The Aphasia Therapy File

Volume 1

Sally Byng, Carole Pound, Kate Swinburn, Sally Byng, Carole Pound, Kate Swinburn

• Publisher: Psychology Press
• Year: 2002
• ISBN:
  9781135471675
• Edition: 1
• Topic: Psicología
• Subtopic: Historia y teoría en psicología

Different from a textbook or academic journal, the File represents a collection of explicit descriptions about therapy interventions written by practitioners themselves. The description of the rationale for the therapy, the intervention itself and evaluation of outcomes are of paramount importance. Each contributor guides the reader through the thinking that they engaged in as they decided what to do, often with considerable frankness about the difficulties involved. The File will be of equal value to experienced practitioners and students alike.

1
Introduction
to the Aphasia Therapy File

This edition of the Aphasia Therapy File marks the first in what will be a regular publication providing a resource of ideas about therapy for speech and language therapists working with people with aphasia. The purpose of the File is to disseminate, encourage, and facilitate writing about therapy interventions for aphasia by the people who implement the therapy.

The idea for this publication emerged some years ago from a question asked by a practising speech and language therapist about where she could send a small case study to be published, which she considered would be of interest to other clinicians. The dilemma was that, if she published the study in a professional magazine it would have meant that it lost its ready accessibility for clinicians to reference and that there would have been constraints on length. However, if she sent it to an academic journal, it had probably to conform to a conventional journal format, having a literature review and considerable theoretical discussion and interpretation. The therapist in question did not have time to do the amount of research necessary to permit this within the constraints of her clinical job and felt that the therapy she had done was not on a large enough scale for such a publication, nor could she write in as much detail as she wished about the therapy in such a forum.

The literature usually comprises one of a number of types of therapy study. These might be studies of the implementation of a therapy technique with a group of individuals where the therapy and the responses of the aphasic people are only described in outline. Alternatively there are a number of examples of in-depth theoretical studies of aphasic people with specific language impairments for which therapy is provided, which are then followed by detailed discussion of the theoretical implications for understanding of the language impairment. Yet again, the study may be a model experimental study to show the very specific effects of an intervention on a specific problem and to account for those effects.

Although this is something of a caricature of the literature, it serves to demonstrate that there is currently little space for more discursive description of what therapists do and why, and how what they do is shaped by the individual with aphasia. Most therapists find that, however they set out to achieve something, it is changed by the reaction/response of the aphasic person. Thus, the published studies that concentrate either solely on the nature of the language impairment or the implementation of a specific predetermined therapy procedure do not reflect therapy as it happens with most therapists, in the UK at least.

The rationale then for providing these in-depth therapy studies, outside the confines of a traditional academic or professional journal or textbook, is to allow therapists a different medium for discussion of their work, which perhaps fits the implementation of therapy better than conforming to existing styles. The purpose behind these studies is to allow therapists to write about what they actually did when working with a specific client, in ways that conform by and large to their own style.

It seemed also that there was a need for a resource for practising clinicians who wanted ideas about what to do in therapy, backed up by some evidence of the effects of those ideas. This publication therefore represents a half-way house—a permanent reference resource in which therapies which are explicit in their design, rationale, implementation, and measurement of outcome are described, but without the requirement necessarily to reference other literature or draw theoretical as well as clinical conclusions. This not only makes the material more easily accessible to busy clinicians, but also provides a realistic medium for therapists to communicate the outcome of their work.

AIMS OF THE APHASIA THERAPY FILE

The Aphasia Therapy File was conceived as a resource about implementing therapy, with the following aims:

• to provide working clinicians with a forum for publishing good quality real-life case studies detailing the effects of speech and language therapy
• to provide a forum for publication unconstrained by the usual demands of academic research journals
• to provide an accessible resource of ideas and directions to take in aphasia therapy
• to encourage the publication of evidence about the effectiveness and utility of a wide range of types of therapy, reflecting real-life needs of people with aphasia
• to support the development of forms of writing about therapy that provide clear guidance to other clinicians about how to apply the same approach
• to provide a resource of material about therapy for academic and clinical researchers, which might support parallel research development.

It is intended that there will be an addition to the File annually, comprising an additional set of therapy studies. A cumulative index and list of contents will be included, so that therapists can keep extending the resource at a reasonable cost. The editors will encourage submissions from clinicians and also receive speculative submissions, much in the way that academic journals operate. All submissions will be reviewed, using external reviewers where necessary.

The Aphasia Therapy File will reflect clinical practice; clinicians have different therapeutic styles, which are demonstrated in the written presentation of those therapies. There is therefore no “house style” nor preferred length or scale of study. Rather we want to stimulate the publication of as wide a variety of studies as possible and avoid constraining the type of material that clinicians submit for publication. A personal style of writing is acceptable, including use of the first person singulars which can seem a more natural medium when writing about therapy.

CRITERIA FOR SUBMISSION

There are some explicit criteria that studies published in the Aphasia Therapy File should meet, as follows:

• a clear description of the nature of the communication impairment and/or disability of the aphasic person or group of people who are the focus of the study
• preferably a transcript of spoken language to assist the reader in familiarisation with the aphasic person in question
• an explicit rationale for the type of therapy implemented
• a clear description of the therapy itself: the materials or resources used (if any), the tasks implemented, the type of facilitation techniques or strategies etc. employed
• if possible, a transcript of a sample from a therapy session to exemplify a specific aspect of therapy (as in Hunt, Chapter 4; Mortley, Chapter 7; and Marshall, Chapter 11; in this volume)
• a detailed account of the evaluation of the intervention
• the evaluation should include a description of the impact of the intervention on the everyday life of the aphasic person.

Not all the studies included in this edition meet all these criteria: in this edition the studies included are of varying length, style and scope. We considered that it was important to publish material currently available from clinicians, with the expectation that the publication of an increasing number of case studies will stimulate future submission of studies from therapists. We hope that some of the existing studies will serve as role models and allow clinicians increasingly in the future to refine the presentation of the therapy study, outside the constraints of more traditional forms of publication.

Studies need not document only therapy for the impairments caused by aphasia; therapies for disabling aspects of aphasia could also be included. Our use of the terms “impairment” and “disability” are largely in accordance with the World Health Organisation, 1980, classifications. Within this framework, impairment refers to abnormality of function and disability reflects the consequences of impairment in terms of functional activities. In line with the views of some disabled groups, including some people with aphasia (e.g. Ireland, 1995), we have chosen not to employ the term “handicap”, but to include issues of social role and lifestyle within a broadened concept of disability. This will be evident in this volume in particular in the chapter by Harding and Pound (Chapter 3). Therapy that involves relatives and friends or other health and social care professionals could also be included. Contributions by clinicians who discuss how, in retrospect, they would have made modifications to the therapy, will be welcomed, especially when those modifications are made explicit.

ABOUT THE STUDIES IN THIS VOLUME

The studies are grouped loosely according to the aims of the therapy, although there is of course considerable overlap between studies even in different parts. Each part is introduced briefly by a review of the studies to be included, pulling out the common and interesting themes raised, and referring to other current literature where relevant. This is intended to put the studies into a context for therapists with limited reading time.

This first edition of the Aphasia Therapy File is divided into three parts, organised around the basic focus of the therapy, although the parts are not mutually exclusive, and all the studies address some common issues and raise common themes. Most of the studies concern therapies aimed primarily at the language and communication impairment. This does not mean that we believe this to be the sole primary area for intervention in aphasia, but rather it reflects the nature of the studies submitted.

The therapies for the language impairments described in this volume come from what has emerged over the past decade as the predominant theoretical background for work on the language impairment in aphasia therapy in the UK. That is, they are all based on an interpretation of the underlying language impairment within a simple cognitive neuropsychological/psycholinguistic model of language processing. The authors assume a basic working knowledge of this kind of model (typical of therapists in the UK), which they use as a point of reference for the explanation of the language impairment and the formulation of aspects of impairment to be addressed in therapy. The fact that this is a characteristic of these studies does not mean that all future submissions will have to conform to this tradition. It merely represents the current predominance of this approach in the UK. Provided therapy studies meet the criteria listed earlier (i.e. explicitness about the person, impairment, and disability, the rationale for therapy, and the therapy itself) they will be accepted for consideration.

A further assumption clearly evident in these studies is the need in each case to address the language impairment itself, in addition to or in support of work to address the functional, social, and emotional impact of that impairment. Each case highlights primarily the work that was undertaken to ameliorate the language and/or communication impairment, but most of the studies also discuss the relevance of this therapy to functional communication. The authors largely take a position (sometimes unconsciously) that there is a continuum between therapy for the impairment and therapy to assist in communicating more effectively and efficiently in everyday life. Often we find these two concepts polarised in the literature—these studies demonstrate the necessary reliance of functional communication strategies on developing the language and communication skills underlying those strategies.

There is not necessarily anything particularly original or unusual about these studies—the aphasic people, the therapies, and the therapeutic dilemmas presented will be familiar to most speech and language therapists/pathologists. We believe, however, that much of the discussion of these latter two issues has not before reached the literature. Here, each author describes in some detail the therapy that they undertook, providing a reasonably detailed rationale for the activities undertaken. The majority of the studies talk the reader through the thinking that the therapist went through as she/he decided what to do next, often with considerable frankness (e.g. Hunt, Chapter 4) about the lack of certainty about what they should be doing, and also in hindsight with some regrets about what they did not do. We hope that this will be an important feature of the Aphasia Therapy File. So often, published therapy studies make it look as though the therapist was quite sure what to do and what the predicted outcomes would be at the outset. Real therapy is more like a voyage of discovery—the therapist starts on a course of action, in discussion with the aphasic person and perhaps those around them, with, often, only a hunch that this will be effective.

These studies also indicate how determining a course of action is not a one-off occurrence. Most of the studies pick up the therapy after other therapies had already been implemented (usually by other people), often to little or no effect. They demonstrate how therapists change course or reevaluate what they are doing in the light of the aphasic person’s response, both in linguistic and emotional terms. We believe that providing a description of the therapists’ thought processes in both setting about and reevaluating therapy will be of interest to experienced therapists and students alike.

Thus, the therapy studies published here do not represent new therapies. Rather we hope that they will help therapists to reflect on their practice, to assist in more detailed analysis of why someone may or may not be able to make use of the therapy provided. They may provide ideas for further developing therapy tasks or reorientating familiar ones to address a difficulty more subtly or more directly. These studies also represent real-life therapies, where the therapists cannot implement or pursue lines of thinking that they think to be of primary importance, because of intervening factors, be they social, psychological, cultural, or logistical (e.g. Harding and Pound, Chapter 3).Changes made under these conditions are even harder to bring about than those achieved under optimal therapy conditions (which are often those described in the literature). All but one of these studies (Marshall, Chapter 11) was carried out during the course, and within the constraints, of “normal” clinical practice in typical UK National Health Service speech and language therapy services.

None of these studies describes complete therapeutic interventions. In almost every case further intervention is indicated, but some of the authors describe the complexity in determining what that further intervention should be. For example in D’s case (Harding and Pound, Chapter3 ), it is clear that he is going to need further support in both using his developing communication skills and in adapting to his new identity and lifestyle. However, how that intervention can be provided is hard to determine given the social and cultural constraints. Some of the studies (especially those by Harding and Pound, Chapter 3; Hunt, Chapter 4; Lawson and Fawcus, Chapter 5; and Marshall, Chapter 13) bring out the complex relationship between therapy for the language impairment and addressing psychological, emotional, and social issues. Marshall (Chapter 11) and Hunt (Chapter 4) both indicate how the depressed status of the women they worked with seemed to impair their ability to use the often considerable communicative strengths at their disposal.

The importance of providing emotional support to people adapting to life with aphasia from very early on post onset of the aphasia seems critical. What is devastatingly apparent is how intractable and destructive the depression accompanying aphasia is; the distress experienced by so many of the people described here is palpable. No wonder it has been so difficult either to establish that therapy is effective, or to bring about carryover of changes to communication skills outside the clinical environment—anybody grappling day by day with such mind-numbing depression and anxiety would find it hard to take on any new behaviours. Even where therapy has been both effective and appreciated, the depression can seem to block further change or use of new communication skills. The need for more attention to the psychological effects of aphasia has been so regularly reiterated but seems as yet to be so little developed.

However, Lawson and Fawcus (Chapter 5) describe a more positive interaction between enhancing communication skills and psychological state. They cite how TS’s wife considered that the establishment of some means of communication for TS had improved the mental health and well-being of them both, in the estimation of his wife keeping them both out of psychiatric care. The role of therapy for communication impairments and disabilities in maintaining and promoting general and mental health has not been well described in the literature, and could represent an important role for therapy in future as health promotion moves high onto the political agenda in health care delivery.

Some interesting general issues abo...

Table of contents

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• LIST OF CONTRIBUTORS
• 1. INTRODUCTION TO THE APHASIA THERAPY FILE
• PART I: ALTERNATIVE FORMS OF OUTPUT
• PART 2: WORD RETRIEVAL THERAPIES
• PART 3: “BEYOND THE SINGLE WORD” THERAPIES