A closer look at the 'hint and guess' sequences in aphasic conversation

The focus of this article is to examine in more detail the collaborative nature of aphasic conversation. In particular, collaborative efforts can be seen in such situations where aphasic problems, such as word searching, emerge. These problems have traditionally been studied as a cognitive process of an aphasic individual. The aim is to demonstrate that in aphasic conversation word search is a visible activity which often initiates a collaborative problem-solving sequence, traditionally called a 'hint and guess sequence. As the special practices by which this collaboration is accomplished are relatively unknown, the 'hint and guess sequences of both fluent and non-fluent aphasic speakers have been analysed in detail. The main findings suggest that these sequences have a regular structure of four distinct phases that are quite similar irrespective of the type of aphasia.     

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.     

Recurring utterances (speech automatisms) without aphasia: A single case study

Background: Regarding the generation of recurring utterances (RUs), there are two lines of research in the literature. The first is that RUs occur in severe aphasia; that is, global aphasia or severe Broca's aphasia. The second is that RUs are a modality-specific and post-phonological speech disorder.

Aims: The aims of this paper are (1) to describe and follow up on the characteristics of non-meaningful RUs observed in a patient, AY, who had no definite aphasic symptoms, and (2) to investigate the mechanism underlying the generation of AY's RUs neurolinguistically and neuroanatomically.

Methods & Procedures: We studied and followed the language functions of AY, including her non-meaningful RUs, using the Japanese Standard Language Test for Aphasia (SLTA; Japanese Society of Aphasiology, 1977) and her conversations with her speech therapists.

Outcomes & Results: The patient was found to present non-meaningful RUs without definite aphasic symptoms. Her speech disorder evolved into pure apraxia of speech about a year after onset.

Conclusions: The results show that AY's non-meaningful RUs are a modality-specific and post-phonological speech disorder, which supports the hypothesis that RUs result from deficits in post-lexical subphonemic processing in the psycholinguistic or neurolinguistic model of speech production.     

Conversational dynamics between aphasics

Abstract

The aim of this study was to determine how aphasic patients take part in conversations, the manner in which their conversations proceed, and how they compensate for their disabilities in maintaining conversational flow. The aphasia group studied contained five aphasics with different symptoms. Four conversations (54 minutes) were videotaped through a one-way mirror and subsequently transcribed. The analysis was based on a seven-category system (moves) and conversational flow was described in terms of active and reactive utterances. The results showed that, using the number of moves and total speech time as criteria, individual speakers varied greatly in their degree of participation in discussions and had different interactive profiles. The speakers were divided into two groups according to the type and severity of aphasia. It was discovered that the groups did not differ in conversational behaviour in terms of active and reactive moves, but the non-fluent speakers differed from the fluent aphasics in their use of deviant conversational moves. There was therefore no clear relation between the type and severity of aphasia and participation in discussions. Implications for aphasia therapy are discussed.     

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.     

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.     

The effects of direct and indirect speech on discourse comprehension in Dutch listeners with and without aphasia

Background: Research on language comprehension in aphasia has primarily focused on comprehension of isolated words and sentences. Even though previous studies have provided insights into comprehension abilities of individuals with aphasia at the word and grammatical level, our understanding of the nature and extent of their language comprehension (dis)abilities is not yet complete. In contrast to the highly restricted semantic and syntactic interpretation of sentences, discourse comprehension requires additional pragmatic and non-linguistic skills.

Aims: The purpose of this study was to assess language comprehension in individuals with and without aphasia at the discourse level. In particular, it addressed the question of whether the use of direct speech, compared to indirect speech, affects comprehension of narrative discourse in Dutch aphasic and non-brain-damaged (NBD) listeners.

Methods & Procedures: The Direct Speech Comprehension (DISCO) test was developed to examine the effects of manipulating direct vs. indirect speech on discourse comprehension. Twenty-three individuals with aphasia and 20 NBD participants were presented with spoken narratives that contained either direct or indirect speech reports. The narratives were presented audio-visually on an iPad, and comprehension was assessed with yes/no questions.

Outcomes & Results: The performance of the participants with aphasia was significantly poorer than that of the NBD participants. Moreover, a main effect for condition type was found, indicating that narratives with direct speech reports were better understood than narratives with indirect speech reports by listeners with and without aphasia. There was no interaction between group and condition type indicating that this main effect held for both the aphasic and the NBD listeners. However, for the participants with aphasia, there was an interaction between condition and Token Test error score indicating that the positive effect of direct speech constructions diminishes for individuals with poorer comprehension.

Conclusions: Direct speech constructions facilitate language comprehension in listeners with and without aphasia. One explanation for this finding is the occurrence of additional “layers” of communication, such as intonation and facial expression, often accompanying direct speech constructions. An alternative account is the degree of grammatical complexity: In Dutch, the syntactic construction of indirect speech requires embedding, whereas in direct speech the introductory sentence and the quote are both main clauses. The finding that the beneficial effect of direct speech on language comprehension diminishes for individuals with severe aphasia may indicate that the DISCO is too difficult for them to reveal an effect of a subtle manipulation such as that of condition type.     

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.     

An analysis of topics and vocabulary in Chinese oral narratives by normal speakers and speakers with fluent aphasia

This study analysed the topic and vocabulary of Chinese speakers based on language samples of personal recounts in a large spoken Chinese database recently made available in the public domain, i.e. Cantonese AphasiaBank (http://www.speech.hku.hk/caphbank/search/). The goal of the analysis is to offer clinicians a rich source for selecting ecologically valid training materials for rehabilitating Chinese-speaking people with aphasia (PWA) in the design and planning of culturally and linguistically appropriate treatments. Discourse production of 65 Chinese-speaking PWA of fluent types (henceforth, PWFA) and their non-aphasic controls narrating an important event in their life were extracted from Cantonese AphasiaBank. Analyses of topics and vocabularies in terms of part-of-speech, word frequency, lexical semantics, and diversity were conducted. There was significant overlap in topics between the two groups. While the vocabulary was larger for controls than that of PWFA as expected, they were similar in distribution across parts-of-speech, frequency of occurrence, and the ratio of concrete to abstract items in major open word classes. Moreover, proportionately more different verbs than nouns were employed at the individual level for both speaker groups. The findings provide important implications for guiding directions of aphasia rehabilitation not only of fluent but also non-fluent Chinese aphasic speakers.     

Language exercises for dinner: Aspects of aphasia management in family settings

Background: The introduction of didactic activities into the aphasic family's everyday interaction is a known aspect of the management of aphasia, and it is also known to be problematic, since didactic activities tend to entail tension and interactive stress. Therefore many therapists may discourage aphasic families from language exercising without professional guidance. However, systematic analyses of comprehensive sets of data documenting language exercises in aphasic families have previously not been available. Aims: This study aims at the analysis of one instance of interactively realised aphasia management, thus broadening the empirical basis of a social approach to aphasia therapy and counselling. It presents a detailed insight into structural and social aspects of language exercises within informal contexts: How are these activities organised? Why do some of them entail tension while others do not? Is "improvement of aphasia" the only function they strive to fulfil? Methods & Procedures: A corpus of 21 hours of video recordings of 10 aphasic families' informal conversations is analysed. The procedure of identifying, describing, and analysing sequences of exercising follows the principles of the qualitative paradigm of Conversation Analysis. Outcomes & Results: In three of the ten families exercising is a relevant activity. In these cases, the exercises draw on an interactive pattern known from institutional teaching and therapy. Dealing exclusively with single words (naming and repeating), the Request-Response-Evaluation pattern is imported and adapted to the conditions of informal talk. The face-threatening potential of exercising in informal contexts appears to be closely linked to the way the adaptation of this format is actually realised. Here the determining structural factors are the positioning of the sequence in the ongoing talk, and the initiation and contextualisation techniques employed. In our corpus, type and severity of aphasia do not emerge as factors predicting either frequencies or formal aspects of language exercises. Conclusions: Families engaging in language-exercising sequences, and those who do not, appear to have different orientations in adapting to aphasia: Exercising can express the family's orientation towards the restoration of linguistic competence as a joint project. Confined to private situations, collaboratively agreed upon and accomplished, exercises may lose their face-threatening potential. Language exercises can also serve to circumvent communicative distress, employing a calculable and precast pattern to maintain interaction and ensure the aphasic partner's participation in family activities. Aphasic family counselling should take into account the family's specific orientations, the face-threatening potential of exercising, and the surplus value of exercising as an interactive practice of adaptation.     

Speech segmentation in aphasia

Background: Speech segmentation is one of the initial and mandatory phases of language learning. Although some people with aphasia have shown a preserved ability to learn novel words, their speech segmentation abilities have not been explored.

Aims: We examined the ability of individuals with chronic aphasia to segment words from running speech via statistical learning. We also explored the relationships between speech segmentation and aphasia severity, and short-term memory capacity. We further examined the role of lesion location in speech segmentation and short-term memory performance.

Methods & Procedures: The experimental task was first validated with a group of young adults (n = 120). Participants with chronic aphasia (n = 14) were exposed to an artificial language and were evaluated in their ability to segment words using a speech segmentation test. Their performance was contrasted against chance level and compared to that of a group of elderly matched controls (n = 14) using group and case-by-case analyses.

Outcomes & Results: As a group, participants with aphasia were significantly above chance level in their ability to segment words from the novel language and did not significantly differ from the group of elderly controls. Speech segmentation ability in the aphasic participants was not associated with aphasia severity although it significantly correlated with word pointing span, a measure of verbal short-term memory. Case-by-case analyses identified four individuals with aphasia who performed above chance level on the speech segmentation task, all with predominantly posterior lesions and mild fluent aphasia. Their short-term memory capacity was also better preserved than in the rest of the group.

Conclusions: Our findings indicate that speech segmentation via statistical learning can remain functional in people with chronic aphasia and suggest that this initial language learning mechanism is associated with the functionality of the verbal short-term memory system and the integrity of the left inferior frontal region.     

A proposed reinterpretation and reclassification of aphasic syndromes

Background: Different classifications of aphasic disorders have been proposed over the years. During recent decades new approaches to aphasia study have been developed, suggesting that current aphasia classifications can and should be reconsidered.

Aims: The purpose of this paper is to attempt to integrate contemporary knowledge about brain organisation of language and to propose a new aphasia classification.

Main Contribution: It is emphasised that there are two fundamental forms of aphasia, which are linked to impairments in the lexical/semantic and grammatical systems of language (Wernicke‐type aphasia and Broca‐type aphasia, respectively). Grammar correlates with the ability to represent actions (verbs) and depends on what is known as Broca's area and its related brain circuits, but it is also related to the ability to quickly carry out the sequencing of articulatory movements required for speaking (speech praxis). Lexical/semantic and grammatical systems not only depend on different brain circuitries, but also on different types of memory and learning (declarative and procedural). Other aphasic syndromes do not really impair language knowledge per se, but rather peripheral mechanisms required to produce language (conduction aphasia and aphasia of the supplementary motor area), or the executive control of the language (extra‐Sylvian or transcortical motor aphasia).

Conclusions: A new classification of aphasic syndromes is proposed: primary (or “central”) aphasias (Wernicke's aphasia—three subtypes—and Broca aphasia); secondary (or “peripheral”) aphasias (conduction aphasia and supplementary motor area aphasia); and dysexecutive aphasia (extra‐Sylvian—transcortical—motor aphasia), are distinguished.     

“I don’t know”: a usage-based approach to familiar collocations in non-fluent aphasia

Background: Familiar collocations (e.g., “it’s alright”) are an important part of everyday conversation. Such word combinations are often retained in speakers with Broca’s aphasia. However, only few investigations have studied the forms and functions of familiar collocations available to speakers with Broca’s aphasia.

Aims: We first apply a frequency-based perspective to word combinations produced by speakers with Broca’s aphasia and their conversation partners (CPs), and compare the frequency characteristics of word combinations in dyadic and non-dyadic speech. Second, we investigate the conversational functions of one prominent familiar collocation, “I don’t know” (IDK).

Methods & Procedures: In the first analysis, speech samples from interactions of nine dyads (each a speaker with Broca’s aphasia and their CP) were examined. Non-dyadic samples were selected from 39 speakers with Broca’s aphasia from AphasiaBank (MacWhinney et al., 2011). The Frequency in Language Analysis Tool (FLAT; Zimmerer & Wibrow, 2015) was used to estimate collocation strength (the degree of association between words in a combination) of well-formed bigrams (two-word combinations) and trigrams (three-word combinations). The second analysis presents a qualitative investigation of uses of IDK in dyadic exchanges.

Outcomes & Results: Analysis 1 revealed that residual trigrams in Broca’s aphasia were more strongly collocated in comparison to language produced by CPs. There was no difference in frequency-based profiles between dyadic and non-dyadic aphasic speech. Analysis 2 indicated that speakers with Broca’s aphasia and CPs used IDK to achieve a variety of communicative functions. However, patterns specific to each participant group were found.

Conclusions: These findings highlight that frequency-based analysis is useful in explaining residual, grammatically well-formed word combinations in Broca’s aphasia. This study provides evidence that IDK can aid turn construction in aphasia.     

Automated analysis of the Cinderella story

Background: AphasiaBank is a collaborative project whose goal is to develop an archival database of the discourse of individuals with aphasia. Along with databases on first language acquisition, classroom discourse, second language acquisition, and other topics, it forms a component of the general TalkBank database. It uses tools from the wider system that are further adapted to the particular goal of studying language use in aphasia.

Aims: The goal of this paper is to illustrate how TalkBank analytic tools can be applied to AphasiaBank data.

Methods &Procedures: Both aphasic (n?=?24) and non-aphasic (n?=?25) participants completed a 1-hour standardised videotaped data elicitation protocol. These sessions were transcribed and tagged automatically for part of speech. One component of the larger protocol was the telling of the Cinderella story. For these narratives we compared lexical diversity across the groups and computed the top 10 nouns and verbs across both groups. We then examined the profiles for two participants in greater detail.

Conclusions: Using these tools we showed that, in a story-retelling task, aphasic speakers had a marked reduction in lexical diversity and a greater use of light verbs. For example, aphasic speakers often substituted “girl” for “stepsister” and “go” for “disappear”. These findings illustrate how it is possible to use TalkBank tools to analyse AphasiaBank data.     

Joint productions as a conversational strategy in aphasia

To address the longstanding question of the conversational ability of persons with aphasia, this study investigated the spontaneous occurrence of a specific type of conversational collaboration, joint production, that is known to occur in the conversation of ordinary speakers. A person with aphasia and his wife videorecorded eight of their naturally occurring conversations. These conversations were analysed and three types of joint productions were identified: word search, turn completion and appendor production. Additional sequential analysis revealed the linguistic, paralinguistic and contextual resources available to the interactants in designing their joint production. Results showed that, despite the presence of aphasia, this couple was able to successfully employ joint production as an interactive technique leading to conversational success. Implications of this study are discussed relative to the understanding of communicative ability of persons with aphasia and how aphasia is diagnostically and therapeutically approached.     

Discrepancy between inner and overt speech: Implications for post-stroke aphasia and normal language processing

Background: Patients with aphasia often complain that there is a poor correlation between the words they think (inner speech) and the words they say (overt speech).

Aims: This study tried to characterise the relation between inner speech and overt speech in post-stroke aphasia.

Methods & Procedures: We tested language abilities, speech apraxia, and performance on inner speech tasks, including homophone and rhyme judgements, of 27 patients with chronic post-stroke aphasia.

Outcomes & Results: The patients with aphasia were distributed across the entire spectrum of abilities related to both inner and overt speech. For most patients, performance levels of inner and overt speech were similar. However, some patients had relatively better-preserved inner speech with a marked deficit in overt speech, while in others the opposite pattern was observed.

Conclusions: The results are discussed within the framework of current models of language, and their implications for language therapy and aphasia diagnosis are outlined.     

Single word intelligibility in aphasia and apraxia of speech

Abstract

Single word speech intelligibility was evaluated in three groups : aphasia with apraxia of speech, aphasia with no apraxia of speech, and normal controls. Intelligibility was significantly lower in the two aphasic groups compared with the normal group and intelligibility did not differ significantly between the aphasia and apraxia of speech and the aphasia only groups. Seventy per cent of the speakers with apraxia of speech obtained intelligibility scores below the normal range and 80% of the speakers with aphasia only obtained intelligibility scores within the normal range. There was a moderate, but statistically nonsignificant, correlation between intelligibility and severity of apraxia of speech on an eight-point rating scale.     

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.