1 part iv: integrated therapy approaches. 2 a. introduction the challenge: how do we enable people...

1

Part IV: Part IV: Integrated Therapy Integrated Therapy

ApproachesApproaches

2

A. Introduction The challenge: How do we enable people with

aphasia to participate once again in meaningful life activities?

Teach communicators to use Teach communicators to use AACAAC andand natural natural communication strategies communication strategies in ain a purposeful purposeful and and understandableunderstandable manner? manner?

3

My hypotheses re: limited intervention outcomes in this

population: * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Individuals with severe aphasia are the Individuals with severe aphasia are the leastleast

likely clients to likely clients to generalizegeneralize communication communication targets that are taught:targets that are taught: in de-contextualized contextsin de-contextualized contexts as “products” (e.g., sounds, symbols, words, as “products” (e.g., sounds, symbols, words,

gestures) vs. communication actsgestures) vs. communication acts OpportunitiesOpportunities to to useuse both AAC strategies and both AAC strategies and

practiced speech targets must be practiced speech targets must be embeddedembedded into into contextual communication activitiescontextual communication activities

4

This is not an entirely new philosophy

Let’s discuss some of the current therapy models that provide support for delivering therapy in a more integrated manner.

5

B. Introduction to Wholistic Therapy Approaches

1. Pragmatic Approach 2. Functional Therapy Approach 3. Life Participation Approach 4. Supported Conversation 5. Environmental Communication

Therapy

6

The “granola” approaches….

7

1. Pragmatic Therapy Approach Promoting Aphasic’s Communicative

Effectiveness (PACE) a. History:

Albyn Davis and Jeanne Wilcox promoted this approach in the 1980’s.

Thought that goal of tx was to improve patient’s ability to communicate in natural conversations.

However, felt that tx approaches to date had not corresponded with this goal.

Felt area of pragmatics (just emerging at that time) supported this alternative approach.

8

b. Description: a formalized structure of interaction

between the clinician and patient that incorporates elements of face-to-face conversation. Clinician and patient take turns sending new information to each other.

9

c. Research Basis:Philosophical work of Searle, etc.Child pragmatics research

(important to focus on USE of language, not just the FORM)

Some efficacy studies exist comparing pragmatic tx to other tx approaches…

10

d. Populations: all communicators with aphasia;

however, must have some expressive ability and awareness of interactions.

11

e. Principles: 1) The clinician and patient participate

equally as senders and receivers of messages

2There is an exchange of new info – this is done by keeping the sender’s message out of view of the receiver (pictures face down)

3) Free choice of channels: (any modality at any moment – whatever works)

12

4) natural feedback – the clinician’s feedback is based FIRST on communicative adequacy of the message. Only then may clinician provide feedback on the form of the message. Also, provide feedback in a sequence from general to specific.

5) Emphasis is on the communication of meaning within a naturalistic context.

13

f. Selecting Treatment Stimuli:

1) Choose pictures that depict specific relationships – for “barrier” communication tasks. Can buy some picture kits for this (see PACE kit, my pics)

2) Design roleplays.

14

Sample P.A.C.E. Stimulus Pictures (Edelman, 1985).

15

g. Implementing the Treatment Task see principles. KG/student Demo

h. Progress – see 5-pt. scoring system on your handout.

16

i. Summary of this approach: Differs significantly from conventional

stimulation approach: Communication target is NOT predetermined Clinician is not in total control of output Focus is on the adequate communication of

intent/meaning Elicits initiations as well as responses 5-point scoring system can apply to verbal

AND nonverbal behavior (see handout) In terms of clinical implementation, is

MORE structured than the general participation philosophy

17

2. Functional Approach

a. History: - 1980’s and 1990’s. Systems theory took hold; rehab dollars

became tighter.

b. Description: Any activity that seeks to improve the

patient’s reception, processing, and use of information pertaining to daily activities, social interaction, and expression of current physical and psychological needs.

Some consider it “task-focused”

18

c. Research Basis: Audrey Holland, 1982, and others.

Work from individuals with severe developmental disabilities was applied, too.

More efficacy research is surfacing all the time, but more difficult to measure because it is defined in many different ways.

19

d. Populations: communicators with aphasia who

can self-correct in some situations; aren’t below the 10th %ile on the

PICA, can sustain attention

20

e. Principles 1) aphasia is more than just a linguistic

deficit – also includes nonverbal communication, impact of environment

2) Treatment of language is important, but in the context of working toward a functional goal

3) First goal is to establish communication interchanges and reinforce all communication modes

4) new and personally relevant information is preferred to arbitrary language exercises

21

5) communication environments are natural ones (or as natural as possible)

6) emphasis on reducing behaviors that block communication

7) increase the frequency of patient communication first, then the accuracy of information exchange in later stages

22

f. Implementing the Treatment Task 1) Eliminate Negative Communication

Behaviors e.g., impulsive patients have to “wait”, patients who fake understanding

have to signal comprehension breakdowns, patients who don’t initiate must try something.

2) Establish a communicative set – determine the best kind of cueing, the best modality for communication

3) Target a specific level of discourse that is most appropriate for the client (conversational narrative, procedural)

23

4) Work within a topic/theme 5) Set up the situation so there’s

a meaningful communication goal with a real communication partner

6) Train significant others

24

g. Measuring progress: Nothing specified. Could use ASHA-FACS, etc.,

language samples, functional communication scales

h. Summary of this approach: Pros Cons With whom When

25

3. Life Participation Approach a.Historical Background –

Consumer-driven service delivery approach Believes the goal of aphasia therapy should

be to help individuals achieve immediate and long term life goals

Developed by several highly experienced clinicians who were frustrated with a “deficit only” approach to tx (Chapey, Elman, Simmons-Mackie, Kagan, Lyon, Duchan).

26

b. Description: Life concerns are at the center of all

decision making. Consumer is encouraged to select and

participate in recovery process; to collaborate on the design of interventions that enable him/her to return to an active life.

Goal: to reduce the consequences of disease by increasing life participation and reducing handicap.

27

c. Populations All people with aphasia and their

partners anyone else affected by aphasia

d. Research Bases: derived from social models of human

interaction and life satisfaction. Now some data-based articles with

outcomes out there too (See Lyon reference - handout)

28

e. Therapy Activities: identify important life activities (most

have some type of communication component)

inventory how that person could participate more fully with therapy or supports

teach partners new skills modify the environment teach within and outside of the clinical

environment

29

f. Measuring Effectiveness:Life satisfaction indices,scales of well-being, # of activities# of hours engaged in meaningful

communication and participationdepression scales, etc.

30

g .Other – developed in direct contrast to

disability-driven therapy. (e.g., stimulation approaches).

Not fully accepted by some clinicians or funders, but Medicare etc. have made changes in this area.

31

Additional References Lyon, J. (1996) Optimizing

communication and participation in life settings for aphasic adults and their primary caregivers in natural settings: A use model for treatment. In GL Wallace (Ed), Adult Aphasia Rehabilitation. Boston: Butterwowrth-Heinemann, 1996; 137-160.

32

4. Supported Conversation Approach (Aura Kagan, Toronto)

a. History Started by Pat Arato, spouse of a man with

aphasia, in 1979, after his discharge from therapy. Originally called the Aphasia Centre-North York; now the Pat Arato Aphasia Centre.

Aura Kagan is presently the director

33

b. Description Communication involves partnerships Partners must be taught to acknowledge and

reveal the inherent competence of adults with aphasia within the framework of natural adult conversation In the Pat Arato model, partners consist of

community volunteers who gently facilitate group discussions

Conversational supports are techniques and resource materials that partners and people with aphasia can use to “build a communication ramp” to maximal/natural participation in conversation

34

Sample techniques include: Augmented input (drawing, writing key words,

use of graphic contextual information) Written choices Cues to choose modalities Cues to interpret vs. interrupt Increasing pause time Provide validation and feedback for

communication effort and message content Communicators with aphasia are the “leaders”,

the volunteer is a facilitator only.

35

Sample page from Kagan et al.’s Pictographic Communication Resources

36

c. Populations All people with aphasia

Some join Introductory Groups (12 weeks) Others participate in weekly activities No time criterion post onset Some people with aphasia on either end of the

severity continuum may not be included, but this is relatively rare.

d. Research Outcome measures are underway * Research basis for program is from social theory

37

e. Activities Primarily group conversation, with

some family counseling available as well. Referrals generated from the larger community of rehabilitation professionals.

We’ll discuss sample activities in more detail in group therapy section.

38

Resources/references

Kagan, A., Winckel, J., & Shumway, E. Pictographic Communication Resources: Enhancing Communicative Access. Pat Arato Aphasia Centre, 53 The Links Road, Toronto, ON, Canada M2P1T7 Fax: (416) 226-3706, Website: www.aphasia.on.ca. Email: [email protected].

Kagan, A. (1998) Supported conversation for adults with aphasia: methods and resources for training conversation partners. Aphasiology, 12, 816-830.

39

5. Environmental Approach

a. History: 1980’s and 1990’s. Systems theory took

hold in U.S.; rehab dollars became tighter.

b. Description: Rosemary Lubinski (2001) summarized

this approach to tx in which environmental and social factors are assessed and then targeted for intervention.

In general, tx starts with the assessment of environmental (systems) factors.

40

c. Research Basis: Mostly conceptual/theoretical to date,

although some “systems theory” research exists for other populations. (e.g., dementia)

d. Populations: all communicators with aphasia KG - especially our nonspeaking

communicators or people in long-term care facilities

41

e. Principles: 1) individuals are affected by their

environment and their communication partners

2) The communication predicament faced by elderly and aphasic individuals escalates as their environment responds minimally or in a disordered way to their communication attempts

Example: Fluent aphasia - confused/jargon output -- nurse caregiver - dining hall - retreat -

42

f. Implementing the Treatment Task 1) Modify the individual as

much as possible 2) Focus on the family or

communication partners

Teach strategies Educate

3) Modify the environment Example - architectural design of room,

visual schedule

43

Sample Environmental Chart with Communication Instructions

Please point to what you are talking about.

Make sure you get my attention before you start talking.

Write down key words – there’s a tablet on the T.V.

Explain what’s coming up…point to my schedule or the calendar.

44

Example of Architectural Modifications to Enhance Communication/Social Roles:

Steinfeld, E. (1997)

gif

45

Example of Architectural Modifications to Enhance Communication/Social Roles

Steinfeld, E. (1997)

Jpeg

46

C. Specific Individual Therapy Techniques to

Improve Communication Skills in Meaningful

Contexts

47

1. Basic Strategy Learners

Emerging (Basic Choice) Communicators Contextual Choice Communicators Transitional Communicators

“anyone who doesn’t think to turn to external symbols/strategies to convey meaning when unable to do so verbally”

48

Tx Strategy #1. Teach referential communication skills

Some communicators with severe aphasia (across modalities) appear to have an elemental challenge in referencing ability

They need explicit instruction to engage in basic referential skills…..

49

Attending to others (especially speakers) Pointing to request Pointing (indexing) an object, picture or

written word to clarify the referent when answering/commenting

Gesturing deictically to request info or indicate another’s turn

Searching for tangible information when answering questions (e.g., in communication notebooks, etc.)

50

Abbeduto, Short-Meyerson, Benson, Dolish, & Weissman (1998) described “physical referencing” as: ...an understanding that an item that is present

in an individual’s proximal life space may be the topic of conversation or concept under discussion.

Their research indicated that referential skills (particularly physical referencing) are present in young children as well as older children with developmental language delays.

51

My Hypotheses

That individuals with severe aphasia may not be able to produce propositional, verbal (speech or nonspeech modalities) communication until basic referential skills emerge (either naturally or with facilitation)

52

My Hypotheses cont.

That the emergence of meaningful spoken or alternative communication coincides/ parallels the reacquisition of basic referential skills such as: pointing to others, shifting gaze to a speaker, physically manipulating externally-stored info (pictures, words, etc.) to answer a question.

53

Target Basic Referential Skills

“It happened right here in Pittsburgh!”

Where did your husband wreck the car?

54

a) Basic Deixis For turn-taking For requesting additional

information

“Dean - ask Jerry what he thought of the election...[hand-over-hand assist to point to Jerry to request info]”

55

John now pointing independently to ask Sara a question.

56

b) Tangible Referent Identification To request visible items (e.g., water) to answer questions

Example: “Show us what you bought this weekend” [visual prompt to encourage Jane to point to her own new sweater]

57

c) Point to objects or photos to answer questions

To teach basic deictic skills with external symbols

There are no wrong answers Partner responds contingently

(“oh, you went to Nova Scotia! I love it up there!” Example: Photo Album Conversations -

point to pictures to answer autobiographical questions “Where was your favorite vacation?”

58

Results of current research project on referential communication in

aphasia & matched peers (Garrett et al. 2004)

In photo-reminiscing task, PWA are as referential as peers with no aphasia -- no difference in pointing

Perhaps less able to think to communicate referentially in group communication situations -- more demands are placed on linguistic and cognitive resources in dynamic conversational contexts

60

Tx Strategy #2. Teach clear signals

Tag “yes/no” questions + provide graphic cues/gestural model for y/no

Hand-over-hand (HOH) assistance to help with point; gradually withdraw

Model use strategies yourself while conversing

(“look, this is what I think – [point to rating scale] – I think it’s a bad idea too”)

61

Teaching John “Yes” and “No”

62

Tx Strategy #3. Gradually extend interactional length Expect full conversations Expansion on a topic Completion of an entire transaction

(e.g., buying EE shoes – not done communicating until the shoes are in the bag)

63

Tx Strategy #4. Use VOCAs to teach independent message initiation

Use hand-over-hand assistance (HOH) to assist PWA to activate 1 message in motivating context -- maximize success. Examples: “Welcome everyone” at the beginning of group

therapy “Tell me about school!” when grandchildren

visit “Did you hear that we’re getting a new car?”

Later, pause before HOH – wait – reinforce ‘independent’ activation

64

STEP 1: Access single message VOCA to greet, say 1 target message (e.g., “Happy Birthday”, “I love you”, “Go Steelers!”)

Big Mack by AbleNet -- $92.00

65

STEP 2: Access sequence of messages to convey “NEWS” on a Voice Output Communication Aid (VOCA) no symbol selection/discrimination

demands (all are activated) Minimal sequencing demands

66

Example

Guess what! We went gambling and I won $500!

I spent it already - a necklace for my wife, and a lobster

dinner.

I’m such a great guy…

#1

67

STEP 3. Access semantically specific messages to answer specific questions – must discriminate between messages and then choose

I’d like to order….

STEAK rare

LOBSTER Well-Well-donedone

PORK CHOPS

68

J.V. telling Sara he wants to watch a movie by pointing to a photo choice after she asked

“Well, what do you feel like doing right now?”

Addition of dental floss and cigarette symbols helped John learn to discriminate between pictures vs. pick them at random

69

Tx Strategy # 5. Gradually increase complexity and number of choices in

partner-supported techniques: Written choices – shift from

egocentric topics (your hobbies) to world events (How improve security?)

VOCA - increase number of levels/pages for situational messages

70

Point to semantically specific written word choices to answer conversational questions (Written Choice Conversation Strategy -- Garrett & Beukelman, 1995) Example: Egocentric choices

“Where do you live?” Squirrel Hill Oakland East Liberty

71

Example: Complex topics/choices “What do you think of the White

House’s policy on Iraq?” I am against war – stay out. We need to be there to fight terrorism See what the other countries say George Bush #2 is at it again – how

ridiculous! I don’t CARE! It’s all politics as usual!

72

Typing out choices on the economy for Dr. D.

73

Tx Strategy #6: Asking questions/becoming an initiator Teach PWA to ask questions by pointing,

using rising intonation, and approximating: “You?” Eventually shift to asking with semantically specific key words: “Wife?”

Goal – increase range of communication acts (i.e., not just responding) and provide means of communicating linguistically difficult question forms.

74

Tx Strategy # 7. Teach PWA s/he is responsible for setting the topic….

And must bring/show SOMETHING All is quiet until they

signal/gesture/reference SOMETHING!

75

Sample topic setter: Travel Brochure

76

Teach family members to place REMNANT of an outing or activity in view or in communicator’s pocket.

Use verbal or physical cues to trigger presentation of remnant in response to peer question “What’s new?”

Fade cues as appropriate

77

Video Illustrations Pointing to ask a question Using a tangible topic setter Telling a story via prestored

symbols on simple VOCA Making simple requests via pictures Using a VOCA to access

conversational phrases

78

Tx strategy #8. Involve client, family, and partners in…

Vocabulary selection System design Identifying communication

opportunities in the community Participating in partner role-plays or

real interactions

79

John & wife Judy – adding info to Dynavox about a story

80

Tx Strategy # 9. Add new strategies 1 at a time. Ex…

Teach PWA to show topic setter Then teach PWA to point and ask “you?”

while showing topic setter Then teach PWA to point to choices to

answer Then teach PWA to find a map to answer

location questions Then teach PWA to find a list of family

members and point to it to answer “who questions etc. Etc.

81

Tx Strategy # 10. Focus on teaching use of strategies in meaningful

contexts from Day 1 Set up scripted conversational routines –

practice then “do it!” Develop roleplays – assemble vocabulary,

make choices, practice script, invite novel partners Ex. Bank

Embed new strategies into real life situations – Ex. Wedding toast for daughter – store on single

message device, have person practice, then access it for real at the wedding

82

Gradually lengthen roleplays Change setting – leave clinic room Add partners Withdraw cues and script after

repeated rehearsals (if possible)

83

Sample Script

85

Video Example – Embedding Strategy

Instruction in Contextual Therapy

Jerry/Kim OR Jerry & Ben OR Ben & Cliff

86

2. Advanced Strategy Learners

Purpose of instruction at this level is to increase PWA’s independence and ability to think purposefully about using communication strategies Transitional Communicators Stored Message Communicators Generative Communicators

87

Tx Strategy #11: Ask PWA -- “Which strategy could you use?”

“How are you going to get your message across?”

“Is that information in your system? If not, then maybe you should write/draw/pantomime”

“Is this person patient? Knowledgeable about your communication disorder? If not, maybe you should: prestore a message explain how you communicate up front

88

Chart Approach: Instead of verbally instructing PWA to use a specific strategy, point to the chart and ask…. “Which strategy will work best?”

Modality Instruction Chart

89

Mike talking about his WWII medal

90

Tx strategy #12. Tax the communication with additional discourse demands

Increase interactional demands Partner pretends to not understand Partner interrupts or requests more info

Deviate from practiced scripts Conduct discourse activities in other

settings with unfamiliar partners Increase difficulty of discourse tasks

From requesting a specific shoe size to negotiating a shoe’s return

From telling 1 item about weekend to telling a story and answering questions about it.

91

Video Illustrations Asking spouses out for a date

Speech/gestures (Steve) VOCA (John)

Conversation with Dynavox – (Don)

92

THINK…DISCUSS

D. Group Intervention Approaches for Long-Term

Aphasia

1. Rationale for Group Therapy/Discussion

2. Descriptions of Various Group Models (note: apology)

3. The Nebraska-Pittsburgh “Thematic Discourse” Model

94

1. Rationale for Group Therapy

Interactional contexts can promote generalization and functional use of communication skills

Groups provide opportunities for peer socialization and cooperative attainment of goals

Efficient and effective way to deliver long-term rehabilitation services

Current Practices: England and the U.S.

Do you offer group therapy in your facility?

95

2. Description of Group Models A) General Types of Groups

Conversational Groups Language Therapy Groups Functional Activity/Skills Groups Support (Psychosocial) Groups Drill and Practice Therapy Groups Spouse/Caregiver Support Groups Spouse/Caregiver Communication

Instruction Groups

96

3. Contemporary Models of Aphasia Group Therapy

* * * * * * * * * * * * Marshall’s Problem-

Solving Approach

Avent’s Cooperative Group Treatment

Kagan’s Toronto CommunityProgram

Holland & Beeson’s Convers. Groups

Aphasia Center of CA

Family Based Intervention (Univ. of WA)

Nebraska Scaffolded Discourse Approach

97

a) Marshall’s Problem-Focused Group Tx – Oregon & Rhode Island

Veteran’s Hospitals

targets independent persons with mild aphasia

designed to help individuals cope with day-to-day problems

clinician serves as a facilitator only

98

Problem-Solving Approach cont.

Organizational Structure meet 1x per week for 60-90 minutes 8-10 participants no predetermined discharge date No charge: VA supported

99


Examples of Activities communicating in an emergency meeting new people preparing for a doctor’s visit self disclosure

100


Outcomes 14/23 showed overall improvement on

the PICA 9 showed little or no change on the

PICA or discontinued tx before retesting anecdotal reports: clients began filling

prescriptions, ordering specialty sandwiches, obtaining bids for repair work, completing paperwork

101

b) Avent’s Cooperative Group Treatment for Mild Aphasia

(Jan Avent, California State University-Hayward)

emphasizes dyadic communication, inquiry and discovery, reflection on performance

clinician facilitates a group member to facilitate the target communicator

102

Avent’s Cooperative Group Treatment cont.

Organizational Structure 2 individuals with aphasia in a treatment

dyad and an SLP facilitator 45 minutes (1 story per session) to 90

minutes (2-3 stories per session) designed for mildly impaired individuals

but has been used with moderate-severely impaired communicators

home program set up prior to discharge funding structure unknown

103


Examples of Activities: summarizing target stories (narrative

and procedural story retells); facilitator with aphasia assists the target individual to improve their rendition.

narrative story topics have included: Alaska, American bison, exercise, dogs

procedural story topics have included: planting a garden, renting a movie, etc.

104


Outcomes multiple baseline study with 8 subjects

conducted 3X weekly for 5 weeks Measures included: Correct Info Units

(CIUs), number of key words used by reteller, number/type of cues supplied by the facilitator, SPICA, WAB, CADL

significant increases in SPICA, WAB, CADL scores for moderate to severe participants at 2 mos and 4 mos

105

c) North York Pat Arato Aphasia Centre (Toronto, Canada -- Kagan, Gailey, &

Cohen-Schneider)

• emphasizes a partnership emphasizes a partnership among members, families, among members, families, volunteers, and volunteers, and professionals & staff professionals & staff

• goals of increased goals of increased independence,community independence,community reintegration, social and reintegration, social and emotional supportemotional support

• large program - 300 large program - 300 members and 100 members and 100 volunteersvolunteers

106

North York Pat Arato Aphasia Centre (Toronto, Canada -- Kagan et al) Continued

Organizational Structure 12 week introductory program

one session per week/105 minutes 20-25 members with aphasia 4-5 people per group separate groups for family members

volunteers are trained extensively to facilitate conversational interactions

107


Organizational Structure - Funding funding is obtained from various

sources, including: Ontario Ministry of Health fundraising Suggested donations for participants

is $160 (Canadian per term)

108


Examples of Volunteer-Facilitated Activities natural topical conversation!!! barrier games/PACE strategies

20 questions watching video clips of news segments or

humorous advertisements, homemade videos of staff engaging in embarrassing situations

109


Outcomes members with aphasia and family members

reported changes in 5 of 6 dimensions on the Ryff’s Psychological Well Being Scale at 6 month intervals

positive changes reflected in: autonomy, environmental mastery, personal

growth, purpose in life, self-acceptance (members) autonomy, personal growth, positive relations with

others, purpose in life, self-acceptance (family)

110

d) Arizona Conversation Groups (Holland & Beeson)

small group format goals are: to provide

communication opportunities, to facilitate communication using all successful modalities, and to teach strategies

111

Arizona Conversation Groups (Holland & Beeson) cont.

Organizational Structure serve approximately 40 individuals with

aphasia (8 groups of 5-7 individuals @) 1 X per week/1 hour sesssions facilitated by graduate students with

supervision separate groups for family members private pay - $10 per session

112


Examples of Activities: topical conversations PACE types of activities games use of memory books discussions about former occupations roleplaying educational/informative lectures self-evaluations

113


Outcomes longitudinal data collected with formal

(WAB) and informal (CETI) measures revealed measureable gains in communication abilities for most group members who were many months or years post onset.

114

e) The Aphasia Center of California (Elman & Bernstein-Ellis)

built on the premise that natural social interaction motivates persons with aphasia to communicate.

work on learning strategies, using multiple modalities.

115

The Aphasia Center of California (Elman & Bernstein-Ellis) continued

******************************* Organizational Structure

70+ members community based (located in Senior

Center) 6 conversational groups weekly (90

minutes sessions) 5 to 8 persons per group caregiver groups bimonthly SLPs facilitate

116


****************************

Organizational Structure - Funding because tx is held in nonprofit community

agency, less overhead Funding is primarily private pay ($15 per

session with sliding fee down to $4 per session).

Several HMOs willing to pay first 10 sessions. Also conduct fundraising activities: individual

contributions, corporate and private foundations

117

The Aphasia Center of California (Elman & Bernstein-Ellis) continued*****************************

Examples of Activities conversational activities reading and writing groups art class supplementary individual treatment not task or theme oriented/conversation

emerges in accordance with the interests of the day

118


************************************** Outcomes

28 subjects - randomly assigned to immediate vs. deferred group tx

dep. measures included: SPICA, WAB AQ + reading/writing measures, CADL, CETI, affect balance scale, connected speech and interviews.

scores on formal test measures (SPICA, WAB, CADL) were better for immediate tx group

119

f) Family Based Intervention for Chronic Aphasia

(Nancy Alarcon, Univ. of Washington)

focus on direct tx of family members re: behaviors affecting communication

goals: increase quality of communication interactions in dyad, decrease breakdowns, increase facilitatory behaviors

120

Family Based Intervention for Chronic Aphasia: (Univ. of Washington) continued

*************************************

Facilitatory Behaviors comment clarify cue

Nonfacilitatory Behaviors interruption interrogation repetition

request

121

Family Based Intervention for Chronic Aphasia: (Univ. of Washington) continued

Treatment consists of: general education (communication

abilities of person with aphasia, facilitatory behaviors)

conversational practice videotape, review, feedback additional practice of facilitatory

behaviors

122

Discussion Which aspects of these group

models appeal to you? Who might benefit from these

approaches? Cautions???

123

g) Group Therapy – The Nebraska-Pittsburgh Model

124

History University of Nebraska-Lincoln - 1993-

1997: Garrett & Ellis Student training programs Adults with a wide variety of aphasia

types, ages, backgrounds Duquesne University (Pittsburgh) - 1998-

present: Garrett & Staltari Ever-increasing demand for services at

the post-acute rehabilitation phase

125

Constituency of Groups (3) Mild Aphasia Group

Difficulties with fluency, semantic flexibility and specificity, organization of discourse, timing, and integration of language with high level social-pragmatic skills

Participants tend to have generally good auditory comprehension; primarily communicate by speaking. Are back to most routine life activities but complain that they “just don’t feel the same”

126

Moderate Aphasia GroupDifficulties with fluency, semantic

flexibility and specificity, grammaticality, phonologic retrieval, repair of online communication breakdowns, organization of discourse, timing, and integration of language with high level social-pragmatic

Some comprehension challenges. May communicate by speaking or

supplement speech with alternative communication strategies

127

Severe Aphasia Group Participants have limited to no verbal

communication. Typically have some degree of auditory comprehension breakdown as well -- from mild to severe.

Have difficulties initiating communication acts; conveying novel,semantically specific information; referencing what they’re talking about; attending to relevant info/conversational partners; engaging in reciprocal exchanges

128

Organizational Structure University-based clinic weekly sessions/1.5 hours 4-8 members; all severity levels SLP graduate students facilitate sessions (with

supervision) break out sessions/individual instruction as needed minimum of $5 per session – max of $25 per session

some insurance payment for a portion of the sessions workman’s comp or Office of Vocational Rehabilitation Sertoma scholarships for individual clients Private pay – reduced fee schedule option

129

Purposes (4) of Therapy Groups 1) To improve linguistic skills

Semantic Discourse

2) To improve interactional skills in Conversational Contexts Transactional Contexts

130

3) To increase communicators’ use of compensatory strategies when appropriate

4) To assist clients and significant others to learn to live with aphasia (after Lyon, 1996)

131

3 Basic Tx Principles: Communication in Meaningful Contexts

1) USE language vs. practice

Embed language targets in a connected sequence of communication acts that have a purpose

EX: Asking your wife out on a date vs. practicing her name and “I love you” in an isolated context

132

Prepare for challenges to resource allocation: practice compensating for situational demands in tx

EX: Practice standing up, walking to movie counter, asking for a ticket, being bumped, getting back on track and requesting a ticket

133

2) Communicate at the level of discourse

Have a GOAL (conduct a transaction, to tell a story, to explain how to do something)

ORGANIZE the communication acts you need to achieve this goal Ex.Hi honey - come here

[gesture]. Date?

134

Add enough REFERENTIAL/ SEMANTIC SPECIFICITY and COHESION to convey ideas

Ex.“Movies - you?” [or show newspaper]

Consolidate multiple communication modalities into one communication act EX: Hand her flowers and say “I

love you” vs. practicing speech and gestures

separately

135

3) utilize thematic, situational activities in tx Examples:

Planning a party for group member Going to the bank Greeting trick-or-treater

May facilitate retrieval of language associated with episodic memory

Preliminary observations: increased complexity and automaticity of expressive communication

136

Structure of the Model – 4 phases 1) Conversation 2) Context-Building 3) Language Mediation 4) Discourse

Turn to the grid representing the group model – Section on group therapy

137

VIDEO ILLUSTRATION – VIDEO ILLUSTRATION – GROUP in ACTIONGROUP in ACTION

138

Figure *.* Aphasia Group Conversational Competence Rating Scale (C) Garrett & Sittner, 1996

Communicator: Context: Rater: Date:_____________

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Instructions: Observe the communicator in an interactive group context. Circle your rating. 1. How much did the communicator participate in the interaction? <-------------------------------------------------------------------------------------------------------------------------------------------------> 1 2 3 4 5 6 7 none some a lot 2. How much of the time was Communicator X able to get his/her message across? <-------------------------------------------------------------------------------------------------------------------------------------------------> 1 2 3 4 5 6 7 none some a lot 3. How much of the time did Communicator X take an active role in the interaction by asking questions, generating unsolicited comments, or expressing opinions? <-------------------------------------------------------------------------------------------------------------------------------------------------> 1 2 3 4 5 6 7 none some a lot 4. How frequently did Communicator X use different ways of communicating when trying to get his or her message across (i.e., speaking, writing, AAC system, etc.)? <-------------------------------------------------------------------------------------------------------------------------------------------------> 1 2 3 4 5 6 7 didn’t use used some used many methods different methods different methods 5. How flexible and strategic was the communicator when trying to convey messages that were not understood by listeners? <-------------------------------------------------------------------------------------------------------------------------------------------------> 1 2 3 4 5 6 7 not flexible some very flexibility flexible 6. How many communication functions (e.g., asking questions, arguing, giving advice, greeting, commenting) did the communicator use when conveying messages? <-------------------------------------------------------------------------------------------------------------------------------------------------> 1 2 3 4 5 6 7 none some a lot 7. On a scale of 1 to 5, how would you rate Communicator X's overall communication ability? <-------------------------------------------------------------------------------------------------------------------------------------------------> 1 2 3 4 5 6 7 poor some good communication communication comm. ability ability ability

Group measurement scale found in your handout packet on page 60

139

Reference

Garrett, K., & Ellis, G. (1999) Group communication therapy for people with long-term aphasia: Scaffolded thematic discourse activities. In R. J. Elman (Ed.), Group Treatment of Neurogenic Communication Disorders: The Expert Clinician's Approach. Boston: Butterworth-Heinemann. Pp. 85-96.

140

Part V: Part V: Professional Issues, Future Professional Issues, Future

Directions, DiscussionDirections, Discussion

141

A. Programmatic Issues 1. Funding for Therapy 2. Funding for Equipment 3. Reestablishing our role 4. Measuring Change/Effectiveness

142

1. Funding for Therapy Write objectives specifically

Examples: “Will initiate request for medical needs or

favorite activities by selecting message from 8-item VOCA display in contextual situations in assisted living environment”

Note the communication function, strategy, and environment that you are aiming for

Caveat about saying “AAC” Reapply for insurance coverage each year

143

2. Funding for Devices 1. State Technology Projects Loaners 2. Private Insurance

Aetna - SGD’s Tri-Care (military)

3. Medicaid (some states) 4. Medicare – SGD’s 5. Private Pay

144

www.aac-rerc.com

145

Special Issues DME - devices should be described as

being “durable medical equipment You need to find an authorized vendor

of DME equipment - usually can’t have it in same hospital

Outside vendors of “orthotics and prosthetics”

146

Only certain devices are covered. Only certain manufacturers are on

the list of Medicare and insurance providers - BECAUSE they are not reimbursed in full (they’re reimbursed at Medicare level rates)

147

Work of Medicare AAC Implementation Team – through ASHA

Joanne Lasker – p. 61 Good organization schema for

ordering Speech Generating Devices (SGD’s) for people with aphasia “No Technology” “Low Technology” – digitized devices “High Technology – combine symbols,

writers

148

3. Reestablishing our Role

Not just swallowing experts Not just stimulation therapists Work on the whole package of communication –

whatever it takes to increase participation, strategic communication in real-life contexts

Partner training is legitimate Other team members can be invaluable in rehab

setting – e.g., rec therapists, religious leaders, etc.

We can do something for these folks and we need to see them.

149

Is AAC is unique, or is it just another enhancement to overall language

therapy?

150

4. Measuring Change/Effectiveness

See Garrett, K., in Elman, R. (Ed). Chapter on Measuring Outcomes of Group Therapy. Group Treatment

My current practices and ideas Triangulation NOMS, ASHA-FACS, Observ. Tools + Tests + Criterion Referenced Measures + # of Life Activities that PWA is participating in +

Discussion

151

B. Delivery of Therapy 1. Increasing contextual

opportunities 2. Implementing group therapy

152

C. Research questions and future directions

Measurement of use of strategies in real-life contexts

Partner training What types/quantity of referential

communication skills do same-age peers use when communicating?

Changes in language expression/comprehension

Changes in comm. Competence with referential communication training?

153

D. Wrap-Up How will you change what you do as

a result of this workshop? What concerns do you have? What goals do you have? Can you suggest additional

directions for me?

Goal Goal = =

CommunicationCommunication

155

The End

156

Discussion!!!

1 part iv: integrated therapy approaches. 2 a. introduction the challenge: how do we enable people...

Documents