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Welcome to this SpeechPathology.com Live Expert e-Seminar!

A Social Networks Approach to Aphasia: Group

Therapy and Communication Partner Training

Presented By:

Candace P. Vickers, Ph.D., CCC-SLP

Moderated By:

Amy Hansen, M.A.,CCC-SLP, Managing Editor,

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A Social Networks Approach to Aphasia: Group Therapy and

Communication Partner Training

Candace P. Vickers, Ph.D., CCC-SLPCreator/Author, Communication Recovery GroupsSt. Jude Centers for Rehabilitation and Wellness

Brea, CaliforniaAdjunct Faculty, Chapman University

Orange, California

Candace.Vickers@gmail.com

What elements make up a Social Networks Approach? Today’s topics…

� Augmentative approach to aphasia

� Group therapy in aphasia� Research evidence� Concepts and

suggestions

� Communication partner training� Research evidence� Selected procedures in

partner training � http://www.freephotos.com/index.php?photoid=13

361&action=viewphoto

Augmentative approach to severe aphasia (From Garrett & Beukelman, 1992, pgs 247-250)

� Communication= holistic process

� Goal=enhance participation in life

� Emphasis on meaning/intent vs. form

� Flexible vs hierarchical approach

� Capitalize on residual strengths vs. focusing on deficits

� Pragmatic skills� Perceptual skills

� Linguistic skills� Experience base

� Emphasis on providing communication opportunities

� Skilled partner makes a difference

� Use ‘whatever works’, multimodal approach

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Life Participation Approach to

Aphasia (Chapey et al., 2000)

Interventions include all those affected by the aphasia into tx� Interventions aim for more rapid return to active

life, focuses on real life goals

� Goal-to strengthen daily participation in activities of choice vs language remediation only

Social approach to aphasia

“The goal of a social approach is to promote membership in a communicating society and participation in personally relevant activities for those affected by aphasia.”

Nina Simmons Mackie, 2001, p. 246

Social networks approach

Partner training: prepare PWA & partner for communication at home and with others

Conversation is context for therapy; train partner in sessions as often as possible

(Boles, 1998)

Group therapy: provide “access to conversation” for PWA by providing conversational support during interactions

(Kagan, 1998; Kagan et al, 2001)

-Trained conversation partners

- interaction with peers

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Conversation groups :part of long term management of aphasia

� Communication is more than information transfer

� Experience social closeness through conversation (Garrett & Beukelman, 1992)

� Conversation allows access to social/community life (Kagan, 1998)

� Participants experience new sense of community (Kagan, 1998)

Research evidence on groups

� Wertz et al(1981)-VA Study found PWA seen in groups vs 1:1 also made significant language improvements

� Elman & Bernstein-Ellis (1999)- significantly improved linguistic and functional communication improvement in treatment group vs deferred tx group

� Vickers (in press) – Significantly less perceived social isolation and greater social connection in aphasia group attendees versus non-attendees

Types of groups

� Traditional clinician led format

� Use of trained conversation partners and volunteers

� Communication partner volunteers (Lyon, ‘92; Lyon et al,

1997; Vickers ’98; Vickers, 2004; Vickers & Hagge, 2005; Vickers & Hagge, 2007)

� Supported conversation; training of conversation partners (Kagan, ’98; Kagan et al, 2001)

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Skills for group leaders

� Skilled communication partner for persons with aphasia

� Knowledge of no tech AAC strategies

� Written choice communication (Garrett & Beukelman, 1992)

� Supported Conversation (Kagan et al, 1998)

Written Choice communication

� First described by Garrett and Beukelman in 1992

� Forced choice format

� Authentic exchange

� Partner training

Groups which are ‘aphasia friendly’

� Resources to enhance comprehension and expression

� Personally relevant topics

� Purposeful use of context to enhance access for all

� Dry boards/markers

� Maps;Pictographs; tangible topic starters which are thematic� Examples

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Cohesive groups� Do:

� Try to encourage cross talk, notice who is trying to speak, who is reacting…

� Use fewer and shorter turns

� Use fewer questions� Recognize novel information being

shared by group members and follow up

� Abandon plan for topic that interests the group most

� Share leadership…

� Don’t…Dominate the leader role, asking each member to speak one at a time going round and round in a circle…

� Above concepts and more are found in Bernstein-Ellis & Elman, 1999

Aphasia Groups: Selection Criteria(Moderate to Mild Aphasia)

� Speak at the phrase/sentence level (even if telegraphically)

� Follow topic changes without need for consistent visual cues

� Comprehend short paragraphs of both oral and written material

� Use a variety of strategies to communicate

� (Vickers, 1998)

Aphasia Groups: Selection Criteria(Moderate to Severe Aphasia)

� Eye contact/ sustained attention 45 min.

� Insight into deficits/respond to cues to gesture,verbalize, point to choices

� Desire treatment/appreciate purpose of therapy

� Some reading recognition of words in context of thematic conversation

� Follow topic changes when given visual and verbal input� (Vickers, 1998)

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Aphasia Groups:Exclusion Criteria

� Severely depressed and angry

� Intolerant of/uncomfortable with peers with disabilities

� Highly anxious or uncomfortable speaking in front of others

� Severely tangential/poor turn-taking skills

� Poor alertness or severely labile

� Strong preference for individual therapy only� (Vickers, 1998)

Target Communication Skills

� Verbal expression for 1:1 or multiple partner interactions

� Practice alternative communication strategies for functional communication

� Auditory/reading comprehension

� Functional writing

� Speech intelligibility/use of strategies

� Pragmatics/memory skills� (Vickers, 1998)

Group therapy planning

� Seating: consider optimal interaction patterns; limitations of members

� Provide topic starters and thematic activities but allow group to set its own topics

� Example

� Encourage cross-talk and interrogatives

� Example

� Basic equipment list

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Therapy planning for persons with moderate to severe aphasia: considerations

� Backgrounds of members� Bio Sketch (Garrett & Beukelman, 1992)

� Possible shared interests/experiences

� Levels and types of aphasia

� Consider visual, hearing, pain and muscle tone sensitivity issues

� Cultural sensitivity

Therapy planning: developing your own ideas and materials

� Start single theme and branch off from there� Visual supports help

� Imagine…. The questions /opinions/advice/feelings/that might be relevant

� Explore-Memories and experiences

� Be ready to follow up on comments/stories from group members

� http://www.freephotos.com/index.php?photoid=16653&action=viewphoto

Special techniques for group interaction

� Seize the right moment to generate cross talk

� Using comments, not just questions

� Using visual materials in an efficient way to get everyone engaged

� Example

� Sharing leadership with a group member

� Bernstein-Ellis & Elman, 1999

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Groups as place to achieve therapy goals during billable tx

� Practicing self-cueing & compensatory strategies� Example

� Practicing responding to multimodality communication to participate in conversation� Example

� Extending conversation skills through practice of interrogative questions and telling of narratives� Example

Achieving Functional Outcomes: Expression

� Expression: Responding to others

� Response to others with assistance (FIM levels 2,3, 4)

� Expression of needs, ideas, comments, preferences, choices, opinions, advice

� Assistance from skilled communication partners (speech and rehab staff, trained family members, trained volunteers)

Achieving Functional Outcomes: Expression

� Expression: Initiating Communication

� Initiating communication towards others in a natural situation (use of words, phrases, interrogative questions, sentences and paragraphs to express ideas)

� with assistance of skilled communication partners (FIM 2, 3, 4)

� with supervision/set up (FIM 5)

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Achieving Functional Outcomes: Comprehension

� Comprehending questions, statements, narratives, and directions from caregivers and peers

� With assistance/supervision from trained communication partners (FIM Level 2,3,4, and 5) offering augmented input to enhance comprehension via augmentative techniques

Achieving Functional Outcomes: Comprehension

� Example:� Functional goal: comprehend/ recall

simple paragraphs (FIM level 5) with 90-100% accuracy, or complex paragraph information (FIM level 6)

� Group member A interviews Group Member B

� Members switch roles� Recall/verbalize what was learned about partner

to whole group or just to clinician

Billing for group therapy

� Must be part of treatment plan

� Sample goal:

� Client will initiate simple

sentences to multiple

partners with moderate assistance at 75%

success across 3 sessions

� Example of treatment plan terms

� Conversational discourse

training

� Sentence production

training

� Interrogative question formulation training

� Narrative discourse

practice

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Groups…a win/win for all…

� Refer people to local groups

� Check website of National Aphasia Association for closest ones

� Start a group of your own

� Groups led by persons with aphasia

Starting community based aphasia groups

� Discover mission statement of your facility

� Demonstrate to management or foundation how group

program fulfills this mission

� Start with 1 or 2 people in active therapy who need conversation practice

� Use discharged patients as conversation partners

� Recruit and train volunteers

� Include persons with aphasia as volunteers

� Try for community partnerships to get space; e.g., churches and senior centers and include their people as volunteers

Communication Partner Training

� New recognition: Importance of Communication Partner

� “Better communication in daily life often has its roots in the changed behavior of the partner..” (Visch-Brink, Hars Kamp, et al ’93, pg. 251).

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Communication Partner training approaches…

� Written choice communication (Garrett & Beukelman, 1992)

� Supported Conversation (Kagan, ’98; Kagan et al, 2001 )

� Communication Partner Volunteers

� Training community members as communication partners(Lyon, 1992; Lyon et al, 1997)

� Extensive training with PWA and spouse (Lyon, 1998)

� Conversational coaching (Boles, 1998)

� Solution Focused Aphasia Therapy (Boles, 2000)

� Evidence from conversation analysis, e.g., “enter the word search” strategy (Oelschlaeger, 1999)

Approach of Jon Lyon, Living with Aphasia

� Address the “handicap” of aphasia

� Work to increase life participation

� Work to include communication partners in tx

� Communication partner volunteers program

� (Lyon, 1992; Lyon et al 1997)

SLP as coach and guide…Larry Boles, Cal State Sacramento

� Conversational coaching

� Boles, 1998

� Solution focused aphasia therapy

� Boles, 2000

� Cross disciplinary focus with social work

� Boles & Lewis, CSHA, 2003

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Partner training: Why do it?

� How Partners benefit

� Learn tools for optimal

communication

� Chance to practice use of

tools with support from clinician during

conversation

� Ongoing contact with

clinician to make needed modifications, learn new

skills

� How PWA benefits

� As partner behaviors change, PWA ‘s communication increases in terms of frequency of initiation and turns, types of communication acts

What do we know about how partners can really help?

� Trained conversation partners were able to bring about increased participation in the conversation for people with aphasia

� Kagan, et. al, 2001

� Examples of skills learned by partners that enhanced communication for PWA

Diagnostic perspective for SLP

� Moderate to severe aphasia scenario:

� Use standardized test to document baseline/medical need (ie., Aphasia Diagnostic Profiles; WAB, BDAE)

� Consider use of functional scales such as ASHA FACS, goals in terms of Functional communication measures from NOMS

� Discover residual language strengths for skill building and for use in 2 way communication with significant other

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Diagnostic Perspective: Learn about social network of PWA

� Ask about social networks of client with aphasia!

Family AND Non Family Partners!!! (Vickers, in press)

Tools:

� The Social Networks Inventory (Blackstone & Berg, 2003)

� Create your own…

� Educate yourself using the Bio Sketch (Garrett & Beukelman, 1992;)

� Create template to collect relevant info

Diagram for “Circle of Communication Partners” –From Social Networks Inventory-Blackstone & Berg 2003

(used by permission)

Key concepts in partner training….

� Different partner needs for different levels of aphasia

� Partner part of each session

� Goals for partner

� As sender of info.

� As receiver of info.

� Partner needs:� Education/training

re: nature of aphasia; support

� Guided conversation practice with PWA

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Typical issues for partners

� You don’t seem like the same person to me…why can’t you say my name?

� How do I communicate with you? Did you forget everything you knew?

� How do I find out what you want or what you mean?

� How can we enjoy each other when communication is so difficult?

� What is still working? Can life ever be good again?

Things to encourage…

� Mod – sev aphasia� Recognizing/using natural

communication opportunities as chances to practice transaction/interaction

� Using written and verbal choices throughout the day in natural situations

� Using multi-modality communication to facilitate comprehension

� Mild and moderate aphasia

� Being an active listener & use reflection and paraphrasing

� Learning when to offer limited alternative questions

� Learning how to “enter the word search” to encourage the flow of conversation

Issues for PWA coping with severe aphasia…

� Partially or completely blocked from spontaneous initiation of ideas

� Co-existing apraxia of speech/limb apraxia possible

� Often has significantly compromised spoken language comprehension

� May look completely global on standardized testing; slp must probe for strengths

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Issues for partner of PWA with severe aphasia…

� In crisis/shock over changes

� Answers all questions directed to PWA

� Focus on accurate speech production as only criteria of success

� Unable determine what PWA wants/needs/thinks-frustrated,

� Unaware of how to provide/create communication opportunities

Typical scenario: interaction� PWA - passive role in communication exchange

� PWA may be persistent in trying to express content when efforts are unsuccessful

� Discord, frustration, feelings of loss for both partners

� PWA/ spouse often leave tx with no tools unless SLP teaches specific behaviors to partner and PWA making an exchange possible

Initial focus: Modeling/demonstration

� Demonstrate patient’s ability use preserved language abilities in a 2 way exchange

� Use written choice communication

� Use of multimodality cues, and augmented input to increase patient’s comprehension

� Discuss/comment; possibly video and discuss

� Have significant other practice techniques with PWA in a real exchange

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Utilize residual language abilities

� Recognition of written words in context- teach family to offer written choices

� Repetition ability at any level -encourage response to verbal choices/and or written choices

� Any gestural ability - teach family to model and encourage/reinforce use of gestures

� Learning strategies for partner

� Have partner check off behaviors observed to increase awareness

� Have partner note which clinician behaviors were most effective for patient/discuss

� Set up role play with PWA and partner-observe/critique

� Set goals for partner, display goals on board

Clinician models techniques in an exchange with PWA

Typical mistakes made by partners during/after training

� Talking too much, too fast to PWA

� Guessing prematurely

� Failing to allow time for responses

� Quick topic changes

� Writing full sentences vs key words for written choices

� Failing to display written choices in PWA’s visual field

� Giving too many options in writing or verbally

� Verbal choices too long

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Desired partner skills for severe aphasia

� Grasps concept of altering own behavior/ carry out in tx room and outside

� Interested, supportive, accepting of PWA

� Demonstrates use of multimodality communication (i.e.., gestures, etc.)

� Provides clear verbal or written choices at appropriate pace while being adult and natural

� Understands how to create/provide communication opportunities

Documentation in medical settings

� Partner receives training in tx session with client

� Changes in PWA are documented in terms of improved levels of independence/ effectiveness during various types of communication interactions with “trained communication partner”

� Medicare

� Max, mod, min, levels of assist

� Improved levels of independence on FIM or ASHA FCM levels (NOMS)

Sample goal: describes how client will improve

� Example: Client will communicate opinions and feelings in 1:1 conversation with trained communication partner with minimal assist

� Minimal assist = 25% assistance

� 25% assistance = what the partner provides by using strategies learned in partner training

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Treatment plan section on Medicare form

� List techniques that reflect skilled, complex care

• Partner training

� Conversation training

� Augmentative strategies

� Compensatory strategies for word finding, etc.

� Solution focused aphasia therapy (Boles, 2000)

Sample social network intervention for a person with severe aphasia

� Train close family members (Circle 1)� Train professional caregivers (Circle 4)� Encourage re-establishment of friendships (Circle 2)� Facilitate development of new friendships (Circle 2,3)� Expand social contacts via

� Group tx

� Volunteerism

� Networking with peers

� Expand ability/opportunities to communicate with multiple unfamiliar partners (Circle 5)

� (Circles refer to Circle of Communication Partners, Blackstone & Berg (2003)

Case of “S”

� 66 year old female

� CVA, right hemi. 3/31/00

� 2 mos. inpatient rehab for very severe aphasia, apraxia of speech and phonation, and dysphagia

� Specific activity limitations for conversation -Understanding topic changes and requests from others in conversation

� Conversing with one person

� Conversing with many people

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Still a great team…

“S” - 2001 (Context dependent communicator)

� ‘E’ and son ‘M’

� 0 partners

� 0 partners

� 3 partners:

(OT, ST, PT therapists)

� 0 partners

S’s life participation Pre-CVA� Wife

Married for 48 years

� 3 children

� 6 grandchildren

� Elementary school teacher

Taught for 42 years � Pianist

http://www.freephotos.com/index.php?

photoid=13353&action=viewphoto

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Participation restrictions/social network reductions – post CVA

� Losses from aphasia:� independent ‘access to conversation’

(Kagan, ’98)

� role as homemaker, now needing a caregiver to help with all ADL’s (spouse)

� vocational roles as tutor and substitute teacher

� creative leisure and volunteer activity –piano playing

Therapy for “S”

� Partner training for all therapy sessions

� Written choice communication used in therapy; husband trained

(Garret & Beukelman,

1992)

� Efforts to expand social network included:

� Group therapy; frequently encouraged to co-lead

� Rehab volunteer designation; playing piano weekly with non-dominant hand

Group treatment used to increase participation in conversation

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Advantages for S in group

� Increased communication opportunities

� Peers with aphasia

� Volunteers with aphasia

� Other volunteers

� Participation in group outings to restaurants, parks, etc.

Expansion of participation and social network

� 2002—Helping lead group by asking questions of others, helping others in group with group leader set up and support

� Leading music from keyboard w/ L hand

� 2004-2007 – Co-facilitating group, welcoming new members, making jokes, monitoring progress of others, making suggestions for improvements in groups

� 2008-2009: Public piano performances (e.g. funeral of friend)

“S” - 2002 to 2005 (Context dependent communicator)

� 5 partners: spouse, son, son

& family moved in

Phrases, short sentences;

limited gestures & writing

� Same as above

� 15-20 partners: retirement

home ministry, exercise

group, CRG

� Eat out w/ husband & 12

friends from past

� 2-4 new partners a week

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Our role:catalyst for change in person’s communication world

� Include communication partners in treatment

� Become a skilled communication partner yourself

� Include and train others

� Bring others along with you to help…

� Recruit and use volunteers

� Bring people together

� Peer mentoring groups with no leader

Facilitating real change for PWA

means helping build community

…

� Between people with aphasia and their

primary communication partners

� With new conversation partners both with

and without support

� With older adults and students

� With the community at large

Selected references

Bernstein-Ellis & Elman (1999). Aphasia group communication treatment: The Aphasia Center of California approach. In Elman, R. (Ed.) Group treatment of neurogenic communication disorders: The expert clinician’s approach, (pgs 47-56). Boston: Butterworth-Heinemann.

Blackstone, S. W. & Hunt Berg, M. (2003). Social Networks: A Communication Inventory for Individuals with Complex Communication Needs and their Communication Partners. Monterey: Augmentative Communication, Inc.

Boles, L. (1998). Conducting conversation: a case study using the spouse in aphasia treatment. Special Interest Division 2 Newsletter: Neurophysiology and Neurogenic Speech and Language Disorders. 8:24-31.

Boles, L. (2000). Solution Focused Aphasia Therapy, CSHA Magazine, 29 (3): 8-12.Chapey, R., Duchan, J., Elman, R., Garcia, L., Kagan, Lyon, J., Simmons-Mackie, N. (2000) Life participation approach to aphasia: a statement of

values for the future. ASHA Leader Feb. 15 edition: pp. 4-6. Elman, Roberta, and Bernstein-Ellis, E. (1999) The efficacy of group communication treatment in adults with chronic aphasia, Journal of Speech

and Hearing Research, 42(2): 411-419.Garrett, K. & Beukelman, D. (1992) Augmentative communication approaches for persons with severe aphasia. In Yorkston, K. (Ed.)

Augmentative communication in the medical setting, (pgs. 245-321). Austin, TX: Pro-Ed.Kagan, A. (1998) Supported conversation for adults with aphasia: Methods and resources for training conversational partners. Aphasiology,

12:816-830.Kagan, A., Black, S., Duchan, J., Simmons-Mackie, N., & Square, P. (2001) Training volunteers as conversation partners using “Supported

conversation for adults with aphasia” (SCA): A controlled trial, Journal of Speech, Language and Hearing Research, 44: 624-638.Lyon, J. (1992) Communication use and participation in life for adults with aphasia in natural settings: The scope of the problem. American

Journal of Speech Language Pathology. 1(3): 7-14.Lyon, J., Cariski, D., Keisler, L., Rosenbek, J., Levine, R., Kumpula, J., Ryff, C., et al. (1997). Communication Partners: Enhancing participation

in life and communication for adults with aphasia in natural settings. Aphasiology, 11(7), 693-708.Lyon, J. (1998) Treating real life functionality in a couple coping with severe aphasia. In Helm-Estabrooks, N. & Holland, A. (Eds.) Approaches to

the treatment of aphasia. (pg. 203-239). San Diego: Singular Publishing.Oelschlaeger, Mary L. 1999. Participation of a Conversation Partner in the Word Searches of a Person with Aphasia. American Journal of Speech-

Language Pathology, 8 (1), 62-71.Simmons-Mackie, N. (2001) Social approaches to aphasia intervention. In R. Chapey, (Ed.) Language intervention strategies in aphasia and

related neurogenic communication disorders. (Pgs. 246-268). New York: Lippincott Williams & Wilkins. Vickers, C. (1998) Communication Recovery: Group Conversation Activities for Adults. San Antonio, TX: Communication Skill Builders. Vickers, C. (2004) Communicating in groups: one stop on the road to improved participation in life for people with aphasia. Perspectives on

Neurophysiology and Neurogenic Speech and Language Disorders, 14(1), 16-20. American Speech Language Hearing Association, Special Interest Division 2.

Vickers, C. & Hagge, D. (2005) Social networks approach for persons with aphasia. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations. 12(3), 6-14. American Speech Language Hearing Association, Special Interest Division 14.

Vickers, C. & Hagge, D. (2007) Therapy for long-term aphasia: Options and Possibilities. Perspectives in Gerontology, 12, 2: 14-16. American Speech Language Hearing Association Special Interest Division 15, Gerontology.

Vickers, C. (in press). Social networks after the onset of aphasia: The impact of aphasia group attendance. Aphasiology. (not yet available)Vischbrink, E.G., van Harskamp, F., Amerongen, N., Wielaert, S. & van de Sandt-Koenderman, M. (1993) A multidisciplinary approach to aphasia

therapy. In (Holland & Forbes, Eds.) Aphasia Treatment: World Perspectives, (pgs. 227-262). San Diego: Singular Publishing.Wertz, R.T., Collins, M.J., Weiss, D., Kurtzke, J.F., Friden, T. et al. (1981) Veterans Administration cooperative study on aphasia: A comparison of

individual and group treatment. Journal of Speech and Hearing Research, 24:580-594.