician. Furthermore, little information exists on generalisation of impairment-based stimulation treatment to conversational outcomes.

Aim: The purpose of this preliminary study was to compare the effects of stimulation therapy and conversation therapy on conversational outcome measures in two cases.

Method: We employed a single-subject AB₁AB₂A design with randomised ordering of interventions across two participants. Primary outcomes included 6-minute conversations coded for discourse functions of an utterance.

Outcomes & Results: The participant who received stimulation therapy first demonstrated improved conversational outcomes after the first phase. The participant who received conversation therapy first demonstrated improved conversational outcomes after the first phase. Although improvements were made in each type of therapy, the highest gains in conversational production were during or following conversation therapy in either treatment order for both participants.

Conclusion: Both types of therapy produced gains in conversational abilities. However, the small number of participants limits the generalisability of this study. Future research is needed to determine which participants may benefit most from conversation therapy and to improve the clinical feasibility of conducting and measuring conversational therapy.     

Reciprocal scaffolding treatment: A person with aphasia as clinical teacher

Background: Reciprocal Scaffolding Treatment (RST) is one of several potentially beneficial life participation approaches for aphasia. In RST, treatment occurs during genuine, relevant, and context dependent interactions that represent goals at the activity and participation levels of the World Health Organization International Classification of Functioning, Disability and Health (ICF; World Health Organization, 2001) and is based on an apprenticeship model of learning where novices are taught skills by a more skilled partner. RST was used to construct a communicatively challenging environment in which an expert with aphasia (AE) taught novices (graduate student clinicians) how to communicate with persons with aphasia in the context of conversation group treatment sessions. This is in contrast to many treatment techniques when the person with aphasia is the novice who is trying to relearn communication skills during treatment sessions with a speech‐language pathologist as the expert.

Aims: The goal of the study was to investigate the effect of RST on improvement in word retrieval and conversational components in an individual with anomic aphasia.

Methods & Procedures: This was a case study using pretreatment – post treatment assessment. The independent variable was application of RST and the contextual variables were the presence of novices (graduate student clinicians) and unfamiliar conversation partners (undergraduate speech‐language pathology students). The dependent variables were scores on a word fluency task (FAS) and conversational measures (CIUs and TTR). Over the course of a seven week training period, AE taught communication strategies to four novice graduate student clinicians, who used the strategies in conversation groups composed of 3 to 4 persons with aphasia.

Outcomes & Results: The individual with aphasia made positive changes in word fluency, Correct Information Units and Type‐Token Ratio.

Conclusions: These findings, while preliminary in nature, show how the authentic use of language in structured reciprocal interactions such as teaching may improve language. A reciprocal teaching environment carries with it the expectation that at least one participant have an intent to participate as an expert in order to convey information to novices. We speculate that the combination of reciprocal interaction and the intent to convey information, in this case in a unique manner, support improved language skills.     

Executive function and conversational strategies in bilingual aphasia

Background: Deficits of executive function (EF) have been proposed as all or part of the underlying mechanisms of language impairment in at least some types of aphasia. Executive functions also play a role in the recovery process. There is evidence that bilingual persons have some executive functioning advantages compared to monolingual persons. In this paper we combine two lines of recent investigation in order to explore the relationship between executive function and conversational strategies in bilingual aphasia.

Aims: The aim of this preliminary research was to compare the executive functioning profiles of bilingual individuals to those of monolingual participants with aphasia. A further aim was to examine evidence in the conversational samples of the participants in relation to the application of a range of executive skills and to link cognitive and conversational profiles using Barkley's (1997) model of executive functions.

Methods & Procedures: The performance of two bilingual individuals with aphasia on a test battery of executive function tests was compared with that of eight monolingual persons (seven with aphasia and one with right hemisphere damage). The test battery included measures of behavioural inhibition, working memory, problem solving, and reconstitution. The presence or absence of executive features in the conversational samples of the participants was judged by four raters using conversational analysis methods.

Outcomes & Results: Significant differences were found between the scores of the bilingual participants and those of the monolingual participants on measures of behavioural inhibition, working memory, planning and problem solving, and reconstitution. The bilingual participants' scores were mostly within normal limits and suggested well‐retained executive functions. Conversation analysis showed evidence of differential application of these executive functions to conversational management. Regardless of severity or type of aphasia, the bilingual participants showed evidence of good topic management, repair, and flexibility compared to the monolingual participants.

Conclusions: The results are interpreted in relation to current issues in bilingualism. Our preliminary findings shed light on differential approaches to assessment, therapy, and choice of language for bilingual aphasia.     

Grammar without sentence structure: A conversation analytic investigation of agrammatism

Background: Although research into agrammatism has done much to characterise the nature of the underlying disorder, most studies have analysed elicited, task‐based data. As a result, little is known about the grammar that people with agrammatism use in everyday talk with habitual conversational partners. There is evidence in the Conversation Analysis (CA) literature to suggest that conversational grammar may not mirror the grammar of elicited language samples.

Aims: To explore the notion that conversation and task‐based data do not necessarily reveal the same grammatical phenomena, addressing the following questions: (1) What resources does a speaker with agrammatism make use of in order to construct a turn at talk? (2) Is the conversational grammar of a speaker with agrammatism organised in a systematic way? (3) What is the relationship between patterns of turn construction in conversation and the grammatical characteristics of output elicited by decontextualised language tests?

Methods & Procedures: A videotaped conversation between an agrammatic speaker and his adult daughter is analysed using CA. Four recurring turn construction formats are described and illustrated with extracts. Background information on the client presents the results of picture‐naming and sentence production tests.

Outcomes & Results: There is great variation between the grammar of conversation and test data. Test results reveal a severe problem with verb access and sentence construction, with ability declining sharply as the number of verb arguments increases. However, the speaker deploys interactional alternatives to standard grammatical structures, and it is possible for him to recount events without explicit articulation of verbs and argument structures, using a combination of talk and mime. Only a minority of his conversational utterances are concerned with recounting events—commenting, assessing, and reasoning are highly prevalent.

Conclusions: Conversation and sentence‐level tests provide complementary but essentially different information about grammatical ability. This implies that assessment of conversational grammar should become a routine part of any investigation of agrammatism in order to gain a more complete picture of an individual's ability to impose structural order on their talk, and to explore implications for successful interaction with others. Currently, approaches to assessment and intervention over‐emphasise events. In conversation, other actions such as giving an opinion are just as prevalent. Findings suggest a mismatch between what appears problematic on testing and what is treated as problematic by the interactants in conversation, and that intervention might profitably seek to address grammatical difficulties that have a basis in interaction.     

Development of a procedure to evaluate the contributions of persons with aphasia and their spouses in an interview situation

Background: Although there has been increasing interest in the study of conversations between people with aphasia and their partners, the participation of persons with aphasia in conversation with their spouses in the presence of a third party has not been extensively investigated. Nevertheless, opportunities for such situations are frequent, and therefore provide an interesting opportunity to examine how couples collaborate.

Aims: (1) To develop a procedure to analyse conversations that would specifically address the contributions of persons with aphasia and their spouses in an interview situation. (2) To describe spousal contributions in an interview situation, including what preceded and followed these contributions, in a group of couples with a member with aphasia. (3) To verify the inter‐judge reliability of the procedure.

Methods & Procedures: Videos of three couples with aphasia in an interview situation were analysed. Contributions of the spouse when the participant with aphasia was clearly speaking with the interviewer, contexts in which spouses contributed, reactions of persons with aphasia, and their participation following contributions were described. Definitions were created, operationalised, tested, and refined on 11 other similar couples in the same interactive situation. Eight other couples were then videotaped and studied.

Outcomes & Results: Results revealed that half the contributions produced by the spouse were “repairs” and the other half were “speaking for” behaviours. Most often, contributions were unsolicited. Generally, the person with aphasia approved the spouse's contribution and continued afterwards to take an active part in the conversation. Inter‐judge reliability coefficients varied between 89% and 97%.

Conclusions: The procedure employed is representative of situations encountered by couples affected by aphasia. The data collection and analysis methods could be applicable to clinical situations. It is important to consider spousal contributions and their impact on the person with aphasia in conversations when helping couples adjust to the consequences of aphasia.     

An application of the experience sampling method to the study of aphasia: A case report

Background: Researchers stress that functional health and psychological well-being are important aspects of quality of life in the investigation of individuals with aphasia. Employed in the social sciences, the experience sampling method (ESM) has begun to shed light on deviations in participants' momentary responses to behavioural contingencies in naturalistic environments. Applications of ESM have demonstrated value in monitoring within-participant variations in mood, psychopathology, and treatment outcomes while minimising the effect of memory bias. Additionally, the application of ESM in psychological cognitive-behavioural therapy and occupational therapy (OT) research reportedly appeared to contribute to treatment success. A time-based, fixed-schedule sampling application of ESM was used in this study to attain self-reports throughout an aphasia treatment programme.

Aims: The current investigation introduced the ESM paradigm to the study of aphasia and piloted its use in measuring psychoemotional variables in an individual with chronic aphasia participating in an intensive treatment regime.

Methods & Procedures: Repeated ESM probes were administered during a university-based treatment programme to measure the daily responses of a 75-year-old participant with a moderate-to-severe communicative impairment secondary to a cerebral vascular accident (CVA). A total of 20 brief ESM probes were cued by clinicians at four fixed times per day, 5 days a week during a 35-hour a week, 6-week programme. Probes conducted throughout each day used a 5-point Likert scale to query participant response to psychoemotional variables perceived happiness, perceived tiredness, perceived stress, and perceived communication satisfaction.

Outcomes & Results: Findings revealed that the participant with aphasia was able to respond to a 5-point Likert scale administered with a personal data assistant (PDA) with 100% compliance when cued by clinicians that it was time to complete the ESM probe (464 responses across 29 days). The internal validity of internal states used in this study is supported by the strong negative correlation found with perceived happiness between both perceived tiredness (p < .01) and perceived stress (p < .01), as well as the positive correlation found between the negative states of perceived tiredness and perceived stress (p < .01).

Conclusions: This initial success of ESM implementation in this case study of aphasia treatment suggests that further explorations are needed in the application of ESM in aphasia research.     

The complexities of speaking for another

Background: While it is recognised that conversation partners of people with aphasia often speak for them, investigation of “speaking‐for” incidents has shown that these comprise a wide range of behaviours, leading Simmons‐Mackie, Kingston, and Schulz (2004 Simmons‐Mackie, N., Kingston, D. and Schultz, M. 2004. “Speaking for another”: The management of participant frames in aphasia.. American Journal of Speech‐Language Pathology, 13: 114–127. [Crossref], [PubMed], [Web of Science ®] , [Google Scholar]) to identify a “fine interactive line” (p. 123) between “speaking for” and “speaking instead of”. To date, however, there has been little exploration of these behaviours in the context of everyday family conversation; furthermore, little is known about how family members themselves interpret the actions of speaking for their relative with aphasia.

Aims: The goal of this paper is to describe how the husband of a woman with progressive nonfluent aphasia (PNFA) and their adult children experienced and interpreted his ways of speaking for her.

Methods & Procedures: Findings are drawn from a qualitative case study exploring a family's experiences of progressive aphasia through analyses of their talk. Methodology included a thematic analysis of in‐depth interviews conducted with each of six family members and conversation analysis of their everyday conversations together, selected and audio recorded by the participants themselves over a 3‐month period.

Outcomes & Results: The husband's “speaking‐for” behaviours, which emerged as a significant theme in the interview data from him and all four adult children, were linked to long‐standing patterns of interaction but were described as problematic in the context of his wife's aphasia. Conversation analysis revealed that he used three patterns of “speaking‐for” behaviours, each with different interactional strategies and consequences.

Conclusions: Discussion highlights the nuances, challenges, and complexities of “speaking for” behaviours when considered in the historical context of relationship.     

Treatment of aphasia through family member training

Background: Studies describing communication between people with aphasia and family members have suggested that family members are not always skilled communication partners. For example, spouses or significant others sometimes adopt conversational strategies that do not facilitate communication with their aphasic loved one. Therefore, management of aphasia should address the communication skills of regular communication partners in order to maximize communication with individuals with aphasia.Aims: This study was designed to provide communication training to the wife of a man with aphasia in order to reduce the occurrence of her behaviors identified as “nonfacililative.” Nonfacilitative behaviors of the wife included spouse interruptions, convergent questions and negative teaching.Methods & Procedures: A single subject multiple baseline design examined the effects of training on the occurrence of three nonfacilitative behaviors across several conditions (spontaneous conversation in the clinic, discussion of television programs in the clinic and conversation at home).Outcomes & Results: Training the spouse resulted in reduced occurrence of the target behaviors (spouse interruptions, convergent questions) in probes of the training condition (news discussions). These improvements consistently generalized from the treatment situation to untrained conditions such as spontaneous conversations with her husband. In addition, this improvement was observed in an untrained behavior (negative teaching). Improvements in both trained and untrained behaviors were maintained on follow-up probes. Furthermore, this training resulted in improvements not only in the spouse's conversational interaction, but also in her aphasic husband's expressive communication during their conversations even though he was not included in the training.Conclusions: Direct training of interactive behaviors of a speaking partner might be an effective and efficient means of enhancing communication between family members and people with aphasia.     

Introducing an intergenerational relationship to improve engagement in aphasia therapy

Background: When the relationship between a clinician and a client with aphasia is not strong, engaging the client in therapy may become a clinical challenge. Engagement, in this context, refers to the client’s interpersonal involvement and emotional connection to the individuals, activities and ideas present in the therapy session. It is foundational for evoking the interest needed to achieve clinical goals. Persons with aphasia may internalise positional designations associated with illness rather than authority, and as a result become disengaged in the therapeutic process. Including an intergenerational participant in therapy may offer those with aphasia an opportunity to assume new roles. Favourable outcomes have been reported when intergenerational relationships are formed for the purpose of generating engagement, although these studies are limited in the field of aphasia.

Aim: The aim of this instrumental case study was to describe how introducing an intergenerational relationship between a participant (Anna) with aphasia and a preschool-age boy (Jacob) influenced Anna’s engagement during aphasia therapy.

Methods & Procedures: Recordings of four routine language therapy sessions with Anna and her clinician, and six intergenerational therapy sessions with Jacob, Anna and Anna’s clinician were examined in this pilot study. The Myers Research Institute-Engagement Scale (MRI-ES) , the Observed Emotion Scale (OES) and a speech act analysis were used to compare Anna’s behaviours during routine language-therapy sessions and intergenerational therapy sessions.

Outcomes & Results: Poor engagement during routine therapy session was considered a barrier to Anna’s clinical progress. Anna’s behaviour suggested that she found the environment created with the intergenerational participant more engaging. She displayed more interpersonal involvement in the session as measured by the MRI-ES and more emotional connection to the activities/participants in the session as measured by the OES. During the intergenerational sessions, the speech acts that Anna used were similar to those reportedly used by speech–language clinicians, which was not the case during routine sessions.

Conclusions: Acknowledging a less than ideal relationship between Anna and her clinician, and then modifying the sessions by introducing an intergenerational participant created an environment that was more engaging for the client with aphasia. Outcomes are discussed from the perspective of interactional role theory.     

Conversation partner responses to problematic talk produced by people with aphasia: some alternatives to initiating,completing, or pursuing repair

Background: Problems with intersubjectivity (i.e., mutual understanding) are prevalent during interactions involving people with aphasia. The linguistic restrictions imposed by aphasia mean that conversation partners must often assist with repairing intersubjective problems if they are to be resolved efficaciously. However, conversation partners can resist participation in repair activities. This may have serious negative implications for how people with aphasia participate in conversation.

Aims: This study uses conversation analysis (CA) to examine responses to problematic talk produced by people with aphasia. It focuses on three alternatives to initiating, completing, or pursuing repair: receipting responses, accounting responses, and “other” responses. The interactional organisation and consequences of these responses are described.

Methods & Procedures: Three people with aphasia and nine of their familiar conversation partners were video-recorded during their everyday conversations. Approximately 9.5 hr of recordings was collected. Ninety-seven responses were identified in this data set and analysed using collection-based conversation-analytic practices.

Outcomes & Results: Receipting responses register that the person with aphasia has produced a turn, but provide little support for the action implemented by the turn. They do not index problems with intersubjectivity and often result in the problematic talk being abandoned. Accounting responses index problems with intersubjectivity, but do not work towards resolving them. Instead, they deal with why an appropriate response to the problematic talk cannot be delivered, and which party is responsible for its absence. “Other” responses comprise a more eclectic category. One type—non-serious responses—is examined. Non-serious responses take the appearance of repair, but ultimately delay authentic repair attempts.

Conclusions: The responses examined can have negative consequences for the participation of people with aphasia, restricting their ability to implement social action, and making relevant their status as linguistically incompetent. However, they can also help with navigating the sensitive environments created by problems with intersubjectivity. Interaction-focused interventions might focus on these practices in addition to repair practices when attempting to improve how communication breakdown is addressed. CA and qualitative interviewing are well suited to future explorations of how conversation partners decide that they will not initiate, complete, or pursue repair.     

Student speech pathologists’ experiences of an aphasia therapy group

Background: There is evidence that group therapy for people with aphasia is effective, but the skills needed to interact with people with aphasia are complex. There is also evidence that training and guided experience can improve the skills of family members and health professionals in communicating with people with aphasia. However, there is limited research into how student speech pathologists learn to develop the communication strategies that they will teach others to use when interacting with people with aphasia.

Aim: This qualitative study aimed to explore perceptions of the student learning experience in aphasia group therapy of four student speech pathologists, their clinical educator and group members with aphasia.

Methods & Procedures: Four student speech pathologists, three clients with aphasia and two spouses participated in four consecutive aphasia group therapy sessions under the supervision of a speech pathology clinical educator. Semi-structured interviews with each student and the clinical educator, following the first, third and final group session, were audio recorded. Following the final session, each participant with aphasia was also interviewed. The interviews were transcribed and qualitative content analysis was used to describe the perspectives of the participants.

Outcomes & Results: Analysis of the interviews revealed that student perceptions of their experience were linked to their understanding of group therapy for aphasia, their understanding of the role of communication strategies and their ideas concerning saving face and discourse equality. Findings indicated a close alignment of the perspectives of students, clinical educator and participants with aphasia in their understanding of the contribution of aphasia group therapy to student learning and client benefits.

Conclusions: The findings of the present study provide preliminary information for the development of educational practices relevant to speech pathology students preparing for work with people with aphasia.