Can impairment-focused therapy change the everyday conversations of people with aphasia? A review of the literature and future directions

Background: The ultimate goal in any programme of aphasia rehabilitation is that behaviours targeted in therapy will generalise to everyday use for people with aphasia (PWA). The pervasiveness of conversation in everyday life has undoubtedly contributed to the recent interest in aphasiology regarding how we facilitate, and capture evidence of, change in conversation following therapy. Given the rich nature of conversation data, various analytical approaches have been utilised within impairment-focused therapy studies; however, much of this work has been carried out in isolation from other methodologies such as conversation analysis (CA)—a field which has historically concerned itself with conversation data. The result is a growing literature base which is dispersed in nature. For clinicians who are faced with the daily challenge of therapeutic management for a diverse population of PWA the literature on generalising therapy gains to everyday conversation may be too unwieldy to be of benefit to current clinical practice.

Aims: This paper aims to synthesise and critically review key papers from impairment-focused studies which have investigated the impact of therapy on the conversations of PWA. For the purposes of this review, conversation is defined as a dialogue between the person with aphasia and a conversation partner.

Main Contribution: First, the motivation to investigate conversation within aphasia assessment is discussed, with consideration of how conversation differs from, but ultimately complements, other forms of language assessment. Following this, five impairment therapy studies will provide a platform for discussion of methodological issues and analytical approaches relating to conversation data. Finally, consideration is given to how researchers and clinicians may build on current literature to develop the use of conversation as an outcome measure in aphasia intervention. Where appropriate, insights are drawn from interaction-focused therapy studies regarding the collection and analysis of conversation data.

Conclusions: There is emerging evidence that impairment-focused therapy can impact on the conversations of PWA. While these early findings are promising, investigations have been limited to naming therapies and the methods of data collection used have implications for ecological validity. Incorporating particular elements of interaction-focused approaches may help to inform data collection, investigations of therapy outcome, and issues of candidacy for specific treatments. Furthermore, combining therapeutic and analytical approaches is likely to be more closely akin to the clinical reality of aphasia intervention, where clinicians are likely to use all resources at their disposal in the rehabilitation of a speaker with aphasia.     

Conversational partner training programmes in aphasia: A review of key themes and participants' roles

Background: Conversational training programmes are increasingly being reported for partners of people with aphasia. While these all aim to increase communicative effectiveness between people with aphasia and their communication partners, and all report measurable success, the programmes vary in terms of selection criteria for participants, the methods used, and the way in which they have been evaluated. This paper critically reviews a group of studies that have carried out conversation partner training (CPT) programmes for both familiar partners of people with aphasia (spouse or relative of a person with aphasia) and volunteers.

Aims: The purpose of the review is (1) to identify the type of people CPT might benefit, i.e., whether particular characteristics of the participants have been considered influential to the outcome of interventions and (2) to consider the outcomes of such training programmes more generally, i.e., whether they have been effective, whether the effectiveness of the programmes is dependent on the format of the training and, to some extent, the measures that have been used to evaluate their effectiveness.

Main Contribution: The review highlighted the positive outcomes reported by the studies, irrespective of whether the usual conversation partner or a volunteer was involved, in relation to the evaluation measures used. A paucity of information was found for the conversation partner participants compared to the person with aphasia, along with a limited analysis of the impact of the partner on the effectiveness of the intervention. Criteria underpinning selection for training programmes was related primarily to availability rather than behavioural or conversational characteristics. Longer‐term follow‐up of interventions was also limited.

Conclusion: That CPT interventions can be effective is not disputed here. However, the measurement of such effectiveness needs scrutiny and for whom these interventions work remains largely unknown. This review highlights the need for more information on both participants, with particular regard to the partner of the person with aphasia, to be both established and documented when reporting the impact of this type of intervention. This will permit an examination of the extent to which particular variables or partner profiles are influential and potentially predictive when determining suitable candidates for CPT. Equally, systematic follow‐up of all those participating in training will enable a clearer picture to emerge of the effectiveness of such interventions.     

Trouble and repair during conversations of people with primary progressive aphasia

Background: Primary progressive aphasia (PPA) affects a range of language domains that impact on communication. Little is known about the nature of conversation breakdown in PPA. The identification of trouble in conversation, its repair and the success of repairs has been used effectively to examine conversation breakdown in neurogenic language disorders such as dementia of the Alzheimer type (DAT) and acute onset aphasia. This study investigated trouble and repair in the conversations of people with PPA.

Aims: The first aim of this study is to describe the contributions of individuals with PPA and their conversation partner to conversation. The second aim is to describe the trouble that occurs in dyadic conversations between three individuals with PPA and their communication partner. The third aim is to describe the repair behaviours used by the individuals with PPA and their communication partners.

Methods & Procedures: Dyadic conversations about everyday activities between three individuals with PPA and their partners and three control dyads were video recorded and transcribed. Number of words, number of turns and length of turns were measured and trouble-indicating behaviours (TIBs) and repair behaviours were categorised.

Outcomes & Results: Individuals with PPA had reduced mean length of turn but maintained their share of turn-taking. They demonstrated a variety of TIBs that differed from the noninteractive repairs, which do not require a response from the partner in the conversation and which have been observed in studies of conversation in DAT. Their partners bore the greater burden of highlighting trouble and need for repair using collaborative, interactive, TIBs. Three different conversational profiles were observed in the three PPA dyads, reflecting different patterns of language and cognitive impairment.

Conclusions: Individuals with PPA were active participants in conversation effectively indicating and responding to trouble. Understanding trouble and repair in the conversations of individuals with PPA has the potential to enhance assessment and inform clinical practice.     

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.     

The evaluation of a learner‐centred training programme for spouses of adults with chronic aphasia using qualitative case study methodology

Background: Family education, training, and counselling programmes have been cited as one way to complement traditional interventions for the individual with aphasia. However, the literature still represents the speech‐language pathologist as the expert in a directive role. Aims: This article describes the second phase of a research study aimed at addressing the psychosocial sequelae of aphasia by developing and studying the effects of a learner‐centred training programme for spouses of adults with chronic aphasia designed to improve conversational interaction between couples. The first phase of this research included the development of a communication‐training programme that integrated principles and strategies from speech‐language pathology and adult education (Sorin‐Peters, 2002). The second phase described in this paper included the delivery and evaluation of the programme using a qualitative case study methodology. The use of the qualitative case study methodology to study the psychosocial consequences of aphasia is described in a companion paper (Sorin‐Peters, 2004). This paper presents the results of one qualitative case study in detail to demonstrate how the qualitative case study methodology was implemented, and a summary of the cross‐case analysis for the five couples, examining the effectiveness of the programme. Methods & Procedures: Using videotaped data, the Couple Questionnaire, and a semi‐structured interview, this study examined changes in attitudes and communication behaviours in five couples immediately after conversation partner training and at 2 months follow‐up. All data were transcribed and analysed for patterns of change. Outcomes & Results: Communication outcomes included changes in conversational interaction as well as in the transaction of information in conversation for all five couples. These included positive changes in the management of conversational repair. There was more balanced control after training and the cognitive competence of the partners with aphasia was revealed following the training. In addition, different conversational genres emerged throughout the programme that could be organised hierarchically. Results indicated ways in which the adult learning principles were actualised across the five cases. Themes emerged related to the expression of emotion about aphasia, including feelings of anger, sadness, and grief, and increased acceptance of the aphasia after the training. Themes related to marital issues emerged and were intertwined with emotions and communication. Conclusions: The adult learning model approach promoted positive and comprehensive changes, and perhaps more than those achieved via existing medical‐model or psychosocial approaches. The adult learning approach to individuals with chronic aphasia extends the existing psychosocial model by acknowledging both the spouse's and person with aphasia's competence as adult learners, by viewing the person with aphasia not only as part of a social unit, including the family, but also as part of a broader system, including multiple environmental and cultural factors that interact interdependently to effect change, and by focusing on the importance of communication for the expression of emotions and the maintenance and development of marital relations. The results suggest the benefits of the expansion of the speech‐language pathologist's role with couples with aphasia to include an adult learning approach to improving conversational interaction between people with aphasia and their spouses.     

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.     

Evaluation of communication,life participation and psychological well‐being in chronic aphasia: The influence of group intervention

Background: The impact of change in communication, life participation, and psychological well‐being in aphasia is recognised but still not fully explored. Further, considerable scope exists to address these factors within the context of intervention. Innovative practices and group intervention are advocated for people with chronic aphasia but detail and evidence remains limited.

Aims: To explore the experience of aphasia within the context of communication, life participation and psychological well‐being and evaluate the outcomes of these phenomena in people with chronic aphasia following participation in a group intervention involving a social model approach.

Methods & Procedures: A group of seven people with chronic moderate aphasia were assessed on communication measures, by means of the Conversational Analysis Profile for People with Aphasia (CAPPA), and aspects of psychological well‐being, by means of The Hospital Anxiety and Depression Scale (HADS) and The Visual Analogue Self‐esteem Scale (VASES) pre, post, and at 3‐month follow‐up of a group intervention. The group involved a social model approach and the use of Total Communication to support conversation. Speech and language therapy and social care personnel, including an equality disability trainer, contributed to the group.

Outcomes & Results: Although variation in individual participants was demonstrated, results showed evidence of statistically significant beneficial change in conversation experiences (many of these related to life participation) and, to a lesser degree, beneficial change in conversation abilities. Additionally there were beneficial changes for some participants on psychological well‐being measures. Due to the small sample, participant variation, and (in the case of psychological well‐being measures) the lack of evidence of serious reduction in psychological well‐being at the outset, the results have to be evaluated with caution.

Conclusions: Appropriately planned group intervention can produce benefits in conversation, life participation, and psychological well‐being in chronic aphasia.     

Clinicians' perceptions of candidacy for conversation partner training in aphasia: How do we select candidates for therapy and do we get it right?

Background: Recent studies have demonstrated success in training partners to facilitate conversation in people with aphasia (e.g., Booth & Swabey, 1999 Booth, S. and Swabey, D. 1999. Group training in communication skills for carers of adults with aphasia.. International Journal of Language & Communication Disorders, 34: 291–310. [Crossref], [PubMed], [Web of Science ®] , [Google Scholar]; Kagan, Black, Duchan, Simmons‐Mackie, & Square, 2001 Kagan, A., Black, S., Duchan, J., Simmons‐Mackie, N. and Square, P. 2001. Training volunteers as conversation partners using “supported conversation for adults with aphasia” (SCA): A controlled trial.. Journal of Speech, Language & Hearing Research, 44: 924–638.  [Google Scholar]). Among other issues highlighted by these studies are those related to partner selection and suitability, or candidacy, for such an approach, and whether outcome may be related to the characteristics of the conversation partner. This paper reports a study of speech and language therapists' perceptions of candidacy requirements for conversation partner training (CPT), exploring both the characteristics that clinicians attend to in judging candidacy for therapy of this nature and whether these have validity with respect to outcome.

Aims: The study aimed first to determine the criteria used by clinicians when making decisions on candidacy of partners of people with aphasia and recruiting to conversation training programmes, and second to use these criteria to develop a method of profiling candidacy for potential partners attending training. The resulting profiling procedure was subsequently piloted within a single case design to evaluate the outcome of intervention against initial candidacy criteria.

Methods & Procedures: A focus group methodology and questionnaires were used to establish the criteria on which experienced therapists based their judgement of conversation ability and their subsequent decisions to offer intervention involving CPT. Following an analysis of how frequently particular behaviours and attitudes needed to be present to influence therapists' decision making, a procedure to profile conversational partner characteristics (the Profile of Partner Candidacy for Conversation Training) was developed which integrated data from a structured interview and an analysis of conversation between the couple. The procedure was used to characterise the suitability of one carer, PM, who was subsequently offered a support and conversation training programme (Lock, Wilkinson, & Bryan, 2001 Lock, S., Wilkinson, R. and Bryan, K. 2001. Supporting partners of people with aphasia in relationships and conversation (SPPARC): Resource pack, Bicester, UK: Winslow Press. [Taylor & Francis Online] , [Google Scholar]) with his spouse who had aphasia. Post‐intervention analysis of conversation evaluated the effectiveness of CPT in the light of partner characteristics.

Outcomes & Results: Clinicians identified a core set of conversational behaviours and attitudes or perceptions about communication as being influential in making decisions, with attitudes to communication being regarded as more influential than conversational behaviours in determining a good candidate for CPT; i.e., a partnership where a positive outcome would be anticipated. Profiling indicated that PM was a good candidate, overall, for CPT, demonstrating positive attitudes towards communication and numerous positive conversational features. However, some conversational behaviours were present that did not fall into the high‐candidacy band. These behaviours were successfully targeted in CPT, and the outcome of the training programme in the context of PM's candidacy profile was evaluated.

Conclusion: Drawing on clinicians' perceptions to highlight partner characteristics has enabled a systematic method of profiling partner attitudes and conversation behaviours to be developed, with an emphasis on the attitudes of the partner. The case of PM demonstrates the positive but complex relationship between profiling behaviour and attitudes pre‐intervention and the outcome of intervention. This study is a preliminary attempt to address this clinically. It is recognised, however, that the use of the profile with a range of different partners is needed to further explore this relationship, along with the links between clinicians' perceptions and outcome. This may in turn assist in determining whether, and how, particular partner characteristics may influence response to intervention.     

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.     

Spontaneous verbal repetition: A social strategy in aphasic conversation

Abstract

This study investigated the spontaneous verbal repetition of a person with aphasia during conversation. Research questions were: Does repetition occur as a spontaneous verbal behaviour? How is repetion effectively used? What are the motivations for its use? A person with aphasia and his wife video recorded eight of their naturally occurring conversations which were subsequently transcribed and sequenced into turns-at-talk. Frequency of repetition and the sequential organization of conversation sequences containing repetition were analysed. Repetition was a frequent behaviour, occurring an average of 8% of the time for all conversations. Repetition was effectively used to meet the social needs of the conversation relating to displays of uncertainty, agreement, alignment and acknowledgement. Motivations for repetition related to its use as a compensatory strategy to overcome specific language barriers and to establish perceptions of conversational proficiency.     

Evaluation of a training programme to facilitate conversation between people with aphasia and their partners

Background: The investigation into conversational interaction in aphasia and its therapeutic implications has received much interest. It is increasingly accepted that people with aphasia cannot be treated in isolation but as part of a social unit. Training conversation partners has been shown to impact on the disabling effect of aphasia. Aims: The principal aim of this study was to evaluate a programme designed to train a relative/friend to communicate more effectively with an aphasic partner. The intervention was assessed in terms of effects on communication and on wellbeing. Methods & Procedures: Four single-case studies were completed. The aphasic participants had severe impairment affecting both comprehension and expression. The baseline was a series of three assessments. The dyads were videotaped having a conversation, and completed a Visual Assessment for Self-Esteem Scale (VASES). The non-aphasic partner also completed a Hospital Anxiety and Depression Scale (HADS). The training programme ran for 5 weeks (1.5 hours/week) at the couples' homes. It included education, video feedback, and role-play. The initial assessments were repeated post-intervention. Outcomes & Results: Conversation data were subject to a conversation analysis as well as frequency counts of nonverbal behaviours. We found positive individual changes and positive trends: three of the four dyads increased their use of gesture and the proportion of successful repair sequences increased post-intervention, although these changes were not statistically significant. There were no significant differences for the HADS but there were differences between the aphasics and the non-aphasics on the VASES. Conclusions: The positive trends suggest that working with couples can produce beneficial effects. Future research may help establish who will benefit from this approach and the optimal number of sessions.     

Singing behaviour in a client with traumatic brain injury: a conversation analysis investigation

Background: Traumatic brain injury (TBI) is associated with pragmatic communication difficulties that lead to difficulty in social interaction. Research on conversation abilities in persons with TBI is limited, but has revealed unique patterns of behaviour that result in success or breakdown in conversation. Only a handful of studies have examined real-world conversations of persons with TBI to better understand how these behaviours might be motivated by conversation moves of partners.

Aims: This study involved an exploration of a particular behaviour in a man with TBI, singing, to better understand the interactional environment, and goals associated with the behaviour.

Methods & Procedures: Over 7 h of conversation data were videorecorded from 10 therapy sessions in which a man with TBI recurrently employed singing during conversation. Instances of singing were identified and transcribed according to principles of conversation analysis (CA). A total of 39 instances were included and analysed independently, focusing on explaining the sequential context of the device and the interactional work that was achieved.

Outcomes & Results: Data analysis revealed four distinct sequences involving instances of singing. These included a normative sequence in which the participant inserted singing in ways similar to neurotypical speakers. The other three sequences comprised of unusual instances of singing that allowed the participant to nominate new topics, demonstrate disalignment, and close topics in conversation.

Conclusions: CA revealed that the participant produced singing in response to the actions of his conversation partners. All sequences were jointly produced and dependent upon the conversation turns before and after the instance of singing. The findings suggest that conversational partners pursue various interactional agendas during conversation in therapy sessions and the participant uses singing to perform facework in this context.     

Communication therapy for people with aphasia and their partners (APPUTE)

Background: Severe aphasia is a chronic condition and can have a big effect on how people with severe aphasia (PWSA) succeed in their communication. The communication partner’s support for the person with aphasia has been shown to be essential in achieving successful communication. However, interventions combining training both the partner and the PWSA to use hierarchical strategies in nonverbal communication are still needed.

Aims: The aim of the present paper is to describe a new intervention (APPUTE) where both the person with aphasia and the partner receive therapy equally and practise finding functional communication strategies to convey everyday messages or more complicated ones. The data collection during the APPUTE intervention is also presented.

Methods & Procedures: The data were collected during a development project including an evaluation period, two rehabilitation periods and follow-up measurement. Thirty-four PWSA and their partners participated. The linguistic functions and communication efficiency of PWSA were evaluated three times during the rehabilitation. The communication skills of the partner were also assessed, along with the success of the mutual communication.

Outcomes & Results: The communication skills and communication efficiency of the PWSA and their partners improved significantly during the rehabilitation period, and the acquired skills were retained for 6 months after the intervention. The linguistic skills of the PWSA also improved. The advanced age of the partner explained both the variance of the partner’s communication skills and the success in the mutual communication. The amount of earlier outpatient speech therapy explained the variance of the communication efficiency of PWSA as evaluated by the partners. Regarding success in mutual communication, all of the couples were able to communicate at least simple issues at the end of the rehabilitation period. The more demanding the tasks, the more difficult it became for them to succeed, especially for older PWSA with severe motor paralysis. Both the people with aphasia and their partners mainly experienced benefits from the APPUTE intervention and for the most part, the benefits were retained during follow-up.

Conclusions: The APPUTE method appears to improve the communication skills of PWSA and their partners, as well as the linguistic skills of PWSA.     

Phonological and orthographic cueing therapy: A case of generalised improvement

Background: Phonological and orthographic cues can both be effective in the treatment of anomia, and are often used clinically. However, studies using phonological and orthographical cues in aphasia therapy have tended to be equivocal about their benefits, and most demonstrate improvements limited to treated items. Few previous studies investigate change in conversation or in people's own views of their aphasia.

Aims: The aim of the study was to investigate the effect of a weekly delivered therapy, using combined phonological and orthographic cues, on word retrieval, connected speech, conversation, and on the participant's own views of his aphasia.

Methods & Procedures: A person with anomia (TE) is presented as a detailed single-case study. Two baselines, 8 weeks apart, were followed by two 8-week phases of therapy, delivered weekly in a clinical setting. The first phase involved the use of combined phonological and orthographic cues to aid retrieval of a targeted set of words. The second phase encouraged the use of targeted words in connected speech and conversation. TE was reassessed after each phase of therapy and again 2 months later, after a period of no therapy. The study involved controls for improvement due to regular contact but without intervention (the baseline phase) and investigated generalisation to untreated items (treated and untreated sets were used, balanced for performance prior to therapy). Finally non-specific effects of therapy were determined by testing throughout the study on a set of language control tasks (predicted to be unaffected by the therapy).

Outcome & Results: TE demonstrated significant and enduring improvements in picture naming, which had generalised to untreated items. Significant improvements were also demonstrated in the broader measures of connected speech, aspects of conversation, and his own views of his aphasia, while performance on control tasks remained fairly stable. There was a significant relationship between changes in word finding and changes in TE's views of his communication activity across the course of the study, with a pattern of stability over baseline and change with intervention, particularly the first phase of therapy, i.e., using cues.

Conclusions: These findings demonstrate that a combined phonological and orthographic cueing therapy targeting word retrieval can have lasting benefits, not just on targeted items but also on untreated words, connected speech, and the views of the person with aphasia. Furthermore, such improvements can be achieved within a prevalent service delivery model.